Vitamin D and Diabetic Retinopathy.

Diabetic retinopathy (DR) is the most common eye disease complication of diabetes, and hypovitaminosis D is mentioned as one of the risk factors. Vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol) are the best-known forms of vitamin D. Calcitriol (1,25-dihydroxycholecalciferol) is the active form of vitamin D, with the sun being one of its main sources. Vitamin D is synthesized in the skin by exposure to sunlight without protective factors, but care must be taken to avoid the development of sunburn. It not only plays an important role in maintaining healthy bones and immune system but has also been highlighted in numerous studies to have an influence on various diseases, including diabetic retinopathy. A large number of people suffer from vitamin D hypovitaminosis worldwide, and diagnosis is made by measuring the concentration of 25-hydroxyvitamin D (25(OH)D) in serum. Its deficiency can cause numerous diseases and, as such, supplementation is necessary. Clinical studies have proven the effectiveness of vitamin D supplementation in the treatment of diabetic retinopathy, but with a doctor's recommendation and supervision due to possible negative side effects.

Liver metastasis in uveal melanoma - treatment options and clinical outcome.

Uveal melanoma (UM) is the most prevalent primary intraocular malignancy in adults with a stable incidence rate between five and seven cases per million in Europe and the United States. Although UM and melanoma from other sites have the same origin, UM has different epidemiological, biological, pathological and clinical features including characteristic metastatic hepatotropism. Despite improvements in the treatment of primary tumours, approximately 50% of patients with UM will develop metastases. In 90% of cases the liver is the first site of metastasis, however the mechanisms underlying this hepatic tropism have not been elucidated. Metastatic disease is associated with a very poor prognosis with a median overall survival of 6 to 12 months. Currently, there is no standard systemic treatment available for metastatic UM and once liver metastases have developed, prognosis is relatively poor. In order to prolong survival, close follow-up in all patients with UM is recommended for early detection and treatment. The treatment of metastatic UM includes systemic chemotherapy, immunotherapy and molecular targeted therapy. Liver-directed therapies, such as resection, radioembolization, chemoembolization, immunoembolization, isolated and percutaneous liver perfusion as well as thermal ablation represent available treatment options. However, to date a consensus regarding the optimal method of treatment is still lacking and the importance of setting guidelines in the treatment and management of metastatic UM is becoming a priority. Improvement in knowledge and a better insight into tumour biology, immunology and metastatic mechanism may improve current treatment methods and lead to the development of new strategies paving the way for a personalized approach.

Prevalence of diabetic retinopathy in the Dubrovnik-Neretva County.

OBJECTIVE: Diabetic retinopathy is one of the leading causes of blindness. We estimated the prevalence of diabetic retinopathy among a diabetic population in the Dubrovnik-Neretva County in the Republic of Croatia and searched for potential risk factors. METHODS: A prospective study was performed with 600 diabetic patients from different parts of the Dubrovnik-Neretva County who attended regular medical and ophthalmological check-ups at the General Hospital Dubrovnik from September 2014 to September 2015. Patients underwent a complete medical assessment by two ophthalmologists. Retinal examination included evaluation of the presence of diabetic retinopathy. Any retinopathy present was graded as mild non-proliferative retinopathy, moderate-severe non proliferative retinopathy or proliferative retinopathy. RESULTS: Retinopathy was present in 44.5% of the study sample. 20.7% had the mild form of diabetic retinopathy, 18.8% had the moderate-severe form, and 5.0% had proliferative diabetic retinopathy. The mean duration of diabetes was 12.94 years ± 6.85; 12.89 years ± 9.18 in men, 12.94 ± 6.54 in women. The mean BMI was 27.14 ± 2.98; for diabetics without diabetic retinopathy 26.19 ± 2.75; for those with the mild form 28.06 ± 3.01; for those with the moderate-severe form 28.49 ± 2.54; for those with proliferative diabetic retinopathy 28.79 ± 3.16. 168 (28%) patients were treated by laser and 22 (3.7%) by vitrectomy. CONCLUSION: The prevalence of diabetic retinopathy in the Dubrovnik-Neretva County is 44.5%. Regular screening to detect diabetic retinopathy is highly recommended as timely intervention can prevent most diabetic causes of blindness.

Influence of hypertension and type 2 diabetes mellitus on cerebrovascular reactivity in diabetics with retinopathy.

BACKGROUND AND OBJECTIVES: Cerebrovascular reactivity (CVR) provides information on the intracerebral arterioles capacity to react to vasodilatory stimuli. The current study aimed to investigate the influence of hypertension and type 2 diabetes mellitus on CVR in diabetics with retinopathy. DESIGN AND SETTING: Retrospective analysis of data prospectively collected over a 1-year period. SUBJECT AND METHODS: Subjects were classified into four groups each comprised of 30 participants: diabetic retinopathy with hypertension (DRH), diabetic retinopathy without hypertension (DR), hypertension without diabetes mellitus (H), and healthy controls without diabetes and hypertension (C). CVR was estimated in relation to the increase in the mean flow velocity compared with the basal velocity in both middle cerebral arteries during hypercapnia. RESULTS: In the DRH group, the mean (SD) increase in CVR was 8.8 (2.49) cm/s, in the H group 14.4 (2.59) cm/s and in the DR group 9.7 (2.97) cm/s. The analysis of variance showed significant differences among the groups in blood flow velocity after a breath-holding test (F=89.83; df=3.116; P < .001). CONCLUSIONS: Diabetes mellitus influences CVR more than hypertension.

