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264 Medicinski Glasnik, Volumen 6, Number 2, August 2009 private data. The fact that majority of participants from both groups do it on an exceptional basis or very rarely implies their awareness of this major security issue. Furthermore, the Internet is a well known source of malicious software. Medical information systems are becoming more and more vulnerable to attacks by malicious software (6). Unaware and unprotected portable PC users who have access to a medical information system also pose a security threat. The only participant from the School of Medicine who has no security software on his portable PC is “secured” by using the LINUX operating system, whereas the majority of the persons tested have at least 2 types of security software installed on their portable PCs. Even though the reason for such consciousness might be just self-protection, it results in a reduced risk not only for the user and his portable PC, but also for the environment in which they operate. The frequency distribution of making security backups in both groups is very low. Only 4 participants from the School of Medicine and 6 from the School of Electrical Engineering make security backups of their important documents once a week or more frequently. The difference in answers on questions about security experts’ REFERENCES 1. 2. 3. 4. 5. Dantu R, Oosterwijk H, Kolan P, Husna H. Securing medical networks. Network Security 2007; 2007: 13-16. Yen-Chiao L, Yan X, Andrew S, Julie A.J. A review and a framework of handheld computer adoption in healthcare. Int J Med Inform 2005; 74: 409-22. Potter B. Mobile security risks: ever evolving. Network Security 200; 2007: 19-20. Hawkins S, Yen D.C, Chou D.C. Awareness and challenges of Internet security. Information Management & Computer Security 2000; 8: 131-43. Kluge E-H.W. Secure e-Health: Managing risks to patient health data. Int J Med Inform 2007; 76: 402-6. terminology between groups investigated was the only difference found between them. It seems that information about the importance of backups and instructions on how to do backup should be presented to each PC user. It is considered to be even more important for users having a mobile device because their portable PCs are not (all the time) part of the secured corporate ICT system. Those instructions should come in the same box with portable PCs (7). The study shows that users’ awareness on security risks plays an important role in securing the data (8,9). Participants did present great knowledge in this matter and their systems are secured. The number of portable PC users is growing every day, as well as their impact on the security of surrounding ICT systems. Although based on a rather small sample, the results of the pilot study may serve as a starting point for further research in security matters in systems consisting of portable PCs and their users, as well as in their security behavior in different environments. ACKNOWLEDGMENT / DISCLOSURE 6. 7. 8. 9. Competing interests: none declared. Gobuty D. Defending medical information systems against malicious software. International Congress Series 2004; 1268: 96-107. Phippen A, Furnell S. Taking Responsibility for online protection - why citizens have their part to play, Computer Fraud & Security 2007; 2007: 8-13. TechNet Security Centre, Microsoft. http://www. microsoft.com/technet/security/ (10th of August 2007) Sophos Security Information web page. http:// www.sophos.com/security/ (10th of August 2007)
CASE REPORT Akutna bruceloza udružena sa Coombs-pozitivnom autoimunosnom hemolitičkom anemijom i diseminiranom intravaskularnom koagulacijom Nerma Mušić, Eldira Hadžić Služba za zarazne bolesti, Kantonalna bolnica Zenica, Bosna i Hercegovina Corresponding author: Nerma Mušić, Služba za zarazne bolesti, Kantonalna bolnica Zenica, Crkvice 67, 72 000 Zenica, Bosna i Hercegovina Phone: +387 32 405 133; Fax: +387 32 405 E-mail: nermamusic@hotmail.com Originalna prijava: 06. decembar 2008.; Korigirana verzija: 12. januar 2009.; Prihvaćeno: 06. mart 2009. Med Glas 2009; 6(2): 265-268 SAŽETAK Hematološke manifestacije bruceloze su različite. Akutna hemoliza i diseminirana intravaskularna koagulopatija (DIK) jako se rijetko viđaju kod bruceloze. Terapijski pristup ovakvim formama bolesti je jako kompleksan. U ovom radu prikazan je slučaj bolesnika s akutnom brucelozom udruženom s Coombs-pozitivnom autoimunom hemolitičkom anemijom i diseminiranom intravaskularnom koagulacijom. Pacijent je dobro reagirao na terapiju antibioticima i kortikosteroidima. Ključne riječi: bruceloza, autoimuna hemolitička anemija, diseminirana intravaskularna koagulopatija UVOD Bruceloza je širom svijeta raširena zoonoza uzrokovana mikroorganizmom iz roda Brucella (1). Bolest zahvata mnoge organe i organske sisteme, gastrointestinalni, kardiovaskularni, hematopoetski, nervni, koštani, respiratorni, kožni i očni (2). Hematološke manifestacije bruceloze su različite i obično se manifestiraju kao blaga anemija i leukopenija (1-3). Anemija u pacijenata sa brucelozom rezultat je poremećaja metabolizma željeza tokom infekcije, hipersplenizma, krvarenja, supresije koštane srži ili autoimune hemolize (2). Teška trombocitopenija, pancitopenija, bicitopenija, akutna hemoliza i diseminirana intravaskularna koagulacija (DIK) su rijetke (2, 3). Infekcija uzrokovana vrstama Brucella može rezultirati pojavom sistemskog autoimunosnog odgovora kod ljudi (3). Pojava Coombs-pozitivne autoimunosne hemolitičke anemije kod akutne bruceloze je rijetka (3). Mehanizam nastanka trombocitopenije nije potpuno jasan, ali neki predloženi mehanizmi su hipersplenizam, diseminirana intravaskularna koagulacija, supresija koštane srži tokom septikemije, hemofagocitoza i imuna destrukcija trombocita (4). Autoimunosna hemolitička anemija (AIHA), kao jedna od posljedica imunosnog razaranja eritrocita, odlikuje se skraćenim vijekom eritrocita preko mehanizama domaćinovih antitijela koja reagiraju sa vlastitim antigenima (5). Može biti dio kliničke slike infekcija uzrokovanih različitim uzročnicima. Najčešće su to vrste Plasmodium, Haemophilus influenzae, Escherichia coli, Salmonella spp., Shigella spp., Mycoplasma pneumoniae, citomegalovirus, varicella zoster i herpes simplex virus, virus influenzae A (5). Klinički autoimuna hemolitička anemija može se očitovati različito, kao teška hemolitička anemija sve do akutnih hemolitičkih kriza sa hemoglobinurijom i akutnom bubrežnom insuficijencijom (5). Diseminirana intravaskularna koagulacija (DIK) često nastaje u sistemskoj upali uzrokovanoj endotoksinom koji istovremeno aktivira imunosni (monocitno-makrofagni) sistem i endotelne stanice koji luče tkivni faktor (6). Između ostalih, i intravaskularna hemoliza jeste stanje kod kojeg se javlja DIK (6). U ovom radu prikazan je slučaj bolesnika s teškim oblikom akutne bruceloze udružene sa kliničkim i hematološkim nalazom Coombspozitivne autoimunosne hemolitičke anemije i diseminirane intravaskularne koagulacije. 265
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