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Background and aims: Genetic polymorphisms of immune mediators have been associated with differences in the natural course of chronic hepatitis C (CHC). The aim of this study was to analyze the association of IL-1β gene polymorphism with the stage of liver fibrosis (LF), grade of necroinflammatory activity (NIA) and fibrosis progression rate (FPR) in CHC patients. Patients and methods: The study included 50 treatment-naive Croatian CHC patients (36 male and 14 female ; age median 37.5 years) with elevated ALT. Diallele polymorphism (C/T) at locus -31 in the IL-1β gene promoter region was determined by restriction fragment length polymorphism (RFLP). Stage of LF and NIA were assessed from liver biopsy sample according to Ishak classification. Results: There was no difference in the stage of LF and NIA level between particular patient genotypes. However, patients with at least 1 C allele at locus -31showed significantly faster FPR than those with no C allele (0.4 vs. 0.258 Ishak's units/year ; p = 0.043). Higher stages of fibrosis were observed in older patients (p = 0.001) and those infected at an older age (p = 0.017). Conclusion: Our study demonstrated that the carriage of at least 1 C allele at -31 locus of IL-1β gene led to faster progression of LF in CHC patients with a biochemically active disease, but did not determine the final stage of fibrosis development. Combined with other risk factors, this finding may serve as a genetic marker to identify patients that require earlier introduction of therapy, since delay could hamper therapeutic success due to rapid disease progression.

Resistant hypertension is defined as hypertension that remains above 140/90 mmHg despite the provision of three or more antihypertensive drugs in a rational combination at full doses and including a diuretic. It is associated with adverse clinical outcome and therefore requires aggressive medical treatment. We present a case of 70-year-old woman who was treated for resistant hypertension with a diuretic, ACE-inhibitor, calcium channel blocker, and with centrally acting antihypertensive, moxonodine. Despite of aggressive medical treatment her blood pressure remained above 160/90 mmHg continuously. Large diagnostic workup excluded common causes of secondary hypertension, but revealed significant carotid stenosis present on left internal carotid artery. Carotid endarterectomy was performed in order to improve cerebrovascular prognosis, but unexpectedly resulted in optimal control of her blood pressure. Two months after operation patient was on only one antihypertensive drug, having blood pressure below 130/85 mmHg. We suggest that in selected patients resistant hypertension could be associated with carotid stenosis and carotid sinus baroreceptor dysfunction. For definite conclusions further studies are warranted.

Resistant hypertension is defined as hypertension that remains above 140/90 mmHg despite the provision of three or more antihypertensive drugs in a rational combination at full doses and including a diuretic. It is associated with adverse clinical outcome and therefore requires aggressive medical treatment. We present a case of 70-year-old woman who was treated for resistant hypertension with a diuretic, ACE-inhibitor, calcium channel blocker, and with centrally acting antihypertensive, moxonodine. Despite of aggressive medical treatment her blood pressure remained above 160/90 mmHg continuously. Large diagnostic workup excluded common causes of secondary hypertension, but revealed significant carotid stenosis present on left internal carotid artery. Carotid endarterectomy was performed in order to improve cerebrovascular prognosis, but unexpectedly resulted in optimal control of her blood pressure. Two months after operation patient was on only one antihypertensive drug, having blood pressure below 130/85 mmHg. We suggest that in selected patients resistant hypertension could be associated with carotid stenosis and carotid sinus baroreceptor dysfunction. For definite conclusions further studies are warranted.

