Istodobna duboka venska tromboza i plućna embolija udružena s hipertireozom: prikaz slučaja

Numerous disorders of coagulation and fibrinolysis have been reported in patients with thyroid diseases, especially with hyperthyroidism. Most articles are focused on deep vein thrombosis risk, however, few of them describe association between hyperthyroidism and pulmonary embolism. We report a case of a 43-year-old woman with long-term uncontrolled hyperthyroidism complicated by venous thromboembolism. The potential mechanisms could be endothelial dysfunction, decreased fibrinolytic activity, and increased levels of coagulation factors. Thyroid evaluation should be recommended in patients with unprovoked venous thromboembolic events.Različiti poremećaji koagulacije ponekad se povezuju s bolestima štitnjače, najčešće hipertireozom. Većina dosadašnjih radova je usredotočena na rizik duboke venske tromboze kod takvih bolesnika, dok je u vrlo malom broju radova opisana povezanost hipertireoze i plućne embolije. Prikazuje se slučaj 43-godišnje bolesnice s dugogodišnjom nekontroliranom hipertireozom i posljedičnim akutnim venskim tromboembolizmom. Vjerojatni patofiziološki mehanizam uključuje oštećenje endotela, smanjenje fibrinolitičke aktivnosti i povećanu razinu faktora koagulacije. Klinička i laboratorijska evaluacija štitnjače preporučljiva je u bolesnika s neprovociranim tromboembolijskim događajem

LATERAL THERMAL DAMAGE OF MESOAPPENDIX AND APPENDICEAL BASE DURING LAPAROSCOPIC APPENDECTOMY IN CHILDREN : COMPARISON OF THE HARMONIC SCALPEL (Ultracision™), BIPOLAR COAGULATION (LigaSure™), AND THERMAL LIGATION (MiSeal™)

