The Impact of Phenotype of Inflammatory Bowel Diseases, Inflammation Activity and Therapy on Mucosal Mature Cd83+ Dendritic Cell

Background: Crohn's disease (CD) and ulcerative colitis (UC) are well-defined phenotypes of chronic inflammatory bowel diseases (IBDs). A mechanism of inflammation in these diseases is partially controlled by the intestinal dendritic cell (DC). In this study, we observed a mature CD83+ DC in colonic bioptic samples, and its correlation with disease phenotype and activity. Methods: The study included 219 subjects: 100 with UC, 44 with CD and 75 healthy subjects. Colonic biopsy specimens were incubated with the primary antibody Anti-CD83. Intraepithelial CD83+ DCs were counted per 100 enterocytes. The presence of CD83+ DC was analysed according to the type of IBD, histopathologic inflammation activity and treatment outcome. Results: The presence of mature CD83+ DCs (0, ≥1) differed according to disease types of IBD (p = 0.001), histologic inflammation activity (p = 0.049) and applied therapy (p = 0.001). The odds for CD83+ DC presence were 5.2 times higher in the CD group than in the control/UC group. The odds for CD83+ DC presence were 2.6 times higher in subjects without inflammation or chronic inflammation than with acute inflammation. They were also 3.7 times higher in subjects without therapy. The cut-off value 0.5 CD83+ DC (Rock analysis area = 0.699; SE 0.046; p < 0.001; 95% CI: 0.609-0.788) had been assessed as a differentiation marker between UC and CD. Conclusion: Presence of CD83+ DC could be used as a possible parameter in distinction between UC and CD, as well as a predictor of inflammation activity and treatment outcome.

Effectiveness of Helicobacter pylori Treatments According to Antibiotic Resistance

INTRODUCTION

Antibiotic resistance is one of the main factors that determine the efficacy of treatments to eradicate Helicobacter pylori infection. Our aim was to evaluate the effectiveness of first-line and rescue treatments against H. pylori in Europe according to antibiotics resistance.

METHODS

Prospective, multicenter, international registry on the management of H. pylori (European Registry on H. pylori Management). All infected and culture-diagnosed adult patients registered in the Spanish Association of Gastroenterology-Research Electronic Data Capture from 2013 to 2021 were included.

RESULTS

A total of 2,852 naive patients with culture results were analyzed. Resistance to clarithromycin, metronidazole, and quinolones was 22%, 27%, and 18%, respectively. The most effective treatment, regardless of resistance, were the 3-in-1 single capsule with bismuth, metronidazole, and tetracycline (91%) and the quadruple with bismuth, offering optimal cure rates even in the presence of bacterial resistance to clarithromycin or metronidazole. The concomitant regimen with tinidazole achieved an eradication rate of 99% (90/91) vs 84% (90/107) with metronidazole. Triple schedules, sequential, or concomitant regimen with metronidazole did not achieve optimal results. A total of 1,118 non-naive patients were analyzed. Resistance to clarithromycin, metronidazole, and quinolones was 49%, 41%, and 24%, respectively. The 3-in-1 single capsule (87%) and the triple therapy with levofloxacin (85%) were the only ones that provided encouraging results.

DISCUSSION

In regions where the antibiotic resistance rate of H. pylori is high, eradication treatment with the 3-in-1 single capsule, the quadruple with bismuth, and concomitant with tinidazole are the best options in naive patients. In non-naive patients, the 3-in-1 single capsule and the triple therapy with levofloxacin provided encouraging results.

A Case Report: Idiopathic or Drug-Induced Autoimmune Hepatitis-Can We Draw a Line?

