Showing papers in "Acta medica Croatica : c̆asopis Hravatske akademije medicinskih znanosti in 2005"

[Hans Berger (1873-1941)--the history of electroencephalography].

Abstract: The discovery of electroencephalography (EEG) in 1929 by the German psychiatrist Hans Berger was a historical breakthrough providing a new neurologic and psychiatric diagnostic tool at the time, especially considering the lack of all those now available in daily practice (EP, CT, MRI, DSA, etc.) whithout which the making of neurologic diagnosis and planning neurosurgical operative procedures would now be unconceivable. There are no recent reports on the topic in the Croatian medical literature. The methods used in the study included search through previous reports, bibliographic notes, Internet sources, and analysis of continuous scientific attempts made through centuries to discover the real nature and meaning of electrical activity. Galvani's accidental discovery of "biological electricity" led to Volta's discovery of the battery (voltaic pile). Using it, Rolando was the first to stimulate cerebral surface. Thus, enabling Fritsch and Hitzig and Ferrier to develop the idea of cerebral localization (Jackson, Gowers, Gotch and Horsley). It was understandable that brain electrical stimulation produces contralateral motor response, but it was unknown whether there was a spontaneous (intrinsic) brain electrical current that could be recorded. Caton was the first to report on the "current in the brain gray substances onto open brain. Based on Caton's discovery and of those of Beck, Danilevsky, Prawdicz-Neminsky and others, Berger made the first EEG (electrocorticogram) recording on July 6, 1924, during a neurosurgical operation on a 17-year-old boy, performed by the neurosurgeon Nikolai Guleke. He reported on the topic in 1929, using the terms alpha and beta waves. The "spike and waves" (Spitzenwellen) were described shortly thereafter by the American group of EEG pioneers (H. and P. Davies, F. and E. Gibbs, Lenox and Jasper), although Berger had also observed them but considered them artifacts. The discovery of electroencephalography was a milestone for the advancement of neuroscience and of neurologic and neurosurgical everyday practice, especially for patients with seizures. The real nature of the disease and its management (anticonvulsants, excision of brain scars, tumors, etc.) were unkonown at that time. Berger's persistent, hardworking and steady personal style overcame all technical and other obstacles during the experiments. Unfortunately, he gained neither acceptance nor recognition, among his fellow contemporaries from abroad. Political turmoils at the dawn of World War II, in the country of Nazi's ideology and finally the outbreak of war, along with the complete ban of any further work on EEG after his forced retirement, led him to an uneasy professional and personal end. In the era when lumbar puncture, pneumoencephalography and ventriculography were the only diagnostic tools to detect and localize "sick sites" in the brain, EEG revolutionized daily neurologic and neurosurgic procedures, and bridged a time period of about 40 years (1930-1970) until the advent of computer tomography. Nowadays its importance is not as great as it was before, but it still has its place in the diagnostic work-up of seizures, brain tumors, degenerative brain changes, and other diseases.

Retreatment of patients with chronic hepatitis C

Abstract: Impressive gains have been made in the treatment of chronic hepatitis C virus (HCV) infection during the past decade. As the treatment for chronic hepatic C has improved, the question has arisen as to whether patients who failed previous HCV treatment regimens should be retreated. Several recent studies involving retreatment have established that a small but significant increase in sustained virologic response (SVR) resulted when nonresponders to prior interferon monotherapy were retreated with interferon and ribavirin. Given the superior results observed with pegylated interferon and ribavirin in the treatment of naive population, it is now appropriate to consider whether retreating previous relapsers and nonreponders, particularly nonresponders to conventional interferon and ribavirin, will be effective. Such treatment would be most advantageous for patients with advanced fibrosis or cirrhosis who are at the highest risk of developing complications of advanced liver disease, including hepatocellular carcinoma. Namely, there is no doubt that interferon-based regimens may reduce hepatic inflammation in the abscence of SVR. For this reason, patients with advanced liver disease receive histologic benefit from therapy in addition to the potential benefit of viral eradication, because progression of fibrosis to cirrhosis is a function of hepatic inflammation. A number of investigator-initiated clinical trials have been started to study response in prior nonresponders and relapsers retreated with pegylated interferon and ribavirin. From the data obtained from these trials, so far is clear that combined therapy can clear HCV-RNA in a significant number of prior nonresponders (25% to 40%) while on treatment, yet the rate of SVR appears to be by far lower (20%). Better results have been reported with relapsers to prior combination therapy. Moreover, preliminary results from the HALT-C trial have shown that maintenance therapy with pegylated interferon and ribavirin can significantly delay fibrosis progression and reduce the risk of hepatic decompensation and hepatocellular carcinoma and the need of liver transplantation. According to these results, many authors have proposed a course of combination therapy with pegylated interferon and ribavirin for relapsers and nonresponders with advanced fibrosis and cirrhosis.

