Ketamine - Undrawn Lines between Medical and Recreational Use - Implications for Clinical Practice.

Ketamine, synthesized in 1962, approved in 1970, is considered safe for use in controlled conditions, mainly as an anesthetic, especially in pediatric populations and in people suffering from pulmonary diseases, as well as in emergency departments and in war situations. Dissociative states (derealization and depersonalization) produced by ketamine made it a popular recreational drug, which led to increased regulation in most countries. Intravenous application of ketamine has shown rapid, although transitory antidepressant and antisuicidal effects in patients with unipolar and bipolar depression. Esketamine, the S(+) enantiomer of ketamine, with better pharmacodynamic selectivity, has just been approved for treatment-resistant major depressive disorder, in the form of a nasal spray. Presently, the high cost of the spray not only limits its widespread use, but also makes it less prone to abuse and diversion. Additional measures are needed to hinder it from becoming a new "street drug".

Regional Differences in Anxiolytic Prescribing in Light of Hofstede's Cultural Dimensions Theory.

BACKGROUND: Anxiolytics such as benzodiazepines are widely used in the treatment of anxiety disorders, although they are no longer recommended as first-line therapy for these conditions due to increased risk of dependence, as well as cognitive adverse effects, especially among the elderly. High prescribing rates of anxiolytics may be indicative of higher prevalence of anxiety-related phenomena in a given society, either in a form of an anxiety disorder or as pressure on physicians to keep prescribing them, against current guidelines. SUBJECTS AND METHODS: We inspected prescribing rates of anxiolytics in 21 European countries and compared them with six dimensions of Hofstede's cross-cultural framework, namely uncertainty avoidance (UAI), power distance (PD), individualism (IDV), masculinity (MAS), long-term orientation (LTO) and indulgence (IND). RESULTS: According to our findings, anxiolytic prescribing patterns in selected European countries correlate positively with Hofstede's dimensions of UAI and PD and negatively with IDV. CONCLUSION: Differences in prescribing rates of anxiolytics and trends in their use may be affected by cross-cultural factors. More research is needed to shed light on these regional differences in anxiolytic prescribing.

HFE mutations and transferrin C1/C2 polymorphism among Croatian patients with schizophrenia and schizoaffective disorder.

The aim of this study was to investigate the possible influence of hemochromatosis gene mutations (HFE-C282Y and H63D) and transferrin gene C2 variant (TF-C2) on susceptibility to schizophrenia and schizoaffective disorder and/or age at first hospital admission. Genotyping was performed in 176 Croatian patients and 171 non-psychiatric Croatian controls using PCR-RFLP analyses. Regarding the H63D mutation, allele and genotype frequencies reached boundary statistical significance. Other allele and genotype distributions were not significantly different between two groups. We also analyzed age at first hospital admission as a continuous variable using the non-parametric Mann-Whitney U-test and Kruskal-Wallis test, and multiple regression analysis. The results of these tests were negative. We concluded that investigated HFE mutations and TF-C2 variant are not high-risk genetic variants for schizophrenia/schizoaffective disorder in our population. Also our data do not support their impact on age at onset of the first psychotic symptoms.

The validity of ESIN method of osteosynthesis compared to other active surgical methods of treatment of diaphyseal fractures of long bones in children and adolescents.

We investigated the relationship of efficiency in the application of the ESIN method of intramedullary osteosynthesis and other active surgical methods in the treatment of diaphyseal fractures of long bones in children and adolescents. The study comprised 100 subjects treated by elastic stable intramedullary osteosynthesis (ESIN - group A) and 50 subjects in whom other active surgical methods were applied (group B). The following criteria of efficiency of treatment were applied: 1. length of perioperative hospitalization, 2. time elapsed since the operation until the beginning of loading of the traumatized extremity, 3. time elapsed since the operation until the full loading of the extremity, i.e. until the recovery of the fracture, 4. incidence of complications, 5. number of post-operative outpatient clinical visits until the recovery of the fracture and 6. overall number of X-ray images of the fractured bone since the accident until the coalescence of the fracture. The results obtained in both groups were compared. 1. The length of perioperative hospitalization is shorter in patients in whom ESIN method was applied. The difference between arithmetic means was 4.45 days and is statistically significant (p < 0.001). 2. The time between the operation until the beginning of loading of the extremity is shorter in patients subjected to ESIN method of osteosynthesis, the difference of mean values being 23.49 days and is statistically significant (p < 0.001). 3. The time between the operation until the full loading of the extremity is shorter in patients subjected to ESIN method of osteosynthesis, the difference being 16.6 days and is statistically significant (p < 0.001). 4. The number of complications in patients treated by the ESIN method of osteosynthesis is not statistically different from that in group B (chi2 = 0.25, p = 0.62). 5. In postoperative period there were fewer outpatient controls in patients to whom ESIN method of osteosynthesis was applied, and the difference is statistically significant (Z = 7.69, p < 0.001). 6. Likewise, the overall number of X-ray controls was lesser (Z = 8.06, p < 0.001). The results of examining the above parameters point to a greater efficiency of treating diaphyseal fractures of long bones in children and adolescents by the ESIN method of osteosynthesis, compared to other active surgical methods.

