THE IMPACT OF OROFACIAL CLEFTS ON QUALITY OF LIFE IN OPERATED CHILDREN

Orofacijalni rascjepi najčešće su prirođene malformacije koje zahvaćaju kraniofacijalne strukture. Djeca rođena s ovom vrstom malformacije imaju poteškoća s govorom, sluhom, dentalnim nepravilnostima i karakterističnim promjenama izgleda nosa i usne koje utječu na sva područja zdravlja. U literaturi se navodi kako orofacijalni rascjepi imaju velik utjecaj na psihološki razvoj pacijenata, ali i njihovih obitelji. U Hrvatskoj nisu objavljeni radovi koji se bave ovom problematikom pa su zbog toga potrebna istraživanja koja bi ispitala utjecaj orofacijalnih rascjepa na kvalitetu života operirane djece i njihovih roditelja. Za potrebe ovog rada izrađeni su originalni anketni upitnici kojima se ispitivao utjecaj orofacijalnih rascjepa na kvalitetu života operirane djece i njihovih roditelja. Istraživanje je provedeno na Kliničkom zavodu za oralnu kirurgiju, Klinike za kirurgiju lica, čeljusti i usta, Kliničke Bolnice Dubrava, Zagreb, a obuhvatilo je 73 ispitanika, odnosno djece u dobi 11 – 18 godina koja imaju jedan oblik operiranog orofacijalnog rascjepa i jednak broj njihovih roditelja/skrbnika. Zahvaljujući ovom radu, izrađeni su originalni upitnici specifični za procjenu estetskih i funkcijskih rezultata liječenja, odnosno za kvalitetu života operiranog djeteta i njegovih roditelja. Prikazani rezultati pokazuju gledišta djece i roditelja na kvalitetu života te estetske i funkcijske čimbenike s najvećim utjecajem na kvalitetu života. Na temelju analiziranih odgovora, vidljivo je da djeca s rascjepom imaju lošiju kvalitetu života u usporedbi s njihovim vršnjacima bez rascjepa te da orofacijalni rascjep ne umanjuje kvalitetu života samih roditelja. Estetski čimbenici koji najviše utječu na kvalitetu života djece rođene s rascjepom usne i nepca su izgled nosa i usne, a funkcijski čimbenici koji najviše utječu na kvalitetu života su dentalna malokluzija i poteškoće s govorom.Introduction: Orofacial clefts are the most common congenital malformations that affect craniofacial structures. Disjunction of skin, muscles, bones and cartilages represents an aesthetic and functional problem. Clefts can be a result of a large number of syndromes or non-syndromic, i.e. isolated, but in both cases, they are divided into cleft lip, cleft lip and palate or isolated cleft palate. Children born with this type of malformation have difficulties with talking, hearing, dental irregularities and characteristic changes in the appearance of the nose and lip, which affect all domains of health. Studies show that orofacial clefts have a major influence on psychological development of the patient and their families. The treatment of children with clefts is comprised of a large number of specialists whose activities are intertwined through the period of growing up, and includes a maxillofacial surgeon who coordinates other team members, a neonatologist, an anaesthesiologist, a paediatrician, an orthodontist, an oral surgeon, an otorhinolaryngologist-audiologist, a logopedist, a psychologist, a psychiatrist, and a paediatric dentist. It is necessary to understand the embryonic development of the nose, lip and palate between the 4th and 10th gestational week in order to grasp the formation of the orofacial cleft. The development of a normal palate is explained by the fusion of facial extensions, i.e. the penetration of mesoderm into the primary and secondary palate. According to His’s theory of facial extensions (1892), orofacial clefts are a consequence of inhibition of growth and binding of embryonic facial extensions. The incidence of orofacial clefts, according to the latest data, is about 1 out of 700 children born in the world. In Croatia, according to Magdalenić-Meštrović's research from 2005, the incidence is somewhat higher, and that is 1 in 581 born children. Cleft lip with or without cleft palate is more common in the male sex, and isolated cleft palate in the female sex, regardless of ethnicity. If the ratio of the sexes only in the white race is taken into consideration, then cleft lip with or without cleft palate is more common in the male sex in the ratio of 2:1. Epidemiological and experimental data suggest that harmful environmental influences may have a significant effect on the formation of cleft lip and/or palate in the form of exposure to the mother's tobacco smoke, alcohol, nutritional deficiency, viral infections, medical preparations and other teratogens at work and at home in the early months of pregnancy. Procedures and protocols for treating children with a cleft lip and palate can be extremely different within and among developed countries. Cleft treatments aim at correcting the broken anatomical relationship and establishing a normal function of the broken tissue and surrounding structures. Irregularities regarding the facial appearance, speech, maxillofacial and dento-occlusal development, hearing, and psychosocial status are attempted to be corrected, i.e. alleviated by various invasive and non-invasive therapeutic procedures. Most maxillofacial surgeons operate the cleft lip after the third month of age. This observes the anaesthetic "rule of ten” when a child is at least 10 weeks of age, has haemoglobin above 10 dg/L and weight above 5000 g (10 pounds). The surgical procedure of closing the soft palate in complete clefts is most commonly performed between the 3rd and 6th month of age, at the same time as the lip operation is performed. The malformation on the hard palate is corrected in the second operation around the child’s second year. In cases of isolated cleft palates, the closure is also performed in two operations; first the soft palate between the 3rd and 6th month, and then the hard at two years of age. In 1948, the World Health Organization defined health as a state of complete physical, mental and social well-being, not just the absence of disease and inactivity. American psychologist John C. Flanagan is considered to be the founder of the concept of quality of life in health care. HRQOL – health related quality of life describes subjective satisfaction with one’s health status. It is an instrument which examines the impact of illnesses and treatment modalities on health, integrating an objective assessment of the health status and its subjective experience (satisfaction with physical, mental and social functioning). The concept of oral health-related quality of life (OHRQOL) has only been developing over the past few decades, since it started to draw close attention. Oral health is considered an important part of a patient's general health. In Croatia, no studies have been conducted on this issue. Therefore, research is needed to investigate the impact of orofacial clefts on the quality of life of operated children and their parents. In this way, the results of the treatment and the quality of work of the health team involved in this process would also be seen. Examinees and research methods: For the purpose of this study, original questionnaires were put