SummaryBackgroundSubclinical hypothyroidism (SCH) is defined as high TSH and normal thyroxine. Data on the effects of early substitution by levothyroxine on psychophysical health in SCH are still not consistent enough to support its introduction.MethodsClinical parameters, biochemical data and quality of life (Short Form 36 questionnaire) were measured before the intervention and 3 months after the euthyroid state had been achieved in SCH patients.ResultsSignificant reduction in body weight (p=0.030), systolic and diastolic blood pressure (p=0.024, p=0.019), homocysteine (p<0.001), leukocytes and neutrophils (p=0.011, p=0.001), INR (p=0.049), K levels (p=0.040, p=0.013), HbA1c (p=0.001), fasting insulin (p<0.001) and insulin resistance measured by HOMA index (p<0.001), lipid parameters (total cholesterol (p<0.001), LDL-cholesterol (p<0.001), triglycerides (p=0.007), apoB (p=0.022), Lp(a) (p<0.001), LDL/HDL (p=0.008), LAP (p=0.04) and apoB/apoA1 ratios (p<0.023)), TSH (p<0.001) and tAbs (p<0.001) was recorded. Frequency of fatty liver (20% to 2.9%, p=0.016), hyperlipidemia (85% to 65.7%, p=0.001) and metabolic syndrome (34.3% to 2.9%, p=0.070) significantly decreased. A statistically significant positive association was found between the average dose of levothyroxine and changes in physical functioning (r=0.391, p=0.020), vitality (r=0.393, p=0.020), mental health (r=0.374, p=0.027) and overall dimensions of mental health (r=0.376, p=0.026). With increasing doses of levothyroxine, the previously listed scores of SF 36 grew (r=0.296, p=0.084).ConclusionsEarly substitution of SCH improved the many clinical and biochemical parameters related to cardiovascular risk. Quality of life was also improved, and correlated only with thyroxine doses suggesting an indirect relationship between the degree of hypothyroidism and quality of life.

Background / Aim. Although subclinical hypothyroidism (SCH) is frequently a biochemical diagnosis, some symptoms and signs of overt disease may be present, influencing our decision to start the treatment with levothyroxine (LT4). The aim of this study was to examine the effect a 3-month LT4 treatment on clinical presentation and quality of life in symptomatic SCH with TSH < 10 mIU/L. We also considered whether treatment discontinuation additionally improves reliability of these findings. Methods. Clinical parameters (disease-specific score) and quality of life (Short Form 36 questionnaire) were measured in 35 patients with persistent symptomatic SCH before the intervention (TSH 7.0±2.1 mIU/L), 3 months after the euthyroid state had been achieved and 3 months after cessation of LT4 substitution. Results. The median of Zulewski index significantly decreased after the treatment with LT4: 5.0 (4.0-7.0) vs 3.0 (2.0-5.0) (p <0.001) representing a reduction of symptoms. The most common ailments before treatment were dry skin (71.4%), hoarseness (65.7%) and rough skin (54.3 %). After the treatment, there was a significant reduction in the frequency of constipation (p=0.004), dry skin (p=0.022), hoarseness (p=0.002), decreased sweating (p=0.006), and delayed Achilles reflex (p=0.002). Quality of life was not changed significantly after LT4 treatment. In the group of 18 patients who discontinued the treatment, many symptoms and signs reappeared with the increasing of TSH (6.8±1.1 mIU/L): periorbital edema, constipation, weight gain, decreased sweating, slow motion and delayed Achilles reflex. The median of the Żulewski index after discontinuation of LT4 was 6.0 (4.0-9.0) (p = 0.010). Also, there was a statistically significant reduction in the general health score, vitality, role emotional and mental health scores. Conclusions. Clinical score based on symptoms and signs is a sensitive and reproducible test for objective estimation of LT4 treatment effects in symptomatic SCH patients with TSH <10 mIU/L and supports individually adjusted treatment. Symptomatic SCH is not necessarily associated with a quality of life impairment that may be significantly improved by thyroxine treatment. Changes in general health, vitality, mental health and emotional role after LT4 cessation suggest that some aspects of life quality can be affected by subtle variations in thyroxine availability.

