The role of asymmetric dimethylarginine (ADMA) response to oxidative damage in acute pancreatitis

Akutna upala gušterače (pankreatitis) praćena je oksidativnim i dušičnim stresom, no doprinos ovih mehanizama oštećenju tkiva i disfunkciji endokrinog dijela gušterače slabo je istražen. U ovom radu istraživana je uloga asimetričnog dimetilarginina (ADMA), endogenog inhibitora sintetaze dušičnog oksida (NOS), u razvoju oksidativno-dušičnog stresa te regulaciji glikemije na kliničkom modelu akutnog pankreatitisa. Rezultati razotkrivaju akutni pankreatitis kao stanje značajnog poremećaja glukoregulacije, pojačanog oksidativnog i dušičnog stresa te poremećene ADMA-om posredovane regulacije sinteze dušičnog oksida (NO). Hiperglikemija i oksidativno-dušični stres identificirani su kao mogući značajni uzroci smanjene bioraspoloživosti ADMA-e tijekom akutnog pankreatitisa, a intolerancija glukoze mjesec dana nakon preboljelog pankreatitisa, koja je nađena u 64% ispitanika, u izravnoj je vezi s razinom ADMA-e tijekom akutne faze bolesti. Do sada nepoznata nedostatna inhibicija sinteze NO u akutnom pankreatitisu značajno pridonosi oštećenju endokrine gušterače i kasnijem razvoju šećerne bolesti.Acute pancreatitis is characterised by the oxidative and nitrosative stress, but contribution of these mechanisms to the tissue damage and endocrine pancreas dysfunction has been insufficiently studied. This study aimed to investigate the role of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric-oxide synthetase (NOS), in development of oxidative-nitrosative stress and potentially disturbed glucoregulation in the clinical model of acute pancreatitis. Results reveal acute pancreatitis as a condition associated with a significant derrangement of glucoregulation and increased oxidative-nitrosative stress, as well as a disturbed ADMAregulated nitric oxide (NO) synthesis. Both hyperglycaemia and oxidative-nitrosative stress were identified as potential significant determinants of decreased ADMA-bioavailibility during acute pancreatitis, while glucose intolerance, found in 64% of patients 1 month after acute pancreatitis, was found to be directly associated with ADMA-level during acute phase of illness. Sofar unrecognized insufficient inhibition of NO-synthesis in acute pancreatitis contributes significantly to the endocrine pancreas damage and might be responsible for subsequent development of diabetes mellitus

Successful Endoscopic Removal of a Lighter Swallowed 17 Months Before

The majority of ingested foreign bodies will pass safely through the gastrointestinal tract, but long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. However, large foreign bodies which have been swallowed can remain trapped in the stomach over a longer period of time without any significant symptoms. This case report describes the case of a 36-year-old man addicted to heroin who purposefully swallowed a lighter (double wrapped in cellophane) and presented with hematemesis and melena 17 months after the ingestion of the foreign body. The lighter was successfully removed via flexible endoscopy using a polypectomy snare. Swallowed long and rigid foreign bodies trapped in the stomach over a long period of time always represent a special clinical and endoscopic challenge. In cases where endoscopic removal fails, a laparoscopic surgical approach may be an alternative

THROMBOEMBOLIC AND BLEEDING RISK ASSESSMENT IN PATIENTS WITH NON-RHEUMATIC ATRIAL FIBRILLATION USING CHA2DS2-VASC AND HAS-BLED SCORING SYSTEMS

