Q Fever in Croatia: War-Induced Changes in Epidemiological Characteristics

The article describes the epidemiological characteristics of Q fever in Croatia, during the period before and after the Homeland War. In the ten years prior to the Homeland War (1983–1992) 1053 cases of Q fever were recorded, 16.2% (171) of which on islands and in coastal areas. In the period after the Homeland War (1995–2008), a total of 654 cases was recorded, 59.9% (392) of which on islands and in coastal areas. In addition to reduced incidence, geographic distribution of the disease also changed. Before the war, the highest morbidity rate was recorded in the Sisak-Moslavina County. After the war, the Split-Dalmatia County recorded the highest morbidity rate because in the post-war period sheep from Bosnia and Herzegovina went to this county for winter grazing. The disease might be relevant to the Croatian Army and other armed forces that stay in Croatia as part of NATO forces

Adenotonsillectomy in a two-year-old boy with extremely severe obstructive sleep apnea

Postoje razne kirurške i ne-kirurške mogućnosti liječenja opstruktivne apneje u snu (OSA) kod odraslih, dok je kod djece kirurško liječenje jedina mogućnost zbog činjenice da je više od 90% slučajeva OSA u djetinjstvu povezano s hipertrofi jom adenoida i tonzila. Dob ispod tri godine često se opisuje kao jedan o najčešćih čimbenika rizika za razvoj poslijeoperacijskih komplikacija. Najvažniji dodatni rizični čimbenik je težina bolesti mjerena polisomnografi jom (PSG). Opisuje se slučaj 20-mjesečnog dječaka s iznimno teškom OSA i anamnezom opetovanog prestanka disanja u snu u trajanju do 30 sekunda i najnižom zabilježenom zasićenošću tijekom PSG od 67%, uz indeks AHI od 58,43/h. Kako se zbog niskog cirkulirajućeg volumena krvi klasična adenotonzilektomija preporuča tek nakon što dijete navrši tri godine, razmatrali su se različiti pristupi, no na koncu je izvedena klasična adenotonzilektomija tehnikom “cold steel” kad je dijete navršilo dvije godine. Ovaj slučaj ukazuje na važnost kirurškog liječenja teških slučajeva OSA-e čak i kod vrlo male djece usprkos preporukama, i to zbog povećanih rizika za neurokognitivni razvoj i smetnje ponašanja.While there is a variety of surgical and non-surgical treatment options for obstructive sleep apnoea (OSA) in adults, surgery remains the option of choice in paediatric patients due to the fact that more than 90% of childhood OSA is associated with adenotonsillar hypertrophy. Age under three years is often described as one of the most common risk factors for developing postoperative complications. The most important additional risk factor is severity of the disease as measured by polysomnography (PSG). The authors report a case of a 20-month-old boy with extremely severe OSA and a history of repeated respiratory cessation during sleep lasting for up to 30 seconds and lowest recorded saturation during PSG of 67% with the apnoea-hypopnoea index 58.43/h. As classical adenotonsillectomy is recommended only after the child has reached three years, due to the small circulating volume of the blood, several solutions were considered but, ultimately, classical ‘cold steel’ adenotonsillectomy was performed when the child reached two years. This case shows the importance of surgical treatment in severe cases of OSA even in very small children, despite the recommendations, due to the increased risks in neurocognitive and behavioural development

Feasibility study of determing a risk assessment model for obstructive sleep apnea in children based on local findings and clinical indicators

Objective: To test a feasible and reliable model for diagnosing obstructive sleep apnea (OSA) in children, based on clinically relevant parameters, in comparison to a polysomnography. Methods: A total of 94 children with the suspected underlying OSA were included in the analyses. An association between clinical parameters (modified Mallampati score, tonsil size, adenoid size, age, gender, and body mass index) and apnea-hypopnea index (AHI) obtained following an overnight polysomnography was assessed, and significant variables were incorporated in the logistic regression model. Also, the sensitivity and specificity calculations of the model with the inclusion of ROC curve analysis were performed. Results: All three local clinical parameters were significantly associated with AHI (p<0.001). The most significant correlation with AHI was shown with the modified Mallampati score (r=0.723), following with tonsil size (r=0.673), and adenoid size (r=0.502). The sensitivity of the tested model was 84%, and specificity was 74%. Conclusion: This study derived a model based on the local clinical findings that significantly overlapped with the results of an overnight polysomnography, in diagnosing OSA in children

