Introduction: MRI examination is a standard procedure requested by physicians of neurologic sciences, for the patient with neurocognitive disorders. Propofol sedation was performed for this examination, and we had the suspicion that children with autism spectrum syndrome (AUT) required higher propofol dose than normal children. Materials and methods: During a six years period, the first group of 30 autistic patients aged 3 to 10 years, received propofol infusion for brain MR, the control group of 30 normal patients with the same age, and the same mid-time of examination MR was also performed. Results: 17 children of AUT group received 3±1 additional doses of propofol, 12 of them had to repeat MR sequences (adequate anesthesia) and the total dose of propofol 4,5 vs 3,6 compare to non-autistic children. Even and the recovery time is a little bit faster compared to the second group. Conclusion: Autistic patients require more propofol dose to achieve a desirable level of anesthesia. All anesthesiologists should be aware in such patients with mental disorders when using propofol anesthesia.

Firearms injuries are a major public health problem in Kosovo. Injuries from firearms injuries are those caused by any firearm (cartridge, Cannonball) and from the special properties war, mine explosive grenades, and other subjects. Epidemiology of the use of firearms in males ranges corresponding 1.9 per 100,000 population, while for women 0.3 per 100,000 inhabitants The most common injuries are caused by weapons fire, rarely with special tools of war, Causes with firearms injuries blamed mental health problems, domestic violence, disparities in family, social cases, use of drugs and alcohol Preventing injuries and deaths by firearms is one of the most complex issues at the country in recent years. Management and Access Principles, Access, Evaluation of Emergency Medical Care at Three Levels of Care based on EMS Standard. It is important to take a step, contributing significantly to the reduction of premature deaths, diseases, and disability. Careful medical certificates should be given for carrying weapons, assessing the psychophysical and social aspects. The Kosovo Police should control nightclubs, schools and universities, respecting, implementing legal and institutional mechanisms, educating communities through brushes, lectures, media, and social networks, as well as international cooperation. The significant number of injuries with disabilities and deaths should be prevented through national preventive strategies and the need to provide emergency medical care for the rapid transport of firearm victims to the emergency clinic for definitive treatment. Educational efforts are trying to promote safer use of firearms, but they have not led to a significant reduction in the number of victims.

The aim is to investigate the association between elective caesarean sections and neonatal respiratory morbidity and the importance of timing of elective caesarean sections Methods: Cohort study with prospectively collected data of all elective Caesarean sections on mothers with a gestational age of 37+0 weeks and more, that were performed in our Hospital from 1 January 2011 to 1 January 2017. Multiple pregnancies, fetuses with congenital anomalies, intrauterine deaths, and emergency Caesarean sections were excluded. Primary outcome measures of neonatal respiratory morbidity included transient tachypnea of newborn, respiratory distress syndrome, persistent pulmonary hypertension of the newborn. Results: 4290 infants were delivered by elective caesarean section at 37+0 and then after Compared with newborns from vaginal delivery, and emergency cesarean section an increased risk of respiratory morbidity was found for infants delivered by elective caesarean section at 37 +0 weeks’ gestation to 37+6 weeks (odds ratio 5.7 95% confidence interval 4.3 to 8.9), 38+0 weeks’ gestation to 38+6 weeks (2.8 , 2.1 to 4.2 ), and 39+0 weeks’ gestation (2.1, 1.5 to 2.8). Also increasing the incidence of admission to the NICU with decreasing gestational age at term birth below the 39 weeks of gestation Conclusions: Compared with newborn delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of respiratory morbidity. The relative risk increased with decreasing gestational age.

