Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a double-blinded randomized placebo-controlled clinical trial

Aim

To assess the effect of peritonsillar infiltration of ketamine and tramadol on post tonsillectomy pain and compare the side effects.

Methods

The double-blind randomized clinical trial was performed on 126 patients aged 5-12 years who had been scheduled for elective tonsillectomy. The patients were randomly divided into 3 groups to receive either ketamine, tramadol, or placebo. They had American Society of Anesthesiologists physical status class I and II. All patients underwent the same method of anesthesia and surgical procedure. The three groups did not differ according to their age, sex, and duration of anesthesia and surgery. Post operative pain was evaluated using CHEOPS score. Other parameters such as the time to the first request for analgesic, hemodynamic elements, sedation score, nausea, vomiting, and hallucination were also assessed during 12 hours after surgery.

Results

Tramadol group had significantly lower pain scores (P = 0.005), significantly longer time to the first request for analgesic (P = 0.001), significantly shorter time to the beginning of liquid regimen (P = 0.001), and lower hemodynamic parameters such as blood pressure (P = 0.001) and heart rate (P = 0.001) than other two groups. Ketamine group had significantly greater presence of hallucinations and negative behavior than tramadol and placebo groups. The groups did not differ significantly in the presence of nausea and vomiting.

Conclusion

Preoperative peritonsillar infiltration of tramadol can decrease post-tonsillectomy pain, analgesic consumption, and the time to recovery without significant side effects.Registration No: IRCT201103255764N2Postoperative pain has not only a pathophysiologic impact but also affects the quality of patients’ lives. Improved pain management might therefore speed up recovery and rehabilitation and consequently decrease the time of hospitalization (1). Surgery causes tissue damage and subsequent release of biochemical agents such as prostaglandins and histamine. These agents can then stimulate nociceptors, which will send the pain message to the central nervous system to generate the sensation of pain (2-4). Neuroendocrine responses to pain can also cause hypercoagulation state and immune suppression, leading to hypoglycemia, which can delay wound healing (5).Tonsillectomy is a common surgery in children and post-tonsillectomy pain is an important concern. Duration and severity of pain depend on the surgical technique, antibiotic and corticosteroid use, preemptive and postoperative pain management, and patient’s perception of pain (6-9). There are many studies that investigated the control of post tonsillectomy pain using different drugs such as intravenous opioids, non-steroidal anti-inflammatory drugs, steroids, ketamine, as well as peritonsillar injection of local anesthetic, opioid, and ketamine (6,7,10-14).Ketamine is an intravenous anesthetic from phencyclidin family, which because of its antagonist effects on N methyl-D-aspartate receptors (that are involved in central pain sensitization) has regulatory influence on central sensitization and opium resistance. It can also band with mu receptors in the spinal cord and brain and cause analgesia. Ketamine can be utilized intravenously, intramuscularly, epidurally, rectally, and nasaly (15,16). Several studies have shown the effects of sub-analgesic doses of ketamine on postoperative pain and opioid consumption (7,13,15-17). Its side effects are hallucination, delirium, agitation, nausea, vomiting, airways hyper-secretion, and increased intra cerebral pressure and intra ocular pressure (10,11,15,16).Tramadol is an opium agonist that mostly effects mu receptors, and in smaller extent kappa and sigma receptors, and like anti depressant drugs can inhibit serotonin and norepinephrine reuptake and cause analgesia (6,12,18). Its potency is 5 times lower than morphine (6,12), but it has lower risk of dependency and respiratory depression, without any reported serious toxicity (6,12). However, it has some side effects such as nausea, vomiting, dizziness, sweating, anaphylactic reactions, and increased intra-cerebral pressure. It can also lower the seizure threshold (6,12,18,19).Several studies have confirmed the efficacy of tramadol and ketamine on post-tonsillectomy pain (6,10-12,20). In previous studies, effects of peritonsillar/ IV or IM infiltration of tramadol and ketamine were compared to each other and to placebo, and ketamine and tramadol were suggested as appropriate drugs for pain management (6,7,10-19,21). Therefore, in this study we directly compared the effect of peritonsillar infiltration of either tramadol or ketamine with each other and with placebo.     

Adverse drug reactions caused by drug-drug interactions reported to Croatian Agency for Medicinal Products and Medical Devices: a retrospective observational study

Aim

To analyze potential and actual drug-drug interactions reported to the Spontaneous Reporting Database of the Croatian Agency for Medicinal Products and Medical Devices (HALMED) and determine their incidence.

Methods

In this retrospective observational study performed from March 2005 to December 2008, we detected potential and actual drug-drug interactions using interaction programs and analyzed them.

Results

HALMED received 1209 reports involving at least two drugs. There were 468 (38.7%) reports on potential drug-drug interactions, 94 of which (7.8% of total reports) were actual drug-drug interactions. Among actual drug-drug interaction reports, the proportion of serious adverse drug reactions (53 out of 94) and the number of drugs (n = 4) was significantly higher (P < 0.001) than among the remaining reports (580 out of 1982; n = 2, respectively). Actual drug-drug interactions most frequently involved nervous system agents (34.0%), and interactions caused by antiplatelet, anticoagulant, and non-steroidal anti-inflammatory drugs were in most cases serious. In only 12 out of 94 reports, actual drug-drug interactions were recognized by the reporter.

