A Practical Approach to Diagnosing Non-Alcoholic Fatty Liver Disease

Dijagnoza bolesti nealkoholne masne jetre (engl. non-alcoholic fatty liver disease, NAFLD) počinje već na temelju kliničkih obilježja bolesnika. Tipičan rizični profil predstavlja bolesnik s prekomjernom tjelesnom težinom, pogotovo ako su tome pridruženi šećerna bolest tipa 2, arterijska hipertenzija i/ili hiperlipidemija, uz uvjet isključene rizične konzumacije alkohola. Postojanje masne jetre najčešće se utvrđuje ultrazvukom na kojem je jetra svjetlija (ehogenija) u odnosu na korteks bubrega. Ultrazvukom se ne može prepoznati blaže oblike steatoze kada je < 20 – 30 % hepatocita masno transformirano. Elastografskim metodama može se kvantificirati stupanj steatoze i stadij fibroze. Stadij fibroze je najznačajniji prognostički čimbenik, dok je značaj upalne aktivnosti dvojben, a stupanj steatoze ne utječe bitno na ishod bolesti jetre. Za neinvazivnu procjenu steatoze i fibroze koriste se i biokemijski testovi, od najjednostavnijih dobivenih iz rutinskih laboratorijskih nalaza do složenih koji uključuju cirkulirajuće makromolekule i komponente izvanstaničnoga matriksa. Neinvazivne metode su pouzdane za isključivanje ciroze, no imaju relativno skromnu pozitivnu prediktivnu vrijednost, jer često precjenjuju stadij fibroze i ne daju informaciju o aktivnosti upale. Objektivniju dijagnozu ovih histoloških komponenti i time pouzdanu prognostičku informaciju pruža biopsija jetre. Obradu bolesnika s NAFLD-om treba započeti na primarnoj razini zdravstvene zaštite jednostavnim biokemijskim testom (npr. FIB-4) kojim se isključuje značajna fibroza. U slučaju povišenih vrijednosti potreban je potvrdni test (najbolje elastografija). Ako taj nalaz isključi značajnu fibrozu, bolesnik ostaje u skrbi obiteljskoga liječnika, a u slučaju teške fibroze/ciroze bolesnik se nastavlja liječiti kod specijaliste. Na ovaj način za 80 % se smanjuje upućivanje bolesnika specijalisti, te za pet puta poboljšava otkrivanje značajne fibroze/ciroze.Diagnosing non-alcoholic fatty liver disease (NAFLD) begins with analysing patient’s clinical features. The typical risk profile includes an overweight patient with comorbidities such as type 2 diabetes mellitus, arterial hypertension and/or hyperlipidaemia, excluding harmful alcohol consumption. Ultrasonography is the most widely used diagnostic tool for detecting fatty liver, which has higher echogenicity, i.e. is lighter in colour, compared to renal cortex. However, ultrasound cannot detect mild steatosis where < 20 – 30% of hepatocytes have been infiltrated by fat. Elastographic methods are used for grading steatosis and staging fibrosis. Liver fibrosis stage is the most significant prognostic indicator. On the other hand, the relevance of inflammatory activity is questionable and the degree of steatosis has no significant impact on the outcome of the disease. Steatosis and fibrosis can be evaluated using non-invasive biochemical tests, ranging from simple routine laboratory tests to more complex tests that include circulating macromolecules and components of extracellular matrix. Non-invasive methods provide reliable results for the exclusion of cirrhosis; however, their positive predictive value is relatively modest, as they often over-estimate the fibrosis stage and provide no information on inflammatory activity. Liver biopsy provides a more objective diagnosis of the histological features and, as a result, a more reliable prognosis. The workup of NAFLD patients should start at the primary healthcare level, with simple biochemical tests such as FIB-4, which excludes significant fibrosis. Elevated results need to be additionally confirmed by another test, most preferably elastography. If this test excludes significant fibrosis, the patient remains under the care of a primary care physician, and if it detects severe fibrosis/cirrhosis, the patient is referred to specialist treatment. This pathway has resulted in an 80 % decrease in referrals to a specialist and a 5-fold improvement in the detection of significant fibrosis/cirrhosis

Calcifying Epithelial Odontogenic Tumor of the Maxilla (Pindborg Tumor)

