MEDIS – International Journal of Medical Sciences and Research
MEDIS – INTERNATIONAL JOURNAL OF MEDICAL SCIENCES AND RESEARCH Vol. 5. Issue 2 / 2026 Distinguished Teachers, Scientists, and Researchers in the field of Medicine We are pleased to inform you of that procedure for applying for your scientific and research papers in the field of Medicine, Medical Sciences, and Health, for the MEDIS IJ Vol. 5 Issue. 2. 2026, has started. The purpose of this publishing venture is to persevere the continuity and raise the quality of the work so far, in order for MEDIS IJ to be included in the SCOPUS or WOS list as soon as possible. From now on we offer a new opportunity to do so in MEDIS IJ, where papers will be published in English only. Important: One author can publish only 1 paper per issue The deadlines are as follows: - 27. 04. 2026 abstract submission deadline - 02. 05. 2026 till 12:00 AM full paper submission deadline More Info... Abstract template
Nonsurgical and surgical endodontic treatment have a rate of high success of periapical lesions. There is a need for less invasive methods that have better outcomes. Treatment of some periapical lesions (like cysts) are a matter of debate and the best possible way to treat them is still unclear. The patient should also participate in decision-making process. The clinician should inform him about the advantages and disadvantages of endodontic-noninvasive and surgical-invasive procedure. The therapeutic options for these lesions are a wide range of treatment from endodontic treatment to different surgical options. We like to find out and present the best way to heal the periapical lesion. We wanted to know whenever surgical or non-surgical treatment is better, and if using some specific procedures might improve healing the lesion. We conducted a search of medical and dental literature up. We searched the following electronic databases: MEDLINE via PubMed and Embase Ovid. Inclusion and exclusion criteria were used to reach the aim of this review study. We place restriction about language (only those articles that are written on English) and publication date (articles that are not older than 2010 year). We excluded duplicate article. We searched the reference lists of included studies and of relevant systematic reviews for additional studies. We handsearched the reference list of the studies retrieved and journals in the fields of endodontics and oral surgery. Every periapical lesion should firstly begin with good performed endodontic treatment. Endodontic treatment is not successful in all the cases and surgical approach is needed. Some cases might fail because of multipurpose factors such as: foreign body reaction, the size of the periapical lesion, biofilm, oral health and oral hygiene. A surgical approach is an option in cases when periapical lesion is large. Marsupialization might be proper of alternative treatment for those lesions in some cases. Surgical retrograde treatment is also an option for treating teeth with postoperative periapical lesion. The procedure can be performed with hand endodontic instruments to clean and shape the root canal especially the untreated part. The advantages, disadvantages and modalities of treatment of periapical lesions are discussed in this review. There is no evidence that a surgical approach leads to better results compared with non‐surgical treatment. It is difficult to draw conclusions, as the evidence currently available on the electronic database. There are several options for treatment to eliminate the clinical problems of periapical lesions but furder research is necessary, especially to understand the effects of surgical and non-surgical approaches, and to determinate which procedures provide the best results for periapical lesion healing and postoperative quality of dental life.
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THE BENEFITS OF USING THE SOCKET SHIELD TECHNIQUE IN PARTIAL EXTRACTION THERAPY: AN ARTICLE REVIEW
The socket shield technique is used as a partial extraction therapy based on preserving segment from one of the sides on the root from the tooth that is going to be extracted. The main use of this technique is in cases for immediate implant placement that is combined with bone grafting. The goal of this technique is to preserve as much as possible tissue from the periodontal ligament and also to spare the gingival tissue from unnecessary damaging during the therapy. Indications for this technique are : 1. To support and to preserve buccofacial bone part of extraction socket in cases that require immediate implants. 2. Socket shield technique is indicated in cases with vertical fractures of teeth that are without any pathology of the pulpal tissue, where the bone tissue preservation and aesthetics are a priority. 3. To preserve the papilla between the placed dental implants. In spite of that to have a full success of this therapy is required to have enough bone tissue that will allow stability of the future implant and also absence of any kind of infection. The advantages from application of this technique are many, such as prevention from resorption of the lamellar bone, high aesthetics results, improved primary stability of the future implant, minimal invasiveness during the procedure, prevention from forming a connective tissue with the implant, low cost compared with other procedures etc. There are also disadvantages such as possibility of displacement of the buccal lamellar bone. The purpose of this study is to evaluate the efficiency of the socket shield technique in immediate implant treatment. This survey is based on Narrative review on published articles, using PubMed, Medscape, Webmd, Mdconsult, Emedicine data bases. The preservation of the whole attachment apparatus of the tooth to maintain complete preservation of the alveolar ridge bone, makes the socket shield technique a very promising procedure that helps to keep the esthetics on high level. The clinical outcomes from different studies show that the presented modified socket shield technique meets the expectations for an ideal method for preventing alveolar ridge resorption and it has minimal material requirements.
PERIODONTAL STATUS OF INSTITUTIONALIZED ELDERLY
Impaired general health in institutionalized elderly has an impact on oral health and dental status, especially on periodontal health and oral hygiene. The periodontal health of institutionalized elderly people is influenced by a number of other factors such as: multimorbidity, dependence in maintaining oral hygiene, limited abilities and mobility and the use of numerous medications. Progression of periodontal disease is characterized by the presence of increased destruction of periodontal tissues. The destruction of periodontal tissues is seen through the presence and increased clinical loss of the attachment, but also through the presence of gingival recession and resorption of the alveolar bone. The most common form of periodontal disease in older adults is chronic periodontitis. Due to the chronicity of this disease, most of the detected periodontal disorders are due to the accumulation of the disease over time. The interaction of the highly prevalent xerostomia and the inability to maintain oral hygiene at a satisfactory level in institutionalized elderly leads to an increased incidence of dental plaque. Due to that, the elderly have an increased risk of manifesting dental caries and periodontal diseases. Taking into account the aforementioned facts about oral health, the presence of numerous dental and oral problems, as well as the increased health needs and impaired health in institutionalized elderly people, the aim of this paper was to assess periodontal health among institutionalized elderly people over 65 years of age. Assessment of periodontal status among institutionalized elderly was done by using the Ramfjord Periodontal Disease Index. The research was conducted in the period from April to July 2018 in the Department "Mother Teresa", part from the Gerontological Institute "Thirteenth November" - Skopje. It included a total number of 75 people over the age of 65 who were accommodated in the department and gave their consent to participate in the research. The dental clinical examination was performed in the long-term care institution, in the office or in the rooms of the institutionalized elderly or in a room determined for that purpose. The examination of the subjects was performed on a patient sitting on a chair, lying in bed or placed in a wheelchair. For the examination a dental probe, a dental mirror and disposable gloves and a portable lamp for artificial illumination were used. The average number of present (remaining) teeth in the respondents was 5.81± 7.34 (range 0-24, with Confidence interval from 4.09 to 5.52).The mean value of the simplified OHI Green Vermilion index obtained for the presence of dental plaque was 2.33 ± 0.51 (range from 1.33 to 3.00, with Confidence interval from 2.15 to 2.51). The average value for the Ramfjord index (for assessment of periodontal health) was 4.57 ± 0.74 (range 2.5 to 6.00, with Confidence interval 4.33 to 4.82). Most of the subjects after the appropriate analysis had moderately advanced periodontitis (68.42% of the subjects). Based on the obtained data and subsequent analysis of the results we had found high percentage of people with unsatisfactory oral hygiene and high prevalence of periodontal disease.
