Publications by authors named "Mario Staresinic"

32 Publications

Stable Gastric Pentadecapeptide BPC 157 and Wound Healing.

Front Pharmacol 2021 29;12:627533. Epub 2021 Jun 29.

Department of Pharmacology, School of Medicine, University of Zagreb, Zagreb, Croatia.

The antiulcer peptide, stable gastric pentadecapeptide BPC 157 (previously employed in ulcerative colitis and multiple sclerosis trials, no reported toxicity (LD1 not achieved)), is reviewed, focusing on the particular skin wound therapy, incisional/excisional wound, deep burns, diabetic ulcers, and alkali burns, which may be generalized to the other tissues healing. BPC 157 has practical applicability (given alone, with the same dose range, and same equipotent routes of application, regardless the injury tested). By simultaneously curing cutaneous and other tissue wounds (colocutaneous, gastrocutaneous, esophagocutaneous, duodenocutaneous, vesicovaginal, and rectovaginal) in rats, the potency of BPC 157 is evident. Healing of the wounds is accomplished by resolution of vessel constriction, the primary platelet plug, the fibrin mesh which acts to stabilize the platelet plug, and resolution of the clot. Thereby, BPC 157 is effective in wound healing much like it is effective in counteracting bleeding disorders, produced by amputation, and/or anticoagulants application. Likewise, BPC 157 may prevent and/or attenuate or eliminate, thus, counteract both arterial and venous thrombosis. Then, confronted with obstructed vessels, there is circumvention of the occlusion, which may be the particular action of BPC 157 in ischemia/reperfusion. BPC 157 rapidly increases various genes expression in rat excision skin wound. This would define the healing in the other tissues, that is, gastrointestinal tract, tendon, ligament, muscle, bone, nerve, spinal cord, cornea (maintained transparency), and blood vessels, seen with BPC 157 therapy.
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http://dx.doi.org/10.3389/fphar.2021.627533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8275860PMC
June 2021

An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine.

Injury 2020 Nov 6. Epub 2020 Nov 6.

Department of Traumatology, Klinikum Bayreuth, Germany.

Introduction: Percutaneous vertebral augmentation is a common therapeutic approach for osteoporotic or osteolytic vertebral fractures. Due to the variable pedicle anatomy two different approaches, the transpedicular and the extrapedicular approach have been established. In particular, in the middle and upper thoracic spine, percutaneous procedures are challenging because of difficult visualisation of anatomical landmarks and a more unfavourable anatomy with smaller and differently orientated pedicles.

Material And Methods: In our cadaveric study we compared the transpedicular and the extrapedicular approach to the thoracic spine. In 26 cadaveric spine specimes, embalmed using Thiel's method, we placed a total of 486 trans- and extrapedicular K-wires through Jamshidi needles in the vertebral bodies T4 - T12 under fluoroscopy. A CT scan was then performed to verify the actual position of the K-wire. Malpositioning was defined as deviation from the planned approach or placement of the K-wire in the spinal canal or outside the vertebral body. Number and direction of malpositionings was recorded.

Results: Malpositioning occurred in 68 of 468 K-wires. It was more frequent in the transpedicular (54) than in the extrapedicular (14) approach. Intraspinal malposition was seen more often in the transpedicular approach (n=36) especially in the upper and middle thoracic spine.

Conclusion: In summary both approaches are relatively safe but in the upper and middle thoracic spine the risk of intraspinal malpositioning seems to be lower when using the extrapedicular approach.
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http://dx.doi.org/10.1016/j.injury.2020.11.017DOI Listing
November 2020

Screw placement in two different implants for proximal humeral fractures regarding regional differences in bone mineral density: An anatomical study.

Injury 2020 Oct 10. Epub 2020 Oct 10.

Department of Orthopedics and Trauma Surgery, Medical University of Graz, Austria.

Background: The aim of this study was to investigate proximal humerus plating regarding drill depth and over penetration of the glenohumeral joint and to find a relation between these findings and different areas of bone mineral density (BMD) in the humeral head.

Material & Methods: The study sample involved 45 upper extremities from human adult cadavers. Two different plates (HOFER; PHILOS) were applied to the proximal humerus. Each hole was drilled until the respective participant thought to have placed the drill bit subchondral. Next, penetration of the far cortex was conducted to determine the residual bone stock. Additionally, the point of screw penetration of the far cortex was identified for each hole of the plates and allocated to five regions with different bone mineral density as described by Tingart et al.

Results: The screw penetration rate and the residual bone stock were compared within the 5 BMD regions. A significantly thicker residual bone stock was found at the central region (SD ± 13.1 mm) than in the anterior region (SD ± 9.5 mm) and in the posterior region (SD ± 8.5 mm). The anterior region revealed a significantly higher penetration rate than the posterior region (p = 0.01) and the central region (p = 0.03).

Conclusion: The anterior region of the humeral head was associated with a higher over penetration rate of the far cortex into the glenohumeral joint and a decreased bone stock after subchondral drilling representing a reduced bone mineral density (BMD).

Level Of Evidence: Cadaver Study.
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http://dx.doi.org/10.1016/j.injury.2020.10.049DOI Listing
October 2020

Evaluation of screw placement in proximal humerus fractures regarding drilling manoeuvre and surgeon's experience.

Injury 2020 Feb 24. Epub 2020 Feb 24.

Trauma and Orthopaedics department, Medical University Hospital LKH Graz, Austria.

Introduction: Following proximal humeral plate osteosynthesis, mechanical complication rates ranging up to 40% have been reported. The study aims to determine the influence of surgeons' experience and the technique of drilling on the complication rate.

Materials And Methods: The sample involved 45 cadaveric humeri. Six orthopaedic surgeons were divided into two groups with regard to their level of experience (novice versus expert group). On each humerus two different proximal humerus plates were applied. Drillings were performed either with a sharp or worn drill bit (to simulate either sharp or blunt drilling). The respective holes were drilled until the respective participant thought to have placed the drill bit subchondrally, followed by perforation of the cartilage of the humeral head. Both these values and cases of unintended penetration of the articular cavity were evaluated.

