Background: Chronic kidney disease-mineral and bone disorder contributes to vascular calcification in kidney transplant recipients. However, the relationship between circulating bone turnover markers, Gla-rich protein (GRP), pelvic arterial calcification, and post-transplant outcomes remains uncertain. Methods: In this prospective single-centre study, 79 kidney transplant recipients underwent pre-transplant assessment of serum calcium, phosphate, alkaline phosphatase, parathyroid hormone, osteoprotegerin (OPG), receptor activator of nuclear factor kappa-B ligand (RANKL), and GRP. Pelvic arterial calcification was quantified using a validated CT-based scoring system. Associations between biomarkers, pelvic calcification severity, graft function, graft survival, patient survival, and major adverse cardiovascular events were evaluated. Results: Serum calcium was associated with serum creatinine (p = 0.039), and serum phosphate was associated with MAG-3 clearance (p = 0.009). OPG concentrations were significantly higher in patients receiving haemodialysis than in those receiving peritoneal dialysis (p = 0.021). No significant associations were observed between pelvic arterial calcification severity and circulating OPG, RANKL, or GRP concentrations. Furthermore, in univariable Cox proportional hazards models, none of the investigated biomarkers was significantly associated with graft or patient survival. Conclusions: Circulating OPG, RANKL, and GRP were not associated with pelvic arterial calcification, graft or patient survival. Larger multicentre studies with longer follow-up are warranted to clarify the prognostic value of these biomarkers.

Background: This study aims to evaluate the impact of various weighting factors (WFs) on the quality of weighted average (WA) dual-energy computed tomography (DECT) non-contrast brain images and to determine the optimal WF value. Because they simulate standard CT images, 0.4-WA reconstructions are routinely used. Methods: In the initial phase of the research, quantitative and qualitative analyses of WA DECT images of an anthropomorphic head phantom, utilizing WFs ranging from 0 to 1 in 0.1 increments, were conducted. Based on the phantom study findings, WFs of 0.4, 0.6, and 0.8 were chosen for patient analyses, which were identically carried out on 85 patients who underwent non-contrast head DECT. Three radiologists performed subjective phantom and patient analyses. Results: Quantitative phantom image analysis revealed the best gray-to-white matter contrast-to-noise ratio (CNR) at the highest WFs and minimal noise artifacts at the lowest WF values. However, the WA reconstructions were deemed non-diagnostic by all three readers. Two readers found 0.6-WA patient reconstructions significantly superior to 0.4-WA images (p < 0.001), while reader 1 found them to be equally good (p = 0.871). All readers agreed that 0.8-WA images exhibited the lowest image quality. Conclusions: In conclusion, 0.6-WA reconstructions demonstrated superior image quality over 0.4-WA and are recommended for routine non-contrast brain DECT.

Background/objectives: Anderson-Fabry disease (FD) is a rare hereditary disorder caused by deficient alpha-galactosidase A activity, which leads to multisystemic complications, including significant cardiac involvement. In this case report, we describe two siblings with distinct cardiac manifestations of FD. Methods: The medical data of two siblings who were managed and treated at a tertiary hospital center in Croatia were obtained by detailed analysis of electronic medical records. All available data were structured in chronological order. Results: A 42-year-old male with chronic renal failure and severe left ventricular hypertrophy (LVH) was diagnosed with FD during testing for inclusion on the kidney transplant waiting list. The diagnosis was confirmed by cardiac magnetic resonance imaging (CMR), which revealed non-ischemic fibrosis typical of FD. Following enzyme replacement therapy (ERT), he underwent a successful kidney transplantation. The second case describes the 36-year-old brother, who was diagnosed through family screening and, despite normal initial cardiac ultrasound findings, exhibited early cardiac involvement through reduced T1-mapping values. Immediate initiation of ERT led to normalization of T1 values and successful renal transplantation. Conclusions: This report underscores the importance of family screening and early diagnosis in FD and highlights the role of CMR in detecting preclinical cardiac involvement.