Introduction: Surgical site infections (SSI) continue to be a major problem for thoracic surgery patients. We aimed to determine incidence rate (IR) and risk factors for SSI in patients with thoracic surgical procedures. Methodology: During 12 years of hospital surveillance of patients with thoracic surgical procedures, we prospectively identified SSI. Patients with SSI were compared with patients without SSI. Results: We operated 3,370 patients and 205 (6.1%) developed SSI postoperatively. We detected 190 SSI among open thoracic surgical procedures (IR 7.1%) and 15 SSI after video-assisted thoracic surgery (IR 2.1%). Five independent risk factors for SSI were identified: wound contamination (p = 0.013; relative risk (RR) 2.496; 95%, confidence interval (CI): 1.208-5.156), American Society of Anesthesiologist (ASA) score (p = 0.012; RR: 1.795; 95% CI: 1.136-2.834), duration of drainage (p < 0.001; RR: 1.117; 95% CI: 1.085-1.150), age (p = 0.036; RR: 1.018; 95% CI: 1.001-1.035) and duration of operation (p < 0.001; RR:1.005; 95% CI:1.002-1.008). Conclusion: The results are valuable in documenting risk factors for SSI in patients undergoing thoracic surgery. The knowledge and prevention of controllable risk factors is necessary in order to reduce the incidence of SSI.

Current controversies related to the treatment of subclinical hypothyroidism (SCH) with thyrotropin (TSH) < than 10 mU/L are based on the lack of evidence that levothyroxine therapy has beneficial effects. The aim of our study is to estimate the effect of levothyroxine treatment on cardiac morphology and function in subclinical hypothyroidism. Body mass index, waist circumference, blood pressure, electrocardiographic and standard echocardiographic parameters were measured before levothyroxine therapy and 3 months after TSH normalization. Significant reduction in systolic and diastolic blood pressure, PR, QT and QT corrected intervals, as well as increase in heart rate were recorded in the group on levothyroxine therapy. The following parameters of the left and right ventricle were significantly decreased in the treatment group: left ventricular mass index and volume, systolic and diastolic time intervals, and mitral annular plane systolic excursion (MAPSE). The increase was recorded as fractional shortening and pressure rise in early systole (dP/dt), right atrial wall thickness and diameters. Our study did not confirm differences in basic echocardiographic parameters between the treated and control groups, apart from an echocardiographic improvement of cardiac structure and function in treated individuals. The findings suggest electrocardiographic and echocardiographic screening in monitoring the therapeutic effect.

SummaryImmunoglobulin (Ig)G4-related sclerosing disease (IgG4-RSD) is a new disease entity first proposed with regard to autoimmune pancreatitis. A 67-year-old male patient was examined because of weight loss and an abdominal pain. Based on the clinical characteristics, laboratory parameters and ultrasound features, we identified the diagnosis of the IgG4-related systemic disease (IgG4-RSD), that was confirmed by the histopathological analysis after the biopsy of the head of pancreas. After confirmation, we started with the corticosteroid therapy with a good clinical, biochemical and morphological response. During the previous therapy, the disturbance of glucoregulation appeared, so we had to change the modality of treatment. We decided to add Azathioprine to the therapy in a dose of 150 mg/day. We achieved a stable phase of the disease with IgG 4.37 g/l and IgG4 0.179 g/l, and with no side effects from the therapy.Learning points There are potential clinical applications of identifying subsets of patients with IgG4 thyroiditis (FVHT and Riedel thyroiditis).A trial of immunosuppressive therapy should be included if a resection is deemed inadvisable.In particular, cases of FVHT that mimic malignancy, tissue and serum IgG4 may provide supportive diagnostic information.

