Obesity and Fatty Liver, Role of Vitamin D

Nealkoholna masna bolest jetre (NAFLD) jedna je od najučestalijih jetrenih bolesti i znači jetrenu manifestaciju metaboličkog sindroma. Debljina je prisutna u 60 – 95% bolesnika s NAFLD-om. Patogenetski učinak debljine temelji se na povećanoj metaboličkoj aktivnosti intraabdominalnoga masnog tkiva koje zbog veće gustoće mitohondrija i posljedično više razine lipolize i glikolize otpušta veće količine slobodnih masnih kiselina. Osim toga, visceralno masno tkivo funkcionira i kao endokrini organ te sudjeluje u lučenju brojnih adipocitokina, na prvome mjestu brojnih proupalnih citokina, koji pridonose metaboličkim poremećajima. Većina je bolesnika asimptomatska, osim u rijetkim slučajevima s osjećajem umora, s alteracijom jetrenih enzima ili bez nje. Liječenje uključuje redukciju tjelesne težine promjenom načina života i redovitim vježbanjem. Učinkovita farmakološka terapija zasad ne postoji iako su mnogobrojna istraživanja u tijeku, uključujući i primjenu vitamina D. Uz prethodne dijetetske mjere, pri liječenju treba uzeti u obzir i intragastrično postavljanje balona te barijatrijsku kirurgiju. Osim ostalih čimbenika rizika od debljine, povezanost debljine i NAFLD-a implicira razvoj ciroze jetre, kao i hepatocelularnog karcinoma.Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases and the hepatic manifestation of metabolic syndrome. Obesity is present in 60-95% of patients with NAFLD. The pathogenic eRect of obesity is based on the increased metabolic activity of intra-abdominal adipose tissue releasing larger amounts of free fatty acids due to greater density of mitochondria and consequently higher levels of lipolysis and glycolysis. In addition, visceral adipose tissue functions as an endocrine organ and participates in the secretion of numerous adipocytokines, primarily numerous proinUammatory cytokines, which contribute to metabolic disorders. The majority of patients are asymptomatic, except in rare cases when fatigue, with or without alterations of liver enzymes, occurs. Treatment involves weight loss by changing lifestyle and exercising regularly. For now, there is no eRective pharmacological therapy although there are numerous ongoing studies, including the administration of vitamin D. Intragastric balloon placement and bariatric surgery, with previous dietetic restrictions, should also be considered in the treatment. Relation between obesity and NAFLD also implicates the development of liver cirrhosis, in addition to other risk factors of obesity, as well as the development of hepatocellular carcinoma

Mysterious atrial mass mimicking severe mitral stenosis

Introduction: The differential diagnosis of an intracardiac mass include benign and malignant primary heart tumors, metastatic tumors and thrombi. Primary tumors of the heart consist mainly of myxomas, with an incidence of less than 0.5%. Clinical manifestations are consequence of embolic phenomena, intracardiac obstruction or constitutional symptoms. In rare instances, myxomas can cause a mass effect, resulting in mitral valve obstruction1. Case report: 68-year-old male with a history of ulcerative colitis complained to his gastroenterologist about having exercise intolerance. Undergoing regular colitis evaluation, CT thorax and abdomen scan was performed incidentally revealing a large intracardiac mass. Echocardiogram ordered by the consulting cardiologist demonstrated a large ellipsoid left atrial cyst (50×31 mm), occupying nearly the entire left atrium (Figure 1). The mass was protruding across the mitral valve orifice in diastole causing functional stenosis with an elevated mean diastolic gradient of 10,9 mmHg. Mitral valve area calculated by pressure half-time was 1.0 cm2. Doppler showed moderate tricuspid regurgitation with a systolic pulmonary artery pressure of 50 mmHg. The systolic function was preserved with an estimated left ventricular ejection fraction of 58%. Transesophageal echocardiography described a cavitating lesion (measuring 15,1 cm2, attached to interatrial septum with 24 mm base), having characteristics consistent with a hemorrhagic cyst (Figure 2). Preoperative coronary angiography displayed coronary artery disease and a rare condition of dual coronary artery supply with left circumflex artery (LCx) providing two (Figure 3) and right coronary artery (RCA) one tumor branch (Figure 4) producing a characteric "tumor blush". CT showed large intracardiac mass (Figure 5 and Figure 6). Patient underwent cardiothoracic surgery with successful excision of the tumor (4,5x3x2 cm), the pathohistology confirmed myxoma. Postoperative course was uneventful, exercise intolerance symptoms improved, and echocardiographic follow up showed no intracardiac mass. Conclusion: We described a rare case of cystic-appearance cardiac myxoma with dual coronary supply mimicking mitral valve stenosis. There are not many patients reported with left atrial myxoma being vascularized from both RCA and LCx as seen in our case2. Although more than half of atrial myxomas show obstructive symptoms, severe mitral valve obstruction is rare1. Early echocardiographic examination of patients presenting with exertional dyspnea is advised, as myxomas have an excellent prognosis following surgical excision, preventing complications and improving quality of life