Učestalost i rizični čimbenici za razvoj oralnog alergijskog sindroma u odraslih bolesnika sa sezonskim alergijskim rinitisom

The aim of this study was to assess the prevalence of oral allergy syndrome (OAS) in patients with seasonal allergic rhinitis (SAR) and the possible risk factors for its development. This cross-sectional study was conducted in primary care offices in the Split-Dalmatia County during the period from March 1 to September 30, 2012. Data sources were medical history with confirmation of SAR (positive skin-prick test to seasonal inhalant allergens: grass, tree and weed pollens), anthropometric patient data (age, sex, weight and height), and a questionnaire in which patients evaluated their nasal and ocular symptoms, comorbidities and lifestyle. The χ2-test, Pearson χ2-test, Spearman\u27s rho correlation coefficient and Kolmogorov-Smirnov test were used on statistical analysis. The prevalence of OAS was 45.7%. The risk factors for OAS development were diabetes (p<0.001), severity of nasal symptoms (p<0.05) and severity of ocular symptoms (p<0.001). In conclusion, the prevalence of OAS in the Split-Dalmatia County is very high. The risks factors for OAS in patients with SAR are diabetes and severity of nasal and ocular symptoms.Cilj našega istraživanja bio je procijeniti učestalost oralnog alergijskog sindroma (OAS) u bolesnika sa sezonskim alergijskim rinitisom (SAR) te moguće rizične čimbenike za njegov nastanak. Ovo presječno istraživanje provedeno je u ordinacijama primarne zdravstvene zaštite Splitsko-dalmatinske županije u razdoblju od 1. ožujka 2012. do 30. rujna 2012. godine. Izvori podataka su bili: medicinska dokumentacija bolesnika (“karton”) u kojemu je potvrda dijagnoze SARa (pozitivan kožni-ubodni test na sezonske inhalacijske alergene: poleni trava, stabala i korova), antropometrijski podatci o bolesniku (spol, dob, težina i visina) i upitnik u kojemu bolesnici ocjenjuju nosne i očne simptome, komorbiditet i stil života. Od statističkih testova koristili smo χ2-test, Pearsonov χ2-test, Spearmanov test korelacije i Kolmogorov-Smirnovljev test. Učestalost OAS-a bila je 45,7%. Rizični čimbenici za njegov nastanak bili su: dijabetes (p<0,001) te ozbiljniji nosni (p<0,05) i očni simptomi (p<0,001). Može se zaključiti da je učestalost OAS-a u Splitsko-dalmatinskoj županiji visoka. Rizični čimbenici za nastanak OAS-a u bolesnika sa SAR-om su dijabetes i veća izraženost očnih i nosnih simptoma

Incidencija akutnih napadaja zatvaranja sobičnog kuta oka u Splitsko -dalmatinskoj županiji, Hrvatska

The aim of the study was to determine the incidence of acute angle-closure attacks among residents of the Split-Dalmatia County, Croatia, during a 6-year period. In this retrospective, interventional case series study, hospital records of 53 consecutive patients (33 female, mean age 71.7}16.6 and 20 male, mean age 66.2}23.2) with acute angle-closure attacks, treated at University Department of Ophthalmology, Split University Hospital Center, Split, Croatia, from January 2002 to December 2007 were reviewed. The annual incidence of acute angle-closure attacks was 2 cases per 100,000 (95% CI, 0-3.4). The incidence of acute angle-closure was 0.6 (95% CI, 0-1.4)cases/100,000 per year. The incidence of acute angle-closure glaucoma was 1.5 (95% CI, 0-2.8) cases/100,000 per year. The incidence was 1.5 (95% CI, 0-3.4) cases/100,000 per year in males and 2.3 (95% CI, 0-4.6) in females. Nine (17%) patients were treated by medicamentous therapy, peripheral iridectomy was performed in 19 (36%) patients and laser iridotomy in 16 (30%) patients, whereas nine (17%) patients underwent filtering surgery. Median time between the onset of symptoms to presentation at the hospital was two days (range 1-21 days). There was no statistically significant association between the acute angle-closure attacks and seasonal variation (χ2-test=4.6; p=0.20). In conclusion, the number of patients with acute angle-closure attacks in the Split-Dalmatia County is relatively small; however, the significant incidence of acute angle-closure glaucoma could pose a social and health care problem in the County.Cilj rada bio je ispitati incidenciju akutnih napadaja zatvaranja sobičnog kuta oka tijekom šest godina kod stanovništva Splitsko-dalmatinske županije. Provedena je retrospektivna, intervencijska analiza. Analizirani su podaci iz povijesti bolesti 53 bolesnika s kliničkom slikom akutnog zatvaranja sobičnog kuta oka (33 žene srednje dobi 71.7}16.6 godina i 20 muškaraca srednje dobi 66.22}3.2 godine) liječenih na Klinici za očne bolesti u Splitu u razdoblju od siječnja 2002. Do prosinca 2007. godine. Ukupna godišnja incidencija svih akutnih napadaja zatvaranja sobičnog kuta oka iznosila je 2 na 100.000 stanovnika (95% CI, 0-3,4). Incidencija samog akutnog zatvaranja sobičnog kuta oka bila je 0,6 (95% CI, 0-1,4), dok je incidencija akutnog napadaja glaukoma zatvorenog kuta bila 1,5 (95% CI, 0-2,8) na 100.000 stanovnika na godinu. Incidencija kod muškaraca bila je 1,5 (95% CI, 0-3,4), a kod žena 2,3 (95% CI, 0-3,4) na 100.000 stanovnika na godinu. Devetoro (17%) bolesnika je liječeno isključivo lokalnom ili općom terapijom. Kod 19 (36%) bolesnika je napravljena periferna iridektomija, a laserska iridotomija kod 16 (30%) bolesnika. Kod 9 (17%) bolesnika izvedena je filtracijska operacija (trabekulektomija). Medijan vremena od nastupa prvih znakova bolesti do javljanja u bolnicu bio je 2 dana (raspon 1-21 dan). Nije ustanovljena statistički značajna povezanost akutnih napadaja zatvaranja sobičnog kuta i godišnjeg doba (χ2- test=4,6; p=0,20). U zaključku, broj bolesnika s akutnim napadajima zatvaranja sobičnog kuta oka u Splitsko-dalmatinskoj županiji je relativno nizak, međutim, značajna incidencija akutnog glaukoma zatvorenog kuta može činiti zdravstveni i socijalni problem u ovoj županiji

Kirurško liječenje recidivirajućeg metastatskog karcinoma doštitne žlijezde

We present the case of a 48-year-old male patient who underwent surgery for a recurrent metastatic parathyroid gland carcinoma in the patient’s right paratracheal space of the neck. The patient had undergone surgery for lower right parathyroid gland carcinoma 28 months earlier. Results: The metastases were resected en bloc with an ipsilateral central neck dissection and with the removal of the enlarged lower left parathyroid gland. After exploration of the remnant parathyroid glands we noticed that lower left parathyroid gland was macroscopically enlarged so we decided to remove it to prevent possible hypercalcemia in future and to also prevent possible recurrence of cancer or development of a new primary, considering the identical embryological origin of the lower parathyroid glands and possibility of synchronous, multiple tumors, which generally follow the same embryological origin if they occur. The patient was also treated with radiation therapy after the surgery. Conclusion: With the present surgical approach to recurrent metastatic parathyroid gland carcinoma, we aimed to prevent the recurrence of cancer or development of new primary and prevent or delay hypercalcemia in the future with all severe adverse metabolic states associated with high serum calcium levels.Prikaz slučaja 48 godišnjeg muškog bolesnika koji je operiran zbog recidvirajućeg metastatskog karcinoma doštitne žlijezde u paratrahealnom prostoru vrata desno. 28 mjeseci prije bolesnik je operiran poradi karcinoma donje desne doštitne žlijezde. Rezultati: Metastaze su odstranjene zajedno s ipsilateralnom centralnom disekcijom desne strane vrata kao i povećana donja lijeva doštitna žlijezda. Naime, nakon eksploracije preostalih doštitnih žlijezda, primjetili smo da je donja lijeva doštitna žlijezda makroskopski povećana, pa smo je odlučili odstraniti zbog te činjenice te da preveniramo razvoj moguće hiperkalcemije u budućnosti, a također i da preveniramo mogući recidiv karcinoma ili razvoj novog primarnog karcinoma uzimajući u obzir istu embriološku osnovu nastanka donjih doštitnih žlijezda i mogućnost razvoja istodobnih, sinhronih karcinoma doštitnih žlijezda koji, ukoliko se pojave, uglavnom prate istu embriološku osnovu. Bolesnik je liječen i radioterapijom nakon operacije. Zaključak: Prikazanim kirurškim pristupom liječenju recidivirajućeg metastatskog karcinoma doštitne žlijezde cilj nam je bio da spriječimo ponovni recidiv karcinoma ili nastanak novog primarnog karcinoma i da spriječimo ili odgodimo razvoj moguće hiperkalcemije u budućnosti sa svim teškim štetnim metaboličkim stanjima povezanima s visokim razinama kalcija u serumu

INCIDENTALNI NALAZ ČVORA NA VRATU KOŽNOG MALIGNOG MELANOMA NAKON 34 GODINE LATENCIJE

The authors report a case of a 64-year-old man who had nodal recurrence of melanoma 34 years after the primary diagnosis of a cutaneous melanoma on his back. Neck ultrasound confirmed an oval anechogenic/hypoechogenic lobular lesion (1.6x1.7 cm) in the right supraclavicular fossa. Fine-needle aspiration revealed sparse population of the poorly preserved malignant cells and bare malignant nuclei with prominent nucleoli. Extirpation of the lymph node was done and the histopathologic diagnosis confirmed metastatic melanoma. The man was referred to positron emission tomography/ computed tomography, dermatologist, ophthalmologist and gastroenterologist for further management to exclude other potential sites of new primary melanoma. It is one of the longest disease-free latency periods between the primary melanoma diagnosis and recurrence reported to date. This article suggests melanoma to be a disease with a potentially lifelong risk of recurrence, however, late recurrences are very rare. The clinicians and patients must be vigilant and aware of the risk of late recurrences.Prikazujemo slučaj 64-godišnjeg muškarca koji je imao metastazu melanoma u limfnom čvoru 34 godine nakon postavljene dijagnoze kožnog melanoma na leđima. Na ultrazvuku je ponađena ovalna anehogena/hipoehogena lobularna lezija (1,6x1,7 cm) u desnoj supraklavikularnoj regiji. Citološka punkcija je ukazivala na slabo diferencirane maligne stanice. Učinjena je ekstirpacija limfnog čvora i patohistološki nalaz je potvrdio metastatski melanom. Daljnjom obradom (pozitronska emisijska tomografi ja, pregled dermatologa, oftalmologa i i gastroenterologa) nije pronađeno novo sijelo primarnog melanoma. To je jedno od najdužih razdoblja između primarnog melanoma i povratka bolesti opisano do danas. Ovaj prikaz pokazuje da se metastaze melanoma mogu javiti tijekom cijelog života. Liječnici i bolesnici moraju biti svjesni rizika kasnih metastaza

Self-Perception of Drug Abusers and Addicts and Investigators’ Perception of Etiological Factors of Psychoactive Drug Addiction

The aim of this study was to compare investigators’ perception of three most important etiological factors for drug addiction and drug abuse with the self-perception of heroin addicts and drug abusers who used cannabis products and/or ecstasy. The study included 207 heroin addicts (mean age, 26.7 ± 5.8 years) and 238 drug abusers (mean age, 19.3 ± 1.9 years). Each study participant selected the three most important etiological factors for drug addiction or drug abuse from the list in the Pompidou questionnaire according to his or her perception. An investigator also selected the three most important etiological factors for drug addiction or abuse according to his or her perception for each study participant. The self-selected factors were compared with those selected by the investigators. Heroin addicts most often selected hedonism as the first (n=97 [46.9%]) and the second (n=87 [42.0%]) most important factor for starting using drugs, whereas family reasons were most often selected as the third most important factor (n=58 [28.0%]). Cannabis and ecstasy abusers most frequently selected hedonism as the first (n=149 [62.6%]), second (n=128 [53.8%]), and third (n=76 [31.9%]) most important factor for starting using drugs. According to investigators’ perception, family reasons were the first most important etiologic factor in both heroin addicts (n=93 [44.9%]) and drug abusers (n=144 [60.5%]). Psychological reasons were significantly more often selected as the first most important factor for heroin addiction than for cannabis or ecstasy abuse by both participants and investigators (P<0.001 for both). Also, according to investigators’ perception, the lack of knowledge was significantly more frequent as the second most important factor in heroin addicts than in cannabis or ecstasy abusers (55 [26.6%] vs 19 [8.0%], respectively; P<0.001). Drug addicts and drug abusers considered hedonism the most important reason for starting drug use, whereas investigators considered family reasons to be the primary reason. Both factors seemed to play the crucial role in the development of both drug addiction and drug abuse