Introduction Simultaneous bilateral spontaneous pneumothorax (SBSP) is a potentially life-threatening state that may imitate many lung diseases. The aim of this report was to describe the presentation and highlight potential difficulties in diagnosis and management of patients with SBSP. Case outline A 23-year-old female patient was urgently assessed because of a progressive two-day-long dyspnoea with associated bilateral chest pain. Lung auscultation revealed equally diminished breath sounds on both sides. During the initial examination, there was evidence of symptomatic deterioration with bilateral pleuritic chest pain, increased dyspnoea, and agitation. The patient was found to have type II respiratory failure with the following biochemical parameters: pH 7.34, PaCO 2 6.3 kPa, and PaO 2 7.9 kPa. A chest radiograph confirmed bilateral partial pneumothoraces of approximately 30%. Both left-and right-sided thoracostomies with large-bore chest drain insertions were performed emergently, followed by partial resolutions of pneumothoraces. CT of the chest demonstrated residual pneumothoraces bilaterally with multiple apical bullae. In the further course, the patient subsequently underwent video-assisted thoracoscopic surgery with bilateral apicoectomies, bullectomies, and pleural abrasion. Her chest drains were removed three days after surgery and a post-treatment chest radiograph demonstrated resolution of the pneumothoraces. She was discharged without complications. Conclusion Using clinical presentation, diagnostic algorithm and therapeutic management applied in the case of our patient, we emphasized a few mandatory steps in establishing the diagnosis of SBSP and further treatment.

Introduction/Objective The aim of the study is to analyze the treatment of spontaneous pneumothorax (PSP) through our 10-year experience. Methods The study included 67 patients with PSP treated with video-assisted thoracoscopic surgery (VATS) or with thoracic drainage (TD) in the Clinic for Chest Surgery at the Military Medical Academy in Belgrade, Serbia in the 2008-2017 period. Results PSP patients with VATS were younger (33.2 ± 16.4 vs. 45.5 ± 21.5 years, p = 0.010), and both groups consisted mainly of males (69.2% vs. 78%). VATS-treated patients were hospitalized shorter and wore drains (p < 0.001, p < 0.002). Recurrence after treatment was more common after TD (61% vs. 3.8%) and in most cases it was treated with VATS (92%). The incidence of intraoperative complications is similar between groups (p = 0.599, p = 0.636, p = 0.311, p = 0.388, p = 0.388, respectively). Pain was more common in TD (p < 0.001). The early complications in the group of patients treated with TD occurred more often (p < 0.001, p < 0.001), without significant difference in the incidence of pleura infections and intercostal blockade between groups (p = 0.388, p = 0.388, respectively). Patients treated for PSP with the VATS method came to the control follow-up later, compared to patients treated with TD (p < 0.001). Conclusion VATS proved to be efficient, which was reflected in the optimal duration of surgery, length of hospitalization, tolerable postoperative pain and satisfactory cosmetic effect, and postsurgical relapse in only one case.

Background: It is well known that less than 1% of the population achieves ideal cardiovascular health as well as 65% of patients do not have their conventional risk biomarkers under control. The military service has its own  particularities that may contribute to the cardiovascular risk . Methods: In order to define the preventive strategy goals, we analyzed the prevalence of traditional cardiovascular risk factors for coronary artery disease and elevated fibrinogen among active military personnel in Republic of Serbia.   Results: The cross-sectional study included 738 individuals older than 20 years, mostly between 31 and 40 years old. The mean value of SBP for the whole group was 122.39±9.42 mmHg, and for the DBP 79.94±6.56 mmHg. Among active military personnel 72.7% (533), had prehypertension and 13.8% (101) was hypertensive. Both body mass and BMI index among the observed age subgroups were found to increase with the age of the patients, as well as cholesterol values. HDL cholesterol values ​​also differed statistically significantly between age subgroups, with the proportion of individuals with HDL less than 1.5 mmol / L in all subgroups was about 85%, the only in the 41-50 age group was lower, 76.4%. LDL cholesterol, as well as the proportion of individuals who had LDL ≥3.5, increases with the age of patients, and an identical trend was recorded with triglycerides. With aging, fibrinogen levels increased. Conclusions: Those findings considering cardio and cerebrovascular risk factors would help to create the new approach for primary prevention for these categories of individuals.