Pitfalls in evaluation of mitral regurgitation severity.

Težina mitralne regurgitacije (MR) s multiplim regurgitirajućim mlazevima često se podcjeni standardnom transtorakalnom ehokardiografskom (TTE) pretragom, jer se svi mlazevi ne otkriju. Od svih Doppler metoda jedino je kvantitativno PW Doppler mjerenje primjenjivo u ovih bolesnika jer PISA nije točna, a vena kontrakta je primjenjiva samo kod jednog regurgitacijskog mlaza. Prikazujemo 57-godišnjeg bolesnika s malim centralnim regurgitacijskim mlazom na TTE u kojeg smo učinili transezofagijskom ehokardiografijom (TEE) zbog smanjene tolerancije napora kod normalne funkcije lijeve klijetke, morfološki nepromijenjene mitralne valvule i normalnog nalaza koronarografije uz prisustvo glasnog apikalnog holostistoličkog šuma. TEE je otkrio dva dodatna ekscentrična regurgitirajuća mlaza. Kvantitativnom PW Doppler metodom izračunan je regurgitacijski volumen od 55 ml i ERO 0.35 cm2, što odgovara srednje teškoj do teškoj MR. Želimo naglasiti da se simptomi i fizikalni nalaz ne smiju zanemariti u postupku integrativne ultrazvučne procjene težine MR.he severity of mitral regurgitation (MR) with multiple regurgitant jets is often underestimated on standard transthoracic ehocardiography (TTE) examination, since all jets are usually not appreciated. On the other hand, of all Doppler methods only quantitative PW Doppler measurement is applicable in these patients since PISA is not as accurate and vena contracta works well only for single jets. We present a 57-year-old patient with small and narrow central jet on TTE in whom transesophageal echocardiography (TEE) was performed because of loud apical holosystolic murmur and low effort tolerance in the presence of normal left ventricular function, normal mitral valve and coronary artery anatomy. TEE disclosed two additional significant eccentric jets. Regurgitant volume of 55 ml/beat and ERO 0,35 cm2 was calculated with quantitative PW Doppler method which corresponded to moderate to severe MR. We stress again the importance of integrative approach in the assessment of MR severity, in which symptoms, physical examination and hemodynamic consequences of MR should not be neglected

Pitfalls in evaluation of mitral regurgitation severity.

Težina mitralne regurgitacije (MR) s multiplim regurgitirajućim mlazevima često se podcjeni standardnom transtorakalnom ehokardiografskom (TTE) pretragom, jer se svi mlazevi ne otkriju. Od svih Doppler metoda jedino je kvantitativno PW Doppler mjerenje primjenjivo u ovih bolesnika jer PISA nije točna, a vena kontrakta je primjenjiva samo kod jednog regurgitacijskog mlaza. Prikazujemo 57-godišnjeg bolesnika s malim centralnim regurgitacijskim mlazom na TTE u kojeg smo učinili transezofagijskom ehokardiografijom (TEE) zbog smanjene tolerancije napora kod normalne funkcije lijeve klijetke, morfološki nepromijenjene mitralne valvule i normalnog nalaza koronarografije uz prisustvo glasnog apikalnog holostistoličkog šuma. TEE je otkrio dva dodatna ekscentrična regurgitirajuća mlaza. Kvantitativnom PW Doppler metodom izračunan je regurgitacijski volumen od 55 ml i ERO 0.35 cm2, što odgovara srednje teškoj do teškoj MR. Želimo naglasiti da se simptomi i fizikalni nalaz ne smiju zanemariti u postupku integrativne ultrazvučne procjene težine MR.he severity of mitral regurgitation (MR) with multiple regurgitant jets is often underestimated on standard transthoracic ehocardiography (TTE) examination, since all jets are usually not appreciated. On the other hand, of all Doppler methods only quantitative PW Doppler measurement is applicable in these patients since PISA is not as accurate and vena contracta works well only for single jets. We present a 57-year-old patient with small and narrow central jet on TTE in whom transesophageal echocardiography (TEE) was performed because of loud apical holosystolic murmur and low effort tolerance in the presence of normal left ventricular function, normal mitral valve and coronary artery anatomy. TEE disclosed two additional significant eccentric jets. Regurgitant volume of 55 ml/beat and ERO 0,35 cm2 was calculated with quantitative PW Doppler method which corresponded to moderate to severe MR. We stress again the importance of integrative approach in the assessment of MR severity, in which symptoms, physical examination and hemodynamic consequences of MR should not be neglected