Results: Fourteen holes (3.6%) were primary penetrated in the joint cavity in the worn-drill-bit-subgroup and 19 holes (5%) in the sharp-drill-bit-group. The latter had an average distance between the chosen subchondral position and the humeral articular surface of 8.3 mm and the worn-drill-bit-subgroup was at 10.6 mm. In the novice group 20 perforations (5.2%) of the joint space occurred and the mean interval between the chosen subchondral point and the humeral articular surface was 4.0 mm. The experienced surgeons showed a perforation rate of 3.4% and were at a mean of 14.9 mm. There were no significant differences regarding drilling manoeuvres and experience.

Conclusion: Although our results are satisfactory, they can be traced back to the relatively high interval between the respective chosen position of the drill bit and the humeral articular surface which may not guarantee screw stability during ORIF of all fracture patterns.
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http://dx.doi.org/10.1016/j.injury.2020.02.120DOI Listing
February 2020

Medial minimally invasive helical plate osteosynthesis of the distal femur - a new technique.

Injury 2020 Feb 11. Epub 2020 Feb 11.

Trauma and Orthopaedics department, Medical University Hospital LKH Graz, Austria.

Introduction: The goal of this study was to evaluate distal femoral minimally invasive plate osteosynthesis (MIPO) from a distal medial approach by use of a pre-bent helical implant.

Material & Methods: A total of 18 lower extremities was evaluated. A 29.6 cm steel plate was constructed and pre-bent on bone specimens with a torsion of 55.7° A 5 cm incision was performed from the tip of the medial epicondyle alongside its centre in a proximal direction. The medial border of the vastus medialis was retracted anteriorly. The level of the proximal skin incision was determined using the length of the pre-bent plates. The proximal incision was performed at a length of 4 cm at the described height at a line between the lateral epicondyle and the tip of the greater trochanter. A raspatory was advanced beneath the vastus medialis in a proximal direction to create an extraperiosteal tunnel for plate insertion. The plate was fixed to the bone at its proximal and distal portion via screws. Following dissection, the distance between the nearest perforator to the proximal plate end was evaluated. The vertical distances between the medial border of the plate and the femoral artery and femoral nerve were measured at the level of the proximal plate end and at the level of the proximal margin of the vastoadductor membrane.

Results: The most proximal perforating artery was located at a mean distance of 20.15 mm starting from the proximal plate margin. The mean interval between the medial border of the plate at the level of its proximal tip and the femoral artery was 51.9 mm. The average distance between the femoral nerve and the medial border of the proximal part of the plate was 42.3 mm. Regarding the interval between the medial border of the plate and the femoral artery, this was at a mean of 40.5 mm at the level of the proximal margin of the vastoadductor membrane. During dissection, none of the specimens showed any lesions of the adjacent anatomical characteristics.

Conclusion: Our results indicate MIPO of the distal femur from a medial approach as a safe technique.
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http://dx.doi.org/10.1016/j.injury.2020.02.051DOI Listing
February 2020

BPC 157 and Standard Angiogenic Growth Factors. Gastrointestinal Tract Healing, Lessons from Tendon, Ligament, Muscle and Bone Healing.

Curr Pharm Des 2018 ;24(18):1972-1989

Department of Pharmacology, Medical Faculty, University of Zagreb, Zagreb, Croatia.

Commonly, the angiogenic growth factors signify healing. However, gastrointestinal ulceration is still poorly understood particularly with respect to a general pharmacological/pathophysiological role of various angiogenic growth factors implemented in growth factors wound healing concept. Thereby, we focused on the stable gastric pentadecapeptide BPC 157, a peptide given always alone vs. standard peptidergic angiogenic growth factors (EGF, FGF, VEGF), and numerous carriers. Further, we reviewed how the gastrointestinal tract healing could be generally perceived (i) in terms of angiogenic growth factors, and/or (ii) through the healing of extragastrointestinal tissues healing, such as tendon, ligament, muscle and bone, and vice versa. Respected were the beneficial effects obtained with free peptides or peptides with different carriers; EGF, FGF, VEGF, and BPC 157, their presentation along with injuries, and a healing commonality, providing their implementation in both gastrointestinal ulcer healing and tendon, ligament, muscle and bone healing. Only BPC 157 was consistently effective in all of the models of acute/chronic injury of esophagus, stomach, duodenum and lower gastrointestinal tract, intraperitoneally, per-orally or locally. Unlike bFGF-, EGF-, VEGF-gastrointestinal tract studies demonstrating improved healing, most of the studies on tendon, muscle and bone injuries provide evidence of their (increased) presentation along with the various procedures used to produce beneficial effects, compared to fewer studies in vitro, while in vivo healing has a limited number of studies, commonly limited to local application, diverse healing evidence with diverse carriers and delivery systems. Contrary to this, BPC 157 - using same regimens like in gastrointestinal healing studies - improves tendon, ligament and bone healing, accurately implementing its own angiogenic effect in the healing. Thus, we claim that just BPC 157 represents in practice a pharmacological and pathophysiological role of various peptidergic growth factors.
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http://dx.doi.org/10.2174/1381612824666180712110447DOI Listing
October 2019

Novel Cytoprotective Mediator, Stable Gastric Pentadecapeptide BPC 157. Vascular Recruitment and Gastrointestinal Tract Healing.

Curr Pharm Des 2018 ;24(18):1990-2001

Department of Pharmacology, Medical Faculty, University of Zagreb, Zagreb, Croatia.

