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Jankovic J, Milenkovic B, Simic A, Skrobic O, Valipour A, Ivanovic N, Buha I, Milin-Lazovic J, Djurdjevic N, Jandric A, Colic N, Stojkovic S, Stjepanovic M. Influence of Achalasia on the Spirometry Flow-Volume Curve and Peak Expiratory Flow. Diagnostics (Basel) 2024; 14:933. [PMID: 38732346 PMCID: PMC11083519 DOI: 10.3390/diagnostics14090933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Achalasia is an esophageal motor disorder characterized by aperistalsis and the failure of the relaxation of the lower esophageal sphincter. We want to find out whether external compression or recurrent micro-aspiration of undigested food has a functional effect on the airway. METHODS The aim of this research was to analyze the influence of achalasia on the peak expiratory flow and flow-volume curve. All of the 110 patients performed spirometry. RESULTS The mean diameter of the esophagus was 5.4 ± 2.1 cm, and nine of the patients had mega-esophagus. Seven patients had a plateau in the inspiratory part of the flow-volume curve, which coincides with the patients who had mega-esophagus. The rest of the patients had a plateau in the expiration part of the curve. The existence of a plateau in the diameter of the esophagus of more than 5 cm was significant (p 0.003). Statistical significance between the existence of a plateau and a lowered PEF (PEF < 80) has been proven (p 0.001). Also, a statistical significance between the subtype and diameter of more than 4 cm has been proved. There was no significant improvement in the PEF values after operation. In total, 20.9% of patients had a spirometry abnormality finding. The frequency of the improvement in the spirometry values after surgery did not differ significantly by achalasia subtype. The improvement in FEV1 was statistically significant compared to the FVC values. CONCLUSIONS Awareness of the influence of achalasia on the pulmonary parameters is important because low values of PEF with a plateau on the spirometry loop can lead to misdiagnosis. The recognition of various patterns of the spirometry loop may help in identifying airway obstruction caused by another non-pulmonary disease such as achalasia.
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Affiliation(s)
- Jelena Jankovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
| | - Branislava Milenkovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
| | - Aleksandar Simic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
- Clinic for Digestive Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
| | - Ognjan Skrobic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
- Clinic for Digestive Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
| | - Arschang Valipour
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Floridsdorf, Vienna Health Care Group, 1210 Vienna, Austria;
| | - Nenad Ivanovic
- Clinic for Digestive Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
| | - Ivana Buha
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
| | - Jelena Milin-Lazovic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
- Institute for Medical Statistics and Informatics, University of Belgrade, 11000 Belgrade, Serbia
| | - Natasa Djurdjevic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
| | - Aleksandar Jandric
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
| | - Nikola Colic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
- Center for Radiology and MR, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Stefan Stojkovic
- Clinic for Gastroenterohepatology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Mihailo Stjepanovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.J.); (B.M.); (I.B.); (N.D.); (A.J.)
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (A.S.); (O.S.); (J.M.-L.); (N.C.)
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Bao S, Zou Y, Firempong CK, Feng Y, Yu Y, Wang Y, Dai H, Mo W, Sun C, Liu H. Preparation and evaluation of sustained release pirfenidone-loaded microsphere dry powder inhalation for treatment of idiopathic pulmonary fibrosis. Eur J Pharm Sci 2023; 188:106509. [PMID: 37356463 DOI: 10.1016/j.ejps.2023.106509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/29/2023] [Accepted: 06/23/2023] [Indexed: 06/27/2023]
Abstract
Pirfenidone (PFND) is a recommended oral drug used to treat idiopathic pulmonary fibrosis, but have low bioavailability and high hepatotoxicity. The study, therefore, seeks to improve the therapeutic activities of the drug via increased bioavailability and reduced associated side effects by developing a novel drug delivery system. The electrostatic spray technology was used to prepare a sustained release pirfenidone-loaded microsphere dry powder inhalation with PEG-modified chitosan (PFND-mPEG-CS-MS). The entrapment efficiency, drug loading, and in vitro cumulative drug release rate (at 24 h and with a sustained release effect) of PFND-mPEG-CS-MS were 77.35±3.01%, 11.45±0.64%, and 90.4%, respectively. The Carr's index of PFND-mPEG-CS-MS powder was 17.074±2.163% with a theoretical mass median aerodynamic diameter (MMADt) of 0.99±0.07 μm, and a moisture absorption weight gain rate (Rw) of 4.61±0.72%. The emptying rate, pulmonary deposition rate (fine particle fraction) and actual mass median aerodynamic diameter (MMADa) were 90%∼95%, 48.72±7.04% and 3.10±0.16 μm, respectively. MTT bioassay showed that mPEG-CS-MS (200 μg/mL) had good biocompatibility (RGR = 90.25%) and PFND-mPEG-CS-MS (200 μg/mL) had significant inhibitory activity (RGR = 49.82%) on fibroblast growth. The pharmacokinetic data revealed that the t1/2 (5.02 h) and MRT (10.66 h) of PFND-mPEG-CS-MS were prolonged compared with the free PFND (t1/2, 1.67 h; MRT, 2.71 h). The pharmacodynamic results also showed that the formulated-drug group had slight pathological changes, lower lung hydroxyproline content, and reduced hepatotoxicity compared with the free-drug group. The PFND-mPEG-CS-MS further significantly down-regulated TGF-β cytokines, Collagen I, and α-SMA protein expression levels compared with the free drug. The findings indicated that the PFND-mPEG-CS-MS had a good sustained release effect, enhanced bioavailability, decreased toxicity, and increased anti-fibrotic activities.
