LARYNGEAL MASK AIRWAY VERSUS ENDOTRACHEAL INTUBATION FOR ADENOIDECTOMY IN OUTPATIENT SURGERY - SINGLE CENTER EXPERIENCE.

Adenoidectomy with or without tonsillectomy remains one of the most routinely performed surgical procedures in children. The duration of the procedure is usually less than half an hour and is done in a day surgery setting. Airway management for adenoidectomy can be especially challenging as the airway is shared between the surgeon and the anesthesiologist. The gold standard for airway management is an endotracheal tube (ETT), even though there has been an increase in the use of laryngeal mask airway (LMA) over the past decade. This retrospective study investigated patient data collected over a 4-year period (2016 to 2020). Data included 210 cases in a day surgery setting. We analyzed the choice of airway device and use of neuromuscular blockers and analgesics for pain management. The use of LMA was noted in 67.62% while endotracheal intubation was performed in 32.38% of cases. LMA resulted in fewer respiratory complications compared to ETT (p=0.006). The need for neuromuscular blockers was also lower in the LMA group (p=0.01). There was no statistically significant difference in the intraoperative dose of opioid analgesia (p=0.09). Flexible LMA is a satisfactory alternative to endotracheal intubation for outpatient pediatric adenoidectomy.

Antibiotic prescription rate for upper respiratory tract infections in general practice - a Croatian study.

Aim Acute upper respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The frequency of antibiotics prescribed to patients with upper respiratory tract infections has been studied. Methods A cross-sectional survey has been conducted from October to December 2017 with participation of 17 General Practices in Croatia. Visits of patients with symptoms of upper respiratory tract infections made the survey framework. A specially structured questionnaire was a tool for the assessment of reasons for encounters, clinical statuses and practitioners' decisions. According to the registered clinical status, two independent doctors classified patients using Centor criteria, which were used to evaluate appropriate indication for antibiotic prescription. Results The survey analysed 709 patients' visits. Seventy three percent of general practice visits due to acute respiratory tract infection were initial. Antibiotics had been prescribed in the total of 32.6% of cases. Analysing upper respiratory tract infections with Centor score 1 and 2, antibiotics had been prescribed in 22.8% cases of the first visit and in 31.7% of the second visit, and with the Centor score 3 and 4 antibiotics had been prescribed in 85.1% of cases during the initial visit, and 66.7% of cases during the second visit. Logistic regression analysis about the contribution of nonclinical variables to antibiotic prescribing showed that most often antibiotics had been prescribed on Mondays. The most prescribed group of antibiotics was the penicillin group (74.8%), followed by macrolides (17.6%) and cephalosporins (4.0%). Conclusion General practitioners prescribe antibiotics for acute respiratory tract infections more than recommended by evidence based medicine and professional criteria.

Missing risks in opportunistic screening for type 2 diabetes - CroDiabGP study.

Aim To examine two methods of extracting risks for undetected type 2 diabetes (T2D): derived from electronic medical record(EMR) and family medicine (FM) assessment during pre-consultation phase. All risks were structured in three lists of patients' data using Wonca International Classification Committee(WICC). Missing data were detected in each list. Methods A prospective study included a group of 1883 patients(aged 45-70) identified with risks. Risks were assessed based on EMR for continuity variables and FM's assessment for episodes of disease and personal related information. Patients were categorized with final diagnostic test in normoglycaemia, impaired fasting glycaemia and undetected T2D. Results Total prevalence of diabetes was 10.9% (new 1.4%), of which 59.3% were females; mean age was 57.4. The EMR risks were hypertension in 1274 patients (yes 67.6%, no 27.9%, missing 4.4%), hypolipemic treatment in 690 (yes 36.6%, no 30.9%, miss 32.5%). In the episodes of disease: gestational diabetes mellitus in 31 women (yes 2.8%, missing 97.2%). Personal information: family history of diabetes in 649 (yes 34.5%, no 12.4%, missing 53.1%), overweight in 1412 (yes 75.0%, no 8.4%, missing 16.6%), giving birth to babies >4000g in 11 women (yes 0.9%, missing 99.1%). Overweight alone was the best predictor for undiagnosed type 2 diabetes, OR: 2.11 (CI: 1.41-3.15) (p<.001). Conclusion Two methods of extraction could not detect data for episodes of the disease. In the list of personal information, FMs could not assess overweight for one in six patients and family history for every other patient. The study can stimulate improving coded and structured data in EMR.

A thin line between Meniere's disease and spontaneous intracranial hypotension syndrome.

AIM: To point out the similarity of Meniere disease and spontaneous intracranial hypotension and difference of their treatment. METHODS: A case of a 54-year-old male patient with previously diagnosed Meniere's disease and newly diagnosed spontaneous intracranial hypotension syndrome is presented. Additional neuroradiological examination, Brain contrast-enhanced MRI and MR myelography were used for diagnosis. RESULTS: Due to deterioration of vertigo, hearing loss and tinnitus in the right ear the patient was referred to the additional neuroradiological examination which confirmed the diagnosis of spontaneous intracranial hypotension syndrome. Brain contrast-enhanced MRI showed increased pachymeningeal contrast enhancement, and MR myelography identified the location of CSF leak. The patient was successfully treated conservatively. CONCLUSION: According to our knowledge this is the fifth case report of Meniere's disease and spontaneous intracranial hypotension coexistence. Both diseases have similar clinical presentation and initial treatment. We suggest procedures of additional examination when the treatment fails and initial diagnosis becomes questionable.

Antibiotic prescription rate for upper respiratory tract infections and risks for unnecessary prescription in Croatia.

Overprescribing of antibiotics in primary care has been recognized as public health problem. We investigated visits prescription rate of antibiotics to patients with upper respiratory tract infections (URTI) and unnecessary prescription for tonsillopharyngitis, in Croatia. In prospective observational study in November 2007. 25 GPs in Croatia recorded all patients' visits with URTI episode according ICPC-2. Clinical status of patients with tonsillopharyngitis were categorized according to Centor Criteria. 689 visits were analysed, 82% of visits were initial. Antibiotics were prescribed in 44.7% visits with URTI. There were no significant differences in antibiotic prescription rates regarding non-clinical factors. Antibiotics were prescribed to patients with tonsillopharyngitis in 62.2% visits. Unnecessary antibiotics were prescribed (Centor 1,2) in 49.6% visits with tonsillopharyngitis. Logistic regression analysis showed significant differences in unnecessary antibiotic prescription rates only with respect to the workday--Wednesday, CI (1.117-2.671), p = 0.0139. Leading antibiotic was amoxicillin + clavulonic acid, second was amoxicillin, the third were macrolides, the fourth was narrow spectrum penicillin and fifth were cephalosporins. This study shows over prescription for URTI. Unnecessary prescription for tonsillopharyngitis depend on non clinical factor--day of the week. This should be further explored and help to improved prescribe antibiotics.

Hedgehog-Patched pathway aberrations in a malignant triton tumor case study.

Transition from malignant schwannoma to malignant triton tumor is analyzed in a case report on a patient with recurring cancers and suspected familial predisposition. It is hypothesized that rhabdomyoblastic differentiation, which distinguishes triton from schwannoma, might be attributable to Hedgehog-Patched pathway malfunctioning. Loss of one Patched gene allele was found in the tissue of advanced triton, but the retained allele had no exon or promoter mutations. Protein levels at early cancer stages indicated possible Patched response to the pathway activation in the first occurrence of triton tumor. Later, in the recurring triton, Patched expression was several times lower than in the control tissue, suggesting that haploinsufficiency was aided by silencing of the remaining allele, although its promoter was not hypermethylated. These findings may justify further investigation of the Hedgehog-Patched pathway role in triton malignancies, especially because of the recent research on the therapeutical potential of the pathway.

Chronic patients--persons with diabetes frequent attenders in Croatian family practice.

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two group of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p = 0.0005), diet-only-treatment (p = 0.0062), treatment by secondary care (p = 0.0116), and if glycated hemoglobin test (HbA1c) is determined (p = 0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems.