Ziel Kohlenmonoxidvergiftung ist allgemein verbreitete Ursache der Morbidität und Mortalität. Kroatien ist da keine Ausnahme, und hier präsentieren wir unsere Daten. Methoden Wir berichten über 20 Patienten, die während des Zeitraums von 2000– 2006 in unser Krankenhaus unter Verdacht einer Kohlenmonoxidvergiftung eingeliefert wurden und deswegen einer Carboxyhämoglobinspiegelmessung unterzogen waren. Nach klinischem Erscheinungsbild unterscheiden wir leichtes, mittelschweres und schweres Vergiftungsniveau. Analysiert wurden Komplikatonen, Behandlung und Ergebnisse. Resultate Alle Vergiftungsfälle waren unbeabsichtigt, 18 davon passierten im Winter. Die meisten Betroffenen waren Frauen (14), in der Altersgruppe 20– 30 und älter als 60 Jahre. Beherrschend waren mittelschwere (9) mit CoHb Median 18, 5% (30– 38, 0%) und leichte (8) Vergiftungsfälle mit CoHb Median 24, 6% (19, 5– 31, 0%). Beobachtete Symptome und Komplikationen betrafen das ZNS (20), kardiovaskuläres (8), Atmungs- (7) und Verdauungssystem (7). Nur eine Patientin erlitt Multiorganversagen. Alle Patienten erhielten 100% Sauerstoff, zwei Patienten mussten künstlich beatmet und zwei Patienten brauchten hyperbare Sauerstofftherapie. Die Länge der Behandlung auf der Intensivstation betrug 2, 3 bei leichter, 3, 1 bei mittelschwerer und 12, 7 Tage bei schwerer Vergiftung. Ein Patient starb, alle anderen konnten im guten Zustand entlassen werden. Konklusion Kohlenmonoxidvergiftung hat eine gute Prognose, sofern früh bemerkt und mit Sauerstoff behandelt. Wegen weiter Verbreitung ist die Prävention am wichtigsten.

Aim of this retrospective study was to present the distinctive features of the patients which were diagnosed with myocardial infarction and stroce during the same hospitalisation. During last 12 years (period between 01.01.1995.-31.12.2006.) we identified 21 such patients in our Intensive care unit (ICU) of the Internal medicine department. This group represents 0.22% of all hospitalized patients in this period. None of these patients undervent thrombolysis, percutaneous coronary intervention or aortocoronary bypass operation. There were more female patients in this group (62%). They were older compared to male patients (mean 73+/-10.2 years, CI 67-79 compared to 68+/-8.1, CI 61-75), and had a greater mortality rate (77%). Fifteen (71%) of these patients died, 5 male and 10 female patients. APACHE II score was higher among female patients than in male (mean 26+/-11, CI 19-33, compared to 19+/-11, CI 9-29), and GCS was somewhat lower (6+/-4, CI 4-8, compared to 8+/-5, CI 4-12). We found statistically significant positive correlation between the incidence of the evevts (acute myocardial infarction and stroke) and hyperglycaemia (blood glucose > or equal to 6.4 mmol/L) in time of admittance to ICU, also between mortality and hyperglycaemia (p5 mmol/L (p

Cilj je prikazati dva bolesnika koji su primljeni u internističku jedinicu intenzivne skrbi i koji su se tijekom hospitalizacije manifestirali i poremećajem svijesti, a na čije je stanje mogla u većoj mjeri utjecati i hiperkalcemija odnosno hipokalcemija. Do podataka se došlo retrospektivnom analizom. Prvi slučaj je bolesnica stara 80 godina koja je primljena radi sumnje na septičko zbivanje. Kod dolaska je somnolentna do soporozna, dehidrirana, pothlađena. Usprkos primijenjenoj terapiji (rehidracija, antibiotici, kasnije i vazopresori), stanje je bez bitnije promjene. Učini se MSCT abdomena koji postavlja sumnju na pararenalni apsces lijevo, a nađe se i hiperkalcemija-4.35 mmol/l. Bolesnica vrlo brzo potom umire pod slikom septičoga šoka, a s obzirom na nalaze postavlja se sumnja i na neoplastičko zbivanje. Bolesnica nije obducirana. Drugi slučaj je bolesnica stara 77 godina koja je primljena zbog grčeva ekstremiteta opće slabosti, povremeno kratkotrajnih gubitaka svijesti uz hipokalcemiju (0.79 mmol/l) bez hipoalbuminemije. Naknadno se dobiva podatak o parcijalnoj tireoidektomiji prije više godina. Uz nadoknadu kalcija dolazi do poboljšanja kliničke slike i laboratorijskih nalaza te se stanje može protumačiti posljedicom neliječenog hipoparatireoidizma, vjerojatno iatrogeno izazvanog parcijalnom tireoidektomijom. Poremećaj svijesti kod obje bolesnice bar djelomično bi se mogao objasniti i poremećajem serumske razine kalcija.

