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Diabetes and its complications causes up to 9% of total mortality worldwide. Peripheral arterial disease is, in addition to cardiovascular diseases, the most common complication of diabetes with a prevalence that increases with age and the duration of diabetes. The specificity of peripheral artery disease in diabetics is the diffuse involvement of the arterial system, especially the popliteal arteries. Consequently, diabetes is still the main cause of small and large limb amputations, which, in addition to a reduction in the quality of life, significantly affects the survival of patients. Since the developed of atherosclerotic disease involves a number of complications from the professional domain of various subspecialties, such as diabetic foot, it is necessary to organize multidisciplinary teams for the diagnostic and therapeutic purposes. For this purpose, the General Hospital “Dr. Josip Benčević” in Slavonski Brod organized a multidisciplinary team with the goal of early recognition of peripheral artery disease and application of timely treatment. Experience from everyday clinical practice indicates that proper functioning of the team requires an accurate diagnostic and therapeutic algorithm to avoid long waiting lists for imaging, which includes Color Doppler and multislice computed tomography. The diagnostic algorithm was based on the ankle-brachial index, and its value and clinical picture guided and determined the degree of urgency and the type of image processing. By integrating the algorithm into the online database registry, we were able to more easily monitor the incidence rate, treatment success, and dependence on the entered variables. We hope that this approach will result in earlier detection of symptomatic disease and thus a significant reduction in lower limb amputations and, ultimately, mortality., Šećerna bolest sa svojim komplikacijama uzrokuje 9 % ukupne smrtnosti diljem svijeta. Periferna arterijska bolest, uz kardiovaskularne bolesti, najčešća je komplikacija šećerne bolesti, čija prevalencija raste s dobi i duljinom trajanja dijabetesa. Specifičnost periferne arterijske bolesti u dijabetičara jest difuzno zahvaćanje arterijskog sustava, poglavito potkoljeničnih arterija. Posljedično tomu, dijabetes je i dalje glavni uzrok malih i velikih amputacija ekstremiteta, što, uz smanjenje kvalitete života, znatno utječe i na preživljenje bolesnika. Budući da razvijena aterosklerotska bolest uključuje niz komplikacija iz stručne domene različitih užih specijalnosti, poput dijabetičkog stopala, u dijagnostici i liječenju nužno je organizirati multidisciplinarne timove. U tu svrhu u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu organiziran je multidisciplinarni tim sa svrhom ranog prepoznavanja periferne arterijske bolesti te pravodobnog liječenja. Dosadašnje iskustvo iz svakodnevne kliničke prakse pokazuje da je za pravilno funkcioniranje tima nužno imati precizan dijagnostičko-terapijski algoritam kako bi se izbjegle duge liste čekanja za slikovnu obradu koja uključuje dupleks ultrazvuk i višeslojnu kompjutoriziranu tomografiju. Dijagnostički algoritam temeljio se na vrijednostima gležanjskog indeksa, a njegova vrijednost i klinička slika usmjeruju i određuju stupanj hitnosti i tip slikovne obrade. Integriranjem algoritma u on-line registar baze podataka dobili smo mogućnost lakšeg praćenja stope učestalosti, uspješnosti liječenja i ovisnosti o unesenim varijablama. Nadamo se da će takav način rada rezultirati ranijim otkrivanjem simptomatske bolesti, a time i znatnim smanjenjem amputacija donjih ekstremiteta te naposljetku i smrtnosti.

