Patient radiation doses in the most common interventional cardiology procedures in Croatia: first results.

Apart from its benefits, the interventional cardiology (IC) is known to generate high radiation doses to patients and medical staff involved. The European Union Medical Exposures Directive 97/43/Euroatom strongly recommend patient dosimetry in interventional radiology, including IC. IC patient radiation doses in four representative IC rooms in Croatia were investigated. Setting reference levels for these procedures have difficulties due to the large difference in procedure complexity. Nevertheless, it is important that some guideline values are available as a benchmark to guide the operators during these potentially high-dose procedures. Local and national diagnostic reference levels (DRLs) were proposed as a guidance. A total of 138 diagnostic (coronary angiography, CA) and 151 therapeutic (PTCA, stenting) procedures were included. Patient irradiation was measured in terms of kerma-area product (KAP), fluoroscopy time (FT) and number of cine-frames (F). KAP was recorded using calibrated KAP-meters. DRLs of KAP, FT and F were calculated as third quartile values rounded up to the integer. Skin doses were assessed on a selected sample of high skin dose procedures, using radiochromic films, and peak skin doses (PSD) were presented. A relative large range of doses in IC was detected. National DRLs were proposed as follows: 32 Gy cm(2), 6.6 min and 610 frames for CA and 72 Gy cm(2), 19 min and 1270 frames for PTCA. PSD <1 Gy were measured in 72 % and PSD >2 Gy in 8 % of selected patients. Measuring the patient doses in radiological procedures is required by law, but rarely implemented in Croatia. The doses recorded in the study are acceptable when compared with the literature, but optimisation is possible. The preliminary DRL values proposed may be used as a guideline for local departments, and should be a basis for radiation reduction measures and quality assurance programmes in IC in Croatia.

C-reactive protein level in severe stenosis of cerebral arteries.

BACKGROUND: C-reactive protein (CRP) as a non-specific inflammatory biomarker has been demonstrated to actively contribute to all stages of atherogenesis. The aim of this study was to investigate the relation between CRP concentrations and the severity of stenosis of cerebral arteries. METHODS: Lipid parameters and CRP levels were measured in the sera of 119 patients with stenosis of the extracranial cerebral arteries established by angiography and compared with the control group, with a normal appearance of the cerebral arteries on ultrasound examination. CRP concentrations were determined by a high-sensitivity assay. RESULTS: CRP concentrations showed a statistically significant difference in the group of patients with cerebrovascular stenosis of more than 70% compared to the control group (median value 3.4 vs. 1.5 mg/l in the control group, p < 0.05). At logistic regression analysis, CRP was significantly associated with stenosis of more than 70%. CONCLUSION: In addition to traditional biochemical risk markers, an elevated CRP level measured on automated analysers using a high-sensitivity assay may be useful in the detection of patients with severe stenosis of the cerebral arteries.

Privatization in the health care system of Croatia: effects on general practice accessibility.

This paper analyzes some effects of the privatization process in primary health care in Croatia, and in particular evaluates actions taken by providers to improve their accessibility for patients. The sample was stratified by regional density of practices and the status of practices in relation to privatization. Three groups of general practices were included in the study and were assessed twice (in 1997/1998 and 1999/2000): (1) 106 privatized before the beginning of the study; (2) 96 privatized during the study period and (3) 65 that were not yet privatized. The research was performed by structured interview with general practitioners as informants. The indicators analyzed were: possibilities of obtaining first and follow-up visit appointments, honouring scheduled appointments, scheduling visits by telephone, visiting the practitioner after hours and obtaining telephone advice after working hours. Number of registered patients in the practice and perception of patients' waiting times were also assessed. Privatized practices performed better in improving the accessibility of their services for patients: they increasingly offered the possibility for first and follow-up appointments at precise times, scheduled visits by telephone and provided telephone advice outside working hours. They showed greater intention to honour made appointments in order to lower their patients' waiting times. The study indicates that, in the initial stage of privatization, practitioners tend to extend accessibility by structural improvements that are not time consuming. It seems that providers adjust the level of offered accessibility benefits according to the intensity of market competitiveness. Further research is needed to precisely delineate the range of structural adjustments that could be expected by privatization and to verify the effect of observed changes on the quality of care and health outcomes.

War injuries of the lungs.

OBJECTIVE: The authors' experience in the treatment of war injuries of the lungs, gained during the war in Croatia, from August 25, 1991 until July 1, 1995, is presented. In that period, 424 patients with injuries of the lungs were treated at the Split Clinical Hospital. METHODS: The paper is a retrospective study of 424 wounded persons with lung injuries gained during the war in Croatia, processed by basic statistical analysis. RESULTS: Penetrating and nonpenetrating wounds were present in 331 (78.1%) and 93 (21.9%) patients, respectively. There were 407 (96.0%) men and 17 (4.0%) women. Explosive wounds were most frequent (n = 251; 59.2%), followed by gunshot wounds (n = 158: 37.3%) and other types of wounds in 15 (3.5%) patients only. Thoracotomy was performed in 89 (22.9%) patients, whereas conservative surgical methods (wound treatment, chest-tube drainage, appropriate fluid therapy, antimicrobial and atelectasis prophylaxis) were used in 300 (77.1%) patients. A great majority of the patients (n = 395; 93.2%) were discharged as fully recovered or in improved condition, 22 (5.2%) patients were referred to other institutions for further treatment, and seven (1.7%) wounded persons died. CONCLUSIONS: It is shown that most war wounds of the lungs can be successfully managed by 'conservative' surgical treatment.

[The age of diagnostic radiologic equipment in Croatia]. / Starost radioloske dijagnosticke opreme u Republici Hrvatskoj.

The quality of health care also depends partly on technological equipment. Among the devices which diminish the quality of services if they are old, increasing at the same time the danger when used, are certainly those in radiodiagnostics. Besides, their age controls the dose of radiation to which patients and professional staff are exposed. The knowledge of the age of this equipment is the basis of the plans for further development. The aim of the study is to determine the age of each individual radiodiagnostic device in Croatian institutions. The assessment of each device was made by a qualified professional. The method of data collection was based on the uniform questionnaire which comprised radiodiagnostic devices older than ten years, classified according to type and location (primary health care center or hospital, in total 655 devices). Determination of the age index of generators and x-ray tubes older than seven years (according to the World Bank recommendation), included also mobile units (55 for fluoroscopy and 68 for radiography), devices for dental radiography, devices in private sector (118) and devices which are out of use but not officially blocked (88), which means in total 859 generators and 1111 x-ray tubes. In addition, the availability of image intensifiers for fluoroscopy and manufactures of all devices were determined. The results of the study reveal that in primary health care centers, out of 248 radiodiagnostic devices, 193 are older than ten years (77.8%), while 4 are of unknown age. In hospitals, out of 407 devices, there are 261 older than ten years (64.1%), while 46 are of unknown age (11.3%). Among devices for fluoroscopy, 97 out of totally 206 have no image intensifier (32%). These devices should be immediately excluded from utilization. The index of age above seven years, which is according to the recommendation of the World Bank the lifetime of devices, reveals that 859 generators out of totally 984 (91%) are too old to be used, while there are 1111 x-ray tubes out of totally 1206 (92%) which are in the same condition. Regarding the manufacturers, the ratio is also unfavourable, since 49.3% of devices have been manufactured by comparies whose technology and spare parts are now inaccessible (Elektronska industrija). Such unacceptable obsoleteness of the radiological equipment requires urgent renewal.

Intrarenal duplex Doppler sonographic evaluation of unilateral native kidney obstruction.

RIs were measured in intrarenal arteries in 66 kidneys of 33 examinees without renal impairment and in 42 kidneys of 21 patients with unilateral urinary obstruction. The mean RI in normal kidneys was 0.593 +/- 0.040. Patients with unilateral obstruction had a mean RI of 0.709 +/- 0.039 in obstructed kidneys and a mean RI of 0.591 +/- 0.033 in contralateral nonobstructed kidneys. Statistically significant differences have been noticed in the groups of normal versus obstructed kidneys (P < 0.001) and of obstructed versus contralateral nonobstructed kidneys (P < 0.001). The mean dRI was 0.118 +/- 0.034 in patients with unilateral obstruction, and it was 0.014 +/- 0.012 in examinees without renal impairment (P < 0.001). A comparison of RI values between the right and left kidneys in a patient with unilateral obstruction proved more useful than using a 0.7 RI cutoff value in a Doppler sonographic diagnosis of unilateral obstruction.

[Injuries of the urinary bladder]. / Povrede mokracnog mjehura.

The authors analyse 32 patients with injuries of the urinary bladder treated in Clinical Hospital Centre "Firule" in the period from 1976 to 1988 (Figure No 1). There were: 10 contusions of the bladder (31%), 5 extraperitoneal ruptures (16%), 16 intraperitoneal ruptures (50%), and 1 combined extra and intraperitoneal rupture (3%). The isolated injuries of the bladder are rare. Extraperitoneal ruptures most of them are connected with the pelvic fractures. The intraperitoneal ruptures of the bladder were connected with splenic rupture in 7 cases, with the rupture of the rectum in 1 case, with the vaginal rupture in 1 case, with the rupture of the aorta in 1 case, with the rupture of the ovarian cyst in 1 case and with the rupture of the ileum in 1 case. All the patients with the urinary bladder rupture were operated, what got sufficient drainage of the urine, and drainage of the perivesical space and closure of the defect of the bladder.

[Fatal postsplenectomy sepsis (OPSI syndrome)]. / Fatalna postsplenektomicna sepsa (OPSI sindrom).

The cases of postsplenectomy sepsis are described at the Clinical Hospital Centre Split. Overwhelming postsplenectomy infection is a unique clinical entity distinguishable from other infections. It may occur during the lifetime of any asplenic patient. The aggressive approach to splenic preservation is a way by reducing the risk of subsequent overwhelming postsplenectomy sepsis. In the case of necessary splenectomy, should be given long-term prophylactic antibiotics preoperative and polyvalent pneumococcal vaccine to it would be given shortly after operation. Autologous splenic implantation is generally recommended when total splenectomy is necessary.

[Permanent decrease in immune function in patients with splenectomy for trauma]. / Dugotrajno smanjena imuna funkcija kod pacijenata splenektomiranih zbog traume.

The authors describe the peripheral blood analyses in patients splenectomized for trauma in consideration on the concentration of the immunoglobulins total complement CH50 levels, T and B lymphocyte populations and compare this with the control group. The levels of the IgM were significantly decreased (p0.001) in splenectomised while the levels of the IgA and IgG were significantly increased (for IgA - p0.001, for IgG p0.01). Total lymphocyte count averaged 54501999 in splenectomized, with number of T cells 2463930 and B lymphocyte 460236. The control group showed total lymphocyte count 460236. The control group showed total lymphocyte count 520235 (p0.001) with number of T cells 314147 (p0.001) and number of B cells 7434 (p0.001), what is significantly less than in splenectomized population. The level of total complement CH50 in splenectomized population was 11216 (p0.01), what is significantly less than in the control group 12515. These data demonstrate persistent abnormalities in immune function and suggest a possible explantation for the increased rizu of sepsis in this group of patients.