Cilj je prikazati dva bolesnika koji su primljeni u internističku jedinicu intenzivne skrbi radi hiponatrijemije praćene soporom. Do podataka se došlo retrospektivnom analizom. Prvi slučaj je bolesnica stara 60 godina s najniže zabilježenom vrijednosti natrija u serumu 119 mmol/l. Zbog pojave febriliteta vađene su hemokulture, a zbog poremećaja svijesti iako bez znakova meningizma učinjena je lumbalna punkcija. Hemokulturama i u likvoru izoliran je Cryptococcus neoformans, a naknadno se učini i serologija na HIV koja je bila pozitivna. Bolesnica je potom premještena u Kliniku za infektivne bolesti na daljnje liječenje. Drugi slučaj je muškarac star 69 godina kod kojega je najniža zabilježena vrijednost natrija u serumu bila 108 mmol/l. Dodatno učinjenom obradom nađe se planocelularni karcinom gornjega režnja pluća desno s multiplim metastazama u medijastinum i plućni parenhim. Također su nađene i metastatske promjene u jetri čijom se biopsijom nađe adenokarcinom, a primarno sijelo se nije uspjelo pronaći. Bolesnik je upućen onkologu. Oba bolesnika su primljena radi poremećaja svijesti praćenog hiponatrijemijom. Iako je osnovna bolest koja je dovela do poremećaja bila različita, nastala hiponatrijemija može se objasniti sindromom neprimjerenog lučenja antidiuretskog hormona (SIADH) već opisivanom u navedenim bolestima.

INTRODUCTION. Appearance of myocardial infarction and stroke during the same hospitalization is rare and has great mortality ratio. It was expected these events to take place more often during winter and in connection with infection. METHODES. We have retrospectively analyzed data of 21 patients with diagnose of acute myocardial infarction and stroce during the same hospitalization, treated in our internal Intensive Care Unit from January 1995 to December 2006. None of thease patients were subjuated to thrombolytic therapy, percuataneus coronary intervention or coronary artery bypass graft. RESULTS. All included were Caucasian (who were maked 0.22% of total number of hospitalised patients during that period), 8 (38%) males and 13 (62%) females. Age of patients was between 49 and 85 years, mean 71+/-6.6 (CI 67-76). Six patients have survived (29%), and 15 died (71%)(5 males and 10 females). The average age of decreasedd males was 66+/-10.1 years (CI 54-79), and females was 76+/-10.1 (CI 69-83). Mean APACHE II score was 23+/-12 (CI 18-29), and mean GCS as 7+/-4 (CI 5-8). Most of the patients (9 patients or 43%) were dmitted during the winter, six in autum (29%), five in spring (24%) and in summer only one patient (4%). In 11 patients (52%) 6 males and 5 females) we found connection between current state with recent infection (within last month) or signs of infection on admission in ICU. Respiratory infection was found in 6 patients, urinary infection in 2, and in 2 cases we have found some other source of infection. Also we found significant connection between current state (myocardial infarction and stroce during sama hospitalisation) and infection during winter (p=0.0369) and positive correlation between infection and mortality of these patients (r=1.0000, p

