Veterinary medicine - Repository of PHD, master's thesis
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Assessment of disease severity in pediatric laryngopharyngeal reflux
No full textLaringofaringealni refluks predstavlja retrogradno kretanje gastroduodenalnog sadržaja iznad gornjeg ezofagealnog sfinktera s mogućnošću dosezanja osjetljive sluznice ždrijela, grkljana i nosne šupljine. Od sredine 1990-ih godina, LPR se sve jasnije diferencira od gastroezofagealnog refluksa i postaje predmet brojnih kliničkih istraživanja. Unatoč tome, zbog nedefiniranih dijagnostičkih kriterija te značajnih ograničenja u dostupnim dijagnostičkim metodama, ne postoje objektivna istraživanja koja bi precizno prikazala stvarnu incidenciju i prevalenciju LPR-a u pedijatrijskoj populaciji. PLPR se učestalije javlja u dojenačkoj dobi što se ponajprije pripisuje nezrelosti antirefluksnih mehanizama. Patofiziologija bolesti temelji se na kombinaciji refluksne i refleksne teorije uz značajnu ulogu psihobihevioralnih čimbenika. Oštećenje sluznice rezultat je djelovanja agresivnih kemijskih
komponenti refluksnog sadržaja kao što su klorovodična kiselina, pepsin, žučne kiseline i tripsin čija štetnost nije strogo ovisna o pH vrijednosti. Refluks može biti kiseli, slabokiseli ili nekiseli po tipu te se može pojaviti u tekućem ili plinovitom obliku. Dijagnostička obrada trebala bi se primarno temeljiti na detaljnoj analizi simptomatologije i lokalnim nalazima uz izbjegavanje invazivnih postupaka kada je to moguće. Međutim, simptomatologija u djece je raznolika i često nespecifična uz jasne razlike po dobnim skupinama. Najčešći simptomi PLPRa uključuju poremećaje disanja, kronični kašalj, promuklost i postnazalno čišćenje sekreta. Postoje brojni upitnici koji procjenjuju vjerojatnost prisutnosti bolesti no većina nije validirana za sve dobne skupine. Nakon početne procjene, definitivna dijagnoza najčešće se postavlja pHmjerenjem ili impedancijskim monitoringom, a u novije se vrijeme pozornost skreće prema neinvazivnim metodama poput određivanja koncentracije salivarnog pepsina. Neophodan je
razvoj standardiziranog, osjetljivog i sveobuhvatnog dijagnostičkog alata koji će biti primjenjiv u različitim dobnim skupinama djece. Liječenje PLPR-a temelji se na stupnjevitom pristupu koji uključuje promjene životnih i prehrambenih navika, farmakološko liječenje (IPP i/ili alginati) i kirurško liječenje koje se primjenjuje samo u najtežim, terapijski rezistentnim slučajevima. Rana identifikacija i pravovremeno liječenje od ključnog su značaja zbog rizika od ozbiljnih komplikacija. Dodatna istraživanja usmjerena na validaciju dijagnostičkih kriterija i optimizaciju terapijskih protokola u djece moraju ostati prioritet kliničkih istraživanja.Laryngopharyngeal reflux refers to the retrograde movement of gastroduodenal contents above the upper esophageal sphincter potentially reaching the sensitive mucosa of the pharynx, larynx and nasal cavity. Since the mid-1990s, LPR has been increasingly recognized as a distinct clinical entity from gastroesophageal reflux and has become the focus of numerous clinical studies. However, due to undefined diagnostic criteria and significant limitations of available
diagnostic methods, there are no objective studies that accurately depict the true incidence and prevalence of LPR in the pediatric population. PLPR is more common in infancy primarily due to the immaturity of anti-reflux mechanisms. The pathophysiology of the condition is based on a combination of reflux and reflex theories with a significant contribution from
psychobehavioral factors. Mucosal damage results from the action of aggressive chemical components of the refluxate such as hydrochloric acid, pepsin, bile acids and trypsin whose harmful effects are not strictly dependent on pH levels. Reflux may be acidic, non-acidic or mixed in type and may occur in liquid or gaseous form. Diagnostic evaluation should primarily
rely on a detailed analysis of symptoms and local findings while avoiding invasive procedures whenever possible. However, symptoms in children are diverse and often nonspecific with clear distinctions across different age groups. The most common symptoms of PLPR include breathing disorders, chronic cough, hoarseness and postnasal drip. Numerous questionnaires exist to assess the likelihood of disease presence but most are not validated across all age
groups. Following initial assessment, a definitive diagnosis is most commonly established via pH monitoring or impedance testing. In recent years, attention has shifted toward non-invasive methods such as measuring salivary pepsin concentration. There is a pressing need to develop a standardized, sensitive and comprehensive diagnostic tool applicable across various pediatric age groups. The treatment of PLPR is based on a stepwise approach that includes lifestyle and
dietary modifications followed by pharmacological therapy (proton pump inhibitors and/or alginates) while surgical intervention is reserved for the most severe, therapy-resistant cases. Early identification and timely treatment are crucial due to the risk of serious complications. Further research focused on validating diagnostic criteria and optimizing therapeutic protocols in children remains a priority
Inflammatory response in patients following aortic root surgery with aortic valve replacement or reconsruction
No full textCilj ovog rada bio je usporediti upalni odgovor kod bolesnika nakon zahvata korijena aorte s rekonstrukcijom ili zamjenom aortnog zaliska te ukazati na jači postoperativni upalni odgovor u bolesnika nakon kirurgije korijena aorte s rekonstrukcijom aortnog zaliska. Provedeno je retrospektivno opservacijsko istraživanje u kojem je proučavana uzastopna populacija bolesnika s dijagnozom aortne regurgitacije, isključujući disekciju aorte, podvrgnutih operativnom zahvatu od 11. studenog 2014. do 20. prosinca 2024. na Zavodu za kardijalnu i transplantacijsku kirurgiju Kliničke bolnice Dubrava. Od ukupno promatranih 154 bolesnika njih 144 je zadovoljilo kriterije ulaska u istraživanje. U skupinu bolesnika podvrgnutih kirurgiji korijena aorte s rekonstrukcijom aortnog zaliska svrstano je njih 113 (78,5%), dok je u skupinu bolesnika podvrgnutih kirurgiji korijena aorte sa zamjenom aortnog zaliska svrstan 31 bolesnik (21,5%). Nakon statističke obrade podataka uočena je viša srednja životna dob bolesnika podvrgnutih kirurgiji korijena aorte uz zamjenu aortnog zaliska (p = <0,001) te više vrijednosti EuroSCORE II (p = 0,009). Nadalje, bolesnici podvrgnuti kirurgiji korijena aorte s rekonstrukcijom aortnog zaliska imali su dulje vrijeme trajanja operacije (p = <0,001), dulje vrijeme ekstrakorporalne cirkulacije (p = <0,001) te dulje vrijeme klemanja aorte (p = <0,001). U bolesnika koji su razvili povišenu tjelesnu temperaturu, najviša izmjerena vrijednost je bila statistički značajno viša u bolesnika podvrgnutih kirurgiji korijena aorte s rekonstrukcijom aortnog zaliska u odnosu na drugu skupinu bolesnika (p = 0,001). Statističkom obradom nisu dokazane statistički značajne razlike između ove dvije skupine bolesnika u vrijednostima CRP- a (p = 0,103), broja leukocita u krvi (p = 0,261) i brzine sedimentacije eritrocita (p = 0,750). Unatoč duljem trajanju zahvata i većoj tehničkoj složenosti kirurgije korijena aorte s rekonstrukcijom zaliska, razlike u postoperativnom upalnom odgovoru nisu dosegle statističku značajnost.The aim of this study was to compare the inflammatory response in patients after aortic root surgery with either aortic valve reconstruction or replacement and to highlight the greater postoperative inflammatory response in patients undergoing aortic root surgery with aortic valve reconstruction. A retrospective observational study was conducted, analyzing a consecutive population of patients diagnosed with aortic regurgitation, excluding aortic dissection, who underwent surgery from November 11, 2014 to December 20, 2024 at the Department of Cardiac and Transplant Surgery, University Hospital Dubrava. Out of a total of 154 patients observed, 144 met the inclusion criteria. A total of 113 patients (78,5%) were included in the group undergoing aortic root surgery with aortic valve reconstruction, while 31 patients (21,5%) were included in the group undergoing aortic root surgery with aortic valve replacement. Statistical analysis revealed a higher