Combining Complementary and Alternative Medicine (CAM) with Conventional Treatments for Major Depressive Disorder.

For many of the complementary and alternative (CAM) medicine methods, it is biologically plausible to expect that they could provide additional benefits in the treatment of major depressive disorder (e.g., enhanced initial response, augmentation, and tolerability) when combined with conventional treatments. Although most likely not comprehensively, herein we critically review current explicit clinical data pertaining to the most extensively evaluated CAMs in this setting: physical activity/exercise, mind and body methods, acupuncture, light therapy, diet, probiotics, various nutrients, and herbal preparations. While the absolute amount of data is enormous, the number of reliable primary studies (randomized controlled trials) and, particularly, meaningful meta-analyses of such studies are very limited. Consequently, the certainty of evidence about benefit or no benefit is very low for each of the addressed CAMs.

Biomarker changes in suspected idiopathic normal-pressure hydrocephalus patients undergoing external lumbar drainage: a pilot study.

AIM: To examine whether changes in biomarker concentrations in patients with idiopathic normal-pressure hydrocephalus (iNPH) during 72 h of external lumbar drainage (ELD) can differentiate between responders and non-responders. METHODS: Twenty patients with clinical and neuroradiological signs of iNPH underwent ELD over a period of 72 h. During this period, changes in cerebrospinal fluid (CSF) concentrations of biomarkers (amyloid-ß, total and phosphorylated tau proteins) and intracranial pressure were monitored, and the volume of drained CSF was measured. Changes in the concentrations of selected biomarkers at three time points (0, 36, and 72 h) during ELD were tested for association with changes in clinical condition. RESULTS: Ten patients showed significant clinical improvement after ELD, quantified as a difference of two or more points on the Mini-Mental State Examination and/or Japanese iNPH grading scale. The concentration of all tested biomarkers increased during the first 36 h. Respondents had higher Aß 1-42 at all time points, with a significant difference seen after 72 h. They also had a significantly higher Aß1-42/Aß1-40 ratio at all time points. CONCLUSION: A gradual increase in Aß 1-42 concentration during three-day ELD represents a possible positive prognostic factor for the placement of permanent CSF drainage in patients with iNPH.

Benefit and harm of lymphadenectomy in intermediate risk prostate cancer: comparison of five nomograms.

BACKGROUND: Pelvic lymph node dissection (PLND) is recommended method for detecting prostate cancer (PCa) nodal metastases although associated with serious complications. In this study, we aimed to assess benefit/harm of routine PLND in intermediate risk PCa patients and to compare diagnostic yield of five different nomograms in predicting lymph node invasion (LNI). METHODS: Retrospective analysis of consecutive PCa patients with intermediate risk of biochemical recurrence who underwent open radical prostatectomy (RP) with bilateral PLND between January 2017 and December 2019 at our institution. Partin, 2012-Briganti, 2018-Briganti, Cagiannos and Memorial Sloan Kettering Cancer Center (MSKCC) values were calculated. To compare accuracy, sensitivity, specificity, and area under receiver-operating curve (AUC) were calculated and then optimal cutoff values were estimated, analyses repeated and compared. To assess benefit and harm of PLND, relative risk (RR) and number need to treat (NNT) with LNI and complications set as outcome were calculated. RESULTS: Total 309 subjects. Average age 62.2 years, average PSA 7.2 ng/mL; 18 (5.8%) had LNI; 88 (28.5%) suffered Clavien-Dindo grade 3-5 complication. AUC for predicting LNI: 0.729 for 2012-Briganti, 0.660 for MSKCC, 0.521 for 2018-Briganti, 0.486 for Cagiannos, and 0.424 for Partin. None of pairwise AUC comparisons based on default and newly established cutoff values were statistically significant. Lowest NNT was for Partin and Cagiannos with default cutoff (≥ 5%). Risks of serious complications between higher/lower than cutoff values were non-significant across nomograms. CONCLUSIONS: 2012-Briganti nomogram outperforms, although not significantly, MSKCC, 2018-Briganti, Cagiannos, and Partin nomograms in classifying LNI in intermediate risk PCa patients. Routine PLND in these patients should be avoided, due to high rate and severity of complications.

Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. METHODS: This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. RESULTS: Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). CONCLUSION: Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.

Mortality and morbidity in surgically treated patients with petroclival meningiomas: a systematic review and meta-analysis of case series.

