Effect of methylprednisolone on small bowel, spleen and liver changes in a murine model of inflammatory bowel disease.

The aim of this study was to evaluate the influence of methylprednisolone (1 mg/kg, i.p.) on inflammatory lesions in the small bowel, liver (pericholangitis) and spleen (lymphofollicular proliferation), in a model of inflammatory bowel disease induced by 2.4-dinitrofluorobenzene in previously sensitized BALB-c mice. As a parameter of corticosteroid anti-inflammatory and immunosuppressive action, we simultaneously investigated its effects on mononuclear cell accumulation within the ileal lamina propria and submucosa during the observed time period (1-30 days). We noted a significant decrease in accumulation of mononuclear cells within the lamina propria (P < 0.001). An effect on mononuclear cell infiltration within the ileal submucosa was also noted but was not statistically significant. In addition, pericholangitis in the liver and lymphofollicular proliferation in the spleen were not observed in the experimental group during treatment with methylprednisolone. The results of this study indicate that the previously described model of intestinal inflammation could be used in further research of present and new therapeutic modalities for inflammatory bowel disease.

The effect of eradicating Helicobacter pylori infection on the course of adenomatous and hyperplastic gastric polyps.

OBJECTIVE: Histopathological and clinical data strongly suggest that Helicobacter pylori is the cause of chronic gastritis and peptic ulceration. However, little has been written about the potential causal relation of H. pylori infection to hyperplastic and adenomatous gastric polyps. We therefore carried out a prospective study to determine the effect of eradicating H. pylori infection on the course of hyperplastic and adenomatous gastric polyps. METHODS: From November 1996 to December 1997, 6700 patients who had undergone upper gastrointestinal endoscopy at the two centres in Zagreb, Croatia, were candidates for participation in the study. Hyperplastic and adenomatous polyps were diagnosed on a basis of at least three histological samples taken from the polyp. In seven patients endoscopy had to be repeated because forceps biopsy sampling either provided inadequate tissue for correct histological diagnosis, or accurate characterization of gastric polyp histology was not possible. Upon completion of all endoscopic examinations before and after treatment, biopsy samples were taken from the antrum (two) and the body of the stomach (two) so that gastritis could be graded and classified, and the presence of H. pylori sought by histology. Two other samples were taken from the antrum for a rapid urease test. Follow-up examinations were performed by using endoscopy. Control endoscopy was performed at least 4 weeks after the treatment of H. pylori infection had been completed, and then every 3-4 months. The follow-up ranged from 4 to 17 months, with a median of 14 months. The treatment of H. pylori infection consisted of a 1-week course of either omeprazole (20 mg twice daily) or pantoprazole 40 mg twice daily), and a 1-week course of amoxicillin 2g twice daily) and metronidazole (400 mg three times daily), and clarithromycin (500 mg twice daily). Eradication of H. pylori infection was assessed by repeated histology and rapid urease test. RESULTS: Twenty-one patients (nine women, 12 men; median age 52 years) with histologically proven hyperplastic gastric polyps, and seven patients (two women, five men; median age, 67 years) with adenomatous gastric polyps were included in the study. Among 21 patients with hyperplastic gastric polyps, 16 patients (76%) were positive for H. pylori infection. Only two patients (29%) with adenomatous gastric polyps were positive for the infection. Complete eradication of H. pylori was initially achieved in all patients positive for H. pylori. Total regression of the gastric polyps was observed only among the patients with hyperplastic gastric polyps in whom H. pylori had been eradicated. Complete regression of the hyperplastic gastric polyps was observed in seven of the 16 evaluable patients (44%; 95% CI, 19-68%) after H. pylori eradication. The endoscopic snare polypectomy was carried out in nine patients with hyperplastic polyps and two patients with adenomatous gastric polyps in whom regression of the polyps was not observed after H. pylori eradication, as well as in five patients with hyperplastic and four with adenomatous gastric polyps who were negative for H. pylori. Exploratory laparotomy and gastrotomy with polyps excision were carried out in one patient with multiple adenomatous gastric polyps. In only one patient who was not positive for H. pylori recurrence of hyperplastic gastric polyp was recorded during follow-up, and no re-infection with H. pylori has been detected. CONCLUSIONS: Our results suggest that the development of hyperplastic gastric polyps may be directly related to chronic active gastritis and concomitant H. pylori infection. Cure of H. pylori infection associated with hyperplastic gastric polyps resulted in complete polyp regression in more than 40% of patients. Therefore, for patients with hyperplastic gastric polyps and concurrent H. pylori infection an antibiotic treatment designed to eradicate H. pylori appears to be recommended before further therapeutic options are consi

The value of ascitic fluid polymorphonuclear cell count determination during therapy of spontaneous bacterial peritonitis in patients with liver cirrhosis.