Aim: Takotsubo cardiomyopathy is a transient dysfunction of the heart muscle that occurs in response to a stressful event. A working diagnosis is mostly made for acute ischemic heart disease due to similar clinical presentation and differential diagnostic doubts. Although it is a reversible disorder of cardiac contractility, mortality rate is similar to that of an acute coronary syndrome due to the development of complications. We report the case of a patient with chronic kidney disease and the consequent development of Takotsubo cardiomyopathy, a possible pathophysiological link that has not been reported in the significant number in literature so far. Case report: An 83-year-old patient on a chronic hemodialysis program, due to the development of anginal symptoms specific for the acute coronary syndrome and with a significant increase in cardiospecific enzymes, was transferred to the Coronary care unit for the necessary invasive cardiac treatment. Echocardiographic and coronarographic findings confirmed the diagnosis of Takotsubo cardiomyopathy, which was the first case in a patient on chronic hemodialysis program in our institution. Conslusions: According to available data, about 30 cases of Takotsubo cardiomyopathy have been reported so far, indicating that transient myocardial dysfunction is a rare cardiomyopathy in patients with chronic kidney disease. A small number of literature-recorded cases do not support the similar pathophysiological basis of increased sympathetic activity present in Takotsubo cardiomyopathy and chronic kidney disease., Sažetak. Cilj: Takotsubo kardiomiopatija prolazna je disfunkcija srčanog mišića koja nastaje kao odgovor organizma na stresorni događaj. Radna se dijagnoza većinom postavlja za akutnu ishemijsku bolest srca radi slične kliničke prezentacije i diferencijalnih dijagnostičkih dvojbi. Iako se radi o reverzibilnom poremećaju srčane kontraktilnosti, smrtnost je slična akutnom koronarnom sindromu uslijed razvoja komplikacija. Izvještavamo slučaj pacijentice s kroničnom bubrežnom bolesti i posljedičnim razvojem Takotsubo kardiomiopatije, moguće patofiziološke poveznice koja do sada literaturno nije zabilježena u značajnom broju. Prikaz slučaja: 83-godišnja pacijentica na programu kronične hemodijalize, uslijed razvoja anginoznih tegoba specifičnih za akutni koronarni sindrom te uz značajan porast kardiospecifičnih enzima, premještena je u koronarnu jedinicu radi potrebne invazivne kardiološke obrade. Ehokardiografski i koronarografski nalaz potvrdio je dijagnozu Takotsubo kardiomiopatije, što je ujedno prvi zabilježen slučaj u pacijenta na programu kronične hemodijalize u našoj ustanovi. Zaključci: Prema dostupnim podatcima, do sada je zabilježeno oko 30 slučajeva Takotsubo kardiomiopatije kod bubrežnih bolesnika, što pokazuje da je prolazna disfunkcija miokarda rijetka kardiomiopatija u pacijenata s kroničnom bubrežnom bolesti. Mali broj literaturno zabilježenih slučajeva ne ide u prilog sličnoj patofiziološkoj osnovi povećane simpatičke aktivnosti prisutne kod Takotsubo kardiomiopatije i kronične bubrežne bolesti.

SUMMARY Postpericardiotomy syndrome (PPS) is worsening or new formation of pericardial and/or pleural effusion mostly 1 to 6 weeks after cardiac surgery, as a result of autoimmune inflammatory reaction within pleural and pericardial space. Its incidence varies among different studies and registries (2% to 30%), as well as according to the type of cardiac surgery performed. We conducted this retrospective analysis of PPS incidence and diagnostic and treatment strategies in patients referred for cardiac surgery for revascularization, valvular and/or aortic surgery. We retrospectively analyzed 461 patients referred for an urgent or elective cardiac surgery procedure between 2009 and 2015. PPS diagnosis was established using well defined clinical criteria. Demographic and clinical characteristics were used in regression subanalysis among patients having undergone surgery of aortic valve and/or ascending aorta. Within 6 weeks after cardiac surgery, 47 (10.2%) patients had PPS. The median time from the procedure to PPS diagnosis was 14 days. The incidence of PPS was 26% after aortic valve and/or aorta surgery, and 7.9% and 8.3% after coronary bypass and mitral valve surgery, respectively. Among patients subjected to aortic valve and/or aortic surgery, regression analysis showed significant association of fever, C-reactive protein (CRP) elevation between 5 and 100 mg/L, urgent procedure and postoperative antibiotic use with PPS diagnosis, whereas younger age showed near-significant association. All patients had complete resolution of PPS, mostly after corticosteroid therapy, with only 2 cases of recurrent PPS that successfully resolved after colchicine therapy. Pleural drainage was indicated in 15 (32%) patients, whereas only one patient required pericardial drainage. In conclusion, PPS incidence in our retrospective analysis was similar to previous reports. Patients having undergone aortic valve and/or aortic surgery were most likely to develop PPS. The most relevant clinical criteria for diagnosis in these patients were fever, CRP elevation between 5 and 100 mg/L, and pericardial and/or pleural effusion formation or worsening 2 weeks after cardiac surgery.

