ICPC-2--international classification of primary health care and its application in Croatian health care

A consensus reached by the medical profession, Croatian Institute of Health Insurance, Croatian Institute of Public Health, and Ministry of Health constitutes a solution to the problem of a data standard required in building an information system for primary health care. This consists of accepting ICPC-2 as a data standard for our Family Medicine, Pediatrics and Women's Health. The classification structure of the International Classification of Primary Care allows, recommends and urges that special codes be established by individual states or local authorities when registering patients' reasons for seeking medical aid or medical procedures. Namely, it urges the authorities to set the codes for such reasons about which a state or local agreement or determination has been made. This is the first public presentation of the proposal Croatia's Additions to the International Classification of Primary Care. They are essential to its implementation in our health insurance, health statistics and medical informatics.     

Cardiac Rhythm and Conduction Disturbances: What is the Role of Autoimmune Mechanisms?

The immunopathogenesis of cardiac rhythm and conduction disorders has been underestimated. Therefore, the aim of this review is to analyze the current data and controversial issues in this area. The incidence of autoantibodies to human conducting tissue has been analyzed in sick sinus syndrome, bradyarrhythmia, and hypersensitive carotid sinus syndrome. Patients with anti-sinus node antibodies (ASNab) have a 10-fold higher risk of developing sick sinus syndrome, compared to age-matched controls. The risk of acquiring an atrioventricular block was up to 3-fold in patients with anti-atrioventricular node antibodies (AAVNab) in comparison to controls. The incidence of anti His antibodies (AHISab) was low both in patients and controls. Anti-cardiac Purkinje cell antibodies (ACPCab) seemed to be an epiphenomenon and not a pathogenetic marker of conduction disorders. In congenital heart block association with HLA-B27 and HLA-DR3 is a possible prerequisite in the pathophysiology of the disease, although transplacental passage of various antibodies and immune complexes is widely recognized. The main autoantibodies detected both in children with congenital heart block and their mothers are anti-Ro/SS-A and anti-La/SS-B antibodies. The cross-reactivity of laminin with anti-La antibodies could be important in the initiation of the autoimmune process. Autoantibodies against adrenoceptors and muscarinic cholinergic receptors of neonatal heart and human endogenous retrovirus-3 expressed in fetal cardiac tissue could also play a role in the pathogenesis of the congenital heart block. Of note, apoptosis could be one of the possible mechanisms of the progression of the congenital conduction disturbances to the complete heart block. In addition, evidence is compiling that cellular activation and cellular cytotoxicity specific for a given target tissue appears to be at least equally important in the pathogenesis of the disease as the humoral response. In conclusion, the immunopathogenesis of certain cardiac rhythm and conduction disorders is well established in sick sinus syndrome, congenital heart block, and connective tissue diseases. ASNab, AAVNab, anti-Ro/SS-A, and anti-La/SS-B antibodies can be regarded as diagnostic and prognostic markers.     

The Armenian healthcare system: recent changes and challenges

Background  Armenian healthcare reforms have been carried out since independence in 1991, but achieved their full scale starting in 1995–1996. Although the healthcare system has already been modified and changed for 10 years, there is a lack of research in this regard. Objectives  This paper aims to present the organization of the healthcare system in Armenia, its changes and challenges throughout the reform process. Methods  This paper is mainly based on a review of the relevant professional literature, a review and interpretation of legal acts in the healthcare field, and a review of research and assessment works done by several international and local organizations. Results  There are still large numbers of elements typical for the Soviet Semashko model in Armenian healthcare structures. Implemented reforms have separated the institutions of the public payer and the providers, but did not manage to change the model of financing to be based on compulsory insurance. The level of financing is similar to the average in Central and Eastern Europe, but is based mainly on out-of-pocket payments contributing to about 80% of all system resources. The informal payments reach even 45% of expenditures. The structure of hospital beds remains ineffective, and there are still no mechanisms of increasing the quality of services. Privatization has been applied, but the role of private providers is still limited. Conclusions  The reforms have not caused satisfactory improvement in healthcare performance, although the health indicators are better than at the beginning of the transformation period. The stability of the reforming processes in previous years as well as the engagement of international institutions is a chance for positive changes in the near future.     

