Začetak transplantacije bubrega u jugoistočnoj Europi

Organ transplantation is one of the most important medical achievements of the 20th century. Kidney transplantation is the most efficient method of renal replacement therapy. The first successful kidney transplantation in human was performed in 1954 in Boston, USA. In former Yugoslavia, the first kidney transplantation was performed on April 16, 1970 in Ljubljana, Slovenia, and second one on January 30, 1971 in Rijeka, Croatia. In both cases, the mother donated kidney to the son. In the article, we describe the prerequisite conditions for this operation, the characteristics of first patients, and the impact of transplantation program on the development of the hospitals and medical schools.Transplantacija organa zasigurno predstavlja jedno od najvećih dostignuća 20. stoljeća. Transplantacija bubrega je najučinkovitija metoda od svih oblika nadomještanja bubrežne funkcije. Prva uspješna transplantacija bubrega u ljudi je učinjena u Bostonu, SAD, 1954. godine. U bivšoj Jugoslaviji prva transplantacija bubrega je učinjena 16. travnja 1970. u Ljubljani, Slovenija, a potom 30. siječnja 1971. u Rijeci, Hrvatska. Darivatelj je kod oba bolesnika bila majka, a primatelj sin. U članku ćemo prikazati što je prethodilo ovim operacijama, značajke prvih bolesnika te utjecaj transplantacijskog programa na razvoj matičnih bolnica i fakulteta

Treatment of Advanced Peripheral Arterial Insuffifi ciency in the Elderly

Peripheral arterial insuffi ciency appears at all stages regardless of the patient age; however its appearance is most common in the elderly in which cases it mostly appears as stage described by Fontaine as stage III or IV. The most common cause of peripheral arterial insuffi ciency is atherosclerotic degeneration, and is remarkably often accompanied by the diabetes. In the years 2012 and 2013 department of vascular surgery, University Hospital Rijeka admitted 169 patients older than 70 with peripheral arterial insuffi ciency of type Fontaine III and IV. That number represents 68.8% of total number of patients admitted for peripheral arterial insuffi ciency. The goal of this research is to identify to what extent and in what percentage can patients older than 70 with advanced peripheral arterial insuffi ciency be subjected to vascular treatment and if there exist and absolute indication for angiographic treatment of such patients. In majority of patients, 148 of them, three or more comorbidities were present. Diabetes was present at almost half of patients, to be exact 46.7%. Assessment of possibility for vascular treatment and the need for angiographic treatment was followed in patients in three age groups: 70–75 years of age, 76–80 years of age and over 80 years of age. Angiography was performed on 69 patients and the insight into angiographic fi nding resulted in only 33 patients being subjected to some type of vascular treatment. From the total number of patient’s subjected to vascular treatment 20 had symptoms of Fontaine III while the remaining 13 had symptoms of Fontaine IV. Amputation procedure was performed 119 times. The research shows that angiographic treatment is not a routine treatment in mentioned patients and that the number of vascular procedures is signifi cantly higher in the 70–75 years age group

Successful Treatment of Acute Aortic Dissection uccessful Treatment of Acute Aortic Dissection Type Stanford A Presenting as Limb Ischemia, ype Stanford A Presenting as Limb Ischemia, Successfully Treated with Operative and uccessfully Treated with Operat

We report a successful treatment of unusual case of a 48 year old male patient with acute aortic dissection type Stanford A that expanded into left common and external iliac artery diagnosed by MSCT angiography, presenting as a single leg paresis, without symptoms of a chest or back pain. Patient was operated with conventional ascending aortic replacement. Patient had no known prior medical condition. He has been treated for acute thrombosis of the left popliteal artery developing one day after ascending aortic replacement surgery, embolectomy was performed. Critical limb ischemia developed due to preocclusive stenosis of the left common and left external iliac artery and was treated by endovascular procedure of iliac artery stenting performed on the fifth postoperative day. After 17 days patient was discharged form hospital, showing no neurological or vascular deficit. For successful treatment of acute aortic dissection type Stanford A complicated with limb ischemia, rapidandaccuratediagnosis is essential, together with close cooperation of cardio surgeons, vascularsurgeonsandinvasiveradiologists and individual approach to these demanding patients

