Parental Attitudes Towards Vaccination and Adolescent Sexual Health - A Cross-sectional Study.

Positive parental role modeling is a protective factor for adolescent sexual and reproductive health (SRH). Our aim was to investigate parental opinion on adolescents' SRH and vaccination as well as sociodemographic determinants of child-parent communication regarding SRH. This nationally representative cross-sectional telephone survey with a random stratified sample included 500 parents from Croatia (74% mothers), with at least one child under 18 years of age. Stratification was performed by (a) region, and (b) size of settlement. Differences were found between parental beliefs regarding quality, safety, and efficacy of vaccines and potential hazardous effects. Although 95% confirmed their child was vaccinated according to the national program, only 12% vaccinated with optional, self-paid vaccines (excluding human papillomavirus). Almost every third parent was not acquainted with SRH, more commonly fathers. The preferred sources of information for parents regarding SRH were friends, followed by the media and professional healthcare sources, while communication with adolescents was reported by 84% respondents. More than 10% parents claimed that their child did not have accurate knowledge regarding SRH. Our study confirms predominantly positive parental attitudes vaccination and communication with adolescents regarding SRH. We emphasize the importance of effective parental engagement and indicate the need for educational interventions to strengthen knowledge on immunization and SRH.

From Morphea to Dermatofibrosarcoma Protuberans.

Dear Editor, Morphea profunda (MP) is a chronic autoimmune disease, a subtype of localized scleroderma that presents clinically as local discomfort due to the impairment of skin motility (1). Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue neoplasm that not only infiltrates the dermis and subcutaneous tissue, but can also affect the muscles and bones with finger-like extensions, usually present on the trunk and the proximal extremities (2). DFSP is known for its indolent clinical course, locally aggressive behavior, and high local recurrence rates, but relatively low risk of metastatic spread (2). DFSP frequently arises in middle-aged adults, affecting both sexes equally with an incidence of 4 per 1,000,000 people (3). We report the case of a 39-year-old female patient who first presented to our clinic at the age of 20 years due to a brownish atrophic coin-sized lesion appearing on the left side of the abdomen. Medical reports indicated that biopsies had been performed previously on 3 occasions, and histopathologic findings confirmed the diagnosis of MP. The aforementioned lesion on the abdomen had been growing slowly over the years, and the patient finally visited our clinic 15 years later after noticing two palpable nodules developing within the affected skin (Figure 1, A, B). Clinical examination revealed an indurated ill-defined plaque measuring 10 cm with partially atrophic surface and 2 centrally located palpable nodules measuring between 3 and 5 mm. A deep biopsy of the lesion was performed, and histopathology and immunohistochemical analysis of CD34 expression confirmed the diagnosis of dermatofibrosarcoma protuberans (Figure 1, C, D). Computed tomography scans of the thorax, abdomen, and pelvic region were subsequently performed, revealing no further disease progression. Complete excision of the tumor was performed and followed by wide scar re-excision due to narrow surgical margins of only 1 mm. No further disease progression or recurrences have been noted during the follow-up, and the patient has been disease-free for one year postoperatively. Although the etiology of DFSP is unknown, trauma has been hypothesized as a predisposing factor. It usually presents on the trunk and the proximal extremities (4). Patients usually report disease progression over a long period of time, ranging from several months to years. The tumor is associated with variable color changes, even proximal skin discoloration, and often presents with a slowly growing indurated dermal plaque or firm nodule attached to the skin (4). Clinically, it can be difficult to distinguish DFSP from a wide number of diagnoses, including morphea, idiopathic atrophoderma, atrophic scar, anetoderma, lipoatrophy, cellular dermatofibroma, fibrosarcoma, malignant fibrous histiocytoma, atypical fibroxanthoma, desmoplastic melanoma, Kaposi sarcoma, and solitary fibrous tumors (5). Immunohistochemistry staining for CD34 cells can be helpful in differentiation, since spindle cells stain positively in DFSP (6). Due to alteration of dermal collagen, histopathological differential diagnoses of DFSP includes lichen sclerosus, atrophic scars and keloids, as well as morphea (7), atrophic dermatofibroma, and undifferentiated pleomorphic sarcoma (6). The mainstay of DFSP treatment is tumor excision performed either by wide local excision or Mohs surgery and having surgical margins between 1 and 5 cm. Several studies have confirmed that patients treated with the Mohs technique have significantly lower recurrence rates (8). Due to the high number of unsatisfactory primary excisions, wide free surgical margins are important for disease control (3). Radiotherapy might be considered as a therapeutic option for inoperable tumors or relapses, as well as an adjuvant therapy after primary excision or re-excision with positive margins (8). Furthermore, recent findings indicate positive therapeutic efficacy after administration of imatinib mesilat - a tyrosine kinase inhibitor due to over expression of PDGFß (9). Clinical follow-up of patients with DFSP after tumor excision should be performed every six months for the first five years, followed by yearly intervals thereafter for up to 10 years (3). Previous case reports have claimed that the diagnosis of DSFP is commonly delayed as a result of slow tumor growth and nonspecific initial clinical findings (10). To the best of our knowledge, our case is the first description in the literature of DFSP developed within a MP plaque. We speculate that trauma from repeated punch biopsies taken from the sclerotic morpheaform plaque may represent the trigger for the development of the DFSP. Another notable clinical challenge was the surgical excision itself, since the majority of cases presented in literature mentioned unsatisfactory resection margins and a high risk of local disease recurrence. Although complete excision of the neoplasm was performed, re-excision was performed in order to provide wider resection margins. Surgical resection remains the main treatment for dermatofibrosarcoma protuberans, with the main challenge being the achievement of clean excision margins. Proper management of the disease and continuous follow-up are important in order to prevent local recurrence of dermatofibrosarcoma protuberans or its potential metastases.