Anatomical Basis of Variability in Injuries of the Medial Malleolus and the Deltoid Ligament: II. Clinical Studies

The anatomical concept of the deltoid ligament as being attached to the anterior colliculus of the medial malleolus by its superficial portion, and to the posterior colliculus by its deep portion has been applied to a clinical material. A number of singular and concurrent lesions of the medial malleolus and the deltoid ligament were recognized: fracture of the anterior colliculus, concurrent fracture of the anterior colliculus and rupture of the deep posterior talotibial ligament, fracture of the posterior colliculus, supracollicular fracture, rupture of the deltoid ligament, and chip fracture of the anterior colliculus. The clinical implications of these lesions are discussed.     

Pericardial Disease in Pregnancy

Background: There is no evidence that pregnancy affects susceptibility to pericardial disease. However, when such a condition occurs, its proper diagnosis and management may be crucial for the outcome of the pregnancy. Incidence and Diagnosis: Hydropericardium is the most frequent form of pericardial involvement in pregnancy. It is typically a small, clinically silent pericardial effusion present in the third trimester in approximately 40% of healthy pregnant women. Small amounts of fetal pericardial fluid (< 2 mm in echocardiography, in diastole) can be detected after 20 weeks of gestation. Larger effusions should raise clinical concern for hydrops fetalis, Rh disease, hypoalbuminemia, and infectious or autoimmune disorder. Wide varieties of etiologic forms of pericardial diseases occur sporadically in pregnant women. Significant symptoms, electrocardiographic changes, or physiologic impairment warrant hospitalization. Treatment: Most pericardial disorders are managed during pregnancy as in nonpregnant patients (i.e., nonsteroidal antiinflammatory drugs for acute, antibiotics and drainage for purulent pericarditis, and corticosteroids for systemic autoimmune disorders). However, colchicine is contraindicated in pregnancy, and pericardiocentesis should be performed only for very large effusions causing clinical signs of cardiac tamponade or if presence of suppurative, tuberculous or neoplastic pericardial effusion is suspected. Echocardiographic guidance of pericardiocentesis is preferred to fluoroscopic guidance in order to avoid fetal X-ray exposure. Pericardiectomy should be reserved for significant pericardial constriction and resistant bacterial infections. Delivery of normal infants in term after pericardiocentesis or pericardiectomy is expected, whenever natural history of causative disease allows. Pericardiectomy itself is not a contraindication for subsequent successful pregnancies. Zusammenfassung. Hintergrund: Hinweise dafür, dass eine Schwangerschaft zur Entstehung von Perikarderkrankungen prädisponiert oder deren Ausbildung beeinflusst, gibt es nicht. Wenn aber während der Schwangerschaft eine Perikarderkrankung auftritt, sind eine schnelle Diagnose und die richtige Behandlung von großer Bedeutung. Inzidenz und Diagnose: Die häufigste Form eines Perikardergusses während der Schwangerschaft ist das "Hydroperikard". Es handelt sich typischerweise um das Auftreten eines kleinen, klinisch nicht relevanten Perikardergusses im dritten Trimenon der Schwangerschaft. Bei ca. 40% aller gesunden Schwangeren ist ein solcher minimaler Erguss nachweisbar. In der 20. Schwangerschaftswoche kann auch bei den Feten ein kleiner Perikarderguss nachgewiesen werden, der in der fetalen Echokardiographie eine Separation von < 2 mm zeigen sollte. Größere Ergüsse sind meist das erste klinische Zeichen für einen Hydrops fetalis, eine Rhesus-Blutgruppenunverträglichkeit, eine Hypoalbuminämie bzw. infektiöse oder autoimmune Erkrankungen des Fetus und/oder der Mutter. Die Ätiologie der Perikarderkrankungen der Mutter während der Schwangerschaft ist vielfältig, wobei die akute virale Perikarditis und Perikardergüsse im Rahmen systemischer autoimmuner Erkrankungen die häufigsten Ursachen darstellen. Selten findet man auch Perikardergüsse bei Schwangeren im Rahmen von Tumorerkrankungen oder einer Tuberkulose. Wenn starke präkordiale Schmerzen, Veränderungen im EKG und eine deutliche Beeinträchtigung der Belastungsfähigkeit auftreten, ist eine Klinikeinweisung unumgänglich. Therapie: Die meisten Perikarderkrankungen bei Schwangeren werden behandelt wie die von Nichtschwangeren, d.h. mit nichtsteroidalen antiinflammatorischen Medikamenten bei akuter Perikarditis, mit Antibiotika und ggf. einer Drainage bei eitrigen Perikardergüssen bzw. der Gabe von Kortikosteroiden bei autoimmunen Systemerkrankungen. Die Gabe von Colchicin ist während der Schwangerschaft kontraindiziert. Eine Perikardpunktion wird nur bei großen Perikardergüssen mit den klinischen Zeichen einer akuten Tamponade bzw. bei Verdacht auf Tuberkulose, infektiösen Erguss oder Tumorerkrankung durchzuführen sein. In diesen wenigen Fällen ist eine echokardiographisch gesteuerte Punktion angebracht, um eine Strahlenbelastung des Ungeborenen zu vermeiden. Eine Perikardektomie sollte nur bei perikardialer Konstriktion und schwerer bakterieller Infektion durchgeführt werden. Die Prozeduren Perikardpunktion und Perikardektomie allein haben, vom Interventions- bzw. Operationsrisiko abgesehen, keinen negativen, sondern eher einen günstigen prognostischen Einfluss auf die Schwangerschaft. Es gibt bislang keine ausreichenden Daten dafür, dass eine Perikardergussbildung in einer vorausgegangenen Schwangerschaft bei erneuter Gravidität zu einem Rezidiv führt. Liegen gleichzeitig allerdings eine linksventrikuläre Dilatation und Dysfunktion vor, ist, wie im Beitrag "Schwangerschaft und Kardiomyopathie" ausgeführt, nach den Empfehlungen der European Society of Cardiology (ESC) von einer erneuten Schwangerschaft abzuraten.     

