Omeprazole, azithromycin and either amoxycillin or metronidazole in eradication of Helicobacter pylori in duodenal ulcer patients.

BACKGROUND: Azithromycin is a new generation, acid stable, macrolide antibiotic that achieves remarkably high concentrations in gastric tissue (above the minimal inhibitory concentration for Helicobacter pylori) after oral administration. AIM: To establish whether azithromycin plus omeprazole in association with either amoxycillin or metronidazole are useful in curing H. pylori infection in patients with a duodenal ulcer. METHODS: One hundred patients with active duodenal ulcers and H. pylori infection were treated with omeprazole (days 1-10, 40 mg b.d.; days 11-24, 40 mg o.m.; days 25-42, 20 mg o.m.) plus azithromycin 500 mg o.m. for the first 6 days. Patients were randomly assigned to receive either amoxycillin 1 g b.d. (OAzA group: n = 50) or metronidazole 400 mg t.d.s. (OAzM group: n = 50) during the first 10 days of treatment. H. pylori status was determined by urease test and histology before the treatment and 6 weeks after completion of therapy. RESULTS: Ninety-seven patients completed the study. H. pylori infection was eradicated in 85% (41/48) of patients in the OAzA group (intention-to-treat analysis 82%) vs. 74% (36/49) of patients in the OAzM group (intention-to-treat analysis: 72%) (N.S.). All ulcers had healed after 6 weeks of omeprazole treatment. Side-effects, usually minor, were recorded in 13% (OAzA group) and 47% (OAzM group) of patients (P < 0.001), but therapy was discontinued for only one patient in the OAzA group (N.S.). CONCLUSION: Ten days of treatment with omeprazole plus (for the first 6 days) azithromycin and either amoxycillin or metronidazole provides effective regimens to cure H. pylori infection in patients with duodenal ulcer disease.

Compartmentalization of NADPH-diaphorase staining in the developing human striatum.

Nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) staining of striatal neuropil showed inhomogeneities in human fetal and adult brains. Highly reactive patches were seen during fetal and neonatal period, distributed in a lighter stained background matrix. In adult, zones of low NADPH-d reactivity appeared against darker background staining. NADPH-d reactive patches corresponded to and showed a similar shift in the intensity of staining during development as acetylcholinesterase (AChE) reactive striosomes.

Analysis of 127 war inflicted missile brain injuries sustained in north-eastern Croatia.

During the 4-year period (1991-1994) there were 127 consecutive patients with missile brain wound treated at the Division of Neurosurgery. They sustained brain injury in the region of east Slavonia, Baranya and north Bosnia, and were admitted mostly during the homeland defensive war in Croatia (1991-1992). Analysing the wounded, we divided them in two groups: "succumbed" (59 wounded) and "survivors" (68 wounded). We applied "less radical type of surgery", i.e. the patients were never re-operated only because of the retained single bone fragment. However, a retained cluster of bone fragments should be reoperated. The higher percentage of retained bone fragments (76.8%) is the result of precise visualization on the postoperative computed tomography (CT) scan. The last few cases have convinced us that the problem of the retained fragments could be solved by using an intraoprative ultrasonography. An intracranial (i.c.) infection (meningitis, abscess) occurred in 10 patients (10%), mostly among the patients who, besides the retained fragments, had cerebrospinal fluid (CSF) leak on the dehiscenced scalp wound. These cases should be reoperated soon after the CSF leak is visible on the dehiscenced wound. The overall mortality rate of 46.4% can be explained since our hospital was located close to the front-line, and some of severely wounded reached our hospital just in time to die. Excluding moribunds and those who died on the operating table (operated immediately after the admission), the mortality was 31.7%.

Skull osteolysis after mild head trauma: case report.

BACKGROUND: To our knowledge, there have been only two reported cases of patients with osteolytic skull lesions secondary to head trauma without concomitant skull fracture. METHODS: We present a case of skull bone lysis, not associated with skull fracture in a 20-year-old male, after mild head injury. During surgery, tumorous skull tissue of benign appearance was excised and primary cranioplasty was performed. RESULTS: The pathological examination showed an inflammatory reactive process within the bone lesion. Three years after surgery the patient was asymptomatic and studies did not show any new bone changes. CONCLUSIONS: The authors draw attention to this exceptionally rare condition, pointing out the necessity of surgical biopsy, contrary to some opinions.