Conclusion

The study confirmed that the Spontaneous Reporting Database was a valuable resource for detecting actual drug-drug interactions. Also, it identified drugs leading to serious adverse drug reactions and deaths, thus indicating the areas which should be in the focus of health care education.Adverse drug reactions (ADR) are among the leading causes of mortality and morbidity responsible for causing additional complications (1,2) and longer hospital stays. Magnitude of ADRs and the burden they place on health care system are considerable (3-6) yet preventable public health problems (7) if we take into consideration that an important cause of ADRs are drug-drug interactions (8,9). Although there is a substantial body of literature on ADRs caused by drug-drug interactions, it is difficult to accurately estimate their incidence, mainly because of different study designs, populations, frequency measures, and classification systems (10-15).Many studies including different groups of patients found the percentage of potential drug-drug interactions resulting in ADRs to be from 0%-60% (10,11,16-25). System analysis of ADRs showed that drug-drug interactions represented 3%-5% of all in-hospital medication errors (3). The most endangered groups were elderly and polimedicated patients (22,26-28), and emergency department visits were a frequent result (29). Although the overall incidence of ADRs caused by drug-drug interactions is modest (11-13,15,29,30), they are severe and in most cases lead to hospitalization (31,32).Potential drug-drug interactions are defined on the basis of on retrospective chart reviews and actual drug-drug interactions are defined on the basis of clinical evidence, ie, they are confirmed by laboratory tests or symptoms (33). The frequency of potential interactions is higher than that of actual interactions, resulting in large discrepancies among study findings (24).A valuable resource for detecting drug-drug interactions is a spontaneous reporting database (15,34). It currently uses several methods to detect possible drug-drug interactions (15,29,35,36). However, drug-drug interactions in general are rarely reported and information about the ADRs due to drug-drug interactions is usually lacking.The aim of this study was to estimate the incidence of actual and potential drug-drug interactions in the national Spontaneous Reporting Database of ADRs in Croatia. Additionally, we assessed the clinical significance and seriousness of drug-drug interactions and their probable mechanism of action.     

The involvement of noradrenergic mechanisms in the suppressive effects of diazepam on the hypothalamic-pituitary-adrenal axis activity in female rats

Aim

To elucidate the involvement of noradrenergic system in the mechanism by which diazepam suppresses basal hypothalamic-pituitary-adrenal (HPA) axis activity.

Methods

Plasma corticosterone and adrenocorticotropic hormone (ACTH) levels were determined in female rats treated with diazepam alone, as well as with diazepam in combination with clonidine (α₂-adrenoreceptor agonist), yohimbine (α₂-adrenoreceptor antagonist), alpha-methyl-p-tyrosine (α-MPT, an inhibitor of catecholamine synthesis), or reserpine (a catecholamine depleting drug) and yohimbine.

Results

Diazepam administered in a dose of 2.0 mg/kg suppressed basal HPA axis activity, ie, decreased plasma corticosterone and ACTH levels. Pretreatment with clonidine or yohimbine failed to affect basal plasma corticosterone and ACTH concentrations, but abolished diazepam-induced inhibition of the HPA axis activity. Pretreatment with α-MPT, or with a combination of reserpine and yohimbine, increased plasma corticosterone and ACTH levels and prevented diazepam-induced inhibition of the HPA axis activity.

Conclusion

The results suggest that α₂-adrenoreceptors activity, as well as intact presynaptic noradrenergic function, are required for the suppressive effect of diazepam on the HPA axis activity.Benzodiazepines are used for their anxiolytic, sedative-hypnotic, muscle relaxant, and anticonvulsant properties in the treatment of a variety of neuropsychiatric disorders (1,2), including anxiety and depression, which are often related to disturbances in the activity of hypothalamic-pituitary-adrenal (HPA) axis (3,4). Although these drugs exert most of their pharmacological effects via γ-aminobutyric acid_A (GABA_A) receptors (5,6), benzodiazepine administration has been associated with alterations in neuroendocrine function both in experimental animals and humans (7-9). However, even after years of extensive studies, the complex mechanisms by which these widely used drugs produce their effects on the HPA axis are still not known.Although most of the previous studies have demonstrated that classical benzodiazepines such as diazepam decrease the HPA axis activity in stressful contexts (10-14), under basal conditions they have been shown to stimulate (9,11,15-18), inhibit (15,19-22), and not affect (17,23-25) the HPA axis activity. Such diverse results might be related to several factors such as the dose and gender (15,16,20,21,26-28), or may also be a consequence of the net effect of non-selective benzodiazepines on the various GABA_A receptor isoforms (9).Our previous studies demonstrated that while diazepam (1 mg/kg) produced no change in plasma corticosterone levels in male rats (15,20), it decreased basal levels of corticosterone in female rats (15,26). However, although diazepam inhibited the HPA axis activity of female rats following administration of lower doses (1 or 2 mg/kg) (15,20,21,26), it stimulated the HPA axis activity following administration of high doses (10 mg/kg) (15,16,26). Moreover, whereas the suppressive effect of the lower doses of diazepam (2.0 mg/kg) on the HPA axis activity in female rats involves the GABA_A receptor complex (21), increases in corticosterone levels by a higher dose of diazepam (10 mg/kg) do not involve the stimulation of GABA_A receptors (16). In addition, stimulatory effect of 10 mg/kg diazepam on the HPA axis activity in rats seems not to be mediated by the benzodiazepine/GABA/channel chloride complex or by peripheral benzodiazepine receptors, but rather by a cyclic adenosine monophosphate (AMP)-dependent mechanism (18).Since our previous results suggested that the effect of a high dose of diazepam on the activity of the HPA axis in female rats might be due to a blockade of α₂-adrenergic receptors (16), the aim of this study was to elucidate whether noradrenergic system also has a modulatory role in the inhibitory effect of 2.0 mg/kg diazepam on basal plasma adrenocorticotropic hormone (ACTH) and corticosterone levels in female rats.     

Psychiatric heredity and posttraumatic stress disorder: survey study of war veterans

Aim

To explore the prevalence of psychiatric heredity (family history of psychiatric illness, alcohol dependence disorder, and suicidality) and its association with the diagnosis of stress-related disorders in Croatian war veterans established during psychiatric examination.

Methods

The study included 415 war veterans who were psychiatrically assessed and diagnosed by the same psychiatrist during an expert examination conducted for the purposes of compensation seeking. Data were collected by a structured diagnostic procedure.

