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BACKGROUND AND AIMS Doppler Ultrasound (DUS) is a superior tool for the assessment of arteriovenous fistula (AVF) functionality. The aim of the study was to determine the association between morphological and haemodynamic characteristics of the blood vessels with AVF maturation. METHOD The study was prospective that analysed 80 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on haemodialysis (CKD5D) with newly created radio cephalic AVF. Haemodynamics and morphological evaluation of blood vessels by DUS was performed in all patients. The diameter of the cephalic vein, radial and brachial artery was measured: before creation, on the first day (24-h after creation) and at 4 weeks. The blood flow (BF) rate of AVF was calculated by DUS on day 1, at 4 and 8 weeks. The successful maturation of AVF was defined with BF ≥ 600 mL/min. RESULTS The mean age of the patients was 59.9 ± 13.5 years, of which 46 (57.50%) were males. Successful AVF maturation at 4 weeks was 43.75% and 62.5% at 8 weeks. The results of six adjusted models in multivariate analyses showed BF rate on day 1 was a predictor for AVF maturation at 4 (P CONCLUSION Our study showed that BF rate of AVF on day 1 was a predictor for AVF maturation at 4 and 8 weeks. The diameter of blood vessels and male gender were statistically associated with AVF maturation.

BACKGROUND: Pulmonary renal syndrome (PRS) is not a single entity but is caused by varied etiologies, including anti-neutrophil cytoplasmic antibody (ANCA), associated small vessel vasculitis (such as Wegener’s granulomatosis, microscopic polyangiitis, and Churg-Strauss vasculitis), Goodpasture’s syndrome, systemic lupus erythematosus, Henoch-Schonlein purpura, cryoglobulinemia, and rare causes such as druginduced vasculitis and subacute endocarditis. CASE REPORT: We report a case of a 51-year-old man who was referred to our hospital with a 2-month history of breathing difficulties, mild hemoptysis, and deteriorated renal function with a serum creatinine of 269 μmol/L. Serological testing was negative for anti-neutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) antibody, and also all cultures, including blood and urine, remained negative. In the renal biopsy, not linear deposition of IgG along the GBM and crescents at varying stages with extracapillary glomerulonephritis emphasizes the possibility of a double-seronegative pulmonary renal syndrome. Regarding therapeutic dilemmas, on the 3rd day of hospitalization, we initiated immunosuppression with cyclophosphamide and corticosteroids as well as plasma exchange (5 treatments). Under immunosuppressive therapy and plasma exchange, the patient’s status continually improved; there was no pulmonary bleeding, but the serum creatinine remained high and renal function remained in stage 4 chronic kidney disease. Four weeks later, he was hospitalized again, and we faced a new therapeutic dilemma because of the rapid relapse during immunosuppressive therapy and renal function deterioration that required hemodialysis treatment. Despite repeatedly negative results for anti-GBM and ANCA, initial immunosuppressive therapy with plasma exchange (9 treatments) was included again. The patient was discharged 30 days after admission in a stable general condition, with the maintenance immunosuppressive therapy with mycophenolate mofetil and hemodialysis 3 times/week. After 24 months, we have received information from the hemodialysis center that he is on regular hemodialysis and that he is in good condition. CONCLUSION: We think that in this atypical case, intensive plasma exchange and immunosuppressive therapy are crucial in the early stage and maintenance therapy is necessary for vasculitis in remission. This reported case has important clinical implications because pulmonary-renal syndrome with negative ANCAs and anti-GBM antibodies is extremely rare and no treatment recommendations have been established yet.

Malignant pleural mesothelioma (MPM) is an aggressive tumor that develops from the mesothelial cells lining the pleural cavity. The most relevant risk factor is asbestos exposure. Despite therapy the median survival is poor ranging from four to 18 months. The aims and objectives of this study were to assess the clinical characteristics and survival of patients with MPM treated at UHC Zagreb. This study included 101 patients diagnosed and treated for MPM at UHC Zagreb from September 1999 to September 2012. We analyzed the overall survival (OS), progression free survival (PFS) and OS depending on histological subtype, clinical stage, age, treatment method and pleurodesis performed using the Kaplan-Meier method. Eighty-nine patients were male and 12 female with the median age of 62 years. Using the TNM staging system, 69.3% were stage IV, 26.73% were stage III and 3.96% were stage II. 73.26% of MPM were epitheloid, 4.95% sarcomatous and 20.79% were NOS (non otherwise specified) histological subtype. 14.85% of patients had surgery, 55.44% of patients received chemotherapy and 9.9% radiotherapy. Median OS was 11 months and PFS was ten months. OS by histological subtype was 11 months for epitheloid, 12.5 months for NOS and 5.5 months for sarcomatous MPM. OS by TNM stage was seven months for stage II, 17.5 months for stage III and 11 months for stage IV disease. Median OS was longer for patients younger than 65 (12 vs. 8.5 months, p=0.28), patients treated with pleurodesis (13 vs. 7.5 months, p=0.06) and patients who received chemotherapy (12.5 vs. 7.5 months, p=0.10). The overall survival and prognosis of patients with malignant pleural mesothelioma in Croatia is poor in accordance with the literature. The studied treatment methods offer only a modest survival benefit to our patients.