An association between niacin skin flush response and plasma triglyceride levels in patients with schizophrenia.

The available data suggest that abnormalities of arachidonic acid-related signaling may be of relevance in attenuated niacin-induced flush responses and lipid and glucose metabolism disturbances, which are all common among individuals with schizophrenia. We previously demonstrated attenuated skin flush responses to niacin in patients with schizophrenia. Here we investigated whether these niacin responses might be associated with elevated plasma lipid and glucose concentrations in this patient group. We found that higher plasma triglyceride levels were associated with higher total volumetric niacin response (VNR) values and that the VNR accounted for ~14.2% of the variability in triglyceride levels. Triglyceride levels were significantly higher in patients with a positive niacin skin flush response compared to those with absent niacin skin flushing at the 5-minute interval with niacin concentrations of 0.1 and 0.01 M, and at the 10- and 15-minute intervals with a niacin concentration of 0.001 M.

Abdominal pain patient referrals to emergency surgical service: appropriateness of diagnosis and attitudes of general practitioners.

This study evaluate the need for general practitioners referrals and self referrals of acute abdominal pain patients to emergency surgical service, the appropriateness of GP referral diagnosis and their attitudes dealing with abdominal pain. In three months period all acute abdominal pain patient referrals to our hospital emergency surgical service were audited. Data on final diagnosis, surgical treatment, admission to hospital and surgery performance were recorded. Self referral or GP referral, referring GP diagnosis, referral letters indicating presenting complaint or history, axillar and rectal temperature measurement, laboratory checking and abdominal radiography checking by GP were recorded as well. Also, GPs examination details as palpation, auscultation and digit-rectal checking were recorded. We calculated sensitivity, specificity, positive and negative predictive value (PV) for referring diagnosis. Self referrals and GP referrals differences were evaluated. During the study 318 patients were admitted. A total of 163 (51.25%) referrals were deemed inappropriate; 102 (52.6% of GP referrals) and 61 (49.2% of self referred) (p < 0.05). There were no differences in general treatment, hospital admission and operative treatment in self referred and GP referred groups (p < 0.05 for all three categories). Sensitivity, specificity, positive and negative predictive values for most frequent GP referral diagnoses were: abdominal colic/abdomen in observation 0.78; 0.66; 0.74; 0.70; acute appendicitis 0.37; 0.92; 0.44; 0.90; acute abdomen/peritonitis 0.30; 0.97; 0.54; 0.92; constipation 0.95; 0.98; 0.85; 0.99; and ileus 0.83; 0.97; 0.50; 0.99. Data on GP including clinical examination, patient history and running basic diagnostics were poor. Our results suggest that a general agreement within the profession about what constitutes a necessary hospital referral is necessary. GP consultation quality must be improved by booking more time per patient and by giving more medical/technical attention to patients.

The relationships between self-esteem, emotional reactions and quality of life in pediatric locomotory trauma patients.