emphasizes on the mechanism and patterns of trauma, with a consideration of why trauma code was activated, and the imaging results in regard to the severity of the trauma. Material and Methods: A descriptive study was conducted in Al Ain Hospital over the year of 2017. 886 patients were included who presented with trauma and considered dangerous according to hospital guidelines. They underwent a full-body trauma CT and got admitted to the hospital. We looked at the mechanisms, patterns, time of the day, and radiological findings. Injury severity score (ISS) and Revised trauma score (RTS) were calculated, and the cause of trauma code activation was evaluated. Results: The study shows that; Positive imaging findings were found in 364 (41%) of patients while 524 (59%) had normal radiological tests. The principal mechanism of injury was motor vehicle accident (54.4%) followed by falls (21%) then pedestrian accidents (10.1%). Overall, 69.75% (618 patients) were admitted to hospital, 22 patients needed immediate interventions and 36 patients needed ICU admission. Only 2 patients died in the emergency room Conclusions: The hospital policy in activating a trauma code should be revised, with more care being paid to the mechanisms of injury and the condition of the patient, without missing any injury that could harm the patient. So, the emergency physician should be better prepared to do a detailed physical examination and weigh the risk of radiation against missing a dangerous injury.

Aim:This study analyzes the epidemiological distribution and the clinical-electric co-relation in carpal tunnel syndrome (CTS). Methods:100 consecutive patients referred to our out-patient service for carpal tunnel syndrome were included in this study. The clinical examination of the stage of CTS and electrophysiological study (EPS)wasconducted and the BCTQ questionnaire was administered with an average of 15 minutes for each.The link between the electrical stage and the total points of the questionnaire was analyzed by the Bivariate Correlation analysis by finding the Pearson coefficient and the level of significance according to the Two-Tailed test of significance. Results: It was found that the female-male ratio was 3.5 to 1 with the predominance of the age 51-60 -year-old. 35% were overweight and 17% were obese.The first predominant symptoms were paresthesia, tingling sensation in their fingertips and pain, which prevailed at night.It was seen that the highest percentage was in those with not more than secondary education. There was no significant relation with family history and CTS.The most common comorbidities were arterialhypertension and rheumatoid arthritis. 43% were referred to the neurologist by the family doctor.In the bivariate analysis a statistically significant link was found with p<0.01 with positive correlation r=0.311for the right hand and p <0.01, r = 0.345 for the left hand. Conclusions: There is still a considerable number of patients diagnosed at an advanced stage,with faded opportunity for maximal benefit from timely treatment.This syndrome is more frequent in women with BMI> 25 and in certain professions that request repetitive flexion of the grip. Family doctor should be more alert on diagnosing this common syndrome in an early stage.

Introduction: the most common thoracic injuries were rib fractures (40%) and simple lung contusions (35%) and the abdominal organs most commonly injured were the spleen (35%), liver (25%), and kidney (20%). Mortality varies from 3-22%. the thoracoabdominal injuries, Purpose: evidence of the role of thoracic trauma in intra-abdominal injuries. evaluation of correlation between rib fractures and intra-abdominal organ injuries after Blunt chest trauma; Materials and methods: the study has a retrospective character, conducted within the period of December 2017 - June 2019. in our study, 890 patients were included in the emergency Department at University Hospital of trauma, tirana, albania. the population sample was selected randomly without any study restrictions. Results: our study includes 890 patients; distribution of gender-based was: 196 (22%) females and 694 (78%) males. the distribution based on age: 116 (13 %); for <14 years old group; 347 (39%); for 14-40 years old; 427 (48%).for >40 years old. Conclusions: in Blunt chest trauma, the incidence of intra-abdominal organ injuries is high as evidenced by our study. all patients with such injuries should be evaluated and evaluated until the possibility of such intra-abdominal damage is ruled out. also, intra-abdominal injuries in multiple rib fractures patients with more than 6 fractures show high gravity, full inspection and observation must be achieved to prepare for possible emergency surgery or other treatment options.

