Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study.

BACKGROUND: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.

The importance of introducing artificial intelligence to the medical curriculum - assessing practitioners' perspectives.

AIM: To assess the attitude about the importance of introducing education on artificial intelligence (AI) in medical schools' curricula among physicians whose everyday job is significantly impacted by AI. METHODS: An anonymous questionnaire was distributed at the national level in Croatia among radiologists and radiology residents practicing in primary, secondary, and tertiary health care institutions, both in the private and the public sectors. The overall response rate was 45% (144 of 321). RESULTS: A large majority of participants - 89.6% (95% Agresti-Coull confidence interval 0.83-0.94) agreed on the need for education on AI to be included in medical curricula. Answers revealed a very high support across age groups and regardless of subspecialty area. A slightly higher support was present among physicians working in university hospitals compared with those in primary care centers, and among radiology residents compared with radiologists - but these estimated differences are uncertain, and the support levels were clearly high across the considered variables. CONCLUSION: Since medical students have previously been shown to support introducing education on AI, a growing literature argues the same for reasons here reviewed, and physicians practicing a highly relevant area (radiology) overwhelmingly agree, we conclude that medical schools should indeed take steps to keep pace with technological progress in medicine by including education on AI in their curricula, be it as part of existing or new courses.

How to face the aging world - lessons from dementia research.

A continuous rise in life expectancy has led to an increase in the number of senior citizens, now amounting to a fifth of the global population, and to a dramatic increase in the prevalence of diseases of the elderly. This review discusses the threat of dementia, a disease that imposes enormous financial burden on health systems and warrants efficient therapeutic solutions. What we learned from numerous failed clinical trials is that we have to immediately take into account two major elements: early detection of dementia, much before the onset of symptoms, and personalized (precision) medicine treatment approach. We also discuss some of the most promising therapeutic directions, including stem cells, exosomes, electromagnetic fields, and ozone.

Croatian dentists' knowledge, experience, and attitudes in regard to child abuse and neglect.

BACKGROUND: Child abuse and neglect (CAN) is a widespread social phenomenon encompassing all forms of maltreatment with serious lifelong consequences. Dentists and dental team members are in the unique position to identify the symptoms of CAN often visible in craniofacial region. AIM: To evaluate Croatian dentists' level of knowledge, experience, and attitude towards CAN issue. DESIGN: Investigation was conducted in five major Croatian cities (Zagreb, Varazdin, Osijek, Rijeka, and Split). A previously used questionnaire regarding knowledge and experience in child protection was adopted to Croatian terminology and distributed to 544 dentists. RESULTS: A total of 510 dentists who returned a questionnaire with valid data 26.27% reported to have had suspicion of CAN during professional career and 5.1% reported their suspicion within the last 6 months, mostly to social services and police. Fear of violence towards the child and uncertainty about observations were the most frequently reported barriers towards referring and only 11.4% knew the procedure. About 80% of respondents want further training in identifying and reporting of physical abuse. CONCLUSIONS: Study showed a lack of knowledge and uncertainty in recognizing and reporting CAN cases in Croatian dentists. They expressed the need for undergraduate and post-graduate continuing education on this issue.

Trends in general practitioners/family doctors workload in Croatia in period 1995-2012.

This research aimed to present public data describing the Croatian family doctors (FDs) workload, presented as the average number of patients on the lists, and annual and daily number of consultations per one FD team during the period 1995-2012. Croatian Health Service Yearbook for consecutive years was used as basis for data collection. Impressive increase number of persons on FD lists and significant increase of rate of persons per FD team were observed. Average number of contact to FD team also showed constant increase, starting at level of 5.9 per year in 1995 and reaching 9.6 per year in 2012. However, average number of direct consultation (including physical examination) to FD showed modest increase from level of 4.1 per year in 1995 till level of 5.8 per year in 2005. The number of referrals per one visit remain stable, but the number of referrals per one direct consultation decreased. The data stress problem of discrepancy of increasing number of persons on FD lists and stagnation trend of number of FD teams in Croatian primary health care. Results suggested problem of increasing workload of FD teams, but further research are needed for deeper amylases of the FDs workload.

Ductal plate malformation in patients with biliary atresia.