Sažetak Background: Provisional stenting is a favorable option for most bifurcation lesions, while two stent techniques show benefits in true bifurcation performed by experts. Using one stent and DCB in true bifurcation lesions still remains questionable.1, 2 Case report: 76-year-old male presented with persisting chest pain. ECG showed no specific ischemic changes, while hsTnI was highly elevated. He had gone PCI LAD 14 years ago. Diagnosis: right coronary angiography revealed occlusion of RCA, while left coronary angiography revealed LLS of 20% in proximal LAD stent, 70% stenosis of mid LAD, and acute occlusion of secondary OM branch on bifurcation level, while CxA was stenosed 70-80%. Management: PCI CxA-OM2 was performed with DES Xience expedition 2, 75/33mm in CxA-OM2 with POT 3, 25/12mm proximally, then after rewiring and adequate lesion preparation a DEB Sequent please 2, 5/25mm in CxA distally was performed. After two months we performed an elective PCI LAD and checked out the result of CxA bifurcation which was optimal. Conclusion: Using one stent and DCB in true bifurcation lesions still remains questionable. There are no data from a prospective study, while there are data from the observational study which enrolled 130 patients. DCB-only strategy was performed in 54% patients, 34.6% had at least one stent in the main branch, 8.5% had at least one stent in the side branch and 3.1% at least one stent in the main branch and side branch. Study follow up lasted for 9.8 months. The TLR rate was 4.5%, MACE was 6.1%, and no stent thrombosis was detected. This study suggested that the DCB+one stent, and DCB-only strategy was safe and effective in selected bifurcations, possibly allowing for an abbreviated antiplatelet regimen.

Introduction: There are limited study data available of the effects of peripheral artery disease (PAD) on patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). According to the PROGRESS-CTO Registry results patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions and lower procedural success.1-3 We present the case of successful opening in stent CTO lesion of right coronary artery (RCA) in patient with PAD. Case report: 59-year-old man with a known history of a coronary vessel disease and PAD presented to our department due to frequent episodes of chest pain under minimal exercise and claudication and pain in the buttocks. The coronary angiography showed unchanged exam in left coronary basin. The RCA was completely occluded in segment two right in the area of the stent that was implanted eight years before. We found collaterals from the left coronary artery system and signs of calcification and autocollaterals for the distal segment of RCA, so the diagnostically criteria of a CTO were fulfilled. Because of the present symptoms of the patient and evidence for vital myocardium by echocardiography and myocardial scintigraphy revascularization of the CTO was performed. An AL 0.75 6F guidance catheter was used and the standard antegrade wire escalation technique attempted. A Turnpike Spiral catheter was inserted with the help of a ASAHI Fielder XT-A wire which was exchanged to an ASAHI Gaia Second which allowed the successful recanalization. Balloon angioplasty was performed with Abbot Traveler 1.5/15mm, Medtronic Euphora 2.57/15mm. Two sirolimus eluting stents (Terumo Ultimaster 3.0/38 mm and Ultimaster 3.0/30 mm) were successfully implanted with very good angiographic result. Three months later, chronic total occlusion of the left external iliac artery was treated successfully by percutaneous intervention and control coronary angiography showed unchanged exam in RCA. Conclusion: Our experience in this case demonstrates the feasibility of recanalization of an in-stent CTO in the patient with PAD and three months follow up showed improved of angina and quality of life. There is a definite and strong correlation between PAD and CAD. A concurrent PAD diagnosis is associated with higher rates of adverse outcomes following CTO PCI which requires additional monitoring.

