Publications by authors named "Ante Rotim"

17 Publications

  • Page 1 of 1

Structural changes in brains of patients with disorders of consciousness treated with deep brain stimulation.

Sci Rep 2021 Feb 23;11(1):4401. Epub 2021 Feb 23.

Department of Neurosurgery, Dubrava University Hospital, Avenija Gojka Suska 6, 10000, Zagreb, Croatia.

Disorders of consciousness (DOC) are one of the major consequences after anoxic or traumatic brain injury. So far, several studies have described the regaining of consciousness in DOC patients using deep brain stimulation (DBS). However, these studies often lack detailed data on the structural and functional cerebral changes after such treatment. The aim of this study was to conduct a volumetric analysis of specific cortical and subcortical structures to determine the impact of DBS after functional recovery of DOC patients. Five DOC patients underwent unilateral DBS electrode implantation into the centromedian parafascicular complex of the thalamic intralaminar nuclei. Consciousness recovery was confirmed using the Rappaport Disability Rating and the Coma/Near Coma scale. Brain MRI volumetric measurements were done prior to the procedure, then approximately a year after, and finally 7 years after the implementation of the electrode. The volumetric analysis included changes in regional cortical volumes and thickness, as well as in subcortical structures. Limbic cortices (parahippocampal and cingulate gyrus) and paralimbic cortices (insula) regions showed a significant volume increase and presented a trend of regional cortical thickness increase 1 and 7 years after DBS. The volumes of related subcortical structures, namely the caudate, the hippocampus as well as the amygdala, were significantly increased 1 and 7 years after DBS, while the putamen and nucleus accumbens presented with volume increase. Volume increase after DBS could be a result of direct DBS effects, or a result of functional recovery. Our findings are in accordance with the results of very few human studies connecting DBS and brain volume increase. Which mechanisms are behind the observed brain changes and whether structural changes are caused by consciousness recovery or DBS in patients with DOC is still a matter of debate.
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http://dx.doi.org/10.1038/s41598-021-83873-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902623PMC
February 2021

THE RISK OF MULTIPLE INTRACRANIAL ANEURYSM FORMATION IN PATIENTS WITH MALIGNANT DISEASE UNDERGOING RADIATION THERAPY: A CASE REPORT AND LITERATURE REVIEW.

Acta Clin Croat 2020 Jun;59(2):359-364

1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 5Department of Neurology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 6Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 7Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia.

Neoplastic etiology of intracranial cerebral aneurysm is rare. Yet, the risk of its development is higher in malignant tumor patients receiving radiation therapy. Due to the possible negative effects of irradiation on intracranial vessel walls, the risk of aneurysm formation after radiation therapy, which is crucial for some types of breast cancer patients, continues to be a matter of debate. The aim of this study was to evaluate the hazard of multiple intracranial aneurysm development in patients with malignant disease undergoing radiation therapy. It is based on literature review and case report of a 77-year-old female patient who underwent surgery for multifocal invasive hormone-receptor positive ductal breast carcinoma of no special type, followed by chemotherapy, adjuvant radiation and hormone therapy. Her comorbidity included arterial hypertension and type 2 diabetes. Six unruptured intracranial aneurysms of different bilateral locations were diagnosed incidentally by multi-slice computed tomography angiography and digital subtraction angiography of cerebral vessels. Due to the bilateral aneurysm multiplicity, tumor characteristics and prognosis, comorbidity and relatively advanced age, the patient was not selected for active endovascular or microsurgical aneurysm treatment but only periodical clinical, oncologic and radiological follow-up was advised. In conclusion, the risk of multiple intracranial aneurysm formation in patients with breast cancer undergoing radiation therapy is low, but still possible. Long-term follow-up and regular cerebral angiographic check-up studies are necessary in selected malignant patients to decrease such a risk and to evade the worst outcome associated with aneurysm rupture.
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http://dx.doi.org/10.20471/acc.2020.59.02.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808237PMC
June 2020

LARGE ANEURYSM OF BASILAR ARTERY TIP MIMICKING MIDBRAIN TUMOR AND CAUSING UNILATERAL OBSTRUCTIVE HYDROCEPHALUS: A CASE REPORT AND TECHNICAL NOTE.

Acta Clin Croat 2020 Mar;59(1):166-172

1Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 3Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 4Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 5Ministry of Health, Republic of Croatia, Zagreb, Croatia; 6Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 7University of Applied Health Sciences, Zagreb, Croatia.

Cerebral ventricular system is a sporadic location of intracranial aneurysms including those of basilar artery tip. Treatment of such aneurysms remains challenging regardless of endovascular or microsurgical techniques applied. Basilar tip aneurysm presenting as third ventricular mass is rarely associated with obstructive hydrocephalus, mimicking midbrain expansive process and urging precise diagnostics and prompt treatment. Hence, the management of such patients may be delicate, having an uncertain outcome. We report on a case of a patient with unilateral hydrocephalus caused by large basilar tip aneurysm mimicking a midbrain tumor. We also discuss different operative strategies influencing the outcome, including our own endovascular treatment technical modification. A 62-year-old female patient presented with slightly decreased cognition, minor gait disturbances and urinary incontinence. Computed brain tomography revealed a third ventricle mass with unilateral ventricular dilatation, indicating hypertensive obstructive hydrocephalus. Magnetic resonance and digital subtraction angiography identified the third ventricular mass as a large saccular basilar tip aneurysm. The patient was selected for endovascular treatment followed by cerebrospinal fluid derivation. After aneurysm endovascular occlusion and temporary external ventricular drainage, the symptoms diminished and ventricular dilatation decreased. On post-procedure day 10, the hydrocephalus was relieved and external drainage removed. The patient recovered fully and was discharged without neurological deficit. In conclusion, large basilar tip aneurysms associated with obstructive hydrocephalus are rare and best treated by a combination of endovascular obliteration and cerebrospinal fluid ventricular diversion. The possibility of such an aneurysm should always be considered on the differential diagnosis of cerebral ventricular growths.
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http://dx.doi.org/10.20471/acc.2020.59.01.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382873PMC
March 2020

Prospective randomized appraisal of the best pain relief option after L4/L5 discectomy.

Neurol Res 2020 Dec 27;42(12):1003-1009. Epub 2020 Jul 27.

Department of Neurosurgery, Dubrava University Hospital , Zagreb, Croatia.

Objectives: To determine the efficacy of paracetamol and tramadol analgesia via patient controlled pump and intermittent administration using the Short-Form McGill Pain Questionnaire after L4/L5 discectomy in neurosurgical patients.

Methods: Fourteen months prospective quantitative study with 200 neurosurgical patients' participation who underwent elective discectomy of the L4/L5 intervertebral disc extrusion. The study was conducted due to a patient-controlled analgesia pump and intermittent analgesia application. Pain was assessed using the Short-Form McGill Pain Questionnaire in the Croatian language during the zero, first, and second postoperative day.

Results: Perception of pain was reduced in patient controlled analgesia pump groups after the second measurement during the first postoperative day [95% CI: -3.89, -0.76], regardless of administered analgesic (< 0.001). After the final measurement, at 7 PM on the second postoperative day, the differences were not significant (= 0.070). This study results are registered and allocated in the Australian New Zealand Clinical Trials Registry (ANZCTR).

Discussion: Analgesia administration via patient-controlled pump contributes to the alleviation of postoperative pain after L4/L5 disc extrusion surgery regardless of administered analgesic.
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http://dx.doi.org/10.1080/01616412.2020.1796383DOI Listing
December 2020

Hemoglobin A1c in Patients with Glioblastoma-A Preliminary Study.

World Neurosurg 2020 09 31;141:e553-e558. Epub 2020 May 31.

Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia; Department of Surgery, Zagreb University School of Medicine, Zagreb, Croatia.

Background: Glioblastomas are among the most common primary brain tumors with an abysmal prognosis. The significance of glucose metabolism in glioblastoma cell metabolism and proliferation is well-known. However, a significant correlation between the systemic metabolic status of the patient and the cellular proliferation of the glioblastoma has not yet been established.

Methods: Our aim was to observe and analyze for a possible correlation between glioblastoma cellular proliferation and patients' glycated hemoglobin (HbA1c) levels as a marker of chronic systemic glycemia. We analyzed the data from 25 patients and compared their Ki-67 values with their preoperative HbA1c values.

Results: We observed a statistically significant correlation (P < 0.03) between chronic glycemia (measured using HbA1c) and the cellular proliferation of glioblastoma (measured by cellular Ki-67 expression).

Conclusions: These results imply a possible positive correlation between glioblastoma cell proliferation and chronic systemic glycemia, a correlation that, to the best of our knowledge, has not yet been reported. Further research in this area could not only lead to a better understanding of glioblastoma but also have significant clinical applications in treating this devastating disease.
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http://dx.doi.org/10.1016/j.wneu.2020.05.231DOI Listing
September 2020

Nocardial brain abscess mimicking lung cancer metastasis in immunocompetent patient with pulmonary nocardiasis: a case report.

Acta Clin Croat 2019 Sep;58(3):540-545

1Department of Surgery, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 2Department of Pathology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 3Department of Neurosurgery, Clinical Centre of Vojvodina, Novi Sad, Serbia; 4Pathology and Histology Center, Clinical Centre of Vojvodina, Novi Sad, Serbia; 5Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 6Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 7Department of Neurosurgery, Clinical Centre of Serbia, Belgrade, Serbia.

Nocardia is a ubiquitous microorganism which can be the cause of local and disseminated infection in humans. Immunocompetent and immunocompromised patients both can be affected and was reported as a pathogen isolated in patients worldwide. In most cases, nocardiosis is present as pulmonary infection because inhalation is the primary way of bacterial exposure. Nocardial brain abscess occurs usually secondary to a septic focus elsewhere in the body. Considering the facts that the elderly population is growing, such as the number of immunocompromised patients together with high mortality rate in patients with nocardial infection of the central nervous system, we have to raise awareness of the possibility for this rare but potentially fatal condition. We present a case where nocardial abscesses of lung and brain were initially suspected as lung cancer with brain metastases. The patient was treated with a combination of surgical resection and antimicrobial therapy with good outcome.
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http://dx.doi.org/10.20471/acc.2019.58.03.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971799PMC
September 2019

LUMBAR SPINE SYNOVIAL CYST: A CASE SERIES REPORT AND REVIEW OF SURGICAL STRATEGIES.

Acta Clin Croat 2019 Sep;58(3):491-496

1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Josip Juraj Strossmayer University of Osijek, School of Dental Medicine and Health, Osijek, Croatia; 4Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 5University of Applied Health Sciences, Zagreb, Croatia; 6Department of Neurosurgery, Varaždin General Hospital, Varaždin, Croatia.

Lumbar spine synovial cysts are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy and neurological deficit. However, they are not well defined concerning their origin, cause and pathology, as well as available treatment strategies. The scope of different surgical procedures includes image-guided epidural steroid injection, direct cyst puncture by percutaneous epidural needle, spinal canal decompression and cyst resection, and spinal bone fusion with/without instrumentation. Hereby, we report institutional experience and discuss surgical strategies of lumbar spine synovial cyst treatment. Presenting symptoms, imaging findings and outcomes were retrospectively analyzed in 15 patients with lumbar spine synovial cyst, operated on during a one-year period. The leading presenting symptom was lumbar radicular pain, while the most commonly involved vertebral level was L5-S1. In a great majority of patients, a single-level interlaminectomy and cyst resection were performed. Most patients recovered without postoperative neurological and functional deficit, as well as surgery-related complications. No poor outcome was noticed in our series. Concerning our results and literature review, the optimal management for patients with symptomatic lumbar synovial cyst has to be highly personalized, which is essential to achieve a favorable outcome. Nonetheless, the best treatment strategy has yet to be affirmed.
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http://dx.doi.org/10.20471/acc.2019.58.03.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971798PMC
September 2019

Association among Clopidogrel Cessation, Platelet Function, and Bleeding in Coronary Bypass Surgery: An Observational Trial.

Thorac Cardiovasc Surg 2019 Jul 30. Epub 2019 Jul 30.

Klinik fur Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, and TEM International GmbH, Munich, Germany.

Objectives:  This study sought to determine (1) the association between the length of preoperative clopidogrel discontinuation, blood loss, and transfusion requirements and (2) whether preoperative platelet function testing predicts excessive postoperative bleeding in patients undergoing coronary artery bypass grafting (CABG) surgery.

Methods:  In this retrospective analysis, patients undergoing CABG were divided into three groups with regard to the period between preoperative clopidogrel cessation and surgery: group 1 ( = 94, ≤3 days), group 2 ( = 100, 4-5 days), and group 3 ( = 83, 6-7 days), respectively. Impedance aggregometry (Multiplate) with arachidonic acid (ASPI) test assay (used for platelets stimulation) and adenosine diphosphate (ADP) test (used for platelets stimulation) was performed before the surgery. Primary outcome was 24 hours chest tube output (CTO) and transfusion requirements (red blood cell concentrate [RBCC], platelet concentrate [PC], fibrinogen concentrate [FC], and fresh-frozen plasma [FFP]) were considered as secondary outcomes.

Results:  CTO during 24 hours was significantly higher in group 1 as compared with groups 2 and 3, respectively ( = 0.003). Considering secondary outcomes, RBCC ( = 0.043), PC ( = 0.001), FC ( = 0.003), and FFP ( = 0.010) were more frequently transfused in group 1 as compared with groups 2 and 3, respectively. Multiple electrode aggregometry ASPI and ADP tests were significantly correlated with the 24-hour CTO (ASPI test-rho = -0.258,  < 0.001; ADP test-rho = -0.164,  = 0.007). A significant correlation was observed between clopidogrel-free interval and 24-hour CTO (rho = -0.200,  < 0.001). Receiver-operating characteristics (ROC) curve analysis revealed cutoff values to delineate bleeding tendency (ASPI test ≤ 25 area under the aggregation curve [AUC], ADP test ≤63 AUC, and clopidogrel-free interval ≤3 days).

Conclusion:  Excessive postoperative bleeding occurred less frequently if the period between clopidogrel discontinuation and surgery was longer than 3 days, as compared with shorter waiting time. Inadequate recovery of the platelets function following clopidogrel cessation in preoperative period was associated with increased bleeding risk. Platelet function testing was found to be a useful tool for postoperative bleeding management in our hands.
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http://dx.doi.org/10.1055/s-0039-1693122DOI Listing
July 2019

PRIMARY EPITHELIOID HEMANGIOENDOTHELIOMA IN THE CEREBELLUM: CASE REPORT WITH REFERENCE TO DRASTIC CHANGE IN THE WHO CLASSIFICATION.

Acta Clin Croat 2018 Sep;57(3):570-576

1Department of Neurosurgery, University Clinical Center of Sarajevo, Sarajevo, Bosnia-Herzegovina; 2Department of Clinical Pathology and Cytology, University Clinical Center of Sarajevo, Sarajevo, Bosnia-Herzegovina; 3School of Medicine, University of Sarajevo, Sarajevo, Bosnia-Herzegovina; 4Department of Radiology, Sarajevo General Hospital, Sarajevo, Bosnia-Herzegovina; 5Department of Neurology, University Clinical Center of Sarajevo, Sarajevo, Bosnia-Herzegovina; 6Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia; 7Semmes-Murphey Clinic and University of Tennessee, Memphis, TN, USA.

- Epithelioid hemangioendothelioma is a rare vascular brain tumor. It develops from endothelial cells, usually in the liver, lung, bone and soft tissue. Primary localization of this tumor in the intracranial space is very uncommon; only 47 cases have been described in the literature. This tumor was initially classified as grade I (benign) in the World Health Organization WHO) 2007 classification. In 2016, this tumor was re-classified as grade III (malignant). Herein, the first case report of epithelioid hemangioendothelioma in the cerebellum of a male patient is presented. Complete surgical excision was done. No adjuvant therapy was administered. Magnetic resonance imaging performed 2 years after the surgery continued to show no recurrence of the tumor. To our knowledge, this is the first report of cerebellar location of this rare tumor. In addition, the authors report drastic re-classification of the epithelioid hemangioendothelioma from the benign tumor (WHO 2007) to a malignant one (2016), which significantly changes postoperative management and follow up of this brain neoplasm.
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http://dx.doi.org/10.20471/acc.2018.57.03.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536283PMC
September 2018

Diagnosis and Management of Acquired von Willebrand Disease in Heart Disease: A Review of the Literature.

Thorac Cardiovasc Surg 2020 04 20;68(3):200-211. Epub 2018 Nov 20.

Department of Cardiac Surgery, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia.

The incidence of acquired von Willebrand syndrome (AvWS) in patients with heart disease is commonly perceived as rare. However, its occurrence is underestimated and underdiagnosed, potentially leading to inadequate treatment resulting in increased morbidity and mortality.In patients with cardiac disease, AvWS frequently occurs in patients with structural heart disease and in those undergoing mechanical circulatory support (MCS).The clinical manifestation of an AvWS is usually characterized by apparent or occult gastrointestinal (GI) or mucocutaneous hemorrhage frequently accompanied by signs of anemia and/or increased bleeding during surgical procedures. The primary change is loss of high-molecular weight von Willebrand factor multimers (HMWM). Whereas the loss of HMWM in patients with structural heart disease is caused by increased HMWM cleavage by von Willebrand factor (vWF)-cleaving protease, ADAMTS13, AvWS in MCS patients is predominantly a result of a high shear stress coupled with mechanical destruction of vWF itself.This manuscript provides a comprehensive review of the evidence regarding both diagnosis and contemporary management of AVWS in patients with heart disease.
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http://dx.doi.org/10.1055/s-0038-1673670DOI Listing
April 2020

Ventricular diastolic dimension over maximal myocardial thickness is robust landmark of systolic impairment in patients with hypertrophic cardiomyopathy.

Med Sci Monit 2018 Mar 31;24:1880-1886. Epub 2018 Mar 31.

Department of Internal Medicine, Medical Faculty "J.J. Strossmayer" University of Osijek, Osijek, Croatia.

BACKGROUND The effects of focal hypertrophy on geometry of the left ventricle and systolic function have not been studied in patients with hypertrophic cardiomyopathy (HCM), despite the fact that the former is the most prominent disease characteristic. The aim of our study was to analyze systolic function over ventricle geometry, generating a functional index made from left ventricle end diastolic dimension (LVEDD) divided by end diastolic thickness of the region with maximal extent of hypertrophy and interventricular septum. MATERIAL AND METHODS Our hospital database of cardiac magnetic resonance was screened for HCM. Geometric functional index (GFI) was calculated for LVEDD over maximal end diastolic thickness (MaxEDT) giving GFI-M, while LVEDD over interventricular septum was expressed as GFI-I. There were 55 consecutive patients with HCM. RESULTS There were 43 males (78.2%) and 12 females (21.8%). The mean age was 52.3±16.7 years (range: 15.5-76.4 years). A significant difference of GFI was found for preserved versus impaired systolic function of the left ventricle (preserved systolic function); GFI-M 2.28±0.60 versus 3.66±0.50 (p<0.001), and GFI-I 2.75±0.88 versus 3.81±0.87 (p<0.001), respectively. Diagnostic value was tested using receiver operating curve (ROC) analyzes, with GFI-M area under curve (AUC)=0.959 (95% CI: 0.868-0.994); (p<0.001) and GFI-I-AUC=0.847 (0.724-0.930); (p<0.001). GFI-M was superior to GFI-I for appraisal of left ventricle systolic dysfunction in HCM; ΔAUC=0.112 (0.018-0.207); (p=0.020). CONCLUSIONS GFI is a simple tool, with high sensitivity and specificity for detecting impairment of systolic function in patients with HCM. Further studies would be necessary to investigate its clinical and prognostic impacts, as well as reproducibility with prospective validation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892461PMC
http://dx.doi.org/10.12659/msm.906111DOI Listing
March 2018

Supplementary Diagnostic Landmarks of Left Ventricular Non-Compaction on Magnetic Resonance Imaging.

Yonsei Med J 2018 Jan;59(1):63-71

Department of Internal Medicine, Medical Faculty "J.J. Strossmayer" University of Osijek, Osijek, Croatia.

Purpose: Diagnostic criteria for left ventricular non-compaction (LVNC) are still a matter of dispute. The aim of our present study was to test the diagnostic value of two novel diagnostic cardiac magnetic resonance (CMR) parameters: proof of non-compact (NC) myocardium blood flow using T2 sequences and changes in geometry of the left ventricle.

Materials And Methods: The study included cases with LVNC and controls, from a data base formed in a period of 3.5 years (n=1890 exams), in which CMR protocol included T2 sequences. Measurement of perpendicular maximal and minimal end diastolic dimensions in the region with NC myocardium from short axis plane was recorded, and calculated as a ratio (MaxMinEDDR), while flow through trabecula was proven by intracavital T2-weighted hyperintensity (ICT2HI). LVNC diagnosis met the following three criteria: thickening of compact (C) layer, NC:C>2.3:1 and NC>20%LV.

Results: The study included 200 patients; 71 with LVNC (35.5%; i.e., 3.76% of CMRs) and 129 (64.5%) controls. MaxMinEDDR in patients with LVNC was significantly different from that in controls (1.17±0.08 vs. 1.06±0.04, respectively; p<0.001). MaxMinEDDR >1.10 had sensitivity of 91.6% [95% confidence intervals (CI) 82.5-96.8], specificity of 85.3% (95% CI 78.0-90.0), and area under curve (AUC) 0.919 (95% CI 0.872-0.953; p<0.001) for LVNC. Existence of ICT2HI had sensitivity of 100.0% (95% CI 94.9-100.0), specificity of 91.5% (95% CI 85.3-95.7), and AUC 0.957 (95% CI 0.919-0.981; p<0.001) for LVNC.

Conclusion: Two additional diagnostic parameters for LVNC were identified in this study. ICT2HI and geometric eccentricity of the ventricle both had relatively high sensitivity and specificity for diagnosing LVNC.
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http://dx.doi.org/10.3349/ymj.2018.59.1.63DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725366PMC
January 2018

Combined Treatment of Ruptured Middle Cerebral Artery Aneurysm Followed by Subarachnoid Hemorrhage and Acute Subdural Hematoma in Multiple Aneurysm Disease of Cerebral Blood Vessels: Case Report

Acta Clin Croat 2016 12;55(4):659-662

Clinical Department of Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia

Aneurysms of blood vessels at the base of the brain are pathological focal out-pouchings, usually found at the branching points of the arteries. Aneurysm can remain silent for life. Clinical presentation is due to rupture and bleeding. In only 1.3% of cases it results in subdural hematoma, which is associated with direct interaction of the aneurysm with the basal arachnoid membrane. Multiple aneurysms are present in 15% to 33% of cases with subarachnoid hemorrhage. Assessment of these patients is more complicated, as there are no specific signs to pinpoint/detect the aneurysm that has ruptured. This report presents a 44-year-old female patient suffering from multiple cerebral aneurysm disease, who was urgently treated after rupture by both endovascular (for multiple aneurysms) and surgical (for acute subdural hematoma) approach in the same act under general anesthesia, which resulted in complete recovery of the patient.
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http://dx.doi.org/10.20471/acc.2016.55.04.19DOI Listing
December 2016

Development of a concept for a personalized approach in the perioperative antiplatelet therapy administration/discontinuation management based on multiple electrode aggregometry in patients undergoing coronary artery surgery.

J Thromb Thrombolysis 2015 Oct;40(3):383-91

Department of Cardiac Surgery, University of Zagreb School of Medicine, University Hospital Center Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia,

In patients undergoing coronary artery surgery, improvements in clinical outcomes currently rely on continued refinements of the surgical technique and modulation of adjuvant pharmacotherapy. Despite medical and technological advances, negligible rate of bleeding and ischemic events still persist necessitating further improvements in patient management. Platelet function testing (PFT) might play an important role in meticulous balancing between the risk of bleeding and thrombotic events. A suitable balance can be achieved by implementing a personalized, PFT based approach in antiplatelet therapy (APT) administration/discontinuation management. Despite emerging evidence on the widespread variability in platelet inhibitory response to APT, numerous PFT devices and heterogeneity in reporting study results hamper pooling of the evidence which in turn results with a lack of consensus in "on treatment" platelet reactivity associated with ischemic and bleeding events in perioperative phase. The literature on multiple electrode aggregometry (Multiplate(®); Roche Diagnostics, Mannheim, Germany) in coronary artery disease patients was reviewed systematically. Based on the evidence evaluating the relationship between "drug specific" PFT and bleeding or adverse ischemic events, we sought to define therapeutic window for the most commonly administered antiplatelet drugs such as aspirin (ASPI test) and adenosine-diphosphate receptor blockers (ADP test). Preoperatively, APT administration was primarily focused to avoid bleeding complications. ASPI test value of 20 AUC and ADP test value of <73 AUC were set as cut-off values that delineate bleeding tendency. Postoperatively, "therapeutic window" was set to avoid both bleeding and adverse ischemic events. Therapeutic ranges were as follows: 20 AUC < ASPItest ≤ 30 AUC and 19AUC < ADP ≤ 46AUC, respectively. This is the first attempt to define PFT based "therapeutic window" according to, perioperative APT administration/discontinuation management would be targeted. It seems that the "one-size-fits-all" concept of perioperative APT administration management is outdated and further development of PFT based, personalized APT administration/discontinuation management is desirable. This concept therefore presents a possible step forward in patient care and provides a platform for further interventional trials whereby the impact of its application on clinical outcomes would be validated.
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http://dx.doi.org/10.1007/s11239-015-1246-yDOI Listing
October 2015

Characteristics of NRS-2002 Nutritional Risk Screening in patients hospitalized for secondary cardiovascular prevention and rehabilitation.

J Am Coll Nutr 2014 11;33(6):466-73. Epub 2014 Nov 11.

a Department of Cardiology.

Objective: The aim of our study was to assess the prevalence and characteristics of nutritional risk in patients scheduled for cardiovascular rehabilitation.

Background: Knowledge concerning nutritional aspects of cardiovascular diseases is contemporary limited.

Methods: Nutritional risk screening using a standardized Nutritional Risk Screening-2002 (NRS-2002) questionnaire was performed on a cohort of consecutive patients scheduled for rehabilitation 1-6 months after treatment for ischemic, valvular, or combined causes of heart diseases. Baseline weight was available for more than 80% of patients.

Results: The study population consisted of 317 patients, aged 23-85 years, with a mean age of 62.5 ± 11.3 years. Male to female share was 253 (79.8%) and 64 (20.2%), respectively. Twenty-eight (8.8%) were treated for myocardial infarction conservatively, 151 (47.6%) by percutaneous coronary interventions, and 145 (45.7%) by surgery. NRS-2002 was 3.56 ± 1.54 in range 0-6. A high correlation was found between the NRS-2002 and percentage weight loss history (rho = 0.813; p <0.001). Significant differences according to increased nutritional risk (NRS-2002 ≥ 3) were found within age groups (p < 0.001), disease etiology (p = 0.002), cardiovascular treatments (p < 0.001), and grades of renal function (p < 0.001). Odds for developing increased nutritional risk (NRS-2002 ≥ 3) were significant for cardiovascular treatments (odds ratio [OR] = 4.35, 95% confidence interval [CI], 2.28-8.30, p < 0.001), age (OR = 3.19, 95% CI, 2.00-5.09, p < 0.001), grade of renal function (OR = 1.91, 95% CI, 1.17-3.09, p = 0.009), diabetes mellitus (OR = 2.37, 95% CI, 1.09-5.16, p = 0.029), and any psychological disturbance (OR = 2.04, 95% CI, 1.06-3.90, p = 0.032).

Conclusions: Pronounced nutritional risk frequently existed among patients at stationary cardiovascular rehabilitation. Nutritional risk was connected with preceding cardiovascular treatments, patient age, and renal function. Further studies concerning nutritional risk and its connections with clinical outcomes might serve as a resourceful perspective to improve outcomes or quality of care for the entities from the cardiovascular diseases continuum.
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http://dx.doi.org/10.1080/07315724.2013.876902DOI Listing
July 2015

Clinical ethics in Croatia: an overview of education, services and research (an appeal for change).

Acta Clin Croat 2014 Jun;53(2):166-75

The aim of this paper is to delineate current position of clinical ethics in the Croatian healthcare system by analyzing the following: representation of clinical ethics contents in the curricula of medical and associated schools; composition and role of clinical ethics consultations; and establishment of an ethical/legal framework for the conduct of research. Curriculum investigation, literature review, arid analysis of the Croatian Act on the Protection of Patients' Rights were performed. The contents of clinical ethics are offered through 63 obligatory and elective subjects at 12 institutions. It is wrongly placed either too early or too late within the curriculum. Continuity at all levels of health professional education is needed. Croatian experience with clinical ethics consultations is shaped only by ethics committees. Problematic is the review of research protocols indicated as their main activity. Inclusion of team and individual consultations would increase the availability and facilitate the usage of ethics support services. The Act on the Protection of Patients' Rights is based on the principles of humanity and availability, ensuring the right to protection when participating in clinical trials. Unfortunately, the outdated paradigm of paternalistic medicine aggravates the respect for patients' rights in cure, care and research. A shift towards the patient/person-centered healthcare system would put the Act into everyday practice. Although clinical ethics has entered the Croatian healthcare system in a formal and practical way, the authors wish to emphasize the need to approach the European and other international standards regarding the recent Croatian accession to the European Union.
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June 2014

Can Croatian medicine do without palliative medicine?--Study investigating the need for formal education.

Coll Antropol 2013 Dec;37(4):1133-7

University of Applied Health Sciences, Zagreb, Croatia.

The aim of this study was to determine the public's, i.e. citizens' attitude on one hand, and health-care professionals' attitude on the other, regarding the public education in palliative care. Also, the assessment of health-care professionals' attitude regarding the need to establish a sub-specialty in palliative medicine in Croatia was performed. The study was carried out during 2007 and 2008 in the capitals of 7 Croatian counties, involving 2353 participants. Two types of anonymous questionnaire were distributed. Citizens were surveyed at public places, business offices, waiting rooms, while health-care professionals were surveyed in medical centers. The survey was conducted personally by the authors, i.e. "face to face" with the respondents. The collected data were entered into a database and analyzed, taking into account the anonymity, privacy and data confidentiality. The response rate was 99% for the public and 97% for health-care professionals. 44% of the public thought that educating the public in palliative care is absolutely necessary, and 42% that it is mostly necessary; compared with 47% of health-care professionals who thought education was absolutely necessary, and 45% who thought it is mostly necessary. In addition, health-care professionals were asked about their opinion regarding the establishment of a sub-specialty in palliative medicine and 76% of respondents considered it absolutely necessary. Both the public and health-care professionals recognize the need for public education in palliative care. The authors wish to especially emphasize health-care professionals' perception of a great need for the establishment of an official medical curriculum and a medical sub-specialty in palliative medicine.
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December 2013