SAŽeTAK:Periferna arterijska bolest (PAB), uz ishemijsku bolest srca i moždani udar, među trima je najznačajnijim dijagnostičkim podskupinama kardiovaskularnih bolesti.Prema procjenama, prevalencija u mlađih od 50 godina je <1 %, a u starijih od 65 godina 6 %.Analiza dinamike kretanja PAB-a upućuje na smanjenje incidencije u EU15+ državama posljednjih 27 godina, ali uz povećanje mortaliteta.Republika Hrvatska ističe se među mediteranskim zemljama po visokom kardiovaskularnom opterećenju, ali nema sustavnih epidemioloških istraživanja dinamike kretanja mortaliteta od PAB-a.U ovom su istraživanju regresijskom analizom dobno standardiziranih stopa mortaliteta od PAB-a prema regijama od 2011.do 2020.godine prikazani trendovi i vremenske točke s promjenama

Background: Negative CCTA can effectively exclude significant CAD, eliminating the need for further noninvasive or invasive testing. However, in the presence of severe CAD, the accuracy declines, thus necessitating additional testing. The aim of our study was to evaluate the diagnostic performance of noninvasive cFFR derived from CCTA, compared to ICA in detecting hemodynamically significant stenoses in participants with high CAC scores (>400). Methods: This study included 37 participants suspected of having CAD who underwent CCTA and ICA. CAC was calculated and cFFR analyses were performed using an on-site machine learning-based algorithm. Diagnostic accuracy parameters of CCTA and cFFR were calculated on a per-vessel level. Results: The median total CAC score was 870, with an IQR of 642–1370. Regarding CCTA, sensitivity and specificity for RCA were 60% and 67% with an AUC of 0.639; a LAD of 87% and 50% with an AUC of 0.688; an LCX of 33% and 90% with an AUC of 0.617, respectively. Regarding cFFR, sensitivity and specificity for RCA were 60% and 61% with an AUC of 0.606; a LAD of 75% and 54% with an AUC of 0.647; an LCX of 50% and 77% with an AUC of 0.647. No significant differences between AUCs of coronary CTA and cFFR for each vessel were found. Conclusions: Our results showed poor diagnostic accuracy of CCTA and cFFR in determining significant ischemia-related lesions in participants with high CAC scores when compared to ICA. Based on our results and study limitations we cannot exclude cFFR as a method for determining significant stenoses in people with high CAC. A key issue is accurate and detailed lumen segmentation based on good-quality CCTA images.

SAŽetAK: Prikazujemo 55-godišnjeg bolesnika sa subakutnim infarktom miokarda i hemoragičnim perikardijalnim izljevom koji je doveo do tamponade srca.Bolesnik se očitovao kliničkom slikom šoka s anamnestičkim podatkom o trodnevnoj vrućici, a u noći prijema opetovanim sinkopama.Učinjenom koronarografijom utvrđena je subakutna okluzija prve marginalne grane lijeve koronarne arterije te je u istom aktu učinjena perkutana koronarna intervencija navedene lezije, kao i perikardiocenteza uz evakuaciju 450 mL hemoragičnog perikardijalnog izljeva.Ekstenzivnom slikovnom obradom isključena je ruptura slobodne stijenke lijeve klijetke

Case report : We present a case report of an 82-year-old male patient with known valvular and ischemic heart disease and a history of paroxysmal atrial fibrillation, iatrogenic hypothyroidism and rheumatoid arthritis who was admitted to our Department in August 2018 due to chest pain. Routine echocardiography revealed a large pericardial effusion and pericardiocentesis was performed with instillation of bleomycin. Cytology of the pericardial effusion showed elements of peripheral blood, but there was no evidence of malignant disease. Ten months later he was admitted again due to non-ST elevation myocardial infarction with clinical symptoms and signs of heart failure. Coronary angio-gram revealed atherosclerotic disease of left and right coronary artery with significant stenosis of the left main, left anterior descending, left circumflex and right coronary artery. Echocardiography revealed an enlarged right atrium and ventricle with severely thickened interventricular septum and anterolateral wall of the right ventricle which was akinetic and seemed infiltrated as well as adjacent pericardium. A small pericardial effusion was also noted. There were no regional wall abnormalities of the left ventricle, and its ejection fraction was preserved. Additionally, severe aortic stenosis was determined. Magnetic resonance imaging of the heart was performed which showed diffuse myocardial and pericardial infiltrative mass along the right ventricular free wall, right ventricular apex, interventricular septum, and right ventricle papillary muscles. Morphological features were indicative of a cardiac lymphoma. Endomyocardial biopsy was performed. Histopathological analysis of right ventricle samples obtained at endomyocardial biopsy confirmed the presence of a diffuse large B-cell lymphoma. Chemotherapy was initiated with R-mini-CHOP protocol. After the seventh cycle the patient developed febrile neutropenia with signs of heart failure. Echocardiographic findings showed thinner myocardial walls and global hypokinesia with reduced left ventricular ejection fraction. Pa - tient died 7 months after the diagnosis. Conclusion :

A 70-year-old female patient was suffering from progressive shortness of breath due to severe aortic regurgitation (AR), followed approximately two years prior to surgery. On physical examination, a murmur with a 3/6 intensity was present and best heard at apex. No history of serious previous illness had been recorded.