Frequency of early postoperative restenosis after carotid artery thrombendarterectomy

Cilj: Ustvrditi postotak pojavnosti poslijeoperacijske restenoze nakon operacijskog liječenja visokopostotne stenoze arterije karotis na godišnjoj razini te podatke usporediti s novijom svjetskom literaturom. Ispitanici i postupci: Podatci su dobiveni analizom ranih poslijeoperacij- skih kontrolnih nalaza dobivenih obojenim dupleks doplerom, izvršenih dva tjedna nakon zahvata trombendaterektomije karotidnog žilja, u laboratoriju za cerebrovaskularne bolesti, Klinike za neurologiju, KBC-a Rijeka, na 104 pacijenta operirana na Zavodu za torakovaskularnu kirurgiju, Kirurške klinike KBC-a Rijeka 2012. godine. Rezultati: U skupini od 104 operirana pacijenta poradi visokopostotne stenoze unutarnje karotidne arterije u ranom poslijeoperacijskom tijeku evidentirano je 11 pacijenata (10,5 %) s pojavom restenoze, no bez neuroloških simptoma. Dodatnim praćenjem naših pacijenata nakon tri i šest mjeseci primijetili smo da se stupanj restenotskog procesa nije povećavao u 8 pacijenata, no u trojice pacijenata (2,9 %) evidentirano je znatno povećanje stupnja restenoze, te su oni podvrgnuti endovaskularnoj tzv. stenting pro- ceduri. Zaključci: Trombendarterektomija karotidnog žilja je operacijski zahvat koji se u KBC-u Rijeka izvodi rutinski. Incidencija pojavnosti poslijeoperacijske restenoze je mala, no nije neuobičajena pojava, ali uz adekvatnu medikamentnu potporu gotovo nikad nije fatalna za pacijenta, te je reparabilna ako je to potrebno. Mnogi svjetski autori također izvještavaju u izvjesnom postotku o pojavnosti poslijeoperacijske restenoze unutarnje arterije karotis. Redovitim ultrazvučnim kontrolama pravovremeno se otkrivaju poslijeoperacijski restenotski procesi koji mogu biti od hemodinamskog značaja u neuroloških pacijenata. U postizanju dobrih kliničkih rezultata kod prevencije i liječenja neuroloških incidenata izuzetno je važna dobra i uska suradnja svih supspecijalističkih timova koji se bave problematikom cerebrovaskularnog inzulta.Aim: To determine the percentage of postoperative restenosis frequency on an annual level after the operative treatement of the high-percent carotid artery stenosis, and to compare the data with recent literature. Subject and methods: Data was obtained by analysing ear- ly postoperative Colour Duplex Doppler control tests, which were performed two weeks after thrombendarterectomy of carotid vesells in the Laboratory of cerebrovascular diseases, Neurology clinic, Clinical hospital centre Rijeka on 104 patients treated at the Thoracovascular insti- tute, Surgery clinic, Clinical hospital centre Rijeka in the year 2012. Results: In a group of 104 treated patients, because of high-percent stenosis of internal carotid artery there was an evi- dent restenotic process without neurological symptoms in the early postoperative stages in 11 patients (10,5 %). With additional follow-up care of our patients after 3 and 6 monts, the level of restenotic proces did not increase in 8 patients, but in 3 (29 %) of our patients there was an evident increase of restenosis and they were treated with stenting procedure. Conclusions: Carotid thrombendarterectomy is a routine operative procedure in our Thoracovascular institute, and has been performed for many years. Fortunately, the frequency of postoperative resteno- sis is small but not unusual, and with adequate drugs support is almost never fatal and treatable if needed. Numerous authors have also reported a certain percentage of postoperative restenosis of internal carotid artery. With frequent ultrasound controls, postoperative restenotic process can be discovered in time, which can be of hemodinamic importance in neurological patients. A good cooperation between all subspecialistic teams involved in the assessment of cerebrovascular stroke is of great importance for accomplishing good clinical results in prevention and treatement of neurological incidents

