Assessment of heavy metal pollutants accumulation in the Tisza river sediments.

In this study we have worked on the evaluation of heavy metal contamination in the sediments taken from the Tisza River and its tributaries, and thereby used the sequential extraction method, geochemical normalization, the calculation of the enrichment factor (EF), and the methods of statistical analysis. The chemical fractionation of Ni, Cu, Zn, Cr, Pb, Fe, and Mn, carried out by using the modified Tessier method, points to different substrates and binding mechanisms of Cu, Zn and Pb in sediments of the tributaries and sediments of the Tisza River. The similarities in the distributions of Fe and Ni in all types of sediments are the result of geochemical similarity as well as of the fact that natural sources mainly affect the concentration levels of these elements. The calculated enrichment factors (EF, measured metal vs. background concentrations) indicated that metal contamination (Cu, Pb, Zn and Cr) was recorded in the sediments of the Tisza River, while no indications of pollution were detected in the tributaries of the Tisza River and the surrounding pools. The maximum values of the EF were close to 6 for Cu and Pb (moderately severe enrichment) and close to 4.5 for Zn (indicating moderate enrichment). It can be said that the Tisza River is slightly to moderately severely polluted with Cu, Zn, and Pb, and minorly polluted with Cr. It is concluded that sediments of the Tisza serve as a repository for heavy metal accumulation from adjacent urban and industrial areas.

Diuretic effects of furosemide infusion versus bolus injection in congestive heart failure.

In a randomized, single-blind, crossover clinical trial, the diuretic efficacy of the same total dose of furosemide (2 x 40 mg) administered in either conventional intravenous bolus injection or continuous infusion was studied in 20 patients (nine males and 11 females), aged 37-75 years, with congestive heart failure. Furosemide infusion, administered first, produced a significantly greater diuresis than the bolus when compared with baseline (86%: 29.6%; p = 0.029). This was followed by a similar increase in 24-h urinary sodium, potassium and chloride excretion, with no significant difference from the bolus effect. The following day, diuretic and saluretic effects of furosemide did not differ significantly between the study groups. Nevertheless, when continuous furosemide infusion was administered first, it produced a greater increase in urinary volume, 24-h urinary sodium, potassium and chloride than when bolus injection was applied the next day. Conversely, when furosemide bolus was administered first, followed by the infusions the next day, the effects were almost equal, regardless of the mode of administration. It is concluded that in the treatment of refractory edema in patients with congestive heart failure, continuous intravenous infusion of furosemide is superior to the conventional intermittent bolus injection, especially if it is administered at the very beginning of the hospital treatment, and presumably is even better with higher dosage and longer infusion time span.

Role of digoxin in right ventricular failure due to chronic cor pulmonale.

The effect of digoxin in the treatment of decompensated chronic cor pulmonale was investigated in a randomized double-blind, cross-over, placebo-controlled trial. A total of 34 successive patients with evident right heart failure were included in the study. The mean maintenance daily dose of digoxin was 0.30 +/- 0.03 mg with the mean serum level of 1.7 +/- 0.7 nmol/L. The severity of heart failure was assessed according to a clinicoradiographic scoring system (Heart Failure Score). The heart failure worsened during the placebo-period in eight (23.5%) patients (four with atrial fibrillation, two with a third heart sound (S3), one with a cardiothoracic ratio of more than 0.5 and one with sinus rhythm). By regression analysis, the heart failure significantly worsened only in the subgroup of patients with atrial fibrillation. Digoxin was successfully (without worsening of the heart failure) discontinued in 26 (76.5%) patients. No significant improvement was observed in the patients with S3 gallop. It was concluded that digoxin had no beneficial effect in chronic cor pulmonale patients with heart failure, except in those with atrial fibrillation.

Comparison of chlorthalidone, propranolol and bopindolol in six-month treatment of arterial hypertension.

