Thrombotic Thrombocytopenic Purpura – The Role of ADAMTS13 Assay in Clinical Practice

Thrombotic thrombocytopenic purpura (TTP) is a disorder characterized by disseminated thrombotic occlusions of the microcirculation. Identification of ADAMTS13 protease and its place in the pathophysiology of TTP led to better understanding of the disease and better survival for the diseased. Here we show a case report of a patient that had a normal ADAMTS13 protease activity and an unusual clinical presentation and utilize that case to highlight how the absence of a severe ADAMTS13 protease deficiency does not preclude a diagnosis of TTP and how early initiation and continuation of plasma exchange therapy can lead to a positive outcome, even in a severely ill patient. Even though ADAMTS13 protease determination has no immediate influence on the decision whether or not to start the plasma exchange therapy, it has great impact on future management of the patient and should be determined whenever possible

Rib stress fracture in a male adaptive rower from the arms and shoulders sport class: case report

Adaptive rowing is rowing or sculling for rowers with a physical disability. It debuted at the Paralympic Games in 2008. In order to ensure an equitable playing field, rowers with similar levels of physical function and disability are classified into different sport classes for competition. Rowers with an inability to use a sliding seat and impaired trunk function resulting in an inability to perform trunk forward and backward lean via hip flexion/extension are assigned to the Arms and Shoulders (AS) class. AS rowers have to use a chest strap set immediately below the chest in order to localize any trunk movement in AS class. Conditions created by adaptations of rowing equipment and technique within the AS class create unique stresses on the upper thoracic region. The following case report demonstrates how etiology and management of a rib stress fracture in an AS rower differs in comparison to able-body rowers. Of significant importance were the limitations imposed on the rower’s ability to maintain rowing-specific fitness, due to the nature of the rib stress fracture and requirement to decrease force transmission through the ribs for several weeks. The rower’s gradual return to full training was further impacted by obligatory use of the chest strap, which directly applied pressure over the injured area. Protective orthosis for the chest was designed and applied in order to dissipate pressure of the chest strap over the thorax during rowing (most importantly at the catch position) both on the ergometer and in the boat

Peripheral Arterial Catheter Related Infections in the Neurosurgical Intensive Care Unit

Intravascular device infections could be serious complications with significant contributable morbidity and mortality. The aim of this prospective clinical study is to demonstrate the infection rate related to peripheral arterial catheters and their clinical significance in neurosurgical intensive care unit (ICU) patients. After removal, all arterial catheter tips were cultivated by semiquantitative method and clinical data were collected. During a period of two years, 186 arterial catheters were placed in 105 neurosugical ICU patients. In 6 cases (3.2%) infection was presumably related to the arterial catheter. The rate of such probable catheter related infections was found to be 5/1000 catheter days. The isolated microorganisms were: Methicillin resistant Staphylococcus epidermidis (MRSE) in 4 cases, Corynebacterium species and Candida albicans each in one case respectively. Thirteen cases (7.0%) were interpreted as contamination and one as colonization. An association was found between the presence of infection from different sources and significant bacterial growth on the catheter. Patients with positive catheter culture had a significantly longer ICU stay, more cumulative catheter days, and a higher mortality rate than those with sterile catheters. We can conclude that the rate of probable peripheral arterial catheter related infection is low. A higher mortality rate in patients who experienced probable catheter related infection does not seem to be a consequence of the aforementioned infection. A more suitable explanation would be that patients with nosocomial infections and higher mortality risk have prolonged ICU stays. There is an increased chance of developing a catheter related infection in those patients who have more cumulative catheter days

Prospektivno istraživanje prevencije kontrastne nefropatije u Republici Hrvatskoj