mean age of patients who underwent aortic root surgery with valve replacement (p < 0,001), as well as higher EuroSCORE II values (p = 0,009). Furthermore, patients who underwent aortic root surgery with valve reconstruction had longer operative time (p < 0,001), longer cardiopulmonary bypass time (p < 0,001), and longer aortic cross-clamp time (p < 0,001). Among patients who developed elevated body temperature, the highest recorded temperature was significantly higher in patients undergoing aortic root surgery with valve reconstruction compared to the other group (p = 0,001). Statistical analysis did not show significant differences between two groups in CRP values (p = 0,103), white blood cell count (p = 0,261) or erythrocyte sedimentation rate (p = 0,750). Despite the longer duration and greater technical complexity of aortic root surgery with valve-sparing reconstruction, the differences in the postoperative inflammatory response did not reach statistical significance
Outcomes of childbirth in the transverse position at the Clinic for Gynecology and Obstetrics at the Clinical Hospital "Sveti Duh" during the period 2016-2024
No full textPoprečni položaj fetusa predstavlja rijetku, ali klinički značajnu malprezentaciju koja zahtijeva pravovremeno prepoznavanje i individualizirano vođenje trudnoće. Cilj rada bio je analizirati ishode poroda kod trudnica s dijagnosticiranim poprečnim položajem fetusa u razdoblju od 2016. do 2024. godine u Klinici za ginekologiju i porodništvo KB Sveti Duh. Retrospektivnom analizom obuhvaćeno je 177 poroda s najmanje jednim fetusom u poprečnom položaju što čini 0,66% svih poroda. U 177 poroda porođeno je 190 djece u poprečnom položaju. Većina trudnoća (63,28%) bila je višeplodna. Analizom je ustanovljeno da je 94,35% poroda dovršeno carskim rezom. Uočen je značajan udio prijevremenih poroda (63,84%) i niže porođajne mase, osobito u višeplodnim trudnoćama. Čimbenici poput multipariteta, mioma, polihidramnija i anomalija maternice identificirani su kao predisponirajući. Rezultati su pokazali visoku stopu neonatalnog preživljenja i povoljne APGAR rezultate što ukazuje na uspješno kliničko zbrinjavanje. Ograničenja istraživanja uključuju retrospektivni dizajn i ograničenu mogućnost uvida u sve kliničke detalje. Ovo istraživanje potvrđuje važnost pravovremene dijagnoze i kirurškog dovršenja trudnoće u slučajevima poprečnog položaja, posebice u višeplodnim i visokorizičnim trudnoćama.Transverse fetal lie represents a rare but clinically significant malpresentation that requires timely recognition and individualized management. The aim of this study was to analyze the birth outcomes of pregnant women diagnosed with transverse fetal lie between 2016 and 2024 at the Clinic of Obstetrics and Gynecology, Clinical Hospital Sveti Duh. A retrospective analysis included 177 births with at least one fetus in transverse lie, accounting for 0.66% of all deliveries. A total of 190 fetuses in transverse lie were delivered. Most pregnancies (63.28%) were multiple gestations. The analysis showed that 94.35% of the deliveries were completed via cesarean section. A significant proportion of preterm births (63.84%) and lower birth weight, particularly in multiple pregnancies, was observed. Risk factors such as multiparity, uterine fibroids, polyhydramnios, and uterine anomalies were identified as contributing. The results demonstrated a high neonatal survival rate and favorable APGAR scores, indicating effective clinical management. Limitations of the study include its retrospective design and limited access to all clinical details. This study confirms the importance of timely diagnosis and surgical delivery in cases of transverse fetal lie, especially in multiple and high-risk pregnancies
Knee joint distraction in treatment of knee osteoarthritis