A model of hydraulic interactions in liver parenchyma as forces behind the intrahepatic bile flow.

The small diameters of bile canaliculi and interlobular bile ducts make it hard to attribute the bile flow solely to the process of secretion. In the model liver within its capsule is considered a limited space in which volume expansions of one part are possible only through the shrinking of other parts. The liver capsule allows only very slow volume changes. The rate of blood flow through the sinusoides is governed by the Poisseuill-Hagen law. The model is based on a concept of circulatory liver units. A unit would contain a group of acini sharing the same conditions of arterial flow. We can imagine them as an acinar group behind the last pressure reducer on one arterial branch. Acini from neighboring units compose liver lobules and drain through the same central venule. One lobule can contain acini from several neighboring circulatory units. The perfusion cycle in one unit begins with a transient tide in the arterial flow, governed by local mediators. Corresponding acini expand, grabbing the space by compressing their neighbors in the same lobules. Vascular resistance is reduced in dilated and increased in compressed acini. Portal blood flows through the dilated acini, bypassing the compressed neighbors. The cycle ends when the portal tide slowly diminishes and acinar volume is back on the interphase value until the new perfusion cycle is started in another circulatory unit. Each cycle probably takes minutes to complete. Increased pressures both in dilated and in compressed acini force the bile to move from acinar canalicules. Both up and down changes in acinar volume might force the acinar biliary flow. In cases of arterial vasoconstriction, increased activity of vasoactive substances would keep most of the circulatory units in the interphase and increased liver resistance can be expected. Liver fibrosis makes all acini to be of fixed volume and result in increased resistance. Because of that, low pressure portal flow would be more compromised, as reported. In livers without arterial blood flow, although some slow changes in the portal flows can be expected, acinar volume changes should be reduced. In acute liver injury, enlarged hepatocytes would diminish sinusoidal diameter and increase acinar resistance. In liver tumors, areas of neovascularization with reduced resistance would divert the arterial flow from the normal tissue, while in the compressed perifocal areas, increased vascular resistance should diminish mainly the portal flow.

Endothelin-secreting tumors and the idea of the pseudoectopic hormone secretion in tumors.

Ectopic hormone secretion in tumor cells is here described as an amplification of hormone production already present in normal, nonendocrine tumor-originated tissue. This idea is tested on the available data regarding endothelin-1 (ET-1) secreting tumors. The endothelins are ubiquitous regulatory peptides produced by various tissues. The precursor cells of many tumor types secrete endothelins. ET-1 protein expression was detected in situ in all tested prostate cancers as well as in normal prostate tissue. The majority of hepatocellular carcinomas produce ET-1, while ET-1 is secreted by the normal hepatic stellate cells. Human breast cancer cells produce immunoreactive ET-1. Similar data exist for pancreatic tissue, the thyroid and large bowel. We can conclude that tumor cells might sustain endothelin secretions already present in the normal tumor-originated tissue. The model that is presented of the pseudoectopic hormone secretion consists of relations between a few parameters. The proportion of hormone-secreting tumors (Th) among all tumors (T) of that organ depends on the amount of the hormone-secreting cells (Ch) among all cells (C) susceptible to malignant transformation. The corrective factor (k) was introduced in the expression Th/T=Ch/C*k, to represent specific conditions altering the malignant transformation probability for a certain normal hormone-secreting cell. In prostate, breast and colon, the kvalue is predicted to be approximately 1, suggesting that ET-1-secreting normal cells are not more prone to the malignant transformation than their neighbours. In liver and pancreas, the incidence of ET-1-secreting tumors outnumbers the proportions of normal ET-1-secreting cells (k values >1). In these organs, normal ET-1-secreting cells seem more likely to turn malignant in comparison to their neighbours, perhaps due to their function, position and exposition to oncogenic factors, or even due to their ET-1 secretion. There are similar data for thyroid and adrenal glands. No ET-1 secretion was reported in kidney neoplasms. Normal renal ET-1 secreting cells might be less prone to turn malignant than other renal cells. Unlse the normal lung tissue, small cell lung cancers often secrete adrenocorticotrophic hormone (ACTH). The pancreatic islet cells do not secrete gastrin, but their tumors often do. Constant k would exceed 1 in both cases. We speculate that these tumors might originate from a small subset of cells with the described feature. Tumor cells sometimes lack features of the normal tissue, as in the cases of the steroid receptor-negative breast cancer. These tumors might originate from the hypothetical subset of receptor-free breast cells. Benign breast epithelial cells lacking oestrogen receptors have been described in cases of megalomastia. These cells might be constituents of normal breasts or, perhaps, present only in cases of increased breast cancer risk.