The aim of the study was to determine whether serum vitamin D level is lower in female patients with glaucoma as compared with control group. The mechanism by which vitamin D reduces intraocular pressure is not fully clarified. Almost all tissues possess vitamin D receptor (VDR). The mice lacking VDR (VDR knockout mice) have greatly contributed to the understanding of the general vitamin D physiologic function. VDR has been found in some ganglion layer cells, external and internal nuclear layers of retina, and in retinal pigment epithelium, while VDR epitopes have also been found in the ciliary body epithelium, pointing to the role of this protein in eye physiology. The 1,25(OH)2D3 modulates expression of the genes involved in the regulation of intraocular pressure in non-human primates. Extracellular matrix can be remodeled by 1,25(OH)2D3 treatment. Actin disruption can lead to cell morphology alteration, trabecular meshwork relaxation and intraocular pressure reduction. This observational cross-sectional study included 90 female glaucoma subjects aged 45-55 and 50 glaucoma free female subjects as control group. Results of a pilot study conducted in 20 glaucoma subjects and 20 control subjects are presented below. All study subjects underwent history taking, complete ophthalmologic examination and serum vitamin D determination. The mean serum vitamin D level was 32.31 nmol/L in glaucoma patients and 64.17 nmol/L in control subjects. Serum vitamin D level was statistically significantly lower in glaucoma patients as compared with control group (p

Objective: Vitamin D deficiency has been associated with cardiovascular disease. The aim of this study was to determine serum concentration of 25 hydroxyvitamin D (25(OH)D) in patients with acute coronary syndrome (ACS) and to assess the prognostic role of serum vitamin D level in ACS patients during 3-year follow up. Methods: The study included 60 ACS patients hospitalized at cardiology department for ACS between March 2012 and October 2012, and 60 age- and sex-matched control patients without ACS. Standard laboratory testing and vitamin D determination were performed in all study patients. In addition, ACS patients underwent coronarography and were followed-up for 36 months of ACS for major adverse cardiac events (MACE). Results: Patients with ACS had a statistically significantly lower mean 25(OH)D level as compared with control group (35.19 nmol/L vs. 58.08 nmol/L, p < 0.001). The lowest mean level of 25(OH)D was recorded in diabetic patients with ACS (30.45 nmol/L). ACS patients were divided into three subgroups according to coronarography findings: single vessel, double vessel and triple vessel coronary artery disease (CAD) with respective serum levels of 25(OH)D of 36.44 nmol/L, 33.65 nmol/L and 31.70 nmol/L. During 36-month follow up, the event-free survival rate was 60% in the ACS group. The ACS patients having sustained MACE during follow up had low serum level of 25(OH)D in the acute phase; however, the difference from ACS patients without MACE during follow up did not reach statistical significance (32.64 nmol/L vs. 37.01 nmol/L). Conclusions: Patients with ACS have low vitamin D level, which is lowest in diabetic patients with ACS. However, during 3-year follow up, vitamin D failed to prove useful as a prognostic biomarker in ACS patients.

The acute coronary syndrome (ACS) network is a complex system of concern for patients with acute coronary syndrome. In order to provide adequate patient care, reduce total mortality and irrational costs of treatment, we need varied algorithms and a patient concern protocols. Outhospital emergency medical services, intrahospital emergency rooms, and coronary care units in percutaneous coronary intervention (PCI) and nonPCI centers participate in the care of ACS patients. Therefore, only algorithms adapted to each of these levels can improve the protocol for patient care. By standardized protocol implementation since January 2016, we compared the results with respect to the total number of patients before the protocol was applied. We analyzed the total number of patients, the relationship between the number of transferred and non-transferred patients, the intra-hospital mortality as well as the total mortality for ST- elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction patients (NSTEMI). The results show that the standardized protocol increases the total number of PCIs in patients with ACS, namely 36% for STEMI and 20% for NSTEMI. However, the total mortality of STEMI patients has increased from 5.2% to 6.9%, which is a consequence of an increased number of patients with cardiogenic shock (2.5% to 7.8%), as well as inappropriately high rates of transfer time from nonPCI hospitals (average time was 160 min). In patients with NSTEMI we recorded an increase in the total number of patients by 20%, while total mortality rate has not been changed. However, we should point out a favorable trend in the increase of PCI within 72 hours in NSTEMI patients. The standardized protocol, along with other organizational improvements, has led to the primary goal of increasing the number of primary PCIs in STEMI and PCI at ACS-NSTEMI at an early stage. It has also revealed the need for additional effort to increase the quality of treatment in terms of reducing patient delay time, proper recognition of STEMI by the outhospital emergency services, as well as the need to reduce transport time for transferred patients. If a transfer within 120 minutes cannot be provided we recommend pharmacoinvasive approach to be applied.