Years ago, we revealed a novel cytoprotective mediator, stable gastric pentadecapeptide BPC 157, particular anti-ulcer peptide that heals different organs lesions when given as a therapy, native in human gastric juice while maintaining GI-tract mucosal integrity, already tested in trials (ulcerative colitis and now multiple sclerosis). The stomach cytoprotection is the most fundamental concept, stomach cell protection and endothelium protection are largely elaborated, but so far cell, protection and endothelium protection outside of the stomach were not implemented in the therapy. However, having managed these two points, stomach cell protection and endothelium protection, either one or together, even much more than standard cytoprotective agents do, BPC 157 employed large scale of its beneficial effects seen in various organs. Providing endothelium protection, BPC 157 was shown to prevent formation and reverse established thrombosis in anastomosed abdominal aorta as well as venous thrombosis after inferior caval vein occlusion, and attenuate bleeding prolongation and thrombocytopenia after amputation, without or with anticoagulants, or venous occlusion, and finally counteract effect of L-NAME and/or L- arginine. Now, with BPC 157 application, we reveal the third most important part of the cytoprotection concept: with the stomach cell and endothelium protection to recover mucosal integrity, BPC 157 as prototype cytoprotective agent should also control blood vessel function, depending upon injury, perforated defect or vessel obstruction. After a perforated injury (i.e., stomach), BPC 157 therapy activates blood vessels "running" towards defect. After obstruction (i.e., inferior caval vein), BPC 157 activates vessels "running" towards bypassing defect, collaterals functioning. Reestablished blood flow, and largely reversed injurious course may practically implement the cytoprotection concept.
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http://dx.doi.org/10.2174/1381612824666180608101119DOI Listing
October 2019

Anatomical and radiological evaluation of less invasive stabilisation system (LISS) in correlation with knee lateral collateral ligament insertion.

Injury 2017 Nov;48 Suppl 5:S56-S60

Department of Trauma and Orthopaedic Surgery, University Medical Centre Regensburg, Germany. Electronic address:

Introduction: The Less Invasive Stabilisation System (LISS) is an angle-stable plate that enables treatment of distal femoral comminuted and periprosthetic fracture. As it is placed through a minimally-invasive lateral approach, lateral knee pain is a commonly described symptom after its application. This study investigates knee lateral collateral ligament (LCL) iatrogenic injury during LISS plate fixation. A cadaver study was performed and a retrospective radiological investigation with the analysis of its clinical application was conducted to evaluate possible knee LCL damage.

Methods: The cadaver study included 13 human lower extremities, treated with LISS. After application, lateral knee side was dissected, implants were removed and distances between the drill holes and LCL origin were measured. In the retrospective radiological evaluation, postoperative X-rays for patients treated with distal femoral LISS plate in the University Hospital Regensburg, Germany from January 2010 to December 2015 were examined. Following a protocol described by Pietrini et al., the LCL origin on postoperative X-rays was calculated, both in lateral and anterior-posterior (AP) view, and distances between the plate and its closest locking screw to the LCL origin were measured.

Results: In the cadaver study, the mean distance between the closest drilling hole and the ligament origin was 14.0mm (range 9-21mm; SD 3.8mm). Twenty-two patients matched the inclusion criteria for the retrospective radiological study. In lateral view, the mean distance between the origin and the closest locking screw was 6.3mm (range 0-16.4mm; SD 4.7mm); the mean distance between the origin and the plate was 3.1mm (range 0-13.9mm; SD 4.1mm). In AP view, the mean distance between LCL origin and the nearest screw was 2.4mm (range 0-7.6mm; SD 2.4mm). The mean distance between the origin and the most distal locking screw was 9.2mm (range 0-17.5mm; SD 4.0mm).

Discussion: The LISS is a safe option to treat distal femoral fractures in respect to the LCL. Due to close proximity, the LCL might be harmed; therefore, lateral knee pain or lateral instability after implantation should be assessed in further treatment.
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http://dx.doi.org/10.1016/S0020-1383(17)30741-6DOI Listing
November 2017

Comparison of volar and dorsal plate osteosynthesis for radial shaft fractures: an anatomical pilot study.

Injury 2017 Nov;48 Suppl 5:S38-S40

Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.

Background: No publication has yet described the interface between the radius and the plate in various positions. Neither clinical examination nor assessment of fracture radiographs provides information about the anatomy of the radius before injury.

Purpose: We investigated radius anatomy to analyse dorsal and volar plate-to-bone fit for radial shaft fracture management.

Methods: We examined 20 specimens from human adult cadavers. An 8-hole 3.5-mm titanium locking plate was used at three different positions on the dorsal and the volar side of the bone. The space between the well-positioned plate and the radial shaft was attained for each hole of the plate.

Results: The average space between the midshaft radial cortex and the plate holes for all positions was 0.69mm (range: 0.0mmto 2.38mm). The greatest mean distance between the plate and the radial cortex was measured at the volar mid-diaphyseal position of the plate with an average of 1.31mm.

Conclusion: This incongruence between the radial cortex at the volar diaphysis and the plate should be considered when applying plates to this position of the radius. The results of this cadaver study indicate that radius plate osteosynthesis should preferably be done from the dorsal side.
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http://dx.doi.org/10.1016/S0020-1383(17)30737-4DOI Listing
November 2017

Avoiding radial nerve palsy in proximal radius shaft plating - a cadaver study.

Injury 2017 Nov;48 Suppl 5:S34-S37

Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.

Background: Opinions vary concerning the position of forearm rotation during detachment of the supinator in radial nerve palsy Henry's and Thompson's approaches.

Purpose: To define the optimal forearm position for a safe detachment of the supinator during these approaches and to clarify their close relationship to the posterior interosseous nerve (PIN).

Methods: The study sample comprised 90 upper extremities of 45 human adult cadavers, embalmed using Thiel's method. After detection of the radial nerve in the interval between the brachialis and brachioradialis, its pathway was traced to the Arcade of Frohse (AF). Measurements involved the distance between the AFand the radial border of the distal biceps tendon (DBT) in pronation and supination, the interval between the AF and the radiocapitellar joint space (RCJS) in supination and the radial length (RL).

Results: Distances between the DBT and the AF were significantly shorter during pronation (right side: 14.1 ± 3.4mm; left side: 13.5 ± 3.2mm) compared with supination (right side: 20.5 ± 3.6mm; left side: 19.8 ± 3.5mm) for both right and left extremities. The mean interval between the AF and the centre of the RCJS was 25.2 ± 5.9mm for the right side and 24.7 ± 5.6mm for the left side, which correlated positively with the RL.

Conclusion: These results indicate a safe detachment of the supinator from the radius with the forearm placed in supination during both Henry's and Thompson's approaches.
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http://dx.doi.org/10.1016/S0020-1383(17)30736-2DOI Listing
November 2017

Safe intramedullary fixation of displaced midshaft clavicle fractures with 2.5mm Kirschner wires - technique description and a two-part versus multifragmentary fracture fixation outcome comparison.