UNLABELLED: The presence of ductal plate malformation (DPM+) on liver histology in children with biliary atresia (BA) is a marker of early intrauterine disease onset and an indication of an unfavorable prognosis. We studied the prognostic value of DPM in infants with BA after hepatoportoenterostomy (HPE). We reviewed 28 BA patients who underwent HPE in a single medical center. We examined the time of jaundice onset after delivery (conjugated hyperbilirubinemia): early onset (fetal phenotype with no jaundice-free interval) vs. late onset (perinatal phenotype with jaundice-free interval) and the presence or absence of DPM (DPM+ or DPM-) histopathology. Primary outcome was jaundice clearance at 3 months after HPE and survival with native liver (SNL). Eight children had fetal and 20 had perinatal BA (8 DPM+, 12 DPM-). At 3 months after HPE, no patients with fetal BA had achieved jaundice clearance, while jaundice clearance was achieved in five patients with DPM+ perinatal disease and four patients with DPM- perinatal BA (P = 0.03, comparing all three groups; P = 0.36, comparing DPM+ vs. DPM- perinatal patients). Median SNL was 8.6 months for fetal BA patients, 148.2 months for DPM+ perinatal BA patients, and 93.2 months for DPM- perinatal BA patients (log-rank test, P < 0.001, comparing all three groups; P = 0.59, comparing DPM+ vs. DPM- perinatal patients). After adjusting for BA type, age older than 2 months at HPE was associated with worse SNL [P = 0.03; hazard ratio = 4.0 (95 % CI, 1.1-14.2)]. CONCLUSIONS: Early onset of jaundice, regardless of DPM histology, was the most ominous sign of poor outcome in infants with BA after HPE.

Regional differences in incidence and clinical presentation of type 1 diabetes in children aged under 15 years in Croatia.

AIM: To determine regional differences in the incidence, incidence trends, and clinical presentation of type 1 diabetes in children under the age of 15 years in Croatia in a 9-year period (1995-2003). METHODS: We included the patients who had been diagnosed with the disease and had started the insulin treatment before they were 15 years old. Regional differences between eastern, central, and southern Croatia were observed. The gross incidence was expressed by the number of newly diagnosed type 1 diabetes patients in 100000 children of the same age and sex per year, ie, for the 0-14 age group, and for the 0-4, 5-9, and 10-14 subgroups. RESULTS: The highest incidence was observed in southern Croatia (10.91 per 100000/y) and the lowest in central Croatia (8.64 per 100000/y), and in eastern Croatia the incidence was 8.93 per 100000/y. All three regions showed a growing incidence trend, which was significant only in eastern and southern Croatia. There was 35.9% of patients with diabetic ketoacidosis in eastern Croatia, 41.7% in central Croatia, and 31.28% in southern Croatia. CONCLUSION: Croatian regions show differences in the incidence, incidence trends, and disease presentation of type 1 diabetes. A further follow-up is needed to establish whether the regional differences are a consequence of the population dynamics in the observed period or they will continue to exist, pointing to differences in environmental risk factors.

Dream recall after night awakenings from tonic/phasic REM sleep.

Eleven healthy subjects, 9 females and 2 males aged 21-23, were submitted to all night polygraphic recording and awaken in REM (Rapid Eye Movements) sleep, randomly upon tonic or phasic REM. Immediately upon awakening subjects were asked about possible dreaming according to the standardized questionnaire. Seventy-seven dreams, i.e. 79% of all 97 REM awakenings, were reported and analyzed. There were no significant differences in reported frequency of dreamings after awakening, mood and dream content due to phasic/tonic REM sleep. Dreams from phasic REM were a bit more colorful. Predictor of morning remembering of dreams was meaninglessness, not meaningfulness of dreams, and, in lesser extent, good mood, colorfulness, dreams with words and phasic REM sleep.

Physicians' strike and general mortality: Croatia's experience of 2003.

The aim of the study was to establish whether the physicians' strike, which took place in Croatia in 2003, had an impact on the mortality of the population. Mortality data from the National Bureau of Statistics relating to the strike period (15 January - 14 February 2003) were selected and compared with the previous and subsequent periods of the same duration in 2001, 2002 and 2004. Of the 52,575 deaths in 2003, Croatia recorded 4,682 (8.9%, 95% Confidence interval 8.4-9.4) in the strike period from the 15th of January to the 14th of February 2003 or 1.1 deaths per 1000. No deviations of the 15th of January to the 14th of February period's share of the death total in relation to other observation periods were noted. It is impossible to associate the strike based on the figures shown in this paper with either an increase or decrease in population mortality.