Smjernice za reanimaciju Europskog vijeća za reanimatologiju 2015. godine [European resuscitation council guidelines for resuscitation 2015]

Adult basic life support and automated external defibrillation – Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical. All CPR providers should perform chest compressions, those who are trained and able should combine chest compressions and rescue breaths in the ratio 30:2. Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. Adult advanced life support – Continued emphasis on minimally interrupted high-quality chest compressions, paused briefly only to enable specific interventions, including interruptions for less than 5 s to attempt defibrillation. Use of self-adhesive pads for defibrillation. Waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation. Cardiac arrest in special circumstances – Special causes: hypoxia; hypo-/hyperkalemia, and other electrolyte disorders; hypo-/hyperthermia; hypovolemia; tension pneumothorax; tamponade; thrombosis; toxins. Special environments are specialised healthcare facilities, commercial airplanes or air ambulances, field of play, outside environment or the scene of a mass casualty incident. Special patients are those with severe comorbidities and with specific physiological conditions. Post resuscitation care is new to the ERC Guidelines. Targeted temperature management remains, now aiming at 36°C instead of the previously recommended 32 – 34°C. Pediatric life support – For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child). For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg–1. Resuscitation and support of transition of babies at birth – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended for term and preterm babies. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. Ventilatory support of term infants should start with air. Acute coronary syndrome (ACS) – Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnea, or heart failure. In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI. First aid is included for the first time in the 2015 ERC Guidelines. Principles of education in resuscitation – Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Whilst optimal intervals for retraining are not known, frequent ‘low dose’ retraining may be beneficial. Training in non-technical skills is an essential adjunct to technical skills. The ethics of resuscitation and end-of-life decisions – Ethical principles in the context of patient-centered health care: autonomy, beneficence, non-maleficence; justice and equal access. The need for harmonisation in legislation, jurisdiction, terminology and practice still remains within Europe

Optimal treatment of patients with chronic coronary syndromes

Aktualne smjernice Europskog kardiološkog društva za stabilnu koronarnu bolest srca ističu dinamičku narav bolesti, uvode novi termin „kronični koronarni sindromi“ i razlikuju šest mogućih stanja ili scenarija. Stoga liječenje ne može kod svih bolesnika biti isto, nego treba biti prilagođeno obliku kroničnog koronarnog sindroma i individualnim osobinama svakog bolesnika. Optimalno liječenje uključuje opće nefarmakološke mjere u smislu zdravog načina života, kombinaciju odgovarajućih lijekova te razmatranje potrebe i moguću revaskularizaciju miokarda. Farmakološka terapija obuhvaća anti-ishemijske lijekove, zatim lijekove za prevenciju kardiovaskularnih događaja te optimalno liječenje glavnih čimbenika koronarnog rizika (hipertenzije, dislipidemije, šećerne bolesti). Odluka o potrebi perkutane ili kirurške revaskularizacije miokarda ovisi o prisutnosti anginoznih tegoba, ishemiji dokazanoj neinvazivnim metodama te lokalizaciji, stupnju i funkcionalnom značenju koronarnih stenoza na invazivnoj koronarografiji

