Impact of Digestive Diseases on Public Health

Stanovništvo u Hrvatskoj bilježi trend progresivnog starenja i nalazi se u depopulacijskoj fazi prirodnog kretanja, što za posljedicu ima nepovoljan omjer kategorija osiguranika budući da aktivni osiguranici ne čine ni trećinu osiguranih osoba. Unutar skupine entiteta deset vodećih uzroka smrti u ukupnome pučanstvu bilježe se i bolesti probavnog sustava: zloćudne novotvorine kolona, rektuma i anusa (5. mjesto s 3,14%), kronične bolesti jetre, uključivši fi brozu i cirozu (7. mjesto s 2,52%) te zloćudne novotvorine želuca (10. mjesto s 1,94%). U 2004. godini, za razliku od opće/ obiteljske medicine u kojoj bolesti probavnog sustava čine 4,63% u broju zabilježenih bolesti i stanja, u bolničkoj/stacionarnoj djelatnosti ista skupina bolesti čini 9,3% u strukturi hospitalizacija. Ukupni broj hospitaliziranih s bolestima i novotvorinama probavnog sustava pokazuje stalan trend porasta uz posljedicu povećanja korištenja zdravstvenih resursa u dijagnostici, liječenju i rehabilitaciji bolesnika. S obzirom na sve veći utjecaj bolesti probavnog sustava na zdravlje stanovništva nuždan je konsenzus zdravstvenih djelatnika na svim razinama zdravstvene zaštite s ciljem odgovornosti u planiranju i provođenju prevencije, programa ranog otkrivanja te učinkovite dijagnostike i liječenja bolesti i novotvorina probavnog sustava.Croatia is faced with progressive ageing of the population and, consequently, the depopulation phase. This results in the unfavorable ratio of the categories of insurants, with active insurants accounting for less than one third. Digestive diseases belong to the group of ten leading causes of death in Croatia: malignant neoplasms of colon, rectum and anus (ranked 5 with 3.14%); chronic liver diseases, including liver fi brosis and cirrhosis (ranked 7 with 2.52%), and malignant gastric neoplasms (ranked 10 with 1.94%). In 2004, digestive diseases accounted for 4.63% of total number of diagnosed diseases and conditions in general/family medicine. On the other hand, they were responsible for 9.3% of hospitalizations. The total number of hospitalized patients with digestive diseases and neoplasms showed an increasing trend that resulted in the increased use of healthcare resources relating to diagnostics, treatment and rehabilitation. Given an increasing impact of digestive diseases on public health, there is a need for consensus of professionals in primary health care, polyclinic care and inpatient care. The purpose of this consensus is to achieve responsibility for planning and performance of prevention measures, early detection and effective treatment of digestive diseases and neoplasms

Impact of Digestive Diseases on Public Health

Stanovništvo u Hrvatskoj bilježi trend progresivnog starenja i nalazi se u depopulacijskoj fazi prirodnog kretanja, što za posljedicu ima nepovoljan omjer kategorija osiguranika budući da aktivni osiguranici ne čine ni trećinu osiguranih osoba. Unutar skupine entiteta deset vodećih uzroka smrti u ukupnome pučanstvu bilježe se i bolesti probavnog sustava: zloćudne novotvorine kolona, rektuma i anusa (5. mjesto s 3,14%), kronične bolesti jetre, uključivši fi brozu i cirozu (7. mjesto s 2,52%) te zloćudne novotvorine želuca (10. mjesto s 1,94%). U 2004. godini, za razliku od opće/ obiteljske medicine u kojoj bolesti probavnog sustava čine 4,63% u broju zabilježenih bolesti i stanja, u bolničkoj/stacionarnoj djelatnosti ista skupina bolesti čini 9,3% u strukturi hospitalizacija. Ukupni broj hospitaliziranih s bolestima i novotvorinama probavnog sustava pokazuje stalan trend porasta uz posljedicu povećanja korištenja zdravstvenih resursa u dijagnostici, liječenju i rehabilitaciji bolesnika. S obzirom na sve veći utjecaj bolesti probavnog sustava na zdravlje stanovništva nuždan je konsenzus zdravstvenih djelatnika na svim razinama zdravstvene zaštite s ciljem odgovornosti u planiranju i provođenju prevencije, programa ranog otkrivanja te učinkovite dijagnostike i liječenja bolesti i novotvorina probavnog sustava.Croatia is faced with progressive ageing of the population and, consequently, the depopulation phase. This results in the unfavorable ratio of the categories of insurants, with active insurants accounting for less than one third. Digestive diseases belong to the group of ten leading causes of death in Croatia: malignant neoplasms of colon, rectum and anus (ranked 5 with 3.14%); chronic liver diseases, including liver fi brosis and cirrhosis (ranked 7 with 2.52%), and malignant gastric neoplasms (ranked 10 with 1.94%). In 2004, digestive diseases accounted for 4.63% of total number of diagnosed diseases and conditions in general/family medicine. On the other hand, they were responsible for 9.3% of hospitalizations. The total number of hospitalized patients with digestive diseases and neoplasms showed an increasing trend that resulted in the increased use of healthcare resources relating to diagnostics, treatment and rehabilitation. Given an increasing impact of digestive diseases on public health, there is a need for consensus of professionals in primary health care, polyclinic care and inpatient care. The purpose of this consensus is to achieve responsibility for planning and performance of prevention measures, early detection and effective treatment of digestive diseases and neoplasms