[Osteoporosis prevalence in Croatian males--the results of calcaneus ultrasound]. / Ucestalost osteoporoze u muskaraca u hrvatskoj--rezultati ultrazvucne denzitometrije petne kosti.

The aim of the study was to establish the normative QUS data in a healthy sample of Croatian males and estimate the prevalence of osteoporosis. A total of 1002 male participants, aged 20-99, were recruited in seven study centers (Zagreb, Ivanic-grad, Koprivnica, Sibenik, Pula, Slavonski Brod, Vukovar). In each subject broadband ultrasound attenuation (BUA), speed of sound (SOS) and quantitative ultrasound index (QUI) of the calcaneus were measured using the Sahara ultrasound device. Significant declining with age was found for all three parameters (p < 0.001). The peak SOS (1562.8 +/- 28.5 m/s) and QUI (103.6 +/- 16.5) values were observed in the third decade, whereas the peak BUA value (86.2 +/- 19.2 db/MHz) was observed in the fourth decade of life. Using the World Health Organization diagnostic criteria for DXA the rates of osteoporosis in the males aged 50 and older were 5.8%, 3.4 and 4.2% for QUI, BUA, and SOS respectively. However, when we used the cut-off value of the T < or = -l.8, prevalence of osteoporosis in Croatian males older than 50 years was 16.2%, 11.7% and 17.2%.

General dentists' awareness of how to cope with medical emergencies in paediatric dental patients.

BACKGROUND: General dentists (GDs) should be aware of the symptoms, signs, diagnoses and treatment of medical emergencies in paediatric patients. AIM: To evaluate the knowledge of GDs in coping with medical emergencies, and to identify whether they are confident to diagnose and treat medical emergencies in paediatric patients. DESIGN: The questionnaire was conducted immediately before the beginning of national dental meetings and continuing education seminars in Croatia, attended by the GDs, in order to obtain a representative sample. RESULTS: Of a total of 498 GDs who returned the questionnaire with valid data, 51.2% reported that a medical history was regularly taken. A high proportion (81.3%) of the GDs had never received any basic life support (BLS) training and education for paediatric patients during their undergraduate studies. After graduation, this value rose to 86.1% of GDs. However, more than two-thirds (68.7%) had experienced some emergency situation in their practice. The most frequent emergency was vasovagal syncope (83.6%) and the most rare was cardiac arrest (8.2%). One-fifth (20.5%) of GDs experienced some emergency but could not make a diagnosis. The more BLS training undergone by a GD, the more self-confident s/he felt in an emergency situation. CONCLUSIONS: Most GDs have a lack of knowledge to cope with medical emergencies in paediatric patients, and do not feel confident to diagnose and treat emergency situations in children. It is suggested that adequate training and education should be provided for all GDs to address this shortcoming.

Effects of inbreeding, endogamy, genetic admixture, and outbreeding on human health: a (1001 Dalmatians) study.

AIM: (1001 Dalmatians) research program collects biomedical information from multiple small isolated populations ((metapopulation)) on Adriatic islands, Croatia, and investigates health effects of human population isolation, inbreeding, admixture, and outbreeding. METHODS: We collected random samples of 100 individuals from 9 island settlements and an additional sample of 101 immigrants to the islands, pooled from all study populations. According to their personal genetic histories, the examinees were categorized as inbred, autochthonous, admixed, and outbred. A total of 76 inbred individuals from a total sample of 1001 examinees were matched to 76 autochthonous, 76 admixed, and 76 outbred controls by gender, age (+/-5 years), village of residence, education, and socio-economic status. We investigated the effects of presumed individual genome-wide heterozygosity predicted from personal genetic histories on the following 10 traits: systolic and diastolic blood pressure, body mass index, high and low density lipoproteins and total cholesterol, triglycerides, uric acid, creatinine, and blood glucose. RESULTS: Personal genetic history significantly affected systolic blood pressure (Spearman rho=0.157, P=0.006), while the effect on cholesterol (rho=0.105, P=0.069), and high density lipoprotein cholesterol (rho=0.104, P=0.071) was suggestive. Admixed individuals and immigrants consistently showed values associated with lower health risk. When inbred and autochthonous samples were merged and compared with the admixed and outbred samples to increase the power of the study, the effects on the three traits above and also on body mass index and diastolic blood pressure became statistically significant. The medians for all 10 medically relevant traits in inbred and autochthonous group, with lower values of presumed individual genome-wide heterozygosity, were less favorable in terms of health. CONCLUSION: The combined effects of founder effect, genetic drift, and inbreeding can increase the frequency of detrimental rare variants in human metapopulations, leading to overall worsening of population health, whereas admixture and outbreeding appear to have the opposite effect.