Results

There was no significant correlation between psychiatric heredity of psychiatric illness, alcohol dependence, or suicidality and diagnosis of posttraumatic stress disorder (PTSD) or PTSD with psychiatric comorbidity. Diagnoses of psychosis or psychosis with comorbidity significantly correlated with psychiatric heredity (φ = 0.111; P = 0.023). There was a statistically significant correlation between maternal psychiatric illness and the patients’ diagnoses of partial PTSD or partial PTSD with comorbidity (φ = 0.104; P = 0.035) and psychosis or psychosis with comorbidity (φ = 0.113; P = 0.022); paternal psychiatric illness and the patients’ diagnoses of psychosis or psychosis with comorbidity (φ = 0.130; P = 0.008), alcohol dependence or alcohol dependence with comorbidity (φ = 0.166; P = 0.001); psychiatric illness in the primary family with the patients’ psychosis or psychosis with comorbidity (φ = 0.115; P = 0.019); alcohol dependence in the primary family with the patients’ personality disorder or personality disorder with comorbidity (φ = 0.099; P = 0.044); and suicidality in the primary family and a diagnosis of personality disorder or personality disorder with comorbidity (φ = 0.128; P = 0.009).

Conclusion

The study confirmed that parental and familial positive history of psychiatric disorders puts the individual at higher risk for developing psychiatric illness or alcohol or drug dependence disorder. Psychiatric heredity might not be necessary for the individual who was exposed to severe combat-related events to develop symptoms of PTSD.There are several risk factors associated with the development of posttraumatic stress disorder (PTSD), such as factors related to cognitive and biological systems and genetic and familial risk (1), environmental and demographic factors (2), and personality and psychiatric anamnesis (3).They are usually grouped into three categories: factors that preceded the exposure to trauma or pre-trauma factors; factors associated with trauma exposure itself; and post-trauma factors that are associated with the recovery environment (2,4).There are many studies which support the hypothesis that pre-trauma factors, such as ongoing life stress, psychiatric history, female sex (3), childhood abuse, low economic status, lack of education, low intelligence, lack of social support (5), belonging to racial and ethnic minority, previous traumatic events, psychiatric heredity, and a history of perceived life threat, influence the development of stress related disorders (6). Many findings suggest that ongoing life stress or prior trauma history sensitizes a person to a new stressor (2,7-9). The same is true for the lack of social support, particularly the loss of support from significant others (2,9-11), as well as from friends and community (12-14). If the community does not have an elaborated plan for providing socioeconomic support to the victims, then the low socioeconomic status can also be an important predictor of a psychological outcome such as PTSD (2,10,15). Unemployment was recognized as a risk factor for developing PTSD in a survey of 374 trauma survivors (16). It is known that PTSD commonly occurs in patients with a previous psychiatric history of mental disorders, such as affective disorders, other anxiety disorders, somatization, substance abuse, or dissociative disorders (17-21). Epidemiological studies showed that pre-existing psychiatric problems are one of the three factors that can predict the development of PTSD (2,22). Pre-existing anxiety disorders, somatoform disorders, and depressive disorders can significantly increase the risk of PTSD (23). Women have a higher vulnerability for PTSD than men if they experienced sexually motivated violence or had pre-existing anxiety disorders (23,24). A number of studies have examined the effects of gender differences on the predisposition for developing PTSD, with the explanation that women generally have higher rates of depression and anxiety disorders (3,25,26). War-zone stressors were described as more important for PTSD in men, whereas post-trauma resilience-recovery factors as more important for women (27).Lower levels of education and poorer cognitive abilities also appear to be risk factors (25). Golier et al (25) reported that low levels of education and low IQ were associated with poorer recall on words memorization tasks. In addition, this study found that the PTSD group with lower Wechsler Adult Intelligence Scale-Revised (WAIS-R) scores had fewer years of education (25). Nevertheless, some experts provided evidence for poorer cognitive ability in PTSD patients as a result or consequence rather than the cause of stress-related symptoms (28-31). Studies of war veterans showed that belonging to racial and ethnic minority could influence higher rates of developing PTSD even after the adjustment for combat exposure (32,33). Many findings suggest that early trauma in childhood, such as physical or sexual abuse or even neglect, can be associated with adult psychopathology and lead to the development of PTSD (2,5,26,34,35). Surveys on animal models confirm the findings of lifelong influences of early experience on stress hormone reactivity (36).Along with the reports on the effects of childhood adversity as a risk factor for the later development of PTSD, there is also evidence for the influence of previous exposure to trauma related events on PTSD (9,26,28). Breslau et al (36) reported that previous trauma experience substantially increased the risk for chronic PTSD.Perceived life threats and coping strategies carry a high risk for developing PTSD (9,26). For instance, Ozer et al (9) reported that dissociation during trauma exposure has high predictive value for later development of PTSD. Along with that, the way in which people process and interpret perceived threats has a great impact on the development or maintenance of PTSD (37,38).Brewin et al (2) reported that individual and family psychiatric history had more uniform predictive effects than other risk factors. Still, this kind of influence has not been examined yet.Keeping in mind the lack of investigation of parental psychiatric heredity on the development of stress-related disorders, the aim of our study was to explore the prevalence and correlation between the heredity of psychiatric illness, alcohol dependence, suicidality, and the established diagnosis of stress-related disorders in Croatian 1991-1995 war veterans.     

Human Umbilical Cord Blood-derived Stromal Cells Suppress Xenogeneic Immune Cell Response In Vitro

Aim

To explore immunological properties of human umbilical cord blood-derived stromal cells (hUCBDSC) and their effect on xenogeneic immune cells in vitro.

