Introduction: Acute coronary syndrome (ACS) is one of the most common health problems in the world and the leading cause of death. Goal: The goals of this study are to determine: ACS type, risk factors, incidence and the seasonal distribution of occurrence Spring/Summer, Autumn/Winter, ACS incidence by age and gender, and complications (post-infarction angina and heart failure) and fatal outcomes of ACS per season. Material and methodology: This study is designed as retrospective-prospective and analytical, which included 250 patients hospitalized in the Intensive Cardiac care unit of the Clinic for heart disease, blood vessels and rheumatism in the period from June 2013 to July 2014. It was assumed that there is the influence of the seasons on the incidence and characteristics of ACS. Material used were the medical records and data from the history of illness. Results: The most common type of ACS was ST elevation myocardial infarction (STEMI), without statistical significant difference between seasons. Presence of risk factors is not significantly different between seasons, with the hypertension as the most common risk factor for ACS during both seasons. The highest incidence of ACS was recorded in December during the winter season, while the lowest incidence was recorded in March. The occurrence of ACS during the Spring/Summer, Autumn/Winter was different according to age, with more frequent occurrence of ACS in older patients during the winter months. ACS complications (postinfaction angina and cardiac insufficiency) were also statistically different between seasons (p=0.048). Fatal ACS is more often recorded during the season Autumn/Winter compared to Spring/Summer season (p=0.001). Conclusion: The results suggest seasonal meteorological impact on the incidence, complications and outcomes of ACS, so there is a necessity that patients adapt their lifestyle and health professionals to improve the ACS treatment.

Objective The aim of the study was to describe the prevalence of hyperlactatemia and emphasis on repeated lactate measurements in critically ill patients, and the associated mortality. Materials and methods The study included 70 patients admitted in the Medical Intensive Care Unit at the Clinical Center, University of Sarajevo, in a 6-month period (July - December 2015). The following data were obtained: age, gender, reason for admission, Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation, lactate concentrations upon admission, after 24 and 48 hours, and outcome (discharge from hospital or death). Results Upon admission,hyperlactatemia was present in 91.4% patients with a mean concentration of lactate 4.13 ±1.21 mmol/L. Lactate concentration at 48 hours was independently associated within creased in-hospital mortality (P = 0.018). Conclusion Persistent hyperlactatemia is associated with adverse outcome in critically ill patients. Lactate concentration at 48 hours is independently associated within creased in-hospital mortality and it represents a statistically significant predictive marker of fatal outcomes of patients. Blood lactate concentrations > 2.25 mmol/L should be used by clinicians to identify patients at higher risk of death.

OBJECTIVE We present the use of targeted temperature management in a tertiary-level intensive care unit, in three patients who experienced an out-of-hospital cardiac arrest. CASE REPORT Three young patients experienced an out-of-hospital non-coronary cardiac arrest. The causes of the cardiac arrest were: Wolf-Parkinson-White syndrome, drug overdose and long-QT syndrome. All patients were resuscitated according to the advanced cardiac life support guidelines, and treated with targeted temperature management, with a target temperature of 33°C for 24 hours. After completion of targeted temperature management, all the patients regained full consciousness and were discharged from hospital without any neurological sequelae. CONCLUSION Targeted temperature management may improve survival and neurological outcome in patients after out-of-hospital cardiac arrest.

OBJECTIVE The aim is to determine SAPS II and APACHE II scores in medical intensive care unit (MICU) patients, to compare them for prediction of patient outcome, and to compare with actual hospital mortality rates for different subgroups of patients. METHODS One hundred and seventy-four patients were included in this analysis over a oneyear period in the MICU, Clinical Center, University of Sarajevo. The following patient data were obtained: demographics, admission diagnosis, SAPS II, APACHE II scores and final outcome. RESULTS Out of 174 patients, 70 patients (40.2%) died. Mean SAPS II and APACHE II scores in all patients were 48.4±17.0 and 21.6±10.3 respectively, and they were significantly different between survivors and non-survivors. SAPS II >50.5 and APACHE II >27.5 can predict the risk of mortality in these patients. There was no statistically significant difference in the clinical values of SAPS II vs APACHE II (p=0.501). A statistically significant positive correlation was established between the values of SAPS II and APACHE II (r=0.708; p=0.001). Patients with an admission diagnosis of sepsis/septic shock had the highest values of both SAPS II and APACHE II scores, and also the highest hospital mortality rate of 55.1%. CONCLUSION Both APACHE II and SAPS II had an excellent ability to discriminate between survivors and non-survivors. There was no significant difference in the clinical values of SAPS II and APACHE II. A positive correlation was established between them. Sepsis/septic shock patients had the highest predicted and observed hospital mortality rate.