Calcifying epithelial odontogenic tumor (CEOT), or the Pindborg tumor, is very rare neoplasm, which accounts up to 1% of all odontogenic tumors. These tumors involve mandible almost twice as common as the maxillary bone, mostly in the premolar and molar region and present at first with local swelling. There is no gender predilection and the tumor usually appears between 2nd and 6th decade of life. We report the case of a 36-year-old male patient with a Pindborg tumor in the maxillary region on the right side, also involving the adjacent maxillary sinus, with destroying of the local anatomical structures. Complete surgical excision of the tumor has been performed and four years after surgical treatment, there is no sign of recurrence

Idiopathic bone cavity of the lower jaw

Autori prikazuju četiri slučaja idiopatskih koštanih šupljina mandibule koje su u zadnjih pet godina registrirali u Klinici za kirurgiju lica, čeljusti i usta Medicinskog i Stomatološkog fakulteta u Zagrebu. U jednom slučaju postojale su i subjektivne smetnje, pa je to bilo razlogom da se izvrši operativni zahvat. Patohistološki nalaz potvrdio je nalaz sijalografije i nalaz u toku operacijskog zahvata, da se u šupljini nalazilo ektopično tkivo žlijezde slinovnice. U ostalim slučajevima lezije su bile asimptomatske te se povremeno rendgenološki kontroliraju, što je i stav većine autora koji su o tom problemu pisali. Dan je pregled svjetske literature od prvih opisa tih lezija i iznesena su značajnija stajališta pojedinih autora o tom problemu.Presentation is made of four cases of idiopathic bone cavity of the mandible seen during the post five years at the Clinic of Dentofacial Surgery of the School oif Medicine and Dental Medicine in Zagreb. In one case surgical intervention was performed because of subjective complaints. The pathohistologic findings confirmed the sialographic and intraoperative findings, which had revealed that the cavity contained ectopic salivary gland tissue. Since the lesions in the remaining three cases were asymptomatic, the patients are periodically subjected to X-rav examinations as proposed by most publications on this problem. By way of conclusion, a short historical review of these lesions is presented and the attitudes of some authors who have written about this problem are evaluated

ASSESSMENT OF LIVER DISEASE SEVERITY IN PATIENTS WITH CHRONIC VIRAL HEPATITIS

Najbolji pokazatelj težine oštećenja jetre i prognoze bolesti u kroničnom virusnom hepatitisu je uznapredovalost jetrene fibroze. Ona se može utvrditi biopsijom jetre ali i neinvazivnim fizikalnim ili biološkim metodama. Biopsiju jetre koristimo za etiološku dijagnozu bolesti jetre, utvrđivanje težine bolesti (stadija fibroze) i za definiranje prognoze. U kroničnom virusnom hepatitisu navedene informacije pomažu i u procjeni omjera koristi i rizika te modaliteta antivirusne terapije. Serološkim testovima i elastografijom moguće je razlikovati značajnu fibrozu (F ≥2) od početne fibroze (AUROC 0,77-0,83 za serologiju i 0,84 za elastografiju) i cirozu od necirotičnih stadija fibroze (AUROC 0,77-0,86 za serologiju i 0,9-0,94 prosječne vrijednosti AUROC u meta-analizama za elastografiju). U pojedinačnoj izvedbi metoda izbora za razlikovanje ciroze od necirotičnih stadija jetrene fibroze je elastografija. Kombinacijom seroloških testova i elastografije moguće je u slučaju podudarnih vrijednosti s točnosti od 93-95 % utvrditi postojanje ciroze i izbjeći biopsije u 77-80 % bolesnika. U slučaju da se vrijednosti testova ne podudaraju ili ukazuju na intermedijarne stadije fibroze treba učiniti biopsiju jetre, jer su u tom kontekstu neinvazivni testovi manje pouzdani. Istraživanja su pokazala kako nalaz tranzijentne elastografije ima visoku prediktivnu vrijednost za razvoj dekompenzacije ciroze i nastanak portohipertenzivnih komplikacija te diskriminira bolesnike u odnosu na prognozu 5-godišnjeg preživljenja.The best indicator of the severity of liver damage and prognosis in chronic viral hepatitis is extension of liver fibrosis. Extension of liver fibrosis can be assessed by liver biopsy and non-invasive physical or biological methods. Biopsy is used to define ethiology, severity (stage of fibrosis) and prognosis of liver disease. These informations are also usefull when estimating the risk-benefit and deciding on the modalities of antiviral therapy. Serological tests and elastography may distinguish significant fibrosis (F ≥2) from baseline fibrosis (AUROC 0.77-0.83 for serology and 0.84 for elastography) and cirrhosis from noncirrhotic stages (AUROC 0.77-0.86 for serology and 0.9-0.94 for elastography). Individual method of choice with best performance to distinguish cirrhosis from noncirrhotic stages of liver is elastography. Combination of serological tests and transient elastography has 93-95% accuracy to predict liver cirrhosis, and in case of concordant values of both tests biopsy could be avoided in 77-80% of patients. In case of discordant values or those in favour of intermediate stages of fibrosis liver biopsy should be performed because in these situations non-invasive tests are less reliable. According to several studies liver stiffness as assessed by transient elastography has high predictive value for the development of decom-pensated cirrhosis and portal hypertensive complications and may also discriminate the patients with respect to the predicted 5-year survival

