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Zagreb, Croatia

Popovic-Grle S.,KBC Zagreb
Medicus | Year: 2011

Severe asthma is present in 5-10% of asthma patients. Its exact pathophysiological mechanisms are not known. However, neutrophilic airway inflammation or absence of inflammatory changes with accelerated bronchial remodelling have been often recorded. Clinically, non-allergic asthma in women, mostly late-onset and aspirin asthma phenotype, is the most common type of severe asthma. Allergic asthma may be classified as severe in a significantly lower number of cases. In every patient with severe asthma, its diagnosis and compliance should be evaluated on several occasions and triggers explored. The administration of oral corticosteroids should be preceded by the administration of the highest doses of inhaled corticosteroids, i.e. up to 2,000 μg of beclomethasone, with the addition of long-acting beta2-agonists, leukotriene receptor antagonists, theophyllin preparations and long-acting anticholinergics. In the event of treatment failure, omalizumab or several months of antifungal therapy, or a patient-tailored approach should be applied. Bronchial thermoplasty has been also developed. The treatment of patients with severe asthma requires 30-50% of funds earmarked for asthma treatment.

Juretic E.,KBC Zagreb
Paediatria Croatica, Supplement | Year: 2011

Antenatal corticosteroids, exogenous surfactant, better understanding of respiratory disorders pathophysiology and the invention of new sophisticated ventilators and ventilatory strategies have improved the outcomes for more and more premature infants. Nevertheless, the occurrence of chronic lung disease has not been reduced. In small infants bronchopulmonary dysplasia has obtained a form of decreased alveolarization that is determined by the stage of intrauterine lung development (canalicular or early saccular phase) and the amount of lung injury. Mechanical ventilation may injure the lungs by causing epithelial and endothelial damage, pulmonary edema, inflammation, and surfactant inactivation. The most important mechanisms of ventilator-induced lung injury include high airway pressures and large gas volumes. In order to avoid a dammaging sequence of alveolar collapse and over-distension and to eliminate need for intubation a less aggressive ventilation mode of delivering continuous positive airway pressure (CPAP) by nasal route (NCPAP - nasal CPAP) has been widely accepted. Short binasal prongs are most often used to connect the CPAP circuit to the infant's airway. Nasal intermittent positive pressure ventilation (NIPPV) is another promising mode of providing respiratory support. A reduction in the incidence of chronic lung disease has been recorded by most neonatal centers after introduction of non-invasive ventilation for the management of less severe respiratory failure. The early initiation of NCPAP has many beneficial effects on premature newborns. It increase stranspulmonary pressure and functional residual capacity, improves lung compliance, prevents alveolar collapse and decreases intrapulmonary shunt, prevents pharyngeal wall collapse, increases airway diameter, and stabilizes the chest wall. It also conserves surfactant and stimulates lung growth. Therefore, CPAP or NIPPV are indicated for the treatment of diseases with low functional residual capacity (like hyaline membrane disease, transient tachypnea of the newborn, pulmonary edema), for apnea of prematurity, meconium aspiration syndrome, partial paralysis of diaphragm, tracheomalacia, or respiratory support after extubation. As the benefits of surfactant are indisputable, especially in the smallest infants who more frequently demonstrate CPAP failure because of surfactant deficiency, approach to intubate infants on CPAP solely for the purpose of giving surfactant (INSURE method: INtubation-SURfactant-Extubation) has gained wide acceptance.

Aim: To show the importance of data obtained by Cardiopulmonary Exercise Testing (CPET). Exercise intolerance is the main problem in pulmonary and cardiac diseases. Lung and cardiac function test results obtained at rest are poorly predictive of the degree of exercise intolerance. Methods: Selective literature review. Results: A good interpretation of CPET results requires an insight into the possible reasons for exercise intolerance and possible indications for CPET. Before CPET, basic medical history, status, and results of any previous tests should be known. It is also very important to know CPET limiting disorders. The CPET interpretation must answer the questions of the referring physician. Recommendations for further processing may be given eventually. Conclusion: CPET can provide an objective measure of exercise capacity, identify the mechanisms limiting exercise tolerance, and establish indices of disease prognosis, disease progression monitoring and/or treatment response. The superiority of CPET results over those obtained at rest is obvious.

Benign prostatic hyperplasia is considered a normal part of the aging process in men and is hormonally dependent on dihydrotestosterone production. The voiding dysfunction that results from prostate gland enlargement and bladder outlet obstruction is termed lower urinary tract symptoms (LUTS). Clinical manifestations of LUTS include urinary frequency, urgency, nocturia, decreased or intermittent force of stream, or a sensation of incomplete emptying. The risk of acute urinary retention (AUR) and the need for surgical treatment increase with age. Patients with mild LUTS should be managed with lifestyle advice and pelvic floor muscle exercise. Alpha-blockers should be offered as a first-line treatment to men with bothersome LUTS who request treatment. Treatment with combined alpha-blocker and 5-alpha-reductase inhibitor therapy can significantly reduce the risk of disease progression and avoid long-term complications such as acute urinary retention and surgery. Surgery is appropriate for patients with moderate to severe LUTS who have not responded to drug treatment, or who have developed AUR or any absolute indication for surgery.

Chronic bacterial prostatitis (CBP) is still an important therapeutic problem due to relatively low treatment success rates. One of the reasons is certainly a poor penetration of most antimicrobial drugs into prostatic tissue and secretions. Special attention given to pharmacokinetic properties of antimicrobial drugs, which could treat these complex infections, is therefore understandable. For a successful treatment of any bacterial infection, including CBP, pathogens and their sensitivity should be identified. The isolation of a pathogen in CPB is still a problem due to an ever present dilemma about the most relevant biological sample for microbiological diagnosis. Therefore, there are some not quite understandable differences in the percentages of CPB pathogens isolated in studies conducted so far. Consequently, the success rates of the empirical CPB therapy are below those desired. Some progress in CBP treatment has been achieved thanks to a better understanding and use of pharmacokinetic properties of antimicrobial drugs. The percentage of successfully treated patients with CBP due to E. coli grew from 40% in those treated with trimethoprim as first-line-treatment to 60% in those treated with fluoroquinolones. It remains to be seen whether 4th generation fluoroquinolones will further improve the CBP treatment due to their enhanced pharmacokinetics and high prostate levels. The treatment of CBP due to C. trachomatis has been also improved thanks to the understanding of the azithromycin pharmacokinetic properties. The fact that anti-inflammatory drugs and alpha- adrenergic blockers are used in a considerable number of CBP patients in addition to antimicrobial drugs indicates the complexity of this clinical entity. The results of clinical studies show that the reasons lying behind the insufficiently successful CBP treatment despite a long-term use of one or more antimicrobial drugs remain to be elucidated.

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