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Percutaneous dilatational tracheostomy is a common surgical procedure that is becoming the method of choice in critically ill patients whenever prolonged airway secure and/ or ventilation support is needed. Although adverse events are relatively uncommon, serious life threatening complications can arise from this bedside procedure. We report a case of a 70-year-old female who developed extensive subcutaneous emphysema and bilateral pneumothorax immediately after a percutaneous dilatational tracheostomy procedure. Different mechanisms, such as damage to posterior or anterior tracheal wall, false passage or paratracheal placement or dislocation of the cannula are considered to be responsible for the development of pneumothorax and subcutaneous emphysema. Although bronchoscopic control after the tracheostomy procedure did not reveal any tracheal injury, we believe that subcutaneous emphysema and bilateral pneumothorax are most likely caused by procedure induced injuries of the trachea in addition to the applied high airway pressure induced by excessive or inappropriate ventilation. In our case report, we would like to emphasize that continuous bronchoscopic guidance during percutaneous tracheostomy is invaluable in decreasing the incidence of its overall complications, especially during enhancing the team experience., Perkutana dilatacijska traheotomija je učestali kirurški zahvat koji postaje metodom osiguravanja dišnoga puta u kritičnih bolesnika i bolesnika na dugotrajnoj mehaničkoj ventilaciji. Iako su popratni učinci relativno rijetki, metoda je vezana uz mogućnost nastanka za život opasnih komplikacija. Prikazujemo slučaj 70-godišnje žene kod koje je došlo do razvoja opsežnog potkožnog emfizema i obostranog pneumotoraksa neposredno nakon izvođenja perkutane traheotomije. Različiti mehanizmi kao što su oštećenje stražnjeg ili prednjeg zida dušnika, lažni prolaz ili paratrahealno postavljanje ili dislokacija kanile mogu se smatrati odgovornim za nastanak pneumotoraksa i potkožnog emfizema. U našem prikazu slučaja, iako nakon perkutane traheotomije bronhoskopskim pregledom nije nađeno oštećenje dušnika, smatramo da je uzrok nastanka potkožnoga emfizema i obostranog pneumotoraksa najvjerojatnije procedurom nastala ozljeda dušnika i primjena visokog tlaka u dišnim putovima izazvanog prejakom ili neodgovarajućom ventilacijom. Ovim prikazom slučaja željeli bismo naglasiti važnost bronhoskopske vizualizacije tijekom izvođenja perkutane traheotomije u prevenciji nastanka mogućih komplikacija, osobito u razdoblju usvajanja ove kliničke vještine.

Obstructive hydrocephalus is a relatively common complication of intraventricular hemorrhage resulting in high morbidity and mortality. We report two cases of transient obstructive hydrocephalus caused by obstruction of mesencephalic duct in patients that presented with altered consciousness which resolved spontaneously in a few hours. In very rare cases, obstructive hydrocephalus due to intraventricular hemorrhage may be transient and does not need neurosurgical or invasive procedures for lowering raised intracranial pressure, which otherwise are currently preferred treatment options., Opstruktivni hidrocefalus je relativno česta komplikacija intraventrikulskog krvarenja, što doprinosi visokom pobolu i smrtnosti. Cilj ovoga rada je prikazati dvoje bolesnika s prolaznim opsktruktivnim hidrocefalusom koji je uzrokovan opstrukcijom u području mezencefaličkog duktusa. Oboje bolesnika su se prezentirali prolaznim poremećajem stanja svijesti u trajanju od nekoliko sati. U rijetkim slučajevima opstruktivni hidrocefalus uzrokovan intraventrikulskim krvarenjem može biti prolazne naravi i tada nema potrebe za neurokirurškim ili drugim invazivnim postupcima radi sniženja povišenog intrakranijskog tlaka.

Naglo nastali bilateralni infarkti u područjima srednjih moždanih arterija javljaju se izrazito rijetko i često za posljedicu imaju smrtni ishod. Cilj je rada prikazati kliničku sliku bolesnice i pregled literature vezan uz naglo nastale bilateralne ishemijske moždane udare u irigacijskim područjima obiju srednjih moždanih arterija., Acute bilateral infarcts in the middle cerebral artery (lat. arteria cerebralis media - ACM) territories are very rare and can have a fatal outcome. The aim is to present the clinical picture of the patient, and the review of literature associated with bilateral stroke in middle cerebral artery territories.

We investigated concentrations and roles of insulin-like growth factor 1 (IGF-1) and its binding protein (IGF1BP-3), growth hormone (GH), insulin, and markers of insulin resistance and inflammation in acute myocardial infarction (AMI). We aimed to assess any possible association between serum GH/IGF-1 axis following AMI and short-term survival rates. A follow up study was performed in 2010. Study group consisted of 75 patients with Killip I and II class AMI. There were 30 control subjects. Blood samples were obtained within 24 hours of admission and analyzed for the aforementioned hormones. Patients were followed-up during 6 months for new cardiac events. Median GH was higher in AMI (0.96; range 0.6-2.4) than in controls (0.26; p, Istraživali smo uloge inzulinu sličnog čimbenika rasta (IGF-1), njegovog vezujućeg proteina (IGF1BP-3), hormona rasta (growth hormone, GH), inzulina, biljega inzulinske rezistencije i upale u akutnom infarktu miokarda (AIM). Cilj je bio utvrditi utjecaj osovine IGF-1/GH na kratkoročnu prognozu AIM. U istraživanje provedeno tijekom 2010. godine bilo je uključeno 75 bolesnika s dijagnozom AIM (ispitna skupina) i 30 ispitanika kao kontrolna skupina. Uzorci krvi su uzimani unutar 24 h od prijma i potom analizirani na navedene hormone. Tijekom šestomjesečnog razdoblja pratili smo hoće li doći do pojave novih srčanih događaja; ultrazvučno se određivala ejekcijska frakcija (EF). Medijan GH bio je veći u skupini s AIM nego u kontrolnoj skupini (0,96 prema 0,26; p

The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. Diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome. We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery., Učestalost traumatskih ozljeda kralježnice je 11.000 na godinu, a 55% ozljeda nastaje u dobi od 16 do 33 godine, od toga 18% u žena reproduktivne dobi. Radiološka dijagnostika, uz ranu kiruršku dekompresiju kralježnice s održavanjem srednjeg arterijskog tlaka za očuvanje perfuzije leđne moždine, uz progesteron kao neuroprotektivni i protuupalni faktor u akutnoj traumi leđne moždine, ima vodeće mjesto u neurološkom oporavku i dobrom kliničkom ishodu. Donosimo prikaz slučaja trudnice u 17. tjednu trudnoće koja je zadobila luksacijsku frakturu petog i šestog vratnog kralješka s razvojem tetraplegije, kod koje su rano operacijsko liječenje i odgovarajući anesteziološki postupak doveli do dobrog kliničkog ishoda.

A 65-year-old man was referred to our department with clinical signs of septic shock and necrotizing soft tissue infection of the scrotal, perianal and right inguinal region. Initial presentation was a typical Fournier’s gangrene. Because of the life-threatening condition, the initial treatment was extensive removal of necrotic tissue. Antibiotic therapy was administered and several debridements of the wound were done afterwards. Three weeks after the initial treatment, wide wound defects of the perianal, scrotal and inguinal regions were closed secondarily and the patient was discharged from the hospital. Fournier’s gangrene is a surgical emergency. Although rare, it remains a life-threatening disease. Rapid and accurate diagnosis remains the key component in achieving successful outcome. Early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics is the essential management to reduce mortality., Šezdesetpetogodišnji muškarac je primljen u našu ustanovu s kliničkom slikom septičkog šoka i nekroze u skrotalnom, perianalnom i desnostranom ingvinalnom području. Postavljena je dijagnoza Fournierove gangrene. Zbog lošeg općeg stanja bolesnik je odmah kirurški zbrinut, učinjena je opsežna nekrektomja. Antibiotska terapija je ordinirana, a nakon prve operacije je učinjeno nekoliko debridmana rane. Sedamnaest dana nakon operacije su postavljeni sekundarni šavi, a 23. dana bolesnik je otpušten na kućnu njegu. Fournierova gangrena je hitno kirurško stanje te, iako je rijetka, predstavlja tešku i za život opasnu bolest. Brza i točna dijagnostika uz agresivnu kiruršku terapiju i opetovane debridmane te antibiotici širokog spektra i dalje su ključ uspješnog liječenja.

The aim of this study was to determine the incidence of acute angle-closure glaucoma in Split-Dalmatia County and correlation between visual acuity and time (days) elapsed from the disease onset to hospital admission. Twenty-nine cases were retrospectively analyzed. There were 19 female patients aged 36-91 (median age 68) years and 10 male patients aged 35-88 (median age 70) years, with attacks of acute closure glaucoma treated at University Department of Ophthalmology, Split University Hospital Center from January 2002 until December 2005. Annual incidence was 1.6 cases per 100,000. The time elapsed from the disease onset to hospital admission was 1-21 (median 2) days. Visual acuity before and after treatment was reversely proportional to the number of days to hospital admission (d=0.466; p=0.011). Visual acuity was found to depend on age as well (z=1.999; p=0.044). The best visual acuity was obtained in those cases that were admitted within two days (z=2.014; p=0.044). There was no significant sex difference in the incidence of angle-closure glaucoma (t=0.389; p=0.699). No statistically significant association was found between acute angle-closure glaucoma and seasonal variation (χ2=5; p=0.167). In conclusion, earlier recognition of the symptoms of acute angle-closure glaucoma and initiation of treatment within two days of the disease onset were associated with better visual acuity., Cilj ove studije bio je odrediti incidenciju akutnih napada glaukoma zatvorenog kuta u Splitsko-dalmatinskoj županiji te ispitati odnos između oštrine vida i broja dana od početka bolesti do hospitalizacije. Ova studija je provedena retrospektivno na 29 slučajeva. Bilo je ukupno 19 žena u dobi od 36 do 91 godine (medijan 68 godina) i 10 muškaraca u dobi od 35 do 88 godina (medijan 70 godina) s akutnim napadima glaukoma zatvorenog kuta liječenih na Očnoj klinici Kliničkog bolničkog centra Split od siječnja 2002. do prosinca 2005. godine. Godišnja incidencija iznosila je 1,6 slučajeva na 100.000. Vrijeme od početka bolesti do javljanja u bolnicu iznosilo je od 1 do 21 dana (medijan 2 dana). Oštrina vida prije i poslije operacije bila je obrnuto proporcionalna broju dana do prijma u bolnicu (d=-0,466; p=0,011). Oštrina vida nakon liječenja ovisila je o ranijem javljanju u bolnicu te o ranije započetom liječenju. Za krajnji ishod oštrine vida je uz ranije javljanje na liječenje bila važna i dob (z=1,999; p=0,044). Najbolju oštrinu vida nakon liječenja imali su oni bolesnici koji su hospitalizirani u prva dva dana (z=2,014; p=0,044). Nije bilo statistički značajne razlike u obolijevanju po dobi između žena i muškaraca (t=0,389, p=0,699), kao ni po godišnjem dobu (c2=5; p=0,167). U zaključku, ranije prepoznavanje simptoma i liječenje akutnog glaukoma zatvorenog kuta započeto u prva dva dana bilo je povezano s boljom vidnom oštrinom.