Frequency of early postoperative restenosis after carotid artery thrombendarterectomy

Cilj: Ustvrditi postotak pojavnosti poslijeoperacijske restenoze nakon operacijskog liječenja visokopostotne stenoze arterije karotis na godišnjoj razini te podatke usporediti s novijom svjetskom literaturom. Ispitanici i postupci: Podatci su dobiveni analizom ranih poslijeoperacij- skih kontrolnih nalaza dobivenih obojenim dupleks doplerom, izvršenih dva tjedna nakon zahvata trombendaterektomije karotidnog žilja, u laboratoriju za cerebrovaskularne bolesti, Klinike za neurologiju, KBC-a Rijeka, na 104 pacijenta operirana na Zavodu za torakovaskularnu kirurgiju, Kirurške klinike KBC-a Rijeka 2012. godine. Rezultati: U skupini od 104 operirana pacijenta poradi visokopostotne stenoze unutarnje karotidne arterije u ranom poslijeoperacijskom tijeku evidentirano je 11 pacijenata (10,5 %) s pojavom restenoze, no bez neuroloških simptoma. Dodatnim praćenjem naših pacijenata nakon tri i šest mjeseci primijetili smo da se stupanj restenotskog procesa nije povećavao u 8 pacijenata, no u trojice pacijenata (2,9 %) evidentirano je znatno povećanje stupnja restenoze, te su oni podvrgnuti endovaskularnoj tzv. stenting pro- ceduri. Zaključci: Trombendarterektomija karotidnog žilja je operacijski zahvat koji se u KBC-u Rijeka izvodi rutinski. Incidencija pojavnosti poslijeoperacijske restenoze je mala, no nije neuobičajena pojava, ali uz adekvatnu medikamentnu potporu gotovo nikad nije fatalna za pacijenta, te je reparabilna ako je to potrebno. Mnogi svjetski autori također izvještavaju u izvjesnom postotku o pojavnosti poslijeoperacijske restenoze unutarnje arterije karotis. Redovitim ultrazvučnim kontrolama pravovremeno se otkrivaju poslijeoperacijski restenotski procesi koji mogu biti od hemodinamskog značaja u neuroloških pacijenata. U postizanju dobrih kliničkih rezultata kod prevencije i liječenja neuroloških incidenata izuzetno je važna dobra i uska suradnja svih supspecijalističkih timova koji se bave problematikom cerebrovaskularnog inzulta.Aim: To determine the percentage of postoperative restenosis frequency on an annual level after the operative treatement of the high-percent carotid artery stenosis, and to compare the data with recent literature. Subject and methods: Data was obtained by analysing ear- ly postoperative Colour Duplex Doppler control tests, which were performed two weeks after thrombendarterectomy of carotid vesells in the Laboratory of cerebrovascular diseases, Neurology clinic, Clinical hospital centre Rijeka on 104 patients treated at the Thoracovascular insti- tute, Surgery clinic, Clinical hospital centre Rijeka in the year 2012. Results: In a group of 104 treated patients, because of high-percent stenosis of internal carotid artery there was an evi- dent restenotic process without neurological symptoms in the early postoperative stages in 11 patients (10,5 %). With additional follow-up care of our patients after 3 and 6 monts, the level of restenotic proces did not increase in 8 patients, but in 3 (29 %) of our patients there was an evident increase of restenosis and they were treated with stenting procedure. Conclusions: Carotid thrombendarterectomy is a routine operative procedure in our Thoracovascular institute, and has been performed for many years. Fortunately, the frequency of postoperative resteno- sis is small but not unusual, and with adequate drugs support is almost never fatal and treatable if needed. Numerous authors have also reported a certain percentage of postoperative restenosis of internal carotid artery. With frequent ultrasound controls, postoperative restenotic process can be discovered in time, which can be of hemodinamic importance in neurological patients. A good cooperation between all subspecialistic teams involved in the assessment of cerebrovascular stroke is of great importance for accomplishing good clinical results in prevention and treatement of neurological incidents

