Acute coronary syndrome and interventional cardiology in Dubrovnik 2013 as the year of professional continuity and territorial discontinuity.

Uz uspjeh Hrvatske mreže primarne perkutane kornarne intervencije ipak su zaostale „sive zone“, kao što je Dubrovačko-neretvanska županija, a grad je uz dva granična prijelaza udaljen 210 km od sljedećeg najbližeg centra. Stoga je od 1. siječnja 2013. godine pokrenut redoviti rad invazivnog laboratorija u Općoj bolnici Dubrovnik, 24 h/7 dana. Od 361 invazivne obrade u 2013. godini 227 (66,8%) učinjeno je kod hitnih bolesnika. Među bolesnicima s akutnim koronarnim sindromom 33,5% imalo je nestabilnu anginu pektoris, 39,2% akutni infarkt miokarda bez elevacije ST-segmenta i 27,2% (N=62) akutni infarkt miokarda s elevacijom ST-segmenta (STEMI). Perkutana koronarna intervencija (PCI) je učinjena kod 167 bolesnika, kod 62% svih bolesnika s AKS. Implantirane su 223 proširnice, 1,33 po postupku, kod 16,2% na dvije ili više žila, uz penetraciju proširnica obloženih lijekovima od 25,6%. Među koronarnim bolesnicima 30% je ostalo na medikamentoznoj terapiji, kod 55% je učinjena PCI, a kod 15% je preporučen kardiokirurški zahvat. Unutarbolnički mortalitet akutnog infarkta miokarda bio je 2,61%, a kod STEMI 4,8%. Bilo je 2,4% tromboza u stentu te 0,8% kirurški liječenih perifernih komplikacija. Gotovo da samo hitni bolesnici opravdavaju postojanje laboratorija u Općoj bolnici Dubrovnik, uz potrebu daljeg povećanja broja elektivnih PCI, osoblja i aparature.Along with the success of the Croatian Network of Primary Percutaneous Coronary Intervention, there are still ”grey zones" remaining, such as the Dubrovnik-Neretva County where the City of Dubrovnik is 210 kilometers away with two border crossings from the nearest center. Therefore, from the first of January 2013, the General Hospital Dubrovnik started a regular operation of the invasive laboratory 24 hours/7 days. Of 361 invasive procedures in 2013, some 227 (66.8%) of them were performed in emergency patients. Among the patients with acute coronary syndrome (ACS), 33.5% had unstable angina pectoris, 39.2% had acute myocardial infarction without ST-segment elevation and 27.2% (N = 62) had acute myocardial infarction with ST-segment elevation (STEMI). Percutaneous coronary intervention (PCI) was performed in 167 patients, in 62% of all patients with ACS. 223 stents were implanted, 1.33 per procedure, in 16.2% of patients on two or more vessels, with the penetration of the drug-eluting stents in 25.6%. Among coronary patients, 30% remained on medical therapy, 55% underwent PCI and 15% of them received a recommendation for cardiac surgery. In-hospital mortality of acute myocardial infarction was 2.61%, and 4.8 % for STEMI. 2.4% stent thrombosis and 0.8% of surgically treated peripheral complications were recorded. It is almost only the emergency patients that justify the existence of the laboratory in Dubrovnik General Hospital, along with a need for further increase in the number of elective PCI, personnel and apparatus