EPISIOTOMY – ¬TRENDS AND PREVALENCE IN HEALTH CENTER VRANJE FOR THE PERIOD 1996 – 2021. YEAR
With this paper, we wanted to determine the prevalence of episiotomy in the completion of childbirth in the Gynecology and Obstetrics Department of the General Hospital in Vranje in the twenty-five-year period (1996-2021), and this is the period since it is recommended to abandon routine episiotomy. We also wanted to compare the obtained results with the results of similar studies by other authors and thus determine whether the general trend of reduced use of this obstetric operation due to the numerous complications that its use causes, exists in our country. Retrospective analysis includes data obtained from birth protocols with special reference to patients born vaginally and their parity. Childbirth completed using a vacuum extractor and caesarean section were analyzed separately. Such births for the first and last year of the examined period were presented and analyzed (1996, 2021). Aggregate data for both years were also analyzed. The obtained results are expressed numerically and presented using tables. Based on the data, it was concluded that the total number of births decreased, that the number of cesarean sections increased, that episiotomy in vaginal delivery was the most common among primiparous women and that episiotomy was significantly higher in our sample than in other studies.
MUSCULOSKELETAL SYMPTOMS IN PATIENTS WITH POST COVID-19 SYNDROME AND OPPORTUNITIES FOR INCREASED FUNCTIONAL ACTIVITY
There is an increasing number of patients surviving SARS-CoV-2 infection who have no evidence of acute infection but who continue to have symptoms that persist and shape the post COVID-19 symptoms (PCS). Musculoskeletal symptoms (MSK), as part of the PCS, lead to reduced functional activity and cause prolonged suffering. The purpose of this review is to identify the main MSK symptoms in PCS and to review physical interventions that may have a beneficial effect in reducing MSK complaints and increasing functional activity in PCS. Materials and methods: A review of the literature was performed, including articles about MSK symptoms in patients with PCS and the possible physical interventions used in rehabilitation of these patients, with impact on symptoms, functional capacity, and functional activity. The scientific articles research took place in the bibliographic database of PubMed. The search results were found for: post-COVID-19 (PCS) syndrome, long COVID, post-acute sequelae of SARS-CoV-2 infection (PASC), chronic COVID syndrome (CCS), Musculoskeletal symptom, Pain post-COVID, physical function, Rehabilitation post-COVID, exercise, physical activity, functional capacity, traditional Chinese medicine. Results: The review found evidence of prolonged persistence of MSK symptoms as part of PCS syndrome. Fatigue, myalgia, back, waist and neck pain and arthralgia (pain in the peripheral joints) are the most reported symptoms. Data showing the need for rehabilitation and the positive effect of physical therapy and therapeutic exercises in patients with PCS to reduce pain and increase functional activity was found. Conclusion: Increasing physical activity in patients with PCS is likely to have a beneficial effect on general conditioning, physical function, and functional recovery, helping to overcome the effects of infection, reducing pain, and reducing emotional stress. Individually targeted physical interventions are recommended, including multimodal programs, exercises for overall muscle strengthening, increasing joint stability, cycling training, Individually targeted physical interventions are recommended, including multimodal programs, exercises for overall muscle strengthening, increasing joint stability, cycling training, electrical modalities -Transcutaneous electrical nerve stimulation (TENS) for pain symptoms. Rehabilitation should be applied after detailed functional assessment and shaped be carried out with the participation of a multidisciplinary rehabilitation team. The development of appropriate rehabilitation strategies will allow the achievement of optimal functional recovery and increased functional activity, satisfactory to the patient and will reduce the economic burden of prolonged reduced work capacity.
THE INFLUENCE OF COVID-19 PANDEMIC ON THE VACCINATION OF THE POPULATION WITH THE INFLUENZA VACCINE IN THE REPUBLIC OF NORTH MACEDONIA
The implemented actions to minimize the spread of the COVID-19 pandemic had a powerful effect on the transmission of other respiratory viruses, particularly influenza viruses. Influenza is a disease of viral aetiology that causes epidemics and occasionally pandemics during the wintertime almost every year. Generally, it is a mild and self-limiting disease, but it can represent high morbidity and even mortality when affecting the elderly population or people with latent chronic diseases. The existing circumstances of a persistent and ongoing epidemic caused by the SARS-CoV-2 virus, increase the probability of having active coincidence with the anticipated annual epidemic of influenza. Thus, the key is a logistic strategy for clinical and viral diagnosis of the SARS-CoV-2 virus that will determine the importance of understanding the role of influenza vaccines in virus-induced COVID-19 disease. This paper aims to compare the potential impact of the COVID-19 pandemic on the vaccination coverage of the population with the influenza vaccine. The official data for seasonal influenza vaccination were used, obtained from the weekly reports on the influenza situation in the Republic of North Macedonia from the Institute of Public Health as well as the data from the national system “MojTermin” for total vaccinated individuals with influenza vaccine for the season 2020/2021 and 2021/2022 including the 5th week. The analyzed data for the season 2021/2022 show an increase of applied doses by 8.3% compared to the season 2020/2021 and an increase of 11.5% compared to the season 2019/2020. Regarding the target groups in the season 2021/2022, including the 5th week, the coverage of influenza vaccination in children aged 6 months to 5 years has a significant decrease of 87.9% compared to the season 2020/2021. There is an increase in coverage in health professionals by 24.3% compared to last season, in the chronically ill the decrease of the applied doses is by 11.4% compared to last season, and in the elderly, over 65 it is noticeable an increase in coverage by 100% compared to the 2020/2021 season. Furthermore, there is a significant decrease of 95.7% in the vaccines administered to pregnant women compared to last season. The reduced coverage of influenza vaccination is partly due to the ambiguities arising from the influenza immunization campaign, which emphasized the importance of receiving a vaccine to minimize the spread of the influenza virus as an additional threat to the presence of COVID-19. Although the influenza vaccine does not protect against COVID-19, influenza vaccination has been part of the public health strategy to flatten the disease curve caused by respiratory viruses that attack the respiratory system, to protect and preserve the health of healthcare professionals providing care to patients with COVID-19. Influenza vaccination is still the most efficient preventive measure against influenza infections at our disposal and it is recommended by the most expert bodies including CDC, WHO, ECDC, and the National Committee for Immunization of the Republic of North Macedonia.
Hidradenitis suppurativa (HS), or still known under the name Acne Inversa is a multifactor disease that has a chronic flow and starts with the capture of follicles of fibers located in intertriginous regions or anogenital regions. It is followed by recurrent, deep, sub connected and painful nodes, connected intertriginous sinus tracts and hypertrophic scars. Women are more versatile from men, according to 3:1 and more likely to develop axillary and genitofemoral lesions than a male population that develops changes that are localized in the perineal region. The disease itself is unpredictable flow and cannot be certain whether the period of menstruation, pregnancy or menopause may affect the deterioration of the patient's condition. Usually, the bacterial infection that builds on the state itself is like a secondary phenomenon and most often isolate beta hemolytic streptococcus or staphylococcus. The pathogenesis of the disease is still unclear, but it is thought that the primary event that occurs is follicular occlusion occurring as a result of infundibular keratosis and epithelial hyperplasia. Features show that patients say that the same changes occur in other members of the family. Some genes from Secretase G family are thought to be responsible for the disease itself. On the other hand, there are autoimmune reasons for the very disease, both of the innate and the acquired immunity. However, this disease is classified as neutrophilic restriction. The simplest and most widely used instrument for HS classification in routine clinical practice. It classifies HS into three stages: Stage I: isolated, single or more painful abscesses, no scars and occurrence of cicatrix. Stage II: recurrent pain abscesses with scars, single or multiple but not so extensive. Stage III: diffuse, similar to plates, inflammatory, sick infiltrates or more mutual abscesses. Contracts of joints as a result of limited mobility associated with pain. Because the disease has more stages and treatment itself will be correlated with the stage of the disease. We should emphasize that the disease can also be worsened by some accompanying diseases from which the type 2 diabetes or some other endocrine and metabolic diseases should be distinguished in the first place. Always put the lifestyle and change in everyday habits as it is in the first place to reduce weight if it is increased as well as the cancellation of cigarette smoking. Primary in treatment is maintaining good personal hygiene with soaps that are antibacterial and pastures with mild disinfection. At the beginning of the disease, antibiotics are usually attached as local and systemic administration, most often from the group of tetracyclines. Anti-inflammatory preparations are given in order to reduce inflammation and drug reduction drugs. As antiseptics use salicylic solution, alcohol pine, camphor, ethyl alcohol or iodine. More recently, it goes to make drinks from iodine and potassium hypermangan. If it is not contraindicated, corticosteroid creams and gels as well as a local anesthetic can be reduced. Surgical intervention can be applied to make an incision of a nodule or an apex to be easier drainage and thus reduced the pain of the region concerned. It should be noted that this disease affects the whole family. In the first place, it is necessary to accept the patient's patient in order not to isolate it from the rest and to participate in social life as before the disease itself. A conversation is necessary by a psychologist with the whole family in order to facilitate life and improve the quality of it.
