Carotid artery stenosis in correlation with neck and carotid artery anatomy.

OBJECTIVES: The purpose of this study was to examine the relationship between neck anatomy, especially its largest muscle - sternocleidomastoid and carotid space, with carotid artery anatomy and stenosis. METHODS: We analysed 102 computed tomography carotid angiograms. The study included the measurement of the neck and sternocleidomastoid length, diameter and volume and the size of the carotid space. Analysis of carotid artery geometry, the length, angle and height of carotid artery bifurcation and the direction of the internal carotid artery origin was also included. RESULTS: We found a positive correlation only between the neck and carotid length. There was no correlation between other neck characteristics and a carotid anatomy or internal carotid artery stenosis. Direction of internal carotid artery origin was significantly different (p < 0.01) between the left and right sides. CONCLUSIONS: We have not found a correlation between the size of sternocleidomastoid and carotid space and carotid stenosis as a hypothetical factor for atherosclerosis. Also, the degree of carotid artery stenosis did not correlate with other neck and carotid measurements. Neck and carotid anatomy correlated only in their lengths. The left internal carotid artery showed mostly posterolateral origin, and right internal carotid artery had no predominate direction.

Predicting the 1-Year All-Cause Mortality After Hospitalisation for an Acute Heart Failure Event: A Real-World Derivation Cohort for the Development of the S2PLiT-UG Score.

BACKGROUND: Acute heart failure (AHF) is a complex syndrome associated with high morbidity and mortality. This study aimed to derive a simple risk score with which to identify AHF patients at high risk for an all-cause death event during the first year after hospital discharge. METHODS: Three hundred AHF patients from the Heart Failure registry were included in the analysis. Cox regression with a forward-conditional algorithm and bootstrapping procedure was used to build the prognostic score, while c-statistic was used to assess the prognostic performance of the score. RESULTS: Seven variables were independently associated with an all-cause mortality event during the 1-year follow-up (FU): estimated glomerular filtration rate of 40-60; estimated glomerular filtration rate <40 mL/min/1.73 m2; uric acid >450 µmol/L; left-ventricular ejection fraction <45%; sodium <136 mmol/L; systolic blood pressure <115 mmHg; and a positive history of previous heart failure-related decompensation event(s). The score derived from significant variables enabled classification of patients into three risk categories: low (0-2 points), intermediate (3 points), and high (4-6 points). Observed all-cause mortality rates during the 1-year FU were 6.1%, 30.5%, and 80.9% across the three risk categories, respectively. The score demonstrated a high level of discrimination for an all-cause death event in the derivation cohort with the c-statistic value of 0.907 (95% CI, 0.867-0.939; p < 0.0001) and adequate calibration. CONCLUSIONS: The S2PLiT-UG score is a simple tool with potential for facilitating risk stratification and therapeutic decision-making during the first year after hospitalisation for an AHF event. Future external validation studies are required to confirm its prognostic performance.

The midrange left ventricular ejection fraction (LVEF) is associated with higher all-cause mortality during the 1-year follow-up compared to preserved LVEF among real-world patients with acute heart failure: a single-center propensity score-matched analysis.

The objectives of the study were to characterize and compare different acute heart failure (AHF) subgroups according to left-ventricular ejection fraction (LVEF) in terms of all-cause mortality and HF-related readmissions during the 1-year follow-up (FU). Three hundred and fifty-six AHF patients admitted to Cardiology ward and/or CCU were retrospectively included in the study and analyzed during the 1-year FU. Patients were stratified according to LVEF as those with preserved (HFpEF), midrange (HFmrEF) and reduced LVEF (HFrEF). During the FU period, 148 (43.3%) patients died, and 116 HF-related readmission events were recorded. HFmrEF group had significantly higher standardized all-cause mortality rate, unadjusted for age, compared to HFpEF group and significantly lower than HFrEF group (41 vs. 18 and 41 vs. 62.5 events per 100 patient-years; χ2 = 41.08, p < 0.001 and χ2 = 16.62, p < 0.001, respectively). A propensity score-matched analysis in which all HF groups were matched for age and other covariates confirmed that HFmrEF group had significantly higher all-cause mortality rate than HFpEF group (χ2 = 15.66, p < 0.001) while no significant differences in readmission rates were observed across all groups (p = NS). The hazard risk for a composite endpoint of death and readmission was highest in HFrEF group (HR 6.53, 95% CI 3.53-12.08, p < 0.001), followed by HFmrEF group (HR 3.30, 95% CI 1.86-5.87, p < 0.001) when compared to HFpEF group set as a reference. Among AHF patients, the HFmrEF phenotype was associated with significantly higher all-cause mortality compared to HFpEF, during the 1-year FU. This finding might implicate more stringent clinical approach towards this patient group.

Prognostic value of low and moderately elevated C-reactive protein in acute coronary syndrome: a 2-year follow-up study.

BACKGROUND: The main goal of this study was to improve diagnostic and predictive value of low and moderately elevated C-reactive protein (CRP) in patients with acute coronary syndrome (ACS), related to noninvasive clinical parameters, in order to improve and prolong patient life with low or no additional costs. MATERIAL/METHODS: A prospective, open clinical study was conducted at the University Hospital Split, Croatia with 112 patients with ACS and low or moderately elevated CRP (<3.0 mg/L). After diagnosing ACS, data on physical activity, alcohol consumption, and functional status were recorded. Anthropometric measurements were made. Blood and urine samples were taken for analyses. Electrocardiographic, ergometric, and echocardiographic testing was performed. A total of 72 parameters were monitored at the time of hospital admission in ACS patients to analyze which ones could predict disease outcome at the end of follow-up in patients with low or moderately elevated CRP. Patients were followed up for 2 years. RESULTS: The variables that were predictive of major adverse cardiac events (MACE) within 2 years of ACS hospitalization were hemoglobin, fibrinogen, antithrombin III, cholesterol levels, brain natriuretic peptide, and microalbuminuria. ACS patients with CRP<3.0 mg/L had significantly higher risk of developing MACE within 2 years if ≥50% of the 8 key parameters were outside the reference values. CONCLUSIONS: Major adverse cardiac events can be predicted in patients with acute coronary syndrome whose CRP values are low or moderately elevated.

In-hospital mortality of patients with acute myocardial infarction before and after introduction of PCI in Split University Hospital Center, Croatia.

Aim of the study was to estimate the in-hospital mortality and death rate in patients with AMI according to gender and location of infarction during 5 years before and after the introduction of percutaneous coronary intervention (PCI) procedures in Split University Hosptial Center, Croatia. The hospitalized patients were divided in two groups, from 2000 to 2004 and from 2005 to 2009. The analysis included total mortality and mortality according to gender and location of AMI. The location of infarction was detected toward typical ECG changes. The analysis included the model of death in patients with AMI and in-hospital mortality of patients undergoing the PCI procedures. The patients in the first group were treated with the standard medication therapy, and the patients in the second group were treated with PCI. The number of hospitalized patients with AMI, in ten years, increased from 475 to 652. A total of 5339 patients with AMI were hospitalized, and included 67.5% males and 32.5% females. The first group included 2336 patients (68% males and 32% females). The second group included 2973 patients (67% males and 33% females). Male patients in average were 5 years younger than female patients. A total in-hospital mortality was significantly higher in the first group (13.5 vs. 7.6%). The mortality in the first group was significantly higher in females (22.7 vs. 12%) and in males (9 vs. 5.5%) comparing with second group. In-hospital mortality in the patients with STEMI was significantly higher in the first group (16.6 vs. 9%). Among the patients with NSTEMI there were no significantly differences in the in-hospital mortality (4 vs. 2.5%). The most frequent trigger of death in males were ventricular fibrillation in both groups such as heart failure in females. Cx occlusion is more often among the male patients treated with PCI. In-hospital mortality in patients with STEMI treated with PCI was 5.7%. A in-hospital mortality in the patients with AIM after PCI was almost halved. Females had two times higher in-hospital mortality before and after PCI introduction.

The epidemiology of non-traumatic prehospital sudden death in Split-Dalmatia County.

The aim of this study was to determine epidemiology of non-traumatic prehospital sudden adult deaths in Split-Dalmatia County from 2000 to 2005. The following information were collected from autopsy reports in the archives of University Hospital Split: gender of deceased, birth date, date of death, location of death, immediate cause of death, previously diagnosed diseases that might lead to terminal outcome. There were 160 non-traumatic prehospital sudden adult deaths in the observed period, with 104 (65%) male and 56 (35%) female autopsies performed. Diseases of cardiovascular system were the main cause of death, responsible for 95 (59.37%) sudden deaths, followed by diseases of respiratory system (14.37%) and central nervous system (8.12%). The most frequent cause of non-traumatic sudden death was myocardial infarction, found in 50 cases. July and September were the months of the most frequent occurrence of sudden death. In this study it was confirmed that sudden death incidence increases with age, with almost half of all deaths occurring in people between ages of 61-80. The result that a fifth of all sudden deaths occurred in people aged 51-60 is troubling and potentially preventable. The most frequent location of death was deceased's place of residence (N = 29), followed by the ambulance vehicle (N = 17). In conclusion, this is the first publication describing the incidence of prehospital sudden non-traumatic adult death in Split-Dalmatia County. Causes of sudden death and its incidence are in accordance with World Health Organization's information on general causes of death in Croatia and Western Europe.

Impact of late hospital admission on the prognosis of patients with acute myocardial infarction.

The objective of this study is to determine the time elapsed from the onset of pain in patients with AMI to their hospital admission (pain to door time) and fibrinolytic administration (door to needle time). The objective is also to determine whether there is a difference between the frequency of fibrinolytic administration to patients and the survival rate of patients with AMI with respect to the location they are transported from. This prospective clinical study included patients manifesting clear clinical, electrocardiographic and biochemical evidence of AMI, according to criteria of ECS (European Society of Cardiology), and who were admitted to the Coronary Care Unit of Split Clinical Hospital in the period from 1 January to 31 December 1999. On the basis of their residence, the patients were divided into three groups: 1. patients from Split and the surrounding area distant up to 15 km from the city; 2. patients from the surrounding area within 15 km from Split, 3. patients living on the islands of Central Dalmatia. 409 patients with AMI were admitted to hospital in the period in question. The first group consisted of 207, the second of 163, and the third of 39 subjects (254:39; p < 0.001). The median time from the onset of pain to hospital admission for all patients with AMI was 7.3 hours, for patients from the islands 13 hours, whereas for those coming from locations distant more than 15 km from Split it amounted to 7.6 hours (p < 0.001). The number of patients that were administered fibrinolysis is extremely low (17.1%) and there is no significant difference in the frequency of fibrinolytic administration between certain patient groups (p > 0.05). Similarly, the mortality rate prior to hospital discharge is high (18.8%) and does not vary among the three studied groups (p > 0.05). The results of this study are in opposition to the assumption that the mortality rate will be lower in patients living in Split and the immediate surroundings when compared to the mortality rate of patients living on the islands of Central Dalmatia (21.7%: 15.4%).

DNA sequence and taxonomic gap analyses to quantify the coverage of aquatic cyanobacteria and eukaryotic microalgae in reference databases: Results of a survey in the Alpine region.

The taxonomic identification of organisms based on the amplification of specific genetic markers (metabarcoding) implicitly requires adequate discriminatory information and taxonomic coverage of environmental DNA sequences in taxonomic databases. These requirements were quantitatively examined by comparing the determination of cyanobacteria and microalgae obtained by metabarcoding and light microscopy. We used planktic and biofilm samples collected in 37 lakes and 22 rivers across the Alpine region. We focused on two of the most used and best represented genetic markers in the reference databases, namely the 16S rRNA and 18S rRNA genes. A sequence gap analysis using blastn showed that, in the identity range of 99-100%, approximately 30% (plankton) and 60% (biofilm) of the sequences did not find any close counterpart in the reference databases (NCBI GenBank). Similarly, a taxonomic gap analysis showed that approximately 50% of the cyanobacterial and eukaryotic microalgal species identified by light microscopy were not represented in the reference databases. In both cases, the magnitude of the gaps differed between the major taxonomic groups. Even considering the species determined under the microscope and represented in the reference databases, 22% and 26% were still not included in the results obtained by the blastn at percentage levels of identity ≥95% and ≥97%, respectively. The main causes were the absence of matching sequences due to amplification and/or sequencing failure and potential misidentification in the microscopy step. Our results quantitatively demonstrated that in metabarcoding the main obstacles in the classification of 16S rRNA and 18S rRNA sequences and interpretation of high-throughput sequencing biomonitoring data were due to the existence of important gaps in the taxonomic completeness of the reference databases and the short length of reads. The study focused on the Alpine region, but the extent of the gaps could be much greater in other less investigated geographic areas.

The role of molecular diagnostics in aneurysmal and simple bone cysts - a prospective analysis of 19 lesions.

Aneurysmal (ABC) and simple bone cysts (SBC) have been traditionally distinguished by radiological and histopathological features. However, there is some radiological and histopathological overlap between ABC and SBC. ABC is characterised by USP6 fusions while, recently, NFATC2 fusions have been found in a large proportion of SBC. Identifying these fusions may assist in confirming the diagnosis of either ABC or SBC. To elaborate the potential benefit of molecular testing, we report a prospective series of 19 consecutive bone cysts with comprehensive radiological, histopathological and molecular diagnostics. Integrating radiological, histopathological and molecular findings, 11 cysts were diagnosed as SBC and 8 as ABC. Radiologically, 6 of 11 SBC and 6 of 8 ABC were diagnosed as ABC. Fibrin-like collagen deposits were identified in 8 of 11 (73%) SBC and 3 of 8 (38%) ABC. Nodular fasciitis-like areas were identified in 6 of 8 (75%) ABC and in 7 of 11 (64%) SBC. A USP6 fusion was identified in all 8 ABC, including a novel RBM5-USP6 fusion. An NFATC2 fusion was found in 7 of 11 SBC (FUS-NFATC2 fusion in 5 and EWSR1-NFATC2 in 2 cases). There is radiological and histopathological overlap between SBC and ABC in a significant proportion of cases. A diagnosis of ABC is frequently suggested radiologically in SBC, and fibrin-like deposits, thought to be specific for SBC, may be found in some ABC. Molecular testing may significantly improve diagnostic accuracy in bone cysts.

Pain to hospital times after myocardial infarction in patients from Dalmatian mainland and islands, southern Croatia.

AIM: To analyze pre-hospital delay in patients with myocardial infarction from mainland and islands of Split-Dalmatian County, southern Croatia. METHODS: The study included all patients with myocardial infarction transported by ambulance to the University Hospital Split in 1999, 2003, and 2005. Pre-hospital delay was analyzed in the following intervals: pain-to-call, call-to-ambulance, ambulance-to-door, and door-to-coronary care unit interval. Patients were categorized according to the location from which they were transported: Split, mainland >15 km from Split, and islands. RESULTS: There were 1314 patients (62.9% men) transported and hospitalized for myocardial infarction. Total pre-hospital delay (pain-to-hospital) was significantly reduced from 1999 to 2005 (5.2 hours vs 4.3 hours, P=0.011). Seventy-five patients (5.7%) were admitted to the coronary care unit within the recommended time-frame of less than 90 minutes, none of which was from the islands, while 248 patients (18.9%) were admitted more than 12 hours from the onset of pain. CONCLUSION: Pre-hospital delay in patients with myocardial infarction in southern Croatia is still too long, especially in patients coming from outside of Split. Prognosis and survival of such patients may be improved by introducing changes to the health care system in remote areas, such as out-of-hospital thrombolysis, greater use of telemedicine, training of lay persons and paramedics in defibrillation, introduction of quality assessment mechanisms, and improved patient transport.

Awareness and use of evidence-based medicine databases and Cochrane Library among physicians in Croatia.

AIM: To assess awareness and use of evidence-based medicine (EBM) databases and The Cochrane Library among physicians in Croatia. METHODS: A cross-sectional study with a telephone survey was performed among 573 physicians (88.6% response rate from 647 contacted physicians) from family practice and 4 major university hospital centers in Croatia. The main outcome measures were physicians' awareness of The Cochrane Collaboration, awareness and use of The Cochrane Library, access to EBM databases, and access to internet at work. RESULTS: Overall, 54% of respondents said they had access to EBM databases, but when asked which databases they used, they named mostly non-EBM databases. The question on the highest level of evidence in EBM was correctly answered by 53% respondents, 30% heard of The Cochrane Collaboration, and 34% heard about The Cochrane Library. They obtained information about The Cochrane Library mostly from colleagues and research articles, whereas the information about EBM was gained mainly during continuous medical education. There were more respondents who thought The Cochrane Library could help them in practice (58%) than those who heard about The Cochrane Library (30%). Only 20% of the respondents heard about the initiative for the establishment of the Croatian branch of The Cochrane Collaboration. Family physicians had significantly lower level of awareness, knowledge, and use of EBM and The Cochrane Library than physicians from university hospitals. CONCLUSION: There is low awareness about EBM and The Cochrane Library among physicians in Croatia, which creates a need for educational interventions about EBM for the benefit of health care in Croatia.

FUS-NFATC2 or EWSR1-NFATC2 Fusions Are Present in a Large Proportion of Simple Bone Cysts.

A simple bone cyst (SBC) is a benign bone lesion of unknown etiology. It can be differentiated from an aneurysmal bone cyst (ABC) by radiologic and histopathologic features, as well as by the absence of fusions of the USP6 gene characteristic of an ABC. In an attempt to differentiate between ABC and SBC in a recurrent bone cyst, we performed targeted RNA sequencing and found an EWSR1-NFATC2 fusion and no fusion of the USP6 gene. We subsequently analyzed additional 10 cysts, consistent with SBCs after radiologic-pathologic correlation, for the presence of an NFATC2 gene fusion, by targeted RNA sequencing, reverse-transcription polymerase chain reaction (RT-PCR) and Sanger sequencing, and fluorescent in situ hybridization. Targeted RNA sequencing showed a FUS-NFATC2 fusion in 4 of 11 SBCs and an EWSR1-NFATC2 fusion in 2 of 11 SBCs. No fusion was identified in 3 SBCs and the analysis was not successful in 2 SBCs because of the low quantity or poor quality of isolated RNA. All the 6 fusions detected by targeted RNA sequencing were confirmed by RT-PCR and Sanger sequencing, and 5 of the 6 fusions by fluorescent in situ hybridization. An additional FUS-NFATC2 fusion was identified by RT-PCR, Sanger sequencing, and fluorescent in situ hybridization in 1 of the 3 cases negative for fusions by targeted RNA sequencing. At least a large subset of SBCs represents cystic neoplasms characterized by FUS-NFATC2 or EWSR1-NFATC2 fusions, which also define a group of distinct, rare "Ewing-like" sarcomas that predominantly arise in long bones. Our results provide additional evidence of the existence of benign lesions with FUS-NFATC2 or EWSR1-NFATC2 fusions. Although they can recur locally in a nondestructive manner, their clinical course and possible relation to sarcoma with EWSR1-NFATC2 or FUS-NFATC2 fusion remains to be elucidated.

Sex-specific differences in risk factors for in-hospital mortality and complications in patients with acute coronary syndromes : An observational cohort study.

BACKGROUND: The goal of this observational cohort study was to examine gender-specific differences in the incidence of acute coronary syndrome (ACS), in-hospital complications and mortality. METHODS: A cohort of 1550 patients with the primary diagnosis of ACS were enrolled in the study over a period of 4 years. The in-hospital mortality and complications were analyzed as the main outcome measures. RESULTS: Women were significantly older compared to men (71 ± 11 years vs. 64 ± 12 years, p < 0.001) and had higher in-hospital mortality and complications due to this age difference. The prevalence of smoking was lower while hypertension and history of angina pectoris was more frequent in women, independent of age. Percutaneous transluminal coronary angioplasty (PTCA) with or without stenting as well as coronary catheterization significantly reduced in-hospital mortality and complications while thrombolytic therapy was associated with a 3.3 times increased mortality odds ratio (OR, p = 0.01). Other significant predictors of in-hospital mortality were in-hospital complications (OR 25, p < 0.001) and ST segment elevation myocardial infarction (STEMI, OR 4.5, p < 0.001). CONCLUSIONS: Women differed from men in terms of ACS clinical characteristics, treatment, invasive procedures and survival outcome and some of these effects were age-related. The future emphasis should be based on the prevention of modifiable risk factors and identification of subgroups of female patients that could benefit from more aggressive therapeutic strategies.

Pain-to-hospital times, cardiovascular risk factors, and early intrahospital mortality in patients with acute myocardial infarction.

BACKGROUND: The aim of the study was to analyze the most recent trends in myocardial infarction (MI) care, the number of patients treated for MI and their outcomes, cardiovascular disease risk factors, and pain-to-hospital times in MI patients. SUBJECTS AND METHODS: For 778 patients treated for acute MI at the Coronary Care Unit (CCU) of University Hospital Split, Croatia the following data were acquired: outcome during hospitalization (survived, deceased), cardiovascular risk factors (hypertension, diabetes, dyslipidemia, previous MI, smoking), and pain-to-CCU time. RESULTS: Among 778 patients treated for acute MI, there were 291 (37%) women and 487 (63%) men. Forty-five patients (6%) died during hospitalization, mostly due to cardiogenic shock. An association was found between early intrahospital mortality and the following risk factors: age >70 years, female sex, previous MI, and smoking. Median pain-to-call time was 2 hours, and median time from the onset of pain to arrival into the CCU was 4 hours. There were 59 (7.6%) patients admitted to the CCU within recommended 90 minutes. Diabetic comorbidity was not associated with early death or with longer time from pain to emergency calls. CONCLUSION: Some of the risk factors associated with adverse outcomes in MI are modifiable. Prehospital delay of 4 hours observed in patients who suffered an MI is too long, and more effort should be devoted to investments in health care and education of the general public regarding chest pain symptoms.

Two Cases of Rare Basilar Hypoplasia.

In this article, we report two cases of basilar artery hypoplasia; the first case was a primitive trigeminal artery, and the second was an isolated basilar artery hypoplasia. Both patients had general neurologic disturbances, including periodic intention tremor of the left hand. Our data underscore the utility of complementary time of flight (TOF) magnetic resonance and multidetector computed tomography (MDCT) angiography as reliable first detection methods for steno-occlusive diseases and in cases of suspected congenital vascular anomalies.

Free wall rupture (FWR) in patients with acute ST-elevation myocardial infarction (STEMI) receiving fibrinolytic therapy (FT): a 7-year prospective study.

Previous studies have shown a paradoxical increase in early mortality in older patients (>70 years) with acute STEMI treated with fibrinolytic therapy (FT), which has been attributed to the development of free wall rupture (FWR). Our aim was to assess occurrence of FWR in STEMI patients receiving FT. In this 7-year prospective study, data from 1701 consecutive patients were obtained. We analyzed predictors of the in-hospital mortality in patients>70 years old. The independent contribution of several variables to overall mortality and FWR development was assessed using multiple logistic regression analyses. The mortality of entire cohort was 18% (306/1701). Diabetes mellitus, anterior infarction, smoking, female gender and hypercholesterolemia were independent predictors of in-hospital mortality. FT was given to 18% of all patients (304/1701) of which 13% died (39/304). FWR was 18.4-times more often in patients who received FT. Among patients younger than 70 years who received FT there was no FWR, while in patients ≥ 70 years of age FWR was found in almost half of the deceased (30/68; 44%). Application of FT in STEMI patients is not associated with higher mortality, but significantly increases number of FWR, especially in patients over 70 years of age.

Interobserver variations in diagnosing asbestosis according to the ILO classification.

Inhalation of asbestos fibres leads to asbestosis of the pleura and the lung, with possible progression to lung cancer and malignant pleural or peritoneal mesothelioma. Asbestosis remains difficult to diagnose, especially in its early stages. The most important role in its diagnosis is that of chest radiographs. The aim of this cross-sectional study was to address interobserver variations in interpreting chest radiographs in asbestos workers, which remain to be an issue, despite improvements in the International Labour Office (ILO) classification system. In our ten-year study, we investigated 318 workers occupationally exposed to asbestos, and in 210 workers with diagnosed asbestos-related changes we compared interpretations of chest radiographs according to ILO by two independent radiologists. The apparent degree of interobserver variation in classifying lung fibrosis was 26.66% for the diameter of changes and 42.2% for the profusion of the changes. In cases with diffuse pleural thickening, the interobserver variation using ILO procedures was 34.93%. This investigation raises the issue of standardisation and objectivity of interpretation of asbestosis according to the ILO classification system. This study has revealed a significant disagreement in the estimated degree of pleural and parenchymal asbestos pulmonary disease. This is why we believe high-resolution computed tomography (HRCT) should also be used as a part of international classification.