2013-05-21T16:49:14Z http://hrcak.srce.hr/oai/

oai:hrcak.srce.hr:12605 2008-06-03 journal:158

The Value of Quantitative Bone Scintigraphy in the Prognosis of Fracture Healing Značenje kvantitativnog scintigrama kosti u prognostici zaraštanja prijeloma Pranić-Kragić, Anka Marković, Vinko Radović, Darijo Dodig, Damir Punda, Ante Čapkun, Vesna Fractures - healing; Bone and bones - diagnosis; Bone and bones - radionuclide imaging; Fractures - radionuclide imaging Prijelomi - zarastanje; Kost i kosti - dijagnostika; Kost i kosti - radionuklidni prikaz; Prijelomi - radionuklidni prikaz Studies of fracture healing are aimed at differentiating normal from delayed bone union. Delayed union, nonunion with the development of pseudarthrosis, and infection are complications of fracture healing. In the present study, quantitative analysis by three-phase bone scintigraphy was evaluated in the early prognosis of the course of fracture healing, to assess its potential in the early detection and therapy of healing complications. In 105 patients with long bone fractures, three-phase bone scintigraphy was performed early (day 4-7), and 3 weeks, 3 months and 6 months of injury. Based on clinical, laboratory and radiological findings, patients were retrospectively divided into four groups of normal healing, pseudarthrosis, delayed union, and healing with infection. The region of interest method was used to analyze all three scintigraphy phases, i.e. perfusion, vascular space image, and static scintigram at 3 h of injection. Comparison of impulse count in the fracture area with the contralateral, intact side produced a relative index for each step of three-phase scintigraphy. Infection at the fracture site can be suspected on the basis of perfusion index in the earliest stages following injury. Delayed bone union can also be predicted very early, within three weeks of injury, by use of perfusion index. Quantitative analysis of the vascular space phase and late static scintigrams can contribute to the diagnosis of complications, however, only in later stages of disease, which in part limits their clinical relevance. Three-phase bone scintigraphy is a valuable study when expecting problems in the process of bone union. Ispitivanje zarastanja prijeloma ima za cilj razlikovanje normalnog od usporenog zarastanja kosti. Odloženo zarastanje, nezarastanje s razvojem pseudoartroze te infekcija komplikacije su zarastanja prijeloma. S ciljem što ranijeg otkrivanja, a time i ranije terapije komplikacija, željeli smo ispitati mogućnosti kvantitativne analize troetapne scintigrafije kosti u ranoj prognozi tijeka zarastanja prijeloma. U 105 ispitanika s prijelomima dugih kostiju učinjena je troetapna scintigrafija kosti neposredno nakon traume (4.-7. dan nakon traume), te 3 tjedna, 3 i 6 mjeseci nakon traume. Ispitanici su na osnovi kliničkih, laboratorijskih i radioloških nalaza retrospektivno podijeljeni u četiri skupine: normalno zarastanje, pseudoartroza, odloženo zarastanje i zarastanje uz infekciju. Metodom regije interesa (ROI) analizirali smo sve tri faze scintigrama: perfuziju, snimku vaskularnih prostora, te statički scintigram 3 sata nakon injiciranja. Uspoređujući broj impulsa područja frakture s kontralateralnom, zdravom stranom dobili smo relativne indekse (RI) za svaku fazu troetapne scintigrafije. U najranijim stadijima nakon povrede moguće je, na temelju indeksa perfuzije, posumnjati na infekciju na mjestu frakture. Odloženo zarastanje također se može predskazati indeksom perfuzije vrlo rano, unutar tri tjedna od prijeloma. Kvantitativna analiza faze vaskularih prostora i kasnih statičkih scintigrama može doprinijeti dijagnostici komplikacija, ali u kasnim fazama bolesti, što donekle umanjuje njihovo kliničko značenje. Troetapna scintigrafija kosti vrijedna je pretraga u slučajevima kada se očekuju problemi zarastanja kosti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12605 http://hrcak.srce.hr/file/19410 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12609 2008-06-03 journal:158

Frank`s Sign as a Risk Factor for Cerebrovascular Disease Frankov znak kao čimbenik rizika cerebrovaskularne bolesti Glavić, Josip Čerimagić, Denis Lovrenčić-Huzjan, Arijana Vuković, Vlasta Demarin, Vida Ear, external – anatomy and histology; Coronary disease – epidemiology; Cerebrovascular disorders – pathology; Cerebrovascular disorders – etiology; Risk factors; Incidence Uho, vanjsko - anatomija i histologija; Koronarna bolest - epidemiologija; Cerebrovaskularne bolesti - patologija; Cerebrovaskularne bolesti - etiologija; Čimbenici rizika; Incidencija Frank’s sign is a dermatological marker, which has in many studies correlated with coronary heart disease. The aim of the study carried out in a sample of 60 subjects was to define whether Frank’s sign belongs to the group of risk factors for cerebrovascular disease. The subjects with the presence of Frank’s sign were assigned to group A, and those without Frank’s sign to group B. All study subjects underwent color Doppler examination of carotid arteries and determination of their common carotid artery intimal wall thickness (ACC IMT). The value exceeding 0.9 mm was considered as an ACC IMT increase. Statistical analysis by use of Pearson’s χ2-test yielded a value of 11.279 and p=0.001. Assessment of the Frank’s sign value in predicting increased ACC IMT showed a sensitivity of 73%, specificity of 70%, positive predictive value of 71% and negative predictive value of 72%. The study indicated a statistically significant correlation between Frank’s sign and increased ACC IMT, supporting the hypothesis according to which this marker is an uncontrollable risk factor for cerebrovascular disease. Frankov znak je dermatološki biljeg koji je u brojnim studijama povezan s koronarnom bolešću srca. Cilj istraživanja provedenog na uzorku od 60 ispitanika bio je utvrditi pripada li Frankov znak čimbenicima rizika cerebrovaskularne bolesti. U skupinu A svrstani su ispitanici s prisutnim, a u skupinu B ispitanici s odsutnim Frankovim znakom te je svima napravljen obojeni Doppler karotidnih arterija i određena debljina intimalne stijenke (IMT) na zajedničkoj karotidnoj arteriji (ACC). Kao povećanje ACC IMT uzeta je vrijednost iznad 0,9 mm. Statističkom analizom Pearsonovim χ2-testom dobivena je vrijednost od 11,279 i p=0,001. Procjenom vrijednosti Frankovog znaka u predviđanju povećanja ACC IMT utvrđena je osjetljivost od 73%, specifičnost od 70%, pozitivna prediktivna vrijednost od 71% i negativna prediktivna vrijednost od 72%. Istraživanje je pokazalo statistički značajnu povezanost Frankovog znaka i povećanja ACC IMT, što podupire hipotezu prema kojoj je ovaj znak čimbenik rizika cerebrovaskularne bolesti na koji se ne može utjecati. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12609 http://hrcak.srce.hr/file/19414 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12610 2008-06-03 journal:158

Whiplash Injury - A Medicolegal Issue Trzajna ozljeda vrata - medicinsko-pravni problem Bošnjak-Pašić, Marija Uremović, Melita Vidrih, Branka Vargek-Solter, Vesna Lisak, Marijana Demarin, Vida Whiplash injuries - diagnosis; Whiplash injuries - physiopathology; Whiplash injuries - legislation and jurisprudence; Cervical vertebrae, injuries - pathology; Neck pain - diagnosis; Accidents, traffic - prevention and control Trzajne ozljede - dijagnostika; Trzajne ozljede - fiziopatologija; Trzajne ozljede - zakonodavstvo i pravosuđe; Vratni kralješci, ozljede - patologija; Bolovi u vratu - dijagnostika; Nesreće, promet - prevencija i kontrola Whiplash injury is the most common injury sustained in traffic accidents. On exposure to different forces, multiple neck injuries may occur. Following the injury, many patients suffer from subjective symptoms that may even persist upon completion of medical treatment. As a result, there are serious problems in the objective evaluation of permanent consequences of the injury. The study included 40 randomly selected whiplash injury victims without previous lesions of cervical spine, and 40 equally selected patients with previously confirmed cervical degenerative changes. They all suffered from permanent whiplash injuries and applied for reimbursement for nonmaterial damage to Zagreb Insurance Company during 2001. Sixty-seven per cent of patients underwent continuous treatment for 5-6 months, however, the sequels of whiplash injury persisted in the form of decreased motility of cervical spine, arm paresthesia, vasospasm of vertebral arteries and permanently narrowed visual field. Pathological findings were verified by objective diagnostic methods: functional x-rays of the cervical part of the spinal cord, electromyoneurographic examination of arms, transcranial Doppler sonography of vertebrobasilar arteries, visual field assessment by Goldman method, and clinical examination by medical censor. The treatment of injured patients with previous degenerative changes of cervical spine took a longer time, with a higher level of head and neck motility reduction. Ultimately, in terms of reimbursement, they were conceded a lesser degree of permanent physical damage than those without previous cervical spine lesions. Trzajna ozljeda vratne kralježnice najčešće se događa u prometnim nesrećama. Djelovanjem sila dolazi do ozljeda brojnih struktura vrata. Nakon završenog liječenja zaostaje velik broj subjektivnih simptoma koji se ne mogu objektivno prikazati i stoga predstavljaju velik problem kod ocjene trajnih posljedica. Istraživanje je provedeno u nasumce izabranih 40 ozljeđenika bez prisutnih ranijih oštećenja vratne kralježnice i 40 isto tako nasumce odabranih ozljeđenika s prisutnim degenerativnim promjenama vratne kralježnice dokazane pomoću RTG. Svi su nakon doživljene prometne nesreće pretrpjeli trzajnu ozljedu vratne kralježnice i podnijeli zahtjev za ostvarivanje nematerijalne štete u OZ Zagreb tijekom 2001. godine. U 67% predmeta ozljeđenici su provodili liječenje tijekom 5-6 mjeseci. Nakon završetka liječenja zaostale su trajne posljedice: ograničena pokretljivost vratne kralježnice, utrnulost ruku, vazospazam vertebralnih arterija, trajno sužena vidna polja; sve prema nalazima objektivne obrade (funkcionalne radiološke snimke vratne kralježnice, elektromi¬oneurografije ruku, transkranijske Doppler sonografije vertebrobazilarnog sliva, vidnog polja po Goldmanu te klinički pregled liječnika cenzora). U ozljeđenika s prisutnim degenerativnim promjenama vratne kralježnice liječenje je u pro¬sjeku bilo dugotrajnije, nakon završetka liječenja imali su veći stupanj ograničenja pokreta glave i vrata, ali su u konačnici dobili u postotku manji stupanj trajnih posljedica u odnosu na ozljeđenike koji nisu imali izrađene degenerativne promjene vratne kralježnice. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12610 http://hrcak.srce.hr/file/19415 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12611 2008-06-03 journal:158

Time to Hospital Admission in Patients with Acute Stroke Observational Study in Split . Dalmatia County, Croatia Vrijeme do prijema u bolnicu kod bolesnika s akutnim moždanim udarom - opservacijska studija u Splitsko-Dalmatinskoj županiji, Hrvatska Bilić, Ivica Filipović-Grčić, Petar Lušić, Ivo Cerebrovascular disorders - therapy; Cerebrovascular disorders - diagnosis; Acute disease; Hospitalization; Emergency medical services - statistics and numerical data; Disability evaluation Cerebrovaskularne bolesti - terapija; Cerebrovaskularne bolesti - dijagnostika; Akutna bolest; Hospitalizacija; Hitne medicinske službe - statistika i brojčani podatci; Procjena invalidnosti The objective of this prospective observational study was to determine and document the time elapsed from symptom onset to hospital admission in patients with acute stroke. The study was conducted at Emergency Department, University Department of Neurology, Split University Hospital in Split, Croatia, from October 1, 2004 to December 21, 2004, and included 115 patients with acute stroke. Data on the time of onset of stroke symptoms, brain computed tomography finding and current clinical status were noted. Fifteen patients were excluded from the study because the exact time of symptom onset could not be determined. A standardized interview with patients and/or their relatives was taken to collect the information needed. Ischemic stroke was diagnosed in 82 of 100 patients. Only 13 patients arrived in hospital within 3 hours of stroke symptom onset, and 29 were admitted to hospital more than 24 hours of stroke symptom onset. Sex had no significant effect on arrival time. It was concluded that the majority of patients with acute stroke did not present to emergency department within 3 hours of symptom onset, the current time window for thrombolytic therapy. It seems crucial to identify the factors associated with late presentation to the hospital. Public recognition of stroke symptoms and understanding of the importance of early hospital admission are mandatory for improving the results recorded in this study with time elapsed from symptom onset to hospital admission and eligibility for thrombolytic therapy taken as the main outcome measures. Additional public education is needed to increase awareness of the stroke warning signs. Cilj ove prospektivne opservacijske studije bio je utvrditi i dokumentirati vrijeme proteklo od nastupa simptoma do prijema u bolnicu kod bolesnika s akutnim moždanim udarom. Studija je provedena na Hitnom odjelu Klinike za neurolog¬iju, Kliničke bolnice Split u Splitu od 1. listopada 2004. do 21. prosinca 2004. godine i uključila je 115 bolesnika s akutnim moždanim udarom. Bilježili su se podatci o vremenu nastupa simptoma moždanog udara, nalazu kompjutorizirane tomografije mozga i aktualnom kliničkom statusu. Iz studije je isključeno 15 bolesnika u kojih se točno vrijeme nastupa simptoma nije moglo utvrditi. Proveden je standardizirani razgovor s bolesnicima i/ili njihovom rodbinom kako bi se dobile potrebne informacije. Ishemijski moždani udar je utvrđen u 82 od 100 bolesnika. Samo je 13 bolesnika stiglo u bolnicu unutar 3 sata od nastupa simptoma akutnog moždanog udara, a 29 ih je u bolnicu primljeno vi.e od 24 sata od nastupa simptoma. Spol nije imao značajnog utjecaja na vrijeme dolaska u bolnicu. Rezultati su pokazali kako većina bolesnika s akutnim moždanim udarom nije pristigla na hitni odjel unutar 3 sata od nastupa simptoma, što danas predstavlja vremen¬ski okvir za trombolitičnu terapiju. Od ključne je važnosti utvrditi čimbenike koji su povezani sa zakašnjelim dolaskom u bolnicu. Opće prepoznavanje simptoma moždanog udara i shvaćanje važnosti ranog prijema u bolnicu neophodno je za poboljšanje rezultata dobivenih u ovoj studiji, u kojoj su glavne mjere ishoda bili vrijeme proteklo od nastupa simptoma do prijema u bolnicu i podobnost za trombolitičnu terapiju. Potrebna je daljnja izobrazba javnosti kako bi se povećala svijest o upozoravajućim znacima moždanoga udara. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12611 http://hrcak.srce.hr/file/19416 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12617 2008-06-03 journal:158

Adrenal Ganglioneuroma Associated with Primary Kidney Cancer. Report of Two Cases and Literature Review Ganglioneurom nadbubrežne žlijezde u kombinaciji s primarnim karcinomom bubrega: prikaz dvaju slučajeva Tomić, Karla Štimac, Goran Kraus, Ognjen Tomić, Leonardo Mijić, August Krušlin, Božo Adenocarcinoma – pathology; Adenocarcinoma – surgery; Adrenal gland neoplasms – surgery; Ganglioneuroma – pathology; Ganglioneuroma – surgery; Kidney neoplasms – surgery Adenokarcinom - patologija; Adenokarcinom - kirurgija; Neoplazme nadbubrežne žlijezde - patologija; Ganglioneurom - patologija; Ganglioneurom - kirurgija; Neoplazme bubrega -kirurgija SUMMARY – Two cases of adrenal ganglioneuromas associated with ipsilateral primary kidney cancer, according to literature review a very rare combination, are presented. Both patients underwent adrenalectomy and nephrectomy. Specimens were formalin fixed, paraffin embedded, cut at 5 µm and routinely stained with hematoxylin and eosin. Primary antibodies to neurofilament protein and S-100 were used to confirm ganglion cells in the ganglioneuromas. Histopathological analysis revealed adrenal gland ganglioneuroma with ipsilateral kidney carcinoma. One of them was renal cell carcinoma and the other one was urothelial carcinoma of the renal pelvis. This combination of malignant kidney tumor and adrenal gland ganglioneuroma is extremely rare, and after literature review we concluded that both cases presenting this combination of tumors were probably incidental. U radu su prikazana dva slučaja ganglioneuroma u nadbubrežnoj žlijezdi u bolesnika s primarnim tumorima bubrega, gdje je u jednog bolesnika primarni tumor bubrega bio karcinom bubrežnih stanica, dok je u drugom slučaju tumor bubrega bio urotelni karcinom nakapnice. U oba slučaja prije operacijski nalaz kompjutorizirane tomografije je uz tumore bubrega otkrio i tumore u nadbubrežnim žlijezdama za koje se smatralo da su metastaze. Iako je kombinacija malignog primarnog tumora bubrega i ganglioneuroma u nadbubrežnoj žlijezdi izrazito rijetka, vrlo je vjerojatno da su to slučajni nalazi, a prije operacijski je takve lezije skoro nemoguće razlikovati od metastatske bolesti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12617 http://hrcak.srce.hr/file/19423 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12709 2008-06-03 journal:158

Endoscopic Treatment of Pancreatic Pseudocyst Endoskopsko liječenje pseudociste gušterače Gojo, Nedjeljko Mustapić, Matej Bilić, Branko Hrabar, Davor Lerotić, Ivan Baršić, Neven Pancreatic pseudocyst – diagnosis; Pancreatic pseudocyst – ultrasonography; Pancreatic pseudocyst – therapy; Endoscopy; Drainage – methods; Stents Pseudocista gušterače - dijagnostika; Pseudocista gušterače - ultrazvuk; Pseudocista gušterače - terapija; Endoskopija; Drenaža - metode; Stentovi Pancreatic pseudocyst, the most common cystic lesion of the pancreas, may occur as a consequence of acute or chronic pancreatitis, pancreatic trauma, or obstruction of the pancreatic duct. Symptomatic, complicated, or enlarging pseudocysts require therapy that can be endoscopic (transmural and transpapillary drainage), percutaneous, or surgical. We present a patient with pancreatic pseudocyst treated by blinded endoscopic transgastric puncture and stenting after an unsuccessful attempt at endoscopic transpapillary drainage, suggesting that this simple approach is safe and effective in a selected group of patients. Pseudocista gušterače kao najčešće cistično oštećenje gušterače može nastati kao posljedica akutnog ili kroničnog pankreatitisa, traume gušterače ili opstrukcije gušteračnog kanala. Simptomatične, komplicirane ili pseudociste koje se povećavaju zahtijevaju liječenje koje može biti endoskopsko (transmuralna i transpapilarna drenaža), perkutano ili kirurško. Prikazuje se bolesnica s pseudocistom gušterače liječenom endoskopskom transgastričnom punkcijom naslijepo i postavljanjem stenta nakon neuspjelog pokušaja endoskopske transpapilarne drenaže. Ukazuje se na to da je ovaj jednostavan pristup siguran i učinkovit u odabranoj skupini bolesnika. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12709 http://hrcak.srce.hr/file/19555 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12710 2008-06-03 journal:158

Biliopancreatic Diversion with Sleeve Gastrectomy and Antroileal Anastomosis - Case Report Biliopankreatično skretanje s gastrektomijom u obliku rukava i antroilealnom anastomozom - prikaz slučaja Kuliš, Tomislav Glavan, Elizabet Škorjanec, Sandra Ledinsky, Mario Bekavac-Bešlin, Miroslav Biliopancreatic diversion – methods; Obesity, morbid – surgery; Gastrectomy – methods; Body weight; Weight loss; Case report Biliopankreatično skretanje - metode; Pretilost, morbidna - kirurgija; Gastrektomija - metode; Tjelesna težina; Smanjenje težine; Prikaz slučaja Obesity is becoming a major epidemiological problem throughout the world. Current estimate of obesity in Croatia is 25% of males and 24% of females (BMI ≥30 kg/m2). Biliopancreatic diversion combines both restrictive and malabsorptive component of bariatric surgery. It was first described by Scopinaro in 1979 and later modified with sleeve gastrectomy by Marceau in 1993. It is reserved for super obese patients with BMI ≥50 kg/m2 and is sometimes done in two acts, i.e. sleeve gastrectomy first and then biliopancreatic diversion. A 61-year-old female patient with BMI 52.6 kg/m2 and multiple comorbidities is presented. She had previously had many unsuccessful attempts at losing weight with conservative methods. Due to the high BMI and comorbidities, we decided to perform biliopancreatic diversion with sleeve gastrectomy and antroileal anastomosis. On postoperative day 12, the patient was discharged with BMI 49.2 kg/m2, yielding a 12% excess weight loss (EWL). After five weeks, she was rehospitalized for suspected pulmonary embolism and was discharged three weeks later. On regular follow up at three months after surgery, the patient had 112 kg, yielding a 35% EWL. Pretilost postaje jedan od vodećih epidemiološ.kih problema današnjice. Trenutna procjena broja pretilih ljudi u Hrvatskoj je 25% muškaraca i 24% žena (indeks tjelesne mase, BMI ≥30 kg/m2). Biliopankreatično skretanje kombinira i restriktivnu i malapsorpcijsku sastavnicu barijatrijske kirurgije. Prvi ga je izveo i opisao Scopinaro 1979. godine, a kasnije ga je Marceau 1993. godine modificirao izvođenjem gastrektomije u obliku rukava. Danas se ova operacija prvenstveno izvodi kod super pretilih bolesnika s BMI ≥50 kg/m2. Ponekad se izvodi u dva akta: prvo resekcija želuca, a potom biliopankreatično skretanje. Prikazuje se slučaj 61-godišnje bolesnice s BMI od 52.6 kg/m2 i više istodobnih bolesti. Bolesnica je prethodno u više navrata neuspješno pokušala smršaviti konzervativnim metodama. Zbog visokog BMI i drugih bolesti odlučili smo se za biliopankreatično skretanje s gastrektomijom u obliku rukava i antroilealnom anastomozom. Dvanaestog poslijeoperacijskog dana bolesnica je otpuštena kući s BMI 49.2%, što je već bio gubitak prekomjerne tjelesne težine (EWL) od 12%. Nakon pet tjedana bolesnica je ponovno hospitalizirana s kliničkim znakovima plućne tromboze te je tri tjedna kasnije otpuštena kući. Na kontrolnom pregledu tri mjeseca nakon operacije bolesnica je imala 112 kg ili EWL 35%. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12710 http://hrcak.srce.hr/file/19556 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Bone Remodeling and Thyroid Function Koštana pregradnja i funkcija štitnjače Altabas, Velimir Berković, Maja Bečejac, Branko Solter, Miljenko Biliopancreatic diversion – methods; Obesity, morbid – surgery; Gastrectomy – methods; Body weight; Weight loss; Case report Koštana pregradnja - fiziologija; Kost i kosti - fiziologija; Kost i kosti - metabolizam; Hormoni štitnjače - fiziologija; Hormoni štitnjače -nedostatak Many diseases are associated with more rapid bone loss and an increased risk of osteoporosis and fractures. Both hyperthyroidism and hypothyroidism as well as use of thyroid hormones or thyrosuppressant treatment influence bone turnover rates and may alter the risk of future fractures. Markers of bone remodeling are good indicators to determine bone turnover rates and potential bone loss, and correlate well with thyroid hormone levels. Untreated hyperthyroidism accelerates bone turnover resulting in net bone loss, while untreated hypothyroidism in adult humans slows down bone turnover resulting in net bone gain. In both cases, damage in bone microarchitecture occurs, leading to an increased relative risk of fractures. Effective therapies for both states are available, and in ideal case, full recovery of mineralized tissue may occur over time. Controversies are still present in patients receiving suppressive thyroxin treatment for thyroid carcinoma. It seems that suppressed thyroid-stimulating hormone with normal levels of peripheral thyroid hormones may increase the relative fracture risk in postmenopausal but not in premenopausal women. However, the exact molecular mechanisms of thyroid hormone and thyroid-stimulating hormone action on bone are not completely understood yet. Mnoge bolesti su udružene s ubrzanom koštanom razgradnjom i povećanim rizikom od nastanka osteoporoze. Poremećaji funkcije štitne žlijezde, kao i liječenje hormonima štitnjače, mogu utjecati na brzinu koštane pregradnje te utjecati na rizik od nastanka fraktura. Biljezi koštane pregradnje su dobri pokazatelji za praćenje brzine koštane pregradnje i utvrđivanje rizika od mogućeg gubitka koštane mase, i dobro koreliraju s razinom hormona štitnjače. Neliječena hipertireoza ubrzava koštanu pregradnju dovodeći do gubitka koštane mase, dok neliječena hipotireoza u ljudi usporava koštanu pregradnju te dovodi do pretjerane mineralizacije skeleta. U oba slučaja dolazi do narušavanja mikroarhitekture i povećanog rizika od nastanka fraktura. Djelotvorna je terapija dostupna za oba poremećaja rada štitne žlijezde i u idealnim će slučajevima dovesti do potpunog oporavka mineraliziranih tkiva. Nesuglasje postoji oko bolesnika koji dobivaju tireosupresivnu terapiju prilikom liječenja karcinoma štitnjače. Izgleda da suprimirane razine TSH i normalne razine perifernih hormona štitnjače mogu povećati relativni rizik za nastanak fraktura u žena nakon menopauze, ali ne i prije nje. Točni molekularni mehanizmi djelovanja hormona štitnjače i TSH na kosti još nisu do kraja rasvijetljeni. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12711 http://hrcak.srce.hr/file/19557 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12712 2008-06-03 journal:158

Pelvic Lymphadenectomy in Prostate Cancer Treatment Zdjelična limfadenektomija u liječenju raka prostate Reljić, Ante Justinić, Danijel Štimac, Goran Spajić, Borislav Kraus, Ognjen Prostatectomy – methods; Prostatic neoplasms – surgery; Prostatic neoplasms – pathology; Lymph node excision – methods Prostatektomija - metode; Neoplazme prostate - kirurgija; Neoplazme prostate - patologija; Izrezivanje limfnih čvorova - metode Despite the increasing number of patients being detected with a clinically localized (T1,2) prostate cancer, pelvic lymphadenectomy remains a standard in determining the exact histological staging as a reliable prognostic parameter. Extended lymphadenectomy is superior to limited lymphadenectomy, and with the use of appropriate surgical technique does not contribute significantly to the operative morbidity while providing an evidence based indication for additional treatment modalities. Lymphadenectomy may not be indicated in patients at a low risk of regional lymphatic metastasis (impalpable T1 carcinoma, PSA less than 10 and Gleason score less than 6), depending on the preferences of the surgeon and the patient. In all other patients, it is reasonable to perform lymphadenectomy, at least a limited one, however, extennded lymphadenectomy is being increasingly recommended. Good cooperation with clinical pathologist is of great importance. Pelvic lymphadenectomy is most probably without an oncologic therapeutic effect in highly selected patients with favorable prognostic factors. Although data concerning therapeutic effect of extended lymphadenectomy are few and contradictory, there are convincing indications of the possible therapeutic effect of such an approach, in particular for patients with micrometastases. Unatoč ranom otkrivanju sve većeg broja bolesnika s klinički lokaliziranim (T1/2) rakom prostate uloga zdjelične limfadenektomije ostaje neprijeporna u smislu točnog utvrđivanja histološkog stupnjevanja kao pouzdanog prognostičkog pokazatelja. S tim ciljem proširena limfadenektomija nadmašuje ograničenu limfadenektomiju te uz dobru kiruršku tehniku ne doprinosi značajno operacijskom pobolu, dok istodobno omogućava utemeljeno indiciranje dodatnog liječenja. Samo se u bolesnika s vrlo niskim rizikom od regionalnih limfnih metastaza (nepalpabilni T1 karcinom, PSA <10 i Gleasonov zbir <6) limfadenektomija može izostaviti kao sastavni dio radikalne prostatektomije, što ovisi o mišljenju operatera i bolesnika. U svih ostalih bolesnika opravdano je učiniti limfadenektomiju, makar i u ograničenim okvirima, a sve se više zastupa mišljenje o nužnosti proširene zdjelične limfadenektomije. Osobito se naglašava potreba uske suradnje s kliničkim patologom. U onkološkom smislu zdjelična limfadenektomija je najvjerojatnije bez terapijskog učinka u visoko selekcioniranih bolesnika s povoljnim prognostičkim pokazateljima. Iako su podaci o terapijskom učinku proširene limfadenektomije malobrojni i proturječni, postoje uvjerljive indicije o mogućem terapijskom učinku takvog pristupa osobito u bolesnika s mikrometastazama. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12712 http://hrcak.srce.hr/file/19558 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:12713 2008-06-03 journal:158

Prominent Features and Variations in Clinical Presentation of Erythema Istaknuta obilježja i raznolikost kliničke slike Erythema multiforme Bulat, Vedrana Lugović, Liborija Šitum, Mirna Erythema multiforme – pathology; Erythema multiforme – etiology; Skin – immunology; Skin – pathology; Herpes simplex – complications Erythema multiforme - patologija; Erythema multiforme - etiologija; Koža - imunologija; Koža - patologija; Herpes simpleks - komplikacije Erythema multiforme (EM) is a heterogeneous syndrome often marked clinically by recurrent episodes of symmetrically distributed round skin lesions that evolve with concentric color changes. The spectrum of EM includes eruptions of typical skin lesions located primarily on the extensor surfaces of extremities (EM minor and EM major) or serious systemic illnesses with erosions on multiple mucosal surfaces along with skin lesions (Stevens-Johnson syndrome, SJS) or confluent areas of epidermal detachment (toxic epidermal necrolysis). Thus, the extent of the disease is quite variable, from typical individual target lesions on the arms or legs without oral lesions, through extensive picture with typical and atypical target lesions on the arms or legs with massive oral involvement and severe general symptoms (SJS). EM usually affects young people and heals within a few weeks, depending on initial involvement. It is considered as a special type of skin reaction to various causative agents such as recurrent herpes simplex virus (HSV) infection, mycoplasma or bacterial infections, rarely drugs, x-rays or sarcoidosis. In many cases, these agents cannot be identified. Therapy includes symptomatic measures for itching and pain, and often prophylactic oral acyclovir for recurrent EM due to HSV. In potentially serious cases, systemic steroids may be appropriately used early in the course to lessen the skin and mucosal damage, but supportive medical care and treatment of secondary infection and other complications are crucial elements of the EM management. Erythema multiforme (EM) je heterogeni sindrom klinički obilježen čestim opetovanim epizodama simetrično raspoređenih numularnih kožnih promjena koje koncentrično prelaze u promjenu izgleda. Spektar EM uključuje izbijanje znakovitih kožnih promjena prvenstveno smještenih na ekstenzornim stranama ekstremiteta (EM minor) ili teške sistemske bolesti s erozijama na nekoliko sluznica zajedno s promjenama kože (Stevens-Johnsonov sindrom, SJS) ili konfluirajuće areale lamelozne deskvamacije (toksična epidermalna nekroliza, TEN). Opseg bolesti je prilično varijabilan: od tipičnih irisu sličnih formacija na gornjim ili donjim ekstremitetima bez promjena na sluznici usne šupljine do opsežne kliničke slike s tipičnim i atipičnim iris formacijama na gornjim ili donjim ekstremitetima uz opsežno zahvaćanje sluznice usne šupljine i teškim općim simptomima (SJS). EM je znatno češći u mladih ljudi i traje nekoliko tjedana, ovisno o početnoj zahvaćenosti kože. Smatra se da je EM poseban oblik kožne reakcije na različite uzročne čimbenike, kao što su opetovana infekcija herpes simpleks virusom (HSV), mikoplazma ili bakterijska infekcija, rijetko lijekovi, x-zrake ili sarkoidoza. U mnogim slučajevima ovi agensi se ne mogu dokazati. Terapija uključuje simptomatske mjere za ublažavanje svrbeža i boli, često profilaktički peroralno aciklovir za ponavljajuće EM uzrokovane virusom HSV. U potencijalno teškim slučajevima sistemski kortikosteroidi mogu se prikladno upotrijebiti u ranoj fazi bolesti radi ublažavanja promjena kože i sluznica, ali potporna njega i suzbijanje sekundarnih infekcija i drugih komplikacija su ključni elementi u liječenju EM. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12713 http://hrcak.srce.hr/file/19559 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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INTRODUCING NEW MEMBERS OF THE EDITORIAL BOARD Rundek, Tatjana Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-03-30 text pdf http://hrcak.srce.hr/12714 http://hrcak.srce.hr/file/19560 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13593 2008-06-03 journal:158

Malignant Thyroid Lymphomas Maligni limfomi štitnjače Bečejac, Branko Gačina, Petar Stančić, Vladimir Čaržavec, Dubravka Čurić-Jurić, Silva Matovinović, Martina Thyroid neoplasms - etiology; Thyroid neoplasms - diagnosis; Thyroid neoplasms - pathology; Lymphoma - etiology; Lymphoma - therapy; Thyroiditis autoimmune - complications Neoplazme štitnjače - etiologija; Neoplazme štitnjače - dijagnostika; Neoplazme štitnjače - patologija; Limfom - etiologija; Limfom - terapija; Tiroiditis Primary thyroid lymphoma is a rare disease that accounts for about 5% of all thyroid neoplasms. It shows a female predominance, especially in women with a pre-existing Hashimoto.s disease. During a 15-year period, 11 patients were diagnosed with primary thyroid lymphoma at Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre milosrdnice University Hospital. There were no records on associated Hashimoto.s thyroiditis in any of them, which is inconsistent with the international literature reporting on such association in 40%-80% of cases. Painless neck edema was the most common physical symptom for patient presentation. The diagnosis was based on fine needle aspiration cytology, while the spread of disease to other organ systems was ruled out by other studies (computed tomography, ultrasonography and gallium scintigraphy). However, it should be noted that diffuse or nodular lymphoma cannot always be classified only by aspiration cytology. The World Health Organization classification was used. Today, it has been generally accepted that thyroid lymphomas belong to a group of lymphomas associated with mucosa-associated lymphoid tissue (MALT). The most common form of nonHodgkin's lymphoma (NHL) of the thyroid was B-cell phenotype lymphoma with a high malignancy grade. All patients were treated with chemotherapy according to the CHOP protocol (cyclophosphamide, doxorubicin, vincristine, prednisone). Eight patients underwent surgical treatment, three of them for compressive syndrome, followed by radiotherapy. The follow-up of patients with primary thyroid lymphoma revealed high disease aggressiveness and short survival, while complete remission was only occasionally recorded. Primarni limfomi štitnjače su rijetka bolest, a pojavljuju se u oko 5% slučajeva svih neoplazma štitnjače. Češće se javljaju kod žena, osobito onih s prethodno postojećom Hashimotovom bolešću. U Zavodu za hematologiju Kliničke bolnice "Sestre milosrdnice" u 15-godišnjem razdoblju dijagnosticirano je 11 bolesnika s primarnim limfomom štitnjače. Ni za jednog bolesnika, međutim, nije se znalo da boluje od pridruženog Hashimotovog tiroiditisa, što se ne uklapa u podatke iz svjetske znanstvene literature koji govore o 40%-80%. Najčešći simptom koji je doveo bolesnika na pregled liječniku bila je bezbolna oteklina vrata. Dijagnoza je postavljena putem aspiracijske citopunkcije, a ostalim pretragama (CT, UZV, scintigrafija tijela radiogalijem) isključena je proširenost bolesti u druge organske sustave (staging). Treba, međutim, napomenuti kako isključivo citopunkcijom nije uvijek moguće klasificirati difuzni i nodularni limfom. Klasifikacija je provedena prema Svjetskoj zdravstvenoj organizaciji. Danas je općenito prihvaćeno mišljenje da limfomi štitnjače pripadaju skupini limfoma pridruženih mukoznom limfatičnom tkivu (MALT, mucosa associated lymphoid tissue). Najčešći oblik ne-Hodgkinovog limfoma (NHL) štitnjače bio je B stanični fenotip visokog stupnja malignosti. Svi bolesnici su liječeni kemoterapijom po shemi CHOP (ciklofosfamid, doksorubicin, vinkristin, prednizon), a kod 8 bolesnika je primijenjen kirurški zahvat, od toga kod troje zbog kompresivnog sindroma, a potom je provedena radioterapija. Praćenjem bolesnika s primarnim limfomom štitnjače uočena je velika agresivnost bolesti i kratko preživljavanje, ali su rjeđe moguće i potpune remisije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13593 http://hrcak.srce.hr/file/20878 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13595 2008-06-03 journal:158