Aim: We aimed to put forward the efficacy of abdominal CT performed for patients diagnosed with acute abdomen and to share our clinical findings in that regard. Methods: 216 patients who had been hospitalized in General Surgery Department due to acute abdomen had been analyzed retrospectively between October 2018- January 2019. Abdominal computerized tomography (CT) results had been discussed in terms of diagnostic accuracy and clinical outcomes. Results: 171 (79.2%) patients (M/F:95/76 (55.6% / 44.4%)) had been evaluated by computerized tomography (CT) due to various causes of acute abdomen. Patients who had been scanned more than once (n=13 (7.6%)) during theirs’ hospitalization period had longer average length of stays compared to those whom had been scanned for only once (n=158 (92.4%)) (multiple scanned:17 days vs single scanned:3 days; p=0.000). Besides, single-scanned patients had showed higher clinical accuracy compared to those with multi-scans (80.4% vs 61.5%, p=0.126). 28 ileus (84.8%) patients had been scanned by non-enteral computerized tomography (CT), and 12 (36.4%) of them had been given false radiological reviews. Conclusion: Improper and redundant use of computerized tomography (CT) may cause prolongation of stays at the hospital, besides performing unnecessary scans do not improve diagnostic accuracy.

Introduction: Monti and co. described in 1997 is a continent catheterizable conduit using short segments of the ileum (1). The use of this technique allows us to obtain 2 to 2.5 cm segment of the ileum to achieve a tabularized segment of 7-8 cm. The 15 cm of terminal ileum was not routinely used for this type of procedure. After the reconstruction of a tunnel, anastomosis was performed on the superior part of the posterio-lateral junction of the bladder. Objectives: To report 6 cases using the Monti procedure with ileum for adult continent cutaneous urinary diversion, from different etiologies. Materials and Methods: From 2007 to 2020 we treated 6 patients with different conditions with this procedure.First case was a middle-aged woman with a big vesico-vaginal fistula (fig.3) It was unappropriated to be closed with satisfactory functional results in terms of continence, because a part of the sphincter was destroyed also. The reason of damage was auto mutilation as a result of borderline personality. Discussion: Monti procedure associating Mitrofanoff principle was mainly used in pediatric patients (1,2,3) That’s because of the relatively easy execution of the “Mitrofanoff principle” and the high degree of continence obtained with its use (4). But can we use the same principle to resolve some difficult cases in adult urology also? Conclusion: The Monti tunnel is a valid option for continent intermittent catheterisation. It’s also an alternative to be adjunct with Mitrofanoff procedure when needed. We used it when the appendix was not appropriate to be used as a tunnel or when it was missing. It has a good continent percentage and it can be done rather easily. Of course, ours is a small series of cases to represent more important conclusions

Background: In this study we investigated the differences between tension free versus not tension free inguinal hernia repair in occurrence of various postoperative complications. Methods: The study included 65 male patients with direct or indirect inguinal hernia operated at the Department of Abdominal and General Surgery, between March 2012 and March 2014. The patients were divided into two groups. Evaluated were postoperative complications.. Results: No statistically significant differences in incidences of postoperative complications between two groups (p<0.05). Conclusion: Obtained results show that tension-free mesh repair is equivalent to the not tension free hernia repair method with regards of postoperative complications, severity of postoperative pain and ambulance.

The process of patient referral system at the level of health care is a comprehensive institutional framework with responsible, welldefined competencies, as a network of cooperation with the general goal of maintaining health, treatment, stabilization, transport and medical care up to in the complete recovery of the sick. The process of patient referral system in most countries in Europe and in the world is a challenge for most developing and developed countries. The mechanisms of the referral system function at different national, regional and municipal levels based on national laws and policies and work on the basis of efficient lines of communication by creating clear and simple steps and procedures described. The referral system in Kosovo is disorganized, chaotic, the Ministry of Health must have a national document of the referral system for patients at the health level, and before that all health care professionals are educated, trained on the way of the referral system, which cases must be sent from the primary, secondary and tertiary level. At the national level, the National Coordinating Council with a national plan of the patient referral system can convey the quality; help the health care professionals based on the current health legislation, the harmonization of unique standardized protocols with follow-up guidelines. Patients at the country level.