The influence of Helicobacter pylori infection on gastrin and somatostatin values present in serum.

BACKGROUND/AIMS: Recent studies on the role of Helicobacter pylori in pathogenesis of duodenal ulcers have focused on the mechanism by which H. pylori infections causes exaggerated gastrin release. METHODOLOGY: We compared the gastrin and somatostatin serum values between two groups of patients; 37 H. pylori-positive ones and 29 H. pylori-negative ones. We applied radioimmunoassay technique to determine the gastrin and somatostatin values in serum. H. pylori was confirmed by urease test and by histopathological color according to Giemsa. RESULTS: The level of gastrin in the serum of Helicobacter pylori-positive patients with chronic gastritis were significantly higher in relation to H. pylori-negative patients. The somatostatin concentration in the sera of H. pylori-positive patients with duodenal ulcer (16.27 +/- 9.49 pg/mL) were less in comparison with those without duodenal ulcer (23.25 +/- 13.59 pg/mL). CONCLUSIONS: The results suggest that H. pylori infection suppresses the somatostatin secretion.

Gastropathy and diarrhea in diabetic patients: the presence of helicobacteriosis and PAS-positive vascular deposits in gastric and duodenal mucosa.

AIM: To determine the presence of vascular periodic acid-Schiff's reagent (PAS) positive deposits in the gastric and duodenal mucosa of diabetic patients and controls. METHODS: Forty-six poorly controlled diabetic patients with digestive symptoms, aged 23 to 63 years (32 type I patients on insulin therapy with a mean diabetes duration of 14.2 +/- 3.1 years (mean +/- SE) and 13 type II patients with a mean diabetes duration of 7.2 +/- 2.3 years) were included. Of these, 17 had mainly gastropathic symptoms while 13 had diarrhea, and the remaining 16 patients had nonspecific symptoms. Forty control individuals of similar age and gender were included. Biopsy specimens were taken from areas of grossly normal gastric and duodenal mucosa. RESULTS: Gastric mucosa samples were pathological in 38 of 46 diabetic patients (18 cases of chronic active H. pylori antral gastritis, 13 cases of chronic active H. pylori pangastritis and 7 cases of nonspecific chronic gastritis). Duodenal mucosa samples were pathological in 32/46 diabetic patients. In the control group, 21 of 40 gastric samples (5 cases of chronic active H. pylori antral gastritis, 3 cases of chronic active H. pylori pangastritis and 13 cases of H. pylori-negative chronic gastritis) and 12/40 duodenal samples were pathological. Both helicobacteriosis and gastric and duodenal mucosa pathologies were significantly (p < 0.01) more common in diabetic patients than in controls. No significant associations were found between histological findings of gastric mucosa and of duodenal mucosa in diabetics and the control group. PAS-positive material in the vascular wall of gastric (16/46 vs. 2/40 in controls) and duodenal mucosa specimens (25/46 vs. 5/40 in controls) was significantly more common among diabetics (p = 0.001 for gastric and p < 0.001 for duodenal mucosa). No significant association was found between the presence of gastropathy or diarrhea compared to the presence of neuropathy, retinopathy, nephropathy or the type of diabetes. CONCLUSION: Endoscopic specimens from the gastroduodenum of diabetic patients revealed a large quantity of PAS positive vascular deposits, probably reflecting the condition of the mucosal vessels in our patients.

Histochemical changes in the rectal mucosa of diabetic patients with and without diarrhea or constipation.

Sixty-four diabetic patients, 35 with diarrhea, 15 with constipation and 14 without stool problems, and forty healthy subjects, were subjected to rectosigmoidoscopy. During rectosigmoidoscopy, rectal biopsy specimens for histological and histochemical analysis were obtained. Histological findings of nonspecific colitis in 25 out of 64 diabetic patients were uniformly distributed among the three groups (p = 0.959). However, the finding was slightly more common in diabetic patients than in controls (eight out of 40 control subjects, p = 0.043). A positive PAS reaction was observed in 30 out of 64 diabetic patients and was also uniformly distributed among the three groups (p = 0.508), but was significantly more common among diabetic patients than controls (three out of 40, p < 0.001). A positive reaction to cholesterol was found in 46 out of 64 diabetic patients, also uniformly distributed among the three groups (p = 0.773). It was significantly more common in diabetic patients than in controls (nine out of 40, p < 0.001). Reactions of the rectal mucosa histological specimens to glycogen and triglycerides were negative, both in diabetic patients and in controls. In conclusion, it appears that stool problems among our diabetic patients were not related to the positivity of PAS or to the positive cholesterol reaction in the rectal mucosa histological specimens. Since positive findings of both reactions were more common in specimens taken from diabetic patients than in controls, positive reactions might be related to metabolic disturbances in diabetic patients.