Background Acute ischemic stroke (AIS) has a high risk of recurrence, particularly in the early stage. Recurrent ischemic stroke (RIS) is associated with adverse neurological outcomes but the phenomenon of early RIS in the endovascular thrombectomy era has not been frequently discussed. We report a case addressing this issue. Case presentation We present a patient who was successfully treated by mechanical thrombectomy (MT) for middle cerebral artery occlusion. Due to an early stroke recurrence, within 72 h after the first MT, he received systemic thrombolysis and repeated MT was performed with excellent clinical outcome. Discussion We discuss the aspects of reperfusion therapy for patients experiencing early stroke recurrence. Consideration was given to stroke etiology and off-label use of thrombolytic therapy. Also, effectiveness of repeated MT for early re-occlusion of initially reanalyzed vessel was evaluated in order to allow more patients with RIS to benefit from reperfusion therapy.

U zadnjem desetljeću paradigma liječenja akutnog ishemijskog moždanog udara značajno je promijenjena. Za razliku od nekadašnjeg pasivnog pristupa koji je podrazumijevao medikamentoznu terapiju i medicinsko praćenje, danas se primjenjuje aktivno liječenje koje uključuje intravensku trombolizu i mehaničku trombektomiju. Mehanička trombektomija počela se provoditi početkom ovog stoljeća, no značajan procvat metode započeo je objavom nekoliko multicentričnih randomiziranih studija (MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, THRACE, PISTE) koje su 2015. godine potvrdile dobrobit ove metode liječenja. Danas je dokazano da je mehanička trombektomija povoljna i poželjna metoda liječenja bolesnika s akutnim ishemijskim moždanim udarom. Razvoj novih dijagnostičkih uređaja i standardizacija protokola snimanja omogućila je objektivniju procjenu stupnja oštećenja parenhima mozga, što je izravno utjecalo na odluku o daljnjem liječenju. Danas je postupak mehaničke trombektomije moguće provesti unutar 24 sata od nastupa simptoma, što su potvrdile i multicentrične randomizirane studije, DAWN i DEFUSE 3. Svakodnevni napredak mehaničke trombektomije doveo je do liječenja i distalnijih okluzija, poput M2 i M3 segmenta srednje moždane arterije i proksimalnih okluzija anteriorne i posteriorne moždane cirkulacije. Istovremeno je neurointervencijski tim postao veoma važna karika u lancu liječenja bolesnika s moždanim udarom. Nedavnom implementacijom mehaničke trombektomije u standardan protokol liječenja bolesnika s akutnim ishemijskim moždanim udarom u sve kliničke bolničke centre u Republici Hrvatskoj, bolesnicima koji borave u Republici Hrvatskoj omogućeno je liječenje najsuvremenijom metodom, sukladno najnovijim smjernicama.

Components of carotid atherosclerotic plaque can be analysed preoperatively by non-invasive advanced imaging modalities such as magnetic resonance imaging (MRI). The expression of matrix metalloproteinase-9 protein (MMP-9), which has a potential role in remodelling of atherosclerotic plaques, can be analysed immunohistochemically. The aim of the present prospective pilot study is to analyse histological characteristics and expression of MMP-9 in carotid plaques of patients undergoing carotid endarterectomy (CEA) and to investigate the correlation with preoperative clinical symptoms and MRI features. Preoperative clinical assessment, MRI imaging, postoperative histological and immunohistochemical analyses were performed. Fifteen patients with symptomatic (7/15; 47%) and asymptomatic carotid artery stenosis undergoing CEA were included. Among symptomatic patients, 5 (71%) had recent stroke and 2 (29%) had recent transient ischaemic attack with a median timing of 6 weeks (IQR: 1, 18) before the surgery. Both groups did not significantly differ in respect to preoperative characteristics. Prevalence of unstable plaque was higher in symptomatic than asymptomatic patients, although it was not significant (63% vs. 37%, p = 0.077). The expression of MMP-9 in CD68 cells within the plaque by semiquantitative analysis was found to be significantly higher in symptomatic as compared to asymptomatic patients (86% vs. 25% with the highest expression, p = 0.014). The average microvascular density was found to be higher and lipid core area larger among both symptomatic patients and unstable carotid plaque specimens, although this did not reach statistical significance (p = 0.064 and p = 0.132, p = 0.360 and p = 0.569, respectively). Our results demonstrate that MRI is reliable in classifying carotid lesions and differentiating unstable from stable plaques. We have also shown that the expression of MMP-9 is significantly higher among symptomatic patients undergoing CEA.

