Predictors of Nonalcoholic Steatohepatitis in Patients with Elevated Alanine Aminotransferase Activity

Incidence of obesity and hepatic steatosis is increasing worldwide. Almost one quarter of western countries population suffer from non alcoholic fatty liver disease (NAFLD). The aim of this study was to investigate the frequency and predictors of nonalcoholic steatohepatitis (NASH) in patients with unexplained alanine aminotransferase activity elevation (ALT), and therefore avoid unnecessary biopsies in cases of simple steatosis. Earlier studies provided different results and have not answered the question how to distinguish NASH from simple steatosis. Ultrasound (US), computed tomography (CT) and magnetic resonance (MRI) can detect steatosis with great sensitivity level, but not NASH. This study included 50 patients (18 women and 32 men) with mean age 43±9 years, and with defined selected biochemical, anthropometric and hormone biomarkers. The average BMI was 27.1±3.81 (kg/m2), insulin resistance HOMA IR 3.89± 3.81. All patients underwent liver biopsy and NASH was staged by NASH activity score (NAS) from 1 to 8. Results are compared to pathohistological finding as relevant method. The results show that 90% of patients (n=45) had NAFLD (minimal stage at least), and 15 (30%) had nonalcoholic steatohepatitis (NASH). High triglyceride, low HDL and high ferritin serum levels correspond with NASH. As in earlier studies, insulin resistance as basic mechanism of NAFLD and NASH was confirmed

WHITE PAPER Croatian Society of Gastroenterology Consensus October 2019

Jedan od ključnih elemenata zdravstvene zaštite nedvojbeno je dostupnost. Imati jednaku zdravstvenu zaštitu i mogućnost ostvarenja najviše razine zdravstvene usluge temeljno je pravo svakog pojedinca. To pravo nije samo humano i etički neosporno, nego je i defi nirano zakonom. U tom smislu jasno je da pravo na zdravstvenu zaštitu ne smije biti privilegija već imperativ postupanja. Znanjem, entuzijazmom i dobrom organizacijom, čak i u materijalno ograničenim okolnostima, može se postići vrlo mnogo. Republika Hrvatska je zemlja posebnih geografskih obilježja i koliko je to čini lijepom u svoj njenoj raznolikosti toliko nerijetko otežava dostupnost najkvalitetnijim oblicima zdravstvene zaštite i zdravstvenih postupaka. Formiranjem visoko specijaliziranih centara objedinjenih u dobro organiziranu mrežu i uz organiziranu i koordiniranu komunikaciju zdravstvenih djelatnika, svim bolesnicima sa specifi čnom i zahtjevnom problematikom može biti pružena najbolja zdravstvena zaštita. U gastroenterologiji akutni kolangitis, akutni bilijarni pankreatitis i komplikacije kolecistektomije u obliku postoperacijskih ozljeda žučovoda, dijagnoze su koje zahtijevaju postupak endoskopske retrogradne kolangiopankreatografi je (ERCP) unutar 72 sata, a u pojedinim slučajevima i unutar 24 sata. Nažalost, činjenica je da trenutno u Republici Hrvatskoj takvi bolesnici nerijetko čekaju na intervenciju znatno duže jer ne postoji organizirana mreža slanja i prihvata spomenute kategorije bolesnika. Radna skupina Hrvatskog gastroenterološkog društva izradila je predložak “Hrvatske mreže intervencijske gastroenterologije – ERCP” i nakon široke javne rasprave Skupština Društva prihvatila je spomenuti dokument kao konsenzus Hrvatskog gastroenterološkog društva. Implementacijom navedenog konsenzusa u svakodnevnu kliničku praksu osigurava se ostvarivanje prava svih građana Republike Hrvatske na jednaku dostupnost najbolje zdravstvene zaštite, očuvanje i poboljšanje zdravlja uz dulji i kvalitetniji život velikog broja ovih bolesnika. Mreža CRO-GASTRONET-ERCP osmišljena je i s nakanom da se svim zdravstvenim djelatnicima, u svim zdravstvenim ustanovama Republike Hrvatske olakša brza komunikacija s devet visoko specijaliziranih tercijarnih centara za djelatnost ERCP-a sa ciljem uske suradnje u smislu najboljeg i najbržeg mogućeg liječenja bolesnika s dijagnozama akutnog kolangitisa, akutnog bilijarnog pankreatitisa ili komplikacija kolecistektomije u obliku postoperacijskih ozljeda žučovoda. Jasno defi niranim postupnicima omogućit će se standardizacija zdravstvenih usluga u korist bolesnika, ali i najučinkovitije korištenje ekonomskih resursa. Svaki početak je težak, ali se kako predvidive tako i nepredvidive prepreke mogu uspješno riješiti zajedničkim konstruktivnim radom i naporima svih dionika zdravstvenog sustava.Availability is undoubtedly one of the key elements of the healthcare system. Th e fundamental right of every person is to have the highest level of healthcare service based on excellence and equality. Th is right is indisputable not only from the human and ethical viewpoint, but is also defined by law. In this regard, it is clear that the right to healthcare service must not be merely a privilege but rather an imperative. A great deal can be achieved with knowledge, enthusiasm and good organization, even under circumstances of material restrictions. Republic of Croatia is a country of specific geographical features, which makes it beautiful in all its diversity but oft en makes the availability of specialized forms of healthcare service and procedures difficult. By forming highly specialized centers integrated into a well-organized network and with organized and coordinated communication of healthcare professionals, all patients with specifi c and demanding problems can be provided with the best healthcare service. In gastroenterology, acute cholangitis, acute biliary pancreatitis and cholecystectomy complications in terms of postoperative bile duct injuries are diagnoses requiring endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours, and in some cases within 24 hours. Unfortunately, the fact is that currently in the Republic of Croatia, such patients oft en have to wait for intervention considerably longer because there is no organized network of referring and admitting this category of patients. A working group of the Croatian Society of Gastroenterology has developed a model for the Croatian Interventional Gastroenterology Network-ERCP and, following a broad public discussion, the Assembly of the Society accepted the document as a consensus of the Croatian Society of Gastroenterology. Th e implementation of this consensus into everyday clinical practice provides for exercising the rights of all citizens of the Republic of Croatia to equal availability of the best healthcare service, and for preservation and improvement of health with longer and better quality life for a large number of these patients. Th e CRO-GASTRONET-ERCP has also been designed to facilitate all healthcare professionals at all healthcare institutions in the Republic of Croatia fast communication with nine highly specialized tertiary centers for ERCP, with the aim of achieving close cooperation in providing the best and fastest possible treatment of patients with the diagnoses of acute cholangitis, acute biliary pancreatitis or cholecystectomy complications in terms of postoperative bile duct injuries. Clearly defined protocols will make it possible to standardize healthcare services to the benefit of patients, but also to use economic resources most efficiently. Every beginning is hard, but both foreseeable and unforeseeable obstacles can be resolved successfully with joint constructive action and efforts of all stakeholders of the healthcare system