Another therapeutic schedule in eradication of Helicobacter pylori.

In this study, the efficacy and tolerability of two different therapeutic schedules in eradicating Helicobacter pylori and healing duodenal ulcer were evaluated. The study included 60 patients with duodenal ulcer and Helicobacter pylori infection. They were randomly allocated to either of two groups: group 1 (N = 30) received omeprazole 20 mg for 28 days, amoxicillin 3 x 500 mg for 7 days and metronidazole 3 x 500 mg for 5 days, and group 2 (N = 30) received omeprazole 20 mg for 28 days, ACA (amoxicillin 500 mg plus clavulanic acid 125 mg) 3 x 625 mg for 7 days and metronidazole 3 x 500 mg for 5 days. Endoscopic examination, bioptic urease test and histologic examination were performed before, and 30 and 90 days after the treatment. Endoscopic examination was also performed one month after the beginning of the treatment, when healing of duodenal ulcer was observed in 90% (27/30) of the group 1 patients and in 93.3% (28/30) of the group 2 patients. The Helicobacter pylori eradication achieved in group 1 and 2 was 76.7% (23/30) and 83.3% (25/30), respectively. Side effects were present in 20% (6/30) of the group 1 patients and in 23.3% (7/30) of the group 2 patients. Side effects were mild and did not require interruption of the treatment. A higher rate of eradication was achieved in group 2 than in group 1, but the difference was not statistically significant.

Infection with Helicobacter pylori and long-term use of non-steroidal antiinflammatory drugs.

The use of nonsteroidal anti inflammatory drugs (NSAID) is associated with an increased risk of peptic ulcer and of ulcer complications. However, the relation between Helicobacter pylori infection and gastroduodenal damage associated with NSAID use is unclear. This study investigated the prevalence of Helicobacter pylori infection in patients with arthritis (n = 85) taking NSAID, trying to find out whether the patients taking NSAID and infected with H. pylori were more likely to have dyspepsia, mucosal damage or chronic active gastritis than those without H. pylori infection. H. pylori was identified by biopsy, rapid urease test and histologic test. Dispeptic symptoms were assessed according to a standardized questionnaire. Gastroduodenal mucosal damage was graded endoscopically (using a modified Lanza scale) and the diagnosis of chronic gastritis was based on the histologic criteria of the Sydney system. The frequency of H. pylori infection was found to increase with age. No statistically significant difference was observed in the presence of damage to gastroduodenal mucosa between the patients with and without H. pylori infection. H. pylori infection was found to be associated with an increased frequency and severity of dyspeptic symptoms in patients with arthritis taking long-term NSAID. Chronic active gastritis was only present in patients with H. pylori infection. H. pylori infection was shown to be associated with an increased frequency and severity of dyspeptic symptoms in patients with arthritis on long-term NSAID therapy, without causing an increased damage to gastroduodenal mucosa.

Omeprazole, azithromycin and amoxicillin or amoxicillin plus clavulanic acid in eradication of Helicobacter pylori in duodenal ulcer disease.

Treatment with omeprazole (OME), azithromycin (AZI) and amoxicillin (AMO) resulted in encouraging Helicobacter pylori cure rates in pilot and control studies. The aim of this study was to establish whether OME + AZI in combination with either AMO or ACA (amoxicillin plus clavulanic acid) are effective in curing H. pylori infection. A hundred patients with active duodenal ulcer and H. pylori infection were treated with OME (day 1-10: 2 x 40 mg/day, day 11-24: 40 mg/day, day 25-42: 20 mg/day) plus AZI 500 mg/day for the first 6 days. Patients were randomly assigned to either AMO 2 x 1000 mg/day (group A, n = 50) or ACA 2 x 1250 mg/day (group B, n = 50) during the first 10 days of treatment. H. pylori status was determined by urease test and histology before and 6 weeks after completion of therapy. Ninety-five patients completed the study. H. pylori infection was eradicated in 85.4% (41/48) patients from group A (intention-to-treat (ITT) analysis: 82%) versus 91.5% (43/47) patients from group B (ITT) analysis: 86%) (NS). All ulcer had healed after 42 days of omeprazole treatment. Side effects, usually minor, were recorded in 12.5% (group A) and 14.9% (group B) of patients (NS). Therapy had to be discontinued in two patients (one in group A and one group B) only. Ten-days treatment with OME and AZI (for the first 6 days) with AMO or ACA are simple and highly effective regimens to cure H. pylori infection in patients with duodenal ulcer disease.

