Abstract Guidewire loss is a rare complication of central venous catheterization. A 65-year-old male was hospitalized in a high-dependency unit for exacerbation of chronic obstructive pulmonary disease, pneumonia, erythrocytosis, and clinical signs of heart failure. Upon admission, after an unsuccessful right jugular approach, a left jugular central venous catheter was placed. The next day, chest radiography revealed the catheter located in the left parasternal region, with suspected retention of the guidewire, visually confirmed by the presence of its proximal end inside the catheter. The left parasternal location of the catheter and the typical projection of the guidewire in the coronary sinus, later confirmed by echocardiography, raised suspicion of a persistent left superior vena cava (PLSVC). Agitated saline injected into the left antecubital vein confirmed bubble entry from the coronary sinus into the right atrium. After clamping the guidewire, the catheter was carefully retrieved along with the guidewire without any complications. This is the first reported case of guidewire retention in PLSVC and coronary sinus. It underscores the potential causes of guidewire loss and advocates preventive measures to avoid this potentially fatal complication.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

BACKGROUND Heart failure due to high cardiac output rarely occurs. Few cases of post-traumatic arteriovenous fistula (AVF) as a cause of high-output failure were reported in the literature. METHODS Herein, we report a case of 33-year-old male who was admitted to our institution due to symptoms of heart failure. He reported a gunshot injury of the left thigh 4 months earlier, when he had been shortly hospitalized and discharged 4 days later. Since the gunshot injury he had exertional dyspnea and left leg edema, so the diagnostic procedures were performed. RESULTS Clinical examination revealed distended neck veins, tachycardia, slightly palpable liver, left leg edema, and thrill over the left thigh. Due to high clinical suspicion, duplex ultrasonography of the left leg was performed that verified femoral AVF. Operative treatment of AVF was made with prompt resolution of symptoms. CONCLUSIONS This case wants to emphasize the importance of proper clinical examination, and duplex ultrasonography in all cases of penetrating injuries.

Aim To assess the prognostic value of lactate level for mortality in patients with pulmonary embolism (PE) and Pulmonary Embolism Severity Index (PESI) I-III and its independence of gas-analysis parameters and acid-base status. Methods This prospective observational study was conducted at the University Clinical Hospital Mostar from 2013 to 2017. On the first day after PE diagnosis, 1.5 mL of arterial blood was collected from 103 patients with PE. Partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide in arterial blood, blood pH value, concentration of bicarbonates in arterial blood (HCO3-), base deficit, and oxygen saturation were analyzed. Lactate levels were assessed using blood samples taken from the cubital vein. Logistic regression analysis was used to assess the predictive value of gas-analysis variables, lactate level, PESI score, age, and sex for in-hospital death due to PE. Results The mortality in the group of PE patients was 19.1% (18 of 103 patients). Lactate level was an independent predictor of mortality (P = 0.002, odds ratio 0.06). HCO3- was also found to be a significant predictor (P = 0.022, odds ratio 2.4). Lactates were independent of other variables. Other gas-analysis parameters were not significant predictors of mortality. Conclusion In PE patients at low-intermediate risk of mortality (PESI I-III), lactate level was associated with a short-term mortality, independently of other gas-analytic parameters. Oxford Centre for Evidence-based Medicine level of evidence: 2.