Impact of Inflammatory Cell Activation on Nasal Hyperreactive Response to Distilled Water Nasal Provocation Učinak aktivnosti upalnih stanica na nosnu hiperreaktivnost u odgovoru na nosnu provokaciju destiliranom vodom Zurak, Krešo Bukovec, Željka Anzic, Srđan Ante Baudoin, Tomislav Kalogjera, Livije Rhinitis - diagnosis; Rhinitis - physiopathology; Rhinitis, allergic - diagnosis; Nasal provocation tests; Water diagnostic use; Nasal mucosa - drug effects Rinitis - dijagnostika; Rinitis - fiziopatologija; Rinitis, alergijski - dijagnostika; Nosni provokacijski testovi; Dijagnostička primjena vode; Nosna sluznica - učinci lijekova The aim of the study was to compare hyperreactive response to nasal distilled water provocation in patients with allergic and non-allergic hyperreactive rhinitis, and to correlate the severity of hyperreactivity with inflammatory cell activation. Cellular activity was measured by the concentration of cellular activation markers in nasal lavage prior to provocation, eosinophil cationic protein (ECP) for eosinophil granulocytes, myeloperoxidase (MPO) for neutrophilic granulocytes and tryptase for mast cells. The study was performed in a group of 78 patients with a history of nasal hyperreactivity, i.e. 48 patients with allergic rhinitis and 30 patients with non-infectious non-allergic rhinitis (NINAR). Prior to provocation, basal nasal airway resistance was measured by active anterior rhinomanometry, and nasal lavage with 5 ccm of saline was taken. Provocation was made by inhalation of 10 ccm of distilled water over 10 minutes. The patients were subdivided into groups according to nasal airway resistance (NAR) increase. In the whole group the provocation induced a significant increase in nasal resistance on the better patent side prior to provocation (p<0.005). The only significant difference between allergic and non-allergic patients was recorded in tryptase concentration in nasal lavage, which was significantly higher in the group of allergic patients. No correlation was found between any of the cellular markers and the level of nasal hyperreactivity. The correlation between ECP and MPO in nasal lavage was significant. As no correlation was found between inflammatory cell activation and hyperreactivity, it appears that neural reflexes in addition to inflammation must be involved in the regulation of hyperreactive response. Cilj istraživanja bio je usporediti hiperreaktivni odgovor na nosnu provokaciju destiliranom vodom u bolesnika s alergijskim i nealergijskim hiperreaktivnim rinitisom i stupanj hiperreaktivnosti s aktivnošću upalnih stanica. Stanična aktivnost mjerena je koncentracijom biljega stanične upalne aktivnosti u nosnom ispirku prije provokacije. To su eozinofilni kationski protein (ECP) za eozinofilne granulocite, mijeloperoksidaza (MPO) za neutrofilne granulocite i triptaza za mastocite. Istraživanje je obuhvatilo skupinu od 78 bolesnika s nosnom hiperreaktivnošću u anamnezi, 48 bolesnika s perenijalnim ili sezonskim alergijskim rinitisom i 30 bolesnika s neinfektivnim nealergijskim rinitisom (NINAR). Provokaciji je prethodilo mjerenje bazalnog nosnog otpora pomoću aktivne prednje rinomanometrije i uzimanje nosnog ispirka s 5 cm3 fiziološke otopine. Provokacija je provedena inhalacijom 10 cm3 destilirane vode tijekom 10 minuta. Prema razini porasta nosnog otpora (NAR) bolesnici su podijeljeni u tri skupine: bez odgovora, srednje do umjereno jak i vrlo jak odgovor. U svih ispitanika provokacija je izazvala značajan porast nosnog otpora na strani koja je prije provokacije bila bolje prohodna (p<0,005). Jedina značajna razlika među ispitanicima s alergijskim i nealergijskim rinitisom bila je u koncentraciji triptaze u nosnom ispirku, koja je bila značajno viša u skupini ispitanika s alergijskim rinitisom. Nije nađena korelacija između staničnih biljega i razine nosne hiperreaktivnosti, ali je zabilježena značajna korelacija između ECP i MPO u nosnom ispriku. Kako nema korelacije između aktivnosti upalnih stanica i hiperreaktivnosti, čini se da su u regulaciji hiperreaktivnog odgovora uz upalne uključeni i neuralni mehanizmi. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13595 http://hrcak.srce.hr/file/20881 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13600 2008-06-03 journal:158

Our Experience in the Treatment of Obstructive Icterus Naša iskustva u liječenju opstrukcijskog ikterusa Grandić, Leo Perko, Zdravko Banović, Josip Pogorelić, Zenon Ilić, Nenad Jukić, Ivana Šarić, Dragan Tripković, Andro Jaundice, obstructive - diagnosis; Jaundice, obstructive - therapy; Cholestasis - etiology; Cholestasis - complications; Common bile duct surgery - complications Žutica, opstrukcijska - dijagnostika; žutica, opstrukcijska, terapija; Kolestaza - etiologija; Kolestaza - komplikacije; Kirurgija glavnog žučovoda - komplikacije The aim of the study was to estimate the prevalence and causes of obstructive icterus in patients operated on during the 2003-2004 period at University Department of Surgery, Split University Hospital in Split. In addition, data on the patient age and sex, type of surgical treatment, and existence and impact of risk factors on operative outcome were analyzed. Data on 114 patients with obstructive icterus treated at the Department during the 2-year period were retrospectively analyzed. Obstructive jaundice is a disease predominantly affecting female population (61.4% of patients), mostly those aged 60-74 (40% of patients). Cholelithiasis with choledocholithiasis is the most common cause of obstructive jaundice. Therefore, the most frequently used procedure for obstructive jaundice is cholecystectomy with or without choledochotomy and concrement extraction. The number of patients diagnosed with obstructive icterus shows a considerable increase. Although the same surgical methods have been applied for years, endoscopic surgery has gradually displaced classic methods of surgical treatment. Cilj rada bio je ispitati učestalost i uzroke opstrukcijskog ikterusa kod bolesnika koji su u razdoblju od 2003. do 2004. godine operirani u Klinici za kirurgiju Kliničke bolnice Split. Uz navedeno analizirali smo dob i spol bolesnika, vrstu primijenjenog kirurškog liječenja, te postojanje i utjecaj čimbenika rizika na ishod kirurškog liječenja. U dvogodišnjem razdoblju retrospektivno su analizirani podaci 114 bolesnika koji su zbog opstrukcijskog ikterusa liječeni u Klinici za kirurgiju KB Split. Opstrukcijska žutica je bolest koja pretežito zahvaća žensku populaciju (61,4% bolesnika) i to najčešće u dobi od 60 do 74 godine (40% bolesnika). Kolelitijaza s koledokolitijazom i dalje je najčešći uzrok opstrukcijske žutice. Sukladno navedenom, najčešće izvođeni zahvat u liječenju opstrukcijske žutice je kolecistektomija s koledokotomijom i ekstrakcijom konkrementa ili bez toga. Broj bolesnika kojima se dijagnosticira opstrukcijski ikterus pokazuje značajan porast. Iako se već dugi niz godina u liječenju primjenjuju iste kirurške metode, endoskopska (laparoskopska) kirurgija postupno istiskuje klasične oblike kirurškog liječenja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13600 http://hrcak.srce.hr/file/20890 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13622 2008-06-03 journal:158

Choroidal Neovascularization in Age-Related Macular Degeneration Treated with Photodynamic Therapy and Intravitreal Triamcinolone Acetonide Koroidna neovaskularizacija kod makularne degeneracije povezane s dobi liječene fotodinamskom terapijom i intravitrealnim triamcinolon acetonidom Vrabec, Romano Vatavuk, Zoran Benčić, Goran Čima, Ivan Zrinšćak, Ognjen Mandić, Zdravko Macular degeneration complications; Macular degeneration therapy; Choroidal neovascularization etiology; Choroidal neovascularization drug therapy; Photochemotherapy Makularna degeneracija - komplikacije; Makularna degeneracija - terapija; Koroidna neovaskularizacija - etiologija; Koroidna neovaskularizacija - terapija The aim of the study was to show the effect of combined photodynamic therapy and intravitreal injection of triamcinolone acetonide in the treatment of choroidal neovascularization due to age-related macular degeneration. This retrospective, nonrandomized study included 20 patients with predominantly classic choroidal neovascularization due to age-related macular degeneration with no prior treatment. At baseline, all patients underwent ophthalmologic examination. Fluorescein angiography and optical coherent tomography were performed and analyzed. Triamcinolone acetonide, 4 mg, was intravitreally applied at 24-48 hours after standard photodynamic therapy. Follow up was scheduled at 3, 6 and 9 months. After 9 months, visual acuity improved in four, remained unchanged in 14 and decreased in two patients. In all patients, complete closure of choroidal neovascularization occurred after 9 months. At that time, a decrease in the central foveal thickness was also recorded in all patients. Combined photodynamic therapy and intravitreal injection of triamcinolone acetonide is a safe method in the treatment of choroidal neovascularization due to age-related macular degeneration, and leads to complete closure of choroidal neovascularization. To prove these promising results, a carefully designed, randomized, controlled study in a larger group of patients is needed. Prikazuju se rezultati kombinirane intravitrealne primjene triamcinolona i fotodinamske terapije kod razvoja koroidnih neovaskularizacija koje su nastale kao posljedica senilne makularne degeneracije. U retrospektivnu nerandomiziranu studiju bilo je uključeno 20 bolesnika s pretežito klasičnom koroidnom neovaskularizacijom, koji do tada nisu bili liječeni. Kod svih bolesnika učinjen je standardni oftalmološki pregled, fluoresceinska angiografija i optička koherentna tomografija. Triamcinolon acetonid, 4 mg, apliciran je intravitrealno 24-48 sati nakon fotodinamske terapije. Praćenje bolesnika je provedeno nakon 3, 6 i 9 mjeseci. Nakon 9 mjeseci kod 4 bolesnika došlo je do poboljšanja vidne oštrine, kod 14 bolesnika vidna oštrina je ostalna stabilna, dok je kod 2 bolesnika zabilježen pad vidne oštrine. Potpun nestanak koroidne neovaskularizacije kod svih je bolesnika zabilježen nakon 9 mjeseci. Kombinirana primjena triamcinolona i fotodinamske terapije sigurna je metoda u liječenju pretežito klasičnih koroidnih neovaskularizacija, koja dovodi do njihovog potpunog zatvaranja i nestajanja, no za potvrdu ovih rezultata potrebna je randomizirana analiza na većem broju bolesnika. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13622 http://hrcak.srce.hr/file/20924 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13624 2008-06-03 journal:158

Video-Assisted Thoracoscopic Lung and Pleural Biopsy in the Diagnosis of Chronic Pleural Effusion Videotorakoskopska biopsija pluća i pleure u dijagnostici kroničnih izljeva prsišta Nikolić, Igor Stančić Rokotov, Dinko Janevski, Zoran Hodoba, Nevenka Kolarić, Nevenka Špiček-Macan, Jasna Sertić-Milić, Helga Pleural effusion - therapy; Pleural effusion - surgery; Lung - pathology; Lung diseases - pathology; Thoracoscopy - methods Pleuralni izljev - terapija; Pleuralni izljev - kirurgija; Pluća - patologija; Plućne bolesti - patologija; Torakoskopija - metode Chronic pleural effusion requires pleural and lung biopsy in more than 60% of patients. Open lung biopsy was formerly considered as the most reliable diagnostic method, whereas now the procedure is mostly performed via video-assisted thoracoscopy. During the last ten-year period (1995­-2005), 96 patients aged 31-72 (mean age 53) years were operated on at University Department of Thoracic Surgery, Jordanovac University Hospital for Lung Diseases by video-assisted thoracoscopy in general anesthesia. All biopsies were done by clamp sampling from parietal or visceral pleura, and in 31 patients lung tissue was sampled by endostapler wedge resection. Conversion to mini-thoracotomy was needed in only 12 patients, due to massive adhesions. Tissue samples were referred for histopathologic analysis. After the procedure, the patients had a thoracic drain connected to negative pressure. Histopathologic diagnosis was made in almost all patients, yielding a 97% success rate. In 16 patients, drain airflow had to be prolonged to more than 5 days, while the mean drainage duration was 4 days and mean hospital stay 8 days. Talc pleurodesis was performed in most patients with malignant effusion to stop effusion accumulation. Video-assisted thoracoscopic biopsy allows for adequate pleural and lung sampling with a high rate of accuracy. Postoperative mortality and morbidity are lower in comparison with open lung biopsy. It is concluded that video-assisted thoracoscopic biopsy is an efficient and safe method in the diagnosis of chronic pleural effusion. Dugotrajni izljevi pleuralne šupljine zahtijevaju biopsiju pleure i pluća kod više od 60% bolesnika. Ranije se otvorena biopsija pluća smatrala najpouzdanijom dijagnostičkom metodom, dok se danas taj zahvat najčešće izvodi videotorakoskopskim putem. U zadnjih deset godina, od 1995. do 2005. godine, u Klinici za torakalnu kirurgiju "Jordanovac" operirano je videotorakoskopskim načinom 96 bolesnika u općoj anesteziji. Prosječna životna dob bila je 53 godine, s rasponom od 31-72 godina. Sve biopsije su rađene uzimanjem uzoraka hvataljkom s parijetalne ili visceralne pleure, a kod 31 bolesnika uzet je i komadić plućevine klinastom resekcijom uz pomoć endostaplera. Samo kod 12 bolesnika učinjena je konverzija u minitorakotomiju zbog opsežnih priraslica. Svi uzorci su upućeni na patohistološku analizu. Nakon zahvata svaki bolesnik je imao torakalni dren koji je spojen na negativni tlak. Histopatološka dijagnoza postavljena je kod gotovo svih bolesnika, tako da je uspješnost zahvata bila 97%. Kod 16 bolesnika postojao je produženi protok zraka na dren kroz više od pet dana, dok je prosječno vrijeme drenaže iznosilo 4 dana, a prosječni boravak u bolnici 8 dana. Kod većine bolesnika s malignim izljevom rađena je pleurodeza talkom kako bi prestalo nakupljanje izljeva. Videotorakoskopska biopsija omogućava uzimanje kvalitetnog uzorka pleure i plućevine (bioptata) uz visok postotak točnosti. Poslijeoperacijska smrtnost i pobol bili su niži nego kod otvorene biopsije pluća. Zaključak je da je videotorakoskopska biopsija pluća učinkovita i sigurna metoda u dijagnostici kroničnog pleuralnog izljeva. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13624 http://hrcak.srce.hr/file/20927 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13625 2008-06-03 journal:158

Retroperitoneal Peripancreatic Bronchogenic Cyst Mimicking Pancreatic Cystic Tumor Retroperitonealna peripankreatična bronhogena cista diferencijalno dijagnostički nalik cističnom tumoru gušterače Vučić, Majda Tomas, Davor Zovak, Mario Mijić, August Krušlin, Božo Bronchogenic cyst - complications; Bronchogenic cyst - diagnosis; Pancreatic neoplasms - pathology; Pancreatic neoplasms - diagnosis; Retroperitoneal neoplasms - diagnosis; Retroperitoneal neoplasms - pathology; Retroperitoneal neoplasms - surgery Bronhogena cista - komplikacije; Bronhogena cista - dijagnostika; Neoplazme gušterače - patologija; Neoplazme gušterače - dijagnostika; Retroperitonealne neoplazme - dijagnostika; Retroperitonealne neoplazme - patologija; Retroperitonealne neoplazme - kir Retroperitoneal cystic tumors are rare and among them retroperitoneal bronchogenic cysts are extremely infrequent. Bronchogenic cyst is a development abnormality of the primitive foregut, which typically occurs in the chest. We describe a rare case of isolated peripancreatic bronchogenic cyst in a 53-year-old-man that presented with intermittent epigastric pain. Abdominal ultrasonography and computed tomography showed a cystic lesion closely related to the superior border of the pancreatic tail. The cystic tumor of pancreas was suspected. The cystic lesion was surgically removed and submitted for histopathologic analysis. Microscopically, the cyst was partially lined with pseudostratified, columnar, ciliated respiratory-type epithelium and partially with a single layer of tall columnar epithelial cells interspersed occasionally with goblet cells, which resided on the fibromuscular wall that contained seromucinous glands, and focally dense inflammatory cells. The diagnosis of bronchogenic cyst was established. Although rare in this region, bronchogenic cyst should be considered on differential diagnosis of peripancreatic cystic lesions. Retroperitonealni cistični tumori su rijetki, a među njima bronhogena retroperitonealna cista je iznimno rijetka. Bronhogene ciste su razvojne anomalije primitivnog crijeva koje najčešće nastaju u području prsne šupljine. Opisan je slučaj izolirane peripankreatične bronhogene ciste u 53-godišnjeg bolesnika koji je došao s anamnezom povremene epigastrične boli. Ultrazvuk abdomena i kompjutorizirana tomografija prikazali su cističnu leziju smještenu neposredno uz gornji rub repa gušterače. Postavljena je sumnja na cistični tumor gušterače. Cistična lezija je kirurški odstranjena u cijelosti, te poslana na patohistološku analizu. Mikroskopski cistu je oblagao pseudostratificirani, cilindrični, cilijarni tip respiracijskog epitela sa žarišnim vrčastim stanicama. Stijenka ciste bila je vezivno-mišićna uz prisutne seromukozne žlijezde i žarišne upalne infiltrate, što je odgovaralo dijagnozi bronhogene ciste. Iako je rijetka u ovom području, bronhogenu cistu treba razmotriti u diferencijalnoj dijagnozi peripankreatičnih cističnih lezija. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13625 http://hrcak.srce.hr/file/20928 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:13627 2008-06-03 journal:158

Sentinel Lymph Node Concept and its Role in the Management of Melanoma Patients Koncept sentinel limfnog čvora i njegova uloga u liječenju bolesnika s melanomom Rogan, Sunčica Andreja Kovačić, Ksenija Kusić, Zvonko Lymphatic metastasis - pathology; Melanoma secondary; Sentinel lymp node; Melanoma pathology; Skin neoplasms - pathology; Lymp neoplasms - radionuclide imaging; Biopsy - methods, classification Metastaze u limfnim čvorovima - patologija; Sekundarni melanom; Sentinel limfnog čvora; Kožne neoplazme - patologija; Neoplazme u limfnim čvorovima - radionuklidsko snimanje; Biopsija - metode, klasifikacija Melanoma is still one of the most life threatening tumors throughout the world. In the United States of America, its mortality rate has raised by 191% in men and 84% in women in the past forty years. It is mainly a cancer of light-pigmented persons like European populations. The incidence and mortality rates have increased substantially during the past decade, although there are extreme variations in the melanoma rates among different countries. Cutaneous melanoma can spread unpredictably and widely through the lymphatics. Identification of patients with occult melanoma metastases is important for accurate staging, treatment planning and prognosis. Based on the AJCC Melanoma Database, the most important prognostic factor in overall survival is melanoma thickness, however, the revised staging system recognizes the presence of metastases in regional lymph nodes as an independent powerful prognostic factor in the 5-year survival rate in stage II and III. Melanoma has a variable lymphatic drainage pathway, particularly those lesions located in the trunk, head and neck. In the past 15 years, a novel approach has been introduced in the management of skin melanoma. As the result of modern nuclear medicine techniques, identification of sentinel lymph node (SLN) by lymphoscintigraphy (LS) and sentinel lymph node biopsy (SLNB) using hand held gamma probe has become a standard procedure. In the early stage disease (AJCC I and II) and intermediate tumor thickness (1.2-3.5 mm), LS with SLNB is the method of choice for nodal staging and to define further surgical procedure, although in melanoma thinner than 1 mm surgical management of regional lymph nodes is still controversial. The overall conclusion from more than 1500 articles published during the last decade is that LS followed by SLNB with selective lymph node dissection in patients with cutaneous melanoma is still only of prognostic value, although it identifies patients with nodal metastases whose survival can be prolonged by immediate lymphadenectomy. Therefore, the AJCC staging system continues to consider micrometastases detected only by immunohistochemistry or polymerase chain reaction to be N0 disease. This article brings a review of current concepts and utility of LS and SLNB in cutaneous melanoma. Melanom je još uvijek jedan od najpogubnijih tumora u čitavom svijetu. U Sjedinjenim Američkim Državama se je stopa smrtnosti povećala u prošlih 40 godina za 191% kod muškaraca i 84% kod žena. To je većinom rak svijetlo pigmentiranih osoba poput europskih populacija. U prošlom desetljeću bitno su se povećale stope incidencije i smrtnosti, no postoje veoma velike razlike u stopi melanoma među različitim zemljama. Kožni melanom može se nepredvidivo i u velikoj mjeri širiti limfnim sustavom. Utvrđivanje bolesnika s okultnim metastazama melanoma važno je radi točnog određivanja stadija, planiranja liječenja te za prognozu. Prema podacima iz AJCC Melanoma Database, debljina melanoma najvažniji je prognostički čimbenik u sveukupnom preživljenju, ali je revidirani sustav određivanja stadija prepoznao i prisutnost metastaza u regionalnim limfnim čvorovima kao snažan neovisan prognostički čimbenik u 5-godišnjoj stopi preživljenja u stadiji I. i II. Melanom ima različite limfne puteve u limfnoj drenaži, poglavito melanomi smješteni na trupu, glavi i vratu. U proteklih 15 godina uveden je nov pristup u liječenju kožnog melanoma. Zahvaljujući suvremenim tehnikama nuklearne medicine, identificiranje sentinel limfnog čvora (SLN) limfoscintigrafijom (LS) i biopsija sentinel limfnog čvora (SLNB) pomoću ručne gama sonde postali su standardnim postupkom. U bolesti ranog stadija (AJCC I i II) i srednje debljine tumora (1,2-3,5 mm) LS uz SLNB čine metodu izbora za određivanje stadija čvora i odluku o daljnjem kirurškom zahvatu, iako je kod melanoma tanjih od 1 mm kirurško liječenje regionalnih limfnih čvorova još uvijek proturječno. Prema više od 1500 članaka objavljenih tijekom prošlog desetljeća, sveukupni zaključak je kako LS sa SLNB uz selektivnu disekciju limfnih čvorova u bolesnika s kožnim melanomom još uvijek ima tek prognostičku vrijednost, iako ukazuje na one bolesnike s metastazama u čvorovima čije se preživljenje može produžiti hitnom limfadenektomijom. Tako sustav određivanja stadija prema AJCC i dalje smatra mikrometastaze otkrivene samo pomoću imunohistokemijskih metoda ili lančanom reakcijom polimeraze kao bolest stadija N0. Ovaj članak donosi pregled današnjih spoznaja i primjene LS i SLNB kod kožnog melanoma. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2007-06-30 text pdf http://hrcak.srce.hr/13627 http://hrcak.srce.hr/file/20931 Acta Clinica Croatica (acta@kbcsm.hr); Vol.46 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Histologic Analysis of Pig Muscle Tissue after Wounding with a High-Velocity Projectile - Preliminary Report Histološka analiza svinjskog mišićnog tkiva nakon ranjavanja projektilom velike brzine - privremeno izvješće Korać, Želimir Crnica, Suad Demarin, Vida Wounds, gunshot - physiopathology; Wounds, gunshot - therapy; Wounds, penetrating - diagnosis; Muscles - pathology; Military medicine - methods; Comparative study; War; Animals Rane, prostrijelne - fiziopatologija; Rane, prostrijelne - liječenje; Rane, penetrirajuće - dijagnostika; Mišići - patologija; Vojna medicina - metode; Usporedbena studija; Rat; životinje Terminal ballistics of high-velocity projectiles is focused primarily on evaluation of the effects of penetrating projectiles on tissue simulants, but there is always a question of their similarity with live tissue. Ethical problems related to using live animals in terminal ballistic researches have resulted in a reduced number of these experiments. The aim of this study was to analyze histologic effects of high-velocity missiles in swine muscle tissue. The hypothesis was that a penetrating projectile caused tissue lesions that could be observed at various distance and at various levels of damage around the wound channel. Hind legs of pigs killed for commercial purposes were used in the study. The time span between killing of pigs and shooting was not longer than half an hour. The shots were made with a Russian AK-74 assault rifle (5.45 mm). A total of 30 fresh swine cadaver legs of an average weight of 15 kg were shot from a distance of 8.5 m. Samples of muscle tissue along the wound channel were collected and analyzed under a light microscope at Department of Histology, School of Veterinary Medicine, University of Zagreb. Muscle tissue analysis revealed four types of findings: normal findings of skeletal muscle, edema between muscle fibers without rupture or bleeding, rupture of individual fibers with bleeding in the interstitium, and massive destruction of muscle fibers with bleeding. Accordingly, the effects of high-velocity projectiles on muscular tissue can be histologically identified in various forms, from edemas to muscle fiber destruction accompanied by bleeding in the interstitium. The extent of particular lesions depends on the distance from the wound channel and projectile behavior. Terminalna balistika projektila velike brzine usmjerena je prvenstveno na analizu učinaka projektila u tkivnim simulantima, ali tu se uvijek postavlja pitanje sličnosti sa živim tkivom. Etički problemi uporabe živih životinja u terminalno balističkim istraživanjima rezultirali su smanjenjem broja takovih pokusa. Cilj ove studije bila je analiza histoloških učinaka projektila velike brzine na mišićnom tkivu svinje. Hipoteza je bila da penetrirajući projektil uzrokuje promjene u tkivu koje se mogu promatrati s različitih udaljenosti i u različitim stupnjevima oštećenja oko strijelnog kanala. Za potrebe našega istraživanja upotrijebili smo zadnje noge svinja koje su usmrćene iz komercijalnih razloga. Vremenski razmak između usmrćivanja svinje i prostrjeljivanja nije bio duži od pola sata. Pucalo se je iz ruske automatske puške AK-74 (5,45 mm). Ukupno 30 svinjskih nogu prosječne težine 15 kg je prostrijeljeno s udaljenosti od 8,5 m. Uzimani su uzorci mišićnog tkiva duž strijelnog kanala, a njihova je analiza izvedena na Zavodu za histologiju Veterinarskog fakulteta Sveučilišta u Zagrebu. Analiza mišićnog tkiva pokazala je 4 tipa nalaza: normalni nalaz skeletnog mišića, edem između mišićnih vlakana bez rupture ili krvarenja, rupture pojedinih vlakana s krvarenjem i masivnu destrukciju mišićnih vlakana s krvarenjem. Učinci projektila velike brzine u mišićnom tkivu mogu se histološki raspoznati u različitim oblicima, od edema do destrukcije mišićnih vlakana praćenih krvarenjem u intersticiju. Opseg pojedinih promjena ovisi o udaljenosti od strijelnog kanala i o značajkama projektila. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14017 http://hrcak.srce.hr/file/21441 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14018 2008-06-03 journal:158

The Changing Incidence of Cerebrovascular Disease in Zagreb over a Ten-Year Period Incidencija cerebrovaskularnih bolesti u Zagrebu tijekom prošloga desetljeća Lovrenčić-Huzjan, Arijana Zavoreo, Iris Rundek, Tanja Demarin, Vida Cerebrovascular accident - epidemiology; Cerebrovascular accident - mortality; Cause of death; Blood pressure - prevention and control; Risk factors; Croatia Cerebrovaskularni ispad - epidemiologija; Moždani udar - smrtnost; Uzrok smrti; Krvni tlak - prevencija i kontrola; Rizični čimbenici; Hrvatska During the last decade Croatia was faced with war and population migration that entailed socioeconomic changes, modification of lifestyle, risk factors and health care, thus influencing the incidence and outcome of stroke. Data on patients admitted to University Department of Neurology in the years 1990 and 1999 were compared to estimate the incidence and prevalence of stroke and stroke subtypes, risk factors and outcome. In 1999, the number of stroke patients was almost twofold that recorded in 1990 and stroke patients were by 5 years younger. In 1999, there were more first-ever strokes (the incidence of crude first stroke increased by 57%), whereas the number of recurrent strokes increased in men and decreased in women. The proportion of ischemic stroke and subarachnoid hemorrhage did not significantly change, whereas parenchymatous hemorrhage increased in women. Hypertension was more common (83% versus 62%), whereas the prevalence of other risk factors did not change significantly. Patients were more often discharged for home care instead of rehabilitation center care. Mortality decreased in men and increased in women, whereas case fatality and crude mortality decreased leading to an increased stroke burden. Tijekom prošloga desetljeća Hrvatska je bila zahvaćena ratnim zbivanjima koja su donijela mnoge političke, socioekonomske i kulturološke promjene. Promjena načina života svakako je utjecala na modifikaciju čimbenika rizika, pa tako i na incidenciju i ishod moždanog udara. U ovom istraživanju uspoređeni su podatci o incidenciji, prevalenciji, vrstama i ishodu moždanog udara kod bolesnika koji su primljeni na Kliniku za neurologiju tijekom prijeratne 1990. i poslijeratne 1999. godine. U 1999. godini bilo je skoro dvostruko više bolesnika, incidencija prvog moždanog udara porasla je za 57%, dok je broj ponovljenih moždanih udara porastao u muškaraca, a pao u žena. Udio ishemijskog moždanog udara i subarahnoidnog krvarenja nije se statistički značajno promijenio, dok je broj parenhimnih krvarenja kod žena porastao. Hipertenzija se javljala češće (83% naprama 62%), dok se zastupljenost drugih čimbenika rizika nije promijenila. Bolesnici su se u 1999. češće otpuštali na kućnu njegu nego na rehabilitaciju. Opća smrtnost i smrtnost u muškaraca je u 1999. godini pala, dok je kod žena bila u porastu. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14018 http://hrcak.srce.hr/file/21443 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Acute Postoperative Pain Therapy: Current State . Patient Experience Liječenje akutne poslijeoperacijske boli: današnje stanje - iskustva bolesnika Lončarić-Katušin, Mirjana Persoli-Gudelj, Marijana Šimić-Korać, Nataša Blažanin, Božidar Žunić, Josip Korać, Želimir Pain, postoperative - prevention and control; Pain, postoperative - therapy; Analgesia - trends; Patient - satisfaction; Quality of health care Bol, poslijeoperacijska - prevencija i kontrola; Bol, poslijeoperacijska - liječenje; Analgezija - trendovi; Bolesnici - zadovoljstvo; Kvaliteta zdravstvene skrbi In effective control of acute postoperative pain, it is essential to respect the principles of multimodal balanced analgesia, and to apply them within organized units for the management of acute postoperative pain (acute pain service). The aim of the study was to find out patient expectations and experience in the intensity of acute postoperative pain, and the efficiency of therapy they received. Between October 11, 2002 and December 14, 2002, 103 patients having undergone elective operative procedures under general endotracheal anesthesia were surveyed at Karlovac General Hospital. All patients were asked the preoperative group of questions on the intensity of pain they expected after surgery and on the intensity of pain at which he/she wanted to be given an analgesic. The postoperative group of questions referred to the intensity of pain 24 hours after the operative procedure and to the reason for not taking an analgesic. Results showed that prior to surgery, 33.98% of patients expected mild and 37.86% moderate postoperative pain. After the surgery, most patients felt moderate pain (33.98%). The study showed the therapy for acute postoperative pain and pain control to be still inadequate. The preconditions for successful pain control are the existence of acute pain service and implementation of the multimodal balanced analgesia concept. In this context, it is important to stress the education of patients as well as of the entire team participating in the management of pain. Za učinkovitu kontrolu akutne poslijeoperacijske boli neophodno je poštivati načela multimodalne balansirane analgezije, te ista provoditi unutar organiziranih jedinica za liječenje akutne perioperacijske boli. Cilj ovoga ispitivanja bio je ispitati očekivanja i iskustva bolesnika o jačini akutne poslijeoperacijske boli te učinkovitost primijenjene terapije. U razdoblju od 11. listopada 2002. do 14. prosinca 2002. godine u Općoj bolnici Karlovac anketirano je 103 bolesnika koji su bili podvrgnuti elektivnom operacijskom zahvatu u općoj endotrahealnoj anesteziji. Svim bolesnicima je nakon pristanka za operacijski zahvat u anesteziološkoj ambulanti postavljena prijeoperacijska skupina pitanja o jačini boli koju bolesnik očekuje poslije operacije te jačini boli kod koje želi dobiti analgetik. Poslijeoperacijska skupina pitanja odnosila se je na jačinu boli 24 sata nakon operacijskog zahvata te razlog neprimanja analgetika. Rezultati su pokazali da je prije operacijskog zahvata 33,98% bolesnika očekivalo blagu, a 37,86% bolesnika srednje jaku poslijeoperacijsku bol. Nakon operacijskog zahvata najveći broj bolesnika imao je srednje jaku poslijeoperacijsku bol (33,98%). Ovo je ispitivanje pokazalo kako je terapija akutne poslijeoperacijske boli, kao i njena kontrola još uvijek nedostatna. Preduvjet za njezinu uspješnu kontrolu je postojanje jedinice za liječenje akutne perioperacijske boli te provođenje koncepta multimodalne balansirane analgezije. U okviru njega važno je staviti naglasak na izobrazbu bolesnika, ali i cjelokupnog tima koji sudjeluje u liječenju boli. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14044 http://hrcak.srce.hr/file/21515 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Is There Still Place for Gallium Scintigraphy in Fever of Unknown Origin? Ima li scintigrafija galijem još uvijek svoje mjesto u dijagnostici vrućice nepoznatog uzroka? Kovačić, Ksenija Gallium radioisotopes - diagnostic use; Fever of unknown origin - etiology; Radiopharmaceuticals - diagnostic use Radioizotopi galija - dijagnostička primjena; Vrućica nepoznatog uzroka - etiologija; Radiofarmaceutici - dijagnostička primjena Owing to its characteristics, gallium 67 citrate still has its place in diagnostic procedures for various diseases, among them fever of unknown origin. Because of the lack of specificity of gallium 67 citrate, which is an advantage in this case, most authors agree that gallium is practically the agent of choice for initial screening of these patients. Gallium 67 citrate accumulates at the site of inflammation/ infection as well as in some neoplasms. Positive gallium finding can demonstrate or exclude a focal or diffuse lesion, indicate the disease extent and activity, and identify an appropriate biopsy site if necessary. Zahvaljujući svojim značajkama, 67-Ga-citrat još uvijek ima svoje mjesto u dijagnostici različitih bolesti, među njima i u vrućici nepoznatog uzroka. Zbog njegove nedovoljne specifičnosti, koja se u tom slučaju pretvara u prednost, većina autora se slaže da je galij zapravo radiofarmaceutik izbora u početnom probiru tih bolesnika. Galij se nakuplja na mjestu upale/infekcije, ali i u tumorima. Pozitivan nalaz potvrđuje ili isključuje žarišno ili difuzno oštećenje, ukazuje na proširenost i aktivnost bolesti, te određuje mjesto biopsije ako je potrebna. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14045 http://hrcak.srce.hr/file/21516 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14046 2008-06-03 journal:158

