Utjecaj izvantjelesne cirkulacijske potpore na viskoelastična svojstva krvnoga ugruška i funkcije trombocita [Impact of extracorporeal life support on blood clot viscoelastic properties and platelet aggregation]

Extracorporeal life support based on extracorporeal membrane oxygenation is the end-stage treatment of heart failure or cardiogenic shock. Systemic anticoagulation is mandatory, and most of the complications such as thrombosis and bleeding, which are also the most common causes of mortality, are often the result of incompatibility of the extracorporeal system and blood. Routinely performed laboratory blood clotting tests and platelet number do not offer sufficient understanding whether qualitative platelet dysfunction is present in a particular patient nor does it denote hypercoagulability, hyper or hypofibrinololysis. The aim of this prospective study on 28 patients is to evaluate the effect of extracorporeal life support on blood clotting viscoelastic properties and platelet function through specific coagulation and aggregation tests. Data obtained by this study indicate that significant bleeding can be predicted by certain ROTEM® analysis tests, such as INTEM CT, EXTEM CT and FIBTEM MCF. It is more accurate and available in a shorter unit of time compared to the prediction of routine tests that study the coagulation status of the patient. The results of these tests have a practical value in treating patients on ECMO / ECLS support. Literature citations and current research clearly call for the formulation of standardized protocols for conducting anticoagulant therapy during ECMO / ECLS support. It is necessary to assess whether these tests are truly superior to available laboratory tests

Postoperative atrial fibrillation is associated with high on-aspirin platelet reactivity

BACKGROUND: Atrial fibrillation (AF) contributes to a prothrombotic state through platelet activation. It is unclear whether increased platelet aggregability in patients with AF is caused by the underlying cardiovascular condition rather than the arrhythmia per se. We investigated the effect of postoperative atrial fibrillation (POAF) on platelet reactivity after coronary artery bypass grafting (CABG). ----- METHODS: This study is a post hoc analysis from a randomized controlled trial (ClinicalTrials.gov: NCT01159639) based on patients undergoing elective primary CABG. Patients were dichotomized according to POAF. Postoperative platelet function testing with arachidonic acid as the platelet agonist (ASPI test) was used to define high on-aspirin platelet reactivity (HAPR). ΔASPI presented the difference between pre- and postoperative ASPI test values. To account for the isolated effect of POAF on platelet reactivity, a propensity score analysis was applied. ----- RESULTS: Overall incidence of POAF was 23% (92 of 398 patients). HAPR was detected in 54% (214 of 398) of patients. HAPR was more prevalent among patients with POAF when compared with patients without POAF (64.1% versus 50.7%; odds ratio [OR], 1.74; 95% confidence interval [CI], 1.08-2.82; p = 0.023). The propensity score model produced a subcohort of patients that was well balanced for comorbidities. When compared with the matched group without POAF, the POAF group maintained its prevalence for HAPR (64.1% versus 45.7%; OR, 2.13; 95% CI, 1.18-3.85; p = 0.012) and had greater ΔASPI values (15.0 [IQR, 0.0-36.0] vs 8.0 [IQR, -5.5-19.5]; p = 0.030). ----- CONCLUSIONS: The main finding of our study indicates there is added platelet activation in patients with POAF after CABG before and after controlling for pathologic conditions through propensity matching. The present study does not prove a causal association between POAF and HAPR