The aim of this study was to test the hypothesis that prolonged treatment of mild to moderate hypertension with low-dose thiazide diuretics or beta blockers does not induce any of the major untoward biochemical changes, such as hypertriglyceridemia, hypercholesterolemia, hyperuricemia and electrolyte imbalances. The effect of these drugs was analyzed in 100 outpatients (52 males and 48 females) aged 52.0 +/- 7.9 years with mild to moderate hypertension, in a prospective 6-month study. After an appropriate workup, the patients were randomized to either 25 mg chlorthalidone (40 patients), 120 mg propranolol (30 patients), or 2 mg per day bopindolol (30 patients). A significant reduction of approximately 10% in systolic and diastolic blood pressure was recorded in all the groups. At the end of the 6th month, in the chlorthalidone group triglycerides increased to 3.0 +/- 2.1 mmol/l from 2.8 +/- 1.6 mmol/l, while cholesterol after an initial increase to 6.6 +/- 1.6 from 6.4 +/- 1.6 mmol/l returned to the baseline level. Uricemia and serum potassium concentration decreased by 4%. The body weight was reduced to 83.8 +/- 13.4 kg from 86.1 +/- 13.4 kg. There was no change in serum glucose level. In the propranolol group, as expected, heart rate decreased by 20%, but there were no significant changes in glucose and potassium plasma concentration. Triglycerides did not change significantly, while cholesterol, after a small increase, returned to the initial levels. Similar results were obtained in the bopindolol group, apart from the triglycerides, which increased significantly (to 2.5 +/- 1.1 from 2.2 +/- 0.4 mmol/l), probably because of the lower baseline concentration. We conclude that in prolonged treatment, chlorthalidone, propranolol and bopindolol do not induce significant untoward biochemical changes that alone might increase cardiovascular risk.

[The electrocardiographic image of acute myocardial infarct in a patient with severe hyperkalemia]. / Elektrokardiografska slika akutnog infarkta miokarda u bolesnika s ekstremnom hiperkalijemijom.

We report herein an insulin dependent diabetic with chronic renal insufficiency on hemodialysis who developed cardiogenic shock, severe metabolic acidosis with kalemia of 9 mmol/L during alimentary intoxication and who presented with an ECG resembling an acute myocardial infarction. Possible pathophysiologic factors in the development of such electrocardiographic patterns have been outlined. It is concluded that in far advanced hyperkalemia an abnormal QRS complex, elevated ST segment and no visible P waves should primarily suggest changes caused by hyperkalemia rather than myocardial infarction.

[Diagnostic characteristics of myxoma of the left atrium]. / Dijagnosticke osobitosti miksoma lijevog atrija.

Three middle-aged patients (38, 40 and 41 years old; two women and one man) with left atrial myxoma diagnosed by echocardiography and successfully operated on are presented. Two patients had tumor embolus as the dominant presenting symptom. The time span between the first symptoms and the echocardiographic diagnosis was 6 months, 12 months, and 12 days, respectively. From that moment to surgery the average lag was 6.3 days only, including the complex transportation to distant surgical centres. All the patients are now alive, all with normal findings more than 2 years after the operation.

[Changes in left ventricular function and structure in hypertensive patients treated with methyldopa and urapidil]. / Promjene funkcije i strukture lijeve klijetke u hipertonicara lijecenih metildopom i urapidilom.

In a randomized cross-over and double-blind trial twenty mild-to-moderate hypertensives (11 males, 9 females, mean age 48.4 +/- 7.6 years) were receiving methyldopa (250 mg b.i.d.) or urapidil (30 mg b.i.d.) for 7 weeks and then treated with alternative drug for additional 7 weeks, separated by one week of wash-out period. Both antihypertensives induced significant reduction (P less than 0.01) in systolic and diastolic arterial pressure, while no significant changes (P greater than 0.20) in the body weight and the heart rate were observed. The echocardiographic features of left ventricular hypertrophy (LVH) did not decrease significantly (P greater than 0.05) on either drug, except for the left ventricular posterior wall thickness (LVPWd), which decreased on methyldopa from 10.4 +/- 1.3 to 9.8 +/- 1.4 mm (P less than 0.05). The drugs under study did not change significantly the echocardiographic indices of left ventricular function. Echocardiography resulted to be more sensitive in detecting LVH than electrocardiography. It is concluded that methyldopa might successfully reduce LVH, while direct and indirect vasodilators (such as urapidil) are less effective.

[Orthostatic hypotension. Case report of the Bradbury-Eggleston syndrome]. / Ortostatska hipotenzija. Prikaz slucaja Bradbury-Egglestonova sindroma.

A case of a 71-year-old woman with idiopathic orthostatic hypotension is presented. Several diagnostic procedures which can detect sympathetic pathway lesion are reported. The value of blood pressure measurement and heart rate response to the supine and standing position deep breath, Valsalva maneuver and cold pressor test in differential diagnosis are emphasized. The venoconstriction, venous reflexes and tyramine tests are described, as well. The authors favour an individual therapeutic approach with no limitation of mineralocorticoid dosage. Nonpharmacological measures, such as an increased salt intake, elastic support stockings and swimming are highly recommended.

[Characteristics of patients with acute myocardial infarction treated in Split 1982-1992]. / Neke osobitosti bolesnika s akutnim infarktom miokarda lijecenih u Splitu od 1982. do 1992. godine.

Three thousand three hundred and fifty-two patients (70% males and 28% females) were hospitalized and treated in Split for acute myocardial infarction (hospital mortality 20%) between 1982-1992. The number of these admissions has been constantly rising from 226 in 1982 to 397 in 1992. Over 45 years of age were 3043 (90.8%) of the patients (70% males and 30% females), while 309 of them (9.2%) were under 45 (93% males, 7% females). The lethality rate was 21% in the first and 8% in the second subgroup. In patients over 45 inferior myocardial infarction was found in 35%, and in patients under 45 in 49%. In the older group there were 40% smokers, 42% hypertensives and 39% hypercholesterolemics, while there were 75% smokers, 35% hypertensives and 33% hypercholesterolemic patients in the younger age group. The results show that the number of patients treated for acute myocardial infarction in the Split region is constantly increasing (p < 0.001). In patients under 45 years of age there is significantly higher inferior infarction prevalence (p < 0.001); a larger percentage of males (p < 0.001) and smokers (p < 0.001), and lower percentage of hypertensives (p < 0.001) and hypercholesterolemic patients (p < 0.05) was observed, as well as lower hospital mortality rate (p < 0.001).

[Significance of right ventricular dimensions in the differential diagnosis of primary and secondary dilated cardiomyopathy]. / Znacenje promjera desne klijetke u differencijalnoj dijagnostici primarnih i sekundarnih dilatacijskih kardiomioptija.

Numerous analyses are used in the differential diagnosis between primary and secondary dilated cardiomyopathy (PDC, SDC). The aim of this study was to assess the dimensions of heart cavities in patients with dilated cardiomyopathy (DC) by 1-D and 2-D echocardiography. Thirty-six consecutive patients who satisfied the PDC criteria, and 103 patients with criteria of SDC, were followed-up clinically, radiographically, electrocardiographically and by 1-D and 2-D echocardiography, in the period from December 1991 to April 1994, at the Department of Internal Medicine of the Clinical Hospital Split. The patients with PDC were significantly younger than those with SDC (44.4 +/- 10.4: 64.4 +/- 8.4 year). There were significantly more males than females in both DC subgroups. NYHA classification, sinus rhythm and atrial fibrillation did not differ considerably in both DC subcategories. The etiologic factor was ischaemic DC in 85.4% (88/103), systemic arterial hypertension in 11.6% (12/103), and thyrotoxicosis in 2.9% (3/103) of patients with SDC. Alcoholic DC in one patient, peripartal DC in two female patients and viral myocarditis in six patients with PDC were suspected. In the total of 75% (27/36) patients with PDC, a clear etiological factor in case histories was not defined. Left ventricular ejection fraction, diameter and myocardial thickness, as well as left atrium diameter, did not differ significantly in patients with PDC, at variance with SDC patients. Right ventricular enddiastolic diameter (31.55 +/- 4.8 mm: 26.62 +/- 8.6 mm, p < 0.05) and the ratio between enddiastolic diameters of the right and left ventricle were significantly larger in patients with PDC than in those with SDC (0.45 +/- 0.03: 0.37 +/- 0.05, p < 0.05). We conclude that right ventricle is significantly wider in PDC than in SDC patients. Compared with other noninvasive methods, 1-D and 2-D echocardiography is probably the method of choice (particularly in our environment) in the differentiation of primary and secondary DC.

