The effect of the COVID-19 pandemic on pediatric physiatric health care in Croatia among children with neurological risk: A retrospective study.

BACKGROUND: Since the start of COVID pandemic, the Croatian government issued many recommendations and guidelines, imposed reorganization of health care system, and ordered two lock-downs to mitigate the spread of the disease. All of this may have had an unwanted effect on the standard of health care for non-COVID-19 patients, including children with neurological risk factors. OBJECTIVE: To highlight the possibility that measures taken to mitigate the COVID-19 pandemic may lead to a substantial delay of examination by physical medicine specialists and timely rehabilitation programs for children with neurological risks. DESIGN: A retrospective medical history-based study between 2020 and 2021. SETTING: The study was performed in Department of Physical and Rehabilitation Medicine at the University Hospital Centre of Split, Croatia. PATIENTS: Children with neurological risk examined by pediatric physical rehabilitation specialists in the Department of Physical and Rehabilitation Medicine between January 2017 and December 2021. METHODS: Case records of patients were reviewed, dividing them into groups according to severity of neurological risk and their age at the time of first examination. We also noted in what months of the year those examinations were performed. MAIN OUTCOME MEASUREMENTS: The outcome was change in the number of the first examinations and the age of the patients when the examination was first performed. RESULTS: During the pandemic year 2020, the total number of first examinations was lower by 244 (38%; 95% confidence interval [CI]: 34%-42%), and the number of first examinations of children with neurological risks was lower by 216 (36%; 95% CI: 33%-40%).On the contrary, in 2021, there was an increase in the total number of first examinations by 114 (18%; 95% CI: 15%-21%) and first examinations of children with neurological risks compared to the pre-pandemic years by 97 (16%; 95% CI: 13%-20%). Furthermore, the division of patients according to age at the time of first examination significantly differed in the pre-pandemic and pandemic 2021 periods (λ = 11.8; p = .018). The greatest contributing factor to this difference was the group of patients older than 12 months. CONCLUSIONS: The study suggests that the chaotic initial stages of the COVID-19 pandemic during 2020 caused delay in examinations by physical medicine specialists for children with neurological risks that could potentially affect neurodevelopmental outcomes.

Formula for the prediction of apnea / hypopnea index in children with obstructive sleep apnea without polysomnography according to the clinical parameters: Is it reliable?

PURPOSE OF THE STUDY: The aim of the study was to propose "the risk formula" for obstructive sleep apnea in children according to the general and local clinical parameters and findings relevant for obstructive sleep apnea (OSA) severity. The unmet need for this formula arises from the economic burden of polysomnography (device, staff, training, special sleep centers, etc) as the golden standard for the diagnostics. MATERIALS AND METHODS USED: The study was performed from January 2013 until January 2016 in the Sleep Center, Department for Neuroscience, School of Medicine of the University of Split, Department of Pediatrics, University Hospital Split, Croatia and ENT Dept. University Hospital in Split, Croatia. Inclusion criteria were: age > two years, AHI >1 diagnosed by polysomnography. Exclusion criteria were: chronic lung disease, active tonsillitis/pharyngitis at the time of the physical exam and syndromes that affect breathing. All polysomnograms were scored by a qualified sleep technologist and interpreted by two board certified sleep physicians independently. Age, sex, BMI, Mallampati score, tonsillar size and adenoids size were recorded. All statistical calculations were performed using SPSS 20. RESULTS: In total 60 children were included in the study. The median of age was 5 years (range 2-9). There were 19 (32%) girls and 41 (68%) boys. Of all evaluated predictors, there were statistically significant differences in the values of AHI among children with different modified Mallampati score (χ2 = 28.2; p < 0.001), different size of tonsils (χ2 = 25.3; p < 0.001) and different size of adenoids (z = 2.7; p = 0,006) in univariate regression analysis. Strong positive association of AHI with modified Mallampati score (standardized B = 0.51; partial correlation = 0.542, r = 0.631) was found, as well as positive correlation of AHI with tonsillar size (standardized B = 0.246; partial correlation = 0.295,R = 0.489) in the multivariate forward stepwise regression analysis. CONCLUSION: Even though we are aware that PSG is the gold standard for diagnostics of SDB there is a significant financial burden for this diagnostic procedure. That is why there is a necessity for establishing good clinical standards and possible formula for OSA severity evaluation. We propose formula which includes Mallampati score and tonsillar size for OSA -risk calculation in order to perform early therapeutic intervention thereby reducing the risk of long-term negative consequences. We recommend this formula as the screening formula in circumstances where PSG is not available, in cases when the "waiting list" is too long or when a child can not cooperate to perform it. In developing countries like Croatia on time intervention with reduced procedure-associated costs is of the utmost importance.

Cathepsin K expression in melanoma is associated with metastases.

INTRODUCTION: Melanoma of the skin shows a tendency to metastasize via lymph or blood secreting matrix metalloproteinases and cathepsins, which enable penetration through the dermis. Cathepsin K acts in cytoplasm of atypical melanocytes and completely cleaves internalized collagen. MATERIALS AND METHODS: Expression of cathepsin K was analyzed immunohistochemically in 45 melanomas and correlated to morphological and clinical parameters. RESULTS: During six years follow up, 13 patients developed lymph node metastases and three of them distant metastases. Positive expression of cathepsin K was found in 19 cases. In univariate regression analysis histological type, pagetoid spread, mitotic activity and cathepsin K expression were significantly connected to metastases. Cathepsin K was significantly associated to histologic type, ulceration, pagetoid spread and mitotic rate. In multiple logistic regression adjusted to these variables, cathepsin K was an independent predictor in occurrence of metastases (P=0.015). Median to the occurrence of metastases was 40 months in patients with cathepsin K positive expression and 71 months in patients with cathepsin K negative expression (P<0.001). CONCLUSIONS: In this preliminary study positive expression of cathepsin K in melanoma of the skin is associated with other unfavorable prognostic factors. We consider cathepsin K expression in primary tumor would significantly precipitate occurrence of metastases.

Anthropological analysis of the Second World War skeletal remains from three karst sinkholes located in southern Croatia.

Although in the cases of war crimes the main effort goes to the identification of victims, it is crucial to consider the execution event as a whole. Thus, the goal of the research was to determine the trauma type and probable cause of death on skeletal remains of civilians executed by partisans from WWS found in the three karst sinkholes and to explain the context in which the injuries occurred. We determined biological profiles, pathological conditions, traumas, and assessed their lethality. Nineteen skeletons were found, 68.4% had, at least, one perimortem trauma, classified as lethal/lethal if untreated in 69.2% cases. The type of execution and administered violence showed to be age and health dependent: elderly and diseased were executed with the intention to kill, by the gunshot facing victims, whilst the more violent behavior expressed towards younger and healthy individuals was indicated by the higher frequency of blunt force trauma.

Bone porosity and longevity in early medieval Southern Croatia.

Porosity of the skull and skeletal remains, especially of the orbital roof, are one of the most frequent pathological findings on ancient human skeletal remains. There are several presumed causes of this condition and anthropologists consider skull porosities as a marker of physical and nutritional stress. A total of 115 graves were discovered at the early-medieval graveyard near Zadar (Croatia) that contained 128 partially preserved skeletons. Average estimated age at death was 37.2 ± 12.6 years for men, 31.9 ± 13.9 for women, and 5.3 ± 3.6 years for subadults. Pathological bone porosity was analysed. Cribra orbitalia was observed on 21 skulls (28.7%), signs of temporal porosity were noticed on six skulls and signs of subperiosteal bleeding on three skulls. Nineteen skulls had bone porosities in other areas. There was a significant difference (p = 0.039) in achieved age of adults with and without cribra orbitalia as those with cribra orbitalia lived on average 8.1 years longer. The bone porosity was probably caused by malnutrition that might have had a beneficial effect on longevity of adults, similar to effects of restricted food intake on extending lifespan through epigenetic signatures influencing gene expression.

The significance of immunohistochemical expression of merlin, Ki-67, and p53 in meningiomas.

Meningiomas are one of the most common CNS tumors whose appearance is closely linked to NF2 gene product merlin. Tumor markers Ki-67 and p53 play established role in tumor progression which should be analyzed in close association with merlin expression. The aim of this study was to investigate the immunohistochemical expression of merlin in meningiomas, correlation with Ki-67 and p53, and to determine the association of these results with histologic grade and subtype. The histologic sections of 170 patients with totally resected meningiomas, between January 2000 and December 2010, were classified according to WHO, immunohistochemically stained for Ki-67, p53, and merlin, and analyzed using light microscope. Ki-67 median was 5.6 times higher in group of patients with negative merlin than in those with positive merlin (P=0.05). Statistically significant correlation of merlin with p53 was found (P<0.001). Merlin expression between 2 combined groups (meningothelial/secretory and fibroblastic/transitional) was statistically significant (P=0.002). By comparing merlin expression and p53 levels, statistically significant difference was found (P=0.017). In the group with positive merlin and negative p53 as well as positive merlin and low p53, meningothelial/secretory subtypes of meningiomas were more common. In combination of negative merlin and negative p53 as well as negative merlin and high p53, there were more meningiomas of fibroblastic/transitional subtype. There was no statistically significant correlation between merlin and tumor grade (P=0.420). There is undeniable influence of merlin on the development and the proliferative ability of meningioma subtypes. Significant role of p53 pathway was confirmed.