[Indikationen fur den Praeprothetischen chirurgischen eingriff an der Hypertrofischen schleimhaut]

Autori polaze od saznanja da, u pravilu, postoji hipertrofija (hiperplazija) submukoze i da je tu glavna masa hiperplastičnog tkiva, a sluznica se hipertrofijom samo prilagodi uvećanoj i promijenjenoj podlozi. Hipertrofija sluznice se razvija na atrofičnom grebenu, kao posljedica atrofije alveolnog nastavka. Prema tomu, treba riješiti hipertrofiju sluznice, ali istovremeno i atrofiju alveolnog grebena, jer se inače ne otklanja uzrok hipertrofije. , Ova saznanja omogućila su autorima da sistematiziraju materijal, a time i probleme i operativne metode za njihovo rješavanje. Hipertrofija mekih tkiva se može razviti na dijelu alveolnog grebena, ili na cijelom alveolnom nastavku. Najčešće je u pomičnoj sluznici, na rubu krila proteze, ali može zahvatiti cijelu pomičnu sluznicu, ili gingivu propriju. Ove se lokalizacije mogu kombinirati. Isto je tako oblik hipertrofične sluznice vrlo raznolik u pojedinoj lokalizaciji, ali i na istoj lokalizaciji može biti vrlo različite konfiguracije. Svi ovi različiti problemi uvjetuju i izbor operativnih metoda, bilo da se u jednom zahvatu upotrebljava jedna metoda ili kombinacija dviju pa i više metoda. Operativni plan treba da predvidi konačni rezultat, izborom podesne operativne metode, kao i ponašanje raznih pa i promijenjenih tkiva u njihovim uzajamnim odnosima. Relevantan je rezultat, jer je on cilj, ali nisu irelevantni postupci, koji do njega dovode. Uspoređivanjem različitih operativnih metoda, s obzirom na hipertrofično stanje i postignuti operativni rezultat,ustvari je vrednovanje svake pojedine metode. Vrednovanje operativnih metoda, na konkretnom materijalu, rezultira sistematizacijom i bolesnih stanja i svrsishodnih metoda za rješavanje tih i takvih stanja. Autori zatim sistematiziraju operativne metode, s obzirom na lokalizaciju hipertrofije, njenu veličinu i konfiguraciju. Određuju uvjete kad se može upotrijebiti samo ekscizija hipertrofije, kad ekscizija do periosta, transplantat sluznice ili kože (Tierschovkalem). Govore o namjeni metoda izrađenih u Zavodu za oralnu kirurgiju Stomatološkog fakulteta u Zagrebu , kao što su otvorena metoda, zatvorena metoda i replantacija hipertrofične sluznice, koje istovremeno rješavaju atrofiju alveolnog grebena i hipertrofiju sluznice. Kombinacijom tih metoda mogu se riješiti hipertrofije bilo kojeg opsega, lokalizacije i konfiguracije, na vrlo adekvatan način.The authors start from the point that there is usually a hypertrophy (hyperplasia) of the submucosa and that the main body of the hyperplastic tissue is placed there, the mucosa is just accomodating to an enlarged and modified base. Hypertrophy of the mucosa develops on an atrophic ridge as a consequence of the atrophy of the alveolar process. Therefore we must at the same time treat the mucous hypertrophy and the atrophy of the alveolar ridge, otherwise the cause of the hypertrophy is not removed. This experiance enabled the authors to systematize their material and consequently the problems and operative methods for their treatment. Hypertrophy of the soft tissue can develop on a part of the alveolar ridge or on the entire alveolar process. It is most frequent in the movable mucosa, on the edge of the prosthesis but it can involve the entire movable mucosa or gingiva propria. These locations can be in combination. The form of the hypertrophic mucosa can be heterogeneous in different locations, but on the other side, it can be of a