Helicobacter pylori resistance as a public health issue

Eradikacija infekcije Helicobacter pylori prvi je korak u liječenju bolesti koje su povezane s ovom infekcijom. U terapijskim protokolima koriste se uobičajeno kombinacije dvaju antibiotika i jednoga lijeka koji suprimira izlučivanje želučane kiseline (inhibitor protonske pumpe – IPP). Kombinacije lijekova podijeljene su u lijekove prve linije, lijekove druge linije i lijekove treće linije, s tim da se u trećoj liniji izbor lijeka zasniva na testiranju osjetljivosti na antibiotik izoliranoga soja H. pylori. Povećana primjena antibiotika dovela je do porasta rezistencije bakterije, te u konačnici do neuspjeha u liječenju. Porast se najviše ogleda u povećanoj rezistenciji na klaritromicin, a novija istraživanja donose podatke o povećanju rezistencije i na levofloksacin. Obzirom da sama bakterija posjeduje izrazitu otpornost na čimbenike okoline, sužen je izbor antibiotika koji bi potencijalno došli u obzir kao lijekovi za eradikaciju. H. pylori je bakterija koja se većim dijelom pojavljuje u nerazvijenim zemljama, u kojima ne postoji učinkovit sustav kontrole nad povećanjem rezistencije. Zbog toga, kao i zbog široke primjene antibiotika uopće, javlja se izazov koji na jednu stranu stavlja eradikaciju infekcije kod zaraženih, a na drugu stranu sve veći postotak rezistencije i samim time neuspješnost liječenja infekcije.Eradication of infection Helicobacter pylori is the first step in curing diseases connected to the infection. The usual combinations of two antibiotics and one drug which suppress the gastric acid secretion (Proton-pump inhibitors – PPI) are used in treatment protocols. Combinations of drugs are divided into first-line drugs, second-line drugs and third-line drugs, taking into account that the choice of drugs in third-line is based on sensibility testing to the antibiotic of isolated strain H. pylori. Increased usage of antibiotics has resulted in greater resistance of the bacteria and finally to failure in treatment. The rise is most evident in increased resistance to clarithromycin, and recent studies show data of increased resistance also to levofloxacin. Considering that the bacteria itself has an extremely high resistance to environmental factors, the choice of antibiotics which could potentially be considered as drugs for eradication is significantly narrowed. H. pylori is a bacterium which is predominant in underdeveloped countries where there is no efficient control system regarding the increase of resistance. Due to that and the wide usage of antibiotics in general, there is a challenge which places eradication of the infection in the already infected patients on one side, and the ever growing resistance which leads to failure of infection treatment on the other side

Correlation between atmospheric air pollution by nitrogen dioxide meteorological parameters and the number of patients admitted to the Emergency Department