BACKGROUND/AIMS: Spontaneous bacterial peritonitis is one of the most common complications attending the onset of ascites in patients with liver cirrhosis. The aim of this study was to demonstrate whether it is possible, on the basis of ascitic fluid polymorphonuclear cell count in patients with liver cirrhosis and spontaneous bacterial peritonitis, to determine the optimal duration of cefotaxime therapy, as the most frequently applied empirical therapy, and possibly anticipate the disease recurrence. METHODOLOGY: In 16 patients with alcoholic liver cirrhosis and confirmed diagnosis of spontaneous bacterial peritonitis, cefotaxime therapy was administered 2g t.i.d. during 5 days. Before the therapy, at 48 hours, 5 days and 15-20 days after the cefotaxime therapy was started, in all patients with spontaneous bacterial peritonitis diagnostic abdominal paracentesis was performed, each time determining the ascitic fluid polymorphonuclear cell count together with microbiological analysis. RESULTS: In the course of the "primary" spontaneous bacterial peritonitis attack, 3 patients died (18.8%). In 4 patients the recurrence of spontaneous bacterial peritonitis was observed within 15-20 days after therapy was discontinued. Two patients died during the therapy of spontaneous bacterial peritonitis recurrence. After 48 hours of therapy, 11 patients with the "primary" spontaneous bacterial peritonitis attack were without any symptoms (68.8%). Out of these 11, 10 patients (62.5%) had the ascitic fluid polymorphonuclear cell count lower than 250/mm3. After 5 days of therapy, 12 patients (75%) were free of symptoms, and the number of ascitic fluid polymorphonuclear cell count < 250/mm3 was still found in 10 (62.5%) patients. No association between the presence of symptoms 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis was established. A significant association was found between the ascitic fluid polymorphonuclear cell count determined 48 hours after the therapy and the recurrence of spontaneous bacterial peritonitis. A recurrence occurred in only 1 patient with the number of ascitic fluid polymorphonuclear cell count < 250/mm3, 48 hours after the therapy was started. A recurrence of spontaneous bacterial peritonitis occurred in all the patients who had an ascitic fluid PMN cell count > or = 250/mm3, 48 hours after the therapy was started. CONCLUSIONS: By monitoring the ascitic fluid PMN cell count it seems to be possible to determine the efficacy and optimal duration of cefotaxime therapy in patients with spontaneous bacterial peritonitis when it is of most importance that the number of ascitic fluid PMN cell count should decrease below 250/mm3 during the therapy.

Doppler evaluation of prosthetic mitral valves.

For the evaluation of patients with prosthetic heart valves Doppler echocardiography is superior over other noninvasive techniques because it allows quantitative assessment of valve function. As a noninvasive method Doppler is safe, easily repeatable and provides haemodynamic data that closely correlate with parameters obtained by invasive procedures (Sagar et al., 1986: Simpson et al., 1986; Wilkins et al., 1986; Gibbs, 1987). The purpose of our study was to evaluate Doppler characteristics of mechanical and tissue mitral prostheses; Starr-Edwards, Björk-Shiley, Hall-Medtronic and Hancock in patients with clinically normal valve function.

Incidence and hospital mortality of acute coronary artery disease among civilians in Zagreb during air-raid alarms.

