Serum vitamin D levels and chronic periodontitis in adult, Caucasian population-a systematic review

The aim of this systematic review was to explore the relationship between serum vitamin D levels and periodontal disease. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The focused PICO question was: Are serum vitamin D levels (I) associated with gingivitis or periodontitis (C) in healthy humans (P)? PubMed (Medline), Embase, Science Direct, the Cochrane library, and grey literature were searched up to 31 July 2017. Two reviewers independently selected studies and extracted data. Quality, risk of bias, and heterogeneity of the studies were assessed using the Newcastle-Ottawa Scale. In total, 365 studies were identified and 24 were analyzed. Seven studies fulfilled the inclusion criteria. Four case-control studies showed an influence of vitamin D and its metabolites on periodontal health status/disease. One interventional study suggested the proposed anti-inflammatory role of vitamin D. Two cross-sectional studies failed to show a relationship between vitamin D and periodontal condition. The literature on the effect of serum vitamin D levels on periodontal status remains scarce and controversial. Some data, however, support a "perio-protective" role for vitamin D. There is a need for well-designed randomized clinical trials to explore the possible anti-inflammatory effect of vitamin D on periodontal health.

Methicillin-resistant Staphylococcus aureus in North-east Croatia

OBJECTIVE

The aim of this 5-year study was to determine the frequency and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA)-related infections at Osijek Clinical Hospital.

MATERIALS AND METHODS

A total of 1987 staphylococci-infected clinical isolates were collected and analysed at the Microbiology Department of the Public Health Institute of Osijek-Baranja County.

RESULTS

Between 2008 and 2012, the average rate of MRSA-related infections in staphylococci-infected patients was 27.4%. The proportion of MRSA-related infections on all Staphylococcus aureus (S. aureus) isolates from clinical specimens showed a decreasing trend, from 32.6% in 2008 to 25.5% in 2012. MRSA-related infections were mostly detected in wound swabs (50.6%) and aspirates (28.8%) of patients hospitalized in the surgical (49.8%) and intensive care units (27.9%). MRSA-related infection showed an increase compared to S. aureus-infections in samples of wounds and aspirates in 2011 and 2012 (57.9%/34.9% and 35.2%/16.3%, respectively). The majority of strains of MRSA-related infections were resistant to several antibiotics, including erythromycin and clindamycin, where susceptibility were less than 10%. All MRSA isolates were susceptible to vancomycin, teicoplanin and linezolid. Therefore, antibiotic therapies for MRSA infections include vancomycin, teicoplanin and linezolid, but microbiological diagnostics need to be performed in order to know when the use of glycopeptides and oxazolidinones is indicated.

CONCLUSION

Our results suggest that appropriate prevention measures, combined with the more rational use of antibiotics are crucial to reduce the spread of MRSA-related infection in healthcare settings. Further monitoring is necessary of the incidence and antibiotic susceptibility of MRSA-related infections in our community.

Polymorphisms of Toll-like receptors 2 and 4 in chronically infected hepatitis C patients from north-east Croatia

Chronic infection with hepatitis C virus (HCV) is caused by an inadequate immune response. Experimental data suggest that the impaired activation of Toll-like receptors (TLRs) 2 and 4 contributes to chronic infection. We assessed the distribution of three single-nucleotide polymorphisms (SNPs) in the TLR2 (Arg753Gln) and TLR4 (Asp299Gly/Thr399Ile) genes in individuals from north-east Croatia and their effect on the outcome of antiviral therapy. The study consisted of 60 chronically infected patients and 40 healthy subjects. TLR polymorphisms were determined by the PCR-based melting curve analysis. HCV genotyping was performed using the Linear Array Hepatitis C Virus Genotyping Test. Thirty-three patients were treated with standard interferon and ribavirin therapy, and their viral load was evaluated at weeks 28 and 53 after the beginning of therapy. The majority of chronic infections were caused by genotype 1 (77%), followed by genotypes 3 (15%) and 4 (7%). Patients with genotype 1 had higher viral loads than patients infected with other genotypes (P = 0.0428). Healthy individuals and patients with chronic infection had similar frequencies of TLR2-Arg753Gln and TLR4-Asp299Gly/Thr399Ile SNPs. Heterozygous and homozygous TLR4-Asp299Gly/Thr399Ile polymorphisms correlated with higher viral loads and delayed responses to antiviral therapy. We have provided the first evidence that TLR4 polymorphisms influence the success of antiviral therapy in our region. This suggests that therapeutic strategies should be adjusted not only according to HCV genotype but also to individual TLR polymorphism(s).