Postperikardiotomni sindrom (PPS) je klinicki sindrom koji nastaje u sklopu autoimune upalne reakcije perikarda i pleure, a klinicki se manifestira novonastalim ili pogorsanjem prisutnog perikardijalnog ili pleuralnog izljeva. Javlja se od prvog do sestog tjedna nakon kardiokiruskih zahvata i spada među najcesce komplikacije kardijalne kirurgije. Ucestalost pojavnosti bolesti je raznolika od 2-30% i ovisi o tipu kardiokirurskog zahvata.1-3 Retrospektivnom analizom PPS registra u Opcoj bolnici “Dr. Josip Bencevic” Slavonski Brod u razdoblju od 1. ožujka 2009. do 1. listopada 2015. godine ucestalost PPS- a sveukupno, neovisno o tipu kardiokiruskog zahvata, iznosila je 10, 1 % , dok je ucestalost PPS-a kod bolesnika podvrgnutih kirurgiji aortne valvule iznosila 26 %. Rutinskim probirom bolesnika dva do cetiri tjedna iza operativnog zahvata moguce je na osnovu jednostavnih dijagnostic- kih kriterija postaviti dijagnozu i zapoceti adekvatno lijecenje, s postizanjem remisije u vise od 95 % bolesnika. U dijagnostici bolesti povisen CRP i febrilitet imaju snažnu prediktivnu vrijednost te su uz prisutnost pleuralnog/perikardijalnog izljeva dovoljni kriteriji za dijagnozu bolesti. Lijecenje se provodi primjenom NSAR, kolhicina ili kortikosteroidima. Profilakticka primjena kolhicina prema COPPS studiji smanjuje ucestalost pojave PPS. Iako za sada nema jasnih preporuka za profilaksu, prema nasem istraživanju, identifikacija bolesnika s visokim rizikom na osnovu tipa operacije, dobi i drugih klinickih parametara podupire hipotezu o korisnosti profilakse.

Introduction and goal: The latest 2011 non-ST- segment elevation acute coronary syndromes (NSTE- ACS) management guidelines indicated that all patients should receive anticoagulation drugs irrespective of the treatment strategy. In this report, 2-year data on anticoagulation therapies for NSTE-ACS are presented, in relation to invasive management selection and treatment outcomes in a clinical setting without registered bivalirudin. Patients and Methods: Data for 374 patients with NSTEACS treated in the Coronary Care Unit in General Hospital Slavonski Brod, Croatia were analyzed from January 2012 to December 2013. Treatment strategies, outcomes and complications among patients treated with different anticoagulation agents (enoxaparine, fondaparinux or unfractionated heparin) were analyzed and compared. Results: In all, 72% of all NSTE-ACS patients were treated invasively, out of which 66% underwent angiography within 72 hours. Urgent and early angiography was performed in 44% of all invasively treated patients. Generally, 58% and 5% of patients received enoxaparine and unfractionated heparin (UFH), respectively, whereas fondaparinux was administered in 37% of patients. Median age of patients treated with enoxaparine was 66, compared to 76 in the fondaparinux group. There were significantly more patients treated with enoxaparine and UFH than with fondaparinux in the invasive strategy group. We observed that the number of patients treated with fondaparinux in the invasive group increased together with the period between symptom onset and angiography. The number of patients treated conservatively with either fondaparinux or enoxaparine was almost equal. There were no patients treated conservatively with UFH. In general, in-hospital mortality was low, 2.6% with no significant differences in bleeding events regarding the selection of anticoagulation therapy. Conclusions: Although the guidelines gave preference to fondaparinux, everyday practice in our hospital showed that enoxaparine was a preferred agent, particularly in younger patients selected for early invasive strategy, most probably because of the risk/benefit ratio and opportunity of avoiding the mixing of anticoagulation agents. Only 5% of patients were selected for urgent invasive approach with UFH, which should probably increase in the future. Considering a higher cost of bivalirudin, the introduction of this agent for non-ST segment elevation myocardial infarction management does not seem to be mandatory in our clinical setting, since this small group of patients was adequately managed with UFH.