Elevated ectodomain of type 23 collagen is a novel biomarker of the intestinal epithelium to monitor disease activity in ulcerative colitis and Crohn's disease

BACKGROUND

Impaired intestinal epithelial barrier is highly affected in inflammatory bowel disease. Transmembrane collagens connecting the epithelial cells to the extracellular matrix have an important role in epithelial cell homeostasis. Thus, we sought to determine whether the transmembrane type 23 collagen could serve as a surrogate marker for disease activity in patients with Crohn's disease and ulcerative colitis.

METHODS

We developed an enzyme-linked immunosorbent assay to detect the ectodomain of type 23 collagen (PRO-C23) in serum, followed by evaluation of its levels in both acute and chronic dextran sulphate sodium colitis models in rats and human inflammatory bowel disease cohorts. Serum from 44 Crohn's disease and 29 ulcerative colitis patients with active and inactive disease was included.

RESULTS

In the acute and chronic dextran sulphate sodium-induced rat colitis model, the PRO-C23 serum levels were significantly increased after colitis and returned to normal levels after disease remission. Serum levels of PRO-C23 were elevated in Crohn's disease (p < 0.05) and ulcerative colitis (p < 0.001) patients with active disease compared to healthy donors. PRO-C23 differentiated healthy donors from ulcerative colitis (area under the curve [AUC]: 0.81, p = 0.0009) and Crohn's disease (AUC: 0.70, p = 0.0124). PRO-C23 differentiated ulcerative colitis patients with active disease from those in remission (AUC: 0.75, p = 0.0219) and Crohn's disease patients with active disease from those in remission (AUC: 0.68, p = 0.05).

CONCLUSION

PRO-C23 was elevated in rats with active colitis, and inflammatory bowel disease patients with active disease. Therefore, PRO-C23 may be used as a surrogate marker for monitoring disease activity in ulcerative colitis and Crohn's disease.

Hepatocellular Carcinoma Surveillance-Experience from Croatian Referral Centre for Chronic Liver Diseases

PURPOSE

For patients at high-risk of developing hepatocellular carcinoma (HCC), biannual ultrasound surveillance has long been recommended, in order to detect the tumor in the early, potentially curative stages. However, globally reported HCC surveillance rates vary greatly, ranging from as low as 1.7 to as high as 80%. Our aim was to assess the utilization of surveillance with biannual ultrasound in high-risk Croatian patients and to identify the factors that impact the implementation of the recommended protocol.

METHODS

This retrospective study included 145 newly diagnosed HCC patients in the period from January 2010 to September 2015. We identified low-risk and high-risk patients. The latter were further subdivided into the regular biannual ultrasound surveillance group and the non-surveillance group. The groups were compared according to demographic characteristics and BCLC stage at the time of HCC diagnosis.

RESULTS

Among 145 patients, 80 patients were classified as high-risk according to EASL criteria. During the relevant period, 28.7% underwent regular surveillance, while 71.25% did not. Younger patients were more likely to undergo surveillance (OR 0.935 CI 0.874-0.999; p = 0.05). The patients who underwent regular surveillance had a higher chance of being diagnosed at a curative stage (BCLC 0 or A) (OR 3.701 CI 1.279-10.710; p < 0.05).Gender was not a predictor of participation in the regular surveillance protocol. Among the high-risk patients who did not undergo regular surveillance, 56.1% were not aware of the chronic liver disease prior to the HCC diagnosis.

CONCLUSION

HCC surveillance is still underutilized in high-risk Croatian patients despite its obvious benefits possibly due to the untimely diagnosis of the chronic liver disease.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology

BACKGROUND & AIMS

Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services.

METHODS

To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients?

RESULTS

For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups.

CONCLUSIONS

This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.

[CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES]

INTRODUCTION

The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia.

PARTICIPANTS

as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines.

EVIDENCE

These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations.

CONCLUSIONS

An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

[Croatian guidelines for screening, prevention and treatment of protein-energy wasting in chronic kidney disease patients]

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW.

[Historical background of the Croatian Medical Association]

Since the establishment of the Croatian Medical Association in 1874, continuing its socializing, collaborative, professional and scientific activities through generations of medical doctors and dental doctors down to the present time. The period has been marked by dedicated work of many generations of physicians, numerous professional and scientific achievements of the medical profession. During their mandates, many presidents guided and directed the activities of the CMA, fervently discussed and fought for progress and prosperity and proudly celebrated important anniversaries and events. Lijednicki vjesnik, the CMA journal, has always been an important factor in the education of its readers, as well as for professional and scientific advancement of many colleagues.

[Guidelines for the management of hyperglycaemia in hospitalised adult patients]

INTRODUCTION

The aim was to prepare guidelines for the management of in-hospital hyperglycaemia in adult patients in intensive care units and regular wards. CONTRIBUTORS: Working group led by two coordinators consists of repre- sentatives of professional societies within the Croatian Medical Association.

EVIDENCE

These guidelines are derived from the guidelines of international professional societies. Level of evidence and strength of recommendation are evaluated according to GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. Decision making process: Working group produced Guidelines draft by a consensus. The draft has been delivered to professional societies for review. Final document is accepted by all included societies.