Methods

Immunological phenotype of freshly isolated and cryopreserved hUCBDSCs was evaluated by flow cytometry. Xenogeneic splenic T-cells were stimulated by phytohemaglutinin A (PHA) or dendritic cells in the absence or presence of hUCBDSCs. T-cell proliferation was measured by cell counting kit-8 after 7-day incubation. The proportion of apoptotic cells and CD4⁺CD25⁺Foxp3⁺ regulatory T-cells (Tregs) was determined in T-cells activated by PHA in the absence or presence of hUCBDSCs by flow cytometry. Phenotype of dendritic cells, cultured alone or with hUCBDSCs, was analyzed by flow cytometry.

Results

Levels of immune molecule expression on freshly isolated hUCBDSCs were as follows: human leukocyte antigen-I (HLA-I) (84.1 ± 2.9%), HLA-II (1.6 ± 0.3%), CD80 (0.8 ± 0.1%), CD86 (0.8 ± 0.1%), CD40 (0.6 ± 0.1%), and CD40L (0.5 ± 0.1%), which was not influenced by cryopreservation. T-cell proliferation in the presence of hUCBDSCs was significantly lower than that of positive control. The coculture led to a 10-fold increase (from 1.2 ± 0.3% to 12.1 ± 1.4%, P < 0.001) in the proportion of CD4⁺CD25⁺Foxp3⁺ regulatory T-cells (Tregs) and a reversion of mature dendritic cells, as indicated by the down-regulation of major histocompatibility complex (MHC)-II molecule (49.3% vs 25.9%, P = 0.001), CD80 (47.2% vs 23.3%, P = 0.001), and CD86 (40.6% vs 25.1%, P = 0.002). When subjected to annexin V binding and propidium iodide uptake assay, the hUCBDSCs did not show the ability to induce apoptosis of xenogeneic T-cells.

Conclusion

These results demonstrate low immunogenicity and immunomodulation effect of the hUCBDSCs. Reversion of mature dendritic cells and increase in Treg proportion, but not cell apoptosis, can possibly contribute to the suppression of xenogeneic T-cell proliferation by the hUCBDSCs.Adherent spindle-shaped, fibroblastoid cells were isolated from the bone marrow by Friedenstein (1) and others (2-4), and are also referred to as multipotent mesenchymal stromal cells (MSC) (5) because of their self-renewal and multilineage differentiation capacity at the population level. One of the main biological functions of bone marrow MSCs is to regulate proliferation, differentiation, and maturation of hematopoietic cells through cell-to-cell interactions and secretion of cytokines and growth factors. Besides, MSCs also probably contribute to regulation of maturation, proliferation, and function of lymphocytes and have been shown to participate in the positive selection of T lymphocytes in the thymus in murine models (6-10).In fact, a variety of studies with human, baboon, and murine MSCs have demonstrated the inability of MSCs to elicit a proliferative response of allogeneic lymphocytes, but instead they showed the capability of MSCs to suppress T lymphocyte activation and proliferation in vitro when stimulated by alloantigens, mitogens, and CD3 and CD28 antibodies (11-17). Different mechanisms are proposed to explain the suppressive effect of MSCs depending on the stimuli. Some animal models, related to alloreactive immunity, autoimmunity, or tumor immunity, have been established to examine the immunomodulatory function of MSCs in vivo. Graft vs host disease (GVHD), induced by donor T-cells, constitutes the most frequent complication after allogeneic hematopoietic cell transplantation (HCT) (18,19). Early and repeated systemic administration of ex-vivo expanded MSCs reduced the incidence and severity of GVHD in mice (20). It was shown clinically that the infusion of MSCs was safe and effective in the treatment of GVHD (21,22). MSCs have been an attractive candidate for cell therapy for GVHD.Although MSCs have also been isolated from other tissues such as adipose tissue (23), placenta (24), amniotic fluid (25), and umbilical cord blood (26,27), most studies on immunomodulatory function focused on bone marrow MSCs. However, the bone marrow collection is an invasive procedure and the number and expansion capacity of bone marrow MSCs decline with age (28,29). Due to easy collection and younger age of donor cells, umbilical cord blood is one of the most attractive alternative sources of MSCs. Our laboratory has previously isolated a novel population of adherent fibroblast-like cells from human umbilical cord blood (hUCB) CD34⁺cells, called hUCB-derived stromal cells (hUCBDSCs) and confirmed their supportive effect on hematopoiesis in vitro (30).Previous studies have usually investigated human MSCs-allogeneic immune cell reaction in vitro (11,14,31-33). To test the feasibility of replacing human immune cells with xenogeneic counterparts in vitro is of significance in establishing an animal model for further in vivo study of immunological properties of human MSCs, such as their inhibitory effect on GVHD. In the present study, we focused on immunological properties of hUCBDSCs and their effect on xenogeneic immune cells and demonstrated that hUCBDSCs suppressed xenogeneic T-cell activation induced by mitogen PHA and dendritic cells, in addition to its low immunogenicity per se, such as the lack of human leukocyte antigen-II (HLA-II) and some costimulator expression.     

Zagreb Amblyopia Preschool Screening Study: near and distance visual acuity testing increase the diagnostic accuracy of screening for amblyopia