Ovdje prikazujemo slučaj sedamdesetogodišnje žene koja je bila primljena pod kliničkom slikom plućne embolije. Perfuzijska scintigrafija pluća nalazi potpuno izostalu perfuziju u projekciji anteriornog segmenta gornjeg režnja desnoga te nekoliko manjih trokutastih, površno smještenih ispada perfuzije lijevoga pluća. Transtorakalni UZV srca nalazi značajnu trikuspidalnu regurgitaciju (II/II angio stupanj) uz umjerenu plućnu hipertenziju (46 mmHg) te urednu sistoličku funkciju lijeve klijetke. Prisutno povišenje troponina I kod prijema tumačeno je posljedicom opterećenja desne klijetke uslijed plućne hipertenzije. Započeta je terapija nefrakcioniranim heparinom. Petoga dana hospitalizacije bilježi se daljnji porast troponina I uz elektrokardiografske promjene-razvoj Q zupca od V1-V3, elevacija ST spojnice za 1-2 mm od V1-V4, ljevkasti, negativni T valovi od V2-V6 i u D1 i D2, a bolesnica signalizira bol u prsima. Kontrolna perfuzijska scintigrafija pluća ne nalazi ispada, a kontrolni trantorakalni UZV srca ne registrira više plućnu hipertenziju uz urednu sistoličku funkciju lijeve klijetke. Pacijentica umire mjesec dana od početka hospitalizacije pod kliničkom slikom sepse. Radi vrlo teškog općeg stanja bolesnice (teško pokretna nakon operacije kuka prije tri godine, parkinsonizam) nije rađena invazivnija obrada. Bolesnica nije obducirana. Na osnovi dostupnih kliničkih parametara smatramo da se kod pacijentice radilo o plućnoj emboliji, a tijekom hospitalizacije bolesnica je razvila i srčani infarkt bez jasno poznatih rizičnih faktora. Do sada je u literaturi opisano nekoliko slučajeva plućne embolije i srčanog infarkta, u većini slulčajeva u podlozi zbivanja radilo se o nezatvorenom foramenu ovale uz prisutan paradoksni embolizam. Također je opisan slučaj razvoja srčanoga infarkta kao posljedice anomalnoga polazišta desne koronarne arterije iz lijevog koronarnog sinusa koja je bila kompromitirana između aorte i plunom hipertenzijom zbog plućne embolije dilatirane plućne arterije.

Introduction. Hemorrhage and anemia cause hypoperfusion and decreased oxigenation of body organs including heart. There is evidence that anemia is a condition recognized as an independent risk for the progression of cardiovascular disease and for mortality after acute myocardial infarction. We supposed that in nonselective group of patients with hemorrhage and/or anemia we could expected more often NSTEMI than STEMI. Methods. We retrospectively analyzed data of 34 patients with hemorrhage and subsequently development of acute myocardial infarction or with severe anemia and concomitant myocardial infarction without signs or data of recent hemorrhage treated in the Intensive Care Unit, Department of Internal Medicine, Dubrava University Hospital from January 2000 to May 2005. Results. All included were Caucasian, 19 males (55.9%) AND 15 (44.1%) FEMALES. Age of patients were between 51 and 94 years (median 73.21 years, SD 11.84). In 25 patients (76.5%) we verified a bleeding from upper part and in 4 (11.8%) from lower part of gastrointestinal tract, two patients (5.9%) had a chronic anemia, in one (2.9%) we found hematuria and one had hemorrhagic pancreatic pseudocyst. The lowest haemoglobin concentration ranged from 36 to 110 g/l (median 69.53 g/l, SD 19.7). Mean APACHE II score was 14.09+/-6.708 (minimal 4, maximal 36). NSTEMI development in 31 pts (91%) while STEMI was present in 3 patients (8.8%). Among NSTEMI patients, 27 (79.4%) had electrocardiographic (ECG) signs of ischemia, 3 (8.8%) had left bundle branch block and one patient (2.9%) with chest pain without ECG changes had increased specific markers of cardiac injury (CK, CK-MB, troponin I). Seven patients, all with NSTEMI, died (20.6%). Conclusion. Anemia can worsening oxygen supplying of myocardial areas with previosly insufficient blood supply causing critical ischemia and severe cases tissue death-necrosis or infarction of subendocardium or diffuse. Today confirmation of myocardial damage can be easily obtained by definite marker like troponin I, which are highly specific and sensitive. In addition we can expected ECG changes related NSTEMI with increasing frequency in anemia and hemorrhage. REFERENCE(S).1) Capell M.S, Gastrointestinal bleeding associated with myocardial infarction. Gastroenterol Clin Nort Am.2000 ; 29:423-444.

Study was coducted to examine the possible relationship between various pre-hospital factors and delays in initiation of thrombolytic therapy(TT) in acute myocardial infarction(AMI).

We report a 57 year-old man with nonobstructive hypertrophic cardiomyopathy (HCM) previously continuosly treated with beta-blockers last ten years, presented with monomorphic and polymorphic runs of NS-VT associated with oscillatory arterial hypertension and symptomatic deterioration. ECG demonstrated abnormal Q-wave in leads II, III, aVF and V4-6 simulating inferolateral infarction with multifocal premature ventricular contractions (PVC) occuring as a single contraction and a complets. Holter recorded frequent multifocal PVCs up to 30 per hour occuring as a single contractions, couplets or repetitive forms mostly salvos or NS-VT. Echocardiography and chest roentgenography showed characteristic morphology of nonobstructive HCM. He was treated unsuccessfully with class I agents disopyramide, mexiletine, propafenone and class III agent amiodarone. In our case, the treatment with low dose d, l-sotalol up to 320 mg, completely controlled NS-VT with decrease in the severity of clinical symptoms. ECG and Holter recording obtained at final assessment two months after the treatment with d, l-sotalol was started, revealed no significant drug-related changes in PR, QRS-duration, ST-segment and rate-corrected Q-T interval. In this report it was intention to show good effect of d, l-sotalol in suppression NS-VT in patients with nonobstructive HCM particularly in comparison with other used antiarrhythmics.

The aim of the present study was to determine: (1) whether the single maximal dose of clonidine, an alpha2-adrenergic agonist, could induce an increase in serum growth hormone (GH) levels in patients with essential hypertension, and (2) whether hypotalamic dopamine and serotonin receptors might be involved in this response. Sixteen patients were studied before and after a 4-day treatment with a selective dopamine-blocking agent, pimozide. Another group of eight hypertensives was studied before and after a 5- day treatment with a specific blocker of serotonin receptors, metergoline. Total clonidine-stimulated GH secretion was assessed by the area under the GH curves from 0 to 180 min. The single maximal dose of clonidine induced in the majority of patients a moderate increase in GH levels, still indicating a subsensitivity in central alpha-adrenergic function in human hypertension. Both pimozide and metergoline failed to change the total secretion as well as the pattern of GH response to clonidine, irrespective of the magnitude of individual responses. In conclusion, the results of this study demonstrate that neither dopaminergic nor serotonergic mechanisms are involved in the alpha2-adrenergic control of GH secretion in patients with essential hypertension.

„Plućna embolija nije bolest. Ona je komplikacija duboke venske tromboze.“ (Ken Moser MD) Plućna embolija je dio kliničkog entiteta koji se zajedno sa venskom trombozom zove venska tromboembolija. Danas se smatra više kao komplikacija duboke venske tromboze, negoli izolirana bolest upravo zbog činjenice da 95% tromba potječe iz dubokih vena nogu. Kao treća najčešća kardiovaskularna bolest, nakon infarkta miokarda i moždanog udara, može se očitovati na različite načine, od asimptomatske bolest pa sve do akutnog fatalnog događanja i kronične bolesti pluća. Stoga je jako važan pravodobni i ispravan dijagnostički postupak, posebice u plućnoj emboliji gdje su simptomi često nespecifični. Veliki je trud uložen kako bi se osmislili načini za lakšim postavljanjem dijagnoze na temelju kliničke slike i neinvazivnih dijagnostičkih postupaka. U kliničkoj se praksi vrlo često nepotrebno šalje na CT anigiografiju što rezultira nepotrebnim zračenjem i komplikacijama. Najčešći simptom plućne embolije je naglo nastala dispneja. Liječenje obuhvaća primjenu antikoagulantne terapije, trombolize ili kirurške trombektomije., „Pulmonary embolism is not a disease. It is a complication of DVT.“(Ken Moser MD) Pulmonary embolism is a part of a clinical entity, together with venous thrombosisand it is called venous thromboembolism,. Today it is considered more like a complication of deep vein thrombosis, than as an isolated disease, because 95% of the thrombus is from the deep veins of the lower limb. As the third most common cardiovascular disease,after myocardial infarction and the stroke, it can present itself in different ways, from the asympotmatic disease, to acute lethal disease and chronic disease of the lungs. Therefore, a timely and appropriate diagnostic procedure is warranted, especially in pulmonary embolism, where the symptoms are often nonspecific. Great efforts where invested to design a way of easier diagnosis with the clinical presentation and noninvasive diagnostics. In clinical practice, patients are unnecessarily referred to CT angiography which results in inneccesary radiation and complications. The most common symptom of pulmonary embolism is sudden onset dyspnea. Pulmonary embolism is treated with anticoagulants, thrombolytics or surgical embolectomy.