EVALUATION OF THE EFFICIENCY OF SINUS LIFTING TECHNIQUES
Right after teeth extraction in posterior regions, there is a following process that consists of physiological resorption and nonfunctional atrophy of the remained alveolar bone ridge. That also impacts the quality on the quality and quantity of the remained bone tissue, what later makes the implant incorporation and the prosthetic restoration much harder and complicated than usual it is. In the posterior region of the upper jaw additional complication of the prosthetic restoration process causes the existing of paranasal sinus that is located right in the body of the upper jaw maxilla. It’s post extraction pneumatization reduces the height of bone tissue what causes difficulties in dental implants placement. The aim of this survey is to evaluate the clinical outcome and the efficiency of the most often used sinus lifting techniques. Were analyzed totally 78 published studies that were done in the last 12 years. The study is made on narrative review of published articles that were investigating the related subject. Research was done by using the most common data bases: NCBI (US National Library of Medicine), Emedicine, PubMEd, Webmd. By using the open method for sinus lifting there needs to be formed lateral window in the bone tissue first by elevating the mucoperiosteal flap on the vestibular surface of the maxillary alveolar ridge and after that creating iatrogenic fenestration on the cortical lamina without perforating the sinus membrane. After the sinus membrane is being separated, the following step is augmentation. For this step are used four different types of bone substituent: autogenous, allogeneic, xenogeneic bone graft and synthetic alloplastic materials. The closed method for sinus lifting is performed after previous created place for the future implant in the residual alveolar bone ridge in the maxilla, after that with special instruments a perforation is being made in the bone floor of the maxillary sinus and carefully elevating the sinus membrane up for a few millimeters. In the created space a bone graft material is being placed and at the same time a dental implant is being applied. From the gathered results, both of the techniques are considered to be effective, in all of the followed cases the implant placements were successful with high rate of postoperative osseointegration, the healing period was without complications and also successful. There was no prosthetic failure in any case. From this survey the final conclusion is that both of the techniques are successful when it comes to sinus lifting. Very important is to have a qualitative imaging like computed tomography or roentgen before placing the implants to be able to estimate the bone volume and height. If the residual bone height is less than 5 mm the survival rate of the future implants is not guaranteed.
EFFECTS OF THE COVID-19 PANDEMIC ON THE VISITS FREQUENCIES IN EMERGENCY SERVICE SKOPJE
The pandemic caused by the COVID -19 virus has affected human health, consequently the health system and health services, both worldwide and in the Republic of North Macedonia. The idea for this research was therefore to examine the impact of the conditions imposed by the pandemic on the visits of the Emergency medical service in Skopje. For this purpose, the frequencies of visits with transport to hospital and just visits, as well as the frequencies of emergency calls and calls only for transport in the periods: before the pandemic (March 2019-February 2020) and during the pandemic (March 2020 to February 2021) were analyzed. The overall number of visits was further analyzed by categories: age and gender. In the period from March 2019 to March 2021, a total of 49,930 visits were performed, of which 24,115 were performed during the pandemic and 25,815 before. In the same period, a total of 13,835 emergency calls were answered, of which 6,434 were during the pandemic and 7,401 before; a total of 9780 calls for transport of patients were carried out, during the pandemic 5602 and 4178 before the pandemic. The analysis showed that the number of transports was increased and the number of emergency calls decreased during the pandemic compared to the pre-pandemic period, while the number of visits during and before the pandemic did not differ significantly. Concerning age and gender, the analysis showed that the number of visits to children, men aged 20 to 40 and women over 60 years was significantly reduced compared to pre-pandemic visits, while there was no difference in other age groups. The contributions of visits related to certain diagnostic and a particular age group are discussed in this paper. We found that the pandemic has not influenced the pace of work, apart from the conditions, only the association between the kind of calls and the diagnoses for which the visits were made has practically changed. During the pandemic, most visits for males and females over 40 were related to COVID diagnosis, while for children, men and women under 40, accidents were the most common cause.
THE ROLE AND SIGNIFICANCE OF HARMFUL HABITS AND HERITABLE FACTORS IN THE DEVELOPMENT OF CHRONIC VASCULAR DISEASES
Chronic Arterial Insufficiency of the Limb is a condition of chronical reduction of blood flow delivered from the arteries to a limb. It is also known as Peripheral Arterial Disease (PAD). The most commonly affected are the aorto-iliac segment and the arteries of the lower extremities. The most common causes are diabetes and / or atherosclerosis, but the bad habits and hereditarity are also important. The varicose disease is a process of superficial venous dilatation of the lower extremities. The most important reason of chronic venous disease is correlated with hereditary factors and the bad habbits. The secondary varicose is caused by malformations, traumatism and deep vein thrombosis. The lymphedema is a chronic disease, manifested by slowly progressing edema of the skin and skin. Due to the reduction of the transport function of the lymphatic system – the flow of lymph slows that leads to an increase in fluid in the intercellular space- edema. May affect any part of the body, but most often are affected one of the upper or lower limb. Purpose: evaluation of the bad habits and the hereditary factors as a reason for chronical vascular diseases. Methodology: for the purpose of this study a new anonymous questionnaires were created. Results: this study includes patients with chronical vascular diseases and was made in university hospital – clinc of Vascular surgery and in heathcare medical center. Conclusions: The bad habits and the hereditary factors are the main reason for development of chronical vascular diseases.
THE VALUES AND THE DIFFERENCES OF THE SEROTONIN LEVELS IN SERUM AND BRAIN TISSUE IN AN INDUCED DIABETIC NEPHROPATHY WHITE LABORATORY RAT UNDER THE IMPACT OF PERINDOPRIL AND CANDESARTAN
Angiotensin II is the primary vasoactive hormone of the renin-angiotensin-aldosterone system (RAAS) and plays a role in the pathophysiology of hypertension, heart failure, renal failure and other cardiovascular disorders. RAAS is activated in diabetic nephropathy (DN) and leads to more renal damage. Angiotensin converting enzyme inhibitors (ACEis) and angiotensin receptor blockers suppress this (ARBs). A large body of evidence demonstrates that, in addition to its typical activity as a hormone, Ang II is a neuropeptide produced by the central nervous system (CNS) that acts as a regulator of neurotransmission and nerve cell excitability. Peripheral serotonin is an endocrine component that promotes energy storage efficiency. Serotonin also enters the bloodstream and interacts with multiple organs, priming the body for energy storage by promoting insulin secretion and de novo lipogenesis in the liver and white adipose tissue. However, the actions of serotonin extend beyond neuronal communication in the CNS and enteric nervous system (ENS) to peripheral tissues. Serotonin mediates numerous nonneuronal processes such as bladder function, respiratory drive, hemostasis, vascular tone, immune function, and intestinal inflammation . The goal of this study is to see how the ACE inhibitor perindopril and the ARB AT1 candesartan, taken singly and in combination (double blockade), affect serotonin levels in the serum and brain tissue of Wistar rats with DN caused by streptozotocin (STZ). The levels of serotonin in the serum and brain of four experimental groups of animals were measured using an enzyme-linked immunosorbent assay (ELISA): a control group with DN, a group with DN treated with perindopril, a group with DN treated with candesartan, and a DN group treated with a combination of perindopril and candesartan. Perindopril (6 mg/Kg/day), candesartan (5 mg/Kg/day), and dual therapy with perindopril (3 mg/Kg/day) and candesartan (2,5 mg/Kg/day) were given orally every day for eight weeks, beginning four weeks after STZ was given, whereas the control group received just water. The rats were slaughtered at the end of the therapy so that the serum and brain tissue could be used to test serotonin levels. The results showed that blocking the renin-angiotensin system (RAS) with perindopril, candesartan, or their combination considerably decreased serotonin levels in the serum but dramatically elevated serotonin levels in the brain tissue in all groups.