Idiosyncratic drug-induced liver injury (DILI) is an unpredictable reaction of individuals exposed to a certain drug, and drug-induced autoimmune hepatitis (DIAIH) presents a DILI phenotype that mimics idiopathic autoimmune hepatitis (AIH) when considering the clinical, biochemical, serological and histological parameters. We present a case report of a 48-year-old male who was hospitalized due to severe hepatocellular liver injury two months after self-treatment with a muscle-building dietary supplement based on arginine-alpha-ketoglutarate, L-citrulline, L tyrosine, creatine malate and beet extract. His immunology panel was positive with increased IgG levels, and radiologic methods showed no signs of chronic liver disease. He underwent corticosteroid treatment with adequate response. After therapy withdrawal, a clinical relapse occurred. Seven months after the initial presentation, liver MR suggested initial cirrhotic changes in the right liver lobe. A liver biopsy revealed abundant lymphoplasmacytic infiltrate with piecemeal necrosis and grade 2 fibrosis. He responded well to the corticosteroid treatment again, and was further treated with low-dose prednisone without additional relapses. Several years later, further management confirmed the presence of liver cirrhosis with no histological or biochemical signs of disease activity. DIAIH is a DILI phenotype that is difficult to distinguish from idiopathic AIH despite a wide armamentarium of diagnostic methods. It should always be considered among the differential diagnoses in patients presenting with hepatocellular liver injury.

Comparison of the management of Helicobacter pylori infection between the older and younger European populations

The prevalence of Helicobacter pylori remains high in the older population. Specific age-related peculiarities may impact the outcomes of H. pylori treatment. The aim of the study was to evaluate the diagnostics and effectiveness of H. pylori eradication between the younger and older European populations. "European Registry on H. pylori Management (Hp-EuReg)" data from 2013 to 2022 were analyzed. Patients were divided into older (≥ 60 years) and younger (18-59 years) groups. Modified intention-to-treat (mITT) and per-protocol (PP) analysis was performed. 49,461 patients included of which 14,467 (29%) were older-aged. Concomitant medications and penicillin allergy were more frequent among the older patients. Differences between younger and older populations were observed in treatment duration in first-line treatment and in proton pump inhibitors (PPIs) doses in second-line treatment. The overall incidence of adverse events was lower in the older adults group. The overall first-line treatment mITT effectiveness was 88% in younger and 90% in the older patients (p < 0.05). The overall second-line mITT treatment effectiveness was 84% in both groups. The effectiveness of the most frequent first- and second-line triple therapies was suboptimal (< 90%) in both groups. Optimal efficacy (≥ 90%) was achieved by using bismuth and non-bismuth-based quadruple therapies. In conclusion, the approach to the diagnostics and treatment of H. pylori infection did not generally differ between younger and older patients. Main differences were reported in the concurrent medications, allergy to penicillin and adverse events both in first- and second-line treatment. Optimal effectiveness rates were mostly achieved by using bismuth and non-bismuth-based quadruple therapies. No clinically relevant differences in the effectiveness between the age groups were observed.

Molecular Characterization and Mutational Analysis of Clarithromycin- and Levofloxacin-Resistance Genes in Helicobacter pylori from Gastric Biopsies in Southern Croatia

Point mutations in the 23S rRNA, gyrA, and gyrB genes can confer resistance to clarithromycin (CAM) and levofloxacin (LVX) by altering target sites or protein structure, thereby reducing the efficacy of standard antibiotics in the treatment of Helicobacter pylori infections. Considering the confirmed primary CAM and LVX resistance in H. pylori infected patients from southern Croatia, we performed a molecular genetic analysis of three target genes (23S rRNA, gyrA, and gyrB) by PCR and sequencing, together with computational molecular docking analysis. In the CAM-resistant isolates, the mutation sites in the 23S rRNA gene were A2142C, A2142G, and A2143G. In addition, the mutations D91G and D91N in GyrA and N481E and R484K in GyrB were associated with resistance to LVX. Molecular docking analyses revealed that mutant H. pylori strains with resistance-related mutations exhibited a lower susceptibility to CAM and LVX compared with wild-type strains due to significant differences in non-covalent interactions (e.g., hydrogen bonds, ionic interactions) leading to destabilized antibiotic-protein binding, ultimately resulting in antibiotic resistance. Dual resistance to CAM and LVX was found, indicating the successful evolution of H. pylori resistance to unrelated antimicrobials and thus an increased risk to human health.

Helicobacter pylori Diagnostic Tests Used in Europe: Results of over 34,000 Patients from the European Registry on Helicobacter pylori Management

BACKGROUND AND AIMS

Several methods are available to diagnose Helicobacter pylori infection. Our objective was to evaluate the tests used for both the initial diagnosis and the confirmation of eradication after treatment in Europe.

METHODS

The European Registry on the management of Helicobacter pylori infection is an international, multicentre, prospective, non-interventional registry aiming to evaluate the management of Helicobacter pylori-infected patients in Europe. Countries with at least 100 cases registered from June 2013 to April 2021, and with a validated diagnostic method were analysed. Data were quality reviewed.

RESULTS

A total of 34,920 adult patients from 20 countries were included (mean age 51 years; 61% women). To establish the initial diagnosis, invasive tests were performed in 19,801 (71%) patients, non-invasive in 11,369 (41%), and both in 3437 (12%). The most frequent were histology (n = 11,885; 43%), a rapid urease test (n = 10,636; 38%) and an urea breath test (n = 7577; 27%). According to the age, invasive tests were indicated in 11,179 (77%) ≥50 years, and in 8603 (65%) <50 years. Depending on the country, the use of invasive tests ranged from 29-99% in <50 years to 60-99% in ≥50. Most of the tests used to confirm eradication were non-invasive (n = 32,540; 93%), with the urea breath test being the most frequent (n = 32,540; 78%). In 2983 (9%) post-treatment tests, histology (n = 1887; 5%) or a rapid urease test (n = 1223; 4%) were performed.

CONCLUSION

A great heterogeneity was observed for the initial diagnosis and confirmation of the eradication. The reasons for the apparent lack of adherence to the clinical guidelines should be further explored.

Helicobacter pylori Diagnostic Tests Used in Europe: Results of over 34,000 Patients from the European Registry on Helicobacter pylori Management

Background and aims: Several methods are available to diagnose Helicobacter pylori infection. Our objective was to evaluate the tests used for both the initial diagnosis and the confirmation of eradication after treatment in Europe. Methods: The European Registry on the management of Helicobacter pylori infection is an international, multicentre, prospective, non-interventional registry aiming to evaluate the management of Helicobacter pylori-infected patients in Europe. Countries with at least 100 cases registered from June 2013 to April 2021, and with a validated diagnostic method were analysed. Data were quality reviewed. Results: A total of 34,920 adult patients from 20 countries were included (mean age 51 years; 61% women). To establish the initial diagnosis, invasive tests were performed in 19,801 (71%) patients, non-invasive in 11,369 (41%), and both in 3437 (12%). The most frequent were histology (n = 11,885; 43%), a rapid urease test (n = 10,636; 38%) and an urea breath test (n = 7577; 27%). According to the age, invasive tests were indicated in 11,179 (77%) ≥50 years, and in 8603 (65%) <50 years. Depending on the country, the use of invasive tests ranged from 29–99% in <50 years to 60–99% in ≥50. Most of the tests used to confirm eradication were non-invasive (n = 32,540; 93%), with the urea breath test being the most frequent (n = 32,540; 78%). In 2983 (9%) post-treatment tests, histology (n = 1887; 5%) or a rapid urease test (n = 1223; 4%) were performed. Conclusion: A great heterogeneity was observed for the initial diagnosis and confirmation of the eradication. The reasons for the apparent lack of adherence to the clinical guidelines should be further explored.

Expression Pattern of DAB Adaptor Protein 2 in Left- and Right-Side Colorectal Carcinoma

Left-sided and right-sided colorectal cancer (L-CRC and R-CRC) have relatively different clinical pictures and pathophysiological backgrounds. The aim of this study was to investigate the presence of DAB adapter protein 2 (DAB2) as a potential molecular mechanism that contributes to this diversity in terms of malignancy and responses to therapy. The expression of the suppressor gene DAB2 in colon cancer has already been analyzed, but its significance has not been fully elucidated. Archived samples from 34 patients who underwent colon cancer surgery were included in this study, with 13 patients with low-grade CRC and 21 with high-grade CRC. Twenty of the tumors were R-CRC, while 14 were L-CRC. DAB2 expression was analyzed immunohistochemically in the tumor tissue and the colon resection margin was used as a control. Tumors were divided into L-CRC and R-CRC, with splenic flexure as the cutoff point for each side. The results showed that R-CRC had lower DAB2 protein expression compared to L-CRC (p = 0.01). High-grade tumors had reduced DAB2 expression compared to low-grade tumors (p = 0.02). These results are consistent with the analysis of DAB2 gene expression data that we exported from the TCGA Colon and Rectal Cancer Study (COADREAD). In 736 samples of colon cancer, lower DAB2 gene expression was found in R-CRC compared to L-CRC (p < 0.0001). DAB2 gene expression was significantly higher in the sigmoid colon than in the cecum and ascending colon (p < 0.01). The analysis confirmed a lower expression of the DAB2 in tumors with positive microsatellite instability (p < 0.001). In conclusion, DAB2 has a role in the biological differences between R-CRC and L-CRC and its therapeutic and diagnostic potential needs to be further examined.

Empirical rescue treatment of Helicobacter pylori infection in third and subsequent lines: 8-year experience in 2144 patients from the European Registry on H. pylori management (Hp-EuReg)

OBJECTIVE

To evaluate the use, effectiveness and safety of Helicobacter pylori empirical rescue therapy in third and subsequent treatment lines in Europe.

DESIGN

International, prospective, non-interventional registry of the clinical practice of European gastroenterologists. Data were collected and quality reviewed until October 2021 at Asociación Española de Gastroenterología-Research Electronic Data Capture. All cases with three or more empirical eradication attempts were assessed for effectiveness by modified intention-to-treat and per-protocol analysis.

RESULTS

Overall, 2144 treatments were included: 1519, 439, 145 and 41 cases from third, fourth, fifth and sixth treatment lines, respectively. Sixty different therapies were used; the 15 most frequently prescribed encompassed >90% of cases. Overall effectiveness remained <90% in all therapies. Optimised treatments achieved a higher eradication rate than non-optimised (78% vs 67%, p<0.0001). From 2017 to 2021, only 44% of treatments other than 10-day single-capsule therapy used high proton-pump inhibitor doses and lasted ≥14 days. Quadruple therapy containing metronidazole, tetracycline and bismuth achieved optimal eradication rates only when prescribed as third-line treatment, either as 10-day single-capsule therapy (87%) or as 14-day traditional therapy with tetracycline hydrochloride (95%). Triple amoxicillin-levofloxacin therapy achieved 90% effectiveness in Eastern Europe only or when optimised. The overall incidence of adverse events was 31%.

CONCLUSION

Empirical rescue treatment in third and subsequent lines achieved suboptimal effectiveness in most European regions. Only quadruple bismuth-metronidazole-tetracycline (10-day single-capsule or 14-day traditional scheme) and triple amoxicillin-levofloxacin therapies reached acceptable outcomes in some settings. Compliance with empirical therapy optimisation principles is still poor 5 years after clinical practice guidelines update.

TRIAL REGISTRATION NUMBER

NCT02328131.

Empirical Second-Line Therapy in 5000 Patients of the European Registry on Helicobacter pylori Management (Hp-EuReg)

BACKGROUND & AIMS

After a first Helicobacter pylori eradication attempt, approximately 20% of patients will remain infected. The aim of the current study was to assess the effectiveness and safety of second-line empiric treatment in Europe.

METHODS

This international, multicenter, prospective, non-interventional registry aimed to evaluate the decisions and outcomes of H pylori management by European gastroenterologists. All infected adult cases with a previous eradication treatment attempt were registered with the Spanish Association of Gastroenterology-Research Electronic Data Capture until February 2021. Patients allergic to penicillin and those who received susceptibility-guided therapy were excluded. Data monitoring was performed to ensure data quality.

RESULTS

Overall, 5055 patients received empiric second-line treatment. Triple therapy with amoxicillin and levofloxacin was prescribed most commonly (33%). The overall effectiveness was 82% by modified intention-to-treat analysis and 83% in the per-protocol population. After failure of first-line clarithromycin-containing treatment, optimal eradication (&gt;90%) was obtained with moxifloxacin-containing triple therapy or levofloxacin-containing quadruple therapy (with bismuth). In patients receiving triple therapy containing levofloxacin or moxifloxacin, and levofloxacin-bismuth quadruple treatment, cure rates were optimized with 14-day regimens using high doses of proton pump inhibitors. However, 3-in-1 single capsule or levofloxacin-bismuth quadruple therapy produced reliable eradication rates regardless of proton pump inhibitor dose, duration of therapy, or previous first-line treatment. The overall incidence of adverse events was 28%, and most (85%) were mild. Three patients developed serious adverse events (0.3%) requiring hospitalization.