During the period of air-raid alarms in Zagreb (September 1991), the influence of war-induced stress on the incidence and mortality of acute coronary artery disease was investigated. Control periods were September 1989 and September 1990. Among 2903 patients admitted to Emergency Care Units, 369 (13%) were examined for suspect acute coronary artery disease. During the same periods in 1989 and 1990, 10% and 11% of acute coronary artery disease patients were recorded, respectively. The percentage of patients with myocardial infarction or unstable angina, admitted to Coronary Care Units during September 1989, 1990 and 1991, was 49%, 50% and 55%, respectively. The number of Q myocardial patients admitted during September 1991 was significantly higher than that recorded during the same period in 1990. The incidence and mortality patterns in acute coronary artery disease patients were also examined during August, September and October 1991. The peak incidence of acute coronary artery disease was found in the first half of September, while the peak mortality in these patients was found during the second half of September. During the second half of September of 1989, 1990 and 1991, the mortality in Q myocardial patients in Coronary Care Units, was 16.7%, 15.2% and 23.8%, respectively. Besides the war-induced stress, transportation of our patients to shelters or inner parts of the hospital caused additional stress, probably contributing to the development of refractory malignant arrhythmia or heart failure.

[The value of exercise tests in the diagnosis of ischemic heart disease]. / Vrijednost testova opterecenja u dijagnostici ishemicne bolesti srca.

New knowledges of contemporary cardiology have created possibilities for critically reevaluation of current criteria in exercise testing and have shown its new diagnostic and prognostic value. A multifactorial approach to exercise testing includes an analysis of ECG criteria and hemodynamic parameters obtained during exercise testing. This approach increases the value of stress testing in diagnosis, assessment of the severity and prognosis of coronary artery disease. The inclination toward arrhythmias, detection of asymptomatic ischemia and early detection of a dysfunction of the left ventricle have been emphasized. The indications for use and termination of exercise testing absolute and relative contraindications for exercise testing are critically discussed. The sensitivity of exercise testing is 60 to 80 percent and specificity level ranges between 85 to 90 percent. The incidence of serious complications is decreased about 50 percent by a careful screening of patients and appropriate safety level.

[Pathophysiologic mechanisms of cardiac decompensation]. / Patofizioloski mehanizmi srcane dekompenzacije.

Heart failure is a complex clinical syndrome in whose manifestations and prognosis compensatory mechanisms have a prominent role as a response of the organism to an elementary disturbance. There are five basic compensatory mechanisms: the Frank-Starling mechanism, structural changes of the heart, activation of neuroendocrine mechanism, adaptation to hypoxia and anaerobic metabolism. The interaction between the two main neurohumoral mechanisms, namely vasodilatation and vasoconstriction, has been drawing much of the attention recently. Vasoconstriction which evolved into maintaining cardiac output in hypovolemic state, leads to a number of deleterious hemodynamic and metabolic disturbances in heart failure. The organism tends to diminish this negative effects by changing beta adrenergic pathway and by activating vasodilative mechanisms. Once heart failure becomes severe, vasoconstriction predominates due to a loss of normal baroreceptor activity. It is considered that too marked activity of neurohumoral mechanisms is a significant cause of disease progression. By use of contemporary drugs (ACE inhibitors, beta blockers, digitalis), excessive vasoconstrictive mechanisms are tried to be diminished and prognosis of the disease improved.

[Echocardiography in the diagnosis and therapy of pulmonary embolism]. / Upotreba ehokardiografije u dijagnostici i terapiji plucne embolije.

A 58 year old woman was admitted to this hospital because of retrosternal pain followed by dyspnea which developed a few hours prior to admission, and two week history of progressive intolerance of physical effort. Echocardiography was done which revealed enlarged cavity of the right atrium (59 x 54 mm) and right ventricle (46 mm) of the heart. (Scintigraphy showed numerous triangular lung zones of sharply decreased or completely absent perfusion. After the diagnosis of recurrent pulmonary embolism, the patient was treated with intravenous heparin at a dosage of 25000 a day for 10 days. Dyspnea settled within 48 hours of starting heparin, analysis of arterial blood gases became normal and the general condition of the patient improved. A repeated echocardigram showed a significantly reduced dilatation of the right atrium from 59 x 45 mm to 47 x 43 mm and decreased pulmonary hypertension from 110 mmHg, on admission, to 65 mmHg.

[Clinical significance of the QRS-complex in the determination of myocardial infarct size]. / Klinicko znacenje QRS-kompleksa u odredivanju velicine infarkta miokarda.