No full textDistrakcija (u nastavku teksta: razdvajanje) zglobnih tijela koljena (engl. knee joint distraction, KJD) predstavlja noviji pristup u liječenju uznapredovalog osteoartritisa (OA) koljena, osobito u mlađih pacijenata kod kojih je cilj odgoditi potrebu za ugradnjom totalne endoproteze koljena (eng. total knee arthroplasty, TKA). Temelji se na privremenom mehaničkom razdvajanju zglobnih tijela femura i tibije pomoću vanjskog fiksatora, čime se smanjuje opterećenje zglobne hrskavice i omogućuje reparaciju tkiva u uvjetima rasterećenja. Pritom dolazi do pozitivnih biomehaničkih i bioloških promjena, koje uključuju smanjenje upalnih medijatora, smanjeno aberantno remodeliranje subhondralne kosti te poticanje reparacije hrskavičnog matriksa. U ovom radu prikazan je mehanizam djelovanja KJD-a, operativna tehnika postavljanja vanjskog fiksatora te protokol praćenja i rehabilitacije pacijenata. Analizirani su dostupni klinički i eksperimentalni dokazi koji ukazuju na kliničko poboljšanje funkcije koljena, smanjenje boli i proširenje zglobnog prostora u značajnog broja bolesnika. Također su prikazane komparativne studije između KJD-a i standardnih zahvata, poput osteotomije proksimalne tibije (eng. high tibial osteotomy, HTO) i TKA koje ukazuju da KJD može biti jednako učinkovit u kratkoročnom ishodu kao i standardne operacijske metode, uz dodatnu prednost očuvanja prirodne anatomije zgloba. Iako su rezultati ohrabrujući, potrebno je dodatno istražiti dugoročne ishode, potencijalne komplikacije i optimalne indikacije za ovu metodu. KJD se pokazuje kao obećavajuća opcija za birane pacijente, osobito mlađe s unilateralnim OA, očuvanim ligamentarnim strukturama i očuvanim preostalim zglobnim prostorom. Time se otvara prostor za nove mogućnosti u liječenju artroze koljena s ciljem očuvanja zgloba i funkcionalne neovisnosti bolesnika.Knee joint distraction (KJD) represents a novel approach in the treatment of advanced knee osteoarthritis, particularly in younger patients for whom the goal is to postpone total knee arthroplasty. The technique is based on the temporary mechanical separation of the femoral and tibial joint surfaces using an external fixator, thereby reducing the load on the articular cartilage and enabling tissue regeneration under unloaded conditions. This results in favorable biomechanical and biological changes, including a reduction of inflammatory mediators, decreased subchondral bone remodeling, and stimulation of cartilage matrix repair. This paper presents the mechanism of action of KJD, the surgical technique for external fixator placement, as well as the protocol for patient follow-up and rehabilitation. Available clinical and experimental evidence is analyzed, indicating improvement in knee function, pain reduction, and joint space widening in a significant number of patients. Comparative studies between KJD and standard procedures such as high tibial osteotomy (HTO) and total knee arthroplasty (TKA) are also presented, suggesting that KJD may achieve similar short-term outcomes, with the added benefit of preserving the native joint anatomy. Although the results are promising, further research is needed to investigate long-term outcomes, potential complications, and optimal patient selection for this method. KJD is emerging as a promising option for selected patients, particularly younger individuals with unilateral osteoarthritis, intact ligamentous structures, and preserved residual joint space. As such, it opens the door to a new paradigm in the treatment of knee osteoarthritis focused on joint preservation and maintaining patients’ functional independence
Human Papilloma Virus Infection in Men: A Specific Human Virome or a Specific Pathology?
No full textBackground: Human papillomavirus (HPV) infections in men remain under-researched despite their critical role in disease transmission and the increasing incidence of HPV-related cancers. This study investigates the clinical and molecular characteristics of anogenital HPV infections in men, emphasizing genotype prevalence, diagnostic methods, and lesion variability.
Methods: A cross-sectional study was conducted on 70 men aged 18–65 years with clinically diagnosed anogenital HPV infection. Lesions were characterized by morphology and location. HPV DNA was analyzed using INNO-LiPA (INNOvative Line Probe Assay), Hybrid Capture II (HC II), and polymerase chain reaction (PCR) assays to determine genotype distribution. Associations between clinical features and HPV genotypes were assessed using multivariate statistical analyses.
Results: Lesions varied in morphology, with verrucous (52.86%) and papular (30%) types being the most common. Localization patterns showed predominance on the penis radix (34.29%) and shaft (27.14%). Molecular testing revealed HPV DNA in 88.57% of the cases using INNO-LiPA, compared to 45% and 40% with HC II and PCR, respectively. Low-risk (LR) genotypes, particularly HPV6, dominated single infections, comprising 68.57% of the cases, while high-risk (HR) genotypes accounted for 20%. Mixed LR and HR infections were observed in 14.29% of the lesions, with greater diversity noted in distal genital regions. Notably, condyloma plana and lesions on the inner prepuce exhibited a higher prevalence of HR and mixed infections. Age and lesion duration showed trends toward older patients and longer disease duration in cases involving perianal and extragenital condylomas, though these findings were not statistically significant. No direct correlation between lesion type or localization and specific genotypes was identified, underscoring the heterogeneity of HPV clinical manifestations in men.
Conclusions: Anogenital HPV infections in men exhibit significant heterogeneity in lesion morphology, localization, and genotype distribution. HR HPV genotypes were detected in a notable proportion of benign lesions, underscoring their potential role in disease progression. INNO-LiPA proved superior in diagnostic accuracy, highlighting the need for standardized and cost-effective diagnostic approaches for men. Further research is crucial to elucidate HPV’s clinical impact in men and inform prevention and treatment strategies
Dabigatran-related nephropathy: a case report and literature review
No full textOralni antikoagulansi mogu dovesti do akutnog bubrežnog oštećenja (ABO), tzv. nefropatije povezane s primjenom antikoagulansa (ARN, engl. anticoagulant-related nephropathy), obilježene glomerularnim krvarenjem i opstrukcijom tubula eritrocitnim cilindrima. Varfarin se najčešće povezuje s ARN-om, no recentna istraživanja pokazala su da i novi antikoagulansi čiji je mehanizam djelovanja neovisan o vitaminu K, poput dabigatrana (DG), mogu uzrokovati ARN koja je u slučaju DG-a nazvana dabigatranskom nefropatijom. Većina slučajeva dabigatranske nefropatije opisana je kod pacijenata s parenhimskom bubrežnom bolešću, najčešće IgA nefropatijom. U ovom radu prikazujemo slučaj dabigatranske nefropatije dokazane bubrežnom biopsijom u pacijentice stare 75 godina bez preegzistentne bubrežne bolesti koja je DG uzimala zbog trajne fibrilacije atrija. Prezentirala se makrohematurijom i teškim ABO-om uz prisutne kliničke i radiološke znakove srčanog popuštanja i infekcije kože potkoljenice. Histološka analiza nakon bubrežne biopsije pokazala je umjereno do teško akutno tubularno oštećenje s intratubularnim eritrocitnim cilindrima i arealima intersticijskog krvarenja. Bubrežna se funkcija poboljšala nakon isključenja DG-a i kratkotrajne terapije glukokortikoidima. Ovaj prikaz pokazuje da i DG, poput varfarina, može povećati rizik od bubrežnog tubularnog krvarenja neovisno o prisutnosti parenhimske bubrežne bolesti.Oral anticoagulants can cause acute kidney injury (AKI) called anticoagulant-related nephropathy (ARN) characterized by glomerular hemorrhage and tubular obstruction by red blood cell (RBC) casts. ARN is most commonly related to warfarin. Recent research showed that non-vitamin K oral anticoagulants (NOACs), such as dabigatran (DG), can also be related to a similar type of AKI consistent with ARN called DG-related nephropathy. The vast majority of previously reported cases of DG-related nephropathy included patients with another parenchymal renal disease, most commonly IgA nephropathy (IgAN). Here, we describe a case of kidney biopsy-confirmed DG-related nephropathy in a seventy-five-year-old female patient without evidence of preexisting renal disease. She has been taking dabigatran due to permanent atrial fibrillation of several years duration. She presented with gross hematuria, severe AKI, clinical and radiological signs of heart failure and skin infection of the lower limb. Renal biopsy revealed normal glomeruli with signs of moderate to severe acute tubular injury with large intratubular RBC casts and zones of interstitial hemorrhage. Renal function improved significantly after DG withdrawal. This case demonstrates that DG, like warfarin, may increase the risk of renal tubular bleeding in patients, irrespective of the absence of other parenchymal kidney disease
An update on multimodal imaging strategies for nipple discharge: from detection to decision
No full textNipple discharge affects over 80% of women at some point in their lives, with malignancy detected in up to 23% of cases. This review highlights the shift from traditional surgical approaches to advanced imaging techniques, which enhance diagnostic accuracy and reduce unnecessary procedures. Diagnosis begins with a thorough medical history and physical examination to assess the need for imaging. Physiological nipple discharge, which is bilateral, multiductal, and non-spontaneous, typically requires no imaging. Conversely, pathological nipple discharge (PND), characteristically unilateral, uniductal, and spontaneous, requires imaging to rule out malignancy. Bloody PND is frequently associated with breast cancer, and up to 12% of non-bloody PND cases also involve malignancy. For women over 40 years, the first-line imaging modality is full-field digital mammography (FFDM) or digital breast tomosynthesis (DBT), usually combined with ultrasound (US). Men with PND undergo FFDM/DBT starting at age 25 years due to their higher risk of breast cancer. For women aged 30-39 years, US is the first assessment tool, with FFDM/DBT added, if necessary, while US is preferred for younger women and men. When initial imaging is negative or inconclusive, magnetic resonance imaging (MRI) is useful, often replacing galactography. With its high sensitivity and negative predictive value of almost 100%, a negative MRI can often obviate the need for surgery. Contrast-enhanced mammography (CEM) offers a viable alternative when MRI is not feasible. Although invasive, ductoscopy helps identify patients who may not require duct excision. This review consolidates the latest evidence and proposes an updated diagnostic algorithm for managing PND effectively. CRITICAL RELEVANCE STATEMENT: Effective management of nipple discharge requires recognising when imaging tests are needed and selecting the most appropriate diagnostic technique to rule out malignancy and avoid unnecessary interventions. KEY POINTS: First-line imaging for pathological nipple discharge (PND) assessment includes ultrasound and mammography. MRI is recommended for patients with PND and negative conventional imaging. A negative MRI is sufficient to justify surveillance rather than surgery. Contrast-enhanced mammography (CEM) is an alternative when MRI is unavailable or contraindicated
Flash Glucose Monitoring for Predicting Cardiogenic Shock Occurrence in Critically Ill Patients: A Retrospective Pilot Study
No full textBackground/Objectives: Continuous and flash glucose monitoring (CGM and FGM) may enhance glucose management by providing real-time glucose data. Furthermore, growing evidence is linking altered blood glucose concentrations and worse short-term outcomes in critically ill patients. While hyperglycemia is more common in these patients and is associated with an increased risk of adverse events, hypoglycemia is particularly concerning and significantly raises the risk of fatal outcomes. This exploratory study investigated the link between FGM variables and cardiogenic shock in critically ill Coronary Care Unit (CCU) patients.
Methods: Twenty-eight CCU patients (1 May 2021–31 January 2022) were monitored using a Libre FreeStyle system. Analyzed data included patient demographic and laboratory data, left ventricular ejection fraction, standard glucose monitoring, APACHE IV scores, and cardiogenic shock occurrence. Analysis was performed using the χ2 test, Mann–Whitney U test, and logistic regression.
Results: Among the patients, 13 (46.43%) developed cardiogenic shock. FGM detected hypoglycemia in 18 (64.29%) patients, while standard methods in 6 (21.43%) patients. FGM-detected hypoglycemia was more frequent in patients who developed cardiogenic shock (p = 0.0129, χ2 test) with a significantly higher time below range reading (p = 0.0093, Mann Withney U test), despite no differences in mean glucose values. In addition, hypoglycemia detected by FGM was an independent predictor of shock (p = 0.0390, logistic regression).
Conclusions: FGM identified more hypoglycemic events compared to standard glucose monitoring in the CCU. Frequent FGM-detected hypoglycemic events were associated with cardiogenic shock, regardless of a history of diabetes. Due to a limited sample size, these results should be interpreted cautiously and further research in this area is justified
Methodological framework of cost and effectiveness analysis with special reference to emergency medicine
No full textDjelatnost hitne medicine jedna je od temeljnih elemenata zdravstvenog sustava. Ona zahtijeva uključivanje svih dionika odlučivanja u sustavu zdravstva. Metode ekonomskih analiza u zdravstvu pomažu u adekvatnom donošenju odluka, posebice novih intervencija u pružanju zdravstvene skrbi. Metoda analize troškova i učinkovitosti uspoređuje razliku u kvaliteti života intervencije prema financijskom trošku njena uvođenja. Potrebno ju je provesti temeljeno na dokazima i strukturirano. Cilj ovog stručnog rada jest izraditi metodološki okvir koji može koristiti donošenju ekonomski argumentiranih odluka u hitnoj medicini. Alat koji se predlaže omogućava provedbu istraživanja usmjeravanjem i standardizacijom analize troškova i učinkovitosti u kontektstu bolničke hitne medicine. Izrađen je temeljem preporuka stručnih tijela i pojedinih autora pregledom literature u skladu s PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) preporukama uključivanjem 155 radova od 2000. do 2022. godine. Metodološki okvir podijeljen je u deset koraka: prva tri koraka bave se definicijom problematike, a ostali ekonomskom i socijalnom analizom sastavnih elemenata. Za svaki korak predložene su ključne sastavnice koje je u analizu potrebno uključiti. Primjenom ovog alata moguće je pružanje hitne medicinske skrbi koja je pristupačna, kvalitetna i pravodobna, uzimajući u obzir svojstva zdravstvenog i ekonomskog sustava u kojem se intervencija provodi.Emergency medicine is one of the fundamental elements of the healthcare system. It requires the involvement of all decision-making stakeholders in the healthcare system. Methods of economic analysis help in adequate decision-making, especially new interventions with healthcare providers. The cost-effectiveness analysis compares different interventions in the quality of life and its financial cost. It needs to be conducted in an evidence-based and structured manner. The goal of this paper is to create a methodological framework that can be used to make economically argued decisions in emergency medicine. The proposed tool enables the implementation of research by directing and standardizing the cost and effectiveness analysis in the context of hospital emergency medicine. It was based on the recommendations of professional bodies and individual authors by reviewing the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), including 155 papers from 2000 to 2022. The methodological framework is divided into ten steps: the first three steps deal with the definition of the problem, and the others with the economic and social analysis of the constituent elements. For each step, key components that should be included in the analysis are proposed. By applying this tool, it is possible to provide emergency medical care that is affordable, high-quality and timely, taking into account the characteristics of the health and economic system in which the intervention is carried out
Adenoviral Pneumonia Outbreak in Immunocompetent Adults—A Missed Antimicrobial Stewardship Opportunity?
No full textBackground/Objectives: While the concept of viral community-acquired pneumonia (CAP) changed with COVID-19, the role of non-influenza viruses as a cause of CAP is less clear. The aim of this study was to describe the clinical course, risk factors, inflammatory profiles, antibiotic use, outcomes and complications of adenoviral (AdV) CAP.
Methods: A prospective, non-interventional, observational cohort study included consecutively hospitalized immunocompetent adult patients with AdV CAP during an 18-month period. Clinical and laboratory data, including lymphocyte subpopulations and serum cytokine profiles were collected and correlated to clinical outcomes.
Results: Fifty-eight patients with AdV CAP were included; 81% were males, with a median age of 33 (IQR 28–41) years and 62% without any comorbidities. All patients initially had high-grade fever for a median duration of 6 (5–7) days and respiratory symptoms. Increased CRP and procalcitonin, lymphopenia, mild thrombocytopenia and liver injury were frequent. Radiographic findings mimicked bacterial pneumonia (83% had unilateral involvement). Twenty-two patients (38%) had criteria for severe CAP, and these patients had higher procalcitonin, NLR, AST, ALT, LDH and CK, and lower T-lymphocyte CD4+ count. In comparison to influenza and bacterial CAP, patients with AdV had higher serum IL-2, IL-1β, IL-8, IL-10, CXCL10 and MCP-1, and lower TGF-β1 concentration. Thirteen patients required low-flow oxygen therapy, and 13 advanced respiratory support. Complications occurred in 29%, with one fatal outcome. While all patients received empirical antibiotic therapy, after AdV detection it was stopped in 21%, although only one patient had detected a possible bacterial coinfection.
Conclusions: Since AdV CAP in immunocompetent patients is clinically and radiologically indistinguishable from bacterial CAP, it is associated with prolonged clinical course and lack of clinical response to antibiotics. This emphasizes the importance of AdV testing which could lead to more rational antimicrobial treatment