Neurogenic Thoracic Outlet Syndrome (NTOS) is a rare, but controversial syndrome in relation to its diagnosis, treatment modality, and approaches in case of surgical treatment. In the English literature, there are sparse studies dealing with these aspects. We conducted a PubMed 2000-2017 literature review and found a total of 3953 cases reported with NTOS. The clinical characteristics, etiology, electrophysiological and radiological work-up and treatment options were reviewed and reported. It seems that, as far as surgical indication criteria are concerned, there is a consensus for NTOS in its motor deficit stage and its techniques are generally well established. This review showed that differential diagnosis, radiological, and electrophysiological criteria for correct diagnosis of NTOS are not controversial. However, surgical indications and types of approaches and techniques reflect the surgeon’s affiliation with specialties dealing with NTOS (vascular, plastic, hand, orthopedic or neurosurgeons), and the surgeon’s experience with this specific and rare syndrome.

Rib fractures are a consequence of the forces of various arthritis that the chest wall and the thoracic cage itself undergo, and are most often due to closed injuries (eg, motor vehicle collision, falls from height, and Hits with strong objects ..), but penetrating injuries (eg, wounds with sharp tools, gunshot injuries ...) can also result in rib fractures. Non-operative treatment is based on pain control and pulmonary support, which mainly aim to avoid the need for intubation, which is associated with increased levels of pulmonary disorders until death. For patients who continue to have acute pain or instability of the chest wall (eg, flail chest), each of which impedes pulmonary function despite maximal medical therapy, or those with non-consolidating rib fractures and causing pain in the persistence and impairment of pulmonary function, surgicalystabilization of fractured ribs, also known as osteosynthesis, are now well-known procedures that improve the quality of treatment of the traumatized patient. The thoracic wall injury association has been established to better study all aspects related to the consequences, diagnosis and treatment of thoracic wall injuries [1]. Indications for osteosynthesis, patient preparation, operative technique for stabilizing fractured ribs and the results are quite significant.

The traumatic extracorporeal ejection of a beating heart has not been witnessed and reported in the literature previously, to our knowledge. Here we present two cases of vehicle accidents leading to this fatal injury, both in a rabbit and a human. One late evening in June, in the land of the midnight sun, a young man was driving to his favourite fishing river for a spot of trout fishing in a remote part of Eastern Finland. While driving his aged Nissan Almera at 60 km/h down a dusty gravel road on this dusky night, suddenly a young male rabbit jumped onto the road and appeared in the beam of his headlights. Despite the man’s evasive manoeuvres, the rabbit was struck by the left front corner of the car. After hitting the brakes and the car eventually coming to a standstill, the young man went to inspect the animal he had hit…. In conclusion, we present that in a very rare constellation of forceful blunt trauma to the chest, the heart can be completely avulsed and ejected from the body in human as in animals. Larger prospective and randomised studies are probably not needed to confirm these findings. Just be careful – it is possible to lose your heart to a car

Background: Left ventricular assist device (LVAD) implantation is not only a bridge-to-transplantation option for patients awaiting a donor heart, but is often used as bridge-to-destination therapy in patients unsuitable for transplantation for various reasons. Device infection remains a threatening complication, which may lead to prolonged hospitalization, need to device exchange, urgent transplantation, and even death of the patient. Infections with multidrug resistant (MDR) organisms pose major difficulties for eradication therapy. Especially patients who are subject to continuous hospital treatments risk contamination or change of resistances spectrum. Gold standard therapy of certain organisms often fails to eradicate surface associated colonization’s of implanted devices such as cardiovascular implants, while failed eradication leads to numerous complications and an increased mortality rate among the affected patients. Device infections through multidrug resistant bacteria, such as MRSA, are often resistant even to first-line antibiotics, due to extended resistance spectrum and reduce tissue penetration in scar tissue after multiple surgical procedures. In addition, a solid biofilm on devices is often impenetrable even for suitable antibiotics because of the isolating nature of biofilms. Case presentation: A 48-year-old patient 72 kg, height 172 cm with dilated cardiomyopathy, his course was complicated by pump failure requiring LVAD HeartMate III placement 3 years (Milan Italy). The parameters of the LVAD pump were determined for the patient from the moment of the Pump speed 5300 rpm Flow 4.4 lpm was set. The patient performed moderate activity under normal conditions. The patient regularly took Coumadin to keep the recommended INR levels at the recommended target values 2.5. At the site of the exit of the cavity from the skin in the region of the right hypochondrium, there was an infection that for a long time was treated with various schemes with ambulatory antibiotics Conclusions: In the present case we showed that successful eradication of a chronic LVAD driveline infection was only possible when approached both surgically and conservatively. It is important to note that a good knowledge of the physiopathology of heart failure, the widest possible information on the treatment of heart failure with the help of LVAD implantation is very important in the treatment and survival of these patients.