In 60 patients myocardial infarction size was determined by electrocardiogram (ECG) using Selvester's QRS scoring system. These values were compared with the size of infarction as determined enzymatically using gram equivalent isoenzyme MB creatine kinase (gEq) and using maximum values of isoenzyme MB-CK. The results showed no statistically significant difference between the size of anterior and inferior infarction determined by gEq (25.19 +/- 13.59 vrs 22.48 +/- 14.04; p = 0.12 NS) and by maximum MB-CK (125.5 +/- 76.0 vrs 98.4 +/- 60.7; p = 0.12 NS). The size of myocardial infarctions determined by ECG was significantly larger anteriorly compared with the inferior infarcts (9.6 +/- 2.9 vrs 4.5 +/- 2.6; p = 0.001). In patients with anterior infarcts good correlations between the size of infarction determined by QRS scoring system and by gEq or maximum MB-CK were found (r = 0.69; p = 0.004 and r = 0.72; p = 0.001). In patients with inferior infarcts the correlations between QRS score and gEq or maximum MB-CK were poor (r = 0.37; p = 0.02 and r = 0.45; p = 0.15). The causes of weak correlations in the results of described methods in inferior infarcts are discussed. Thus QRS scoring system provides new noninvasive and simple possibilities in determining the size of anterior and in inferior infarctions of the left ventricle.

[The importance of the claudication test performed on a treadmill and its use in clinical practice]. / Vrijednost klaudikacijskog testa na pokretnom sagu i njegova primjena u klinickoj praksi.

A group of 55 patients with lower limb occlusive arterial disease was submitted to a treadmill walking exercise test in order to estimate the walking exercise length. The treadmill speed was fixed at 3 km/h and the carpet incline was 0% and 12% respectively. Doppler method for blood pressure estimation was applied in 10 patients to art. brachialis and art. dorsalis pedis bilaterally prior to and 2.5 and 10 minutes after the test. The ankle pressure index was calculated prior and post exercise. Results showed 51 +/- 9% difference between patients walking (3 km/h/0%) and patients climbing (3 km/h/12%). Ischaemic pain and blood pressure fall over art. dorsalis pedis during exercise correlated significantly 2 and 5 minutes after the test. Arteria dorsalis pedis pressure at rest and 2 and 5 minutes post exercise was statistically significant. Blood pressure indices prior and post exercise were related in the same manner. There was no difference in art. dorsalis pedis pressure and ankle pressure indices in our control group. The walking treadmill exercise test showed to be a simple reliable method for estimation of the functional degree of lower limb arterial insufficiency and for assessment of their surgical or drug therapy.

[Infarct of the right half of the heart]. / Infarkt desne polovice srca.

Isolated right ventricular infarction is not rare, as it is generally believed. As a rule, right ventricular infarction occurs in association with left ventricular infarction. Diagnosis of right ventricular infarction can not be made clinically alone. It should be confirmed on the basis of the following diagnostic procedures: the transient ST-segment elevation derived from the electrocardiogram, formation of QS-complex in V4 right, hemodynamic monitoring, echocardiography and radionuclide ventriculography. Of all the diagnostic criteria the best sensitivity and specificity is achieved by a rise in right ventricular filling pressure, respectively, the ratio of the right to left ventricular filling pressure should be equal or higher than 0.65. Increasing importance is being attached to the diagnosis of right ventricular infarction, since the treatment of patients with predominant right ventricular insufficiency and low cardiac output differs considerably from that of left ventricular insufficiency. Comparing our experience with previous reports, it may be concluded that adequate fluid administration with positive inotropic drugs, particularly adrenergic substances, if required, is essential in the medical treatment of right ventricular infarction. Vasodilator therapy may be administered, too. If frequent bradyarrhythmias do not respond to usual treatment, atrial pacing or atrioventricular sequential pacing should be initiated.

Hemodynamically unstable pericardial effusion in the Intensive Cardiac Unit: prospective study.