Posljednjih godina sve je više saznanja o utjecaju zagađenosti zraka na pojavnost akutnih i kroničnih bolesti. Cilj ovog istraživanja je procjena ovisnosti pojedinih meteoroloških parametara, koncentracije dušikovog dioksida (NO2) u zraku i broja bolesnika koji su se javili u Hitnu službu Interne klinike Kliničkoga bolničkog centra Sestre milosrdnice u Zagrebu u vremenskom razdoblju od dvije godine. Ukupno je pregledano 44.245 bolesnika. U obzir su uzeti promatrani meteorološki parametri (temperatura, tlak zraka i vlaga zraka) tijekom toplijeg i hladnijeg dijela godine, te koncentracije dušikovog dioksida tijekom razdoblja praćenja. Rezultati pokazuju kako je ukupan broj bolesnika koji se javljaju u Hitnu službu najveći ljeti. Ukupan broj bolesnika koji su se javili u Hitnu službu proporcionalno je veći s većom temperaturom zraka i većom koncentracijom dušikovog dioksida, a obrnuto proporcionalan s prosječnom dnevnom vlagom u zraku i atmosferskim tlakom. Uzimajući u obzir doba godine, veći je broj pacijenata primljen u Hitnu službu tijekom ljetnih mjeseci, osobito u danima kada je razina dušikovog dioksida bilavisoka (r = 0,569, p < 0,001) i kada su temperature bile visoke (r = 0,195, p = 0,008). Navedeni rezultati ukazuju na potrebu za daljnjim istraživanjem važnosti fotokemijskih procesa i njihova učinka na ljudsko zdravlje, osobito u kroničnih bolesnika.In recent years there has been more awareness about the impact of air pollution on the incidence of acute and chronic diseases. The aim of this study was to evaluate the correlation of certain meteorological factors, the concentration of nitrogen dioxide (NO2) in the air and the number of patients who were admitted in the Emergency Department of Internal Medicine, Sestre milosrdnice University Hospital Center in Zagreb, over the period of two years. The total number of patients was 44,245. The study took into consideration the observed meteorological parameters (temperature, atmospheric pressure, atmospheric moisture) during the cooler and warmer periods of the year and the nitrogen dioxide concentrations during the study period. The results showed that the total number of patients coming to the Emergency Department was the largest in summer. The correlation of the number of patients admitted to the Emergency Department with meteorological conditions and air pollution parameters showed that the total number of patients in the Emergency Department was proportionally higher with higher temperature (r = 0.164, p < 0.001), higher concentration of nitrogen dioxide (r = 0.219, p < 0.001) and inversely proportional with the average daily moisture (r = -0.116, p = 0.002) and the average daily atmospheric pressure (r = -0.096, p = 0.009). Taking account of the time of the year, more patients were admitted in the Emergency Department in the summer months, especially during days when the value of nitrogen dioxide was high (r = 0.569, p < 0.001), as well as when the temperatures were high (r = 0.195, p = 0.008). According to these results, there is a need for further research into the importance of the photochemical processes and their impact on human health, especially on chronic patients

Use of bendamustin instead of carmustin in autologous stem cell transplantation conditioning – toxicity and infectious complications comparison

Unatrag nekoliko godina u hematologiji i onkologiji globalno sve češći problem postaje prikladna opskrba „starijim i manje zanimljivim“ kemoterapeuticima. Zbog povremene nestašice karmustina, jednog od osnovnih kemoterapeutika pri kondicioniranju prije autologne transplantacije krvotvornih matičnih stanica (ATK S) u oboljelih od limfoma, u našem se centru od 2016. godine on zamjenjuje bendamustinom. U ovom radu retrospektivno analiziramo tijek ATK S-a u 41 bolesnika koji su primili bendamustin u sklopu protokola BeEA M te ga uspoređujemo s tijekom ATK S-a u 40 bolesnika koji su primili karmustin u sklopu protokola BEA M. Medijan oporavka vrijednosti neutrofila (> 0,5 × 109/l) u skupini koja je primila bendamustin iznosio je 11 dana, dok je u skupini kondicioniranoj karmustinom iznosio 10 dana. Medijan oporavka vrijednosti trombocita (> 20 × 109/l) bio je duži kod skupine koja je primala bendamustin (16 prema 13 dana) te su ti bolesnici bili duže ovisni o transfuzijama eritrocita (7 prema 5 dana). Infektivne komplikacije nisu bile češće nakon primjene bendamustina, ali smo nakon primjene karmustina imali veću pojavu mukozitisa II. – III. stupnja (35% prema 12%). Nakon primjene bendamustina zabilježen je jedan slučaj nefrotoksičnosti i kardiotoksičnosti terapije, dok kod primjene karmustina te komplikacije nisu zabilježene. Pri upotrebi bendamustina kod kondicioniranja u naših bolesnika u ovom trenutku nije utvrđena znatnija hematološka toksičnost u odnosu prema karmustinu, ali su prisutni dulji period oporavka vrijednosti trombocita te niža incidencija mukozitisa.Inadequate supply of „old and less interesting“ chemotherapeutic agents is becoming a global issue in hemato-oncology today. In 2016 we were faced with occasional carmustin shortage, one of the most commonly used in autologous transplant conditioning regimens for lymphoma in our centre, so we decided to use bendamustin instead. We performed a retrospective analysis of 41 patients treated at our centre who had received bendamustin within BeEA M protocol and compared them with 40 patients who had received carmustin within BEA M protocol. Both protocols were used as conditioning protocols before autologous stem cell transplantation. Neutrophil recovery median following transplantation (AN C>0,5x109/l) was 11 days in the bendamustin group in comparison to 10 days in the carmustin group.Platelets recovery median following transplantation (PLT>20x109/l) was longer in the bendamustin group (16 vs.13 days) as was blood transfusion dependency (7 vs. 5 days). Infectious complications were not more frequent after bendamustin, but grade II–III mucositis was more frequent in patients who received carmustin (35% vs.12%). Following bendamustin we had one reported case of nephrotoxicity and cardiac toxicity, not reported with carmustin. Bendamustin has shown similar hematologic toxicity compared to carmustin but a longer platelet recovery period and a lower mucositis incidence

PERFORMANCE ASSESSMENT TOOL FOR QUALITY IMPROVEMENT IN HOSPITALS (PATH): FIRST EXPERIENCES IN CROATIA

PATH (Performance Assessment Tool for Quality Improvement in Hospitals), projekt Regionalnog ureda Svjetske zdravstvene organizacije (SZO) za Europu pruža bolnicama sveobuhvatan i standardiziran alat za vrednovanje vlastitih rezultata i razvoj mjera za unapređenje kvalitete. Program PATH pokrenut je 2008. godine i u Hrvatskoj, a od 2009. godine provodi se u bolnicama koje su se dobrovoljno odlučile u njega uključiti. U ovom radu prikazujemo prva iskustva probne faze uspostavljanja programa PATH, utemeljena na podacima koji su prikupljani u 22 hrvatske bolnice. Analiza prvih rezultata upozorila je na postojanje izraženih razlika među bolnicama, koje su se na primjeru postotka carskih rezova kretale od najmanje 1,1% do najviše 21,4% zabilježenih carskih rezova u pojedinim bolnicama tijekom razdoblja prikupljanja podataka. Stopa smrtnosti infarkta miokarda kretala se od 1,9 do 21,4%, dok se smrtnost moždanog udara kretala od 12,5 do 45,5%. Najviši postotak prijavljenih ubodnih ozljeda za liječnike iznosio je 16,2% osoblja tijekom jedne godine, 6,1% za medicinske sestre i 4,6% za spremačice. Ovo istraživanje upućuje na postojanje mnogih problema i ograničenja u prikupljanju pokazatelja na bolničkoj razini, njihovoj analizi i stvaranju preporuka za unapređenje kvalitete koje se moraju uzeti u obzir prilikom usporedbe bolnica na nacionalnoj ili međunarodnoj razini.PATH (Performance Assessment Tool for Quality Improvement in Hospitals), a project of the World Health Organization (WHO) for Europe offers hospitals a comprehensive and standardized tool (a set of indicators) to evaluate their own performance and development of measures for quality improvement. PATH Program was launched in Croatia in 2008, and it was conducted in 2009 in hospitals that have voluntarily decided to be involved. Here we present the results of the first phase of pilot experience of establishing the program, based on data collected in 22 Croatian hospitals. Analysis of the first results indicated the existence of marked differences among the hospitals that have taken the example of the percentage of cesarean sections ranging from 1.1% to 21.4%. The mortality rate of myocardial infarction ranged from 1.9 to 21.4%, while the mortality of stroke ranged from 12.5 to 45.5%. The highest percentage of needle-stick injuries reported for physicians was 16.2% of entire hospital staff in one year, 6.1% for nurses and 4.6% for the supportive staff. The result suggests the existence of many problems and limitations in data collection at hospital level, limitations in their analysis and creates recommendations for quality improvements, which must be taken into account when hospitals are compared on the national or international level

Techniques and methods of teaching ultrasound examination of the inferior vena cava for the purpose of central venous pressure and volume status assessment