Aim: To explore the protective role of hydration, urine alkalization (Na bicarbonate) and high doses of antioxidant (N-acetylcysteine) in the prevention of CIN. Material and methods: In a prospective, randomized, single-blinded study patients were divided into three groups: 1) peroral hydration, 2) Na bicarbonate infusion and 3) N-acetylcysteine (NAC) plus NaHCO3 infusion. Serum creatinine (SCr), blood urea nitrogen (BUN), and neutrophil gelatinase-associated lipocalin (NGAL) were measured before and 48 hours after the angiography. Mehran score was calculated for each patient. Results: The study included 106 patients. Groups were comparable regarding the baseline characteristics. According to Mehran risk score 70 % of patients had a low risk, 24% medium and 6% high risk score for development of CIN. After the procedure renal function was preserved in all patients (SCr 103(87.0-121.5), BUN 5.8 (4.9-7.6), creatinine clearance 74.7(55.3-97.6), NGAL 11.4(5.4-19.9)) regardless of the Mehran risk score. The follow up was completed for 73 patients (68 %). Twenty two patients (32 %) developed chronic kidney disease, mostly classified as G3a and G3b according to KDIGO guidelines. Chronic kidney disease developed in patients with the positive history of diabetes and in patients who had higher Mehran score before the diagnostic procedure. Conclusion: The study showed that patients with preserved renal function are not prone to CIN. Regardless of the protocol used, no case of CIN was observed. Our results indicate that adequate hydration is a key component in maintaining the renal function. Higher Mehran score might be useful in predicting the development of chronic kidney disease.Cilj: Ispitati protektivnu ulogu hidracije, alkalizacije mokraće (natrijevim bikarbonatom) i visokih doza antioksidansa (N-acetilcistein) u prevenciji kontrastne nefropatije. Materijali i metode: U prospektivnom istraživanju pacijenti su bili podijeljeni u tri skupine: 1) peroralna hidracija, 2) infuzija natrijevog bikarbonata i 3) infuzija N-acetilcisteina (NAC) i NaHCO3. Serumska vrijednost kreatinina, ureje i neutrophil gelatinase-associated lipocalin (NGAL) izmjerene su prije i 48 sati nakon angiografije. Svakom pacijentu izračunati su Mehran bodovi koji predstavljaju rizik razvoja kontrastne nefropatije. Rezultati: U istraživanje je uključeno 106 pacijenata. Sve tri skupine pacijenata imale su usporedive osnovne karakteristike. Prema bodovima po Mehranu, 70 % pacijenata imalo je niski rizik, 24 % srednji i 6 % visoki rizik razvoja kontrastne nefropatije. Nakon kontrastne pretrage bubrežna funkcija bila je očuvana u svih pacijenata (serumski kreatinin 103 (87.0 – 121.5), urea 5.8 (4.9 – 7.6), klirens kreatinina 74.7 (55.3 – 97.6), NGAL 11.4 (5.4 – 19.9)) neovisno o riziku procijenjenom bodovima po Mehranu. Praćenje je završeno za 73 pacijenta (68 %). Dvadeset i dva pacijenta (32 %) razvila su kroničnu bubrežnu insuficijenciju, klasificiranu prema KDIGO smjernicama kao G3a i G3b. Kronična bubrežna insuficijencija razvila se u pacijenata sa šećernom bolesti i u pacijenata koji su imali viši broj bodova prema Mehranu prije dijagnostičke pretrage. Zaključak: Istraživanje je pokazalo da pacijenti s normalnom bubrežnom funkcijom imaju mali rizik razvoja kontrastne nefropatije. U ispitivanoj skupini pacijenata nije zabilježen niti jedan slučaj kontrastne nefropatije bez obzira na vrstu protokola koji je korišten za hidraciju. Naši rezultati ukazuju na to da je adekvatna hidracija ključna u prevenciji kontrastne nefropatije. Nadalje, postoji mogućnost da viši broj bodova po Mehranu može poslužiti kao prediktor razvoja kronične bubrežne bolesti