An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of the study was to determine the factors associated with the achievement of adequate blood flow (BF) of AVFs at the 4th week after creation. Created AVFs in 63 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on hemodialysis (CKD5D) were analyzed in a prospective study. Doppler ultrasound (DUS) was used for measuring the diameter of the radial artery, the brachial artery and the cephalic vein before AVF creation. The BF of AVF was calculated by DUS at the 4th week after creation and adequate BF was defined as ≥ 600 mL/min. The average age of patients was 61.31 ± 12.9 years. An adequate BF of AVF at the 4th week after creation was achieved in 43.54% of patients. The BF of AVF measured in male patients was significantly higher compared to the BF of AVF obtained in females (576.03 mL/min vs 375.12 mL/min, P = 0.004). The diameter of the blood vessels with achieved adequate BF was significantly larger compared to the diameter of the blood vessels without adequate BF (radial artery: 2.45 mm vs 2.03 mm, P = 0.000; brachial artery: 4.78 mm vs 4.06 mm, P = 0.001 and cephalic vein: 3.12 mm vs 2.83 mm P = 0.018). The gender and the diameter of the blood vessels before AVF creation were significantly associated with achievement of adequate BF of AVF at the 4th week of creation.

Background and Aims The association between serum uric acid (UA) and left ventricular hypertrophy (LVH) is controversial in chronic kidney disease, whereas in hemodialysis (HD) patients has not been studied until now. Thus, we evaluated the relationship of baseline and time-averaged UA with echocardiographic LVH over a 5-year period in HD patients. Method This longitudinal study was conducted on 225 prevalent HD patients over a 5-year period. Patients were stratified into 3 groups according to their baseline and time-averaged UA levels: lower group (UA450µmol/l). Echocardiography was performed on a non-dialysis day and the presence of LVH was defined based on the left ventricular mass index (LVMI) >131 and >100 g/m2, for men and women, respectively. The patients were followed during a 60 month period. Results During the 5-year follow-up, 81 patients died (36%), and the main causes of death were cardiovascular (CV) related (70%). Survival analysis show that patients with time-averaged UA450µmol/l, but this difference was not statistically significant in terms of baseline UA level. A negative correlation was observed between LVH and time-averaged UA (r=-0.26, p=0.001), but not with LVH and baseline UA. Patients in lower time-averaged UA group had significantly higher LVMI compared to patients in intermediate and higher group (153.10± 59.89, 131.62±40.99, 131.19±44.49 g/m2, p=0.029), but from the lowest to the highest baseline UA levels, LVH was not significantly different (146.99±59.20, 141.38±37.52, 126.85±42.48 g/m2, p=0.07). Unadjusted odd ratio of LVH risk in the lower time-averaged UA compared to the reference time-averaged UA group was 3.11 (95% CI=1.38-7.05; p=0.006); and after adjustment for age, gender, diabetes and CV disease, ORs for LVH persisted significant only in the lower time-averaged UA group (OR = 2.82, 95% CI = 1.16–6.88, P = 0.002). On the contrary, baseline UA did not affect unadjusted and adjusted LVH. Conclusion In HD patients the prolonged exposure to hypouricemia is associated with LVH. This paradoxical association can only be explained by the hypothesis that uremic milieu in HD patients changes the influence of uric acid. However, these results should be the subject of further research.

SUMMARY Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis.

BACKGROUND: Lung cancer is the leading cause of cancer-related death worldwide, with 5-year overall survival less than 15%. Therefore, it is essential to find biomarkers for early detection and prognosis. Aberrant DNA methylation is a common feature of human cancers and its utility is already recognized in cancer management. The aim of this study was to explore the diagnostic and prognostic value of the promoter methylation status of the ASC/TMS1/PYCARD and MyD88 genes, key adaptor molecules in the activation of the innate immune response and apoptosis pathways. METHODS: A total of 50 non-small cell lung cancer (NSCLC) patients were enrolled in the study. Methylation of bisulphite converted DNA was quantified by pyrosequencing in fresh frozen malignant tissues and adjacent non-malignant tissues. Associations between methylation and lung function, tumor grade and overall survival were evaluated using receiver-operating characteristics (ROC) analysis and statistical tests of hypothesis. RESULTS: Methylation level of tested genes is generally low but significantly decreased in tumor tissues (ASC/TMS1/PYCARD, P