Treatment of West syndrome

Abstract: Purpose West syndrome (WS) is one of the catastrophic epileptic syndromes in infancy characterized by a triad of infantile spasms, psychomotor deterioration and hypsarrhythmic EEG pattern. WS is commonly associated with poor long-term outcome, especially in symptomatic cases, with development of other seizure types, impaired cognitive and psychosocial functioning. The aim of our study was to evaluate the efficacy of the control of infantile spasms using synthetic ACTH or vigabatrin in newly diagnosed cases and to correlate it with the underlyning causes, outcome and adverse effects. Patients and methods The database of children with WS seen at the Neuropediatric Unit and followed at outpatient clinics from January 1, 1994 until December 31, 2003 were reviewed. The diagnosis of WS following the criteria of ILAE was made in 32 patients. Results Data were collected for 32 children (9 girls and 23 boys). According to the etiology, 5 (15.6%) were cryptogenic, and 1 (3.1%) was idiopathic. In 26 (81.2%) symptomatic cases, hypoxic-ischemic encephalopathy (69.2%) was the most common etiologic factor, followed by central nervous system anomaly including malformation of cortical development (11.5%), and Sturge Weber syndrome (3.8%), and chromosomal translocation with Down syndrome (11.5%). In 65.1% of symptomatic cases birth occurred prematurely. The mean age at spasm onset was 5.8 months, and mean age at diagnosis and treatment 7.2 months. Between 1994 and 1996 synthetic ACTH was used for treatment of WS in 7 patients (1 cryptogenic and 6 symptomatic), spasm control was achieved in 6, hypsarrhythmia disappeared in 5, and vigabatrin was added after synthetic ACTH in 3 patients. In one child synthetic ACTH was stopped because of arterial hypertension. All children had Cushing syndrome. After 1996, vigabatrin was administrated to 5 children with cryptogenic and 20 children with symptomatic WS. In 22/32 spasm control was achieved within 15 days. Synthetic ACTH was added in 3 children with spasms and hypsarrhythmia disappeared in 1 child. There was no recurrence of WS. The mean follow-up in 27 children was 4.6 (0.5 to 9.9 years) whereas 5 were lost from follow-up. Of 6/27 children with cryptogenic WS, 1 had idiopathic WS, 3 had normal psychomotor development and 2 had psychomotor retardation, without epileptic fits and still receiving AED. Of 21/27 children with symptomatic WS 76.2% had severe psychomotor retardation, 42.8% had epilepsy, 23.8% had intractable epileptic fits, and 2 children with Down syndrome were without epilepsy and without AED. Lennox-Gastaut syndrome developed in 14.2% (3/21 children); 1 of them died at the age of 3.5 years from acute gastric bleeding during the administration of synthetic ACTH, and an other child died at the age of 5.5 years from infection and respiratory insufficiency. The mortality rate was 7.4% (2/27 children). Discussion and conclusion The cryptogenic etiology is associated with a very low risk of poor outcome in WS. In children with normal development and regular school performance an idiopathic etiology can be presumed. The children with Down syndrome had a relatively benign outcome with regard to seizure control compared with symptomatic infantile spasms in the general population. In symptomatic WS caused by hypoxic-ischemic encephalopathy the outcome was linked with coexistence of other forms of epilepsy and neurologic deficit. The poor prognosis concerning intractable nature of the seizures and serious neurologic deficit is recorded in children with malformation of cortical development and Sturge Weber syndrome. The outcome of these children is determined by the brain damage other than by epilepsy itself. Regarding the treatment with synthetic ACTH or vigabatrin, the control of WS was the same for cryptogenic and symptomatic forms, one drug may be effective if the other drug fails. Synthetic ACTH can have many side effects, even death. The visual field defect is associated with vigabatrin, but can be avoided with careful funduscopic follow-up. Vigabatrin can be suggested as the first drug for WS; if spasms persist after 15 days with a dose of 150 mg/kg, synthetic ACTH should be considered.

The correlation of inflammation and epithelial changes in the Pap smears of cervix uteri

Abstract: UNLABELLED: A modification of The Bethesda System classification of cytologic findings of uterine cervix named Zagreb 1990 has been accepted in Croatia as a unique classification, the use of which has begun after the publication and printing of the new, uniform method of cytologic examination. AIM: The aim of this study was to assess the number and type of cytologic abnormalities of uterine cervix classified according to Zagreb 1990, on routinely examined Pap smears during the 6-year period, and to investigate the connection of these abnormalities with lower genital tract infections. MATERIAL AND METHODS: The retrospective study included Pap smears from the City of Zagreb and from the town of Imotski. A total of 59901 Pap smears (patients aged 17-79) were routinely examined: the cytopathologic diagnosis of CIN I or higher recorded in 3664 (6.12%) of them. The control group consisted of 401 Pap smears of age-matched women referred by the same gynecologists and free from cytologic abnormalities. The most frequently diagnosed epithelial change was CIN 1 (84.57% of all epithelial changes, and 5.17% of total study population), followed by CIN II (10.92%; 0.67%), CIN III (3.11%; 0.19%), and invasive squamous carcinoma (1.31%; 0.08%). Endocervical adenocarcinoma was cytologically diagnosed in only 0.0055% of all Pap smears examined. Inflammation was significantly more common in the group with epithelial dysplasia/carcinoma than in the control group (p < 0.01). Of specific causative agents HPV and Chlamydia trachomatis were significantly more frequently found in the group with epithelial dysplasia/carcinoma than in the control group (p < 0.05 both), however, Gardnerella vaginalis, Trichomonas vaginalis or Candida yielded no significant differences. It is concluded that inflammation very likely contributes to the development of precancerous lesions of the cervix, HPV and Chlamydia showing strongest correlation, at least in a part of our population.

Epileptic patient compliance with prescribed medical treatment

Abstract: UNLABELLED Medically treated patients' non-compliance with the prescribed scheme is an exceptionally important issue, faced relatively often in medical treatment of epilepsy. OBJECTIVE, PATIENTS AND METHODS Different demographic and clinical data, collected upon questionnaire completion from 146 patients suffering from epilepsy, were sorted out and integrated in the present research analyses with the objective to determine the possible correlation of collected data and compliance level recorded in the observed patients. RESULTS AND DISCUSSION Generally, the subjects took pretty the prescribed therapy regularly: in 62% of subjects the compliance level was recorded as good, in 23% as satisfactory, and in the remaining 15% as unsatisfactory. The following factors were identified as possible predictors of the less precise adherence to the prescribed therapeutic regimen (p<0.01): regular consumption of alcohol, medical treatment of 6 or more years, and three or more daily drug doses. The correlation between the greater number of prescribed anti-epileptic medicines and lower compliance level (p=0.05) was also assessed. The study revealed a tendency towards lower compliance level in patients aged below 30. Surprisingly, the same tendency was observed in the subjects with more thoroughly controlled epileptic condition. In spite of different experiments aimed to improve the regularity in taking the prescribed therapy, the issue of non-compliance still poses a considerable obstacle to the more successful treatment of epileptic patients.