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Affiliation(s)
- Shixue Bao
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China
| | - Yi Zou
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China; Suzhou Zelgen Biopharmaceutical Co., Ltd, Kunshan, 215300, PR China
| | | | - Yingshu Feng
- Zhenjiang Key Laboratory of Functional Chemistry, Institute of Medicine & Chemical Engineering, Zhenjiang College, Zhenjiang, 212028, PR China; Postdoctoral Programme of JiangSu CTQJ Pharmaceutical Co., Ltd., Huaian, 223001, PR China
| | - Yang Yu
- Jiang Sunan Pharmaceutical Industrial CO., Ltd, Zhenjiang, 212400, PR China
| | - Ying Wang
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China
| | - Huiying Dai
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China
| | - Weiwei Mo
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China
| | - Changshan Sun
- Department of Pharmaceutics, College of Pharmacy, Shenyang Pharmaceutical University, Shenyang, 110016, PR China.
| | - Hongfei Liu
- College of Pharmacy, Jiangsu University, Zhenjiang, 212013, PR China; Jiang Sunan Pharmaceutical Industrial CO., Ltd, Zhenjiang, 212400, PR China; Jiangmen Hongxiao Biomedical Technology Co., Ltd, Jiangmen, 529040, PR China.
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Nazemiyeh M, Nouri-Vaskeh M, Somi MH, Saeedi E, Sharifi A. Lung function parameters in patients with gastroesophageal reflux without respiratory symptoms: a case-control study. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2019; 12:287-291. [PMID: 31749916 PMCID: PMC6820839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/18/2019] [Indexed: 06/10/2023]
Abstract
AIM This research aimed to evaluate the effect of gastroesophageal reflux disease (GERD) on pulmonary volumes, airflows, and airway resistance in the patients without respiratory symptoms and compare them with the healthy subjects. BACKGROUND GERD is the return of gastric content into the esophagus and beyond. GERD may play an essential role in the extraesophageal diseases, including chest pain, asthma, laryngitis, chronic cough, and sinusitis. The relation between GERD and airway involvement in asthma and also bronchoconstrictor effects of GERD are well recognized, but its impact on lung parameters in the patients with GERD without respiratory symptoms is unclear. METHODS In a case-control study, 78 GERD patients without pulmonary symptoms and 93 healthy subjects as control group were enrolled. The impulse oscillometry examined airway resistance. The body plethysmograph measured the pulmonary volumes and airflows. RESULTS The mean age of GERD patients and the healthy subjects were 37.30±9.76 and 34.74±11.10, respectively. A total of 53.8% of patients and 67.7% of healthy subjects were male. The lung volumes measured by the body plethysmography were normal in both patients and healthy subjects. However, there was a significant difference between the groups in forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) (P=0.01) and maximal mid expiratory flow (MMEF) (P=0.008). Airway resistance at R5Hz was significantly higher in the case group than the control group (P=0.001). CONCLUSION The results of the current study demonstrated that GERD patients have small airway disease even in the absence of respiratory symptoms.
