Do početka 90-ih godina prevladavalo je uvriježeno mišljenje da su bolesnici s uznapredovalom jetrenom bolesti prirodno autoantikoagulirani i time zaštićeni od tromboembolijskih zbivanja. Međutim, ...novim saznanjima dugogodišnja je paradigma srušena. U bolesnika s cirozom jetre paralelno je reducirana sinteza prokoagulansa i endogenih antikoagulansa, dok je produkcija ekstrahepatalno sintetiziranih faktora, važnih za proces zgrušavanja i fibrinolize, očuvana. U stabilnoj jetrenoj bolesti sustav je „rebalansiran”, ali funkcionira u uskom rasponu homeostaze, što ga čini izuzetno fragilnim te ga i minimalni stres može uvesti u neželjeni ekstrem, trombozu ili krvarenje. Uz navedeno niz je drugih čimbenika koji prate jetrenu bolest, kao što su hemodinamske promjene, oštećenja drugih organa, ponajprije bubrega, te sklonost infekcijama, a koji pomiču ravnotežu prema sklonosti krvarenju ili pojačanom zgrušavanju. Konvencionalni laboratorijski testovi nisu prikladni za procjenu rizika od krvarenja u cirozi, rizični čimbenici za razvoj tromboze nisu nedvojbeno dokazani, a sigurnosni profil antitrombotskih lijekova u cirozi nije precizno utvrđen jer su ti bolesnici uglavnom isključeni iz velikih kliničkih studija. Zbog svega navedenoga dijagnostički i terapijski pristup u ovom je kontekstu kompleksan te nalaže timski rad hematologa, hepatologa i u fazi operativnog liječenja anesteziologa. U ovome preglednom radu osvrnut ćemo se na mehanizme poremećaja hemostaze i fibrinolize u bolesnika s cirozom jetre, incidenciju tromboembolijskih zbivanja, laboratorijsku dijagnostiku te profilaktičke i terapijske opcije u okviru internističke skrbi.
Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order ...to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events.
This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis.
21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %;
= 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %;
> 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %,
= 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event.
Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.
Inflammatory bowel diseases (IBD) are chronic diseases of unknown etiology and pathogenesis in which genetic factors contribute to development of disease. MDR1/ABCB1 is an interesting candidate gene ...for IBD. The role of two single nucleotide polymorphisms, C3435T and G2677T remains unclear due to contradictory results of current studies. Thus, the aims of this research were to investigate the association of MDR1 polymorphisms, C3435T and G2677T, and IBD.
A total of 310 IBD patients, 199 Crohn's disease (CD) patients and 109 ulcerative colitis (UC) patients, and 120 healthy controls were included in the study. All subjects were genotyped for G2677T/A and C3435T polymorphism using RT-PCR. In IBD patients, review of medical records was performed and patients were phenotyped according to the Montreal classification.
Significantly higher frequency of 2677T allele (p=0.05; OR 1.46, 95% CI (1.0-2.14)) and of the 3435TT genotype was observed among UC patients compared to controls (p=0.02; OR 2.12; 95% CI (1.11-4.03). Heterozygous carriers for C3435T were significantly less likely to have CD (p=0.02; OR 0.58, 95% CI (0.36-0.91)). Haplotype analysis revealed that carriers of 3435T/2677T haplotype had a significantly higher risk of having UC (p=0.02; OR 1.55; 95% CI (1.06-2.28)).
MDR1 polymorphisms are associated with both CD and UC with a stronger association with UC.
Thoracoabdominal actinomycosis is rare, especially in the context of readily available medical facilities.
Case report and review of the literature.
A 54-year-old male patient was admitted because of ...hemoptysis and a pulmonary infiltrate in the left lower lobe. His history was unremarkable except for chronic gastritis and an elective laparoscopic cholecystectomy performed 10 years earlier. Following persistent hemoptysis, elevated inflammatory markers, and a non-revealing bronchoscopy, a computed tomography scan of the thorax and upper abdomen revealed a tumor in the upper part of the left kidney spreading directly to the adjacent diaphragm and left lower lobe. Laparotomy revealed a granulomatous mass containing a gallstone, as well as orange granular content. The treatment involved surgical removal of the mass, splenectomy, excision of the infiltrated part of the left hemidiaphragm, and decortication of the left lower lobe. Because of a prolonged post-operative low-grade fever and radiologically confirmed encapsulation in the lingula, the patient was given ceftriaxone. Repeat bronchoscopy revealed Actinomyces meyeri. The initial antibiotic therapy was replaced with amoxicillin-clavulanic acid, after which the patient's health improved.
Actinomycosis is still a highly intriguing disease, as initial symptoms often mislead clinicians. It is important to consider the disease whenever we are challenged diagnostically or when risk factors are present.