Guidelines for the diagnosis and treatment od chronic constipation in children – Recommendations from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Kronična opstipacija, prvenstveno funkcijska, jedna je od najčešćih gastrointestinalnih tegoba u djece i jedan od najčešćih razloga posjeta gastroenterologu. S ciljem adekvatne dijagnoze i liječenja Hrvatsko društvo za pedijatrijsku gastroenterologiju, hepatologiju i prehranu (HDPGHP) revidiralo je smjernice za dijagnostiku i liječenje kronične opstipacije u djece. Metode: Prilikom kreiranja novih smjernica pretražena je dostupna znanstvena i stručna literatura, uključujući i smjernice relevantnih europskih društava. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje kronične opstipacije u djece s predloženim postupnicima i praktičnim savjetima o dozama lijekova. Zaključci: Dijagnoza funkcijske opstipacije postavlja se na temelju kliničke slike i fizikalnog pregleda i vrlo dobro liječi osmotskom laksativnom terapijom.Introduction and aim: Chronic constipation, primarily functional, is one of the most common gastrointestinal problems in children and one of the most common reasons for referral to gastroenterologist. With the aim to promote adequate diagnosis and treatment, the Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition (HDPGHP) has revised guidelines for the diagnosis and treatment of constipation in children. Methods: The available scientific and clinical literature, including the guidelines of relevant European societies, was searched before creating the guidelines. Results: This manuscript represents guidelines for the diagnosis and treatment of chronic constipation in children and contains detailed algorithm and practical advice on therapy including doses. Conclusions: Functional constipation is diagnosed based on clinical symptoms and physical examination and can be adequately managed with osmotic laxative therapy

Vegetarijanska i veganska prehrana u dječjoj dobi - smjernice Hrvatskog društva za pedijatrijsku gastroenterologiju, hepatologiju i prehranu Hrvatskog liječničkog zbora [Vegetarian and vegan diet in children - guidelines of the Croatian society for pediatric gastroenterology, hepatology and nutrition of the Croatian Medical Association]

The influence of vegetarian and vegan diet on children’s health has been discussed not only by pediatricians but also by other professionals who take care of children. Therefore, the aim of this recommendations, based on presented and summarized scientific evidences on the effect of vegetarian and vegan diet on children’s and adolescents’ health, was to state the instructions of the Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association. Vegetarian, and especially vegan diet, is not only the omission of meat and other food of animal origin, but has to represent balanced nutrition adjusted for children. Such a child requires continuous supervision not only by primary health physician but also by pediatric nutritionist, who both have to be specially educated in the field. As restrictions in diet significantly increase the risk for nutritional deficiencies, parents who decide to follow such a diet, and all professionals who take care of such children, have to be aware of possible nutritional risks that are much bigger than in adulthood

Diagnostic and Practical Value of Abbreviated Contrast Enhanced Magnetic Resonance Imaging in Breast Cancer Diagnostics

Background: Although MRI is the most efficient method of detecting breast cancer, its standard protocol is time-consuming and expensive. The objective of this study was to compare the diagnostic accuracy of the modified innovative abbreviated MRI protocol (AMRP) and the standard magnetic resonance protocol (SMRP) when detecting breast cancer. Methods: The research involved 477 patients referred for breast MRI due to suspected lesions. They were randomly assigned to the AMRP group (N = 232) or the SMRP group (N = 245). The AMRP comprised one native (contrast-free) and four post-contrast dynamic sequences of T1-weighted volume imaging for breast assessment (VIBRANT) and 3d MIP (maximum intensity projection) lasting for eight minutes. All the patients underwent a core biopsy of their lesions and histopathological analysis. Results: The groups were comparable regarding the pre-screening and post-diagnostic characteristics and were of average (±SD) age at breast cancer diagnosis of 53.6 ± 12.7 years. There was no significant difference between the two protocols in terms of specificity or sensitivity of breast cancer diagnosis. The sensitivity (95% Cis) of the AMRP was 99.05% (96.6–99.9%), and its specificity was 59.09% (36.4–79.3%), whereas the sensitivity of the SMRP was 98.12% (95.3–99.5%) and its specificity was 68.75% (50.0–83.9%). Most of the tumors comprised one solid lesion in one of the breasts (77.3%), followed by multicentric tumors (16%), bilateral tumors (4.3%), and multifocal tumors (1.7%). The average size of tumors was approximately 14 mm (ranging from 3 mm to 72 mm). Conclusion: Our innovative AMR protocol showed comparable specificity and sensitivity for the diagnosis of breast cancer when compared to SMRP, which is the “gold standard” for histopathological diagnosis. This can lead to great savings in terms of the time and cost of imaging and interpretation

Inflammatory bowel disease in children – from the diagnosis to the treatment Recommendations from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Dijagnoza kronične upalne bolesti crijeva, u svakog četvrtog oboljelog postavlja se u dječjoj dobi, tj. prije navršene osamnaeste godine života. Svjedoci smo značajnog porasta incidencije posljednjeg desetljeća, odnosno danas se ubraja među najčešće kronične gastroenterološke bolesti dječje dobi. Nedavno je određena incidencija i u našoj državi, koja je potvrdila da je ukupna incidencija 7,05/100,000 djece do navršene 18. godine života, što je slično ostalim razvijenim zemljama svijeta. Metode: S ciljem ranog otkrivanja te kako bi se olakšalo liječenje kronične upalne bolesti crijeva u svjetlu dostupnih novih terapija, Hrvatsko društvo za pedijatrijsku gastroenterologiju, hepatologiju i prehranu Hrvatskog liječničkog zbora izradilo je smjernice za dijagnostiku i konzervativno liječenje ovih bolesti. Prilikom kreiranja smjernica pretražena je dostupna znanstvena i stručna literatura, uključujući i smjernice relevantnih europskih društava. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje Crohnove bolesti i ulceroznog kolitisa sa predloženim algoritmima, praktičnim savjetima o dozama lijekova te mogućim nuspojavama. Zaključci: Pravovremena dijagnoza te odgovarajuća terapija smanjuju komplikacije bolesti te omogućuju adekvatan rast i razvoj djece oboljele od IBD-a.Introduction and aim: In every fourth person with inflammatory bowel disease (IBD), the diagnosis is made in childhood, before the age of eighteen. We are witnessing a significant increase in the incidence in the last decade and today IBD is one of the most common chronic gastrointestinal diseases of childhood. Recently, incidence in Croatia has been determined (7.05/100,000 children below 18 years), confirming that the incidence resembles those in developed countries. Material and methods: With the aim to enable early diagnosis and assure adequate treatment with currently emerging new therapies, the Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association has developed guidelines for the diagnosis and pharmacological treatment of IBD in children, taking into account relevant European guidelines, scientific literature and expert opinions of members of this society who are providing long-term care of these patients. Results: These guidelines represent detailed recommendation for the diagnosis and treatment of Crohn’s disease and ulcerative colitis with proposed diagnostic and therapeutic algorithms, medication dosing regimens and possible side effects. Conclusion: Early diagnosis and personally tailored therapy are key factors in preventing disease complication and for and for assuring normal growth and development in children with IBD

Celiac disease – new guidelines, what is new? – diagnostic algorithm from Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association