Injury 2017 Nov;48 Suppl 5:S27-S33

Department of Trauma & Orthopaedics, General Hospital Karlovac, Croatia.

Introduction: The aim of this study was to present a modified Murray and Schwarz 2.5-mm Kirschner wire (K-wire) intramedullary (IM) technique for fixation of displaced midshaft clavicle fractures (DMCF), and to compare the differences in treatment outcome of two-part (Robinson 2B.1) and multifragmentary (Robinson 2B.2) DMCF.

Methods: A retrospective analysis of 91 patients who underwent IM fixation with a 2.5-mm K-wire for DMCF and had a 1-year post-operative follow-up between 2000 and 2012 was performed. The patients were allocated into two groups: Robinson 2B.1 (n = 64) and Robinson 2B.2 (n = 27). Assessed outcomes were non-union, reoperation rate, wire migration and infection.

Results: There was no statistically significant difference in the rate of non-union (2B.1,2B.2; 3.13%, 7.41%; p = 0.365), reoperation (2B.1, 2B.2; 3.13%, 7.41%; p = 0.365), K-wire migration (2B.1, 2B.2; 0.00%, 0.00%; p = 1.00) and clavicle shortening at 12-months (2B.1, 2B.2; 3.13%, 7.41%; p = 0.365).

Conclusion: Intramedullary clavicle fixation with a 2.5-mm K-wire is a safe surgical technique. 2B.1 injuries treated with 2.5-mm IM K-wire fixation have relatively improved outcome compared with displaced 2B.2 fractures for both non-union and reoperation rates. There were no occurrences of implant migration with either 2B.1 or 2B.2 injuries, and a non-significant difference in implant irritation was documented with IM K-fixation. The non-union rate with K-wire IM fixation of 2B.1 injuries concords with the published results of other IM devices and thus this technique should be added to the surgeon's armamentarium when considering surgical treatment of such injuries.
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http://dx.doi.org/10.1016/S0020-1383(17)30735-0DOI Listing
November 2017

Humeral shaft cerclage wiring: a safe technique to prevent radial nerve injury.

Injury 2017 Nov;48 Suppl 5:S12-S14

Clinic of Trauma Surgery, University of Regensburg, Regensburg 93053, Germany.

Humeral periprosthetic fractures are a challenging problem and their occurrence has increased, particularly over the last decade. The role of cerclage wires or cables in these fractures includes revisions with longer stems, and augmentation of a plate osteosynthesis in which the stem does not allow additional screw placement or structural bone grafts as supplementary fixation. These procedures are demanding because of the proximity of the radial nerve within the operating field. Placing a cerclage wire or cable around the fractured fragments offers a simple and safe procedure to avoid radial nerve injury or palsy in the treatment of complex humeral shaft fractures. This new technique is a simple and safe procedure to place a cerclage wire or cable around the humeral shaft.
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http://dx.doi.org/10.1016/S0020-1383(17)30732-5DOI Listing
November 2017

Variations of treatment in selected proximal femur fractures among surgeons with different surgical experience--A survey at an international AO course.

Injury 2015 Nov 18;46 Suppl 6:S57-60. Epub 2015 Nov 18.

Department of Trauma, Orthopaedics and Hand Surgery, Wolfsburg, Germany.

Introduction: Different modalities of treatment for hip fractures have been discussed in the literature; however, practice may vary between centres. A survey was conducted on participants at an international AO course to assess the current management of pertrochanteric fractures (AO/OTA 31-A2) and displaced, non-impacted, subcapital fractures (AO/OTA 31-B3) in a 35-year-old patient and an 85-year-old patient.

Methods: Surgeons taking part in an international orthopaedic course were invited to participate in a survey and were divided into two groups: inexperienced (one-to-three years since qualification) and experienced (four or more years). A survey was conducted to assess the management modalities used for pertrochanteric fractures (AO/OTA 31-A2) and displaced, non-impacted, subcapital fractures (AO/OTA 31-B3) in a 35-year-old patient and an 85-year-old patient.

Results: Fifty-two surgeons participated: 18 were inexperienced and 34 were experienced. The method of operative fixation for the pertrochanteric fracture was gamma-nailing for 95% of the surgeons in the inexperienced group; in the experienced group, 56% opted for gamma-nailing and 38% for dynamic hip screw (DHS). For the displaced subcapital fracture in a 35-year-old, screw fixation was the dominant treatment option for both groups. For the displaced subcapital fracture in an 85-year-old, most of the surgeons in both groups preferred hemiarthroplasty: 59% in the inexperienced group chose cemented bipolar hemiarthroplasty and 12% uncemented, whereas 56% of the experienced group suggested cemented bipolar hemiarthroplasty and 25% uncemented.

Discussion: This survey shows that a variety of methods are used to treat femoral neck fractures. A prospective randomised trial has shown the DHS to be the implant of choice for pertrochanteric fractures; however, this was not considered an option in the inexperienced group of surgeons and was the treatment of choice in only 13 out of 34 experienced surgeons. There is a general consensus for femoral head-conserving surgery in young patients with displaced subcapital fractures. Replacement arthroplasty was considered in the 85-year-old with a subcapital fracture. In the inexperienced group, 10 of 17 surgeons would cement the prosthesis, as would 27 of 36 in the experienced group.
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http://dx.doi.org/10.1016/j.injury.2015.10.066DOI Listing
November 2015

Is chronic groin pain a Bermuda triangle of sports medicine?

Acta Clin Croat 2014 Dec;53(4):471-8

Chronic groin pain is one the most complex conditions encountered in the field of sports medicine. Conservative treatment is long lasting and the result of treatment is often uncer- tain and symptom recurrences are common, which can be very frustrating for both the patient and the physician. The complex etiology and uncertainties during treatment of chronic groin pain is the reason why some authors call it the Bermuda Triangle of sports medicine. In our prospective, 7-year study, 114 athletes with chronic groin pain resistant to conservative therapy were treated surgically. In 109 athletes with sports hernia, we performed nerve neurolysis along with resection of the genital branch of the genitofemoral nerve and we also reinforced the posterior wall of inguinal canal using a modified Shouldice technique. In 26 athletes that had concomitant adductor tendinosis and in 5 athletes with isolated tendinosis we performed tenotomy. Eighty-one of 83 patients with isolated sports hernia returned to sports within a mean of 4.4 (range, 3-16) weeks. Thirty-one athletes with adductor tenotomy returned to sports activity within a mean of 11.8 (range, 10-15) weeks. If carefully diagnosed using detailed history taking, physical examination and correct imaging techniques, chronic groin pain can be treated very successfully and quickly, so it need not be a Bermuda Triangle of sports medicine.
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December 2014

Aggressive granulomatosis after cementless total hip arthroplasty as a result of inflammatory reaction to metal debris: case report.