The authors have conducted a prospective investigation on 15 patients with hemodynamically unstable pericardial effusion (main criteria: echocardiographic signs of various degrees of right ventricular diastolic collapse and clinical instability) hospitalized in the Intensive Cardiac Unit (1.97% of all patients) for one year and have compared the results with literature data. The causes of pericardial effusion were neoplasms, infections, rupture of heart of aorta and hypothyroidism. Investigation revealed the most frequent findings: symptoms (dyspnea, retrosternal pain, loading intolerance, nonproductive cough), clinical signs (soft heart sounds, changes in pulmonal findings, fever, jugular venous distention, tachycardia, arterial hypotension and hepatomegaly), laboratory changes (elevated erythrocyte sedimentation rate, leukocytosis), ECG changes (ST-T abnormality, microvoltage, tachycardia) and chest X-rays changes (enlarged cardiac silhouette, pleural effusion). Echocardiography found an average width of pericardial effusion of 2.5 cm (+/- 1.2), frequently thickened pericardium and changes in heart motions. The most used drugs in therapy were indomethacin, antibiotics, analgesics and corticosteroids. In three patients pericardiocentesis, and in two pericardiectomy were performed. Two patients died, 13 patients were discharged from the ICU with an improved health condition. Literature data on this condition are either lacking, or differ from the above findings.

Daily administration of furosemide in dilated cardiomyopathy--yes or no?

Seventeen patients with dilated cardiomyopathy (mean ejection fraction 22%) in the NYHA state III or IV were investigated. All patients fulfilled the criteria of an indication for administration of furosemide, since left ventricular filling pressure (LVFP, measured as pulmonary capillary pressure) was 20 or more mm Hg in all. This study investigates the effects of an acute (40 mg i.v.) administration of furosemide (observation period 0 to 90 minutes after administration). Conventional M-mode, 2-dimensional and Doppler-echocardiography was performed in all patients. Patients were divided into 2 groups according to the degree of (relative) mitral regurgitation (MR): group 1 with moderate to severe (n = 10) and group 2 with mild or no MR (n = 7), 90 minutes after administration of furosemide LVFP decreased by 76%. In group 1 this occurred together with a 23% rise of cardiac index and a fall of systemic vascular resistance of 21%. In group 2 cardiac index decreased by 22% with a rise of systemic vascular resistance of 14%. The chronic oral administration of furosemide over 4 weeks ameliorated the NYHA state of all patients by one grade. We conclude from our results that patients with advanced dilated cardiomyopathy profit only from acute administration of furosemide if a significant (relative) MR is present also. A low dose chronic oral administration of the drug, however, leads in any case to clinical amelioration.

Global and regional parameters of left ventricular performance in healthy subjects during rest and exercise assessed by radionuclide ventriculography.

The aim of our study was to analyze numerous global and regional parameters of left ventricular (LV) performance during rest and exercise, in the group of 14 healthy subjects, by quantitative gated equilibrium ventriculography in left anterior oblique view (45 degrees). The global LV parameters at rest vs. exercise in our study were: heart rate 68.9 +/- 18.4 vs. 137.5 +/- 38.6; systolic blood pressure (mmHg) 121.8 +/- 18.2 vs. 178.6 +/- 31.2; diastolic blood pressure (mmHg) 82.1 +/- 10.8 vs. 90.7 +/- 12.4; double product 8,368.6 +/- 2,308.8 vs. 24,589.3 +/- 8,357.8; global ejection fraction (%) 61.9 +/- 15.4 vs. 72.8 +/- 12.8, end-diastolic volume index (ml/m2) 82.5 +/- 23.2 vs. 96.9 +/- 27.8; end-systolic volume index (ml/m2) 31.8 +/- 19.8 vs. 26.9 +/- 15.4; stroke volume index (ml/m2) 50.6 +/- 17.6 vs. 70.0 +/- 22.6; peak emptying rate (EDV/s) 3.4 +/- 2.6 vs. 8.3 +/- 3.8 and peak filling rate (EDV/s) 3.6 +/- 2.6 vs. 9.6 +/- 3.8. A significant difference (p < 0.05) between rest and exercise was found for all parameters. The highest values of LV regional ejection fraction were found in anterolateral and posterolateral region, while the lowest values were observed in inferoseptal and inferior regions. During exercise a significant increase of regional ejection fraction was found in all regions. The highest percent of radius shortening during rest was in anterolateral and posterolateral regions, and lowest in inferoseptal and inferior regions. The same sequence was found during exercise, and the difference in percent of radius shortening, between rest and exercise was significant in all regions. The observed normal values of global and regional parameters of LV function during rest may serve as a contribution for referent values. Our results on regional ejection fraction and the percent of radius shortening in rest, and their change during exercise, offer the possibility of additional information in the investigation of cardiac patients by means of radionuclide ventriculography.

