Liječiti ili ne visoko normalan krvni tlak?

Vrijednosti sistoličkoga krvnog tlaka od 130 do 139 mmHg te dijastoličkog od 85 do 89 mmHg smatraju se visoko normalnim krvnim tlakom. Već se duže vrijeme raspravlja treba li bolesnike s visoko normalnim krvnim tlakom medikamentno liječiti. Odgovor su dali Europsko društvo za hipertenziju i Europsko kardiološko društvo 2007. godine kada su objavljene smjernice za dijagnosticiranje i liječenje arterijske hipertenzije. Po smjernicama, medikamentno liječenje visoko normalnoga krvnog tlaka ovisi o ukupnome kardiovaskularnom riziku (ostali rizični čimbenici, druge bolesti), pa se tako intervencija kod bolesnika s visoko normalnim krvnim tlakom kreće od promjene životnih navika do medikamentne terapije. Rezultati novih studija (TROPHY, PHARAO) govore u prilog medikamentnom liječenju bolesnika s visoko normalnim krvnim tlakom, ali su potrebna daljnja istraživanja

Hypertension in the elderly

Arterijska hipertenzija (AH) u starijih osoba predstavlja veliki javnozdravstveni problem zbog visoke prevalencije i trenda starenja svjetske populacije. Najčešće se radi o izoliranoj sistoličkoj hipertenziji (90% bolesnika iznad 70 godina) te se kod osoba starije životne dobi kao najbitniji čimbenici rizika izdvajaju vrijednosti tlaka pulsa i sistoličkog tlaka. Patofiziološki u podlozi su brojne strukturne (gubitak elastičnosti velikih krvnih žila, smanjena rastezljivost, porast brzine pulsnog vala) i funkcionalne (endotelna disfunkcija, smanjena osjetljivost beta receptora, smanjena funkcija baroreceptora, osjetljivost na sol) promjene. Liječenje AH u starijih do sada je bilo veliki izazov jer nije bilo dovoljno studija koje su se bavile tom populacijom, što se promijenilo objavom rezultata studije HYVET. Ova je studija uključila najstarije bolesnike (iznad 80 godina) te je dokazala kako sniženje vrijednosti arterijskog tlaka za 15/6 mmHg dovodi do značajno manje opće smrtnosti (21%), kardiovaskularne smrtnosti (23%), incidencije moždanog udara (30%) i srčanog zatajivanja (64%). Kao lijek prvog izbora u starijoj populaciji izdvojili bismo tijazidski diuretik, a budući ti pacijenti većinom zahtijevaju višestruku terapiju izdvojili bismo blokatore kalcijskih kanala ili ACE inhibitore. Naravno i komorbiditeti određuju osnovnu ili dodatnu terapiju.Hypertension in the elderly is a major public health problem due to high prevalence and the world population ageing trend. Most often it is the isolated systolic hypertension (90% of patients over 70 years of age) that is concerned. Furthermore, pulse pressure and systolic pressure are the most important risk factors in elderly persons. Pathophysiologically, there is a great number of structural (loss of elasticity of large blood vessels, decreased elasticity, increased pulse wave velocity) and functional (endothelial dysfunction, decreased sensitivity of beta receptors, decreased baroreceptor function, sensitivity to salt) changes in the background. Treatment of hypertension in the elderly has so far been a big challenge, because there were not enough studies that have dealt with this population. Now this has changed after results of the HYVET study have been published. HYVET study included the oldest patients (above 80 years of age) and has proven that lowering pressure by 15/6 mmHg, leads to significantly lower overall mortality (21%), cardiovascular mortality (23%), incidence of stroke (30%) and heart failure (64%). We emphasize thiazide diuretic as the first choice drug in the elderly population, and since these patients usually require multiple treatment, we emphasize calcium channel blockers or ACE inhibitors. Comorbidities, naturally, determine the basic or additional therapy

Initial experiences of hemodialysis HeRO graft in University Hospital Dubrava – A report of two cases and review of literature