Optimal treatment of patients with chronic coronary syndromes

Aktualne smjernice Europskog kardiološkog društva za stabilnu koronarnu bolest srca ističu dinamičku narav bolesti, uvode novi termin „kronični koronarni sindromi“ i razlikuju šest mogućih stanja ili scenarija. Stoga liječenje ne može kod svih bolesnika biti isto, nego treba biti prilagođeno obliku kroničnog koronarnog sindroma i individualnim osobinama svakog bolesnika. Optimalno liječenje uključuje opće nefarmakološke mjere u smislu zdravog načina života, kombinaciju odgovarajućih lijekova te razmatranje potrebe i moguću revaskularizaciju miokarda. Farmakološka terapija obuhvaća anti-ishemijske lijekove, zatim lijekove za prevenciju kardiovaskularnih događaja te optimalno liječenje glavnih čimbenika koronarnog rizika (hipertenzije, dislipidemije, šećerne bolesti). Odluka o potrebi perkutane ili kirurške revaskularizacije miokarda ovisi o prisutnosti anginoznih tegoba, ishemiji dokazanoj neinvazivnim metodama te lokalizaciji, stupnju i funkcionalnom značenju koronarnih stenoza na invazivnoj koronarografiji

Soluble adhesion molecules in patients with acute coronary syndrome after percutaneous coronary intervention with drug-coated balloon, drug-eluting stent or bare metal stent

Adhesion molecules play an important role in inflammation, atherosclerosis and coronary artery disease (CAD). These molecules are expressed on the surface of dysfunctional endothelial cells, causing inflammatory cells from the circulation to adhere and migrate through the endothelium. Their expression is upregulated in acute coronary syndrome (ACS) and after percutaneous coronary intervention (PCI). The contact between stent struts and endothelium upregulates endothelial cell gene expression, endothelial cell activation and inflammation. The paclitaxel or sirolimus eluting stents inhibited expression of adhesion molecules in several studies and reduced the incidence of major adverse cardiac events (MACE) after drug-eluting stent (DES) over bare metal stent (BMS) implantation. Therefore, we propose that elevated serum levels of the soluble adhesion molecules after primary PCI in patients treated with BMS or DES implantation versus drug-coated balloon (DCB) application to the vulnerable coronary plaque might be a predictor of MACE and further adverse outcomes. Consequently, DCB-only strategy in patients with ACS might be a superior approach in comparison to BMS implantation and non-inferior approach when compared to DES implantation

Cardiac manifestations in alcoholic liver disease

Alcoholic liver disease is the most prevalent cause of progressive liver disease in Europe. Alcoholic cirrhosis occurs in 8%-20% of cases of alcoholic liver disease. It has significant influence on cardiovascular system and haemodynamics through increased heart rate, cardiac output, decreased systemic vascular resistance, arterial pressure and plasma volume expansion. Cirrhotic cardiomyopathy is characterised by systolic and diastolic dysfunction and electrophysiological abnormalities, if no other underlying cardiac disease is present. It is often unmasked only during pharmacological or physiological stress, when compensatory mechanisms of the heart become insufficient to maintain adequate cardiac output. Low-to-moderate intake of alcohol can be cardioprotective. However, heavy drinking is associated with an increased risk of cardiovascular diseases, such as alcoholic cardiomyopathy, arterial hypertension, atrial arrhythmias as well as haemorrhagic and ischaemic stroke. Alcoholic cardiomyopathy is characterised by dilated left ventricle (LV), increased LV mass, normal or reduced LV wall thickness and systolic dysfunction