Knowledge of Stroke Risk Factors and Warning Signs among Adults in Slavonski Brod Region Poznavanje rizičnih čimbenika i znakova upozorenja za moždani udar među odraslim žiteljima Slavonsko Brodske regije Vuletić, Vladimira Bosnar-Puretić, Marijana Lovrenčić-Huzjan, Arijana Demarin, Vida Cerebrovascular accident - prevention; Health education; Data collection; Risk factors; Croatia Moždani udar - prevencija; Zdravstveno obrazovanje; Prikupljanje podataka; Rizični čimbenici; Hrvatska The increased incidence of stroke in Croatia is presumed to be the consequence of low awareness in the general population. Therefore, assessment of the general knowledge of stroke risk factors and warning signs was performed. A randomized sample of symptom-free subjects were administered a multiple-choice questionnaire to assess the knowledge of stroke risk factors, warning signs, planned response and source of information. Statistical analysis was performed by the SigmaStat (Version 2.0) software. All study subjects filled out the complete questionnaire. Between the correct and incorrect answers offered, 42% of subjects identified more than four correct stroke warning signs, mostly speech problems (72.5%); and 41.1% identified more than seven correct stroke risk factors, mostly hypertension (73.5%). Television was the most common source of information identified (73.1%). Study results pointed to inadequate public awareness of stroke risk factors and warning signs, which could be improved through mass media campaigns. Smatra se kako je povećana incidencija moždanog udara u Hrvatskoj posljedica niske svijesti u općoj populaciji. Stoga se je provela procjena općeg znanja o rizičnim čimbenicima i znacima upozorenja za moždani udar. Ispitivanje je provedeno u nasumce odabranom uzorku građana bez simptoma moždanog udara. Primijenjen je anketni upitnik s višestrukim odgovorima za procjenu znanja o čimbenicima rizika i znacima upozorenja za moždani udar, te o planiranom odgovoru i izvorima podataka. Statistička obrada je izvedena pomoću statističkog programa SigmaStat (inačica 2,0). Svi su ispitanici ispunili čitav anketni upitnik. Među ponuđenim točnim i netočnim odgovorima 42% ispitanika je navelo više od četiri točna znaka upozorenja za moždani udar, uglavnom govorne probleme (72,5%); 41,1% ih je prepoznalo više od sedam točnih čimbenika rizika za moždani udar, uglavnom hipertenziju (73,5%). Televizija je bila najčešće navedeni izvor informacija (73,1%). Rezultati ovoga ispitivanja ukazali su na nedostatnu svijest o rizičnim čimbenicima i znacima upozorenja za moždani udar, koju se može poboljšati izobrazbom pomoću sredstava javnog priopćavanja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14046 http://hrcak.srce.hr/file/21517 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Treatment of Venous Thromboembolism during Pregnancy and Puerperium Liječenje venske tromboembolije za vrijeme trudnoće i babinja Gaćina, Petar Čaržavec, Dubravka Stančić, Vladimir Pejša, Vlatko Venous thrombosis -etiology; Pregnancy - complications; Venous thrombosis - therapy; Risk factors Venska tromboza - etiologija; Trudnoća - komplikacije; Venska tromboza - terapija; Čimbenici rizika Venous thromboembolism (VTE) occurs infrequently but remains the leading cause of pregnancy- and puerperium-related mortality in industrialized countries. In pregnant women, the risk of VTE is about 4- to 5-fold that in non-pregnant women. The pathogenesis of VTE is associated with venous stasis, endothelial damage to pelvic veins at delivery, and procoagulant changes that occur during pregnancy and puerperium. The most common risk factors for VTE during pregnancy and puerperium are previous thrombotic event(s), thrombophilia, age over 35, obesity and operative delivery. Deep venous thrombosis in pregnancy and puerperium is usually left-sided (85% versus 55% in non-pregnant patients) and iliofemoral (72% in pregnancy versus 9% in non-pregnant patients). Low-molecular weight heparins (LMWHs) are the drugs of choice for the treatment of VTE during pregnancy and puerperium, as they are effective and have substantially fewer side effects such as heparin-induced thrombocytopenia, bleeding and osteoporosis as well as more reliable antithrombotic activity compared with unfractionated heparin. Venska tromboembolija (VTE) nije učestala, ali ostaje vodećim uzrokom smrtnosti za vrijeme trudnoće i babinja u razvijenim zemljama. Rizik VTE je oko 4-5 puta veći u trudnica nego u žena iste dobi bez trudnoće. Nastanak VTE je povezan s venskom stazom, oštećenjem endotela vena zdjelice uslijed poroda, te povećanom sklonošću zgrušavanju krvi za vrijeme trudnoće i babinja. Najčešći rizični čimbenici VTE za vrijeme trudnoće i babinja su prethodna tromboza(e), nasljedna sklonost trombozi, trudnice starije od 35 godina, debljina i porod operacijskim zahvatom. Duboka venska tromboza za vrijeme trudnoće i babinja je češće lijevostrana (85% nasuprot 55% u žena iste dobi koje nisu trudne) i iliofemoralna (72% u trudnica nasuprot 9%). Heparini male molekularne težine su lijekovi izbora u liječenju VTE za vrijeme trudnoće i babinja, jer su djelotvorni i imaju znatno manje nuspojava, kao trombocitopeniju potaknutu heparinom, krvarenje i osteoporozu te pouzdaniju protutrombotsku aktivnost u odnosu na nefrakcionirani heparin. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14047 http://hrcak.srce.hr/file/21518 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Benefit from Beta Interferon in the Treatment of Multiple Sclerosis Korist od liječenja multiple skleroze beta interferonom Bošnjak-Pašić, Marija Lisak, Marijana Uremović, Melita Vidrih, Branka Demarin, Vida Interferons - therapeutic use; Multiple sclerosis - drug therapy; Interferons - adverse effects; Treatment outcome; Clinical trials Interferoni - terapijska primjena; Multipla skleroza - liječenje lijekovima; Interferoni - štetni učinci; Liječenje - ishod; Klinička ispitivanja Over the past twelve years, beta interferons 1a and 1b have been increasingly used as immunomodulatory agents in the treatment of multiple sclerosis as well as for prophylaxis of disease progression. In Croatia, the cost of beta interferons 1a and 1b has been covered by the Croatian Institute of Health Insurance since 1997. Despite numerous doubts about their real benefit, having in mind their price, side effects and occurrence of neutralizing antibodies, numerous clinical trials have confirmed their efficacy. The most efficient are interferon beta 1a (Rebif® in a dose of 12 MIU, subcutaneously, three times per week), interferon beta 1b (Betaferon® in a dose of 8 MIU, subcutaneously, every other day) and interferon beta-1a (Avonex® in a dose of 6 MIU weekly intramuscularly). Posljednjih dvanaest godina u svrhu profilakse pogoršavanja bolesti, odnosno u imunomodulacijskom pristupu u liječenju bolesnika oboljelih od multiple skleroze u svijetu se rabe interferoni beta 1a i 1b. U Republici Hrvatskoj se na teret Hrvatskoga zavoda za zdravstveno osiguranje u liječenju multiple skleroze interferoni beta 1a i 1b primjenjuju od 1997. godine. Iako postoje brojne dvojbe o njihovoj stvarnoj koristi s obzirom na cijenu, nuspojave te pojavu neutralizirajućih antitijela, dosad je objavljeno više kliničkih studija koje su pokazale njihovu učinkovitost. Najučinkovitiji su interferon beta 1a (Rebif® u dozi od 44 mikrograma (mcg) subkutano, tri puta na tjedan), interferon beta 1b (Betaferon® 8 MIU subkutano svaki drugi dan) i interferon beta 1a (Avonex® 6 MIU intramuskularno jedanput na tjedan). Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14048 http://hrcak.srce.hr/file/21519 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Johann Sebastian Bach's Strokes Moždani udari kod Johanna Sebastiana Bacha Breitenfeld, Tomislav Vargek Solter, Vesna Breitenfeld, Darko Zavoreo, Iris Demarin, Vida History of medicine, 18th century; Cerebrovascular disorders - etiology; Famous persons; Johann Sebastian Bach; Portraits; Case report Povijest medicine, 18. stoljeće; Cerebrovaskularne bolesti - etiologija; Poznate osobe; Johann Sebastian Bach; Portreti; Prikaz slučaja Bach's origin is from the sixth generation of a large family of musicians from Mid-Germany, the Thyrings. He was famous, but more so as an organist and a specialst fine organ builder than as a composer. He married twice. From each marriage, two well-known musician-composers were bom: Wilhelm Friedmann and Carl Phillip Emanuel from the first marriage, and Johann Christoph Friedrich and Johann Christian from the second. The Bachs were destined to live into their sixties, a good age at that time, and several lived longer. Bach was healthy and shortsighted, and a strong man. He probably had high blood pressure, and maybe diabetes. His vision was said to be damaged by writing and copying notes in the dark from his early days. It is possible he had a mild stroke before 1746 and another one in 1749 which, with his previous blindness, affected him seriously. At that time, while touring Europe, "chevalier and gentleman"- an Englishman oculist and operator, John Taylor came to Leipzig. Bach was operated on twice in 1750. His vision did not improve and inflammation developed, probably glaucoma with postoperative infection. He had several cerebrovascular risk factors, i.e. age, obesity, possible hypertension and diabetes, and he died in 1750 after another stroke complicated by pneumonia. His grave was known only by oral tradition and was mentioned in just one local newspaper as an incidental remark. It took more than one hundred years after his death for his grave to be found nearby St Thomas Church. His remains were identified by Professor His together with Professor Politzer, an authority in the field of otology. Johann Sebastian Bach pripadao je šestom naraštaju obitelji glazbenika podrijetlom iz središnje Njemačke. U svoje doba bio je poznatiji po umijeću izgradnje i sviranja orgulja nego po svom skladateljskom talentu. U svakom od njegova dva braka rođena su dva sina koji su kasnije nastavili obiteljsku skladateljsku tradiciju: Wilhelm Friedmann i Carl Phillip Emanuel iz prvog braka, te Johann Christoph Friedrich i Johann Christian iz drugog braka. U obitelji Bach prosječna životna dob bila je oko šezdeset godina, što je za tadašnje prilike bilo više od prosjeka, tek je nekoliko pripadnika obitelji živjelo duže. Johann Sebastian Bach je bio zdrav, nizak, ali jak čovjek još od najranijih dana. Najvjerojatnije je imao povišen krvni tlak, a moguće je da je bolovao i od šećerne bolesti. Vid mu je bio oslabljen, jer je još od djetinjstva pisao i kopirao note u mraku. Prije 1746. te opet 1749. godine je najvjerojatnije prebolio moždani udar. Posljednje dvije godine života Bach se suočava sa znatnim slabljenjem vida. U to doba u Leipzigu se na proputovanju Europom zatekao engleski okulist-operater "'kraljevski gentleman" John Taylor koji je Bacha operirao dva puta 1750. godine. Bachov vid se nije oporavio, naprotiv, došlo je do infekcije. Prema anamnezi i tijeku bolesti najvjerojatnije se radilo o glaukomu s poslijeoperacijskom infekcijom. Bach je imao nekoliko čimbenika rizika za nastanak cerebrovaskularne bolesti - dob, prekomjernu tjelesnu težinu, moguće hipertenziju i šećernu bolest. Tijekom 1750. Bach ponovno doživljava moždani udar kompliciran upalom pluća, što je dovelo do njegove smrti. Bachovo posljednje počivalište ostalo je zabilježeno tek slučajnom bilješkom u lokalnom glasilu, te u usmenoj predaji. Prošlo je više od sto godina dok njegov grob nije otkriven nedaleko od crkve St. Thomas. Bachovi ostaci identificirani su uz pomoć Profesora Hisa koji je bio vodeći autoritet u anatomiji te Profesora Politzera, vodećeg autoriteta u otologiji. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14049 http://hrcak.srce.hr/file/21520 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Carotid Intima-Media Thickness (Imt): A Surrogate Marker of Atherosclerosis Debljina intime medije karotidnih arterija: zamjenski biljeg ateroskleroze Rundek, Tanja Demarin, Vida Carotid arteries - pathology; Cerebrovascular disorders - pathology; Cerebrovascular disorders - etiology; Arteriosclerosis - diagnosis Karotidne arterije . patologija; Cerebrovaskularne bolesti . patologija; Cerebrovaskularne bolesti . etiologija; Arterioskleroza . dijagnostika Atherosclerosis is chronic, progressive disease of the arterial wall with onset decades prior to its clinical manifestations. Carotid intima-media thickness (IMT) measurement by ultrasound is an important tool for evaluation of early stages of atherosclerosis. Also, carotid intima-media thickness can be used for assessment of therapeutic effect of various regimens. Carotid IMT is sensitive marker of atherosclerosis. The causal relationship between carotid IMT and the clinical endpoint has been established on the basis of epidemiological studies and clinical trials. The strength of carotid IMT as a marker of atherosclerosis is enhanced by the fact that it may yield pathophysiological information at an early stage of atherogenic process. Ateroskleroza je kronična progresivna bolest stjenke arterija koja počinje desetljećima prije kliničkih manifestacija. Mjerenje zadebljanja intime i medije karotidnih arterija ultrazvukom je značajna metoda za procjenu ranijih stadija ateroskleroze. Osim toga, mjerenje zadebljanja intime i medije karotidnih arterija može poslužiti za procjenu učinka različitih terapijskih postupaka. Zadebljanje intime i medije karotidnih arterija je osjetljiv pokazatelj ateroskleroze. Utvrđena je uzročna povezanost zadebljanja intime i medije karotidnih arterija i kliničkog ishoda temeljem epidemioloških studija i kliničkih pokusa. Značaj zadebljanja intime i medije karotidnih arterija kao pokazatelja ateroskleroze je povećan činjenicom da može pružiti patofiziološke podatke o ranim stadijima aterogenog procesa. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text pdf http://hrcak.srce.hr/14050 http://hrcak.srce.hr/file/21523 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Transsphenoidal Approaches in Pituitary Tumor Surgery - A Review Smjerovi razvoja kirurškog liječenja tumora hipofize Gnjidić, Živko Sajko, Tomislav Kudelić, Nenad Malenica, Maša Pituitary neoplasms - surgery; Skull base neoplasms -surgery; Neurosurgical procedures Neoplazme hipofize . kirurgija; Neoplazme baze lubanje . kirurgija; Neurokirurški zahvati Transsphenoidal approach to pituitary tumors was for a long time reserved for sellar region tumors, whereas tumors expanding into extrasellar region were treated by transcranial approach. With the development of surgical equipment and gaining surgical experience, indications for the transsphenoidal approach and its modifications have become wider and ever more frequently used for pituitary tumors with extrasellar expansion. During the twenty-five years of performing pituitary surgery, we have operated on more than 1400 tumors of the sellar region using the transsphenoidal approach and its modifications. The novel transsphenoidal endoscopic approach is strongly taking more place in pituitary surgery, advancing the possibilities of the standard transsphenoidal approach. A review is presented of surgical approaches to pituitary tumors. Transsfenoidni pristup tumorima hipofize dugo je bio rezerviran za intraselarne neoplazme, dok se ekstraselarno proširene tumore rješavalo transkranijskim pristupom. Zahvaljujući razvoju kirurške opreme i instrumentarija te većem iskustvu operatera indikacije za ovaj pristup i njegove modalitete postale su šire pa se češće rabe i za ekstraselarno proširene tumore. Tijekom 25 godina bavljenja kirurgijom hipofize operirali smo preko 1400 tumora selarne regije rabeći transsfenoidni pristup i njegove modalitete. Novi endoskopski transsfenoidni pristup zauzima sve više mjesta u kirurškom liječenju hipofize te tako povećava lepezu mogućnosti proširenog transsfenoidnog pristupa. Prikazani su kirurški pristupi liječenju tumora hipofize. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-03-01 text rtf http://hrcak.srce.hr/14051 http://hrcak.srce.hr/file/21524 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Early Detection of Mild Cognitive Impairment in Patients with Cerebrovascular Disease Rano otkrivanje blagog oštećenja spoznajne funkcije u bolesnika s cerebrovaskularnom bolešću Martinić-Popović, Irena Šerić, Vesna Demarin, Vida Brain - pathology; Brain - physiopathology; Cerebrovascular disease - diagnosis; Dementia - Alzheimer disease; Dementia - vascular dementia Mozak - patologija; Mozak - fiziopatologija; Cerebrovaskularna bolest - dijagnostika; Demencija - Alzheimerova bolest; Demencija - vaskularna demencija Evaluation of mild cognitive impairment (MCI) is important because it can enable early medical management in order to prevent severe dementia of Alzheimer's or vascular type. In this pilot study, patients admitted to University Department of Neurology for first ever stroke/transient ischemic attacks (patient group, N=81, mean age 56±7.0 years) and control subjects without signs of cerebrovascular disease (CVD) but with vascular risk factors present (control group, N=45, mean age 53±6.0 years) were tested by use of Mini Mental State Exam (MMSE) and Montreal Cognitive Assessment (MoCA) on admission, and retested at three and six months. In all study subjects standard brain computed tomography, color Doppler flow imaging of carotid arteries with intima-media thickness (IMT) measurement and transcranial Doppler sonography (TCD) were performed. Multiple risk factors were present in 56 (69.1%) patients. Arterial hypertension, hyperlipoproteinemia and diabetes mellitus were most common diagnoses in control subjects. All study subjects had normal initial MMSE, whereas MoCA score was decreased (<26 points) in 52 (57.2%) patients and 23 (9.6%) control subjects. Six months later, the mean MoCA score was 18.87 and mean MMSE 25.25 in patient group. Patients with stroke and multiple risk factors showed a statistically significant cognitive decline in comparison to patients with transient ischemic attacks. At six months, the greatest cognitive decline in patient group was recorded in patients with arterial hypertension and increased IMT. In subjects with cerebrovascular risk factors, early signs of cognitive impairment exist even before the cerebrovascular disease becomes clinically evident. MoCA proved to be an appropriate tool for cognitive evaluation of patients with mild cognitive impairment of vascular type. Procjena blagog spoznajnog oštećenja je važna, jer može omogućiti rano medicinsko zbrinjavanje kako bi se spriječila teška demencija Alzheimerova ili vaskularnog tipa. U ovom probnom ispitivanju su bolesnici primljeni na Kliniku za neurologiju zbog prvog moždanog udara/prolaznog ishemijskog ispada (skupina bolesnika, n=81, srednja dob 56±7,0 godina) i kontrolni ispitanici bez znakova cerebrovaskularne bolesti, ali s prisutnim vaskularnim čimbenicima rizika (kontrolna skupina, n=45, srednja dob 53±6,0 godina) ispitani pomoću Mini Mental State Exam (MMSE) i Montreal Cognitive Assessment (MoCA) kod prijma te ponovno nakon tri i šest mjeseci. U svih osoba provedena je standardna kompjutorizirana tomografija mozga, prikaz protoka pomoću obojenog Dopplera u karotidnim arterijama uz mjerenje debljine intime medije te transkranijska Dopplerova sonografija. Višestruki rizični čimbenici bili su prisutni u 56 (69,1%) bolesnika. Kontrolni ispitanici najčešće su imali arterijsku hipertenziju, hiperlipoproteinemiju i šećernu bolest. Svi ispitanici su imali normalan početni MMSE, dok je zbir MoCA bio snižen (<26 bodova) u 52 (57,2%) bolesnika i 23 (9,6%) kontrolne osobe. Nakon šest mjeseci je u skupini bolesnika srednji zbir MoCA bio 18,87, a srednji MMSE 25,25. Bolesnici s moždanim udarom i višestrukim čimbenicima rizika iskazali su statistički značajno spoznajno urušavanje u usporedbi s bolesnicima s prolaznim ishemijskim ispadima. U kontrolnoj skupini je najveće opadanje spoznajnih funkcija nakon šest mjeseci zabilježeno u osoba s arterijskom hipertenzijom i povećanom debljinom intime medije. U osoba s cerebrovaskularnim čimbenicima rizika rani znaci oštećenja spoznajne funkcije postoje čak i prije negoli cerebrovaskularna bolest postane klinički očita. MoCA se je pokazao odgovarajućim pomagalom za spoznajnu procjenu bolesnika s blažim oštećenjem spoznajne funkcije vaskularnog tipa. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14052 http://hrcak.srce.hr/file/21525 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Complications of Transrectal Ultrasound Guided Prostate Needle Biopsy: Our Experience and Review of the Literature Komplikacije transrektalne ultrazvučno vođene biopsije prostate: naša iskustva i pregled literature Spajić, Borislav Brigić, Ivica Štimac, Goran Justinić, Danijel Krušlin, Božo Kraus, Ognjen Biopsy - methods; Biopsy - adverse effects; Prostatic neoplasms - pathology; Prostatic neoplasms - ultrasonography; Biopsy - needle Biopsija - metode; Biopsija - štetni učinci; Neoplazme prostate - patologija; Neoplazme prostate - ultrasonografija; Biopsija - iglena Transrectal ultrasound guided prostate needle biopsy is the most important diagnostic procedure for early prostate cancer detection. It is a safe diagnostic tool with very few complications and well tolerated by patients. The aim of the study is to report complication rates after transrectal ultrasound guided prostate needle biopsy. All study patients, mean age 68.8 years, received antibiotic prophylaxis and a laxative was administered on the day prior to the procedure. A mean of 8.03 biopsy cores per patient were obtained. Laterally directed sextant biopsy plus two cores from transition zone of the prostate was performed along with biopsy of any hypo- or hyperechoic lesion seen on transrectal ultrasound. Results of 224 prostate biopsies performed in selected patients are reported. Biopsy proved negative in 54%, prostate cancer was confirmed in 31%, and prostatic intraepithelial neoplasia was detected in 15% of patients. Complications occurred in 35 (14%) patients: two were hospitalized for urinary retention, 15 (6.15%) patients had prolonged hematuria lasting for more than five days, and 18 patients showed clinical signs of urinary tract infection. The mean level of discomfort was 2.8 on a 10­point pain scale. Study results were generally consistent with other recent reports on complication rates, while showing a significantly lower rate of hematuria. Prostate biopsy is the only accurate method of preoperative prostate cancer detection; the more so, there is no need of hospitalization, regional or local anesthesia, and there are no false-positive results. Biopsija prostate kao najznačajnija dijagnostička metoda u otkrivanja raka prostate je indicirana većinom kod muškaraca bez kliničkih smetnja i vrlo je važno da je to siguran dijagnostički postupak s malo komplikacija koji bolesnici dobro podnose, iako ulazi u skupinu agresivnih dijagnostičkih pretraga. U radu su opisani rezultati biopsije prostate na ukupno 224 bolesnika s indikacijom. Prosječna starost je bila 68,8 godina, svi su prethodno dobili antibiotsku profilaksu i pripremljeni su davanjem laksativa dan ranije. Uzimalo se je prosječno 8,03 uzoraka po bolesniku. Svakom bolesniku je učinjena lateralna sekstant biopsija i transrektalnim ultrazvukom vidljive hipo- i hiperehogene lezije u prostati. Kod 54% bolesnika nalaz je bio negativan, 31% ih je imalo rak prostate, dok je u ostalih 15% nađena predmaligna lezija, prostatična intraepitelna neoplazija (PIN). Komplikacije su zabilježene kod 35 (14%) bolesnika, od kojih su dvojica liječeni bolnički zbog potpune retencije, hematurija duža od pet dana zabilježena je kod 15 (6,15%) bolesnika, a znakove upale ili febrilitet je imalo 18 (7,38%) bolesnika. Bolesnici su ocijenili razinu boli tijekom zahvata prosječnom ocjenom 2,8 na ljestvici od 1 do 10. Rezultati dobiveni u našem istraživanju sukladni su u većini parametara novijim studijama u kojima je obrađena ista tematika, a za razliku od drugih imali smo značajno manje hematurija. U zaključku se navodi kako je biopsija prostate jedina točna prijeoperacijska metoda otkrivanja raka prostate koja se radi ambulantno i bez potrebe za regionalnom ili lokalnom anestezijom, i nema lažno pozitivnih rezultata. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14053 http://hrcak.srce.hr/file/21526 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Advantages and Disadvantages of the Supraorbital Keyhole Approach to Intracranial Aneurysms Prednosti i nedostatci supraorbitalnog pristupa "ključanice" u liječenju intrakranijskih aneurizma Lupret, Velimir Sajko, Tomislav Beroš, Vili Kudelić, Nenad Lupret Jr., Velimir Intracranial aneurysm - surgery; Craniotomy - methods; Neurosurgical procedures; Surgical procedures minimally invasive Intrakranijska aneurizma - kirurgija; Kraniotomija - metode; Neurokirurški zahvati; Kirurški zahvati, minimalno invazivni The fundamental tendency to be as minimally invasive as possible and to achieve a maximum of efficacy in the treatment of patients has existed since the beginning of surgery. In treating intracranial aneurysms the most widely used approach is pterional or frontotemporal approach described by Yasargil. The increasing knowledge of microsurgical anatomy, improved preoperative diagnostic techniques, and well adapted microsurgical instruments have led to the development of minimally invasive approaches. The supraorbital keyhole approach via an eyebrow incision is one of these minimally invasive procedures. Since it was first described by Perneczky it has raised debates on its advantages and disadvantages. The authors present their experience in using the supraorbital keyhole approach in treating intracranial aneurysms. Cilj ovoga istraživanja bila je procjena prednosti i nedostataka supraorbitalnog pristupa "ključanice" u neurokirurškom liječenju intrakranijskih aneurizmatskih tvorba. Supraorbitalni pristup "ključanice" predstavlja minimalno invazivni operacijski zahvat u liječenju intrakranijskih aneurizma. Od 2000. do 2003. godine 30 bolesnika s 30 intrakranijskih aneurizma operirano je supraorbitalnim pristupom "ključanice" na Klinici za neurokirurgiju, KB "Sestre milosrdnice". U većini slučajeva bolesnici su dobro podnijeli operacijski zahvat, a poslijeoperacijski oporavak je bio zadovoljavajući. Ukupni pobol iznosio je 16%, dok su zabilježena dva smrtna slučaja zbog komplikacija nevezanih za operacijski zahvat. Supraorbitalni pristup "ključanice" predstavlja razumnu opciju u neurokirurškom liječenju intrakranijskih aneurizma kod bolesnika pažljivo prijeoperacijski odabranih s obzirom na kliničku sliku, neurološki status i lokalizaciju aneurizmatske tvorbe. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14054 http://hrcak.srce.hr/file/21527 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Leukocyte and other Hematology Parameters in Croatian Veterans with Posttraumatic Stress Disorder Leukociti i drugi hematološki pokazatelji u hrvatskih ratnih veterana s posttraumatskim stresnim poremećajem Miklić-Bublić, Martina Karlović, Dalibor Martinac, Marko Marčinko, Darko Stress disorders, post-traumatic - immunology; Anxiety disorders - immunology; Hypersensitivity - immunology; Veterans - psychology; Leukocyte count; Croatia; War Stresni poremećaji, post-traumatski - imunologija; Anksiozni poremećaji - imunologija; Preosjetljivost - imunologija; Veterani - psihologija; Broj leukocita; Hrvatska; Rat The aim of the study was to assess differences in white blood cell (WBC), neutrophil, monocyte, basophil, eosinophil and lymphocyte counts between Croatian veterans with combat-related posttraumatic stress disorder (PTSD) and those with combat-related PTSD comorbid with major depressive disorder (MDD). PTSD and/or MDD were diagnosed according to a structured clinical interview based on DSM-IV criteria. Additional criteria were Clinician Administered PTSD Scale (CAPS) for PTSD and Montgomery-Asberg Depression Rating Scale (MADRAS) for MDD. WBC was measured on an automatic blood counter. Results showed no statistically significant difference in WBC, neutrophil, lymphocyte, monocyte, eosinophil, basophil and red blood cell counts (RBC), hemoglobin, hematocrit, MCV, MCH, MCHC and platelet count between the veterans with combat-related PTSD, veterans with combat-related PTSD + MDD comorbidity, and patients with MDD only. In conclusion, there were no differences in WBC, neutrophil, lymphocyte, monocyte, eosinophil, basophil and RBC counts, hemoglobin, hematocrit, MCV, MCH, MCHC and platelet count among veterans with combat-related PTSD, veterans with combat-related PTSD comorbid with MDD, and patients with MDD only. Cilj ove studije bio je ispitati razlike u broju leukocita, neutrofila, monocita, bazofila, eozinofila i limfocita u hrvatskih ratnih veterana s post-traumatskim stresnim poremećajem (PTSP) uzrokovanog ratnim traumama u usporedbi s istim poremećajem uz istodobno prisutan velik depresivni poremećaj (VDP). Dijagnoza PTSP i/ili VDP postavljena je pomoću strukturiranog kliničkog upitnika prema kriterijima DSM-IV. Kao dopunski kriteriji primijenjena je Clinician Administered PTSD ljestvica (CAPS) za PTSP te Montgomery-Asberg Depression Rating Scale (MADRAS) za VDP. Broj leukocita izmjeren je na automatskom hemaološkom brojaču. Rezultati nisu pokazali nikakvu statistički značajnu razliku u broju leukocita, neutrofila, limfocita, monocita, eozinofila, bazofila, eritrocita, trombocita, kao ni u razini hemoglobina, hematokrita, MCV, MCH i MCHC između veterana s PTSP uzrokovanog ratnim traumama, veterana s PTSP uzrokovanog ratnim traumama i istodobnim VDP i bolesnika koji boluju samo od VDP. Zaključuje se kako ne postoje razlike u broju leukocita, neutrofila, limfocita, monocita, eozinofila, bazofila, eritrocita, trombocita, kao ni u razini hemoglobina, hematokrita, MCV, MCH i MCHC između veterana s PTSP uzrokovanog ratnim traumama, veterana s PTSP uzrokovanog ratnim traumama i istodobnim VDP i bolesnika koji boluju samo od VDP. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14055 http://hrcak.srce.hr/file/21528 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Dental Procedures in Patients Receiving Oral Anticoagulant Therapy Stomatološki zahvati u bolesnika liječenih protuzgrušavajućom terapijom Gaćina, Petar Čaržavec, Dubravka Stančić, Vladimir Pejša, Vlatko Anticoagulants - therapeutic use; Oral surgical procedures -adverse effects; Blood loss, surgical - prevention and control; Anticoagulants -contraindications; Thromboembolism - prevention and control; Oral hemorrhage -prevention and control Antikoagulansi - terapijska primjena; Stomatološki zahvati - štetni učinci; Gubitak krvi, kirurški - prevencija i kontrola; Antikoagulansi - kontraindikacije; Tromboembolija - prevencija i kontrola; Oralno krvarenje - prevencija i kontrola There is a widespread belief among physicians and dentists that oral anticoagulant therapy must be discontinued before and for some time after dental procedures. This practice may increase the risk of potentially life-threatening thromboembolism. The present literature does not support routine discontinuation of anticoagulant therapy for dental patients. There is a theoretical risk of bleeding after dental surgery in patients at therapeutic levels of anticoagulation, however, it is minimal and may be greatly outweighed by the risk of thromboembolism upon anticoagulant therapy withdrawal. Thus, dental extractions can be performed without modification of oral anticoagulant therapy. In most patients local hemostasis with gelatin sponge, fibrin glue, sutures and/or mouthwash with tranexamic acid or e­aminocaproic acid is sufficient to prevent postoperative bleeding. Prošireno je mišljenje među liječnicima i stomatolozima da se oralna protuzgrušavajuća terapija mora prekinuti prije i kroz neko vrijeme nakon stomatoloških zahvata. Ova navika može povećati rizik od moguće za život ugrožavajuće tromboembolije. Sadašnja literatura ne podupire rutinski prekid protuzgrušavajuće terapije u stomatoloških bolesnika. U bolesnika na protuzgrušavajućoj terapiji u terapijskim vrijednostima nakon zubnog zahvata teorijski postoji minimalan rizik od krvarenja, dok prekidom protuzgrušavajuće terapije rizik može biti znatno veći zbog moguće tromboembolije. Stoga se vađenje zuba može izvesti bez promjene protuzgrušavajuće terapije. U većine bolesnika je lokalna hemostaza želatinoznom spužvom, fibrinskim ljepilom, šavovima i/ili ispiranje usne šupljine traneksamičnom ili epsilon amino kaproičnom kiselinom dostatno da spriječi poslijeoperacijsko krvarenje. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14056 http://hrcak.srce.hr/file/21529 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Recurrent Hyperparathyroidism: Case Report Recidivirajući hiperparatiroidizam: prikaz slučaja Bečejac, Branko Misjak, Mira Altabas, Velimir Berković, Maja Mirošević, Gorana Vrkljan, Milan Hyperparathyroidism - complications; Hyperparathyroidism - pathology; Hyperparathyroidism - surgery; Hyperplasia; Recurrence; Adenoma - complications; Calcium - blood; Case Report Hiperparatireoidizam - komplikacije; Hiperparatireoidizam - patologija; Hiperparatireoidizam - kirurgija; Hiperplazija; Ponovno izbijanje bolesti; Adenom - komplikacije; Kalcijum - krv; Prikaz slučaja A 57-year-old man with a history of primary hyperparathyroidism, consequential chronic renal failure and associated chronic Hashimoto.s thyroiditis presented with recurrent hypercalcemia. Hypercalcemia persisted despite three resections of enlarged parathyroid glands and multiple sclerosations of the remaining parathyroid tissue. The possible causes of persisting hypercalcemia include unrecognized asymmetric parathyroid hyperplasia, multiple parathyroid adenomas, however, parathyromatosis as a complication of parathyroid resection could not be ruled out. Dispersion of parathyroid tissue and growth of multiple parathyroid nodules could lead to primary hyperparathyroidism. With intermittent parenteral pamidronate normocalcemia was temporarily achieved, although fourth resection of parathyroid tissue and subtotal thyroidectomy eventually led to normocalcemia and normal parathyroid hormone levels in this patient. Prikazuje se 57-godišnji bolesnik s recidivirajućim primarnim hiperparatiroidizmom i posljedičnom kroničnom bubrežnom insuficijencijom.U tri navrata učinjena je ekstirpacija povećanih paratiroidnih žlijezda i višekratna sklerozacija preostalog paratiroidnog tkiva, uz i dalje prisutnu hiperkalcemiju. Moguća objašnjenja su da se kod bolesnika radilo o višestrukim adenomima paratiroidnih žlijezda koji su se razvili metakrono ili se od samog početka radilo o neprepoznatoj asimetričnoj hiperplaziji svih paratiroidnih žlijezda. Ne može se, međutim, isključiti niti paratiromatoza kao posljedica poslijeoperacijske rupture kapsule adenoma, što je dovelo do rasapa i ponovnog rasta višestrukih paratiroidnih čvorova i recidiva primarnog hiperparatiroidizma. Bolesnik je uz intermitentnu parenteralnu terapiju pamidronatom bio u prolaznoj normokalcemiji, a nakon ponovne pojave hiperparatiroidizma učinjena je radikalna disekcija paratiroidnog tkiva i subtotalnalna resekcija štitne žlijezde, čime je uspostavljena normokalcemija i postignuta uredna razina paratiroidnog hormona. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14057 http://hrcak.srce.hr/file/21530 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Brainstem (Duret) Hemorrhage: A Rare Complication of Ischemic Stroke in the Middle Cerebral Artery Territory: A Case Report Duretovo krvarenje: rijetka komplikacija ishemijskog moždanog udara u području središnje moždane arterije - Prikaz slučaja Gur, Alexandar Y. Reider-Groswasser, Irith Irena Segev, Yoram Hoffman, M. Bornstein, Natan M. Brain-Stem hemorrhage - diagnosis; Brain-Stem hemorrhage - physiopathology; Cerebral hemorrhage - radiogarphy; Case report Krvarenje u moždanom deblu - klinička slika; Krvarenje u moždanom deblu - fiziopatologija; Krvarenje u moždanom deblu - neurološka obrada We report on an unusual case of brainstem Duret hemorrhage after ischemic stroke in the anterior circulation. The patient showed a clinical and neuroradiological picture of an acute and malignant middle cerebral artery infarct with increased intracranial pressure followed by a brainstem hemorrhage. The report suggests that the descending transtentorial herniation of any etiology might be complicated by a Duret hemorrhage. Opisuje se rijedak slučaj Duretova krvarenja moždanoga debla nakon ishemijskog moždanog udara u prednjem krvotoku. Bolesnik je pokazivao kliničku i neuroradiološku sliku akutnog i zloćudnog infarkta središnje moždane arterije uz povišen intrakranijski tlak, nakon čega je uslijedilo krvarenje u moždanom deblu. Ovaj prikaz ukazuje na to da se Duretovo krvarenje može pojaviti kao komplikacija kod silazne transtentorijske hernijacije bilo koje etiologije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-06-01 text pdf http://hrcak.srce.hr/14058 http://hrcak.srce.hr/file/21531 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Stromal Reaction in Synchronous in Situ and Invasive Urothelial Carcinoma of the Bladder Stromalna reakcija u sinkronom in situ i invazivnom urotelnom karcinomu mokraćnog mjehura Reljić, Ante Tomas, Davor Gabelić, Tereza Zarubica, Jelena Bulimbašić, Stela Fazlić, Hana Čupić, Hrvoje Krušlin, Božo Bladder neoplasms - pathology; Bladder neoplasms - diagnosis; Urothelium - pathology; Urologic neoplasms - classification; Stromal cells - pathology Neoplazme mokraćnog mjehura - patologija; Neoplazme mokraćnog mjehura - dijagnostika; Urotel - patologija; Urološke neoplazme - klasifikacija; Stromalne stanice - patologija The aim was to investigate stromal reaction, including inflammation and stromal desmoplasia in in situ and invasive urothelial carcinoma of urinary bladder and to determine the possible value of reactive stromal changes in the diagnosis of lamina propria invasion. We analyzed specimens from 24 consecutive patients with synchronous in situ and invasive urothelial carcinoma in the same biopsy. Specimens were obtained by transurethral resection, fixed and routinely stained with H&E and Mallory method. Immunohistochemistry was performed by monoclonal antibodies to vimentin, smooth muscle actin and desmin. The intensity of immunostaining was graded semiquantitatively on a scale of 0-3, and expressed as 0 = 0%; 1 = up to 33%; 2 = more than 33% to 66%; and 3 = more than 66% of positive stromal cells. The intensity of inflammation was labeled as 0 = no inflammation, 1 = weak, 2 = moderate, and 3 = dense inflammatory reaction. Mallory trichrome method showed predominantly no staining or weak green staining in 14/24 invasive and 20/24 in situ urothelial carcinomas (p>0.05). There was statistically significantly increased vimentin and smooth muscle actin immunostaining in the stroma of invasive carcinoma as compared with in situ carcinoma (p<0.05). Inflammatory reaction was statistically stronger in invasive carcinoma (p<0.05). The immunohistochemical expression of myofibroblastic markers was significantly stronger in invasive urothelial carcinoma. This may aid in the diagnosis of lamina propria invasion in urothelial carcinoma of urinary bladder. Cilj istraživanja bio je analizirati stromalnu reakciju, uključujući upalu i dezmoplaziju strome, u in situ i invazivnim urotelnim karcinomima mokraćnog mjehura te odrediti moguću vrijednost reaktivnih stromalnih promjena u dijagnostici invazije lamine proprije. Analiza je provedena na 24 uzorka tumora s istodobnom in situ i invazivnom sastavnicom urotelnog karcinoma u istoj biopsiji. Uzorci su dobiveni transuretralnom resekcijom, fiksirani i bojeni standardnom metodom hemalaun-eozinom te metodom po Malloryju. Imunohistokemija je učinjena pomoću monoklonskih protutijela protiv vimentina, glatkomišićnog aktina i dezmina. Intenzitet imunohistokemijskih reakcija je određen semikvantitativno i označen kao 0 = negativna reakcija, 1 = do 33% pozitivnih stanica u stromi, 2 = više od 33% do 66% pozitivnih stromalnih stanica i 3 = više od 66% pozitivnih stromalnih stanica. Intenzitet upale označen je kao 0 = nema upale, 1 = slaba upalna reakcija, 2 = umjerena upalna reakcija i 3 = jaka upalna reakcija. Metoda po Malloryju je pokazala negativnu odnosno slabu reakciju zelenog bojenja u 14/24 invazivna i 20/24 in situ urotelna karcinoma (p>0,05). Utvrđena je statistički značajno jača reakcija na vimentin i glatkomišićni aktin u stromi invazivnih karcinoma u odnosu na karcinom in situ (p<0,05). Upalna reakcija je bila statistički značajno jača u invazivnim karcinomima (p<0,05). Imunohistokemijska izraženost miofibroblastičnih biljega bila je statistički značajno jača u invazivnim urotelnim karcinomima. Ovakvi rezultati mogu pomoći u dijagnozi invazije lamine proprije u invazivnom karcinomu mokraćnog mjehura. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14059 http://hrcak.srce.hr/file/21532 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Management of Helicobacter Pylori-Associated Diseases: Survey of Attitudes and Applied Algorithms in Primary Health Care in Bosnia and Herzegovina Liječenje bolesti udruženih s Helicobacter pylori: Pregled stavova i algoritama u primarnoj zdravstvenoj skrbi u Bosni i Hercegovini Mimica, Mladen Helicobacter infection - drug therapy; Anti-bacterial agents - therapeutic use; Gastroenterology - education; Health - knowledge - attitudes - practice Infekcija Helicobacter - liječenje lijekovima; Antibakterijski lijekovi - terapijska primjena; Gastroenterologija - izobrazba; Zdravlje - znanje - stavovi - praksa The aim of the study was to identify key decision points in the management of Helicobacter (H.) pylori-associated diseases by general practitioners (GPs) in Bosnia and Herzegovina (BH), in relation to standard protocols. A questionnaire especially designed for this survey was distributed to 500 randomly selected primary health care physicians in Bosnia and Herzegovina. Two hundred and sixty-four of them responded (response rate 53%), and their answers were included in the study and analyzed. It appears that the most important source of information about H. pylori management were pharmaceutical industry-sponsored symposia (53%). The main obstacle in the application of full-scale worldwide accepted diagnostic and therapeutic protocols was the lack of inexpensive and easy-to-get diagnostic test. Seventy-one percent of GPs treated H. pylori infection in their practice. Of those who prescribed eradication therapy only 9% had the evidence of infection by rapid urease test before starting eradication. More than two-thirds of the surveyed GPs prescribed H. pylori eradication therapy, but only one tenth based such therapeutic decision on the positive evidence for the presence of H. pylori infection because of the lack of proper laboratory test. Cilj studije bio je utvrditi ključne odluke u liječenju bolesti udruženih s Helicobacter (H.) pylori koje donose liječnici opće prakse u Bosni i Hercegovini u odnosu na standardne protokole. Anketni list izrađen upravo za ovaj pregled razaslan je 500 nasumce odabranih liječnika opće prakse u Bosni i Hercegovini, od kojih je 264 (53%) odgovorilo; njihovi su odgovori uključeni u studiju i analizirani. Analiza je pokazala kako su simpoziji uz potporu farmaceutske industrije najvažniji izvor podataka o liječenju H. pylori (53%). Glavna prepreka primjeni cjelokupnog širom svijeta prihvaćenog dijagnostičkog i terapijskog protokola je nedostatak jeftinog i lako dostupnog dijagnostičkog testa. Sedamdesetjedan posto liječnika opće prakse liječi infekciju H. pylori u svojim ordinacijama. Od onih koji propisuju liječenje iskorjenjivanjem samo ih 9% ima dokaze infekcije dobivene brzim testom ureaze prije uvođenja terapije iskorjenjivanjem. Više od dvije trećine liječnika opće prakse iz ove studije je propisivalo terapiju iskorjenjivanja H. pylori, ali ih je zbog nedostatka odgovarajuće laboratorijske pretrage samo jedna desetina takvu terapijsku odluku temeljila na sigurnim dokazima prisutnosti infekcije H. pylori. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14060 http://hrcak.srce.hr/file/21533 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Choice of Operative Methods for Primary Vesicoureteral Reflux Izbor operativne metode za liječenje primarnog vezikoureteralnog refluksa Spajić, Borislav Ðelmiš, Jasna Spajić, Marija Štimac, Goran Katušić, Josip Kraus, Ognjen Vesico-ureteral reflux - therapy; Vesico-ureteral reflux - surgery; Ureter surgery - methods; Child Vesiko-ureterni refluks - terapija; Vesiko-ureterni refluks - kirurgija; Kirurgija uretera - metode; Dijete Results of ureteral reimplantation in infants with primary vesicoureteral reflux (VUR) were retrospectively reviewed and evaluated. From January 1991 till December 2000, a total of 156 patients with primary VUR underwent ureteral reimplantation at University Department of Urology, Sestre milosrdnice University Hospital, Zagreb, Croatia. The indications for surgery were high-grade reflux, breakthrough urinary tract infections, and non-compliance with medical treatment. Ureteral reimplantation was performed according to Cohen.s method (134/156) and Gil-Vernet (22/156) transvesical method. Out of 156 patients treated for primary VUR, 57 patients presented with left sided VUR and 40 with right sided VUR, whereas 52 patients required treatment for bilateral VUR, giving a total of 219 VUR repairs. Five patients had ureteral duplication accompanied by one sided VUR, whereas two patients had ureteral duplication accompanied by bilateral VUR. Out of the 156 surgically treated patients 2 (1.28%) presented with recurrent VUR, 3 (1.93%) with contralateral VUR, 5 (3.2%) patients were treated for urinary tract infection postoperatively, and none of our patients presented with stenosis. The overall complication-free percentage of surgically treated VUR in our study was 93.6%, while 96.8% were successfully treated for VUR. The present results show that transvesical ureteral repairs in infants are safe and very effective for the prevention of urinary tract infections. After surgical treatment in infancy, the individual renal growth of children with primary VUR is stable. Proveden je retrospektivni pregled i procjena rezultata reimplantacije uretera u dojenčadi s primarnim vezikoureteralnim refluksom (VUR). Od siječnja 1991. do prosinca 2000. godine ukupno je 156 bolesnika s primarnim VUR podvrgnuto reimplantaciji uretera na Klinici za urologiju Kliničke bolnice Sestara milosrdnica u Zagrebu, Hrvatska. Indikacije za operaciju bile su refluks visokog stupnja, masivna infekcija mokraćnog sustava te nepridržavanje medikamentnog liječenja. Reimplantacija uretera provedena je prema Cohenovoj metodi (134/156) i Gil-Vernetovoj transvezikalnoj metodi (22/156). Od 156 bolesnika liječenih zbog primarnog VUR 57 ih je imalo lijevostrani VUR, a 40 desnostrani VUR, dok je 52 bolesnika imalo obostrani VUR, tj. ukupno 219 popravaka zbog VUR. Petoro bolesnika je imalo duplikaciju uretera praćenu jednostranim VUR, dok ih je dvoje imalo duplikaciju uretera praćenu jednostranim VUR. Od 156 kirurški liječenih bolesnika dvoje (1,28%) ih je došlo s ponovljenim VUR, troje (1,93%) s kontralateralnim VUR, petoro (3,2%) ih je poslijeoperacijski liječeno zbog infekcije mokraćnog sustava, dok se stenoza nije razvila ni u jednog od naših bolesnika. Sveukupni postotak kirurški liječenog VUR bez komplikacija u našoj studiji je iznosio 93,6%, dok je postotak uspješnog izlječenja VUR bio 96,8%. Ovi rezultati pokazuju kako je transvezikalni popravak uretera u dojenčadi siguran i vrlo učinkovit u sprječavanju infekcije mokraćnog sustava. Rast pojedinog bubrega u djece s primarnim VUR je stabilan nakon kirurškog liječenja u dojenačkoj dobi. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14061 http://hrcak.srce.hr/file/21534 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14062 2008-06-03 journal:158