CONCLUSIONS

Empiric second-line regimens including 14-day quinolone triple therapies, 14-day levofloxacin-bismuth quadruple therapy, 14-day tetracycline-bismuth classic quadruple therapy, and 10-day bismuth quadruple therapy (as a single capsule) provided optimal effectiveness. However, many other second-line treatments evaluated reported low eradication rates. ClincialTrials.gov number: NCT02328131.

Difference in Presence and Number of CD83+ Dendritic Cells in Patients with Ulcerative Colitis and Crohn's Disease

Different pathophysiological models provide insight into the important role of CD83+ dendritic cells (DCs) in the pathogenesis of Crohn's disease (CD) and ulcerative colitis (UC). There were 154 subjects included in this study: 60 with UC, 19 with CD and 75 in the control group. Colonic biopsy was performed in all subjects. Specimens were incubated with a primary anti-CD83 antibody. Intraepithelial DCs per 100 enterocytes were counted. The results were analysed according to demographic data, type of IBD and histological inflammation pattern. The odds ratio for CD83+ DCs=0 in the UC group was 3.4 times higher than that in the control group (OR = 3.4; 95% CI: 1.63-7.14; p = 0.001), and the odds ratio for CD83+ DCs ≥1 in the CD group was 5.3 times higher than that in the UC group (OR = 5.3; 95% CI: 1.4-20.2; p = 0.014). The odds ratio for CD83+ DCs=0 in the acute inflammation group was 2.7 times higher than that in the group without inflammation (OR = 2.7; 95% CI: 1.2-5.9; p = 0.011). In the group of patients with CD and acute inflammation (n = 11), there was only one subject without CD83+ DCs (p = 0,024). These results suggest an association of CD83+ DCs with the type of IBD and the histological inflammation pattern.

[Croatian guidelines for diagnostics and treatments of Helicobacter pylori infection]

In the past 30-year period of investigations, the crucial role of Helicobacter pylori in chronic gastritis, gastric and duodenal ulcer development, and subsequently in gastric cancer and MALT lymphoma pathogenesis, has been recognized. During the first meeting of European Helicobacter Study Group in 1996 in Maastricht, the first recommendations for diagnostics and treatments of Helicobacter pylori infection were published, later reviewed in 2000, 2007 and 2010. The first meeting of Croatian doctors focusing on the same topics, but suitable to specific national circumstances, was held as early as 1998. The need for updating the old guidelines has emerged during the last years. The working expert group of gastroenterologists was formed and gathered on Consesus Conference in December 2012 in Zagreb, to arrive to current guidelines for the clinical management of Helicobacter pylori infection in Croatia. The following topics relating to Helicobacter pylori infection were examined: 1. indications and contraindications for diagnostics and treatments; 2. diagnostic methods and 3. treatments applicable in our country.

[Croatian consensus on the treatment of inflammatory bowel diseases with biologic therapy]

Introduction of biologic therapy in clinical practice represented significant progress in the treatment of inflammatory bowel diseases (IBD) because of its proven efficacy and due to the fact that biologics are the first drugs used in the treatment of IBD that can change the natural course of this diseases. At the same time, biologics are very expensive drugs with complex mechanism of action and important side effects and their use requires evidence-based clinical guidelines. These were the reasons that Referral Center of the Croatian Ministry of Health for IBD and the IBD Section of the Croatian Society of Gastroenterology organised Croatian consensus conference that defined guidelines for the treatment of IBD with anti-TNF drugs. The text below includes definitions of IBD, general principles of IBD therapy, comments on the importance of mucosal healing, analysis of reasons for nonresponse and loss of response to anti-TNF drugs, recommendation for the duration of anti-TNF therapy, rules of screening for opportunistic infections prior to anti-TNF therapy, comments on the problems with reproduction in IBD and finally guidelines for the treatment of various phenotypes of IBD including extraintestinal manifestations with anti-TNF therapy.

[Treatment of fistulizing Crohn's disease]

The treatment of fistulating Crohn's disease should include a combined medical and surgical approach and should be defined on an individual basis. Asymptomatic enteroenteric fistulas usually require no treatment, but internal fistulas (gastrocolic, duodenocolic, enterovesical) that cause severe or persistent symptoms require surgical intervention. While low asymptomatic anal-introital fistula may not need surgical treatment, in case of a symptomatic enterovaginal fistula surgery is usually required. There are no controlled-randomized trials to assess the effect of medical treatment for non-perianal fistulating Crohn's disease. The incidence of perianal fistulae varies according to the location of the disease, with its occurrence varying between 21-23%. The diagnostic approach should include an examination under anesthesia, endoscopy, and either MRI or EUS before the treatment begins. Asymptomatic simple perianal fistulas require no treatment. The presence of a perianal abscess should be ascertained and if present should be drained urgently. In case of a complex perianal disease, seton placement should also be recommended. Antibiotics (metronidazole and ciprofloxacine) are useful for treating complex perianal disease, however, when discontinued, most of the fistulas relapse. The current consensus suggests that azathioprine/6-mercaptopurine is the first line medical therapy for complex perianal disease, which is always given in combination with surgical therapy (seton, fistulotomy/fistulectomy). Anti TNF-alpha agents (infliximab and adalimumab) should be used as a second choice medical treatment. In refractory and extensive complex perianal disease a diverting stoma or proctectomy should be performed.

Interleukins IL-33 and IL-17/IL-17A in patients with ulcerative colitis

BACKGROUND/AIMS

Disturbance of immune homeostasis in ulcerative colitis (UC) is related to the predominance of T-helper-2 (Th2) immune response. Interleukin (IL)-33 stimulates Th lymphocytes to produce Th2 cytokines, such as IL-4, IL-5, and IL-13, which are believed to induce pathological changes in the intestinal mucosa. The pro-inflammatory role of IL-17 in UC is still unclear. Our aim was to determine serum concentrations of IL-33 and IL-17 in patients with UC and healthy controls.

METHODOLOGY

Serum concentrations of IL-33 and IL-17 were measured in 18 patients (10 men) with UC and 16 control subjects (10 men) by using two-layer immunoenzyme procedure (ELISA).

RESULTS

Median serum concentrations of IL-33 in patients with UC and controls were 140 pg/ mL (interquartile range [IQR], 72.5 pg/mL) and 165 pg/mL (IQR, 140.0 pg/mL), respectively, but the difference was not statistically significant (Mann-Whitney U=112, p = 0.281). The median serum concentration of IL-17/IL-17A in patients with UC was significantly higher (100 pg/mL, IQR 35.75pg/mL) than that in controls (65 pg/ mL, IQR 32.25 pg/mL) (Mann-Whitney U=55, p = 0.002).

CONCLUSION

Serum concentration of IL-33 in patients with UC was not increased in comparison with that in controls, which is in accordance with current evidence that its primary biological effect is transcriptional rather than cytokinal. Further research is needed to explain whether increased concentration of IL-17 in UC is protective or harmful and to elucidate its immunological and pathogenic role.

Lamotrigine therapy for resistant pain in radicular lesions of cervical segments C4-C5 and C5-C6: a case report

Radicular pain syndromes caused by disk herniation are often accompanied by incomplete central cord syndrome. Intensive pain is difficult to control with standard analgesics. Antiepileptics of new generation have shown significant efficacy in treating pain syndromes, trigeminal neuralgia, diabetic neuropathy, migraines, etc. The treatment of radicular pain with lamotrigine, a new generation antiepileptic, turned out to be effective in lumbar disk radicular conflicts, justifying its application for resistant pain in cervical segment. In our patient, pain intensity was significantly reduced with gradual titration of lamotrigine to a dose of 200 mg/day. Pain intensity measured by the visual analog scale significantly decreased from 100 to 20 mm during eight weeks of titration. The blood concentration of the drug measured by the method of high performance liquid chromatography was 13.65 micromol/L. The patient's quality of life improved greatly. It is necessary to further evaluate the efficacy of lamotrigine in the treatment of resistant radicular damage.

[Brain damage assessment in patients with multiple sclerosis by means of MRI]

Brain magnetic resonance imaging (MRI) findings in 32 patients recently clinically diagnosed with multiple sclerosis (MS) by McDonald's criteria are presented. Demyelinization plaques were examined according to their number, size and location in brain tissue. Classification was done by Frederiksen's quantification. The study included 18 (56.3%) female and 1-4 (43.7%) male patients aged 17-44, mean 32 +/- 2.4 years. The predominant plaque location was periventricular (100%), involving lateral brain chambers, followed by subcortical, pontine, corpus callosum, cerebellar and other locations (medulla oblongata, spinal marrow). According to plaque number, patients were divided into six groups, from 2-6 plaques (group 1), to 26 lesions (divided into four subgroups). Patients with at least one plaque 15 mm in diameter were allocated to a separate group. The largest was the group with 7-15 plaques (37%). According to plaque size, patients were divided into three groups: plaque of up to 6 mm in diameter, 6-15 mm in diameter, and at least one plaque 15 mm in diameter. Patients with plaque size 6-15 mm were found to predominate (64%). There was a surprisingly high incidence of severe brain damage, i. e. higher degrees by Frederiksen's quantification. The third and fourth quantification degrees were most common, with a significant number of plaques not exceeding 15 mm in diameter; however, there also were been patients with plaques of 15 mm in diameter, which is quite surprising at this early stage of the disease. This pilot study indicated that research should be extended to patients newly clinically diagnosed with MS, comparing their clinical symptoms and Frederiksen's quantification.

[Study of quality of life in patients with multiple sclerosis]

INTRODUCTION

Multiple sclerosis (MS) is a neurological impairment mostly affecting younger adults substantially decreasing their working and living abilities. Different rating scales to determine disabilities are being used: EDSS, NRS, and CAMBS. The objective of this study was to assess the quality of life in MS patients, with reference to the disease itself and its treatment, comparing patients with MS and a matching healthy control group.

METHODS AND SUBJECTS

Subjects were divided into two groups, a group of patients with MS and a control group of healthy subjects. There were 37 MS patients, 25 women and 12 men. Control group consisted of 51 subjects, 39 women and 12 men. There was no statistically significant sex difference. The mean age of the MS patients was 45.9 +/- 12.4 years, and of control group 42.4 +/- 10.3 years; yielding no statistically significant difference. The severity of impairment in MS patients according to EDSS scale was 3 to 3.5. The quality of life determined by the prediction and criterion variables was studied in both MS patients groups and control group. All variables were graded on a 1 to 5 scale. On statistical data processing chi2 test and t-test were used.

RESULTS AND DISCUSSION

Predictors referring to family history, sexual life, social life, satisfaction with education, job, social environment, religious life, housing status, financial status and present family life did not differ between the MS and control group. MS patients were less satisfied with their place in society, their state of health and ways of spending their free time. The decrease of satisfaction correlated with the areas generally known to be directly or indirectly affected by MS. As to the criterion variable of 'satisfaction with former way of life' no significant differences were found, since the disease did not affect previous life achievements. MS patients were less satisfied with their status in society, their state of health and ways of spending their free time. Changes occurred as a consequence of substantial life changes caused by the disease, results of treatments and circumstances in which the patients lives. Results obtained indicated that patients were aware of their disease, lower quality of life that limited their daily activities and future plans. Answers referring to the state of health, social status, and sexual activities did not show any statistically significant difference between the groups of MS patients and healthy controls, although it could have been expected according to the experience and customary expectations in such cases.

CONCLUSION

MS patients are mainly satisfied with what they have achieved previously as young people; they become dissatisfied in relation to the possible economic and social prospects, and they are aware of their disabilities and weaknesses, inability for professional development, working and workplace relationships, more difficult money acquisition, etc.

Psychosis and Wilson's disease: a case report

In this article we present a case of a 26-year-old woman with clinical picture of acute psychosis, as the first and main manifestation of Wilson's disease, who developed abnormal involuntary choreoathetoid limb movements, few days after initiation of neuroleptic therapy. At the first movement neurological symptoms were misinterpreted as side effect of haloperidol, but consulted neurologist suggested additional diagnostic procedure which confirmed Wilson's disease. Psychiatric symptomatology and abnormal involuntary movements were the clinical manifestation of this disease, which improved with neuroleptic and chelating treatment. Interdisciplinary approach with good collaboration of psychiatrists and neurologists is crucial for Wilson's disease, because early diagnosis and treatment without delay is critical to the prognosis. This case serves as a reminder that involuntary movements can be side effect of antipsychotics but also the clinical manifestation of some illnesses, for example Wilson's, Huntington's and Fuhr's diseases.

Hemifacial spasm in vertebrobasilar dolichoectasia

Vascular compression of the facial nerve is a well recognized cause of hemifacial spasm (HFS). Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) provide vascular and brain tissue diagnosis in a single non-invasive examination and should be recommended as primary neuroradiological procedure in HFS. We report a rare case of symptomatic HFS caused by a vertebrobasilar dolichoectasia. A 49-year-old women experienced left hemifacial spasm for 10 months. MRI showed an enlarged vertebrobasilar dolichoectasia of the left vertebral artery which compressed the seventh cranial nerve at its exit from the caude pons. MRI is essential in establishing the cause of HFS. Together with MR angiography it shows the correlation among the seventh cranial nerve, blood vessels and the structures of mid-brain. Vertebrobasilar delichoestasia is just one of the blood vessel anomalies which causes HFS and which can be shown by MRI. HFS caused by vertebrobasilar dolichoectasia is quite rare.

Multidose activated charcoal in the treatment of carbamazepine overdose with seizures: a case report

Serious complications after carbamazepine poisoning, such as coma, seizures, respiratory failure, cardiac conduction abnormalities, and death are more likely with serum levels greater than 170 micromol L(-1). We report a case of a single massive carbamazepine overdose in a 19-year-old male, following attempted suicide, without prior history of seizure disorder. On admission, three hours after ingestion, serum carbamazepine concentration was 179 micromol L(-1) and Glasgow Coma Scale scored 6. The patient was intubated and treated with multiple doses of activated charcoal for 48 hours. Twelve hours after ingestion, two repeated generalised myoclonic seizures were noted when serum carbamazepine levels peaked at 181 micromol L(-1), and were successfully treated with diazepam. Carbamazepine serum level fell within the therapeutic range 63 hours after ingestion and the patient was discharged without any long-term sequelae. As there is no antidote for carbamazepine poisoning, supportive treatment remains the only, but usually potent option.

[A controlled clinical trial of methylprednisolone in patients with the cholestatic form of alcoholic liver cirrhosis]

Fourty patients with alcoholic liver cirrhosis and refractory hyperbilirubinaemia were included in a prospective, double blind, comparative trial. Twenty of them were randomized to methylprednisolone (1 mg/kg/day i.m. over 3 days), and 20 to placebo (saline) of identical shape. In the active group a significant decrease in the bilirubin level (from 248 to 191 mumol/l, a drop by 23%; p < 0.05) was observed, which was not the case in the control group (from 292 to 300 mumol/l, an increase by 2.7%; p > 0.05). A decrease in the alkaline phosphatase activity was observed in both groups (by 11% in the active and by 20% in the control group: p < 0.05) while the encephalopathic indices did not improve in either. It is concluded that a short course of corticosteroid could speed-up the hospital stay and possibly slow down the progression of alcoholic cirrhosis.

Similar concentrations of thyroidal iodothyronines and T3/T4 ratio in normal thyroids from two Yugoslav districts with different iodine intake

In spite of different daily iodine intake in two yugoslav districts (littoral-Split 297 +/- 76 (Mean +/- SD) and continental-Zagreb 111 +/- 36 micrograms/g creatinine, p less than 0.001), thyroidal iodothyronine concentrations and T4/T3 ratio in normal post mortem thyroids were comparable. T4 was 260.0 +/- 42.6 micrograms/g w.w. (Mean +/- SE) in Split group vrs. 279.9 +/- 59.4 in Zagreb. T3 was 12.8-2.0 vrs. 12.8 +/- 2.2 and T4/T3 ratio 21.6 +/- 1.9 vrs. 21.1 +/- 2.9 in Split and Zagreb, respectively. It has been concluded that relatively small difference in iodine intake has no effect on thyroidal concentrations of iodothyronines and T4/T3 ratio.

Serum thyroid hormones in two Yugoslav districts with different iodine intake

Serum thyroid hormones were measured in two areas of Yugoslavia, one with relatively low iodine intake, Zagreb (urinary iodide 111 +/- 36 microgram/g creatinine), and the island of Brac with higher iodine intake (247 +/- 76 microgram/g creatinine). The serum concentration of T4 and T3 in two groups were not different. These data confirm previous findings that iodine intake within accepted normal range, is not a factor in determining serum thyroid hormone levels.