TRANSRADIAL APPROACH IN INTERVENTIONAL CARDIOLOGY: »QUOD LICET FEMORALISTI, NON LICET RADIALISTI«

Transradijalni pristup rabi se u invazivnoj kardiologiji od 1989., a od 1995. godine i za intervencije. Hrvatska kasni u toj tehnici 10-ak godina. Prednost transradijalnog pred femoralnim pristupom jesu teške lokalne komplikacije kod potonjega (2,6–2,8%), učestalije uz modernu terapiju (7,4%), koje povremeno iziskuju kiruršku korekciju (2,4%). Neželjene kardiološke komplikacije značajno su češće kod femoralnog (3,8–6,55%) nego kod transradijalnog pristupa (2,5–3,7%), a u studiji MORTAL veći je i ukupni mortalitet. Bolesnici preferiraju transradijalni pristup zbog manje boli, nelagode i mogućnosti kretanja nakon zahvata, sestre zbog upola manjeg vremena zbrinjavanja, a štedi se i 290 $po bolesniku. Nepovoljni je aspekt klinički neznačajna okluzija radijalne arterije (0,6$290. An unfavorable aspect of transradial approach is clinically insignificant radial artery occlusion (0.6%–1.4%), as well as higher radiation exposure, for 12% in practice. Procedural time is similar, but it could take up to 3 minutes longer. Access site crossover is more often with transradial (4.7–7.6%), compared to femoral procedure (1.4–2.0%), but PCI failure is independent of approach. All unfavorable aspects are diminishing with experience of a cardiologist. Now, some of the Croatian centers, such as General Hospital Zadar, use transradial approach in 67% of catheterizations, 64% of PCI, and 38% of all primary PCIs

Acute coronary syndrome and interventional cardiology in Dubrovnik 2013 as the year of professional continuity and territorial discontinuity.

Uz uspjeh Hrvatske mreže primarne perkutane kornarne intervencije ipak su zaostale „sive zone“, kao što je Dubrovačko-neretvanska županija, a grad je uz dva granična prijelaza udaljen 210 km od sljedećeg najbližeg centra. Stoga je od 1. siječnja 2013. godine pokrenut redoviti rad invazivnog laboratorija u Općoj bolnici Dubrovnik, 24 h/7 dana. Od 361 invazivne obrade u 2013. godini 227 (66,8%) učinjeno je kod hitnih bolesnika. Među bolesnicima s akutnim koronarnim sindromom 33,5% imalo je nestabilnu anginu pektoris, 39,2% akutni infarkt miokarda bez elevacije ST-segmenta i 27,2% (N=62) akutni infarkt miokarda s elevacijom ST-segmenta (STEMI). Perkutana koronarna intervencija (PCI) je učinjena kod 167 bolesnika, kod 62% svih bolesnika s AKS. Implantirane su 223 proširnice, 1,33 po postupku, kod 16,2% na dvije ili više žila, uz penetraciju proširnica obloženih lijekovima od 25,6%. Među koronarnim bolesnicima 30% je ostalo na medikamentoznoj terapiji, kod 55% je učinjena PCI, a kod 15% je preporučen kardiokirurški zahvat. Unutarbolnički mortalitet akutnog infarkta miokarda bio je 2,61%, a kod STEMI 4,8%. Bilo je 2,4% tromboza u stentu te 0,8% kirurški liječenih perifernih komplikacija. Gotovo da samo hitni bolesnici opravdavaju postojanje laboratorija u Općoj bolnici Dubrovnik, uz potrebu daljeg povećanja broja elektivnih PCI, osoblja i aparature.Along with the success of the Croatian Network of Primary Percutaneous Coronary Intervention, there are still ”grey zones" remaining, such as the Dubrovnik-Neretva County where the City of Dubrovnik is 210 kilometers away with two border crossings from the nearest center. Therefore, from the first of January 2013, the General Hospital Dubrovnik started a regular operation of the invasive laboratory 24 hours/7 days. Of 361 invasive procedures in 2013, some 227 (66.8%) of them were performed in emergency patients. Among the patients with acute coronary syndrome (ACS), 33.5% had unstable angina pectoris, 39.2% had acute myocardial infarction without ST-segment elevation and 27.2% (N = 62) had acute myocardial infarction with ST-segment elevation (STEMI). Percutaneous coronary intervention (PCI) was performed in 167 patients, in 62% of all patients with ACS. 223 stents were implanted, 1.33 per procedure, in 16.2% of patients on two or more vessels, with the penetration of the drug-eluting stents in 25.6%. Among coronary patients, 30% remained on medical therapy, 55% underwent PCI and 15% of them received a recommendation for cardiac surgery. In-hospital mortality of acute myocardial infarction was 2.61%, and 4.8 % for STEMI. 2.4% stent thrombosis and 0.8% of surgically treated peripheral complications were recorded. It is almost only the emergency patients that justify the existence of the laboratory in Dubrovnik General Hospital, along with a need for further increase in the number of elective PCI, personnel and apparatus

HIV Infection, as Opposed to Antiretroviral Therapy, Does not Cause Changes in the Concentration Levels of Specific Salivary Electrolytes

The concentration levels of salivary calcium, magnesium and zinc can vary in different localized oral, as well as systemic diseases and conditions. So far changes in the concentration levels of specific electrolytes in stimulated parotid saliva in HIV-positive/AIDS patients have been proven. The objective of this research was not only to study the concentration levels of calcium in non-stimulated total saliva, but also the concentration levels of magnesium and zinc, which have not been studied so far, and the influence of antiretroviral therapy (HAART). This research was conducted on 60 healthy subjects with an average age of 40.4 years, and 60 HIV-positive patients with an average age of 43.7 years, 45 of whom took HAART therapy. The concentration levels of calcium, magnesium and zinc in saliva were determined by means of an atomic absorption spectrophotometry. No significant differences in the levels of excreted saliva/5 minutes (p=0.116), the concentration levels of salivary calcium (p=0.713), magnesium (p=0.600), nor zinc (p=0.162) were found between HIV-positive patients and the control group. No any correlation was determined between all three types of electrolytes and the number of CD4+ cells, nor the number of HIV-virus copies in peripheral blood of patients. Within the HIV-positive group, with respect to HAART therapy, no differences were found in the concentration levels of salivary magnesium (p=0.588), nor zinc (p=0.096). However, the concentration levels of salivary calcium were significantly higher in HIV-positive patients who underwent HAART treatment (p=0.004). The results of this research show that HIV, as a systematic infection, does not cause changes in the excretion of magnesium, zinc nor calcium in non-stimulated total saliva. Furthermore, it has been proven that HAART treatment does not cause changes in the concentration levels of magnesium or zinc, but can cause an elevation in the concentration level of saliva, which could be related to the calcium mobilization in blood

Corneal collagen crosslinking: from basic research to clinical application

Corneal collagen crosslinking is a promising new treatment of progressive corneal ectasia. Its clinical use has been rapidly increasing since it was originally introduced in 1997 as the first treatment that can improve biomechanical stability of theweakened cornea. The method is based on the combined action of photosensitizer riboflavin (vitamin B2) and ultraviolet A light, which induce the formation of new covalent bonds between the collagen fibers. Our systematic search of literature in English has yielded only eight prospective trials with the efficiency and safety data published to date. However, all of the published studies reveal a halt in the progression or a slight improvement of corneal ectasia with the low complication and failure rates after the treatment. In this review we are highlighting the method’s history, scientific basis and its current clinical application in order to provide clinicians with the recent data on its benefits and potential risks

Dry Eye Symptoms and Signs in Long-Term Contact Lens Wearers

The aim of this study is to analyze the relationship between the self-reported symptoms and objective signs of dry eye disease in long-term rigid gas-permeable (RGP) or soft contact lens (SCL) wearers. The study included 32 eyes of Caucasian RGP and SCL wearers between the age of 21 and 42 who wore contact lenses continuously on a daily basis for more than 2 years. Symptoms were assessed according to the Ocular Surface Disease Index (OSDI). Clinical assessments included corneal fluorescein staining according to the National Eye Institute (NEI) staining grid, tear film break-up time (TBUT) and Schirmer II test. There were more male (62.5%) than female (37.5%) patients with a higher proportion of RGP wearers among males (40% vs. 17%) in the study. The mean duration of daily lens wear was 10.6 ± 5.37 hours, with a significantly higher proportion of patients who wore their lenses for prolonged hours in the soft contact lens group (p<0.05). There was a trend towards a higher proportion of self reported mild and moderate dry eye in females and soft contact lens wearers. No RGP wearer in this study had a NEI corneal staining grid score higher than 2. A moderate negative correlation was found between daily lens wear duration and TBUT (Pearson’s coefficient, r=–0.47) as well as Schirmer II values and higher OSDI score, i.e. mild and moderate dry eye categories (r=–0.50). A strong positive correlation was found between and TBUT and Schirmer II values (r=0.74). The results of the study emphasize the importance of early and accurate diagnosis of dry eye disease for successful long term RGP and SCL contact lens wear which will hopefully motivate future larger scale investigations on dry eye related problems in contact lens wearers

Oral burning symptoms and burning mouth syndrome-significance of different variables in 150 patients

Objectives: Despite the extensive amount of published literature upon burning symptoms in patients with clinically healthy appearance of the oral mucosa, as well as burning mouth syndrome (BMS) itself, they both remain still challenging topics. The aim of this study was to determine the real prevalence of ?true? BMS in comparison to other patients with burning symptoms with clinically healthy appearance of the oral mucosa and then to compare ?true? BMS patients with healthy controls regarding gastritis and intake of anxiolytics and angiotensin converting enzyme inhibitors. Study design: In 150 patients with burning symptoms of clinically healthy oral mucosa, local and systemic investigations were performed and they included detection of candidal infection, salivary flow rate, presence of oral galvanism and parafunctional habits as well as complete blood count, serum ferritin, serum glucose levels, serum antibodies to Helicobacter pylori together with detailed medical history with special regard to medication intake. After ?true? BMS patients were identified they have been compared to the controls with regard to the presence of gastritis and the intake of anxiolytics and angiotensin converting enzyme inhibitors. Results: Our results show that gastritis were significantly more present among ?true? BMS patients and that they also significantly more intake anxiolitics, when compared to the control group. Conclusions: Our findings might lead to the conclusion that every ?true? BMS patient should be referred to the gastroenterologist and psychiatrist

Diabetic retinopathy – risk factors and treatment

Dijabetička retinopatija najčešća je mikrovaskularna komplikacija šećerne bolesti i jedan od vodećih uzroka novonastale sljepoće radno sposobnih osoba u razvijenim zemljama. Prevalencija retinopatije u oba tipa dijabetesa povećava se s trajanjem šećerne bolesti, a njena je učestalost usko povezana s nazočnošću hiperglikemije, hipertenzije, hiperlipidemije, trudnoće, nefropatije i anemije. Glavni uzroci gubitka vida u ovih bolesnika su dijabetička makulopatija i proliferativna dijabetička retinopatija. Za očuvanje i poboljšanje vidne oštrine oboljelih nužno je smanjiti povećanu propusnost stijenki krvnih žila i makularni edem, poboljšati perfuziju retine, smanjiti retinalnu ishemiju i razvoj neovaskularizacija te spriječiti nastanak vitrealnog krvarenja i trakcijskog odignuća retine. Sprječavanje nastanka i usporavanje razvoja dijabetičke retinopatije strogom kontrolom i regulacijom poznatih čimbenika rizika primarni je cilj liječenja. Laser fotokoagulacija retine trenutno je osnovna metoda liječenja makularnog edema i ranih stadija proliferativne dijabetičke retinopatije, dok se u slučajevima uznapredovale bolesti s dugotrajnim vitrealnim krvarenjem i/ili trakcijskim odignućem retine primjenjuje operativni zahvat pars plana vitrektomija. Boljim razumijevanjem patofizioloških mehanizama nastanka i razvoja dijabetičke retinopatije omogućen je razvoj novih metoda liječenja primjenom različitih farmakoloških tvari, među kojima su najznačajniji kortikosteroidi, antagonisti vaskularnog endotelnog čimbenika rasta (anti-VEGF) i lijekovi koji djeluju na biokemijske puteve nastanka dijabetičke retinopatije poput inhibitora protein kinaze C, analoga somatostatina, inhibitora aldoza reduktaze i inhibitora krajnjih produkta glikacije.Diabetic retinopathy, the main microvascular complication of diabetes mellitus, is also estimated to be the leading cause of new blindness in the working population of developed countries. The prevalence of retinopathy in both types of diabetes increases with the duration of diabetes and is highly related to hyperglycemia, hypertension, hyperlipidemia, pregnancy, nephropathy and anemia. The most common causes of visual loss in diabetic patients are diabetic maculopathy and proliferative diabetic retinopathy. Therefore, the main goal of treatment in protecting or improving vision in these patients is to reduce vascular leakage and macular edema, retinal ischemia and growth of fragile new vessels. This would in turn prevent vitreous hemorrhages and tractional retinal detachment. The first step in managing diabetic retinopathy is to reduce the risk of retinopathy development and progression by controlling and treating the underlying risk factors. Laser photocoagulation is the primary method of treatment of macular edema and early stages of proliferative diabetic retinopathy, while pars plana vitrectomy is reserved for severe complications such as severe persistent vitreous hemorrhages or/and tractional retinal detachment. However, more recently, many researches have directed their efforts towards better understanding the microvascular changes in diabetic retinopathy in order to develop more effective pharmacologic prevention and treatment, and determine new treatment strategies. The three major classes of agents currently being studied are: corticosteroids, vascular endothelial growth factor antagonists and agents that are involved in biochemical pathways (protein kinase C inhibitors, somatostatine analogue, aldose reductase and advanced glycation end products inhibitors)

NIJEMI AKUTNI INFARKT MIOKARDA KOD BOLESNIKA SA ŠEĆERNOM BOLESTI U IZVANBOLNIČKOJ HITNOJ MEDICINI

Aim of the Study: Silent acute myocardial infarction occurs commonly in diabetic patients. Currently, it is not fully understood whether altered perception of ischemia also predisposes atypical presentations, and therefore leads to under-diagnosing the acute myocardial infarction (AMI) in diabetic patients. In this study, we tried to determine whether chest pain in AMI occurred less frequently in diabetic patients. Methods: In this retrospective study, we included patients admitted from April 2014 to November 2019. Data were collected using eHitna and BIS as the nation-wide programs for patient tracking and registry in Croatia. All patients included in the study had initially called Department of Emergency Medicine of Brod-Posavina County, which then resulted in an intervention. Patients were then transferred to Dr Josip Benčević General Hospital, where they were hospitalized. All patients had discharge letters with the diagnosis specifi ed by ICD-10 classifi cation as I21 spectrum (I21.0, I21.1, I21.2, I21.3, I21.4, I21.9), i.e. AMI. Results: In this study, we included 180 patients having suffered AMI who were hospitalized and treated. There were 35 (19%) diabetic patients (DP) and 145 (81%) non-diabetic patients (non-DP). Chest pain was absent in nine (26%) DP and 13 (9%) non-DP (p=0.007). There was no difference in sex distribution within the two groups, with 60% and 68% male patients in DP and non-DP, respectively (p=0.395). The mean patient age was signifi cantly different between the two groups, i.e. 69 years in DP and 64 years in non-DP (p=0.034). Discussion: AMI in diabetic patients could have altered clinical presentation, which has often been researched therefore. Some researchers have reported that atypical or silent presentations are more frequent in DP with AMI, whereas others found no differences when compared to non-DP. In our study, absence of chest pain as a characteristic of silent AMI was experienced by 17% more DP as compared to non-DP, suggesting that DM infl uences clinical presentation of AMI. It is important to emphasize the importance of such fi ndings in emergency medicine where patients often describe their various symptoms. The mean age of DP having suffered AMI was signifi cantly higher (even up to 5 years) in comparison to non-DP. Despite the fact that DM is a risk factor for developing AMI, this fi nding could be explained by the fact that DM is more common in elderly population. Conclusion: Chest pain occurs signifi cantly less frequently in DP that develop AMI than in non-DP. Therefore, DP have a higher probability of developing silent AMI.Cilj: Nijemi akutni infarkt miokarda (AIM) se pojavljuje češće u bolesnika s dijabetesom. Predisponira li izmijenjena percepcija ishemije atipičnu prezentaciju te se zbog toga nedovoljno dijagnosticira AIM u bolesnika s dijabetesom, nije još dovoljno istraženo. U ovoj studiji pokušali smo utvrditi pojavljuje li se bol u prsištu kod AIM rjeđe kod bolesnika s dijabetesom. Metode: U ovu retrospektivnu studiju uključili smo bolesnike primljene od travnja 2014. do studenoga 2019. godine. Koristili smo bazu podataka programa “e-hitna” i “BIS” te sakupljali i analizirali podatke o bolesnicima koji su zatražili intervenciju izvanbolničke hitne medicinske službe u našoj županiji, bili prevezeni u Opću bolnicu “Dr. Josip Benčević”, hospitalizirani te im je kao otpusna dijagnoza postavljena prema klasifi kaciji MKB-10 bila u spektru dijagnoze I21 (I21.0, I21.1, I21.2, I21.3, I21.4, I21.9), tj. AIM. Dijabetes je zabilježen kod bolesnika koji su bili na inzulinu ili oralnim hipoglikemicima, uključujući dijabetes tip 1 i tip 2. Rezultati: U studiju smo uključili 180 bolesnika koji su doživjeli AIM. Od tog broja ih je 35 (19,4 %) imalo dijabetes (DP), a 145 (80,6 %) nije imalo dijabetes (ne-DP). Bol u prsištu nije bila prisutna u devet (26 %) DP i 13 (9 %) ne-DP (p=0,007). Nije bilo značajne razlike u distribuciji prema spolu ni u jednoj skupini bolesnika (p=0,35). Muškaraca je bilo 60 % u DP i 68 % u ne-DP. Prosječna dob značajno se razlikovala u dvjema skupinama. U DP je prosječna dob bila 69 godina, a u ne-DP 64 godine (p=0,034). Rasprava: Akutni infarkt miokarda u bolesnika s dijabetesom može se prezentirati izmijenjenom kliničkom slikom i zbog toga se često istraživao. Neki istraživači su pokazali da je atipična ili nijema prezentacija infarkta češća u bolesnika s dijabetesom, dok drugi nisu pronašli razlike u usporedbi s nedijabetičarima. U ovoj studiji smo primijetili da je izostanak boli u prsištu kao karakteristika nijemog AMI učestaliji u dijabetičara s AIM. To dovodi do zaključka da dijabetes utječe na kliničku sliku AIM. Treba istaknuti važnost takvog rezultata u izvanbolničkoj hitnoj medicini gdje se bolesnici često prezentiraju raznim simptomima. Srednja vrijednost dobi dijabetičara koji su doživjeli AIM bila je značajno veća nego u nedijabetičara. Unatoč činjenici da je dijabetes rizični čimbenik za razvoj AIM, ovaj rezultat možemo tumačiti činjenicom da je dijabetes zastupljeniji u starijoj populaciji. Zaključak: Bol u prsištu se javlja rjeđe u bolesnika s dijabetesom koji imaju AIM nego u onih koji nemaju dijabetes. Zbog toga dijabetičari imaju veće izglede da razviju nijemi AIM.

Retinal nerve fibre layer thickness in conditions of severe ischemia in patients without glaucoma

Introduction: Ischemia, most often caused by carotid disease, contributes to or causes a numerous ocular changes including optic nerve and ganglion cell damage, glaucoma, anterior and posterior segment changes. The perimetric changes in ischemia partially overlap with those caused by glaucoma. New diagnostic tools such as scanning laser polarimetry can detect retinal nerve fiber layer loss in glaucoma up to 6 years earlier than the first perimetric changes. Still, it is not yet clear if and up to what level laser polarimetry can show changes in RNFL caused by ischemia only, and whether these changes differ from the pure glaucomatous ones. In our pilot study we tried to investigate influence of significant carotid stenosis on retinal nerve fiber layer. Materials and Methods: Eight consecutive patients with carotid stenosis of more than 70% and no other eye disease influencing optic nerve. Results: RNFL loss can be found in the most of analyzed patients. The level of the RNFL impairment is not equal in the both eyes of patients having a different degree of stenosis on two sides probably due to the factors such as microvascular status. Conclusion: RNFL suffers changes in carotid stenosis. The results demand further investigation because the possibility of the precise estimation of ischemical damage to the RNFL can be of crucial importance in diagnosing and treatment of patients having glaucoma and ocular ischemia at the same time