Cilj istraživanja: Korištenjem novijih instrumenata za hemostazu i rezanje, duljina operacijskog zahvata i komplikacije tijekom laparoskopske kirurgije značajno su smanjene. Danas se za izvođenje laparoskopske apendektomije koriste različiti instrumenti za rezanje i koagulaciju tkiva. Cilj ovog istraživanja je usporediti postranično termičko oštećenje u laparoskopskoj apendektomiji korištenjem tri različita instrumenta (LigaSure™, Ultracision™ i MiSeal™). Ispitanici i metode: Od prosinca 2013. do svibnja 2015. u Zavodu za dječju kirurgiji KBC Split 99 djece (54 dječaka i 45 djevojčica) kojima je učinjena laparoskopska apendektomija uključeno je u prospektivnu studiju. Bolesnici su bili podijeljeni u tri skupine ovisno o korištenom instrumentu za skeletiranje crvuljka: Ultracision™ (Skupina I., n=36), LigaSure™ (Skupina II., n=32) i MiSeal™ (Skupina III., n=31). Svim ispitanicima izmjereno je postranično termičko oštećenje na bazi crvuljka i mezoapendiksu. Skupine su uspoređivane ovisno o postraničnom termičkom oštećenju baze crvuljka i mezoapendiksa, intraoperacijskim i poslijeoperacijskim komplikacijama, trajanju kirurškog zahvata, duljine boravka u bolnici i ekonomske isplativosti zahvata. Rezultati: Prosječno termičko oštećenje baze crvuljka korištenjem Ultracision™ iznosilo je 0,120 mm na bazi i 0,100 mm na mezenteriolu crvuljka, korištenjem MiSeal™ 0,120 mm na bazi i 0,100 mm na mezenteriolu, dok je najveće postranično oštećenje nađeno korištenjem LigaSure™ i to 0,170 mm na bazi i 0,140 mm na mezenteriolu. Statističkom obradom podataka utvrđena je statistički značajna razlika između skupina u veličini postraničkog termičkog oštećenje mezoapendiksa i baze crvuljka. (p=0,015, p=0,012). Nije nađena statistički značajna razlika u termičkom oštećenju tkiva u skupini bolesnika u kojih je dokazan apendicitis (0,139 mm na bazi i 0,119 mm na mezenteriolu) i skupini bolesnika koja nije imala apendicitis (0,110 mm na bazi i 0,081 mm na mezentetiolu) (p=0,170 mm, p=0,266). Duljina trajanja kirurškog zahvata i duljina boravka u bolnici bila je nešto veća u bolesnika operiranih Ultracisionom™ (p=0,007; p=0,012). Nisu zabilježene statistički značajne razlike u stopi intraoperacijskih i poslijeoperacijskih komplikacija između tri ispitivane skupine (p=0,098). Zaključci: Korištenje instrumenata Ultracision™, LigaSure™ i MiSeal™ u laparoskopskoj apendektomiji je podjednako sigurno i učinkovito. LigaSure™ značajno više termički oštećuje tkivo u odnosu na ostale ispitivane instrumente. Ekonomski je najisplativiji instrument MiSeal™ obzirom da isti proizvodi najmanje termičko oštećenje tkiva, te time smanjuje automatski mogućnost komplikacija, a uz to ima i najmanju cijenu.Objectives and background: Complications during laparoscopic surgery are being made substantial less by newer electrosurgery instrument when comparing with convential instruments as well as duration of surgical procedure is shorter. The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using the harmonic scalpel (Ultracision™), bipolar coagulation (LigaSure™), and thermal ligation (MiSeal™). Patients and Methods: From December 2013 to May 2015 at the Department of Pediatric surgery, Split University Hospital 99 (54 boys and 45 girls) undergoing laparoscopic appendectomy were included in prospective study. The patients were divided in three groups regarding technique used for sealing and cuting mesoappendix and base of appendix: Ultracision™ (Group 1., n=36), LigaSure™ (Group 2., n=32) and MiSeal™ (Group 3., n=31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay and economic value were compared within groups. Results: The mean lateral thermal damage using Ultracision™ was 0,120 mm on base of appendix and 0,100 mm on mesoappendix, for MiSeal™ 0,120 mm on appendiceal base and 0,100 mm on mesoappendix and for LigaSure™ 0,170 mm on base of appendix and 0,140 mm on mesoappendix. The difference in thermal damage among instruments was significant for mesoappendix and base of appendix (p=0,015, p=0,012). There was no statistical difference in thermal damage between appedicitis group (0,139 mm on appendiceal base and 0,119 mm on mesoappendix) and non appendicitis group (0,110 mm on base of appendix and 0,081 mm on mesoappendix) (p=0,170, p=0,266). Duration of surgery and lenght of hospital stay were significant higher using Ultracision™ (p=0,007, p=0,012). There were no statistical difference among the groups regarding intraoperative and postoperative complications (p=0,098). Conclusions: Using of Ultracision™, LigaSure™ and MiSeal™ in laparoscopic appendectomy in children is safe and useful. In group of patients operated using LigaSure™ lateral thermal damage was significantly greater compared to other intruments. MiSeal™ is economically the most cost effective and produces at least termal damage comparing to other instruments

Podvodno mokro zavarivanje REL postupak

U ovom radu opisana je važnost podvodnog zavarivanja kao i razvoj istog kroz godine zbog zahtjeva industrije. Navedene su karakteristike i parametri klasičnog postupka REL zavarivanja u suhoj atmosferi, te oprema. Usporedno s time navedene su razlike između klasičnog REL postupka i onog u vodenoj atmosferi. Prikazana je podjela podvodnog REL zavarivanja, te detaljno opisan postupak, oprema te dodatni materijal specifičan za mokri postupak podvodnog REL zavarivanja. Uz to navedene su tehnike rada i potrebna obuka zavarivača/ronioca kako bi se postupak uspješno izveo. Zaključno, navedeni su osnovni, najbitniji problemi kod ovog postupka.This thesis describes the importance of underwater welding as well as development of the same for years due to industry requirements. The characteristics and parameters of the classic SMAW welding procedure in the dry atmosphere and the equipment are listed. At the same time, there are differences between the classical SMAW procedure and the one in the aqueous atmosphere. The underwater SMAW welding is described and detailed description of the procedure, equipment and additive specific for the wet underwater SMAW welding process. In addition to this, the techniques of work and the training of the welders / divers have been described in order for the process to be successfully carried out. In conclusion, the basic, most important problems in this procedure are listed