Chronic respiratory symptoms in Croatian Adriatic island metapopulations.

AIM: To investigate the prevalence of chronic respiratory symptoms in 9 metapopulations on Adriatic islands in Croatia, and the relationship between respiratory symptoms and individual genetic background. METHODS: We obtained random sample of 1001 adult inhabitants of 9 Adriatic island villages in Croatia, that also included immigrants to these villages. European Union respiratory health questionnaire and World Health Organization non-communicable diseases questionnaire were used. Personal genetic histories were reconstructed, based on the two-generation ancestral pedigrees. Bivariate and multivariate methods were used in the analysis. RESULTS: Women reported the occurrence of acute dyspnea (P=0.017), cough (P=0.002), and asthma (P=0.002) more often than men. Gender was the strongest predictor for acute and/or chronic cough (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.23-2.33) and asthma (OR, 2.00; 95% CI, 1.00-4.01), whereas smoking was the strongest risk factor for acute and chronic dyspnea (OR, 1.90; 95% CI, 1.21-2.99) and airway narrowing (OR, 1.84; 95% CI, 1.18-2.87). Residence on the northern islands increased the odds of allergy, whereas the highest odds ratio of 3.20 was associated with the interaction of northern residence and immigrant background. Genetic background was a significant predictor only for the occurrence of allergy symptoms. CONCLUSION: Differences in respiratory findings among the island inhabitants were often associated with smoking prevalence. Interaction of residence on northern Adriatic islands and immigrant background proved to be the strongest predictor for the occurrence of allergy symptoms. This study indicated that environmental factors played a very important role in the occurrence of respiratory symptoms.

Expression and possible prognostic role of MAGE-A4, NY-ESO-1, and HER-2 antigens in women with relapsing invasive ductal breast cancer: retrospective immunohistochemical study.

AIM: To evaluate the possible prognostic role of the expression of MAGE-A4 and NY-ESO-1 cancer/testis antigens in women diagnosed with invasive ductal breast cancer and determine the expression of HER-2 antigen. METHODS: The expression of MAGE-A4, NY-ESO-1, and HER-2 antigens was evaluated immunohistochemically on archival paraffin-embedded samples of breast cancer tissue from 81 patients. All patients had T1 to T3, N0 to N1, M0 tumors and underwent postoperative radiotherapy and, if indicated, systemic therapy (chemotherapy and hormonal therapy). The antigen expression in women who were disease-free for 5 years of follow up (n=23) was compared with that in women with either locoregional relapse (n=30) or bone metastases (n=28). Patient survival after 10 years of follow up was assessed. RESULTS: The three groups of women were comparable in terms of age, type of operation, tumor size, tumor grade, number of metastatically involved axillary lymph nodes, Nottingham prognostic index (NPI), progesterone receptor (PR) status, and adjuvant hormonal therapy. Estrogen receptors (ER) were positive in 13 women in the 5-year relapse-free group vs 8 in locoregional relapse and 7 in bone metastases group (P=0.032). There were significantly fewer women who received adjuvant chemotherapy in the 5-year relapse-free group than in other two groups (7 vs 23 with locoregional relapse and 25 with bone metastases; P<0.001). This group also had a significantly better 10-year survival (14 women vs 1 with locoregional relapse and 1 with bone metastases; P<0.001). The three groups did not differ in the NY-ESO-1 or HER-2 expression, but the number of patients expressing MAGE-A4 antigen was significantly lower in the group with locoregional relapse (P=0.014). In all groups, MAGE-A4 antigen expression was associated with the NY-ESO-1 antigen expression (P=0.006), but not with tumor size and grade, number of metastatically involved axillary lymph nodes, or the ER and PR status. MAGE-A4-positive patients had a significantly longer survival than the MAGE-A4-negative patients (P=0.046). This was not observed with NY-ESO-1 and HER-2 antigens. CONCLUSION: Our results suggest that the MAGE-A4 antigen may be used as a tumor marker of potential prognostic relevance.