Background Inflammatory bowel diseases (IBD) are chronic diseases of unknown etiology and pathogenesis in which genetic factors contribute to development of disease. MDR1/ABCB1 is an interesting ...candidate gene for IBD. The role of two single nucleotide polymorphisms, C3435T and G2677T remains unclear due to contradictory results of current studies. Thus, the aims of this research were to investigate the association of MDR1 polymorphisms, C3435T and G2677T, and IBD. Methods A total of 310 IBD patients, 199 Crohn's disease (CD) patients and 109 ulcerative colitis (UC) patients, and 120 healthy controls were included in the study. All subjects were genotyped for G2677T/A and C3435T polymorphism using RT-PCR. In IBD patients, review of medical records was performed and patients were phenotyped according to the Montreal classification. Results Significantly higher frequency of 2677T allele (p = 0.05; OR 1.46, 95% CI (1.0-2.14)) and of the 3435TT genotype was observed among UC patients compared to controls (p = 0.02; OR 2.12; 95% CI (1.11-4.03). Heterozygous carriers for C3435T were significantly less likely to have CD (p = 0.02; OR 0.58, 95% CI (0.36-0.91)). Haplotype analysis revealed that carriers of 3435T/2677T haplotype had a significantly higher risk of having UC (p = 0.02; OR 1.55; 95% CI (1.06-2.28)). Conclusion MDR1 polymorphisms are associated with both CD and UC with a stronger association with UC. Keywords: MDR1, Crohn's disease, Ulcerative colitis, IBD
Tiopurin S-metiltransferaza (TPMT) je enzim koji sudjeluje u konverziji tiopurinskih lijekova u inaktivne metabolite. Dosad je otkriveno više od 20 varijanti TPMT-kodirajućih alela. Ovi aleli ...uzrokoju smanjenu enzimatsku aktivnost. Naš cilj je bio istražiti frekvenciju varijantnih alela odnosno genotipova u bolesnika oboljelih od upalnih bolesti crijeva i u zdravih osoba te usporediti dobivene frekvencije s frekvencijama odabranih svjetskih populacija. Najčešći varijantni aleli TPMT*2, TPMT*3A, TPMT*3B i TPMT*3C analizirani su metodama lančane reakcije polimeraze, odnosno alelspecifičnim metodama lančane reakcije polimeraze. U istraživanje je bilo uključeno 685 ispitanika; 459 ispitanika bili su bolesnici s upalnom bolesti crijeva, a 226 bili su zdravi dobrovoljci. Rezultati su pokazali da su 434/459 (94,55%) pacijenata s upalnom bolesti crijeva i 213/226 (94,25%) zdravih osoba homozigoti za divlji tip alela (TPMT*1/*1). Genotipovi TPMT*1/*2 i TPMT*1/*3C nađeni su u 4/459 (0,87%) odnosno 7/459 (1,53%) bolesnika; u zdravih dobrovoljaca nisu nađeni. Genotip TPMT*1/*3A nađen je u 14/459 (3,05%) bolesnika i 13/226 (5,75%) zdravih dobrovoljaca. Varijantni
genotipovi bili su statistički značajno češći u podskupini bolesnika s Crohnovom bolešću, s učestalošću od 23/338 (6,80%) u odnosu na podskupinu bolesnika s ulceroznim kolitisom, gdje je učestalost varijantnih genotipova bila 2/121 (1,65%) (χ2=4,46; p=0,035). U zaključku, najčešći nefunkcionalni TPMT alel u Hrvatskoj populaciji je TPMT*3A. Ukupna frekvencija varijantnih alela u našoj je populaciji statistički neznačajno niža u odnosu na druge populacije bjelačkog podrijetla. Bolesnici s Crohnovom bolešću imaju više varijantnih alela u odnosu na podskupinu bolesnika s ulceroznim kolitisom.
Povećani je opseg struka dobar predskazatelj rizika za razvoj srčanih bolesti, no gotovo da nema podataka o odnosu opsega struka i plućnih bolesti. Cilj ove studije bio je ispitati utjecaj veličine ...opsega struka na funkcionalnu plućnu sposobnost prema klasifikaciji GOLD (Global Initiative for Lung Diseases). Tijekom 2009. godine 70 bolesnika u dobi od 33 do 80 godina podijeljeno je u skupine GOLD2 i GOLD3 ovisno o težini bolesti. Dijagnostička razdioba ovih skupina temelji se na razlici dobivenih vrijednosti predviđenog forsiranog ekspiracijskog volumena u prvoj sekundi. Analizirane su brojne antropometrijske mjere, testovi plućne funkcije i prognostički bodovni sustavi. U statističkoj je obradi korištena logistička regresijska analiza. Razlika u veličini opsega struka između stupnjeva GOLD2 i GOLD3 nije dosegla statističku značajnost (p>0,5). Nađena je slaba pozitivna korelacija između opsega struka i postotka predviđene udaljenosti u 6-minutnom hodu (r=0,237; p=0,001). No, statistički značajna razlika između dviju ispitivanih skupina nađena je u debljini suprailijačnog nabora (19,41 prema 15,32 mm; p=0,047). Opseg struka je jedan od parametara koji definiraju abdominalnu pretilost. Iako pretilost utječe na plućnu funkciju, ova studija nije dokazala da postoji korelacija između veličine opsega struka i funkcionalne plućne sposobnosti u odabranoj populaciji bolesnika s kroničnom plućnom bolešću. No, daljnju evaluaciju i vrednovanje u kliničkoj praksi zaslužuje mjerenje suprailijačnog nabora.
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