LATERAL THERMAL DAMAGE OF MESOAPPENDIX AND APPENDICEAL BASE DURING LAPAROSCOPIC APPENDECTOMY IN CHILDREN : COMPARISON OF THE HARMONIC SCALPEL (Ultracision™), BIPOLAR COAGULATION (LigaSure™), AND THERMAL LIGATION (MiSeal™)

Cilj istraživanja: Korištenjem novijih instrumenata za hemostazu i rezanje, duljina operacijskog zahvata i komplikacije tijekom laparoskopske kirurgije značajno su smanjene. Danas se za izvođenje laparoskopske apendektomije koriste različiti instrumenti za rezanje i koagulaciju tkiva. Cilj ovog istraživanja je usporediti postranično termičko oštećenje u laparoskopskoj apendektomiji korištenjem tri različita instrumenta (LigaSure™, Ultracision™ i MiSeal™). Ispitanici i metode: Od prosinca 2013. do svibnja 2015. u Zavodu za dječju kirurgiji KBC Split 99 djece (54 dječaka i 45 djevojčica) kojima je učinjena laparoskopska apendektomija uključeno je u prospektivnu studiju. Bolesnici su bili podijeljeni u tri skupine ovisno o korištenom instrumentu za skeletiranje crvuljka: Ultracision™ (Skupina I., n=36), LigaSure™ (Skupina II., n=32) i MiSeal™ (Skupina III., n=31). Svim ispitanicima izmjereno je postranično termičko oštećenje na bazi crvuljka i mezoapendiksu. Skupine su uspoređivane ovisno o postraničnom termičkom oštećenju baze crvuljka i mezoapendiksa, intraoperacijskim i poslijeoperacijskim komplikacijama, trajanju kirurškog zahvata, duljine boravka u bolnici i ekonomske isplativosti zahvata. Rezultati: Prosječno termičko oštećenje baze crvuljka korištenjem Ultracision™ iznosilo je 0,120 mm na bazi i 0,100 mm na mezenteriolu crvuljka, korištenjem MiSeal™ 0,120 mm na bazi i 0,100 mm na mezenteriolu, dok je najveće postranično oštećenje nađeno korištenjem LigaSure™ i to 0,170 mm na bazi i 0,140 mm na mezenteriolu. Statističkom obradom podataka utvrđena je statistički značajna razlika između skupina u veličini postraničkog termičkog oštećenje mezoapendiksa i baze crvuljka. (p=0,015, p=0,012). Nije nađena statistički značajna razlika u termičkom oštećenju tkiva u skupini bolesnika u kojih je dokazan apendicitis (0,139 mm na bazi i 0,119 mm na mezenteriolu) i skupini bolesnika koja nije imala apendicitis (0,110 mm na bazi i 0,081 mm na mezentetiolu) (p=0,170 mm, p=0,266). Duljina trajanja kirurškog zahvata i duljina boravka u bolnici bila je nešto veća u bolesnika operiranih Ultracisionom™ (p=0,007; p=0,012). Nisu zabilježene statistički značajne razlike u stopi intraoperacijskih i poslijeoperacijskih komplikacija između tri ispitivane skupine (p=0,098). Zaključci: Korištenje instrumenata Ultracision™, LigaSure™ i MiSeal™ u laparoskopskoj apendektomiji je podjednako sigurno i učinkovito. LigaSure™ značajno više termički oštećuje tkivo u odnosu na ostale ispitivane instrumente. Ekonomski je najisplativiji instrument MiSeal™ obzirom da isti proizvodi najmanje termičko oštećenje tkiva, te time smanjuje automatski mogućnost komplikacija, a uz to ima i najmanju cijenu.Objectives and background: Complications during laparoscopic surgery are being made substantial less by newer electrosurgery instrument when comparing with convential instruments as well as duration of surgical procedure is shorter. The aim of this study was to compare lateral thermal damage of mesoappendix and appendiceal base using the harmonic scalpel (Ultracision™), bipolar coagulation (LigaSure™), and thermal ligation (MiSeal™). Patients and Methods: From December 2013 to May 2015 at the Department of Pediatric surgery, Split University Hospital 99 (54 boys and 45 girls) undergoing laparoscopic appendectomy were included in prospective study. The patients were divided in three groups regarding technique used for sealing and cuting mesoappendix and base of appendix: Ultracision™ (Group 1., n=36), LigaSure™ (Group 2., n=32) and MiSeal™ (Group 3., n=31). Lateral thermal damage, intraoperative and postoperative complications, duration of surgery, hospital stay and economic value were compared within groups. Results: The mean lateral thermal damage using Ultracision™ was 0,120 mm on base of appendix and 0,100 mm on mesoappendix, for MiSeal™ 0,120 mm on appendiceal base and 0,100 mm on mesoappendix and for LigaSure™ 0,170 mm on base of appendix and 0,140 mm on mesoappendix. The difference in thermal damage among instruments was significant for mesoappendix and base of appendix (p=0,015, p=0,012). There was no statistical difference in thermal damage between appedicitis group (0,139 mm on appendiceal base and 0,119 mm on mesoappendix) and non appendicitis group (0,110 mm on base of appendix and 0,081 mm on mesoappendix) (p=0,170, p=0,266). Duration of surgery and lenght of hospital stay were significant higher using Ultracision™ (p=0,007, p=0,012). There were no statistical difference among the groups regarding intraoperative and postoperative complications (p=0,098). Conclusions: Using of Ultracision™, LigaSure™ and MiSeal™ in laparoscopic appendectomy in children is safe and useful. In group of patients operated using LigaSure™ lateral thermal damage was significantly greater compared to other intruments. MiSeal™ is economically the most cost effective and produces at least termal damage comparing to other instruments