Rhabdomyolysis as a side effect of simvastatin treatment

Abstract: Myopathy and rhabdomyolysis are rare adverse effects of treatment with hydroxymethylglutaryl-coA reductase inhibitors. The risk of adverse effects is increased with the concomitant use of statin and specific drugs that can induce myopathy, in patients with liver and renal function impairment, hypothyroidism and diabetes mellitus. The clinical picture of rhabdymyolysis with acute renal failure caused by the use of simvastatin in a 54-year-old patient with diabetes mellitus and hypertension is described.

[HL7 standard--features, principles, and methodology].

Abstract: The mission of HL7 Inc. non-profit organization is to provide standards for the exchange, management and integration of data that support clinical patient care, and the management, delivery and evaluation of healthcare services. As the standards developed by HL7 Inc. represent the world's most influential standardization efforts in the field of medical informatics, the HL7 family of standards has been recognized by the technical and scientific community as the foundation for the next generation healthcare information systems. Versions 1 and 2 of HL7 standard have solved many issues, but also demonstrated the size and complexity of health information sharing problem. As the solution complete new methodology has been adopted that is encompassed in the HL7 Version 3 recommendations. This approach standardizes Reference Information Model (RIM), which is the source of all derived domain models and message structures. Message design is now defined in detail, enabling interoperability between loosely coupled systems that are.designed by different vendors and deployed in various environments. At the start of the Primary Healthcare Information System project in the Republic of Croatia in 2002, the decision was to go directly to Version 3. The target scope of work includes clinical, financial and administrative data management in the domain of healthcare processes. By using HL7v3 standardized methodology we were able to completely map the Croatian primary healthcare domain to HL7v3 artefacts. Further refinement processes that are planned for the future will provide semantic interoperability and detailed description of all elements in HL7 messages. Our HL7 Business Component is in constant process of studying different legacy applications, making solid foundation for their integration to HL7-enabled communication environment.

Comparison of local acetylcysteine and artificial tears in the management of dry eye syndrome

Abstract: Dry eye syndrome is a common clinical entity causing difficulties to many people, especially the elderly. Standard substitution therapy with artificial tears may frequently prove inadequate, thus any new treatment modality is highly welcome. The syndrome implies lacrimal hyperosmolality, which in turn results in mucus accumulation in the conjunctival sac causing additional irritation. Locally applied acetylcysteine, a mucolytic, regulates mucus secretion and reduces mucus accumulation. The aim of the study was to compare the efficacy of artificial tear therapy and therapy with local acetylcysteine. The study included 32 patients with the symptoms and signs of dry eye attending our department between March 20 and May 9, 2003. All study patients were on long-term substitution therapy with artificial tears. Upon evaluation of subjective discomforts and objective signs, the patients were switched from artificial tear therapy (Isopto-Tears, Alcon, with polyvinyl alcohol as active ingredient) to therapy with locally applied acetylcysteine (Brunac, Bruschettini). All parameters were re-evaluated at 2-week control visit. Thirty of 32 patients (94%) completed the study with control visit. Of these, 18 (60%) patients reported reduction of subjective discomforts, ten (33%) patients observed no change, and two (7%) patients experienced more discomforts with acetylcysteine than with artificial tear therapy. On objective sign evaluation, 12 (40%) patients showed less discomforts, unchanged condition was recorded in 13 (43%) patients, and five (17%) patients had more discomforts as compared with artificial tear therapy. A statistically significant difference (p=0.05) between artificial tear therapy and acetylcysteine therapy was found for the subjective symptom score but not for the objective sign score. Therapy with acetylcysteine proved more efficient than artificial tears in reducing subjective symptoms but had no effect on the objective signs of dry eye syndrome. The advantages of acetylcysteine include more convenient instillation timing (4 times daily) and reduced nocturnal discomfort, whereas shortcomings are the sense of burning on instillation, bad odor, and as yet relatively high price on the Croatian market.

[CroDiab NET--electronic diabetes registry].

Abstract: INTRODUCTION AND AIM National diabetes registry has been an important aim of Croatian diabetology for a long time. Currently, efforts are made to define a national registry based upon Cro Diab NET, a computer software designed as a patient record form and suitable for automatic extraction of data for the registry. METHODS Diagnostic entities captured are defined by the International Classification of Diseases and Related Health Problems, 10th rev. (E10--E14, G63.2, and H36) and ICF (b540, b279, b298, b2108). Central CroDiabNET module is BIS (Basic Informatic Sheet), recognized by the international diabetology community as optimal data collection form for the follow-up and improvement of diabetes care. There are several ways of data collection: secondary and tertiary health centers with diabetes care within their scope of activities send BIS on their patients to the central base by a modem, other secondary and tertiary health centers as well as primary health care will send data on their diabetic patients either via the Internet or by mail (interactive BIS will be available on the registry www page). The preferred method of data collection is the electronic one. The central base automatically links records of uniquely identified patients. Other records are checked separately, compared with the existing records and linked manually. Data confidentiality is ensured by double password protection of excess at the level of both users and registry. Unauthorised access is highly unlikely. RESULTS So far, most of the secondary and tertiary health centers dealing with diabetology have been active in data collection. Inclusion of primary care (family physicians) is in progress. The last report covered data from 13 centers. Besides data on the number of patients, the reports contained analyses of BIS patient data availability. This is a tool for the analysis of the quality of registry and it can also provide basic data for planned actions aimed at quality of care improvement. Regular data collection from all levels of health care with concomitant connection of the registry to the national death registry started in 2004. With complete implementation of these processes a unique national diabetes database will be defined. CONCLUSION Results of the use of CroDiabNET so far confirm its potency as a valuable tool for population registry of diabetes as well as for improvement of diabetes health care. Regular periodic reports reveal an increasing number of centers involved. With continuation of this trend the registry will become a national, population-based database.

