Ivan Budimir

Glasgow Blatchford, pre-endoscopic Rockall and AIMS65 scores show no difference in predicting rebleeding rate and mortality in variceal bleeding

Abstract Objective: To compare the performance of the Glasgow Blatchford score (GBS), pre-endoscopic Rockall score (PRS) and AIMS65 score in predicting specific clinical endpoints following variceal upper gastrointestinal hemorrhage (UGIH). Material and methods: Between January 2008 and December 2013, we retrospectively analyzed 225 consecutive hospitalized patients managed for endoscopically confirmed UGIH. Results: A total of 225 patients (mean age 61.3 years), mostly diagnosed with alcoholic cirrhosis (195/86.7%), presented with variceal UGIH during the study period. Rebleeding occurred in 22 (9.8%) patients and 30-day mortality was 39 (17.3%). Initial hemostasis was achieved with N-butyl cyanoacrylate (151/79.1%) and endoscopic variceal ligation (40/20.9%), while secondary rebleeding prophylaxis in 110 (48.9%) patients was accomplished using endoscopic variceal ligation (92%). The majority of patients died from the underlying disease, while 12 (30.8%) died from bleeding. Median hospital stay was 6 (1–35) days. There was no statistically significant difference among AIMS65, GBS and PRS in predicting mortality (AUROC 0.70 vs. 0.64 vs. 0.66) or rebleeding rates (AUROC 0.74 vs. 0.60 vs. 0.67). The GBS was superior in predicting the need for blood transfusion compared to AIMS65 score (AUROC 0.75 vs. 0.61, p = 0.01) and PRS (AUROC 0.75 vs. 0.58, p = 0.009). Conclusions: The AIMS65, GBS and PRS scores are comparable but not useful for predicting outcome in patients with variceal UGIH because of poor discriminative ability. The GBS is superior in predicting the need for transfusion compared to AIMS65 score and PRS.

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

AIM To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer. METHODS Between January 2005 and December 2009, 150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed (Forrest IIa) were included in the study. Patients were randomized to receive a small-volume epinephrine group (15 to 25 mL injection group; Group 1, n = 50), a large-volume epinephrine group (30 to 40 mL injection group; Group 2, n = 50) and a hemoclip group (Group 3, n = 50). The rate of recurrent bleeding, as the primary outcome, was compared between the groups of patients included in the study. Secondary outcomes compared between the groups were primary hemostasis rate, permanent hemostasis, need for emergency surgery, 30 d mortality, bleeding-related deaths, length of hospital stay and transfusion requirements. RESULTS Initial hemostasis was obtained in all patients. The rate of early recurrent bleeding was 30% (15/50) in the small-volume epinephrine group (Group 1) and 16% (8/50) in the large-volume epinephrine group (Group 2) (P = 0.09). The rate of recurrent bleeding was 4% (2/50) in the hemoclip group (Group 3); the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution (P = 0.0005 and P = 0.045, respectively). Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups. CONCLUSION Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.

Decrease in insulin resistance has a key role in improvement of metabolic profile during intragastric balloon treatment

To the Editor, Obesity is a chronic polygenic disease in most cases [1]. Despite the different pathogenesis, all obese individuals have something in common: low growth hormone (GH) levels and increased insulin levels [2]. This hormonal imbalance plays an important role in other metabolic disorders, such as glucose intolerance and dyslipidemia. Adipose tissue mass is also important factor. It is an endocrine organ that secrets several metabolic hormones and proinflammatory cytokines. The intensity of their secretion positively correlates with adipose tissue mass [3]. Weight loss improves metabolic profile, although the exact mechanism is poorly understood. A detailed study regarding this matter was published only 1 year ago. The authors disclosed that diet-induced weight loss increases GH and ghrelin levels and decreases insulin and leptin levels [2]. However, neither one study analyzed parallel changes in metabolic hormones and metabolic profile in short time intervals during weight loss. Hence, the exact causative relations between these hormones are unknown. BioEnterics intragastric balloon (BIB) is a endoscopic method in obesity treatment. The balloon placed in the stomach delays stomach emptying and enhances the feeling of satiety [4]. We aimed to investigate changes in serum insulin, C-peptide, GH, blood glucose, glycated hemoglobin, insulin resistance and lipid profile in first, third and sixth month after BIB placement. Since our previous study showed that the change in ghrelin and leptin levels during BIB treatment considerably depends on body mass index (BMI) [5], we analyzed those changes separately in obese (BMI \40 kg/m) and morbid obese (BMI \40 kg/m) patients.

Changes in metabolic hormones after bariatric surgery and their predictive impact on weight loss

Although various metabolic hormones have been implicated in bariatric‐related weight loss, their use as predictors of weight loss is unknown. Our study evaluates changes in metabolic hormones after bariatric surgery, and their role as predictors of weight loss.