Digital technology and HIV, HCV and STI voluntary counselling and testing: good practice example from Croatia.

The aim of this paper is to introduce the digitalization process and its effects on better reach of the target population. Progress in the digitalization and e-health tools worldwide enables new opportunities in prevention, diagnostics and treatment for people living with HIV (PLHIV) and people in the risk of HIV infection, hepatitis C (HCV) and other sexually transmitted infections (STIs), especially in the context of the COVID-19 pandemic. The system already used for voluntary counselling and testing (VCT) at the CheckPoint Centre Zagreb run by the non-governmental organization (NGO) Croatian Association for HIV and Viral Hepatitis (CAHIV) was upgraded and adapted (due to the COVID-19 prevention epidemiological measures) and developed for implementation of the pilot project of feasibility and acceptability of home HIV self-testing (HIVST) among men who have sex with men (MSM) in Zagreb. A special feature of the HIVST mobile application enables an innovative approach in collecting clients' test result feedback. This paper presents the method of use digitalization of the VCT and HIVST activities to support and increase availability of screening testing. Described procedures of new technologies application in VCT services and preliminary results of the HIVST pilot project indicate that technology-delivered interventions can contribute and improve access and utilisation of HIV/STI prevention and care services.

Brentuximab-induced splinter nail haemorrhages in a patient with Sézary syndrome: A case report.

Sézary syndrome is a systemic variant of cutaneous T-cell lymphoma characterized by erythroderma, lymphadenopathy and circulating atypical lymphocytes (Sézary cells). It may present with nonspecific lesions on multiple digits. We describe an atypical case of brentuximab-induced splinter nail haemorrhages in a patient with Sézary syndrome, associated with a poor prognosis during follow-up. Concomitantly with the appearance of nail lesions, significant lymphocytosis was detected as well as infiltration of bone marrow and nail matrices. The lesions followed a precise sequence, which can be traced back to the monthly application of brentuximab and its direct cytotoxic effect on CD30+ T lymphocytes in the nail matrix. Brentuximab-induced nail lesions might be associated with decreased efficacy of brentuximab in this patient with advanced cutaneous T-cell lymphoma.

SCABIES CASES MISDIAGNOSED AND TREATED AS ALLERGIC DISEASES: ITCH AS ALARM.

