CLINICAL COMPARISON OF INVOS OXYMETRY AND ARTERIAL LACTATE LEVELS AS A PREDICTOR OF PERIPHERAL PERFUSION AND REPERFUSION IN VASCULAR SURGERY PATIENTS

Cilj ovog probnog projekta je evaluacija primjene INVOS oksimetrije za optimalizaciju anesteziološkog postupka kod operacija reperfuzije donjih ekstremiteta u bolesnika s perifernom arterijskom bolešću (PAB). Ispitanici: U probnom projektu evaluirana su 4 bolesnika s kritičnom ishemijom donjih ekstremiteta. Uz elektrodu za indikaciju cerebralne perfuzije (crSO2), drugu INVOS elektrodu za indikaciju periferne perfuzije, postavili smo distalno od vaskularne kleme (prSO2). Dobivene podatke smo koristili kao prediktore periferne perfuzije i nužnosti intervencije, a podatke smo usporedili s koncentracijom laktata arterijske krvi. Rezultati: Početne prosječne crSO2 vrijednosti bile su 62,25 %, a prSO2 53,5 %. Prosječno trajanje arterijske okluzije bilo je 61 min. Pacijenti su primili u prosjeku 1275 mL kristaloida i 500 mL koloida. Najviše izmjerene vrijednosti laktata aterijske krvi bile su 0,7 mmol/L. Postoperacijski crSO2 iznosio je prosječno 73 %, a prSO2 69,75 %. Prosječna hospitalizacija trajala je 19,25 dana, s 30-dnevnim preživljavanjem od 100 %, bez potrebe reoperacije ili amputacije. Rasprava: Pretragom dostupne literature nismo pronašli sličnih kliničkih iskustava primjene optičke spektrometrije kao metode mjerenja intraoperacijske perfuzije ishemičnog ekstremiteta. Koristeći INVOS za poboljšanje perfuzije periferije koristili smo minimalnu vazoaktivnu potporu i restriktivnu bolusnu primjenu intravenskih tekućina uz zadovoljavajući klinički ishod.The aim of this pilot project was to evaluate the use of INVOS oxymetry to optimize anesthesia in lower extremities in patients with peripheral arterial disease (PAD). Four patients with critical ischemia of lower extremities were evaluated. With the electrode indicating cerebral perfusion (crSO2), another INVOS electrode was placed distally from the vascular clamp (prSO2). The data obtained were used as predictors of peripheral perfusion and necessity of intervention. We compared the aforementioned data with the arterial blood lactate levels. The initial mean crSO2 and prSO2 value was 62.25% and 53.5%, respectively. The mean duration of arterial occlusion was 61 minutes. The patients received a mean of 1275 mL crystalloids and 500 mL colloids. The highest measured lactate value was 0.7 mmol/L. Postoperative crSO2 averaged 73% and prSO2 69.75%. The mean length of hospital stay was 19.25 days, with a 30-day survival rate of 100%, without the need of reoperation or amputation. Reviewing the scientific literature available, we found no similar clinical experiences of optical spectrometry used as a method of measuring intraoperative perfusion of the ischemic extremity. Utilizing INVOS data to improve perfusion of periphery, we used minimal vasoactive support and restrictive bolus administration of intravenous fl uids with a satisfactory clinical outcome

Hrvatske smjernice za farmakološko liječenje šećerne bolesti tipa 2 [Croatian guidelines for the pharmacotherapy of type 2 diabetes]

Introduction: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. Participants: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. Evidence: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. Conclusions: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes

CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES

Uvod: Hrvatsko društvo za dijabetes i bolesti metabolizma Hrvatskoga liječničkog zbora izradilo je 2011. godine prve nacionalne smjernice o prehrani, edukaciji i samokontroli te farmakološkom liječenju šećerne bolesti tipa 2. Sukladno povećanom broju dostupnih lijekova te novim spoznajama o učinkovitosti i sigurnosti primjene već uključenih lijekova, pokazala se potreba za obnovom postojećih smjernica za farmakološko liječenje šećerne bolesti tipa 2 u Republici ­Hrvatskoj. Sudionici: Kao koautori Smjernica navedeni su svi članovi Hrvatskog društva za dijabetes i bolesti metabolizma Hrvatskoga liječničkog zbora, kao i ostalih uključenih stručnih društava, koji su svojim komentarima i prijedlozima pridonijeli izradi Smjernica. Dokazi: Ove su Smjernice utemeljene na dokazima, prema sustavu GRADE (engl. Grading of Recommendations, Assessment, Development and Evaluation) koji uz razinu dokaza opisuje i snagu preporuke. Zaključci: Individualan pristup temeljen na fiziološkim principima regulacije glikemije nuždan je u liječenju osoba sa šećernom bolesti. Ciljeve liječenja i odabir medikamentne terapije treba prilagoditi oboljeloj osobi, uzimajući u obzir životnu dob, trajanje bolesti, očekivano trajanje života, rizik od hipoglikemije, komorbiditete, razvijene vaskularne i ostale komplikacije, kao i ostale čimbenike. Zbog svega navedenoga od nacionalnog je interesa imati praktične, racionalne i provedive smjernice za farmakološko liječenje šećerne bolesti tipa 2.Introduction: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of ­diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the ­pharmacotherapy of type 2 diabetes in the Republic of Croatia. Participants: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. Evidence: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. Conclusions: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes’ patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglycemia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Effect of environmental enrichment on morphology of deep layer III and layer V pyramidal cells of occipital cortex in oldest-old rat – a quantitative Golgi Cox study [Utjecaj stimulativne okoline na morfologiju piramidnih neurona dubokih slojeva III i V okcipitalnog korteksa vrlo starih štakora: kvantitativna Golgi Cox studija]

Dendrites and dendritic spine density regress extensively during aging in rats housed under standard conditions (SC), which can be ameliorated by housing in the enriched environment (EE). This event is particularly pronounced on neurons where high rates of plasticity are conceivable, such as on projection neurons of archicortical regions of dentate gyrus1. However, effects of EE on neocortical projection neurons are still poorly understood. Therefore, we investigated the effect of EE housing on a deep layer III (L3) and layer V pyramidal cell (L5) morphology in the associative occipital neocortex of male Sprague-Dawley rats at 24 months of age. Rats were randomly distributed in two groups and reared under either SC (n=5) or EE conditions (n=6) for 26 days. In depth quantitative analysis of dendritic tree morphology and spine density on occipital projection neurons, from Golgi-Cox stained sections, showed similar trend in both EE occipital layers L3 and L5. Significant increase was found in total number of dendritic segments (L3 – 37.5 %, L5 – 33 %) and in dendritic diameter of intermediate segments (for more than 20 %), while increase in total spine number was around the level of significance (p>0.55; L3 – 30 %, L5 – 64 %). These findings suggest an outgrowth of new dendritic segments. When compared to archicortical region of dentate gyrus, effects of aging in the associative occipital cortex were less pronounced. Taken together, these findings suggest that structures being more affected by the aging process are more susceptible to the environmental enrichment in old age

The Limits of Acute Anemia

For many years, physicians’ approach to the transfusion of allogeneic red blood cells (RBC) was not individualized. It was accepted that a hemoglobin concentration (Hb) of less than 10 g/dL was a general transfusion threshold and the majority of patients were transfused immediately. In recent years, there has been increasing evidence that even significantly lower hemoglobin concentrations can be survived in the short term without sequelae. This somehow contradicts the observation that moderate or mild anemia is associated with relevant long-term morbidity and mortality. To resolve this apparent contradiction, it must be recognized that we have to avoid acute anemia or treat it by alternative methods. The aim of this article is to describe the physiological limits of acute anemia, match these considerations with clinical realities, and then present “patient blood management” (PBM) as the therapeutic concept that can prevent both anemia and unnecessary transfusion of RBC concentrates in a clinical context, especially in Intensive Care Units (ICU). This treatment concept may prove to be the key to high-quality patient care in the ICU setting in the future

Utjecaj stimulativne okoline na morfologiju piramidnih neurona dubokih slojeva III i V okcipitalnog korteksa vrlo starih štakora: kvantitativna Golgi Cox studija

Dendrites and dendritic spine density regress extensively during aging in rats housed under standard conditions (SC), which can be ameliorated by housing in the enriched environment (EE). This event is particularly pronounced on neurons where high rates of plasticity are conceivable, such as on projection neurons of archicortical regions of dentate gyrus1. However, effects of EE on neocortical projection neurons are still poorly understood. Therefore, we investigated the effect of EE housing on a deep layer III (L3) and layer V pyramidal cell (L5) morphology in the associative occipital neocortex of male Sprague-Dawley rats at 24 months of age. Rats were randomly distributed in two groups and reared under either SC (n=5) or EE conditions (n=6) for 26 days. In depth quantitative analysis of dendritic tree morphology and spine density on occipital projection neurons, from Golgi-Cox stained sections, showed similar trend in both EE occipital layers L3 and L5. Significant increase was found in total number of dendritic segments (L3 – 37.5 %, L5 – 33 %) and in dendritic diameter of intermediate segments (for more than 20 %), while increase in total spine number was around the level of significance (p>0.55; L3 – 30 %, L5 – 64 %). These findings suggest an outgrowth of new dendritic segments. When compared to archicortical region of dentate gyrus, effects of aging in the associative occipital cortex were less pronounced. Taken together, these findings suggest that structures being more affected by the aging process are more susceptible to the environmental enrichment in old age.Dendriti i gustoća dendritičkih trnova pokazuju značajne regresivne promjene tijekom starenja kod štakora koji borave u standardnim laboratorijskim uvijetima (engl. standard conditions, SC), a koje se mogu ublažiti boravkom u uvijetima stimulativne okoline (engl. enriched environment, EE). Taj efekat je osobito izražen na neuronima s velikim stupnjem plastičnosti kao što su projekcijski neuroni arhikortikalne regije gyrusa dentatusa. Međutim, utjecaj boravka u EE na projekcijske neurone u neokorteksu je još uvijek nedovoljno istražen. U ovoj studiji ispitali smo utjecaj boravka u stimulativnoj okolini na morfologiju piramidnih neurona dubokog sloja III (L3) i sloja V (L5) u asocijativnoom okcipitalnom neokorteksu muških Sprague-Dawley štakora starih 24 mjeseca. Štakori su nasumično raspoređeni u dvije grupe koje su boravile u SC (n=5) ili EE (n=6) kroz 26 dana. Detaljna kvantitativna analiza morfologije dendritičkog stabla i gustoće dendritičkih trnova na projekcijskim neuronima okcipitalnog korteksa prikazanih Golgi Cox metodom pokazala je sličan utjecaj boravka u EE u oba analizirana sloja – L3 i L5. Statistički značajan porast nađen je u ukupnom broju segmenata (L3 – 37,5%, L5 – 33%), te u promjeru dendrita na intermedijarnim segmentima (za više od 20%), dok je porast ukupnog broja dendritičkih trnova bio vrlo blizu statističke značajnosti (p>0,55; L3 – 30%, L5 – 64%). Ti podaci pokazuju da je najizraženiji efekat boravka u EE okolini bio izrastanje novih dendritičkih segmenata. S obzirom da je utjecaj starenja u okcipitalnom korteksu bio manje izražen nego u ontogenetski starijim moždanim strukturama kao sto je gryus dentatus, smatramo da strukture koje su jače zahvaćene staračkom regresijom plastičnije reagiraju na boravak u stimulativnoj okolini tijekom starenja

