Assessment of heavy metal pollutants accumulation in the Tisza river sediments.

In this study we have worked on the evaluation of heavy metal contamination in the sediments taken from the Tisza River and its tributaries, and thereby used the sequential extraction method, geochemical normalization, the calculation of the enrichment factor (EF), and the methods of statistical analysis. The chemical fractionation of Ni, Cu, Zn, Cr, Pb, Fe, and Mn, carried out by using the modified Tessier method, points to different substrates and binding mechanisms of Cu, Zn and Pb in sediments of the tributaries and sediments of the Tisza River. The similarities in the distributions of Fe and Ni in all types of sediments are the result of geochemical similarity as well as of the fact that natural sources mainly affect the concentration levels of these elements. The calculated enrichment factors (EF, measured metal vs. background concentrations) indicated that metal contamination (Cu, Pb, Zn and Cr) was recorded in the sediments of the Tisza River, while no indications of pollution were detected in the tributaries of the Tisza River and the surrounding pools. The maximum values of the EF were close to 6 for Cu and Pb (moderately severe enrichment) and close to 4.5 for Zn (indicating moderate enrichment). It can be said that the Tisza River is slightly to moderately severely polluted with Cu, Zn, and Pb, and minorly polluted with Cr. It is concluded that sediments of the Tisza serve as a repository for heavy metal accumulation from adjacent urban and industrial areas.

Early cardiac rupture following streptokinase in patients with acute myocardial infarction: retrospective cohort study.

AIM: To assess the incidence and timing of cardiac rupture following streptokinase (SK) administration in acute myocardial infarction (AMI). METHODS: We analyzed retrospectively the clinical sheets of AMI patients treated at the Coronary Care Unit in University Hospital Split, Croatia, between January 1, 1996, and December 31, 1998. We selected the patients who died after SK administration (1.5 million U in a 30 min iv. infusion), with a discharge diagnosis of "AMI" and "cardiac tamponade - ventricular rupture". AMI was defined by typical chest pain, ECG, and/or enzymatic changes. Echo or autopsy verified diagnosis of cardiac tamponade and/or rupture, as well as pericardial effusion and/or free-wall rupture. RESULTS: Out of 726 AMI patients, 136 (18.7%) were treated with SK, and 6 had cardiac rupture (4 men and 2 women; 4.4%). Autopsy revealed that 1 patient had ischemic and 2 had transmural hemorrhagic AMI. Three out of 6 patients died 2-4, and 3 died 5-7 hours after SK administration. Six patients who died from cardiac rupture (mean age 72.3+/-9.0) were significantly older than AMI survivors treated with SK (121 patients, mean age 60.5+/-12.0 years, p<0.001). CONCLUSION: In case of unexplained clinical deterioration in AMI patients over 70 during the first hours after SK administration, cardiac tamponade due to a free-wall rupture should be suspected. SK administration in patients with AMI over 70 years should be a selective and not a routine treatment.

Diuretic effects of furosemide infusion versus bolus injection in congestive heart failure.

In a randomized, single-blind, crossover clinical trial, the diuretic efficacy of the same total dose of furosemide (2 x 40 mg) administered in either conventional intravenous bolus injection or continuous infusion was studied in 20 patients (nine males and 11 females), aged 37-75 years, with congestive heart failure. Furosemide infusion, administered first, produced a significantly greater diuresis than the bolus when compared with baseline (86%: 29.6%; p = 0.029). This was followed by a similar increase in 24-h urinary sodium, potassium and chloride excretion, with no significant difference from the bolus effect. The following day, diuretic and saluretic effects of furosemide did not differ significantly between the study groups. Nevertheless, when continuous furosemide infusion was administered first, it produced a greater increase in urinary volume, 24-h urinary sodium, potassium and chloride than when bolus injection was applied the next day. Conversely, when furosemide bolus was administered first, followed by the infusions the next day, the effects were almost equal, regardless of the mode of administration. It is concluded that in the treatment of refractory edema in patients with congestive heart failure, continuous intravenous infusion of furosemide is superior to the conventional intermittent bolus injection, especially if it is administered at the very beginning of the hospital treatment, and presumably is even better with higher dosage and longer infusion time span.

Comparison of chlorthalidone, propranolol and bopindolol in six-month treatment of arterial hypertension.