A rare type of Usher's syndrome.

A case is presented of a very rare type of Usher's syndrome detected in a 30-year-old woman in her 28th week of pregnancy. She reported left eye visual impairment with a one-month history. She underwent standard ophthalmologic examination with additional procedures scheduled after childbirth, including fluorescein angiography, visual field (Goldman and Octopus) and electroretinography. Fundus examination revealed pallor of the optic disk, diffuse retinal blood vessel narrowing, no retinal pigmentation, left macular edema, vitreous liquefaction, and posterior vitreous detachment. Goldman perimetry showed narrowing of all isopters to 10 degrees, and Octopus perimetry showed peripheral decrease of retinal sensitivity. Electroretinography confirmed the diagnosis of retinitis pigmentosa sine pigmento. Upon collecting case history records, hearing disorders originating from childhood were discovered. To our knowledge, this type of retinitis in Usher's syndrome has been reported only once in the available literature.

The incidence of stroke at Department of Neurology, Dubrovnik General Hospital in 2008.

Data on all patients admitted in 2008 to the Department of Neurology, Dubrovnik General Hospital, were retrospectively analyzed. In a total of 663 patients, there were 247 (37.25%) stroke patients. Ischemic stroke was diagnosed in 217 (87.85%) and hemorrhagic stroke in 30 (12.15%) patients. In the cohort of stroke patients, there were 136 (55.00%) women and 111 (45.00%) men. The group of patients with ischemic stroke consisted of 124 (57.15%) women and 93 (42.85%) men, and the group of those with hemorrhagic stroke of 12 (40%) women and 18 (60%) men. The majority of patients with ischemic stroke (89.86%) and hemorrhagic stroke (76.66%) were over 60 years of age. Only 9 (4.14%) patients with ischemic stroke and 5 (16.66%) patients with hemorrhagic stroke were employed. The mortality rate was 20.24% in the overall stroke group and 19.35% in the ischemic stroke group. In the group of patients with hemorrhagic stroke, 26.66% of patients died at our Department, however, additional 20% of patients with this type of stroke were transferred to the Hospital Intensive Care Unit or to Departments of Neurosurgery in Split and Zagreb, so precise data on the disease outcome in these patients were missing. Eighteen (7.29%) patients were from other countries, mostly from Bosnia and Herzegovina. The majority of them had ischemic stroke (83.33%) and 12 (66.66%) patients were over 60 years of age.

From recurrent peripheral facial palsy to multiple sclerosis.

Peripheral facial palsy is a clinical entity, which may be presented as the first symptom of multiple sclerosis (MS). Although MS is mostly a multifocal chronic inflammation of the central nervous system, peripheral nervous system can also be involved. Isolated cranial nerve palsies are rare and occur in 1.6% of MS patients. In this report, a case is presented of a 35-year-old woman who developed isolated seventh nerve palsy that was misdiagnosed as Bell's palsy. Despite recurrent peripheral facial palsy, positive cerebrospinal fluid finding and magnetic resonance imaging, the diagnosis of MS could only be confirmed when the patient developed other neurologic symptoms and when the criteria for dissemination in space were satisfied. In clinical presentation, the patient had only cranial nerve involvement, with complete recovery.

Benign angiopathy of the central nervous system or reversible cerebral vasoconstriction syndrome.

Benign angiopathy of the central nervous system is a subset of primary angiitis of the central nervous system characterized by "benign" course. It means that changes of cerebral vessels are reversible after treatment with corticosteroids and calcium channel blockers, so these abnormalities are believed to reflect vasospasm rather than true vasculitis. The diagnosis is made on the basis of clinical presentation, brain magnetic resonance imaging and cerebral angiography. We present a young man with acute onset of headache and neurologic impairment secondary to ischemic stroke with intracerebral and subarachnoid hemorrhage. Cerebral angiography showed characteristic findings of diffuse vasculitis but good response to treatment with corticosteroids and calcium channel blockers distinguish this benign angiopathy from the more aggressive form of the central nervous system vasculitis.

Prevalence of migraine, probable migraine and tension-type headache in the Croatian population.