Markers of periodontal destruction in saliva of periodontitis patients

Abstract: Periodontal diseases result from interactions between periodontal microflora and the multifaceted response of the host. Markers of this interrelationship can be found in gingival crevicular fluid and saliva samples indicating early periodontal disease activity. Studies of host defense mediators in saliva of patients with periodontal diseases are very scarce. AIM: The goal of this study was therefore to investigate interrelationships between mediators of local immunity in host saliva and clinical parameters of periodontal destruction in persons with chronic and aggressive periodontitis. METHODS AND SUBJECTS: Host defense indicators were measured using enzyme-immunochemistry tests in unstimulated saliva samples of persons with periodontitis. The degree of periodontal destruction was determined by measuring attachment loss. Subjects were divided into two groups: persons with mild signs of chronic periodontitis and persons with severe signs of aggressive periodontitis. Hypotheses about the structure of those samples and their interrelationship were tested using non-parametric methods. RESULTS: Results indicated that C-reactive protein, C3 component of the complement, alfa 2-macroglobulin and interleukin-6 levels differ significantly between patients with chronic and aggressive periodontitis. Interleukin-6, influencing cells with osteoblastic phenotype, is present at a high level in patients with aggressive periodontitis. Calcium was much lower than in healthy persons. Trypsin levels were lower in patients with periodontitis than in healthy persons. We found a significant interrelationship between host response mediators as measured in saliva and periodontal destruction measured by clinical attachment loss. CONCLUSION: The levels of host defense mediators in saliva are different for chronic and aggressive periodontitis. This findings might help in estimating the course and progression of periodontal destruction, thus providing clinical benefits in treatment planning.

[Hepatitis caused by tick-borne meningoencephalitis virus (TBEV)--a rare clinical manifestation outside the central nervous system involvement].

Abstract: Objective North part of Croatia, especially the Koprivnica-Krizevci County has been a well-known endemic area of tick-borne encephalitis (TBE) for more than 50 years. To date, this disease caused by tick-borne encephalitis virus (TBEV) has retained the leading position among inflammatory diseases of the central nervous system (CNS), with an average morbidity of 19 patients per year. In 88% of patients the infection manifested with signs of meningitis or meningoencephalitis with a biphasic course. TBE may take a more severe course with different neurologic dysfunction or even lethal outcome. There have been isolated reports on some rare clinical manifestations outside CNS involvement caused by TBEV, including transient hepatitis, pancreatitis, and myocarditis. These manifestations have been most frequently detected during the initial stage of disease but also as a complication, or as an individually separate clinical entity. The incidence rate of these manifestations is not known. Until now, such clinical manifestations outside CNS have not been reported in the county. It was the reason to present the characteristics of liver failure in our patients suffering from TBE. Purpose of Work: To determine the frequency of elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in patients with TBEV infection, to note the time from the detection to disappearance of elevated AST and to investigate and establish whether the degree of liver failure influences the course and outcome of TBE. Patients and methods The study was conducted from January 1991 until September 2004, and included patients with TBEV infection and elevated AST and ALT, examined at the Department of Infectious Diseases, Koprivnica General Hospital. Study patients were of all age groups and occupation. On their first examination detailed epidemiologic and patient history data were collected, with special reference to the history of alcohol abuse, disease of the liver or biliary tract, or any other apparent cause of liver failure. Clinical examination and laboratory tests were performed. Patients were classified into four groups as suffering from meningitis, meningoencephalitis, meningoencephalomyelitis, or abortive form of disease. The acute stage of meningoencephalitis was classified as mild, moderate or severe, depending on meningeal symptoms and severity of clinical signs of encephalitis, and presence of focal CNS signs. ELISA test was used to detect specific IgM and IgG antibodies. Serum samples were tested for other tick-borne diseases, including human monocyte and granulocyte ehrlichiosis. Oral consent was obtained from all patients enrolled in the study. Results and discussion During the study, recent infection with TBEV was proven in 261 patients. Liver function tests were done in 115 (44%) patients. Elevated AST and ALT activity was found in 25 (22%) patients, without bilirubin and alkaline phosphatase increase. All these were County residents, with a male sex predominance, aged 28-70 (median 41) years, and none had received TBE vaccination. Elevated AST and ALT activities were detected during the first stage of TBE in 16 (64%) and during the second stage of meningoencephalitis in 9 (36%) patients suffering from TBE. Elevated activity of AST was observed in 76% and of ALT in 96% of study patients. The most frequently observed elevated AST and ALT activity was two- or threefold the usual normal values. The time of the first detection of elevated AST and ALT activity could not be precisely determined, since all laboratory findings were performed during the first examination of patients. In the initial stage of disease, patients were mostly tested between 2-5 days from the onset of disease, and during the first week in the second stage of meningoencephalitis. Elevated AST and ALT activities were transient and normalized in 3-4 weeks. The importance of elevated AST and ALT activity for the course and prognosis of TBE was not verified in this study. Conclusion The first patients with hepatitis as one of the possible manifestation outside CNS involvement caused by TBEV are described. The prevalence and new concepts on this type of the disease were investigated in the study.

Epidemiology of hepatitis B and C in Croatia

Abstract: The incidence of HBV and HCV infection is hard to determine because of the high number of asymptomatic infections. According to data of the Croatian Institute of Public Health, there are 200 newly infected persons with hepatitis B and approximately the same number of newly identified HBsAg carriers occur each year. Accordingly, Croatia is among the countries with less than 2% of HBsAg carriers in the general population. In these circumstances, HBV infection is most often spread among adolescents and younger adults. The route of transmission is most often sexual (semen) or through the skin in high-risk groups. An increased risk of infection is found in newborns of HBsAg positive mothers, i.v. addicts, promiscuous individuals, male homosexuals, person in close contact with acutely ill or chronic HBsAg carriers, persons that come in contact with blood and other potentially contaminated body fluids, dialysis patients, patients with multiple blood transfusions, patients with transplanted organ or tissue, patients treated for hematologic malignancies and hemophilia, and persons who undergo acupuncture, tattooing or piercing, or travel to areas with a high prevalence of HBV infection. The estimated prevalence of HCV infection marker (anti-HCV) in the Croatian general population is more than 1% and the number of yearly infected with hepatitis C reported to the Croatian Institute of Public Health is around 200 cases. The highest incidence is found in the 20-40 age groups at a high risk of infection by the use of drug injection. At risk are persons who received transfusion of blood or blood products prior to the availability of blood screening of voluntary blood donors.