Severe Acute Pancreatitis as a Part of Multiple Dysfunction Syndrome

Acute pancreatitis is a disease with various degrees of clinical manifestations. Mild and moderate severe acute pancreatitis is an illness characterized with chemical inflammation which, in general, passes without major complications. Clinical picture of severe acute pancreatitis other side is commonly complicated with functional deterioration of other organs, and frequently has characteristics of multiple organ dysfunction or failure syndrome with or without bacterial super infection. We studied 82 patients admitted to the intensive care unit with severe acute pancreatitis, 14 died. The mortality was in statistically significant correlation with the severity of clinical condition at admission assessed by APACHE II score, and higher Ranson’s and Glasgow criteria by admission. Adequate volume supplementation, on time, as well as percutaneous drainage of infected pancreas collection reduces a risk of pure outcome

Metolachlor and Metobromuron - Induced Methaemoglobinemia

An 81-year-old man was admitted in the emergency department approximately four hours after accidental ingestion of an unknown quantity of herbicide »Galex 500 EC«. This product contains 25% of metolachlor and 25% of metobromuron dissolved in xylene. In spite of the fact that the combination of aniline and urea-substituted derivatives is widely used in agriculture as herbicide, there are very few data available about their harmful effects on humans. These agents appear to be mildly toxic, and rarely has a major systemic effect been reported after the poisoning. On admittance, our patient showed remarkable cyanosis and his methaemoglobin level was 38.4% of the total haemoglobin, rising next day to 46.2%. Only mild transient signs of hypoxic effects on central nervous system were observed and the laboratory findings indicated mild haemolysis. Methylene blue was applied intravenously in a dose of 1.5 mg/kg (10 ml, 1% solution) on the second day of admission. Administration of methylene blue was very effective and the patient was discharged from the hospital fully recovered.U radu je prikazano otrovanje metolaklorom i metobromuronom, nastalo nakon slučajne ingestije nepoznate količine kombiniranog herbicida »Galex 500 EC«. Unatoč širokoj primjeni herbicida iz skupine anilida i derivata ureje, nema mnogo podataka o njihovu učinku na ljude. Otrovanja su rijetka zbog njihove relativno niske akutne toksičnosti. U našeg bolesnika kliničkom je slikom dominirala cijanoza, uz methemoglobinemiju koja je premašila 46% vrijednosti ukupnog hemoglobina, što je indiciralo intravensku primjenu 10 ml 1%-tne otopine metilenskog modrila (1,5 mg/kg). Učinak takve terapije bio je vrlo povoljan, cijanoza i znakovi hipoksije središnjega živčanog sustava ubrzo su nestali. Znakova lezije parenhimnih organa nije bilo, a laboratorijski se mogla uočiti blaža hemoliza. Bolesnik je nakon 12 dana otpušten bez trajnih posljedica otrovanja

Metolachlor and Metobromuron - Induced Methaemoglobinemia

An 81-year-old man was admitted in the emergency department approximately four hours after accidental ingestion of an unknown quantity of herbicide »Galex 500 EC«. This product contains 25% of metolachlor and 25% of metobromuron dissolved in xylene. In spite of the fact that the combination of aniline and urea-substituted derivatives is widely used in agriculture as herbicide, there are very few data available about their harmful effects on humans. These agents appear to be mildly toxic, and rarely has a major systemic effect been reported after the poisoning. On admittance, our patient showed remarkable cyanosis and his methaemoglobin level was 38.4% of the total haemoglobin, rising next day to 46.2%. Only mild transient signs of hypoxic effects on central nervous system were observed and the laboratory findings indicated mild haemolysis. Methylene blue was applied intravenously in a dose of 1.5 mg/kg (10 ml, 1% solution) on the second day of admission. Administration of methylene blue was very effective and the patient was discharged from the hospital fully recovered.U radu je prikazano otrovanje metolaklorom i metobromuronom, nastalo nakon slučajne ingestije nepoznate količine kombiniranog herbicida »Galex 500 EC«. Unatoč širokoj primjeni herbicida iz skupine anilida i derivata ureje, nema mnogo podataka o njihovu učinku na ljude. Otrovanja su rijetka zbog njihove relativno niske akutne toksičnosti. U našeg bolesnika kliničkom je slikom dominirala cijanoza, uz methemoglobinemiju koja je premašila 46% vrijednosti ukupnog hemoglobina, što je indiciralo intravensku primjenu 10 ml 1%-tne otopine metilenskog modrila (1,5 mg/kg). Učinak takve terapije bio je vrlo povoljan, cijanoza i znakovi hipoksije središnjega živčanog sustava ubrzo su nestali. Znakova lezije parenhimnih organa nije bilo, a laboratorijski se mogla uočiti blaža hemoliza. Bolesnik je nakon 12 dana otpušten bez trajnih posljedica otrovanja