The main aim of this study was to establish the relationships between several psychosocial characteristics in children and adolescents differently treated for isolated long tubular bones' fractures. Examined variables were: self-esteem, basic emotional reactions toward illness or injury including depression and anxiety, as well as perception of quality of life and social support during the treatment. Whole sample comprehends 135 patients, both gender, 10-18 years of age, treated for mentioned fractures in period 2003-2005 at the Departments of Pediatric Surgery of 3 hospitals: University Hospital Centre in Rijeka and Clinical Children's Hospital in Zagreb, both in Croatia and University Hospital in Mostar, BiH. 73 patients were treated conservatively (CT), 40 of them underwent Elastic Stable Intramedullary Nailing (ESIN) and 22 of them underwent other surgical techniques (OST). Basic methods of work were: interview to collect data for half-structured socio-demographical questionnaire, evaluation of medical records and self-reported questionnaires including: Rosenberg Self-esteem Scale (RSS), Children Depression Inventory (CDI), Spielberg State Trait Anxiety Inventory (STAI), Short Form 36 Health Survey (SF-36) and Test of Perception of Social Support (TPSS). RSS, CDI and STAI were administered to the patients at baseline and after 6 months of the trauma, while SF-36 and TPSS after 1 month of the trauma. Results of this study point to close and strong relationships between examined variables, mostly statistically significant at level p < 0.01 in all patients with fractures, regardless of the type of the treatment. There were also statistically significant differences in all variables between first and second measure; self-esteem increased and depression and anxiety decreased during the time in all patients (with different dynamics regarding the type of treatment); higher perception of social support enhanced that effect. Perception of quality of life in whole sample in summary measures was statistically significant at level p < 0.01 correlated positively with self-esteem and negatively with depression and anxiety, thus connection with perception of social support was statistically significant only in sibdomain of physical pain. There was also statistically significant difference in self-perception of quality of life related to psychosocial variables according to the type of treatment (F = 3.27; p = 0.01). Results of this study suggest that there are strong connections between physical trauma and different psychosocial variables in patients which point at need of understanding locomotory trauma in children in wider context including physical state and social functioning of the patient as well as the choice of type of treatment of fractures which influences complete process of healing.

Ethical approach to pharmacotherapy of comorbid states.

Ethics is an indispensable component of health care policy. Pharmacotherapy of comorbidity requires the use of a greater number of different drugs that have complex drug-drug interactions and drug-patient interactions which can cause various side-effects in the patient. The basic moral questions that justify the applied psychopharmacotherapy are the patient's welfare and preference, optimal relationship between risk and gain for the patient, and some include cost benefit as well.

The influence of temperament and character of psychotic individuals on the possibility of committing criminal offences.

Cloninger's theoretical biosocial model of personality represents the personality as a hierarchical organisational system consisting of 4 temperament dimensions and 3 character dimensions as 3 aspects of self-concept. It attempts to define behavioural and bio-genetic aspects of temperament, and the neuroanatomical and biochemical brain network responsible for activation, maintenance and inhibition of behaviour. The basic objective of this research is to establish whether temperament and character act as measures of personalities in psychotic persons on the possibility of committing criminal offences. This study is part of wider prospective clinical research on criminogenetic specificities of psychotic patients treated in the Psychiatric Hospital Rab, Croatia, in the period 2005.-2007. It encompasses 122 patients of male gender, up to 60 years of age, treated with the diagnosis paranoid schizophrenia (F20.0; MKB-10), of which half (n = 61; test group) with committed criminal offence and in forensic treatment, while the other (n = 61; control group) without committed criminal offence. The methods encompassed a socio-demographic questionnaire (for processing of general patient data with an emphasis on the characteristics of the committed criminal offence) and Temperament-Character Inventory (TCI) which was filled out once. The Statistical package for social sciences (SPSS) especially the chi2 test, t-test, analysis of variances (ANOVA), matrices for intercorrelation and graded logistical regression analysis for construction of predictor models were used for statistical analysis. According to the results obtained, the tested groups significantly statistically differ with the average results on all scales of the TCI survey (Self-Directedness (SD): F = 34.32; p < 0.05; Cooperativeness (CO): F = 81.54; p < 0.05; Novelty Seeking (NS): F = 42.83; p < 0.05; Harm Avoidance (HA): F = 6.01; p < 0.05; Persistence (PE): F = 4.87; p < 0.05; Reward Dependence (RD): F = 10.91; p < 0.05) except on the scale of Self-Transcendence (self--awareness) (ST), which is not an expected result. Upon further analysis 3 reliable predictor models were established with 1, 2 and 3 independent predictors (cooperativeness, novelty seeking and persistence) which can be identified in about 78-82% of cases in the group of perpetrators of criminal offences or the overall sample. Finally, although this research established some significant distinguishing traits in the observed variables between the respondent groups of perpetrators and non-perpetrators of criminal offences within the framework of diagnostic categories of paranoid schizophrenia, as well as some significant predictive factors in the prediction of psychosis (operationalised in the psychosis scale) that is aggression (operationalised in the spontaneity and reactive aggression scales), we hold that the research results are more probable tendencies rather than staunch facts which should be further researched on a larger sample.