Colonic Pseudo-Obstruction and Severe Hypokalemia in an Anuric Diabetic Patient on Hemodialysis: Case Report and Review of the Literature Pseudoopstrukcija debelog crijeva i teška hipokalemija u anurične dijabetične bolesnice liječene hemodijalizom: Prikaz bolesnice i literature Kovačević, Igor Šefer, Siniša Ratković-Gusić, Iva Degoricija, Vesna Szavits-Nossan, Janko Intestinal pseudo-obstruction - etiology; Intestinal pseudo-obstruction - diagnosis; Intestinal pseudo-obstruction - therapy; Hypokalemia - etiology; Chronic diseases - therapy; Risk factors; Case report Crijevna pseudoopstrukcija- etiologija; Crijevna pseudoopstrukcija- dijagnostika; Crijevna pseudoopstrukcija - terapija; Hipokalemija - etiologija; Kronične bolesti - terapija; Rizični čimbenici; Prikaz slučaja Hypokalemia is a rare condition in the end-stage renal disease patients on hemodialysis, and especially in those with no residual diuresis. If hypokalemia occurs, it is usually transient and mostly associated with gastrointestinal loss of potassium (massive diarrheal stools), or appears immediately after hemodialysis with the use of dialysis solutions with potassium concentrations lower than 2 mmol/L. The aim of this report is to present a case of a female diabetic patient on hemodialysis with permanent severe hypokalemia associated with chronic colonic pseudo-obstruction and secretory diarrhea, and to point to the possible rare causes of permanent hypokalemia in anuric patients with end-stage renal disease as well as to the causal relations of persistent hypokalemia with changes in different organ systems. Hipokalemija je vrlo rijetka u bolesnika s kroničnim bubrežnim zatajenjem koji se liječe hemodijalizom, a pogotovo u onih koji nemaju ostatnu diurezu. Ako se hipokalemija pojavi, obično je prolazna i najčešće povezana s gubitkom kalija putem probavnog sustava (obilne proljevaste stolice) ili se javlja neposredno nakon hemodijalize uz primjenu otopine za dijalizu u kojoj je koncentracija kalija manja od 2 mmol/L. Cilj ovoga rada je prikazati slučaj dijabetične bolesnice liječene hemodijalizom s trajno prisutnom teškom hipokalemijom praćenom pseudoopstruk¬cijom debelog crijeva i sekretornom dijarejom, te ukazati na moguće rijetke uzroke trajne hipokalemije u anuričnih bolesnika s kroničnim bubrežnim zatajenjem i na uzročno-posljedične veze dugotrajne hipokalemije s promjenama na različitim organskim sustavima. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14062 http://hrcak.srce.hr/file/21535 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Acquired Factor V Inhibitor: A Case Report Stečeni inhibitor faktora V: Prikaz slučaja Gaćina, Petar Kušec, Rajko Čaržavec, Dubravka Raić, Biserka Stančić, Vladimir Blood coagulation factors - antagonists and inhibitors; Antibodies - immunology; Blood coagulation disorders - immunology; Factor V - immunology; Factor V - adverse effects; Case report Faktori zgrušavanja krvi - antagonisti i inhibitori; Protutijela - imunologija; Bolesti zgrušavanja krvi - imunologija; Faktor V - imunologija; Faktor V - štetni učinci; Prikaz slučaja A 19-year-old asymptomatic man who was admitted to our hospital for investigation of prolonged screening coagulation assays, prothrombin time and activated partial thromboplastin time is presented. Further evaluation revealed factor V deficiency and the presence of specific factor V inhibitors. The appearance of these inhibitors may be associated with administration of some antibiotics, topical bovine thrombin preparations containing bovine factor V during surgical or dental procedures, after blood transfusions and in patients with malignancy or autoimmune diseases. Factor V inhibitors may also develop spontaneously in patients without any clearly identifiable cause. Our patient had no personal or family history of bleeding tendency or thromboembolic event. There is a general consensus that asymptomatic patients should not be treated regardless of their inhibitor titer and residual factor V levels. Prikazan je slučaj 19-godišnjeg bolesnika bez simptoma, koji je upućen u našu bolnicu zbog ispitivanja uzroka produljenih probnih testova zgrušavanja, protrombinskog vremena i aktiviranog parcijalnog tromboplastinskog vremena. Daljnje istraživanje ukazalo je na nedostatak faktora V i prisutnost specifičnog inhibitora faktora V. Prisutnost ovih inhibitora može biti povezana s primjenom antibiotika, goveđeg trombina koji sadrži goveđi faktor V primijenjenih lokalno za vrijeme kirurških i zubnih zahvata, nakon transfuzije krvi i u bolesnika s malignim ili autoimunim bolestima. Inhibitori faktora V mogu također nastati spontano u bolesnika bez jasno otkrivenog uzroka. Naš bolesnik i njegova obitelj nisu imali anamnestičkih podataka o sklonosti krvarenju niti tromboemboliji. Opći je stav da bolesnike bez simptoma nije potrebno liječiti, bez obzira na titar inhibitora i preostalu razinu faktora V. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14063 http://hrcak.srce.hr/file/21536 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Contact Allergic Sensitivity to Clostridium Peptidase with Chloramphenicol in a Patient with Venous Leg Ulcer Kontaktna alergijska preosjetljivost na klostridiopeptidazu s kloramfenikolom u bolesnice s venskim ulkusom potkoljenice Tomljanović-Veselski, Mirna Zelić, Ines Leg ulcer - drug therapy; Dermatologic agents - adverse effects; Dermatitis, allergic-contact - etiology; Dermatitis, allergic-contact - diagnosis; Patch tests; Case report Ulkus donjih ekstremiteta - terapija lijekovima; Dermatološki lijekovi - štetni učinci; Dermatitis, alergijski-kontaktni - etiologija; Dermatitis, alergijski-kontaktni - dijagnostika; Patch testovi; Prikaz slučaja Contact dermatitis caused by topical drugs is rather common all over the world. A case is presented of a 76-year-old female patient with venous leg ulcer, who developed contact sensitivity to Clostridium peptidase with chloramphenicol, i.e. Iruxol, a topical antiulcerative used for years for leg lesions. Patch testing confirmed sensitivity to Iruxol, and specific testing for chloramphenicol confirmed sensitivity to the antibiotic component of the ointment. Contact allergic dermatitis is a very common disease in patients with lower limb ulcer and venous hypostatic dermatitis. Lijekovi za lokalnu primjenu česti su uzročnici kontaktnog dermatitisa širom svijeta. Opisuje se slučaj 76-godišnje bolesnice s venskim ulkusom u koje se je tijekom dugogodišnje terapije rana na potkoljenicama razvila kontaktna preosjetljivost na klostridiopeptidazu s kloramfenikolom, topičnim pripravkom za liječenje ulkusa poznatim pod imenom Iruxol. Kod bolesnice se epikutanim testom potvrdila preosjetljivost na mast Iruxol, dok se izoliranim testiranjem na kloramfenikol potvrdila preosjetljivost na antibiotsku sastavnicu pripravka. Kontaktni alergijski dermatitis česta je pojava u bolesnika s venskim ulkusom i hipostatičnim dermatitisom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14064 http://hrcak.srce.hr/file/21537 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Descending Necrotizing Mediastinitis Descendentni nekrotizirajući medijastinitis Nikolić, Igor Bumber, Željko Stančić-Rokotov, Dinko Slobodnjak, Zoran Bumber, Boris Hodoba, Nevenka Kolarić, Nevenka Mediastinitis - etiology; Mediastinitis - diagnosis; Mediastinitis - therapy; Mediastinitis - surgery; Mediastinitis - complications; Case report Medijastinitis - etiologija; Medijastinitis - dijagnostika; Medijastinitis - terapija; Medijastinitis - kirurgija; Medijastinitis - komplikacije; Prikaz slučaja Descending necrotizing mediastinitis is a severe septic infection of the mediastinum, mostly resulting from an infectious process originating from the neck or oral cavity. The mortality rate associated with descending necrotizing mediastinitis remains high (>40%) in spite of the current medical and surgical treatment options. The disease may occur at any age and in either sex. Early diagnosis is of utmost importance to immediately initiate intensive antibiotic therapy or surgical intervention in case of the infectious process descent to the thoracic cavity. A patient with descending necrotizing mediastinitis, initially treated with antibiotic therapy followed by surgical intervention due to the disease propagation, is presented. Intraoperatively, a life threatening complication of the left venous angle erosion developed. Descendentni nekrotizirajući medijastinitis je ozbiljna gnojna infekcija medijastinuma koja najčešće nastaje spuštanjem infekta iz područja usne šupljine ili vrata. Smrtnost je i dalje vrlo visoka (preko 40%) usprkos današnjim mogućnostima liječenja konzervativnim ili kirurškim putem. Bolest se može pojaviti kod svih dobnih skupina, kako kod muškaraca tako i kod žena. U liječenju bolesti najvažnije je rano postavljanje dijagnoze kako bi se odmah započela intenzivna antibiotska terapija, a u slučaju spuštanja gnojnog procesa u prsni koš kirurška intervencija. Prikazuje se bolesnik s descendentnim nekrotizirajućim medijastinitisom koji je u početku liječen antibioticima, a zbog propagacije bolesti i kirurškim zahvatom. Tijekom kirurškog zahvata razvila se za život opasna komplikacija, erozija lijevostranog venskog spoja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14065 http://hrcak.srce.hr/file/21538 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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The Development of Telemedicine in Improving Access to Health Care in Remote and Isolated Areas Razvoj telemedicine u promicanju zdravstvene skrbi u udaljenim i izoliranim područjima Carić, Tea Ðerek, Ozren Carić, Drago Telemedicine - utilization; Quality Assurance health care; Primary health care; Technology assessment; Rural health; Croatia - island Telemedicina - iskorištenje; Zdravstvena skrb osigurane kvalitete; Primarna zdravstvena skrb; Procjena tehnologije; Zdravlje u seoskoj sredini; Hrvatska - otok Telemedicine is a relatively new way of clinical practice. It enables rapid access to remote medical expertise by means of telecommunication and information technologies, no matter where the patient or relevant expertise is located. The focus of the telemedicine project was to improve access to quality health services and to reduce the isolation of remote health care. Almost every clinical specialty has used telemedicine in some way, even though radiologists, cardiologists, dermatologists, and psychiatrists have been the clinical specialists most actively involved in telemedicine. In order to put the system to life in the isolated areas such as islands, it is necessary to keep the system functioning 24 hours a day. The need for consultations through telemedicine appears in real time, and not at an expected moment. With the development of a new information age telemedicine has been slowly incorporating into all aspects of medical practice. Telemedicina je relativno nov način iskorištenja saznanja i resursa kliničke medicine. Omogućava brz pristup specijalistima putem telekomunikacijskih i informatičkih tehnologija, bez obzira gdje se bolesnik ili specijalist nalazi. Cilj joj je unaprijediti zdravstvenu skrb i smanjiti zdravstvenu izoliranost udaljenih područja. Gotovo je svaka grana kliničke medicine prihvatila telemedicinu, iako je ona ponajviše uključena u radiologiju, kardiologiju, dermatologiju i psihijatriju. Da bi sustav zaživio u izoliranim područjima kao što su otoci neophodno je da bude u funkciji 24 sata na dan, jer se potreba za konzultacijom putem telemedicine događa u stvarnom, a ne u zadanom vremenu. S razvojem novog informatičkog doba telemedicina će polako zauzimati sve va.nije mjesto u svakom vidu kliničke medicine. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14066 http://hrcak.srce.hr/file/21539 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14067 2008-06-03 journal:158

Recommendations for Stroke Management 2006 Update Demarin, Vida Lovrenčić-Huzjan, Arijana Trkanjec, Zlatko Vuković, Vlatka Vargek Solter, Vesna Šerić, Vesna Lušić, Ivo Kadojić, Dragutin Bielen, Ivan Tuškan-Mohar, Lidija Aleksić-Shibabi, Anka Dikanović, Marinko Hat, Josip DeSyo, Drago Lupret, Velimir Beroš, Vili Stroke; Cerebrovascular disorders; Stroke therapy; Guidelines; Thrombolytic therapy; Stroke units This article brings an update of the Recommendations for Stroke Management, first published in this journal in 2001. The Recommendations are consistent with the Recommendations of three European societies represented Iri the European Stroke Initiative: the European Stroke Council, the European Neurological Society, and the European federation of Neurological Societies, and are in concordance with the Guidelines of the American Heart Association/American Stroke Association Council on Stroke, approved by the American Academy of Neurology. The Recommendations have been endorsed by the Croatian Society for Neurovascular Disorders of Croatian Medical Association, Croatian Stroke Society, and University Department of Neurology, Sestre milosrdnice University Hospital, Reference Center for Neurovascular Disorders of the Croatian Ministry of Health. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-09-01 text pdf http://hrcak.srce.hr/14067 http://hrcak.srce.hr/file/21540 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14068 2008-06-03 journal:158

Changes of Cerebral Hemodynamics During Music Perception: A Functional Transcranial Doppler Study Promjene moždane hemodinamike za vrijeme slušanja glazbe: funkcionalna transkranijska Doppler studija Antić, Sonja Jensen, Ulf Lovrenčić-Huzjan, Arijana Vuković, Vlasta Mukhtarova, Roxana Verónica, Sandra Sáo, Ferreira González Treviño, Roberto Jurašić, Miljenka-Jelena Santos, Silva Morović, Sandra Demarin, Vida Auditory perception - physiology; Cerebrovascular circulation - physiology; Music; Ultrasonography - Doppler - transcranial Slušna percepcija - fiziologija; Cerebrovaskularna cirkulacija - fiziologija; Glazba; Ultrazvuk - Dopplerov - transkranijski Studies have shown that the perception of musical information differs between musically educated and musically non-educated individuals. The aim of the study was to determine the time course and lateralization of changes in mean blood flow velocity (MBFV) in the middle cerebral artery (MCA) during auditory stimulation between musically educated and musically non-educated listeners as well as between sexes. Using transcranial Doppler (TCD), MBFV was assessed in 61 healthy right-handed subjects (18 musical educated and 43 musically non-educated). The ability to play an instrument was considered the minimum criterion for musical education. In both musically educated and non-educated groups, left MCA was activated earlier (p=0.013) and had higher MBFV (p=0.046). In the right MCA, habituation was obtained earlier in musically non-educated than in musically educated group (p=0.019). Female listeners had a shorter activation time of MBFV in the left MCA than in the right MCA (p=0.002), while in males no difference was found. Male listeners had a longer first activation time in the left MCA (p=0.003) and higher first maximal amplitude in the right MCA (p=0.038) than female listeners. Also, the time of activation of MBFV in the left MCA was longer in male than in female listeners (p=0.013). Study results suggest that music perception requires bilateral activation of cerebral hemispheres. The left hemisphere is firstly and predominantly activated regardless of musical education, whereas the right hemisphere is associative and is connected to the experience of music. Results from this study indicated sex differences in the perception. To confirm our preliminary results, further studies involving larger groups are needed. Studije su pokazale da se percepcija glazbe razlikuje između glazbeno obrazovanih i glazbeno neobrazovanih osoba. Svrha studije je bila utvrditi vremenski slijed i lateralizaciju promjena u srednjoj vrijednosti strujanja krvi (SBSK) u arteriji cerebri mediji (ACM) kako između glazbeno obrazovanih i glazbeno neobrazovanih ispitanika, tako i između spolova za vrijeme slušne stimulacije. Kod 61 zdravog dešnjaka (18 glazbeno obrazovanih, 43 glazbeno neobrazovanih) pratila se SBSK pomoću transkranijskog Dopplera (TCD). Sposobnost sviranja instrumenta je bio minimalni kriterij glazbene izobrazbe. U objema skupinama glazbeno obrazovanih i glazbeno neobrazovanih ispitanika lijeva ACM se aktivirala ranije (p=0,013), a SBSK je bila viša u lijevoj ACM (p=0,046). Nije bilo razlike u habituaciji u lijevoj ACM između ovih dviju skupina. U desnoj ACM je kod glazbeno neobrazovanih došlo ranije do habituacije nego kod glazbeno obrazovanih (p=0,019). Kod žena je zabilježena brža aktivacija SBSK u lijevoj ACM nego u desnoj (p=0,002), dok kod muškaraca nije nađena razlika. Muški ispitanici su imali duže razdoblje prve aktivacije u lijevoj ACM (p=0,003) i višu amplitudu prve reakcije u desnoj ACM (p=0,038) nego ispitanice. Vrijeme reakcije SBSK u lijevoj ACM je također bilo duže u muških nego u ženskih ispitanika (p=0,013). Naši rezultati upućuju na to da je za percepciju glazbe potrebna aktivacija obiju hemisfera. Pretežito i prvenstveno se aktivira lijeva moždana hemisfera bez obzira na glazbenu izobrazbu, dok desna moždana hemisfera ima više asocijativnu funkciju i povezana je s glazbenim iskustvom. Kod muškaraca i žena su uz pomoć funkcionalnog TCD također zabilježene razlike u precepciji. Za potvrdu ovih preliminarnih rezultata našega istraživanja potrebno je proširiti istraživanje na veći broj ispitanika. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14068 http://hrcak.srce.hr/file/21541 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14069 2008-06-03 journal:158

Analysis of Mean Blood Flow Velocities in Posterior Cerebral Arteries by Transcranial Doppler - During Visual Stimulation Analiza srednjih brzina krvnog protoka u bazalnim moždanim arterijama pomoću transkranijskog dopplera tijekom vidne stimulacije Lisak, Marijana Trkanjec, Zlatko Mikula, Ivan Demarin, Vida Aleksić-Shibabi, Anka Šulentić, Vlatko Cerebrovascular circulation - physiology; Cerebrovascular disorders - ultrasonography; Blood flow velocity - physiology; Brain physiology Cerebrovaskularna cirkulacija - fiziologija; Cerebrovaskularne bolesti - ultrazvuk; Brzina krvnog protoka - fiziologija; Fiziologija mozga Changes of mean blood flow velocities (MBFV) in the posterior cerebral arteries (PCA) during visual stimulation were recorded in a group of 51 healthy, right-handed volunteers. There were 27 (52.9%) males and 24 (47.1%) females aged from 20 to 59 (mean age 36.98) years. Measurements were performed with a hand-held 2 MHz transcranial Doppler (.I.CD) probe through temporal window, while the subjects had their eyes open, closed, and when looking at white light. In half of the subjects, the right PCA was insonated first and then the left PCA, while in the other half a reverse procedure was used. Statistical analysis was performed using Wilcoxon.s matched-pair signed-rank test. In the left PCA, MBFV was 41.2±8.6 cm/s (mean ± SD) with eyes open, 27.8±8.5 cm/s with eyes closed, and 42.3±9.1 cm/s while looking at white light. In the right PCA, MBFV was 41.7±8.9 cm/s with eyes open, 28.2±9.1 cm/s with eyes closed, and 42.4±8.8 cm/s while looking at white light. In the left PCA, differences between eyes open and closed, and between eyes open and while looking at white light were statistically significant (p<0.001, z=-6.2146, and p<0.001, z=-3.4836, respectively). In the right PCA, a statistically significant difference was found between eyes open and closed (p<0.001, z=-6.2146 and p<0.001, z=-3.6928), but not between eyes open and looking at white light (p=0.03, z=-2.1693). Study results demonstrated that straightforward visual stimulation had an effect on blood flow velocities in PCA and that it could be measured with TCD. Promjene srednjih brzina krvnog protoka (MBFV) u stražnjim moždanim arterijama (PCA) bilježene su tijekom vidne stimulacije u skupini od 51 zdravog desnorukog dobrovoljca. Skupina se sastojala od 27 (52,9%) muških i 24 (47,1%) ženskih ispitanika u dobi od 20 do 59 (srednja dob 36,98) godina. Mjerenja su se izvodila pomoću ručne sonde od 2 MHz za transkranijski Doppler (TCD) kroz temporalni prozor, dok su ispitanici oči držali otvorenima, zatvorenima i dok su gledali u bijelo svjetlo. U polovice ispitanika najprije je ispitana desna PCA, a potom lijeva PCA, a u druge polovice primijenjen je obrnuti postupak. Statistička analiza je provedena pomoću Wilcoxonova parnog rank testa. U lijevoj PCA je MBFV bila 41,2±8,6 cm/s (srednja vrijednost ± SD) uz otvorene oči, 27,8±8,5 cm/s uza zatvorene oči i 42,3±9,1 cm/s dok su gledali u bijelo svjetlo. U desnoj PCA je MBFV bila 41,7±8,9 cm/s uz otvorene oči, 28,2±9,1 cm/s uza zatvorene oči i 42,4±8,8 cm/s dok su gledali u bijelo svjetlo. Razlike u MBFV između zatvorenih i otvorenih očiju, te između otvorenih očiju i gledanja u bijelo svjetlo bile su statistički značajne za lijevu PCA (p<0,001, z=-6,2146, odnosno p<0,001, z=-3,4836). U desnoj PCA je razlika u MBFV bila statistički značajna između otvorenih i zatvorenih očiju (p<0,001, z=-6,2146, odnosno p<0,001, z=-3,6928), ali ne između otvorenih očiju i gledanja u bijelo svjetlo (p=0,03, z=-2,1693). Rezultati su pokazali da izravna vidna stimulacija utječe na brzinu krvnog protoka u PCA te da se to može mjeriti pomoću TCD. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14069 http://hrcak.srce.hr/file/21542 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Correlation of Neurological Symptoms and Breath Holding Index Values in Patients With Severe Internal Carotid Stenosis Korelacija neuroloških simptoma i vrijednosti indeksa zadržavanja daha u bolesnika sa značajnom stenozom unutarnje karotidne arterije Zavoreo, Iris Aleksić-Shibabi, Anka Demarin, Vida Cerebral arteries - physiopathology; Carotid artery diseases - diagnosis; Carotid stenosis - ultrasonography; Ultrasonography, Doppler, transcranial Moždane arterije - fiziopatologija; Bolesti karotidnih arterija - dijagnostika; Karotidna stenoza - ultrazvuk; Ultrazvuk, Dopplerov, transkranijski The aim of the study was to evaluate the role of cerebral vasoreactivity measurement in the follow up of patients with severe internal carotid stenosis. We used breath holding index (BHI) as a quantitative parameter of cerebral vasoreactivity and functional state of cerebral hemodynamics. We evaluated data of 150 patients with high grade carotid stenosis (definition according to standardized criteria of the Cerebrovascular Laboratory, Reference Center for Neurovascular Disorders of the Ministry of Health of Republic of Croatia). All patients underwent CDFI, TCD and CT/MR imaging tests, complete laboratory work-up, ECG, chest x-ray, and spinal tap in selected cases. CDFI and TCD findings were obtained in a standardized manner. BHI was calculated as percentage increase in mean blood flow velocity (MBFV) occurring during breath holding divided by the time (seconds) for which the subject hold his/her breath. All patients had verified recent ischemia of brain parenchyma on CT/MR scan. There were 29 (19%) symptom-free patients, 14 (9%) men and 15 (10%) women, who had BHI >0.7; 35 (24%) patients, 15 (10%) men and 20 (14%) women, with transient neurological symptoms, without recent ischemic lesions on CT/MR scan and BHI ≥0.7; and 86 (57%) patients with first ever stroke, 54 (36%) men and 32 (21%) women, who had hemispheric symptoms according to the site of stenosis (BHI <0.7). BHI is an easy and reproducible, real time method in the follow up of patients with severe carotid disease. It is very useful in predicting decompensation of intracranial collateral circulation, hemodynamic insufficiency and cerebrovascular accident. Cilj ovoga istraživanja bio je utvrditi značenje procjene moždane vazoreaktivnosti u bolesnika sa značajnom stenozom unutarnje karotidne arterije (ACI). Za procjenu stanja moždane vazoreaktivnosti te kvantifikaciju njezine funkcije služili smo se mjerenjem indeksa zadržavanja daha (IZD). U istraživanje smo uključili 150 bolesnika sa značajnom stenozom ACI. Svim bolesnicima je učinjen ekstrakranijski i intrakranijski dopler krvnih žila, snimanje mozga pomoću CT/MR, potpune laboratorijske pretrage, te EKG i RTG torakalnih organa. Sve ultrazvučne pretrage učinjene su prema standardnom protokolu, IZD je izračunat kao postotak porasta vrijednosti srednjih brzina strujanja krvi u srednjoj moždanoj arteriji u mjerenom vremenu. Bilo je 29 (19%) bolesnika bez simptoma, 14 (9%) muškaraca i 15 (10%) žena, koji su imali IZD >0,7, a CT/MR nije pokazao svježih lezija moždanog parenhima; 35 (24%) bolesnika, 15 (10%) muškaraca i 20 (14%) žena, s tranzitornim neurološkim simptomima, u kojih CT/MR nije pokazao svježih lezija moždanog parenhima, a BHI je bio ≥0,7; 86 (57%) bolesnika s prvim moždanim udarom, 54 (36%) muškaraca i 32 (21%) žene, koji su imali dokazanu svježu ishemijsku leziju na CT/MR mozga koja je odgovarala strani stenoze uz kontralateralne neurološke simptome (BHI <0,7). Mjerenje indeksa zadržavanja daha je jednostavna, reproducibilna metoda u stvarnom vremenu koja je vrlo korisna u praćenju bolesnika sa značajnom stenozom ACI. Vrlo je korisna u procjeni trenutka dekompenzacije intrakranijskih kolateralnih puteva te posljedične hemodinamske insuficijencije i ishemijskog inzulta. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14070 http://hrcak.srce.hr/file/21543 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Transcranial Sonography in Movement Disorders Transkranijski ultrazvuk kod poremećaja kretanja Budišić, Mislav Lovrenčić-Huzjan, Arijana Vuković, Vlasta Bošnjak, Jelena Trkanjec, Zlatko Aleksić-Shibabi, Anka Demarin, Vida Parkinson disease - diagnosis; Parkinson disease - ultrasonography; Substantia nigra - ultrasonography; Ultrasonography, Doppler - transcranial Parkinsonova bolest - dijagnostika; Parkinsonova bolest - ultrazvuk; Supstancija nigra - ultrazvuk; Ultrazvuk, Dopplerov - transkranijski Neuroimaging techniques are nonspecific for basal ganglia impairment in the majority of movement disorders, therefore the diagnosis is still based on clinical examination. Recent reports show the substantia nigra (SN) hyperechogenicity detected by transcranial sonography (TCS) to be a specific finding in Parkinson.s disease (PD). The aim of the study was to assess the possibility of TCS to help differentiate PD from essential tremor (ET) by measuring SN echogenicity. The study included 50 PD patients, 20 ET patients, and 50 healthy control subjects. The recordings were done in axial plane by a standardized protocol; SN was displayed, encircled, measured two times, and mean value was calculated and presented in cm2. In the control, PD and ET groups, bilateral combined mean SN size was 0.17 cm2 (±0.06), 0.26 cm2 (±0.06) and 0.16 cm2 (±0.04), respectively. Our data showed a significant difference in SN echogenic size between PD and control group as well as between ET and PD group (p<0.001) but not between control and ET group (p=0.240). The measurement of SN by use of TCS was found to be a valuable tool in differentiating PD from other movement disorders. Due to the portability, noninvasiveness and easy reproducibility, TCS might help in diagnosing PD, or in the differential diagnosis of vague clinical cases. Metode slikovnog prikaza mozga su kod većine poremećaja kretanja nespecifične te se dijagnosticiranje takvih poremećaja većinom temelji na kliničkom pregledu. Dok u 90% zdravih pojedinaca supstancija nigra (SN) prikazuje urednu ehogenost (<0,20 cm2), u većine bolesnika s Parkinsonovom bolešću (PB) transkranijskom sonografijom (TCS) se bilježi povećanje njene ehogenosti. Cilj studije bio je ispitati mogućnosti razlikovanja bolesnika s PB i bolesnika s esencijalnim tremorom (ET) pomoću transkranijskog mjerenja SN. Pregled je učinjen standardiziranom metodom; SN je prikazana, obilježena te dva puta izmjerena. Izračunata je srednja vrijednost. Primijenjen je Mann-Whitney U-test i Kruskal Wallis test za usporedbu između skupina. Istraživanje je provedeno u 50 bolesnika s PB, 20 bolesnika s ET te 50 zdravih kontrolnih osoba. Kao granica vrijednosti prema hiperehogenom prikazu primijenjena je vrijednost od 0,20 cm2. Bilateralna hiperehogenost nađena je kod 88% bolesnika s PB, 20% bolesnika s ET i 14% kontrolnih osoba. Rezultati su pokazali statistički značajnu razliku u veličini ehogenosti SN između bolesnika s PB i ET (p<0,001), kao i razliku između bolesnika s PB i kontrolne skupine (p<0,001), ali ne i značajnu razliku između kontrolne skupine i skupine bolesnika s ET (p=0,240). Zaključeno kako je povećana ehogenost SN na TCS specifičan nalaz Parkinsonove bolesti. Mjerenje veličine SN pomoću TCS omogućuje razlikovanje bolesnika s Parkinsonovom bolešću od bolesnika s esencijalnim tremorom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14071 http://hrcak.srce.hr/file/21544 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Vertebral Artery Hypoplasia: Characteristics in a Croatian Population Sample Hipoplazija vertebralne arterije: značajke u uzorku hrvatske populacije Morović, Sandra Škarić-Jurić, Tatjana Demarin, Vida Vertebral artery - abnormalities; Vertebral artery - ultrasonography; Brain blood supply; Brain blood ischemia - etiology; Croatia - epidemiology Vertebralna arterija - nenormalnosti; Vertebralna arterija - ultrazvuk; Opskrba mozga krvlju; Moždana ishemija - etiologija; Hrvatska - epidemiologija Vertebral arteries are responsible for 1/3 of the brain blood supply, supplying primarily posterior parts of the brain. About 15% of all strokes occur in posterior parts of the brain, which should be kept in mind when dealing with disorders that can cause hemodynamic changes in vertebral arteries. Vertebral artery hypoplasia (VAH) is an inborn abnormality of vertebral artery defined by smaller lumen diameter and lower blood flow velocities, and is most commonly found in healthy subjects. The aim of this study was to establish the characteristics of VAH in a Croatian population sample, and to determine differences in its presentation according to sex and affected side. Study results may prove valuable for future identification of individuals at an increased risk of cerebrovascular incidents or traumatic injuries that could lead to adverse changes of posterior circulation. Color Doppler flow imaging (CDFI) reports of 277 patients were analyzed. All measurements were obtained in the V2 segment of vertebral artery, between the C6-C5 vertebrae, using a linear 7.5 MHz probe on an Aloka Prosound SSD-5500. The criteria for normal vertebral arteries were lumen diameter of 2.5-4.5 mm, systolic mean blood flow velocity of 0.35-0.70 m/s, and normal resistance pattern. Study results showed the left vertebral artery to be dominant in 57% of study subjects, VAH to be more common in women, and right vertebral artery to be more often involved by hypoplasia than the left one. The width of the .wider. vertebral artery was greater in the group with VAH, suggesting a way of the deficit compensation. The study demonstrated that the deficit caused by VAH cannot be fully compensated for despite larger arterial diameter. Vertebralne arterije čine 30% krvne opskrbe mozga, opskrbljujući pretežito stražnje dijelove mozga. Petnaest posto svih moždanih udara nastaje u stražnjim dijelovima mozga, stoga je važno imati na umu značenje poremećaja koji uzrokuju hemodinamske promjene u vertebralnim arterijama. Hipoplazija vertebralne arterije je urođeno stanje koje obilježava uži lumen krvne žile i snižene srednje brzine strujanja krvi. Najčešće je prisutna kod zdravih pojedinaca. Cilj ovoga istraživanja bio je ustanoviti prisutnost i značenje hipoplazije vertebralne arterije u hrvatskoj populaciji, odrediti njenu pojavnost među spolovima i prema strani na kojoj se pojavljuje. Vjerovanja smo da je ovo istraživanje vrijedno zbog buduće lakše identifikacije pojedinaca izloženih većem riziku od nastanka cerebrovaskularnih poremećaja ili ozljeda koje mogu dovesti do problematičnih promjena u stražnjoj cirkulaciji. Analizirali smo nalaze 277 ispitanika. Sva mjerenja su izvedena u segmentu V2 vertebralne arterije, najčešće između vratnih kralježaka C6 i C5, upotrebom linearne sonde od 7,5 mHz na uređaju Aloka Prosound SSD¬5500. Kriteriji za uredan nalaz CDFI nad vertebralnim arterijama su: promjer vertebralne arterije od 2,5-4,5 mm, sistolične srednje brzine strujanja krvi od 0,35-0,70 m/s i zadovoljavajući cirkulacijski otpor u vertebralnim arterijama. Dobiveni rezultati su pokazali da je lijeva vertebralna arterija dominantna kod 57% ispitanika, hipoplazija vertebralne arterije češće zahvaća žene, a desna vertebralna arterija je češće hipoplastična od lijeve. Također, širina "šire" vertebralne arterije je veća kod ispitanika s hipoplazijom vertebralne arterije, što bi moglo upućivati na mehanizam kompenzacije deficita uzrokovanog hipoplazijom. Ovo istraživanje je pokazalo kako unatoč većoj širini nehipoplastične vertebralne arterije nije moguće u potpunosti nadoknaditi nedostatak uzrokovan hipoplazijom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14072 http://hrcak.srce.hr/file/21545 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Neuroimaging Techniques . Improving Diagnostic and Therapeutic Options in Acute Stroke Tehnike neuroslikovnog prikazivanja - poboljšane dijagnostičke i terapijske mogućnosti kod moždanog udara Vuković, Vlasta Molina, Carlos A Ribo, Mark Lovrenčić-Huzjan, Arijana Budišić, Mislav Demarin, Vida Cerebrovascular accident - diagnosis; Cerebrovascular accident - ultrasonography; Brain ischemia - diagnosis; Brain ischemia - physiopathology Cerebrovaskularni incident - dijagnostika; Cerebrovaskularni incident - ultrazvuk; Moždana ishemija - dijagnostika; Moždana ishemija - fiziopatologija Transcranial Doppler (TCD) has been in use for over 20 years, mainly as a diagnostic tool to assess intracranial hemodynamics in basal arteries. Recently, TCD has been used as a combined diagnostic and therapeutic tool in the assessment of acute stroke. The combination of TCD and extracranial Doppler may help in the selection of patients that require more aggressive therapeutic approach. Furthermore, neurovascular ultrasound in combination with other imaging techniques such as magnetic resonance imaging (MRI) and computed tomography with specially developed imaging possibilities (DWI and PWI in MRI) may allow for better patient selection for rt-PA treatment, especially in cases where the time window has passed 3 hours, which is one of the criteria for treatment with rt-PA in acute stroke according to the worldwide accepted recommendations based on clinical trials so far. This article presents up-to-date experience with the use of multimodal techniques in acute stroke treatment. Transkranijski Doppler (TCD) u upotrebi je preko 20 godina, uglavnom kao dijagnostička metoda za procjenu hemodinamike u intrakranijskim bazalnim arterijama. Odnedavno se TCD rabi kao dijagnostička i terapijska metoda u akutnom moždanom udaru. Kombinacija TCD i ekstrakranijskog Dopplera može pomoći u odabiru bolesnika kojima je potreban terapijski agresivniji pristup. Nadalje, neurovaskularne ultrazvučne metode u kombinaciji s ostalim tehnikama slikovnog prikaza poput magnetske rezonance (MR) i kompjutorske tomografije sa specijalno razvijenim mogućnostima prikaza (DWI i PWI kod MR) omogućuju bolji odabir bolesnika za liječenje pomoću rt-PA, osobito u slučajevima gdje je vremenski prozor prešao 3 sata, što je jedan od kriterija za liječenje pomoću rt-PA u akutnom moždanom udaru prema svjetskim preporukama temeljenim na dosadašnjim kliničkim istraživanjima. U članku se navode najnovije mogućnosti i iskustva multimodalnih tehnika koje se rabe u akutnom moždanom udaru. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14073 http://hrcak.srce.hr/file/21546 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Ultrasound Enhanced Thrombolysis for Stroke Ultrazvukom pojačana tromboliza kod moždanog udara Alexandrov, Andrei V. Cerebrovascular accident - therapy; Thrombolytic therapy; Ultrasonography, Doppler, transcranial - therapy; Fibrinolytic agents - therapeutic use; Thrombolysis - outcomes Cerebrovaskularni incident - terapija; Trombolitična terapija; Ultrazvuk, Doppler, transkranijski - terapija; Fibrinolitična sredstva - terapijska primjena; Tromboliza - ishodi Spontaneous arterial recanalization occurs at a rate of 6% per hour, and it can be doubled with intravenous tissue plasminogen activator (TPA) therapy since early dramatic clinical improvement, a substitute for early thrombus break-up, occurs in TPA treated patients. TPA activity can be enhanced with ultrasound including 2 MHz transcranial Doppler (TCD). TCD identifies residual blood flow signals around thrombi, and, by delivering mechanical pressure waves, exposes more thrombus surface to circulating TPA. In the CLOTBUST trial, the dramatic clinical recovery from stroke coupled with complete recanalization within 2 hours after TPA bolus occurred in 25% of patients treated with TPA+TCD compared to 8% of those that received TPA alone (p=0.02). Complete clearance of a thrombus and dramatic recovery of brain function during treatment are feasible goals for ultrasound-enhanced thrombolysis that can lead to sustained recovery. An early boost in brain perfusion seen in the CLOTBUST target group resulted in a trend of 13% more patients achieving favorable outcome at 3 months, thus providing the rationale for a pivotal trial. The ability of TPA to break up thrombi can be further enhanced with harmless diagnostic ultrasound contrast agents. Current ongoing clinical trials include phase II studies of 2 MHz TCD with ultrasound contrast agents, or microbubbles: TCD+TPA+Levovist; TCD+TPA+MRX nano-platform (C3F8 ImaRx). Intra-arterial ultrasound-enhanced TPA delivery is tested in the Interventional Management of Stroke (IMS) clinical trial using 1.7-2.1 MHz pulsed wave ultrasound catheter (EKOS). Dose escalation studies of microbubbles, ultrasound exposure and the development of an operator independent ultrasound device are currently underway. Spontana arterijska rekanalizacija odvija se po stopi od 6% na sat, što se može udvostručiti pomoću terapije intravenskim aktivatorom tkivnog plazminogena (TPA), jer u bolesnika liječenih pomoću TPA dolazi do ranog dramatičnog kliničkog poboljšanja kao nadomjestak za rano razbijanje tromba. Aktivnost TPA može se pojačati ultrazvukom uključujući transkranijski Doppler (TCD) od 2 MHz. TCD identificira signale ostatnog krvnog protoka oko trombusa te kroz stvaranje valova mehaničkog tlaka izlaže veću površinu tromba cirkulirajućem TPA. U pokusu CLOTBUST je značajan klinički oporavak od moždanog udara uz potpunu rekanalizaciju unutar 2 sata od davanja bolusa TPA nastupio u 25% bolesnika liječenih pomoću TPA+TCD, u usporedbi s 8% bolesnika koji su primili samo TPA (p=0,02). Potpuno uklanjanje tromba i značajan oporavak moždane funkcije tijekom liječenja izvedivi su ciljevi ultrazvukom pojačane trombolize koji mogu dovesti do održivog oporavka. Kao rezultat ranog stimuliranja moždane perfuzije, zabilježenog u ciljnoj skupini studije CLOTBUST, 13% više bolesnika postiglo je povoljan ishod nakon 3 mjeseca, pruživši time razlog za ključni pokus. Sposobnost TPA da razbije trombe može se dodatno pojačati neškodljivim dijagnostičkim kontrastnim sredstvima za ultrazvuk. Upravo su u tijeku kliničke studije 2. faze s kontrastnim sredstvima za ultrazvuk od 2 MHz ili mikrokuglicama TCD+TPA+Levovist; TCD+TPA+MRX nano-platforma (C3F8 ImaRx). Intraarterijsko davanje TPA pojačano ultrazvukom ispituje se u kliničkom pokusu Interventional Management of Stroke (IMS) uz primjenu ultrazvučnog katetera pulsnih valova od 1,7-2,1 MHz (EKOS). U tijeku su studije pojačavanja mikrokuglica, izlaganja ultrazvuku, kao i razvoj ultrazvučnog uređaja neovisnog o operatoru. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14074 http://hrcak.srce.hr/file/21547 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Invasive Treatment of Symptomatic Carotid Artery Stenosis - Present Status of Carotid Endarterectomy and Carotid Angioplasty Invazivno liječenje simptomatske stenoze karotidne arterije - trenutno stanje karotidne endarterektomije i karotidne angioplastike Brčić, Iva Klein, Günther E. Niederkorn, Kurt Carotid stenosis - therapy; Endarterectomy, carotid - stents; Cerebrovascular accident - prevention and control Karotidna stenoza - terapija; Endarterektomija - karotida, stentovi; Cerebrovaskularni incident - prevencija i kontrola In this paper we present carotid angioplasty with stenting (CAS) as a relatively new endovascular treatment for carotid stenosis. It has become an established alternative to carotid endarterectomy (CEA) for high-risk patients not eligible for surgery. After presenting data on CEA and CAS and studies comparing CEA and CAS, our results comparing the outcome of patients after CAS and carotid endarterectomy (CEA) are presented. Until December 2004, 183 patients with carotid artery desease (37% of asymptomatic and 63% of symptomatic internal carotid artery stenosis), mean age 68 years, were followed up for 133 days. During the first 24 hours of percutaneous transluminal coronary angioplasty with stenting (stent-PTA), 4 (2.2%) patients had transient ishemic attack (TIA) and 3 (1.5%) patients suffered stroke, and within 30 days post-intervention, another patient presented with TIA and another 2 patients had stroke. Overall 12 of 183 patients (6.6%) had cerebrovascular event (6 TIA and 6 stroke) during the 6-month follow up period. Clinical prognosis of this cohort treated with stent-PTA is comparable with data published in the literature. U ovom radu predstavlja se karotidna angioplastika sa stentiranjem (CAS) kao relativno nov postupak u liječenju karotidne stenoze koji može biti zamjena za karotidnu endarterektomiju (CEA) kod bolesnika s visokim rizikom koji nisu pogodni za operacijsko liječenje. Nakon prikaza podataka i studija o karotidnoj angioplastici i karotidnoj endarterektomiji prikazuju se vlastiti rezultati usporedbe i ishoda kod bolesnika liječenih karotidnom angioplastikom i karotidnom endarterektomijom. Do prosinca 2004. godine u studiju je uključeno 183 bolesnika sa stenozom karotidne arterije (37% asimptomatskih i 63% simptomatskih stenoza unutarnje karotidne arterije), prosječne dobi 68 (raspon 20-84) godina, od kojih su 64% bolesnika bili muškarci. Prosječno vrijeme praćenja bolesnika bilo je 133 dana. Tijekom prva 24 sata nakon izvođenja karotidne angioplastike 4 (2,2%) bolesnika je zadobilo TIA, a 3 (1,5%) bolesnika moždani udar. Nakon 30 dana još jedan bolesnik je zadobio tranzitornu ishemijsku ataku (TIA), a 2 bolesnika moždani udar. Ukupno je nakon 6 mjeseci 12 od 183 (6,6%) bolesnika imalo cerebrovaskularnu bolest (6 TIA i 6 moždani udar). Ishod bolesnika u ovoj studiji je usporediv s dosadašnjim rezultatima objavljenim u literaturi. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14075 http://hrcak.srce.hr/file/21548 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14076 2008-06-03 journal:158