Complications of recent luxations in glenohumeral joint – case report

Cilj: Komplikacije svježih luksacija su prijelomi, rupture rotatorne manžete, ozljede živaca i vaskularne ozljede. Ozljede žila (a. axillaris, v. axillaris, grana aksilarne arterije – a. circumflexa anterior i posterior, a. subscapularis) mogu nastati za vrijeme iščašenja ili pokušaja repozicije. Prikaz slučaja: 68-godišnji muškarac pao je i ozlijedio lijevo rame. Verificira se luksacijski prijelom humerusa, uz avulziju a. circumflexe posterior, intimalna lezija i tromboza aksilarne arterije. Učini se rekonstrukcija resekcijom mjesta ozljede uz graft-interpozitum v. saphene magne te suture mjesta rupture a. circumflexe posterior, a zatim i osteosinteza phylos pločom i vijcima. Rasprava i zaključak: Nakon kliničke sumnje na iščašenje nadlaktice u ramenom zglobu ili na prijelome preporučujemo utvrđivanje vaskularnog i neurološkog statusa ruke, a kod sumnje na leziju žila i MSCT angiografiju.Aim: Complications of recent luxations are fractures, ruptures of rotator cuff, nerve and vascular lesions. Vascular lesions (a. axillaris, v. axillaris, branch of axillary artery – a. circumflexa anterior and posterior, a. subscapularis) can occur during luxation or attempt of reposition. Case report: A 68-year-old man fell and injured the shoulder. We have verified shoulder fracture with luxation, avulsion of posterior circumflex artery and thrombosis of axillary artery. Reconstruction included partial resection of artery, graft-interpositum using v. saphena magna and sutures of ruptured part of a. circumflexa posterior. Afterwards, osteosynthesis with phylos plate and screws was performed. Discussion and conclusion: After clinical predicament of shoulder luxation or fractures, we suggest defining of vascular and neurological status of the arm. When there is suspicion of vascular injury, MSCT angiography is recommended

An overview of replantation and transplantation of the upper extremity

Glavni cilj replantacije ponovna je uspostava perfuzije ekstremiteta te minimiziranje vremena ishemije. Operacijski mikroskop i mikrovaskularna kirurška tehnika osnove su na kojima se temelji replantacija i revaskularizacija. Kod replantacije koristimo sljedeće operacijske zahvate: osteosintezu, anastomozu i rekonstrukciju vaskularnih elemenata, rekonstrukciju živaca, tetive ili mišića te pokrova. Kontraindikacije za replantaciju dijele se na apsolutne i relativne. U apsolutne kontraindikacije ubrajaju se: amputacija s politraumom, opsežna ozljeda i kronične bolesti. Relativne kontraindikacije su: amputacija jednog prsta, bolesnik iznad 50 godina, avulzijske ozljede, duga topla ishemija (više od 12 sati za prste te 6 – 8 sati za nadlakticu i podlakticu), jaka kontaminacija te ranija ozljeda s lošim funkcijskim ishodom. Replantacije se favoriziraju kada su u pitanju djeca, palac šake te više prstiju šake. Transplantacija vaskulariziranog ekstremiteta ili njegovih dijelova definira se kao alotransplantacija kompozitnog tkiva te nudi novu terapijsku mogućnost za bolesnike s gubitkom ruke. Rutinska skrb tijekom poslijeoperacijske njege uključuje elevaciju replantiranog ekstremiteta, antikoagulacijsku zaštitu, praćenje boje, turgora, kapilarnog punjenja i temperature, primjenu antibiotske terapije te zabranu pušenja i konzumacije kave i čokolade, kako bi se prevenirao periferni vazospazam i time rizik od razvoja vaskularne tromboze. Prva uspješna replantacija palca šake u KBC-u Rijeka učinjena je 1980. godine, dok je replantacija podlaktice učinjena 1983. godine. Iako replantacija može biti izuzetno skupa te zahtijevati produženu hospitalizaciju i poslijeoperacijsku terapiju, ukupni troškovi mogu biti značajno niži od mioelektrične proteze koja se mora periodično mijenjati. Unatoč svemu, iskusan tim liječnika i izuzetno motiviran bolesnik pridonose uspješnosti operacije te zadovoljstvu, kako kozmetičkim, tako i funkcijskim rezultatom.The main goal of replantation is the re-establishment of extremity perfusion and minimization of ischemia time. Operational microscope and microvascular surgical technique are the basis of replantation and revascularization. The following operations are used in replantation: osteosynthesis, anastomosis and reconstruction of vascular elements, reconstruction of nerves, tendons or muscles and cover. Contraindications for replantation are classified as absolute and relative ones. Absolute contraindications include amputation with polytrauma, extensive injury and chronic diseases. Relative contraindications are one finger amputation, patient older than 50 years, avulsions, long warm ischemia (more than 12 hours for fingers and 6-8 hours for upper arm and forearm), severe contamination and earlier injury with poor functional result. Favored replantations include children, thumb and more hand fingers. Transplantation of vascularized extremity or its parts is defined as allotransplantation of composite tissue, offering new therapeutic opportunities for patients with an amputated arm. The common postoperative care consists of elevation of replanted extremity, anticoagulation therapy, monitoring of color, skin turgor, capillary filling and temperature, administration of antibiotics, prohibition of smoking, coffee and chocolate, in order to prevent peripheral vasospasm and eventual risk of vascular thrombosis. The first successful thumb replantation in Clinical Hospital Center Rijeka was performed in 1980, and forearm replantation in 1983. Although replantation can be extremely expensive, requiring extended hospitalization and postoperative therapy, total expenses could be considerably lower than myoelectrical prosthesis which must be changed periodically. Nevertheless, an experienced team of doctors and highly motivated patients contribute to operation success, as well as satisfaction with both cosmetic and functional result