The most common influenza A (H1N1)-associated complications are pulmonary, but other organ systems, such as kidneys and nervous system can be affected too. There are no sufficient data about the development of acute kidney injury (AKI) related to A (H1N1) infection. Neurological complications, especially encephalitis with or without seizures, have been documented among pediatric patients, but data of influenza A (H1N1) related focal neurological deficits in adults are scarce. Here we describe a previously fit 46-year-old male patient with influenza A (H1N1) infection presenting with multi-organ failure (acute respiratory distress syndrome and AKI) accompanied by muscular and unusual neurological complications. We found hypoglossal nerve paralysis and unilateral peroneal nerve paralysis in the course of the influenza A (H1N1) infection, but with no permanent neurological sequelae. Renal function was fully recovered one month after patient’s discharge. Keywords : influenza A (H1N1), pulmonary complications, acute kidney injury, hypoglossal nerve paralysis

Introduction: Hyperglycemia is a common complication of critical illness. Patients in intensive care unit with stress hyperglycemia have significantly higher mortality (31%) compared to patients with previously confirmed diabetes (10%) or normoglycemia (11.3%). Stress hyperglycemia is associated with increased risk of critical illness polyneuropathy (CIP) and prolonged mechanical ventilation. Intensive monitoring and insulin therapy according to the protocol are an important part of the treatment of critically ill patients. Objective: To evaluate the incidence of stress hyperglycemia, complications and outcome in critically ill patients in our Medical intensive care unit. Materials and methods: This study included 100 patients hospitalized in Medical intensive care unit during the period January 2014–March 2015 which were divided into three groups: Diabetes mellitus, stress-hyperglycemia and normoglycemia. During the retrospective-prospective observational clinical investigation the following data was obtained: age, gender, SAPS, admission diagnosis, average daily blood glucose, highest blood glucose level, glycemic variability, vasopressor and corticosteroid therapy, days on mechanical ventilation, total days of hospitalization in Medical intensive care unit, and outcome. Results: Patients with DM treated with a continuous insulin infusion did not have significantly more complications than patients with normoglycemia, unlike patients with stress hyperglycemia, which had more severe prognosis. There was a significant difference between the maximum level of blood glucose in recovered and patients with adverse outcome (p = 0.0277). Glycemic variability (difference between max. and min. blood glucose) was the strongest predictor of adverse outcome. The difference in glycemic variability between the stress-hyperglycemia and normoglycemic group was statistically significant (p = 0.0066). There was no statistically significant difference in duration of mechanical ventilation and total days of hospitalization in the intensive care unit between the groups. Conclusion: Understanding of the objectives of glucose regulation and effective glycemic control is essential for the proper optimization of patient outcomes.

Intensive care medicine is a relatively new specialty, which was created in the 1950's, after invent of mechanical ventilation, which allowed caring for critically ill patients who otherwise would have died. First created for treating mechanically ventilated patients, ICUs extended their scope and care to all patients with life threatening conditions. Over the years, intensive care medicine developed further and became a truly multidisciplinary speciality, encompassing patients from various fields of medicine and involving specialists from a range of base specialties, with additional (subspecialty) training in intensive care medicine. In Bosnia and Herzegovina, the founding of the society of intensive care medicine in 2006, the introduction of non invasive ventilation in 2007, and opening of a multidisciplinary ICUs in Banja Luka and Sarajevo heralded a new age of intensive care medicine. The number of admissions, high severity scores and needs for mechanical ventilation during the first several months in the medical ICU in Banja Luka confirmed the need of these kinds of units in the country. In spite of still suboptimal personnel training, creation of ICUs in Bosnia and Herzegovina may serve as example for other developing countries in the region. However, in order to achieve modern ICU standards and follow European trends toward harmonisation of medicine, Bosnia and Herzegovina needs to take up this challenge by recognizing intensive care medicine as a distinctive specialty, by implementing a specific training program and by setting up multidisciplinary ICUs in acute care hospitals.