Cerebral Vasomotor Reactivity and Carotid Occlusive Disease Moždana vazomotorna reaktivnost i okluzivna bolest karotidnih arterija Bornstein, Natan M. Gur, Alexander Y. Cerebrovascular circulation - ultrasonography; Vasomotor system - physiopathology; Carotid artery diseases - physiopathology; Arterial occlusive diseases - diagnosis Cerebrovaskularna cirkulacija - ultrazvuk; Vazomotorni sustav - fiziopatologija; Bolesti karotidnih arterija - fiziopatologija; Okluzivne arterijske bolesti - dijagnostika Cerebral autoregulation is a mechanism that enables relatively constant cerebral blood flow during variations of cerebral perfusion pressure. The differences between cerebral blood flow at rest and after administration of a potent vasodilatory stimulus test such as hypercapnia reflect cerebral vasomotor reactivity defined as the vasodilation capacity of cerebral arterioles to external stimuli, providing important information about the cerebral hemodynamic status. Cerebral vasomotor reactivity provides important information about the cerebral hemodynamic status. In this article, cerebral vasomotor reactivity assessment tests are presented, with emphasis on transcranial Doppler, as well as the use of transcranial Doppler in assessing cerebral vasomotor reactivity in carotid stenosis, occlusion, and the importance of cerebral vasomotor reactivity for carotid surgery. Moždana autoregulacija je mehanizam koji omogućava relativno ustaljeni moždani protok krvi za vrijeme promjena tlaka prokrvljenosti mozga. Razlike između moždanog protoka krvi u mirovanju i nakon testa snažne vazodilatacijske stimulacije poput hiperkapnije odražavaju moždanu vazomotornu reaktivnost definiranu kao vazodilatacijski kapacitet moždanih arteriola za vanjske poticaje, pružajući važne podatke o moždanom hemodinamskom statusu. Moždana vazomotorna reaktivnost daje važne informacije o statusu moždane hemodinamike. U članku se prikazuju testovi za procjenu moždane vazomotorne reaktivnosti s naglaskom na transkranijski Doppler, te primjena transkranijskog Dopplera u procjeni moždane vazomotorne reaktivnosti kod karotidne stenoze, okluzije, kao i važnost moždane vazomotorne reaktivnosti za kirurgiju karotidnih arterija. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14076 http://hrcak.srce.hr/file/21549 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14077 2008-06-03 journal:158

Transcranial Doppler as a Confirmatory Test in Brain Death Transkranijski doppler kao potvrdna pretraga kod moždane smrti Lovrenčić-Huzjan, Arijana Vuković, Vlasta Jergović, Krešimir Demarin, Vida Brain death - ultrasonography; Brain death - diagnosis; Brain death - physiopathology; Ultrasonography, Doppler - transcranial Moždana smrt - ultrazvuk; Moždana smrt - dijagnostika; Moždana smrt - fiziopatologija; Ultrazvuk, Doppler - transkranijski Brain death is defined as the irreversible loss of all brain functions, including the brainstem. The diagnosis of brain death allows organ donation or withdrawal of support. Therefore, the exact criteria for the diagnosis should be determined. In the Croatian legal acts on transplantation, repeated neurological examination must show the loss of brainstem reflexes, and one confirmation test has to be done. Several tests are available to show cessation of the brain or brainstem activity, or to confirm the cerebral circulatory arrest. Bedside evaluation is preferred, with the use of neurosonologic tests that show a high resistance pattern in hemodynamics, in parallel with the increase of intracranial pressure, eventually leading to cerebral circulatory arrest. Trained personnel and strict protocols are required. Bedside transcranial Doppler is presented along with the criteria and its value in brain death confirmation. Definicija moždane smrti uključuje gubitak svih funkcija mozga, uključujući onu moždanog stabla. Dijagnostika moždane smrti omogućava donaciju organa ili prekid potpore. Stoga se moraju točno odrediti kriteriji dijagnoze. Prema hrvatskom zakonu o transplantaciji, ponovljeni neurološki pregled mora pokazati gubitak refleksa moždanog stabla, a obvezan je i jedan od testova potvrde. Dostupno je nekoliko testova koji pokazuju prastanak funkcije mozga ili moždanog stabla ili daju potvrdu cerebralnog cirkulacijskog aresta. Prednost se daje primjeni uz krevet bolesnika neurosonoloških testova koji pokazuju porast rezistencije hemodinamskih krivulja usporedno s porastom intrakranijskog tlaka, što konačno dovodi do razvoja cerebralnog cirkulacijskog aresta. Za dijagnostiku je potrebno uvježbano osoblje i strogi protokoli. Prikazana je primjena transkranijskog Dopplera uz krevet bolesnika s kriterijima i vrijednosti testa u potvrdi moždane smrti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14077 http://hrcak.srce.hr/file/21550 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14078 2008-06-03 journal:158

Three-Dimensional Ultrasound in Cerebrovascular Evaluation Trodimenzionalni ultrazvuk u procjeni moždanog krvožilja Jurašić, Miljenka-Jelena Zavoreo, Iris Demarin, Vida Cerebral arterial diseases - ultrasonography; Carotid stenosis - ultrasonography; Carotid arteries - ultrasonography; Cerebrovascular circulation - physiology; Cerebrovascular circulation - ultrasonography Bolesti moždanih arterija - ultrazvuk; Karotidna stenoza - ultrazvuk; Karotidne arterije - ultrazvuk; Cerebrovaskularna cirkulacija - fiziologija; Cerebrovaskularna cirkulacija - ultrazvuk Three-dimensional ultrasound has started developing in the fifth decade of the last century using numerous imaging innovations. For the exploration of extracranial circulation, three-dimensional ultrasound is used primarily on carotid arteries that are easy to access due to their anatomical position. In the evaluation of intracranial circulation, three-dimensionality can be achieved only partially due to the size of the bony window that prevents probe movement in all 360°. Three-dimensional ultrasound allows greater spatial resolution than conventional two-dimensional ultrasound. In comparison with magnetic resonance, three-dimensional ultrasound reaches transaxial resolution of 5 mm, longitudinal resolution of up to 10 mm and rotational resolution of up to 40º. Other advantages are noninvasiveness, volumetric tissue analysis instead of planimetric analysis, relatively low cost with high reproduction accuracy, high sensitivity and specificity (r=0.982). The principal shortcomings of three-dimensional ultrasound are the impossibility to distinctly differentiate between periarterial and intra-arterial tissue that will cause problems with tissue segmentation, cost of the ultrasound device that is somewhat more expensive, and the need for a skilled operator. Movement artifacts are most responsible for all artifacts but are easy to diminish with the use of the mechanical arm and ECG synchronization. Three-dimensional ultrasound is best used as a complimentary method of examination along with conventional ultrasound that enables mandatory hemodynamic evaluation. Recently, along with three-dimensional ultrasound, four-dimensional ultrasound is being developed that will allow real time tissue movement analysis and thus atherosclerotic plaque instability assessment. Trodimenzionalni ultrazvuk se razvija od sredine pedesetih godina prošloga stoljeća uporabom raznih inovacija u slikovnom prikazu. U ispitivanju ekstrakranijske cirkulacije rabi se prvenstveno trodimenzionalni ultrazvuk karotidnih arterija koje su lako dostupne pregledu zbog obilježja njihovog smještaja. U procjeni intrakranijske cirkulacije trodimenzionalnost je moguće samo djelomice postići, jer zbog veličine koštanoga prozora opseg pokreta sondom u svih 360° nije moguće napraviti. Trodimenzionalni ultrazvuk dopušta veću prostornu rezoluciju od konvencionalnog, dvodimenzionalnog ultrazvuka. U usporedbi s magnetnom rezonancijom trodimenzionalni ultrazvuk omogućuje transaksijalnu rezoluciju od 5 mm, longitudinalnu rezoluciju do 10 mm i rotacijsku rezoluciju do 40º. Ostale prednosti su neinvazivnost, volumetrijska analiza tkiva umjesto planimetrijske, relativno niska cijena uz veliku točnost reprodukcije, te visoka osjetljivost i specifičnost (r=0,982). Glavni nedostaci trodimenzionalnog ultrazvuka su nemogućnost jasnog razlikovanja periarterijskog i intraarterijskog tkiva, što uzrokuje probleme u segmentaciji tkiva, trošak nabave ultrazvučnog uređaja koji je nešto veći od troška nabave konvencionalnog uređaja, a uz to je potreban i vrsni operater. Pomaci tkiva također uzrokuju brojne artefakte, no uporabom mehaničke ruke i EKG sinhronizacije moguće je umanjiti navedene poteškoće. Trodimenzionalni ultrazvuk najbolje je rabiti kao dopunsku metodu pregleda uz konvencionalni ultrazvuk koji dopušta nužnu hemodinamsku procjenu. Uz trodimenzionalni ultrazvuk razvija se i četverodimenzionalni ultrazvuk koji omogućava prikaz pomaka tkiva u stvarnom vremenu, čime su dostupne informacije o nestabilnosti aterosklerotskog plaka. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14078 http://hrcak.srce.hr/file/21551 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14079 2008-06-03 journal:158

Neurosonology in Stroke Neurosonologija kod moždanog udara Lovrenčić-Huzjan, Arijana Vuković, Vlasta Demarin, Vida Brain diseases - ultrasonography; Cerebrovascular disorders - ultrasonography; Ultrasonography - Doppler - transcranial Bolesti mozga - ultrazvuk; Cerebrovaskularne bolesti - ultrazvuk; Ultrazvuk - Doppler - transkranijski This article presents the use of neurosonology in stroke. It is an extended presentation of its use in stroke, as part of the Recommendations for Stroke Management . 2006 Update, published in 2006, endorsed by the Croatian Society for Neurovascular Disorders of Croatian Medical Association; Croatian Stroke Society; and University Department of Neurology, Sestre milosrdnice University Hospital, Reference Center for Neurovascular Disorders of the Croatian Ministry of Health and Welfare. The Recommendations are in concordance with those issued by three European societies represented in the European Stroke Initiative: the European Stroke Council, the European Neurological Society, and the European Federation of Neurological Societies, as well as with the Guidelines of the American Heart Association/American Stroke Association Council on Stroke, affirmed by the American Academy of Neurology. Ovaj članak prikazuje upotrebu neurosonologije u moždanom udaru. Ovo je prošireni prikaz upotrebe u moždanom udaru kao dijela "Preporuka za zbrinjavanje moždanog udara - osuvremenjeno 2006.", koje su objavljene 2006. godine, a odobrilo ih je Hrvatsko društvo za neurovaskularne poremećaje Hrvatskoga liječničkog zbora, Hrvatsko društvo za prevenciju moždanog udara i Klinika za neurologiju KB .Sestre milosrdnice. kao Referalni centar za neurovaskularne poremećaje Ministarstva zdravstva i socijalne skrbi Republike Hrvatske. Preporuke su u skladu s preporukama triju europskih društava uključenih u Europsku inicijativu za moždani udar (European Stroke Initiative, EUSI): Europsko vijeće za moždani udar, Europsko neurološko društvo i Europsko udruženje neuroloških društava, kao i s Preporukama Američkoga udruženja za srce/Američkoga društva za moždani udar, što ih je odobrila Američka akademija neurologa. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-12-01 text pdf http://hrcak.srce.hr/14079 http://hrcak.srce.hr/file/21552 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.4; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14080 2008-06-03 journal:158

Alcohol Dependence in a Patient with Brain Tumor Alkoholna ovisnost u bolesnika s tumorom mozga Čatipović, Vinko Drobac, Radomir Brain neoplasms - etiology; Brain neoplasms - diagnosis; Alcoholism - complications; Risk factors; Case report Neoplazme mozga - etiologija; Neoplazme mozga - dijagnostika; Alkoholizam - komplikacije; Rizični čimbenici; Prikaz slučaja Alcoholism is accompanied by many physical, neurological, psychical and social complications. Relevant literature explains the etiologic association between alcoholism and upper gastrointestinal tract carcinoma; however, alcoholism may also be associated with tumors of other localizations. Presentation is made of a patient with alcohol dependence with development of meningioma. The patient was admitted to Department of Psychiatry, Bjelovar General Hospital, for the treatment of alcoholism. The history and hetero-history data showed prolonged intensive alcoholism associated with impaired family and occupational functioning. The immediate reason for presentation was his employer.s demand to undergo treatment due to severe impairment of occupational functioning. On admission, discrepancy between pronounced memorizing and recollection deficits, and relatively preserved somatic status, free from personality deterioration was observed. Mild dysarthria and coordination disturbances along with verified memorizing deficit indicated neuroradiological studies, which confirmed the suspected brain tumor. Although there are no literature reports suggesting an etiologic association of alcoholism and brain meningioma, the concurrence of alcoholism and many other diseases, with the possible overlooking either of them, was already indicated by Bleuler, noting that the comorbid groups of symptoms may assume an .alcoholic tinge.. The aim of the present report is to point to difficulties in the differential diagnosis of alcoholism and to the risk of independent pathologic conditions being masked by alcohol dependence. Alkoholizam je praćen brojnim tjelesnim, neurološkim, psihičkim i socijalnim komplikacijama. Stručna literatura objašnjava etiološku povezanost alkoholizma i karcinoma gornjeg probavnog sustava, ali je moguća povezanost i s tumorima drugih lokalizacija. Prikazuje se bolesnik ovisan o alkoholu kod kojega se je razvio meningeom. Bolesnik je primljen na Odjel za psihijatriju Opće bolnice Bjelovar radi liječenja alkoholizma. Anamneza i heteroanamneza su ukazale na intenzivni višegodišnji alkoholizam sa zakazivanjem u obitelji i na radnom mjestu. Neposredni razlog za upućivanje na liječenje bio je ultimatum poslodavca zbog zakazivanja na radnom mjestu. U statusu je već kod prijma uočen nesklad između izraženog mnestičnog deficita i relativno očuvanog somatskog statusa, bez pogoršanja ličnosti. Blaža dizartrija i smetnje koordinacije uz potvrđene mnestične smetnje ukazivale su na potrebu neurološke obrade, koja je potvrdila sumnju na tumor mozga. Literatura ne ukazuje na etiološku povezanost alkoholizma i meningeoma mozga, ali je još Bleuler pisao o istodobnoj pojavi alkoholizma i mnogih drugih bolesti, uz opasnost previda jedne od njih, navodeći kako komorbidne skupine simptoma mogu dobiti "alkoholnu boju". Cilj rada je ukazati na diferencijalno dijagnostičke teškoće pri obradi alkoholičara i opasnost prekrivanja nezavisnih patoloških stanja plaštem alkoholne ovisnosti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14080 http://hrcak.srce.hr/file/21553 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14081 2008-06-03 journal:158

Hospital Ecology Ekologija bolničkih ustanova Čiček, Josip Hospitals - environmental monitoring; Ecology; Occupational diseases - etiology; Risk factors Bolnice - motrenje okoliša; Ekologija; Profesionalne bolesti - etiologija; Rizični čimbenici A review of hospital ecology during the history of mankind is presented. It is noted that hospitals in ancient times and sanatoriums in subsequent historical periods were not accidentally located in natural ambient to take advantage of the most favorable factors of natural environment. Ancient medicine lacked the knowledge of the etiology of many diseases, thus tending to ensure optimal ambient and environmental conditions in the then hospitals. This tendency continued up to the discovery of infectious disease agents. Owing to the significant amount of knowledge and huge technological progress in current clinical medicine, modern hospitals are characterized by immense interpenetration and interaction of numerous factors, producing a major problem of preserving and maintaining the premises as free as possible from the potential adverse effects on both service users and providers. The use of novel materials and technologies entails new problems such as the sick building syndrome. The most important elements of hospital ecology are presented in detail, along with proposals for improvement of the condition in this segment of health care. Razmatra se ekologija bolničkih ustanova tijekom povijesti ljudskog roda. Naglašava se činjenica kako nije slučajno da su u antičkim vremenima bolnice, a kasnije i sanatoriji bili smješteni u prirodnim ambijentima koji su trebali koristiti najpovoljnije činitelje prirodne okoline. Pramedicina je bila bez saznanja o etiologiji brojnih bolesti, stoga je u prabolnicama nastojala osigurati optimalne ambijentalne i okolišne uvjete. Taj se trend nastavio do otkrića uzročnika zaraznih bolesti U modernim bolničkim ustanovama zahvaljujući značajnim saznanjima i velikom tehnološkom napretku u suvremenoj kliničkoj medicini postoji tijesna isprepletenost i interakcija brojnih činitelja, tako da se javlja značajan problem očuvanja i održavanja tih prostora sa što manje možebitnih štetnih učinaka za korisnike i pružatelje usluga. Uporabom pak novih materijala i tehnologija pojavljuju se novi problemi poput "sindroma bolesne zgrade". U radu se podrobno razmatraju bitni elementi ekologije bolnica i daju prijedlozi za unaprjeđenje stanja u tom području. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14081 http://hrcak.srce.hr/file/21554 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Self-Induced Ulceration of Ala Nasi in Trigeminal Trophic Syndrome . Operative Psychiatric Approach Samoizazvana ulceracija nosnog krila u trigeminalnom trofičnom sindromu - kirurško psihijatrijsko liječenje Grabovac, Stjepan Skin ulcer - etiology; Skin ulcer - surgery; Skin ulcer - psychology; Reconstructive surgical procedures - methods; Nose; Trigeminal nerve injuries; Self mutilation psychology Kožni ulkus - etiologija; Kožni ulkus - kirurgija; Kožni ulkus - psihologija; Rekonstrukcijski kirurški zahvati - metode; Nos; Ozljede trigeminalnog živca; Psihologija samoozljeđivanja Self-induced ulceration of ala nasi in trigeminal trophic syndrome is a rare complication secondary to trigeminal nerve peripheral or central lesion, which occurs as a sequel of anesthesia and facial paresthesias associated with compulsive touching of the nose. Two patients with trigeminal trophic syndrome associated with facial and statoacoustic nerve lesion following statocoustic neurinoma surgery are described. Successful ala nasi reconstruction with psychiatric treatment for prevention of compulsive nose touching was performed in one patient. Samoizazvana ulceracija nosnog krila u okviru trigeminalnog trofičnog sindroma rijetka je komplikacija koja nastaje nakon periferne ili središnje ozljede trigeminalnog živca, kao posljedica anestezije i parestezija lica udruženih s prisilnim diranjem nosa. Opisuju se dvojica bolesnika s trigeminalnim trofičnim sindromom i ozljedom ličnog i statoakustičnog živca nakon operacije statoakustičnog neurinoma. Kod jednog bolesnika učinjena je uspješna rekonstrukcija nosnog krila u kombinaciji s psihijatrijskim liječenjem radi sprječavanja prisilno uvjetovanog diranja nosa. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14082 http://hrcak.srce.hr/file/21555 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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The Experience of the Croatian Army Brigade 105 Medical Corps Unit as a Mobile Surgical Team 1991-1992 Iskustva saniteta 105. brigade Hrvatske vojske kao mobilnog kirurškog tima tijekom 1991-1992. godine Grabovac, Stjepan Ferenčak, Vladimir Habek, Dubravko Košćak, Darko Mobile surgical team; Military medicine; War; Croatia Mobilni kirurški tim; Vojna medicina; Rat; Hrvatska The fierce and abrupt aggression on Croatia in 1991-1992, characterized by practically no border between the battlefield and the rear, communication breakdown, destroyed economy, and great psychological impact on both civilians and army units imposed the need of high-professional, independent mobile medical corps units qualified for providing highly differentiated health care immediately upon wound infliction, and for efficient evacuation and transportation of patients in extremely difficult conditions. The structure and work of the Medical Corps Unit working as a mobile surgical team of the Croatian Army Brigade 105 from Bjelovar, Croatia, from September 1, 1991 till October 1, 1992 is presented. With such a unit structure, the time of patient transfer to operative theater was considerably reduced, thus decreasing the overall patient morbidity and mortality, and minimizing the definitive grade of disability. During the study period, 242 operative procedures were performed in 228 patients, 222 of these in local anesthesia and 20 in general anesthesia. The overall Brigade 105 mortality was 2.16%. Snažna i iznenadna agresija na Hrvatsku tijekom 1991. i 1992. godine, praktično izjednačavanje bojišnice i pozadine, prekinute prometnice, gospodarsko osiromašenje te snažan psihološki učinak kako na civilno stanovništvo tako i na vojne postrojbe zahtijevali su osnivanje visokostručnih, neovisnih mobilnih sanitetskih timova osposobljenih za pružanje visoko diferencirane zdravstvene zaštite neposredno nakon nastanka ozljede te za evakuaciju i prijevoz ranjenika pod najtežim uvjetima. Prikazuje se rad i organizacija brigadnog sanitetskog voda 105. brigade Hrvatske vojske iz Bjelovara u razdoblju od 1. rujna 1991. do 1. listopada 1992. godine, koji je djelovao kao mobilna kirurška ekipa. Ovakav ustroj je skratio put ozlijeđenih prema kirurškoj sali i tako smanjio pobol i smrtnost ranjenika, a konačni invaliditet sveo na najmanju moguću mjeru. U navedenom razdoblju liječeno je 228 ranjenika u kojih su izvedena 242 operacijska zahvata, od toga 122 u lokalnoj, a 20 u općoj anesteziji. Ukupna smrtnost u 105. brigadi bila je 2,16%. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14083 http://hrcak.srce.hr/file/21556 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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When to Use and How to Interpret Ambulatory Blood Pressure Monitoring Findings Kada primijeniti i kako tumačiti nalaz kontinuiranog mjerenja arterijskog tlaka Ivanac, Renata Ivanuša, Mario Jelaković, Bojan Blood pressure monitoring; Hypertension - diagnosis; Hypertension - etiology; Hypertension - prevention and control; Cardiovascular diseases - prevention and control Motrenje krvnog tlaka; Hipertenzija - dijagnostika; Hipertenzija - etiologija; Hipertenzija - prevencija i suzbijanje; Srčanožilne bolesti - prevencija i suzbijanje Ambulatory blood pressure monitoring (ABPM) is a noninvasive diagnostic method performed for 24-48 hours, along with daily activities and during sleep, thus being highly useful in cases where the need of antihypertensive medication should be evaluated, in patients with suspected white coat hypertension, nocturnal hypertension, hypertension resistant to combined therapy, and those with borderline hypertension. ABPM helps in the evaluation of the prescribed therapy effects, hypotension, autonomic dysfunction, hypertension in pregnancy, in the elderly and type 1 diabetics, as well as in elucidation of syncopal states and "accidental" hypertension. With appropriate use of ABPM the optimal therapeutic effect can be achieved and the risk of arterial hypertension sequels assessed. Kontinuirano mjerenje arterijskog tlaka (KMAT) je neinvazivna dijagnostička metoda koja se primjenjuje tijekom 24-48 sati uz obavljanje uobičajenih dnevnih aktivnosti i spavanja, pa je njezina korist dokazana u slučajevima gdje treba prosuditi nužnost primjene antihipertenzivnih lijekova, kod osoba sa sumnjom na hipertenziju bijelog ogrtača, noćnu hipertenziju, hipertenziju otpornu na kombiniranu terapiju te u bolesnika s graničnom hipertenzijom. KMAT pomaže i u procjeni učinka propisane terapije, procjeni hipotenzije, autonomne disfunkcije, hipertenzije u trudnica, starijih osoba i dijabetičara tipa 1, kao i u razjašnjavanju sinkopalnih stanja te "slučajnih" hipertenzija. Pravilnom uporabom KMAT postiže se optimalan učinak terapije i procjenjuje opasnost od posljedica arterijske hipertenzije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14084 http://hrcak.srce.hr/file/21557 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Development of Noninvasive Cardiology Diagnosis at Bjelovar General Hospital 1975-2005 Razvoj neinvazivne kardiološke dijagnostike u Općoj bolnici Bjelovar od 1975. do 2005. godine Ivanuša, Mario Cardiovascular diseases - diagnosis; Diagnostic techniques cardiovascular - methods; Diagnostic techniques cardiovascular - history; Internal department hospital; Croatia Srčanožilne bolesti - dijagnostika; Dijagnostičke tehnike, srčanožilne - metode; Dijagnostičke tehnike, srčanožilne - povijest; Odjel za unutarnje bolesti, bolnica; Hrvatska The rising tendency of cardiovascular disease morbidity and mortality has entailed an increased demand of noninvasive cardiology diagnostic procedures. The aim of this study was to analyze the number of procedures performed at Cardiology Laboratory, Bjelovar General Hospital, in order to emphasize the role of education of all personnel involved in the process of organization, prevention, diagnosis and treatment of cardiovascular disease, substantiated by our own experience in the field. From May 15, 1975 till December 31, 2004, a total of 32,026 diagnostic procedures were performed, with a predominance of exercise test (52%), followed by 24-h electrocardiography (26%), transthoracic echocardiography (18%), 24-h ambulatory blood pressure monitoring (3%), and lower extremity arterial and venous Doppler (<1%). During 1995-2004 period, 2074 procedures were performed per year on an average, yielding a 12-fold increase relative to the first ten years of work. The use of an integrated software system enables efficient processing of medical documentation thus produced, along with its professional, scientific and economic evaluation. The experience acquired should be communicated not only to medical professionals from the Hospital catchment area but also to the community at large, in the form of lectures and continuous publication of results in scientific and professional periodicals. Evaluation of the results and continuing education of all medical personnel, along with appropriate education of the general population are the basis of successful management and prevention of cardiovascular disease. Rastući trend pobola i smrtnosti od srčanožilnih bolesti očituje se u povećanim zahtjevima za neinvazivne kardiološke dijagnostičke postupke. Cilj ovoga prikaza je analiza broja učinjenih postupaka u Kardiološkom laboratoriju Opće bolnice Bjelovar. Prikazom vlastitih iskustava želi se naglasiti važnost izobrazbe svih djelatnika koji sudjeluju u procesima organizacije, prevencije, dijagnostike i zbrinjavanja srčanožilnih bolesti. U razdoblju od 15. svibnja 1975. do 31. prosinca 2004. godine učinjeno je 32.026 dijagnostičkih postupaka. Najviše je bilo ergometrija (52%), slijede 24-satno snimanje elektrokardiograma (26%), transtorakalna ehokardiografija (18%), 24-satno kontinuirano mjerenje arterijskog tlaka (3%), te Doppler arterija i vena donjih ekstremiteta (<1%). U odnosu na prvih deset godina rada, od 1995. do kraja 2004. godine prosječno je učinjeno 2.074 postupaka na godinu, što čini porast broja pretraga za 12 puta. Učinkovitu obradu nastale medicinske dokumentacije i njenu procjenu u stručnom, znanstvenom i ekonomskom smislu omogućuje primjena integriranog softverskog sustava. O stečenim iskustvima treba obavijestiti ne samo krug liječnika koji gravitira bolnici, nego i širu zajednicu, i to kroz predavanja i stalno objavljivanje rezultata u znanstvenim i stručnim časopisima. Procjenjivanje vlastitih rezultata rada i stalna medicinska izobrazba svih zdravstvenih djelatnika, ali i cjelokupnog stanovništva čine temelj uspješnog liječenja i prevencije srčanožilnih bolesti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14085 http://hrcak.srce.hr/file/21558 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Laparoscopic Three-Trocar Cholecystectomy at Bjelovar General Hospital Laparoskopska kolecistektomija pomoću tri trokara u Općoj bolnici Bjelovar Košćak, Darko Lovrić, Josip Key words: Cholecystectomy, laparoscopic -methods; Cholecystectomy, laparoscopic - instrumentation; Cholecystectomy, laparoscopic - complications; Cholelithiasis - surgery; Hospital Bjelovar; Croatia Kolecistektomija, laparoskopska - metode; Kolecistektomija, laparoskopska - instrumentarij; Kolecistektomija, laparoskopska - komplikacije; Kolelitijaza - kirurgija; Bolnica Bjelovar; Hrvatska A modified European technique of laparoscopic cholecystectomy with the use of three trocars, employed in 599 patients at Bjelovar General Hospital from July 1999 till July 2004, is described. The indications and patient selection for this operative method are the same as for laparoscopic cholecystectomy performed with four trocars. There is no modification in the preoperative procedure and treatment, anesthesia, patient.s position and preparation for the operation either. The instrumentarium and equipment used on laparoscopic cholecystectomy were manufactured by Olympus. In 577 (96%) cases, the procedure was completed laparoscopically, whereas conversion to open procedure was required in 22 (4%) cases. A fourth trocar had to be placed in 20 (3.5%) of 577 (96%) successful three-trocar procedures of laparoscopic cholecystectomy. The procedure took about 45 min on an average. Considering complications, shoulder pain developed in 60, minor hematoma in 12, and nausea for more than 12 hours in 40 patients. There was no mortality. Bile leak from the gallbladder bed that spontaneously stopped within 72 hours and postoperative drain bleeding that resolved spontaneously requiring no blood transfusion were recorded in one patient each. The mean patient stay at hospital was 2.7 days. It is concluded that laparoscopic cholecystectomy with a reduced number of incisions, i.e. with three trocars, is as successful procedure of gallbladder removal without increasing the rate of complications. However, a fourth trocar should be placed or conversion to open procedure performed whenever indicated by the local finding. Prikazuje se modificiran europski način izvođenja laparoskopske kolecistektomije pomoću tri trokara, koji je u razdoblju od srpnja 1999. do srpnja 2004. godine u Općoj bolnici u Bjelovaru primijenjen kod 599 bolesnika. Indikacije za ovaj način operiranja jednake su kao i za dosadašnji način s četiri trokara, a razlike nema niti u odabiru bolesnika. Prijeoperacijska priprema i obrada, anestezija, položaj bolesnika i priprema bolesnika za operaciju se ne razlikuju. Upotrebljavao se je instrumentarij i oprema za laparoskopsku kolecistektomiju tvrtke Olympus. U 577 (96%) slučajeva zahvat je izvršen laparoskopski, a u 22 (4%) slučaja učinjena je konverzija u otvoreni postupak. Od 577 (96%) uspješno izvedenih kolecistektomija laparoskopskim putem s tri trokara kod 20 (3,5%) slučajeva bilo je potrebno postaviti i četvrti trokar. Operacijski zahvati u prosjeku su trajali oko 45 minuta. Od komplikacija je bol u ramenu nastupila kod 60, manji krvni podljev u 12, te mučnina duže od 12 sati kod 40 bolesnika. Nije zabilježen niti jedan smrtni slučaj. U jednog bolesnika došlo je do curenja žuči iz ležišta žučnjaka, što je spontano prestalo kroz 72 sata. Poslijeoperacijsko krvarenje na dren nastupilo je kod jednog bolesnika, što je spontano prestalo i nije zahtijevalo transfuziju krvi. Bolesnici su boravili u bolnici prosječno 2,7 dana. Izvođenjem laparoskopske kolecistektomije s manjim brojem incizija, a to znači kroz tri trokara, uspješno se postiže isti cilj, tj. odstranjenje žučnog mjehura, ali bez porasta broja komplikacija. Kadgod to nalaže lokalni nalaz, treba postaviti četvrti trokar ili učiniti konverziju u otvoreni postupak. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14086 http://hrcak.srce.hr/file/21565 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Perforation of Meckel.S Diverticulum . Case Report Perforirani Meckelov divertikul - prikaz slučaja Košćak, Darko Allouch, Ali Lovrić, Josip Meckel's diverticulum - surgery; Meckel's diverticulum - pathology; Meckel's diverticulum - complications; Laparoscopy Meckelov divertikul - kirurgija; Meckelov divertikul - patologija; Meckelov divertikul - komplikacije; Laparoskopija Perforated callous ulcer of Meckel.s diverticulum on the base of heterotopic gastric mucosa, in a 20-year-old man is presented as a relatively rare and unusual case interesting for its localization and histopathologic substrate. Preoperative diagnosis of Meckel.s diverticulum is extremely rare, as there is no efficient and reliable diagnostic procedure in spite of the great diagnostic progress in general. In case of clinical suspicion, multiple diagnostic procedures should be performed to increase the likelihood of preoperative diagnosis. Meckel.s diverticulum is usually detected when inflammatory complications mimicking the clinical picture of acute appendicitis have already set in. There are no specific symptoms of the pathologic changes in Meckel.s diverticulum, thus the diagnosis is most frequently reached intraoperatively, as in the case presented. The patient underwent laparotomy for the clinical picture of diffuse peritonitis. During the operative procedure, a gangrenous, inflamed perforated Meckel.s diverticulum was found, at 80-cm distance from ileocecal valve. The diverticulum was of a thumb size, with a perforation orifice at the base, located on the mesenterial aspect of the intestine. Due to its position, the perforation orifice was located in the triangle formed by the base of diverticulum, ileum and respective mesenterium. Such a localization of Meckel.s diverticulum and perforation orifice required resection of the diverticulum, segments of the intestine with mesenterium, and terminoterminal anastomosis. Based on the heterotopic gastric mucosa, the histopathologic finding indicated a callous perforated ulcer of Meckel.s diverticulum. As the Meckel.s diverticulum consisted of all layers of the ileum wall, there was no doubt that it was a true Meckel.s diverticulum. The postoperative course proceeded uneventfully and the patient was discharged from the hospital on postoperative day 14, in good general condition and with normal abdominal finding. Prikazuje se slučaj perforiranog kaloznog ulkusa Meckelova divertikula na osnovi heterotopne želučane sluznice kod dvadesetogodišnjeg muškarca. Slučaj je relativno rijedak i neuobičajen, te zanimljiv zbog lokalizacije i patohistološkog supstrata. Prijeoperacijsko dijagnosticiranje Meckelova divertikula iznimno je rijetko. Usprkos velikom napretku u dijagnostici još uvijek nema učinkovitog i pouzdanog dijagnostičkog postupka. U slučaju kliničke sumnje treba primijeniti višestruke dijagnostičke pretrage kako bi se povećali izgledi za postavljanje prijeoperacijske dijagnoze. Meckelov divertikul uglavnom se otkriva onda kad nastanu upalne komplikacije koje oponašaju kliničku sliku akutnog apendicitisa. Ne postoje znakoviti simptomi patoloških promjena kod Meckelova divertikula, pa se dijagnoza najčešće postavlja intraoperacijski, kao i u ovdje prikazanom slučaju. Laparotomija je učinjena zbog kliničke slike difuznog peritonitisa. Za vrijeme operacije nađen je gangrenozno upalno promijenjen perforirani Meckelov divertikul, udaljen 80 cm od ileocekalne valvule. Divertikul je bio veličine ručnog palca s perforacijskim otvorom na bazi, a bio je smješten na mezenterijskoj strani crijeva. Zbog takvog položaja perforacijski otvor se je nalazio u trokutu baze divertikula, ileuma i pripadajućeg mezenterija. Takav smještaj Meckelova divertikula i perforacijskog otvora zahtijevao je resekciju divertikula, dijela crijeva i pripadajućeg mezenterija, te terminoterminalnu anastomozu. Patohistološki nalaz ukazivao je na kalozni perforirani ulkus Meckelova divertikula, na osnovi heterotopne želučane sluznice. Kako se je opisani Meckelov divertikul sastojao od svih slojeva stijenke ileuma, bilo je izvan svake sumnje da se radi o pravom Meckelovom divertikulu. Poslijeoperacijski tijek je kod bolesnika protekao uredno te je otpušten iz bolnice četrnaestog dana poslije operacije u dobrom općem stanju s urednim abdominalnim nalazom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14087 http://hrcak.srce.hr/file/21566 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Is Hyperhomocysteinemia Approaching Traditional Risk Factors for Cardiovascular Diseases? Približava li se hiperhomocisteinemija tradicionalnim čimbenicima rizika za srčanožilne bolesti? Lovčić, Vesna Klobučić, Mislav Bašić-Jukić, Nikolina Lovčić, Petra Hyperhomocysteinemia - complications; Hyperhomocysteinemia - physiopathology; Cardiovascular diseases Hiperhomocisteinemija - komplikacije; Hiperhomocisteinemija - fiziopatologija; Kardiovaskularne bolesti - fiziopatologija; Kardiovaskularne bolesti - komplikacije Hyperhomocysteinemia is an independent risk factor for cardiac, cerebral and peripheral vascular disease as well as for venous thromboembolic disease. Its clinical relevance appears to approach the known, traditional risk factors such as hypercholesterolemia, diabetes mellitus, hypertension, and cigarette smoking. The benefit of homocysteine concentration reduction has been demonstrated in cardiovascular disease. The recommended drug dosage varies among clinical studies, depending on the etiology of hyperhomocysteinemia and on homocysteine and folic acid concentrations in patient serum; however, there is general consensus that folic acid and vitamin B12 are first line treatment. In addition, measurement of homocysteine concentration is advised in patient groups at risk, with an increased daily dietary vitamin intake in these patients. Hiperhomocisteinemija je neovisan čimbenik rizika za bolesti krvnih žila srca, mozga, periferije i tromboembolijske bolesti vena. Po važnosti se približila dosadašnjim tradicionalnim čimbenicima rizika: hiperkolesterolemiji, šećernoj bolesti, hipertenziji i pušenju. Dokazana je korist sniženja koncentracije homocisteina u srčanožilnim bolestima. Zaključci kliničkih pokusa se razilaze u preporuci o dozi lijeka, ovisno o etiologiji hiperhomocisteinemije te koncentraciji homocisteina i folne kiseline u serumu bolesnika, no svi se slažu da je davanje folne kiseline i vitamina B12 osnova liječenja. Uz to se preporuča mjerenje koncentracije homocisteina u rizičnim skupinama bolesnika i savjetuje pojačan dnevni unos vitamina hranom u ovih bolesnika. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14088 http://hrcak.srce.hr/file/21567 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Trisomy 8: A Case Report Trisomija 8: prikaz bolesnika Lui-Peranić, Jadranka Petković, Iskra Sekelj-Fureš, Jadranka Abnormalities, multiple - genetics; Chromosomes, human - pair 8; Immunologic diseases - genetics; Mosaicism; Trisomy Nenormalnosti, višestruke - genetika; Kromosomi, ljudski - par 8; Imune bolesti - genetika; Mozaicizam; Trisomija An 8-month-old infant with trisomy 8 mosaicism is described. Chromosome 8 trisomy was present in 36% of cells. Clinical characteristics were so typical that cytogenetic analysis only confirmed the diagnosis. Deep skin furrows on the palms and soles were the most pronounced phenotype characteristics, whereas most numerous alterations were those involving skeletal system and urinary tract. Prikazuje se osmomjesečno dojenče s mozaicizmom trisomije 8, kod kojega je trisomija kromosoma 8 bila prisutna u 36% stanica. Kliničke značajke bile su tako znakovite da je citogenetska analiza samo potvrdila dijagnozu. Od fenotipskih oznaka naročito su se isticale duboke brazde dlanova i tabana, a najbrojnije promjene bile su na koštanom i mokraćnom sustavu. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14089 http://hrcak.srce.hr/file/21568 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14090 2008-06-03 journal:158