Pulmonary hamartoma is the most common benign tumor of the lung. It accounts for 77% of all benign lung tumors but less than 1% of all lung tumors. Malignant alteration is ­extremely rare. Surgical removal is therapy of choice. Uniportal video-assisted thoracic surgery is an easy-to-learn variant of video-assisted thoracic surgery. The approach is very similar to classic thora-cotomy. Instruments for both classic and video-assisted thoracic surgery can be combined. A case is presented of a 44-year-old female patient with pulmonary hamartoma treated by uniportal video-assisted ­thoracic surgery as a new method used for the first time at our department., Hamartom pluća je najčešći benigni tumor pluća. Predstavlja 77% svih dobroćudnih tumora pluća, ali manje od 1% svih plućnih tumora. Maligna alteracija je izrazito rijetka. Metoda izbora za liječenje hamartoma pluća je kirurška ekstirpacija. Uniportalna video-potpomognuta torakalna kirurgija je varijanta video-potpomognute torakalne kirurgije koja se brže svladava te omogućava kombiniranje postojećih klasičnih torakokirurških instrumenata i instrumenata za video-potpomognutu torakalnu kirurgiji. Prikazuje se slučaj bolesnice u dobi od 44 godine s hamartomom pluća koja je operirana metodom uniportalne video-potpomognute torakalne kirurgije, prvi put primijenjene u našoj klinici.

Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis., Primarni maligni tumori traheje su iznimno rijetki s incidencijom manjom od dva slučaja na milijun stanovnika u jednoj godini, a adenoidni cistični karcinom čini samo deset posto. Osamdeset posto svih tumora traheje je maligno. Dijagnoza se obično postavlja kasno, jer su početni simptomi slični astmi. Ponekad je klinička slika dramatična kada dođe do opstrukcije dišnog puta i potrebe za hitnom rekanalizacijom. Dijagnoza se potvrđuje kompjutorskom tomografijom prsišta ili magnetnom rezonancom. Definitivno liječenje je resekcija tumora sama ili uz adjuvantnu radioterapiju, ili radioterapija sama. Radikalna resekcija se postiže samo u oko polovice svih slučajeva zbog submukoznog rasta tumora i ograničene duljine resekcije traheje. Uloga adjuvantne radioterapije u slučajevima s negativnim resekcijskim rubom je nejasna, dok svi bolesnici s pozitivnim resekcijskim rubom imaju koristi od adjuvantne radioterapije. Prikazujemo slučaj 43-godišnjeg bolesnika s adenoidnim cističnim karcinomom distalnog dijela traheje koji je liječen bronhoskopskom rekanalizacijom i resekcijom traheje s terminoterminalnom anastomozom.

Background: Lung cancer is the leading cause of cancer-related death worldwide, with 5-year overall survival less than 15%. Therefore, it is essential to find biomarkers for early detection and prognosis. Aberrant DNA methylation is a common feature of human cancers and its utility is already recognized in cancer management. The aim of this study was to explore the diagnostic and prognostic value of the promoter methylation status of the ASC/TMS1/PYCARD and MyD88 genes, key adaptor molecules in the activation of the innate immune response and apoptosis pathways. Methods: A total of 50 non-small cell lung cancer (NSCLC) patients were enrolled in the study. Methylation of bisulphite converted DNA was quantified by pyrosequencing in fresh frozen malignant tissues and adjacent non- malignant tissues. Associations between methylation and lung function, tumor grade and overall survival were evaluated using receiver- operating characteristics (ROC) analysis and statistical tests of hypothesis. Results: Methylation level of tested genes is generally low but significantly decreased in tumor tissues (ASC/TMS1/PYCARD, P

Localized amyloid deposits (tumoral amyloidosis or amyloidoma) are uncommon form of amyloidosis and nodular pulmonary amyloidomas are rarely found. This incidental finding can mimic a bronchopulmonary neoplasm and may occur secondarily to an infectious, inflammatory or lymphoproliferative disease. We report a case of a 62-year-old female with long-standing systemic lupus erythematosus (SLE) with low compliance who presented with radiologically-verified solitary pulmonary nodule. Work-up included positron emission tomography–computed tomography (PET-CT) scan, which revealed hypermetabolic uptake of 18F-fluorodeoxyglucose, and lobectomy was performed. Staining of the tissue was positive for Congo red and was green birefringent under polarized light. Immunohistochemical methods excluded lymphoproliferative disease and confirmed amyloidoma. SLE was controlled with antimalarials and glucocorticoids. Pulmonary amyloidoma should be considered in the differential diagnosis of solitary lung nodules.