together to research the effect of orofacial clefts on the quality of life in operated children and their parents. In cooperation with a maxillofacial surgeon, an orthodontist, a psychologist and a logopedist who have longterm experience in treating clefts, questionnaires for children with clefts, their parents/guardians, and a form for taking the clinical status, which the examiner fills in during the interview and examination of the patient, were made. The questions were carefully designed and chosen to be as adjusted as possible to research groups, and to achieve the main goals of the research. The study was conducted at the Clinical Institute for Oral Surgery, the Clinic for Face, Jaw, and Mouth Surgery, Clinical Hospital Dubrava, Zagreb, and it includes 73 examinees, or 11 – 18 year-old children, who have one form of operative orofacial cleft and the equal number of their parents/guardians. The female sex was more represented with 56.2% of respondents, or 57.1% in the control group. The respondents were divided into two age categories (groups) to identify possible differences in early and late puberty. From the collected questionnaires, it was determined that representation in the older age group was similar for both groups of respondents (57.5% vs. 62.9%). The questionnaires consist of a general part, which the respondents filled in with their sex and age, and questions that examined quality of life. The questionnaire for children contains 46 questions/claims, and the one for parents 28 questions/claims. The questionnaires are made of simple statements which are evaluated with a 5-degree Likert scale (from 1 – fully disagree to 5 – fully agree) so they do not require specific additional clarifications, and are easy to fill in. After the questionnaires were completed, the examiner checked the patients/children and filled in the clinical status template located on a separate questionnaire sheet. The described study focuses on the fact of obtaining the patients and their parents’views on the long-term treatment process and the impact of the treatment on the quality of life. Results and discussion: Most children (46.6%) had unilateral cleft lip and palate. Only 6.8% of children had cleft presence in family, and less than 10% of children had 7 or more surgeries. Most children were happy with the appearance of the nose and lip. Almost a third of the respondents have a fistula on the palate, whereas 45.2% of the respondents have an occlusion Class 3 by Angle. Original questionnaires specific for assessing aesthetic and functional outcomes of the treatment, i.e. the quality of life in the operated child and his parents, were designed in this research. The illustrated results show the children and parent’s views, as well as aesthetic and functional factors that have the highest impact on the quality of life. Analysing the results of this research, we come to the conclusion that the studied group has worse results (higher score in response evaluation) compared to its control group, resulting in poorer quality of life as a consequence of the orofacial cleft. The results of this study did not reveal statistically significant differences in the responses of children with clefts regarding the sex. The proportion of male and female respondents was 32- 43.8%: 41-56.2%. Despite the fact that the female respondents were more dissatisfied with the aesthetic component of the cleft (external appearance, nose, lip and teeth), and the male respondents with the functional component (speaking, chewing), there were no major differences in the responses on the Likert scale. We divided the respondents into two age groups: younger adolescents 11 – 14 years (31 respondents – 42.5%) and older adolescents 15 – 18 years (42 respondents – 57.5%). The results show that there are differences in the responses between these two groups,but they are not statistically significant. The exploratory factor analysis of all 46 claims in the questionnaire intended for studying children with clefts gave three factors that evaluate the effect of the orofacial cleft on the quality of life. Three factors represent three categories: 1.Relationship with parents, success, society, 2.Appearance and 3.Function, which are integral part of a conceptual life quality scheme that consists of three main domains: physical, psychological and social health. Factor 1 Relationship with parents, success, society is a component of social health, factor 2 Appearance is a component of psychological health, and factor 3 Function is a component of physical health. The observed results show that the differences were significant for all three domains, with the emphasis on the fact that the biggest difference was in the domain of psychological health, i.e. appearance, which is the expected result since the answers given to individual questions referred to such a result. The data from the clinical form were compared with individual domains, and thus an "external" response validation was made, i.e. a comparison of subjective and objective experience of the cleft. A positive correlation was determined between a worse nose and lip appearance and the appearance domain, as well as a higher class by Angle (maxillary retrognathia / mandibular progenia) and the function domain. The questionnaire intended for parents shows that they have a satisfying quality of life. Factorial analysis of the questionnaire for parents of children with the orofacial cleft has formed two domains: Social health of parents and Social health of the child. Despite the fact that the results of this research have confirmed that the parents’quality of life is not disturbed, and taking into consideration the children’s quality of life as perceived by the parents, it has been confirmed that their opinion is closely related to the children’s opinion. There are positive correlation coefficients if we analyse similar questions in both questionnaires and when the parents’perception on the child's social health is analysed with the children’s perception in all three domains. Conclusion: The scientific contribution of this research consists of created and applicable original questionnaires specific for assessing the influence of orofacial clefts on the quality of life in operated children and their parents. Aesthetic factors which affect the quality of life of children born with a cleft lip and palate the most are the appearance of the nose and lip, and the functional factors with the most influence are dental malocclusion and speech difficulties. Based on the presented results, it can be concluded that the congenital malformation, the orofacial cleft, with its clinical manifestation and the scope of affected anatomic structures, decreases the quality of life in treated children regarding the postoperative function and aesthetic outcome. On the other hand, we have come to the conclusion that the quality of life in parents of treated children is not diminished, although the parents’ opinion coincides with the children’s opinion on their quality of life