Numerical analysis of Wells turbine for wave power conversion

The sea wave energy is one of the high potential renewable energy sources. The Wells turbine as the main part of the Oscillalting Water Column energy plant is analyzed in this paper.  The Wells turbine uses air flow produced by the pressure change inside the oscillating water column. Efficient energy transformation is achieved with the use of self-rectifying Wells air turbine. Since the tangential force of the rotor acts only in one direction even though airflow is oscillating, turbine rotates always in the same direction. Series of numerical simulations are performed using software package FLUENT for the wide span of non-dimensional flow rate coefficient (fi) and employing three different turbulent models. Structured numerical mesh and application of the axisymmetric periodical boundary conditions raised the accuracy of the numerical model while reducing computational load three times compared to the model with the fully meshed domain. Finally, operation of the OWC plant consisting of the air chamber and the turbine was simulated for the Adriatic sea maritime conditions, giving satisfactory energy output considering compact dimension of the whole plant

Uloga standardne video-kromokolonoskopije u razlikovanju adenomatoznih od neadenomatoznih sitnih kolorektalnih polipa

To date, there are no reliable endoscopic criteria to discriminate a diminutive (<5 mm) colorectal adenomatous from nonadenomatous polyps. Studies have demonstrated the usefulness of high-resolution chromoendoscopy (high-resolution colonoscopy with topically applied indigo carmine dye) in discrimination of adenomatous from nonadenomatous colorectal polyps. However, the clinical utility of standard videocolonoscopy and chromoscopy with indigo carmine dye in differentiating diminutive colorectal polyps has not yet been completely defined. The aim of this study was to determine whether a combination of standard videocolonoscopy and staining with indigo carmine dye could differentiate between adenomatous and nonadenomatous colorectal polyps smaller than 5 mm. Colonoscopy by use of an Olympus EVIS 140 video system was performed in 42 patients in whom colorectal polyps smaller than 5 mm were found. Polyps were sprayed with up to 40 ml of 0.5% indigo carmine dye, and polypectomy was performed, and the material was referred for histology. In 42 patients included in the study, 48 polyps sized <5 mm were detected. Histologic analysis showed 14 of them to be adenomatous and 34 nonadenomatous polyps. Endoscopist\u27s diagnosis was confirmed by histology in 12 of 14 (85.7%) adenomatous and 31 of 34 (91.2%) nonadenomatous colorectal diminutive polyps. The sensitivity, specificity, positive predictive value and negative predictive value of standard videochromocolonoscopy in distinguishing between adenomatous and nonadenomatous polyps sized <5 mm were 85.7%, 91.2%, 80% and 93.9%, respectively. The likelihood ratios (LR) were 0.157 (LR-) and 9.74 (LR+). In conclusion, standard videocolonoscopy combined with indigo carmine dye is a reliable method to differentiate adenomatous from nonadenomatous colorectal polyps sized <5 mm. Such a technique could limit the requests for unnecessary biopsies and repeat colonoscopy, thus significantly reducing the cost of colorectal cancer screening.Danas ne postoje pouzdani endoskopski kriteriji koji bi razlikovali sitne (<5 mm) kolorektalne adenomatozne od neadenomatoznih polipa. Ranije su studije pokazale korisnu uporabu visoko-rezolucijske kromoendoskopije (visoko-rezolucijska kolonoskopija s topičkom primjenom indigo crvene boje) u razlikovanju adenomatoznih od neadenomatoznih kolorektalnih polipa. Ipak, klinička upotreba standardne video-kolonoskopije i kromoskopije s indigo crvenom bojom u razlikovanju sitnih kolorektalnih polipa nije još potpuno utvrđena. Namjera ovoga ispitivanja bila je utvrditi može li se kombinacijom standardne video-kolonoskopije i bojanja indigo crvenom bojom razlikovati adenomatozne od neadenomatoznih kolorektalnih polipa manjih od 5 mm. Kolonoskopija uz primjenu video sustava Olympus EVIS 140 izvedena je u 42 bolesnika u kojih su nađeni kolorektalni polipi manji od 5 mm. Polipi su poprskani 0,5%-tnom indigo crvenom bojom u količini do 40 mL, izvedena je polipektomija i provedena histološka analiza. U 42 bolesnika uključenih u ispitivanje nađeno je 48 polipa manjih od 5 mm. Histološka analiza pokazala je postojanje 14 adenomatoznih i 34 neadenomatoznih polipa. Endoskopist je ispravno predvidio histološki nalaz u 12 od 14 (85,7%) adenomatoznih, te u 31 od 34 (91,2%) neadenomatoznih kolorektalnih sitnih polipa.Osjetljivost, specifičnost, pozitivna prediktivna vrijednost i negativna prediktivna vrijednost standardne video-kromokolonoskopije u razlikovanju adenomatoznih od neadenomatoznih polipa manjih od 5 mm bile su 85,7%, 91,2%, 80%, odnosno 93,9%. Omjer vjerojatnosti (LR) iznosio je 0,157 (LR-) i 9,74 (LR+). Standardna video-kolonoskopija u kombinaciji s indigo crvenom bojom pouzdana je metoda za razlikovanje adenomatoznih od neadenomatoznih kolorektalnih polipa manjih od 5 mm. Ovakvom bi se tehnikom mogli smanjiti zahtjevi za nepotrebnim biopsijama i opetovanim kolonoskopijama, te tako značajno sniziti troškovi probiranja na kolorektalni karcinom

Uloga standardne video-kromokolonoskopije u razlikovanju adenomatoznih od neadenomatoznih sitnih kolorektalnih polipa