BACKGROUND: Reports on petroclival meningioma (PCM) surgical mortality and morbidity often deviate from established standards; as such, a comprehensive summary is lacking. METHODS: Eligibility/sources. Peer-reviewed case series of at least 10 PCM patients identified from PubMed, Web of Science, Ovid, or Google Scholar. Outcomes. Primary: mortality, tumor recurrence, any cranial nerve deficit (CND); other: individual CNDs, other complications. Data synthesis. Random-effects meta-analysis/meta-regression [effects: surgical approach (supratentorial, S; infratentorial, I; combined, (C), average age and follow-up, sample size, and percent of patients with gross-total resection (GTR)] of logit-transformed proportions. RESULTS: Data. 73 case-series/3553 patients. Mortality. Adjusted predicted mortalities of 2.4%, 2.5%, and 1.2% (50-month follow-up) for the S, I, and C approaches, respectively, with the upper limits of the 95% credibility intervals at 3.3%, 3.7%, and 3.6%, respectively. Recurrence. Adjusted predicted recurrences of 5.5%, 11.1%, and 12.0% (50-month follow-up and 57% GTR) for the S, I, and C approaches, respectively; recurrence was positively associated with follow-up period and negatively associated with having received GTR. At all covariates at median values but at GTR 90% predictions: 3.1% (95%CI 3.1-9.8), 6.3% (3.8-10.4), and 6.9% (3.4-13.2) with the S, I, and C; prediction credibility intervals 1-4% and 22.4%. Any CND. Adjusted predicted probabilities of 37.2%, 23.4%, and 29.5% (at median covariate values) for the S, I, and C approaches, respectively; prediction credibility intervals ranged from <10% to 78%. Other outcomes. The most common individual CNDs were nVII (14.4%), nV (11.5%), and nIII (10.2%); other common complications included motor deficit (10.8%), infection (9.8%), and CSF leak (7.5%). CONCLUSION: This is the first systematic review on PCM surgical mortality, recurrence, and morbidity. Outcomes differ between surgical approaches and reporting quality varies greatly.

Current Research on Complementary and Alternative Medicine (CAM) in the Treatment of Major Depressive Disorder: An Evidence-Based Review.

Complementary and alternative medicine (CAM) encompasses a wide range of different non-mainstream therapies that have been increasingly used for treatment or adjunctive treatment of various ailments with mood disorders and "depressive difficulties" being two of the commonly CAM (self-)medicated conditions. We focus specifically on clinically diagnosed (in line with the standard criteria) depressive disorders, primarily major depressive disorder (MDD), and overview evidence of efficacy/safety of a range of CAM modalities addressing exclusively randomized controlled trials (RCTs) and systematic reviews/meta-analyses of RCTs. The list of addressed CAM interventions is not exhaustive: due to space limitation, addressed are interventions with at least a few conducted RCTs in the specific clinical conditions. We try to provide numerical and meaningful data as much as it is possible and to (a) indicate situations in which the reported data/estimates might have been "too enthusiastic" and (b) warn about heterogeneity of results that, together with other possible limitations (various biases and imprecision), results in uncertainty about the effects.

Spinal dural arteriovenous fistulas: a report on outcomes in a single-center retrospective cohort treated surgically and/or endovascularly.

AIM: To report on the outcomes of spinal dural arteriovenous fistulas (sDAVFs) treatment in a single-center retrospective cohort. METHODS: Data were retrieved on sDAVF cases treated surgically and endovascularly between January 2009 and January 2020. Sociodemographic, clinical, imaging data, and outcomes were analyzed. RESULTS: Thirty-four patients were identified: 11 female, mean age 64.1 ± 11.5 years; mean time of symptom duration 12 (range 1-149) months. The sDAVF locations were the following: 18 (62.1%) thoracic, 4 (13.8%) lumbar, 4 (13.8%) sacral, and 3 (10%) with multiple location feeders. All patients had a motor deficit and affected walking, and the majority had a sensory deficit, bowel, and bladder dysfunction. Fifteen (44.1%) patients underwent surgical treatment, 7 (20.6%) underwent endovascular treatment, and 12 (35.3%) underwent both (crossover). Radiological myelopathy showed regression in 19 (55.9%) patients. Overall, clinical improvement (decrease in modified Rankin score) following treatment was observed in 14 patients (41.2%), worsening in 1 (2.9%), while other had unchanged status. The proportion of patients with initial treatment failure markedly differed between the before-2014 and after-2014 period. Patients who failed to improve had more extensive myelopathy. CONCLUSION: Patients who underwent surgery or endovascular treatment had on average significant clinical recovery, while those who underwent treatment crossover had negligible improvement. The extent of myelopathy seems to be associated with clinical improvement.