Importance of preserving self-esteem at work

Osobe sa visokim stupnjem samopoštovanja sposobne su izgraditi vlastiti život baš onako kako žele i zadovoljne su u vlastitoj koži. Kad se suočavaju s problemima, čine to mirno i stabilno znajući da su kompetentni za zadatke s kojima se svaki dan suočavaju. Takve osobe nisu sebične i spremne su pomoći drugim ljudima te je upravo to jedan od segmenata zašto su uspješniji od ljudi sa niskim samopoštovanjem na svim područjima života. Cilj ovog rada je pružiti viziju kako samopoštovanje utječe na određene aspekte, kako u poslovnom svijetu, tako i u ostalim sferama koje direktno i indirektno utječu na život pojedinca. Samopoštovanje je preduvjet za uspješno obavljanje bilo kakve vrste posla a samim time i za uspješni međuodnos s kolegama. Samopoštovanje nije nepromijenjiva značajka stoga moramo biti svjesni važnosti očuvanja istog.People with a high degree of self-esteem are able to build their own life exactly the way they want and are happy in their own skin. When faced with problems, they are doing it calmly and stably knowing that they are competent for the tasks they face every day. Such individuals are not selfish and willing to help other people and it is just one of the segments why they are more successful than people with low self-esteem in all areas of life. The aim of this paper is to provide a vision of how self-esteem affects certain aspects, both in the business world and in other spheres that directly and indirectly affect an individual's life. Self-esteem is a prerequisite for successful performance of any kind of work and therefore for successful interaction with colleagues. Self-esteem is not an unchangeable feature, therefore we must be aware of the importance of preserving it

PARTICULARITIES OF CLINICAL PRESENTATION AND FREQUENCY OF NEWLY DISCOVERED CASES OF MULTIPLE SCLEROSIS IN THE CLINIC OF NEUROLOGY FROM THE YEAR 2009 TO 2014