[Granular cell tumor]. / Tumor granularis.

Eighteen granular cell tumors (GTC) were detected from January 1976 until September 1988. GTC is found in 0.03% of all the biopsy specimens. Women have been found to be affected more frequently. The most common anatomic sites where it appears are the skin and subcutaneous tissue of the trunk and the vulva. Tumors ranged in sizes from 0.6 to 4 cm (average 1.5 cm). One patient had multiple lesions. The lesions show typical histologic features, usually with ill-defined edges. The preoperative diagnoses were never determined as GTC. Pseudoepitheliomatous hyperplasia of the overlying epithelium led to the wrong intraoperative diagnosis of squamous cell carcinoma in one lingual GTC. On gross inspection, one breast GTC was mistaken for invasive carcinoma with desmoplasia. One vulvar lesion was previously diagnosed as pseudo-decidual reaction. Malignant behaviour could not have been noticed, since it is of importance to pathologists and clinicians not to misinterpret this lesion as carcinoma.

[Civilian massacre near Podravska Slatina, 3 September 1991]. / Pokolj civila blizu Podravske Slatine 3. rujna 1991.

Twenty one civilians, 5 women and 16 men, were found dead in their doorways and yards after Serbian terrorists attacked the village of Cetekovac on 3 September 1991. The age of the decedents ranged from 18 to 91 years. The oldest victims were women (aged 63, 68, 72, 86 and 91). The wounds found on 19 decedents were characteristic of the long-range gunshot wounds, with projectiles fired mostly from the back or/and the side of the body. The autopsy of one decedent (J. B.) revealed that he died from two stabbing wounds and that those were the only wounds inflicted to the body. The body of the decedent (M. S.) was heavily carbonized so that the cause of the death or even whether he was alive when his body was set on fire could not be estimated.

[Omeprazole and azithromycin with and without metronidazole in the eradication of Helicobacter pylori in duodenal ulcer disease]. / Omeprazol i azitromicin s metronidazolom ili bez njega za eradikaciju Helicobactera pylori u duodenalnoj ulkusnoj bolesti.

This prospective, single blind, randomized study was designed to compare the efficacy and tolerance of two therapeutic schedules for eradication of H. pylori in patients with duodenal ulcer. Patients were randomized into two groups. Group 1 (n = 25) was treated with omeprazole 20 mg each morning for 28 days, azithromycin 500 mg/day for 5 days and metronidazole 3 x 500 mg/day for 5 days. Group 2 (n = 25) was treated with omeprazole 20 mg/day for 28 days and azithromycin 500 mg/day for 5 days. H. pylori status was determined by rapid urease test and histology before and 1, 6 and 12 months after the therapy. After 4 weeks of treatment ulcers healed in 96% (24/25) of patients in the first group and in 92% (23/25) of patients in the second group. One and 12 months after the treatment, eradication of Helicobacter pylori was achieved in 72% (18/25) of patients in the first group and in 64% (16/25) of patients in the second group. In 12 months after the treatment ulcer recurred in 43.7% (7/16) of patients in whom H. pylori was not eradicated and in 2.9% (1/34) of patients with eradicated H. pylori. The side effects were minor and/or transitory and did not require discontinuation of the treatment.

The occurrence of Rosenthal fibres in the brain tissue around meningioma.

A case of endotheliomatous type of meningioma arising from the falx and dura of the left anterior cranial fossa is reported. Numerous Rosenthal fibres were observed in the gliotic tissue around the meningioma. Authors present a brief data about the nature and occurrence of Rosenthal fibres. The occurrence of the pilocytic astrocytes and Rosenthal fibres in the gliotic tissue around slow-growing falx meningioma is an additional evidence for a peculiar type of changes in astrocytes of the long-standing gliosis of piloid type.