DEBRIDEMENT POSSIBILITIES IN FAMILY MEDICINE

Kronične rane su značajni zdravstveno-sociološki i eikonomski problem za društvo. Zahtijevaju dodatni angažman medicinskog i nemedicinskog osoblja u prehospitalnim i hospitalnim ustanovama, troše značajne materijalne i nematerijalne resurse te dovode do smanjene kvalitete života bolesnika i njegove obitelji, odnosno skrbnika. napretkom medicine i tehnologije na području liječenja rana otvaraju se mogućnosti za provođenje jedne ili više kvalitetnih metoda debridmana od medicinskog osoblja, bez potrebe za stručnim angažmanom bolničkog osoblja. U današnje se vrijeme boljom i sveobuhvatnijom edukacijom medicinskog osoblja, pa tako i timova obiteljske medicine, stvara mogućnost ranog početka kvalitetnog liječenja akutnih i kroničnih rana. Pravodobna indikacija i adekvatna provedba debridmana kao početnog i krucijalnog postupka nameće se kao temeljni postupak prema izliječenju. obavljanjem spomenutog postiže se značajna vremenska korist u procesu liječenja, a izbjegava gubitak dragocjenog vremena utrošenog na naručivanje pacijenta i njegov dolazak do specijalističkih hospitalnih ambulanti.Life expectancy of the population is increasing every day. Accurate and timely diagnosis and appropriate therapeutic approach prevent exacerbation and complications of chronic noninfectious diseases. The result is the increasing trend in life expectancy and the growing proportion of elderly population. The increasing life expectancy is associated with a rising incidence of injuries and failing ill from chronic noninfectious diseases. The increase in comorbidity additionally decreases the biological potential of tissue regeneration, which results in an increasing number of chronic, slow-healing wounds in the elderly population. Chronic wounds represent a signiicant health, social and economic problem for the society. They require additional involvement of medical and non-medical staff in prehospital and hospital institutions, as well as substantial inancial resources. These wounds reduce quality of life of the patient, his/her family or custodian. nowadays, better and comprehensive education of medical staff, including teams of family medicine, make it possible to start early with quality healing of acute and chronic wounds. Timely indication and appropriate use of debridement as the initial and crucial procedure are the basic procedures to support wound healing. Implementing these procedures properly will save precious time in the process of healing, while avoiding wasting time for patient referral and admission to specialist hospital clinics