Acta Clin Croat 2013 Dec;52(4):492-6

Massive osteolysis and granulomatous pseudotumor tissue reactions are long-term complications of total hip replacement. It is a condition of localized bone resorption in contact with prosthetic material. It is speculated to be a consequence of metal hypersensitivity or inflammatory reaction to excessive wear. Ten years after total cementless hip replacement (metal on polyethylene surface), a 70-year-old patient presented with hip pain and pseudotumor with massive osteolysis of proximal femur on x-ray. Intraoperatively, extensive metallosis with significantly worn metal head (316L stainless steel) and only slightly worn polyethylene insert was found. Upon extraction, parts of the affected tissue and bone that were in direct contact with the prosthesis were sent for histopathologic analysis. Microscopic examination showed necrotic soft and bone tissue, mainly bone marrow with numerous histiocytes and multinucleated giant cells containing lots of pigmented particles (presumed to be metal particles as a result of implant surface wear). In this case, the primary cause of osteolysis and granulomatosis was inflammatory reaction to metal debris. Aggressive granulomatosis has been first described in cemented prostheses and afterwards also in cementless ones. Conditions such as primary or metastatic neoplastic processes and infection should be excluded. The presence of foreign molecular particles due to wear of the prosthesis by different mediators has been presumed to cause an inflammatory reaction that leads to bone resorption and loosening of the prosthesis.
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December 2013

The role of external fixation in displaced pilon fractures of distal tibia.

Acta Clin Croat 2013 Dec;52(4):478-84

Results of treatment in patients with high-energy displaced pilon fractures are presented. During five years, 15 patients with displaced pilon fractures (AO type C2 and C3) were treated. All other types of fracture were excluded from the study. Fractures were identified using standard radiographs and computed topography scanning. The method and timing of the operation were dictated by the status of soft tissues. In all fractures, external fixation was placed immediately and was left until the initial callus bridged the fracture fragments. In case of moderate contusion of soft tissues, limited incision and minimal internal osteosynthesis was done in the same act. In patients with more severe soft tissue damage, limited open reduction and restoration of articular surface was undertaken in second procedure after 7 days on average. All fractures united and the average time of healing was 4 months. Two patients had superficial infections that resulted in prolonged wound healing, and another four patients had pin site infection. There were no cases of deep infection, nonunion or malunion, but we had five cases of secondary osteoarthritis. Results were evaluated by Teeny and Wiss rating system. The results were as follows: 5 excellent results, 10 good and fair results, and no poor results. This study showed that external fixation with open reduction and limited internal osteosynthesis, with or without bone grafting, could be an option in the management of displaced multifragmentary pilon fractures with soft tissue injury. It was followed by significantly less complications with better functional results compared to open reduction and internal plate fixation.
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December 2013

Isolated inferior peroneal retinculum tear in professional soccer players.

Injury 2013 Sep;44 Suppl 3:S67-70

Surgery Clinic, Department of Traumatology, University Hospital Merkur, Zagreb, Croatia.

Introduction: Peroneal tendon dislocations are rare injuries that can easily be misdiagnosed. Up to date literature mostly describes proximal peroneal tendon dislocations due to superior peroneal retinaculum (SPR) tear. In this article, we present the assessment, diagnostic algorithm and a new therapeutic option for the distal dislocation of the long peroneal tendon due to isolated inferior peroneal retinaculum (IPR) tear.

Patients And Methods: Between 2001 and 2011 three patients with distal peroneal tendon dislocation were operated. All of them were competitive athletes in the national soccer league. They presented with an ankle sprain and prolonged problems on the lateral side of the foot with no improvement after conservative therapy measures. Coleman block test was performed; ultrasound and MRI showed a tendon dislocation under the IPR. The patients underwent surgical repair that consisted of peroneal tubercle excision, a new lateral calcanear groove formation for both peroneal tendons and IPR plasty.

Results: At the two year follow up the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score showed a significant increase. The decrease of painful stimuli assessed by a Visual Analogue Scale (VAS) was significant as well. At an average of 12 weeks after the surgery, the patients returned to their level of sport activity before injury and didn't report similar problems later.

Conclusion: Description of distal peroneal tendon dislocations is limited in the literature. This topic should be considered in differential diagnostics of an acute and chronic ankle sprain which leads to chronic ankle pain and instability. The authors recommend surgical treatment as a method of choice especially in professional athletes.
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http://dx.doi.org/10.1016/S0020-1383(13)70202-XDOI Listing
September 2013

Awareness, attitudes, and perceptions of Croatian-based orthopedic and trauma surgeons toward scientific manuscripts, publishing internationally and medical writing. Results of an online questionnaire.

Coll Antropol 2013 Mar;37(1):165-8

AO Clinical Investigation and Documentation, AO Foundation, Dübendorf, Switzerland.

The objective of this survey was to identify the importance placed by Croatian-based surgeons on writing scientific manuscripts and publishing them internationally, as well as their awareness of and attitudes toward medical writing. A link to an online survey was sent to 327 Croatian-based orthopedic and trauma surgeons. The electronic questionnaire consisted of rating scales, multiple choice questions and free text reply boxes. A total of 61 surgeons based in Croatia replied to the survey, yielding a response rate of 19% (61/327). The survey results indicate that surgeons in Croatia are active in both research and the writing of manuscripts. There is also a high level of interest among them to publish internationally in English to further their careers. While 68% (38/56) of respondents initially claimed to know about medical writing, further questioning on the subject revealed a reduced level of familiarity with the concept. Only 19% (11/58) of respondents had ever engaged the services of a medical writer and they were generally satisfied with the work done across the three areas of language, editing and scientific knowledge. Medical writers are advised to increase awareness of their services among Croatian-based orthopedic and trauma surgeons who may well have a need for their expertise.
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March 2013

Mangled extremity--case report, literature review and borderline cases guidelines proposal.

