Telemedicine for Diabetic Retinopathy Screening in Croatia: A Dream That Could Become a Reality

Diabetic retinopathy (DR) is the leading cause of preventable blindness in working-age adults associated with devastating personal and socioeconomic consequences. The increasing use of anti-vascular endothelial growth factor (anti-VEGF) agents over the past decade and telemedicine implementation in systematic DR screening resulted in a decliningtrend of new blindness due to diabetes in several countries. Telemedicine is the remote delivery of healthcare services over the telecommunications infrastructure. It allows healthcare providers to evaluate, diagnose, and treat patients without the need for an in-person visit. Teleophthalmology is a telemedicine branch, mostly focused on diabetic retinopathy and retinopathy of prematurity. Screening for DR in Croatia is commonly performed annually, only by ophthalmologists using dilated slit-lamp biomicroscopic fundus examination. Due to the insufficient number of ophthalmologists and the lack of a formal call system, many diabetic patients do not perform annual screening. In an ideal DR screening model in Croatia, each diabetes center in university or general hospitals throughout Croatia (17 centers) would have one small digital fundus camera and an educated nurse who would perform dilated fundus photography. Electronic images from diabetes centers would be transferred for remote grading to the same hospitals’ ophthalmology departments or a central grading center for DR screening in Croatia. Grading for DR would be performed by an ophthalmologist, medical retina specialist. Patients would be annually invited by mail from the National Diabetes Registry to come to the nearest diabetes center for a fundus photographing and DR screening. Each patient with a positive result would be promptly referred to the medical retina specialist at the closest ophthalmology department for further examination and treatment

Therapeutic Efficacy of 5% NaCl Hypertonic Solution in Patients with Bullous Keratopathy

A clinical trial was undertaken to evaluate the efficacy of hypertonic solution (5% NaCl) in patients who have bullous keratopathy (BK). The aim of the study was to define the stage of the disease and the thickness of cornea in micrometers, which would be the threshold for therapeutic approach. This was a prospective study on 70 eyes of 55 patients. Patients were divided in two groups at the beginning of the study.The first group (n=33 eyes) included patients with initial stage of BK: only stromal component of corneal oedema was present. The second group (n=37 eyes) included patients with advanced stage of BK: the epithelial component of the disease with bullae on the corneal surface had already developed. Visual acuity, central and peripheral thickness of cornea and morphology of the disease was recorded before therapy, 7 days and 4 weeks after administration of hypertonic solution. Our results shown that the efficacy of hypertonic solution correlates with the severity of clinical picture in patients with BK. When 5% NaCl hypertonic solution was applied in the early stage of the disease, when only stromal component of corneal oedema was presented, visual acuity and pachymetry readings were significantly improved. The threshold pachymerty measurement of corneal thickness justifying the application of hypertonic solution was 613–694 _m(in the central corneal area), and 633–728 _m(at corneal periphery). It seems reasonable to apply hypertonic solution to the patients who have BK and whose pachymetric values are below mentioned range. In terminal stages of BK, when superficial bullae (epithelial component) had already developed, treatment with NaCl was not effective and patients had to be submitted to penetrating keratoplasty

DO NEW THERAPEUTIC INTERVENTIONS IN CARDIOLOGY BRING NEW CHALLENGES FOR PATIENTS AND DOCTORS?

Transplantacija srca, elektrofiziološki postupci, terapija elekrostimulatorima, zamjenske elektro-mehaničke pumpe, samo su neke od novijih metoda liječenja, koje se danas primjenjuju u kardiologiji, a donose nove izazove kako za bolesnike, tako i za liječnike koji sudjeluju u praćenju istih. Požeškoslavonska županija broji oko 80.000 stanovnika. U zadnjih sedam godina učinjene su četiri transplatancije srca, ugrađena četiri kardioverter- defibrilatora (ICD), dva resinhronizacijska elektrostimulatora, dva elektrostimulatora (ES) s epikardnim elektrodama, uz 21 katetersku ablaciju, te je više od 70 bolesnika podvrgnut redovnoj ugradnji ES nakon dijagnosticiranih smetnji u atrioventrikulskoj kondukciji. U ovom radu prikazujemo učinjene spomenute postupke. Namjera nam je procijeniti mogućnost daljnjeg praćenja ovih pacijenata od strane obiteljskog liječnika i kardiologa pripadajuće ustanove. Želimo prikazati prednosti suvremene, moderne, kardiologije koja pacijentima omogućava nastavak i unapređenje života nakon učinjenih intervencija. Kroz rad ćemo pokazati koje sve izazove donosi napredak u elektroindustriji koja postaje sastavni dio kirurških disciplina. Uz očekivanje dobre kvalitete života ovih bolesnika, koje će osim kardiologa kontrolirati i liječnici obiteljske medicine, namjera nam je ovu problematiku približiti svim suučesnicima u praćenju ovih bolesnika.Heart transplantation, electrophysiological procedures,pacemaker therapy, electromechanical pump replacement, are some of the new methods, which are now frequently used, bringing new challenges to the patients and doctors who participate in their follow up. Our county has about 80,000 inhabitants. In the last seven years, four heart transplantations were performed, four built-in electrical cardioverter defibrillators (ICD), two cardiac resynchronization pacemakers, two ES with epicardial electrodes were placed, with 21 catheter ablations done, and more than 70 patients underwent regular ES installation for total atrioventricular block. In this article we present procedures performed in our patients. Our aim is to estimate the possibility of monitoring them by the cardiologist and also by the family doctor. We want to show advantages of modern cardiology that provides good quality of life after cardiac interventions. The article will point the progress of electro-industry which has become an important part of surgical disciplines. Expecting good quality of life for our patients who will be monitored by the cardiologist and the family doctor, we would like to make this issue familiar to all participants in the patients’ follow up