Biomechanical stability analysis of transpedicular screws combined with sublaminar hook-rod system using the finite element method.

AIM: To develop and test a new posterior stabilization system by augmenting the posterior hook-rod system with screws and rods. METHODS: A biomechanical analysis was performed using the finite element method. The anatomical structures were modeled based on computed tomography data. Instrumentation (hooks, rods, and screws) was modeled based on the data obtained by 3D scanning. The discretized model was verified by converging solutions and validated against data from a previously published experiment. A Th12-L1 spinal segment was modeled and modified by removing the body of the L1 vertebra (corpectomy) and the entire L1 vertebra (spondylectomy). The model was additionally modified by incorporating stabilization systems: i) posterior stabilization (transpedicular screws and rods); ii) combined posterior stabilization with sublaminar hooks; and iii) combined anterior (titanium cage) and posterior (sublaminar hooks) stabilization. The rotation angles in each group, and the strains on each part of the three stabilization constructs, were analyzed separately. RESULTS: The combined anterior and posterior stabilization system was the stiffest, except in the case of lateral bending, where combined posterior stabilization was superior. Stress analysis showed that the posterior stabilization system was significantly unloaded when augmented with a hook-rod system. A significant strain concentration was calculated in the cranially placed hooks. CONCLUSION: Stiffness analysis showed comparable stiffness between the tested and proposed stabilization construct. Stress analysis showed luxation tendency of the cranially placed hooks, which would most likely lead to system failure.

Current Research on Complementary and Alternative Medicine (CAM) in the Treatment of Anxiety Disorders: An Evidence-Based Review.

Complementary and alternative medicine (CAM) encompasses a wide range of different nonmainstream therapies that have been increasingly used for treatment or adjunctive treatment of various ailments with anxiety/anxiety disorders being one of the commonly CAM (self)-medicated conditions. Thousands of published papers refer to use of CAM in various psychiatric disorders or in healthy or medically ill patients with mood or anxiety difficulties. In this chapter we focus specifically on clinically diagnosed (in line with the standard criteria) anxiety disorders and overview evidence of efficacy/safety of a range of CAM modalities: biologically based therapies (typically herbal preparations and less so nutraceuticals); manipulative and body-based therapies (acupuncture, aerobic exercise, massage, therapeutic touch, repetitive transcranial magnetic stimulation, balneotherapy, and others); mind-body therapies (yoga, Morita therapy, Tai Chi, reiki, Chinese cognitive therapy, religious and spiritual interventions, relaxation, mediation, and mindfulness-based interventions); and alternative medical systems (Ayurveda, homeopathy). We focus exclusively on randomized controlled trials and attempt to evaluate the existing body of evidence in the same manner that is applied to mainstream treatments.

Attitudes Towards Older People in Croatian and Slovenian Nursing Students.

BACKGROUND: Croatia and Slovenia are neighboring countries with marked differences in high school and undergraduate nursing curricula. The aim was to assess and compare attitudes toward the elderly among undergraduate nursing students in Croatia and Slovenia and identify factors associated with positive/negative attitudes. SUBJECTS AND METHODS: This was a cross-sectional survey conducted between September, 2017 and July, 2018 among undergraduate nursing students at five higher education institutions: three in Slovenia and two in Croatia. The following data were gathered: age, sex, year of study, previous education, employment status, previous education in gerontolgy, desired professional role after graduating, previous experience with the elderly. Kogan`s Attitude Towards Old People Scale (KATOPS) score was the primary outcome measure. Pairwise comparisons were conducted between Croatian and Slovenian students. KATOPS score was dichotomized with values above the 3rd quartile considered excellent - the dichotomized score was used as the dependent variable in a binary logistic regression model. RESULTS: Overall, 825 students completed the questionnaire, 85.5% were women, 417 from Slovenia, 408 from Croatia, and 80% were under 22 years of age (80%). The average score on the KATOPS was 127.4, 95% CI 126.6-128.2. Variables associated with excellent scores on the KATOPS, based on the binary regression were: studying in Slovenia (OR=2.05, 95% CI 1.39-3.03), age group 28-32 years (OR=3.9, 95% CI 1.53-9.98); previous education gerontic nursing (OR=2.45, 95% CI 1.34-4.47), and full-time study (OR=2.12, 95% CI 1.38-3.55). Variables not associated with excellent scores were: being married (OR=0.44, 95% CI 0.22-0.92) and having previous experience in working with the elderly (OR=0.5, 95% CI 0.3-0.86). CONCLUSION: Attitudes toward old age are mildly positive in Slovenian and Croatian nursing students. Slovenian students have significantly more positive attitudes toward old age and these differences are most probably due to marked differences in undergraduate nursing curricula between the two countries.