an unknown etiology which was first described by Dego in 1942 (1), but another case, reported in 1941 by Köhlmeier, who interpreted it as thromboangiitis obliterans of the mesenteric vessels (2). It is an occlusive arteriopathy involving small-caliber vessels. Specifically, it is a progressive, small- and medium-size arterial occluding disease, leading to tissue infarction and initially involving the skin. Degos disease occurs both in a limited benign, cutaneous form and in a potentially lethal multiorgan, systemic variant. The disease has a male predominance (3:1), and sporadic cases of familial involvement have been recorded. (3-7). The involvement of the gastrointestinal tract and other organs has been noted in approximately 60% of reported cases (8). There are fewer than 50 living patients presently known worldwide, and fewer than 200 reported in medical literature. However, many individuals may go undiagnosed due to rarity of the disease (9,10). Most individuals develop symptoms between the ages of 20-50; however, cases outside of this age range have been reported as well, even as early as 8 months (1,6).

Background: Nowadays anesthesia and outcome of morbidly obese patients became not only challenges but and an obligation in abdominal surgery. Sometimes morbidly obese patients postponed from all the kinds of surgery till it is life-threatening. The ward of anesthetists is obligate for a very careful preoperative evaluation, anesthesia, and outcome of morbidity obese patients. These include the preoperative evaluation of obesity, particularly on cardiac, respiratory, and metabolic systems; airway management; perioperative management (i.e., hemodynamic, respiratory, and hyperglycemic) and postoperative care. Case description: A 62 years old female with BMI=63.7 kg/m² with severe hypertension treatment came to a surgery ward for the plastic abdomen. After a careful preoperative preparation for the respiratory system and prophylaxis for thrombosis home, we started preoperative care 72 hours before surgery done in our hospital. We used general anesthesia for operation, the surgery lasts 190 minutes, and the patient was extubated according to weaning criteria only 16 hours after surgery. The patient stayed 2 days in intensive care and left a safe hospital on her ten days of recovery. Discussion: Super obese surgical patients represent numerous challenges to the anesthetist. Conclusion: A better understanding of the pathophysiology and complications that accompany obesity may improve their care and outcome.

Introduction: Nowadays, we need to deal with heart transplanted patients for other medical concerns. So, it is important to see in detail different aspects and modalities of their care during other types of surgery. A transplant team will carefully monitor each heart trans-plant recipient and should be possible to seek information on the patient’s overall status. They will be able to inform on the most recent investigations (ECG to assess graft function, recent biopsy for rejection, angiography for coronaries, etc.). Case report: Our patient, a 65-year-old lady underwent heart transplantation 5 years before. The cardiac situation was stable and she was doing fine. She was recovered in the gynaecological clinic with a diagnosis of vaginal prolapse with surgical indication General anaesthesia was done with fentanyl 7 ml, pavulon 4 mg, propofol 200 mg and sevoflurane 1.5-2.2%. The patient was monitored during surgery with SpO2, ECG, IBP, CVP. The operation technique was open of vaginal plastic repair. Discussion: By 3 months, most recipients of heart transplant came under New York Heart Association (NYHA) I class. The last UK national survey about health-related quality of life after cardiac transplantation indicates that, 1 year after surgery, there is an improvement in quality of life (60% are much better; 28% somewhat better) and there is no deterioration in general health at 3–5 years, except that many of them have symptoms compatible with depression. Conclusion: Perioperative care of heart transplant recipients will entail a greater attention to maintaining an adequate preload and vascular tone, to avoiding infections and to being aware of the multiple side effects of immunosuppressive therapy. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue