Thrombotic thrombocytopenic purpura--possibilities of treatment and results.

Results of treatment of 13 patients fulfilling the criteria for TTP are presented. Thrombocytopenia was present in all patients (100%). Eleven of 13 patients (84.6%) had conciousness disorder, and seven of 13 patients (53.8%) had renal impairment. Immunosuppressive therapy with plasmapheresis and replacement of removed volume with fresh frozen plasma in a dosage of 25 ml/kg body weight resulted in statistically significant increase of platelet count (p = 0.0033), and significant improvement of consciousness as defined by increased Glasgow Coma Score (GCS) (p = 0.0524). In two patients, renal function recovered and, in one patient, hemodialysis was no longer needed. This improvement in a small patient group has no statistical significance.

Possibilities and limits of treatment in patients with thrombotic thrombocytopenic purpura.

Results of treatment of 18 patients fulfilling the criteria for TTP are presented. Thrombocytopenia was present in all patients (100%). Sixteen of the 18 patients (88.8%) had mental status changes, and seven of the 18 patients (38.8%) had renal impairment. One patient had a secondary type of TTP, caused by non-Hodgkin's lymphoma of the large intestine (that was diagnosed later) and was excluded from the study. Immunosuppresive therapy with steroids, plasma exchange and replacement of removed volume with fresh frozen plasma in a dosage of 25 ml/kg body weight resulted in a statistically significant increase of platelet count (P = 0.00222), and a significant improvement in consciousness defined by increased GCS after 2 weeks (P = 0.00222). In two patients renal function recovered, and in one of them hemodialysis was no longer needed. This improvement in a small group of patients had no statistical significance. TTP recurred in seven patients. High doses of steroids caused serious side effects in two patients: in one patient, steroid diabetes, and in the other one, intestinal perforation.

[Methemoglobinemia caused by accidental poisoning with metolachlor and metobromuron]. / Methemoglobinemija uzrokovana akcidentalnom intoksikacijom metolaklorom i metobromuronom.

An 81-year-old man was admitted in the emergency department approximately four hours after accidental, ingestion of an unknown quantity of herbicide "Galex 500 EC". This product contains 25% of metolachlor and 25% of metobromuron dissolved in xylene. In spite of the fact that the combination of aniline and urea-substituted derivatives is widely used in agriculture as herbicide, there are very few data available about their harmful effects on humans. These agents appear to be mildly toxic, and rarely has a major systemic effect been reported after the poisoning. On admittance, our patient showed remarkable cyanosis and his methaemoglobin level was 38.4% of the total haemoglobin, rising next day to 46.2%. Only mild transient signs of hypoxic effects on central nervous system were observed and the laboratory findings indicated mild haemolysis. Methylene blue was applied intravenously in a dose of 1.5 mg/kg (10 ml, 1% solution) on the second day of admission. Administration of methylene blue was very effective and the patient was discharged from the hospital fully recovered.

[Causes of disorders of consciousness in internal medicine intensive care units]. / Uzroci poremecaja svijesti u internoj intenzivnoj jedinici.

The present study on 5330 patients admitted to the internal intensive care unit over the five year period (1990-1994) indicated that consciousness disorders are most frequently associated with poisoning. On admission, the state of consciousness of 665 of these 5330 patients was retrospectively evaluated. Poisoning by drugs was most common among intoxications (93 patients of 154 cases of poisoning). Coma, which is the most severe manifestation of consciousness disorder, occurred very often in these patients. Poisoning caused by other agents was connected with other forms of consciousness disorders. Low Glasgow Coma Score (GCS) was a severe predictor, while the number of deaths among patients with GCS > 10 was low. Sepsis was the next most common cause of consciousness disorder among our patients (88 patients). Death rate in these patients was high, amounting to almost 50%, regardless of GCS on admission, suggesting that the severity of main event determines the outcome. Glycemia disorders, including hypoglycemia, hyperglycemia as well as hyperosmotic state, did not result in lethal outcome, regardless of GCS on admission. The highest death rate was registered in patients with cardiopulmonary arrest and lowest GCS on admission. Patients with cardiogenic shock, despite high GCS on admission, had high death rate.

[Disorders of consciousness due to disorders of body fluid composition--case report of a female patient]. / Poremecaj svijesti zbog poremecaja sastava tjelesnih tekucina--prikaz bolesnice.

We report a female patient presenting with sepsis and multi-organ failure following eclampsia and intrauterine childdeath. In the phase of recovery, the patient developed consciousness disorder and coma characterized by fasciculation, generalized myoclonia and respiratory insufficiency. The clinical picture corresponded to that of Lance Adam's syndrome. A quick change in the composition of body fluids in the polyuric phase of renal insufficiency associated with an antidiuretic hormone deficit was a cause of that disorder. Metabolic dysfunction and hyperexcitability of neurons developed as a result. Hyperexcitability of the caudal part of the medulla oblongata was responsible for the development of myoclonia. Following the correction of that disorder, the patient completely improved.

[Immunotherapy of sepsis and septic shock]. / Imunoterapija sepse i septickog soka.

An extraordinary advance in basic sciences and technology did not reduce high lethality rate of the septic shock patients. The lethality rate of those patients was and still is around 50%. A new knowledge about a role of an inflammatory response on the infection in the later fatal course of the septic patients, led to the new approach in the treatment. A trial to block an endotoxin, cytokines, especially TNF and IL-1, as well as some other substances, in experimental models of sepsis, in spite of inconsistent results, is promising. A clinical experiences are disappointing, at first because of our still poor knowledge about various cytokines cascade, feedback mechanisms, cellular protective mechanisms, etc. The new chapter on the treatment of that highly lethal syndrome is open, though a final achievement of that approach is not clear till now.

Incidence and hospital mortality of acute coronary artery disease among civilians in Zagreb during air-raid alarms.

During the period of air-raid alarms in Zagreb (September 1991), the influence of war-induced stress on the incidence and mortality of acute coronary artery disease was investigated. Control periods were September 1989 and September 1990. Among 2903 patients admitted to Emergency Care Units, 369 (13%) were examined for suspect acute coronary artery disease. During the same periods in 1989 and 1990, 10% and 11% of acute coronary artery disease patients were recorded, respectively. The percentage of patients with myocardial infarction or unstable angina, admitted to Coronary Care Units during September 1989, 1990 and 1991, was 49%, 50% and 55%, respectively. The number of Q myocardial patients admitted during September 1991 was significantly higher than that recorded during the same period in 1990. The incidence and mortality patterns in acute coronary artery disease patients were also examined during August, September and October 1991. The peak incidence of acute coronary artery disease was found in the first half of September, while the peak mortality in these patients was found during the second half of September. During the second half of September of 1989, 1990 and 1991, the mortality in Q myocardial patients in Coronary Care Units, was 16.7%, 15.2% and 23.8%, respectively. Besides the war-induced stress, transportation of our patients to shelters or inner parts of the hospital caused additional stress, probably contributing to the development of refractory malignant arrhythmia or heart failure.

[Ultrasound in the diagnosis and therapy of collections of fluid in the abdomen]. / Ultrazvuk u dijagnosticiranju i lijecenju nakupina tekucine u trbuhu.

The procedure of percutaneous, echosonographicaly guided puncture and drainage of localized abdominal fluid collections by use of fine-needle and catheter is described in this review. The care prior to and after the puncture is also reported. This diagnostic as well as therapeutic modality can delay or make unnecessary surgical intervention resulting in a complete improvement. Twenty patients were treated with this procedure and we describe three cases in whom this treatment was successfully applied.

[Mushroom poisoning with a long period of development]. / Otrovanje gljivama s dugim periodom inkubacije.