Alterations of action potentials and the localization of Nav1.6 sodium channels in spared axons after hemisection injury of the spinal cord in adult rats

Previously, we reported a pronounced reduction in transmission through surviving axons contralateral to chronic hemisection (HX) of adult rat spinal cord. To examine the cellular and molecular mechanisms responsible for this diminished transmission, we recorded intracellularly from lumbar lateral white matter axons in deeply anesthetized adult rats in vivo and measured the propagation of action potentials (APs) through rubrospinal/reticulospinal tract (RST/RtST) axons contralateral to chronic HX at T10. We found decreased excitability in these axons, manifested by an increased rheobase to trigger APs and longer latency for AP propagation passing the injury level, without significant differences in axonal resting membrane potential and input resistance. These electrophysiological changes were associated with altered spatial localization of Nav1.6 sodium channels along axons: a subset of axons contralateral to the injury exhibited a diffuse localization (>10 μm spread) of Nav1.6 channels, a pattern characteristic of demyelinated axons (Craner MJ, Newcombe J, Black JA, Hartle C, Cuzner ML, Waxman SG. Proc Natl Acad Sci USA 101: 8168-8173, 2004b). This result was substantiated by ultrastructural changes seen with electron microscopy, in which an increased number of large-caliber, demyelinated RST axons were found contralateral to the chronic HX. Therefore, an increased rheobase, pathological changes in the distribution of Nav1.6 sodium channels, and the demyelination of contralateral RST axons are likely responsible for their decreased conduction chronically after HX and thus may provide novel targets for strategies to improve function following incomplete spinal cord injury.