[Comparison of auscultation findings using a classic stethoscope (Litmann 2120) and electronically amplified stethoscope (Medmax2)]. / Usporedba auskultacijskih nalaza stetoskopom s elektronskim pojacalom (Medmax2) prema klascnom (Litmann 2120).

Heart auscultation has one of the key roles in beside diagnosis, especially in patients with cardiovascular diseases. Sometimes, because of the human cars' low sensitivity, a problem emerges in the proper evaluation of heart sounds and murmurs of lower frequencies. Our study compared two stethoscopes, the classic acoustic stethoscope (Littmann 2120) and an electronic one with the sound amplifier and the noise filtering system (Medmax2) in 10 patients examined by 10 physicians. Significantly better detection of low frequency sounds was found in favour of electronic stethoscope (chi 2 = 17.9; p < 0.0001). It is concluded that the selective amplificator improves the stethoscope performance and has its place in everyday bedside practice, especially in departments of cardiology.

[Occurrence of thromboembolic complications in patients with dilated cardiomyopathy. Retrospective-prospective study]. / Ucestalost tromboembolijskih komplikacija u bolesnika s dilatacijskom kardiomiopatijom. Retrospektivno-prospektivna studija.

The purpose of the present study was to determine the prevalence of thromboembolic events in patients with primary and secondary (ischemic) dilated cardiomyopathy (DC), with regard to basic rhythm, sinus or atrial fibrillation. Retrospectively, over three years, from January 1, 1989 to December 31, 1991, the case histories of 75 inpatients with DC, mean age 56.2 +/- 14.1 years, 41 in sinus rhythm and 34 in atrial fibrillation from Clinic Hospital Split were analyzed and compared to those of 75 controls (heart failure with no DC). The incidence of thrombi, embolisms and mortality in both subgroups was similar, while the prevalence of thromboembolic events was significantly higher in the analyzed than in the control group (decompensated patients with ischemic cardiomyopathy and without cardiomegaly) (9/75:1/75, p < 0.05). Prospectively, between 9 and 22 months, from December 1, 1991 to September 30, 1993 51 consecutive decompensated outpatients with DC, in NYHA class II and III, mean age 54.2 +/- 15 years, were followed-up. Bilirubin, lactic dehydrogenase, prothrombin time and activated partial thromboplastin time were determined. 1-D and 2-D transthoracic echocardiographic exam was performed and clinical status was assessed. There were 24 patients in sinus rhythm and 27 patients in atrial fibrillation. The prevalence of thromboembolic events, thrombi and mortality in both subgroups was similar. The laboratory findings, indicators of possible thrombogenesis or thrombolysis, did not show any significant difference in both subgroups. The incidence of thrombi in both parts of this study was low, amounted to only 9.5% (12/126) with no clear signs of thromboembolism (these patients were anticoagulated!). Altogether 12.6% (16/126) patients suffered thromboembolic events, 9 in retrospective and 7 in prospective part of the trial (more patients were anticoagulated in prospective then in retrospective study, 5 versus 19; p < 0.05). We conclude that thromboembolism in patients with decompensated DC are rare, but appear at significantly higher rate than in decompensated patients with ischemic cardiomyopathy and no cardiomegaly. The beneficial effects of anticoagulant therapy are to be expected in these patients regardless of the basal rhythm. This hypothesis must, however, be assessed in a prospective, multicentric trial.

[Comparison of single and double doses of hydrochlorothiazide in the treatment of arterial hypertension with special emphasis on changes in vascular reactivity]. / Usporedba jednokratne i dvokratne doze hidroklorotiazida u lijecenju arterijske hipertenzije s posebnim osvrtom na promjenu zilne reaktivnosti.

The hypotensive effects of 100 and 50 mg hydrochlorothiazide (HTZ) were evaluated in 30 mild-to-moderate hypertensives, divided into two groups, with diastolic pressure between 95 and 110 mmHg. In both groups, the average MAP reduction was 15% (P less than 0.05). There were no significant differences in antihypertensive effects between single (50 or 100 mg o.d.) and double (25 or 50 mg b.i.d.) doses of the same drug. Blood pressure control was better after two than after one month on each of the various dosing schedules. Side-effects were mild and well tolerated: observed was a significant increase in triglyceride level from 3.0 +/- 1.8 to 4.8 +/- 2.4 mmol/L under the treatment with 100 mg HTZ o.d. and a statistically significant decrease in potassium level from 4.4 +/- 0.3 mmol/L to 4.1 +/- 0.3 mmol/L after two months treatment with 50 mg HTZ o.d. Unexpectedly, these changes were not dose-related. The venous reflexes showed atenuated response to norepinephrine after HTZ treatment, while arterial inflow, venous capacity and venous outflow increased significantly (P less than 0.05). It is concluded that HTZ exhibits some direct vasodilator activity and that the pharmacokinetic features of this drug do not correlate with the pharmacodynamic ones. At least in the management of mild-to-moderate arterial hypertension single daily dosage is quite adequate.

[Association of platelet aggregation with the extent of myocardial infarction]. / Povezanost agregabilnosti trombocita s velicinom infarkta miokarda.

The aim of this study was to evaluate the association between the type of myocardial infarction (MI) and the circulating platelet aggregates [circulating aggregates of thrombocytes (CAT)]. The size of MI was assessed by the maximal values of creatine-kinase (CK). In 80 patients in the acute phase of MI the values of CAT and CK were manifold increased, mostly in 30 patients with anteroseptal MI (CAT 34.1 +/- 8.3%, CK: 920 +/- 340 IU), less markedly in 30 patients with inferior MI (CAT: 25 +/- 6.7%, CK: 739 +/- 263 IU) and in 20 patients with non-Q-wave MI (CAT: 20.7 +/- 1.9%, CK 518 +/- 224 IU). The differences between the groups were significant (p < 0.05). There was a significant linear correlation between CAT and CK in anteroseptal MI (r = 0.57, p < 0.01) and in inferior MI (r = 0.54, p < 0.01), but not in non-Q-wave MI (r = 0.15, p > 0.05). The results are concordant with the hypothesis that thrombotic event contributes more significantly to the pathogenesis of transmural acute myocardial infarction.

[Biochemical changes in hypertensive patients during a 1-year cross-over study of treatment with hydrochlorothiazide and propranolol]. / Biokemijske promjene u hipertonicara tijekom jednogodisnjeg krizanog lijecenja hidroklorotiazidom i propranololom.

A prospective, randomized, cross-over trial comparing the antihypertensive efficacy and biochemical changes during treatment with either hydrochlorothiazide (HTZ: 25 mg o.d.) or propranolol (PRO: 40 mg t.i.d.), included 55 mild to moderate hypertensives (diastolic blood pressures ranged from 90 to 110 mmHg), aged 25-65 years. Forty patients completed the study; during the first six months 20 of them (12 males and 8 females) were taking HTZ, and the remaining 20 (13 males and 7 females) PRO. After a one-week wash-out period, for the next six months the alternative drug was administered. Antihypertensive efficacy of both drugs was nearly equal: systolic and diastolic blood pressure significantly decreased already after the first month (approximately by 10%), and kept unchanged until the end of the study. The analyzed biochemical parameters, i.e. blood glucose, cholesterol, and triglycerides did not increase significantly, while serum potassium level remained almost unchanged during the trial. Furthermore, during PRO in group B, cholesterol significantly decreased (3rd month), as well as blood glucose during HTZ treatment (10th month). Only the uric acid level, although unsignificantly, increased in group A (from 326.2 to 365.3 +/- 125.2 on HTZ, and to 391.4 +/- 120.0 mumol/l on PRO). It is concluded that HTZ and PRO are comparably effective antihypertensives. During the long-term treatment in small doses these drugs do not induce significant biochemical disturbances.