Abdominalni parakordom – prikaz slučaja

We report a very rare case of abdominal parachordoma. Parachordoma is indolent in nature, grows slowly and it has occasional recurrence after 3 months to 12 years and rare metastases. A 70-year-old female presented to our Department complaining of abdominal pain. Clinical examination showed a tumor mass in the pelvis and abdomen. Surgery was indicated. Histopathological and immunohistochemical analysis of resected tumor tissue confirmed the diagnosis of parachordoma with metastases in the sigma and omentum.Prikazujemo vrlo rijedak slučaj abdominalnog parakordoma. Parakordom raste sporo, rijetko metastazira, a recidiv se može pojaviti nakon 3 mjeseca do 12 godina. Sedamdesetogodišnja pacijentica primljena je na Odjel za ginekološko-onkološku kirurgiju Klinike za tumore KBC „Sestre milosrdnice“ zbog bolova u donjem dijelu trbuha. Kliničkom obradom dijagnosticirana je tumorska masa u zdjelici i trbuhu. Učinjen je kirurški zahvat. Histološka i imunohistokemijska analiza potvrdila je dijagnozu parakordoma s metastazama u sigmi i omentumu

Abdominalni parakordom – prikaz slučaja

We report a very rare case of abdominal parachordoma. Parachordoma is indolent in nature, grows slowly and it has occasional recurrence after 3 months to 12 years and rare metastases. A 70-year-old female presented to our Department complaining of abdominal pain. Clinical examination showed a tumor mass in the pelvis and abdomen. Surgery was indicated. Histopathological and immunohistochemical analysis of resected tumor tissue confirmed the diagnosis of parachordoma with metastases in the sigma and omentum.Prikazujemo vrlo rijedak slučaj abdominalnog parakordoma. Parakordom raste sporo, rijetko metastazira, a recidiv se može pojaviti nakon 3 mjeseca do 12 godina. Sedamdesetogodišnja pacijentica primljena je na Odjel za ginekološko-onkološku kirurgiju Klinike za tumore KBC „Sestre milosrdnice“ zbog bolova u donjem dijelu trbuha. Kliničkom obradom dijagnosticirana je tumorska masa u zdjelici i trbuhu. Učinjen je kirurški zahvat. Histološka i imunohistokemijska analiza potvrdila je dijagnozu parakordoma s metastazama u sigmi i omentumu