The aim of this study was to test the hypothesis that prolonged treatment of mild to moderate hypertension with low-dose thiazide diuretics or beta blockers does not induce any of the major untoward biochemical changes, such as hypertriglyceridemia, hypercholesterolemia, hyperuricemia and electrolyte imbalances. The effect of these drugs was analyzed in 100 outpatients (52 males and 48 females) aged 52.0 +/- 7.9 years with mild to moderate hypertension, in a prospective 6-month study. After an appropriate workup, the patients were randomized to either 25 mg chlorthalidone (40 patients), 120 mg propranolol (30 patients), or 2 mg per day bopindolol (30 patients). A significant reduction of approximately 10% in systolic and diastolic blood pressure was recorded in all the groups. At the end of the 6th month, in the chlorthalidone group triglycerides increased to 3.0 +/- 2.1 mmol/l from 2.8 +/- 1.6 mmol/l, while cholesterol after an initial increase to 6.6 +/- 1.6 from 6.4 +/- 1.6 mmol/l returned to the baseline level. Uricemia and serum potassium concentration decreased by 4%. The body weight was reduced to 83.8 +/- 13.4 kg from 86.1 +/- 13.4 kg. There was no change in serum glucose level. In the propranolol group, as expected, heart rate decreased by 20%, but there were no significant changes in glucose and potassium plasma concentration. Triglycerides did not change significantly, while cholesterol, after a small increase, returned to the initial levels. Similar results were obtained in the bopindolol group, apart from the triglycerides, which increased significantly (to 2.5 +/- 1.1 from 2.2 +/- 0.4 mmol/l), probably because of the lower baseline concentration. We conclude that in prolonged treatment, chlorthalidone, propranolol and bopindolol do not induce significant untoward biochemical changes that alone might increase cardiovascular risk.

[Occurrence of thromboembolic complications in patients with dilated cardiomyopathy. Retrospective-prospective study]. / Ucestalost tromboembolijskih komplikacija u bolesnika s dilatacijskom kardiomiopatijom. Retrospektivno-prospektivna studija.

The purpose of the present study was to determine the prevalence of thromboembolic events in patients with primary and secondary (ischemic) dilated cardiomyopathy (DC), with regard to basic rhythm, sinus or atrial fibrillation. Retrospectively, over three years, from January 1, 1989 to December 31, 1991, the case histories of 75 inpatients with DC, mean age 56.2 +/- 14.1 years, 41 in sinus rhythm and 34 in atrial fibrillation from Clinic Hospital Split were analyzed and compared to those of 75 controls (heart failure with no DC). The incidence of thrombi, embolisms and mortality in both subgroups was similar, while the prevalence of thromboembolic events was significantly higher in the analyzed than in the control group (decompensated patients with ischemic cardiomyopathy and without cardiomegaly) (9/75:1/75, p < 0.05). Prospectively, between 9 and 22 months, from December 1, 1991 to September 30, 1993 51 consecutive decompensated outpatients with DC, in NYHA class II and III, mean age 54.2 +/- 15 years, were followed-up. Bilirubin, lactic dehydrogenase, prothrombin time and activated partial thromboplastin time were determined. 1-D and 2-D transthoracic echocardiographic exam was performed and clinical status was assessed. There were 24 patients in sinus rhythm and 27 patients in atrial fibrillation. The prevalence of thromboembolic events, thrombi and mortality in both subgroups was similar. The laboratory findings, indicators of possible thrombogenesis or thrombolysis, did not show any significant difference in both subgroups. The incidence of thrombi in both parts of this study was low, amounted to only 9.5% (12/126) with no clear signs of thromboembolism (these patients were anticoagulated!). Altogether 12.6% (16/126) patients suffered thromboembolic events, 9 in retrospective and 7 in prospective part of the trial (more patients were anticoagulated in prospective then in retrospective study, 5 versus 19; p < 0.05). We conclude that thromboembolism in patients with decompensated DC are rare, but appear at significantly higher rate than in decompensated patients with ischemic cardiomyopathy and no cardiomegaly. The beneficial effects of anticoagulant therapy are to be expected in these patients regardless of the basal rhythm. This hypothesis must, however, be assessed in a prospective, multicentric trial.