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Affiliation(s)
- Masoud Nazemiyeh
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran,
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Hossein Somi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ehsan Saeedi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Akbar Sharifi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Bohman JK, Kashyap R, Lee A, He Z, Soundar S, Bolling LL, Kor DJ. A pilot randomized clinical trial assessing the effect of cricoid pressure on risk of aspiration. CLINICAL RESPIRATORY JOURNAL 2016; 12:175-182. [DOI: 10.1111/crj.12508] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/25/2016] [Accepted: 05/13/2016] [Indexed: 12/28/2022]
Affiliation(s)
- J. Kyle Bohman
- Department of Anesthesiology, Division of Critical Care Medicine; Mayo Clinic; Rochester MN USA
| | - Rahul Kashyap
- Department of Anesthesiology, Division of Critical Care Medicine; Mayo Clinic; Rochester MN USA
| | - Augustine Lee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Mayo Clinic; Jacksonville FL USA
| | - Zhaoping He
- Gastroenterology Research and Clinical Laboratories, Alfred I. duPont Hospital for Children; Wilmington DE USA
| | - Sam Soundar
- Gastroenterology Research and Clinical Laboratories, Alfred I. duPont Hospital for Children; Wilmington DE USA
| | - Laura L. Bolling
- Gastroenterology Research and Clinical Laboratories, Alfred I. duPont Hospital for Children; Wilmington DE USA
| | - Daryl J. Kor
- Department of Anesthesiology, Division of Critical Care Medicine; Mayo Clinic; Rochester MN USA
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Gastroesophageal Reflux Disease in Children with Interstitial Lung Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 912:57-64. [DOI: 10.1007/5584_2016_229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Gao F, Hobson AR, Shang ZM, Pei YX, Gao Y, Wang JX, Huang WN. The prevalence of gastro-esophageal reflux disease and esophageal dysmotility in Chinese patients with idiopathic pulmonary fibrosis. BMC Gastroenterol 2015; 15:26. [PMID: 25881023 PMCID: PMC4349612 DOI: 10.1186/s12876-015-0253-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 02/06/2015] [Indexed: 01/26/2023] Open
Abstract
Background The cause of idiopathic pulmonary fibrosis (IPF) remains unknown, yet gastro-esophageal reflux disease (GERD) is highly prevalent in this population. GERD prevalence was studied, and esophageal function tests (EFT) were assessed in Chinese IPF patients. Methods We prospectively studied 69 IPF patients who undertook both stationary High Resolution esophageal Manometry/Impedance (HRiM) and 24-hour esophageal Multi-Channel Intraluminal Impedance with pH Recordings (MII/pH). Patients were divided into GERD+ and GERD- groups according to pH results. Controls were HRiM treated healthy volunteers, and patients without IPF received HRiM and MII/pH diagnosed with GERD. Results 69 IPF patients, 62 healthy volunteers, and 88 IPF negative GERD patients were selected. GERD prevalence in IPF was 43/69 (62.3%), and 58.1% of patients presented with at least one typical symptom. Symptoms had a sensitivity of 58.1%, a specificity of 61.6%, a positive predictive value of 71.4% and a negative predictive of 47.1%. Compared with healthy volunteers, IPF patients had significantly decreased lower esophageal sphincter pressure (LESP), upper esophageal sphincter pressure (UESP) and complete bolus transit rate (CBTR). By contrast, IPF patients had increased total bolus transit time and prevalence of weak peristalsis. MII/pH showed that one third of IPF patients had abnormal distal and proximal reflux, especially non-acid reflux. Compared with GERD patients without IPF, GERD patients with IPF had significantly decreased CBTR and UESP with increased bolus exposure time. Conclusions GERD prevalence in IPF was high, but symptoms alone were an unreliable predictor of reflux. IPF patients had lower LESP and UESP, impaired esophageal peristalsis and bolus clearance function with more proximal reflux events.
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Affiliation(s)
- Feng Gao
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
| | | | - Zhan Min Shang
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
| | - Yan Xiang Pei
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
| | - Yan Gao
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
| | - Jian Xin Wang
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
| | - Wan Nong Huang
- Digestive Department, Beijing Chao-Yang Hospital, Capital Medical University, No.8 Gong Ren Ti Yu Chang South Road, Chao Yang District, Beijing, 100020, China.