Uvod i cilj: Celijakija je imunosno posredovana, kronična sistemska bolest uzrokovana glutenom i srodnim prolaminima koja se pojavljuje u genetski predisponiranih osoba, a liječi se strogom, doživotnom prehranom bez glutena. To je jedna od najčešćih gastrointestinalnih i sistemskih bolesti s prevalencijom od 1%, ali nerijetko se, zbog različitih kliničkih prezentacija, ne prepoznaje ili se dijagnosticira kasno, ponekad i nakon višegodišnjeg trajanja simptoma. S ciljem ranijeg prepoznavanja te ujednačavanja dijagnostike, liječenja i daljnjeg praćenja oboljele djece, Hrvatsko društvo za dječju gastroenterologiju, hepatologiju i prehranu HLZ-a (HDPGHP) odlučilo je izraditi ovaj postupnik. Metode: Postupnik se temelji na europskim smjernicama, spoznajama dobivenim pretragom dostupne znanstvene i stručne literature te na stručnom mišljenju članova Upravnog odbora HDPGHP. Rezultati: U detalje su razrađene smjernice za dijagnostiku i liječenje celijakije u dječjoj dobi s predloženim postupnikom. Zaključak: Pravovremeno prepoznavanje i postavljanje dijagnoze celijakije te pravilno liječenje dovodi do nestanka simptoma i oporavka djeteta, sprječava razvoj komplikacija i poboljšava kvalitetu života.Introduction and aim: Celiac disease is immune mediated, chronic systemic disorder elicited by gluten and related prolamines in genetically susceptible individuals that is treated with strict, life-long gluten-free diet. It is one of the most common gastrointestinal and systemic diseases with the prevalence of 1%, but often, due to different clinical presentations, it is not recognized or diagnosed with delays, sometimes after several years of having symptoms. In order to identify patients earlier and to harmonize the diagnostic procedures, treatment and follow-up of children with celiac disease, the Croatian Medical Association, Croatian Society of Pediatric Gastroenterology, Hepatology and Nutrition (HDPGHP) decided to develop this algorithm. Methods: The algorithm is based on European guidelines, the knowledge gained from searching available scientific and clinical literature and on expert opinion of HDPGHP Board members. Conclusion: Timely recognition and diagnosis of celiac disease and proper treatment lead to the disappearance of symptoms and recovery of the child, prevents the development of complications and improves quality of life

Recommendation on diagnosis and treatment of Helicobacter pylori infection in children and adolescents

Obilježja infekcije Helicobacterom (H.) pylori kod djece razlikuju se od infekcije u odraslih pa su tako i dijagnostički i terapijski pristupi različiti. Osim toga, brojni podatci ukazuju na zabrinjavajući porast rezistencije na antibiotike i na nezadovoljavajuću stopu eradikacije H. pylori u dječjoj dobi. Zbog svega toga, a i budući da u Hrvatskoj postoje samo smjernice za odrasle, javila se potreba za smjernicama o dijagnozi i liječenju infekcije H. pylori kod djece i adolescenata. Pristup “testiraj i liječi” nije opravdan u dječjoj populaciji. Dijagnostičke se pretrage trebaju usmjeriti na otkrivanje uzroka simptoma, a ne na traženje H. pylori. Dijagnozu infekcije treba temeljiti na pozitivnom mikrobiološkom nalazu kulture ili kombinaciji nalaza bakterije u histopatološkom preparatu uz još jedan pozitivan test u bioptatu. Eradikacijska terapija treba se temeljiti na antimikrobnoj osjetljivosti/rezistenciji, koristeći dovoljno visoke doze lijekova tijekom 14 dana. Ako je osjetljivost na antibiotike nepoznata, prva linija terapije uključuje visoku dozu inhibitora protonske pumpe, amoksicilin i metronidazol kroz 14 dana. Nakon provedenog liječenja treba provjeriti eradikaciju koristeći ili C13-urejni izdisajni test ili dokazivanjem antigena u stolici, najmanje četiri tjedna nakon završetka terapije. U slučaju neuspjele eradikacije koristi se druga linija terapije uzimajući u obzir već korištene antibiotike u prvoj liniji i trajanje terapije, a terapiju treba temeljiti na antibiogramu ako je moguće.The characteristics of Helicobacter (H.) pylori infection in children differ from the infection in adults, so diagnostic and treatment approaches are different. In addition, numerous data point to a worrying increase of antibiotic resistance and unsatisfactory eradication rate of H. pylori in children. Due to all this, and since there are only guidelines for adults in Croatia, there is a need for recommendation on diagnosis and treatment of H. pylori infection in children and adolescents. The approach “test and treat” is not justified in children. Diagnostic tests should focus on detecting the cause of symptoms, and not on searching for H. pylori. The diagnosis of infection should be based on positive culture or a combination of finding bacteria on histopathology and one more positive biopsy-based test. The eradication treatment should be based on antimicrobial sensitivity/resistance, using adequate therapy dosages for 14 days. If sensitivity for antibiotics is not known, the first line of therapy includes high dosage of proton pump inhibitors, amoxicillin and metronidazol for 14 days. After treatment, the eradication should be checked using C13-urea breath test or stool antigen test, at least four weeks after therapy. In case of unsuccessful eradication, the second line treatment is used, taking into account antibiotics already used as the first line, duration of therapy, and if possible the treatment should be based on culture and antibiotic sensitivity