Dissection of thoracic aortic aneurysm

Aneurizme predstavljaju nenormalna proširenja arterija uzrokovana slabljenjem arterijskoga zida. Česti uzroci proširenja su hipertenzija, ateroskleroza, infekcije, traume, te stečene i nasljedne bolesti vezivnoga tkiva. Proširenje stijenke prsne aorte s disekcijom je teško, kompleksno kliničko stanje koje nerijetko završava smrću. Bolesnici koji ne umru odmah, tuže se na jaku bol u prsima, hipotenzivni su i u šoku. Dolazi do krvarenja najčešće u perikardni i pleuralni prostor. Dijagnozu postavljamo na temelju kliničke slike, rendgenske i ultrazvučne dijagnostike, odnosno dijagnostike koja posjeduje trodimenzionalni slikovni prikaz; transezofagealni ultrazvuk (TEE), kompjuterizirana angiografija (CTA). U ovom članku prikazujemo bolesnika koji je s navedenom bolešću bio bez liječničke skrbi dva tjedna, tijekom kojih je proputovao 1000 kilometara. Ipak je, s odgođenim dijagnostičkim i terapijskim mjerama, na kraju izliječen. Kroz raspravu ćemo naglasiti važnost ranog postavljanja dijagnoze, kako bi se pravodobno moglo terapijski i operativno djelovati i time poboljšati kvalitetu i duljinu trajanja života bolesnika kojima je ova bolest bila potvrđena.Aneurysm is an abnormal enlargement of the arteries caused by the weakening of the arterial wall. Frequent causes of enlargement are: hypertension, atherosclerosis, infection, trauma, and acquired and hereditary connective tissue diseases. Extension of the thoracic aortic wall with dissection is difficult, a complex clinical condition that often results in death. Patients who do not die immediately, complain of severe chest pain, they are hypotensive and in shock. They bleed usually in the pericardial and pleural space. The diagnosis is based on clinical symptoms, X-ray and ultrasound, or the three-dimensional imagery, transesophageal ultrasound (TEE), computed angiography (CTA). In this article we report a patient walking around without medical treatment for two weeks while he was traveling 1000 kilometers without adequate medical accompaniment, and he was cured, even with delayed diagnostic and therapeutic measures. Through discussion we emphasize the importance of early diagnosis confirmation, in order to act therapeutically and surgically and thus improve the quality and length of life of these patients