Headache and Pregnancy. A Multidisciplinary Approach Glavobolja i trudnoća - multidisciplinski pristup Šklebar, Duška Vrabec-Matković, Dragica Šklebar, Ivan Vuković, Ante Pregnancy complications - etiology; Pregnancy complications - diagnosis; Head and neck neoplasms - diagnosis; Pituitary neoplasms - diagnosis Komplikacije trudnoće - etiologija; Komplikacije trudnoće - dijagnostika; Neoplazme glave i vrata - dijagnostika; Neoplazme hipofize A 34-year-old pregnant woman presented for neurologic examination for headache and vision impairment. Neurologically, decreased responsiveness of the right pupil and discrete hemiparesis with positive Babinski reflex were objectively observed. During clinical monitoring, periods of neurologic deficit improvement and exacerbation with alternating lateralization were recorded. The appropriate diagnostic (neuroradiologic) work-up could not be employed because of pregnancy and the patient.s refusal to undergo these examinations; therefore, the patient was monitored clinically and by use of methods posing no fetal risk. Upon delivery that proceeded uneventfully, the patient underwent neuroradiologic examinations that revealed an expansive neoplasm in the pituitary region. The patient was operatively treated by transsphenoidal selective adenomectomy. Preoperative hormone test findings as well as histology and immunohistochemistry findings confirmed it to be macroprolactinoma of the pituitary gland. The diagnosis and treatment of this patient required team work of a number of different specialties. Opisuje se slučaj 34-godišnje trudnice koja se je u četvrtom mjesecu trudnoće javila neurologu zbog glavobolje i osjećaja slabljenja vida. Objektivno je neurološki utvrđena slabija reaktibilnost desne zjenice te diskretna hemipareza lijevo, uz pozitivan Babinskijev refleks. Tijekom kliničkog praćenja zabilježena su razdoblja poboljšanja i pogoršanja neurološkog deficita uz promjenu lokalizacije. Primjerena dijagnostička (neuroradiološka) obrada nije se mogla provesti zbog trudnoće i poglavito zbog odbijanja same trudnice, pa je ona praćena klinički i metodama koje nisu predstavljale rizik za plod. Nakon poroda koji je protekao bez komplikacija provedena je neuroradiološka obrada koja je pokazala ekspanzivnu tvorbu u području hipofize. Bolesnica je liječena operacijski transsfenoidnom selektivnom adenomektomijom. Hormonski nalazi dobiveni prije operacije te histološki i imunohistokemijski nalazi potvrdili su makroprolaktinom hipofize. Tijekom dijagnostike i liječenja postojala je potreba za timskom suradnjom više različitih specijalnosti. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14090 http://hrcak.srce.hr/file/21570 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14091 2008-06-03 journal:158

Possibilities of Anesthesia Cost Management by Analysis of Different Anesthesiology Techniques Mogućnosti upravljanja materijalnim troškovima anestezije analizom različitih anestezioloških tehnika Šklebar, Ivan Vranko-Nagy, Nada Šklebar, Duška Anesthesia - economics; Health care costs; Cost and cost analysis; Anesthesia - methods Anestezija - ekonomika; Troškovi u zdravstvu; Troškovi i analiza troškova; Anestezija - metode The must of material cost rationalization in medical practice has stimulated the authors to analyze the structure of material expenses of spinal and general anesthesia on a model of arthroscopic knee surgery. The aim was to determine whether the cost of spinal anesthesia was still lower than that of general anesthesia after the introduction of expensive atraumatic needles. In addition, we were interested in the extent to which our daily practice correlated with that in industrialized countries and what were the possibilities of cost rationalization. Using retrograde analysis of two comparable groups of 40 patients each, submitted to arthroscopic knee surgery in general or spinal anesthesia, the anesthesia material expenses were divided into variable and constant expenses that are partially common to both types and partially specific for each type of anesthesia. The sums of variable and specific expenses were compared between the two types of anesthesia, amounting to 78,26 HRK for spinal anesthesia and 115,19 HRK for general anesthesia. There were no major operative or postoperative complications in either patient group. As only 40% of the procedures were performed in spinal anesthesia, whereas the respective figure in industrialized countries exceeds 70%, there is obviously much room for savings. If the percent of the procedures performed in spinal anesthesia were increased to the feasible 60%, a saving of 1470 HRK would be achieved exclusively in knee arthroscopy surgery, considering that some 200 procedures have been performed per year. Imperativ racionalizacije materijalne potrošnje u medicinskoj praksi potaknuo je autore da na modelu artroskopske operacije koljena analiziraju strukturu materijalnih troškova spinalne i opće anestezije. Cilj je bio utvrditi je li spinalna anestezija i nakon uvođenja skupih atraumatskih igala i dalje jeftinija od opće anestezije. Zanimalo nas je kako naša dnevna praksa korelira s onom u razvijenim zemljama i koje su mogućnosti racionalizacije. Retrogradnom analizom dviju usporedivih skupina od po 40 bolesnika artroskopiranih u općoj, odnosno spinalnoj anesteziji materijalni troškovi anestezije podijeljeni su na varijabilne i stalne, od kojih je dio univerzalan za obje anestezije, a dio specifičan za svaki tip anestezije. Uspoređivane su sume varijabilnih i specifičnih troškova dvaju tipova anestezije koje za spinalnu anesteziju iznose 78,26 kn, a za opću 115,19 kn. Ni u jednoj skupini nisu zabilježene značajne operacijske ili poslijeoperacijske komplikacije. Kako je od spomenutih operacija samo 40% operirano u spinalnoj anesteziji, dok je prosjek razvijenih zemalja iznad 70%, postoji dosta prostora za uštedu. Samo na artroskopijama koljena kojih se godišnje radi oko 200 uštedjelo bi se 1470 kn kad bismo postotak operiranih u spinalnoj anesteziji podigli na realno ostvarivih 60%. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14091 http://hrcak.srce.hr/file/21572 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14092 2008-06-03 journal:158

Effect of Amniotomy on Uterine Muscle Electrical Activity During Labor Induction with Oxytocin and Prostaglandins Utjecaj amniotomije na električnu aktivnost materničnog mišića tijekom indukcije poroda oksitocinom i pripravcima prostaglandina Toth, Tibor Labor, induced - physiology; Labor, induced - methods; Uterus - physiology; Uterine contraction - drug effects; Oxytocin - therapeutic use; Prostaglandins - physiology Porod, izazvani - fiziologija; Porod, izazvani - metode; Maternica - fiziologija; Maternična kontrakcija - učinci lijekova; Oksitocin - terapijska primjena; Prostaglandini - fiziologija The aim of the study was to find out whether noninvasive recording of uterine muscle electrical activity could help monitor the development of mechanical myometrial activity during induced labor. Myometrium electrical activity during labor induction was analyzed in 110 gravidas hospitalized at Maternity Ward, Bjelovar General Hospital in Bjelovar. The means used for labor induction was oxytocin infusion in 54, intracervical prostaglandin (dinoprostone 0.5 mg) in 20, intravaginal prostaglandin (dinoprostone 2 mg) in 21, and intravenous prostaglandin (dinoprostone 0.75 mg) in 15 women. Electromyographic measurement was done at 30, 90, 150 and 270 minutes of the induction agent administration. In all pregnancies, silence of the uterus was electromyographically confirmed before the study. During the study, amniotomy was performed in 54 patients: soon after 1st measurement (30th minute of induced labor) in 6, after 2nd measurement (90th minute of induced labor) in 20, after 3rd measurement (150th minute of induced labor) in 10 and after 4th measurement (210th minute of induced labor) in 18 patients. Characteristics of electrical discharge were analyzed separately (number of impulses, amplitudes, series, shape) and each record was merged by index of uterine activity according to .krablin­Kuèiæ formula: uterine activity index (UAI)=number of impulses during 10 minute period + amplitude (µV) of highest potential divided by 100, by which the series of discharge were marked by additional 20, biphasic waves with 2, and polyphasic with 3 points. Statistical analysis of EMG UAI values obtained on oxytocin labor induction according to modified Bishop cervical index and amniotomy yielded statistically significant differences in the EMG UAI value increase between the patients with and without amniotomy (p<0.05). On measurements done at 210 and 270 minutes at Bishop index >8, the values of UAI after amniotomy were not statistically significant (p>0.05). Analysis of EMG UAI values in patients administered intracervical prostaglandin for labor induction revealed a statistically significant difference between patients with and without amniotomy (p<0.05). Analysis of EMG UAI values in patients administered intravaginal (dinoprostone 2 mg) and intravenous (dinoprostone 0.75 mg) prostaglandin preparation for labor induction showed no statistically significant difference between patients with and without amniotomy (p>0.05). Accordingly, recording electrical myometrial activity before and after amniotomy by transcutaneous uterine electromyography during labor induction showed positive correlation with the course and outcome of induced labor, which may prove useful in the induced labor monitoring and guidance. Cilj ispitivanja bio je utvrditi može li neinvazivno praćenje električne aktivnosti materničnog mišića pomoći u praćenju razvoja mehaničke aktivnosti miometrija nakon amniotomije tijekom induciranog poroda. Električna aktivnost miometrija tijekom indukcije poroda ispitana je u 110 trudnica hospitaliziranih u Rodilištu Opće bolnice u Bjelovaru. Sredstvo za indukciju poroda je u 54 ispitanice bila infuzija oksitocina, u 20 ispitanica intracervikalni oblik prostaglandina (dinoproston 0,5 mg), u 21 ispitanice intravaginalni oblik prostaglandina (dinoproston 2 mg) i u 15 ispitanica intravenski oblik prostaglandina (dinoproston 0,75 mg). U svih ispitanica je prije početka indukcije poroda elektromiografski dokazan miran uterus. Elektromiografsko mjerenje učinjeno je 30, 90, 150, 210 i 270 minuta nakon primjene sredstva za indukciju. Tijekom ispitivanja u 54 ispitanice učinjena je amniotomija. Neposredno nakon prvog mjerenja (30. minuta induciranog poroda) učinjena je amniotomija u 6, nakon drugog mjerenja (90. minuta indukcije) u 20, nakon 3. mjerenja (150. minuta indukcije) u 10 te nakon 4. mjerenja (210. minuta indukcije) u 18 ispitanica. Obilježja električnih izbijanja obrađena su pojedinačno (broj impulsa, amplitude, serije, oblik), a svaki zapis je objedinjen indeksom uterine aktivnosti prema formuli Škrablin-Kučić: indeks uterine aktivnosti (IUA) = broj pojedinačnih impulsa tijekom 10-minutnog razdoblja + amplituda (ìV) najvišeg potencijala podijeljena sa 100, pri čemu su serije izbijanja ocijenjene s dodatnih 20, bifazni valovi s 2 i polifazni s 3. Statističkom analizom vrijednosti EMG IUA dobivenih pri indukciji poroda oksitocinom s obzirom na modificirani cervikalni indeks po Bishopu i amniotomiju dobivene su statistički značajne razlike u porastu vrijednosti EMG IUA između trudnica u kojih je učinjena amniotomija i onih u kojih ona nije učinjena (p<0,05). U mjerenjima nakon 210 i 270 minuta pri Bishopovu indeksu >8 vrijednosti IUA nakon amniotomije nisu bile statistički značajne (p>0,05). Analizom vrijednosti EMG IUA u amniotomiranih ispitanica u odnosu na one u kojih amniotomija nije učinjena pri indukciji intracervikalnim pripravkom prostaglandina utvrđena je statistički značajna razlika u vrijednostima IUA (p<0,05). Statistička analiza vrijednosti EMG IUA tijekom indukcije poroda intravaginalnim (dinoproston 2 mg) i intravenskim (dinoproston 0,75 mg) pripravcima prostaglandina nije pokazala da amniotomija uzrokuje statistički značajnu razliku EMG aktivnosti u odnosu na neamniotomirane ispitanice (p>0,05). Bilježenje elektromiografskih zbivanja prije i nakon amniotomije transkutanom elektromiografijom uterusa u trudnica tijekom indukcije poroda u pozitivnoj je korelaciji s tijekom i ishodom induciranog poroda te može biti korisno u praćenju i vođenju induciranog poroda. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14092 http://hrcak.srce.hr/file/21573 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14093 2008-06-03 journal:158

Epidemiology of Multiple Sclerosis in the Bjelovar-Bilogora County Epidemiologija multiple skleroze u Bjelovarsko-Bilogorskoj županiji Vrabec-Matković, Dragica Ivanuša, Zrinka Šarko, Borislav Golubić, Jela Šklebar, Duška Mulitple sclerosis - epidemiology; Multiple sclerosis - etiology; Croatia Multipla skleroza - epidemiologija; Multipla skleroza - etiologija; Hrvatska Multiple sclerosis (MS) is a chronic neurologic disease of unknown etiology, which shows a peculiar pattern of prevalence in the world, varying among different countries and regions of a particular country. The aim of the study was to assess the prevalence and incidence of MS in the Bjelovar-Bilogora County in the last two decades (1982-2001), including the period of war in Croatia. Retrospective analysis of a database containing medical history of 71 patients using Poser's criteria revealed the prevalence and incidence of MS to have significantly increased during the study period, in the years preceding the war in particular. At the beginning of the study period (1982), the prevalence of MS was 13.38/100,000, ranking the County an area of moderate risk, whereas at the end of the study period (2001) the prevalence of MS was 47.36/100,000, characterizing the County as an area of high risk of MS. In the first and last 5­year period, the incidence was 0.53 and 2.40, respectively, showing a female predominance (F:M: 2.40:1). According to Poser.s criteria, the relapsing remitting type of disease was present in 54%, secondary progressive in 21% and primary progressive in 17% of patients, whereas 8% of patients remained unclassified. Optic neuritis was found in 14.96% of study patients. The mean age at disease onset was 32.5 years. The study showed the County to have become an area of high risk of MS in the last decade of the twentieth century. Multipla skleroza (MS) je kronična neurološka bolest nepoznate etiologije koja pokazuje neobičan model rasprostranjenosti u svijetu s različitom učestalošću u pojedinim zemljama, kao i u različitim regijama iste zemlje. Cilj istraživanja bio je utvrditi učestalost i incidenciju MS u Bjelovarsko-bilogorskoj županiji u posljednjih dvadeset godina (1982.-2001.) uključujući razdoblje rata. Retrospektivnom analizom obrađena je na temelju Poserovih kriterija baza podataka koja sadrži povijesti bolesti 71 bolesnika. Zabilježen je značajan porast učestalosti i incidencije MS tijekom ispitivanog razdoblja, osobito u godinama koje su prethodile ratu. Učestalost MS na početku promatranog razdoblja (1982. g.) iznosila je 13,38/100.000 te je županija bila područje srednje izloženosti; na kraju razdoblja (2001. g.) učestalost je bila 47,36/100.000 i županija je postala zona visokog rizika za MS. Prosječna incidencija u prvom petogodišnjem razdoblju iznosila je 0,53, a u zadnjem 2,40. Spolna predilekcija bila je u korist žena (2,40 :1). Prema Poserovim kriterijima 54% bolesnika imalo je relaps-remitirajući oblik bolesti, 21% sekundarno progresivni, 17% primarno progresivni, dok se 8% bolesnika nije moglo klasificirati. Optički neuritis je bio prisutan u 14,96% oboljelih. Srednja dob kod pojave bolesti bila je 32,5 godina. Istraživanje pokazuje da je naša županija postala zona visokog rizika za MS u zadnjih deset godina prošloga stoljeća. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14093 http://hrcak.srce.hr/file/21576 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14094 2008-06-03 journal:158

Effect of Carbon Dioxide for Laparoscopic Cholecystectomy on Arterial Pressure in Obese and Nonobese Patients Djelovanje upuhivanja ugljičnog dioksida u trbušnu šupljinu kod laparoskopskih kolecistektomija na arterijski tlak u pretilih i nepretilih bolesnika Vranko, Nada Šklebar, Ivan Laparoscopic cholecystectomy; Pneumoperitoneum; Carbon dioxide; Intra-abdominal pressure; Overweight; General endotracheal balance anesthesia Laparoskopska kolecistektomija; Pneumoperitoneum; Ugljični dioksid; Intraabdominalni tlak; Prekomjerna tjelesna težina; Opća endotrahealna balansirana anestezija The effect of carbon dioxide induced pneumoperitoneum and anti-Trendelenburg.s position on arterial pressure was retrospectively analyzed in 34 patients with cholelithiasis and overweight and 34 patients with cholelithiasis and normal body weight. According to general condition, all patients belonged to ASA II and ASA III groups. Upon induction in general endotracheal balanced anesthesia, patients received intermittent positive pressure ventilation. At the time of arterial pressure measurement, the following parameters were determined: respiratory volume 12 mL kg-1 body weight, respiration rate 12 breaths per minute, and inhalation to exhalation time ratio I:E=1:2. Arterial pressure was measured by automated noninvasive method in horizontal position before induction in general anesthesia (T1), upon induction in general anesthesia (T2), upon carbon dioxide inflation into abdominal cavity and anti­Trendelenburg.s position at 25° (T3), upon carbon dioxide deflation from abdominal cavity (T4), and upon completion of the operation and patient extubation (T5). Arterial pressure showed a statistically significant increase after carbon dioxide inflation and a statistically significant decrease upon carbon dioxide deflation (p<0.002 both) in both study groups. In overweight patients, both systolic and diastolic pressure increased with carbon dioxide induced pneumoperitoneum to a mean value of 167±18 mm Hg and 102±10 mm Hg, respectively, as measured at T3. In the group of patients with normal body weight, the respective pressure values were 156±19 mm Hg and 98±9 mm Hg at the same time point. Retrospektivno je analizirano djelovanje pneumoperitoneuma izazvanog ugljičnim dioksidom i anti-Trendelenburgova položaja na arterijski tlak u 34 bolesnika s kolelitijazom i prekomjernom tjelesnom težinom i 34 bolesnika s kolelitijazom i normalnom tjelesnom težinom. Svi su bolesnici prema općem stanju pripadali skupinama ASA II. i ASA III. Nakon uvoda u opću endotrahealnu balansiranu anesteziju bolesnici su umjetno ventilirani intermitentnim pozitivnim tlakom (IPPV). U vrijeme mjerenja arterijskog tlaka zabilježeni su slijedeći parametri: respiracijski volumen 12 mL kg-1 tjelesne težine, frekvencija disanja 12 udisaja u minuti, odnos udisajnog i izdisajnog vremena I:E=1:2. Arterijski tlak mjeren je automatski neinvazivno u vodoravnom položaju prije indukcije u opću anesteziju (T1), nakon uvoda u opću anesteziju (T2), nakon upuhivanja ugljičnog dioksida u trbušnu šupljinu i anti-Trendelenburgova položaja od 25o (T3), nakon ispuhivanja ugljičnog dioksida iz trbušne šupljine (T4) i nakon završetka operacije i ekstubacije bolesnika (T5). Arterijski tlak nakon upuhivanja ugljičnog dioksida u trbušnu šupljinu pokazao je statistički značajan porast (p<0,002) u obje analizirane skupine. Nakon ispuhivanja ugljičnog dioksida iz trbušne šupljine u obje analizirane skupine arterijski tlak je pokazao statistički značajan pad (p<0,002). Sistolični tlak u bolesnika s prekomjernom tjelesnom težinom je porastao nakon pneumoperitoneuma izazvanog ugljičnim dioksidom, srednja vrijednost 167±18 mm Hg (T3). Dijastolični tlak u istih bolesnika je također porastao, srednja vrijednost 102 ±10 mm Hg (T3). U skupini bolesnika normalne tjelesne težine sistolični je tlak dosegao srednju vrijednost od 156±19 mm Hg, a dijastolični 98±9 mm Hg u isto mjerno vrijeme. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2006-05-01 text pdf http://hrcak.srce.hr/14094 http://hrcak.srce.hr/file/21578 Acta Clinica Croatica (acta@kbcsm.hr); Vol.45 No.1 - Supplement 1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14228 2008-06-03 journal:158

The Risk of Thyroid Malignancy in Patients with Solitary Thyroid Nodule Versus Patients with Multinodular Goiter Rizik od maligniteta štitne žlijezde u bolesnika s pojedinačnim čvorom štitne žlijezde prema bolesnicima s multinodularnom strumom Mateša, Neven Tabain, Irena Kusić, Zvonko Thyroid neoplasms - pathology; Thyroid neoplasms - immunology; Carcinoma papillary; follicular - immunology; Goiter nodular - pathology; Biopsy needle - methods Neoplazme štitne žlijezde . patologija; Neoplazme štitne žlijezde . imunologija; Karcinom papilarni; folikularni . imunologija;Struma nodularna . patologija; Iglena biopsija . metode The aim of the study was to compare the risk of thyroid malignancy in patients with a solitary thyroid nodule vs. patients with multinodular goiter. The prospective study included 406 patients who had one or more thyroid nodules and underwent ultrasound guided fine needle aspiration. There were 29 males and 377 females (male to female ratio 1:13). There were 117 (29%) patients (12 males and 105 females) with a solitary thyroid nodule, and 289 (71%) patients (17 males and 272 females) with multinodular goiter, age range 11-86 years, median 55 years. Upon cytologic examination definitive diagnosis of malignant tumor was made in six (5%) patients with a solitary thyroid nodule and in 15 (5%) patients with multinodular goiter. All patients with malignant tumors in both groups were females. It was concluded that there was no difference in the risk of thyroid malignancy between patients with a solitary thyroid nodule and patients with multinodular goiter. Cilj studije bio je usporediti rizik of maligniteta štitne žlijezde u bolesnika s pojedinačnim čvorom štitne žlijezde prema bolesnicima s multinodularnom strumom. U prospektivnu studiju bilo je uključeno 406 bolesnika koji su imali jedan ili više čvorova štitne žlijezde i podvrgnuti su ultrazvučno vođenoj tankoiglenoj biopsiji. Bilo je 29 muškaraca i 377 žena (omjer muških i ženskih bolesnika 1:13). Bilo je 117 (29%) bolesnika (12 muških i 105 ženskih) s pojedinačnim čvorom štitne žlijezde i 289 (71%) bolesnika (17 muških i 272 ženskih) s multinodularnom strumom, dobnoga raspona 11-86 godina, medijan 55 godina. Nakon citološke analize konačna dijagnoza zloćudnog tumora postavljena je u šestoro (5%) bolesnika s pojedinačnim čvorom štitne žlijezde i u 15 (5%) bolesnika s multinodularnom strumom. Sve osobe s malignim tumorom u objema skupinama bile su žene. Zaključeno je kako nema razlike u riziku od maligniteta štitne žlijezde među bolesnicima s pojedinačnim čvorom štitne žlijezde i onih s multinodularnom strumom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14228 http://hrcak.srce.hr/file/21787 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14230 2008-06-03 journal:158

Evaluation of Functional Status during Beta-Interferon Therapy Procjena funkcijskog statusa tijekom liječenja beta interferonom Lisak, Marijana Trkanjec, Zlatko Bošnjak-Pašić, Marija Demarin, Vida Multiple sclerosis - drug therapy; Interferon-beta - therapy use; Adjuvants immunology therapeutic use Twenty patients (11 female and 9 male) with remitting relapsing multiple sclerosis were treated with beta interferon at University Department of Neurology, Sestre milosrdnice University Hospital. Thirteen patients were treated with interferon beta-1a (6 MIU 3 times weekly) and seven patients with interferon beta-1b (9.6 MIU every other day). The Expanded Disability Status Scale (EDSS) was recorded before interferon therapy and six months after initiation of interferon therapy. The mean EDSS score was slightly lower after six months of interferon therapy in both groups, but the difference was not statistically significant (p=0.17 in interferon beta-1a group and p=0.36 in interferon beta-1b group). Results in this small group of patients showed early improvement in the functional status of multiple sclerosis patients during interferon therapy. Further follow-up is required to get additional information on the course of functional improvement in multiple sclerosis patients after a prolonged period of interferon therapy. Dvadesetoro (11 ženskih i 9 muških) bolesnika s remitentnom rekurentnom mulitiplom sklerozom liječeno je beta interferonom na Klinici za neurologiju Kliničke bolnice "Sestre milosrdnice" u Zagrebu. Trinaestoro bolesnika liječeno je interferonom beta-1a (6 MIJ 3 puta na tjedan), a sedmoro bolesnika interferonom beta-1b (9,6 MIJ svakog drugog dana). Ljestvica EDSS (Expanded Disability Status Scale) bilježena je prije i šest mjeseci od početka liječenja interferonom. Prosječan zbir na ljestvici EDSS bio je u objema skupinama nešto manji nakon šest mjeseci liječenja interferonom, ali razlika nije bila statistički značajna (p=0,17 u skupini na interferonu beta-1a i p=0,36 u skupini na interferonu beta-1b). Rezultati dobiveni u ovoj maloj skupini bolesnika pokazali su rano poboljšanje funkcijskog statusa u bolesnika s multiplom sklerozom za vrijeme liječenja interferonom. Potrebno je daljnje praćenje kako bi se dobili dodatni podaci o tijeku funkcijskog poboljšanja u bolesnika s multiplom sklerozom uz dugotrajno liječenje interferonom. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14230 http://hrcak.srce.hr/file/21790 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14231 2008-06-03 journal:158

Expression and Processing of Somatostatin in Developing Pancreas and Pancreatic Ductal Adenocarcinoma Ekspresija i obrada somatostatina u gušterači u razvoju i u duktalnom adenokarcinomu gušterače Tamiolakis, D. Simopoulos, C. Venizelos, J. Lambropoulou, M. Nikolaidou, S. Tsikouras, P. Alexiadis, G. Tsalkidis, A. Jivannakis, T. Papadopoulos, N. Pancreatic neoplasms - pathology, Pancreatic neoplasms - physiopathology, Pancreatic neoplasms - therapy; Gastrointestinal hormones - physiology; Somatostatin - physiology; Neoplasms metastasis - prevention control Somatostatin is a gastrointestinal peptide hormone that inhibits growth of pancreatic cancer as reported by an increasing body of evidence. Yet this is not always the case. To clarify the controversy we aimed to identify the expression of somatostatin in developing human embryonic pancreatic tissue and pancreatic adenocarcinoma given that somatostatin positive cells were shown either into primitive pancreatic ductal epithelium or into pancreatic carcinoma. Tissue sections representing pancreatic fetal specimens (n=15) and ductal pancreatic adenocarcinoma specimens (n=15) were assessed using immunohistochemical methods for somatostatin expression. Normal primitive exocrine ductal epithelium and endocrine epithelium showed a definite, statistically significant, higher expression of somatostatin over neoplastic pancreatic tissue of mixed (ductal-endocrine) and pure ductal type (p1=0.021, p2=0.001, p3<0.0001and p4=0.003 respectively) during the 8th to the 10th week. No statistically significantly different expression of somatostatin in the mantle zone of the islets over neoplastic tissue of mixed (p5=0.16) and pureductal type (p6=0.65), from the 13th to the 24th week was demonstrated. Pancreatic cancer cells can express somatostatin in a model that reproduces the normal expression of the peptide by d-cells during embryonal organogenesis. Therapy aimed at pancreatic cancer must be targeted to somatostatin and analogues as a potential adjuvant novel option. Somatostatin je probavni peptidni hormon koji suzbija rast raka gušterače, za što postoji sve više dokaza. No to se ne događa uvijek. Cilj studije bio je utvrditi ekspresiju somatostatina u ljudskom embrijskom tkivu gušterače u razvoju i u adenokarcinomu gušterače, s tim da su na somatostatin pozitivne stanice dokazane ili u primitivnom duktalnom epitelu gušterače ili u karcinomu gušterače. Tkivni isječci koji su predstavljali uzorke fetalne gušterače (n=15) i uzorke adenokarcinoma gušterače (n=15) ispitani su pomoću imunohistokemijskih metoda za ekspresiju somatostatina. Normalan primitivni egzokrini duktalni epitel i endokrini epitel pokazao je konačnu, statistički značajno višu ekspresiju somatostatina iznad neoplastičnog tkiva gušterače miješanog (duktalno-endokrinog) i čistog duktalnog tipa (p1=0,021, P2=0,001, p3<0,0001 odnosno p4=0,003) tijekom 8. do 10. tjedna. Nije dokazana statistički značajno različita ekspresija somatostatina u ovojnom sloju (mantle zone, mantle layer) otočića iznadneoplastičnog tkiva miješanog (p5=0,16) i čistog duktalnog tipa (p6=0,65) od 13. do 24. tjedna. Dakle, stanice raka gušterače mogu izražavati somatostatin na naein koji ponavlja normalnu d-staničnu ekspresiju peptida za vrijeme embrijske organogeneze. Liječenje zbog raka gušterače usmjereno na somatostatin i njegove analoge moglo bi predstavljati novu mogućnosti adjuvantne terapije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14231 http://hrcak.srce.hr/file/21791 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14232 2008-06-03 journal:158