Role of military medicine in massive immediate threat situations

Pandemija COVID-19 je ukazala na inkluzivnu ulogu nezdravstvenih aktera u procesu prilagodbe i odgovora na ugrozu. U Republici Hrvatskoj, navedeno je posebno vidljivo u višestrukim krizama koje su nas pogađale istovremeno – potresi i pandemija. U bliskoj budućnosti broj infektivnih agenasa sposobnih izazvati novu pandemiju postat će veći, kao i mogućnost suočavanja s drugim vrstama katastrofe. Danas, više nego ikad prije potrebna je unaprijed pripremljena i multidisciplinarno organizirana zdravstvena skrb. Buduća pripremljenost na katastrofu ne bi trebala podrazumijevati višestruke protokole za upravljanje rizikom, već jedan jedinstveni višeslojni protokol koji uključuje sve aktere državnih i javnih službi. Vojska je zbog svoje povijesne uloge, misije i sustava organizacije u potpunosti spremna postati dio multidisciplinarnog tima koji upravlja ugrozama masovnog stradavanja. Ključni elementi koji su potrebni za učinkovitu nacionalnu civilno-vojnu suradnju u području zdravstva s ciljem sprječavanja, otkrivanja, odgovaranja i oporavljanja od zdravstvenih kriza ili katastrofa uključuju (a) uspostavljanje strateškog plana suradnje za hitne zdravstvene intervencije; (b) uvažavanje razlika između civilnog i vojnog sustava; (c) utvrđivanje potencijalnih područja za suradnju na nacionalnoj razini; (d) standardizacija i institucionaliziranje civilno–vojne suradnje u području zdravstva; i (e) zajednička obuka i uvježbavanje civilnovojnih zdravstvenih kapaciteta pripravnosti za hitne slučajeve.The COVID-19 pandemic has highlighted the inclusive role of non-health actors in the process of adaptation and response to the threat. In the Republic of Croatia, this is particularly visible in the multiple crises that hit country at the same time – several earthquakes and the pandemic. In the near future, the number of infectious agents capable of causing a new pandemic will increase, as will the possibility of facing other types of disasters. Today, more than ever before, we need pre-prepared and multidisciplinary organized health care. Future disaster preparedness should not imply multiple protocols for risk management, but one single multi-layered protocol involving all actors of government and public services. Due to its historical role and organizational system, the army is fully prepared to become part of a multidisciplinary team that manages mass casualty threats. Key elements required for effective national civil-military health cooperation in planning, detecting, responding to, and recovering from health crises or disasters include (a) establishing a strategic cooperation plan for emergency health interventions; (b) appreciation of the differences between the civilian and military systems; (c) identification of potential areas for cooperation at the national level; (d) standardization and institutionalization of Civil Military Cooperation; and (e) joint training and exercise of civil-military emergency medical preparedness capacities

Pretransplant and perioperative predictors of early heart transplantation outcomes

Aim To identify predictors of 3-month mortality after heart transplantation in a Croatian academic center. Methods A retrospective review of institutional database identified 117 heart transplantations from January 2008 to July 2014. Two children <14 years were excluded from the study. The remaining 115 patients were dichotomized into survivors and non-survivors adjudicated at 3-months postoperatively, and their demographic, clinical, and longitudinal hemodynamic data were analyzed. Results 3-month survival after heart transplantation was 86%. Nonsurvivors were older (59 ± 8 vs 50 ± 14 years, P = 0.009), more likely to have previous cardiac surgery (44% vs 19%; odds ratio [OR] 3.28, 95% confidence interval [CI] 1.08-9.90; P = 0.029), lower body mass index (BMI) (25 ± 4 vs 28 ± 2 kg/m2, P = 0.001), and be diabetics (44% vs 23%; OR 2.57, 95% CI 0.86-7.66; P = 0.083). Creatinine clearance was marginally superior among survivors (59 ± 19 vs 48 ± 20 mL/ min, P = 0.059). Donor age and sex did not affect outcomes. Nonsurvivors were more likely to have had ischemic cardiomyopathy (69% vs 32%, P = 0.010). Postoperative utilization of epinephrine as a second line inotropic agent was a strong predictor of mortality (63% vs 7%; OR 21.91; 95% CI 6.15-78.06; P < 0.001). Serum lactate concentrations were consistently higher among non-survivors, with the difference being most pronounced 2 hours after cardiopulmonary bypass (9.8 ± 3.5 vs 5.2 ± 3.2 mmol/L, P < 0.001). The donor hearts exhibited inferior early hemodynamics in non-survivors (cardiac index 3.0 ± 1.0 vs 4.0 ± 1.1 L/min/m2, P = 0.001), stroke volume (49 ± 24 vs 59 ± 19 mL, P = 0.063), and left and right ventricular stroke work indices (18 ± 8 vs 30 ± 11 g/beat/m2, P < 0.001 and 5 ± 3 vs 7 ± 4 g/ beat/m2, P = 0.060, respectively). Non-survivors were more likely to require postoperative re-sternotomy (50% vs 12%; OR 7.25, 95% CI 2.29-22.92; P < 0.001), renal replacement therapy (RRT) (69% vs 9%; OR 22.00, 95% CI 6.24-77.54; P < 0.001), and mechanical circulatory assistance (MCS) (44% vs 5%; OR 14.62, 95% CI 3.84-55.62; P < 0.001). Binary logistic regression revealed recipient age (P = 0.024), serum lactates 2 hours after CPB (P = 0.007), and epinephrine use on postoperative day 1 (P = 0.007) to be independently associated with 3-month mortality. Conclusion Pretransplant predictors of adverse outcome after heart transplantation were recipient age, lower BMI, ischemic cardiomyopathy, reoperation and diabetes. Postoperative predictors of mortality were inferior donor heart hemodynamics, epinephrine use, and serum lactate concentrations. Non-survivors were more likely to require re-sternotomy, MCS, and RRT

Definition of Acetylsalicylic Acid Resistance Using Whole Blood Impedance Aggregometry in Patients Undergoing Coronary Artery Surgery

A beneficial effect of acetylsalicylic acid (ASA) on vein graft patency has been described, but some patients experience adverse cardiac events despite appropriate ASA treatment. Study aim was to define ASA resistance using Multiple elec- trode aggregometry (MEA) preoperatively in group of patients undergoing coronary artery bypass grafting (CABG). Pro- spective observational trial at University Hospital Center Zagreb enrolled 131 patients scheduled for CABG, and divided them into 4 groups with respect to preoperative antiplatelet therapy (APT). Group 1 received 100 mg ASA per day, Group 2 100 mg ASA + 75 mg clopidogrel per day, Group 3 75 mg clopidogrel per day, and Group 4 did not receive any APT. MEA with ASPI test (sensitive to ASA) and ADP test (sensitive to clopidogrel) was performed prior to surgery. In Group 1, patients were characterized as ASA resistant if their ASPI test value exceeded the 75 th percentile distribution. Study en- rolled 131 patients. Significant differences both in the ASPI (p<0.001) and the ADP test (p=0.038) were observed be- tween patients in different APT groups. In Group (1) ASPI test value of 30 AUC presented 75 th percentile of distribution, thus indicating ASA resistance. Group 2 patients had slightly lower ADP test values, but no significant difference oc- curred (mean 60.05 vs. 63.32 AUC, p=0.469). In Group 1 and 2, significant correlations between the ADP test and both, platelet count (r=0.347, p<0.001) and fibrinogen level (r=0.364, p<0.001) were observed. Association between low re- sponse to ASA and post-CABG major adverse ischemic events risk increase has been described thus indicating need for ASA resistant patients detection. In patients with preoperative ASPI test exceeding 30 AUC postoperative, ASA dose ad- justment or clopidogrel addition according to MEA results should be considered

Significance of clinical stage, extent of surgery and outcome in cutaneous squamous cell carcinoma of the head and neck

The authors analyzed a new clinical staging system and its correlation with pathologic findings and patient survival. Patients were eligible for inclusion in this longitudinal retrospective cohort study if they had cutaneous squamous cell carcinoma on the head or neck, underwent surgery and had a minimum 3 year follow-up. The primary study variable was using a new clinical staging system. Secondary variables included the parotid as a predictor of metastatic spread to the lymphatic nodes in the neck and primary lesion histopathologic traits. The outcome variable was patient survival. Associations between variables were assessed using Fisher's exact test, Mann-Whitney test, Kaplan-Meier method and Mantel log-rank test. p<0.05 was considered significant. The sample comprised 103 patients. Regional metastatic disease was found in 24 patients. Histopathological analysis showed a higher frequency of neck metastatic disease if the parotid was positive for metastases (p=0.022). An extended staging system showed significant correlation between survival rate and substages (p=0.0105). Perineural invasion was a negative prognostic factor (p=0.0151). The results of this study suggest that combining curative parotidectomy and elective neck dissection could be beneficial in high risk patients. Both neck and parotid metastases should be included in the clinical and histological N classification

Special tax on coffee and non-alcoholic beverages

Posebni porezi na promet (trošarine) porezni su oblik kojim se oporezuje jedan ili grupa istovrsnih proizvoda, svrstavaju se u skupinu neizravnih poreza. Trošarine su jedan od najstarijih poreza, poznat još u antičkim državama, koji je puni zamah primjene ostvario u 16. stoljeću kada se oporezivao promet soli, žita, kave, alkohola, šećera, voska, mesa. Poseban porez na kavu i bezalkoholna pića prihod je državnog proračuna Republike Hrvatske, a sustav oporezivanja uređuje se Zakonom o posebnom porezu na kavu i bezalkoholna pića i Pravilnikom o posebnom porezu na kavu i bezalkoholna pića. U radu je definirano koji se proizvodi smatraju kavom i bezalkoholnim pićima i kako se predmet, porezna osnovica i visina poreza mijenjala od uvođenja posebnog poreza na kavu i bezalkoholna pića u Hrvatskoj do danas. Obveznik plaćanja posebnog poreza je: ovlašteni držatelj poreznog skladišta, proizvođač i trgovac izvan sustava odgode, primatelj i osoba za koju se utvrdi da je nezakonito postupala s predmetom oporezivanja u Republici Hrvatskoj

Impact of extracorporeal life support on blood clot viscoelastic properties and platelet aggregation

Liječenje izvantjelesnom cirkulacijskom potporom koje se bazira na tehnici izvantjelesne membranske oksigenacije završni je stadij liječenja srčanog zatajenja ili kardiogenog urušaja. Sistemska antikoagulacija je nužna, a većina komplikacija poput tromboze i krvarenja, koji su i najčešći uzroci mortaliteta, je često posljedica upravo nekompatibilnosti stijenki sustava i krvi. Iz rutinskih laboratorijskih koagulacijskih testova i broja trombocita ne može se spoznati da li u određenom slučaju postoji kvalitativan poremećaj funkcije trombocita, hiperkoagulabilnost, hiper- ili hipofibrinoliza. Cilj ovog prospektivnog istraživanja provedenog na 28 bolesnika liječenih venoarterijskim izvantjelesnom cirkulacijskom je evaluirati učinak izvantjelesne cirkulacijske potpore na viskoelastična svojstva krvnoga ugruška i funkciju trombocita upotrebom specifičnih testova koagulacije i agregacije. Značajno krvarenje kao mjera ishoda je zabilježeno u 8/28 bolesnika (28 %). Podaci dobiveni ovim istraživanjem pokazuju da je značajno krvarenje moguće predvidjeti određenim testovima ROTEM® analize. Ona je točnija i dostupna u kraćoj jedinici vremena u odnosu na predviđanje prema rutinski izvođenim testovima koji proučavaju koagulacijski status bolesnika. Vrijednosti INTEM CT testa su po danima najpouzdanije korelirale s rizikom krvarenja, dok su vrijednosti EXTEM CT testa korelirale s rizikom krvarenja prva dva postoperativna dana. Vrijednosti FIBTEM MCF testa su snažno povezane s rizikom krvarenja svih pet dana postimplantacijskog praćenja. Rezultati navedenih testova imaju praktičnu vrijednost u liječenju bolesnika na ECMO/ECLS potpori.Extracorporeal life support based on extracorporeal membrane oxygenation is the end-stage treatment of heart failure or cardiogenic shock. Systemic anticoagulation is mandatory, and most of the complications such as thrombosis and bleeding, which are also the most common causes of mortality, are often the result of incompatibility of the extracorporeal system and blood. Routinely performed laboratory blood clotting tests and platelet number do not offer sufficient understanding whether qualitative platelet dysfunction is present in a particular patient nor does it denote hypercoagulability, hyper or hypofibrinololysis. The aim of this prospective study on 28 patients is to evaluate the effect of extracorporeal life support on blood clotting viscoelastic properties and platelet function through specific coagulation and aggregation tests. Data obtained by this study indicate that significant bleeding can be predicted by certain ROTEM® analysis tests, such as INTEM CT, EXTEM CT and FIBTEM MCF. It is more accurate and available in a shorter unit of time compared to the prediction of routine tests that study the coagulation status of the patient. The results of these tests have a practical value in treating patients on ECMO / ECLS support. Literature citations and current research clearly call for the formulation of standardized protocols for conducting anticoagulant therapy during ECMO / ECLS support. It is necessary to assess whether these tests are truly superior to available laboratory tests

Impact of extracorporeal life support on blood clot viscoelastic properties and platelet aggregation

Liječenje izvantjelesnom cirkulacijskom potporom koje se bazira na tehnici izvantjelesne membranske oksigenacije završni je stadij liječenja srčanog zatajenja ili kardiogenog urušaja. Sistemska antikoagulacija je nužna, a većina komplikacija poput tromboze i krvarenja, koji su i najčešći uzroci mortaliteta, je često posljedica upravo nekompatibilnosti stijenki sustava i krvi. Iz rutinskih laboratorijskih koagulacijskih testova i broja trombocita ne može se spoznati da li u određenom slučaju postoji kvalitativan poremećaj funkcije trombocita, hiperkoagulabilnost, hiper- ili hipofibrinoliza. Cilj ovog prospektivnog istraživanja provedenog na 28 bolesnika liječenih venoarterijskim izvantjelesnom cirkulacijskom je evaluirati učinak izvantjelesne cirkulacijske potpore na viskoelastična svojstva krvnoga ugruška i funkciju trombocita upotrebom specifičnih testova koagulacije i agregacije. Značajno krvarenje kao mjera ishoda je zabilježeno u 8/28 bolesnika (28 %). Podaci dobiveni ovim istraživanjem pokazuju da je značajno krvarenje moguće predvidjeti određenim testovima ROTEM® analize. Ona je točnija i dostupna u kraćoj jedinici vremena u odnosu na predviđanje prema rutinski izvođenim testovima koji proučavaju koagulacijski status bolesnika. Vrijednosti INTEM CT testa su po danima najpouzdanije korelirale s rizikom krvarenja, dok su vrijednosti EXTEM CT testa korelirale s rizikom krvarenja prva dva postoperativna dana. Vrijednosti FIBTEM MCF testa su snažno povezane s rizikom krvarenja svih pet dana postimplantacijskog praćenja. Rezultati navedenih testova imaju praktičnu vrijednost u liječenju bolesnika na ECMO/ECLS potpori.Extracorporeal life support based on extracorporeal membrane oxygenation is the end-stage treatment of heart failure or cardiogenic shock. Systemic anticoagulation is mandatory, and most of the complications such as thrombosis and bleeding, which are also the most common causes of mortality, are often the result of incompatibility of the extracorporeal system and blood. Routinely performed laboratory blood clotting tests and platelet number do not offer sufficient understanding whether qualitative platelet dysfunction is present in a particular patient nor does it denote hypercoagulability, hyper or hypofibrinololysis. The aim of this prospective study on 28 patients is to evaluate the effect of extracorporeal life support on blood clotting viscoelastic properties and platelet function through specific coagulation and aggregation tests. Data obtained by this study indicate that significant bleeding can be predicted by certain ROTEM® analysis tests, such as INTEM CT, EXTEM CT and FIBTEM MCF. It is more accurate and available in a shorter unit of time compared to the prediction of routine tests that study the coagulation status of the patient. The results of these tests have a practical value in treating patients on ECMO / ECLS support. Literature citations and current research clearly call for the formulation of standardized protocols for conducting anticoagulant therapy during ECMO / ECLS support. It is necessary to assess whether these tests are truly superior to available laboratory tests