An outbreak of haemorrhagic fever with renal syndrome linked with mountain recreational activities in Zagreb, Croatia, 2017.

In 2017 Zagreb faced the largest outbreak of haemorrhagic fever with renal syndrome (HFRS) to date. We investigated to describe the extent of the outbreak and identify risk factors for infection. We compared laboratory-confirmed cases of Hantavirus infection in Zagreb residents with the onset of illness after 1 January 2017, with individually matched controls from the same household or neighbourhood. We calculated adjusted matched odds ratios (amOR) using conditional logistic regression. During 2017, 104 cases were reported: 11-81 years old (median 37) and 71% (73) male. Compared with 104 controls, cases were more likely to report visiting Mount Medvednica (amOR 60, 95% CI 6-597), visiting a forest (amOR 46, 95% CI 4.7-450) and observing rodents (amOR 20, 95% CI 2.6-159). Seventy per cent of cases (73/104) had visited Mount Medvednica prior to infection. Among participants who had visited Mount Medvednica, cases were more likely to have drunk water from a spring (amOR 22, 95% CI 1.9-265), observed rodents (amOR 17, 95% CI 2-144), picked flowers (amOR 15, 95% CI 1.2-182) or cycled (amOR 14, 95% CI 1.6-135). Our study indicated that recreational activity around Mount Medvednica was associated with HFRS. We recommend enhanced surveillance of the recreational areas during an outbreak.

Operative treatment of intraarticular calcaneal fractures: Anatomical and functional outcome of three different operative techniques.

INTRODUCTION: Management of the intraarticular calcaneal fracture is a challenge. The optimal method of treatment remains controversial. This study evaluates the anatomical and functional postoperative outcomes of displaced intraarticular calcaneal fractures that have been treated using three different techniques of ORIF. PATIENTS AND METHODS: Between 2004 and 2011 we treated 143 patients with calcaneal fractures, 40 of these patients (28%) were treated conservatively. This is a retrospective study of the remaining 103 patients (72%) who were operated on consecutively, mainly by one surgeon (NG). Calcaneal fractures were classified according to the Sanders classification. Three types of osteosynthesis were used: standard anatomical plate (SP), locking anatomical plate (LCP) and standard anatomical plate with autologous bone graft (SP+ABG). Clinical outcome was assessed one year after the operation: anatomical reduction was evaluated according to the analysis of Bohler's angle at final follow-up, and functional assessment was conducted using the Maryland Foot Score (MFS). RESULTS: The fractures were classified as follows: 35 (34%) Sanders type II, 47 (45.6%) Sanders type III and 21 (20.4%) Sanders type IV. The SP was used in 67 (65%) fractures, LCP in 16 (15.5%) and SP+ABH in 20 (19.4%). The correlation test showed a weak association between the Sanders fracture type and the operation technique (Pearson correlation coefficient r=0.26). The non-parametric tests showed that the fracture type did not significantly influence the postoperative Bohler's angle outcome (p=0.132), or the type of operation (p=0.664). Excellent or good reduction of the posterior calcaneal facet was achieved in all operated fractures. One year after the operation, the distribution of Bohler's angle was normal with a mean 31.9° (SD 4.84) in all three groups. There was no significant difference in the functional postoperative outcome in terms of MFS in the three groups (p=0.601), but the Sanders fracture type had significant influence on the functional postoperative outcome in terms of MFS (p=0.001). CONCLUSION: In the representative sample of 103 operatively treated intraarticular calcaneal fractures, anatomical and functional postoperative efficacy outcomes appeared to be similar in all three treatment groups. High-grade displaced intraarticular calcaneal fractures (Sanders IV) had worse functional results irrespective of the type of operation. The optimal method for management of intraarticular calcaneal fracture is operative, using the standard anatomic calcaneal plate. Autologous bone grafting is not required. Large sample comparative studies are still needed.

[Total hip arthroplasty by neuromuscular impairment: functional outcome]. / Hüftendoprothetik bei neuromuskulärem Impairment: Funktionelles Outcome.

INTRODUCTION: Studies which deal with the problems of total hip arthoplasty (THA) in patients with neuromuscular impairments are rare. The aim of this study was to examine whether THA for painful coxarthrosis in such patients relieved pain and improved functional outcome and how high the complication rate was. MATERIAL AND METHODS: For this study 10 patients (13 hips) with neuromuscular impairment who had received a total hip arthroplasty for painful coxarthrosis were retrospectively identified. A chart review determined the preoperative functional level. For postoperative evaluation all patients completed a questionnaire, including a self-created modified hip score. RESULTS: The average age of the patients at the time of follow-up was 42.1 years (range 26.5-62.2 years, standard deviation SD 9.9 years) and the minimum follow-up was 24 months (average 80.3 months, range 24-143 months, SD 47 months). Pain relief was obtained for all patients but two patients had a postoperative dislocation and four patients had a major complication (infection) requiring removal of the implant. Therefore, the follow-up rate at the final examination with completed questionnaires was 69% (9 out of 13 excluding patients with removal of THA). These patients showed an improved function from 42.2-83.66 points in the hip score (p=0.0006) and there was general satisfaction with the procedure. DISCUSSION: Total hip arthroplasty can provide improved function in patients with neuromuscular impairment and severe coxarthrosis. The rate of complications was moderate in this series; however, the high infection rate in these patients should be kept in mind.