Dabigatran Use Associated with Hemopericardium and Hemothorax

Concurrent spontaneous hemopericardium and hemothorax due to anticoagulant use are extremely rare in clinical practice. Dabigatran is an oral direct thrombin inhibitor approved to prevent stroke or thromboembolic episodes in patients with nonvalvular atrial fibrillation. We report the case of a 73-year-old man who received dabigatran therapy (150 mg twice a day) for 3 months and developed massive spontaneous hemothorax and hemopericardium associated with fever. Emergency chest computed tomography scan established higher-density pericardial effusion (22HU) and left pleural effusion of heterogeneous density (5–15 HU) which could be hemorrhagic content while the heart ultrasound finding confirmed pericardial effusion 7–9 mm thick, without affecting hemodynamics. Almost 1100 mL of blood was drained by ultrasoundguided thoracentesis. After excluding other possible causes, diagnostic withdrawal was performed for dabigatran and no further pleural or pericardium effusion developed after dabigatran was discontinued. Therefore, practitioners could be aware of hemothorax as well as hemopericardium as a potential complication of dabigatran therapy

Lijevi lateralni pogled tijekom perkutane koronarne intervencije kod akutnog infarkta donje stijenke miokarda s podizanjem ST spojnice i dekstrokardijom

Rapid recognition of ST-segment elevation myocardial infarction and electrocardiogram interpretation in patients with dextrocardia could be a challenging situation. This case report discusses presentation in a patient with dextrocardia and situs inversus who was found to have acute inferior myocardial infarction. Percutaneous coronary intervention in cases of dextrocardia can be technically challenging considering coronary origin and orientation, and difficulty in appropriate catheter selection.Pravodobno prepoznavanje infarkta miokarda s elevacijom ST segmenta i interpretacija elektrokardiograma u bolesnika s dekstrokardijom predstavlja klinički izazov. Ovim prikazom slučaja opisujemo bolesnika s dekstrokardijom i situs inversusom za kojeg je utvrđeno da ima akutni infarkt miokarda s podizanjem ST segmenta. Perkutana koronarna intervencija u slučajevima dekstrokardije može biti tehnički izazovna s obzirom na poziciju ušća koronarnih arterija te poteškoće u odgovarajućem odabiru i manipulaciji intervencijskim kateterima

Effects of Biomotor Structures on Performance of Competitive Gymnastics Elements in Elementary School Female Sixth-Graders