The aim of the work is to present the way how the latest insult might cause hyperosmolar coma. Case report: About 10 o'clock a.m. the dispatcher received a call by the police who having broken into the apartment found N.M. 73, in the unconscious state. On coming to the case spot the emergency aid team found the patient on the floor unconscious with vomited content on the dress and carpet, urinated. From the heteroanaemnesis (taken from a nearby merchant): the woman was on her own, and the last time seen in the grocery two days before. From the status: The patient was in a deep comatose state, did not react to tough stimulations, febrilous, with her tongue extremely dry, coated with brownish layers, the skin also dry. Cor: heart beating rhythmical, tachycardiac, tones lower, slight systolic murmur above ictus, frequency 150/min, TA unmesaurable. Pulmo: airways murmor normal. Other findings insignificant. Glucose highly unmeasurable on the glucometer. The tablets of glibenklamid, metformin and lizinopril were found on the dresser. The venuous ways were hardly open, and cardiotonic, physiological solution was given immediately on the spot and after that the patient was transported to to the clinic. In the course of the transportation, another venuous way was open, included physiological solution with 10 I.J. of efficient insuline. On arriving to the clinic, the next laboratory fin-dinggs were carried out within the intensive care unit: On 157:K 5,4: GUK 104 mmol/l: urea 28,0: creatinine 206: ABS: normal. The therapy at the clinic: fractioned 4 x s.c. effective insuline, hypotonic solution of natrium chloride with effective insuline, cardiotonic, wide spectrum antibiotic. After 48 hours, glycaemia stable, from 9,8 to 14,5:Na 147:K 4,2: urea 9,8: creatinine 123, the patient conscious, somnolent, does not speak with a right hemiplegia. An urgent head CT is done with the evidence of fresh lesion on the left parietally. .

Panhypopitutarism is a decreased hormone activity of hypophysis. The aim of the study is to present the case of the patient with a previous diagnosed disease and regular therapy together with occurrence of a new symptomology resulting in pondering over another diseases. A female fifty-seven-year-old patient was admitted to the Clinic of Intensive Care Unit for Endocrinology, Diabetes and Metabolism Disorders. The patient was in a comatose state. According to heteroanaemnestic analysis, the patient had been feeling weakness, lack of appetite, sickness, stomach pain accompanied with vomiting and every-day headaches. The same patients has also been treated for psychiatric disorders for 15 years. She suffers from hypothyreosis and is inclined to anaemia. In 1994 she was admitted to hospital due to medicament poisoning. In the course of the last month she has been at general practitioner's due to her general bad health condition who eliminated the possibility of anaemia and acute disorders of thyroid gland and liver, according to the previous laboratory results. Gastritis was recorded through gstroscopic survey. Psychiatrist was asked to contribute with his advice. Due to low blood pressure attributed to high temperatures, the patient was provided with infusion. While being checked up, the patient was asthenic, in a certain comatose state, with reactions to any kind of external irritation, extremely pale with watery and yellowish mucous membrane without distinctive lateralization. Cor: the rhythmical heart action, clear tones, murmurs almost inaudible. Frequency 60/30 mm Hg. Other results insignificant, no signs of fresh bleeding. By ECG, it is registered chronic ischaemia in precordial arteries. Due to hyponatraemia, hypochloremia, hypoglycaemia, bradycardia, hypotension, weakness and prevailing paleness of the skin, the White Addison was presumed. On the ground of clinical picture, it was concluded that it was the case of panhypopitutarism of unknown cause. The patient was at the state of well-being because of substitutional therapy and indirect implications of cortisoic activity (GUK, Na, Cl, K, tension, frequency) were good. The conclusion was that even in patients with previous verified diagnoses, it is essential that we should think and act differentially and diagnostically.

