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Pula, Croatia

Hrstic I.,Pula General Hospital | Ostojic R.,University of Zagreb
Acta Medica Croatica | Year: 2013

Infection with non-1 genotype in Croatia is detected in 41.2% of patients with chronic hepatitis C. Since the last treatment guidelines for hepatitis C patients, little has been changed. With today's standard of care, sustained viral response can be achieved in 43% to 85% of non-1 CHC patients, which is not satisfactory at all. The lowest cure rate is usually found among patients with genotype 3 and 4 infection. The grouping of genotype 2 and genotype 3 patients to easy to treat genotypes was an unfortunate consequence of their underrepresentation in previous large registration clinical trials. Careful re-examination of the data obtained shows clearly enough that patients with genotype 3 infection respond less to treatment than genotype 2 patients. They sometimes behave more like patients with genotype 1 infection. Small progress is found in treatment approach and viral kinetics might be a useful tool for tailoring therapy to improve efficacy. Rapid virologic response is the best parameter to predict success of therapy. For patients who achieve a rapid viral response, consideration of shortened therapy (<24 weeks) may be reasonable although sustained viral response is still slightly higher with 24 weeks of therapy. Nevertheless, the presence of poor prognostic factors (high viral load, advanced fibrosis, obesity, increased age, insulin resistance and liver non-viral steatosis) may discourage a shortened course of therapy. Extending therapy (>24 weeks) in patients who do not achieve a rapid viral response would be beneficial, particularly in patients with genotype 3 infection and poor prognostic factors, but formal recommendation should be confirmed in prospective trails. New data suggest a prognostic role for IL28B polymorphisms mostly in genotype 3 patients not achieving a rapid viral response and these could also be considered for improved tailoring of therapy. In conclusion, new treatments are urgently needed for non-1 genotype chronic hepatitis C patients. So far, telaprevir and boceprevir have failed to show a satisfactory activity in these genotypes. Evaluation of many promising molecules such as second generation of protease inhibitors or NS5B nucleos(t)ide inhibitors, NS5A inhibitors, cyclophilin inhibitors or their combinations with or without pegylated interferon or ribavirin is still in progress. Source


Franolic M.,Oxy Clinic for Baromedicine and Occupational Medicine | Markus B.,Oxy Clinic for Baromedicine and Occupational Medicine | Ostric M.,Oxy Clinic for Baromedicine and Occupational Medicine | Vidos R.,Pula General Hospital
Acta Medica Croatica | Year: 2010

Hyperbaric oxygen (hbO2) as a drug in clinical medicine is in general use since the mid-1950s. 'Problem wounds' including diabetic foot were added to the list of indications in the mid-1970s. Numerous scientific and technical studies examined the effectiveness of hbO2. The vast majority of them found clear evidence for its favorable effects on the course of chronic wound healing in diabetics, based on numerous physiologic effects, among them neoangiogenesis and antimicrobial activity. The application of hyperbaric oxygen for therapeutic purposes (HBOT) significantly raises partial oxygen pressure (pO2) in the blood, which makes its transfer to peripheral cells independent of receptors on red blood cells. Transcutaneous oximetry in diabetic wound and surrounding area shows insufficient pO2 for normal wound healing process, while stimulating proliferation of bacterial flora and development of infection. hbO2 promotes wound healing by changing the wound dynamics, increasing the network of collagen and fibroblasts, reactivating leukocytes, stimulating neoangiogenesis with compromised circulation, and increasing the efficiency of leukocyte elimination of microbial pathogen flora. Transcutaneous oximetry (tcpO2) and measurement of laser-Doppler perfusion is a precondition for timely assessment of the use of hbO2 in diabetic foot. HBOT, as part of a multidisciplinary approach to the problem of diabetic foot, is a safe and effective method, without significant adverse effects, which certainly reduces the number of major amputations due to diabetic foot. Source


Grgurevic I.,University of Zagreb | Hrstic I.,Pula General Hospital | Vucelic B.,University of Zagreb
Acta Medica Croatica | Year: 2013

The best indicator of the severity of liver damage and prognosis in chronic viral hepatitis is extension of liver fibrosis. Extension of liver fibrosis can be assessed by liver biopsy and non-invasive physical or biological methods. Biopsy is used to define ethiology, severity (stage of fibrosis) and prognosis of liver disease. These informations are also usefull when estimating the risk-benefit and deciding on the modalities of antiviral therapy. Serological tests and elastography may distinguish significant fibrosis (F !2) from baseline fibrosis (AUROC 0.77-0.83 for serology and 0.84 for elastography) and cirrhosis from noncirrhotic stages (AUROC 0.77-0.86 for serology and 0.9-0.94 for elastography). Individual method of choice with best performance to distinguish cirrhosis from noncirrhotic stages of liver is elastography. Combination of serological tests and transient elastography has 93-95% accuracy to predict liver cirrhosis, and in case of concordant values of both tests biopsy could be avoided in 77-80% of patients. In case of discordant values or those in favour of intermediate stages of fibrosis liver biopsy should be performed because in these situations non-invasive tests are less reliable. According to several studies liver stiffness as assessed by transient elastography has high predictive value for the development of decom-pensated cirrhosis and portal hypertensive complications and may also discriminate the patients with respect to the predicted 5-year survival. Source


Maldini B.,University of Zagreb | Novotny Z.,University of Zagreb | Letica-Brnadic R.,University of Zagreb | Brkljacic A.,Pula General Hospital | Bartolek D.,Sveta Katarina Special Hospital
Acta Clinica Croatica | Year: 2012

Tis clinical report describes an emergency case of a 49-year-old man, AsA e iii status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of difcult intubation (mallampati test Class iii, short thyro-mental (>6 cm) and sterno-mental distance (>10 cm) with limited mouth opening (inter-incisor gap >3 cm) were associated with signifcant comorbidity (rheumatoid arthritis, heart disease, obesity (body mass index 32.6 kg m-2), cervical spine mobility and generalized vascular disease). A specialist experienced in airway management decided on one attempt of Bonfls fberoptic intubation as primary intervention and urgent tracheotomy, if needed, as secondary intervention. immediately after assuming supine posi¬tion on the operating table, the patient lost consciousness and cardiac arrest developed. successful intubation with oxygenation was followed by cardiopulmonary resuscitation. upon stabilization of the patient's vital functions, urgent surgery was performed. in the emergency case presented, we succeeded quickly to secure the airway with Bonfls fberoptic intubation, which allowed for appro¬priate oxygenation and starting resuscitation. Te high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands. Source


Morovic M.,Zadar General Hospital | Hrstic I.,Pula General Hospital
Acta Medica Croatica | Year: 2013

Clinical practice guidelines for the management of chronic hepatitis B infection continue to evolve from year to year but the goal remains the same, i.e. long-term continued suppression of viral replication to prevent disease progression and development of cirrhosis and hepatocellular carcinoma. Out of seven drugs approved for the treatment of chronic hepatitis B, current guidelines recommend entecavir and tenofovir from the nucleos(t)ide analogues and pegylated interferon alfa-2a for the selected group of patients as first-line monotherapies. Both groups showed good results in a number of clinical trials and are used according to the consensus criteria. The treatment of special populations with chronic HBV infection, i.e. those with HCV/HDV/HIV co-infections, immunocompromised patients, patients who have undergone transplantation, patients with solid tumor and cirrhosis, patients with chronic renal failure on dialysis, pregnant women and children, is more often required and more demanding than for usual chronic hepatitis B. Source

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