AimTo present and evaluate a new screening protocol for amblyopia in preschool children.MethodsZagreb Amblyopia Preschool Screening (ZAPS) study protocol performed screening for amblyopia by near and distance visual acuity (VA) testing of 15 648 children aged 48-54 months attending kindergartens in the City of Zagreb County between September 2011 and June 2014 using Lea Symbols in lines test. If VA in either eye was >0.1 logMAR, the child was re-tested, if failed at re-test, the child was referred to comprehensive eye examination at the Eye Clinic.Results78.04% of children passed the screening test. Estimated prevalence of amblyopia was 8.08%. Testability, sensitivity, and specificity of the ZAPS study protocol were 99.19%, 100.00%, and 96.68% respectively.ConclusionThe ZAPS study used the most discriminative VA test with optotypes in lines as they do not underestimate amblyopia. The estimated prevalence of amblyopia was considerably higher than reported elsewhere. To the best of our knowledge, the ZAPS study protocol reached the highest sensitivity and specificity when evaluating diagnostic accuracy of VA tests for screening. The pass level defined at ≤0.1 logMAR for 4-year-old children, using Lea Symbols in lines missed no amblyopia cases, advocating that both near and distance VA testing should be performed when screening for amblyopia.Vision disorders in children represent important public health concern as they are acknowledged to be the leading cause of handicapping conditions in childhood (1). Amblyopia, a loss of visual acuity (VA) in one or both eyes (2) not immediately restored by refractive correction (3), is the most prevalent vision disorder in preschool population (4). The estimated prevalence of amblyopia among preschool children varies from 0.3% (4) to 5% (5). In addition, consequences of amblyopia include reduced contrast sensitivity and/or positional disorder (6). It develops due to abnormal binocular interaction and foveal pattern vision deprivation or a combination of both factors during a sensitive period of visual cortex development (7). Traversing through adulthood, it stands for the leading cause of monocular blindness in the 20-70 year age group (8). The main characteristic of amblyopia is crowding or spatial interference, referring to better VA when single optotypes are used compared to a line of optotypes, where objects surrounding the target object deliver a jumbled percept (9-12). Acuity is limited by letter size, crowding is limited by spacing, not size (12).Since amblyopia is predominantly defined as subnormal VA, a reliable instrument for detecting amblyopia is VA testing (13-15). Moreover, VA testing detects 97% of all ocular anomalies (13). The gold standard for diagnosing amblyopia is complete ophthalmological examination (4). There is a large body of evidence supporting the rationale for screening, as early treatment of amblyopia during the child’s first 5-7 years of life (8) is highly effective in habilitation of VA, while the treatment itself is among the most cost-effective interventions in ophthalmology (16). Preschool vision screening meets all the World Health Organization’s criteria for evaluation of screening programs (17). Literature search identified no studies reporting unhealthy and damaging effects of screening. The gold standard for screening for amblyopia has not been established (4). There is a large variety of screening methodologies and inconsistent protocols for referral of positives to complete ophthalmological examination. Lack of information on the validity (18,19) and accuracy (4) of such protocols probably intensifies the debate on determining the most effective method of vision screening (8,20-29). The unique definition of amblyopia accepted for research has not reached a consensus (4,5,30,31), further challenging the standardization of the screening protocols.Overall, two groups of screening methods exist: the traditional approach determines VA using VA tests, while the alternative approach identifies amblyogenic factors (27) based on photoscreening or automated refraction. The major difference between the two is that VA-based testing detects amblyopia directly, providing an explicit measure of visual function, while the latter, seeking for and determining only the level of refractive status does not evaluate visual function. In addition, the diagnosis and treatment of amblyopia is governed by the level of VA. On the other hand, amblyogenic factors represent risk factors for amblyopia to evolve. There are two major pitfalls in screening for amblyogenic factors. First, there is a lack of uniform cut-off values for referral and second, not all amblyogenic factors progress to amblyopia (19).Besides the issue of what should be detected, amblyopia or amblyogenic factors, a question is raised about who should be screened. Among literate children, both 3- and 4- year-old children can be reliably examined. However, 3-year-old children achieved testability rate of about 80% and positive predictive rate of 58% compared to >90% and 75%, respectively in the 4-year-old group (32). In addition, over-referrals are more common among 3-year-old children (32). These data determine the age of 4 years as the optimum age to screen for amblyopia. Hence, testability is a relevant contributor in designating the optimal screening test.If VA is to be tested in children, accepted standard tests should be used, with well-defined age-specific VA threshold determining normal monocular VA. For VA testing of preschool children Lea Symbols (33) and HOTV charts (22,32) are acknowledged as the best practice (34), while tumbling E (28,35,36) and Landolt C (28,37-39) are not appropriate as discernment of right-left laterality is still not a fully established skill (34,40). The Allen picture test is not standardized (34,41). Both Lea Symbols and HOTV optotypes can be presented as single optotypes, single optotypes surrounded with four flanking bars, single line of optotypes surrounded with rectangular crowding bars, or in lines of optotypes (22,33,34,41-53). The more the noise, the bigger the “crowding” effect. Isolated single optotypes without crowding overestimate VA (24), hence they are not used in clinical practice in Sweden (32). If presented in lines, which is recognized as the best composition to detect crowding, test charts can be assembled on Snellen or gold standard logMAR principle (34,42,51,54). Age-specific thresholds defining abnormal VA in preschool screening for amblyopia changed over time from <0.8 to <0.65 for four-year-old children due to overload of false positives (20).The outline of an effective screening test is conclusively demonstrated by both high sensitivity and high specificity. Vision screening tests predominately demonstrated higher specificity (4). Moreover, sensitivity evidently increased with age, whereas specificity remained evenly high (4). The criteria where to set the cut-off point if the confirmatory, diagnostic test is expensive or invasive, advocate to minimize false positives or use a cut-off point with high specificity.On the contrary, if the penalty for missing a case is high and treatment exists, the test should maximize true positives and use a cut-off point with high sensitivity (55). A screening test for amblyopia should target high sensitivity to identify children with visual impairment, while the specificity should be high enough not to put immense load on pediatric ophthalmologists (14). Complete ophthalmological examination as the diagnostic confirmatory gold standard test for amblyopia is neither invasive nor elaborate technology is needed, while the penalty for missing a case is a lifetime disability.In devising the Zagreb Amblyopia Preschool Screening (ZAPS) study protocol, we decided to use Lea Symbols in lines test and to screen preschool children aged 48-54 months to address the problems declared. Near VA testing was introduced in addition to commonly accepted distance VA testing (14,22,24,32,45,56-69) due to several reasons: first, hypermetropia is the most common refractive error in preschool children (70), hence near VA should more reliably detect the presence of hypermetropia; second, the larger the distance, the shorter the attention span is; and third, to increase the accuracy of the test.The pass cut-off level of ≤0.1 logMAR was defined because of particular arguments. Prior to 1992 Sweden used the pass cut-off level for screening of 0.8 (20). A change in the referral criteria to <0.65 for four-year-old children ensued, as many children referred did not require treatment (20). In addition, amblyopia treatment outcome of achieved VA>0.7 is considered as habilitation of normal vision (3,14). At last, the pass cut-off value ≤0.1 logMAR at four years can hardly mask serious visual problems, and even if they are present, we presume they are mild and can be successfully treated at six years when school-entry vision screening is performed. The aim of the ZAPS study is to present and evaluate new screening protocol for preschool children aged 48-54 months, established for testing near and distance VA using Lea Symbols in lines test. Furthermore, we aimed to determine the threshold of age-specific and chart-specific VA normative, testability of the ZAPS study protocol, and the prevalence of amblyopia in the City of Zagreb County. By delivering new evidence on amblyopia screening, guideline criteria defining optimal screening test for amblyopia in preschool children can be revised in favor of better visual impairment clarification.     