different configuration on equal locations. All these different problems have influence on the choise of the surgical method, whether one of them is applied or a combination of two or more. The plan of operation must envisage the final result by choosing an adequate operative method, as well as the behaviour of different and even changed tissues in their interrelationship. The result is relevant, becaus that is the aim, but the procedure which led to it is not irrelevant. Comparison of different operative methods in connection with the hypertrophic condition and the obtained result is in fact the evaluation of every particular method. The evaluation of the operative method on a given material results in a systematization of both pathologic conditions and the methods useful in such conditions. The author systematize the operative methods in connection with the location of the hypertraphy, ist size and configuration. They decide upon the cases when only an excision of the hypertrophy can be applied, when an excision up to the periosteum, and when a transplantation of the mucosa or a skin fragment (Tiersch’s graft ). They discuss the aims of the methods developed on the Department for Oral Surgery of the Stomatologic Faculty in Zagreb , as for instance open method, closed method, and the replantation of the hypertrophic mucosa which at same time cures the atrophy of the alveolar ridge and the mucous hypertrophy. By a combination of these methods it is possible to cure hypertrophies of any extent, location or configuration in an appropriate manner.In der Regel besteht keine Hypertrofie der Schleimhaut sondern bloss der Submucosa, die Schleimhaut passt sich bloss der vergrösserten und veränderten Unterlage an. Diese Hypertrofie ist die Folge der Atrofie des Alveolarfortsatzes. Um ursächlich vorzugehen muss gleichzeitig mit der Schleimhauthypertrofie auch die A trofie des Alveoiarfortsatzes angegangen werden. Diese grundsätzliche Erkenntnis ermöglicht die Systematisierung der operativen Methoden. Die Hypertrofie der Weichteile kann den Alveolarfortsatz zur Gänze oder nur teilweise erfassen. Am häufigsten tr ifft man sie in der beweglichen Schleimhaut an den Prothesenrändern an, kann jedoch die gesamte bewegliche Schleimhaut oder die Gingiva propria erfassen. Die Hypertrofie w eist keine einheitliche Form auf; an verschiedenen Kieferabschnitten aber auch an dersalben Lokalisation zeigen sich sehr unterschiedliche Konfigurationen. Diese Unterschiede bedingen die Auswahl der Operationsmethoden, unter Berücksichtigung der Unterschiedlichkeit der hypertrofischen Gewebe und ihrer Interaktionen. Man kann mit einer Methode auskommen oder muss zwei oder mehrere Methoden kombinieren. Durch Vergleich verschiedener Operationsmethoden mit Rücksicht auf hypertrofische Zustände ergibt sich die Bewertung und Systematisierung dieser Methoden. Als Kriterium Kommen Lokalisation, Grösse und Konfiguration in Betracht, was die Methode der Exzision, der Exzision bis zum Periost, der Schleimhaut oder des Hautlappen transplantats indiziert (Thiersch— Lappen). Weiterhin werden die Methoden der offenen und geschlossenen Schleimhautreplantation unserer Konzeption ausgearbeitet, an der Klinik für orale Chirurgieder Stomatologischen Fakultätin Zagreb angeführt. Hiemit wird zugleich das Problem der Alveolarkammatrofie als die Schleimhauthypertrofie gelöst. Die Kombination dieser Methoden ermöglicht die Schleimhauthypertrofie jeden Umfangs, Lokalisation und Konfiguration auf günstige Art und Weise zu behandein