Mobile surgical teams of Croatian Special Police Forces: analysis of casualties during combat.

The purpose of this article is to present medical results of mobile surgical teams (MST) supporting units of Croatian Special Police Forces in three attack combat actions. The rate of injury was from 2.0 to 1.3%, Whereas the combat mortality rate was between 0.20 and 0.17%. No postoperative mortality occurred. Heavy injuries were found in 45% of all injured, among them 57% caused by shell fragments. Extremities were involved in 92% of all injuries, whereas 50% were injuries of the calf. All the injured were surgically managed by MST at the site of deployment or in mobile surgical hospitals and evacuated to general hospitals within 12 hours, where 80% of all heavily injured patients underwent additional operations with no postoperative mortality. Eight to 36 months after injury, we found major functional disability in 2% of all injured. NATO schemes served as a basis for the formation of the Croatian war surgical care system with certain modifications dictated by specific situations at the beginning of the aggression against Croatia. MST of Croatian Special Police Force presented second- and third--echelon staged management of the wounded, which was adequate for this type of attack combat situation.

Tourniquet occlusion technique for lower extremity artery reconstruction in war wound.

Reconstruction of blood vessels after war injuries is mandatory for life and limb salvage. In an effort to prevent prolonged major bleeding and make reconstruction quicker and technically more comfortable, thigh pneumatic tourniquet occlusion was performed pre- and intraoperatively in eleven of 53 wounded with injuries of the arteries of the lower extremities during 1991/92 war against Croatia at the Department of Surgery, Osijek Clinical Hospital. This method benefits life and limb salvage under war conditions.

Ballistic trauma in 1991/92 war in Osijek, Croatia: shell fragments versus bullets.

During 18 months of the 1991/92 war against Croatia, 4,545 injured were treated at the Department of Surgery of Osijek Clinical Hospital. Some, 2,544 (55.9%) sustained shell fragment injuries and 807 (17.8%) bullet injuries. Shell fragments lead to a higher number of polytraumatized patients than did bullets (6.8% versus 5.3%). The postoperative complication rate for fragment injury (5.8%) was significantly higher than that for bullet injury (4.1%). Mortality rate did not differ significantly (3.9% versus 4.5% respectively).

Reconstruction of major arteries of lower extremities after war injuries. Long-term follow up.

During 18 months' period of war in northeastern Croatia 38 wounded with injuries of lower extremity arteries were operated on in Osijek Department of Surgery demanding the use of substitute conduit for vascular reconstruction; 26 synthetic prosthesis and 12 vein grafts were applied. Ankle-brachial index and life-table method were used for the construction of the initial and cumulative limb salvage rate at 40 months. Cumulative graft patency and limb salvage rates for synthetic grafts was 87.67% +/- 6.9 and for vein grafts 91.67% +/- 8.0 respectively and did not differ significantly for both synthetic prosthesis and autologous vein grafts.

Determination of bioequivalence of two furosemide preparations; the effect of high doses of furosemide on some pharmacokinetic parameters.

The bioequivalence of two oral preparations of the diuretic furosemide, namely (i) a Croatian pharmaceutical product (test preparation A) and (ii) a reference preparation B, both in a dose of 500 mg was assessed in an open, cross-over, randomized trial in 15 healthy male volunteers, in whom the HPLC method with a fluorescent detector was used to determine its concentrations. The test preparation (A) was found to achieve a considerably higher concentration (17.2 +/- 9.304 mg/l) than the reference preparation (11.1 +/- 6.484 mg/l); the time to peak concentrations was statistically significantly shorter for the test preparation (1.033 +/- 0.743 h) than for the reference preparation (1.656 +/- 0.586), and the areas under the concentration curves were statistically significantly greater for the examined preparation (65.9 mg.h/l) than for the reference preparation (46.845 mg.h/l). The relative bioavailability of the test preparation was 129%, i.e. it was not bioequivalent with the reference preparation. This finding was consistent with the previously performed laboratory quality testing in vitro, where the release of the reference preparation was found to be considerably slower and weaker than that of the test preparation. High doses of furosemide exemplified by 500 mg were found to affect only some of the pharmacokinetic parameters, i.e. they induce an accelerated absorption, an increase in serum concentration, and a prolongation of its half-life.