IS DOPPLER ULTRASOUND OF UPPER AND LOWER EXTREMITIES INTENDED ONLY FOR VASCULAR PATHOLOGY? - OUR EXPERIENCE

Zadnjih četrdesetak godina ultrazvučna (UZ) dijagnostika nalazi svoje mjesto u gotovo svim medicinskim disciplinama. Udruživanjem CW dopplerske tehnike i B moda ultrazvuka uz dodatak obojenog prikaza intravaskularnog protoka (color flow imaging, CFI) stvorena je moćna pretraga. Arterijske okluzije otkrivaju se mjerenjem brzine vršnog vala pulsa (Peak Systolic Velocity Ratio – PSVR), koji se uspoređuje s brzinom protoka proksimalnog kraja žile koji nema UZ elemenata stenoze. U dijagnostici venske patologije pomoću faze respiracije, kompresibilnosti vena, kontinuiranosti protoka i fenomena augumentacije potvrđujemo patologiju venske cirkulacije s visokom specifičnošću i osjetljivošću. Godišnje se dopplerski u našoj ustanovi pregleda oko 600 bolesnika. Kontrole ranije dijagnosticiranih stanja još uvijek zauzimaju gotovo dvije trećine svih pregleda. Novih žilnih dijagnoza bude godišnje oko 120 ili 25% svih pregleda, uglavnom su to duboke venske tromboze i periferne okluzivne bolesti arterija. Otkriva se mali broj aneurizmi koje su češće u muškaraca te mali broj AV fistula koje su većinom jatrogene. Neočekivane „nevaskularne“ dijagnoze nisu rijetkost; ima ih oko 10%. Korist od utvrđivanja ovih stanja je velika, kako za samoga bolesnika, tako i za odjel gdje se bolesnik liječi.In the last 40 years ultrasound (US, echosonography) has found its place in almost all medical disciplines. A powerful diagnostic method has been created by joining CW Doppler technique and B mode ultrasound with Colour Flow Imaging (CFI)Arterial occlusion is detected by measuring the Peak Systolic Velocity Ratio (PSVR) which differentiates the flow rate in the proximal and in the stenotic portion of the vessel. In diagnosing venous pathology we use respiratory phase, compressibility of the veins, flow continuity, and augmentation phenomenon with high specificity and sensitivity. In our institution over 600 patients are submitted annually to vascular US examination. Follow-ups of previously diagnosed conditions still occupy nearly two-thirds of them. New vascular diagnoses occur on average in about 120 cases (around 25%). These are mainly deep vein thrombosis and peripheral occlusive arterial disease. A small number of aneurysms which are more common in the male population, and a small number of AV fistulas, usually iatrogenic, have also been found. Unexpected “nonvascular” findings are not so rare, occurring in about 10% of the examinations, with a huge benefit for the patients and for the wards as well

DO NEW THERAPEUTIC INTERVENTIONS IN CARDIOLOGY BRING NEW CHALLENGES FOR PATIENTS AND DOCTORS?

Transplantacija srca, elektrofiziološki postupci, terapija elekrostimulatorima, zamjenske elektro-mehaničke pumpe, samo su neke od novijih metoda liječenja, koje se danas primjenjuju u kardiologiji, a donose nove izazove kako za bolesnike, tako i za liječnike koji sudjeluju u praćenju istih. Požeškoslavonska županija broji oko 80.000 stanovnika. U zadnjih sedam godina učinjene su četiri transplatancije srca, ugrađena četiri kardioverter- defibrilatora (ICD), dva resinhronizacijska elektrostimulatora, dva elektrostimulatora (ES) s epikardnim elektrodama, uz 21 katetersku ablaciju, te je više od 70 bolesnika podvrgnut redovnoj ugradnji ES nakon dijagnosticiranih smetnji u atrioventrikulskoj kondukciji. U ovom radu prikazujemo učinjene spomenute postupke. Namjera nam je procijeniti mogućnost daljnjeg praćenja ovih pacijenata od strane obiteljskog liječnika i kardiologa pripadajuće ustanove. Želimo prikazati prednosti suvremene, moderne, kardiologije koja pacijentima omogućava nastavak i unapređenje života nakon učinjenih intervencija. Kroz rad ćemo pokazati koje sve izazove donosi napredak u elektroindustriji koja postaje sastavni dio kirurških disciplina. Uz očekivanje dobre kvalitete života ovih bolesnika, koje će osim kardiologa kontrolirati i liječnici obiteljske medicine, namjera nam je ovu problematiku približiti svim suučesnicima u praćenju ovih bolesnika.Heart transplantation, electrophysiological procedures,pacemaker therapy, electromechanical pump replacement, are some of the new methods, which are now frequently used, bringing new challenges to the patients and doctors who participate in their follow up. Our county has about 80,000 inhabitants. In the last seven years, four heart transplantations were performed, four built-in electrical cardioverter defibrillators (ICD), two cardiac resynchronization pacemakers, two ES with epicardial electrodes were placed, with 21 catheter ablations done, and more than 70 patients underwent regular ES installation for total atrioventricular block. In this article we present procedures performed in our patients. Our aim is to estimate the possibility of monitoring them by the cardiologist and also by the family doctor. We want to show advantages of modern cardiology that provides good quality of life after cardiac interventions. The article will point the progress of electro-industry which has become an important part of surgical disciplines. Expecting good quality of life for our patients who will be monitored by the cardiologist and the family doctor, we would like to make this issue familiar to all participants in the patients’ follow up