Coll Antropol 2012 Dec;36(4):1419-26

Karlovac General Hospital, Department of Traumatology, Karlovac, Croatia.

Treatment of a mangled lower extremity represents a major challenge. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this paper is to propose a new approach to surgical evaluation based on scoring systems, local clinical status of the patient as well as comorbidities, mechanism of trauma and hospital resources. Available literature regarding this topic was evaluated and a case of patient with mangled extremity is presented. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations. We describe a 44-year old male patient who presented with mangled lower left leg. Despite a borderline Mangled Extremity Severity Score (MESS), due to the overall health status of the patient and local clinical status with preserved plantar sensitivity and satisfactory capillary perfusion, reconstruction was attempted. After 6 months of treatment, all wounds healed completely with no pain, and satisfactory motor and sensory function was achieved. In conclusion, the treatment of mangled extremity treatment should be based on evidence based literature along with a clinical evaluation of every individual patient. Scores are helpful, but should not be taken as the sole indication for amputation.
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December 2012

Surgical treatment of chronic groin pain in athletes.

Int Orthop 2012 Nov 10;36(11):2361-5. Epub 2012 Aug 10.

Clinical Hospital Dubrava, Zagreb, Croatia.

Purpose: Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities.

Methods: We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure.

Results: Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three-16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten-15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12-16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity.

Conclusion: Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.
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http://dx.doi.org/10.1007/s00264-012-1632-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479270PMC
November 2012

Minimally invasive hip arthroplasty: advantages and disadvantages.

Med Glas (Zenica) 2012 Feb;9(1):160-5

Department of Traumatology, Surgery Clinic, Merkur University Hospital, Zagreb, Croatia.

Background: To present the method and advantages of anterior minimally invasive surgery (AMIS) in coxarthrosis and hip fractures treatment.

Methods: During 2008 and 2009, 35 patients were treated with AMIS method. They were compared with 35 patients treated with lateral, transgluteal approach (control group) in the same period. All operations were performed by the same surgical team. The main reason for surgery was hip arthrosis, only two patients in AMIS group underwent surgery because of femoral neck fracture. Early postoperative complications and functional status are followed by Haris Hip Score (HHS).

Results: Operation time was shorter and postoperative blood loss was lesser in AMIS group (78 min, 490 ml) than in the control group (85 min, 570 ml). In the AMIS group one patient had each post-operative knee pain, fractured tip of a large trochanter, acetabular overreaming, perforation of shaft with rasp, and two patients had parestesis n.cutaneus femoris lat. They had no infections or hip luxation. In the control group early hip luxation and superficial wound infections have occurred in one and two cases, respectively. Patients in the AMIS group were more satisfied, demanded less analgesics and their rehabilitation was faster. Haris Hip Score in the AMIS group after 2 months was 80 compared with 69 in the controls, and after 4 months 92 compared to 88 in controls.

Conclusions: AMIS is a safe, reproducible and rewarding technique which provides low morbidity and fast postoperative recovery for the patient.
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February 2012

Axillary artery dissection after scapular fracture.

Ann Vasc Surg 2011 Aug 6;25(6):837.e5-7. Epub 2011 May 6.

Department of Vascular Surgery, University Hospital Merkur, Zagreb, Croatia.

Blunt shoulder trauma rarely causes damage to either arteries or nerves. Neurovascular structures are covered by muscles and protected by the surrounding bones deep in the axilla. We report a case of a 34-year-old male motorbike driver referred to us 5 hours after injury. Standard X-ray of the left shoulder revealed multipart fracture of the left scapula, and angiography showed that the first segment of the left axillary artery was dissected proximal to the minor pectoral muscle. Urgent diagnosis using imaging techniques and restoration of blood flow using open or endovascular repair are crucial for optimal outcome. Damage to the nerves predicts the final functional outcome regardless of prompt revascularization.
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http://dx.doi.org/10.1016/j.avsg.2011.02.014DOI Listing
August 2011

Impact of pentadecapeptide BPC 157 on muscle healing impaired by systemic corticosteroid application.

Med Sci Monit 2010 Mar;16(3):BR81-88

Department of Pharmacology, University of Zagreb Medical School, Zagreb, Croatia.

Background: The effect of systemic and local peptide treatment effective in muscle contusion and then on counteraction of corticosteroid-induced impairment was tested. The pentadecapeptide BPC 157, given without a carrier, improved the healing of transected quadriceps muscle. It also improved muscle healing in rats with muscle crush injury when applied systemically or locally. Importantly, it counteracted corticosteroid-impairment in tendon to bone healing. Thus BPC 157 is proposed as an effective treatment that can improve muscle healing in spite of corticosteroid treatment.

Material/methods: After the gastrocnemius muscle complex had been injured, rats received BPC 157 (intraperitoneally or locally as a cream) and/or 6alpha-methylprednisolone (intraperitoneally) only once (immediately after injury, sacrifice at 2 h) or once daily (final dose 24 hours before sacrifice and/or assessment procedure at days 1, 2, 4, 7, and 14). Muscle healing was evaluated functionally, macroscopically, and histologically.

Results: Without therapy, crushed gastrocnemius muscle complex controls showed limited improvement. 6alpha-methylprednisolone markedly aggravated healing. In contrast, BPC 157 induced faster muscle healing and full function restoration and improved muscle healing despite systemic corticosteroid treatment when given intraperitoneally or locally and demonstrated functionally, macroscopically, and histologically at all investigated intervals.

Conclusions: BPC 157 completely reversed systemic corticosteroid-impaired muscle healing.
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March 2010

Gastric pentadecapeptide BPC 157 as an effective therapy for muscle crush injury in the rat.

Surg Today 2008 31;38(8):716-25. Epub 2008 Jul 31.

Department of Pharmacology, Institute of Pathology, University of Zagreb Medical School, Salata 11, 10 000, Zagreb, Croatia.