The progressive nature of glaucoma suggests it should be possible to detect structural changes such as retinal nerve fiber layer (RNFL) thickness loss before the condition becomes clinically apparent with visual field (VF) impairment. Therefore, the aim was to analyze RNFL thickness and VF changes in study groups with unilateral exfoliation syndrome (XFS), bilateral XFS and bilateral exfoliative glaucoma (XFG), and compare it with controls. The study included 114 subjects (228 eyes) divided into 4 groups according to the presence of exfoliation: 30 subjects with unilateral XFS (30 with clinically visible XFS and 30 fellow eyes), 24 subjects (48 eyes) with bilateral XFS, 28 (56 eyes) subjects with bilateral XFG, and control group (32 subjects). All subjects underwent VF and RNFL measurements after ophthalmologic examination. Both eyes of unilateral XFS (clinically -visible and fellow eye) showed positive correlation between Mean Defect (MD) and square root of Loss of Variance (sLV) and between MD and inferior quadrant RNFL thickness. In bilateral XFS and XFG, there was negative correlation between MD and inferior quadrant RNFL thickness. Inferior, superior and nasal quadrant RNFL thickness was lower in XFG group than in other groups. In bilateral XFS group, the inferior quadrant RNFL thickness was lower as compared with unilateral XFS group (in both eyes). The mean RNFL thickness negatively correlated with MD in bilateral XFS and XFG groups. In conclusion, structural changes before VF impairment have an important role in early detection of glaucoma in subjects at risk.

The aim of the study was to evaluate macular thickness and macular volume in unilateral and bilateral exfoliation syndrome and to compare them with exfoliative glaucoma and control eyes using optical coherence tomography. This prospective study included 114 subjects (228 eyes) divided into 4 groups according to the presence of exfoliation: 30 patients with unilateral syndrome, 24 patients with bilateral syndrome, 28 patients with bilateral glaucoma and control group without glaucoma or exfoliation syndrome (32 subjects). All subjects were older than 50 years. Patients with visual acuity under 0.6 according to Snellen were excluded, as well as those with refraction errors, i.e. hypermetropia over +3 spherical diopters, myopia over -5 spherical diopters, astigmatism over 2 cylindrical diopters, patients with affections that might affect the macula or the optic nerve, such as diabetic retinopathy, macular degeneration, macular edema, epiretinal membrane, vascular occlusions, neuropathies, and patients having undergone eye surgery except for pseudophakic patients with visual acuity within the set limits. Study results confirmed the hypothesis on the existence of structural changes of macular parameters before the functional ones, thus representing an early sign of glaucomatous damage in risk groups such as unilateral and bilateral exfoliation syndrome. If the glaucoma had already manifested (exfoliative glaucoma in this study) with changes in optic disc and visual field, structural changes confirmed the clinical findings and warned of the disease severity.

A 40-year-old man was hospitalized in the coronary care unit with chest pain and abnormal electrocardiogram. Twenty days earlier, the patient underwent laparoscopic gallbladder surgery. Due to chest pain and ischemic ECG changes, patient was subjected to coronary angiography. The selective coronary angiography revealed multiple multilateral fistulae arising from the left anterior descending artery, circumflex artery, and the right coronary artery draining to the left ventricle. Multislice computed tomography showed hypoplastic coronary sinus and minor cardiac venous system.

AIMS Contrast-induced nephropathy (CIN) is a frequent complication of many radiological procedures involving the application of contrast media. It represents a significant health problem that causes the increase in mortality, morbidity, and medical costs. For the prevention of CIN, a number of methods have been proposed to be effective. Among them, alkalinization of urine takes an important place. Although the Na/K citrate is a well-known agent for urine alkalinization, it has not been studied in the prevention of CIN. METHODS AND RESULTS Two hundred and two patients who underwent coronary angiography were included in the study. They were randomized into groups receiving the drug Na/K citrate per os and to the control group. Serum creatinine and glomerular filtration rate were determined in all patients immediately before coronary angiography, and 48 h after the procedure. CIN criteria were a creatinine increase of >25%, reduction in the glomerular filtration rate by >25%, or an increase in serum creatinine of >44 μmol/L. The incidence of CIN in the group receiving Na/K citrate was significantly lower when compared with the control group (4% compared with 20%, P = 0.0001). Patients who had a urine pH <6 had a more than ten-fold higher incidence of contrast nephropathy compared with patients whose urine pH was >6. CONCLUSION Alkalinization of urine using the Na/K citrate may reduce the incidence of CIN.