How to improve opportunistic screening by using EMRs and other data. The prevalence of undetected diabetes mellitus in target population in Croatia.

OBJECTIVES: Opportunistic screening for type 2 diabetes (T2D) has not been adopted as part of routine practice. The aim of the study was to investigate the yield of opportunistic target screening for T2D in Croatia and to evaluate the process of screening by using data from electronic medical record. STUDY DESIGN: We conducted opportunistic screening in 23 general practitioners (GPs) in a population of 13,344 patients aged 45-70 years. METHODS: First, after excluding patients with T2D, patients with risk factors for T2D were derived from the electronic medical record and GP's assessment during the preconsultation phase. Second, those with data about normoglycemia in past three years were excluded. Remaining patients started the consultation phase during their usual visit, when they were offered capillary fasting plasma glucose testing in the next consultation. RESULTS: Prevalence of T2D was 10.9% (new 1.4%). A total of 5568 (46.1%) patients had risks and 2849 (51.2%) had data about normoglycemia in the last three years. Using those data, number needed to invite to screening (NNI) was reduced to half: from 46.1% to 22.5%. One hundred eighty-four patients were screened positive for T2D in two capillary fasting plasma glucose tests (yield 9.8%). Number needed to screen (NNS) in order to detect one T2D was 10.3 patients. Among risks for T2D, overweight was the best predictive factor for undiagnosed T2D (odds ratio [OR]: 2.11, confidence interval [CI]:1.41-3.15, P < .001). Logistic regression showed that in targeted population, overweight patients with a family history in fold were 2.5 times more likely to have T2D (OR: 2.54, CI 1.78-.61, P < .001). CONCLUSIONS: Total yield in targeted population was 1,4%. By using data about normoglycemia from EMRs, NNI was reduced by half and NNS was 10.3 patients. Our findings suggest the model for improvement in opportunistic screening.

The use of visual evoked potentials to follow-up prisoners of war after release from detention camps.

Visual evoked potentials were examined in released prisoners of war (POWs) in order to evaluate the extent of neurological impairment after imprisonment in Serbian detention camps. On two occasions visual evoked potentials were determined in a group of 11 released prisoners of war (POWs): 157 days and 379 days after release from detention camp. During the first examination no significant differences were found in VEP parameters between the right and left eye. However, during the second examination significant differences were found in the latencies of waves P100 and N145, statistically significantly prolonged latencies of the P100 wave and significantly greater amplitudes of waves P50 and N75. The results can be regarded as progression of the VEP changes in the released POWs. It is hypothesized that these changes are a result of a demyelination process, caused by the altered immunological status of the POWs during posttraumatic stress syndrome.

Some etiologic factors of speech comprehension disturbances.

Disturbances of speech comprehension were analyzed in a prospective study of 97 children, aged from 23 to 77 months. Pregnancy, birth and early psychomotor development were normal for all the children and no focus of neurological deficit was found. A tonal audiometer did not detect any auditory disturbances, and psychological testing with non-verbal tests showed normal mental functioning for the age. In this group of selected subjects, family and personal case histories were taken. In addition, a detailed neurological physical examination, standard EEG and auditory evoked potentials, and a psychiatric examination were performed during several appointments. The results showed that disturbances in speech comprehension were more frequent in boys, and that in 13.4% of cases it was caused by pervasive developmental disturbances and in 41.24% of cases by external stimulating factors of speech development (pedagogy, social and emotional stimulation and growing up in a multilingual community). The study emphasizes the importance of non-verbal methods for the study of speech and the use of auditory evoked potentials.

Importance of early drug treatment in prognosis of the Landau-Kleffner syndrome.

An expert team conducted a ten-year survey of eight children with Landau-Kleffner syndrome (LKS) identified among children referred to Polyclinic "SUVAG" in Zagreb because of hearing disturbances. Although LKS is a rare disorder it is extremely important to detect it because early diagnosis and prompt medicinal treatment may improve the prognosis, whereas neglect and late diagnosis result in language disability. Standard diagnostic criteria must be established to enable timely treatment.

Visual evoked potentials in two groups of prisoners of war after release from Serbian detention camps.

Visual evoked potentials (VEP) were determined in two groups of released prisoners of war (POWs) from Serbian detention camps during the war in Croatia 1991/92. The first group comprised 22 POWs (group I), examined 10 to 60 days after release, and the second group comprised 24 POWs (group II), examined 6 to 9 months after release. The third group comprised 36 control subjects. Statistically significant increases in the amplitude of waves P50, N75, P100, N145, and significant prolongation of the latencies of wave N145 were found in group I. In group II, significant increases were found in the latencies of waves P50, N75, P100 and N145, and increased amplitude of wave P50. The greater significance of wave latencies compared to amplitudes, and greater significance of changes in early VEP waves than later VEP waves, can be considered evidence of future progression of these changes in the released POWs. This was confirmed by the significant increases in VEP parameters in groups I and II, which exceed +/- 2SD of the relevant control group, and significantly greater number of the same parameters in group II in relation to group I. There was no significance (i.e. asymmetry) among the three groups when the parameters of the determined visual evoked potentials were compared for the left and right eye.

Brain stem evoked potentials and visual evoked potentials in relation to the length of occupational exposure to low levels of toluene.