Pharmacotherapy of treatment-resistant combat-related posttraumatic stress disorder with psychotic features

Aim

To assess retrospectively the clinical effects of typical (fluphenazine) or atypical (olanzapine, risperidone, quetiapine) antipsychotics in three open clinical trials in male Croatian war veterans with chronic combat-related posttraumatic stress disorder (PTSD) with psychotic features, resistant to previous antidepressant treatment.

Methods

Inpatients with combat-related PTSD were treated for 6 weeks with fluphenazine (n = 27), olanzapine (n = 28) risperidone (n = 26), or quetiapine (n = 53), as a monotherapy. Treatment response was assessed by the reduction in total and subscales scores in the clinical scales measuring PTSD (PTSD interview and Clinician-administered PTSD Scale) and psychotic symptoms (Positive and Negative Syndrome Scale).

Results

After 6 weeks of treatment, monotherapy with fluphenazine, olanzapine, risperidone, or quetiapine in patients with PTSD significantly decreased the scores listed in trauma reexperiencing, avoidance, and hyperarousal subscales in the clinical scales measuring PTSD, and total and subscales scores listed in positive, negative, general psychopathology, and supplementary items of the Positive and negative syndrome scale subscales, respectively (P<0.001).

Conclusion

PTSD and psychotic symptoms were significantly reduced after monotherapy with typical or atypical antipsychotics. As psychotic symptoms commonly occur in combat-related PTSD, the use of antipsychotic medication seems to offer another approach to treat a psychotic subtype of combat-related PTSD resistant to previous antidepressant treatment.In a world in which terrorism and conflicts are constant threats, and these threats are becoming global, posttraumatic stress disorder (PTSD) is a serious and global illness. According to the criteria from the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (1), exposure to a life-threatening or horrifying event, such as combat trauma, rape, sexual molestation, abuse, child maltreatment, natural disasters, motor vehicle accidents, violent crimes, hostage situations, or terrorism, can lead to the development of PTSD (1,2). The disorder may also be precipitated if a person experienced, saw, or learned of an event or events that involved actual or threatened death, serious injury, or violation of the body of self or others (3,4). In such an event, a person’s response can involve intense fear, helplessness, or horror (3,4). However, not all persons who are exposed to a traumatic event will develop PTSD. Although the stress reaction is a normal response to an abnormal situation, some extremely stressful situations will in some individuals overwhelm their ability to cope with stress (5).PTSD is a chronic psychiatric illness. The essential features of PTSD are the development of three characteristic symptom clusters in the aftermath of a traumatic event: re-experiencing the trauma, avoidance and numbing, and hyperarousal (1,6). The core PTSD symptoms in the re-experiencing cluster are intrusive memories, images, or perceptions; recurring nightmares; intrusive daydreams or flashbacks; exaggerated emotional and physical reactions; and dissociative experiences (1,6,7). These symptoms intensify or re-occur upon exposure to reminders of the trauma, and various visual, auditory, or olfactory cues might trigger traumatic memories (3,4). The avoidance and numbing cluster of symptoms includes efforts to avoid thoughts, feelings, activities, or situations associated with the trauma; feelings of detachment or alienation; inability to have loving feelings; restricted range of affect; loss of interest; and avoidance of activity. The hyperarousal cluster includes exaggerated startle response, hyper-vigilance, insomnia and other sleep disturbances, difficulties in concentrating, and irritability or outbursts of anger. PTSD criteria include functional impairment, which can be seen in occupational instability, marital problems, discord with family and friends, and difficulties in parenting (3,4,8). In addition to this social and occupational dysfunction, PTSD is often accompanied by substance abuse (9) and by various comorbid diagnoses, such as major depression (10), other anxiety disorders, somatization, personality disorders, dissociative disorders (7,11), and frequently with suicidal behavior (12). Combat exposure can precipitate a more severe clinical picture of PTSD, which may be complicated with psychotic features and resistance to treatment. War veterans with PTSD have a high risk of suicide, and military experience, guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD are significantly associated with suicide attempts (12).The pharmacotherapy treatment of PTSD includes the use of antidepressants, such as selective serotonin reuptake inhibitors (fluvoxamine, fluoxetine, sertraline, or paroxetine) as a first choice of treatment, tricyclic antidepressants (desipramine, amitriptyline, imipramine), monoamine oxidase inhibitors (phenelzine, brofaromine), buspirone, and other antianxiety agents, benzodiazepines (alprazolam), and mood stabilizers (lithium) (13-16). Although the pharmacotherapy of PTSD starts with antidepressants, in treatment-refractory patients a new pharmacological approach is required to obtain a response. In treatment-resistant patients, pharmacotherapy strategies reported to be effective include anticonvulsants, such as carbamazepine, gabapentine, topiramate, tiagabine, divalproex, lamotrigine (14,17); anti-adrenergic agents, such as clonidine (although presynaptic α2-adrenoceptor agonist, clonidine blocks central noradrenergic outflow from the locus ceruleus), propranolol, and prazosin (13,14), opiate antagonists (13), and neuroleptics and antipsychotics (14,17,18).Combat exposure frequently induces PTSD, and combat-related PTSD might progress to a severe form of PTSD, which is often refractory to treatment (19-21). Combat-related PTSD is frequently associated with comorbid psychotic features (11,14,17,19-21), while psychotic features add to the severity of symptoms in combat-related PTSD patients (19,22-24). These cases of a more severe subtype of PTSD, complicated with psychotic symptoms, require the use of neuroleptics or atypical antipsychotic drugs (14,17,25-27).After the war in Croatia (1991-1995), an estimated million people were exposed to war trauma and about 10 000 of the Homeland War veterans (15% prevalence) have developed PTSD, with an alarmingly high suicide rate (28). The war in Croatia brought tremendous suffering, not only to combat-exposed veterans and prisoners of war (29), but also to different groups of traumatized civilians in the combat zones, displaced persons and refugees, victims of terrorist attacks, civilian relatives of traumatized war veterans and terrorist attacks victims, and traumatized children and adolescents (30). Among Croatian war veterans with combat-related PTSD, 57-62% of combat soldiers with PTSD met criteria for comorbid diagnoses (8-11), such as alcohol abuse, major depressive disorder, anxiety disorders, panic disorder and phobia, psychosomatic disorder, psychotic disorders, drug abuse, and dementia. In addition to different comorbid psychiatric disorders, a great proportion of war veterans with combat-related PTSD developed psychotic features (8,11,25,26), which consisted of psychotic depressive and schizophrenia-like symptoms (suggesting prominent symptoms of thought disturbances and psychosis). Psychotic symptoms were accompanied by auditory or visual hallucinations and delusional thinking in over two-thirds of patients (25,26). Delusional paranoid symptoms occurred in 32% of patients (25,26). The hallucinations were not associated exclusively with the traumatic experience, while the delusions were generally paranoid or persecutory in nature (25,26). Although psychotic PTSD and schizophrenia share some similar symptoms, there are clear differences between these two entities, since PTSD patients still retain some insight into reality and usually do not have complete disturbances of affect (eg, constricted or inappropriate) or thought disorder (eg, loose associations or disorganized responses).This proportion of veterans with combat-related PTSD refractory to treatment (18-20) and with co-occurring psychotic symptoms requires additional pharmacological strategies, such as the use of neuroleptics (25) or atypical antipsychotics (14,17,26). Studies evaluating the use of antipsychotics in combat-related PTSD with psychotic features are scarce, and antipsychotics were frequently added to existing medication in the treatment of PTSD.In this study, we compared retrospectively the clinical effects of four antipsychotic drugs – a neuroleptic drug (fluphenazine) and three atypical antipsychotics (olanzapine, risperidone and quetiapine) – in treatment-resistant male war veterans with combat-related PTSD with psychotic features.     