The aim of this study is to investigate whether there was a considerable difference in the survival of patients with malignant pleural effusion (MPE) depending on the pleural effusion treatment option. One hundred and seven patients with proven MPE (metastatic lung and breast cancer) were included in the retrospective study. Fifty six patients were treated with talc pleurodesis and a control group of 51 patients with similar characteristics (in age, sex and disease) were treated with serial thoracentesis. The patients of both groups underwent chemotherapy and/or radiotherapy. The overall survival and the survival in subgroups of patients with different tumour types and different performance status (PS) equal 1, 2 and 3 were compared. The patients who underwent talc pleurodesis had a longer average survival interval (MS) than the patients without such a treatment (n = 56; MS = 21,5 and n = 51; MS = 9 weeks, respectively; p

Background: Lung cancer is the leading cause of malignant pleural effusion (MPE). Management of MPEs remains a clinical challenge due to recurrence and poor quality of life. An ideal sclerosing agent has yet to be found. The aim of this cohort pilot study was to evaluate the role of mitoxantrone pleurodesis (MP) as an alternative to talc sclerotherapy for managing MPEs in lung cancer patients. Methods: A retrospective chart review was conducted on consecutively admitted patients with MPE to the Department of Post-Intensive Care at the Clinic for Respiratory Diseases “Jordanovac”, University Hospital Centre Zagreb, in Croatia. Results: Of 34 patients with MPE, twenty-one (64.8±9.46 years; 47–84 years) with primary lung carcinoma who received MP (30 mg of mitoxantrone) between December 2003 and February 2009 were included in this study. Chest radiographs taken prior to sclerotherapy and at 1-, 2-, and 3-month follow-up were compared. At the post-sclerotherapy evaluation periods, overall success (OS) rates of MP were 88.2% [17.6%, complete response (CR); 70.6%, partial response (PR)], 53.9% (7.7% CR; 46.2% PR), and 45.5% (PR), respectively. Kaplan-Meier median survival from MP until death was 5.2 months, while that from diagnosis of primary lung cancer was 12.3 months. Conclusions: MP may be a safe and effective method of managing MPE due to lung cancer. Future randomized controlled studies comparing mitoxantrone and talc pleurodesis in lung cancer patients are warranted to elucidate whether a significant difference exists between these agents. Factors affecting success, survival probability, and quality of life also require further investigation.

Cilj: Prikazati slučaj 42-godišnjeg bolesnika koji je upućen zbog aspiracijske pneumonije srednjeg režnja pluća, refrakterne na terapiju, koja je nastala kao posljedica aspiracije nafte. Prikaz slučaja: Nakon učinjene bronhoskopske i radiološke obrade, na nalazu kompjutorizirane tomografije grudnog koša i dalje perzistira infiltrat srednjeg režnja s destrukcijom i nekrozom, pa se torakokirurški odstranila tvorba. Patohistološki nalaz odgovara kroničnoj lipoidnoj bronhopneumoniji. Zaključak: Lipoidna pneumonija je rijedak oblik pneumonije koji predstavlja dijagnostički i terapijski izazov. Potrebno je razmišljati o ovoj bolesti, koja se može javljati u akutnom, ali i kroničnom obliku. Katkad može izazvati destrukciju i nekrozu, refrakternu na svu terapiju, pa torakotomija može biti najbolje rješenje za bolesnika., Aim: To report the case of a 42-year old patient, who was was reffered because of non resolving middle lobe aspiration pneumonia caused by petroleum aspiration. Case report: Fiberopticbronchoscopy and chest radiograph were performed to evaluate the non resolving pneumonia. Chest radiography and bronchoscopy revealed consolidation in the middle lobe. Computerized tomography scan revealed the same consolidation in the middle lobe with cavitation and necrosis, and toracotomy was indicated. Histological analysis revealed chronic lipoid pneumonia. Conclusion: Lipoid pneumonia is a rare condition, which represents a diagnostic and therapeutic challenge. Therefore, physicians should be aware of this disease, which can present in an acute, as well as a chronic respiratory illness. Once diagnosed, it can be progressive, causing necrosis and cavitation, which may require thoracotomy as the best solution for the patient.