[The effect of war-induced stress in Croatia on the incidence and mortality of acute ischemic heart disease]. / Der Einfluss des kriegsbedingten Stresses in Kroatien auf die Häufigkeit und Mortalität der akuten ischämischen Herzkrankheit.

During war operations in Croatia and air alarms in Zagreb, a significantly higher incidence of patients with acute coronary artery disease was registered. Higher incidence of patients with acute myocardial infarction was present and the incidence of hospital mortality among patients with myocardial infarction was significantly higher than earlier. Significant difference was not found between various study periods neither for sex ratio, localization of myocardial infarction (anterior vs. inferior) nor in the ECG form of myocardial infarction (Q vs. Non-Q).

The value of the QRS scoring system in assessing regional and global left ventricular ejection fraction early after myocardial infarction.

In 71 patients with a myocardial infarction (MI) (anterior in 27, inferior in 44 patients) global (GEF) and regional (REF) left ventricular ejection fractions were determined by radionuclide ventriculography and estimated from a 12 lead electrocardiogram (ECG), using Selvester's QRS score, during the early phase of a MI (15 to 21 days following MI). Global ejection fractions determined by radionuclide ventriculography and from ECG using Palmeri's method were: for all MI 40.8 +/- 12.6% vs 39.6 +/- 11.4%; in the group of anterior MI 32.0 +/- 10.0% vs 30.0 +/- 9.7% and in the group of inferior MI 48.9 +/- 12.0% vs 45.1 +/- 8.2%. A good correlation was found between global ejection fractions determined by radionuclide ventriculography and ECG, as well as between radionuclide GEF and ECG score. A weaker correlation was found between radionuclide GEF and enzymes among all MIs and in the group of anterior MI, while in the group of inferior MI this correlation was insignificant. The analysis of REF determined by radionuclide ventriculography and ECG showed the greatest abnormalities in the infarct region, but in the group of anterior MI, dysfunction was present in the whole left ventricle. The comparison of infarct-related REF derived from radionuclide ventriculography, with the QRS score showed a significantly higher correlation than the comparison with enzymes. ECG estimation of REF from a modified Palmeri's equation showed a better correlation with radionuclide REF than did GEF derived from the standard Palmeri's equation: anterior MI; r = 0.90 vs r = 0.82, inferior MI; r = 0.84 vs r = 0.69, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Regression of ECG signs of myocardial infarction related to infarct size and left ventricular function.

Quantitative and qualitative analyses of Q waves and QRS scores were performed on 69 patients during the early phase of first myocardial infarction (MI) and 6 months subsequently. The regression of ECG signs of MI were compared with the enzymatically estimated size of MI, the location of MI, and with the changes of global ejection fraction (GEF) assessed by radionuclide ventriculography. Among 57 patients with Q wave MI a complete disappearance of ECG signs of MI was found in 9 (15.7%). Patients with MI of inferior location showed a significantly higher reduction of Q waves (p < 0.001) and QRS scores (p < 0.001) than the anterior MI group. In the group of 12 patients with non Q wave MI, 11 demonstrated complete regression of MI signs. Among all Q wave and non Q wave MIs, the authors found no significant difference in the size of MI between patients with and without complete regression of ECG signs of MI. The median of the percent of change of the QRS score was significantly higher (p = 0.04) in the group of patients with improved GEFs than in the group of patients with decreased or unchanged GEFs 6 months following acute MI. The sensitivity, specificity, and predictive values for improved left ventricular function according to the change of Q waves and ECG scores were 91%, 32%, and 62%; for changes of Q waves, 81%, 40%, and 63%; and for changes of ECG scores, 91%, 36%, and 64%, respectively. In the group of patients with non Q wave MI these values were 100%, 50%, and 91% as a result of ST-T disappearance.