In 49 printing-press workers occupationally exposed to toluene for approximately 21.6 years, the values of BEAP and VEP parameters were examined in relation to the length of exposure. With the exception of P2 wave, there was a significant increase in the latencies of all the BEAP waves examined as well as in the interpeak latency (IPL) P3-P4, whereas IPL P4-P5 decreased significantly with the length of exposure. The amplitude of all the VEP examined decreased significantly with the length of exposure. Toluene exposure was evaluated by measuring the concentration of toluene in peripheral blood and of hippuric acid in urine on Wednesday morning prior to the workshift, and of hippuric acid in urine after the workshift on the same day. According to the average concentration of hippuric acid in urine after the workshift, the levels of toluene exposure were estimated to range from 40-60 ppm. Evoked potentials were determined on Mondays 10-12 hours after a nonworking weekend.

Cognitive evoked potentials VEP P300 persons occupationally exposed to low concentrations of toluene.

Cognitive evoked potentials VEP P300 were examined in 49 workers at printing press occupationally exposed to low concentrations of toluene for averagely 20 years, and in 59 control subjects. The exposure level of toluene was evaluated in randomly selected subgroups comprising 36 exposed and 27 control subjects. The concentrations of toluene were measured in peripheral blood on Wednesday morning before entering the work area, while the hippuric acid in urine was measured before and after entering the work area. The results show that the absolute number of exposed subjects displaying lower amplitude of cognitive wave VEP P300R and prolonged latency of the accompanying spontaneous wave VEP P300F was significantly greater than that of the controls.

Brainstem evoked potentials in three groups of prisoners after release from detention camp.

Brainstem evoked potentials (BAEPs) were determined in three groups of male prisoners of war (POWs) released from detention camps and a control group. The first group comprised 21 POWs in whom BAEPs were determined 10-60 days after release (group I). The second group comprised 24 POWs in whom BAEPs were determined 6-9 months after release (group II), and the third group comprised 22 POWs in whom BAEPs were determined 12-18 months after release (group III). The control group comprised 32 subjects. The following changes were found in relation to the control group: in group I significantly longer interpeak latencies (IPLs) P1-P3; in group II significantly longer IPLs P1-P3 and P3-P5; and in group III significantly longer IPLs P1-P3. The subjective symptomatology of the POWs and the results of a routine examination indicate subclinical functional changes of the central nervous system, reflecting the dynamics of these changes. It is suggested that the basis of these changes may be a demyelinization intrathecal process, which occurred as a result of immunological changes during prolonged and intensive post-traumatic stress syndrome.

Visual evoked potentials in relation to factors of imprisonment in detention camps.

Visual evoked potentials (VEPs) of the pattern shift reversal type were determined in a representative group of 57 prisoners of war (POWs) released in 1992 from detention camps in former Yugoslavia. The parameters were correlated with the conditions in four camps (1-4). All subjects were male, with a mean age of 34.75 years (SD +/- 8.92), average length of imprisonment 192.7 days (SD +/- 77.6), mean loss of body mass during imprisonment 19.32% (SD +/- 9.54), and the average number of reported blows to the head and neck was 25.7 (SD +/- 20.3). VEPs were determined on average 290.5 days after the last craniocerebral trauma caused by blows to the head and neck (SD +/- 152.0) i.e., on average 218.5 days after release from the camp (SD +/- 164.3). Although all the 57 POWs reported being maltreated to a certain extent, 14 reported being subjected to particularly brutal forms of torture, 5 had been held in solitary confinement and 25 had lost consciousness at least once. Solitary confinement and loss of consciousness had the most significant effect on VEPs, and the altered VEP parameters correlated significantly with the craniocerebral trauma experienced, loss of body mass and the length of time since the last craniocerebral trauma until examination, and from release until examination. However, the length of imprisonment and treatment in the camps did not have a significant effect on VEP parameters. The study confirmed that under such conditions the age of the subject is a risk factor. The results of this study also confirmed that prisoners in one camp had been subjected to the worst maltreatment.

Brainstem auditory evoked potentials in individuals exposed to long-term low concentrations of toluene.

Brainstem auditory evoked potentials (BAEPs) were examined in 49 workers employed in a printing press, who were occupationally exposed to low concentrations of toluene for an average of 20.3 years, and in 59 subjects in a control group. In the group of exposed workers, a significant decrease was found in all wave amplitudes examined, a significant prolongation of P1 wave latency, and an increased interval of interpeak latencies (P3-P5), indicating that the extramedullary and high medullary part of the auditory pathway are biologically most frequently affected by chronic exposure to low concentrations of toluene. The level of exposure to toluene in both groups was evaluated by defining the concentration of toluene in peripheral blood and the concentration of hippuric acid and ortho-cresol in urine.

Visual evoked potentials in individuals exposed to long-term low concentrations of toluene.

An investigation of visual evoked potentials was carried out in two groups of subjects; 49 workers employed in a printing-prss where toluene has been used exclusively as an organic solvent for the last 30 years, and 59 workers not occupationally exposed to any known neurotoxic substances. The average length of work service in the printing-press was 21.4 years. The level of exposure was assessed by determination of the concentration of toluene in peripheral blood, the concentration of hippuric acid and ortho-cresol in urine in subgroups of subjects chosen at random from both groups. N75, P100 and N145 waves of the pattern reversal visual evoked potentials were analyzed. In the group of exposed subjects, significantly greater amplitudes were found in all waves, with significantly longer latency of the P100 wave.