[Significance of right ventricular dimensions in the differential diagnosis of primary and secondary dilated cardiomyopathy]. / Znacenje promjera desne klijetke u differencijalnoj dijagnostici primarnih i sekundarnih dilatacijskih kardiomioptija.

Numerous analyses are used in the differential diagnosis between primary and secondary dilated cardiomyopathy (PDC, SDC). The aim of this study was to assess the dimensions of heart cavities in patients with dilated cardiomyopathy (DC) by 1-D and 2-D echocardiography. Thirty-six consecutive patients who satisfied the PDC criteria, and 103 patients with criteria of SDC, were followed-up clinically, radiographically, electrocardiographically and by 1-D and 2-D echocardiography, in the period from December 1991 to April 1994, at the Department of Internal Medicine of the Clinical Hospital Split. The patients with PDC were significantly younger than those with SDC (44.4 +/- 10.4: 64.4 +/- 8.4 year). There were significantly more males than females in both DC subgroups. NYHA classification, sinus rhythm and atrial fibrillation did not differ considerably in both DC subcategories. The etiologic factor was ischaemic DC in 85.4% (88/103), systemic arterial hypertension in 11.6% (12/103), and thyrotoxicosis in 2.9% (3/103) of patients with SDC. Alcoholic DC in one patient, peripartal DC in two female patients and viral myocarditis in six patients with PDC were suspected. In the total of 75% (27/36) patients with PDC, a clear etiological factor in case histories was not defined. Left ventricular ejection fraction, diameter and myocardial thickness, as well as left atrium diameter, did not differ significantly in patients with PDC, at variance with SDC patients. Right ventricular enddiastolic diameter (31.55 +/- 4.8 mm: 26.62 +/- 8.6 mm, p < 0.05) and the ratio between enddiastolic diameters of the right and left ventricle were significantly larger in patients with PDC than in those with SDC (0.45 +/- 0.03: 0.37 +/- 0.05, p < 0.05). We conclude that right ventricle is significantly wider in PDC than in SDC patients. Compared with other noninvasive methods, 1-D and 2-D echocardiography is probably the method of choice (particularly in our environment) in the differentiation of primary and secondary DC.

[Comparison of auscultation findings using a classic stethoscope (Litmann 2120) and electronically amplified stethoscope (Medmax2)]. / Usporedba auskultacijskih nalaza stetoskopom s elektronskim pojacalom (Medmax2) prema klascnom (Litmann 2120).

Heart auscultation has one of the key roles in beside diagnosis, especially in patients with cardiovascular diseases. Sometimes, because of the human cars' low sensitivity, a problem emerges in the proper evaluation of heart sounds and murmurs of lower frequencies. Our study compared two stethoscopes, the classic acoustic stethoscope (Littmann 2120) and an electronic one with the sound amplifier and the noise filtering system (Medmax2) in 10 patients examined by 10 physicians. Significantly better detection of low frequency sounds was found in favour of electronic stethoscope (chi 2 = 17.9; p < 0.0001). It is concluded that the selective amplificator improves the stethoscope performance and has its place in everyday bedside practice, especially in departments of cardiology.

[Biochemical changes in hypertensive patients during a 1-year cross-over study of treatment with hydrochlorothiazide and propranolol]. / Biokemijske promjene u hipertonicara tijekom jednogodisnjeg krizanog lijecenja hidroklorotiazidom i propranololom.

A prospective, randomized, cross-over trial comparing the antihypertensive efficacy and biochemical changes during treatment with either hydrochlorothiazide (HTZ: 25 mg o.d.) or propranolol (PRO: 40 mg t.i.d.), included 55 mild to moderate hypertensives (diastolic blood pressures ranged from 90 to 110 mmHg), aged 25-65 years. Forty patients completed the study; during the first six months 20 of them (12 males and 8 females) were taking HTZ, and the remaining 20 (13 males and 7 females) PRO. After a one-week wash-out period, for the next six months the alternative drug was administered. Antihypertensive efficacy of both drugs was nearly equal: systolic and diastolic blood pressure significantly decreased already after the first month (approximately by 10%), and kept unchanged until the end of the study. The analyzed biochemical parameters, i.e. blood glucose, cholesterol, and triglycerides did not increase significantly, while serum potassium level remained almost unchanged during the trial. Furthermore, during PRO in group B, cholesterol significantly decreased (3rd month), as well as blood glucose during HTZ treatment (10th month). Only the uric acid level, although unsignificantly, increased in group A (from 326.2 to 365.3 +/- 125.2 on HTZ, and to 391.4 +/- 120.0 mumol/l on PRO). It is concluded that HTZ and PRO are comparably effective antihypertensives. During the long-term treatment in small doses these drugs do not induce significant biochemical disturbances.

Peculiarities of myocardial infarction at young age in Southern Croatia.

The aim of this study was to assess whether acute myocardial infarction (AMI) in younger patients (< 45 years) differs from that in the older individuals (> 45 years). We have studied the records of all patients admitted to the Department of Medicine, Clinical Hospital of Split, Croatia, because of AMI from January 1st, 1987 to December 31st, 1991. The study group consisted of 1406 patients, 130 (9.2%) below, and 1276 (90.8%) above the age of 45. In the ¿young¿ subgroup there were only 9 females (6.9%), significantly less than in the ¿old¿ one (399 out of 1276 or 31.3%, p < 0.001). There were many more smokers among the younger (100 out of 130 or 76.9%) than among the older patients (524 out of 1276 or 41.1%, p < 0.001). The location of myocardial necrosis was also different: inferior infarction occurred in 65 out of 130 or 50% young patients and in 442 out of 1276 or 34.6% old patients; p < 0.001). Finally, the hospital mortality rate among the younger AMI patients was quite low (8 out of 130 or 6.2%) when compared to that of the older patients (282 out of 1276 or 22.1%, p < 0.001). In conclusion, AMI in younger individuals shows relevant peculiarities: the background of such patients almost invariably includes cigarette smoking; the female gender is about five times less affected, the diaphragmatic location is nearly two times more frequent, and the hospital mortality rate of these patients is almost four times lower than that of older patients.

[Characteristics of patients with acute myocardial infarction treated in Split 1982-1992]. / Neke osobitosti bolesnika s akutnim infarktom miokarda lijecenih u Splitu od 1982. do 1992. godine.

Three thousand three hundred and fifty-two patients (70% males and 28% females) were hospitalized and treated in Split for acute myocardial infarction (hospital mortality 20%) between 1982-1992. The number of these admissions has been constantly rising from 226 in 1982 to 397 in 1992. Over 45 years of age were 3043 (90.8%) of the patients (70% males and 30% females), while 309 of them (9.2%) were under 45 (93% males, 7% females). The lethality rate was 21% in the first and 8% in the second subgroup. In patients over 45 inferior myocardial infarction was found in 35%, and in patients under 45 in 49%. In the older group there were 40% smokers, 42% hypertensives and 39% hypercholesterolemics, while there were 75% smokers, 35% hypertensives and 33% hypercholesterolemic patients in the younger age group. The results show that the number of patients treated for acute myocardial infarction in the Split region is constantly increasing (p < 0.001). In patients under 45 years of age there is significantly higher inferior infarction prevalence (p < 0.001); a larger percentage of males (p < 0.001) and smokers (p < 0.001), and lower percentage of hypertensives (p < 0.001) and hypercholesterolemic patients (p < 0.05) was observed, as well as lower hospital mortality rate (p < 0.001).

[Association of platelet aggregation with the extent of myocardial infarction]. / Povezanost agregabilnosti trombocita s velicinom infarkta miokarda.

The aim of this study was to evaluate the association between the type of myocardial infarction (MI) and the circulating platelet aggregates [circulating aggregates of thrombocytes (CAT)]. The size of MI was assessed by the maximal values of creatine-kinase (CK). In 80 patients in the acute phase of MI the values of CAT and CK were manifold increased, mostly in 30 patients with anteroseptal MI (CAT 34.1 +/- 8.3%, CK: 920 +/- 340 IU), less markedly in 30 patients with inferior MI (CAT: 25 +/- 6.7%, CK: 739 +/- 263 IU) and in 20 patients with non-Q-wave MI (CAT: 20.7 +/- 1.9%, CK 518 +/- 224 IU). The differences between the groups were significant (p < 0.05). There was a significant linear correlation between CAT and CK in anteroseptal MI (r = 0.57, p < 0.01) and in inferior MI (r = 0.54, p < 0.01), but not in non-Q-wave MI (r = 0.15, p > 0.05). The results are concordant with the hypothesis that thrombotic event contributes more significantly to the pathogenesis of transmural acute myocardial infarction.

[Orthostatic hypotension. Case report of the Bradbury-Eggleston syndrome]. / Ortostatska hipotenzija. Prikaz slucaja Bradbury-Egglestonova sindroma.

A case of a 71-year-old woman with idiopathic orthostatic hypotension is presented. Several diagnostic procedures which can detect sympathetic pathway lesion are reported. The value of blood pressure measurement and heart rate response to the supine and standing position deep breath, Valsalva maneuver and cold pressor test in differential diagnosis are emphasized. The venoconstriction, venous reflexes and tyramine tests are described, as well. The authors favour an individual therapeutic approach with no limitation of mineralocorticoid dosage. Nonpharmacological measures, such as an increased salt intake, elastic support stockings and swimming are highly recommended.

Actions of halothane and isoflurane on Purkinje fibers in the infarcted canine heart: conduction, regional refractoriness, and reentry.

The actions of halothane (HAL) and isoflurane (ISO) on conduction and regional refractoriness were studied in infarcted canine hearts to compare their effects on reentry in vitro. In two anesthetic groups of 8 hearts, high and low dose effects were assessed using action potentials recorded from Purkinje fibers located in the nonischemic and ischemic regions. An extrastimulus technique was used to determine the relationship between delay of conduction of premature impulses into the more refractory ischemic region and induction of reentrant responses. At high doses (HAL 0.60 mM and ISO 0.64 mM, approximately 2.3 minimum alveolar anesthetic concentration [MAC]) both anesthetics decreased (P < or = 0.05) the effective refractory period for direct intracellular stimulation of nonischemic fibers (local ERP, initial control: 294 +/- 8 ms); the decrease with HAL (-29 +/- 6 ms) was smaller (P < or = 0.05) than with ISO (-50 +/- 7 ms). HAL and ISO also decreased (P < or = 0.05) the coupling interval of the earliest premature impulse which conducted into the infarct (system effective refractory period [SERP], control: 301 +/- 7 ms) by -31 +/- 11 and -44 +/- 8 ms, respectively. In contrast, the functional refractory period (FRP) in the ischemic region (control:354 +/- 4 ms) was increased by HAL (26 +/- 8 ms; P < or = 0.05) but decreased by ISO (-14 +/- 4 ms, P < or = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Actions of volatile anesthetics on ischemic and nonischemic Purkinje fibers in the canine heart: regional action potential characteristics.

The effects of halothane, isoflurane, and enflurane on proximal (false tendon) and distal (apical) Purkinje fibers were measured in vitro in infarcted canine hearts to assess their effects on action potentials of fibers located within the nonischemic and ischemic regions, respectively. High- and low-dose anesthetic effects were evaluated in three groups of eight preparations and compared to changes occurring at identical times in eight infarcted control preparations. Under control conditions in all groups, the action potential duration at 90% repolarization (APD90, mean +/- SEM) of ischemic distal fibers (396 +/- 9 ms) was longer (P < or = 0.01) than that of nonischemic proximal fibers (344 +/- 5 ms) and the ischemic fibers exhibited (P < or = 0.05) reduced maximum diastolic potential, amplitude, and Vmax relative to nonischemic fibers. Halothane (0.25 and 0.6 mM), isoflurane (0.4 and 0.8 mM), and enflurane (0.8 and 1.6 mM) produced dose-dependent decreases of nonischemic fiber APD90 with less decrease (P < or = 0.01) of ischemic fiber APD90 and thereby accentuated (P < or = 0.05) regional differences of APD90 at high dose. The decreases of nonischemic fiber APD90 were greater (P < or = 0.01) for 0.8 mM (2.9 minimum alveolar anesthetic concentration [MAC]) isoflurane (-95 +/- 5 ms) and 1.6 mM (2.5 MAC) enflurane (-79 +/- 12 ms) than for 0.6 mM (2.2 MAC) halothane (-41 +/- 3 ms). Isoflurane increased the pathologic difference (ischemic > nonischemic) between the repolarization times (APD90) of Purkinje fibers in the infarcted heart more (P < or = 0.05) than halothane.(ABSTRACT TRUNCATED AT 250 WORDS)

[The electrocardiographic image of acute myocardial infarct in a patient with severe hyperkalemia]. / Elektrokardiografska slika akutnog infarkta miokarda u bolesnika s ekstremnom hiperkalijemijom.

We report herein an insulin dependent diabetic with chronic renal insufficiency on hemodialysis who developed cardiogenic shock, severe metabolic acidosis with kalemia of 9 mmol/L during alimentary intoxication and who presented with an ECG resembling an acute myocardial infarction. Possible pathophysiologic factors in the development of such electrocardiographic patterns have been outlined. It is concluded that in far advanced hyperkalemia an abnormal QRS complex, elevated ST segment and no visible P waves should primarily suggest changes caused by hyperkalemia rather than myocardial infarction.

Actions of halothane, isoflurane, and enflurane on the regional action potential characteristics of canine Purkinje fibers.

The effects of halothane, isoflurane, and enflurane on proximal (false tendon) and distal (apical) canine Purkinje fibers were measured in vitro to assess their comparative effects on fibers exhibiting characteristically long (proximal) and short (distal) action potential duration. High- and low-dose anesthetic effects were evaluated in three groups of six left ventricular preparations and were compared with the changes occurring at identical times in six control preparations using analysis of variance with repeated measures. Under control conditions in all groups, the action potential duration, measured at 90% repolarization (APD90, mean +/- SEM), of proximal fibers was longer than that of distal fibers (320 +/- 16 vs 252 +/- 11 ms, P less than or equal to 0.01). Halothane (0.3 and 0.7 mM), isoflurane (0.4 and 0.8 mM), and enflurane (0.6 and 1.0 mM) produced a dose-dependent decrease (P less than or equal to 0.01) of proximal fiber APD90 with less (P less than or equal to 0.01) change of distal fiber APD90 and reduced (P less than or equal to 0.05) regional differences of APD90 at the higher dose. The decreases of proximal fiber APD90 were greater (P less than or equal to 0.01) for 1.0 mM (1.7 MAC) enflurane (-66 +/- 7 ms) and 0.8 mM (3.0 MAC) isoflurane (-69 +/- 9 ms) than for 0.7 mM (2.9 MAC) halothane (-33 +/- 8 ms). We conclude that the regional actions of anesthetics on Purkinje fiber repolarization may influence conduction during the relative refractory period and the occurrence of arrhythmias associated with disparity of regional refractory characteristics in the ventricular conduction system.

Halothane, enflurane and isoflurane on abnormal automaticity and triggered rhythmic activity of Purkinje fibers from 24-hour-old infarcted canine hearts.

The effects of inhalation anesthetics halothane, enflurane, and isoflurane on spontaneous impulse initiation (automaticity) and triggered sustained rhythmic activity were examined in Purkinje fibers derived from normal (n = 38) and 24-h-old infarcted canine hearts (n = 27) to further understanding of their influence on the cellular mechanisms underlying generation of cardiac arrhythmias. Purkinje fibers from normal or infarcted hearts were superfused with modified Krebs' solution (37 degrees C) with or without epinephrine (2 or 15 microM) and equilibrated with a 97% O2-3% CO2 gas mixture (control). Transmembrane action potentials were recorded using conventional microelectrode techniques, and Purkinje fibers were exposed to anesthetic concentrations equivalent to 2.0 MAC. Normal Purkinje fibers were not spontaneously active unless exposed to epinephrine. All anesthetics (enflurane greater than halothane, isoflurane; P less than 0.05) increased automaticity of normal Purkinje fibers exposed to either epinephrine concentration. Partially depolarized Purkinje fibers from infarcted hearts were either spontaneously active or were quiescent. For ischemic fibers that beat spontaneously, abnormal automaticity was sustained (duration greater than 300 s) or periodic (duration less than 300 s). Sustained abnormal automaticity was elicited by epinephrine (15 microM) in some quiescent partially depolarized fibers. None of the anesthetics affected the rate of sustained abnormal automaticity, regardless of whether the induction of such automaticity required epinephrine, nor did anesthetics significantly affect the duration of trains of periodic abnormal automaticity. Finally, quiescent, partially depolarized Purkinje fibers were tested for triggered rhythmic activity during pacing at a cycle length of 800 ms.(ABSTRACT TRUNCATED AT 250 WORDS)