Lung Ultrasound in Patients with COVID-19

COVID-19 je infektivna bolest koja se nakon pojave (prosinac 2019., Wuhan, Kina) tijekom sljedeća 3 mjeseca proširila na sve kontinente i izazvala pandemiju s kojom je čovječanstvo prvi put suočeno. S obzirom na to da bolesnici imaju pretežito respiratornu simptomatologiju često s razvojem intersticijske upale pluća te da se radi o visoko kontagioznoj bolesti, nameće se potreba brze, pouzdane i sigurne dijagnostike plućnih komplikacija ove bolesti. U COVID-19 bolesnika ciljani ultrazvuk pluća je superioran u odnosu na klasičnu Rtg snimku srca i pluća te se u dijagnostičkoj pouzdanosti približio MSCT-u toraksa. Razlog tomu je činjenica da su upalni infiltrati lokalizirani prvenstveno bazalno i periferno gdje su dostupni UZV pregledu. Najčešće zahvaćene regije su 5 i 6 obostrano, a u nalazu dominiraju multiple B linije u 2 i više regija u kombinaciji s pojedinačnim B linijama. U ožujku 2020. osnovan je Primarni respiracijsko-intenzivistički centar u KB Dubrava (PRIC KBD) s ciljem zbrinjavanja COVID-19 bolesnika s umjerenom do teškom kliničkom slikom i znacima respiracijske insuficijencije. Za dijagnostiku i praćenje bolesnika, uz Rtg snimku srca i pluća te MSCT toraksa, korišten je ciljani UZV pluća. Osim dobre korelacije s kliničkom slikom i stupnjem respiracijske insuficijencije, ciljani UZV pluća pokazao se korisnim zbog kratke izloženosti aerosolu tijekom pretrage, a bez potrebe za mobilizacijom bolesnika ili korištenjem mobilnog Rtg uređaja. Postao je suverena zamjena za stetoskop uz mogućnost pridržavanja svih mjera za prevenciju širenja aerosola: mobilni uređaj bez kabela, mogućnost dezinfekcije pa čak i korištenje samo jednog uređaja po bolesniku u intenzivističkom centru, čime je postao važna dijagnostička metoda kod COVID-19 pozitivnih bolesnika.COVID-19 is an infectious disease which surfaced in December 2019 (Wuhan, China) and swept across all the continents in a matter of 3 months, triggering a pandemic faced by humanity for the first time. Given the predominance of respiratory symptoms in patients, often accompanied by the development of interstitial pneumonia, and the fact that it is a highly contagious disease, it called for a prompt, reliable and safe diagnosis of pulmonary complications of the disease. In COVID-19 patients, focused lung ultrasound is superior to the classical heart or chest X-ray, and in terms of diagnostic reliability, is almost up to par to an MSCT of the thorax. This is due to the fact that inflammatory infiltrates are localized primarily basally and peripherally where they are accessible to ultrasound examinations. Regions 5 and 6 (both sides) are most commonly affected, and medical reports show a predominance of multiple B lines in 2 or more regions in combination with individual B lines. In March 2020, the Primary Respiratory Intensive Care Center at Clinical Hospital Dubrava (PRIC KBD) was founded to treat COVID-19 patients with a moderate to severe clinical picture and signs of respiratory failure. In addition to an X-ray of the heart and lungs and MSCT of the thorax, patients were diagnosed and monitored using focused lung ultrasound. Besides a good correlation with the clinical picture and degree of respiratory failure, focused lung ultrasound has shown to be favorable due to short aerosol exposure during screening, without the need to mobilize patients or use a mobile X-ray device. It has become an unrivalled replacement for the stethoscope, capable of adhering to all measures to prevent the spread of aerosols: a cordless mobile device, disinfectable, with even the ability to use only one device per patient in the intensive care unit, rendering it an important diagnostic tool in COVID-19 positive patients

Comparison of hepatoprotective effect from ischemia-reperfusion injury of remote ischemic preconditioning of the liver vs local ischemic preconditioning of the liver during human liver resections