Cilj istraživanja: Cilj ovog istraživanja je provjeriti koliko je bilo novodijagnosticiranih slučajeva multiple skleroze na Klinici za neurologiju KBC-a Split u razdoblju od 2009. do 2014. godine, dobiti uvid u osnovne epidemiološke i kliničke značajke njihove bolesti te analizirati dobivene rezultate uspoređujući ih s rezultatima i zaključcima drugih svjetskih istraživanja. Materijal i metode: Uzorak potreban za provedbu istraživanja dobiven je retrospektivnim pregledom arhive Klinike za neurologiju KBC-a Split u potrazi za medicinskom dokumentacijom svih pacijenata hospitaliziranih na klinici u razdoblju od 1. siječnja 2009. do 31. prosinca 2014. godine. Kriteriji uvrštavanja bili su da su pacijenti hospitalizirani u navedenom razdoblju te im je tada prvi put postavljena dijagnoza multiple skleroze. Ulazni podaci za statističku obradu bili su: dob pri dijagnozi, spol, trajanje simptoma prije postavljanja dijagnoze, pozitivna obiteljska anamneza na malignome, multiplu sklerozu, bolesti štitnjače i/ili autoimune bolesti, pozitivna osobna anamneza na malignome, bolesti štitnjače, depresiju, dijabetes i/ili autoimune bolesti, simptomi pacijenata otkriveni anamnestički, simptomi pacijenata otkriveni u neurološkom statusu pri hospitalizaciji, EDSS rezultat i pušenje. Rezultati: U razdoblju 2009. - 2014. godine u Klinici za neurologiju KBC-a Split dijagnosticirano je 202 novih slučajeva multiple skleroze, učestalije kod žena i to u omjeru 2,96:1. Prosječna dob bila je 37,93 (SD 11,12) godina. Većina pacijenata je bila stara između 20 i 40 godina (55,45%), a pacijenti mlađi od 20 godina (4,95%) i stariji od 60 godina (4,45%) su bili vrlo rijetki. Na temelju skupine od 168 pacijenta koji su imali podatak o trajanju simptoma izračunali smo prosječno vrijeme od nastupa prvih simptoma do konačne dijagnoze multiple skleroze, a iznosi 16,87 mjeseci. Medijan trajanja simptoma je bio 3,25 mjeseci što znači da je 50% pacijenata dijagnosticirano unutar 3,25 mjeseci od nastupa simptoma. Većina pacijenata (77,38%) je bilo dijagnosticirano unutar 12 mjeseci od nastupa simptoma indikativnih za multiplu sklerozu. U obiteljskoj anamnezi pacijenata većinom smo zabilježili pojavu malignoma (28,22%) nakon čega se najčešće bilježila pojava multipe skleroze (5,45%). Od ostalih zabilježili smo još pojavu autoimunih bolesti (3,47%) i bolesti štitnjače (2,97%). U osobnoj anamnezi pacijenata zabilježili smo pojavu bolesti koje su nam bile od interesa kod njih 15,84%. Najčešće su to bile bolesti štitnjače koje smo zabilježili kod 10,89% pacijenata. U manjem broju su se još pojavljivali malignomi, depresija i dijabetes. Od simptoma koje su osjećali pacijenti su dominantno opisivali poteškoće s motoričkim (47,03%) i osjetnim (47,03%) sustavom. Također su jedni od češće opisivanih simptoma bili vidni simptomi (36,63%) i simptomi moždanog debla (22,77%). Nešto rjeđe pacijenti su opisivali glavobolje (15,84%), poremećaje sfinktera (15,35%) i cerebelarne simptome (11,88%). Od ostalih simptoma zapaženi su još umor, vrtoglavica, bol, smetnje koncentracije i pamćenja. Pri kliničkom pregledu pacijenata u statusu su najčešće zapaženi motorički (68,32%), cerebelarni (44,55%) i osjetni simptomi (42,57%). Zabilježeni su još simptomi moždanog debla, vidni simptomi i poremećaji sfinktera, a čak 16,83% pacijenata je pri hospitalizaciji bilo urednog statusa. Pri hospitalizaciji većina pacijenata imala je EDSS rezultat od 0 do 1 (51,49%). Rezultat od 1,5 do 4 imalo je 40,59% pacijenata, a samo 7,92% pacijenata imalo je EDSS rezultat veći od 4. Udio pušača među novodijagnosticiranim pacijentima bio je 37,62%, a 4,95% je nekoć pušilo. Zaključak: U šestogodišnjem razdoblju 2009. - 2014. godine u Klinici za neurologiju KBC-a Split dijagnosticirano je 202 novih slučajeva multiple skleroze. Gotovo trostruko češće je bolest dijagnosticirana kod osoba ženskog spol što smatramo da je u skladu s trendom porasta tog omjera u posljednjim desetljećima. Prosječna dob pri dijagnozi je bila 37,93 godine, a većina je pacijenta imala između 20 i 40 godina (55,45%). Prosječno vrijeme trajanja simptoma indikativnih za multiplu sklerozu prije postavljanja dijagnoze je bilo 16,87 mjeseci, međutim daljnjom analizom podataka utvrđeno je da je 77,38% pacijenata dijagnosticirano unutar 12 mjeseci od početka simptoma. Kod otprilike 1/3 pacijenata (35,64%) u obiteljskoj anamnezi zabilježena je pojava nekih bolesti za koje svjetska literatura pokazuje korelaciju s multiplom sklerozom. Najčešće su to bili malignomi, dok je multipla skleroza zabilježena u relativno malih 5,45%. 15,84% pacijenata ima zabilježeno pojavu nekakve bolesti uz multiplu sklerozu, od čega je najviše bilo bolesti štitnjače (10,89%). Što se tiče kliničke slike novodijagnosticiranih pacijenata, ona je najčešće bila obilježena pojavom motoričkih i osjetnih ispada. Očekivano većina pacijenata kod kojih je tek postavljena dijagnoza multiple skleroze nije imala visok EDSS rezultat, te su pacijenti bili većinom bez simptoma ili s minimalnim ispadima. Od novodijagnosticiranih pacijenata u razdoblju 2009. - 2014. 37,62% su bili pušači što je udio pušača za otprilike 10% veći nego u općoj populaciji.Objectives: The aim of this study is to verify how many cases of newly diagnosed multiple sclerosis was there in the Clinic of Neurology in KBC Split in the period from the year 2009 to 2014, to get the insight in the basic epidemiological and clinical features of their disease and to analyze the results we get by comparing them with results and conclusions from other world researches. Patients and Methods The sample needed for the implementation of our research was obtained by retrospective inspection of the Clinic of neurology archive in KBC Split in search of medical documentation of all the patients hospitalized in the clinic from January 1st 2009 to December 31st 2014. The criteria of inclusion were that the patients were hospitalized in the aforementioned period and that they were then diagnosed with multiple sclerosis for the first time. Data for statistical analysis were: age at diagnosis, gender, duration of symptoms before diagnosis, positive family history for malignancies, multiple sclerosis, thyroid diseases and/or autoimmune diseases, positive personal history for malignancies, thyroid diseases, depression, diabetes and/or autoimmune diseases, patient symptoms discovered anamnestically, patient symptoms discovered in neurological status at hospitalization, EDSS score and smoking. Results: In the period 2009 - 2014 in the Clinic of neurology of KBC Split 202 new cases of multiple sclerosis were diagnosed, more frequently in women in a rate of 2,96:1. Average age was 37,93 (SD 11,12) years. Most of the patients were between 20 and 40 years old (55,45%) and patients younger than 20 (4,95%) and older than 60 (4,45%) were very rare. Based on a group of 168 patients who had data of symptom duration we calculated the average time of first symptom onset to final diagnosis of multiple sclerosis and it was 16,87 months. The median of symptom duration was 3,25 months which means that 50% of patients were diagnosed within 3,25 months from symptom onset. Most of the patients (77,38%) were diagnosed within 12 months of symptoms indicative for multiple sclerosis onset. In patients family history we mostly noted malignancies (28,22%) after which multiple sclerosis (5,45%) was most frequently noted. Of the rest we noted autoimmune diseases (3,47%) and thyroid diseases (2,97%). In patients personal history we noted appearance of disease of interest in 15,84% of them. Most often those were thyroid diseases which we noted in 10,89% of patients. In smaller number appeared malignancies, depression and diabetes. Of the symptoms that they had patients dominantly described difficulties with motor (47,03%) and sensory (47,03%) system. Also more often described symptoms were visual (36,63%) and brainstem (22,77%) symptoms. Slightly rarely patients desribed headaches (15,84%), bowel/bladder (15,35%) and cerebellar (11,88%) symptoms. Of other symptoms fatigue, vertigo, pain, concentration and memory problems were noted. At clinical examination of patients in status most frequently noticed were motor (68,32%), cerebellar (44,55%) and sensory (42,57%) symptoms. Also noted were brainstem, visual and bowel/bladder symptoms and even 16,83% of patients had a normal status at hospitalization. At hospitalization most of the patients had an EDSS score of 0-1 (51,49%). EDSS score 1,5-4 had 40,59% of patients and only 7,92% of patients had an EDSS score higher than 4. The rate of smokers among newly diagnosed patients was 37,62% and 4,95% used to smoke. Conclusion: In the six year period 2009 - 2014 in the Clinic of neurology of KBC Split 202 new cases of multiple sclerosis were diagnosed. Almost three times more often the disease was diagnosed in women what we consider to be in accordance with the trend of that rate's increase in the last decades. Average age at diagnosis was 37,93 years and most of the patients were between 20 and 40 years old (55,45%). Average duration of symptoms indicative for multiple sclerosis before diagnosis was 16,87 months, but with further analysis of data it was established that 77,38% of patients were diagnosed within 12 months of symptom onset. At around 1/3 of patients (35,64%) in their family history an appearance of some diseases that world literature shows correlation to multiple sclerosis has been noted. Most often those were malignancies, while multiple sclerosis was noted in relatively little 5,45%. 15,84% of patients had some kind of disease along multiple sclerosis noted, of which thyroid disease (10,89%) were the most. About the clinical presentation of newly diagnosed patients, it was most often marked by appearance of motor and sensory deficit. As expected most of the patients which were just diagnosed with multiple sclerosis didn't have a high EDSS score and patients were mostly without symptoms or with minimum deficit. Of newly diagnosed patients in the period 2009 - 2014. 37,62% were smokers which is a rate about 10% higher than in the general population

THE IMPACT OF OROFACIAL CLEFTS ON QUALITY OF LIFE IN OPERATED CHILDREN

Orofacijalni rascjepi najčešće su prirođene malformacije koje zahvaćaju kraniofacijalne strukture. Djeca rođena s ovom vrstom malformacije imaju poteškoća s govorom, sluhom, dentalnim nepravilnostima i karakterističnim promjenama izgleda nosa i usne koje utječu na sva područja zdravlja. U literaturi se navodi kako orofacijalni rascjepi imaju velik utjecaj na psihološki razvoj pacijenata, ali i njihovih obitelji. U Hrvatskoj nisu objavljeni radovi koji se bave ovom problematikom pa su zbog toga potrebna istraživanja koja bi ispitala utjecaj orofacijalnih rascjepa na kvalitetu života operirane djece i njihovih roditelja. Za potrebe ovog rada izrađeni su originalni anketni upitnici kojima se ispitivao utjecaj orofacijalnih rascjepa na kvalitetu života operirane djece i njihovih roditelja. Istraživanje je provedeno na Kliničkom zavodu za oralnu kirurgiju, Klinike za kirurgiju lica, čeljusti i usta, Kliničke Bolnice Dubrava, Zagreb, a obuhvatilo je 73 ispitanika, odnosno djece u dobi 11 – 18 godina koja imaju jedan oblik operiranog orofacijalnog rascjepa i jednak broj njihovih roditelja/skrbnika. Zahvaljujući ovom radu, izrađeni su originalni upitnici specifični za procjenu estetskih i funkcijskih rezultata liječenja, odnosno za kvalitetu života operiranog djeteta i njegovih roditelja. Prikazani rezultati pokazuju gledišta djece i roditelja na kvalitetu života te estetske i funkcijske čimbenike s najvećim utjecajem na kvalitetu života. Na temelju analiziranih odgovora, vidljivo je da djeca s rascjepom imaju lošiju kvalitetu života u usporedbi s njihovim vršnjacima bez rascjepa te da orofacijalni rascjep ne umanjuje kvalitetu života samih roditelja. Estetski čimbenici koji najviše utječu na kvalitetu života djece rođene s rascjepom usne i nepca su izgled nosa i usne, a funkcijski čimbenici koji najviše utječu na kvalitetu života su dentalna malokluzija i poteškoće s govorom.Introduction: Orofacial clefts are the most common congenital malformations that affect craniofacial structures. Disjunction of skin, muscles, bones and cartilages represents an aesthetic and functional problem. Clefts can be a result of a large number of syndromes or non-syndromic, i.e. isolated, but in both cases, they are divided into cleft lip, cleft lip and palate or isolated cleft palate. Children born with this type of malformation have difficulties with talking, hearing, dental irregularities and characteristic changes in the appearance of the nose and lip, which affect all domains of health. Studies show that orofacial clefts have a major influence on psychological development of the patient and their families. The treatment of children with clefts is comprised of a large number of specialists whose activities are intertwined through the period of growing up, and includes a maxillofacial surgeon who coordinates other team members, a neonatologist, an anaesthesiologist, a paediatrician, an orthodontist, an oral surgeon, an otorhinolaryngologist-audiologist, a logopedist, a psychologist, a psychiatrist, and a paediatric dentist. It is necessary to understand the embryonic development of the nose, lip and palate between the 4th and 10th gestational week in order to grasp the formation of the orofacial cleft. The development of a normal palate is explained by the fusion of facial extensions, i.e. the penetration of mesoderm into the primary and secondary palate. According to His’s theory of facial extensions (1892), orofacial clefts are a consequence of inhibition of growth and binding of embryonic facial extensions. The incidence of orofacial clefts, according to the latest data, is about 1 out of 700 children born in the world. In Croatia, according to Magdalenić-Meštrović's research from 2005, the incidence is somewhat higher, and that is 1 in 581 born children. Cleft lip with or without cleft palate is more common in the male sex, and isolated cleft palate in the female sex, regardless of ethnicity. If the ratio of the sexes only in the white race is taken into consideration, then cleft lip with or without cleft palate is more common in the male sex in the ratio of 2:1. Epidemiological and experimental data suggest that harmful environmental influences may have a significant effect on the formation of cleft lip and/or palate in the form of exposure to the mother's tobacco smoke, alcohol, nutritional deficiency, viral infections, medical preparations and other teratogens at work and at home in the early months of pregnancy. Procedures and protocols for treating children with a cleft lip and palate can be extremely different within and among developed countries. Cleft treatments aim at correcting the broken anatomical relationship and establishing a normal function of the broken tissue and surrounding structures. Irregularities regarding the facial appearance, speech, maxillofacial and dento-occlusal development, hearing, and psychosocial status are attempted to be corrected, i.e. alleviated by various invasive and non-invasive therapeutic procedures. Most maxillofacial surgeons operate the cleft lip after the third month of age. This observes the anaesthetic "rule of ten” when a child is at least 10 weeks of age, has haemoglobin above 10 dg/L and weight above 5000 g (10 pounds). The surgical procedure of closing the soft palate in complete clefts is most commonly performed between the 3rd and 6th month of age, at the same time as the lip operation is performed. The malformation on the hard palate is corrected in the second operation around the child’s second year. In cases of isolated cleft palates, the closure is also performed in two operations; first the soft palate between the 3rd and 6th month, and then the hard at two years of age. In 1948, the World Health Organization defined health as a state of complete physical, mental and social well-being, not just the absence of disease and inactivity. American psychologist John C. Flanagan is considered to be the founder of the concept of quality of life in health care. HRQOL – health related quality of life describes subjective satisfaction with one’s health status. It is an instrument which examines the impact of illnesses and treatment modalities on health, integrating an objective assessment of the health status and its subjective experience (satisfaction with physical, mental and social functioning). The concept of oral health-related quality of life (OHRQOL) has only been developing over the past few decades, since it started to draw close attention. Oral health is considered an important part of a patient's general health. In Croatia, no studies have been conducted on this issue. Therefore, research is needed to investigate the impact of orofacial clefts on the quality of life of operated children and their parents. In this way, the results of the treatment and the quality of work of the health team involved in this process would also be seen. Examinees and research methods: For the purpose of this study, original questionnaires were put