A misdiagnosed case of neurinoma of the 8th cranial nerve and adult respiratory distress syndrome.

A case of a 81-year old female patient with a clinically non-verified neurinoma of the 8th cranial nerve is presented. According to symptoms and radiological examinations, esophageal neoplasm with esophago-tracheal fistula was suspected. The patient died on the 4th day after radiological examination due to progressive respiratory failure. Autopsy revealed neurinoma of the 8th cranial nerve as well as adult respiratory distress syndrome due to aspiration of the radiological contrast medium.

A model of the gastric gland ejection cycle: low ejection fractions require reduction of the glandular dead space.

This paper was inspired by the reported results of authors from Uppsala and Lund that gastric glands in rats rhythmically contract 3-7 cycles per minute and develop luminal pressures more than 10 mmHg. To ensure that pepsinogen is not retained in the acid-rich section of the gland, ejection fractions would need to be more than 50% of the gland volume. We have tried to calculate the ejection fraction of such contractions. Dimensions of human gastric glands were measured on the fresh frozen samples of macroscopically and histologically normal gastric mucosa. In total, 18 specimens (from nine persons) were measured under the microscope. The density of glands was 135 +/- 11 (mean +/- S.D.) glands per mm( 2) of gastric mucosa. A typical gastric gland is a tubular structure 1.2 +/- 0.22 mm long and 0.03-0.05 mm wide. We have used 1 mm for length and 0.03 mm for the gland diameter to calculate that each gland approximates a volume of 707 pl, suggesting that the total glandular volume for 15 million glands reaches 10.6 ml. Further calculations based on one to five contractions per minute on an average and on the total volume of gastric glands of 10 ml showed that only ejection fractions less than 10% deliver daily volumes less than 3 l. The presented model of the gastric gland activity is based on the idea that the low ejection fractions require a reduction of the glandular dead space. The reduced luminal pressure during the gland relaxation might cause backflux of hydrophobic viscoelastic mucus through the gland aperture. Repeated glandular contractions and relaxations would move the mucus all the way to the gland bottom, filling the gland cavity below the neck with an axial semisolid mucous cylinder. This filling would reduce the gland dead space. During contractions, the gland would eject mainly the peripheral, the more liquid part of its content. The decreasing luminal pressure in the relaxing gland would pull the outlet mucus inside, protecting gland apertures from the gastric juice.

Management of missile wounds of the cerebral dura mater: experience with 69 cases.

Over the period of seven months: from July 1991 to January 1992 sixty-nine patients with penetrating head war-injuries, were admitted in our hospital. Missile wounds of the dura mater require in most cases urgent operative management: watertight closure of the dura defects. However, a dilemma still exists as to the best material to be used to restore the missile dural defects. There are several possibilities: an autologous substitute as periosteum (pericranium) from surrounding, fascia of the temporalis muscle, fascia lata, or allograft transplant as lyophilised cerebral dura mater (lyodura). In the group of 69 patients, 7 were treated conservatively, 13 were treated surgically, but without closing the dural wounds because of their critical condition, and in 45 surgically treated patients the dural defects were covered with 53 transplants: with periosteum in 22 patients but 24 coverings, with fascia of temporalis muscle in 2 patients, with lyodura in 6 patients, with fascia lata in 15 patients but 21 coverings. In 4 patients the dura wounds were sutured by interrupted sutures. The best results were obtained in the fascia lata group.

View of a war from a pathology department: Croatian experience.

This report presents an analysis of autopsy records from the Department of Pathology and Forensic Medicine, Osijek General Hospital, in the period from 2 May 1991, when 12 Croatian policemen were killed in an ambush in Borovo Selo and the war against Croatia unofficially began, until 15 January 1992, when the last cease-fire agreement between Croatia and Serbia, sponsored by the United Nations, became effective. During that time, 651 war-related autopsies were performed, constituting 42 per cent of all the deaths recorded in eastern Slavonia for that period. This number presents an 11-fold increase in the number of violent deaths in comparison to the same period of the pre-war year 1989 to 90. Forty-four per cent of all deaths were civilian ones. Explosive wounds were the most frequent cause of death: they accounted for 60 per cent of the civilian and 49 per cent of all the deaths. This fact and the extensive destruction of the cities in eastern Slavonia, including their hospitals, indicate that a principal characteristic of this and many modern wars is sudden and unexpected ground and air attacks on civilian targets.