Chronic pleural effusion requires pleural and lung biopsy in more than 60% of patients. Open lung biopsy was formerly considered as the most reliable diagnostic method, whereas now the procedure is mostly performed via video-assisted thoracoscopy. During the last ten-year period (1995­-2005), 96 patients aged 31-72 (mean age 53) years were operated on at University Department of Thoracic Surgery, Jordanovac University Hospital for Lung Diseases by video-assisted thoracoscopy in general anesthesia. All biopsies were done by clamp sampling from parietal or visceral pleura, and in 31 patients lung tissue was sampled by endostapler wedge resection. Conversion to mini-thoracotomy was needed in only 12 patients, due to massive adhesions. Tissue samples were referred for histopathologic analysis. After the procedure, the patients had a thoracic drain connected to negative pressure. Histopathologic diagnosis was made in almost all patients, yielding a 97% success rate. In 16 patients, drain airflow had to be prolonged to more than 5 days, while the mean drainage duration was 4 days and mean hospital stay 8 days. Talc pleurodesis was performed in most patients with malignant effusion to stop effusion accumulation. Video-assisted thoracoscopic biopsy allows for adequate pleural and lung sampling with a high rate of accuracy. Postoperative mortality and morbidity are lower in comparison with open lung biopsy. It is concluded that video-assisted thoracoscopic biopsy is an efficient and safe method in the diagnosis of chronic pleural effusion., Dugotrajni izljevi pleuralne šupljine zahtijevaju biopsiju pleure i pluća kod više od 60% bolesnika. Ranije se otvorena biopsija pluća smatrala najpouzdanijom dijagnostičkom metodom, dok se danas taj zahvat najčešće izvodi videotorakoskopskim putem. U zadnjih deset godina, od 1995. do 2005. godine, u Klinici za torakalnu kirurgiju "Jordanovac" operirano je videotorakoskopskim načinom 96 bolesnika u općoj anesteziji. Prosječna životna dob bila je 53 godine, s rasponom od 31-72 godina. Sve biopsije su rađene uzimanjem uzoraka hvataljkom s parijetalne ili visceralne pleure, a kod 31 bolesnika uzet je i komadić plućevine klinastom resekcijom uz pomoć endostaplera. Samo kod 12 bolesnika učinjena je konverzija u minitorakotomiju zbog opsežnih priraslica. Svi uzorci su upućeni na patohistološku analizu. Nakon zahvata svaki bolesnik je imao torakalni dren koji je spojen na negativni tlak. Histopatološka dijagnoza postavljena je kod gotovo svih bolesnika, tako da je uspješnost zahvata bila 97%. Kod 16 bolesnika postojao je produženi protok zraka na dren kroz više od pet dana, dok je prosječno vrijeme drenaže iznosilo 4 dana, a prosječni boravak u bolnici 8 dana. Kod većine bolesnika s malignim izljevom rađena je pleurodeza talkom kako bi prestalo nakupljanje izljeva. Videotorakoskopska biopsija omogućava uzimanje kvalitetnog uzorka pleure i plućevine (bioptata) uz visok postotak točnosti. Poslijeoperacijska smrtnost i pobol bili su niži nego kod otvorene biopsije pluća. Zaključak je da je videotorakoskopska biopsija pluća učinkovita i sigurna metoda u dijagnostici kroničnog pleuralnog izljeva.

Deformiteti stijenke prsnog koša su relativno rijetke bolesti nepoznate etiologije koje se javljaju u djetinjstvu i adolescenciji. Primjetna je obiteljska pojavnost deformiteta uz vrlo rijetko spontano izlječenje. Kirurško liječenje predstavlja jedinu mogućnost ispravljanja deformiteta bilo klasičnim operacijskim načinom ili minimalno invazivnom metodom liječenja (endoskopskim putem). Među kirurzima nema ujednačenog stava o tome u kojem je životom razdoblju najbolje učiniti ispravljanje deformiteta, jer su rezultati vrlo dobri bez obzira na primijenjenu metodu liječenja. U ovom radu prikazani su rezultati liječenja kod 105 bolesnika operiranih klasičnim načinom između 1985. i 2005. godine u Klinici za torakalnu kirurgiju Kliničke bolnice za plućne bolesti „Jordanovac“., Chest wall deformities are relatively rare diseases of unknown etiology, which occur in childhood and adolescence. Pectus deformities show familial occurrence with very rare spontaneous resolution. Operative treatment is one of the possible therapeutic options for deformity correction by classic operative procedure or by minimally invasive method of treatment (endoscopic). There is no consensus among surgeons about the age at which correction of the chest wall deformity should best be performed because therapeutic results are very good irrespective of the method of treatment employed. Therapeutic results in 105 patients operated on by the classic method during the 1985-2005 period at University Department of Thoracic Surgery, Jordanovac University Hospital for Lung Diseases in Zagreb, Croatia, are reported.