BACKGROUND/AIM: Population-based epidemiological studies about headaches, especially migraine, have been carried out in many countries. The aim of this study was to assess the 1-year prevalence of migraine, probable migraine and tension-type headache (TTH) in the Croatian population. METHODS: The design of the study was a cross-sectional survey of an adult population sample using a self-completed questionnaire. RESULTS: The 1-year crude prevalence of migraine without and with aura in this study was 7.5%, of probable migraine 11.3%, and of TTH 21.2%. The 1-year age- and sex-adjusted prevalence of migraine was 6.2%, of probable migraine 8.8%, and of TTH 20.7%; the prevalence of migraine combined with probable migraine was 15.0%. Total crude prevalence of headache (combination of migraine, probable migraine and TTH) was 39.9%. Prevalence of migraine was higher in continental than in Mediterranean areas of Croatia. Multivariate regression analysis showed that the highest risk of suffering from any kind of headache is observed for the following people: living in Dubrovnik, being female, having elementary or high school education, being married, employed and living in an urban or suburban area. CONCLUSION: The prevalence of migraine and probable migraine is similar as in other Western countries. Certain demographic characteristics differ among patients with and without headache.

Neurological manifestation of Fabry disease--a case report.

Fabry disease is an X-linked recessive glycolipid storage disease. It is caused by deficiency of the lysosomal enzyme alpha-galactosidase A and leads to the accumulation of the enzyme substrate, globotriasylceramide (Gb3) in many tissues including endothelial cells, pericytes and smooth muscle cells of blood vessels, renal epithelial cells, cardiac myocytes and numerous neuronal cells. In this report, we present 20-year-old male patient with ischemic stroke in pons. The case had previously been misdiagnosed as polimyositis and vasculitis. Angiokeratomas, neuropathic pain and ischemic stroke in young age suggested a Fabry disease. The diagnosis was confirmed biochemically and genetically. All young adults with stroke, especially if they have additional symptoms like angiokeratomas, proteinuria, neuropathic pain in toes and fingers should be tested for Fabry disease.

Neuropathic pain.

Neuropathic pain refers to pain that originates from pathology of the nervous system. Common causes of neuropathic pain are diabetes mellitus, reactivation of herpes zoster, nerve compression or radiculopathy, alcohol, chemotherapy or abuse of some drugs, and trigeminal neuralgia. Specific symptoms of neuropathic pain are mechanical allodynia and cold hyperalgesia. Drugs to treat neuropathic pain can be divided into adjuvant analgesics (antidepressants and anticonvulsants), opioids and topical agents. The use of multiple drug therapies is common in practice. Despite considerable increase in the number of randomized placebo-controlled trials in neuropathic pain in the last few years, the medical treatment of neuropathic pain is still far from being satisfactory, with less than half of patients achieving significant benefit with any pharmacological drug.

[Vascular age assessment in smokers]. / Vaskularna dob pusaca.

AIM: Smoking is the most harmful social habit and is the origin of many diseases including direct damaging of arterial walls. The aim of this study was to assess the possible differences in vascular age of smokers versus never smokers, measured in common carotid artery (CCA). METHODS: The study included healthy volunteers with age and sex risk factors for cerebrovascular disease development. Measurements in CCA were performed in M mode on an Aloka 5500 Prosound ultrasound platform bilaterally. Carotid intima-media thickness (IMT), carotid interadventitial diameter (CID) and carotid interadventitial diameter change (CIDc) were recorded, and carotid interadventitial strain (CIS) was calculated. Median age subanalysis was performed for IMT, CIDc and CIS. Mann-Whitney statistics was used to determine group differences. RESULTS: There were 121 subjects, 80 women and 41 men, mean age 47.43 +/- 14.15 years. There were 23 (19%) current smokers, 17 (14%) occasional smokers, 11 (9%) past smokers, and 70 (58%) non-smokers. A statistical increase in IMT was found in the group of previous smokers (the eldest) in the left CCA (P < 0.05). CIDc and CIS were statistically higher in the right CCA in the group of current smokers (P < 0.05 both). Older subjects had an increase in IMT values in both CCA and decrease in CIDc and CIS in the right CCA. CONCLUSIONS: The results indicated cigarette smoking to primarily cause an increase in CIDc, whereas CIS remained preserved. Smoking influences vascular age. Additional studies are necessary to address the issue in a greater number of smokers.

Recommendations for neuropathic pain treatment.

Damage to the somatosensory nervous system poses a risk for the development of neuropathic pain. Such an injury to the nervous system results in a series of neurobiological events resulting in sensitization of both the peripheral and central nervous system. The symptoms include continuous background pain (often burning or crushing in nature) and spasmodic pain (shooting, stabbing or "electrical"). The diagnosis of neuropathic pain is based primarily on the history and physical examination finding. Although monotherapy is the ideal approach, rational polypharmacy is often pragmatically used. Several classes of drugs are moderately effective, but complete or near-complete relief is unlikely. Antidepressants and anticonvulsants are most commonly used. Opioid analgesics can provide some relief but are less effective than for nociceptive pain; adverse effects may prevent adequate analgesia. Topical drugs and a lidocaine-containing patch may be effective for peripheral syndromes. Sympathetic blockade is usually ineffective except for some patients with complex regional pain syndrome.