Bioequivalence of two oral cyclosporine preparations.

A comparison of bioequivalence of two cyclosporine (CAS 59865-13-3) preparations was performed. Ten cyclosporine treated patients with transplanted kidneys were included. Criteria were successful transplantation and minimum period from transplantation of at least 6 months. Two months before the experiment, cyclosporine concentrations had to be in therapeutic range without significant oscillation, and kidney function stabile. There had to be no signs of cyclosporine nephrotoxicity. During the objective biochemical analysis it was not allowed to find malfunction in any of the patient's organ important for cyclosporine pharmacokinetics. Cyclosporine concentrations in whole blood were measured with a specific fluoroimmunoassay. Cyclosporine and metabolites concentrations were measured with radioimmunoassay with non-specific antibody. Mean value and standard deviations and shape of distribution were calculated for all numeric data of patients, measured biochemical and other laboratory parameters. Variance analysis for all measured cyclosporine concentrations according to sampling times (C0 to C12, maximal concentrations C(M), time to maximal concentrations t(M), times of absorption delaying t(Lag) and area under the measured concentration curves (AUC) were statistically checked. According to these data it is concluded that the preparations are bioequivalent; a time to reach maximum concentration was slightly shorter for test preparation (2.5 and 3.2 h, respectively), but not statistically significant. There are no significant differences between the areas under the concentration curves (1667 and 1665 ng.h/ml, respectively). After the calculation of pharmacokinetic parameters of concentration data measured by a non-specific method a significant difference for areas under concentration curves was seen (3709 and 4600 ng.h/ml, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Foot injuries caused by anti-personnel mines.

During 18 months of the 1991-1992 war against Croatia, 14 persons wounded by antipersonnel mines were admitted to the Department of Surgery at Osijek University Hospital. Twelve had injury of the calcaneal region. Kirschner wires were used for minimal osteosynthesis. Delayed wound closure was performed 14 to 21 days after injury. The methods used were delayed direct closure, split skin-thickness graft, or microvascular free flaps. Osteitis did not develop, and all patients walked with full weight after 1 year.

Tendon injury repair in a war wound.

During 18 months of the 1991-1992 war against Croatia, 4425 injured were treated at the Department of Surgery, Osijek University Hospital. Among them 46 had tendon injuries, 20 with tendon laceration and 26 with total rupture. In 12 wounded primary repair was performed, 4 of an extensor tendon, 7 of a flexor tendon and 1 of both flexor and extensor. Four patients with primary flexor tendon repair had a good functional result. In other 34 no primary repair was done. Good function was achieved in 18 cases.

Reconstruction of the popliteal artery after war injury.

During the war against Croatia in 1991-1992, 85 wounded with war injuries of major vessels in the extremities were admitted to the Department of Surgery, Osijek Clinical Hospital. These 85 included 13 (15.3%) wounded with injuries of the popliteal artery. In 12 cases an allograft was used as a substitute conduit. One early thrombosis and two infections occurred. Two amputations had to be performed because of massive soft tissue destruction and infection in the leg tissue. Our experience shows that an allograft is an acceptable choice for popliteal artery reconstruction in a highly contaminated war wound.

War injuries of the colon and rectum.

During the war in Croatia, 77 wounded with colon (64) and rectum (13) injuries were treated at Osijek Hospital in the Department of Surgery from June 1991 to September 1992. Shrapnel wounds accounted for 68.8% of the injuries. Forty-seven (61.0%) had unilocular penetrating injury, 15 (19.5%) had multilocular penetrating injuries, 10 (13.0%) had crush injuries, and 5 (6.5%) had contusion of the colon. All who died (14) had associated intra-abdominal and other injuries. Primary repair was possible for 7 (9.1%) injuries, while 4 (5.2%) were repaired and extraperitonealized, 19 (24.6%) exteriorized injuries, 17 (22.1%) were resected followed by oral derivation, 21 (27.2%) sutured followed by oral derivation, and 6 (7.8%) had resection and anastomosis. In 3 (3.9%) patients no colon repair was performed as they died on the table. We had 13 (16.9%) complications and 14 (18.2%) mortalities, 11 (14.3%) postoperatively including 9 within the first 24 h after surgery.

War injuries of major extremity vessels.