Treatment of polytrauma

Posljednja dva desetljeća relevantni svjetski podaci uspoređuju problem politraume s epidemijom, koristeći se sintagmom „traumatizirani bolesnik”, svrstavajući ga na treće mjesto svih uzroka smrtnosti, a na prvo mjesto u dobnoj skupini od 1. do 44. godine života. Zbog složenosti samih ozljeda, kao i zbog nedovoljno objašnjenih odgovora organizma na samu traumu i na terapijske postupke, liječenje politraumatiziranih bolesnika jedno je od najsloženijih u suvremenoj medicini. U suvremenom pristupu liječenju od velike su pomoći algoritmi, čijom se točnom primjenom postižu bolji rezultati uz smanjenje propusta i pogrešaka na najmanju moguću mjeru. Osnovni princip liječenja politraumatiziranih bolesnika jest da ono počinje na mjestu nezgode, traje tijekom transporta i nastavlja se u bolnici uz poštovanje principa istovremenosti dijagnostike i liječenja. Uspostava registra traume i neprestano vrednovanje rezultata liječenja predstavljaju jedan od osnovnih preduvjeta za osnivanje centra trauma prve kategorije, a samim time i za poboljšanje kvalitete zbrinjavanja politraumatiziranih bolesnika.In the last two decades polytrauma is compared with the epidemic and the phrase »trauma disease« is used, classifying it in the third place of general population mortality and in the first place in the age group from 1-44 years. Due to the complexity of the injuries and insufficiently explained patient response to the trauma itself and to the therapeutic procedures, treatment of polytraumatized patients is one of the most demanding in the modern medicine. The algorithms are of great help in the modern polytrauma treatment and by using it we achieve better results and reduce omissions and errors to a minimum. The basic principle of polytraumatized patients treatment is that it starts at the site of the accident and continues during the transport and after arrival to the hospital with the fundamental rule that the diagnostic and treatment procedures are performed simultaneously. Establishing a trauma registry and constantly evaluating the results of patients treatment are one of the main preconditions for the establishment of the first level trauma centre and improving care quality of polytraumatized patients

ATHEROSCLEROTIC DISEASE OF THE CAROTID ARTERY - A REVIEW ARTICLE

Moždani udar je u Republici Hrvatskoj i u svijetu vodeći uzrok invaliditeta te drugi uzročnik mortaliteta. Jedan od uzroka moždanog udara je i stenoza karotidne arterije uzrokovana aterosklerotskim plakom. Brojni su rizični faktori koji dovode do ateroskleroze, a time i do stenoze karotidne arterije, a mogu biti promijenjivi i nepromjenjivi. Pravovremenim djelovanjem na promjenjive rizične faktore kao što su pušenje, hiperlipoproteinemija i povećana tjelesna težina na vrijeme bi se mogla spriječiti ova teška bolest. Moždani udar je bolest koja zbog fizičkih, socijalnih i kognitivnih ograničenja dovodi do smanjene kvalitete života samog bolesnika, ali i njegove obitelji. Pravovremenim otkrivanjem rizičnih faktora te time prevencijom moždanog udara spriječio bi se ovaj veliki zdravstveni problem koji zahvaća veliki broj bolesnika svake godineStroke is a leading cause of disability in the Republic of Croatia and in the world. It is also the second cause of mortality. One of the causes of stroke is the carotid artery stenosis caused by atherosclerotic plaque. There are numerous risk factors that lead to atherosclerosis, and thus to carotid artery stenosis, and may be variable and invariable. Timely action on variable risk factors such as smoking, hyperlipoproteinemia and increased body weight could prevent this serious illness. Stroke is a disease that, due to physical, social and cognitive limitations, leads to a reduced quality of life of the patient but also his family. By timely detection of risk factors and thus preventing stroke, this major health problem that affects a large number of patients every year could be prevented