Primary Extragastrointestinal Stromal Tumor of the Sigmoid Mesocolon with Metastatic Spread to Greater Omentum: Case Report

A 71-year-old female complained of abdominal pain, weight loss and abdominal distension. Gynecologic examination revealed a hardly movable, palpable mass in the lower abdomen, reaching the umbilicus. An abdominal ultrasound and computed tomography (CT) scan suggested a large abdominal mass with the possible origin in the left ovary and without significant lymph node enlargements. The patient subsequently underwent complete evacuation of tumor tissue, omentectomy and total abdominal hysterectomy and bilateral salpingo-ovariectomy. Immunohistochemical examination revealed strongly positive staining of tumor cells for CD117. The final pathologic diagnosis was a primary extragastrointestinal stromal tumor (EGIST) of the sigmoid mesocolon with omental metstasis. The differential diagnosis of the tumor presented in the lower abdomen should consider the EGIST as well

Real-time two-dimensional shear wave ultrasound elastography of the liver is a reliable predictor of clinical outcomes and the presence of esophageal varices in patients with compensated liver cirrhosis

Aim Primary: to evaluate predictivity of liver stiffness (LS), spleen stiffness (SS), and their ratio assessed by real-time 2D shear wave elastography (RT-2D-SWE) for adverse outcomes (hepatic decompensation, hepatocellular carcinoma or death; “event”) in compensated liver cirrhosis (LC) patients. Secondary: to evaluate ability of these measures to discriminate between cirrhotic patients with/without esophageal varices (EV). Methods Predictivity of LS, SS, and LS/SS was assessed in a retrospectively analyzed cohort of compensated LC patients (follow-up cohort) and through comparison with incident patients with decompensated cirrhosis (DC) (cross-sectional cohort). Both cohorts were used to evaluate diagnostic properties regarding EV. Results In the follow-up cohort (n = 44) 18 patients (40.9%) experienced an “event” over a median period of 28 months. LS≥21.5 kPa at baseline was independently associated with 3.4-fold (95% confidence interval [CI] 1.16-10.4, P = 0.026) higher risk of event. Association between SS and outcomes was weaker (P = 0.056), while there was no association between LS/SS ratio and outcomes. Patients with DC (n = 43) had higher LS (35.3 vs 18.3 kPa, adjusted difference 65%, 95% CI 43%-90%; P < 0.001) than compensated patients at baseline. Adjusted odds of EV increased by 13% (95% CI 7.0%-20.0%; P < 0.001) with 1 kPa increase in LS. At cut-offs of 19.7 and 30.3 kPa, LS and SS had 90% and 86.6% negative predictive value, respectively, to exclude EV in compensated patients. Conclusion This is the first evaluation of RT-2D-SWE as a prognostic tool in LC. Although preliminary and gathered in a limited sample, our data emphasize the potential of LS to be a reliable predictor of clinical outcomes and the presence of EV in LC patients

DEPRESSION AND SERUM INTERLEUKIN-6 LEVELS IN PATIENTS ON DIALYSIS

Background: Depression is a common psychiatric problem in patients undergoing dialysis. Several studies have been performed to validate the association between depression and inflammation in haemodialysis patients. The levels of proinflammatory cytokines are increased in chronic renal failure patients, as in depression. The objective of this study was to compare the incidence of depression in the patients on dialysis (on hemodialysis /HD/ and on continuous ambulatory peritoneal dialysis /CAPD/), and a relationship between depression and the presence of inflammation. Subjects and methods: 88 patients (52 on HD and 36 on CAPD) were enrolled in this study. Depressive symptoms were measured with the Beck Depression Inventory (BDI). The BDI is a 21-item self-report instrument, and the elevated symptoms of depression were defined as a BDI score ≥16. HD patients were treated with high-flux polysulphone biocompatible dialyzers and CAPD patients were treated with usual dwell time (4-6 hours during the day and 8–10 hours at night). The presence of an inflammatory state was assesded by determinations of plasma interleukin-6 (IL-6) levels. Results: Depression (BDI ≥ 16) was present in 28.4% of dialysis patients, 35% of patients on hemodialysis (HD) and 18.1% of patients on continous ambulatory peritoneal dialysis (CAPD). The BDI score was significantly lower in CAPD patients comparing to HD patients, as well as the levels of albumin, C-reactive protein (CRP) and interleukin-6 (IL-6). IL-6 serum levels were similar in patients with depression and patients without depression in the whole group, as in HD patients. In CAPD patients without depression IL-6 levels were significantly lower. Conclusions: The prevalence of depression was higher in HD comparing to CAPD patients. Although IL-6 level was higher in HD compared to CAPD patients, the relationship between depression and presence of inflammation parametars were observed in CAPD, but not in HD patients