CONCLUSION

Hyperglycaemia is a frequent, serious and demanding complication in hospitalized patients. Results of published studies suggest that its regulation decreases morbidity and mortality. Implementation of locally developed standardized protocols promoting basal-bolus insulin regimen is regarded as the most important measure for management of hyperglycaemia in hospital. Present guidelines are a set of practical, rational and feasible recommendations and suggestions.

[Croatian Medical Association--Branch Zagreb]

The available literature shows us that "Druztvo ljeciteljah u Zagrebus (the Society of Healers in Zagreb) was founded as far back as the year 1845 by a total of thirteen members. This data allows us to follow the role of doctors and health workers in Zagreb through their everyday profession, research, organizational and social work as well as management through a period of over one hundred to seventy years. The Branch Zagreb was active before the official establishment of subsidiaries of CMA which is evident from the minutes of the regular annual assembly of the Croatian Medical Association on 21 March 1948. Until the end of 1956, there was no clear division of labor, functions and competencies between the Branch and the Main Board. Their actions were instead consolidated and the Branch operated within and under the name of Croatian Medical Association. In that year the Branch became independent. The Branch Zagreb is the largest and one of the most active branches of the Croatian Medical Association. At the moment, the Branch brings together 3621 members, regular members--doctors of medicine (2497), doctors of dental medicine (384), retired physicians (710), and associate members (30 specialists with higher education who are not doctors). The Branch is especially accomplished in its activities in the area of professional development of its members and therefore organizes a series of scientific conferences in the framework of continuous education of physicians, allowing its members to acquire necessary points for the extension of their operating license. The choir "Zagrebacki lijecnici pjevaci" (Zagreb Physicians' Choir) of the Croatian Medical Music Society of the CMA and its activities are inseparable from the Branch Zagreb. The Branch is firmly linked to the parent body, the CMA, and thus has a visible impact on the strategy and the activities of the Association as a whole. Most professional societies of the CMA have their headquarters in Zagreb and this is inevitably reflected in their overall function. The Branch Zagreb supports the harmonious development of health care throughout the territory of the Republic of Croatia. Cities of Zagreb and Mainz, are cities--friends and the CMA Branch Zagreb works together and exchanges visits with mem- bers of the Medical Society of Mainz for years. Next year professional and scientific cooperation between the Branch Za- greb of CMA and the Medical Society of Mainz will mark four decades.

[Croatian guidelines for perioperative enteral nutrition of surgical patients]

Nutritional status of patients significantly affects the outcome of surgical treatment, whether it's about being obese or malnutrition with loss of muscle mass. Inadequate nutritional support in the perioperative period compromises surgical procedures even in patients who are adequately nourished. In this paper, particular attention was paid to malnourished patients, and their incidence in population hospitalized in surgical wards can be high up to 30%. Special emphasis was paid to the appropriateness of preoperative fasting and to the acceptance of new knowledge in this area of treatment. The aim of this working group was to make guidelines for perioperative nutritional support with different modalities of enteral nutrition. The development of these guidelines was attended by representatives of Croatian Medical Association: Croatian Society for Digestive Surgery, Croatian Society for Clinical Nutrition, Croatian Society of Surgery, Croatian Society for Endoscopic Surgery, Croatian Trauma Society and the Croatian Society of Anesthesiology and Intensive Care. The guidelines are designed as a set of questions that arise daily in clinical practice when preparing patients for surgery and after the surgical treatment, which relate to the assessment of nutritional status, perioperative nutritional support, duration of preoperative fasting period and the selection of food intake route. Assessment of nutritional status and the use of different modes of enteral nutrition should enter into standard protocols of diagnosis and treatment in the Croatian hospitals.

[Croatian guidelines for gastric cancer prevention by eradication of Helicobacter pylori infection]

Gastric cancer is the fourth most common type of cancer and the second leading cause of cancer-related death in the world. Although gastric cancer has a multifactorial etiology, infection with Helicobacter pylori is highly associated with gastric carcinogenesis. Carcinogenesis is also influenced by some environmental factors and host genetic diversity, which engenders differential host inflammatory responses that can influence clinical outcome. Chronic gastritis induced by H. pylori is the strongest known risk factor for adenocarcinoma of the distal stomach, but the effects of bacterial eradication on carcinogenesis have remained unclear up to now. Although eradication of H. pylori infection appears to reduce the risk of gastric cancer, several recent controlled interventional trials by H. pylori eradication to prevent gastric cancer have yielded disappointing results. To clarify this problem in a high-risk population, the investigators conducted a prospective, randomized, double-blind, placebo-controlled, population-based studies. The results of previous studies highlight the importance of longer and careful follow-up after eradication therapy. It seems that eradication treatment is effective in preventing gastric cancer if it is given before preneoplastic conditions/lesions, gastric atrophy, metaplasia, and dysplasia, have had time to develop. Furthermore, the significant efficacy of treatment observed in younger patients suggests the need to eradicate H. pylori as early as possible. This consensus aimed to propose guidelines for the diagnosis, management and control of individuals with chronic gastritis, atrophy, intestinal metaplasia, or dysplasia.

[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.

Polymorphisms of interleukin-23 receptor in patients with inflammatory bowel disease in a Croatian tertiary center

The Interleukin-23 signalling pathway is important for the differentiation of TH17 lymphocytes and is involved in the pathogenesis of Inflammatory bowel disease. Polymorphisms in the IL-23 receptor gene were previously found to be associated with Inflammatory bowel disease in various populations. The aim of this study was to determine whether the specific rs11209026 and rs7530511 single-nucleotide polymorphisms in the Interleukin-23 receptor gene are associated with Crohn's disease and ulcerative colitis in a Croatian patient population. A total of 50 patients with Crohn's disease and 93 patients with ulcerative colitis, as well as 99 healthy control subjects were included in the study. The results determined a significantly higher occurrence of rs11209026 in control group compared to patients with inflammatory bowel disease, suggesting a protective effect of this polymorphism. The rs11209026 variant was strongly associated with Crohn's disease, but it was absent in ulcerative colitis. However, there was no significant association between the rs7530511 polymorphism with either ulcerative colitis or Crohn's disease. Associations presented in this study give potentially important insight into the roles of specific Interleukin-23 receptor polymorphisms in Crohn's disease pathogenesis in the Croatian population.

[Place of biologic therapy in the treatment of inflammatory bowel diseases and assessment of its efficacy]

Biological therapy (infliximab and adalimumab) in inflammatory bowel diseases is based on the IgG1 anti-TNF monoclonal antibodies with potent anti-inflammatory effects whose main mechanism of action is thought to be the induction of inflammatory cell apoptosis. Unquestionably, which arises from the most recent studies and meta-analysis, anti-TNF angents are an effective therapy primarily for the treatment of Crohn's disease, but also ulcerative colitis, in different clinical situations. Infliximab has the most extensive clinical trial data, but other biological agents, such as adalimumab and certolizumab pegol appear to have similar benefits. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn's disease and adalimumab in ulcerative colitis. Important role in the application of biological therapy is assessing its effectiveness and cost-benefit relationships that are estimated by regular follow-up. In the absence of response (primary and secondary) therapeutical options are dose increase, giving the drug in shorter intervals and substitution with other biological drug.

[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.

Nutritional and behavioral modification therapies of obesity: facts and fiction

Current practice guidelines for management of overweight and obesity recommend a tripartite treatment - lifestyle modification program of diet, exercise, and behavior therapy for all persons with a body mass index of at least 30 (and those with body mass index 25 plus two weight-related comorbidities). Behavior therapy provides the structure that facilitates meeting goals for energy intake and expenditure. Lately, there has been a shift in focus from behavior change to cognitive change because it improves long-term results of lifestyle modification programs. Weight loss diets based on the amounts of individual macronutrients (high-protein diets, low-fat diets and low-carbohydrate diets, etc.) in the diet are not more effective than 'classical' low-calorie and balanced diets. An exception has been detected only in short-term diets with a low glycemic load. Also, epidemiological studies show that there is an inversely proportional relationship between body weight and Mediterranean diet. Cognitive behavioral therapy based on the Mediterranean diet has proven to be effective in clinical practice with regard to weight loss, body fat distribution, biochemical parameters, blood pressure and simplicity of following the diet.

Gut microbiota and obesity

The human gut hosts more than 100 trillion microorganisms, encompassing thousands of species. In adults, Bacteroidetes and Firmicutes are the most prevalent phyla. Experimental data in animal and observational studies in obese patients suggest that obesity is associated with substantial changes in the composition and metabolic function of the gut microbiota. The initial findings linked obesity with the decreased relative proportion of Bacteroidetes to Firmicutes. There are some authors who suggest that probiotics and prebiotics can modulate obesity-host metabolism in obesity and obesity-related disorders.

[Croatian guidelines for the management of pancreatic exocrine insufficiency]

Pancreatic exocrine insufficiency is a major consequence of pancreatic diseases (e. g. chronic pancreatitis and cystic fibrosis), extrapancreatic diseases like celiac disease and Crohn's disease, and gastrointestinal and pancreatic surgical resections. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function should be assessed by measuring levels of faecal elastase-1. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. Administration of enzymes in form of enteric-coated minimicrospheres avoids acid-mediated lipase inactivation and ensures gastric emptying of enzymes in parallel with nutrients. In adults, the initial recommended dose of pancreatic enzymes is 25.000 units of lipase per meal, titrating up to a maximum of 80000 units of lipase per meal. Large meals require 25.000 - 80.000 units of lipase per meal while snacks require 10.000 - 40.000 units of lipase per meal. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid-suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high-dose enzyme therapy. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Dietary fat restriction is not recommended for patients with PEI.

Quantitative analysis of troponin I serum values in patients with acute cholecystitis

The diagnosis and staging of acute cholecystitis, upon a lot of diagnostic methods and some scoring systems, is still a great clinical problem. The aim of the study was to investigate if serum Troponin I is elevated in patients with acute cholecystitis. Following informed consent, 65 patients with clinical and laboratory signs of acute cholecystitis were enrolled. All patients had measured serum Troponin I level and an abdominal ultrasound was done before definitive treatment was performed. Increased serum Troponin I level was found in most patients with severe form of acute cholecystitis (p < 0.00001). It reached sensitivity of 94.5% and specificity of 57.1% of this test. In multiple regression analysis Troponin I significantly correlated (p < 0.05) with the serum aspartate aminotransferase (r = 0.27), gamma-glutamyl transferase (r = 0.25) and gallbladder wall (> 6 mm) thickness (r = 0.58). Our study confirms that in most patients with severe and acute cholecystitis, serum Troponin I is increased. Troponin I level is in a lower range than it would be in patients with cardiac muscle damage or necrosis. Measuring serum Troponin I is a fast, reliable and widely performed test that could, with other routinely measured parameters, help in early diagnosis of the severe form of acute cholecystitis.

[Croatian guidelines for nutrition in the elderly, part II--clinical nutrition]

Malnutrition and sarcopenia are frequent in the hospitalized and institutionalized elderly. They have negative consequences on morbidity, mortality, function and quality of life. Enteral and parenteral nutrition are valid options in the malnourished elderly, both in the hospital and at home. Elderly patients share most indications and complications with adult patients, even though more focus needs to be put on function and quality of life than on mortality. In these guidelines we discuss the indications and special considerations of enteral and parenteral nutrition in geriatric patients as well as guidelines for clinical nutrition in three common pathologies in the elderly: decubital ulcers, dysphagia and dementia.

[Croatian guidelines for nutrition in the elderly, part I]

Aging produces numerous physical and physiologic changes, which in turn alter nutritional requirements and affect nutritional status. The presence of chronic disease, and/or medications can enhance potential disparities between nutrient needs and dietary intake, leading to malnutrition. Indeed, research suggests that malnutrition is a common condition among the elderly. Therefore, regular nutritional assessment should be done as an integral part of healthcare for elderly. Also, it is important to take in consideration all determinants of geroanthropometry. The physiologic changes associated with aging affect requirement for several essential nutrients. In general, the requirement for many nutrients decreases, concomitant with the decrease in energy needs. However, some nutrients are needed in higher amounts. Additionally, various psychosocial and socioeconomic changes that often attend aging may also alter dietary intake. Dietary planning is important part of nutritional care in the elderly. Also, some elderly persons can benefit with dietary supplements and oral nutritional supplements (enteral formulas) which can be prescribed by diagnosed or threatening malnutrition. Croatian guidelines for nutrition in the elderly have been developed by interdisciplinary expert group of Croatian clinicians, gerontologists, anthropologists, nutritionists and other professionals involved with care for elderly population. The guidelines are based on evidence from relevant medical literature and clinical experience of working group.

The influence of the different morphological changes on gastric mucosa on somatostatin cell number in antrum mucosa and serum somatostatin

The aim of our paper was to investigate the influence of the different morphological changes on gastric mucosa on somatostatin D-cell number in antral mucosa and serum Somatostatin. We analyzed according to Sydney classification to what extent the severity of gastritis affect the observed hormonal values. somatostatin D-cell number in antral mucosa and serum Somatostatin values were compared between three groups of patients; mild, moderate and severe chronic gastritis. The average number of somatostatin cell in biopsy sample of antrum mucosa was 30.41 +/- 35.38 (N = 17) in the case of middle form, 18.69 +/- 26.65 (N = 56) in moderate and in severe case of chronic gastritis 5.23 +/- 5.93 (N = 7) cells in mm2 of mucosa. The level of somatostatin in the serum of middle form gastritis were 26.43 +/- 28.76, moderate 19.95 +/- 35.93 and severe 17.88 +/- 17.66 pg/mL. In order to determine the number of somatostatin cells in antrum mucosa and serum somatostatin with present morphological changes of mucosa, it might helpful to exclude the patients with non-ulcer dyspepsia, but with the higher risk of premalignant and malignant changes.

Spontaneous perforation of the small intestine, a novel manifestation of classical homocystinuria in an adult with new cystathionine beta-synthetase gene mutations

The clinical picture of classical homocystinuria is diverse. This is the first report of an adult homocystinuric patient with non-traumatic spontaneous small bowel perforation. A 47-year old man presented with abdominal rebound tenderness, hypotension and tachycardia, anemia, and elevated markers of inflammation. Other routine laboratory tests were normal. Abdominal x-ray showed no free air. An emergency laparotomy revealed jejunal perforation in the left upper quadrant. Histologic specimen showed full-thickness nonspecific inflammation of the intestinal wall with granulocytic infiltration, hemorrhage and necrosis. Tuberculosis, actinomycosis and typhus were histologically and clinically excluded. After excluding all known possible causes of perforation, we presumed a causative relationship between homocystinuria and small bowel perforation. It could be hypothesized that connective tissue weakness in homocystinuria is a result of homocysteine interference with recombinant human fibrillin-1 fragments or cross-linking of collagen through permanent degradation of disulfide bridges and lysine amino acid residues in proteins. DNA analysis showed three detectable mutations in the cystathionine beta-synthetase gene, 1278T:c.833T>C, and two new mutations, V372G:c.1133T > G, and D520G:c.1558A > G in the aternatively spliced exon 15.

Assessment of nutritional status of gastroenterology patients in Croatia

Malnutrition is a common feature of gastroenterological diseases. In this study, nutritional status of the patients admitted to Department of Gastroenterology at University Hospital Center Zagreb was assessed. Anthropometric, dietetic, biochemical methods and method of Subjective Global Assessment (SGA) was used. The study group included 284 patients admitted to the Hospital. Malnutrition, as defined by SGA, was found in 61.1% of the patients, of whom 75% were moderately and 25% severely malnourished. Those patients classified as moderately and extremely malnourished by SGA were found to have statistically lower values of BMI, albumin, total proteins, calcium, iron, triglycerides, cholesterol, vitamin A and lymphocytes as compared to those who were adequately nourished. The prevalence of malnutrition in hospitalized patients treated at the Department of Gastroenterology is high. The use of nutritional screening with multiple measures would be important in the early identification and treatment of these patients and would help decrease this high prevalence.

Lactobacillus GG in the prevention of nosocomial gastrointestinal and respiratory tract infections

OBJECTIVE

The incidence of nosocomial infections, predominantly gastrointestinal and respiratory, in children in developed countries is high, ranging from 5% to 44%. There is no effective strategy for preventing these infections. The objective of our study was to investigate the role of Lactobacillus GG (LGG) in preventing nosocomial gastrointestinal and respiratory tract infections at a pediatric hospital.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of 742 hospitalized children. They were randomly allocated to receive for their hospitalization LGG at a dose of 10(9) colony-forming units in 100 mL of a fermented milk product (LGG group, n = 376) or placebo that was the same postpasteurized fermented milk product without LGG (placebo group, n = 366).

RESULTS

In the LGG group, compared with the placebo group, we found a significantly reduced risk for gastrointestinal infections (relative risk [RR]: 0.40 [95% confidence interval (CI): 0.25-0.70]; number needed to treat: 15 [95% CI: 9-34)], respiratory tract infections (RR: 0.38 [95% CI: 0.18-0.85]; number needed to treat: 30 [95% CI: 16-159]), vomiting episodes (RR: 0.5 [95% CI: 0.3-0.9]), diarrheal episodes (RR: 0.24 [95% CI: 0.10-0.50]), episodes of gastrointestinal infections that lasted >2 days (RR: 0.40 [95% CI: 0.25-0.70]), and episodes of respiratory tract infections that lasted >3 days (RR: 0.4 [95% CI: 0.2-0.9]). Groups did not differ in hospitalization duration (P = .1).

CONCLUSIONS

LGG administration can be recommended as a valid measure for decreasing the risk for nosocomial gastrointestinal and respiratory tract infections in pediatric facilities.

[Croatian guidelines for use of enteral nutrition in Crohn's disease]

Nutrition has an important role in the management of inflammatory bowel disease (IBD), especially in patients with Crohn's disease (CD). This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and the promotion of optimal growth and development in children. In active Crohn's disease, nutritional therapy (in the form of enteral feeding) is an effective primary therapy for pediatric patients. Studies have shown that there is no difference in the efficacy of elemental, oligomeric and polymeric enteral formulas. Therefore, the use of polymeric formula is recommended because of higher palatability, better acceptance by patients, lower rate of complications and lower cost when compared with other enteral formulas. Today we have knowledge that some nutrients which are added to modified special enteral formulas have almost pharmacological terapeutic potential in the management of inflammatory bowel disease. Novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta-enriched (TGF-beta2) enteral feeding, showed beneficial effects in several clinical studies. Croatian guidelines for enteral nutrition in Crohn's disease have been developed by interdisciplinary expert group of Croatian clinicians involved with inflammatory bowel disease. The guidelines are based on evidence from relevant medical literature and clinical experience of working group.

[High resolution B-mode and Doppler ultrasound in diagnostic evaluation of Crohn's disease]

Evaluation of extension and complications as well as assessment of Crohn's disease activity, include different diagnostic methods, of which many utilize ionizing radiation. In our routine work, high resolution B-mode and Doppler ultrasound with measurements of bowel wall thickness and hyperemia, as well as calculation of resistance index of mural arteries and visualisation of extramural changes, represent valuable diagnostic tools in screening, assessment of disease activity, and follow up of the patients with Crohn's disease. Therefore, we reduce the use of ionization radiation in diagnostic workup, which is particulary important considering the fact that Crohn's disease predominantly affects young patients.

Effects of nutritional support in patients with colorectal cancer during chemotherapy

Nutritional support, addressing the specific needs of this patient group, is required to help improve prognosis, and reduce the consequences of cancer-associated nutritional decline. Early intervention with nutritional supplementation has been shown to halt malnutrition, and may improve outcome in some patients. In our study we tried to assess the influence of nutritional support (counseling, oral liquids, megestrol acetate) on nutritional status and symptoms prevalence in patients with colorectal cancer during chemotherapy. Group I consisted of 215 (55%) patients with medium age 68 +/- 2.6 years who were monitored prospectively and were given nutritional support. Group II included 173 (45%) patients (medium age 67 +/- 2.9 years) without the proper nutritional counseling, in whom the data were collected retrospectively during a 6 years period of time. After evaluation Nottingham Screening Tool Score, Appetite Loss Scale and Karnofsky Performance Status) all patients in the group I received nutritional counseling, 153 of them (72%) were taking form of enteral food supplement and 103 (48%) patients were using megestrol acetate. Evaluating the initial risk measurements according to BMI, decrease in weight gain and NST, we did not find any significant difference between the two groups. After chemotherapy completion, patients in group I had a 15.3% drop of those who's BMI was < 20.65% patients increased their body weight, with an average weight gain of 1.5 kg (0.6-2.8 kg). Contrary, in group II we found increase in weight loss > or = 2 kg/month in 39% of patients. The appetite improvement was detected on Appetite Loss Scale from 3.1 (pre-chemotherapy) to 4.7 (post-chemotherapy) in group I, especially in those receiving megestrol acetate. In both groups Karnofsky Performance Status didn't change significantly reflecting the impact of the disease itself and chemotherapy procedures to the patient's condition. Nutritional counseling, supplemental feeding and pharmacological support do temporarily stop weight loss and improve appetite, social life and quality of life in those groups of patients. However, this improvement have no implications on patients KPS and course of their disease.

Nutritional and pharmacologic support in patients with pancreatic cancer

The aim of our study was to assess whether the influence of nutritional support, consisting of counseling, enteral liquids support and pharmacologic support, can slow down weight loss and whether the change in weight has the impact on the performance status in our patients. In our study 44 patients with pancreatic cancer were included--26 males (mean age 69 years +/- 2.4 years) and 18 females (mean age 63 +/- 3.2 years). Metastatic disease was found in 21 patients, 15 patients had liver metastasis. Locally advanced disease was found in 24 patients and metastatic and locally advanced disease in 17 patients. Surgery was performed in 34 patients. Forty four (100%) patients underwent nutritional counseling, 33 of them (75%) took supplemental enteral feeding and 44 (100%) took megestrol acetate 400 mg per a day. The patients were followed up during 8 weeks during 5 visits. At first visit we took initial nutritional status of patients. Appetite loss, weight gain and Karnofsky performance status were monitored at every visit. All patients were treated with gemcitabin for a 7 week period.

RESULTS

NTS score at initial visit in 44 patients (100%) was > or = 5. Using nutritional counseling, enteral food substitution and pharmacological support, weight gain was observed in 61.1% patients and appetite improved. Average KPS mostly improved after first month of therapy while after two months was again at the basal level. With nutritional counseling, supplemental feeding and pharmacologic support weight loss in our patients slowed down and appetite improved. Despite of that, Karnofsky Performance Status didn't change significantly, reflecting the impact of the disease itself and chemotherapy procedures to the patient's condition. We can conclude that nutritional and pharmacological support can temporarily stop weight loss and improve appetite, social life and quality of life in those groups of patients but have no implications on patients KPS and course of their disease.

Assessment of Crohn's disease activity by doppler ultrasound of superior mesenteric artery and mural arteries in thickened bowel wall: cross-sectional study

AIM

To define sensitive and reliable Doppler parameters for measurements in the superior mesenteric artery and mural arteries of affected bowel loops used in the assessment of Crohn disease activity.

METHODS

We performed cross-sectional study at a tertiary care setting in Zagreb, Croatia, between January 2001 and March 2005. We measured arterial flow in the superior mesenteric artery and affected bowel wall in 138 patients with Crohn disease (74 with active, 64 with inactive disease) and 67 healthy volunteers. The disease activity was determined by the clinical examination, Crohn disease activity index, and standard laboratory tests. Superior mesenteric artery color and pulsed Doppler parameters were peak systolic velocity, end-diastolic velocity, resistance index, mean velocity flow, cross-sectional area, and flow volume. When gut mural vessels were identified, we performed spectral analysis of mural arteries by pulsed Doppler, with a measurement of resistance index.

RESULTS

The measurements in the superior mesenteric artery showed statistically and clinically significant difference in flow volume in active group, compared with inactive and control groups (C+/-Q=564+/-263 mL/min for active, 421+/-157 for inactive and 416+/-248 for control group). Affected bowel loops analysis showed significant difference between inactive and active Crohn disease group in wall thickness (3.1+/-1.4 vs 5.0+/-1.8 mm, P<0.001, Mann-Whitney test) while all participants from control group had thickness below 2mm. Intensity of color Doppler signals was different for all groups (P<0.001, chi(2) test) with the highest level of hyperemia in the active group. Resistance index measurements of mural arteries in bowel wall revealed differences between all three groups (0.61+/-0.05 in active group, 0.71+/-0.05 in the inactive group and 0.80+/-0.11 in the control group, P<0.001, Kruskal-Wallis test).

CONCLUSION

Intensity of color Doppler signals and resistance index measurements of mural arteries in the thickened bowel wall can be used as quantitative diagnostic tool in the assessment of Crohn disease activity.

[Croatian guidelines for use of eicosapentaenoic acid and megestrol acetate in cancer cachexia syndrome]

Among many oncological patients we can notice a substantial loss of body weight, fat and proteins with significant proinflammatory activity at the time of diagnosis. This wasting condition is well known as cancer cachexia syndrome. Anorexia is important part of this syndrome. Because cancer cachexia reduces tumor response to treatment and it is an indicator of poor prognosis, we need to start correcting these nutritional deficits at once. In the presence of cancer cachexia it is extremely difficult to achieve protein anabolism and stop the body wasting by standard nutritional formulas only. During the last few years, the use of eicosapentaenoic acid (EPA) and megestrol acetate (MA) as anticahectic agents has been tested. These guidelines are intended to give evidence-based recommendations for the use of eicosapentaenoic acid and megestrol acetate in cancer cachexia syndrome. These guidelines have been developed by interdisciplinary expert group of Croatian clinicians. Based on relevant literature, we have concluded that the use of metabolic modulators such as eicosapentaenoic acid and megestrol acetate for 8 weeks may help to improve nutritional status in cachectic patients.