Purpose Weighted average dual-energy computed tomography (DE-CT) reconstructions are considered a proxy of standard CT images of the brain, recommended for routine clinical use and used as a reference standard in DE-CT research. However, their image quality has not been assessed, which was the aim of our study. Methods Images from 81 consecutive patients who underwent both non-contrast single-energy (SE)-CT and DE-CT of the brain on the same scanner were retrospectively evaluated. Attenuation values (HU) and SD of grey matter/white matter (GM/WM) pairs, along with SD in the posterior fossa and subcalvarial region were measured. Four readers evaluated image noise, GM/WM contrast, posterior fossa and subcalvarial artefacts, as well as overall image quality. Results Weighted average DE-CT GM and WM HU were significantly lower and noise higher compared to SE-CT (GM HU 36.46 v. 41.82; WM HU 28.18 v. 29.94; GM SD 2.93 v. 2.49; and WM SD 3.16 v. 2.44, all p < 0.0001). After correcting the measured SE-CT noise for 37% higher acquisition dose, DE-CT GM noise became significantly lower (2.93 v. 3.11, p = 0.0121). Measured and dose corrected SE-CT GM/WM contrast-to-noise ratio was superior to weighted average DE-CT (3.42 and 2.74 v. 1.95, both p < 0.0001). Weighted average DE-CT had significantly less artifacts on qualitative analysis. Conclusion Weighted average DE-CT images of the brain yield less artefacts at 37% dose reduction and lower noise at SE-CT equivalent dose. Dose-adjusted GM/WM contrast-to-noise ratio of weighted average DE-CT with 0.4 weighting factor remains inferior to SE-CT images.

Background An assessing of the in-hospital mortality risk for an emergency hospitalized patient with acutely decompensated heart failure (ADHF) is challenging task. Simple formula can help. Methods On the base of six indicators identified in derivation group, simple formula for assessing the risk for in-hospital mortality of ADHF patients was derived and later tested in validation group. Results The retrospective analysis of a derivation group (533 survivors, 121 deceased) identified six risk indicators: age, heart rate (HR), systolic blood pressure (SBP) and serum concentrations of urea, sodium (Na) and uric acid (UA). The final formula was created ([age/10](2) x HR/SBP)+(Urea-Na/10)+UA/100 and formula result of 53 was established as cut-off result. In the derivation group, at the cut-off point of 53, area under the ROC curve (AUC) was 0.741 (95% CI 0.701-0.776); with sensitivity 54% and specificity 83%. The discriminative capacity of the formula was significantly higher than each of its components. In the validation group of 591 patients (527 survived, 64 died) AUC was also 0.741 (95% CI 0.706-0.774), sensitivity was 66% and specificity 76%. Positive predictive value (PPV) of the developed formula was modest (34%), but negative predictive value (NPV) was 95%. N-terminal pro-B type natriuretic peptide and troponin I were determined, but not included into formula. Conclusions The developed formula enables simple, rapid and inexpensive risk assessment, but its disadvantage is a low PPV. However, a high NPV permits the identification of patients with a low risk of in-hospital mortality, which could lead to a more rational patient treatment.

Renal cysts are a common, usually incidental finding on routine radiological studies, including ultrasound (US), computed tomography (CT), and magnetic resonance (MR).In general, renal cysts may be classified as simple or complicated.Simple cysts are benign and do not require any follow-up or treatment.Most of the cysts belong to this category.Complicated cysts however include a wide range of cystic kidney lesions, from completely benign to definitely malignant.Bosniak classification is a useful and applicable method for renal cyst evaluation.It was developed from clinical experience with the intent that morphologic features of a cyst could serve as a predictor for reliable categorization and differentiation of "nonsurgical" and "surgical" lesions.Although other imaging modalities like MR and US are used for diagnosing renal cysts, CT is the imaging method of choice.Standard CT protocol includes a noncontrast and postcontrast arterial and/or parenhymal phases.Size, location within the kidney, shape, and density of the cyst, the number and morphology of the septa and/or calcification, and postcontrast opacification are evaluated.US is most commonly used as a "screening" method, appropriate for frequent examinations, while MR is the initial method of choice for young patients, those with renal insufficiency and hypersensitivity to iodinated contrast agents, and is proven helpful when CT findings are equivocal.