U ovom istraživanju pokušali smo procijeniti broj pregleda ultrazvukom potrebnih da student medicine nakon praktične i teorijske obuke dosegne zadovoljavajuću razinu u procjenjivanju centralnog venskog tlaka (CVT) pregledom donje šuplje vene (DŠV) ultrazvukom. Također smo provjerili je li neki od pristupa za dobivanje slike superiorniji nad ostalima. Promjer DŠV mjeren je u inspiriju i ekspiriju pristupom iz epigastrija i interkostalnim pristupom. U oba pristupa DŠV je mjerena na poprečnom i uzdužnom prikazu. Svakog bolesnika ultrazvukom su pregledali student i iskusni liječnik vičan ultrazvuku. Za svaki pristup su procijenili CVT na temelju promatranja kolabiranja donje šuplje vene tijekom disanja te proveli mjerenja promjera vene i na temelju njih procijenili tlak koristeći ASE tablicu. Niti jedan ispitivač nije imao uvid u rezultate drugog ispitivača kao niti u vrijednost CVT-a izmjerenog pomoću postavljenog centralnog venskog katetera. U istraživanje je bilo uključeno 30 bolesnika. Nakon prvih 15 bolesnika podudaranje između studenta i specijalista prema Cohenovom kapa koeficijentu se nalazilo u stupnju blagoga podudaranja kako za slobodnu procjenu kategorije CVT-a tako i za mjerenja u B i M modu ultrazvuka, a nakon pregledanih idućih 15 bolesnika podudaranje se poboljšalo do stupnja umjerenog podudaranja oba ispitivača za slobodnu procjenu i za mjerenja u B i M modu. Nakon 30 pregleda ultrazvukom student je poboljšao svoje sposobnosti procjene CVTa na temelju pregleda DŠV ultrazvukom. Niti iskusni specijalist nije pokazao da može precizno procijeniti CVT ovom metodom u populaciji intenzivističkih bolesnika u kojih osim volemije i drugi čimbenici utječu na promjer DŠV. Stoga nije moguće sa sigurnošću procijeniti studentovu osposobljenost za upotrebu ove metode nakon pregledanih 30 bolesnika. Slobodna procjena pokazala se manje uspješnom za predikciju CVT-a nego metoda temeljena na mjerenjima. Različite metode mjerenja, uz uzdužni ili poprečni prikaz DŠV, iz epigastrija ili interkostalnim pristupom, te u B ili u M modu nisu pokazale značajnu međusobnu razliku.The aim of this study was to assess the number of ultrasound examinations needed for the medical student to reach a reasonable level of proficiency in ultrasonic evaluation of central venous pressure (CVP), and to check the value of different inferior vena cava (IVC) assessment methods in CVP estimation. The diameter of the IVC in the inspiration and the expiration was evaluated and measured by the epigastric and the intercostal approach, showing the transverse and longitudinal section in the B and M modes. Without insight into the value of CVP and the results of other examiner, a student and a specialist experienced in ultrasonography examined each patient. CVP was predicated by free evaluation and by the reading from the ASE table based on the measurements. Neither examiner had insight into other examiners results nor had the examiners insight into the CVP measured via the central venous catheter. Thirty patients were included in the study. After the first 15 patients, the agreement between the student’s and the specialist’s categorization of CVP according to the Cohen’s kappa coefficient was in a slight degree for both the free evaluation of CVP and B and M mode. After the examination of the next 15 patients, the agreement was in the fair degree for both the free evaluation of CVP and B and M mode. After 30 ultrasound examinations the student improved his capabilities of assessing CVP based on ultrasonic evaluation of IVC. Experienced specialist, as well as student, wasn’t efficient in accurate assessment of CVP by this method in the population of adult intensive care unit patients that, besides volume status, had other factors that influence the diameter of IVC. Therefore it is not possible to assess the student’s capabilities of using this method with certainty after examining 30 patients. The free estimate was found to be less accurate in CVP prediction than the measurement of the IVC diameter. With the respect to the CVP prediction, no significant differences were found between the measurements in the longitudinal or transverse plane as well as between examinations from the epigastrium or intercostal spaces. This was found in both B and M mode

Techniques and methods of teaching ultrasound examination of the inferior vena cava for the purpose of central venous pressure and volume status assessment

U ovom istraživanju pokušali smo procijeniti broj pregleda ultrazvukom potrebnih da student medicine nakon praktične i teorijske obuke dosegne zadovoljavajuću razinu u procjenjivanju centralnog venskog tlaka (CVT) pregledom donje šuplje vene (DŠV) ultrazvukom. Također smo provjerili je li neki od pristupa za dobivanje slike superiorniji nad ostalima. Promjer DŠV mjeren je u inspiriju i ekspiriju pristupom iz epigastrija i interkostalnim pristupom. U oba pristupa DŠV je mjerena na poprečnom i uzdužnom prikazu. Svakog bolesnika ultrazvukom su pregledali student i iskusni liječnik vičan ultrazvuku. Za svaki pristup su procijenili CVT na temelju promatranja kolabiranja donje šuplje vene tijekom disanja te proveli mjerenja promjera vene i na temelju njih procijenili tlak koristeći ASE tablicu. Niti jedan ispitivač nije imao uvid u rezultate drugog ispitivača kao niti u vrijednost CVT-a izmjerenog pomoću postavljenog centralnog venskog katetera. U istraživanje je bilo uključeno 30 bolesnika. Nakon prvih 15 bolesnika podudaranje između studenta i specijalista prema Cohenovom kapa koeficijentu se nalazilo u stupnju blagoga podudaranja kako za slobodnu procjenu kategorije CVT-a tako i za mjerenja u B i M modu ultrazvuka, a nakon pregledanih idućih 15 bolesnika podudaranje se poboljšalo do stupnja umjerenog podudaranja oba ispitivača za slobodnu procjenu i za mjerenja u B i M modu. Nakon 30 pregleda ultrazvukom student je poboljšao svoje sposobnosti procjene CVTa na temelju pregleda DŠV ultrazvukom. Niti iskusni specijalist nije pokazao da može precizno procijeniti CVT ovom metodom u populaciji intenzivističkih bolesnika u kojih osim volemije i drugi čimbenici utječu na promjer DŠV. Stoga nije moguće sa sigurnošću procijeniti studentovu osposobljenost za upotrebu ove metode nakon pregledanih 30 bolesnika. Slobodna procjena pokazala se manje uspješnom za predikciju CVT-a nego metoda temeljena na mjerenjima. Različite metode mjerenja, uz uzdužni ili poprečni prikaz DŠV, iz epigastrija ili interkostalnim pristupom, te u B ili u M modu nisu pokazale značajnu međusobnu razliku.The aim of this study was to assess the number of ultrasound examinations needed for the medical student to reach a reasonable level of proficiency in ultrasonic evaluation of central venous pressure (CVP), and to check the value of different inferior vena cava (IVC) assessment methods in CVP estimation. The diameter of the IVC in the inspiration and the expiration was evaluated and measured by the epigastric and the intercostal approach, showing the transverse and longitudinal section in the B and M modes. Without insight into the value of CVP and the results of other examiner, a student and a specialist experienced in ultrasonography examined each patient. CVP was predicated by free evaluation and by the reading from the ASE table based on the measurements. Neither examiner had insight into other examiners results nor had the examiners insight into the CVP measured via the central venous catheter. Thirty patients were included in the study. After the first 15 patients, the agreement between the student’s and the specialist’s categorization of CVP according to the Cohen’s kappa coefficient was in a slight degree for both the free evaluation of CVP and B and M mode. After the examination of the next 15 patients, the agreement was in the fair degree for both the free evaluation of CVP and B and M mode. After 30 ultrasound examinations the student improved his capabilities of assessing CVP based on ultrasonic evaluation of IVC. Experienced specialist, as well as student, wasn’t efficient in accurate assessment of CVP by this method in the population of adult intensive care unit patients that, besides volume status, had other factors that influence the diameter of IVC. Therefore it is not possible to assess the student’s capabilities of using this method with certainty after examining 30 patients. The free estimate was found to be less accurate in CVP prediction than the measurement of the IVC diameter. With the respect to the CVP prediction, no significant differences were found between the measurements in the longitudinal or transverse plane as well as between examinations from the epigastrium or intercostal spaces. This was found in both B and M mode

Techniques and methods of teaching ultrasound examination of the inferior vena cava for the purpose of central venous pressure and volume status assessment

U ovom istraživanju pokušali smo procijeniti broj pregleda ultrazvukom potrebnih da student medicine nakon praktične i teorijske obuke dosegne zadovoljavajuću razinu u procjenjivanju centralnog venskog tlaka (CVT) pregledom donje šuplje vene (DŠV) ultrazvukom. Također smo provjerili je li neki od pristupa za dobivanje slike superiorniji nad ostalima. Promjer DŠV mjeren je u inspiriju i ekspiriju pristupom iz epigastrija i interkostalnim pristupom. U oba pristupa DŠV je mjerena na poprečnom i uzdužnom prikazu. Svakog bolesnika ultrazvukom su pregledali student i iskusni liječnik vičan ultrazvuku. Za svaki pristup su procijenili CVT na temelju promatranja kolabiranja donje šuplje vene tijekom disanja te proveli mjerenja promjera vene i na temelju njih procijenili tlak koristeći ASE tablicu. Niti jedan ispitivač nije imao uvid u rezultate drugog ispitivača kao niti u vrijednost CVT-a izmjerenog pomoću postavljenog centralnog venskog katetera. U istraživanje je bilo uključeno 30 bolesnika. Nakon prvih 15 bolesnika podudaranje između studenta i specijalista prema Cohenovom kapa koeficijentu se nalazilo u stupnju blagoga podudaranja kako za slobodnu procjenu kategorije CVT-a tako i za mjerenja u B i M modu ultrazvuka, a nakon pregledanih idućih 15 bolesnika podudaranje se poboljšalo do stupnja umjerenog podudaranja oba ispitivača za slobodnu procjenu i za mjerenja u B i M modu. Nakon 30 pregleda ultrazvukom student je poboljšao svoje sposobnosti procjene CVTa na temelju pregleda DŠV ultrazvukom. Niti iskusni specijalist nije pokazao da može precizno procijeniti CVT ovom metodom u populaciji intenzivističkih bolesnika u kojih osim volemije i drugi čimbenici utječu na promjer DŠV. Stoga nije moguće sa sigurnošću procijeniti studentovu osposobljenost za upotrebu ove metode nakon pregledanih 30 bolesnika. Slobodna procjena pokazala se manje uspješnom za predikciju CVT-a nego metoda temeljena na mjerenjima. Različite metode mjerenja, uz uzdužni ili poprečni prikaz DŠV, iz epigastrija ili interkostalnim pristupom, te u B ili u M modu nisu pokazale značajnu međusobnu razliku.The aim of this study was to assess the number of ultrasound examinations needed for the medical student to reach a reasonable level of proficiency in ultrasonic evaluation of central venous pressure (CVP), and to check the value of different inferior vena cava (IVC) assessment methods in CVP estimation. The diameter of the IVC in the inspiration and the expiration was evaluated and measured by the epigastric and the intercostal approach, showing the transverse and longitudinal section in the B and M modes. Without insight into the value of CVP and the results of other examiner, a student and a specialist experienced in ultrasonography examined each patient. CVP was predicated by free evaluation and by the reading from the ASE table based on the measurements. Neither examiner had insight into other examiners results nor had the examiners insight into the CVP measured via the central venous catheter. Thirty patients were included in the study. After the first 15 patients, the agreement between the student’s and the specialist’s categorization of CVP according to the Cohen’s kappa coefficient was in a slight degree for both the free evaluation of CVP and B and M mode. After the examination of the next 15 patients, the agreement was in the fair degree for both the free evaluation of CVP and B and M mode. After 30 ultrasound examinations the student improved his capabilities of assessing CVP based on ultrasonic evaluation of IVC. Experienced specialist, as well as student, wasn’t efficient in accurate assessment of CVP by this method in the population of adult intensive care unit patients that, besides volume status, had other factors that influence the diameter of IVC. Therefore it is not possible to assess the student’s capabilities of using this method with certainty after examining 30 patients. The free estimate was found to be less accurate in CVP prediction than the measurement of the IVC diameter. With the respect to the CVP prediction, no significant differences were found between the measurements in the longitudinal or transverse plane as well as between examinations from the epigastrium or intercostal spaces. This was found in both B and M mode