Purpose: Stable gastric pentadecapeptide BPC 157 accelerates the healing of a transected Achilles tendon and a transected quadriceps muscle. It may also be of clinical relevance as a systemic and local peptide treatment for crush injury of a major muscle, such as gastrocnemius muscle complex. BPC 157 is effective without a carrier, and it is presently undergoing trials for inflammatory bowel disease, and no toxicity has so far been reported.

Methods: In crushed rats (force delivered 0.727 Ns/cm2), BPC 157 was applied either intraperitoneally or locally, as a thin cream layer, immediately after injury (sacrifice at 2 h), and once a day for 14 days.

Results: BPC 157 improved muscle healing, macroscopically (less hematoma and edema, no post-injury leg contracture), microscopically, functionally, and also based on enzyme activity (creatine kinase, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase).

Conclusion: BPC 157, at all investigated intervals, given locally or intraperitoneally, accelerated post-injury muscle healing and also helped to restore the full function.
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http://dx.doi.org/10.1007/s00595-007-3706-2DOI Listing
January 2009

Therapy for unhealed gastrocutaneous fistulas in rats as a model for analogous healing of persistent skin wounds and persistent gastric ulcers: stable gastric pentadecapeptide BPC 157, atropine, ranitidine, and omeprazole.

Dig Dis Sci 2009 Jan 23;54(1):46-56. Epub 2008 Jul 23.

Department of Pharmacology, Medical School, University of Zagreb, Salata 11, 10000, Zagreb, Croatia.

Objective: This study focused on unhealed gastrocutaneous fistulas to resolve whether standard drugs that promote healing of gastric ulcers may simultaneously have the same effect on cutaneous wounds, and corticosteroid aggravation, and to demonstrate why peptides such as BPC 157 exhibit a greater healing effect. Therefore, with the fistulas therapy, we challenge the wound/growth factors theory of the analogous nonhealing of wounds and persistent gastric ulcers.

Methods: The healing rate of gastrocutaneous fistula in rat (2-mm-diameter stomach defect, 3-mm-diameter skin defect) validates macro/microscopically and biomechanically a direct skin wound/stomach ulcer relation, and identifies a potential therapy consisting of: (i) stable gastric pentadecapeptide BPC 157 [in drinking water (10 microg/kg) (12 ml/rat/day) or intraperitoneally (10 microg/kg, 10 ng/kg, 10 pg/kg)], (ii) atropine (10 mg/kg), ranitidine (50 mg/kg), and omeprazole (50 mg/kg), (iii) 6-alpha-methylprednisolone (1 mg/kg) [intraperitoneally, once daily, first application at 30 min following surgery; last 24 h before sacrifice (at postoperative days 1, 2, 3, 7, 14, and 21)].

Results: Greater anti-ulcer potential and efficiency in wound healing compared with standard agents favor BPC 157, efficient in inflammatory bowel disease (PL-14736, Pliva), given in drinking water or intraperitoneally. Even after 6-alpha-methylprednisolone aggravation, BPC 157 promptly improves both skin and stomach mucosa healing, and closure of fistulas, with no leakage after up to 20 ml water intragastrically. Standard anti-ulcer agents, after a delay, improve firstly skin healing and then stomach mucosal healing, but not fistula leaking and bursting strength (except for atropine).

Conclusion: We conclude that BPC 157 may resolve analogous nonhealing of wounds and persistent gastric ulcers better than standard agents.
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http://dx.doi.org/10.1007/s10620-008-0332-9DOI Listing
January 2009

Prolonged esophagitis after primary dysfunction of the pyloric sphincter in the rat and therapeutic potential of the gastric pentadecapeptide BPC 157.

J Pharmacol Sci 2007 May 24;104(1):7-18. Epub 2007 Apr 24.

Department of Pharmacology, Medical School, University of Zagreb, Croatia.

Seven or fourteen days or twelve months after suturing one tube into the pyloric sphincter (removed by peristalsis by the seventh day), rats exhibit prolonged esophagitis with a constantly lowered pressure not only in the pyloric, but also in the lower esophageal sphincter and a failure of both sphincters. Throughout the esophagitis experiment, gastric pentadecapeptide BPC 157 (PL 14736) is given intraperitoneally once a day (10 microg/kg, 10 ng/kg, last application 24 h before assessment), or continuously in drinking water at 0.16 microg/ml, 0.16 ng/ml (12 ml/rat per day), or directly into the stomach 5 min before pressure assessment (a water manometer connected to the drainage port of a Foley catheter implanted into the stomach either through an esophageal or duodenal incision). This treatment alleviates i) the esophagitis (macroscopically and microscopically, at either region or interval), ii) the pressure in the pyloric sphincter, and iii) the pressure in the lower esophageal sphincter (cmH2O). In the normal rats it increases lower esophageal sphincter pressure, but decreases the pyloric sphincter pressure. Ranitidine, given using the same protocol (50 mg/kg, intraperitoneally, once daily; 0.83 mg/ml in drinking water; 50 mg/kg directly into the stomach) does not have an effect in either rats with esophagitis or in normal rats.
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http://dx.doi.org/10.1254/jphs.fp0061322DOI Listing
May 2007

An experimental model of prolonged esophagitis with sphincter failure in the rat and the therapeutic potential of gastric pentadecapeptide BPC 157.

J Pharmacol Sci 2006 Nov;102(3):269-77

Department of Pharmacology, Medical Faculty, University of Zagreb, Zagreb, Croatia.