Polymethylmethacrylate cranioplasty using low-cost customised 3D printed moulds for cranial defects - a single Centre experience: technical note.

We report our experience with 3D customised cranioplasties for large cranial defects. They were made by casting bone cement in custom made moulds at the time of surgery. Between October 2015 and January 2018, 29 patients underwent the procedure; 25 underwent elective cranioplasties for large cranial defects and four were bone tumour resection and reconstruction cases. The majority of patients (96.5%) reported a satisfactory aesthetic outcome. No infections related to the surgical procedure were observed in the follow-up period. The method proved to be effective and affordable.

Malignant brain neoplasms incidence and mortality trends in Croatia from 2001 to 2014.

AIM: To analyze the sex-specific incidence and mortality trends of brain malignancies in Croatia from 2001 to 2014. METHODS: Incidence and mortality rates per 100000 population were calculated using data obtained from the Croatian National Cancer Registry and the Croatian Bureau of Statistics. Rates were age-standardized to the European Standard Population, and trends were assessed using joinpoint regression. RESULTS: In the observed period there were 6634 new brain malignancy cases (52% men) and 5379 deaths due to this diagnosis (52% men). Age-standardized incidence rates ranged from 9.2-11.5 per 100000 in men and from 7-8.8 per 100000 in women. Mortality rates ranged from 7.5-8.7 per 100 000 in men and from 5-6.5 in women. Incidence trends in men, mortality in men, and mortality in women were not statistically significant, while a significant trend was observed in incidence in women (annual percent change -1.5; 95% confidence interval -2.3 to -0.6). No joinpoints were observed in any of the joinpoint analyses by sex for incidence and mortality. Age-specific incidence and mortality rates in both sexes indicate a trend shift toward older age. The proportion of morphologically verified cases ranged from 40.2%-62.4% in men and from 38.6%-56.3% in women; the proportion of death-certificate-only cases ranged from 3.3%-9.4% in men and from 3.3%-17.5% in women. CONCLUSION: Incidence and mortality of brain malignancies in Croatia are among the highest in Europe, while reporting on brain malignancies is still poor. There is a need for improved care of patients with brain malignancies and detailed and accurate data reporting.

Validation of the Croatian version of the Oswestry Disability Index.

PURPOSE: To translate, cross-culturally adapt, and validate the Croatian version of the Oswestry Disability Index (ODI). METHODS: The original English-language ODI was cross-culturally adapted into Croatian and then evaluated in a group of 114 patients with chronic low back pain (LBP) at the Department of Neurosurgery, Zagreb University School of Medicine. Confirmatory factor analysis (CFA) was conducted with three models: two were theory driven (unidimensional and two dimensional-static and dynamic factors); the other was based on our exploratory factor analysis (EFA). Internal consistency and test-retest reliability were evaluated using Cronbach's α and the intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by evaluating the correlation between the ODI and Visual Analogue Scale (VAS), and between the ODI and 36-item short form survey (SF-36) scores. RESULTS: The EFA-derived two-dimensional structure explained 82.7% of the total variance and was significantly better than the other models (P < 0.001); however, none of the models had acceptable fit. Internal consistency (Cronbach α = 0.84) and test-retest reliability (ICC = 0.94) were satisfactory. The ODI was positively correlated with VAS (rs = 0.54, P < 0.001) and negatively correlated with all of the SF-36 sections (rs = - 0.35 to - 0.64, P < 0.001, all), apart from the role-physical (rs = - 0.02, P = 0.767). CONCLUSIONS: The Croatian version of the ODI has acceptable psychometric properties. It appears to be suitable for assessment of LBP and treatment outcomes in Croatian-speaking patients. Overall, there was no evidence to reject the original unidimensional structure in favor of a two-factor solution. As such, the unidimensional structure should continue to be used in future studies. These slides can be retrieved under Electronic Supplementary Material.

