Treatment of severe ARDS caused by legionnaires' disease with extracorporeal membrane oxygenation

Povijesno je ARDS nosio smrtnost veću od 50%. Razvojem medicine, posebice intenzivnog liječenja postupno se poboljšava preživljenje pacijenata oboljelih od ARDS-a. Tijekom 2009. godine objavljene su CESAR i ANZ ECMO studije koje donose dokaze o uspješnoj primjeni ECMO potpore u liječenju teškog ARDS-a u odraslih, podižući preživljenje na oko 70%. ECMO potpora dijeli se u venoarterijsku, koja osim oksigenacije pruža i hemodinamsku potporu, te venovensku, koja nadomješta funkciju pluća. Provedba ECMO potpore zahtjeva posebno educirano osoblje, zbog povišenog rizika od komplikacija i složenosti samog postupka, stoga se izvodi u specijaliziranim centrima. Legionarska bolest, klinički se očituje kao atipična pneumonija, a uzrokovana je L.pneumophilom. Prirodno stanište su joj vodene površine, a ljudi se najčešće zaraze inhalacijom kontaminiranih vodenih kapljica. Procjenjuje se da uzrokuje do 9% pneumonija opće populacije, a smrtnost joj iznosi do 10%. Dijagnoza se najčešće postavlja otkrivanjem antigena u urinu. Brzo postavljanje dijagnoze iznimno je važno, jer je rano započinjanje odgovarajuće terapije povezano sa boljim ishodom liječenja. Prikazan je slučaj tridesettrogodišnjeg bivšeg intravenskog ovisnika koji se prezentira sa kliničkom slikom akutnog jetrenog oštećenja praćenog žuticom, te teškom pneumonijom. Hospitaliziran je te mu je uvedena antimikrobna terapija meropenemom, vankomicinom i metronidazolom. Dijagnoza legionarske bolesti postavlja se kasno, 13. dana od početka bolesti, kada se u terapiju uvodi azitromicin. Tijekom hospitalizacije dolazi do postupnog pogoršanja kliničkog stanja i razvoja ARDS-a, te se pacijent isprva mehanički ventilira, a potom sanitetskim zrakoplovom premješta u ECMO centar. Pacijent je ovisan o VV ECMO potpori tijekom 27 dana, a potom još 9 dana o mehaničkoj ventilaciji. Liječenje se komplicira pneumonijom povezanom sa mehaničkom ventilacijom, koja se uspješno liječi. Godinu dana poslije, pacijent je bez funkcionalnih deficita. Ovaj rad daje kratak pregled činjenica o ARDS-u, VV ECMO-u, legionarskoj bolesti, te prikazuje uspješnu primjenu VV ECMO potpore u liječenju teškog ARDS-a uzrokovanog legionarskom bolesti, i na taj način u malom opsegu, doprinosi rastućoj planini dokaza o uspješnosti liječenja ovom metodom.Historically ARDS was associated with case fatality rate greater than 50%. Breakthroughs in medicine, especially in intensive care, gradually increased survival rate of ARDS patients. CESAR and ANZ ECMO studies published in 2009. brought new evidence about successful use of ECMO support in treatment of severe ARDS in adults, increasing the survival rate to about 70%. ECMO support can be divided into venoarterial, which provides oxygenation and hemodynamic support, and venovenous, which serves as an artificial lung. Due to the complexity and increased risk of complications ECMO support is being held at specialised centers with highly trained personnel. Legionnaires' disease which clinically manifests as atypical pneumonia is caused by L.pneumophila. Fresh water systems are natural habitat of legionella, most frequently people become infected through inhalation of contaminated water droplets. It is estimated that it causes up to 9% of community aquired pneumonias, and has case fatality rate around 10%. Diagnosis is most commonly established through urinary antigen testing. Rapid and correct diagnosis is of great significance, as early start of the correct treatment is related to better patient outcome. The case report shows a 33 year old former intravenous drug user male patient, who presents with acute liver injury, jaundice, and severe pneumonia. The patient is hospitalised, and initial antibiotic therapy consisted of meropenem, vancomycin, metronidazole is started. Diagnosis of legionnaires' disease is established late, 13 days after the first symptoms. During hospitalisation, patient's condition progressively deteriorated. As the ARDS developed, patient was put on mechanical ventilation, and shortly after transferred by air medical services to the ECMO center. For 27 days patient was dependant on VV ECMO support, and thereafter for 9 days on mechanical ventilation. The treatment was complicated with ventilator associated pneumonia, which was treated successfully. On one year follow-up patient was without functional deficits. This thesis gives a short review of facts about ARDS, VV ECMO, legionnaires' disease, and presents a case of severe ARDS caused by legionnaires' disease successfully treated with VV ECMO support. It contributes, in small amount, to constantly growing body of evidence in use of ECMO for ARDS

ZBRINJAVANJE BOLESNIKA S HIPERTENZIVNOM KRIZOM U IZVANBOLNIČKIM UVJETIMA

Background: Hypertensive urgencies are common conditions treated in out-of-hospital Emergency Medical Service units, whereas treatment of hypertensive emergencies from current guidelines is hospital based. Current guidelines do not cover in detail the management of hypertensive urgencies, let alone their management in out-of-hospital setting. Our main goal was to evaluate adherence to the existing guidelines. Patients and Methods: We analyzed data collected by out-of-hospital Emergency Medical Service unit set up in the Community Health Center in the town of Sveti Ivan Zelina, Croatia. During the one-year period, a total of 2911 patients were treated by Emergency Medical Service unit. Arterial hypertension was the primary diagnosis in 177 (6%) patients, of which 143 patients met the inclusion criteria. We further divided patients into two groups, i.e. hypertensive urgency group (blood pressure >180/120 mm Hg) and control group (systolic blood pressure 180/120 mm Hg) bez oštećenja ciljnih organa i kontrolna skupina (krvni tlak <180/120 mm Hg). Uspoređivane su razlike u primjeni antihipertenzivnih i anksiolitičkih (benzodiazepin) lijekova. Rezultati: U skupini hipertenzivne hitnosti sniženje krvnog tlaka iznosilo je 19,5±7,1 %, a u kontrolnoj skupini 10,1±7 %. Najveće sniženje krvnog tlaka zabilježeno je u bolesnika s hipertenzivnom hitnosti koji su primali kombiniranu antihipertenzivnu terapiju uz dodatak nitrata i benzodiazepina (21,9±5,2 %), 14 % bolesnika. Zaključak: Bolesnike koji se očituju hipertenzivnom hitnosti bez oštećenja ciljnih organa (hipertenzivna urgencija) potrebno je liječiti kombiniranom terapijom u kojoj ima mjesta za dodatnu anksiolitičku terapiju benzodiazepinom. Daljnja istraživanja pokazat će značenje tog zaključka

THE ROLE OF ANXIOLYTICS IN HYPERTENSIVE URGENCY MANAGEMENT

Current guidelines do not cover hypertensive urgency management in out-of-hospital setting. Main goal of this study was to evaluate the value of anxiolytic therapy in hypertensive urgencies. We analyzed data gathered by out-of-hospital unit set up during one year. Arterial hypertension was the primary diagnosis in 178 (6.11%) patients, of whom 144 had hypertensive urgency with mean SBP reduction 19.5±7.2%; control group 10.1±6.9%. Anxiolytic therapy was administered in 60% of patients in hypertensive urgency group, and they had a statistically significant greater SBP reduction (p=0.03) than patients who did not receive anxiolytic therapy. There is a place for anxiolytic therapy in hypertensive urgency management

Wnt signaling transcription factors TCF-1 and LEF-1 are upregulated in malignant astrocytic brain tumors

Since the discovery of the TCF/LEF family of transcription factors, their functions have been under intensive investigation in the area of cancer biology. The work presented in this paper focused on the changes in TCF-1 and LEF-1 expression levels in a set of astrocytic brain tumors. Protein expression was detected using immunohistochemistry and then evaluated by Ellipse software (ViDiTo, Slovakia). Statistical evaluations were performed with the SPSS statistical package, version 14.0 (SPSS Inc., Chicago, IL, USA). Strong TCF-1 and LEF-1 expression was observed in 51.6% and 71% of glioblastoma samples. Statistical analysis confirmed significant differences in protein expression levels associated to 3 important values, weak expression of TCF-1, weak expression of LEF-1 and strong expression of LEF-1. Analysis of variances performed on the total sample also indicated significant differences in the values of TCF-1 weak (F=2.804; p=0.045), LEF-1 weak (F=4.255; p=0.008) and LEF-1 strong (F=5.498; p=0.002) with regard to malignancy grade. Thus, glioblastomas were characterized by –in relative terms- the lowest values for weak expression of TCF-1 and LEF-1, combined with the highest values of LEF-1 strong expression. The F-ratios for two variables (LEF-1 strong and LEF-1 weak) indicated that differences between astrocytomas (II, III) and glioblastomas were statistically significant (p<0.02). Discriminant function analysis further showed that strong LEF-1 expression alone could discriminate between astrocytomas (II, III) and glioblastomas. Elevated TCF-1 and LEF-1 expression is characteristic of malignant gliomas. LEF-1, in particular, may serve as a potential marker for malignant transformation