We report a simple novel rat model that combines prolonged esophagitis and parallel sphincters failure. The anti-ulcer gastric pentadecapeptide BPC 157, which was found to be stable in gastric juice, and is being evaluated in inflammatory bowel disease trials, is an anti-esophagitis therapy that recovers failed sphincters. Twelve or twenty months after the initial challenge (tubes sutured into sphincters for one week and then spontaneously removed by peristalsis), rats exhibit prolonged esophagitis (confluent hemorrhagic and yellowish lesions, thinner epithelium and superficial corneal layer, with stratification derangement); constantly lowered pressure of both sphincters (assessed by using a water manometer connected to the drainage port of a Foley catheter implanted into the stomach either through esophageal or duodenal incision); and both lower esophageal and pyloric sphincter failure. Throughout the esophagitis experiment, BPC 157 was given at either 10 micro g/kg, i.p., once a day (last application 24 h before assessment) or alternatively, it was given continuously in drinking water at 0.16 micro g/ml (12 ml/rat). This treatment recovers i) esophagitis (macroscopically and microscopically, at either region or investigated time period) and ii) pressure in both sphincters (cmH2O). In addition, BPC 157 (10 micro g/kg) or saline (1 ml/rat, 5 ml/kg) was specifically given directly into the stomach; pressure assessment was performed at 5 min thereafter. The effect of BPC 157 is specific because in normal rats, it increases lower esophageal sphincter-pressure, but decreases pyloric sphincter-pressure. Ranitidine, given as the standard drug using the same protocol (50 mg/kg, i.p., once daily; 0.83 mg/ml in drinking water; or 50 mg/kg directly into the stomach) had no effect.
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http://dx.doi.org/10.1254/jphs.fp0060070DOI Listing
November 2006

Effective therapy of transected quadriceps muscle in rat: Gastric pentadecapeptide BPC 157.

J Orthop Res 2006 May;24(5):1109-17

Department of Pharmacology, School of Medicine, University of Zagreb, Salata 11, P.O.B. 916, 10000 Zagreb, Croatia.

We report complete transection of major muscle and the systemic peptide treatment that induces healing of quadriceps muscle promptly and then maintains the healing with functional restoration. Initially, stable gastric pentadecapeptide BPC 157 (GEPPPGKPADDAGLV, M.W. 1419, PL-10, PLD-116, PL 14736 Pliva, Croatia; in trials for inflammatory bowel disease; wound treatment; no toxicity reported; effective alone without carrier) also superiorly accelerates the healing of transected Achilles tendon. Regularly, quadriceps muscle completely transected transversely 1.0 cm proximal to patella presents a definitive defect that cannot be compensated in rat. BPC 157 (10 microg, 10 ng, 10 pg/kg) is given intraperitoneally, once daily; the first application 30 min posttransection, the final 24 h before sacrifice. It consistently improves muscle healing throughout the whole 72-day period. Improved are: (i) biomechanic (load of failure increased); (ii) function (walking recovery and extensor postural thrust/motor function index returned toward normal healthy values); (iii) microscopy/immunochemistry [i.e., mostly muscle fibers connect muscle segments; absent gap; significant desmin positivity for ongoing regeneration of muscle; larger myofibril diameters on both sides, distal and proximal (normal healthy rat-values reached)]; (iv) macroscopic presentation (stumps connected; subsequently, atrophy markedly attenuated; finally, presentation close to normal noninjured muscle, no postsurgery leg contracture). Thus, posttransection healing-consistently improved-may suggest this peptide therapeutic application in muscle disorders.
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http://dx.doi.org/10.1002/jor.20089DOI Listing
May 2006

Gastric pentadecapeptide BPC 157 effective against serotonin syndrome in rats.

Eur J Pharmacol 2005 Apr;512(2-3):173-9

Department of Pharmacology, Medical Faculty, University of Zagreb, Salata 11, POB 916, 10000 Zagreb, Croatia.

Serotonin syndrome commonly follows irreversible monoamine oxidase (MAO)-inhibition and subsequent serotonin (5-HT) substrate (in rats with fore paw treading, hind limbs abduction, wet dog shake, hypothermia followed by hyperthermia). A stable gastric pentadecapeptide BPC 157 with very safe profile (inflammatory bowel disease clinical phase II, PL-10, PLD-116, PL-14736, Pliva) reduced the duration of immobility to a greater extent than imipramine, and, given peripherally, has region specific influence on brain 5-HT synthesis (alpha-[14C]methyl-L-tryptophan autoradiographic measurements) in rats, different from any other serotonergic drug. Thereby, we investigate this peptide (10 microg, 10 ng, 10 pg/kg i.p.) in (i) full serotonin syndrome in rat combining pargyline (irreversible MAO-inhibition; 75 mg/kg i.p.) and subsequent L-tryptophan (5-HT precursor; 100 mg/kg i.p.; BPC 157 as a co-treatment), or (ii, iii) using pargyline or L-tryptophan given separately, as a serotonin-substrate with (ii) pargyline (BPC 157 as a 15-min posttreatment) or as a potential serotonin syndrome inductor with (iii) L-tryptophan (BPC 157 as a 15 min-pretreatment). In all experiments, gastric pentadecapeptide BPC 157 contrasts with serotonin-syndrome either (i) presentation (i.e., particularly counteracted) or (ii) initiation (i.e., neither a serotonin substrate (counteraction of pargyline), nor an inductor for serotonin syndrome (no influence on L-tryptophan challenge)). Indicatively, severe serotonin syndrome in pargyline + L-tryptophan rats is considerably inhibited even by lower pentadecapeptide BPC 157 doses regimens (particularly disturbances such as hyperthermia and wet dog shake thought to be related to stimulation of 5-HT2A receptors), while the highest pentadecapeptide dose counteracts mild disturbances present in pargyline rats (mild hypothermia, feeble hind limbs abduction). Thereby, in severe serotonin syndrome, gastric pentadecapeptide BPC 157 (alone, no behavioral or temperature effect) has a beneficial activity, which is likely, particular, and mostly related to a rather specific counteraction of 5-HT2A receptors phenomena.
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http://dx.doi.org/10.1016/j.ejphar.2005.02.033DOI Listing
April 2005

Spontaneously ruptured gastrointestinal stromal tumor (GIST) of the jejunum mimicking acute appendicitis.

Coll Antropol 2004 Dec;28(2):937-41

Department of Surgery, University Hospital Merkur, Zagreb, Croatia.

Gastrointestinal stromal tumors (GISTs) are characterized with diverse clinical presentations, including acute and chronic gastrointestinal bleeding, abdominal pain, presence of an intra-abdominal mass, anorexia, and intestinal obstruction. A 60-year-old obese woman presented as an acute abdominal emergency with right lower quadrant (RLQ) pain and tenderness, nausea and leukocytosis, all mimicking acute appendicitis. Laparotomy revealed a spontaneously ruptured GIST of the jejunum, which was localized to the RLQ due to postoperative adhesions following previous two cesarean sections and cholecystectomy. Complete surgical resection was performed, followed by an uneventful early postoperative course.
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December 2004