This work is to show hypertireosis as provoking factor of katoacidosis incentive in diabetes, type 2, verified at an early chilhood and treated by insuline. A 33-year-old female patient who has been suffering from diabetes since being only six months old, has been treated by fixed mixture therapy of intermediate-acting and rapid-acting insulin (70/30). The patient complains about weakness, loss of appetite, vomitting urge and vomitting itself. In the course of general medical examination the patient is somnolent, extremely dehidrated, slight exoftalmus, anisocoric, sight impaired, with dry tongue coated by whitish layers. Thyroid gland is palpatory slightly increased. Heart beat is tachycardiac, tones clear, heart murmur inaudible. Frequency 150/min, TA 90/40 mm Hg. Weakened respiratory murmur is basal followed by audible inspiratory tone, inclined to the left side. Below chest, abdomen is soft, palpatory sensitive to pain in the area of epigastrium, liver and spleen do not palpate. Extremities: Without oedema, weakened pulse of dorsalis pedis artery at both sides. According to the admission results it is as follows: SE 50/80, Fe 3,8: TIBC 38,7: UIBC 34,9: index saturation 0,10: Na 128: K 56: Cl 89: Ca 2,56: urea 10,6: creatinin 127: GUK 40,8: ABS: pH 7,059: pCO2 1,78: HCO3 3,6: total CO2 4: excess base - 27: pO2 10,66: saturation O2 91,7%: HbA ic 10,0 %: thyroid gland hormone: FT4 98,2: FT3 14,0: TSH 0,01. Medical examination control on discharge: Na 137: K 4,2: Cl 99: urea 3,0: creatinine 52: GUK 4,1: ABS: all parameters within referent value limits. Thyroid gland hormones: FT4 56,9: FT3 10,3: TSH 0,007. On admission, the patient was administered with a four dose crystal insuline s.c. crystal solutions of a wide range usage from the group of cephalosporine, parenterally. Due to repeated disturbances of ABS, and the oscillation of glycaemia, gastroscopy was carried out. Even after regular rehydration and suitable therapy, the occurrence of slight disturbances of ABS followed by tachycardia, about 100/min, was registered. After hormonal status analysis of thyroid gland, a high dosage of ureostatics was administered which resulted in stabilizing of glyacemia and ABS. Gland thyroid control results showed a significant improvement in the patient after 7 days of therapy. Siderosis anaemia is to be corrected by paranteal application of Fe elements. The final regulation of glycaemia is achieved by intensive regime of insuline therapy. After improving the general health condition, the standard analyses were carried out with a view to evaluating diabetes complications. On the ground of clinical survey and other relevant researches, we made the conclusion that diabetes mellitus, type 1, in concerned in this case. All complications detected on target organs of a registered hypertireosis which, together with lungs infiltration, resulted in decompensation of basic disease and hence lead the patient to ketoacidosis. Moreover, the very hypertireosis lead to hyperglyacemia, glyacemia oscillation and repeated ketoacidosis after which, the adequate therapy was applied.

The goal of the work is to demonstrate the way of controlling kidney function with patients suffering from diabetes and to harmonise the medicament dosage with the emphasis on elimination and semi-existence of the same one. A fifty-year-old patient was admitted to the clinic in a state of deep coma. The team of Emergency Aid Department applied the ampulla of glucogen i.m. and 50ml of glucose i.v., due to GUK being registered at 2,1 mmol/l. After the therapy treatment GUK was 7,9 mmol/l but the patient was still in unconscious state. The patient being suspected of insult, was immediately sent to the clinic. After having been admitted at the Health Emergency Department, GUK was recognised at 1,9 and another 50 ml 50% of glucose was applied with the patient. Since the patient could not regain cosciousness, he was sent to the clinic. The patient had been found by his spouse. The patient has suffered from diabetes for 15 years. Glibenclamid had been randomly taken by the patient (1-4 pills a day), depending on what he ate, having been hypertronic for about ten years, not regularly taking enalapril pills, an alcohol consumer. This patient had not had a proper check-up for 5 years, since having been retired. The spouse noticed the patient's legs, hands and face swelling followed by being sick, lack of appetite and vomiting. Referring to status: the patient is in deep coma, does not react to external stimuli, his respiration is deep, and face yellowish. Conspicuous water oedema is visible on hands, legs with aescites, frequency 80/min, TA 145/95mm Hg., other analysis insignificant. The urgent laboratory analyses were carried out, the neurologist was summoned. GUK was checked by means of glucometer with the result: 6,5l/L. Taking all implications into consideration, the patient is suspected of prolonged hypogycaemia and brain oedema. 50% glucose was given in continuation i.v. After 220ml 50% glucose, the depth of respiration altered and after another 30ml, the patient regained consciousness, stood up and wondered what had happened. Referring to the laboratory results: GUK 6,0: urea 29,5: creatinin 565: at 134:K 5,9. The patient was treated by intensive diuretic therapy followed by infusion 5% glucose. In the course of the next 4 days the patient experienced shallow and short term hypoglycaemic coma and with applying 20-40ml 50% glucose he regained consciousness. Before being admitted to hospital he had taken 4 pills of glibenclamid since he had lunch and the next morning he took 2 pills and did not remember having breakfast. People suffering from diabetes are supposed to be regularly checked by practitioners GUK monthly, postprandially. Hemoglobin is supposed to be checked at least once in the period of 3 months. Kidney function is supposed to be checked once in six months or more frequently, if needed. The prospective complications are to be followed with the emphasis on certain organs, the diet is supposed to be strictly controlled. The doctors are to estimate giving the adequate medicine (dosage). Furthermore, the patients are to be continually educated so as to be fully aware of how to prevent later diabetes complications. .

INTRODUCTION Tumors of the pituitary gland can be adenomas, and more often, cancers, representing 10-15% of intracranial neoplasm. We make a difference between them according to their size, expansion, hormone's activity and local and endocrinological manifestations. The goal of the research was to reveal the presence of tumors of the pituitary gland in the period 2000-2005 among patients hospitalized on the Intensive Care of the Endocrinology Clinic. PATIENTS AND METHODS Data from anamnesis of all patients with verified tumor of the pituitary gland between 2000.-2005 were used in the research work. RESULTS Total number of patients with the tumor of pituitary gland was 40, 29 women and 11 men, and 35 % of patients were aged between 45 and 60. Main symptoms: headache -16, eye trouble -17, sexual dysfunction -8, growth of acres -5, and others symptoms -8 patients. There were 23 (57,5%) cases of micro adenoma and 17 (42,5 %) macro adenomas. From the total number of patients 23 were operated, 8 micro adenomas and 15 macro adenomas. The number of secreting adenomas was 25 (62,5 %) and 15 (37,5 %) were non-secreting. Secreting adenomas were: prolactinomas--14, acromegalies -7, Cushing syndromes -2, TSH producing -2. Non-secreting adenomas were: craniopharyngeomas--11, meningiomas -2, and 2 non-secreting micro adenomas. Most of prolactinomas were treated with drugs, and 3 cases of prolactinoma were operated. 6 cases of acromegaly were operated and 1 micro adenoma is still under medical supervision, with the therapy of bromocriptine. 3 of those patients have the residuum, and 4 of them have high level of hGH. 11 craniopharyngeomas were operated and all patients, except one, are under substitution therapy. 2 meningiomas were operated and those patients are also under substitution therapy. 1 case of TSH producing tumor was operated, but residuum and hyperthyroidism are still presents, and the micro adenoma, for the hyperplasia reason, disappeared with adequate substitution therapy. The Cushing syndrome, confirmed with MRI diagnostics, wasn't operated; it remained under conservative therapy, and in the other case, where we didn't isolate a pathological substrate, the patient exited. CONCLUSION Tumors of the pituitary gland we mainly treat applying surgery methods, together with post operational substitution therapy or additional therapy with drugs. Only prolactinomas are tumors which are successfully treated with drugs.