Utjecaj stimulativne okoline na morfologiju piramidnih neurona dubokih slojeva III i V okcipitalnog korteksa vrlo starih štakora: kvantitativna Golgi Cox studija

Dendrites and dendritic spine density regress extensively during aging in rats housed under standard conditions (SC), which can be ameliorated by housing in the enriched environment (EE). This event is particularly pronounced on neurons where high rates of plasticity are conceivable, such as on projection neurons of archicortical regions of dentate gyrus1. However, effects of EE on neocortical projection neurons are still poorly understood. Therefore, we investigated the effect of EE housing on a deep layer III (L3) and layer V pyramidal cell (L5) morphology in the associative occipital neocortex of male Sprague-Dawley rats at 24 months of age. Rats were randomly distributed in two groups and reared under either SC (n=5) or EE conditions (n=6) for 26 days. In depth quantitative analysis of dendritic tree morphology and spine density on occipital projection neurons, from Golgi-Cox stained sections, showed similar trend in both EE occipital layers L3 and L5. Significant increase was found in total number of dendritic segments (L3 – 37.5 %, L5 – 33 %) and in dendritic diameter of intermediate segments (for more than 20 %), while increase in total spine number was around the level of significance (p>0.55; L3 – 30 %, L5 – 64 %). These findings suggest an outgrowth of new dendritic segments. When compared to archicortical region of dentate gyrus, effects of aging in the associative occipital cortex were less pronounced. Taken together, these findings suggest that structures being more affected by the aging process are more susceptible to the environmental enrichment in old age.Dendriti i gustoća dendritičkih trnova pokazuju značajne regresivne promjene tijekom starenja kod štakora koji borave u standardnim laboratorijskim uvijetima (engl. standard conditions, SC), a koje se mogu ublažiti boravkom u uvijetima stimulativne okoline (engl. enriched environment, EE). Taj efekat je osobito izražen na neuronima s velikim stupnjem plastičnosti kao što su projekcijski neuroni arhikortikalne regije gyrusa dentatusa. Međutim, utjecaj boravka u EE na projekcijske neurone u neokorteksu je još uvijek nedovoljno istražen. U ovoj studiji ispitali smo utjecaj boravka u stimulativnoj okolini na morfologiju piramidnih neurona dubokog sloja III (L3) i sloja V (L5) u asocijativnoom okcipitalnom neokorteksu muških Sprague-Dawley štakora starih 24 mjeseca. Štakori su nasumično raspoređeni u dvije grupe koje su boravile u SC (n=5) ili EE (n=6) kroz 26 dana. Detaljna kvantitativna analiza morfologije dendritičkog stabla i gustoće dendritičkih trnova na projekcijskim neuronima okcipitalnog korteksa prikazanih Golgi Cox metodom pokazala je sličan utjecaj boravka u EE u oba analizirana sloja – L3 i L5. Statistički značajan porast nađen je u ukupnom broju segmenata (L3 – 37,5%, L5 – 33%), te u promjeru dendrita na intermedijarnim segmentima (za više od 20%), dok je porast ukupnog broja dendritičkih trnova bio vrlo blizu statističke značajnosti (p>0,55; L3 – 30%, L5 – 64%). Ti podaci pokazuju da je najizraženiji efekat boravka u EE okolini bio izrastanje novih dendritičkih segmenata. S obzirom da je utjecaj starenja u okcipitalnom korteksu bio manje izražen nego u ontogenetski starijim moždanim strukturama kao sto je gryus dentatus, smatramo da strukture koje su jače zahvaćene staračkom regresijom plastičnije reagiraju na boravak u stimulativnoj okolini tijekom starenja

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following