Peripheral Arterial Catheter Related Infections in the Neurosurgical Intensive Care Unit

Intravascular device infections could be serious complications with significant contributable morbidity and mortality. The aim of this prospective clinical study is to demonstrate the infection rate related to peripheral arterial catheters and their clinical significance in neurosurgical intensive care unit (ICU) patients. After removal, all arterial catheter tips were cultivated by semiquantitative method and clinical data were collected. During a period of two years, 186 arterial catheters were placed in 105 neurosugical ICU patients. In 6 cases (3.2%) infection was presumably related to the arterial catheter. The rate of such probable catheter related infections was found to be 5/1000 catheter days. The isolated microorganisms were: Methicillin resistant Staphylococcus epidermidis (MRSE) in 4 cases, Corynebacterium species and Candida albicans each in one case respectively. Thirteen cases (7.0%) were interpreted as contamination and one as colonization. An association was found between the presence of infection from different sources and significant bacterial growth on the catheter. Patients with positive catheter culture had a significantly longer ICU stay, more cumulative catheter days, and a higher mortality rate than those with sterile catheters. We can conclude that the rate of probable peripheral arterial catheter related infection is low. A higher mortality rate in patients who experienced probable catheter related infection does not seem to be a consequence of the aforementioned infection. A more suitable explanation would be that patients with nosocomial infections and higher mortality risk have prolonged ICU stays. There is an increased chance of developing a catheter related infection in those patients who have more cumulative catheter days

Acute kidney injury, uncontrolled arterial hypertension and resulting chronic kidney disease after severe COVID-19 infection

Osobe s teškim oblikom COVID-19 najčešće se prezentiraju respiracijskom insuficijencijom i razvojem akutnoga plućnog distres sindroma (ARDS), ali su moguće i razne izvanplućne komplikacije. Prikazali smo četrdesetdevetogodišnjeg bolesnika s ranije poznatom arterijskom hipertenzijom koji je razvio teški oblik infekcije COVID-19 komplicirane akutnim bubrežnim oštećenjem i kasnije nekontroliranom arterijskom hipertenzijom. Pacijent je hospitaliziran desetog dana bolesti zbog pogoršanja plućne funkcije koja je progredirala do globalne respiracijske insuficijencije i potrebe za orotrahealnom intubacijom. Bolesnik je ispunjavao kriterije ARDS-a. U ranom tijeku liječenja razvio je treći stupanj akutnoga bubrežnog oštećenja prema smjernicama KDIGO. Bilo je potrebno dugotrajno nadomještanje bubrežne funkcije. Uz oporavak diureze zabilježena je značajna proteinurija uz arterijsku hipertenziju, zbog čega je učinjena imunološka obrada i biopsija bubrega. Biopsija bubrega pokazala je akutno tubularno oštećenje bez značajnih promjena glomerula. Rezultati imunoloških testova bili su neupadljivi. Unatoč redovitoj procjeni volumnog statusa i nadomještanja bubrežne funkcije u bolesnika je perzistirala nekontrolirana arterijska hipertenzija koja je zahtijevala uvođenje niza antihipertenziva. Bolest je dodatno komplicirana krvarenjima iz probavnog i dišnog trakta te sekundarnim bolničkim infekcijama. Četiri mjeseca nakon izlječenja akutne bolesti bolesnik ima sniženu glomerularnu filtraciju (e-GFR 55 ml/min/1,73m2 ) bez albuminurije koja se može svrstati u 3A stadij kronične bubrežne bolesti. Cilj ovog rada bio je prikazati razvoj teškog oblika COVID-19 komplicirane akutnim bubrežnim oštećenjem i razvojem nekontrolirane arterijske hipertenzije u kasnijem tijeku liječenja. Navedeni poremećaji prezentirali su se u relativno mlađeg, prethodno zdravog pacijenta te također ostavili kronične posljedice na bubrežnu funkciju. Navedeno bi trebalo potaknuti kliničare na razmatranje i uvrštenje redovite evaluacije bubrežne funkcije i arterijske hipertenzije kao sastavnog dijela praćenja bolesnika nakon COVID-19.The primary clinical feature in patients suffering from severe COVID-19 is respiratory insufficiency and acute respiratory distress syndrome (ARDS). However, extrapulmonary complications are also possible. We present a case of a forty-nine-year-old male patient with arterial hypertension who developed a severe form of COVID-19 complicated with acute kidney injury and later with uncontrolled arterial hypertension. The patient was hospitalized on the 10th day of the disease due to deterioration of pulmonary function, which progressed to global respiratory insufficiency and necessitated orotracheal intubation and mechanical ventilation. The patient met the criteria of severe ARDS. In the early course of the disease the patient developed grade 3 acute kidney injury according to KDIGO guidelines. Long-term renal replacement therapy was necessary. Along with the recovery of diuresis, significant proteinuria was noted accompanied by high blood pressure values, for which immunological assessment and kidney biopsy were performed. Kidney biopsy showed acute tubular necrosis without significant glomerular changes. The results of immunological tests were unremarkable. The disease was also complicated by gastrointestinal and respiratory haemorrhage and secondary hospital infections. Four months after the acute illness, the patient had decreased glomerular filtration (e-GFR 55 ml/min/1.73m2) without albuminuria, which could be classified as stage 3A of chronic kidney disease. This case report aims to present a case of a severe form of COVID-19, complicated by acute kidney injury followed by uncontrolled arterial hypertension in the later course of the treatment. The mentioned disorders occurred in a relatively younger, previously healthy patient and caused chronic consequences on kidney function. The above should encourage clinicians to consider and introduce regular evaluation of renal function and arterial hypertension as part of the follow-up of patients after the COVID-19

Epidemiologic and social-medical characteristic of BEN (Balkan endemic nephropathy) in Brodska Posavina focus

Balkanska endemska nefropatija je uočena 1955\u27/56. godine, a dokazana 1957. godine, kao posebni nozološki entitet u brodsko posavskom žarištu. Stalnim populacijskim ispitivanjima posljednjih 14 godina, praćenjem novooboljelih na bolničkim odjelima u Medicinskom centru Slavonski Brod, kao i istraživanjem smrtnosti, utvrđeno je da je bolest podjednako prisutna kroz 30-godišnje razdoblje. Ni iz jednog endemskog sela nije iščezla, niti se pro­ širila izvan utvrđenih granica žarišta. Bolest nije opažena na širem području Slavonije prema ispitivanjima u 6 sela, smještenih uz Savu, Dravu i Dunav.BEN was noticed in 1955/6 and proved to be a specific nosologic entity in the Brodska Posavina focus in 1957. Constant investigations among population in the last 14 years, observation of the newly diseased at the Medical Centre Slavonski Brod accompanied by investigation of mortality have shown that the disease has been about equally present through the 30-year long period. It has not disappeared from any of the endemic villages but it either has not emerged beyond any of the set focus boundaries. According to the investigations in six villages near large water currents, the disease has not been found in the broader region of Slavonia