Background: An aneurysm of the superior mesenteric artery (SMA) with a diameter of 2.2 cm was found incidentally on an ultrasound (US) examination in a 26-year-old woman. The only known risk factor was an intracranial aneurysm that was found on her grandmother's autopsy. Based on pregnancy planning and the current literature, endovascular management with a covered stent was proposed.Case Report: Self-expandable, covered stent (Bard, Fluency (R)) was implanted using a single transfemoral approach. A stiff guidewire and a large sheath distorted the anatomy, which resulted in an incomplete aneurysmal neck covering. In the absence of additional covered stents, the procedure was terminated. Two weeks later, computed tomographic angiography (CTA) confirmed persistent aneurysmal perfusion due to the incomplete neck coverage. A multidisciplinary board opted for a second endovascular attempt, this time with a longer covered stent via the transaxillary approach in order to reduce anatomical distortion. Balloon, expandable, cobalt-chrome covered stent (Jotec, E-ventus BX (R)) was implanted in the SMA, covering the aneurysmal neck and overlapping the previously implanted covered stent. Angiography confirmed a complete exclusion of the aneurysm. A control US performed three weeks later confirmed a patent covered stent and complete aneurysmal exclusion. There was a mild median nerve damage periprocedurally that resolved in three months. The most recent US control examination, performed eleven months after the procedure, showed an excluded aneurysm and a patent covered stent. There were no clinical signs of bowel ischaemia during the follow-up period.Conclusions: Endovascular management of SMAA proved to be safe and efficient. The "access from above" is probably safer and should be considered in the majority of cases with acceptable sizes of access vessels. Mid-term results in our patient are good and life-long follow-up is planned to prevent late complications.

Introduction: Myxomas are the most common benign primary cardiac tumors with the majority (85%) located in the left atrium.Clinical manifestations are diverse and are consequence of embolic phenomena, intracardiac obstruction or constitutional symptoms.Early diagnosis, most perplexing in a patient with constitutional symptoms, remains an important challenge for the clinician, as they have an excellent prognosis following surgical excision, preventing complications and improving quality of life. 1-3 Case report: We report a case of a 75-year-old female presented with fatigue and weight loss.Symptoms were first attributed to her history of hyperthyroidism.After series of normal hormonal and thyroid ultrasound findings she was referred to gastroenterologist for the evaluation of microcytic anemia (Hb 101g/L).Even though results of fecal occult blood testing were negative, esophagogastroduodenoscopy and colonoscopy were performed subsequently having sent our patient to hematologist for further examinations regarding anemia.After a year of anemia assessment she underwent transthoracic echocardiography which demonstrated an intraatrial mass.Immediately hospitalized, transesophageal echocardiography (Figure 1, Figure 2) and magnetic resonance imaging (Figure 3) were performed.Features of the mass were consistent with notably large myxoma, occupying nearly the entire left atrium and prolapsing across the mitral valve during diastole.Coronary angiography showed no obstructive coronary artery disease.Our patient underwent urgent cardiothoracic surgery with successful excision of atrial mass attached to the interatrial septum, pathologically confirmed myxoma (Figure 4).Cardiac rehabilitation followed immediately after discharge, with normalization of hemoglobin levels.

Svrha. Prikaz timskog pristupa u lijecenju bolesnika s malfunkcijom arteriovenske (AV) fistule za hemodijalizu i rezultata klinickog pracenja u prvih sest mjeseci. Ispitanici i metode: deset bolesnika s malfunkcijom AV fistule prezentirano je multidisciplinarnom timu koji obuhvaca nefrologa, radiologa i urologa. Klinicke manifestacije bile su nedostatan protok krvi i / ili visoki venski otpor na hemodijalizi, zgrusavajne krvi u vantjelesnom krvotoku, duže krvarenje nakon punkcije, bolovi u ruci, otok ruke ili nesazrijevanje AV fistule. U svih bolesnika ucinjen je angiografski pregled s neposrednim endovaskularnim zahvatom, ako je bio indiciran, i hemodijalizom. Rezultati: Angiografski pregled je pokazao razlicitost patologije arterijskog i venskog segmenta. U vecine bolesnika klinicki ishod je bio uspjesan uz dobar protok krvi na postupcima hemodijalize koji su bili urednog tijeka. Zakljucak: Iako je broj ispitanika relativno malen, postigli smo znacajan klinicki uspjeh kao rezultat uspjesne suradnje clanova multidisciplinarnog tima.