Most common HCV genotypes in patients from north-eastern Croatia

OBJECTIVE

The aims of this study were to determine the HCV-RNA viral load, genotype distribution, risk factors and symptoms of HCVRNA positive viral load in HCV antibody-positive patients from north-eastern Croatia.

MATERIALS AND METHODS

From January 2009 to December 2011, 203 HCV antibody- positive patients (130 men and 73 women; median age 44.5 years) were analyzed for HCV-RNA by the COBAS TaqMan HCV test and genotyped by the Linear Array HCV Genotyping test (both from Roche). All patients completed a structured questionnaire about risk factors and symptoms.

RESULTS

The HCV-RNA percentage was 61.1% and was similar for men and women. The HCV-RNA viral load increased with age: while 55% of 20-50 year old patients were HCV-RNA positive, 73% of patients >50 years were positive (p=0.021). Genotype 1 was the most prevalent genotype (79.8%), followed by 3 (12.9%), 4 (6.5%), and 2 (0.8%); genotypes 5 and 6 were not determined. Patients with genotype 1 (median, 50 years) were older than patients with 3 (median, 33.5 years) or 4 (median, 38 years). The blood transfusions performed in Croatian hospitals before 1993 was significantly associated with HCV-RNA positive viral load (p<0.05).

CONCLUSION

These data indicated an elevated prevalence of genotype 1 in elderly HCV-RNA positive patients and it may continue to rise. Using RNA-based detection in HCV positive-antibody patients would allow early detection of HCV in the acute stage of HCV disease and the increased risk of HCV genotyperelated treatment failure.

Distribution of genital human papillomavirus (HPV) genotypes in Croatian women with cervical intraepithelial neoplasia (CIN)--a pilot study

Genital infection with high-risk human papillomavirus (HR HPV) associates with increased risk of developing precancerous lesions, such as cervical intraepithelial neoplasia (CIN). The objective of this pilot study conducted in north-east Croatia was to determine the prevalence of HPV genital infection in women with abnormal cervical cytology and to determine its association with their age and HPV genotype(s). From March 2009 to December 2011, cervical swabs from 100 women were analysed for HR HPV infection (AMPLICOR HPV Test, Roche Diagnostics) and genotyped for high risk (HR), intermediate (IR) and low risk (LR) HPVs (Linear Array HPV Genotyping Test, Roche Diagnostics). The most prevalent HR genotypes in women with CIN were HPV 16 (27.6%), HPV 31 (11.8%), HPV 51 and HPV 52 (10.2% each). The most prevalent IR genotypes were HPV 66 (30%) and HPV 62 (23.3%). The most prevalent LR genotype was HPV 6 (20.3%). Women between 21 and 25 years of age showed the highest rate of HPV infection (44.2%). Moreover, women younger than 35 years showed a significant association (p < 0.01) and positive correlation (r = 0.67; p < 0.05) between HR HPV infection and CIN stages 1 and 2. Multiple HPV infections were found in almost half of the women. This is the first study that analysed the prevalence of genital infection with HR/IR/LR HPVs in women with CIN from north-east Croatia. Despite the preliminary nature of this pilot study, the lower prevalence of some HR HPVs (HPV18) and the higher prevalence of other HR HPVs (HPVs 51, 52 and 31) may imply the necessity for the development of more targeted anti-HPV vaccines or other strategies for more efficient protection against oncogenic HPV infection in women from our region.

Prevalence and genotype distribution of high-risk human papillomavirus (HR HPV) in male genital samples of Osijek-Baranja County

This is a first cross-sectional study on the prevalence and distribution of HPV infection in asymptomatic, heterosexual men from Osijek-Baranja County, Croatia. Between 2009 and 2011, 330 men tested for sexually transmitted diseases (STDs) were recruited. Their genital swabs were tested for high-risk HPV (HR HPV) infection by the AMPLICOR HPV test and further genotyped by the Linear Array HPV Genotyping Test (both by Roche). Infection with a single HR HPV was detected in almost one third of men (39%) whereas multiple HPV types, in more than a half of HR HPV-positive men (61%). The highest HR HPV prevalence was detected in those younger than 20 (37.5%) and lowest in 31-35 year old men (27.8%). The most common genotypes were HPV 6 (24%), 16 (17.8%), 51 (9%), 52 (6%), 35, 55, 66, 84 (each 5%), 31, 62 (each 4%), 39, 58, 59, 83 (each 2.5%), and finally 56, 18, 53, and 54 (each 1.3%). Having more than one sexual partner per year was significantly associated with HR HPV infection in age group between 26 and 30 years (p = 0.001). Due to the high prevalence of HR HPV infection in men of this County and its risk of transmission to women, we recommend more public awareness about this particular STD and initiating vaccination programs of young men and women.

An ab initio study of the vibronic structure in the a1Delta g electronic state of C2H2++

The results of an ab initio study of the vibronic structure in the a1Deltag electronic state of C2H2++ and its deuterated species (C2D2++) are presented. They are generated employing a simple model that incorporates the minimal number of terms contributing to the Renner-Teller effect. The trans- and cis-bending potential curves at planar nuclear arrangements are obtained by means of large-scale configuration interaction calculations. The corresponding harmonic vibrational frequencies are 717 and 650 cm-1 for C2H2++, and 549 and 477 cm-1 in the case of C2D2++. It is found that the splitting of the potential surfaces is moderate at trans-distortions of linearity, while it is extremely small at cis-bending vibrations. The eigenvalues and eigenfunctions of the model Hamiltonian employed are obtained by means of a perturbative and a variational approach.

[Assisted circulation. I. Systems with short-term mechanical circulatory support]

The concept of artificial circulatory support has been established almost 200 years ago. It has only been within the last four decades that physicians and engineers have developed mechanical assist devices that can temporarily support the circulation until the native heart recovers from a reversible injury. If the heart does not recover sufficient function to maintain adequate hemodynamics, long-term circulatory support or permanent replace (biologically--heart transplant or permanent mechanical circulatory support) is needed. In this paper we describe the devices (intraaortic balloon pump, roller, centrifugal and axial pumps), that are in current clinical use for temporary (short-term) mechanical circulatory support.

[Use of the internal thoracic artery in repeat myocardial revascularization surgery]

The incidence of redo myocardial revascularization is increasing lately. These procedures are accompanied by the higher operative risk, and the use of internal thoracic artery graft may have additional negative impact on early-rization. Mortality and morbidity in this group did not differ significantly compared to a group where only venous grafts were used. Independent predictors of the unfavorable outcome (for both groups) were the presence of the chronic pulmonary disease, age over 65 and NYHA functional class IV. In the group with internal thoracic graft it was the age over 65, while in the group with only vein grafts it was chronic pulmonary disease. We have discussed potential problems during the redo procedure in patients in whom internal thoracic graft was used during the first procedure.

[Myocardial revascularization using the internal thoracic artery: pro and con]

Internal thoracic artery (ITA) has superior histological, physiological and pharmacological properties over the venous grafts, and it is considered to be the graft of choice for myocardial revascularization. It has low incidence of late atherosclerotic lesions, and excellent long-term patency. Usage of ITA yields improved clinical results in all subgroups of patients with coronary artery disease, including patients with poor left ventricular function (EF%), left main stenosis, diffuse coronary artery disease and octogenarians. Since superior long-term results (to be expected only 10-15 years after the operation) may be outweighed with slightly higher incidence of early morbidity and mortality, many cardiac surgeons are reluctant to use it routinely. However, this attitude is difficult to justify, since early operative results in patients that have received ITA graft are superior as well, compared to patients that have received vein grafts only.

Partial left ventriculectomy and limited heart transplantation availability

BACKGROUND AND AIM

Partial left ventriculectomy, a novel cardiac volume reduction operation, is applied in countries without a developed heart transplantation program. We sought to determine its impact in our population of patients.

METHODS

Partial left ventriculectomy was performed in 38 patients during the last 4 years. Basic inclusion criteria were nonischemic dilated cardiomyopathy and poor response to medical therapy for heart failure. Hemodynamic evaluation was carried out before and after operation. A modified surgical technique of mitral valve repair and ventricle suturing was applied.

RESULTS

Thirty-day, 6-month, and 2-year survival rates were 82% +/- 7%, 65% +/- 8%, and 61% +/- 9%, respectively. Duration of heart failure symptoms was the only predictor of survival (p = 0.042). A high proportion of noncardiac causes of death was noted. Functional capacity in surviving patients improved at every successive measurement up to 1 year postoperatively.

CONCLUSIONS

The introduction of partial left ventriculectomy in a country with limited heart transplantation availability had a great impact on the management of end-stage heart failure and may represent the only surgical option for some patients. The average cost per patient was substantially lower when compared to heart transplantation.

[History of surgical treatment of atherosclerosis of the coronary arteries--the first 100 years]

Atherosclerotic coronary artery disease is the most common cause of morbidity and mortality. The incidence of cardiovascular morbidity and mortality has been doubled in our country during the period 1980 through 1996. Surgical treatment of the atherosclerotic coronary artery disease is already a century old, ever since Francois-Franck (in 1899) tried to achieve sympathetic denervation of the cervical ganglion. After the interim period of indirect myocardial revascularization, during the last 30 years, direct surgical revascularization has reached excellent early and long-term results, and became one of the most frequently performed procedures in the surgical practice. Use of arterial grafts and, introduced recently, procedures on the beating heart, minimally invasive procedures and, so called, port-access procedures became a daily routine in many centers. Surgical revascularization of the ischaemic cardiac muscle is the rapidly changing entity, along with diagnostic, technical and other improvements. We present a brief historical overview of the efforts of cardiac surgeons to combat the "disease of the century" atherosclerotic coronary artery disease.

[Occlusion of a calcified ascending aorta with a Foley catheter in aortocoronary bypass--case report]

Heavily calcified ascending aorta predisposes to aortic injury and distal embolization during total or partial cross-clamping, during the performance of open-heart procedures. Placement of the arterial cannula may be particularly difficult, occasionally virtually impossible using the standard technique, while placing the clamp on such aorta may be extremely risky. We present a case where we have used a Foley-balloon catheter to occlude the densely calcified ascending aorta, during a aorta-coronary bypass procedure, thus completely avoiding the use of the total aortic clamp.

Safety of simultaneous resections of colorectal cancer and liver metastases

Liver resection is the only potentially curative method for patients with colorectal cancer metastases and 5-year survival rates are 20%-40%. Simultaneous resection of colorectal cancer and synchronous liver metastases has been recommended if minor hepatectomy is indicated. The purpose of this paper is to analyze the treatment of hepatic colorectal secondaries and to assess the safety of simultaneous and delayed liver resections and relations of morbidity to the extensiveness of hepatectomy and perioperative factors. Analyzed were 21 patients with liver metastases from colorectal cancer operated between 1997 and 1999 in the Clinical Hospital "Sestre milosrdnice". Operating time for simultaneous colorectal and liver resections was not significantly longer compared to liver resections alone. No significant difference in complication rate was found after simultaneous procedures and liver resection alone (38% vs. 31%). Complication rate after major liver resections was not significantly greater than after minor resections (38% vs. 31%). No statistically significant differences were found in operation time and blood replacement between patients who developed postoperative complications and those who did not. In conclusion, simultaneous resections of primary colorectal cancer and liver metastases may be considered safe. Morbidity rates are not significantly different from those after liver resections alone, nor depend significantly upon the extensiveness of liver resection, providing that the operation time and blood loss are within the range observed in this study.

[Angiographic characteristics of the internal thoracic artery--anatomic variations and their surgical importance]

INTRODUCTION

The internal thoracic artery is considered the graft of choice for surgical revascularization of the ischemic myocardium. The real incidence of anatomic variations of the internal thoracic artery is not known, although it is an extremely important issue, considering surgical strategy, as well as immediate and long-term outcome.

MATERIAL AND METHODS

During a period of three months (Jun. 1st-Aug. 31st 1998) we have evaluated the left internal thoracic artery (ITA) in 80 randomly selected patients (62 men, average age being 57.4 +/- 5.2).

RESULTS

Typical take-off, side branches, terminal division and absence of any atherosclerotic lesions were noted in 69 patients (86.25%). Angiographically apparent atherosclerotic lesions were not noted; anomalous take-off from the left subclavian artery was noted in 9 cases (11.25%--including one case of aneurysmatic proximal portion of the ITA); there were two cases where the lateral thoracic artery was present (2.5%) and three cases where the distal division was of a trifurcation type, which is not of surgical importance (3.75%). Average diameter of the left ITA was 2.19 +/- 0.24 mm for the entire group (2.20 +/- 0.19 mm for men, and 2.10 +/- 0.21 mm for women, p = NS).

DISCUSSION

Results that we have obtained are in accordance with previously published data. We did not find significant (angiographically visible) atherosclerotic lesions of the ITA, however variations in the take-off and branching were found to be frequent (11.25%). Aneurysmatic left ITA is an extremely rare finding in the literature. Angiographically found variations (capable of causing coronary steal) are impossible to be detected during operation. This raises a question of a need for routine angiographic evaluation of the ITA before operation. For some patients, routine angiographic evaluation of the ITA before myocardial revascularization is mandatory: in pts with previous myocardial revascularization, in whom ITA was not used, but could have been damaged; in pts with atherosclerotic lesions of the supraaortic vessels; in pts with previous irradiation of the anterior mediastinum (ITA could be fibrotic); in pts with actual or corrected coarctation of aorta (ITA could be aneurysmatic).

CONCLUSION

The incidence of anatomic variations of the ITA (that may be of surgical importance) is not negligible (13.25%). These data indicate that routine angiographic evaluation of the ITA should be considered in all patients in need for myocardial revascularization.

Active infective endocarditis: low mortality associated with early surgical treatment

BACKGROUND

Early surgical treatment is important for successful outcome in selected cases of active, either native (NVE) or prosthetic valve endocarditis (PVE). The aim of this study was to evaluate the early results of the surgical treatment of active NVE and PVE.

METHODS

During a 3-yr period (January 1 1996-December 31 1998), 57 out of 60 patients (pts) with active, either NVE (46 pts) or PVE (11 pts) underwent surgical treatment. There were 11 women (23.9%), average age of the group being 43.3+/-9.1yr (18-73). They were operated on 12-35days, mean 17.7+/-7.5days (for NVE) and 5-33days, mean 13.2+/-10.1days (for PVE) after the diagnosis of endocarditis was first suspected. All pts had at least one absolute indication for early surgical treatment, the most frequent being (in NVE) worsening heart failure (19 cases) and inability to control the infection (10 cases), while in PVE it was valve dehiscence (8 cases). In 8 cases of NVE and 2 cases of PVE fresh, antibiotic sterilized aortic homograft was used to replace the aortic valve.

RESULTS

Operative mortality was 1.8% (1/57) and hospital mortality 5.2% (3/57). Three pts with PVE died before they were operated on, giving an overall mortality of 10% (6/60). Postoperative morbidity included valve dehiscence in two pts (probable late onset recurrent endocarditis - 3.5%), three episodes of acute renal failure (5.3%), four cases of respiratory insufficiency (7.0%) and one chronic pleural effusion (1.8%). All pts that were discharged from the hospital (54/60), are still alive and well 1-35months postoperatively (mean 20.3+/-9.6months), including pts with recurrent endocarditis and valve dehiscence, after they were successfully reoperated.

CONCLUSIONS

Along with early diagnosis and appropriate antibiotic treatment, aggressive surgical attitude is of importance for the successful outcome in this group of seriously ill patients. Our data indicate that early surgical treatment in cases of active endocarditis may be associated with low mortality and morbidity.

[Use of the internal thoracic artery in patients with stenosis of the left main branch of the coronary artery]

Internal thoracic artery (ITA) is the graft of choice in myocardial revascularization. However, superiority of the ITA graft in patients (pts) with left main coronary artery disease is still a matter of debate.

PATIENTS

In the period from November 1986 through February 1999, ITA graft was used for myocardial revascularization in 2860 pts. Stenosis of the left main stem was present in 229 patients (8.0%); there were 39 women (17.0%) and 26 diabetics (11.4%). Severely depressed left ventricular function was present in 32 pts (14.0%), while the average age was 56.4 +/- 7.2 years.

RESULTS

Operative mortality was 1.3% and postoperative morbidity was 5.2%. Average postoperative hospital stay was 7.9 days (6-29). There were no differences in analyzed parameters between patients who received ITA graft and similar group of 240 patients who received vein grafts only, during the same period of time. All 16 patients operated on in the period 1986-1992 (6-12 years follow-up) are alive.

CONCLUSION

It is safe to use ITA graft for myocardial revascularization in patients with left main coronary artery stenosis. Early operative results are favorable and these patients should not be denied the benefit of the ITA graft, since long-term results are proved to be good as well.

Chromosome aberrations in operating room personnel

BACKGROUND

Long-term occupational exposure to volatile anesthetic agents may result in various adverse health effects. Additionally, certain surgical procedures involve exposure to the other agents such as X rays. Identification of chromosome damages in peripheral blood lymphocytes serves as a useful indicator of exposure to mutagenic agents.

METHODS

The frequency of chromosomal aberrations was assayed in peripheral lymphocytes obtained from 129 subjects working in operating theatres and 41 control subjects.

RESULTS

The results show an increased rate of chromosome aberrations in the exposed subjects. The differences in frequency of chromosome aberrations between particular job tasks were not distinct. Acentric fragments in anesthesiologists and dicentrics in surgeons seem to stand out.

CONCLUSIONS

As the findings do not differ significantly between the exposed groups, one can hardly distinguish radiation and anesthetics effects from one another.

Combined carotid and coronary artery surgery: what have we learned after 15 years?

Optimal surgical strategy in patients with concomitant coronary and carotid artery disease is debatable. We have analysed 15-years of experience (January 1981-August 1996) with 195 consecutive patients in whom we have used two different surgical approaches. Group A consisted of 48 patients who underwent a single-stage surgical procedure, and group B (147 patents) underwent a two-stage procedure, either as carotid endarterectomy followed by coronary artery bypass surgery (group B1, 97 patients), or as coronary artery bypass surgery followed by carotid endarterectomy (group B2, 50 patients). Overall, there were 40 (20.5%) patients with left main coronary artery disease, 49 (25.1%) with poor left ventricular function, 128 (65.6%) with previous myocardial infarction, 134 (68.7%) were in New York Health Authority (NYHA) functional class III or IV, and bilateral carotid involvement was present in 57 patients (29.2%). Unstable angina was more frequent in groups A and B2 (P < 0.0001), NYHA class III-IV was more frequent in group A (versus B1, P = 0.001 and versus B2, P = 0.02), low ejection fraction (EF) was more frequent in groups A and B2 (P < 0.0001 for both), bilateral carotid stenosis in groups A and B1 (P = 0.02 and P = 0.0001, respectively) and ulcerated plaque in group B1 (versus A, P = 0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management.