SIGNIFICANCE OF INCREASED D-DIMER VALUES IN FRESH FRACTURES IN ORTHOPEDICS AND CORRELATIONS WITH THROMBOEMBOLIC COMPLICATIONS
background/aim. At the end of the process of separating clots composed of fibrin we have a D-dimer. This process involves thrombin, which is formed during the process where fibrinogen is converted into fibrin, a factor whose role is to bind the basic units of clots and plasmin, the final participant in the breakdown of fibrin. In medicine, we should not use value of D-dimers as the only parameter for thrombosis. The aims of are research is to investigate correlation between clinical signs of venous thrombosis and D-dimer values in fresh bone fractures and demonstrate, that there is momentous correlation between high values of D-dimers and clinical signs of venous thrombosis, which is often a contraindication for surgical treatment of fractures. Methods: D-dimer levels of 211 patients with fresh bone fractures. They are classified into groups based on D-dimer values as follows: <250 ng/ml, 250–1000 ng/ml, 1000-5000 ng/ml, 5000-10 000ng/ml. Results: D-dimer values are not statistically significant with clinical symptoms of venous thrombosis in recent fractures in orthopedics. Discussion: D-dimer is an indicator related to fibrin degradation that has been used in the past as a prevalence in patients with chances of venous thrombosis. In inflammatory processes, we also have increased values of this parameter, which suggests the existence of some inflammatory change in the body or infection. Оur research is among the first to compare D-dimer values in recent fractures in orthopedics and thromboembolic complications. In our research, we showed that there is no significant correlation between elevated D-dimer values in hospitalizations of fresh fractures with clinical signs and a diagnosis of vascular thrombosis. We showed that there is no significant correlation between elevated D-dimer values in hospitalizations of fresh fractures with clinical signs and a diagnosis of vascular thrombosis. With this study, we proved that elevated D dimer is a consequence of trauma and disruption of the continuity and integrity of bone blood vessels, both endosteal and periosteal, which results in thrombosis of small blood vessels. Conclusions: There is no momentous correlation between elevated D-dimer values in fresh fractures and venous thrombosis. High values of D-dimer are not a contraindication for surgical treatment of fresh fractures.
FIBROMYALGIA - CHARACTERISTICS AND PROOF OF PAIN
Fibromyalgia is a disease that remains unrecognized due to ignorance and misinterpretation of symptoms. This article presents a clinical case from the medical practice of Fibromyalgia, while characterizing the pain syndrome and the necessary tests to prove the diagnosis. The clinical case concerned a patient with lumbar pain syndrome who did not respond to non-steroidal anti-inflammatory drugs. No connection has been established with the diseases provided for in the differential diagnosis, such as disc herniation, acute arterial insufficiency, rheumatoid arthritis. The laboratory tests performed are normal, except for a slight increase in AST of about 200 U / l, as well as high CRP values. No instrumental studies such as endophotonic emission computed tomography (SPECT), positron emission tomography (PET), magnetic resonance imaging (MRT) and electroencephalogram (EEG) were performed. The case describes a modified symptom in the elderly. Modified symptoms are experienced differently by patients. In this case, our own (from the doctor's experience) paradigm was used for diagnosis. The paradigm consists of four main steps, which are: description of the specifics of each symptom; two aspects of the diagnosis: what is and what is not; the symptoms form a whole which represents the diagnosis with a logical connection and sequence and analysis of small deviations and nuances - a way of accurate diagnosis. The burning nature of the pain, the presence of painful nodules in the lumbar and scapular areas bilaterally, point to myositis. Various non-steroidal anti-inflammatory drugs have been administered in various forms (oral, topical and injectable), with no effect. As a last resort, a tricyclic antidepressant, amitriptyline, was included, which showed that the pain disappeared within a month. The presence of a mental component in the field of rheumatic disease, the effect of amitriptyline pain and the presence of sore spots at the predilection sites, led to the disease "Fibromyalgia". Diagnosis of fibromyalgia is necessary to comply with two conditions clinical analysis of pain with the detection of painful points and instrumental nuclear magnetic resonance imaging to demonstrate dysfunction of the central nervous system and electroencephalogram for sleep disorders. To improve the diagnostic process, it is necessary in practice to apply tests of hormones and neurotransmitters.
endophotonic emission computed tomography
MICROBIOLOGICAL ISOLATES AND IT'S RESISTOTYPE FROM CLINIC OF VASCULAR SURGERY FOR THE FIRST QUATER OF 2022
One of the most common complications of surgical exposures is the surgical site infection (SSI). Although it varies between different surgical profiles, it can reach up to one third of all complications. In vascular surgery patients ischemic ulcers are very common, as well as factors, compromising the immune system such as diabetes, chronic kidney disease etc. One of the main surgical exposures in vascular surgery is inguinal, providing access to the femoral artery and its bifurcation. Although it allows a wide range of reconstructions, implanting different types of prosthetic materials, stents and providing anastomosis site, it contains lymph nodes, which can contaminate the reconstruction and cause SSI with severe consequences. Patients, prone to SSI due to concomitant diseases, are threatened by sepsis, limb loss and even death, which makes prevention of those type of complications essential. Aim: To investigate etiological spectrum of microbiological isolates and their resistance against most common antimicrobials among vascular surgery patients. Materials and methods: The study is retrospective, conducted in the period 01 January 2022 – 31 March 2022. All of the samples were obtained from patients of Clinic of Vascular Surgery. After isolation of pure culture from the samples, the strains were identified by MALDI TOF MS and Vitec – 2 Compact. Antibiotic resistance was determined with Bauer-Kirby disk diffusion method. Results: From all 419 of the patients, hospitalized in the Clinic of Vascular surgery for this period, 28 isolates from 26 (6,21%) patients were obtained, of which Gram-negative were 19 (67,86%) and Gram-positive - 9 (32,14%). From Gram-negative - enterobacteria – 14 (73,68%), and non-fermenting gram-negative bacteria (NFGNB) were 5 (26,32%). Only 3 (21,43%) from all enterobacteria were extended spectrum beta-lactamases producing strains (ESBLs). No strains, resistant to carbapenems (RCP) were isolated. Five (55,55%) of the Gram-positive isolates were Staphylococcus aureus, 4 (80%) of which were methicillin resistant Staphylococcus aureus (MRSA). Two of the Gram-positive species isolated were Enterococcus faecalis, of which 1 with a high-level aminoglycoside resistance (HLAR). No Vancomycin resistant enterococci (VRE) were discovered. There were no colistin-resistant Acinetobacter baumannii and Pseudomonas aeruginosa strains. Conclusion: From all 28 isolates 8 (28,57%) were with acquired types of antimicrobial resistance. With almost one third of the isolates that are problematic in terms of antibiotic susceptibility, treatment of those patients can be challenging. Prevention of in hospital contamination with polyresistant strains, associated with medical care it is crucial for reducing the number of severe complications, decreasing of hospital stay and cost for treatment.
