Primary total hip arthroplasty: health related quality of life outcomes.

PURPOSE: The health related quality of life (HRQoL) outcomes of total hip arthroplasty (THA) present a pertinent and clinically important problem in modern orthopaedics. Our goal was to report and compare the health-related outcomes after THA in respect to type of fixation in patients with hip osteoarthritis (H-OA) one year after operation. METHODS: A total of 145 patients with H-OA who received THA were evaluated. Uncemented and cemented subjects were evaluated using generic measures, i.e. the EQ-5D questionnaire, and the disease-specific measures designed by the authors, i.e. the Total Hip Arthroplasty Questionnaire (THAQ). Obtained data was statistically processed at the level of pain, functionality and general health perception. Patient-reported outcomes were measured differences between pre-operative measures and those at one-year follow-up visit. RESULTS: Significant improvement in health outcomes was reached in both groups regardless of the type of fixation (p < 0.001). Uncemented fixation exhibited better results for EQ-5DINDEX, pain (p = 0.004) and self-care on EQ-5D (p = 0.043), as well as increased magnitude of change for functionality on THAQ (p = 0.002). However, additional analysis of the subset did not reveal a significant difference between cemented vs. uncemented groups with regard to function on THAQ, but the significant difference on self-care and pain dimensions of EQ-5D remained. CONCLUSIONS: Uncemented endoprosthesis generally achieved better short-term outcomes in some dimensions. However, painless mobility has been restored in most of the patients, regardless of the fixation type. Both methods reached good clinical outcomes in their respective domains; therefore, we would emphasise prevention of osteoarthritis and the quality of care as the more important predictors of good clinical outcomes.

The possibilities and limitations of direct digital radiography, ultrasound and computed tomography in diagnosing pleural mesotelioma.

The goal of this study was to compare the possibilities and limitations of direct digital radiography of the chest (DDR), the use of ultrasound of the chest (US) and single slice computed tomography of the chest (CT) in diagnosing pleural mesothelioma. The study was conducted during the course of one year, on 80 patients who were successively referred to a specialized institution, under clinical suspicion of mesothelioma. The method of investigation was the comparison of findings, obtained by the reviewed methods of examination, with the pathohistologic results of a biopsy performed on each patient. The findings that were obtained by the enumerated methods were classified according to the radiologic signs that were found in each individual patient. We evaluated following radiological findings (signs), on each of the investigated methods: plaques, localized and generalized pleural thickenings, calcifications of the pleura, pleural effusions, parapneumonic effusions, pleural empyema, (round) atelectasis, pneumothorax, tumor mass or node, inflammatory infiltrate, elevation of the hemidiaphragm and osteolysis. The results of these were compared with pathohistologic findings and analyzed by means of standard statistical methods. The highest sensitivity was found for CT (94.4%), followed by US (92.6%), and by DDR (90.7%). The highest specificity was obtained with DDR (46.2%), followed by CT (35.5%) and US (23.8%). The comparison of these methods showed 90% diagnostic accuracy for DDR in relation to CT CT as an individual method best satisfied most of the criteria for diagnosing mesothelioma. No pathognomonic radiologic sign for mesothelioma was found.

Atherosclerotic lesions of supra-aortic arteries in diabetic patients.

The aim of this prospective study was to determine the prevalence and localization of stenotic atherosclerotic lesions of supra-aortic arteries in diabetic patients according to age and sex. Angiograms obtained by digital subtraction angiography were analyzed in 150 diabetic patients (study group) and 150 non-diabetic patients (control group) with symptoms of cerebral ischemia. Diabetic patients were found to have a significantly higher prevalence of stenotic atherosclerotic lesions of the internal carotid artery. Lesions of the large supra-aortic arteries were significantly more common in the left than in the right side of the neck (p < 0.001), but the difference between the diabetic and the non-diabetic group did not reach statistical significance. Hemodynamic conditions were found to be more important than diabetes for the occurrence of atherosclerotic lesions in these arteries. Changes in the proximal segment of the left common carotid artery were the most common finding in diabetic patients, hence attention should be paid to this localization on control examinations.

Stenotic occlusive lesions of internal carotid artery in diabetic patients.

Diabetes deteriorates atherosclerotic changes in the arteries. The aim of the study was to assess the prevalence and localization of stenotic atherosclerotic lesions of the internal carotid artery (ICA) in patients with diabetes. A prospective analysis of angiography findings was carried out in 150 diabetic and 150 non-diabetic patients with symptoms of cerebral ischemia using double-blind angiogram readings by two independent investigators. The degree of stenosis was determined using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Stenoses of the proximal arterial segment accounted for the majority of extracranial ICA stenoses, being more frequent in diabetic (left ICA 50.7%, right ICA 58.0%) than in the non-diabetic patients (left ICA 29.3%, right ICA 32.7%). Diabetic patients revealed a more significant rate of unilateral tandem ICA stenoses (14.0-21.3%), as well as a statistically significantly higher prevalence of intracranial ICA stenoses (left ICA 24.0% and right ICA 17.3%) than did non-diabetic patients (left and right ICA 3.3% each). Our results confirm that there is a morphological basis in ICA for increased incidence of ICA lesions in patients with diabetes as compared to those without it. Data on the incidence of stenotic ICA lesions in diabetes suggest the importance of assessing overall ICA status using digital subtraction angiography. Such an assessment is a precondition for an optimal therapeutic approach, especially in diabetic patients who are at an increased risk of cerebrovascular disease.

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.

Evacuation times of civilians and soldiers wounded during the war in Croatia.

OBJECTIVE: The goal of this study was to estimate the mean time needed for evacuation of wounded persons from the site of injury to a medical institution. METHODS: A database that includes medical and demographic data for persons treated in Croatian hospitals during the 1991-1995 war in Croatia was used. RESULTS: A total of 61.11% of wounded persons was evacuated within 1 hour. The mean evacuation time was 2.26 hours, and times for civilians and army units did not vary significantly. After wounded patients were admitted to medical institutions, the chances of survival were 98.36%. CONCLUSION: Because the wartime medical system in Croatia depended on army units for transport and on civilian medical institutions for medical procedures and later care, we conclude that the integrated model of medical care led to short evacuation times, with no significant differences between soldiers and civilians or soldiers on the two sides.

[Care of military and civilian casualties during the war in Croatia]. / Analiza zbrinjavanja vojnih i civilnih ranjenika u ratnoj agresiji na Republiku Hrvatsku.

AIM: The Yugoslav People's Army as aggressor on Croatia was well organized and equipped with weapons and medical supplies. On the other hand, the Republic of Croatia as a new country had no army of nor medical corps of its own. At the beginning of aggression we decided to establish an integrated civilian-military medicine system. This system started as a civilian organization, to develop along with the army structure. The aim of the study was to analyze the overall result of such organization all over the Croatian territory throughout war period. METHOD: Data on 30,520 wounded were collected from all military and civilian hospitals. The registration of information on all hospitalized wounded was established at the beginning of war. For this analysis, a questionnaire was structured consisting of 150 data per person. Data were entered in digital form and analyzed by surgeons and general medicine specialists. RESULTS: The wounded were hospitalized at 58 institutions, 43 of them civilian hospitals adjusted to military purposes. In total, there were 7 163 wounded civilians (23.5%) and 23,351 wounded soldiers. Only 613 (2%) soldiers were registered as members of enemy units, most of them treated as civilians because they had enough time to remove their uniforms. Among civilian casualties, there were 1132 (15.8%) children and 1 985 (27.7%) women. The wounds were inflicted by artillery (n = 9 652, 31.6%), small arms (n = 7 302, 23.9%) and mines (n = 4587, 15.0%). First aid was administred at frontline to 5065, 25.5% soldiers), at echelon II-IV to the majority of them, while there are no data on 10,644 wounded. Among the wounded, 61.1% were evacuated within one hour and 76.3% within two hours. On admission, 313 patients were unconscious, and 1913 somnolent or disoriented. Pneumothorax was present in 740, respiratory insufficiency in 1570, and pulmonary edema in 48 patients. Hemorrhage of varying grade was present in 11,967 and hemodynamic shock in 1802 patients. The most common injuries were those involving the muscles in 26,339 (37.7%), bones in 19,452 (27.9%), abdominal region in 4312 (6.2%), neural system in 3809 (5.5%), thoracic organs in 2443 (3.5%) and cardiovascular system in 2164 (3.1%) patients. Only very simple diagnostic procedures were used. Standard radiography was performed in 25403 (83,2%) and contrast medium examination in 790 (2.6%) patients. Very useful methods in traumatology like CT and US were only used in 1277 (84.2%) and 1103 (3.6%) patients, respectively, due to the lack of modern diagnostic equipment. In total, 25,745 (84.4%) patients were surgically treated. A total of 42,239 operations were performed including one per patient in 15,611 cases, two per patient in 6 184 cases, and three per patient in 23,380 cases. Hospital treatment resulted in recovery or improvement in 20,777 (79.8%) patients, whereas 334 patients were transferred to another hospital. Data were not recorded for 1688 patients. In total, good results were achieved in 81% of all treated cases. The mortality was 3.9% (n = 284) in hospitalized civilians and 1.95% (n = 395) in soldiers, yielding a mean mortality of 2.22%. The mortality of enemy soldiers was similar (2.85%). Taking into account 15 000 wounded persons treated on outpatient basis, total mortality was 1.49%. DISCUSSION: The high number of civilian casualties (23.5%) was the result of the aggressor's war strategy. They surrounded a number of civil settlements including large towns bombing them for months or even years. The enemy strategy is best illustrated by the number of wounded children and women. Unfortunately, the mortality in civilians (3.9%) exceeded that in soldiers (1.95%), for several reasons, primarily age, distance from surrounded villages and number of destroyed hospitals. The favorable aspect of the organization was cooperation of the first aid teams at the battle field and transportation organized by medical corps, and excellent definitive treatment at the adapted civilian hospitals to serve as military hospitals. The relatively good status on the admission was the result of good preparation for transport performed by high qualified doctors dislocated very close to the frontline. CONCLUSION: Despite the lack of diagnostic equipment and medical vehicles, and the availability of improvised military hospitals, good results were achieved in overall patient survival. The very high rate of success in hospital treatment and very low mortality rate were the result of excellent medical staff and integrated civilian-military medical service.

[Diagnostic results of the carotid artery duplex ultrasonography performed in the private offices in Zagreb]. / Dijagnosticki rezultati dupleks ultrasonografije arterije karotis u privatnim ordinacijama grada Zagreba.

The purpose of the investigation was to evaluate the diagnostic value of duplex ultrasonography (DU) of the cerebral arteries in the patients with cerebrovascular insufficiency performed in private offices in Zagreb town. The investigation was performed for all patients referred to digital subtraction angiography (DSA) after DU examination performed in one of private offices (in total, 12 offices) during the period of three years. During mentioned period 127 patients were examined (100 male, 67 female, age 28-79 y, mean 62 y) according to DU exams performed in private offices. Other patients, who had DU examinations in offices other than private, were not examined in present investigation. The method of investigation was prospective comparison between DSA and DU findings, where DSA was used as the gold standard. The investigation was performed by three radiologists prospectively. They did not know DU findings before performing DSA. The pathological findings of the supraaortal arteries and especially significant stenoses (70%-99%) of the extracranial part of the carotid arteries, obliteration and ulcerated plaques were examined. For the significant stenoses of the carotid arteries, which are indication for operative treatment, DU showed sensitivity of only 63%, specificity 79%, positive predictive value 60% and negative predictive value 81%. The diagnostic difference between occlusion and subtotal stenosis of the carotid artery was also very important. DSA showed 18 occluded arteries, while DU presented 20, nine of them false positive and seven false negative (sensitivity 36%). DU diagnosed ulcerated plaque in only three out of 37 patients, including two false positive and 36 false negative results. According to results presented here, DU of the carotid arteries performed in analysed practices are not reliable and the price of DU presents expense without benefit. The insufficient education of the doctors and defective regulations of the private practices are the possible reasons for such results.

Usefulness of Doppler waveform analysis in differential diagnosis of cervical lymphadenopathy.

We compared Doppler spectral parameters in acute inflammatory, reactive, lymphomatous, and metastatic lymph nodes, and evaluated pulsed Doppler sonography as a method for distinguishing between different causes of cervical lymphadenopathy. Spectral Doppler analysis with measurements of resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) was performed in 197 patients with cervical lymphadenopathy. Results of Doppler analysis were compared with findings of cytology and histology or with clinical presentation and follow-up. Student's t-test was used to assess statistical significance of differences in Doppler parameters between groups of patients. Significant differences for RI and PI were shown between all groups of patients except between lymphomatous and reactive nodes. Specificity of 100% for metastatic nodal involvement was shown for cutoff values RI>0.80 and PI>1.80. A positive predictive value (PPV) of 100% for acute lymphadenitis was shown for cutoff values RI<0.50 and PI<0.60. An EDV>9 cm/s has 100% negative predictive value for nodal metastasis, and EDV<1 cm/s has 100% specificity and PPV for metastasis. Although there exist differences in RI, PI, PSV, and EDV between different nodal diseases, none of these parameters offer both good sensitivity and good specificity, and only extreme cutoff values may occasionally be helpful in differential diagnosis. Doppler spectral analysis is a valuable noninvasive adjunct which can help in differentiation between metastatic, lymphomatous, acute inflammatory, and reactive lymphadenopathy, but cannot obviate biopsy in the majority of cases.

Biochemical risk factors in angiographically established stenosis of cerebral arteries.