Croatia is a safe tourist destination - study of foreign citizen mortality in Splitsko-dalmatinska and Primorsko-goranska County during the period 2001-2010.

AIM: To investigate the mortality rate of foreign citizens in Croatia. METHODS: Data were collected from the Departments for Forensic Pathology in Split and Rijeka, which are the autopsy centers of the counties with approximately 35% of total foreign visitors, as well as from the Croatian Central Bureau for Statistics for the period 2001-2010. The mortality rate (number of deaths of members of each nationality per 100000 entrances ratio) and standardized mortality ratio (ratio between the observed and expected number of deaths) were calculated, and χ(2) goodness of fit test was used for statistical analyses. RESULTS: There were 447 deaths (325 men, 72.7%) of foreign citizens (mortality rate of 0.0015%). A total of 207 deaths (46.3%) were by natural causes, more often among older people, and 240 deaths (53.7%) were injury deaths, more often among younger people, mostly by drowning or traffic-related (22.2% and 18.6% of all deaths, respectively). Most represented were citizens of German, Austrian, Czech, and Italian nationality, with 115 (25.7%), 59 (13.2%), 58 (13.0%), and 52 deaths (11.6%), respectively. Mortality rate by nationality showed no significant difference (P<0.05). The standardized mortality ratio was lowest in Hungarian and Czech citizens (0.17) and highest in US citizens (0.35). CONCLUSIONS: Croatia has low foreign citizens' mortality rate and could be considered a safe tourist destination.

Association of TNF promoter polymorphisms with type 1 diabetes in the South Croatian population.

Type 1 diabetes mellitus (TIDM) is an autoimmune disease characterized by the destruction of pancreatic p cells. Tumor necrosis factor (TNF) is a pleotropic cytokine with potent immunomodulatory and inflammatory activity. Association studies of TNF polymorphisms and type 1 diabetes (TIDM) frequently demonstrated TNF involvement with TIDM. Although TNF may play an important role in the pathogenesis of TIDM, the genetic association of TNF región with the disease has not been conclusive because of the strong linkage disequilibrium with HLA genes. In this study, we examined two TNF promoter variants (rs 1800629 at position -308, and rs361525 at position -238) for TIDM association in 233 patients and 144 controls from the population of South Croatia. A higher frequency of TNF -308 A alíele and also, a more frequent specific -308A -238G haplotype in TIDM patients were observed with a limited significance. However, we did not find strong evidence of association of TNF promoter polymorphisms with TIDM. In order to elucidate the trae contribution of TNF to TIDM susceptibility in our population, more comprehensive studies with HLA adjustment in a larger sample are required.

[Postoperative closed suction drainage following hip and knee aloarthroplasty: drain removal after 24 or after 48 hours?]. / Poslijeoperacijska drenaza nakon aloartroplastike kuka i koljena: odstranjivanje drenaze nakon 24 ili nakon 48 sati?

The use of closed-suction drainage systems after total hip and knee replacement is a common practice. It is believed that drainage reduces the haematomas and infection. The usual time to remove drains is 48 hours. Usefulness of the long time drainage of the haematomas and possible harmfulness of infection is still a subject of discussion. In this article, using our own operative material, we want to show the justification of the 48 hour duration of closed-suction drainage. The investigation was done on the patients with hip replacement (45 patients) and knee replacement (11 patients). The amount of blood in the drainage systems in the first 24 hours after the surgery and after 24 hours till the removal of drainage was observed. The results show that the amount of blood lost in the drainage system in the first 24 hours was on average 95.29%, and only 4.71% in the next 24 hours. This article supports the opinion that postoperative drainage has to be removed after 24 hours, i.e. the 48 hours-drainage seems not to be justified.

Association of TNF promoter polymorphisms with type 1 diabetes in the South Croatian population

Type 1 diabetes mellitus (TIDM) is an autoimmune disease characterized by the destruction of pancreatic p cells. Tumor necrosis factor (TNF) is a pleotropic cytokine with potent immunomodulatory and inflammatory activity. Association studies of TNF polymorphisms and type 1 diabetes (TIDM) frequently demonstrated TNF involvement with TIDM. Although TNF may play an important role in the pathogenesis of TIDM, the genetic association of TNF región with the disease has not been conclusive because of the strong linkage disequilibrium with HLA genes. In this study, we examined two TNF promoter variants (rs 1800629 at position -308, and rs361525 at position -238) for TIDM association in 233 patients and 144 controls from the population of South Croatia. A higher frequency of TNF -308 A alíele and also, a more frequent specific -308A -238G haplotype in TIDM patients were observed with a limited significance. However, we did not find strong evidence of association of TNF promoter polymorphisms with TIDM. In order to elucidate the trae contribution of TNF to TIDM susceptibility in our population, more comprehensive studies with HLA adjustment in a larger sample are required.