Use of concentrated bone marrow aspirate and platelet rich plasma during minimally invasive decompression of the femoral head in the treatment of osteonecrosis

The aim of this paper is to describe our surgical procedure for the treatment of osteonecrosis of the femoral head using a minimally invasive technique. We have limited the use of this procedure for patients with pre-collapse osteonecrosis of the femoral head (Ficat Stage I or II). To treat osteonecrosis of the femoral head at our institution we currently use a combination of outpatient, minimally invasive iliac crest bone marrow aspirations and blood draw combined with decompressions of the femoral head. Following the decompression of the femoral head, adult mesenchymal stem cells obtained from the iliac crest and platelet rich plasma are injected into the area of osteonecrosis. Patients are then discharged from the hospital using crutches to assist with ambulation. This novel technique was utilized on 77 hips. Sixteen hips (21%) progressed to further stages of osteonecrosis, ultimately requiring total hip replacement. Significant pain relief was reported in 86% of patients (n = 60), while the rest of patients reported little or no pain relief. There were no significant complications in any patient. We found that the use of a minimally invasive decompression augmented with concentrated bone marrow and platelet rich plasma resulted in significant pain relief and halted the progression of disease in a majority of patients.Osteonecrosis of the femoral head (ONFH) occurs when the cells of the trabecular bone and marrow in the femoral head spontaneously die, leading to fracture and collapse of the articular surface (1,2). In the US, every year ONFH occurs in 10 000-20 000 adults between the ages of 20 and 60 (1,3,4). Once collapse occurs, severe pain ensues, and the disease course rarely regresses (5-8). In order to halt disease progression and provide pain relief, 80% of patients suffering from ONFH will require a total hip arthroplasty (THA); typically at a younger age than patients undergoing a THA for osteoarthritis (9-11).Although ONFH is a common indication for THA, the etiology of the disease is still unknown (12,13). ONFH is thought to be a multifactorial disease, with patients reporting a history of exposure to one or more risk factors, including trauma to the hip, alcohol abuse, corticosteroid use, hemoglobinopathies, pregnancy, coagulopathies, organ transplant, chemotherapy, Caisson disease, HIV, and autoimmune conditions; however in some patients the risk factor remains unknown, and the disease is termed “idiopathic” ONFH (12-16). Recent studies looking at the gentics risks of ONFH have resulted in identifying an autosomal dominant mutation in collagen type II gene (COL2 A1 gene) (17); which has been associated with genetic polymorphisms in alcohol metabolizing enzymes and the drug transport proteins (18,19).If the disease course is recognized before collapse of the subchondral bone and cartilage, patients can be treated with core decompression of the femoral head including Ficat Stage I or II (12,20,21). This technique has been used for over four decades, however randomized control trials have failed to show that this procedure alone halts disease progression and collapse (4). Recently, concentrated bone marrow autograft has been used to augment the decompression site to attempt to repopulate the femoral head with human mesenchymal stem cells (hMSC) (13,22,23). This aim of this paper is to describe our surgical technique and early clinical results using autologous bone marrow concentrate with platelet rich plasma and a minimally invasive decompression for the treatment of ONFH.     