AIM: To determine the significance of the association between biochemical risk factors for cerebrovascular atherosclerosis (lipid parameters, lipoprotein(a), total homocysteine, total antioxidant status, trace elements, and electrolytes) and the degree of stenosis of cerebral arteries scored by digital subtraction angiography. METHODS: The study included 35 patients with angiographically established < 50% stenosis of cerebral arteries and 55 patients with > or =50% stenosis of cerebral arteries, including obliteration. The control group consisted of 51 patients with normal cerebral arteries on ultrasound examination. Biochemical parameters were measured in all participants according to the standard laboratory protocols. RESULTS: Logistic regression analysis showed two independent and significant biochemical risk factors associated with the severity of cerebrovascular stenosis: lipoprotein(a) for patients with different degrees of stenosis, and total antioxidant status for patients with severe stenosis of more than 50%. Univariate statistical evaluation showed significantly higher homocysteine levels in the group of patients with > or =50% stenosis than in the control group (median 14.84 micromol/L vs median 12.40 micromol/L, p < 0.05). CONCLUSION: Increased lipoprotein(a) and low total antioxidant status values seem to be the most significant independent biochemical risk factors for the development of cerebrovascular stenosis. Mild hyperhomocysteinemia seems to be an additional discriminating indicator of the severe cerebrovascular stenosis. These factors may be useful for early identification and recognition of patients with cerebrovascular atherosclerosis.

[Role of 0.5 T magnetic resonance and duplex ultrasonography in the imaging of stenotic and oblitertive changes in the carotid arteries]. / Uloga magnetskog rezonatora 0.5 T i dupleks ultrasonografije u prikazu stenoticko-obliterativnih promjena arterije karotis.

The aim of the study was to determine diagnostic value of magnetic resonance angiography (MRA) of the carotid artery, performed with less expensive machine of 0.5 T, and value of duplex ultrasonography (DU) in the same patients. Diagnostic values of MRA and DU were examined by comparison with the results of digital subtraction angiography (DSA) or with the operative finding. All MRA examinations were performed in the same diagnostic center, but DU diagnostic procedures were performed in five different centres. In total, we examined 70 arteries in 37 patients. Among them, 66 arteries in 33 patients were compared with DSA and four arteries in four patients with operative findings. All patients were referred to DSA after MRA and DU. In four patients four carotid arteries were operated without DSA due to previous allergic reaction to iodinated contrast agent. The positive result in present examination was stenosis of the carotid artery more than 70% of the arterial lumen. Such stenosis is considered as an indication for active therapeutic approach using vascular surgery or transluminal angioplasty. Results indicate more true positive results for MRA (21 patients) than for DU (20 patients). Also, we found more true negative results for MRA (45 patients) than for DU (44 patients). MRA had one false positive and three false negative results, and DU two false positive and 4 false negative results. Sensitivity of MRA in our group of patients was 88% and specificity 98%. In the same group DU had sensitivity 83% and specificity 96%. Our results showed that neither MRA nor DU separately could replace DSA in diagnosis of high grade carotid stenosis. Because of high specificity, negative MRA or DU can exclude significant stenosis and avoid DSA. In the case of similar positive results of MRA and DU, the number of DSA can be reduced.

[Privatization of the Croatian health care system: effect on indicators of health care accessibility in general medicine]. / Privatizacija u hrvatskom zdravstvenom sustavu: ucinak na neke pokazatelje dostupnosti usluge u ordinacijama opce medicine.

The aim of the privatization of the primary health care is to reduce cost and improve the quality of service by introducing the market-based system. In the Republic of Croatia, the privatization of the primary health care started in 1995. It was based on renting the existing facilities at a moderate price to the practitioner. After that, the practitioner registers the private practice and signs a contract with the obligatory health insurance institution. The aim of this article is to present a part of the project of long-term research of privatization related to the health care accessibility in general practices. The research sample consisted of three groups: privatized general practices, to-be-privatized general practices and non-privatized general practices during 1997 and 1999. Privatized general practices have exhibited a significant improvement in the number of registered patients, the scheduling of first visit appointments during working hours, the possibilities of scheduling follow-up visit appointments during working hours, scheduling visits by telephone, obtaining telephone advice after working hours and visiting the practitioner after working hours. This kind of research is vital in order to bring about the necessary changes in the existing system by scientifically approved methods.

[Epidemiology of Helicobacter pylori infection]. / Epidemiologija infekcije Helicobacterom pylori.

About 50% of adults in the developed and 80-90% in the developing countries are estimated to be infected by Helicobacter pylori. Being 68% nationally, this rate is higher in the northern continental parts of Croatia, which also have higher gastric cancer rates. Low socio-economic status, poor living conditions in childhood (the age when Helicobacter pylori is typically acquired), and exposure to the stomach content of an infected person are risk factors for Helicobacter pylori. Most of the infected are symptomless, with 10 to 20% subsequently developing the disease, and this mainly from peptic ulcer, asymptomatic chronic gastritis and chronic dyspepsia. Less than 5/10,000 become affected with adenocarcinoma, MALT lymphoma or primary non-Hodgkin's gastric lymphoma. Helicobacter pylori is under intensive study for possible association with other diseases. As transmission route of the infection is still unclear, any mechanism allowing the bacteria entry into a non-infected individual's stomach is probably a possibility. In addition to improved socio-economic status, eradication or vaccination may be contributors to the reduction in the number of the infected.