To date, there are no reliable endoscopic criteria to discriminate a diminutive (<5 mm) colorectal adenomatous from nonadenomatous polyps. Studies have demonstrated the usefulness of high-resolution chromoendoscopy (high-resolution colonoscopy with topically applied indigo carmine dye) in discrimination of adenomatous from nonadenomatous colorectal polyps. However, the clinical utility of standard videocolonoscopy and chromoscopy with indigo carmine dye in differentiating diminutive colorectal polyps has not yet been completely defined. The aim of this study was to determine whether a combination of standard videocolonoscopy and staining with indigo carmine dye could differentiate between adenomatous and nonadenomatous colorectal polyps smaller than 5 mm. Colonoscopy by use of an Olympus EVIS 140 video system was performed in 42 patients in whom colorectal polyps smaller than 5 mm were found. Polyps were sprayed with up to 40 ml of 0.5% indigo carmine dye, and polypectomy was performed, and the material was referred for histology. In 42 patients included in the study, 48 polyps sized <5 mm were detected. Histologic analysis showed 14 of them to be adenomatous and 34 nonadenomatous polyps. Endoscopist\u27s diagnosis was confirmed by histology in 12 of 14 (85.7%) adenomatous and 31 of 34 (91.2%) nonadenomatous colorectal diminutive polyps. The sensitivity, specificity, positive predictive value and negative predictive value of standard videochromocolonoscopy in distinguishing between adenomatous and nonadenomatous polyps sized <5 mm were 85.7%, 91.2%, 80% and 93.9%, respectively. The likelihood ratios (LR) were 0.157 (LR-) and 9.74 (LR+). In conclusion, standard videocolonoscopy combined with indigo carmine dye is a reliable method to differentiate adenomatous from nonadenomatous colorectal polyps sized <5 mm. Such a technique could limit the requests for unnecessary biopsies and repeat colonoscopy, thus significantly reducing the cost of colorectal cancer screening.Danas ne postoje pouzdani endoskopski kriteriji koji bi razlikovali sitne (<5 mm) kolorektalne adenomatozne od neadenomatoznih polipa. Ranije su studije pokazale korisnu uporabu visoko-rezolucijske kromoendoskopije (visoko-rezolucijska kolonoskopija s topičkom primjenom indigo crvene boje) u razlikovanju adenomatoznih od neadenomatoznih kolorektalnih polipa. Ipak, klinička upotreba standardne video-kolonoskopije i kromoskopije s indigo crvenom bojom u razlikovanju sitnih kolorektalnih polipa nije još potpuno utvrđena. Namjera ovoga ispitivanja bila je utvrditi može li se kombinacijom standardne video-kolonoskopije i bojanja indigo crvenom bojom razlikovati adenomatozne od neadenomatoznih kolorektalnih polipa manjih od 5 mm. Kolonoskopija uz primjenu video sustava Olympus EVIS 140 izvedena je u 42 bolesnika u kojih su nađeni kolorektalni polipi manji od 5 mm. Polipi su poprskani 0,5%-tnom indigo crvenom bojom u količini do 40 mL, izvedena je polipektomija i provedena histološka analiza. U 42 bolesnika uključenih u ispitivanje nađeno je 48 polipa manjih od 5 mm. Histološka analiza pokazala je postojanje 14 adenomatoznih i 34 neadenomatoznih polipa. Endoskopist je ispravno predvidio histološki nalaz u 12 od 14 (85,7%) adenomatoznih, te u 31 od 34 (91,2%) neadenomatoznih kolorektalnih sitnih polipa.Osjetljivost, specifičnost, pozitivna prediktivna vrijednost i negativna prediktivna vrijednost standardne video-kromokolonoskopije u razlikovanju adenomatoznih od neadenomatoznih polipa manjih od 5 mm bile su 85,7%, 91,2%, 80%, odnosno 93,9%. Omjer vjerojatnosti (LR) iznosio je 0,157 (LR-) i 9,74 (LR+). Standardna video-kolonoskopija u kombinaciji s indigo crvenom bojom pouzdana je metoda za razlikovanje adenomatoznih od neadenomatoznih kolorektalnih polipa manjih od 5 mm. Ovakvom bi se tehnikom mogli smanjiti zahtjevi za nepotrebnim biopsijama i opetovanim kolonoskopijama, te tako značajno sniziti troškovi probiranja na kolorektalni karcinom