Lymph Node Frozen Section Analysis during Radical Prostatectomy Intraoperacijska analiza limfnih čvorova kod radikalne prostatektomije: Je li ona doista neophodna? Krušlin, Božo Bulimbašić, Stela Čupić, Hrvoje Reljić, Ante Tomas, Davor Tomašković, Igor Kraus, Ognjen Belicza, Mladen Prostatic neoplasms - pathology; Prostatic neoplasms - surgery; Lymp node excision; Lymp node - pathology; Frozen sections Radical prostatectomy is a treatment of choice for localized prostatic adenocarcinoma. In most cases, radical prostatectomy is combined with pelvic lymph node dissection. During the last decade, the necessity to perform lymphadenectomy in all patients has been questioned. Lymph node dissection adds the risk of complications, and increases operation time and medical costs. Data of patients with prostatic adenocarcinoma who underwent radical prostatectomy at Department of Urology, Sestre milosrdnice University Hospital, Zagreb during the period from January 1, 1998 till December 31, 2002, were analyzed. There were 110 patients who had complete preoperative data including prostate-specific antigen (PSA) value, Gleason score, T stage and lymph node status on frozen section analysis. Using predictive nomograms the patients were divided into different risk groups. Positive lymph node(s) were found in one patient with T2 and in five patients with T3, whereby three, two and one of these patients had Gleason score 6, 7 and 8, respectively. There was a correlation between increasing PSA value and positive lymph nodes (p<0.005). A statistically significant correlation between T stage and PSA value (p<0.005) as well as between T stage and Gleason score (p=0.0014) was also observed. The majority of patients belonged to low and intermediate risk groups, known to benefit very little from lymph node dissection and frozen section analysis. Thus, it seems reasonable to reconsider the use of these predictive nomograms on advising and therapy strategy planning for newly diagnosed patients, especially those with clinically organ-confined disease. Radikalna prostatektomija je metoda izbora u liječenju lokaliziranog karcinoma prostate, a najčešće se izvodi u kombinaciji s disekcijom zdjeličnih limfnih čvorova. Disekcija zdjeličnih limfnih čvorova povećava rizik komplikacija, produžava trajanje operacije, povisuje troškove liječenja i medicinske skrbi, pa se je potreba za njenim provođenjem u svih bolesnika s dijagnosticiranim karcinomom prostate tijekom prošloga desetljeća višekratno preispitivala. Radi boljeg probira bolesnika sa značajnijom koristi od disekcije zdjeličnih limfnih čvorova različiti autori su obrađivali čimbenike kojima je moguće predvidjeti rizik metastaziranja u regionalne limfne čvorove. Studijom su obuhvaćeni svi bolesnici kojima je zbog dijagnoze karcinoma prostate u razdoblju od 1. siječnja 1998. do 31. prosinca 2002. u Kliničkoj bolnici Sestara milosrdnica učinjena radikalna prostatektomija. Uz primjenu prediktivnih nomograma bolesnici su bili podijeljeni u različite rizične skupine. Većina bolesnika pripadala je skupini niskog i srednjeg rizika metastaziranja, s vrlo ograničenom koristi od disekcije zdjeličnih limfnih čvorova i njihove intraoperacijske analize. Od 110 bolesnika za koje su dobiveni svi podaci uključujući vrijednost antigena specifičnog za prostatu (PSA), Gleasonov zbroj, T stadij i stanje limfnih čvorova analiziranih na intraoperacijskim rezovima, pozitivni limfni čvorovi su utvrđeni u 6 slučajeva. Utvrđena je statistički značajna povezanost između vrijednosti PSA i pozitivnih limfnih čvorova (p<0,005). Također je opažena korelacija između T stadija i vrijednosti PSA (p<0,005) odnosno T stadija i Gleasonova zbroja (p=0,0014). Zaključeno je kako bi bilo uputno razmotriti uporabu prediktivnih nomograma kod planiranja terapijskog pristupa bolesnicima s novootkrivenim, a poglavito onima s klinički lokaliziranim karcinomom prostate. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14232 http://hrcak.srce.hr/file/21792 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14234 2008-06-03 journal:158

Assessment of Injury Extensiveness at Ankle Distortion by Magnetic Resonance Imaging Magnetska rezonanca u procjeni razmjera ozljede kod distorzije skočnog zgloba Puljiz, Zvonimir Matejčić, Aljoša Krolo, Ivan Aljinović, Ana Franjić, Bjorn Dario Bekavac Bešlin, Miroslav Ankle, injury - diagnosis; Magnetic resonance imaging; Ankle injuries - surgery The aim of the study was to evaluate the status of all soft tissue and osseous structures by magnetic resonance imaging (MRI) in patients with acute ankle injury. During a two-year period (2001-2003), 50 patients with acute ankle injury (osseous injury excluded by conventional radiography) underwent MRI evaluation within 7 days of injury infliction. The following injuries were confirmed: joint effusion, joint capsule extension, lateral collateral ligament injury, fibular malleolus infraction, flexor hallucis longus tendon injury, brevis and longus peroneus tendon injury, infraction of talus and injury of tibiofibular syndesmosis. Study results pointed to a great variety of capsule-ligament andosseous structure injuries as well as to the existence of injuries undetectable by clinical examinationi and conventional radiography, where MRI proved highly useful in identifying selected patients sustaining ankle injury. Cilj studije bio je procijeniti stanje svih mekih tkiva i koštanih struktura u bolesnika s akutnom ozljedom gležnja pomoću prikaza magnetskom rezonancom (MRI). Tijekom dvogodišnjeg razdoblja (2001. - 2003.) procjena pomoću MRI provedena je u 50 bolesnika s akutnom ozljedom skočnog zgloba (u kojih je koštana ozljeda isključena konvencionalnom radiografijom) unutar 7 dana od nastupa ozljede. MRI je potvrdila slijedeće ozljede: zglobni izljev, ekstenziju zglobne kapsule, ozljedu lateralno kolateralnih ligamenata, infrakciju fibularnog maleolusa, ozljedu tetive dugog palčanog fleksora, ozljedu tetive kratkog i dugog peroneusa, infrakciju talusa i ozljedu tibiofibularne sindesmoze. Dobiveni rezultati pokazali su raznovrsne ozljede kapsulno-ligamentnih i koštanih struktura, kao i postojanje ozljeda nevidljivih na kliničkom pregledu i konvencionalnoj radiografiji, za koje je MRI vrlo korisna dijagnostička metoda u odabranih bolesnika s ozljedom skočnog zgloba. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14234 http://hrcak.srce.hr/file/21794 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14239 2008-06-03 journal:158

Microembolus Detection by Transcranial Doppler Sonography . Technical and Clinical Aspects Otkrivanje mikroembolusa transkranijskom Doppler sonografijom - tehnički i klinički aspekt Vuković, Vlasta Lovrenčić-Huzjan, Arijana Demarin, Vida Brain - physiopathology; Brain - pathology; Intracranial embolism - physiopathology; Intracranial embolism - complications; Intracranial embolism - ultrasonography Transcranial Doppler can detect microembolic signals which are characterized by unidirectional high intensity increase, short duration, random occurrence, producing a "whistling" sound. Microembolic signals have been proven to represent solid or gaseous particles within the blood flow. Microemboli have been detected in a number of clinical settings: carotid artery stenosis, aortic arch plaques, atrial fibrillation, myocardial infarction, prosthetic heart valves, patent foramen ovale, valvular stenosis, during invasive procedures (angiography, percutaneous transluminal angioplasty), surgery (carotid, cardiopulmonary bypass, orthopedic), and in certain systemic diseases. Despite numerous studies performed so far, clinical significance of microembolic signals is still unclear. This article provides an overview of the development and current state of technical and clinical aspects of microembolus detection. Pomoću transkranijskog doplera mogu se otkriti mikroembolijski signali koji su obilježeni pojavom jednosmjernih signala visokog intenziteta, kratkog su trajanja, pojavljuju se u vremenski nepravilnom slijedu, a zvuče "poput zvižduka". Smatra se da mikroembolijski signali predstavljaju solidne čestice ili mjehuriće zraka koji putuju krvnom strujom. Mikroembolijski signali otkriveni su dosad kod bolesnika s karotidnom stenozom, plakom luka aorte, atrijskom fibrilacijom, infarktom miokarda, s umjetnim srčanim zaliscima, kod prohodnog foramena ovale, valvulne stenoze, za vrijeme invazivnih zahvata (angiografija, perkutana transluminalna angioplastika), za vrijeme operacija (karotidnih arterija, kardiopulmonalne premosnice, ortopedske operacije) i kod nekih sistemskih bolesti. Usprkos brojnim istraživanjima kliničko značenje mikroembolijskih signala nije sasvim razjašnjeno. U ovom članku iznosi se pregled razvoja i najnovija tehnološka dostignuća, kao i klinički aspekti otkrivanja mikroembolusa. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14239 http://hrcak.srce.hr/file/21799 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14241 2008-06-03 journal:158

Renal Artery Thromboembolism: An Unrecognized Cause of Acute Renal Failure Tromboembolija bubrežne arterije: neprepoznati uzrok akutnog bubrežnog zatajenja Šefer, Siniša Kes, Petar Ratković-Gusić, Iva Renal artery obstruction - diagnosis; Renal artery obstruction - complications; Kidney failure, acute - etiology; Kidney failure, acute - drug therapy; Thromboembolism - complications Acute renal artery thromboembolism is a critical condition and significant but commonly misdiagnosed and possibly reversible cause of kidney ischemic disease. This disorder is commonly overlooked, and an early and proper diagnosis can lead to proper therapy with greater chance for recovery of renal function and avoidance of unnecessary invasive diagnostic and therapeutic procedures. When encountering a patient suffering from acute renal failure and atypical lower back or abdominal pain, especially one who has high risk factors, we recommend diagnostic screening based on serum lactate dehydrogenase determination with other diagnostic procedures and therapeutic algorithm for renal artery thromboembolism. Akutna tromboembolija bubrežne arterije je kritično stanje za bolesnika. Značajan je, ali često pogrešno dijagnosticiran te potencijalno reverzibilan uzrok ishemijske bolesti bubrega. Ova se bolest često previđa, a rana i ispravna dijagnoza vode ka ispravnom liječenju uz dobre izglede za oporavak bubrežne funkcije i izbjegavanje nepotrebnih, agresivnih dijagnostičkih i terapijskih postupaka. Kada se susretnemo s bolesnikom koji ima akutno bubrežno zatajenje i atipičnu bol u križima ili trbuhu, poglavito u onih s visokim čimbenicima rizika, preporučamo provođenje dijagnostičkog postupka koji se temelji na određivanju serumske razine laktat dehidrogenaze u kombinaciji s ostalim dijagnostičkim metodama i postupnikom za liječenje tromboembolije bubrežne arterije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14241 http://hrcak.srce.hr/file/21801 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Evidence-Based Treatment of Chronic Rhinosinusitis Na dokazima zasnovano liječenje kroničnog rinosinusitisa Kalogjera, Livije Baudoini, Tomislav Sinusitis - surgery; Chronic diseases; Evidence based medicine Although chronic rhinosinusitis is one of the most common chronic disorders, and major advances in minimally invasive surgery and potent antimicrobial and anti-inflammatory conservative treatment have been accomplished in the past decade, evidence for the most effective treatment of chronic rhinosinusitis is still lacking. Randomized controlled trials, which provide the best possible evidence in terms of testing the efficacy of chronic rhinosinusitis treatment, are too few. Those that have been done so far, have proven advantages of endoscopic sinus surgery over classic radical surgery in terms of providing better health related quality of life. Case controlled studies of endoscopic sinus surgery have shown a 91% (73.0%-97.5%) improvement with a major complication rate of 1.6%. Still, at long-term follow up, improvement rate drops to 50% in revision cases and in patients with systemic disease (allergy, asthma). Further improvement in surgical failures can be achieved with long-term topical steroid and low-dose macrolide treatment. Conservative treatment, which includes aggressive long-term steroid and antibiotic therapy, with permanent nasal saline douches and short-term decongestants, has proved successful in half of the treated patients, yet with a shorter follow up. However, only few of clinical trials are randomized controlled trials, and placebo-controlled studies have not recognized significant advantage of any conservative treatment. The level of evidence for the treatment for pediatric sinusitis is satisfactory, and meta-analysis of conservative treatment has been cited in the Cochrane Library Database. Meta-analysis of surgical treatment for pediatric sinusitis yields a success rate of 88% with a mean follow up of 3.7 years and major complication rate of 0.6%. Iako je kronični rinosinusitis jedna od najčešćih kroničnih bolesti, a u prošlom su desetljeću postignuti veći pomaci u minimalno invazivnoj kirurgiji, kao i u pojačanoj antimikrobnoj i protuupalnoj konzervativnoj terapiji, još uvijek nedostaju dokazi o najdjelotvornijem liječenju kroničnog rinosinusitisa. Premalo je randomiziranih kontroliranih studija koje pružaju najbolje moguće dokaze u smislu ispitivanja učinkovitosti liječenja kroničnog rinosinusitisa. Dosad provedene studije dokazale su prednosti endoskopske operacije sinusa pred klasičnog radikalnom kirurgijom, jer osigurava bolju zdravstvenu kvalitetu života. Kontrolirane studije endoskopske kirurgije sinusa pokazale su 91.%-tno (73,0%-97,5%) poboljšanje sa stopom većih komplikacija od 1,6%. Međutim, uz dugotrajnije praćenje stopa poboljšanja opada na 50% kod ponovno ispitanih slučajeva i u bolesnika sa sistemskim bolestima (alergija, astma). U slučajevima gdje operacija zakaže daljnje poboljšanje može se postići dugotrajnim liječenjem topičnim steroidima i niskim dozama makrolida. Konzervativno liječenje, koje uključuje agresivnu dugotrajnu terapiju steroidima i antibioticima uz trajnu primjenu nazalnom ispiranja fiziološkom otopinom i kratkoročno sredstvima za dekongestiju, pokazalo se je uspješnim u polovice tako liječenih bolesnika, no uz kraće vrijeme praćenja. Međutim, tek je nekoliko randomiziranih kontroliranih kliničkih studija, dok placebom kontrolirane studije nisu dokazale nikakvu značajnu prednost bilo koje konzervativne terapije. Razina dokaza za liječenje sinusitisa u djece je zadovoljavajuća, a meta-analiza konzervativnog liječenja navedena je u Cochrane Library Database. Meta-analiza kirurškog liječenja sinusitisa u djece pokazuje stopu uspješnosti od 88% uz prosječeno vrijeme praćenja od 3,7 godina i stopu ozbiljnijih komplikacija od 0,6%. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14244 http://hrcak.srce.hr/file/21804 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Kidneys in Anderson-Fabry Disease Bubreg u Anderson-Fabrijevoj bolesti Kes, Petar Bašić-Jukić, Nikolina Fabri disease - complications; Fabri disease - genetics; Kidney disease - therapy; Kidney disease - diagnosis Anderson-Fabry disease is an X-linked recessive glycolipid storage disease caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. Numerous mutations are responsible for development of the disease. Clinical manifestations include acroparesthesia from childhood, corneal dystrophy, angiokeratomas, hypohidrosis, hearing loss and, with aging, development of cardiovascular and renal disease. Renal failure typically begins in the third decade of life. A young male patient presents with proteinuria and impaired urinary concentrating ability, or reaches end-stage renal disease of unknown origin without prior supervision of nephrologist. Polyuria and nicturia are the first signs of disease caused by urinary concentration defect. Proteinuria begins in the second decade of life, and is usually below the nephrotic level. Urinalysis is characterized by hematuria and lipiduria. Urinary sediment contains lipid globules and characteristic .Maltese crosses.. Enzyme replacement therapy has recently become available. Two formulations of alpha-galactosidase A have received marketing authorization. It seems possible to halt and probably even reverse the progression of Fabry disease before the irreversible organ damage has set in. Clinical trials have proved the efficacy and safety of treatment with agalsidase alpha or beta. Besides its beneficial effect on renal function, enzyme replacement therapy improves cardiac parameters and quality of life in patients with Anderson-Fabry disease. The main disadvantage of enzyme replacement therapy is the very high cost of treatment, posing a challenge even to the most industrialized countries in the world. Anderson-Fabrijeva bolest se nasljeđuje recesivno putem X kromosoma. Nedostatna aktivnost lizosomskog enzima a-galaktozidaze A uzrokuje nakupljanje glikolipida u različitim tkivima i organima. Dosad su prepoznate brojne mutacije odgovorne za razvoj bolesti. Kliničke manifestacije uključuju akroparestezije od djetinjstva, distrofiju mrežnice, angiokeratome, hipohidrozu, slabljenje sluha, te razvoj kardiovaskularne i bubrežne insuficijencije. Zatajenje bubrega započinje u trećem desetljeću života. Obično mladi muškarac dolazi s proteinurijom i poremećenom sposobnošću koncentriranja mokraće ili nastupa završno zatajenje bubrega bez prethodnog nadzora nefrologa. Poliurija i nikturija su prvi znakovi bolesti uzrokovani poremećenom sposobnošću koncentriranja mokraće. Proteinurija počinje u drugom desetljeću života i obično je ispod nefrotske razine. Analizom mokraće nađu se hematurija i lipidurija. U sedimentu su prisutne nakupine lipida i znakoviti "malteški križevi". Odnedavno je u kliničkoj praksi dostupna enzimska nadomjesna terapija za liječenje Anderson-Fabrijeve bolesti. Dosad su na tržištu registrirana dva pripravka rekombinantnog enzima a-galaktozidaze A. Čini se da je moguće zaustaviti i možda čak ispraviti poremećaje u ciljnim organima pogođenim Anderson-Fabrijevom bolešću ako u njima nisu nastupile nepovratne promjene. Klinička istraživanja su dokazala učinkovitost i neškodljivost liječenja agalsidazom alfa ili beta. Uz povoljan učinak na bubrežnu funkciju, enzimska nadomjesna terapija je značajno poboljšala srčanu funkciju i kvalitetu života bolesnika. Glavni nedostatak nadomjesne terapije je vrlo visoka cijena liječenja koja predstavlja izazov čak i za najrazvijenije zemlje svijeta. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14245 http://hrcak.srce.hr/file/21805 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Consensus Opinion on Diagnosing Brain Death - Guidelines for use of Confirmatory Tests Konsenzus za dijagnosticiranje moždane smrti - smjernice za primjenu potvrdnih pretraga Demarin, Vida Lovrenčić-Huzjan, Arijana Vargek-Solter, Vesna Vuković, Vlasta Miškov, Snježana Mikula, Ivan Perić, Mladen Gopčević, Aleksandar Kusić, Zvonko Balenović, Antonija Klanfar, Zoran Bušić, Mirela Brain Death - diagnosis; Brain Death - ultrasonography; Severity of illness; Predictive Value of Tests; Guidelines; Brain death - legislation and jurisprudence; Croatia Brain death is defined as the irreversible loss of all brain functions, including the brainstem. The diagnosis of brain death allows organ donation or withdrawal of support. Therefore the exact criteria for the diagnosis of brain death must be determined. In the Croatian Act on Transplantation, repeated neurologic examination must show loss of brainstem reflexes, and one confirmation test must be done. Several tests are available, showing the cessation of brain or brainstem activity, or confirming the cerebral circulatory arrest. Bedside evaluation is possible through electroencephysiologic and neurosonologic tests. Conventional or digital subtraction angiography is done in radiology suite, and isotope angiography and technetium-99m hexamethylpropyleneamine oxime (99Tc-HMPAO) at the Department of Nuclear Medicine. Such tests require special settings, therefore bedside test like electroencephalography, evoked potentials and neurosonology tests are preferred. All tests require trained personnel and strict protocols, which differ from routine investigations The confirmatory tests used in brain death confirmation, the techniques, criteria, results and validity of the tests are presented. Definicija moždane smrti obuhvaća gubitak svih funkcija mozga, uključujući moždanog stabla. Dijagnostika moždane smrti omogućava donaciju organa ili prekid potpore. Stoga se moraju točno odrediti kriteriji dijagnoze. Prema Hrvatskom zakonu o transplantaciji, ponovljeni neurološki pregled mora pokazati gubitak refleksa moždanog stabla a obavezan je i jedan od testova potvrde. Nekoliko je testova dostupno, koji pokazuju prestanak aktivnosti mozga ili moždanog stabla ili potvrđuju nastup moždanog prekida cirkulacije. Procjena uz krevet bolesnika je moguća upotrebom elektrofizioloških i neurosonoloških testova. Konvencionalna ili digitalna subtrakcijska angiografija se izvodi na radiologiji, a izotopna angiografija i perfuzija mozga heksametil-propilen-amin-oksimom (99mTc-HMPAO) u Klinici za nuklearnu medicinu. Takvi testovi zahtijevaju posebne pogodnosti, stoga se preferiraju testovi koji se primjenjuju uz krevet bolesnika kao elektroencefalografija, evocirani potencijali i neurosonološki testovi. Svi testovi zahtijevaju uvježbano osoblje i striktne protokole koji se razlikuju od onih koji se upotrebljavaju u rutinskoj dijagnostici. Prikazani su testovi koji se primjenjuju u potvrdi moždane smrti, tehnike, kriteriji, rezultati i vrijednosti testova. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-03-03 text pdf http://hrcak.srce.hr/14250 http://hrcak.srce.hr/file/21810 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.1; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14252 2008-06-03 journal:158

The Role of Conventional and some less Conventional Risk Factors in the Pathogenesis of Acute Ischemic Stroke Uloga konvencionalnih i nekih manje konvencionalnih rizičnih čimbenika u patogenezi akutnog ishemijskog moždanog udara Bašić-Kes, Vanja Šimundić, Ana-Marija Vargek-Solter, Vesna Topić, Elizabeta Demarin, Vida Cerebrovascular disorders - etiology; Brain ischemia - physiopathology; Risk factors; C-reactive protein analysis; Leukocyte count Cerebrovaskularne bolesti - etiologija; Moždana ishemija - fiziopatologija; Rizični čimbenici; Analiza C-reaktivnog proteina; Broj leukocita The aim of the study was to determine the role of some conventional and some less conventional risk factors for stroke, such as inflammatory adhesion cell molecules, in the pathogenesis of ischemic stroke, and their relationship. Sixty-seven subjects with acute ischemic stroke and 76 healthy controls were enrolled in the study. On admission, the concentration of soluble adhesion molecules, C-reactive protein, erythrocyte sedimentation rate and total leukocyte count were determined. The concentrations of soluble adhesion molecules were determined using quantitative sandwich enzyme immunoassay. On the next morning, fasting blood glucose, triglycerides, total cholesterol, HDL-cholesterol and LDL-cholesterol con¬centrations were determined in patient sera. Results showed the mean levels of sICAM-1, sVCAM-1 and sE-selectin to be higher, and that of sL-selectin lower in patients with acute ischemic stroke than in controls. In patients, soluble adhesion molecule levels did not differ with respect to carotid atherosclerotic disease, smoking status, hypertension and hypercholesterolemia. Some soluble adhesion molecules correlated with blood glucose, lipid parameters and markers of inflammation. Cilj istraživanja bio je utvrditi ulogu konvencionalnih i nekih manje konvencionalnih rizičnih čimbenika za moždani udar, poput upalnih adhezijskih staničnih molekula, u patogenezi ishemijskog moždanog udara, kao i njihov međuodnos. šezdesetsedmoro bolesnika s akutnim ishemijskim moždanim udarom koji su bili primljeni na Kliniku za neurologiju, KB "Sestre milosrdnice" u razdoblju od ožujka 2000. do ožujka 2001. godine, te 76 zdravih dobrovoljaca iz Doma zdravlja "Centar" bilo je uključeno u istraživanje. Pri dolasku je svim bolesnicima određena koncentracija adhezijskih molekula, C-reaktivnog proteina te ukupan broj leukocita u serumu. Koncentracija topljivih adhezijskih molekula određena je kvantitativnim enzimskim imunotestom. Dan nakon dolaska određena je serumska koncentracija glukoze, triglicerida, ukupnog kolesterola, HDL-kolesterola. Rezultati su pokazali da su vrijednosti konvencionalnih čimbenika u bolesnika značajno veće nego u kontrolnoj skupini. Odds omjer bio je 15,8 (95% CI 6,69-37,36) za hipertenziju, 12,6 (95% CI 2,78-56,85) za stenozu karotida >50%, 2,6 (95% CI 0,98-6,9) za šećernu bolest, 6,5 (95% CI 1,36-30,79) za atrijsku fibrilaciju, te 1,6 (95% CI 0,51-4,81) za pušenje. Vrijednosti unutarstaničnih adhezijskih molekula -1 (ICAM-1), vaskularnih staničnih adhezijskih molekula -1 (VCAM-1) i E-selektina bile su više u bolesnika nego u kontrolnih osoba (p<0,001, 0,034, 0,002), dok je vrijednost sL-selektina bila niža u skupini bolesnika (p=0,043). Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14252 http://hrcak.srce.hr/file/21813 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14253 2008-06-03 journal:158

Time to First EEG Seizure During Continuous Video/EEG Telemetry Vrijeme do prvog EEG napadaja tijekom kontinuirane Video/EEG telemetrije Hećimović, Hrvoje Gilliam, Frank Electroencephalography - methods; Seizures - diagnosis; Epilepsy - diagnosis; Continuous video/EEG monitoring Elektroencefalografija - metode; Napadaji - dijagnostika; Epilepsija - dijagnostika; Kontinuirana Video/EEG telemetrija Correlation between time to first scalp EEG seizure during video/EEG telemetry and self-reported seizure frequency was determined in refractory epilepsy patients. Eighty two consecutive epilepsy patients were preoperatively evaluated, as part of a larger study, during their video/EEG monitoring at the Adult Epilepsy Center at Washington University. Self-reported seizure frequency, time to first seizure in the monitoring unit, and clinical variables of age, sex and seizure focus localization were analyzed. Mean age of the patients was 35±11 years and 54.9% were women. In 51 patients with temporal and 19 patients with extra temporal epilepsy, the mean time to first scalp EEG seizure was 44±48 h. Self-reported seizure frequency did not predict the time to first scalp EEG seizure in the seizure monitoring unit. The majority of patients had their first scalp EEG seizure during the first two days of video/EEG telemetry. Self-reported seizure frequency was a poor predictor of time to first scalp EEG seizure. This finding suggests that patients with less frequent self-reported seizure rates should also be considered as good candidates for further evaluation, including scalp and intracranial video/EEG telemetry. Određivala se je korelacija između vremena do prvog napadaja kod EEG vlasišta tijekom Video/EEG telemetrije i učestalosti napadaja koju su navodili sami bolesnici s refraktornom epilepsijom. Prijeoperacijski su obrađena 82 uzastopna bolesnika s epilepsijom, kao dio veće studije, tijekom njihova Video/EEG praćenja u Centru za epilepsiju odraslih pri Sveučilištu u Washingtonu. Analizirana je učestalost napadaja koju su naveli sami bolesnici, vrijeme do prvog napadaja u kabinetu za praćenje, te kliničke varijable za dob, spol i žarišnu lokalizaciju napadaja. Srednja dob bolesnika bila je 35±11 godina, a 54,9% bile su žene. U 51 bolesnika s temporalnom i 19 bolesnika s ekstratemporalnom epilepsijom srednje vrijeme do prvog napadaja na EEG bilo je 44±48 h. Učestalost napadaja koju su navodili sami bolesnici nije predskazala vrijeme do prvog napadaja kod EEG telemetrije. U većine bolesnika prvi je napadaj na EEG nastupio tijekom prva dva dana Video/EEG telemetrije. Učestalost napadaja koju su navodili bolesnici bila je loš predskazatelj vremena do prvog napadaja na EEG. Ova studija ukazuje na to da bolesnike koji navode rjeđu učestalost napadaja treba također smatrati dobrim kandidatima za daljnju procjenu, uključujući Video/EEG telemetriju. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14253 http://hrcak.srce.hr/file/21814 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Massive Pulmonary Embolism Following Heparin-Induced Thrombocytopenia Masivna plućna embolija nakon trombocitopenije izazvane heparinom Vučičević, Željko Degoricija, Vesna Alfirević, Zrinka Sharma, Mirella Pulmonary embolism - chemically induced; Thrombocytopenia - chemically induced; Anticoagulants - adverse effects; Heparin - adverse effects Plućna embolija - kemijski izazvana; Trombocitopenija - kemijski izazvana; Antikoagulansi - štetni učinci; Heparin - štetni učinci Immunomediated heparin-induced thrombocytopenia still presents a serious problem, especially when accompanied by thromboembolic complications. We report on a rare case of massive pulmonary embolism following perioperative prophylaxis with unfractionated and low-molecular-weight heparin. The lack of efficacious and safe heparin substitution only allowed for immediate heparin discontinuation and application of adjuvant therapy. A few days after heparin cessation the platelet count tended to return to normal, leading to the patient's full recovery and discharge from the hospital. Heparin therapy requires careful examination of previous history of heparin use as well as close platelet monitoring for up to three weeks of therapy cessation. Imuna trombocitopenija izazvana heparinom još uvijek predstavlja ozbiljan problem, osobito ako je praćena tromboemboličnim komplikacijama. Ovdje prikazujemo rijedak slučaj masivne plućne embolije nastale nakon profilaktične primjene nefrakcioniranog i niskomolekularnog heparina. Manjak učinkovitog i sigurnog nadomjeska za heparin ostavio je samo mogućnost neposrednog ukidanja heparina i uvođenja pomoćne terapije. Nekoliko dana nakon prestanka liječenja heparinom broj trombocita počeo se je normalizirati, a nakon toga bolesnica se je potpuno oporavila i bila otpuštena iz bolnice. Liječenje heparinom zahtijeva brižno prikupljanje anamnestičnih podataka o ranijoj primjeni ovoga pripravka te pažljivo praćenje broja trombocita i do tri tjedna nakon prekida heparinske terapije. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14254 http://hrcak.srce.hr/file/21815 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14255 2008-06-03 journal:158

Alopecia Areata in a Female Patient Suffering from Borderline Personality Disorder with Comorbid Mood Disorder - Depressive Episode Alopecia areata u bolesnice s graničnim poremećajem osobnosti uz istodobni poremećaj raspoloženja u obliku depresivne epizode Gruber, Ema N. Crnković, Danijel Bjedov, Mirjana Alopecia areata - diagnosis; Alopecia areata - psychology; Life change events; Mental disorders - therapy Alopecia areata - dijagnostika; Alopecia areata - psihologija; životne promjene; Psihički poremećaji - liječenje A case is presented of a 44-year-old female patient, highly educated, suffering from borderline personality disorder with comorbid mood disorder, manifested as a depressive episode, who had been suffering from acute emotional stress for a few months. She was through the procedure of divorce, losing her children by the court decision. Over a two-month period she had lost over 90% of her hair and started treatment for alopecia areata. She was simultaneously treated by a dermatologist and a psychiatrist, and attended group psychotherapy. The impact of psychological factors in the development, evolution and therapeutic management of alopecia areata was documented in this case. Life events and intrapsychically generated stress played an important role in triggering the disease. The treatment for the concomitant psychiatric disorder had a crucial role in this case because it had a favorable effect on the patient's adaptation to her alopecia areata and social setting, and led to better dermatologic evolution of the disease. Prikazan je slučaj 44-godišnje visoko obrazovane bolesnice s graničnim poremećajem osobnosti uz istodobni poremećaj raspoloženja u obliku depresivne epizode, koja je nekoliko mjeseci proživljavala akutni emocionalni stres. Prošla je postupak razvoda braka, a sudskom joj odlukom djeca nisu dodijeljena. Kroz dva mjeseca izgubila je preko 90% kose i započela je liječenje zbog alopecie areate. Istodobno su ju liječili dermatolog i psihijatar, a pohađala je i grupnu terapiju. U ovom je slučaju dokumentiran utjecaj psiholoških čimbenika na razvoj, evoluciju i liječenje alopecie areate. životni događaji i psihički stres imali su važnu ulogu u pokretanju bolesti. Uloga liječenja u istodobnom psihičkom poremećaju bila je presudna u ovom slučaju, jer je imala pozitivan učinak na način na koji se je bolesnica prilagodila nastalom opadanju kose i društvenom okruženju, što je dovelo do boljeg dermatološkog razvoja alopecie areate. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14255 http://hrcak.srce.hr/file/21816 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14256 2008-06-03 journal:158

Intracranial Venous Angiomas - Case Report Intrakranijski venski angiomi - prikaz slučaja Kudelić, Nenad Lupret, Velimir Sajko, Tomislav Tonković, Vladimir Kalousek, Miljenko Central Neuro System Venous Angioma; Case Report Venski angiom središnjeg živčanog sustava; Prikaz slučaja Two cases of intracranial venous angiomas, one in a 42-year-old woman and another one in a 27-year-old-man, are presented. Intracranial venous angiomas, also known as developmental venous anomalies, represent one of four cerebral vascular malformations. Usually they are incidentally discovered on cerebral imaging. These lesions have a characteristic appearance in the venous phase of angiography, a starburst pattern or umbrella sign, described as caput medusae. Most of the lesions are clinically silent, however, they can be symptomatic with clinical presentation including seizures, headache, dizziness and focal neurologic deficits. They are sometimes associated with cerebral hemorrhage. In general, no treatment is required. Surgery is only indicated if seizures attributed to the lesion or hemorrhage occur. Prikazana su dva slučaja intrakranijskih venskih angioma, jedan u 42-godišnje žene i drugi u 27-godišnjeg muškarca. Intrakranijski venski angiomi, također poznati kao razvojne venske anomalije, čine jednu od četiri cerebralne malformacije. Obično se slučajno otkrivaju neuroradiološkom obradom. Ove lezije se znakovito prikazuju u venskoj fazi angiograma kao zvjezdasti uzorak ili poput kišobrana, što se opisuje kao caput medusae. Većina venskih angioma su klinički asimptomatski, iako mogu biti i simptomatski te se tada klinički očituju epileptičnim napadajem, glavoboljom, vrtoglavicom i žarišnim neurološkim deficitom. Ponekad su povezani s intracerebralnim krvarenjem. U većini slučajeva ne zahtijevaju liječenje. Operacijsko liječenje je indicirano samo u slučajevima dokazane povezanosti angioma i epileptičnih napadaja odnosno u slučaju krvarenja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14256 http://hrcak.srce.hr/file/21817 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14258 2008-06-03 journal:158

Wartime Craniobasal Injuries in Southern Croatia Ratne kraniobazalne ozljede u južnoj Hrvatskoj Tudor, Mario Tudor, Lorainne Tudor, Katarina Ivana Brain injuries - epidemiology; Craniobasal trauma - complications; War; Wounds, penetrating - complications; Croatia Ozljede glave - epidemiologija; Kraniobazalna trauma - komplikacije; Rat; Rane, penetrirajuće - komplikacije; Hrvatska During the war in Croatia (1991-1995), 26 patients with craniobasal (facio-orbital) injuries were treated in southern Croatia. Numerous complications that accompany these lesions give them specific neurosurgical importance. Patient records were retrospectively analyzed in order to assess outcome in this group of patients. Cerebrospinal fluid fistula was observed in one third of the patients. Cerebrospinal fluid fistula based infection occurred in over 50% of cases. Endocranially located retained foreign bodies were seen in 10 patients. A higher rate of reoperation (mostly for cerebrospinal fluid fistula) was recorded in this group of patients as compared with other sites of head injuries. Favorable outcome was recorded in 18 and unfavorable outcome in 8 patients, whereas 3 patients died. This survey of patient records showed it to be of utmost importance to follow the well defined neurosurgical policy according to which the primary wound repair (especially of the torn basal dura mater) should be a definitive one. Cerebrospinal fluid fistula, retained foreign bodies, low Glasgow Coma Scale on admission, and reoperation exert an unfavorable effect on patient outcome. Tijekom rata u Hrvatskoj (1991.-1995.) u južnoj Hrvatskoj liječeno je 26 bolesnika s kraniobazalnim (facio-orbitalnim) ozljedama. Brojne komplikacije koje prate ove ozljede čine ih osobito značajnim za neurokirurgiju. Provedena je retrospektivna analiza bolesničkih kartona kako bi se procijenio ishod u ovoj skupini bolesnika. Likvorska fistula zabilježena je u jedne trećine bolesnika. Infekcija proizišla iz takve fistule nastupila je u preko 50% slučajeva. Zaostala strana tijela u endokranijumu nađena su u 10 bolesnika. U ovoj skupini bolesnika zabilježena je viša stopa ponovnih operacijskih zahvata (uglavnom zbog likvorske fistule) u usporedbi s drugim mjestima ozljeda glave. Povoljan ishod zabilježen je u 18, a nepovoljan ishod u 8 bolesnika, dok su trojica umrla. Zaključuje se kako je od vrhunske važnosti slijediti dobro utvrđen neurokirurški protokol prema kojemu primarno zbrinjavanje rane (poglavito pokidane bazalne dure mater) mora biti konačno. Likvorska fistula, zaostala strana tijela, niska vrijednost na Glasgowskoj ljestvici kome kod prijma te ponovna operacija nepovoljno utječu na ishod. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14258 http://hrcak.srce.hr/file/21820 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14260 2008-06-03 journal:158

Lipid Lowering Treatment in Secondary Stroke Prevention Liječenje snižavanjem masti u sekundarnoj prevenciji moždanog udara Lisak, Marijana Trkanjec, Zlatko Demarin, Vida Cerebrovascular accident - prevention and control; Cerebrovascular accident - etiology; Lipoproteins - drug effects; Hypercholesterolemia - drug therapy; Risk factors; Anticholesteremic agents Cerebrovaskularni incident - prevencija i kontrola; Cerebrovaskularni incident - etiologija; Lipoproteini - učinak lijekova; Hiperkolesterolemija - terapija lijekovima; Čimbenici rizika; Antikolesteremični lijekovi Secondary preventive measures such as measuring serum cholesterol levels and treatment of hypercholesterolemia with statins, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, are insufficiently used in patients with acute stroke or transient ischemic attack, although statins offer potential benefits for reducing the incidence and improving the prognosis of stroke. Besides lipid lowering, statins could have additional effects such as improvement of endothelial-dependent flow-mediated vasodilatation, modulating inflammatory response, decreasing clot formation, and decreasing platelet adherence to ruptured plaque, thus stabilizing the atherosclerotic plaque. Other antiatherosclerotic properties of statins include reduction of inflammatory cell accumulation in atherosclerotic plaques, inhibition of vascular smooth muscle cell proliferation, inhibition of platelet function, and improvement of vascular endothelial function. Randomized clinical trials and evidence based medicine support the role of statin therapy in preventing ischemic stroke in patients at risk of cerebrovascular disease. Mjere sekundarne prevencije, kao što su mjerenje serumskih razina kolesterola i liječenje hiperkolesterolemije statinima, inhibitorima reduktaze 3-hidroksi-3-metilglutaril koenzima A (HMG-CoA), nedovoljno se primjenjuju u bolesnika s akutnim moždanim udarom ili prolaznim ishemijskim ispadom, iako statini nude moguće koristi u snižavanju incidencije i poboljšanju prognoze moždanog udara. Uza snižavanje masti, statini bi mogli imati i dodatne učinke, kao što je poboljšanje o endotelu ovisne i protokom posredovane vazodilatacije, moduliranje upalnog odgovora, smanjeno stvaranje ugrušaka, te smanjeno prianjanje trombocita uz rasprsnuti plak, stabilizirajući time aterosklerotski plak. Ostala antiaterosklerotska svojstva statina uključuju smanjeno nakupljanje upalnih stanica u aterosklerotskom plaku, suzbijanje proliferacije krvožilnih glatkomišićnih stanica, suzbijanje funkcije trombocita, te poboljšanje funkcije krvožilnog endotela. Randomizirana klinička ispitivanja i medicina zasnovana na dokazima govore u prilog uloge liječenja statinima u sprječavanju ishemijskog moždanog udara u bolesnika s rizikom za cerebrovaskularnu bolest. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14260 http://hrcak.srce.hr/file/21823 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14261 2008-06-03 journal:158