Biliary leakage after urgent cholecystectomy: Optimization of endoscopic treatment

AIM To investigate the results of endoscopic treatment of postoperative biliary leakage occurring after urgent cholecystectomy with a long-term follow-up. METHODS This is an observational database study conducted in a tertiary care center. All consecutive patients who underwent endoscopic retrograde cholangiography (ERC) for presumed postoperative biliary leakage after urgent cholecystectomy in the period between April 2008 and April 2013 were considered for this study. Patients with bile duct transection and biliary strictures were excluded. Biliary leakage was suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. Procedural and main clinical characteristics of all consecutive patients with postoperative biliary leakage after urgent cholecystectomy, such as indication for cholecystectomy, etiology and type of leakage, ERC findings and post-ERC complications, were collected from our electronic database. All patients in whom the leakage was successfully treated endoscopically were followed-up after they were discharged from the hospital and the main clinical characteristics, laboratory data and common bile duct diameter were electronically recorded. RESULTS During a five-year period, biliary leakage was recognized in 2.2% of patients who underwent urgent cholecystectomy. The median time from cholecystectomy to ERC was 6 d (interquartile range, 4-11 d). Endoscopic interventions to manage biliary leakage included biliary stent insertion with or without biliary sphincterotomy. In 23 (77%) patients after first endoscopic treatment bile flow through existing surgical drain ceased within 11 d following biliary therapeutic endoscopy (median, 4 d; interquartile range, 2-8 d). In those patients repeat ERC was not performed and the biliary stent was removed on gastroscopy. In seven (23%) patients repeat ERC was done within one to fourth week after their first ERC, depending on the extent of the biliary leakage. In two of those patients common bile duct stone was recognized and removed. Three of those seven patients had more complicated clinical course and they were referred to surgery and were excluded from long-term follow-up. The median interval from endoscopic placement of biliary stent to demonstration of resolution of bile leakage for ERC treated patients was 32 d (interquartile range, 28-43 d). Among the patients included in the follow-up (median 30.5 mo, range 7-59 mo), four patients (14.8%) died of severe underlying comorbid illnesses. CONCLUSION Our results demonstrate the great efficiency of the endoscopic therapy in the treatment of the patients with biliary leakage after urgent cholecystectomy.

North vs south differences in acute peptic ulcer hemorrhage in Croatia: hospitalization incidence trends, clinical features, and 30-day case fatality.

Aim To assess the seven-year trends of hospitalization incidence due to acute peptic ulcer hemorrhage (APUH) and associated risk factors, and examine the differences in these trends between two regions in Croatia. Methods The study collected sociodemographic, clinical, and endoscopic data on 2204 patients with endoscopically confirmed APUH who were admitted to the Clinical Hospital Center “Sestre Milosrdnice,” Zagreb and Clinical Hospital Center Split between January 1, 2005 and December 31, 2011. We determined hospitalization incidence rates, 30-day case fatality rate, clinical outcomes, and incidence-associated factors. Results No differences were observed in APUH hospitalization incidence rates between the regions. Age-standardized one-year cumulative APUH hospitalization incidence rate calculated using the European Standard Population was significantly higher in Zagreb than in Split region (43.2/100 000 vs 29.2/100,000). A significantly higher APUH hospitalization incidence rates were observed in the above 65 years age group. Overall 30-day case fatality rate was 4.9%. Conclusion The hospitalization incidence of APUH in two populations did not change over the observational period and it was significantly higher in the Zagreb region. The incidence of acute duodenal ulcer hemorrhage also remained unchanged, whereas the incidence of acute gastric ulcer hemorrhage increased. The results of this study allow us to monitor epidemiological indicators of APUH and compare data with other countries.

Changes in pulmonary artery systolic pressure correlate with radiographic severity and peripheral oxygenation in adults with community‐acquired pneumonia

The aim of this prospective observational study was to evaluate the relationship between changes in pulmonary artery systolic pressure (ΔPASP) and both severity of community‐acquired pneumonia (CAP) and changes in peripheral blood oxygen partial pressure (PaO2).

Aesthetic Value of Mirror Symmetry in Graphic Design

The paper presents the results of the research on the manifestation of the chromatic effect crispening, where the primary stimuli are designed as squares in the blue-green color with the values of 55% RTV and 65% RTV, while the secondary stimuli are designed as backgrounds in the purple color and their variations are made in the values of 25% RTV, 50 % RTV, 75% RTV and 100% RTV that surrounds the primary stimuli. Ten respondents of both sexes participated in the research. They had the task to match on a computer screen through the binocular harmonization technique the test primary stimuli with the referential stimuli, so that the test primary stimuli are perceived the same or equal to the referential primary stimuli. The intensity of the effect was determined and presented in the CIEDE00 system. The results of the research show that the intensity of the effect was more pronounced on the test primary stimuli of 65% RTV, where the deviations in the perception of color were more pronounced. The smallest deviation was measured on the primary stimulus of 55% RTV with the background of 75% RTV, which is also a recommendation to the designers when creating a conceptual solution with the combination of pairs presented in this paper.The machine printing and rapid cultural development in Europe begins with the discovery of metal lettering at the end of the 15th century. This printing technique has been named the letterpress printing and is one of the greatest inventions of mankind. The development of printing was one of the main indicators of the development of individual countries. We believe that today in the world and in Europe the Croatian development of that age is significantly neglected. This paper presents European development and development in Croatia. This paper will contribute to a more accurate evaluation of Croatian printing and cultural level of that time by displayingCroatian achievements of that era, the printing staff, printed works and printing houses, throughout European and Croatian development of printing.This paper presents a novel highly directive ultra-wide band antenna for using in microwave imaging systems. Defected Ground Structure (DGS) is incorporated in the top and side of the ground plane to enhance the bandwidth impedance matching. Subsequently, for the further improvement in the bandwidth, gain and directivity staircase slot and square slot is etched at the bottom and top edge of the square patch plane. The low-frequency performance of the proposed antenna can be achieved by adjusting the gap between the ground and patch plane. The proposed microstrip antenna is fabricated on a Flame Retardant (FR4) plate of laminate substrate with dielectric constant of 4.3. The result shows that a directivity of 2.2-8.4dBi is achieved across a bandwidth from 1.43-8.92GHz. Furthermore, gain, directivity, radiation pattern characteristic and reflection coefficient have also been analyzed at the different resonant frequency.The most important role of packaging is protecting a product, but also stimulating purchasing decision. Products on store shelfs can often be found packaged in different materials, even when they are of the same net weight. This study investigated how different packaging materials affect purchasing decision. The aim was to evaluate the user’s tendency towards a particular packaging material in relation to its functionality and environmental protection. Test samples were three common powder products: instant coffee, cocoa and sugar. Respondents’ task was to select one of the following packaging materials: glass, tin and composite material for coffee; rigid and flexible plastics for cocoa and sugar. The results showed that the user’s tendency towards packaging material is influenced by packaging functionality. In addition, technical (protection, recyclability) and ergonomic (presence of the lid, easy to dose and reusability) attributes have found to be essential criteria for the choice of packaging. Furthermore, this study showed that customers are ecologically aware since they tend to re-use the packaging, thus enhancing environmental care.Unique Arabic typography has different applications in local newspapers whether traditional newspapers or online forms. It started as an art and developed as a science which has been utilized to improve the way of communicating ideas. In Egyptian newspapers, typography has been used as a medium for transmitting news with roughly similar identities among different newspapers. This similarity has been reflected clearly in online newspaper versions due to either missing the visual identity criteria or technological deficiencies, or both. This study tries to explore three main Egyptian national newspapers’ visual identity as represented in their Arabic typography traditionally and via the web. The paper also discusses the readers’ and designers’ feedback regarding visual identity and technological changes in a bid to rebrand online newspaper visual identity.

The intensity of the background visual effect of crispening depending on background lightness

The paper presents the results of a research of the background visual effect of crispening depending on background lightness. An research on graphic reproductions with specifically designed solutions that involve the mentioned effect was conducted. Reproductions were designed through the variations of four different types of background lightness of 25%, 50%, 75% and 100% RTV (secondary stimuli), on which there are internal rectangles of lightness of 45%, 50% and 55% RTV (primary stimuli). The visual experiment was carried out through the use of the technique of simultaneous binocular harmonization with a 10 respondents. The ANOVA with repeated measures revealed statistically differences between the arithmetic means of variations in lightness for four variations of the background in all three primary stimuli. Further post-hoc analysis by Fisher identified the groups that mutually differ. The results indicate the regularities to which the effect of crispening is subjected in the selected graphic medium.

Portal systemic shunt between the hepatic portal vein and right renal vein in a patient with multifocal hepatocellular carcinoma: Case report

Portal hypertension is a clinical syndrome characterized by the development of collateral circulation and portosystemic shunts, as well as ascites and hepatic encephalopathy. We present the case of a large portosystemic shunt between the hepatic portal vein and aneurysmal right renal vein in a cirrhotic 64‐year‐old man with thrombosis of the portal vein and hepatocellular carcinoma. This is a very rare clinical manifestation which, to our knowledge, has been described only once previously in the literature.