Atypical congenital cartilaginous rest of the neck in a one-year-old female patient

Škržni ostatak u vratu je rijetko opisana prirođena anomalija za koju nema utvrđenog imena u literaturi, a često se pogjrešno dijagnosticira kao prirođena lateralna cista i/ili vratna fi stula. Autori opisuju slučaj jednogodišnje djevojčice koja je praćena od rođenja zbog čvornatih tvorbi na vratu kako bi upozorili na važnost i širinu diferencijalne dijagnostike prirođenih malformacija lateralne regije vrata kao i na ulogu ultrazvuka u diferencijalnoj dijagnostici, jer kirurško liječenje ovisi o tome. Kliničkim pregledom nađena je tvorba veličine 2x1 cm, dobro diferencirana od površine, na desnoj strani vrata u II./III. regiji. Ultrazvuk vrata nije otkrio nikakve fi stule ili ciste. Kirurškom incizijom nađena je hrskavična srž tvorbe koja je kirurški odstranjena u općoj anesteziji bez ikakvih problema.Cartilaginous rests of the neck are rarely described congenital anomaly for which there is no defi nite name in the literature, and is often misdiagnosed as congenital lateral cysts and/or neck fi stulas. The authors present a case of a one-year old girl monitored from birth due to nodular formations on the neck, in order to highlight the importance and span of diff erential diagnosis of congenital malformations of the lateral neck region and the role of ultrasonography in diff erential diagnosis since the surgical treatment plan depends on it. Clinical examination revealed a formation of 2x1 cm, well diff erentiated from the surface, on the right side of the neck in region II/III. On the left side in region II/III, there was a smaller formation of 2-3 mm in diameter. Sonography of the neck did not reveal any fi stulae or cysts. On surgical excision in general anaesthesia, the cartilaginous core was found and excised without any problems

THE EPIDEMIOLOGICAL CHARACTERISTICS OF HEPATITIS B IN CROATIA: THE RESULTS OF THE PREVENTION

Aim. This study shows epidemiological characteristics and preventive measures implemented for the prevention and control of hepatitis B infections in Croatia. Method. We analyzed the data from obligatory infectious disease reports and notifications of death due to infectious diseases, data on the hepatitis B infections in Croatia, and data collected by survey of the population. Results. The average prevalence of the disease is 3.67 per 100,000 annually. All age groups are affected, but still a higher rate of the disease is found in the age groups from 15 – 19 and 20 – 29 years of age. Hepatitis B disease is 1.4 times more likely in men than in women. For the past 18 years, the average rate of mortality was 0.2%. The incidence of HbsAg-positive donors of blood is within the range of 0.65% in 1992 to 0.012% in 2011. The largest part of preventive measures implemented in Croatia against hepatitis B is predicted and required by legislation. The registrations of acute and chronic carriers of the virus are obligatory. High-risk groups have started being vaccinated since 1992. The obligatory vaccination of infants was introduced in the mandatory vaccination program in 2007. Routine testing of blood exclusively from voluntary donors for HbsAg presence is obligatory. The non-governmental organization ’Help’ created for intravenous drug users, along with the ’Harm reduction’ program implemented hepatitis B, C, and HIV/AIDS prevention program in 1995. Conclusion. In order to gain a better understanding of epidemiological characteristics of hepatitis B in Croatia, the specifics of its dynamics in small communities are required since the research of Croatian public health officials and researchers have shown that hepatitis B is spread in different ways