Goran Kardum

Desfecho funcional de crianças tratadas em unidade de terapia intensiva

OBJETIVO: O desfecho de pacientes nao e somente determinado pelo indice de gravidade de doenca, mas tambem pelo impacto do estado pre-admissao de comorbidade dos pacientes. Portanto, este artigo buscou avaliar o desfecho de pacientes tratados em uma unidade de terapia intensiva pediatrica, com foco especial no grupo de criancas com doencas cronicas. METODOS: Os dados foram obtidos prospectivamente, e o desfecho foi avaliado segundo a escala Pediatric Overall Performance Category para 449 pacientes de uma unidade de terapia intensiva pediatrica do Split University Hospital. O desempenho funcional foi avaliado como o escore pre-admissao e o escore na alta hospitalar em pacientes com alteracoes neurodesenvolvimentais, com outras doencas cronicas e sem doenca cronica. RESULTADOS: O estado funcional a alta hospitalar foi significativamente dependente do estado funcional pre-admissao e da mortalidade prevista. Criancas com alteracoes neurodesenvolvimentais apresentaram escore basal significativamente pior e deterioracao de morbidade funcional na alta hospitalar significativamente menor, comparadas com criancas sem doenca cronica e com criancas com outras doencas cronicas. CONCLUSOES: A escala Pediatric Overall Performance Category demonstrou sua aplicabilidade em uma pequena unidade de terapia intensiva com uma populacao heterogenea de pacientes. Deve, portanto, ser considerada para avaliacao regular de qualidade de cuidados a saude como uma ferramenta simples e precisa. Ao contrario do que acontece com outros pacientes, o estado funcional de criancas com alteracoes neurodesenvolvimentais foi marcadamente influenciado por sua comorbidade. Seu estado pre-admissao foi pior do que o de outras criancas e, por isso, nao poderia estar significativamente deteriorado na alta hospitalar.

Rocuronium attenuates oculocardiac reflex during squint surgery in children anesthetized with halothane and nitrous oxide

Background:  The oculocardiac reflex (OCR) may be activated during squint surgery. The aim of this study was to test whether rocuronium 0.4 mg kg−1 could reduce the frequency of OCR, and also whether a single dose of succinylcholine 1 mg kg−1 could affect the frequency of OCR during anesthesia with halothane in a nitrous oxide/oxygen mixture.

Neurodevelopmental disabilities and quality of life after intensive care treatment

Aim:  To analyze the quality of life after Pediatric Intensive Care Unit (PICU) treatment and compare the differences between quality of life in children who suffer chronic health conditions, and those who do not, post discharge from PICU.

Association of oculocardiac reflex and postoperative nausea and vomiting in strabismus surgery in children anesthetized with halothane and nitrous oxide.

Background:  Postoperative nausea and vomiting (PONV) occurs frequently after strabismus surgery. The controversy still exists regarding the association of PONV and the oculocardiac reflex (OCR). A recent study has proven that rocuronium attenuates OCR. If these two occurrences are dependent, it is expected that with the diminution of OCR, occurrence of PONV will also be reduced. The goal of this randomized, controlled study was to prove an association between OCR and PONV by attenuating OCR with 0.4 mg·kg−1 of rocuronium and subsequently diminishing PONV if these occurrences are associated.

Applicability of the Australian and New Zealand Paediatric Intensive Care Registry diagnostic codes and Paediatric Index of Mortality 2 scoring system in a Croatian paediatric intensive care unit

The severity of illness scoring systems enable benchmarking of standard of care among various paediatric intensive care units (PICU). The most accurate validation of a scoring system is the system’s evaluation in a population other than that from which the score is derived [3]. PICUs that collaborated in the Paediatric Index of Mortality (PIM2) study are large units, and most of them pertain to the Australian centralised paediatric intensive care service [5]. The PIM2 evaluates the condition of the patient at the first contact, during the first hour after arrival in the PICU. The score is calculated on linear regression equations from ten physiological and clinical data that can be routinely collected by trained medical staff. The Australian and New Zealand Paediatric Intensive Care Registry (ANZPIC Registry) diagnostic codes is a proposed diagnostic coding system for international use. The Registry codes the principal and up to five associated diagnoses [4]. We performed a prospective, observational study to evaluate the applicability of the ANZPIC Registry diagnostic codes, and validity of the PIM2 scoring system in a PICU diverse from those in which the two systems were created. The PICU of the Clinical Hospital Split is a regional, sevenbed, tertiary multidisciplinary unit of a public, university-affiliated hospital. Between June 2002 and July 2004, admission data were prospectively collected for 591 consecutively admitted patients aged £ 18 years, excluding preterm infants. PIM2-based mortality risk was calculated according to the equations published in the literature [5]. Diagnoses of all patients were classified according to the ANZPIC Registry diagnostic codes. The median age of our patients was 62 months (range 0.03–216 months). There were 89 (15%) elective admissions, and 168 patients (28.4%) were mechanically ventilated during the first hour. Median length of stay was 2 days. For 2.5% of patients, the exact principal diagnosis could not be selected from the ANZPIC Registry diagnostic codes. Among the 370 codes that create the system, 109 were eligible for our population of patients as principal diagnoses. The five most frequent diagnoses were: pneumonia or pneumonitis (8.6%), head trauma (8%), seizures (7.6%), laryngobronchoscopy (4.1%), and ingestion (4.1%). Out of 158 (26.7%) surgical patients, 46 (29.1%) were admitted for head trauma. Observed mortality was 35/591 (5.9%, 95% confidence interval (CI) 4.0 to 7.9%). All deaths were from the unscheduled admissions. The most frequent cause of death was head trauma (7/35, 20%). Predicted mortality was 35/591 (5.9%). Standardised mortality ratio (ratio of observed to expected deaths, SMR) was 1.00. Calibration, assessed by the Hosmer-Lemeshow goodness of fit test [2] in deciles of mortality risk is shown in Table 1. The Hosmer-Lemeshow goodness of fit test showed v=19.59, P =0.012. The sensitivity of the PIM2 was 65.7%, and the specificity was 99.3%. Predictive capability was assessed by calculating the area under the receiver operating characteristic curve (ROC). The predictive power for PIM2, expressed as area under the ROC curve, was 0.97 (95% CI 0.96 to 0.99). Results of previous external validation studies showed adequate performance of the PIM and prediction of death in heterogeneous groups of PICU patients [1,6]. The continuous improvement in paediatric intensive care requires the updating of existing mortality prediction models. Therefore, we conducted a study with the revised PIM scoring system. In spite of the relatively J. Mestrovic (&) Æ B. Polic Æ A. Omazic Æ L. Stricevic Paediatric Intensive Care Unit, Department of Paediatrics, Clinical Hospital Split, Spinciceva 1, 21000 Split, Croatia E-mail: julije.mestrovic@st.t-com.hr Tel.: +385-21-556686 Fax: +385-21-556590

Suicidal ideations and sleep‐related problems in early adolescence

Suicidal ideation and sleep‐related problems are associated with many common psychopathological entities in early adolescence. This study examined possible association between suicidal ideation and sleep‐related problems.

Family medicine practice and research : Survey of physicians' attitudes towards scientific research in a post-communist transition country

ZusammenfassungHINTERGRUND: Obwohl das Paradigma der evidenz-basierten Praxis in der modernen Medizin vorherrscht, gibt es nur wenig wissenschaftliche Arbeiten bzw. wissenschaftliches Interesse im Bereich der Allgemeinmedizin. Wir untersuchten die Einstellung zur wissenschaftlichen Forschung bei Allgemeinmedizinern in einem Land, das sich im post-kommunistischen sozioökonomischen Übergang befindet. Diese Einstellung wurde ihrer Haltung zur Alternativmedizin und dem für ihre Praxis relevanten klinischen Wissenstand gegenübergestellt. METHODEN: Wir befragten 427 Allgemeinmediziner in Kroatien bezüglich ihrer Einstellung zur wissenschaftlichen Forschung (5 Punkte-Beurteilungs-Skala; Score-Bereich 20–100) und zur Alternativmedizin (5-Punkte-Beurteilungs-Skala; Score-Bereich: 14–70). Zusätzlich wurde das Wissen im Bezug auf das diagnostische und therapeutische Management von Hypertonie (10 Fragen) und Diabetes mellitus (12 Fragen) geprüft. ERGEBNISSE: Die Einstellung zur wissenschaftlichen Forschung war positiv (Score 79,0 ± 7,1 bei einem möglichen Maximum von 100). Diese Einstellung war signifikant positiver als die zur Alternativmedizin (Score 45,0 ± 9,9 von maximal 70; t425 = 19,06; p < 0,001). Die Befragten beantworteten etwa die Hälfte der Fragen über Hypertonie und Diabetes korrekt. Das Wissen über neue Leitlinien der Diagnose und Therapie ging über das Lehrbuchwissen hinaus. Die Ergebniswerte bezüglich der Einstellung zu den befragten Themen waren unabhängig vom Wissen, von der Forschungsaktivität und der medizinischen Erfahrung der Teilnehmer der Studie. SCHLUSSFOLGERUNGEN: In einem Land, das sich sozioökonomisch in einem Übergang befindet haben allgemeinmedizinisch tätige Ärzte eine positivere Einstellung zur Wissenschaft als zur Alternativmedizin, trotz der schwierigen Umstände, unter denen sie ihre Praxis betreiben. Um Allgemeinmediziner in die Forschung einzubinden, müssen Maßnahmen gesetzt werden, die eine Verhaltensänderung bewirken – Maßnahmen, die nur eine positivere Einstellung zum Ziel haben, sind nicht ausreichend.SummaryBACKGROUND: Although the paradigm of modern medicine is evidence-based practice, there is a lack of research output and interest in research in family medicine. We investigated attitudes towards scientific research among family medicine practitioners in a country in post-communist socioeconomic transition, and related it to their attitudes towards alternative medicine and clinical knowledge relevant for their practice. METHODS: We surveyed 427 family medicine practitioners in Croatia about their attitudes towards scientific research (5-point rating scale, total score range 20–100) and alternative medicine (5-point rating scale, total score range 14–70). We also tested their knowledge on diagnosis and treatment of hypertension (10 questions) and diabetes (12 questions). RESULTS: The attitude towards scientific research was positive (score 79.0 ± 7.2 out of maximum 100) and significantly more positive than that towards alternative medicine (score 45.0 ± 9.9 out of maximum 70; t425 = 19.06, P < 0.001). The respondents correctly answered about half the questions on hypertension and diabetes; knowledge on new diagnostic and treatment guidelines was better than their textbook knowledge. The attitude scores were not related to knowledge or research activity or the medical practice of the respondents. CONCLUSIONS: Family medicine practitioners in a transition country have a more positive attitude towards science than towards alternative medicine, despite the adverse situation in which they practice. To involve family medicine practitioners in research, interventions must be directed towards changes in behavior and practice and not only towards increasing positive attitudes.

Are postoperative behavioural changes after adenotonsillectomy in children influenced by the type of anaesthesia?: A randomised clinical study.

BACKGROUND Negative postoperative behavioural changes (NPOBCs) are very frequent in children after surgery and general anaesthesia. If they persist, emotional and cognitive development may be affected significantly. OBJECTIVE To assess whether the choice of different anaesthetic techniques for adenotonsillectomy may impact upon the incidence of NPOBC in repeated measurements. DESIGN A randomised, controlled, parallel-group trial. SETTING University Hospital Split, Croatia. PATIENTS Sixty-four children (aged 6 to 12 years, ASA 1 to 2) undergoing adenotonsillectomy assigned into one of two groups: sevoflurane (S) (n = 32) or total intravenous anaesthesia (TIVA) (n = 32). INTERVENTIONS Permuted-block randomisation with random block sizes of 4, 6 and 8, administering anaesthesia, and evaluation of NPOBC with the Post Hospitalization Behavior Questionnaire (PHBQ: 27 items describing six subscales). The PHBQ was filled out by parents at postoperative days (POD) 1, 3, 7 and 14, and 6 months after surgery. MAIN OUTCOME MEASURES Differences in numbers of NPOBCs between two anaesthesia techniques, and NPOBC analysis by subscales. RESULTS The prevalence of at least one NPOBC after surgery ranged from a maximum of 80% [95% confidence interval (CI) 71 to 90%] on POD 1 to a minimum of 43% (95% CI 31 to 56%) 6 months after surgery. Absolute risk reduction for at least one NPOBC in the TIVA group compared with the S group increased from 0.24 on POD 1 to 0.55 6 months after surgery. The number of NPOBCs was also lower in the TIVA group [median 5, interquartile range (IQR) 2 to 10] than in the S group (median 22, IQR 10 to 32) (P < 0.001). The overall number of NPOBCs within PHBQ subscales was significantly lower in the TIVA group than in the S group. The largest difference in the number of NPOBCs between groups was observed for the separation anxiety subscale (mean 5, 95% CI 1 to 9; P < 0.001) followed by the general anxiety subscale (mean 4, 95% CI 3 to 5; P < 0.001) and apathy/withdrawal subscale (mean 3, 95% CI 1 to 5; P < 0.001). CONCLUSION The prevalence of NPOBC after elective adenotonsillectomy in 6 to 12-year-old children was very high (80%). The choice of anaesthetic technique for adenotonsillectomy in children influenced the incidence and type of NPOBC. Sevoflurane/nitrous oxide anaesthesia was associated with more frequent and prolonged NPOBCs than TIVA, especially in the separation anxiety, general anxiety and withdrawal/apathy subscales.

Health-care seeking behaviour for tuberculosis symptoms in Croatia

BACKGROUND Early detection and treatment of tuberculosis (TB) patients have been key principles of TB control. Therefore, it is important to understand the causes of delay and to estimate their magnitude in order to plan interventions that yield the maximum benefit. METHODS A total of 240 subjects aged ≥ 15 year with pulmonary TB were interviewed. Patient delay was defined as the period (in days) from the appearance of any symptoms to the first visit to a medical provider. RESULTS The median patient delay was 38 days. When using the median as a cut-off to define long patient delay, being an ex-smoker (P = 0.036), current smoker (P = 0.030), coughing (P = 0.021) and losing weight (P = 0.050) were found to be significant. Having high level of education (P = 0.014) was associated with short delay. Being an ex-smoker (P = 0.050, adjusted odds ratio (aOR) = 1.940, 95% CI 1.001-3.759), current smoker (P = 0.029, aOR = 2.077, 95% CI 1.076-4.012) and having a cough (P = 0.022, aOR = 2.032, 95% CI 1.108-3.727), were significant in multivariate logistic regression, while having high level of education remained associated with short delay (P = 0.016, aOR = 0.286, 95% CI 0.103-0.791). The most common reasons for delay were supposed influenza or symptoms improving over time (34.5%) and underestimated symptoms (32.9%). CONCLUSION People with smoking habits and health-seeking behaviour that may favour advanced disease and prolonged infectiousness as well as people with the lowest level of education contributed to TB delay. To reduced patient delay, efforts should be made to increase TB knowledge, which has to be adjusted to the less-educated segments of the population.

Early adolescence and suicidal ideations in Croatia: sociodemographic, behavioral, and psychometric correlates.

BACKGROUND/AIMS Suicidal ideations (SI) indicate and predict psychological distress. We examined the prevalence of SI among early adolescents and its association with parental war participation, personal, behavioral, and sociodemographic characteristics. METHODS We performed a cross-sectional questionnaire study on 803 12-year-old adolescents. Data were collected using a sociodemographic questionnaire, the Junior Eysenck Personality Questionnaire and Children Depression Inventory. Unintentional injuries, physical fighting, and involvement in bullying behavior were assessed using questions from the World Health Organization (WHO) survey Health Behavior in School-aged Children. Suicidal ideations were assessed with three dichotomous items. RESULTS There were no gender differences in SI prevalence. SI in males were associated with lower maternal education, crowded families, birth order, parental war participation, physical fighting, being bullied, and substance use. In females, we found associations with lower parental educational level, number of brothers, lower perception of the relationship with parents, parental relationship, family cohesion and parental control, negative attitude toward school, rare church attendance, fighting, and being bully or bullied. Depressive symptoms and SI were associated in both genders. CONCLUSIONS SI showed gender-specific associations that may partially be explained with parental war involvement. These findings may have potentially important clinical and preventive implications.