Use of Urinary Collection Devices in Community and Nursing Homes in Istria County.

INTRODUCTION: This study is aimed at assessing the use of various types of urinary catheters, appropriateness of catheter placement and factors associated with antibiotic use in a population of chronically catheterized patients in Istria County. MATERIALS AND METHODS: This cross-sectional study, conducted between March and June 2017 in Istria County, Croatia, was initiated through a network of general family medicine offices. Data were collected from general practitioners (GPs) and from medical managers in nursing homes. Participants were asked to review medical records of their patients and to complete a 10-item questionnaire designed to retrieve information on patients with urinary catheter. RESULTS: All GPs in the county were surveyed. We identified 309 patients with urinary catheter: 216 men (70%) and 93 women (30%). The overall prevalence of individuals with urinary catheters was 0.18%: 4.7% in nursing home population and 0.1% among non-institutionalized adult population. Most common indication for catheterization was chronic urinary retention (52%). One hundred eighty-six patients (60.4%) reported antibiotic usage in the previous 3 months for treating urinary infection. CONCLUSIONS: In Istria County, the prevalence of indwelling urinary catheters is highest in males, especially among patients in nursing homes. There is a need for focused education among GPs regarding urinary catheter maintenance and antibiotic prescription for suspected urinary tract infections.

Intracranial Epidural Haematoma following Surgical Removal of a Giant Lumbosacral Schwannoma: A Case Report and Literature Review.

Postoperative intracranial epidural haematoma (EDH) is an extremely rare complication following spinal surgery, with only a handful of cases described in the literature. We report the case of a 16-year-old girl who underwent a successful subtotal resection of a giant lumbosacral schwannoma (L2-S2 level). Recovery from general anaesthesia was uneventful; however, her neurological status deteriorated rapidly within 24 h after surgery. A head computed tomography scan revealed a large right frontoparietal EDH with midline shift. An immediate frontotemporoparietal osteoplastic craniotomy and evacuation of the EDH were performed. At 1 year postoperatively, the patient regained full neurological recovery with no radiological signs of growth of the residual tumour.

Declining health anxiety throughout medical studies: it is mainly about a more relaxed perception of the health-related concerns.

BACKGROUND: Reports on effects of advancing medical education on health anxiety are scarce and contradictory. AIM: To evaluate a hypothesis that its components could be differently affected. METHOD: A cross-sectional study assessed the Health Anxiety Questionnaire (HAQ), Anxious Thoughts Inventory, and Somatosensory Amplification Scale scores in medical (n = 214) and law (controls, n = 821) students at different study years. RESULTS: In the controls, all outcomes minimally differed across the study-year levels. Medical scores were similar to control scores at the lower and intermediate level and were significantly lower at higher study years. However, health worry, fear, and reassurance seeking only differed mildly between the medical study levels (adjusted effect sizes ≤ 0.23), whereas tendency toward amplification, meta-worry, social worry, and the HAQ interference with life score were significantly lower at higher than at the lower years (adjusted effect sizes 0.31-0.47). In the medical students, the HAQ interference with life score was affected mainly by the level of meta-worry, whereas in controls the major impact was that of health-related concerns. CONCLUSIONS: Studying medicine does not seem to relevantly affect the level of health-related concerns, but the degree by which they are perceived as disruptive declines as a specific function of advancing stages of education. This is closely related to progressively declining tendency toward amplification and levels of meta-worry.

Endoscopic Endonasal Surgery for a Pterygopalatine Fossa Hydatid Cyst.

Background: Cystic echinococcosis is a manifestation of a zoonosis caused by larvae of the tapeworm Echinococcus granulosus sensu lato and pterygopalatine fossa cases are extremely rare. Clinical Presentation and Findings: A 45-year-old Caucasian female with a history of repeated surgeries for HC was referred to our center for treatment of a cystic mass of the pterygopalatine fossa. Multiorgan dissemination was noted on preoperative imaging. Interventions: An endonasal endoscopic procedure was carried over under general anesthesia and the CE completely removed. Etiology was confirmed by molecular diagnostics. Three weeks after the skull base procedure, the patient underwent a combined abdominal/urological procedure for treatment of other cysts. Conclusion: This case shows that the pterygopalatine fossa HC are amenable to surgical treatment using the endonasal endoscopic approach. Extensive preoperative workup is essential to assess the extent of the disease.