U Kliničkoj bolnici Dubrava u Zagrebu prvi je put u Hrvatskoj ugrađen novi sustav za krvožilni pristup kod bolesnika koji se liječi kroničnom hemodijalizom. Radi se o kombinaciji centralnoga venskog katetera i grafta engleskog naziva Hemodialysis Reliable Outflow (HeRO) device, skraćenog naziva HeRO-graft. Glavna je indikacija za primjenu ovoga krvožilnog pristupa okluzija ili značajna stenoza centralnih vena. Iz literature se doznaje da ovaj krvožilni pristup ima značajne prednosti u odnosu na tunelirani centralni venski kateter koji bi trebao biti zadnja opcija kod bolesnika koji zahtijevaju trajno nadomještanje izgubljene bubrežne funkcije. Za razliku od tuneliranih katetera ovaj je sustav u potpunosti smješten potkožno, što ga čini otpornijim na infekcije. Do sada su u Kliničkoj bolnici Dubrava ugrađena dva HeRO-grafta za hemodijalizu i prema prvim iskustvima potrebna je detaljna obrada kandidata za ovu proceduru. Potrebno je dobro poznavati indikacije i kontraindikacije te je nužna suradnja više timova: nefrološkog, anesteziološkog, radiološkog i kirurškog. Osobito je potrebno obratiti pažnju na stanje arterijske cirkulacije okrajine koja se koristi za ovaj krvožilni pristup kako bi se izbjegle moguće ishemijske komplikacije. Kod obaju naših bolesnika postupak ugradnje protekao je uredno te smo započeli s korištenjem HeRO-grafta za potrebe hemodijalize.A new vascular access system in patients undergoing chronic hemodialysis was implanted for the first time in Dubrava University Hospital in Zagreb. It is a combination of a central venous catheter and a graft known as Hemodialysis Reliable Outflow device (HeRO graft). The main indication for this vascular access is the occlusion or a significant stenosis of the central veins. Literature supports the significance of this type of vascular access over tunneled central venous catheters which should be the last option for patients requiring permanent renal replacement therapy. Unlike tunneled catheters, this system is completely located subcutaneously which makes it more resistant to infections. So far, two HeRO grafts for hemodialysis have been implanted in Dubrava University Hospital, and according to the first experiences, detailed workup on candidates is required before this procedure. It is necessary to be well aware of the indications and contraindications, and the cooperation of several specialties is required: nephrology, anesthesiology, radiology and surgery. It is especially important to pay attention to the condition of the arterial circulation of the arm used for this vascular access in order to avoid possible ischemic complications. In both of our patients, the implantation procedure had no immediate complications and we started using the HeRO graft

Mobile applications based on databases

Mobilne aplikacije temeljene na bazama podataka. Komunikacija s Web poslužiteljem. Opis Android sustava, komponenata aplikacije i alata za razvoj

Mobile applications based on databases

Mobilne aplikacije temeljene na bazama podataka. Komunikacija s Web poslužiteljem. Opis Android sustava, komponenata aplikacije i alata za razvoj

Mobile applications based on databases

Mobilne aplikacije temeljene na bazama podataka. Komunikacija s Web poslužiteljem. Opis Android sustava, komponenata aplikacije i alata za razvoj

The performance of the WHO COVID-19 severity classification, COVID-GRAM, VACO Index, 4C Mortality, and CURB-65 prognostic scores in hospitalized COVID-19 patients: data on 4014 patients from a tertiary center registry

Aim: To evaluate the predictive properties of several common prognostic scores regarding survival outcomes in hospitalized COVID-19 patients. Methods: We retrospectively reviewed the medical records of 4014 consecutive COVID-19 patients hospitalized in our tertiary level institution from March 2020 to March 2021. Prognostic properties of the WHO COVID-19 severity classification, COVID-GRAM, Veterans Health Administration COVID-19 (VACO) Index, 4C Mortality Score, and CURB-65 score regarding 30-day mortality, in-hospital mortality, presence of severe or critical disease on admission, need for an intensive care unit treatment, and mechanical ventilation during hospitalization were evaluated. Results: All of the investigated prognostic scores significantly distinguished between groups of patients with different 30-day mortality. The CURB-65 and 4C Mortality Score had the best prognostic properties for prediction of 30-day mortality (area under the curve [AUC] 0.761 for both) and in-hospital mortality (AUC 0.757 and 0.762, respectively). The 4C Mortality Score and COVID-GRAM best predicted the presence of severe or critical disease (AUC 0.785 and 0.717, respectively). In the multivariate analysis evaluating 30-day mortality, all scores mutually independently provided additional prognostic information, except the VACO Index, whose prognostic properties were redundant. Conclusion: Complex prognostic scores based on many parameters and comorbid conditions did not have better prognostic properties regarding survival outcomes than a simple CURB-65 prognostic score. CURB-65 also provides the largest number of prognostic categories (five), allowing more precise risk stratification than other prognostic scores