Structure of visits persons with diabetes in Croatian family practice--analysis of reasons for encounter and treatment procedures using the ICPC-2.

The reasons for encounter and the procedures conducted during the visit persons with diabetes to family practice have been investigated. Five family practitioners located in two Croatian counties took part in this study. In this study patients with diagnoses E10-E14 according to International Classification Disease-10 (ICD-10), were involved. There were 543 persons with diabetes (women 324) in the total population of 10,150 patients Data were registered according to the International Classification Primary Care-2 (ICPC-2) (components 1-7 for reasons of encounter, and components 2-6 for procedures during the visit), in period october till december 2005. 871 visits of persons with diabetes (average age 65.7 +/- 12.5 were registered. Patients presented in total 1921 reasons for encounter or 2.1 +/-1.1 per visit. Family practitioner made in total 2,341 procedures or 2.6 +/- 1.5 procedures per visit. 85.0% of patients had 1 to 3 reasons for encounter, 78.4% of patients had 1 to 3 procedures per visit. 64.4% of patients with diabetes presented at least one reason for encounter connected to diabetes. The most common reasons for encounter were prescriptions of medication 46.4 per 100 reasons for encounter, the second was dignostic procedure 19.9, request for analysis of findings 11.1, symptoms complaints 11, request for referrals to diagnostic procedures or specialist consultation 8.9 and administrative reuqests 1.6 per 100 reasons for encounter. Family practitioner performed procedure prescriptions of medication 47 per 100 procedures. The second was dignostic procedure 32.8 per 100 procedures, referrals to diagnostic procedures or specialist consultation 14.7 and administrative procedures 1.7 per 100 procedures. From the total number of 100 referrals to specialist, 23 were to diabetologist, 15 to ophtalmologist, 13 to cardiologist. The largest proportion of procedure belong to diabetics 33.8%, followed by the circulatory system 25.4%, musculosceletal 6.9%, symptoms 5.1%, respiratory 4.5%. The reasons for encounter and the procedures conducted during the visit have direct influence to the quality of care for persons with diabetes. It is necessery collecting the data and research in the field of reasons for encounter and procedures during the visit of person with diabetes. The results then can be compared to the results already found in literature.

Frequent attenders in family practice in Croatia: retrospective study.

AIM: To determine the number of "frequent attenders" in family practice offices in Croatia according to the number and proportion of frequent attender visits in the total number of visits, and to follow up the frequent attenders and the number of visits they made over a period of three years. METHODS: The retrospective study involved 8 family practice offices in Northern Croatia. The number of visits to family practice was determined for 4,312 patients aged over 18 years. There were 1,826 men (42.3%) and 2,486 (57.7%) women. The follow up period lasted from January 1, 1997 to December 31, 1999. The borderline value that divided the frequent from non-frequent attenders was the value at the third quartile of the number of visits in a single age-sex group of patients. RESULTS: We recorded a total of 58,088 visits of patients older than 18 years to 8 family practice offices in the three-year period. In 1997, out of 4,312 patients who made a total of 17,938 visits, 944 (22%) frequent attenders made 11,257 (63%) visits. In 1998, there were a total of 20,350 visits made, with 966 (22%) frequent attenders making 12,145 (60%) visits. In 1999, a total of 20,725 visits were made, with 988 (23%) frequent attenders making 12,259 (59%) visits. The differences in the distribution of frequent vs non-frequent attenders according to age and sex were not statistically significant in any of the three study years (chi-square, p=0.727). Older men and older women were not more often frequent attenders than younger men and younger women, respectively. Out of 4,312 patients, 1,714 (40%) were frequent attenders in one of the three study years. Of these, 884 (21%) were frequent attenders in one year, 476 (11%) in two years, and 354 (8%) in all three subsequent study years. Out of 4,312 patients, 1,762 (41%) patients in 1997, 1,139 (26%) in 1998, and 1,116 (26%) patients in 1999 did not make a single visit to a family physician. CONCLUSION: Frequent attender visits make a great proportion of the total number of visits to family practice offices in Croatia, a country with a health care system in transition. Eight percent of patients remained being frequent attenders during all three study years.