Evidence Based Guidelines for Treatment of Primary Headaches Na dokazima zasnovane smjernice za liječenje primarnih glavobolja Demarin, Vida Vuković, Vlasta Lovrenčić-Huzjan, Arijana Lušić, Ivo Jančuljak, Davor Wilheim, Ksenija Zurak, Niko Migraine; Tension headache; Cluster headache; Headache management; Pharmacotherapy Migrena, tenzijska glavobolja, cluster glavobolja, liječenje glavobolje, farmakoterapija A proportion of headache patients should be evaluated by a neurologist. These guidelines are developed to help physicians in making appropriate choice in the work-up and treatment of headache patients. Most migraine sufferers have not been diagnosed by a physician and are not receiving medical guidance to effectively address their migraine attacks. In the past 15 years new therapies (acute and preventive) have been introduced. In migraine patients nonresponders to analgesics, especially in patients with moderate to severe migraine, triptans should be introduced. In migraine with frequent attacks or long lasting attacks, preventive treatment according to comorbid diseases should be recommended. In tension type headache, an underlying pathology should be excluded; management includes pharmacological and non-pharmacological treatment. Although rare, patients with cluster headache experience major pain and disability; in acute management oxygen inhalation or triptans are recommended, in certain cases prophylaxis is indicated. These guidelines contain classification, diagnostic criteria, and principles of management of all primary headaches. These recommendations for headache treatment are based on a comprehensive review and meta-analysis of scientific literature with regard to treatment possibilities in Croatia. U dijela bolesnika koji pate od glavobolja potreban je neurološki pregled. Smjernice za dijagnostiku i liječenje glavobolja imaju za cilj pomoći liječnicima u svakodnevnom radu s bolesnicima s glavoboljom. U većine bolesnika migrenu nije dijagnosticirao liječnik, te im nije pružena odgovarajuća pomoć za liječenje napadaja. U proteklih petnaestak godina uvedene su nove terapijske metode (za akutno i preventivno liječenje). Bolesnicima koji ne reagiraju na obične analgetike, osobito onima s umjerenim i jakim migrenama, treba ponuditi triptane. Preventivnu terapiju, ovisno o drugim pridruženim bolestima, treba preporučiti osobama s učestalim ili dugotrajnim napadajima migrene. Kod osoba s tenzijskim glavoboljama potrebno je isključiti organsku podlogu glavobolja, a liječenje uključuje farmakološke i nefarmakološke mjere. Premda rijetki, bolesnici s cluster glavoboljama imaju jake bolove; u akutnom napadaju preporuča se inhalacija kisika ili triptani, a u pojedinim slučajevima indicirana je i preventivna terapija. Smjernice uključuju klasifikaciju, dijagnostičke kriterije i načela liječenja primarnih glavobolja. Sve preporuke u Smjernicama se temelje na meta-analizama i preporukama iz svjetske literature s osvrtom na terapijske mogućnosti u Hrvatskoj. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-06-01 text pdf http://hrcak.srce.hr/14261 http://hrcak.srce.hr/file/21824 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.2; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14263 2008-06-03 journal:158

Detection of Chromosome 1 Deletion by FISH on Ependymoma Touch Imprints Suggests a Region out of Chromosome 22 as Important for Tumor Relapse Otkrivanje delecije kromosoma 1 pomoću tehnike FISH na otiscima ependimoma ukazuje na regiju izvan kromosoma 22 važnu za recidiv tumora Tamiolakis, Demetrio Papadopoulos, Nikolas Venizelos, John Lambropoulou, Maria Nikolaidou, Sylva Bolioti, Sophia Kiziridou, Artemis Alexiadis, George Simopoulos, Constantine Brain neoplasms - genetics; Ependymoma - genetics; Ependymoma - pathology; Chromosomes - human - pair 1; Chromosomes - human - pair 22 Neoplazme mozga - genetika; Ependimom - genetika; Ependimom - patologija; Kromosomi - ljudski - par 1; Kromosom - ljudski - par 22 Ependymomas are glial tumors. They constitute approximately 5%-10% of intracranial tumors. Ependymomas are tumors which can recur. Predictive factors of outcome in ependymomas are not well established. Karyotypic studies are relatively scarce and loss of chromosome 22 has been described to correlate with recurrence. We are unaware of any reports involving chromosome 1 aberrations in the malignant progression of ependymomas. Cytogenetic analysis of 4 ependymomas was performed using double-target fluorescent in situ hybridization (FISH) and focusing on chromosomes 1 and 22. One patient had recurrent tumor. FISH was performed on 500 nuclei/tumors. All four cases showed a loss of chromosome 22q, while only one showed an additional loss of chromosome 1p, and it was the one with tumor relapse. We support the presence of tumor suppressor gene on 1p associated with relapse in ependymomas and suggest that the chromosome 1p status by FISH may identify a high risk group of patients harboring this tumor. Additional studies in this direction are needed, as our results refer to a minimal number of individuals analyzed. Ependimomi su glialni tumori. Oni čine otprilike 5%-10% intrakranijskih tumora. Ependimomi su tumori koji se mogu ponavljati. Čimbenici koji bi ukazivali na ishod ependimoma nisu dobro utvrđeni. Kariotipska ispitivanja su relativno rijetka, a opisano je kako gubitak kromosoma 22 korelira s ponovnom pojavom tumora. Nisu nam poznata izvješća o upletenosti aberacija kromosoma 1 u malignoj progresiji ependimoma. U ovoj studiji je citogenetska analiza 4 ependimoma provedena pomoću dvociljne fluorescentne in situ hibridizacije (FISH) i fokusiranja na kromosomima 1 i 22. U jednog se bolesnika radilo o ponovnoj pojavi tumora. FISH je izvedena na 500 jezgara/tumora. Sva četiri slučaja pokazala su gubitak kromosoma 22q, dok je samo jedan, i to onaj s ponovnim razvojem tumora, pokazao dodatni gubitak kromosoma 1p. Priklanjamo se mišljenju kako je prisutnost gena tumorske supresije na 1p udru žena s recidivom kod ependimoma i ukazujemo na to da bi status kromosoma 1p utvrđen pomoću FISH mogao identificirati visoko rizičnu skupinu bolesnika koji nose ovaj tumor. Potrebne su daljnje studije u ovom smjeru, jer se naši rezultati odnose na mali broj analiziranih osoba. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14263 http://hrcak.srce.hr/file/21827 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14264 2008-06-03 journal:158

Asthma and Eosinophilic Cationic Protein as an Indicator of Disease Control Astma i eozinofilni kationski protein kao pokazatelj uspješnosti liječenja bolesti Čičak, Biserka Verona, Eva Bukovac, Željka Mihatov, Iva Asthma - physiopathology; Asthma - blood; Eosinophils - immunology; Asthma - therapy Astma - fiziopatologija; Astma - krv; Eozinofili - imunologija; Astma - terapija Asthma is the most common chronic disease in children and adolescents. It is necessary to develop objective methods for assessment of disease activity, treatment efficacy, and prevention of attacks. Measurements of eosinophilic cationic protein (ECP) should serve as an objective indicator of allergic inflammation activity. This follow-up study included 100 children treated with inhaled corticosteroid (fluticasone propionate) or sodium cromoglycate over a 12-month period. The values of (ECP) and forced expiratory volume in the first second (FEV1) were measured at the beginning of the study and then once a month for a year, to evaluate treatment efficacy. The fastest drop in ECP values and the highest increase in FEV1 were found in children with newly diagnosed asthma, who were treated with inhalation corticosteroid. This result supports the importance of early introduction of anti-inflammatory therapy in childhood asthma. Astma je najčešća kronična bolest djece i mladeži. Zahtijeva razvoj objektivnog mjerila kojim će se moći pratiti aktivnost bolesti, učinkovitost primijenjene terapije te eventualno predvidjeti napadaji. Mjerenje eozinofilnog kationskog proteina (ECP) ima upravo vrijednost jednog takvog objektivnog parametra aktivnosti alergijske upale. Tijekom 12 mjeseci pratili smo stotinu djece s astmom koji su u terapiji dobivali inhalacijski kortikosteroid (flutikazon propionat) ili natrijev kromoglikat. Kao pokazatelj učinkovitosti primijenjene terapije kod bolesnika se je pratila vrijednost serumskog ECP i forsiranog ekspiracijskog volumena (FEV1) u 1 sekundi prije početka ispitivanja te jedanput na mjesec tijekom 12 mjeseci. Najbrži pad ECP uz najviši porast FEV1 zabilježen je u skupini djece s novootkrivenom astmom na terapiji inhalacijskim kortiko-steroidom. Ovo ukazuje na značenje ranog uvođenja protuupalne terapije u liječenju dječje astme. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14264 http://hrcak.srce.hr/file/21828 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14265 2008-06-03 journal:158

Transcranial Sonography can Discriminate Parkinson's Disease from other Movement Disorders Transkranijska sonografija razlikuje Parkinsonovu bolest od drugih poremećaja kretanja Budišić, Mislav Lovrenčić-Huzjan, Arijana Trkanjec, Zlatko Lisak, Marijana Kesić, Miljenka-Jelena Vuković, Vlasta Demarin, Vida Parkinson disease - diagnosis; Parkinson disease - ultrasonography; Ultrasonography, Doppler, transcranial; Neurologic examination Parkinsonova bolest - dijagnostika; Parkinsonova bolest - ultrasonografija; Ultrasonografija, Doppler, transkranijski; Neurološki pregled While nigral substance (NS) is either barely detectable or undetectable in healthy individuals, the majority of patients with Parkinson's disease (PD) display its increased echogenicity on transcranial sonography (TCS). The aim of the study was to assess the possibility of TCS to differentiate PD from other movement disorders by the measurement of NS. TCS was performed in 28 PD patients, 10 patients with movement disorders different from PD (4 with essential tremor, 2 with neuroleptic parkinsonism, 4 with cervical dystonia) and 18 age-matched healthy controls. Fifteen patients were excluded due to inappropriate temporal acoustic bone window. TCS was applied by standardized protocol; NS was displayed, encircled, and measured twice, and mean area was calculated. Mann Whitney U-test was used for between-group comparison. TCS was possible to perform in 56 of 71 (79%) subjects. NS was undetectable or barely detectable in 9 (50%) healthy controls and 2 (20%) patients with movement disorders. Median NS size in controls was 0.17 (0.16-0.21) cm2. A 0.21 cm2 cut-off margin was used for detection of hyperechogenicity. Combined hyperechogenic NS was detected in 25 (89%) PD patients , 2 (20%) patients with movement disorders and 3 (16%) healthy individuals. Study results showed a statistically significant difference in NS echogenic size between PD patients and control group (Mann Whitney u=42; p<0.001) as well as between patients with movement disorder and PD group (Mann Whitney u=23.5; p<0.001) but no significant difference between controls and patients with movement disorders (Mann Whitney u=83.0; p=0.737). Thus, assuming appropriate temporal "bone-window", the measurement of NS by use of TCS is a valuable tool in differentiating PD from other movement disorders. Za razliku od bolesnika s Parkinsonovom bolesti (PB), prikazivanje substancije nigre (SN) pomoću transkranijske sonografije (TCS) u zdrave populacije je često nepotpuno. Većina PB bolesnika na TCS prikazu pokazuje SN povećane ehogenosti. Cilj studije bio je ispitati mogućnosti razlikovanja PB bolesnika i bolesnika sa sličnim poremećajima kretanja putem otkrivanja substancije nigre. Istraživanje je provedeno u 28 bolesnika s PB, 10 bolesnika s poremećajima kretanja različitim od PB (4 s esencijalnim tremorom, 2 s parkinsonizmom izazvanim upotrebom neuroleptičnih lijekova, 4 s cervikalnom distonijom) te 18 zdravih kontrolnih osoba iste dobi. Zbog nemoguće ili nepotpune insonacije 15 bolesnika je naknadno isključeno iz studije. Otkrivanje je provedeno standardiziranom metodom; prikazom SN, zatim ručnim obilježavanjem te dvostrukim mjerenjem. Izračunata je srednja vrijednost, a statistika je obrađena Mann-Whitney U-testom. Pretraga je bila izvediva u 56 od 71 osobe (79%). U 50% osoba kontrolne skupine i 20% bolesnika iz skupine s poremećajima kretanja različitim od PB prikazivanje je bilo nemoguće ili nepotpuno. Srednja vrijednost veličine SN u kontrolnoj skupini bila je 0,17 cm2 (0,16- 0,21). Kao granica vrijednosti prema hiperehogenom prikazu primijenjena je vrijednost od 0,21cm2. Obostrana hiperehogenost nađena je u 25 bolesnika s PD (89%), 2 (20%) u skupini s poremećajima kretanja različitim od PB i u (16%) kontrolne osobe. Rezultati su pokazali statistički značajnu razliku u veličini ehogenosti SN između PB bolesnika i kontrolne skupine (Mann Whitney u=42; p<0,001), kao i razliku između PB i skupine s poremećajima kretanja različitim od PB (Mann Whitney u=2 ,5; p<0,001), ali ne i značajnu razliku između kontrolne skupine i bolesnika s poremećajima kretanja različitim od PB (Mann Whitney u=8 ,0; p=0,7 7). Zaključeno je kako otkrivanje i mjerenje ehogenosti SN putem TCS omogućuje razlikovanje Parkinsonove bolesti od sličnih motoričkih poremećaja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14265 http://hrcak.srce.hr/file/21829 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Beta Stiffness Index by Three-Dimensional Ultrasound Beta indeks žilne krutosti pomoću trodimenzijskog ultrazvuka Jurašić, Miljenka-Jelena Lovrenčić-Huzjan, Arijana Šarac, Rada Demarin, Vida Arteries - physiology; Carotid arteries - ultrasonography; Carotid artery diseases - ultrasonography; Imaging, three-dimensional; Atherosclerosis - diagnosis; Elasticity Arterije - fiziologija; Karotidne arterije - ultrasonografija; Bolesti karotidnih arterija - ultrasonografija; Slikovno prikazivanje, trodimenzijsko; Ateroskleroza - dijagnostika; Elastičnost Beta stiffness index is the most common marker for assessment of subclinical atherosclerosis. The aim of the study was to explore the new technique of three-dimensional ultrasound for carotid stiffness evaluation. This pilot investigation was conducted in ten healthy volunteers. Measurements were performed in common carotid artery (CCA) on an Aloka 5500-SSD Prosound ultrasound platform in B and M modes. Data were collected freehandedly over 10 seconds and post processing analysis was performed using TomTec Imaging software. Beta indexes were mathematically computed and statistically evaluated by use of nonparametric statistics for two related samples. There were nine women and one man aged 39.3±9.23 years. There was one borderline hypertensive subject and four subjects were active smokers. The mean body mass index was 23.85±5.83 kg/m2, and mean intima-media thickness on CCA bilaterally 0.42±0.063 mm. Statistically, comparison between conventional and three-dimensional ultrasound corroborated consistency in the left CCA (p>0.05). This investigation proved that three-dimensional ultrasound could be used as a complementary method for evaluation of subclinical carotid atherosclerosis, with a greater sensitivity in the left CCA. Beta indeks krutosti jedan je od najčešće upotrebljavanih za opisivanje pretkliničke ateroskleroze. Cilj ovoga istraživanja bio je utvrditi je li moguće upotrijebiti novu metodu trodimenzijskog ultrazvuka karotidnih arterija za ispitivanje žilne krutosti. Ovo probno istraživanje provedeno je u 10 zdravih dobrovoljaca na ultrazvučnom uređaju Aloka 5500-SSD Prosound uporabom B i M prikaza na zajedničkoj karotidnoj arteriji (ACC). Za trodimenzijsku analizu rabila se je metoda "slobodne ruke" tijekom 10 sekunda uz pomoć programske potpore TomTec Imaging. Beta indeksi žilne krutosti izračunati su matematičkim putem, za analizu se je rabila neparametrijska statistika s dva povezana uzorka. U ispitivanje je bilo uključeno 9 žena i 1 muškarac prosječene dobi 9, ±9,2 godine. Jedan ispitanik je imao granično povišene vrijednosti krvnoga tlaka, a 4 ispitanika su bili aktivni pušači. Srednji indeks tjelesne težine bio je 2 ,85±5,8 kg/m2, a srednja vrijednost intimalnog dijela stjenke ACC obostrano 0,42±0,06 mm. Statističkom usporedbom vrijednosti beta indeksa krutosti dobiveni su podudarajući rezultati u lijevoj ACC (p>0,05). Istraživanje je potvrdilo da se trodimenzijski ultrazvuk može rabiti kao komplementarna metoda za ispitivanje pretkliničke karotidne ateroskleroze s većom osjetljivosti na lijevoj ACC. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14266 http://hrcak.srce.hr/file/21830 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Brenner Tumor of the Ovary Brennerov tumor jajnika Soljačić-Vraneš, Hrvojka Klarić, Petar Bolf-Benković, Lada Pirkić, Ahmed Ovarian neoplasms - diagnosis; Ovarian neoplasms - pathology; Brenner tumors - diagnosis; Brenner tumors - pathology; Ovary - ultrasonography Neoplazme jajnika - dijagnostika; Neoplazme jajnika - patologija; Brennerovi tumori - dijagnostika; Brennerovi tumori - patologija; Jajnik - ultrasonografija Brenner tumor of the ovary is very rare, mostly benign, small, and unilateral. It mostly occurs in elderly women and produces no symptoms. In the last ten years (1994-2004), seven women were operatively treated at Sestre milosrdnice University Hospital in Zagreb for Brenner tumor. Six patients were treated for this type of tumor, whereas in one patient Brenner tumor was an accidental finding. The former six patients underwent preoperative ultrasonography and Ca 125 determination. The patient age ranged from 41 to 72 years. In six cases, the tumor was unilateral. One patient had a mucionus proliferating cystadenoma in the same ovary affected with benign Brenner tumor. The size of tumors varied from 0.5 to 20 cm in diameter. Brennerov tumor jajnika je vrlo rijedak, uglavnom benigan, većinom malen, najčešće jednostran. Obično se javlja u starijih osoba i ne izaziva nikakve smetnje. U posljednjih 10 godina (1994.-2004.) u Kliničkoj bolnici "Sestre milosrdnice" operirano je sedam bolesnica s Brennerovim tumorom. Šest ih je operirano zbog tumora jajnika, dok je kod jedne bolesnice Brennerov tumor otkriven kao slučajan histopatološki nalaz. Kod šest bolesnica koje su operirane zbog tumora jajnika prijeoperacijski je učinjena ultrasonografija i pretraga na biljeg Ca 125. žene su bile u dobi od 41 do 72 godine. U šest bolesnica je tumor bio jednostran. Kod jedne žene nađen je mucinozni proliferirajući cistadenom u istom ovariju s benignim Brennerovim tumorom. Tumori su bili promjera od 0,5 do 20 cm. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14268 http://hrcak.srce.hr/file/21833 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Magnetic Resonance Imaging and Magnetic Resonance Angiography in the Management of Patients with Ischemic Stroke in Vertebrobasilar Circulation Magnetska rezonanca mozga i magnetska angiografija u zbrinjavanju bolesnika s ishemijskim moždanim udarom u vertebrobazilarnoj cirkulaciji Špero, Martina Kalousek, Miljenko Hat, Josip Bedek, Darko Marotti, Miljenko Cerebrovascular accident - diagnosis; Cerebrovascular circulation - diagnosis; Cerebral arteries - pathology; Ischemic attack - diagnosis; Magnetic resonance imaging - methods; Magnetic resonance angiography Moždani udar - dijagnostika; Cerebrovaskularna cirkulacija - dijagnostika; Moždane arterije - patologija; Ishemijski udar - dijagnostika; Prikazivanje magnetskom rezonancom - metode; Magnetska angiografija Vertebrobasilar occlusion is a life-threatening event that requires prompt diagnostic evaluation and subsequent therapy. Advanced magnetic resonance imaging (MRI) methods, including diffusion-weighted imaging and magnetic resonance angiography (MRA), are highly sensitive for the detection of ischemic tissue injury, and for the detection and localization of intracranial arterial occlusion and stenosis. In the era of thrombolytic therapy, MRI and MRA provide useful information for therapeutic decision making in the early stage of stroke evaluation. This retrospective review included patients with posterior circulation symptomatology examined at our Department between July 2002 and January 2005, 8 female and 11 male, mean age 54.9 years. The aim was to present the possibilities of MRI and MRA in the management of patients with ischemic stroke in posterior circulation. In 19 patients with an ischemia in the vertebrobasilar circulation detected by MRI of the brain, MRA identified 8 cases of basilar artery occlusion, 4 cases of basilar artery stenosis, 3 cases of multiple atherosclerotic stenoses of the vertebral arteries with 2 cases of concurrent vertebral artery occlusion, 2 cases of vasculitis in the posterior circulation, 1 case of proximal posterior cerebral artery occlusion, and 1 case of posterior cerebral artery stenosis. In 8 patients with basilar artery occlusion, the site of occlusion was proximal in 3 cases, proximal and middle in 2 cases, middle and distal in 2 cases, and distal in 1 case. MRI is a powerful tool to detect ischemic changes in stroke immediately upon stroke onset, while MRA is highly sensitive for the detection of occlusive disease in large intracranial arteries as well as in posterior circulation. In the acute stroke setting, MRI and MRA are useful for: 1) early and reliable identification of ischemic stroke; 2) improved choice of treatment modality by helping exclude from thrombolysis patients at high risk of hemorrhage and by identifying those patients most likely to benefit from it; 3) pinpoint the vascular origin of ischemic stroke; 4) determination of neurologic consequences of stroke, including final infarct size, clinical outcome and hemorrhagic risk. Vertebrobazilarna okluzija je za život opasno stanje koje zahtijeva brzu dijagnostičku obradu i terapiju. Suvremene metode magnetske rezonance (MR) mozga, uključujući difuzijski mjerenu sliku i magnetsku angiografiju (MRA), imaju visoku osjetljivost u otkrivanju ishemijske lezije moždanog parenhima, te u otkrivanju i lokalizaciji okluzije i stenoze intrakranijskih arterija. U doba trombolitične terapije MR mozga i MRA daju korisne podatke bitne za donošenje odluke o izboru terapije u procjeni ranog stadija ishemijskog moždanog udara. Proveden je retrospektivni pregled bolesnika sa simptomatologijom stražnje cirkulacije koji su na našem Zavodu pregledani u razdoblju od srpnja 2002. do siječnja 2005. godine, 8 žena i 11 muškaraca srednje životne dobi od 54,9 godina. Cilj je bio pokazati mogućnosti MR mozga i MRA u zbrinjavanju bolesnika s ishemijskim moždanim udarom stražnje cirkulacije. U 19 bolesnika s ishemijskim moždanim udarom vertebrobazilarnog sliva, koji je dokazan pomoću MR mozga, MRA je otkrila 8 okluzija bazilarne arterije, 4 stenoze bazilarne arterije, 3 slučaja višestrukih aterosklerotskih stenoza vertebralnih arterija s 2 slučaja istodobne okluzije vertebralne arterije, 2 vaskulitisa u stražnjoj cirkulaciji, 1 okluziju proksimalnog dijela i 1 stenozu stražnje moždane arterije. Među 8 bolesnika s okluzijom bazilarne arterije mjesto okluzije bilo je proksimalni dio arterije u 3, proksimalni i srednji dio u 2, srednji i distalni dio u 2 slučaja i distalni dio bazilarne arterije u 1 slučaju. MR mozga je moćno sredstvo u otkrivanju ishemijskih promjena neposredno nakon nastupa moždanog udara, dok MRA ima visoku osjetljivost za otkrivanje okluzivne bolesti velikih intrakranijskih arterija. Kod zbrinjavanja akutnog moždanog udara MR mozga i MRA su korisne zbog: 1) brzog i sigurnog otkrivanja ishemije; 2) sigurnijeg izbora oblika terapije pomažući da se tromboliza ne primijeni kod bolesnika s visokim rizikom za razvoj krvarenja te da se otkriju bolesnici koji će imati najviše koristi od iste; 3) mogućnosti točnog određivanja vaskularnog podrijetla ishemijskog moždanog udara; 4) određivanja neuroloških posljedica moždanog udara uključujući konačnu veličinu ishemijske lezije, klinički ishod i rizik od krvarenja. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14269 http://hrcak.srce.hr/file/21834 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Clinical Staging of Central Non-Small Cell Bronchial Carcinoma Klinička procjena stadija centralnog nemikrocelularnog karcinoma bronha Bekić, Anto Nikolić, Igor Turčin, Srebrenka Gorečan, Marijan Križanac, Šimun Morović, Sandra Plavec, Davor Lung neoplasms - diagnosis; Carcinoma non-small-cell, lung - diagnosis; Carcinoma, bronchogenic - diagnosis; Neoplasm staging - methods Plućne neoplazme - dijagnostika; Nemikrocelularni karcinom, plućni - dijagnostika; Karcinom, bronhogeni - dijagnostika; Određivanje stadija neoplazme - metode The aim of the study was to establish the value of clinical preoperative staging of central bronchial carcinoma according to TNM classification (cTNM). Postoperative histopathologic staging of bronchial carcinoma according to TNM classification (pTNM) was used as a reference value. The study included patients with central non-small cell bronchial carcinoma. Preoperative staging was correctly assessed in 50%, underestimated in 32%, and overestimated in 18% of patients. The difference between preoperative and postoperative staging was not statistically significant. In order to be as precise as possible on preoperative bronchial carcinoma staging, all diagnostic methods available should be used to distinguish resectable from nonresectable tumors. The extent of diagnostic work-up should be coordinated with therapeutic consequences. U radu se vrednuje klinička prijeoperacijska procjena stadija centralnog karcinoma bronha prema klasifikaciji TNM (cTNM). Kao referentna vrijednost rabila se je poslijeoperacijska patohistološka procjena stadija karcinoma bronha prema klasifikaciji TNM (pTNM). Analizirani su operirani bolesnici s centralnim nemikrocelularnim karcinomom bronha. Prijeoperacijski je stadij bolesti bio točno procijenjen u 50,00%, podcijenjen u 2,00%, a precijenjen u 18,00% bolesnika. Razlika između prijeoperacijske i poslijeoperacijske procjene nije bila statistički značajna. Treba rabiti sve raspoložive dijagnostičke metode radi što točnijeg prijeoperacijskog određivanja stadija karcinoma bronha u cilju razdvajanja resektabilnih i neresektabilnih tumora. Opseg dijagnostike mora se uskladiti s terapijskim posljedicama. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14270 http://hrcak.srce.hr/file/21835 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Pseudocyesis: A Case Report Pseudocieza: prikaz slučaja Marušić, Srđan Karlović, Dalibor Zoričić, Zoran Martinac, Marko Jokanović, Ljubomir Pseudopregnancy - diagnosis; Pseudopregnancy - psychology; Pseudopregnancy - psychotherapy; Case report Umišljena trudnoća - dijagnostika; Umišljena trudnoća - psihologija; Umišljena trudnoća - psihoterapija; Prikaz slučaja Pseudocyesis is a disorder that is rarely encountered in psychiatric practice. It is characterized by numerous signs and symptoms of pregnancy, except for confirmation of the presence of a fetus. The aim of this article is to present a patient with pseudocyesis. A 24-year-old woman, married, childless, was admitted to gynecology emergency clinic for metrorrhagia, after delivery that had allegedly occurred earlier that day. Gynecologic examination showed neither pregnancy nor postpartum state, therefore consultant psychiatrist was included in patient examination. Upon interview with the patient and her family, and in agreement with gynecologists, the diagnosis of pseudocyesis (undifferentiated somatoform disorder, according to ICD 10 criteria) was made, and the patient who was acutely restless, tearful, occasionally agitated, exhibiting referential ideas, was hospitalized at psychiatry department for treatment. The need of team work of gynecologists and psychiatrists in the treatment of patients suffering from pseudocyesis is emphasized. Pseudocieza je danas rijetko stanje koje se susreće u psihijatrijskoj praksi, a obilježeno je brojnim znakovima i simptomima trudnoće osim potvrde o prisutnosti ploda. Cilj ovoga rada je prikazati slučaj bolesnice s pseudociezom. Bolesnica u dobi od 24 godine, udana, bez djece, primljena je u hitnu ginekološku ambulantu zbog metroragije, navodno nakon obavljenog poroda toga dana. Ginekološkim se pregledom nije utvrdilo postojanje eventualne trudnoće ili stanja nakon poroda, pa je konzilijarno pozvan psihijatar. Nakon razgovora s bolesnicom i njezinom obitelji, te u dogovoru s ginekolozima postavljena je dijagnoza pseudocieze (nediferencirani somatoformni poremećaj, prema ICD 10 kriterijima) te je bolesnica, koja je bila akutno uznemirena, plačljiva, na trenutke agitirana, s idejama odnosa, primljena na daljnje liječenje na psihijatrijsku kliniku. Naglašena je potreba timskog rada ginekologa i psihijatara u liječenju bolesnica koje boluju od pseudocieze. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14272 http://hrcak.srce.hr/file/21838 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Isolated Clitoral Enlargement due to True Hermaphroditism Izolirano povećanje klitorisa zbog pravog hermafroditizma Stipančić, Gordana La Grasta-Sabolić, Lavinija Krušlin, Božo Kraus, Ognjen Hermaphroditism - diagnosis; Hermaphroditism - surgery; Gonadal dysgenesis; Gender identity; Karyotyping; Sex differentiation disorders - surgery; Case report Hermafroditizam - dijagnostika; Hermafroditizam - kirurgija; Gonadna disgeneza; Spolni identitet; Kariotipiziranje; Poremećaji spolne diferencijacije - kirurgija; Prikaz slučaja True hermaphroditism represents a heterogeneous condition in terms of its phenotypic presentation and genetic background. There is a wide spectrum ranging from frankly male to frankly female external genitalia, however, with a predominance of ambiguity. The most frequently observed karyotype is 46,XX, followed by various types of chromosome mosaicism, whereas the rarest one is 46,XY. Simultaneous presence of testicular and ovarian tissue either in separate gonads or in one named ovotestisis required for the diagnosis. In neonatal period our patient was noted to have isolated clitorimegaly (15 mm) with otherwise normal female external genitalia and no palpable gonads either in labia or in inguinal areas. The levels of electrolytes, 17-hydroxyprogesterone (17 OH P), androstenedione and renin were within the reference values. Baseline plasma level of testosterone was elevated as well as its response in the human chorionic gonadotropin (hCG) stimulation test. The presence of uterus was discovered by imaging techniques but gonadal localization was not possible. Karyotype was 46,XY. According to clinical and laboratory findings, the diagnosis of 46,XY partial gonadal dysgenesis was made. During surgery, reduction of clitoris was performed while laparotomy revealed a right ovotestis (confirmed by histology) which was removed. The left gonad was not identified and biopsy of suspected tissue revealed fallopian tube. Considering obvious female appearance of external genitalia and its potential function, it was suggested that the baby should be reared as a girl. As there is no clinical, laboratory or imaging finding which could differ true hermaphroditism from some other types of intersex, definitive diagnosis depends on gonadal histology. Pravi hermafroditizam heterogena je skupina stanja prema o fenotipskoj prezentaciji i genetskoj osnovi. Moguć je cijeli spektar od potpuno muških do potpuno ženskih vanjskih genitalija, ipak uz prevlast dvosmislenih genitalija. Najzastupljeniji je kariogram 46 XX, zatim razni oblici mozaicizma, a tek potom 46 XY. Istodobno prisutno tkivo testisa i ovarija nalazi se u odvojenim gonadama ili u okviru jedne gonade, ovotestisu. Naše dijete je u novorođenačkoj dobi imalo izoliranu hipertrofiju klitorisa (15 mm), uz inače uredne ženske vanjske genitalije, bez palpabilnih gonada bilo u labijama ili ingvinalnom području. Razina elektrolita, 17 OH P, androstenediona i renina bila je uredna. Bazalna razina testosterona te odgovor u HCG testu bili su pozitivni. Slikovnim pretragama utvrdili smo prisutnost uterusa, ali lokalizacija gonada nije bila moguća. Kariogram je 46,XY. Prema kliničkim i laboratorijskim nalazima postavljena je dijagnoza 46,XY parcijalne gonadne disgeneze. Tijekom operacijskog zahvata učinjena je redukcija klitorisa te laparotomija kojom se je locirala i odstranila desna gonada, patohistološki nalaz koje je upućivao na ovotestis. Lijeva gonada nije sa sigurnošću locirana pa je učinjena samo biopsija pretpostavljenog tkiva PHD nalaz kojega je odgovarao stjenci jajovoda. S obzirom na izrazitu feminiziranost vanjskih genitalija u fenotipskom i funkcionalnom smislu preporučeno je da se dijete odgaja kao žensko. Kako ne postoji osobitost koja bi klinički, laboratorijski ili slikovno razlikovala pravi hermafroditizam od nekih drugih oblika interseksa, konačna dijagnoza ovisi o patohistološkom nalazu gonada. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14273 http://hrcak.srce.hr/file/21839 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

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Localized Tracheal Amyloidosis Lokalizirana amiloidoza dušnika Juričevski, Ivan Vrčić, Mihovil Vrčić, Alka Budimir, Ivan Križanac, Šimun Tuđman, Zdenko Varga, Damir Amyloidosis - diagnosis; Respiratory tract diseases - diagnosis; Tracheal diseases - diagnosis; Amyloidosis - therapy; Bronchoscopy; Case report Amiloidoza - dijagnostika; Bolesti dišnoga trakta - dijagnostika; Bolesti dušnika - dijagnostika; Amiloidoza - terapija; Bronhoskopija; Prikaz slučaja Amyloidosis is a disorder characterized by localized or diffuse deposition of fibrillary proteins in the extracellular space, causing progressive damage to tissue structure and organ function. Any organ system of the body may be involved by amyloidosis. A case is presented of localized tracheal amyloidosis in a 62-year-old man treated for active lung tuberculosis. Among other procedures, diagnostic workup included bronchoscopy, which revealed tumor-like lesions of tracheal mucosa. Histologic analysis of the involved mucosa biopsy sample pointed to amyloidosis. Treatment with laser photocoagulation resulted in remarkable regression of the lesions. Amiloidoza je poremećaj lokaliziranog ili difuznog nakupljanja fibrilarnih proteina u izvanstaničnom prostoru, koji progresivno oštećuju strukturu tkiva i funkciju organa. Poremećaj može zahvatiti bilo koji organski sustav u tijelu. Prikazuje se slučaj lokalizirane amiloidoze dušnika u 62-godišnjeg bolesnika liječenog zbog aktivne tuberkuloze pluća. Između ostalih dijagnostičkih postupaka učinjena je i bronhoskopija, pri čem su uočene tumoru slične promjene na sluznici dušnika. Histološka pretraga uzorka dobivenog biopsijom sluznice sa zahvaćenog mjesta ukazala je na amiloidozu. Liječenje laserskom fotokoagulacijom rezultiralo je znatnim povlačenjem nastalih promjena. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14274 http://hrcak.srce.hr/file/21840 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en

oai:hrcak.srce.hr:14277 2008-06-03 journal:158

Intraoperative Transcranial Doppler Ultrasound Monitoring of the Cerebral Blood Flow during Carotid Endarterectomy, Surgical Management of Intracranial Aneurysms and Coronary Artery Bypass Grafting Intraoperacijsko praćenje moždanog krvnog protoka transkranijskim Dopplerom tijekom karotidne endarterektomije, kirurškog liječenja moždanih aneurizma i koronarnog premošćivanja Tetičković, Erih Menih, Marija Miksić, Kazimir Flis, Vojko Košir, Gorazd Bunc, Gorazd Aortic diseases - ultrasonography; Coronary artery bypass; Endarterectomy carotid; Ultrasonography - Doppler - transcranial; Monitoring - intraoperative Bolesti aorte - ultrasonografija; Premošćenje koronarne arterije; Endarterektomija karotide; Ultrasonografija - Dopplerova - transkranijska; Praćenje - intraoperacijsko Intraoperative transcranial Doppler monitoring of intracranial blood flow during carotid endarterectomy, surgical management of intracranial aneurysms and coronary artery bypass grafting is important because it enables recording of the flow in the middle cerebral artery in real time. An adequate blood flow through the middle cerebral artery during carotid endarterectomy allows for selective choice of intraluminal shunt as well as an operation without it, timely identification of cerebral hyperperfusion, vasospasm and hypoperfusion, and detection of cerebral microembolisms, thus minimizing postoperative neurologic complications such as cerebrovascular events or cognitive dysfunction. Intraoperacijsko praćenje moždanog krvnog protoka transkranijskim Dopplerom za vrijeme karotidne endarterektomije, kirurškog liječenja moždanih aneurizma i koronarnih premoštenja veoma je značajno, jer omogućava promatranje protoka u srednjoj moždanoj arteriji u stvarnom vremenu. Dostatan protok krvi u srednjoj moždanoj arteriji za vrijeme karotidne endarterektomije omogućava selektivan izbor intraluminalog spoja (shunt) i operaciju bez njega, pravodobno otkrivanje moždane hiperperfuzije, vazospazma, hipoperfuzije i cerebralnih mikroembolija, što može bitno smanjiti poslijeoperacijske neurološke komplikacije kao cerebrovaskularni incident ili kognitivnu disfunkciju. Sestre Milosrdnice University hospital and Institute of Clinical Medical Research; acta@kbcsm.hr 2005-09-01 text pdf http://hrcak.srce.hr/14277 http://hrcak.srce.hr/file/21843 Acta Clinica Croatica (acta@kbcsm.hr); Vol.44 No.3; ISSN 0353-9466 (Print); ISSN 1333-9451 (Online) en 1369154955253