Izazovi i mogućnosti za ostvarenje primjerenih starosnih mirovina u Hrvatskoj

Ovim su istraživanjem pripremljene projekcije, procjene i ocjene stanja i budućnosti mirovinskog sustava u Hrvatskoj, a posebna je pozornost posvećena razmatranju primjerenosti mirovina. Iako razumijevanje „primjerenosti mirovina“ nije jednoznačno i za različite ljude ima različito značenje, ovo ga istraživanje, kao i većina analitičkih radova, određuje u relativnom smislu, u odnosu na plaće. Zato se kao glavni pokazatelj primjerenosti promatrao početni omjer (stopa) zamjene mirovina, odnosno omjer prve mirovine i posljednje plaće. U okviru istraživanja posebno su pripremljene projekcije budućeg kretanja omjera zamjene. Projektna studija ukazuje na moguće osjetno smanjivanje omjera zamjene mirovina u sljedećih 40 godina. Početni omjer zamjene za osobu s prosječnom plaćom koja odlazi u mirovinu sa 65 godina starosti uz 40 godina radnog staža 2010. godine iznosio je oko 54 posto. Ako se ništa ne promijeni, postojeći parametri mirovinskog sustava ukazuju na to da će za osobu istih karakteristika početni omjer zamjene u 2050. godini iznositi samo 37 posto, što bi tada bio najniži omjer u zemljama Europske unije. Projekcije, nadalje, ukazuju na to da će mirovine koje se isplaćuju temeljem osiguranja u oba mirovinska stupa biti osjetno niže od mirovina koje se isplaćuju na osnovi sudjelovanja samo u prvom stupu. U pogledu fiskalne ravnoteže javnog mirovinskog sustava, dugoročne projekcije pokazuju da će doći do postupnog smanjivanja deficita koji bi oko 2050. godine trebao u potpunosti nestati, odnosno sve isplate mirovina iz javnog sustava u potpunosti bi bile pokrivene prihodima od doprinosa. To će se poboljšanje prvenstveno postići uštedama na strani rashoda, odnosno smanjivanjem relativne visine mirovina u odnosu na prosječnu plaću. Predlaže se poduzimanje deset reformskih aktivnosti u cilju osiguranja primjerenih mirovina: 1. uravnotežiti mirovine koje se isplaćuju iz mješovitog sustava (prvi i drugi stup) s mirovinama koje se isplaćuju samo iz prvog stupa, ponajprije proširenjem dodatka na sve korisnike mirovina i promjenom formule osnovne mirovine, dok se dopuštanje povratka u prvi stup u trenutku umirovljenja ne smatra prikladnom opcijom, 2. osnažiti vezu između uplaćenih doprinosa i primljenih mirovina, 3. uvesti pravila za automatsku korekciju parametara javnog mirovinskog sustava u skladu s očekivanim trajanjem života i gospodarskim okolnostima, 4. razmotriti socijalno prihvatljiv i fiskalno održiv sustav valorizacije i indeksacije mirovina; 5. uvesti temeljni mirovinski stup (nulti stup) za siromašne umirovljenike i starije osobe koje ne primaju mirovinu, 6. unaprijediti kontrolu rizika prinosa u drugom stupu, 7. povećati transparentnost mirovinskog sustava, 8. reformske aktivnosti temeljiti na rezultatima znanstvenih i stručnih istraživanja, 9. poticati rad i zapošljavanje u okviru svih mjera i politika, 10. ojačati svijest o individualnoj odgovornosti za primanja u starosti, promicanjem financijske i mirovinske pismenosti. U okviru projekta pripremljena je procjena učinaka izabranih reformskih mjera na visinu budućih mirovina i fiskalnih troškova, koja pokazuje kako do viših mirovina uz umjerene fiskalne troškove može doći samo ako i društvo i građeni podijele teret odgovornosti za primanja u starosti