The quality of life during the treatment of long bone fractures in children and adolescents.

This paper evaluates and compares basic emotional reactions towards the illness, as well as the quality of life in relation to the various types of treatment of isolated long tubular bone fractures of extremities in children and adolescents. This prospective clinical research comprehends 135 patients (94 males and 41 females), aged 10 to 18, treated for the mentioned bone fractures in the period from October 2003 till March 2005 at The Departments for Pediatric Surgery of three hospitals: the Clinical Hospital Centre in Rijeka (88.8% of the patients), the Clinical Children's Hospital in Zagreb (9.7% of the patients) both in Croatia, and 1.5% of the patients in the Clinical Hospital in Mostar (Bosnia and Herzegovina). 53.3% of the patients were treated conservatively, 29.6% of them underwent the elastic stable intramedullary nailing (ESIN), while the remaining 17.1% of the patients were treated with other surgical techniques (AO-plates or Kirschner-wire ostheosyntheses). The basic methods were self-reported questionnaires: the Spielberg State Trait Anxiety Inventory (STAIl) to establish momentary anxiety and the Short Form-36 Health Survey (SF-36) to evaluate quality of life, i.e. the perception of the illness during treatment. The STAI1 was administered twice to the patients: within 1 week of the experienced trauma (at baseline) and 6 months after the trauma, whereas the SF-36 was administered only once, i.e. a month after the experienced trauma. Our results point at an increased anxiety indicators in all the patients immediately after the experienced trauma, mostly in patients treated surgically, especially those who underwent the ESIN method; whereas after 6 months from the experienced trauma the anxiety indicators were greatly reduced. The quality of life was better in patients who underwent a conservative treatment, both physically and mentally, than in those surgically treated. This points to the fact that the surgical method itself despite its type, is an additional stressor which causes additional anxiety and depressive reaction. Our results suggest (from psychological point of view) that the conservative method of treating long bone fractures in children and adolescents should be used since it causes less emotional reactions on the illness ascertaining a better health experience during the treatment than the active surgical treatment (regardless of the type), which should be practised with criticism and according to strict surgical indications. If the surgical treatment should be necessarily adopted, we should take into consideration the possibility of psychologically preparing the patients in order to diminish the psychological reaction on the surgical treatment.

The role and importance of consulting psychiatry in paediatric surgery.

The main aim of this study was to point on role and importance of consulting psychiatry in paediatric population of patients particularly in branch of paediatric surgery. This study is a view to a few years research on biopsychosocial aspect of treatment of long bones fractures in children and adolescents realized in Departments for paediatric surgery of three hospitals, in Zagreb and Rijeka, Croatia, as well as in Mostar, Bosnia and Herzegovina, in period 2003.-2007. There have been investigated 135 patients, both gender, 10-18 years of age differently treated for long bones limbs' fractures. Basic methods of work were self-reported questionnaires to evaluate the degree of self-esteem, depression, anxiety, quality of life and perception of social support in mentioned patients. Our results pointed at the influence of type of treatment of long bones fractures on psychological variables, mostly on self-esteem and self-perception of quality of life. As a conclusion, we suggest the possibility of psychological preparation of the patients in order to diminish the psychological reaction to the surgical treatment, as well as individual consulting (liaison) psychiatric intervention during the treatment of fractures of long bones according to the individual needs.

Mental illness and ethnicity - being a stateless person (apatride).

The main aim of this study has been to perceive the state of mentally ill stateless person hospitalized in Psychiatric Hospital Rab, Croatia with forensic status. This is a case report of such a person, F.V., 25 years old female, with no documents and other affirmed auto and heteroanamnestic data. Her psychical state and ability of communication do not allow realization of certain autoanamnesis and in the same time she has no family or relatives to give heteroanamnestic data. It is also unknown exact date and place of birth. Only certain data were that she lived in many orphanages, refugees' camps and communes in several European countries. She immigrated illegally in Croatia where she has made some criminal acts and earned forensic status. We tried to evaluated the complex status of our patient from several points of view and tried to answer to the questions where to start and what to do with such a person to do the best for her and including her human rights. As a conclusion, we could say that holistic and individual approach to such patients has been necessary with engagement of many profiles of professionals.