together to research the effect of orofacial clefts on the quality of life in operated children and their parents. In cooperation with a maxillofacial surgeon, an orthodontist, a psychologist and a logopedist who have longterm experience in treating clefts, questionnaires for children with clefts, their parents/guardians, and a form for taking the clinical status, which the examiner fills in during the interview and examination of the patient, were made. The questions were carefully designed and chosen to be as adjusted as possible to research groups, and to achieve the main goals of the research. The study was conducted at the Clinical Institute for Oral Surgery, the Clinic for Face, Jaw, and Mouth Surgery, Clinical Hospital Dubrava, Zagreb, and it includes 73 examinees, or 11 – 18 year-old children, who have one form of operative orofacial cleft and the equal number of their parents/guardians. The female sex was more represented with 56.2% of respondents, or 57.1% in the control group. The respondents were divided into two age categories (groups) to identify possible differences in early and late puberty. From the collected questionnaires, it was determined that representation in the older age group was similar for both groups of respondents (57.5% vs. 62.9%). The questionnaires consist of a general part, which the respondents filled in with their sex and age, and questions that examined quality of life. The questionnaire for children contains 46 questions/claims, and the one for parents 28 questions/claims. The questionnaires are made of simple statements which are evaluated with a 5-degree Likert scale (from 1 – fully disagree to 5 – fully agree) so they do not require specific additional clarifications, and are easy to fill in. After the questionnaires were completed, the examiner checked the patients/children and filled in the clinical status template located on a separate questionnaire sheet. The described study focuses on the fact of obtaining the patients and their parents’views on the long-term treatment process and the impact of the treatment on the quality of life. Results and discussion: Most children (46.6%) had unilateral cleft lip and palate. Only 6.8% of children had cleft presence in family, and less than 10% of children had 7 or more surgeries. Most children were happy with the appearance of the nose and lip. Almost a third of the respondents have a fistula on the palate, whereas 45.2% of the respondents have an occlusion Class 3 by Angle. Original questionnaires specific for assessing aesthetic and functional outcomes of the treatment, i.e. the quality of life in the operated child and his parents, were designed in this research. The illustrated results show the children and parent’s views, as well as aesthetic and functional factors that have the highest impact on the quality of life. Analysing the results of this research, we come to the conclusion that the studied group has worse results (higher score in response evaluation) compared to its control group, resulting in poorer quality of life as a consequence of the orofacial cleft. The results of this study did not reveal statistically significant differences in the responses of children with clefts regarding the sex. The proportion of male and female respondents was 32- 43.8%: 41-56.2%. Despite the fact that the female respondents were more dissatisfied with the aesthetic component of the cleft (external appearance, nose, lip and teeth), and the male respondents with the functional component (speaking, chewing), there were no major differences in the responses on the Likert scale. We divided the respondents into two age groups: younger adolescents 11 – 14 years (31 respondents – 42.5%) and older adolescents 15 – 18 years (42 respondents – 57.5%). The results show that there are differences in the responses between these two groups,but they are not statistically significant. The exploratory factor analysis of all 46 claims in the questionnaire intended for studying children with clefts gave three factors that evaluate the effect of the orofacial cleft on the quality of life. Three factors represent three categories: 1.Relationship with parents, success, society, 2.Appearance and 3.Function, which are integral part of a conceptual life quality scheme that consists of three main domains: physical, psychological and social health. Factor 1 Relationship with parents, success, society is a component of social health, factor 2 Appearance is a component of psychological health, and factor 3 Function is a component of physical health. The observed results show that the differences were significant for all three domains, with the emphasis on the fact that the biggest difference was in the domain of psychological health, i.e. appearance, which is the expected result since the answers given to individual questions referred to such a result. The data from the clinical form were compared with individual domains, and thus an "external" response validation was made, i.e. a comparison of subjective and objective experience of the cleft. A positive correlation was determined between a worse nose and lip appearance and the appearance domain, as well as a higher class by Angle (maxillary retrognathia / mandibular progenia) and the function domain. The questionnaire intended for parents shows that they have a satisfying quality of life. Factorial analysis of the questionnaire for parents of children with the orofacial cleft has formed two domains: Social health of parents and Social health of the child. Despite the fact that the results of this research have confirmed that the parents’quality of life is not disturbed, and taking into consideration the children’s quality of life as perceived by the parents, it has been confirmed that their opinion is closely related to the children’s opinion. There are positive correlation coefficients if we analyse similar questions in both questionnaires and when the parents’perception on the child's social health is analysed with the children’s perception in all three domains. Conclusion: The scientific contribution of this research consists of created and applicable original questionnaires specific for assessing the influence of orofacial clefts on the quality of life in operated children and their parents. Aesthetic factors which affect the quality of life of children born with a cleft lip and palate the most are the appearance of the nose and lip, and the functional factors with the most influence are dental malocclusion and speech difficulties. Based on the presented results, it can be concluded that the congenital malformation, the orofacial cleft, with its clinical manifestation and the scope of affected anatomic structures, decreases the quality of life in treated children regarding the postoperative function and aesthetic outcome. On the other hand, we have come to the conclusion that the quality of life in parents of treated children is not diminished, although the parents’ opinion coincides with the children’s opinion on their quality of life