The objective of this prospective observational study was to determine and document the time elapsed from symptom onset to hospital admission in patients with acute stroke. The study was conducted at Emergency Department, University Department of Neurology, Split University Hospital in Split, Croatia, from October 1, 2004 to December 21, 2004, and included 115 patients with acute stroke. Data on the time of onset of stroke symptoms, brain computed tomography finding and current clinical status were noted. Fifteen patients were excluded from the study because the exact time of symptom onset could not be determined. A standardized interview with patients and/or their relatives was taken to collect the information needed. Ischemic stroke was diagnosed in 82 of 100 patients. Only 13 patients arrived in hospital within 3 hours of stroke symptom onset, and 29 were admitted to hospital more than 24 hours of stroke symptom onset. Sex had no significant effect on arrival time. It was concluded that the majority of patients with acute stroke did not present to emergency department within 3 hours of symptom onset, the current time window for thrombolytic therapy. It seems crucial to identify the factors associated with late presentation to the hospital. Public recognition of stroke symptoms and understanding of the importance of early hospital admission are mandatory for improving the results recorded in this study with time elapsed from symptom onset to hospital admission and eligibility for thrombolytic therapy taken as the main outcome measures. Additional public education is needed to increase awareness of the stroke warning signs., Cilj ove prospektivne opservacijske studije bio je utvrditi i dokumentirati vrijeme proteklo od nastupa simptoma do prijema u bolnicu kod bolesnika s akutnim moždanim udarom. Studija je provedena na Hitnom odjelu Klinike za neurolog¬iju, Kliničke bolnice Split u Splitu od 1. listopada 2004. do 21. prosinca 2004. godine i uključila je 115 bolesnika s akutnim moždanim udarom. Bilježili su se podatci o vremenu nastupa simptoma moždanog udara, nalazu kompjutorizirane tomografije mozga i aktualnom kliničkom statusu. Iz studije je isključeno 15 bolesnika u kojih se točno vrijeme nastupa simptoma nije moglo utvrditi. Proveden je standardizirani razgovor s bolesnicima i/ili njihovom rodbinom kako bi se dobile potrebne informacije. Ishemijski moždani udar je utvrđen u 82 od 100 bolesnika. Samo je 13 bolesnika stiglo u bolnicu unutar 3 sata od nastupa simptoma akutnog moždanog udara, a 29 ih je u bolnicu primljeno vi.e od 24 sata od nastupa simptoma. Spol nije imao značajnog utjecaja na vrijeme dolaska u bolnicu. Rezultati su pokazali kako većina bolesnika s akutnim moždanim udarom nije pristigla na hitni odjel unutar 3 sata od nastupa simptoma, što danas predstavlja vremen¬ski okvir za trombolitičnu terapiju. Od ključne je važnosti utvrditi čimbenike koji su povezani sa zakašnjelim dolaskom u bolnicu. Opće prepoznavanje simptoma moždanog udara i shvaćanje važnosti ranog prijema u bolnicu neophodno je za poboljšanje rezultata dobivenih u ovoj studiji, u kojoj su glavne mjere ishoda bili vrijeme proteklo od nastupa simptoma do prijema u bolnicu i podobnost za trombolitičnu terapiju. Potrebna je daljnja izobrazba javnosti kako bi se povećala svijest o upozoravajućim znacima moždanoga udara.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) has recently reached the goal of becoming standard therapy in the acute stage of ischemic stroke in many countries. This appears to be one of the first pilot study reports from the region of Central and Eastern Europe. From January 1998 till October 2002, 56 consecutive patients underwent rt-PA thrombolysis at the University Department of Neurology, Nitra University Hospital, Slovakia. Selection criteria for the study were based on the NINDS study, with emphasis on the 3-hour therapeutic window. The mean baseline NIHSS wasR14.5, mean therapeutic interval 167 minutes, and mean intravenous rt-PA dose 0.7 mg/kg body weight. AtR3 months, mRS 0-1 was recorded in 33.9%, mRS 2-3 in 37.5%, and mRS 4-5 in 16.1% of study patients. Clinically relevant mRS 0-2 was achieved in 44.6% of study patients. The mortality was 12.5%. The rate of symptomatic and fatal intracerebral hemorrhage was 8.9% and 5.3%, respectively. Asymptomatic hemorrhagic transformation of a benign course was relatively frequently recorded (19.6%). Results of the study showed our stroke patients treated with intravenous rt-PA to have a favorable prognosis, and were comparable with those reported from the NINDS study and recent clinical studies., Intravenska tromboliza pomoću rekombinantnog aktivatora tkivnog plazminogena (rt-PA) odnedavno je postigla svoj cilj i u mnogim zemljama postala standardnim načinom liječenja akutnog stadija ishemijskog moždanog udara. Ovo je, čini se, jedno od prvih objavljenih probnih ispitivanja u području središnje i istočne Europe. U razdoblju od siječnja 1998. do listopada 2002. godine je na Klinici za neurologiju Sveučilišne bolnice Nitra iz Nitre, Slovačka, 56 uzastopnih bolesnika podvrgnuto trombolizi. Kriteriji za odabir bolesnika zasnivali su se na studiji NINDS, poglavito terapijski prozor od 3 sata. Postignuli smo prosječan bazalni NIHSS od 14,5, prosječan terapijski interval bio je 167 minuta, a prosječena doza intravenskog rt-PA bila je 0,7 mg/kg tjelesne težine. Nakon 3 mjeseca mRS 0-1 dostignulo je 33,9%, mRS 2-3 37,5%, te mRS 4-5 16,1% bolesnika. Klinički važan mRS 0-2 postiglo je 44,6% bolesnika. Smrtnost je bila 12,5%. Stopa simptomatskog unutarmoždanog krvarenja bila je 8,9%, a fatalnog 5,3%. Asimptomatska hemoragijska transformacija bila je relativno česta, tj. u 19,6% bolesnika s benignim tijekom. Zaključeno je kako bolesnici s moždanim udarom koji se liječe intravenskom rt-PA trombolizom u našoj bolnici imaju dobru prognozu, usporedivu s rezultatima studije NINDS i drugim novijim kliničkim studijama.

Rapidly progressive periodontitis (RPP) results from the interaction between the periodontal microflora and the host. Stress is believed to play an important role in determining host responses, and it has been proposed that hyperactivity of host defense mechanism significantly incresed tissue destruction tipical for this disease. During period of four months we have diagnosed 20 patients with acute RPP, all of them active participants in battles of the Croatian liberation war with posttraumatic stress disorder (PTSD) related simptoms. In these patients we analysed biochemical parameters in unstimulated saliva and performed microbiological analysis of periodontal pockets. These findings we compared with those of patients with adult periodontitis (AP), edentulous and healthy persons, none of whom participated in the war. Persons with AP had reduced concentrations of host humoral defense factors in saliva (C-reactive protein, C3 component of complement and alpha-2 macroglobulin), while patients with RPP had increased concentration of interleukin-6 (IL-6). IL-6 is released by host inflammatory cells and is mediator of bone resorption. Actinobacillus actinomycemcomitans and Peptostreptococcus were more frequently isolated in patients with RPP. We interpret these results as indicators of the importance of stress in causation of RPP, with host inflammatory hyperactivity playing an imporatnt role in tissue destruction, especially alveolar bone resorption, possibly caused by increased local levels of IL-6.