Psychological consequences of war trauma and postwar social stressors in women in Bosnia and Herzegovina.

AIM: To assess the consequences of psychotrauma in civilian women in Herzegovina who were exposed to prolonged and repetitive traumatic war events and postwar social stressors. METHODS: The study included a cluster sample of 367 adult women, divided into two groups. One group (n=187) comprised women from West Mostar who were exposed to serious war and posttraumatic war events. The other group (n=180) comprised women from urban areas in Western Herzegovina who were not directly exposed to war destruction and material losses, but experienced war indirectly, through military drafting of their family members and friends. Demographic data on the women were collected by a questionnaire created for the purpose of this study. Data on trauma exposure and posttraumatic stress disorder (PTSD) symptoms were collected by Harvard Trauma Questionnaire (HTQ)--Bosnia-Herzegovina version. General psychological symptoms were determined with Symptom Check List-90-revised (SCL-90-R). Data on postwar stressors were collected by a separate questionnaire. RESULTS: In comparison with the control group, women from Western Mostar experienced significantly more traumatic events (mean+/-standard deviation [SD], 3.3+/-3.2 vs 10.1+/-4.9, respectively, t=15.91; P<0.001) and had more posttraumatic symptoms (12.3+/-10.3 vs 21.2+/-10.9, respectively, t=8.42; P<0.001). They also had significantly higher prevalence of PTSD (4.4% vs 28.3%, respectively; chi(2)=52.56; P<0.001). The number of traumatic events experienced during the war was positively associated with postwar stressful events both in the West Mostar group (r=0.223; P=0.002) and control group (r=0.276; P<0.001). Postwar stressful events contributed both to the number and intensity of PTSD symptoms and all general psychological symptoms measured with SCL-90 questionnaire, independently from the number of experienced traumatic war events. CONCLUSION: Long-term exposure to war and postwar stressors caused serious psychological consequences in civilian women, with PTSD being only one of the disorders in the wide spectrum of posttraumatic reactions. Postwar stressors did not influence the prevalence of PTSD but they did contribute to the intensity and number of posttraumatic symptoms.

Burkitt's lymphoma in the boy: infiltration in the stomach, colon and the retroperitoneum--ileocecal invagination.

A 4-year-old boy was hospitalised because showing signs of weakness, slight pain in the abdomen and while urinating. The symptoms occurred 7 days before hospitalisation. The boy did not vomit, nor did he have the urge to vomit, the defecation was regular showing no traces of blood. The physical visit a soft and painless tumefaction was confirmed ileocecally. The echography tests and the computed tomography suggested invagination, not excluding the second substrate. Barium enema showed irreductible invagination. The operative test showed that it was about the ileocolic invagination with extreme thickening of the cecum, the ascedental colon, the intestine and the retroperitoneum walls. A resection of the small intestine and a ileocolic anastomosis was performed. The pathohistological test shows the primar abdominal Burkitt's lymphoma. In spite of the subsequent therapy the boy dies three weeks after the first symptoms' manifestation. We, herewith, suggest at the importance of the echography analysis when diagnosing the Burkitt's tumor and give advantage to this analysis against the computerized tomography. We also point at the huge level of malignancy of the Burkitt's tumor in this boy.

Self-esteem in children and adolescents differently treated for locomotory trauma.