Procjenjuje se da od nereumatske atrijske fibrilacije (nAF) boluje 1–2% svjetskog stanovništva. Najčešća komplikacija te aritmije jesu tromboembolijski događaji, među kojima prednjači ishemijski moždani infarkt. On je u bolesnika s nAF, u odnosu na bolesnike sa sinusnim ritmom, praćen težim kliničkim tijekom, značajno većom smrtnošću, a u preživjelih bolesnika značajno sporijim oporavkom i težim trajnim duševnim i tjelesnim oštećenjima. Primjena antikoagulantnog liječenja u bolesnika s nAF značajno smanjuje pojavnost ishemijskih moždanih infarkta, a u onih koji ga dožive tijekom njegove primjene poboljšava ishod liječenja. Stoga smjernice stručnih društava preporučuju primjenu antikoagulantnog liječenja u većine bolesnika s nAF. Istodobno, strah od krvarenja uzrokovanog antikoagulantnim liječenjem uzrok je njegova, često neopravdanog, neprimjenjivanja u bolesnika s velikim tromboembolijskim rizikom. U ovom radu prikazujemo sustave CHA2DS2-VASc i HAS-BLED, koji su preporučeni u procjeni tromboembolijskog rizika i rizika od krvarenja, prilikom odabira tromboprofilaktičkog liječenja u bolesnika s nAF.It is estimated that approximately 1–2% of the world population are affected with non-rheumatic atrial fibrillation (nAF). The most frequent complications of this arrhythmia are thromboembolic events, primarly ischemic stroke. In comparison with patients in sinus rhythm, stroke affected nAF patients have more severe clinical course and significantly higher mortality rate, and the survivors have significantly lower recovery rate and more serious permanent mental and physical impairments. The administration of anticoagulants to patients with nAF significantly reduces the incidence of stroke, while those who were stroke affected during the anticoagulant therapy show better treatment outcomes. Therefore, professional associations guidelines recommend the anticoagulant treatment for the majority of patients with nAF. The fear of bleeding caused by anticoagulants results in their frequently unjustified omission from the therapy in patients with high thromboembolic risk. This paper presents CHA2DS2-VASc- and HAS-BLED systems recommended for thromboembolic and bleeding risk assessment when deciding on thromboprophylactic therapy in patients with nAF

ANTICOAGULANT THERAPY IN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION – EVIDENCE BASED MEDICINE AND CLINICAL PRACTICE

Cilj istraživanja bio je procijeniti usklađenost propisivanja tromboprofilaktičkog liječenja u bolesnika s permanentnom atrijskom fibrilacijom (pAF) s kliničkim smjernicama Europskoga kardiološkog društva. U prospektivno presječno istraživanje susljedno su uključena 674 bolesnika (59% muškaraca) otpuštenih s kardiološkog odjela s dijagnozom pAF. Težina tromboembolijskog (TE) rizika procijenjena je CHA2DS2-VASc-sustavom, a rizik od krvarenja HAS-BLED-sustavom. U skupinu velikog TE rizika klasificirano je 578 (86%), umjerenog 57 (8%), a malog 39 (6%) bolesnika. Tromboprofilaksa je primijenjena u 601 (89%) bolesnika: varfarin u 310 (46%), acetilsalicilna kiselina u 258 (38%), a klopidogrel u 33 (5%). Varfarin je propisan u 47% bolesnika velikog, 49% bolesnika umjerenog te u 26% bolesnika malog TE rizika (P=0,03), a acetilsalicilna kiselina u 39% bolesnika malog, 39% bolesnika umjerenog i 38% bolesnika velikog TE rizika (P=0,998). Acetilsalicilna kiselina (P<0,001) i varfarin (P=0,007) bili su značajno češće korišteni u skupini bolesnika s velikim rizikom od krvarenja, u kojoj je zabilježena jednaka učestalost propisivanja varfarina i acetilsalicilne kiseline (53% prema 47%; P=0,416). Dob ³75 godina bila je nezavisni prediktor neprimjenjivanja (OR 1,7; 95% CI 1,2–2,4; P=0,003), a anamneza moždanog infarkta primjenjivanja varfarina (OR 0,47; 95% CI 0,29–0,76;P=0,002). Prilikom propisivanja tromboprofilaktičkog liječenja bolesnicima s pAF liječnici se ne pridržavaju preporučenih smjernica. Unatoč nepostojanju kontraindikacija značajan udio bolesnika s velikim TE rizikom nije dobio varfarin. Istodobno, varfarin je propisivan bolesnicima s malim TE rizikom čime su nepotrebno izloženi neželjenim učincima antikoagulantnog liječenja.Objective of study was to assess the concordance of the tromboprophylactic treatment in patients with permanent atrial fibrillation (pAF) with guidelines of the European Society of Cardiology. Prospective cross-sectional study consecutivelly included 674 patients (400 Š59%Ć male) discharged from cardiology department with the diagnosis pAF. The thromboembolic risk (TE) has been established according to CHA2DS2-VASc score, whereas the bleeding risk has been assessed according to HAS-BLED score. 578 (86%) belonged to the group of high, 57 (8%) to the group of moderate, and 39 (6%) patients to the group of low TE risk. 601 (89%) patients received thromboprophylaxis: 310 (46%) warfarin, 258 (38%) acetylsalicylic acid, and 33 (5%) patients clopidogrel. Warfarin has been prescribed to 47% of patients with high, 49% of patients with moderate and to 26% of patients with low TE risk (P=0.03). Acetylsalicylic acid (ASA) has equally been prescribed to patients of all TE risk groups: low, moderate and high (39% vs. 39% vs. 38%; P=0.998). ASA (P<0.001) and warfarin (P=0.007) have been used more frequently in the group of patients with high bleeding risk, in which the same incidence of warfarin and ASA administration has been registered (53% vs. 47%; P=0.416). Age ³75 has been an independent predictor of non-administration (OR 1.7; 95% CI 1.2–2.4; P=0.003), whereas the history of stroke was for warfarin administration (OR 0.47; 95% CI 0.29–0.76; P=0.002). In prescribing thromboprophylaxis to patients with pAF, cardiologists do not observe the recommended clinical guidelines. Despite nonexistence of contraindications, a significant number of patients with high TE risk has not been administered warfarin. At the same time, warfarin has been administered to the patients with low TE risk, exposing them unnecessarily to the undesired effect of anticoagulant treatment

