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The goal of therapy with vitamin K antagonists (warfarin), and new direct oral anticoagulant drugs (NOAC or DOAC) is the prevention of stroke and embolic events in patients with non-valvular atrial fibrillation and treatment and prevention of venous thromboembolism. In all cases it is necessary to determine renal function with creatinine clearance because it determines the choice and dosage of NOAC’s. It is extremely important to pay attention to older patients with a number of associated conditions and drug interactions, with a high incidence of neurological symptoms and worse outcomes. Oral anticoagulation can represent a challenge, especially in cases of drug overdose or emergencies such as bleeding and need for urgent surgery. The need for the guidelines has emerged during the last years because of new classes of oral anticoagulants being prescribed more frequently. The expert working group of emergency specialists was formed and gathered on Consensus Conference in October 2015 in Zagreb, to design guidelines for the patients with NOAC therapy and provides details of preoperative management and managements in emergency conditions.

Physicians are very often called on by their patients to give lifestyle advice to reduce the odds of contracting a certain disease. Also, it is necessary for physicians to adequately choose among different therapeutic modalities for any given disease. The data that may make these choices easier come in part from cohort and case-control studies. These studies are of relatively low cost and simple to undertake and the results are available in a relatively short time. However, one must be aware of advantages and disadvantages of these types of studies so that the results can be interpreted with certainty in order to make correct clinical decisions., Liječnici vrlo često svojim bolesnicima trebaju dati savjet o stilu života kako bi se na najmanju moguću mjeru svela vjerojatnost od oboljenja od neke bolesti. Također, potrebno je odabrati i ispravan lijek za liječenje određenih bolesti. Podatke koji im mogu olakšati ove odluke moguće je pronaći i u kohortnim i case-control studijama. Ove studije su relativno jeftine, jednostavne za provođenje, a rezultati su dostupni u relativno kratkom vremenu. Međutim, potrebno je biti svjestan prednosti i nedostataka ovakvih studija kako bi se rezultati mogli interpretirati sa sigurnošću i kako bi se mogle donositi ispravne kliničke odluke.

Cilj terapije antagonistima vitamina K (varfarin) i novim oralnim antikoagulantnim lijekovima (NOAK-ima) jesu prevencija moždanog udara i drugih embolija kod bolesnika s nevalvularnom fibrilacijom atrija te liječenje i prevencija venske tromboembolije. Kod svih bolesnika potrebno je odrediti bubrežnu funkciju klirensom kreatina jer o tome ovise izbor i doziranje NOAK-a. Izuzetno je važno obratiti pozornost na starije bolesnike s brojnim pridruženim stanjima i interakcijama lijekova zbog velike učestalosti neuroloških simptoma i lošijeg ishoda. Oralno antikoagulantno liječenje izazov je, posebno u stanjima nenamjernog predoziranja lijeka, u krvarenjima ili u stanjima hitnoga prijeoperacijskog zbrinjavanja. Zbog sve većeg broja bolesnika koji uzimaju NOAK-e osnovana je 2015. godine ekspertna grupa specijalista hitne medicine koja je u listopadu 2015. održala u Zagrebu Konsenzusnu konferenciju radi donošenja postupnika za prijeoperacijsko zbrinjavanje i zbrinjavanje bolesnika u hitnim stanjima koji uzimaju NOAK-e u Hrvatskoj.

Background Ultrasound and liver function tests (serum bilirubin and serum alkaline phosphatase) are used as screening tests for the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ultrasound and liver function tests. Objectives To determine and compare the accuracy of ultrasound versus liver function tests for the diagnosis of common bile duct stones. Search methods We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. We searched the references of included studies to identify further studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects, Health Technology Assessment, Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ultrasound, serum bilirubin, or serum alkaline phosphatase. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test result, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test result as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently. Data collection and analysis Two authors independently collected data from each study. Where meta-analysis was possible, we used the bivariate model to summarise sensitivity and specificity. Main results Five studies including 523 participants reported the diagnostic accuracy of ultrasound. One studies (262 participants) compared the accuracy of ultrasound, serum bilirubin and serum alkaline phosphatase in the same participants. All the studies included people with symptoms. One study included only participants without previous cholecystectomy but this information was not available from the remaining studies. All the studies were of poor methodological quality. The sensitivities for ultrasound ranged from 0.32 to 1.00, and the specificities ranged from 0.77 to 0.97. The summary sensitivity was 0.73 (95% CI 0.44 to 0.90) and the specificity was 0.91 (95% CI 0.84 to 0.95). At the median pre-test probability of common bile duct stones of 0.408, the post-test probability (95% CI) associated with positive ultrasound tests was 0.85 (95% CI 0.75 to 0.91), and negative ultrasound tests was 0.17 (95% CI 0.08 to 0.33). The single study of liver function tests reported diagnostic accuracy at two cut-offs for bilirubin (greater than 22.23 μmol/L and greater than twice the normal limit) and two cut-offs for alkaline phosphatase (greater than 125 IU/L and greater than twice the normal limit). This study also assessed ultrasound and reported higher sensitivities for bilirubin and alkaline phosphatase at both cut-offs but the specificities of the markers were higher at only the greater than twice the normal limit cut-off. The sensitivity for ultrasound was 0.32 (95% CI 0.15 to 0.54), bilirubin (cut-off greater than 22.23 μmol/L) was 0.84 (95% CI 0.64 to 0.95), and alkaline phosphatase (cut-off greater than 125 IU/L) was 0.92 (95% CI 0.74 to 0.99). The specificity for ultrasound was 0.95 (95% CI 0.91 to 0.97), bilirubin (cut-off greater than 22.23 μmol/L) was 0.91 (95% CI 0.86 to 0.94), and alkaline phosphatase (cut-off greater than 125 IU/L) was 0.79 (95% CI 0.74 to 0.84). No study reported the diagnostic accuracy of a combination of bilirubin and alkaline phosphatase, or combinations with ultrasound. Authors' conclusions Many people may have common bile duct stones in spite of having a negative ultrasound or liver function test. Such people may have to be re-tested with other modalities if the clinical suspicion of common bile duct stones is very high because of their symptoms. False-positive results are also possible and further non-invasive testing is recommended to confirm common bile duct stones to avoid the risks of invasive testing. It should be noted that these results were based on few studies of poor methodological quality and the results for ultrasound varied considerably between studies. Therefore, the results should be interpreted with caution. Further studies of high methodological quality are necessary to determine the diagnostic accuracy of ultrasound and liver function tests.

Već dulji niz godina endoskopija je nezaobilazna u dijagnostici gastrointestinalnih, uroloških i plućnih malignih oboljenja. Novije endoskopske metode, zahvaljujući tehnikama poboljšanja slike, pružaju sve više mogućnosti za točnu dijagnozu već tijekom endoskopskog pregleda. U posljednje vrijeme unaprjeđenjem endoskopskih tehnika moguće je odstraniti sve veći broj već razvijenih malignih lezija ili učiniti neki od palijativnih zahvata u svrhu održanja prohodnosti probavne cijevi., Endoscopy is corner stone in diagnostics of gastrointestinal, urological and pumological malignancies. Some newer imaging enhancement techniques improve diagnostics accuracy during endoscopy. Endoscopy now offers a greater possibility of removing malignant lesions or performing palliative procedure sin order to maintain patency of gastrointestinal tract.

Već dulji niz godina endoskopija je nezaobilazna u dijagnostici gastrointestinalnih, uroloških i plućnih malignih oboljenja. Novije endoskopske metode, zahvaljujući tehnikama poboljšanja slike, pružaju sve više mogućnosti za točnu dijagnozu već tijekom endoskopskog pregleda. U posljednje vrijeme unaprjeđenjem endoskopskih tehnika moguće je odstraniti sve veći broj već razvijenih malignih lezija ili učiniti neki od palijativnih zahvata u svrhu održanja prohodnosti probavne cijevi., Endoscopy is corner stone in diagnostics of gastrointestinal, urological and pumological malignancies. Some newer imaging enhancement techniques improve diagnostics accuracy during endoscopy. Endoscopy now offers a greater possibility of removing malignant lesions or performing palliative procedure sin order to maintain patency of gastrointestinal tract.

Although celiac disease (CD) may occur in patients with other immune-mediated disorders, its coexistence with multiple autoimmune diseases is not frequently described. We report the case of a 23-year-old woman referred to our centre because of jaundice and diarrhoea, who was diagnosed with CD in childhood. She complied with a gluten-free diet until puberty. Laboratory tests and liver biopsy were performed to establish the diagnosis of autoimmune hepatitis. Her thyroid- specific peroxides levels and thyroid gland function tests were altered as well, indicating the presence of an autoimmune disorder of the thyroid gland. Immunosuppressive treatment led to normalization of transaminases levels and bilirubin. In conclusion, other autoimmune diseases should be ruled out in patients with CD., Iako celijakija ili glutenska enteropatija može biti udružena s drugim imunološkim bolestima, udruženost celijakije s više autoimunih bolesti nije česta. U ovom radu prikazujemo slučaj 23- godišnje bolesnice, liječene u našem Centru zbog ikterusa i proljeva, a kojoj je dijagnoza celijakije postavljena još u djetinjstvu. Do početka puberteta pacijentica se pridržavala bezglutenske dijete. Tijekom boravka u našem Centru, učinjenom dijagnostičkom obradom (laboratorijski pokazatelji i patohistološki nalaz bioptata jetre), dokazan je autoimuni hepatitis. Nadalje, funkcionalni testovi štitnjače, kao i pozitivan nalaz antitijela na tkivnu peroksidazu, ukazivali su na autoimunu bolest štitnjače. Primjenom imunosupresivne terapije došlo je do normalizacije vrijednosti aminotransferaza, kao i regresije ikterusa. Slijedom navedenog, u bolesnika s celijakijom nužno je razmišljati i o drugim imunološkim bolestima.