Self-esteem involves the evaluative and affective dimensions of self-concept. It could be influenced by stress situations such as diseases or injuries, especially in the period of puberty and adolescence. The aim of this study was to establish the influence of isolated long tubular bone limbs' fractures in children and adolescents and type of its treatment (conservative or active surgical treatment-various techniques) on self-esteem of patients, as well as to establish relationships between self-esteem, depression, anxiety and perception of the social support in the mentioned patients. This prospective clinical trial comprehends 135 patients, 94 male and 41 female, aged 10 to 18, treated for the mentioned fractures in the period from October 2003 until March 2005 in Departments for Pediatric Surgery of three hospitals: the Clinical Hospital Center in Rijeka (88.8% patients), the Clinical Children's Hospital in Zagreb (9.7%), both in Croatia, and 1.5% of the patients in the Clinical Hospital in Mostar (Bosnia and Herzegovina). 53.3% of the patients were treated conservatively, 29.6% of them underwent the elastic stable intramedullary nailing (ESIN), while the remaining 17.1% of the patients were treated with other surgical techniques (AO-plates or Kirschner-wire ostheosyntheses). The basic methods of work were self-reported questionnaires: Rosenberg Self-esteem Scale (RSS), to establish the degree of self-esteem; Children Depression Inventory (CDI), to establish existence and degree of depression; Spielberg State Trait Anxiety Inventory (STAI)-form STAI2, to establish general anxiety; and Test of Perception of Social Support (TPSS). RSS, CDI and STAI2 were administered twice to the patients: at baseline and after 6 months of the trauma, whereas TPSS once, after 1 month of the trauma. Our results point at an decreased self-esteem followed by increased depression and increased general anxiety indicators in all patients within 1 week of experienced trauma, especially in those who underwent the ESIN method, whereas after 6 months of the experienced trauma, self-esteem significantly increased and depression and general anxiety indicators were greatly reduced in all patients. The type of treatment of fractures has no influence on the perception of the social support. Our results suggest that the ESIN method (regardless of its good surgical results and advantages in relation to many other surgical techniques) reduces self-esteem more than conservatively treatment of fractures and AO-plates and K-wire ostheosyntheses. At the same time self-esteem has been recuperated faster in patients treated with ESIN method. Thus, there is no difference in the influence of the type of the treatment of fractures on self-esteem, but in the dynamics of its recuperation in patients according to type of treatment of fractures. Anyway, from a psychological point of view, any type of surgical treatment could be additional stressor, so it should be practiced with criticism and according to the strict surgical indications.

Has Ombrëdanne's method of hypospadic urethra reconstruction been ignored with reason?

From January 1970 to December 1979 inclusive, 193 boys (aged 2 to 16) underwent surgery for distal hypospadia using Ombredanne's method at the Department of Pediatric Surgery University Hospital Center Rijeka and at the Department of Pediatric Surgery Zagreb. Follow-up period was 7 to 20 years (mean 13.4). 20 (10.36%) subjects had post-operative organic complications and 15 (7.77%) of them required surgical correction. According to these findings, the success rate using Ombredanne's method of reconstruction of the hypospadic urethra in no way lags behind the success rate using MAGPI and Mathieu's methods as well as Preputial island flap urethroplasty for analogous cases. Out of 193 subjects who underwent surgery, 80 (41.45%) of those who were sexually mature and had normal psychosexual development were questioned. In this sample, 75 (93.75%) were satisfied with the post-operative appearance of the penis while only 5 (6.25%) were dissatisfied, 3 of which had hypoplastic penis. In 78 (97.50%) subjects questioned, the post-operative urinary squirt was normal and two of them had weak urinary squirt (2.50%), due to meatal stenosis. In conclusion, Ombredanne's method of reconstruction of the urethra in boys with distal hypospadia is equally successful as other methods used for this purpose.

The impact of PLA2G4A and PTGS2 gene polymorphisms, and red blood cell PUFAs deficit on niacin skin flush response in schizophrenia patients.

We investigated the etiology of the attenuated niacin skin flush response in schizophrenia patients. Skin response to topical niacin of 0.1M, 0.01 M, 0.001 M, and 0.0001 M concentrations was rated using method of volumetric niacin response (VNR) and correlated to two functional A/G polymorphisms in genes: phospholipase A2 group IVA (BanI of the PLA2G4A), and rs689466 of the prostaglandin synthase-2 (PTGS2). We further tested the possible correlation between niacin response and fatty acid (FA) content of red blood cells (RBCs). We detected statistically significant but weak impact of both polymorphisms on niacin flush response in schizophrenia patients. The dosage of the G alleles of both polymorphisms was associated with higher VNR values, although each polymorphic variant accounted for only 1% of the overall flush response variability. Regarding FA content, both n-3 and n-6 polyunsaturated FAs (PUFAs) were significantly reduced in the patient group, but an association with niacin sensitivity was not detected.