A group of 87 patients with the signs of poisoning with mushrooms with along period of incubation (t = 12.4 +/- 6.2 h) has been reported. Nausea, vomiting and diarrhea dominate in the clinical picture in the first phase and hepatic and/or renal insufficiency in the second phase. Forty-one patients (47.1%) had "only" clinical symptoms without severe parenchymatous impairments. Forty-six (54.9%) had evidence of a hepatic lesion and 8 patients (10.8%) had renal function impaired, 6 of which needed hemodialysis. There was a significant correlation between elevation of serum transaminases and prolongation of prothrombin complex, resulting from the decreased synthetic liver function (SGPT1/PV1r = -0.424, p = 0.00; SGOT1/PV1r = -0.448, p = 0.000) during the first days after poisoning. Hepatic and renal damage was not identical in all the cases, and there was no correlation between the elevation of serum transaminases and retention of nitrogen substances. When analysing the effect of therapy on elevation of serum transaminases and prolongation of prothrombin complex, a significant difference between elevation of serum transaminases and prolongation of prothrombin time was found in patients on competitive inhibition with penicillin or silibinin, as compared to the patients only on plasmapheresis (p = 0.004 for SGOT, p = 0.000 for SGPT). These data unquestionably suggest the efficacy of competitive inhibition in the treatment of poisoning with mushrooms of a long period of incubation. In favour of this therapy also speaks the group of seriously ill patients who were simultaneously on plasmapheresis and competitive inhibition and who had better improvement than those "only" on plasmapheresis (p = 0.004 for SGOT).(ABSTRACT TRUNCATED AT 250 WORDS)

[Is there a correlation between changes in the electrocardiogram and high serum digoxin levels in the aged?]. / Postoji li povezanost promjena u elektrokardiogramu i visoke koncentracije digoksina u serumu u starijih osoba?

In a group of 84 patients aged 65 to 89 years with the high serum digoxin levels, electrocardiograms, as well as serum creatinine and serum potassium levels were analysed. In an electrocardiogram, a rhythm and conduction disturbances, PR interval, PTQ index, corrected QT interval, both a corrected QT interval I using the second root from a heart frequency and a corrected QT interval II using the third root from a heart frequency were studied. A rhythm disturbances were seen in 37% and a conduction disturbances in 39% of the patients, but no changes were observed in 24% of the patients. There was no correlation between serum digoxin levels and the PR interval. There was a slight correlation between serum digoxin levels and the PTQ index, and no correlation could be demonstrated between serum digoxin levels and a corrected QT interval I as well as a corrected QT interval II. Also, no correlation was evident between serum digoxin levels and serum creatinine levels, although many of those patients suffered from chronic renal failure. In an analysis of the influence of digoxin on the heart, electrocardiographic changes together with serum digoxin levels and serum potassium levels have to be followed. Only one of these parameters is not enough for the analysis of the effect of digoxin on the heart. It is concluded that clinical examination is most important in the analysis of digoxin action.

[Evaluation of the effectiveness of streptokinase in acute myocardial infarct with respect to the pump function of the heart]. / Ocjena djelotvornosti streptokinaze u akutnom infarktu miokarda s obzirom na pumpnu funkciju srca.

During 2 years and 3 months 230 patients suffering from acute myocardial infarction were treated at an Intensive Care Unit and a Department of Cardiology. Streptokinase was given intravenously to 54 of them. Out of 54 patients, in 52% the localisation of the myocardial infarction was in the anterior and in 48% in the posterior wall. The patients were divided in the three categories according to the onset of symptoms: up to 2 hours, 2-4 hours and 4-6 hours. The dose of streptokinase was 1,500,000 i.u. during 1.5 hours. The CPK and MBCPK level reached the maximum values up to 12 hours and was to lowest in the first group. In 74% of the patients the serum enzyme level showed successful reperfusion of a coronary artery. Electrocardiographic findings of a successful myocardial reperfusion amounted to 36% in the first, 40% in the second, and 17% in the third group. Malignant ventricular arrhythmias appeared in the first group in 3.6%, in the second in 12.5% and in the third group in 14.2%. The criteria for successful myocardial reperfusion by echocardiography (analysed regional wall motion) were present in 52% in the first, in 50% in the second, and in 17% in the third group. Coronarography and ventriculography were performed in 17 patients after 21 days of treatment, with successful results in 88% (15 out of 17 patients). In a group of 176 patients unable to be treated with streptokinase because of the onset of symptoms of myocardial infarction (more than 6 hours) or because of contraindications for that treatment, the lethality rate reached 17.6%. The lethality rate in the group of 54 patients treated with streptokinase was 5.5%. Local complication (hemorrhage) during the treatment was observed in one patient (2%).