Etiology and treatment of epilepsy in the elderly

Abstract: UNLABELLED Epilepsy currently affects 1.0%-1.5% of elderly population, and its prevalence and incidence rise as the number of old people increases worldwide. Antiepileptic drugs are the mainstay of treatment. Their phrarmacokinetics differ in old age and polypharmacotherapy often leads to drug interactions. Many of the affected have concomitant cardiovascular, metabolic, cerebrovascular, neurodegenerative or neoplastic diseases. Antiepileptic drugs add to the burden of medication and may produce neurotoxicity or cognitive impairment. PURPOSE To give an overview of epidemiologic data and pharmacological management of epilepsy in the elderly. It is a common and important clinical problem. The increased awareness of this phenomenon has led to better understanding of the etiology of seizures and complexity of the pharmacokinetics in the elderly. METHOD Data of 246 patients with epilepsy admitted to our Department during the year 2001 were retrospectively analyzed. RESULTS Forty-three (17.4%) patients were older than 65. Thirty-two (74.4%) patients, 20 male and 12 female, had a newly diagnosed epilepsy. The etiology of seizures included cerebrovascular diseases in 22 (68.8%), trauma in 4 (12.5%), primary tumors in 3 (9.4%) and metastases in 3 patients (9.4%). The initial antiepileptic drug (AED) was phenytoin in 15 (46.9%), carbamazepine in 14 (43.8%), carbamazepine plus phenytoin in 2 (6.3%), valproic acid in 1 (3.1%), diazepam in 3 (9.4%) and oxazepam in 2 (6.3%) patients. Later, during follow-up, lamotrigine was introduced in 4 (12.5%) patients as a monotherapy and in 3 (9.4%) patients as add-on therapy. Topiramate was introduced in 1 patient as monotherapy and add-on therapy each. Gabapentin was introduced in one patient as add-on therapy. CONCLUSION Cerebrovascular disease is the most common cause of new-onset seizures in the elderly. Pharmacological treatment is complicated by the age related changes of pharmacokinetics and pharmacodynamics and drug-drug interactions. Phenytoin and sodium valproate are the first choice agents for generalized tonic-clonic seizures, with carbamazepine preferred for partial seizures. The newer AEDs, such as gabapentin and lamotrigine, also warrant some consideration as the first-line agents because of their efficacy and favorable effect profile. The optimal management of epilepsy requires rapid investigation, accurate diagnosis, effective therapy, education and assured support.

Founding and development of the Croatian Health Information System

Abstract: Informacijski sustavi, bilo kompjuterizirani ili papirnati, kljucni su za djelotvorno i ucinkovito poslovanje zdravstvenih ustanova. Racionalnost zapocetih velikih informacijskih projekata u Ministarstvu zdravstva može se objasniti s dvije grupe argumenata: potreba za transformiranjem zdravstvenih podataka u informacije važne za donosenje kljucnih javnozdravstvenih odluka i mjera iz domene ekonomike zdravstva, odnosno sustavnog pracenja troskova i utvrđivanja potencijala racionalizacije potrosnje u zdravstvu bez smanjenja razine zdravstvene zastite (procjenjuje se da je moguce racionalizirati trosenje 20-30% sredstava), kao i potreba za povecavanjem transparentnosti sustava i prilagođavanja standardima važecim u EU. Integrirani zdravstveni sustav u konacnici mora imati nekoliko grupe temeljnih funkcionalnosti: stvaranje centraliziranog javno-zdravstvenog informacijskog sustava koji ce omoguciti uvid u procese generiranja zdravstvene potrosnje na razini PZZ, a koji bi bio koristen kao podloga u donosenju zdravstveno-ekonomskih odluka i mjera, odnosno za stvaranje mogucnosti za informatiziranje i automatiziranje procesa izrade konsolidiranog zdravstvenog proracuna s ukljucenim proracunima HZZO i bolnickog sustava, te konsolidiranih financijskih izvjesca svih ukljucenih strana u zdravstvenom sustavu. Opisan je model nacionalnog integriranog zdravstvenog informacijskog sustava u Republici Hrvatskoj.

[Hepatitis B and C: natural course of disease].

Abstract: Significant progress in the understanding of the natural history of hepatitis B and C has been made in recent years due to molecular diagnosis techniques. The most important biologic feature of hepatitis B and C viruses (HBV, HCV) is their ability to cause chronic hepatitis. The natural course of HBV infection is variable, ranging from inactive HBsAg carrier state to progressive chronic hepatitis that can evolve into liver cirrhosis and hepatocellular carcinoma. HBeAg-negative chronic hepatitis is due to a naturally occurring HBV variant with mutations in the precore or basic core promoter regions. It accounts for the majority of cases in many European countries and is generally associated with a more severe liver disease. The morbidity and mortality in chronic hepatitis B are linked to the evolution to cirrhosis and hepatocellular carcinoma. The progression of fibrosis is strongly associated with persistent active viral replication When the diagnosis is made, the 5-year cumulative incidence of developing cirrhosis ranges from 8% to 20%. The 5-year cumulative incidence of hepatic decompensation is 20%. Hepatocellular carcinoma is one of the most common cancers worldwide, 75% of which are related to chronic HBV infection. Coinfection with hepatitis D virus can lead to a more progressive liver disease in a shorter period of time. Hepatitis C virus infection becomes chronic in 80% of infected persons resulting in different stages of chronic hepatitis, with 20%-30% progressing to cirrhosis within 20 years period. The progression of fibrosis determines the ultimate prognosis. The major factors known to be associated with fibrosis progression are older age, male gender and alcohol consumption. Viral load and genotype do not play a role in the disease progression. Progression to fibrosis is more rapid in immunocompromised patients.

Information system in primary health care

Abstract: The Croatian Ministry of Health started a health care system computerization project aimed at strengthening the collaboration among health care institutions, expert groups and individual health care providers. A tender for informatic system for Primary Health Care (PHC) general practice, pediatrics and gynecology, a vital prerequisite for project realization, has now been closed. Some important reasons for undertaking the project include rationalization of drug utilization, savings through a reduced use of specialists, consultants and hospitalization, then achievement of better cooperation, work distribution, result linking, data quality improvement (by standardization), and ensuring proper information-based decision making. Keeping non-standardized and thus difficult to process data takes too much time of the PHC team time. Since, however, a vast amount of data are collected on only a few indicators, some important information may remain uncovered. Although decisions made by health authorities should rely on evidence and processed information, the authorities spend most of the time working with raw data from which their decisions ultimately derive. The Informatic Technology (IT) in PHC is expected to enable a different approach. PHC teams should be relieved from the tedious task of data gathering and the authorities enabled to work with the information rather than data. The Informatics Communication Technology (ICT) system consists of three parts: hardware (5000 personal computers for work over the Internet), operative system with basic software (editor, etc.), and PHC software for PHC teams. At the national level (National Public Health Informatics System), a software platform will be built for data collection, analysis and distribution. This data collection will be based on the International Classification of Primary Care (ICPC-2) standard to ensure the utilization of medical records and quality assessment. The system permits bi-directional data exchange between a central database and sources at different levels, across the spectrum from basic PHC teams to local authorities. This will enable data collection control, comparisons with national averages and prompt distribution of information over the Internet. The investment into IT is a strategic imperative having no alternative. A cost/benefit analysis has shown its operation in the PHC system to return the investment in two years. As defined according to the Project priorities (with measurable objectives), the use of new technologies will be introduced by stages.

Epidemiology of hepatitis B and C in Croatia

Abstract: The incidence of HBV and HCV infection is hard to determine because of the high number of asymptomatic infections. According to data of the Croatian Institute of Public Health, there are 200 newly infected persons with hepatitis B and approximately the same number of newly identified HBsAg carriers occur each year. Accordingly, Croatia is among the countries with less than 2% of HBsAg carriers in the general population. In these circumstances, HBV infection is most often spread among adolescents and younger adults. The route of transmission is most often sexual (semen) or through the skin in high-risk groups. An increased risk of infection is found in newborns of HBsAg positive mothers, i.v. addicts, promiscuous individuals, male homosexuals, person in close contact with acutely ill or chronic HBsAg carriers, persons that come in contact with blood and other potentially contaminated body fluids, dialysis patients, patients with multiple blood transfusions, patients with transplanted organ or tissue, patients treated for hematologic malignancies and hemophilia, and persons who undergo acupuncture, tattooing or piercing, or travel to areas with a high prevalence of HBV infection. The estimated prevalence of HCV infection marker (anti-HCV) in the Croatian general population is more than 1% and the number of yearly infected with hepatitis C reported to the Croatian Institute of Public Health is around 200 cases. The highest incidence is found in the 20-40 age groups at a high risk of infection by the use of drug injection. At risk are persons who received transfusion of blood or blood products prior to the availability of blood screening of voluntary blood donors.

[Virtual polyclinic--consultant health service for rural areas and islands].

Abstract: The development of medical sciences and digital revolution in health care have made possible the creation of new models for hospital care and primary health care. Health care management usually does not follow all possible solutions of new computer technology. Croatian health system is based on large hospital centers in the mainland and small, poorly equipped remote medical units. The possibility of sharing medical information using telematic technologies brings all knowledge of the large, powerful hospital centers close to remote medical units. Working in a small, remote consultation office on the island Cres, the author A. M. became part of medical periphery far from the security of hospital on the mainland. After five years of the work on telemedicine projects for the islands, we have introduced a new medical practice concept of communication between remote medical units and clinical hospital centers in the mainland. The pilot project Virtual Polyclinic-Medical Consultation System for the Islands and Remote Areas is a good example of the possible new models in health care structure. Our experience indicates that organization of health care in remote areas depends not only on advanced technical solutions but also on team work and medical professionals.

[Implementation of integrated hospital information system in the existing hospital organization--experience at Dubrava Clinical Hospital in Zagreb].

Abstract: In the modern hospital information systems govern extremely important functions such as patient management, control of work flows, administration, etc., with a great variety of recommended standards used in functional integration of healthcare information systems. The main parts of the original idea of the integrated Hospital Information System have been implemented at Dubrava University Hospital in Zagreb through several phases, resulting in data production covering distinct areas of hospital administration. This paper describes the basic idea of information, organization problems and steps taken in the implementation. International standards in communication have been implemented in the system.

[The risk of second seizure in children with benign childhood epilepsy with centrotemporal spikes without treatment--a prospective study].

Abstract: PURPOSE: To determine the rate of second seizure occurrence within and after six months of the first seizure in children with benign childhood epilepsy with centrotemporal spikes (BECTS) who did not undergo treatment after the first seizure. The results of this analysis may help elucidate the dilemma whether or not to treat the child after the first seizure. PATIENTS AND METHODS: Thirty-nine children with BECTS from our department (aged 3-11 years) were analyzed as candidates to be enrolled in a prospective multicenter randomized double-blind placebo controlled study on therapeutic efficacy of sulthiame. Thirty-four of 39 children were not treated after the first seizure. Four children were lost from the study, thus 30 children were included in final analysis. After the first seizure, the parents were instructed to apply diazepam rectal solution in case of second seizure, and were warned to observe the child, particularly during the first sleep and before awaking. RESULTS: Twenty of 30 (66.6%) children experienced second seizure within six months of the first one. Some of these children entered the group treated with sulthiame vs. placebo, and those who did not meet the criteria for sulthiame group were treated with carbamazepine. Ten of 30 (33.4%) children did not experience second seizure within six months of the first one. In only one of them, the second seizure occurred 14 months of the first one. The epileptic status did not appear as second seizure, irrespective of whether or not the children received rectal diazepam at seizure onset. CONCLUSIONS: In children with BECTS, a high incidence of second seizure was recorded within six months of the first seizure, whereas the rate of second seizure after six months of the first one was very low. The probability of the occurrence of epileptic status in children with BECTS could be neglected. These results may be viewed as a small contribution to clarifying the dilemma of whether or not, and when to treat children with BECTS. Because of the high incidence of second seizure, we decided to treat all children with BECTS after the first seizure.

Intraocular pressure values following vitrectomy with silicone oil tamponade

Abstract: Secondary glaucoma is a relatively common complication after pars plana vitrectomy and silicone oil injection for repair of complex retinal detachment. The aim of this study was to evaluate the influence of silicone oil tamponade on intraocular pressure elevation and to identify the mechanism of this elevation. The study included 45 eyes of 45 patients who had undergone pars plana vitrectomy and silicone oil tamponade for repair of complex retinal detachment. Ophthalmic examination was performed before vitrectomy, and one and six months after vitrectomy. The increase in intraocular pressure was measured one month postoperatively in 37.77% of patients. The mechanism of intraocular pressure increase was silicone oil emulsification in 52.98%, closure of Ando's iridectomy in 23.54%, and idiopathic angle closure glaucoma in 23.54% of patients with elevated intraocular pressure. After silicone oil removal, elevated intraocular pressure persisted in 7 (15.55%) patients; in 5 patients it was controlled medically, while two patients underwent glaucoma surgery. Six months postoperatively 3 patients developed secondary neovascular glaucoma due to the prolipherative ischemic disease. Elevation of intraocular pressure following vitrectomy with silicone oil tamponade had a temporary effect, as it did not lead to permament intraocular pressure elevation but regressed after silicone oil removal from the eye.

Development of information system at Sestre Milosrdnice Clinical Hospital

Abstract: Information Systems (IS) in healthcare are complex with a heterogeneous structure. They support decision making in healthcare and therefore must be integrated, consistent, reliable, secure and simple for use and maintenance. Data entry is strongly controlled, data are coded and ready for inventory printing or scientific analysis. Efforts in developing the Integrated Hospital Information System (IHIS) at Sestre Milosrdnice University Hospital, Zagreb (Croatia) from a Hospital Information System (HIS) are presented. From the very beginning, the Information System was developed without planning, only to satisfy the current needs and to stay within financial possibilities. Today, many hospital departments have their own Information Subsystems and one or two servers. All local area networks and offline computers are connected to optical ring and through the farm of servers (firewall, www, e-mail, DNS-Domain Name System) to the Internet. We need a long time to achieve the current degree of development of IS. However, today we can obviously recognize a few layers of information applications just like business application, medicine application, scientific application, education application, telemedicine and Internet application. Very powerful information technology and very fast progress in communications leads to digital or paperless hospital.

Possibilities of governmental quality support of scientific journals in Croatia

Abstract: The measure of success for a scientific journal, which publishes original research, is its visibility in the international scientific community. The most comprehensive bibliographical database of the Institute for Scientific Information (ISI, now Thomson ISI), Web of Science, indexes 13 out of 176 journals that received financial support from the Ministry of Science in 2003, and 7 of them are in the 9 divisions of the most selective ISI bibliographic database, Current Contents. Taking into account the specificities of the small scientific community, or the so-called scientific "periphery" to which Croatia belongs, we proposed a new system of financial support of scientific journals in Croatia. Such system would support all scientific journals fulfilling basic requirements of scholarly publishing, such as structure of the editorial board and office, editorial procedures and records. Indexing in professional and general bibliographic databases would be encouraged by additional financial support and continual control of the editorial work in the journals.

Introducing computer units into the reception office as part of the Vrapce Psychiatric Hospital Information System

Abstract: Computerized medical record has become a necessity today, because of both the amount of present-day medical data and the need of better handling and processing them. In more than 120 years of the Vrapce Psychiatric Hospital existence, the most important changes in the working concept of the reception office took place when computer technology was introduced into the routine use. The reception office of the Hospital is the vital place where administrative activities intersect with medical care for a patient presenting to the Hospital. The importance of this segment of the Hospital is emphasized by the fact that the reception office is in function and at patients' disposition round-the-clock, for 365 days a year, with great frequency of patients. The shift from the established way of registering medical data on patient admission in handwriting or, later, typescript, to computer recording was a challenging and demanding task (from the aspects of hardware, software, network, education) for the development team as well as for the physicians because it has changed the concept (logic of the working process) of previous way of collecting the data from the patient (history, status, diagnostic procedures, therapy, etc.). The success in the development and implementation of this project and the confirmation of its usefulness during the four-year practice at Vrapce Psychiatric Hospital are best illustrated by the fact that other psychiatric hospitals in Croatia have already introduced or are introducing it in their daily practice.

Role of standardization in health care system computerization

Abstract: Standardization system includes development, publishing and promotion of standards, as well as their use in practice. Products, services and processes in a variety of human activities should be standardized. The goal of standardization is to achieve a high security level, a high quality, usefulness and effectiveness as well as limitation of variability, ensuring compatibility and replacement (of products), and to eliminate technical problems in the international exchange of people, work, products and services. The leading areas/objects of standardization in medical informatics are electronic health record, classification in health care, communication and message exchange as well as data security and protection of the whole health information system. Technical Committee for Standardization in Medical Informatics (TC215) has so far accepted fifteen standards and prestandards. The affiliate HL7 Croatia works on localization of communication standard HL7 and adaptation to the Croatian requirements.