In order to identify biomotor systems that determine performance of competitive gymnastics elements in elementary school female sixth-graders, factor structures of morphological characteristics and basic motor abilities were determined first, followed by relations of the morphological-motor system factors obtained with a set of criterion variables evaluating specific motor skills in competitive gymnastics in 126 female children aged 12 years ±3 months. Factor analysis of 17 morphological measures yielded three morphological factors: factor of mesoendomorphy and/or adipose body voluminosity; factor of longitudinal body dimensionality; and factor of transverse arm dimensionality. Factor analysis of 16 motor variables produced four motor factors: general motoricity factor (motor system); general speed factor; factor of explosive strength of throwing type (arm explosiveness); and factor of arm and leg flexibility. Three significant canonical correlations, i.e. linear combinations, explained the association between the set of seven latent variables of the morphological and basic motor system, and five variables evaluating the knowledge in competitive gymnastics. The first canonical linear combination was based on a favorable and predominant impact of the general motor factor (a system integrating whole body coordination, leg explosiveness, relative arm strength, arm movement frequency and body flexibility) on performance of gymnastics elements, cartwheel, handstand and backward pullover mount in particular, and to a lesser extent front scale and double leg pirouette for 180°. The relation of the second pair of canonical factors additionally explained the role of transverse dimensionality of arm skeleton, arm flexibility and explosiveness in performing cartwheel and squat vault, whereas the relation of the third pair of canonical factors explained the unfavorable impact of adipose voluminosity on the performance of squat vault and backward pullover mount

Flail aortic valve leaflet due to high-voltage electrical injury

Introduction: Electric shock is the set of pathophysiological events resulting from the action of an electric current on the human body1. Electrical injuries involve both direct (caused by contact with electricity arc) and indirect mechanisms (mechanical trauma due to falls). The most common sequels after electrical injury in the heart are arrhythmias and myocardial contusion2. Large arteries like aorta are rarely affected because their rapid flow allows them to dissipate the heat produced by the electric current. However, they are susceptible to medial necrosis, with aneurysm formation and rupture at a later point of time. There is one case in the literature which described aortic valve rupture due to high-voltage electrical injury3. Case report: 47-year-old male patient was admitted to our echo lab for ultrasound examination of the heart. In the last two months he had been complaining about exertional dyspnea. His medical history was quite poor: he had never been admitted to the hospital until two months ago when he had been observed for 24 hours after he had suffered a high-voltage electric injury. The transthoracic echocardiography was performed, and we discovered moderately enlarged left ventricle (LVED volume 180 ml) due to severe aortic regurgitation on bicuspid aortic valve with holo-diastolic retrograde flow. The regurgitation jet that filled the two thirds of left ventricular outflow tract with laceration and flail of bicuspid cusps confirmed on transesophageal ultrasound. The patient underwent surgery. The aortic valve was removed and replaced with a mechanical prosthesis. Conclusion: Cardiac symptoms and echocardiographic findings that initiated two months after a high-voltage electric injury led us to conclusion that bicuspid valve was probably injured by electrical shock. To the authors’ knowledge, this is the first reported case of valvular rupture due to electrical injury in Croatian population

Unruptured non-coronary sinus of Valsalva aneurysm – case report

Introduction: Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction. The estimated rate of SVA is approximately 0.09% of the general population and involve up to 3.5% of all congenital heart defects1. Aneurysm predominantly originates from the right coronary sinus and may rupture up to 35% of the time commonly to the right cardiac chambers2. We present an unusual case of a patient with SVA originating from the non-coronary sinus. Case report: 63-old-year male with no history of prior cardiovascular disease was presented to department with shortness of breath and chest pain. Physical examination showed blood pressure of 140/80mmHg, respiratory rate of 18/min and heart rate of 84 beats/min. Electrocardiogram revealed complete right bundle-branch block. A routine transthoracic echocardiography showed the enlargement of the left ventricle with large aneurysm originating from non-coronary sinus measuring 3.6x4cm. Echocardiography also revealed a trileaflet aortic valve with moderate aortic regurgitation and normal systolic function of the left ventricle. TEE demonstrated a non-coronary SAV protruding into the left atrium cavity with no signs of rupture. Selective angiography showed normal epicardial coronary arteries, and SAV with dilatation of ascending aorta measuring up to 40 mm. Moderate aortic insufficiency was also detected. The patient was referred to the cardiothoracic surgery ward for further operative treatment. Conclusion: Although rare, SAV can be a cause of sudden death. Therefore, a combination of transthoracic echocardiography with other imaging techniques, such as TEE, 3D echocardiography, CT angiography and aortic angiography is recommended to obtain comprehensive information and to improve diagnostic accuracy3