[Percutaneous endoscopic gastrostomy: 5-year experience at out center (1997-2002)]

Gauderer and Ponsky first described percutaneous endoscopic gastrostomy (PEG) in 1979. It was introduced as a routine method in the Division of Gastroenterology, University Hospital Rebro, Zagreb, in 1995. Over the years the number of PEG insertions has increased significantly. We reviewed the available literature and compared the results with our experience according to indications, complications and efficacy of the procedure. We inserted PEG in 86 patients from January 1, 1997 until January 31, 2002. There were 40 females and 46 males. The most frequent indication for PEG insertion was a neurological condition (60/86). There were no deaths directly related to the procedure. One patient had a leakage of PEG feeding into the peritoneal cavity that caused severe peritonitis and required urgent laparatomy within 24 hours of the PEG insertion. Two patients had local infection and the tube had to be removed. The antibiotic prophylaxis has been given to 65 patients. Our experience confirms that PEG is a relatively safe and well tolerated procedure.

Influence on gallbladder volume of early postoperative gastric supply of nutrients

BACKGROUND & AIM

The gallbladder volume is a predictor of biliary stasis and the formation of biliary sludge. Biliary stasis and sludge have been recently recognized as the precursors of acute acalculous cholecystitis, as well as 'idiopathic' postoperative pancreatitis, rare but very serious complications after surgery. The aim of the study was to establish how early postoperative gastric supply of nutrients affects the gallbladder volume in patients after noncardiac and cardiac surgery.

METHODS

In the two prospective, randomized studies 40 patients (study I-noncardiac surgery) treated at surgical ICU after major elective extrahepatobiliary and extragastrointestinal surgeries (7 thoracic, 19 vascular, 14 urological) and 40 patients (study II-cardiac surgery) treated at cardiosurgical ICU after CABG surgery were analyzed. In both studies the patients were divided into two groups: control group C (study I: 20 patients, age 45+/-18 yrs, male 65%; study II: 20 patients age 58+/-7 yrs, male 60%) and group E (group of early postoperative gastric supply of nutrients) (study I: 20 patients, age 52+/-17 yrs, male 50%; study II: 20 patients; age 59+/-8 yrs, male 65%). For the first 24 hours the patients in group C received only crystalloid solutions and the gallbladder volume was verified 24 hours after the surgery. In group E, postoperative gastric supply of nutrients began 18 hours after surgery (Osmolite, Ross; first 3 hours 30 ml/h and second 3 hours 50 ml/h; total 240 ml after 6 hours). In all patients sonographic measurement of gallbladder volume was performed immediately before surgery and 6 hours after the start of feeding (24 hours after surgery). The measurement was done with ultrasonographic scanner Hitachi 405 EUB (convex probe 3.5-5MHz) by the same specialist, and the volume was calculated using the ellipsoid method.

RESULTS

The gallbladder volume measured by ultrasonography 24 hours after surgery in study I (noncardiac surgery) in group E amounted to 43+/-25 ml while in control group C it was significantly higher, i.e. 67+/-30 ml (P<0.05). In study II (cardiac surgery) in group E gallbladder volume amounted to 59+/-15 ml while in control group C it was also significantly higher, i.e. 71+/-11 ml (P<0.05).

CONCLUSION

An early postoperative gastric supply of nutrients after both noncardiac and cardiac adult surgery diminishes the volume and probably stimulates the motility of the gallbladder, thus preventing biliary stasis and the formation of biliary sludge.

Antibodies to Tamm-Horsfall protein in endemic nephropathy

BACKGROUND

The aim of the study was to investigate the possible role of antibodies to Tamm-Horsfall protein (anti-THP) in the early diagnosis of endemic nephropathy (EN).

METHODS

Anti-THP (IgA, IgM, IgG classes) antibodies were determined by direct ELISA in a random sample of 159 subjects from the endemic village of Kaniza who were divided into four groups according to the WHO criteria, i.e., 'diseased', 'suspect', 'at risk', and 'others'. These groups were compared to subjects from the non-endemic village of Klakar and healthy subjects from Zagreb.

RESULTS

No differences for all the classes of antibody were observed among the groups of subjects from the endemic village of Kaniza (P>0.05) or between these subjects and those from the non-endemic village of Klakar (P>0.05). The values of IgM anti-THP antibodies exceeded those of the IgA and IgG classes in all groups of subjects (P<0.05). The values for all three classes of antibodies were higher in the rural than the urban population (P<0. 05).

CONCLUSION

Determination of anti-THP antibodies was not found to be useful in the early diagnosis of endemic nephropathy. The results suggest that most of the anti-THP antibodies are 'natural' and/or cross reactive. The highest values observed in the rural population could probably be explained by exposure to some ubiquitous antigen or more likely they are consequences of fever.

[Palliative treatment of malignant esophageal obstruction with a new endoscopically administered self-expanding nitinol stent: case report]

The endoscopic methods of palliative treatment in malignant esophageal stenoses caused by neoplasm which have been performed so far unfortunately do not provide permanently satisfying results. The implantation of self-expanding stents with the purpose of removing malignant esophageal obstructions has recently become the most acceptable method of treatment. By using that method it is possible to reduce or even completely remove difficulties in swallowing. In that way a significant improvement in life quality of patients with inoperable esophageal cancer is possible. The various types of metal endoprostheses used for the palliative treatment of esophageal malignant stenoses are described in this paper. Here is also presented a case of nitinol stent implantation in a 50 year old woman suffering from esophageal cancer. This type of therapeutic treatment has been applied in Croatia for first time.

Antibodies to Tamm-Horsfall protein in patients treated with extracorporeal shock wave lithotripsy (ESWL)

The aim of this study was to determine antibodies to Tamm-Horsfall protein in patients with nephrolithiasis treated with extracorporeal shock wave lithotripsy (ESWL). The values of antibodies to Tamm-Horsfall protein were determined by direct enzyme immunoassay. No statistically significant differences (P > 0.05) were observed for the IgG and IgM classes of antibodies between the groups of healthy subjects and patients with nephrolithiasis before, and 30 and 60 days after ESWL. The values of IgA class determined 30 days after treatment were significantly higher (P < 0.05) in patients, which could be due to the stimulation of the immune system. The highest values of antibodies to Tamm-Horsfall protein were obtained in both groups in the test with secondary antibodies directed toward IgM class, implicated at the presence of cross-reactive antibodies. Determination of antibodies to THP subunits isolated form urine of patients with nephrolithiasis should be performed.

Antibodies to Tamm-Horsfall protein subunits prepared in vitro, in patients with acute pyelonephritis

The aim of this study was to determine antibodies to Tamm-Horsfall protein subunits in patients with acute pyelonephritis. The protein subunits used in this determination were prepared by chemical treatment of Tamm-Horsfall protein isolated from the urine of healthy individuals. Values for IgG and IgA were significantly higher (p < 0.05 and p < 0.01 respectively) in patients than in healthy persons, while IgM class antibodies were significantly higher only in the test performed with subunits obtained with 8.3 mol/l acetic acid (THP-A) (p < 0.05). Values for all three classes determined in the test with THP-A were significantly higher in patients with vesicoureteral reflux than in patients with normal radiological findings (p < 0.05). Antibodies to Tamm-Horsfall protein subunits isolated from the urine of patients with acute pyelonephritis should also be determined.

Comparison of injection sclerotherapy and laser photocoagulation for bleeding peptic ulcers

BACKGROUND AND STUDY AIMS

The most widely used endoscopic procedures in the management of patients with bleeding peptic ulcer are at present sclerotherapy and thermal methods. In an attempt to assess the most effective method of achieving hemostasis, we compared injection sclerotherapy and laser photocoagulation in terms of the efficacy of initial hemostasis, rebleeding, need for surgery, mortality, and the appearance of the ulcer after the hemostatic procedure.

PATIENTS AND METHODS

In this prospective, randomized trial, 160 patients were treated with injection sclerotherapy (1% polidocanol), and 155 patients with laser photocoagulation (Nd:YAG laser) in cases of Forrest I, Forrest IIa, and Forrest IIb hemorrhage. The bleeding activity was classified according to the modified Forrest criteria. Polidocanol injection and Nd:YAG laser photocoagulation were not preceded by epinephrine administration.

RESULTS

There were no significant overall differences between the groups in the outcome in terms of definitive hemostasis, rebleeding, urgent surgery, and death (p = 0.487). In the case of the subgroup with Forrest I lesions, laser photocoagulation was more efficacious than sclerotherapy (p = 0.0078). In the Forrest IIa and Forrest IIb subgroups, the two methods were equally effective (p = 0.202 and 0.513 respectively). In the sclerotherapy patients, definitive initial hemostasis in Forrest IIa was achieved in 100%, whereas in the laser group this rate was 92%, with 28% of patients initially developing hemorrhage after one or two laser pulses. Ulcer healing was slower following sclerotherapy than after photocoagulation.

CONCLUSION

Injection sclerotherapy and laser photocoagulation are equally effective in achieving definitive hemostasis in bleeding peptic ulcers. Laser photocoagulation is more efficacious in patients with active bleeding, whereas injection sclerotherapy is more effective in patients with a nonbleeding visible vessel.

[Value of C-reactive protein in the evaluation of activity in ulcerative colitis and Crohn's disease]

We studied a value of measuring the C-reactive protein (CRP) serum concentration in the assessment of ulcerative colitis and Crohn's disease activity. From a large register of patients with the inflammatory bowel disease (IBD), we have chosen randomly 91 patients: 61 with ulcerative colitis and 30 with Crohn's disease. As a reference point in the assessment of ulcerative colitis we have used the Powell-Tuck clinical index. Nineteen patients had an active disease, and 42 were in a remission. Patients with the active disease had significantly higher levels of the CRP then the patients in remission (chi 2 = 4.99; alpha less than 0.05). Serum CRP levels and the disease activity assessment by Powell-Tuck index were in a positive correlation, according to the Fisher's exact test (p less than 10(-8)). In the group of 30 patients with Crohn's disease, the disease activity was assessed by CDAI ("The Crohn's Disease Activity Index") and by van Hees index. According to CDAI, 26 patients were in a remission, and only 4 had an active disease. According to van Hees index, there was no patient in a complete remission, 17 patients had a partial remission and 13 had an active disease. Patients with the active disease had significantly higher CRP levels then the patients in remission, according to van Hees index (chi 2 = 7.863; alpha less than 0.01), but not according to CDAI (not significant). Meanwhile, the Fisher's exact test suggested a high positive correlation between the disease activity assessment with both indexes, either CDAI or van Hees, and the CRP serum values (alpha less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)