RESULTS

Early mortality for the entire group was 4.6% (9/195-6.2% in group A, 6.2% in group B1 and 0% in group B2, respectively P > 0.05). Serious morbidity occurred in 7.3% of patients (14/195-8.3% in group A, 7.2% in group B1 and 6% in group B, respectively P > 0.05). Univariate analysis revealed only bilateral carotid stenosis as a predictor of outcome (P = 0.04). Follow-up was completed for 156 patients (80.0%) and averaged 84.1 +/- 13.3 months (range 1-180 months). Kaplan-Meier survival estimate for the entire group was 81% and event-free survival was 76% at 5 years. Actuarial and event-free survivals were similar for all groups. Early and late outcome in these patients were influenced more by their preoperative clinical status than by the surgical strategy itself. It is therefore concluded that surgical approach should be individualized for the majority of patients.

The effects of levcromakalim and pinacidil on the human internal mammary artery

The present study was undertaken to examine the effects of pinacidil and levcromakalim, two potassium, channel openers, on human internal mammary artery (HIMA) obtained from patients undergoing coronary artery bypass surgery, and to clarify the contribution of different K+ channel subtypes in pinacidil and levcromakalim action in this blood vessel. Pinacidil and levcromakalim induced a concentration-dependent relaxation of the precontracted arterial segments (pEC50 = 5.77 +/- 0.05 and 6.89 +/- 0.03, respectively), 4-Aminopyridine (3 mM), a non-selective blocker of K+ channels, induced significant shifts to the right of the concentration-response curves for pinacidil and levcromakalim. Tetraethylammonium (6 mM), charybdotoxin (0.4 microM) and apamin (0.1 microM), blockers of Ca(2+)-sensitive K+ channels, had no effect on the pinacidil- and levcromakalim-evoked relaxation. Glibenclamide (0.1-10 microM), a selective blocker of adenosine triphosphate (ATP)-sensitive K+ channels, competitively antagonized the response to levcromakalim (pKB = 7.92 +/- 0.07). In contrast, glibenclamide, in significantly higher concentrations (3-30 microM), non-competitively antagonized the response to pinacidil. High concentrations of pinacidil (> 10 microM) relaxed arterial rings bathed by a medium containing 100 mM K+ with maximum response 83 +/- 6%. Under the same conditions, the maximum levcromakalim-induced relaxation on HIMA was almost abolished (15 +/- 2%). It is concluded that pinacidil and levcromakalim do not relax the HIMA through the same subtype of K+ channel. ATP-sensitive K+ channels are probably involved in levcromakalim- but not in a pinacidil-induced relaxation in the HIMA. In addition, in pinacidil-induced relaxation of the HIMA, K+ channel-independent mechanisms seem to be involved.

Cardiac events after combined surgery for coronary and carotid artery disease

OBJECTIVE

To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease.

METHODS

We have analyzed our 15 year experience (January 1981-September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B1- 103 patients), or as CAS followed by CEA (group B2- 50 patients). Five patients from B1 group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B2 (P < 0.0001). NYHA class III/IV in group A (versus B1, P = 0.001 and versus B2, P = 0.02), low ejection fraction in groups A and B2 (P < 0.0001), bilateral carotid stenosis in group B1 (versus A, P = 0.003 and versus B2, P < 0.0001), and ulcerated plaque in group B1 (P < 0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management.

RESULTS

Early mortality for the entire group was 5.5% (11/201) 6.2% in group A, 7.8% in group B1 and 0% in group B2, respectively; (P > 0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B1 and 6% in group B2, respectively; P > 0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P = 0.04).

CONCLUSION

Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B2 indicating possible protective effect of prior CAS in patients with concomitant disease.

Civilian medicine and war: transformation of a health centre to a war hospital in Croatia (July 1991-October 1992)

Organization of the first war hospital (War Hospital Dakovo) in the 1991/1992 war in Croatia is presented. During the 13-month period 15123 patients were examined, among them 747 wounded. Complete treatment in the hospital was provided for 334 wounded. Only 23 wounded died immediately after admission, or later on in other hospitals. Most wounds were single and caused by shrapnel. Among the wounded, 75.8 per cent were Croatian soldiers, 22 per cent civilians and 2.2 per cent enemy soldiers.

Clinical course in 52 severely wounded patients treated in the intensive care unit during the war in Croatia

Fifty-two severely wounded patients, admitted directly from a battlefield or after surgical treatment in a war hospital, were treated in the Surgical Intensive Care Unit of the 'Sisters of Mercy' University Hospital in Zagreb during the 1991 war in Croatia. Considering the severity of the wounds, blood loss was not as severe as expected. This can be attributed to the nature of the injuries as most of the patients were wounded by fragments of explosive devices which cause less tissue destruction than military bullets. Low serum potassium levels, metabolic acidosis, low total protein levels and consequently low serum calcium levels correlated with wound severity. Low serum potassium levels were caused by its redistribution. Reperfusion liver injury was also present. Consumption coagulopathy was one of the characteristic disturbances in this type of injury. There was a relatively big difference between fluid input and output caused by fluid loss through drain sites and large open wound surfaces. The low mortality of the severely wounded was due to their young age and the well-organized military medical service which was developed from the civilian medical service in a short time.

[Etiology and incidence of amaurosis in war injuries of the eye]

Retrospective analysis of the medical documentation of 506 wounded treated at the Ophtalmological Clinic of the Military Medical Academy, was used to separate the cases where, due to the injury, the eyesight was destroyed or reduced to "the sense and projection of the light". The groups were formed according to the mechanism of injury and etiological factor. In 41.03% of eyes described sight impairment was established on admission, and the perforative injury of the eye was the basic etiological factor in 64.26% of the cases.

[Perioperative myocardial failure and mechanical cardiac support --a five year experience]

Inability to wean a patient from the cardiopulmonary bypass after open heart procedure is reality of the clinical practice. The only realistic chance for these patients is some form of mechanical circulatory support. Over the period from November 1988 to November 1993, in 17 patients the roller-pump mechanical assist device was inserted, i.e. 0.47% of 3589 patients were operated on during this period. Thirteen patients required mechanical circulatory support immediately after surgical procedure due to inability to wean them from cardiopulmonary bypass. In three patients the roller-pump was inserted preoperatively (percutaneous insertion), and in one patient mechanical circulatory support was started six hours after the procedure for sudden cardiac deterioration. Partial and temporary "bypass" of the damaged left ventricular function is achieved by insertion of inflow cannula into the left atrium, and outflow cannula into the ascending aorta. Depending on the inflow cannula size and volume load, we were able to achieve blood flow of 3.5 to 5 liters/minute. Using this system we were able to improve the left ventricular function in eight patients (47%), and five patients were discharged from hospital (29.4%). The roller-pump mechanical circulatory support proved to be efficient, reliable, easy to monitor and operate. Overall results are comparable to the published data as well as to other types of more versatile and costly devices for mechanical circulatory support.

Age-dependent haematological disturbances in anaesthetic personnel chronically exposed to high occupational concentrations of halothane and nitrous oxide

Anaesthetic staff chronically exposed to high occupational concentrations of halothane and nitrous oxide were tested for numerous haematological and cellular function parameters at the peak of the working season and after 3 weeks vacation. The analysis of data was performed to compare differences in subjects younger and older than the age of 40 years, respectively when compared with normal controls. The analysis revealed a higher recovery of erythrocyte count in the blood of older staff, and stronger disturbance of leucocyte formation in younger staff. In contrast, monocytes appeared to be more stable in the younger staff as were the T and B lymphocyte counts. After stimulation with PHA, Con A and PWM mitogens, lymphocytes from the older age group incorporated a significantly higher amount of tritiated thymidine, but stimulation indices did not differ. Natural killer cell numbers appeared equally affected; natural killer cell activity was unaffected, but there was an increase in activity in the younger staff after the vacation. Serum immunoglobulin concentrations tended to be more affected in older individuals at the peak of the working season.