Micromotion-induced Limit to Atom-Ion Sympathetic Cooling in Paul Traps

We present and derive analytic expressions for a fundamental limit to the sympathetic cooling of ions in radio-frequency traps using cold atoms. The limit arises from the work done by the trap electric field during a long-range ion-atom collision and applies even to cooling by a zero-temperature atomic gas in a perfectly compensated trap. We conclude that in current experimental implementations this collisional heating prevents access to the regimes of single-partial-wave atom-ion interaction or quantized ion motion. We determine conditions on the atom-ion mass ratio and on the trap parameters for reaching the s-wave collision regime and the trap ground state

UPCOMING CHALLENGES ON REGULATING REMUNERATION OF THE DIRECTORS AND IMPLEMENTING REMUNERATION POLICIES

The European Parliament adopted the Directive 2017/828 as regards the encouragement of long-term shareholder engagement that grants shareholders to hold the right to vote on the remuneration policy for employees and directors. Following the collapse of large companies in the USA and common agency problem, the intent of regulators on capital markets was to ensure preconditions for stable companies, so remuneration policies were prescribed by the recommendations and through corporate governance mechanisms, such as is say on pay. In order to align interests of the companies and their directors, remuneration policy was recognized as one of the key instruments introduced by the EU legislator for financial institutions, primarily investment funds and banks. The implementation of the Directive into national legislation is mandatory, so for the first time the regulator gives shareholders the right to decide on the remuneration of directors, it gives them the option of setting the framework within the pay of directors is to be held and proposing public disclosure of remuneration policy. One of the major issues that will be imposed by the new Directive will be how and to what extent the decision on the remuneration of directors, will be left to the shareholders to vote at the general meeting. The authors in this paper analyze new system on remuneration policies, opportunities and obstacles that companies may face, as well as the challenges imposed to directors, in the implementation of the Directive in national legislation and practice

Lijekovi uzročnici osteonekroze čeljusti

Medikamentozno uzrokovana osteonekroza čeljusti (MRONJ) jedna je od težih komplikacija invazivnih stomatoloških zahvata u pacijenata podvrgnutim antiresorptivnim, antiangiogenim i imunomodulativnim vrstama farmakoloških terapija. Neadekvatno cijeljenje ili izostanak istog prezentirat će se pojavom nekrotičnih žarišta u području čeljusti s tendencijom širenja i posljedičnim prekidom kontinuiteta koštanog tkiva (patološkim prijelomima). Mehanizmi u podlozi već spomenute komplikacije mogu biti vezani uz samu mogućnost cijeljenja, pregradnju ili vaskularizaciju kosti. Teška sistemska stanja kao što su koštane metastaze solidnih tumora (dojke, bubrega, pluća, prostate), hiperkalcemija i patološki prijelomi uzrokovani karcinomima, osteoporoza, multipli mijelomi te koštane displazije zahtijevaju oblike terapije koji će preko različitih mehanizama onemogućiti daljnju progresiju bolesti. Terapije mogu uključivati direktno inhibitorno djelovanje na same osteoklaste i osteoblaste antiresorptivnim lijekovima (bisfosfonati i denosumab) ili onemogućavanjem procesa angiogeneze antiangiogenim lijekovima (anti-VEGF i anti-TKI). Neselektivno djelovanje već spomenutih lijekova narušit će fiziološki proces cijeljenja. U kombinaciji s medijem bogatim mikroorganizmima kao što je usna šupljina, ovakav tip lezije posjeduje veći potencijal progresije u nekrotičnu leziju. Treba naglasiti da se MRONJ može razviti kao progresivna infekcija pri primjeni imunosupresivnih lijekova ili imunomodulativnih lijekova, antiinflamatornih anti-TNF agensa, metotreksata, everolimusa i temsirolimusa. Dodatna terapija kortikosteriodima uz bilo koji od ranije navedenih lijekova također predstavlja povećani rizik. S obzirom na to da nema specifičnog terapijskog postupka liječenja MRONJ-a, veliki naglasak stavlja se na samu prevenciju koja je uvjetovana održavanjem stabilnog zdravlja usne šupljine pacijenta i uvidom u potencijalne rizične farmakološke terapije povezane s osteonekrozom

Observation of Cold Collisions between Trapped Ions and Trapped Atoms

We demonstrate a double-trap system well suited to study cold collisions between trapped ions and trapped atoms. Using Yb$^+$ ions confined in a Paul trap and Yb atoms in a magneto-optical trap, we investigate charge-exchange collisions of several isotopes for collision energies down to 400 neV (5 mK). The measured rate coefficient of $6 \times 10^{-10}$ cm$^{3}$s$^{-1}$, constant over four orders of magnitude in collision energy, is in good agreement with that derived from a semiclassical Langevin model for an atomic polarizability of 143 a.u.Comment: 4 pages, 4 figures; Revision 1/V2: Revised in response to PRL Referees' comment

Bright Source of Cold Ions for Surface-Electrode Traps

We produce large numbers of low-energy ions by photoionization of laser-cooled atoms inside a surface-electrode-based Paul trap. The isotope-selective trap loading rate of $4\times10^{5}$ Yb$^{+}$ ions/s exceeds that attained by photoionization (electron impact ionization) of an atomic beam by four (six) orders of magnitude. Traps as shallow as 0.13 eV are easily loaded with this technique. The ions are confined in the same spatial region as the laser-cooled atoms, which will allow the experimental investigation of interactions between cold ions and cold atoms or Bose-Einstein condensates.Comment: Paper submitted to PRL for review on 2/1/0

The modification of rotation - advancement flap made in 1950

The early techniques of cleft lip repair involved the straight-line technique, the triangular flap technique or some kind of geometric line (triangular, quadrangular closure). A turning point in cleft lip surgery was in 1955 when doctor. Millard presented his method: the rotation-advancement technique or flap, at the First International Congress of Plastic Surgery in Stockholm. Today, the technique, with or without some modifications, is used by more than 85% of cleft surgeons around the world. We are presenting a patient with complete unilateral cleft lip and palate who underwent surgery sixty-five years ago. The scar on his lip was similar to rotation advancement line. Cheiloplasty was performed by Professor Šercer in 1950, five years before Millard's publication. Professor Ante Šercer was an internationally recognized Croatian scholar in the area of ear, nose and throat diseases. He also gave a significant contribution to surgical management of velopharyngeal insufficiency and plastic surgery of the nose and ear