AIM: To compare and evaluate the hepatoprotective effect of remote ischemic preconditioning (RIPC) with local ischemic preconditioning (LIPC) of the liver during human liver resections. ----- METHODS: A prospective, single-centre, randomised control trial was conducted in the Clinical Hospital "***" from April 2017 to January 2018. A total of 60 patients, who underwent liver resection due to colorectal cancer liver metastasis, were randomised to one of three study arms: 1) a RIPC group, 2) an LIPC group and 3) a control group (CG) in which no ischemic preconditioning was done before liver resection. The hepatoprotective effect was evaluated by comparing serum transaminase levels, bilirubin levels, albumin, and protein levels, coagulograms and through pathohistological analysis. The trial was registered on ClinicalTrials.gov (NCT****). ----- RESULTS: Significant differences were found in serum levels of liver transaminases and bilirubin levels between the groups, the highest level in the CG and the lowest level in the LIPC group. Levels of cholinesterase were also significantly higher in the LIPC group. Pathohistological findings graded by the Rodriguez score showed favourable changes in the LIPC and RIPC groups versus the CG. ----- CONCLUSION: Strong evidence supports the hepatoprotective effect of RIPC and LIPC preconditioning from an ischemia-reperfusion injury of the liver. Better synthetic liver function preservation in these two groups supports this conclusion

Indeks ALBI kao prediktor preživljenja nakon resekcije hepatocelularnog karcinoma u bolesnika s kompenziranom cirozom jetre: usporedba s indeksima PALBI i MELD

The aim of the study was to explore predictive value of the ALBI, PALBI and MELD scores on survival in patients resected for hepatocellular carcinoma with compensated liver cirrhosis and no macrovascular infi ltration. In this retrospective study, longitudinal survival analysis was performed. We analyzed patient/tumor characteristics and MELD, ALBI and PALBI scores as liver function tests for predicting survival outcome. Survival was analyzed from the date of liver resection until death, liver transplantation, or end of follow-up. Patients were stratifi ed for age, cirrhosis etiology, presence of esophageal varices, hepatocellular carcinoma stage, microvascular invasion, histologic diff erentiation, and resection margins. We identifi ed 38 patients (alcoholic cirrhosis in 84.2% of patients) resected over an 8-year period. Median preoperative MELD score was 8, ALBI score -2.63, and PALBI score -2.38. During the follow-up period, 24 patients died. Estimated median survival time was 36 months. Microvascular invasion was observed in 33 patients. Higher ALBI score was associated with 23.1% higher relative risk of death. PALBI score was associated with 12.1% higher relative risk of death, whereas MELD score was not associated with the risk of death. In conclusion, ALBI score demonstrated signifi cant predictive capabilities for survival in patients with compensated cirrhosis resected for hepatocellular carcinoma.Cilj je bio istražiti prediktivnu vrijednost zbira ALBI, PALBI i MELD za preživljenje bolesnika s kompenziranom cirozom reseciranih zbog hepatocelularnog karcinoma bez makrovaskularne invazije. Provedena je retrospektivna longitudinalna analiza preživljenja. Testirane su karakteristike bolesnika/tumora kao i jetreni funkcijski testovi MELD, ALBI i PALBI za predviđanje preživljenja. Bolesnici su praćeni nakon resekcije jetre do smrti, transplantacije jetre odnosno do kraja vremena praćenja. Bolesnici su kategorizirani po dobi, etiologiji ciroze, prisutnosti varikoziteta jednjaka, stadiju karcinoma, mikrovaskularnoj invaziji, histološkom stadiju i resekcijskim rubovima. Identifi cirali smo 38 bolesnika (alkoholna ciroza kod 84,2% bolenika) reseciranih kroz razdoblje od 8 godina. Medijan prijeoperacijskog zbira MELD bio je 8, zbira ALBI -2,63 i zbira PALBI -2,38. Tijekom praćenja 24 bolesnika su umrla. Očekivani medijan preživljenja iznosio je 36 mjeseci. Mikrovaskularna invazija pronađena je u 33 bolesnika. Veći ALBI je bio povezan s 23,1%, a PALBI s 12,1% većim relativnim rizikom od smrtnog ishoda. MELD nije bio povezan sa smrtnim ishodom. Zbir ALBI je pokazao značajnu prediktivnu vrijednost preživljenja u skupini bolesnika s kompenziranom cirozom reseciranih zbog hepatocelularnog karcinoma