Haemoptysis

Hemoptiza je iskašljavanje krvi, odnosno pojava krvi u iskašljaju. Ishodište krvarenja može biti larings, dušnik, bronhi, te parenhim pluća. Iskašljavanje krvi traži hitan pregled specijaliste pulmologa, te zbrinjavanje pacijenta. Tijekom 2010. godine na hitnom prijmu Klinike za plućne bolesti KBC-a Split su obrađena ukupno 123 pacijenta s krvi u iskašljaju. Analizirajući podatke koje smo prikupili iz povijesti bolesti, došli smo do određenih rezultata. Hemoptize su bile učestalije kod muškaraca u starijoj životnoj dobi i to u mjesecu svibnju. Kod 80% bolesnika je rađen standardni radiogram torakalnih organa. Kod 5 pacijenata su izmjerene vrijednosti arterijskoga tlaka više ili jednake 180 mmHg. Kod pacijenata kod kojih je rađena mikrobiološka obrada, u 83,3% slučajeva rezultati su bili uredni. Što se tiče bronhoskopskog nalaza, u 57% hospitaliziranih se vidio uzrok, odnosno mjesto krvarenja. Kao uzrok krvi u iskašljaju na prvom mjestu se nalazi upala pluća s udjelom od 31% u ukupnoj etiologiji, slijede tumori na koje otpada 15%, a sve ostalo su bili sporadični uzroci krvarenja iz respiratornog trakta.Haemoptysis is coughing blood or bloody sputum. The bleeding point could be the larynx, trachea, bronchi, lung parenchyma. Blood coughing requires immediate examination by a pulmology specialist and provided care. During the year 2010 at emergency reception of the Clinic for Pulmonary Diseases of Split Clinical Hospital Centre, 123 patients with haemoptysis were examined. Fifty patients were hospitalized and their cases were evaluated. Haemoptysis appeared more often in elderly men during May. Standard chest radiography was performed in 80 percent of the hospitalized patients. Systolic arterial blood pressure values equal or higher than 180 mmHg were measured in five patients. Microbiological analysis showed normal findings in 83.3 percent of cases. The cause of the bleeding was seen during bronchoscopy in 57 percent of the patients. Pneumonia with 31% and lung cancer with 15% were the leading causes of haemoptysis, while other causes were sporadic