During the war in Croatia, the surgical department of Osijek Hospital was the place of primary and definitive surgical management of the wounded from the city of Osijek and the entire northeastern region of Croatia. Our surgical experience with the management of war injuries of major extremity vessels, collected from May 2, 1991, through April 12, 1992, is reviewed. During that time, 60 wounded were admitted to the hospital with injuries of major blood vessels of the extremities, all of them directly from the battlefield or from the streets of Osijek. The method of surgical treatment depended on the type of vascular injury and associated injuries. Our methods were arterial injury reconstruction and monitoring of the early results when autogenous vein grafts or synthetic prostheses were used. The results indicate that one should not resist using synthetics for reconstruction of arterial injuries in a highly contaminated area.

The reconstruction of major femoral vessels in a four-year-old girl wounded with shrapnel.

A four-year-old girl who sustained an explosive injury to the femoral artery and vein underwent vascular reconstruction. An allograft was used as a substitute conduit for both the artery and the vein. Eight months after reconstruction there was no pulse deficit and decrease in systolic blood pressure, nor were there any signs of venous obstruction.

Reconstruction of major arteries of extremities after war injuries.

This paper reports on the experience regarding the reconstruction of arterial injuries gained at the Department of Surgery, Osijek General Hospital during the first year of war against Croatia. In the period between May 1991 and May 1992, 57 wounded with 60 injuries of the major arteries of the extremities were admitted to the hospital, all of them directly from the battlefield or from the streets of Osijek. As there is no consensus on the application of autologous vein graft or allograft in arterial injury reconstruction, our choice of surgical management and early results are reviewed. In the surgical repair of 60 injured major arteries of the extremities, 17 allografts and 19 autologous vein grafts were used. In conclusion, our results indicate that the use of allografts for arterial injury reconstruction may be useful in a highly contaminated area of war wound.

Clinical and functional evaluation of the Carbomedics Prosthetic Heart Valve in the mitral position. Preliminary results.

The Carbomedics Prosthetic Heart Valve is a new bileaflet pyrolite carbon prosthesis. This paper reports the preliminary results in 40 patients who underwent mitral valve replacement (MVR) using the Carbomedics Valve in 1988. The operative mortality rate was 5% and the early results have been encouraging, with no valve related complications observed in the first post-operative year.

The "regulatory" sulfhydryl group of Penicillium chrysogenum ATP sulfurylase. Cooperative ligand binding after SH modification; chemical and thermodynamic properties.

ATP sulfurylase from Penicillium chrysogenum is a homohexamer that contains three free sulfhydryl groups/subunit, only one of which (designated SH-1) can be modified by disulfide, maleimide, and halide reagents under nondenaturing conditions. Modification of SH-1 has only a small effect on kcat but causes the [S]0.5 values for MgATP and SO4(2-) (or MoO4(2-) to increase by an order of magnitude. Additionally, the velocity curves become sigmoidal with a Hill coefficient (nH) of about 2 (Renosto, F., Martin, R. L., and Segel, I. H. (1987) J. Biol. Chem. 262, 16279-16288). Direct equilibrium binding measurements confirmed that [32P]MgATP binds to the SH-modified enzyme in a positively cooperative fashion (nH = 2.0) if a sulfate subsite ligand (e.g. FSO3-) is also present. [35S]Adenosine 5'-phosphosulfate (APS) binding to the SH-modified enzyme displayed positive cooperativity (nH = 1.9) in the absence of a PPi subsite ligand. The results indicate that positive cooperativity requires occupancy of the adenylyl and sulfate (but not the pyrophosphate) subsites. [35S]APS binding to the native enzyme displayed negative cooperativity (or binding to at least two classes of sites). Isotope trapping profiles for the single turnover of [35S]APS: (a) confirmed the equilibrium binding curves, (b) indicated that all six sites/hexamer are catalytically active, and (c) showed that APS does not dissociate at a significant rate from E.APS.PPi. The MgPPi concentration dependence of [35S]APS trapping was indicative of MgPPi binding to two classes of sites on both the native and SH-modified enzyme. Inactivation of the native or SH-modified enzyme by phenylglyoxal in the presence of saturating APS was biphasic. The semilog plots suggested that only half of the sites were highly protected. The cumulative data suggest a model in which pairs of sites or subunits can exist in three different states designated HH (both sites have a high APS affinity, as in the native free enzyme), LL (both sites have a low APS affinity as in the SH-modified enzyme), and LH (as in the APS-occupied native or SH-modified enzyme). Thus, the HH----LH transition displays negative cooperativity for APS binding while the LL----LH transition displays positive cooperativity. The relative reactivities of like-paired SH-reactive reagents were in the order: N-phenylmaleimide greater than N-ethylmaleimide; dithionitropyridine greater than dithionitrobenzoate; thiolyte-MQ greater than thiolyte-MB. The log kmod versus pH curve indicates that the pKa of SH-1 is greater than 9.(ABSTRACT TRUNCATED AT 400 WORDS)