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Mirić M, Turkalj M, Nogalo B, Erceg D, Perica M, Plavec D. Lung diffusion capacity in children with respiratory symptoms and untreated GERD. Med Sci Monit 2014; 20:774-81. [PMID: 24816214 PMCID: PMC4026150 DOI: 10.12659/msm.890336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is associated with many respiratory disorders, among which, chronic cough, laryngitis, and asthma are among the most common. We investigated lung function, including gas diffusion capacity, in children with poor asthma control or chronic laryngitis with untreated GERD. MATERIAL AND METHODS A total of 71 children, aged 6-17 years, with chronic respiratory and other symptoms suggestive for GERD, were enrolled and divided into 2 groups: chronic laryngitis and asthma. Participants underwent 24-hour pH monitoring and lung function assessment, measurement of single-breath diffusing capacity of the lung for carbon monoxide (DLCO), and fraction of exhaled nitric oxide (FENO) measurement. RESULTS 24-hour pH monitoring was positive for GERD in 92.1% of preselected children with asthma and 90.1% of children with chronic recurrent laryngitis. All flows (PEF, MEF75, MEF50, and MEF25) were significantly lower in the asthma group, while FENO and DLCO were significantly lower in the laryngitis group. A significant inverse relationship was found between DLCO and all reflux indexes in the laryngitis group. Each unit change of Johnson-DeMeester score and Boix-Ochoa score increased the odds for significantly lower DLCO in laryngitis patients by 3.9% and 5.5%, respectively. CONCLUSIONS In children with uncontrolled asthma and chronic laryngitis, the regurgitation of gastric contents due to GERD contributes to poor asthma control and aggravation of chronic laryngitis. Despite having normal lung function, the gas diffusion capacity should be controlled in patients with GERD and chronic laryngitis, and it might be the very first abnormality in distal airways.
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Affiliation(s)
- Mirjana Mirić
- Department for Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mirjana Turkalj
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Boro Nogalo
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Damir Erceg
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Marija Perica
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
| | - Davor Plavec
- Department of Pediatric Allergology and Pulmonology, Children's Hospital Srebrnjak, Reference Center for Clinical Immunology in Children Aappointed by the Ministry of Health and Social Welfare of the Republic of Croatia, Zagreb, Croatia
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Lozo Vukovac E, Lozo M, Mise K, Gudelj I, Puljiz Ž, Jurcev-Savicevic A, Bradaric A, Kokeza J, Mise J. Bronchoalveolar pH and inflammatory biomarkers in newly diagnosed IPF and GERD patients: a case-control study. Med Sci Monit 2014; 20:255-61. [PMID: 24535066 PMCID: PMC3930643 DOI: 10.12659/msm.889800] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Several studies have suggested that idiopathic pulmonary fibrosis (IPF) may be related to repeated aspiration of gastric contents over long periods of time. We aimed to investigate differences between pH measured directly in the lung, and biomarkers of acute inflammation in patients with newly diagnosed IPF and in patients with newly diagnosed GERD. Material/Methods All subjects (N=61) underwent collection of medical history, physical examination, pulmonary function testing, bronchoscopy, endoscopy, arterial blood gas analyses, and biochemical testing. Results Previously diagnosed GERD was found in 56.7%, typical symptoms of reflux in 80%, and Helicobacter pylori in gastric biopsy specimens in 76.6% of the cases. pH in peripheral branches of bronchi in the cases was 5.32±0.44 and was 6.27±0.31 (p<0.001) in the control group. The average values of LDH, ALP, and CRP in bronchoalveolar aspirate and in serum, as well as TNF-α in bronchoalveolar aspirate, were significantly higher in IPF patients. Conclusions The more acidic environment in the bronchoalveolar aspirate of the IPF subjects could contribute to the development or progression of IPF, possibly via changes in local metabolism or by damaging local cells and tissue. However, further studies with larger numbers of patients are required to clarify the role of gastric fluid aspiration in IPF pathogenesis. Our preliminary work has identified inflammatory biomarkers LDH, ALP, and TNF-α as potentially important in the pathologic processes in IPF. Further research is needed to determine their importance in clinical intervention and patient care.
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Affiliation(s)
- Emilija Lozo Vukovac
- Department of Pulmonary Diseases and School of Medicine, Split University Hospital, University of Split, Split, Croatia
| | - Mislav Lozo
- Department of Cardiology, Split University Hospital, Split, Croatia
| | - Kornelija Mise
- Department of Pulmonary Diseases and School of Medicine, Split University Hospital, University of Split, Split, Croatia
| | - Ivan Gudelj
- Department of Pulmonary Diseases and School of Medicine, Split University Hospital, University of Split, Split, Croatia
| | - Željko Puljiz
- Department of Gastroenterology, Split University Hospital, Split, Croatia
| | - Anamarija Jurcev-Savicevic
- Depatrment of Epidemiology, Teaching Public Health Institute of Split and Dalmatia County and School of Medicine, University of Split, Split, Croatia
| | - Anteo Bradaric
- Department of Cardiology, Split University Hospital, Split, Croatia
| | - Josipa Kokeza
- Department of Pulmonary Diseases and School of Medicine, Split University Hospital, University of Split, Split, Croatia
| | - Josko Mise
- School of Medicine, University of Zagreb, Zagreb, Croatia
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