Irrigation of human prepared root canal �C ex vivo based computational fluid dynamics analysis

Aim

To analyze the influence of the needle type, insertion depth, and irrigant flow rate on irrigant flow pattern, flow velocity, and apical pressure by ex-vivo based endodontic irrigation computational fluid dynamics (CFD) analysis.

Methods

Human upper canine root canal was prepared using rotary files. Contrast fluid was introduced in the root canal and scanned by computed tomography (CT) providing a three-dimensional object that was exported to the computer-assisted design (CAD) software. Two probe points were established in the apical portion of the root canal model for flow velocity and pressure measurement. Three different CAD models of 27G irrigation needles (closed-end side-vented, notched open-end, and bevel open-end) were created and placed at 25, 50, 75, and 95% of the working length (WL). Flow rates of 0.05, 0.1, 0.2, 0.3, and 0.4 mL/s were simulated. A total of 60 irrigation simulations were performed by CFD fluid flow solver.

Results

Closed-end side-vented needle required insertion depth closer to WL, regarding efficient irrigant replacement, compared to open-end irrigation needle types, which besides increased velocity produced increased irrigant apical pressure. For all irrigation needle types and needle insertion depths, the increase of flow rate was followed by an increased irrigant apical pressure.

Conclusions

The human root canal shape obtained by CT is applicable in the CFD analysis of endodontic irrigation. All the analyzed values –irrigant flow pattern, velocity, and pressure – were influenced by irrigation needle type, as well as needle insertion depth and irrigant flow rate.It is of essential importance that the root canal treatment, besides mechanical cleaning and shaping procedures, includes simultaneous chemical processing (1,2). Chemical processing implies root canal irrigation by various antimicrobial means, which enable the removal of bacteria, necrotic pulp tissue, debris, and smear layer (3). Taking into account the differences between root canal morphology and endodontic files properties, irrigation of root canals is an extremely important addition to mechanical processing (4). The shape of root canals, characterized by numerous irregularities, anastomoses, and curvatures, often does not match the regular geometrical construction and mechanical properties of endodontic files, which results in inefficient and inadequate mechanical treatment of root canals (5). Even though endodontic files, both manual and rotary, are constantly improved (6), up to 50% of root canal surface may remain intact after mechanical processing (7). In these cases, successful endodontic treatment can be provided by additional proper and effective root canal irrigation. The efficiency of irrigation depends on the possibility of mechanical removal of residual necrotic and infected material from the canal by flushing, as well as on chemical activity of the irrigant (4,8).In terms of chemical activity of the irrigant, different means are used in everyday clinical practice, depending on the desired effect in the root canal (3). The most common and most often used irrigant in clinical practice is sodium hypochlorite (NaOCl), which is applied in concentrations ranging from 0.5 to 5.25% aqueous solution (3). Due to irrigant’s cytotoxicity, it is desirable to completely replace it during endodontic irrigation, while avoiding extrusion into periapical tissue (9).In terms of physical removal of material from the root canal, irrigation efficiency depends on the possibility of proper application of irrigation system, or proper application depth, irrigation dynamics, irrigant quantity, and irrigant fluid characteristics (4,10-15). In conventional clinical procedure, irrigant is applied during and after root canal cleaning and shaping, by disposable syringes and needles (7,16). Irrigation needles used, such as closed-end, side-vented, or notched open-end needles, vary in diameter and are specifically designed and intended for use in endodontics. It was recommended that the needle should be applied to the working length (WL) of instrumentation, or a millimeter shorter, in the root canal for flushing efficiency and removal of unwanted content from the root canal (17,18). However, recent studies have indicated that efficient irrigant replacement is achieved if the needle is applied to the root canal’s apical third (19-23). However, the effectiveness of flushing in the apical third of the root canal, which is most difficult to access (17), remains questionable (14,24,25).Computational fluid dynamics (CFD) is a discipline of fluid mechanics that uses numerical methods and algorithms to solve and analyze problems involving fluid flow (gas or liquid) (26). The basis of mathematical modeling that is used for subsequent computer simulations are the Navier-Stokes (NS) equations that define the single-phase fluid flow. Numerous calculations are necessary to simulate the interactions of liquids or gases in contact with surfaces defined as boundary conditions. There are different approaches to solve CFD problems, but they all follow the same basic process (27).CFD analysis was initially designed for various engineering and industrial purposes. In biomedicine, CFD was introduced in respiratory (28,29) and cardio-vascular (26,30) system research. Recent studies (31,32) confirmed CFD as a powerful analytic tool in the research of endodontic irrigation. The possible shortcomings of previous CFD studies are the strictly geometrical model design and insufficient emphasis on irrigant apical pressure.The aim of this study was to explore and analyze the influence of the needle type, insertion depth, and irrigant flow rate on irrigant flow pattern, flow velocity, and apical pressure by ex-vivo based CFD analysis.     

Attitudes of Slovenian family practice patients toward changing unhealthy lifestyle and the role of family physicians: cross-sectional study

Aim

To assess patients’ attitudes toward changing unhealthy lifestyle, confidence in the success, and desired involvement of their family physicians in facilitating this change.

Methods

We conducted a cross-sectional study in 15 family physicians’ practices on a consecutive sample of 472 patients (44.9% men, mean age  [± standard deviation] 49.3 ± 10.9 years) from October 2007 to May 2008. Patients were given a self-administered questionnaire on attitudes toward changing unhealthy diet, increasing physical activity, and reducing body weight. It also included questions on confidence in the success, planning lifestyle changes, and advice from family physicians.

Results

Nearly 20% of patients planned to change their eating habits, increase physical activity, and reach normal body weight. