Showing papers in "Acta medica Croatica : c̆asopis Hravatske akademije medicinskih znanosti in 2016"

A clinical algorithm for wound biofilm identification.

Abstract: Recognition of the existence of biofilm in chronic wounds is increasing among wound care practitioners, and a growing body of evidence indicates that biofilm contributes significantly to wound recalcitrance. While clinical guidelines regarding the involvement of biofilm in human bacterial infections have been proposed, there remains uncertainty and lack of guidance towards biofilm presence in wounds. The intention of this report is to collate knowledge and evidence of the visual and indirect clinical indicators of wound biofilm, and propose an algorithm designed to facilitate clinical recognition of biofilm and subsequent wound management practices.

Quality of life and psychological aspects in patients with chronic leg ulcer

Abstract: Wound represents a disruption of anathomic and physiologic continuity of the skin. Regarding to the healing process, wounds can be classified as acute or chronic wounds. Quality of life is primarily concerned with the impact of chronic wounds. A wound is considered chronic if healing does not occur within expected period of time regarding to its etiology and localization. Chronic wounds can be classified as typical and atypical. The majority of wounds (95 percent) are typical ones which include ischaemic, neurotrophic and hypostatic ulcer and two separate entities: diabetic foot and decubital ulcers. An 80 percent of chronic wounds localized on lower leg are result of chronic venous insufficiency, in 5-10 percent cause is of arterial etiology, whereas the remainder is mostly neuropathic ulcer. Chronic wounds represent a significant burden to patients, health care professionals and the entire health care system. Chronic wounds affect the elderly population and it is estimated that 1-2 percent of western population suffer from it. This estimate is expected to rise due to an increasing population of the elderly and the diabetic and obesity epidemic. The WHO definition of health is "A state of complite physical, mental and social well-being and not merely the absence of disease or infirmity". Based on this definition, quality of life in relation to health may be defined as "the functional effect of an illness and it's consequent therapy upon a patient, as perceived by the patient". The domains that contribute to this effect are physical, psychological and social functioning. The patient's own perceptions of an illness were found to play an important role in explainig quality of life. Chronic wounds significantly decrease the quality of life in a number of ways such as reduced mobility, pain, unpleasant odor, sleep disturbances, social isolation and frustration, and inability to perform everyday duties. Among the most common psychological reactions to chronic diseases, including chronic wounds, are depression, anxiety, aggression and frustration. Psychological factors may not only be a consequence of delayed healing, but may also impact on wound healing. Anxiety and depression have direct influences on endocrine and immune function. About the impact of disease on quality of life and individuals' perceptions of illness, there are questionnaires and methods to analyze this, but the challenge is to move from a focus on wound management to understanding the specific needs of each individual within the context of their life.

Quality of life of dialysis patients

Abstract: Measuring the Health Related Quality of Life (HRQOL) is part of the general concept of quality of life. According to the survey, quality of life in dialysis patients is significantly lower as compared to general population. The aim is to show the importance and impact of the quality of life in dialysis patients on treatment outcomes. In October 2016, the MEDLINE and EBSCO databases were searched for the 2005-2016 period. Kidney transplantation offers better HRQOL as compared to dialysis, since there is no significant difference in HRQOL between patients on hemodialysis and those on peritoneal dialysis. Good clinical practice in the treatment of dialysis patients is based on individual approach and on improving the quality of life, for which collaboration of family doctors and consultant nephrologists is necessary. In daily practice, using questionnaires on the quality of life of dialysis patients would increase the awareness of this very important segment of care for dialysis patients because quality of life is an outcome measure of treatment in these patients.

Parent’s and children’s behavior and knowledge about oral health

Abstract: Responsible health behavior plays an important role in every individual. Oral health quality results from the level of information available, attitudes, habits and nutrition. Family is the most important environment where children can acquire knowledge, attitudes and habits related to oral health. The aim of the study was to compare the habits of parents and children related to their oral health, and to conclude how parental behavior influences oral health of their children. The study included 101 parent-child pairs (age 11-15 years), their knowledge and behavior according to their oral hygiene, fluoro-prophylaxis and nutrition assessed by anonymous questionnaire. Oral health of parents was estimated according to their tooth loss and compensation, while oral health of children was assessed by dental examination. A total of 101 child-parent pairs were included. Most children were excellent pupils (43.56%). In the group of parents, most participants were mothers (73.27%). Most parents had high school education (65.35%) and were employed (61.62%), and most perceived themselves to be living with average financial situation (86%). A comparable proportion of parents (95%) and children (87%) believed that it was necessary to wash teeth at least twice a day (p=0.125) and most of them thought it necessary to brush teeth for 1-3 minutes (57% of children and 57.43% of parents; p=0.599). The majority of children (56%) and parents (72%) considered it necessary to use dental floss with a toothbrush and toothpaste (p=0.065), while 63% of children and 71.72% of parents believed that toothpaste contained fluoride (p=0.156). Most of the parents (72.3%) and children (65.35%) brushed teeth in the morning and at bedtime (p=0.167) for 1-3 minutes (p=0.098). About 30% of parents and children used the handler for brushing teeth (p=1). Most children (86.32%) and parents (92.1%) had 3-5 meals a day (p=0.181), and 80% of them had their teeth examined by a dentist the year before (p=0.658). The children believing that teeth should be brushed only in the morning have a 3.38-fold greater chance to develop tooth disorders (DMFT >0; p=0.004). Those that do not know that caries and periodontal diseases can be prevented have a 26.3-fold greater chance to develop caries compared to those who are aware of it. Children of parents who only brush their teeth in the morning have a 25 times higher chance of developing CEP >0 as compared with those that brush their teeth after each meal (p=0.016). Children of parents who give them money to buy snacks are 2.9 times more likely to develop CEP >0 (p=0.01) compared to children without money for snack. Children of parents who feel that their health is not good have 3.9 times higher chance of developing CEP >0 as compared to those whose parents think they have a neat bite (p=0.017). Oral hygiene in Croatia is still not at a level of the standards in Western countries. Ignorance about oral hygiene and irresponsible health behavior are the main causes of the poor condition of the teeth. Results of this study showed the close relationship between family attitudes about oral hygiene, as children follow their parents’ habits and behavior. In conclusion, by educating parents, we influence their children’s behavior and knowledge about oral health, and this is the way that health workers should plan interventions to prevent oral diseases.

Development of a next-generation antimicrobial wound dressing.

Abstract: Delayed wound healing due to infection is a burden on healthcare systems, and the patient and caregiver alike. An emerging factor in infection and delayed healing is the presence development of biofilm in wounds. Biofilm is communities of microorganisms, protected by an extracellular matrix of slime in the wound, which can tolerate host defences and applied antimicrobials such as antibiotics or antimicrobial dressings. A growing evidence base exists suggesting that biofilm exists in a majority of chronic wounds, and can be a precursor to infection while causing delayed healing itself. In vivo models have demonstrated that the inflammatory, granulation and epithelialization processes of normal wound healing are impaired by biofilm presence. The challenge in the development of a new antimicrobial wound dressing was to make standard antimicrobial agents more effective against biofilm, and this was answered following extensive biofilm research and testing. A combination of metal chelator, surfactant and pH control displayed highly synergistic anti-biofilm action with 1.2% ionic silver in a carboxymethylcellulose dressing. Its effectiveness was challenged and proven in complex in vitro and in vivo wound biofilm models, followed by clinical safety and performance demonstrations in a 42-patient study and 113 clinical evaluations. Post-market surveillance was conducted on the commercially available dressing, and in a 112-case evaluation, the dressing was shown to effectively manage exudate and suspected biofilm while shifting difficult-to-heal wounds onto healing trajectories, after an average of 4 weeks of new dressing use in otherwise standard wound care protocols. This was accompanied by a low frequency of dressing related adverse events. In a second evaluation, clinical signs of infection and wound dimension data, before and after the evaluations, were also available. Following an average of 5.4 weeks of dressing use, all signs of clinical infection were reduced, from an average frequency of 36% to 21%. An average of 62% wound size reduction was achieved, with 90% of wounds reducing in size and 10 wounds healing completely. The new clinical evidence for this next-generation antimicrobial wound dressing suggests it is safe and effective at managing exudate, infection and biofilm, while it can shift established, stubborn wounds onto healing trajectories. The scientific rationale for this new dressing technology is supported by in vitro and in vivo evidence, so now further comparative, randomized and outcome-based clinical studies are required to fully understand the clinical and economic benefits this new dressing technology can bring.

The role of antiseptics and strategy of biofilm removal in chronic wound

Abstract: Chronic wound does not heal within the expected time frame because it remains in the inflammation phase of healing. The reason for this is the presence of necrotic tissue and a large number of microorganisms, primarily bacteria that secrete the biofilm, along with ischemia, hypoxia and edema. Biofilm is present in 90% of chronic wounds and 6% of the acute ones. Biofilm is a corporative association of microbes which adhere to the surface of the wound, guided by quorum sensing molecules. The association is surrounded by a moisturizing matrix of extracellular polymeric substances (slime) which protect the microbes from the impact of antibiotics, antiseptics, macro-organism defense and stress. Biofilm is the primary cause of the wound chronicity because it causes permanent inflammation, delayed granulation tissue formation and migration of epithelium cells, thus providing a reservoir of microbes that lead to infection of the chronic wound. The aim of good clinical practice is to enable healing of a chronic wound within the expected time frame. In order to achieve this aim, it is necessary to reduce and thoroughly remove the biofilm from the wound and prevent its reappearance. This is achieved by the application of active anti-biofilm compounds and procedures that disintegrate the quorum sensing molecules, degrade the extracellular polymeric substances and block adherence to the surfaces. Recent researches have shown that the application of antiseptics is effective in the prevention of infection and is a support to targeted treatment. However, the fact is that only some antiseptics are applicable to chronic wounds and can have an impact on biofilms of the primary infective agents such as Staphylococcus spp., Streptococcus spp., and Pseudomonas aeruginosa. Effective antiseptics are octenidine dihydrochloride, polyhexanides, povidone and cadexomer iodine, nanocrystal silver and Manuka-type honey. Immobile biofilm is a persistent problem of chronic and chronic infected wounds. In fact, there is no isolated therapeutic procedure or an individual antiseptic that can fully destroy the biofilm. For this reason, modern strategy in the management of chronic wound applies a multimodal approach which combines mechanical-chemical procedures such as debridement, antiseptics, and antimicrobial supportive compresses. Debridement creates a therapeutic 'window' for the action of antiseptics and antibiotics in a 72-hour period, which enables removal of the biofilm and active destruction of the sessile and planktonic bacteria. This approach also prevents de novo formation of the biofilm. The above procedures must be intensively repeated, and antiseptics and supportive compresses changed, depending on the phase of the wound bed and comorbidity factors in the patient. The results of clinical studies show that only such a proactive approach to chronic wound enables achievement of healing within the expected period of time.

Pressure ulcer prevention: fundamentals for best practice.

Abstract: This introduction has highlighted both the complex nature of the aetiology of pressure ulcer development and the complex nature of the assessment process intended to identify those patients who are or might be at an enhanced risk of pressure ulcer development The latter statement assumes that all patients cared for in any healthcare setting are vulnerable to pressure ulcer development Whilst it is acknowledged that the use of a risk assessment tool can be important in an overall pressure ulcer prevention strategy, it is important that the limitations of these tools are acknowledged and that they are not an finite assessment in themselves and that they should be used by a practitioner with a fundamental breadth of relevant knowledge and an appreciation of the range of appropriate preventative equipment/techniques available and the role of the multi-disciplinary team in the prevention of all avoidable pressure ulcers

Biofilm and our clinical experience.

Abstract: Bacteria organized in biofilms are insensitive to the usual treatment with dressings or antibiotics. Most successful is surgical debridement to remove their colonies, but this option may not be possible in all environments. Dressings with silver and other antiseptics are often the only tools available to nurses at patient homes or to dermatologists at outpatient clinics. In our clinical studies conducted several years ago, we demonstrated that dressings with antiseptics were an effective tool in daily clinical practice to remove bacteria/biofilms from chronic wounds.

Characteristic features of pressure ulcer infection

Abstract: Pressure ulcer is a localized injury of the skin and/or adjacent tissue, usually above bone protrusions It is a result of pressure or pressure combined with shear stress, friction and humidity With regard to long life and delayed healing, it is a chronic wound Pressure ulcer appears as a consequence of a combination of micro-embolism, ischemia and myonecrosis These pathophysiological processes provide an ideal medium for proliferation of microorganisms, predominantly bacteria, and development of infection Progression in the development of pressure ulcer is a dynamic process manifesting in phases, each of which is characterized by its own physiological-anatomical peculiarities and microbiological status An open lesion without protective barrier becomes contaminated immediately, and, shortly afterwards, colonized by physiological microflora of the host and microbes from the environment In the absence of preventive measures, the wound becomes critically colonized and infected The characteristic of chronic wound/pressure ulcer is that it is colonized, and the infection develops depending on various factors in 5% to 80% of cases The ability of microbes to cause infection depends on a number of factors, which include the pathogen and the host The number and quantity of virulent factors, microbes, determines the virulence coefficient, which is responsible for overcoming the host’s immune system and development of infection In the development of pressure ulcer infection, two essential microbial factors predominate, ie the presence of adhesin and association with biofilm Thus, pressure ulcer infection as a chronic wound is characterized by a polymicrobial and heterogeneous population of microbes, domination of biofilm phenotype as a primary factor of virulence present in 90% of cases, phenotype hypervariability of species, and resistance or tolerance of the etiological agents to all types of biocides The most significant virulence factor is biofilm It is a corporative community of microbes with a clear architecture managed by quorum sensing molecules It is through them that the communication between species takes place, the phenotype and virulence change, and resistance develops at the level of genome The formation of biofilm takes place in several stages, and the speed is measured in hours Microorganisms in the biofilm are protected from the action of the host’s immune system and, likewise, they are tolerant or resistant to antibiotics, antiseptics, and stress Bacteria causing pressure ulcer infection are characterized as opportunistic, but also primarily pathogenic The dominance and combination of species depend on the duration, localization and stage of pressure ulcer The predominant etiological agents are Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa and Peptostreptococcus spp Nowadays, multiple-resistant strains predominate, such as MRSA, Acinetobacter spp and Pseudomonas spp A chronic wound such as pressure ulcer is ideal for the development of infection, especially if targeted preventive measures are not applied The diagnosis of infection is complex and is based on the combination of primary and secondary clinical symptoms, tissue in the wound, status of the wound environment, inflammation markers, and results of microbiological examination of targeted samples – biopsies, which are the gold standard In reaching the diagnosis of infection, it is crucial to differentiate critical colonization from deep tissue infection, which is based on clinical criteria called NERDS-STONEES The frequency of pressure ulcer infection is 5% to 80%, and biofilm is present in 90% of cases Due knowledge of the epidemiology of pressure ulcer and follow up of complications such as infection make the basis for the understanding of chronic wound, efforts to improve necessary care, prevention of development and application of a combination of treatment strategies

Impact of biofilm on healing and a method for identifying it in the wound

Abstract: The skin microbiome is the aggregate of microorganisms that reside on the surface and in deep layers of the skin. Skin is colonized by bacteria, fungi, viruses and mites, maintaining a balance. Disruption in the ecosystem results in skin infections. Chronic wounds in diabetics, elderly and immobile individuals are at risk of skin organisms to invade and become pathogenic upon breach of the skin barrier. The bacteria of the skin microbiome may contribute to delayed healing and persistent inflammation. Staphylococcus epidermidis is an invasive skin organism that causes infection, i.e. hospital acquired infection (HAl) on medical devices and form biofilm. At the most basic level, biofilm can be described as bacteria embedded in a thick, slimy barrier of sugars and proteins. The biofilm barrier protects the microorganisms from external threats. Biofilms provide a reservoir of potentially infectious microorganisms that are resistant to antimicrobial agents, and their importance in the failure of medical devices and chronic inflammatory condition is increasingly being recognized. Particular research interest exists in the association of biofilms with wound infection and non-healing, i.e. chronic wounds. There is now strong evidence that biofilm is present in the majority of chronic wounds. Specialized microscopic techniques used since 2008 have allowed several research groups to demonstrate that 60% to 90% of chronic wounds have biofilm versus only 6% of acute wounds. While many studies confirm that chronic wounds often contain a polymicrobial flora, controversy remains with regard to whether these organisms directly contribute to non-healing. It seems most likely that individual bacteria themselves are not directly responsible for non-healing wounds. Rather, there is direct correlation between the presence of four or more distinct bacterial species in a wound and non-healing, suggesting that mixed microbial populations are the cause of pathology. The most reliable method to confirm the presence of a biofilm is specialized microscopy, e.g., bright-field, fluorescence in situ hybridization (FISH), and environmental scanning electron microscope (ESEM). Surface wound cultures underestimate total wound microbiota--misleading. Histological staining of deep debrided tissue shows evidence of biofilms. Now it is recognized that the majority of microbial species in chronic wounds are anaerobic bacteria (deep swabbing techniques yield similar findings to biopsies) if samples are processed within two hours. Traditional (wound culture method) cultures have limitations because all microbes (the organisms within the biofilm) cannot be isolated in culture or cannot be detected. Therefore, the most effective methods are molecular

Urate as a potential risk factor of cardiovascular and renal diseases

Abstract: Although asymptomatic hyperuricemia is rather often in laboratory reports, it cannot be considered a disease. Despite the high prevalence of hyperuricemia in patients with arterial hypertension (AH), chronic kidney disease (CKD), cardiovascular disease (CVD) or metabolic syndrome, hyperuricemia is not confirmed as a causative factor of these disorders. The aim is to point to the latest studies of the importance of urate as a possible cardiorenal risk factor. The literature published in 2015 and 2016 was searched for the possible impact of urate level on the development of cardiorenal diseases. The PubMed, Cochrane, Medline, and UpToDate databases were searched for the literature published between November 2009 and October 2016 using the following key words: urate, hyperuricemia, cardiovascular disease, and chronic kidney disease. Causative correlation of hyperuricemia is confirmed only in disorders where deposits of monosodium urate crystals are present. Results of recent studies do not justify routine use of xanthine oxidase inhibitors in asymptomatic hyperuricemia. Some studies with small numbers of patients and short follow up report on endothelial function improvement on therapy with xanthine oxidase inhibitors. Nonpharmacological intervention by changing unhealthy lifestyle is preferred. Treatment of asymptomatic hyperuricemia in CKD is still debated, and additional studies are necessary to demonstrate the benefit of lowering urate level in CKD. Family doctors (general practitioners) should be familiar with the recommended approach to patients with asymptomatic hyperuricemia. Evidence based medicine still does not recommend target determination of serum urate level for identifying CVD and CKD risk factors. Recent studies suggest the possible effect of uric acid in cardiorenal diseases and that treatment of asymptomatic hyperuricemia with xanthine oxidase inhibitors may also be useful in CVD prevention. Additional studies are needed to prove this statement.

Pressure ulcer as the principal indicator of health care quality at neurology department

Abstract: According to the European Pressure Ulcer Advisory Panel (EPUAP) definition, pressure ulcer is a local skin or subcutaneous tissue damage due to the force of pressure or friction or their combination. Pressure ulcers have accompanied humans since the beginning and respective descriptions are found in the 19th century literature. Pressure ulcer is a major medical, social and health-economic problem because it is associated with a number of complications that require multidisciplinary approach in care and treatment. In affected patients, pressure ulcer causes quality of life reduction, discomforts, pain, emotional problems and social isolation. If the process of tissue decay is not halted, tissue damage will spread involving deep and wider structures, thus seriously compromising the patient general condition. Pressure ulcer usually develops at the sites of protrusions formed by lumbar spine, ischium, hip, ankle, knee or elbow, as well as in the areas with less developed adipose tissue. Any temporary or permanent immobility should be perceived as a milieu favoring the onset of pressure ulcer. Advances in medicine and standards of living in general have prolonged life expectancy, thus also increasing the population at risk of chronic diseases including pressure ulcer. The aim of the study was to determine the relationship between the length of bed-ridden condition and the occurrence of pressure ulcers in patients treated at Department of Cerebrovascular Diseases and Intensive Neurology from January 1, 2012 until December 31, 2015. The study included patients with pressure ulcer verified on admission and those having developed pressure ulcer during hospital stay. Clinical picture of severe stroke predominated in the majority of study patients. Patients were divided into groups according to health care requirements as classified by the Croatian Chamber of Nurses. Preliminary results indicated the length of bed-ridden condition to be associated with the occurrence of chronic wounds, and thus with increased cost and length of hospital treatment. Therefore, health care methods and procedures should be focused on reduction of pressure ulcer development, quality health care, implementation of preventive measures, and continuous education of health care professionals.

[Vascular Vibration Injury and Paget-Shroetter Syndrome].

Abstract: Paget-Schroetter syndrome is a relatively uncommon condition related to primary thrombosis of the axillary/subclavian vein at the costoclavicular junction. Vibration injury is an unusual cause of this syndrome. We report on a 28-year-old man who presented with acute onset left arm swelling after whole-day work with a pneumatic drill. Duplex ultrasound confirmed the presence of a thrombus in his left axillary and subclavian vein, which was treated with low molecular weight heparin, eventually switched to oral anticoagulation.

Carotid Endarterectomy in Patients with Antiaggregation Therapy

Abstract: Carotid endarterectomy is a common way of surgical treatment of extracranial carotid artery disease caused by atherosclerosis. Patients are often operated on under local anesthesia with intraoperative application of heparin. Postoperative bleeding occurs in up to 8% of cases, and up to 4.7% of patients need reoperation due to bleeding. TachoSil is a medical sponge consisting of collagen with added human coagulation factors (fibrinogen and thrombin). In contact with water, blood or bodily fluids, it forms a clot that adheres to the surface. The hypothesis and aim of our study was to show that TachoSil could be topically administered during surgery on carotid arteries in order to prevent minor bleeding, without causing any local signs of inflammation or infection. The study included a prospective series of consecutive patients that underwent surgery for extracranial carotid stenosis with concomitant antiplatelet therapy at Department of Vascular Surgery, Merkur University Hospital in Zagreb. All patients received antiplatelet therapy with aspirin or aspirin and clopidogrel until the day before surgery. From April 2, 2012 to February 8, 2013, a total of 24 patients with extracranial carotid artery stenosis were operated on, along with receiving antiplatelet therapy. All patients received 100 mg of acetylsalicylic acid and/or 75 mg of clopidogrel until one day prior to surgery. Patients had been treated with antiplatelet drugs for at least six months prior to carotid endarterectomy. Four patients had been on dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg) because of percutaneous transluminal angioplasty (PTA) and a stent placed in pelvic arteries or superficial femoral artery. Due to speech disturbances following clamping of carotid arteries in two study patients a temporary intraluminal shunt was created. These two patients underwent longitudinal arteriotomy and longitudinal endarterectomy. Arteriotomy was closed by direct suture without a patch. Following arteriotomy and partial conversion of heparin with protamine, six patients needed additional individual sutures. Then, protamine was added again to up to the full dose of conversion (50 mg). In 19 patients, only one TachoSil medical sponge (9.5 cm x 4.8 cm) was placed, whereas in fi ve patients two sponges were placed. None of the patients (24 of them operated on between April 2, 2012 and February 8, 2013) with TachoSil placed intraoperatively had any signs of postoperative wound infection. Carotid artery stenosis is a very common disease the incidence of which increases proportionally with age of the population observed. Bleeding is a relatively common and significant complication following surgical treatment, particularly in case of arterial bleeding. Bleeding and other complications in the neck can be very serious and challenging for surgical treatment. With the present guidelines for the administration of clopidogrel in the evening before surgery, in some circumstances an increased incidence of postoperative hemorrhage or prolonged duration of surgery can be expected. Intraoperative use of hemostatics may reduce the postoperative bleeding complications. Intraoperative application of TachoSil does not increase the rate of postoperative complications such as infection and delayed healing. TachoSil may reduce the rate of postoperative complications in carotid surgery.

[chronic wound--a new etiopathogenetic state and modern therapeutic approach].

Abstract: Lower leg ulcer is the most common form of ulceration of lower extremities. The prevalence of leg ulcer varies among studies from 0.1% to 0.6%. During the last decade, new concepts on the inflammatory phase in chronic ulcer have been discovered, such as the importance of metalloproteinases, growth factor, irregular muscular function, vascular insufficiency and presence of biofilm in the ulcer that prevents healing. There are several hypotheses to explain the pathophysiological steps, referring to popliteal venous hypertension. Currently, the treatment of leg ulcer relies on due knowledge of ulcer pathophysiology and making an accurate diagnosis. Today, modern supportive dressings improve the patient's quality of life; however, their targeted application according to the protocol and indications is required. A new method of efficient wound biofim exclusion today is the application of hydrofiber dressings containing a combination of silver ions and two disinfectants because they influence the exclusion and prevention of new biofilm formation in the ulcer.

[surgical treatment of thyroid gland in elderly patients: our experiences].

Abstract: The share of elderly persons in the population is growing rapidly and continuously. Requirements for their surgical treatment are increasing and so is the number of published papers on the safety and success of some surgical procedures performed in these patients. The present study included 183 patients aged ≥65 out of 897 patients surgically treated for thyroid gland diseases. They were divided into two groups (group 1 aged 65-69 and group 2 aged ≥70) in order to determine between-group differences in the indications, surgical strategy, final histopathologic analysis, preoperative physical status, number of comorbid diseases and postoperative complications. Analysis of the results justified our decision to divide our patients into two groups of younger and older ones. In group 1, the indications for surgery were mostly benign changes (93.2%), whereas malignant, verified and suspected disease was considerably more frequent in group 2 (21.8%), with a significantly higher percentage of compressive syndrome. Significant between-group differences were recorded in the preoperative physical status (group 2: ASA III and IV, 73.8% and 5%, respectively), number of thyroidectomies performed (group 1, 56.2% vs. group 2, 77.3%) and secondary hemithyroidectomy. A difference was also found in the number of surgical and non surgical complications. The absence of a higher percentage of permanent complications, hypocalcemia and recurrent laryngeal nerve paralysis, in total and by groups, confirmed that surgical treatment of thyroid gland diseases can be considered safe and successful in older age groups, regardless of the between-group differences observed.

Pathophysiology of the cardiorenal syndrome

Abstract: Cardiorenal syndrome, a complex pathophysiological disorder of both the heart and kidneys, is a condition in which acute or chronic damage to one organ can lead to acute or chronic dysfunction of the other organ. Depending on primary organ dysfunction and disease duration, there are five different types of cardiorenal syndrome. Type 1 cardiorenal syndrome (acute cardiorenal syndrome) is defined as acute kidney injury caused by sudden decrease in heart function. Type 2 cardiorenal syndrome (chronic cardiorenal syndrome) refers to chronic kidney disease linked to chronic heart failure. Type 3 cardiorenal syndrome (acute renocardial syndrome) is caused by acute kidney injury that leads to heart failure. Type 4 cardiorenal syndrome (chronic renocardial syndrome) includes chronic heart failure due to chronic kidney disease. Type 5 cardiorenal syndrome (secondary cardiorenal syndrome) is reversible or irreversible condition marked by simultaneous heart and kidney insufficiency, as a result of multiorgan disease such as sepsis, diabetes mellitus, sarcoidosis, amyloidosis, etc. The pathophysiological patterns of cardiorenal syndrome are extremely complicated. Despite numerous publications, perplexed physiological, biochemical and hormonal disturbances as parts of the main pathogenic mechanisms of cardiorenal syndrome remain obscure. Even though there are guidelines for the treatment of patients with heart failure and chronic kidney disease, similar guidelines for the treatment of cardiorenal syndrome are lacking. In everyday practice, it is crucial to diagnose cardiorenal syndrome and use all diagnostic and therapeutic procedures available to prevent or alleviate kidney and heart failure.

Pressure ulcer – healthcare quality and patient safety indicator

Abstract: Pressure ulcer is an undesired event for patient, frequently used in quality monitoring as an indicator of healthcare quality and patient safety According to legal regulations in the Republic of Croatia, pressure ulcer is included in the group of indicators of other undesired events (patient safety) and healthcare institutions are obliged to monitor the applicable indicator and submit report to the Agency every six months Annual reports on the patient safety indicators are available on the Agency website The article presents the descriptive list of indicators and descriptive list for the Pressure Ulcer indicator

[effects of platelet-rich plasma in the treatment of chronic ulcer].

Abstract: A venous ulcer is area of discontinuity of the skin, usually localised in distal parts of the lower legs. The aetiology is associated with chronic venous disease-venous hypertension. The size and shape of venous ulcer can be different and it may even cover all circumferential of extremity. Additionally, along with basic therapy possibilities, there are many different dressings. Therefore the knowledge of each characteristic of dressing on process of epithelisation is essential as well as treating the biofilm that is responsible for complications and persistence of ulcer. One of additional therapy possibility is platelet-rich plasma.

[rare localization of osteoid osteoma--distal phalanx of the ring finger].

Abstract: With this clinical observation we would like to bring to mind osteoid osteoma as a possible cause of problems of distal phalanx of the fingers. Osteoid osteoma occurs rarely at this location and has atypical presentation. The main symptoms are swelling and redness of the fingertip with nail deformity, while typical night pain may not be present. Unusual clinical and x-ray presentation of tumor in this localization can make diagnosis of osteoid osteoma very difficult. A 20-year-old patient reported pain in the fingertip of his right ring finger persisting for five years. Swelling and redness of the fingertip combined with nail deformity was also present. X-rays showed osteolysis in the base of distal phalanx. Magnetic resonance imaging showed suspicion of osteoid osteoma, which was confirmed by computed tomography (CT). We performed surgical removal of osteoid osteoma in February 2014. The tumor was approached by longitudinal incision on the lateral side of the distal phalanx of the ring finger and the basal part of distal phalanx was cut with a small chisel to enable access to cystic change of the bone. Tumor removal with excochleation was performed and the material thus obtained was sent for histopathologic analysis. After surgery, the ring finger was immobilized in a plaster splint for a three-week period. After removal of immobilization, the patient was referred to physical therapy consisting of individual exercises in order to obtain the full range of motion in all joints of the hands and strengthen hand and forearm muscles. After surgical removal of osteoid osteoma, all symptoms disappeared completely. Histopathologic findings confirmed the diagnosis of osteoid osteoma. After physical therapy, he returned to daily activities without any problems. On regular follow ups at 3, 6 and 12 months after surgery, clinical findings were normal and the patient had no pain or discomforts. Full recovery was shown by the result of the DASH questionnaire three months after the procedure. Preoperative DASH score 54.4 decreased to 0. Distal phalanx of the finger is a very rare localization of osteoid osteoma, and typical night pain may not be present. In addition, appearance on x-rays is not typical. Instead of central enlightenment surrounded with sclerosis, x-rays usually show a lytic lesion. For this reason, it may be difficult to make the diagnosis of osteoid osteoma. The main symptom is permanent pain, swelling and redness of the finger, with nail deformity. The imaging method of choice is CT, which must be performed with thin layers of 1 to 2 mm. Furthermore, cooperation of surgeon and radiologist is extremely important to reach the accurate diagnosis. Many treatment options are described in the literature, such as CT-guided percutaneous thermocoagulation, destruction of lesions with alcohol, or CT-guided radiofrequency ablation. However, due to the proximity of neurovascular structures, tendons and joints, the best method for treatment osteoid osteoma in distal phalanx of the fingers is surgical excision or excochleation. Our conclusion is that one should always bear in mind that osteoid osteoma can be the cause of swelling of distal phalanx of the finger with nail deformity, and pain that alleviated with the use of non-steroidal anti-infl ammatory drugs. Surgical excision or excochleation is the best method for the treatment osteoid osteoma of distal phalanx of the finger.

Multidisciplinary Management and Neurorehabilitation of Patients with Amyotrophic Lateral Sclerosis

Abstract: Patients with amyotrophic lateral sclerosis require comprehensive care with a multidisciplinary approach, which is individually adjusted to each patient. The goals of neurorehabilitation should be adjusted to the stage of disease. In early stages, physical therapy is focused on preserving and optimizing motor and respiratory function. At this stage, family should be involved to partake in desired activities and be informed regarding the natural course of the disease. In late stages, physical therapy is focused on preventing respiratory complications and contractures, and orthotics may also be recommended. The onset of dysarthria should trigger swallowing and pulmonary function testing. Swallowing maneuvers should be tried at the onset of symptoms, later feeding tubes or percutaneous gastrostomy tube is necessary. Noninvasive mechanical ventilation may delay the need of tracheostomy and invasive mechanical ventilation. The key objectives of multidisciplinary teams are to optimize medical care, facilitate communication, and thus to improve the quality of care and quality of life.

[end-stage renal disease, dialysis treatment and management of comorbidity].

Abstract: Chronic kidney disease is clearly defined as a state of damaged kidney function lasting for more than three months. Changes manifest in serum and urine pathological findings with frequent morphological changes in the kidneys and reduction in glomerular filtration. The aim is to show the possibilities of renal replacement therapy and waste related disease during dialysis treatment. The methods are based on strong evidence and guidelines. Glomerular filtration is the basis in evaluating the stage of chronic kidney disease. Based on the measures of glomerular filtration reduction, chronic kidney disease is classified into five stages, thus facilitating approach to treatment of particular groups of patients depending on the level of glomerular filtration damage. Kidney function can be replaced by dialysis or transplantation and in certain cases symptomatically if the patient refuses dialysis treatment. Malnutrition, hypertension, kidney anemia and bone-mineral disease are often present in patients with higher stages of chronic kidney disease, particularly stage 5 and kidney function replacement by dialysis. In conclusion, timely treatment reduces morbidity and mortality in patients with chronic kidney disease.

The role of wound dressing in biofilm destruction and reformation

Abstract: Application of supportive wound dressing is an important segment for successful result of modern treatment of chronic ulcers. The right choice of dressing is the key to faster, better, and ultimately more cost-effective treatment outcome. Due to the extremely large number of generic types and variants, the main element for proper dressing selection is to know the mechanisms of action and clinical evidence of the effectiveness because of many local factors that delay ulcer healing. The advent of wound dressing that is efficient at the three clinically identified key local factors that largely impede the healing of ulcers, i.e. exudate, infection and biofilm, has made a significant step forward in the creation of optimal conditions for faster healing of chronic ulcers. The complexity of the effects of new technologies, which integrate hidrofiber technology and Ag + technology, provides effective antimicrobial control while at the same time preventing biofilm reformation.

Antimicrobial dressings for infected ulcer and clinical comprehension of biofilm

Abstract: Current knowledge and proofs of biofilm, interactions between various bacterial species and overall virulence of microbes play a role in delayed healing of wound and development of infection. High quality description of clinical symptoms and current knowledge of microbes provide an excellent guideline for creating the strategy of wound treatment. Owing to better understanding of the role of biofilm in prolongation of healing time and facts about biofilm system and structure, scientists have developed the Ag+ technology. This technology has strong synergistic effects of the general and antimicrobial activity of ionic silver and specific compounds, which have proved efficient in biofilm obstruction and removal.

[kidney disease in diabetic patients – the role of family medicine physician].

Abstract: The alarming rates of diabetes mellitus incidence and progression continue despite deployment of all current treatments. Kidney disease can be a particularly devastating complication, as it is associated with significant reductions in both length and quality of life. A variety of forms of kidney disease can be seen in people with diabetes, including diabetic nephropathy, ischemic damage related to vascular disease and hypertension, as well as other renal diseases that are unrelated to diabetes. Following an extensive PubMed search, this review provides a brief view on the screening for chronic kidney disease (CKD) in people with diabetes, how to treat them to slow down the progression of CKD and when to refer them to specialist care. This review also emphasizes the basic challenge in treating diabetic patients, which is to shift the main criterion from the disease-oriented to person-centered approach in the context of treating the patient as a whole.

Use of statins in patients with chronic kidney disease to prevent cardiovascular disease

Abstract: Chronic kidney disease (CKD) is one of the leading public health issues due to frequent and serious complications Once the function of kidneys is disrupted, regardless of etiology, there are numerous factors that can speed up decrease of glomerular filtration rate, including hypertension, proteinuria and dyslipidemia Statins are widely used in primary and secondary prevention of cardiovascular diseases in general population Clinical advantages of statins in CKD patients are not as clear The aim of this paper is to present lipid status in CKD patients and indications for statin therapy with the aim to reduce cardiovascular risk in this group of patients CKD is a well-known independent risk factor in cardiovascular events, but professional associations issuing guidelines differ in the approach to treatment of dyslipidemia The results of some studies indicate that treatment with statins may slow down the rate of kidney function reduction in patients with mild to moderate kidney damage, whereas other studies deny this effect Furthermore, CKD patients have a higher risk of side effects, in part due to the reduced kidney excretion, polypharmacy, and numerous other comorbidities Family physician has the role of providing preventive measures, with focus on appropriate treatment of patients with hypertension or diabetes, as the most common cause of CKD, and timely detection of CKD in initial stage

Diagnostic approach to patients with chronic kidney disease

Abstract: According to consensus definition, chronic kidney disease (CKD) includes urinary excretion of albumin >30 mg/day and/ or reduction in kidney function defined as a decrease in estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 for a period longer than three months, in the presence of kidney tissue damage verified by imaging or histologic methods. In developed world, the first cause of CKD is diabetes, followed by arterial hypertension, and the less frequent causes are inflammatory disease (glomerulonephritis, interstitial nephritis) and congenital condition (polycystic kidney disease). Currently, there is valid classification under the acronym CGA, where C stands for the cause, G for glomerular filtration rate (GFR category) and A for the level of albuminuria category. In early stages, patients usually have no symptoms but there are changes in creatinine values, estimated GFR (eGFR) reduction and presence of albuminuria, especially in patients at risk. Determining the grade of renal impairment is important because of different approaches to treatment, monitoring, expected complications, and patient education. Due to improved diagnostic methods and population aging, CKD is diagnosed ever more increasingly. Family physicians should be familiar with the basic principles of screening and diagnosis of CKD to provide them with appropriate care in collaboration with secondary and tertiary health care.