[Hospital information system--project of implementation of SAP information system at Sveti Duh General Hospital].

Abstract: Nowadays, as medical and hospital institutions have been facing a growing need of a more efficient provision of healthcare services to patients, with simultaneous complete monitoring of the successfulness of business activities, integrated information systems appear as the logical choice for the support to hospital business processes. The integrated business information system implemented at Sveti Duh General Hospital is a comprehensive system that supports all hospital, clinical and administrative processes, while providing the basis for decision making regarding the patients and hospital management. The system also enables transfer of all data with specific medical business segments such as laboratory device management. The project for the implementation of the information system was realized in accordance with the requests from the Ministry of Health, applying the proven methodology for the execution of such complex projects. The project team consisted of a number of consultants from b4b Co. from Zagreb, as well as Hospital employees. The new information system is completely ready for going live; however, the necessary decisions have to be made first. The application of the system gives the medical staff more time for their professional work with patients, and through longterm collection and analysis of data on symptoms, illnesses and medical treatments, the information system becomes an important tool for the improvement of health and quality of healthcare system in general.

Data sources on drug utilization in Croatia and Europe

Abstract: The costs for drugs account for a significant proportion of total health care cost in every country. This is especially pronounced in welfare states and less developed countries. Therefore, each government has to take protective measures against uncontrolled rise in drug expenses and tend to the ideal, rational drug utilization. One of these measures is systematic monitoring of drug utilization. The data on drug utilization thus obtained provide a basis for appropriate interventional measures and their evaluation. In Croatia, no systematic measures in the field of drug utilization have yet been employed. In this brief survey, the methodology of drug utilization monitoring is critically reviewed, emphasizing the need of implementing the World Health Organization (WHO) Anatomical-Therapeutic-Chemical (ATC) system of drug classification and drug utilization monitoring by use of WHO Defined Daily Doses (DDD). The use of ATC/DDD system and other methods of drug utilization monitoring in Scandinavian countries is then presented. The third section deals with the current situation concerning data sources on drug utilization in Croatia. In Croatia, the ATC/DDD system has to date been only used by researchers and Zagreb Institute of Public Health in the work on the project entitled Drug Utilization in the City of Zagreb, launched in 2002.

Prevention and treatment of hepatitis B in patients on hemodialysis and vaccination of hemodialysis health personnel against hepatitis B

Abstract: The prevalence and incidence of hepatitis B in hemodialysis patients in Croatia have been estimated to 1.3% and 0.03%, respectively. HBV infection in dialysis patients is usually asymptomatic, has a prolonged course, and progresses to chronic HBsAg hepatitis in 50% of cases. Some 15%-40% of HBsAg carriers on dialysis will develop cirrhosis, liver decompensation or hepatocellular carcinoma. Strict adherence to the standard infection prevention measures, continuous monitoring of HBV markers in patients on hemodialysis, patient and personnel immunization and hepatitis B treatment in hemodialyzed patients are mandatory. Each new patient in a dialysis center must be tested for HBV markers irrespective of prior immunization. All patients in the center should be routinely screened every 3-4 months. HBV immunization is mandatory for all patients on dialysis. In patients with uremia the anti-HBs antibody production is decreased (antibodies will develop in 50%-60% of cases after immunization). It is recommended to immunize all patients with progressive kidney disease, preferably in the preterminal stage. Hepatitis B therapy is recommended in all patients with biopsy proven chronic liver disease. Patients should be treated with standard interferon alpha and/or lamivudine, or peginterferon alpha monotherapy. Hepatitis B treatment is most important in kidney and/or liver transplant candidates. HBV immunization is obligatory for all hospital personnel who are in close contact with infected patients and infective materials.

Hepatitis virus infection among hemodialysis patients

Abstract: AIM, PATIENTS AND METHODS The high prevalence of anti-hepatitis C virus antibodies (anti-HCV) in hemodialyzed (HD) patients has been recognized since the early 1990s. Over the last decade, a significant decrease of anti-HCV prevalence among HD patients has been observed in many west European countries. In order to evaluate whether this trend is also present in Dialysis Center of Dubrava University Hospital, Zagreb, we tested HD patients for anti-HCV and HCV RNA in serum. ELISA 3 (Sorin) was used as a screening anti-HCV test, and confirmatory testing relied on western blotting (BioRad). HCV RNA was tested by HCV RNA PCR (Roche) and AMPLICOR, HCV test, version 2.0 (Roche). RESULTS AND DISCUSSION The low prevalence of HCV infection is a consequence of the screening of blood donors with increasingly sensitive anti-HCV tests, followed by the progressive reduction of blood transfusion due to the availability of erythropoietin and the reinforcement of universral hygienic precautions and strict infection control in our HD unit. A contributing factor was the prevention of nosocomial transmission by the separation of anti-HCV positive from anti-HCV negative patients. Thus, the low prevalence of HCV infection in our HD center contributes-to an improved prognosis in end stage renal disease patients by additionally reducing the risk of nosocomial HCV infection.

[Renovascular hypertension--diagnosis and treatment].

Abstract: The approach and treatment of renovascular hypertension are presented. The study include 65 patients with severe arterial hypertension (31 men and 34 women), mean age 52 years, 26 of them with renovascular hypertension. Along with the usual diagnostic work-up, renal angiography using Seldinger method and renin measurement were performed in all patients through renal vein. Twelve patients underwent renal artery dilatation (PTRA), six patients kidney autotransplantation, and the rest were treated by medications. In nine patients, complete cure or improvement was achieved by PTRA, whereas unsuccessful renal artery dilatation was recorded in three patients. Surgical therapy for renovascular hypertension was used in six patients and proved successful. It is concluded that the earliest possible detection of renovascular hypertension is of utmost importance because this form of arterial hypertension is one of the most common potentially curable types of secondary hypertension. Concerning the methods of treatment, their invasiveness, and differences between various therapeutic procedures, it is important to make an algorithm of treatment for each individual patient.