ANTI–TNF THERAPY IN TREATMENT OF LUMINAL CROHN’S DISEASE

Intenzivna terapija primjenom anti-TNF lijekova infliksimaba i adalimumaba u luminalnoj Crohnovoj bolesti može biti učinkovitija od konvencionalne terapije u postizanju i održavanju kliničke remisije, zacijeljenju sluznice te postizanju i održavanju “duboke remisije”. Odluka o početku terapije anti-TNF lijekovima ovisi o nekoliko čimbenika: aktivnosti, težini, lokalizaciji i proširenosti bolesti, o fenotipu i ponašanju bolesti, o pridruženim bolestima i odgovoru na druge terapijske opcije te o mogućim komplikacijama. Sve je više dokaza da je rana intenzivna terapija luminalnog oblika Crohnove bolesti primjenom anti-TNF lijekova i imunosupresiva povezana s povećanom vjerojatnošću cijeljenja sluznice i održavanjem remisije bolesti bez steroida. Također, sve je vise podataka o kliničkim, epidemiološkim i laboratorijskim biljezima u času dijagnoze koji mogu predskazati nepovoljnu prognozu i nastanak teškog oblika bolesti te su bolesnici s nepovoljnim navedenim pokazateljima kandidati za rano započinjanje terapije anti-TNF lijekovima. Kandidati za anti-TNF terapiju su i bolesnici koji nisu odgovorili na konvencionalnu terapiju, bolesnici s umjerenim i teškim oblikom bolesti koji ne podnose steroide, bolesnici u kojih bi primjena steroida izazvala značajne neželjene učinke, bolesnici koji ne žele steroidnu terapiju te bolesnici s potrebom opetovanih ciklusa steroidne terapije.Biologic drugs directed against main proinflammatory mediator in inflammatory bowel disease (IBD) - tumor necrosis factor α (TNF α) – represent very effective and clinically proven therapy of IBD. Meta-analysis and daily clinical practice confirm efficacy of infliximab and adalimumab in induction and maintenance of remission without steroids in patients with luminal Crohn’s disease. Main therapeutic goals are reduction of complications, reduction of number of hospitalizations and surgical interventions and improvement of quality of life, work capacity and reproductive ability of patients. There are few very important issues that one must consider before starting an anti-TNF therapy in patients with luminal Crohn’s disease. First, it is necessary to identify patients who failed to respond to conventional drugs and who would benefit the most from early application of biologics. It is very important to exclude presence of strictures or other complications like intraabdominal fistulas and collections before starting anti-TNF therapy. Once we decide to start biologic therapy, it is important to apply adequate dose and regime of anti-TNF therapy and to change and adjust treatment to achieve and maintain remission in patients who lose response. In general, treatment recommendations depend on disease activity and severity, extension and localization of lesions, comorbidities and possible complications of disease and/or treatment. There are few clinical instruments and laboratory surrogates that help us to assess disease activity. Most used are Crohn’s Disease Activity Index (CDAI), Harvey – Bradshaw index (HBI), concentration of C-reactive protein (CRP) and fecal lactoferrin and calprotectin. In assessment of mucosal injury we rely on two complementary endoscopic indices of activity - Crohn’s Disease Endoscopic Index of Severity (CDEIS) and Simple Endoscopic Score for Crohn’s Disease (CD-SES). However, in time of diagnosis of Crohn’s disease available clinical, serological or laboratory markers do not have acceptably predictive value for future disease behavior and there are still no genetic indicator that could predict disease course. There are some clinical and epidemiologic factors that could be related to unfavorable disease course. Age less than 40 years, extended disease, need for steroid therapy early after diagnosis and perianal disease are considered to predict worse prognosis in patients with luminal Crohn’s disease. According to available data, it seems that early intensive therapy with anti-TNF drugs as monotherapy or in combination with immunosuppressive drugs in this group of patients increases possibility of induction of remission, mucosal healing and maintenance of steroid-free remission. Candidates for anti-TNF therapy are also patients who did not respond to conventional treatment, patients with moderate or severe disease who are intolerant to steroids, patients in whom we expect severe adverse effects from steroid treatment, patients who do not accept steroid treatment and patients with frequent relapses and need for steroids

IMMUNOSENESCENCE, INFLAMMAGING AND RESILIENCE: AN EVOLUTIONARY PERSPECTIVE OF ADAPTATION IN THE LIGHT OF COVID-19 PANDEMIC

The evolution of immunology enabled the study of role of innate and adaptive immunity in systems biology network of immunosenescence and inflammaging. Due to global reduction in birth rates and reduced mortality, in year 2025 there will be about 1.2 billion of people over age of sixty, worldwide. The notion that the real age is not chronological, but the biological one led to the concept of "bioage", defining the biologic reactivity and resilience, including the immune competence of an individual. A competent immune network, systemic and mucosal is intrinsic to resilience and homeostasis of the human holobiont as the unit of evolution. In elderly, the immunosenescence could be associated with higher levels of proinflammatory mediators (such as IL-6), frialty and mortality. Proi-inflammatory state in elderly is denoted as inflammaging, characterized with low-grade (sterile) inflammation, as a physiologic response to life-long antigenic stimuli. When under control, inflammaging could be regarded as an efficient defense mechanism, oposed and regulated by anti-inflammatory pathways and molecules. Immunosensecence. The emerging concepts of "individual immunobiography" and "trained immunity" speak in favour that the immunological experience during the life would shape the ability of each individual to respond to various stimuli, strongly influencing the elements of innate and adaptive immunity, including macrophages and innate lymphoid cells. Older age is one of the main risk factors for the severe clinical picture and adverse outcome of COVID-19 infection, due to immunosenscence and chronic low-grade inflammation (inflammaging), both characterizing the immune reactioin in elderly. The senescent immune system, along with the advanc ed process of inflammaging is prone to react with uncontrolled activation of innate immune response that leads to cytokine release syndrome, tissue damage and adverse outcome of infection. Further research is aimed to nutritional and pharmacologic (immunomodulatory) interventions to influence the process of bioaging and immunosenscence, and to modulate the reaction of elderly to infection, including the COVID-19