The lack of scabies recognition by physicians is often caused by its similarity with other dermatoses and allergies such as eczema, urticaria, atopic dermatitis, allergic contact dermatitis, etc. The aim of this study was to present the most common misdiagnoses of scabies in physician's work. With the aim of preventing future misdiagnoses in physicians' work, we present 6 cases of patients (1 woman and 5 men, aged 23-82) who had been misdiagnosed prior to admission to our ward (tertiary care unit). In our patients, scabies was unrecognized for months during which time the patients were treated for allergic/immune diseases (nummular eczema, drug-induced reaction, allergic contact dermatitis, autoimmune skin disease). Additionally, none of our patients had lived in unhygienic conditions or were close to infected persons, but all had concomitant itch. Because of the similarity between scabies and pruritic allergic disorders, it is important to exclude scabies before diagnosing an allergy, based on patient history and skin examination. Early scabies recognition in practice is crucial for minimizing the disease societal impacts.

Ultrasound Assessment of Regional Lymph Nodes in Melanoma Staging.

BACKGROUND: Melanoma can early metastasize to regional lymph nodes. The sentinel lymph node (SLN) is the first lymph node draining directly from the site of primary melanoma, and the pathohistological status of the SLN is the most significant prognostic factor for overall survival prevalence and prognosis in patients with melanoma. Ultrasound is a very useful for the imaging of regional lymph node metastases, combined with Doppler and cytopuncture. OBJECTIVE: The aim of this study was to investigate the role of ultrasound assessment of regional lymph nodes in melanoma staging. PATIENTS AND METHODS: The study included all patients with primary melanoma detected in the period between 2003 and 2012, in whom diagnostic processing has not proven distant metastases or physical examination did not find enlarged lymph nodes. In total, 202 surgically treated patients were included in the study, of which 101 patients underwent ultrasound examination of regional lymph nodes using a linear probe of at least 12 MHz, while ultrasound of regional lymph nodes was not performed for 101 patients. RESULTS: The results of this study emphasize the importance of ultrasound in the diagnostics and treatment of patients with melanoma. Based on the observation of the occasional positive ultrasound and fine needle aspiration cytology (FNAC) in regional lymph nodes, our results indicate that a proportion of patients can avoid sentinel lymph node biopsy (SLNB). In case of a positive ultrasound findings (complemented with FNAC of suspicious nodes), direct dissection of regional lymph nodes is recommended. However, negative ultrasound findings do not exclude the presence of micrometastases due to poor sensitivity of this method and is not a contraindication for SLNB. CONCLUSION: Therefore, there is a need for further studies on metastatic melanoma, especially those in the sentinel lymph nodes and in its early stage.

Study on the Impact of Psoriasis on Quality of Life: Psychological, Social and Financial Implications.

BACKGROUND: Psoriasis is a chronic and stigmatising disease with significant and hard to meet clinical needs in patient management. Psoriasis is a relatively common disease, affecting up to 2% of the population. The impact of psoriasis on quality of life is significant given its chronicity and visibility. Psychological stress is a well-established systemic triggering factor in psoriasis. It has been associated with initial presentation of the disease as well as exacerbations of pre-existing psoriasis. The purpose of this study is to assess the psychological, social and financial implications of psoriasis. SUBJECTS AND METHODS: 51 patients participated in this study. After dermatological examination and determination of Psoriasis Area and Severity Index score, patients were referred to a psychological consult. Assessment was done through questionnaires concerning quality of life, depression, anxiety, illness perception, financial domain and personal data. RESULTS: Results of our study indicate that psoriasis has a strong impact on patients' life. It influences working habits, poses a significant financial burden, but most of all, significantly impairs their quality of life and psychological status. CONCLUSION: Psoriasis poses a substantial threat to several dimensions in patient's quality of life. Patients feel that the current treatment, although often effective, does not provide a satisfactory long-term solution. Thus, long-term psychologic support for patients with psoriasis is desirable.

The effect of high-fat diet and 13-cis retinoic acid application on lipid profile, glycemic response and oxidative stress in female Lewis rats.

Vitamin A and its metabolites are key regulators of the development of adipose tissue and associated metabolic complications. The aim of this study was to determine the effect of high fat diet and 13-cis retinoic acid (13 cRA) application on metabolic parameters, adipogenic and inflammatory indicators in female Lewis rats. Female rats of Lewis strain were fed standard laboratory diet (STD) and high fat diet (HFD, 45% of saturated fatty acids) during 30 days. The groups were divided into additional 3 groups (6 rats each): two experimental groups that received 13 cRA orally on a daily basis during 30 days (7.5 mg/kg and 15 mg/kg, respectively) and the control group that was given sunflower oil. Animals were sacrificed after 60 days. Feeding of Lewis rats with chronic HFD diet with 13 cRA supplementation increased weight gain, adiposity index, dyslipidaemia, hyperleptinaemia, insulin resistance, VLDL concentrations, oxidative stress and atherogenic indices. Administration of 13 cRA in Lewis rats fed STD did not change the weight of the animals, but it slightly increased the atherogenic parameters. 13 cRA and HFD affect metabolic parameters, glucose and lipid metabolism in Lewis rats and its administration has a completely different effect on metabolism in rats fed STD, highlighting the complex role of vitamin A supplementation in obesity. Other factors, such as genetics, age, sex, adipose tissue distribution, also must be taken into consideration.

Vemurafenib and cobimetinib-induced toxic epidermal necrolysis in a patient with metastatic melanoma.

Combination therapy in the treatment of metastatic melanoma has been associated with more durable response rate compared to monotherapy. However, previous studies have shown that combined target therapy commonly causes a wide spectrum of adverse events. These adverse reactions are usually manageable, however, it is always necessary to compare drug efficacy with its potential adverse effects. Toxic epidermal necrolysis represents severe mucocutaneous reaction, usually triggered by medications and characterized by extensive necrosis and detachment of the epidermis. Here we present a first case of toxic epidermal necrolysis induced by combined target therapy (vemurafenib plus cobimetinib). The case was observed in a young patient with BRAF mutant melanoma who was started on first-line metastatic immunotherapy with pembrolisumab.

Outpatient benzodiazepine utilization in Croatia: drug use or misuse.

Background Benzodiazepines are commonly prescribed medications, especially among elderly, despite known risks and guidelines focused on short term usage. There is an increased trend of benzodiazepine consumption in Croatia. Consumption of anxiolytics in 2015 and 2016 in Croatia can almost entirely be ascribed to benzodiazepines, with diazepam being the most commonly prescribed drug, followed by alprazolam. Objective The aim of this study was to examine benzodiazepine utilization habits among the Croatian population. Setting This study was conducted on the national level, based on digital prescribing data. Method Data regarding the prescription of anxiolytics in Croatia was sourced and analyzed from the Croatian Health Insurance Fund database for the years 2015 and 2016. Drugs included in the study were classified according to The Anatomical and Therapeutic Classification of Medicines System, and consist of several chemical therapeutic subgroups (N05BA, N05BC, N05CD, N05CF). Main outcome measures The prescribing frequency of the most often prescribed benzodiazepines in Croatia. Results The total number of benzodiazepine prescriptions was 5,085,695 in 2015, and 5,294,075 in 2016; this represents a 208,380 increase in prescriptions, or 4.1% more than the previous year. The number of patients who utilized benzodiazepines showed an increase from 860,664 (8.67%) in 2015 to 876,046 (8.76%) in 2016. In relation to gender, benzodiazepine consumption was higher among female patients in all age groups, with the number of utilized benzodiazepine prescriptions per patient being highest in the oldest age group (80 +), comprising 7 prescriptions per patient in a 12 months period. Conclusion Increased utilization and long-term treatment with benzodiazepines remains a serious challenge for the health care system in Croatia. National prescription guidelines, improved control of benzodiazepine usage and prescriptions, along with restricted release drug lists, should all be considered as potential measures to rationalize benzodiazepine prescription, control unnecessary expenditure in the country and improve the well-being of the patients.

A cross sectional study of salt content in bakery bread in Zagreb, Croatia.

Reducing salt content in bread is the essential part of a national strategy for salt reduction with the goal of long-term national general health improvement. In this study we have analysed salt content in three types of bread available in 25 small and five national industrial bakeries in Zagreb, Croatia. Samples of white wheat bread, dark wheat bread, and other types of bread were collected, and the salt content was determined with the Mohr method. Salt content varied widely between bakeries, with an average content of 2.30±0.22 g per 100 g of bread, which is almost twice the threshold content (1.4 %) defined by the Croatian National Regulation on Cereals and Cereal Products. Further efforts are necessary to teach bakers how to reduce salt content without affecting quality or flavour. These should go hand in hand with continuous monitoring of how the legal provisions are implemented.