THE ROLE OF PROPRIOCEPTIVE FACILITATION AND ITS APPLICATION AS AN INDISPENSABLE PART OF PRACTICAL PHYSIOTHERAPY
The essence of proprioceptive neuromuscular facilitation consists in the application of specific reinforcement techniques to enhance central arousal by volitional movements to improve active capacity of the affected muscle and muscles groups. This is a method of rising the muscle reaction and volitional impulses, which can be reached during stimulation of proprioceptive nerve endings. Proprioceptive neuromuscular facilitation consists is a philosophy and a concept treatment (Kabat, 1950) and for the first time the method was applied in physiotherapy practice in 1947. Dr. Kabat and Maggie Knott was the founders which started and continued to expand the development of techniques. Nowadays patients with traumatic as well as orthopaedic symptoms are treated with this concept successful. Development of PNF concept followed some specific techniques and patterns responsible to the neuromuscular facilitation. Movements are our natural way to interact with our environment. Interactions are directed by the mechanism of motor learning principles includes a progression from hands-on to hands-off treatment strategy. The mean goal is functional oriented activities and independence. The physiotherapy should be focussed always to mobilize the reserves to reach the highest point of function. Especially in the first and cognitive stage of motor control, the therapists manual facilitation will be a helpful tool in reaching this goal (Adler et. al, 2007).
ASSOCIATION OF AUTOIMMUNE STATUS WITH ASST, AUTOIMMUNE AND ATOPIC DISEASES IN CSU PATIENTS
Chronic spontaneous urticaria (CSU) is a mast cell-driven skin disease characterized by the recurrence of transient wheals, angioedema, or both for more than 6 weeks. Autoimmunity is thought to be one of the most frequent causes of CSU.CSU represents an important burden that compromises patient’s quality of life, interferes with routine daily activities. Aim of the study: The aim of this study is to make an association of autologous skin serum test (ASST), autoimmune diseases and atopic diseases with the autoimmune status in patients with HSU. Materials and methods: This study assessed 230 patients with CSU. The study is prospective, proceeding at the Department of Dermatology at City General Hospital “8mi Septemvri”, Skopje, in the period from January - November 2021. The study and the data collection were conducted with the approval of the institutional and ethical committee. Inform consent was obtained from all patients. Patients were divided in two groups according to their autoimmune status: patients with positive and patients with negative autoimmune status. Autoimmunity was defined in the case of a personal history of autoimmune disease or in the presence of at least one type of autoimmune antibodies (AAbs) (included anti- TPO, anti-nuclear antibodies (ANA) and rheumatoid factor (RF)).ASST was performed on untreated patients by the intradermal injection of 50 μL of the patient’s own serum into the volar part of the forearm. Anamnestic data on the course of the disease, accompanying autoimmune diseases and allergic diseases were taken. Results: Positive autoimmune status was confirmed in 40.28% of patients with HSU. Patients with a positive autoimmune status significantly more often than patients without an autoimmune status had a certain autoimmune disease (75.17% vs 10.59%):Hashimoto Tireoiditis39.31% vs10.59 %,Vitiligo13.79% ,Arthritis Rheumatica9.66 %,Morbus Crohn 5.52%, Hashimoto Tireoiditis + Vitiligo6.9% . Patients had a personal history of atopy (67.59% vs 55.29%), asthma (61.38% vs 44.71%), personal history for allergic rhinitis (57.24% vs 49.41%), positive ASST (86.9% vs 16.47%). To conclude, in this study, we obtained a high incidence of association of ASST, autoimmune diseases and atopic diseases with positive autoimmune status in CSU patients, thus providing additional evidence in the association of HSU with autoimmunity.
COMPARATIVE ANALYSIS OF THE ECONOMIC INDICATORS OF THE ACTIVITIES OF MULTI-PROFILE HOSPITALS FOR ACTIVE TREATMENT IN BULGARIA AND THEIR CHANGE AS A RESULT OF THE COVID-19 PANDEMIC
The purpose of the present study is to perform a comparative analysis of the change in the economic indicators for the activity of the multi-profile hospitals for active treatment from the public health care system in Bulgaria before and during the COVID-19 pandemic. Methodology: The study used the following methods for processing and analyzing the received information: documentary method; system analysis method; comparative-analytical method; economical analysis; statistical methods – analysis of the dynamics of phenomena and graphic analysis. The need to determine and compare the economic indicators of hospitals of one group is, on the one hand, for managers of inpatient facilities to compare the hospital they manage with other hospitals of the same group, and on the other hand, the problem is particularly relevant for financing institutions - the National Health Insurance Fund, the Ministry of Health and Municipalities. Results and discussion: The main economic indicators for the activity of the medical institutions reflect the ratio of the expenses incurred by the medical institutions to the achieved results of the activity (patients passed, realized bed days, etc.), are used to evaluate the economic efficiency of the activity of the medical institutions and provide information about the "cost" of a particular type of medical care. For the observed five-year period before the COVID-19 pandemic, an increase in the average values of all economic indicators for the activity of the University and national multi-profile hospitals for active treatment, as well as the Municipal multi-profile hospitals for active treatment is characteristic - with the exception of the decrease in their value per drug day. At the Regional multi-profile hospitals for active treatment, there is a decrease in the values of the economic indicators "average cost per bed", "average cost per food-day" and "average cost per medicine day" and a slight increase in the values of the indicators "average cost per single received patient" and "average cost per bed-day". In the first year of the pandemic, 2020, in contrast to the previous year - 2019, there was an increase in the value of all economic indicators for the activity in the group of multi-profile hospitals for active treatment, most pronounced in the indicator "average cost per patient treated". Conclusions: The healthcare crisis caused by the pandemic raises many questions about the adequacy of the healthcare system in the country, its capacity, opportunities and problems. In response to the crisis, the government of the Republic of Bulgaria is increasing public spending on healthcare in 2020 by approximately BGN 628 million.
multi-profile hospitals for active treatment
STUDENT ASSESSMENT FROM THE FACULTY OF "PUBLIC HEALTH, HEALTHCARE AND SPORTS" SOUTH-WEST UNIVERSITY "NEOPHIT RILSKY" ON THE ONLINE TRAINING
The COVID-19 pandemic is having an unprecedented impact on human behavior and everyday life. One of the most characteristic post-COVID effects that has occurred is the increasingly imposed digital communication in all public and personal spheres. Higher education institutions stopped the face-to-face form of education and switched to online education. Digital literacy was required for university teachers and students to use online platforms. For large part of the students this process was easier due to their almost daily presence in the Internet space, use of various communicative social networks and applications. For the teachers, it became necessary to adapt the teaching material for application in an environment, to prepare in a short period of time to move to a different learning environment and to overcome the existing deficits for teaching in an online environment, to develop different forms of testing, to use webinars as a means of synchronous learning. The purpose of the present study is to examine the opinion of the students from the Faculty of Public Health, Health Care and Sport, South-West University „Neofit Rilski“-Blagoevgrad for the quality of online education. An anonymous survey was conducted among students of medical and non-medical specialties – nursing, midwifery, kinesiotherapy, speech therapy and social work. The results show that part of the students accept the online training as effective in terms of the theoretical material, but all of the them express a definite opinion about conducting hands-on training. Students expect from teachers more attractive methods, more time for direct dialogue and discussions. The technical problems in implementing online learning and the difficulties experienced by both students and teachers are reported. The technical problems in implementing online learning and the difficulties experienced by both students and teachers are reported. The obtained results show that both countries are facing a number of problems in the digital reality rethinking the traditional way of teaching.
DISTAL RADIUS FRACTURES IN CHILDHOOD - OUR FIVE-YEAR EXPERIENCE
The most common fractures in children are those of the distal radius. There are relatively scanty publications devoted to this specific pathology in childhood. The timely diagnosis and proper treatment of the distal radius fractures are of undoubted significance. The purpose of the present communication is to share our recent practical experience with the management of the distal radius fractures in children. 2. Methodology. During the period between January 1, 2017 and December 31, 2021, 34 children at an average age of 10,85±3,00 years (between two and 17) with wrist joint injuries resulting in distal radius fractures were examined in the Clinic of Orthopedics and Traumatology, St. Anna Multiprofile Hospital of Varna. There were 21 boys at an average age of 11,43±3,39 years (between two and 17) and 13 girls at an average age of 9,92±2,38 years (between six and 12). Diagnosis was based on clinical and x-ray examinations. Therapeutic behavior included operative treatment, administration of analgesic means, immobilization, and, in some cases, subsequent rehabilitation. Surgery was accomplished under general anaesthesia in most cases. 3. Results. Mean age did not differ statistically reliably between both groups (t=1,524; p>0,05). The left radius fractures (13 in boys and 11 in girls) were statistically significantly more common than right radius ones (eight in boys and two in girls) (t=3,726; p<0,001). Most commonly, a closed reduction technique with or without internal fixation of the radius and ulna was made use of (in 15 boys and in seven girls) followed by reposition and fixation with one Kirschner wire (in one girl), with two Kirschner wires (in five boys and one girl), or with three ones (in five boys and two girls). An open reduction technique was applied in six boys and in six girls followed by reposition and fixation with one Kirschner wire (in one girl), with two Kirschner wires (in two boys and two girls), or with three ones (in two boys). It should be noted that internal fixation was not carried out in two boys and three girls. Control x-ray examination was performed in all the children. Cast immobilization for a period between 28 and 35 days, most often, for one month, was obligatorily done. Subsequently, Kirschner wires were removed in eight boys and in four girls. One complication was observed in a six-year old girl. It was caused by mechanical damage of the left wrist joint following the implantation of the internal orthopedic devices, i.e. three Kirschner wires. They were removed two months after the operation. Complete healing was achieved in all the children. 4. Conclusions. Based on these results of ours, the conclusion can be drawn that these surgical procedures along with the precise diagnosis and immobilization have proven to be safe and effective in the children with distal radius fractures. Obviously, modern strategies to successfully prevent the fractures in children should be developed.
RELATIONSHIP BETWEEN VISFATIN AND SOME BIOMARKERS OF BONE TURNOVER IN PATIENTS WITH CHRONIC KIDNEY DISEASE
Chronic kidney disease (CKD) is a progressive disease that might result in an end stage renal disease (ESRD), raising cardiovascular morbidity and mortality. Life expectancy among patients with CKD could significantly be reduced as a result of an advanced atherosclerosis and followed by a premature death from cardiovascular disease (CVD). CVD is a condition of a subclinical systematic inflammation that involves cytokines produced by adipose tissue. Visfatin is an adipocytokine with potentially important effects on glucose metabolism and atherosclerosis. Therefore, it could be treated like a new marker of endothelial dysfunction (ED) in CKD patients. It has been suggested that visfatin levels could increase as CKD progresses, which could be due to either the chronic inflammation associated with CKD and/or the hypoxia resulting from tubular necrosis, anemia and reduced capillary blood flow. As CKD progresses, visfatin levels among these patients most often spell increased mortality caused by cardiovascular events. The current research has been conducted among a total of 80 subjects with CKD who were divided into two groups - pre-dialysis (30) and hemodialysis treatment (50) patients from the Nephrology and Dialysis Clinic at the UMHAT "Sveta Marina" Varna. Demographics indicators and levels of visfatin, iFGF-23 and iPTH were inevstigated.
CHRONIC PAIN IN STUDENTS OF THE UNIVERSITY OF MONTENEGRO-ATTITUDES AND EXPECTATIONS
Chronic pain is a significant health problem for university students. However, research on the impact of chronic pain on students is lacking, as well as the support they need to overcome the consequences of chronic pain. The goals of this research were to examine chronic pain in students of natural and social sciences at the University of Montenegro, to determine personal emotions, attitudes and expectations towards pain. Methods. Cross-sectional research was conducted among students from the first to the fifth year of the Faculty of Philosophy in Nikšić (Psychology, Teacher Education), the Faculty of Science and Mathematics in Podgorica (Mathematics, Physics and Physiotherapy) and the Control Group (outside the University). A total of 1,500 students and the control group completed online questionnaire, of which 990 participants met the conditions). Statistical differences between groups, female and male individuals were tested using the chi-square test and t-test.( p-value of <0.05 was considered statistically significant).Results. In the observed groups of students of natural and social sciences there are differences in experiencing and describing pain. Social science students showed passivity in dealing with chronic pain. They prefer to leave the decision on the method of treatment to the doctor, and a third of them just take pills. Conclusions. By applying the obtained questionnaire, we can be determined different attitudes of students of natural and social sciences towards chronic pain, therapeutic approaches, as well as expectations. Students of natural sciences had more education about pain, so the emotion, attitude and approach to solving the problem was simpler.
Iatrogenic (a subtype of traumatic) pneumothorax commonly occurs as a complication of transthoracic puncture biopsy (TTPB), central venous catheterization (especially the subclavian vein), thoracocentesis, positive pressure mechanical ventilation (PPMV), transbronchial (TBB) and pleural biopsy. The incidence has recently been increasing due to the increasing use of invasive diagnostic and therapeutic procedures. The aim of this reseacrh is to present the results and the efficiency in the care of iatrogenic pneumothorax in the pneumophtisiologist practice in general hospital. Material and methods: the analysis includes 290 hospital histories (mainly from the Pulmonology Department, in a much smaller number from other Internal Medicine or Surgery Department at the GOB "September 8") for a 4-year period (January 2018 - December 2021) with final discharge diagnoses: pleural effusion, pyothorax, lung cancer, pulmonary infiltration, pleural mesothelioma and metastatic pleural fluid - ICD codes: J90, J91, J86.9, C34, C45.0 and C78.2. All underwent an invasive diagnostic or therapeutic procedure. The diagnosis of pneumothorax included a radiological examination (PA-posteroanterior proection and LL -profile chest X-ray). Results: from 290 diagnostic-therapeutic procedures, immediately and up to 24 hours after the intervention, a total of 24 (8.3%) pneumothoraxes were recorded, namely: 15 (27%) out of 54 after TTPB, 3 (4.8%) of 62 after TBB and 3 (2%) of 124 after thoracocenthesis and percutaneous biopsyes of the parietal pleura. In 2 (4%) of 49 cases after lavage of the pleural space, partial pneumothorax was recorded, 1 complete hematopneumothorax after catheterization of the subclavian vein. Thoracic drainage was performed in 12 (50%) (initially in 9, and in 3 after 24 hours due to progression of incomplete lung collapse). Of the remaining 12 patients, the pneumothorax was treated with exufflation in 4, and in 8 conservatively (with a procedure of forced expiration and respiratory exercises). No case requiring a surgical approach has been registered. Conclusion: a condition for successful care of iatrogenic pneumothorax is compliance with standards in the application of diagnostic procedures in pulmonology and related areas, careful observation and efficient application of modern attitudes in care of complications from invasive-interventional diagnostic-therapeutic procedures.
DIAGNOSTIC CONTRIBUTION OF CLOSED NEEDLE PLEURAL BIOPSY – A 10-YEAR RETROSPECTIVE ANALYSIS
Determining the etiology of a pleural effusion can present a major problem for the clinician. Diagnostic evaluation of pleural effusions should include relevant history, clinical course, radiographic abnormalities, and take into account the patient's desire and consent for further invasive investigations. The seventies were dominated by specific pleural effusions, but in the last three decades effusions of malignant etiology have dominated. Despite advances in diagnostics, about 20% of pleural effusions remain etiologically unexplained. Objective: we present data on the diagnostic contribution and complications when using a Ramel‘s needle (Wolf's set) in investigating the nature of pleural effusions from an etiopathogenetic aspect. Methods: This retrospective study included 284 transparietal closed pleural biopsies performed between January 2011 and December 2020. Local anesthesia with 2% lidocaine was applied to the skin and subcutaneous tissue in all subjects (premedication with 1 mg of atropine or 10 mg of apaurin was sporadically applied); a chest radiograph was taken immediately before and within 4 to 12 hours after the procedure to rule out complications. The diagnostic positivity, accuracy and complication rate of the technique were evaluated. Results: 175 men and 109 women (median age 60 years, range 19–88) underwent transparietal pleural biopsy with a Ramel‘s needle, 96% of pleural effusions were unilateral (53% in the right hemithorax). Pleural tissue was obtained in 98%. The most common histological diagnosis included: malignancy (34.7%), nonspecific inflammation and mesothelial hyperplasia (32.3%), chronic inflammation with fibrosis (23.5%), granulomatous disease (4.3%), normal pleura and striated muscle (5.2%). Microbiological examination was performed in 24 samples (8.4%): Mycobacterium tuberculosis was present in 1 case, Escherichia Coli in one and Candida albicans in another patient. No pathogenic bacteria or fungi were identified in the rest of the examined. The procedure was well tolerated. Complications occurred in 7 (2.4%): pneumothorax in 4 patients (1.4%), vasovagal reaction in 2 cases (0.7%), local hematoma (0.3%). Conclusion: closed (percutaneous, blind) pleural biopsy with a Ramel‘s needle appears to be a simple technique, well tolerated, with a low complication rate and high diagnostic efficiency. Closed pleural biopsy has a relatively high sensitivity in the diagnosis of exudative pleural fluid, especially in tuberculous pleurisy and may provide an alternative technique in clinical practice. It can be applied to any unexplained pleural effusion, in cooperative patients with no coagulation abnormalities, in relation to standard biochemical, microbiological and cytological investigations, especially in hospital units without thoracoscopy. In our series, nonspecific inflammation was the most common histological diagnosis, and repeated biopsies significantly increased the diagnostic contribution.
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. The first diagnosed case of COVID 19 in Macedonia with a PCR diagnostic test was on February 27, 2020. The first diagnosed case of COVID 19 in Bitola with a PCR diagnostic test was on April 03, 2020. The purpose of this paper is to present our experiences in the fight against the new unknown disease, with special reference to clinical expressions and post-covid conditions. A great problem and challenge for the infectologists in Clinical Hospital, Bitola, were the therapeutic possibilities, especially in treatment of patients with multiple comorbid conditions. This paper covers patients who were treated in the Infectious Diseases department’s COVID-19 center at the Clinical Hospital, over a period of 2 years.The fight against the SARS-CoV 2 continues and we are already facing the new - seventh wave of the pandemic.
GMP AUDIT CHECKLIST – A VALUABLE MANAGEMENT TOOL IN PHARMACEUTICAL INDUSTRY
Internal audit is an effective independent activity within a pharmaceutical industry quality management system. It ensures a thorough analyses and evaluation of the company activities and helps prevent, predict and detect mistakes and weaknesses in order to minimize losses. Internal audits help the organization achieve its goals and ensures all the involved parties that a program complies with regulatory and Good Manufacturing Practice (GMP) requirements. A successful audit, is carried out by quality auditor or audit team members, chosen carefully and properly trained. The auditor should gain as much information in advance before the auditing process begins that should help him to design tools useful in achieving the desired results. There are several sections recommended to be included in the GMP audit checklist: Quality management, Personnel, Facility and Equipment System, Documentation, Production System, Packaging and Labelling System, Storage System, and Laboratory Control System. A quality management system (QMS) is a formalized collection of processes, procedures, and documented policies, therefore the auditor looks to find out if the system complies with GMP requirements. As for the personnel, GMP audit checklist cover all the necessary procedures to ensure that the organization’s hiring and supervising practices are in compliance to GMP requirements, such as competences, trainings, dressing, and hygiene of the employees. Documentation ensures traceability of all development, manufacturing and testing activities, so the auditor needs to verify major types of documents that should be kept and recorded. The checklist includes questions addressing review of the layout, construction, size, location of the facility and main areas such as production area, storage, and laboratory, as well as the installation, operation, instructions, maintenance and cleaning of the equipment used in the manufacture. The production and process audit checklist include organization’s various stages of manufacturing such as weighing or measuring of raw materials, appropriate storage conditions for intermediates, In-Process sampling and controls, contamination control, process validation. Checklist points for internal audit of Packaging and Labelling System include elements ensuring the security and quality of packaging and as well elements that relate to labelling such as documentation, storage of starting materials and finished products, packaging and labelling operations. Internal auditing of storage system should prevent occurrence of mix-ups, damage, physical, chemical or microbial contamination. As for the Laboratory Control System, the GMP checklist questions aim to ensure that pharmaceutical products meet safety, efficacy, purity, and stability standards. The checklist is a good and critical tool to assist in conducting an in-depth and consistent audit and will serve as guideline for evaluation of compliance to standards and documentation, as well as for the effectiveness of the audited process.
MANAGING THE MOST COMMON COMPLICATIONS OF RADIATION THERAPY IN PATIENTS WITH HEAD AND NECK CANCER
Radiation therapy is widely used approach in treatment of head and neck cancer, unfortunately it leaves consequences that are influencing the patients’ life in a negative way. During and after the treatment with ionizing irradiation it affects not only the malignant area that is being treated, but also the surrounding tissues and organs that are located near the region that is targeted (oral mucosa, jaw bones, teeth, salivary glands, surrounding muscles and the temporomandibular joints), leaving changes in their structure and functions. Many of the patients that are treated, have not been prepared optimally for the radiation treatment, what also affects the post operative condition of their tissues and organs that are located nearby to the radiation treated area. The aim of this study was to define the most common postradiation complications in patients with head and neck cancer and to evaluate the efficiency of the solutions that are used to manage them. For this study were analyzed in details 37 published articles on the studied topic, the research was done online using the data bases NCBI, Cochrane Library, Medline, PubMed and Webmd. The inclusion criteria were: studies made in vivo; studies written in English; case reports on head and neck cancer patients; surveys on patients after radiation therapy; studies on patients with intraoral complications from after radiation therapy. Results showed that radiation induced complications in the head and neck cancer patients can be classified in three groups as early, intermediate and late changes. The most common changes were found in the tissues (mucosa, skin, subcutaneous connective tissues, salivary glands, the bone tissues and the teeth), resulting with: hyposalivation (xerostomia), mucositis, opportunistic infections, radiation caries, dysphagia, altered taste and difficulties with the chewing and swallowing. Many studies have shown that the percent of damage on the oral mucosa is strongly related to the radiation dose and the type of ionizing irradiation that patients are being treated with. Treatment consists of application of lubricants; usage of substitutes for saliva; and stimulants for the saliva production, with preparations like pilocarpine and cevimeline, and electro stimulation. The loss of the taste after the treatment can be partial or total. Mostly affected are the sour and bitter tastes, rarely the sweet and the salty taste, and very rare is total loss on all of the flavors. Fortunately in most of the studied cases has been show that the changes in the taste were reversible after a period of time, in some cases a few months and in others it can happen even up to a few years until it reaches total recovery. It is crucial to implement more solutions and to find new ways to manage the complications that follow after the irradiation, so the quality of the life in these patients can be spared in any possible way. Using the new approaches such as IMRT and VMAT on these patients, could also improve their condition after the treatment, and reduced dosage of the irradiation also could be tested and implemented if it is possible.
MANAGING QUALITY IN HEALTH CARE: PROCESS OF ACCREDITATION IN HEALTHCARE INSTITUTIONS IN REPUBLIC OF NORTH MACEDONIA
The quality of health care is a system of measures and activities that, in accordance with the modern achievements of medical, dental, and pharmaceutical science and practice, as well as the knowledge and skills of health professionals, increase the opportunities for the most favorable outcome of the medical treatment and reducing the risk of adverse effects on the health and well-being of the individual and the community. Improving the quality and safety of patients is an integral part of the daily activities of healthcare professionals, healthcare providers and all stakeholders in the healthcare system. Accreditation is the oldest and most widespread independent mechanism for external evaluation of the quality of work of healthcare institutions. The general understanding of the accreditation of healthcare institutions is defined as a procedure for assessing the quality of the work of a healthcare institution, based on the application of the optimal level of the established standards for work of a healthcare institution in a certain area of ​​health care. In response to these challenges, several approaches, activities, measures, and programs have been developed to improve the quality of health care. In the Republic of North Macedonia, the quality of health care is recognized as one of the most important features of the healthcare system, both in the state sector and in the private sector. Continuous improvement of the quality of work and patient safety are an integral part of the daily activities of healthcare professionals and all other employees in the healthcare system. From a formal aspect, accreditation in the Republic of North Macedonia is mandatory and is performed at the request of a healthcare institution. Therefore, a separate institution has been established for this purpose, namely the Agency for Quality and Accreditation of Healthcare Institutions in the Republic of North Macedonia. The accreditation process includes five characteristic stages: 1. Preparation of the healthcare institution 2. Self-evaluation 3. Evaluation made by external evaluators of the adaptation of the institution work with the accreditation standards 4. Preparation of the final report and the decision for granting accreditation by the Agency for Quality and Accreditation of Healthcare Institutions 5. Continuous evaluation and monitoring of the execution of the quality improvement plan. Improving the health care is based on the values that are embedded in the concept of quality of work and the following adopted daily practice of healthcare institutions: patient orientation, safety, effectiveness, timeliness, efficiency, fairness. To achieve and implement each of the principles, it is necessary clearly to define objective, measurable and evidence-based standards, and indicators for the three basic aspects of health care: structure, process, and outcome/result. The standards, which are clustered in six chapters, may be divided into three categories: management standards, patient care standards and support service standards. According to the Law on Health Care, the Agency for Quality and Accreditation of Healthcare Institutions in the Republic of North Macedonia determines the standards for accreditation of healthcare institutions and evaluates the quality of the provided health care. The agency issues a certificate for a certain period, but not longer than five years. Until and including the third quarter of 2022, in the Republic of North Macedonia, a total of 20 healthcare institutions were accredited.
STUDY OF CHANGES IN APPENDIX 3 OF THE POSITIVE DRUG LIST IN R BULGARIA
The public nature of health care obliges the state to conduct a consistent policy that aims to ensure the protection of human health with optimal use of public funds. Achieving better management in the health care system is in the interest of individuals and society as a whole. And decisions in health care, as in any other area of human activity, must be economically rational, since all economic goods, including those related to health care, are limited in nature. The medicinal products included in Appendix 3 of the Positive Drug List have a reimbursement level of 100% and are negotiated and paid for from the budget of the Ministry of Health. These are medicinal products intended for the treatment of AIDS, infectious diseases, diseases outside the scope of the Health Insurance Act, paid according to a certain order of the Health Act, as well as vaccines for mandatory immunizations and re-immunizations, vaccines for special indications and in emergencies circumstances, specific sera, immunoglobulins. The purpose of the present study is to perform a comparative analysis of the changes in the reference values of the medicinal products included in Appendix 3 of the Positive Drug List. Methodology: The following research methods were used - documentary method, economic analysis, comparative analysis, statistical methods - analysis of the dynamics of phenomena and tabular analysis to visualize the obtained results. Results and analysis: From the research done, it is clear that for the period 2016-2019 only a decrease was observed, while for 2020 there was also an increase in the reference values of some medicinal products included in Appendix 3 of the Positive Drug List, the reasons for this being exclusion of a medicinal product from the list, increase in the price of a medicinal product and new grouping of medicinal products by therapeutic indication. Conclusion: Medicines are of fundamental importance in maintaining life, improving its quality and alleviating suffering. This determines the need to ensure equal access to medicinal products for citizens, according to their needs and regardless of their financial capabilities.
HEALTH AND SOCIAL CARE FOR ADULTS WITH FUNCTIONAL DEPENDENCE IN CONDITIONS OF COVID 19 PANDEMIC
The importance of Public Healthcare as a science originates from the measures in an integrated manner, targeted at the health of the public through prevention and extending life in good health. Home health care for elderly people with chronic illnesses and functional dependence is one of the priorities of the social politics of Bulgaria, through the creation of regulations for the interaction when organising and planning the support that supplies their health and social needs. in the competencies of nurses is the provision of health and social care for people with chronic diseases and functional dependence. The covid 19 pandemic has presented challenges in implementing nursing interventions. Due to the declared global pandemic on 19.03.2020 of COVID-19, many countries including Bulgaria, introduced strict measures for maximal isolation and social distancing with the aim of reducing transmission to the minimum. This presented an array of challenges for the teams, carrying out the activities for patronage care in the homes of the care receivers. Objective: To review and analyze the impact of the COVID 19 pandemic on changes in the daily activities of health care providers in the municipalities of Burgas region. Methods: documentary - research and analysis of information; sociological-anonymous survey; statistically. Results: developed and implemented additional module "Patronage Care +" with expansion of the target group of users and services provided; provided personal protective equipment and disinfectants to the multidisciplinary team providing care; not all project managers have provided antigenic tests for the teams; communication between the team and the GPs of the users - difficult; periodic briefings for compliance with anti-epidemic measures; Of the 41 nurses, 19.51% were quarantined with complaints and positive PSR tests - without hospitalization, and of the home nurses 26.23%. Vaccinated nurses - certainly 2 / project managers are not familiar /; ineffective medical waste management. Conclusion: The provisioning of health and social services and care is absolutely necessary for the maintenance of the quality of life of people with chronic illnesses with functional dependencies and under the existing pandemic situation; The care receivers are willing to accept alternative approaches for realizing the activities, providing them with quality of life even with their chronic ailments and degree of disability; The managers and coordinators of project “Patron care” have the capabilities and the resources to maintain the quality of the offered integrated health and social service; The absence of medical nurses in the teams of some municipalities in the Burgas region negatively affects the carrying out of activities of the project. The high percentage of nurses placed under quarantine and home nurses supports the tendency for lack of emergency and periodic instruction, i.e. unsatisfactory activity of the occupational medicine services.
TRAUMATIC DENTAL INJURIES: ETIOLOGY, PREVALENCE AND POSSIBLE OUTCOMES
Traumatic dental injuries are significant public health problem because of its frequency, impact on economic productivity and quality of life. It is not a disease and no individual is ever at zero risk of sustaining these potentially life-changing injuries. Traumatic dental injuries occur most frequently in children and young adults. Older adults also suffer from traumatic dental injuries but at significantly lower rates than individuals in the younger cohorts. Luxation injuries are the most common traumatic dental injuries in the primary dentition, whereas crown fractures are more commonly reported for the permanent teeth. Proper diagnosis, treatment planning and follow up are very important to assure a favorable outcome. The aim was to overview the etiology, prevalence and possible outcomes of dental trauma. An electronic search of Medline (PubMed), Cochrane, SSCI (Social Citation Index), SCI (Science Citation Index) databases from 2000 to the present, using the following search words: tooth injuries, tooth trauma, traumatized teeth, dental trauma, dentoalveolar trauma, oral trauma, epidemiology, etiology, prevalence, prevention, pulp necrosis, inflammatory resorption, ankylosis, cervical resorption, was performed. The current revision represents the best evidence based on the available literature and expert opinions. During last decade traumatic dental injuries were recognized as public dental health problem worldwide. Prevalence of traumatic dental injuries varies between countries. According to the existing data they are more prevalent in permanent than in primary dentition. All treatment procedures in case of dental trauma are directed to minimize undesired consequences despite that treatment of traumatic dental injuries in the young patient is often complicated and can continue during the rest of his/her life. The changing lifestyle and requirements of modern society lead to an emergence of new patterns of dental trauma. Successful treatment of traumatic injuries depends on timely action by the patient and a quick and accurate diagnosis by the dentist. Although most injuries are minor and of an urgent nature, displaced or missing teeth are true emergencies. The mismanagement of traumatic dental injuries has provided much information as well as questions for research that have resulted in the increased retention of teeth with as little treatment as possible. Maintaining pulp vitality when possible, utilizing the therapeutic effects of calcium hydroxide, and returning teeth to function as soon as possible are keys to predictable prognosis. It is the responsibility of the dentist to stay current on the latest techniques available to treat traumatic injuries. The charts included provide most of the potential emergency treatment possibilities, recommended follow-up treatment, and final treatment outcomes essential to providing the best care for our child patients. It is also the responsibility of the dentist to use evidence-based research when adopting treatment protocols.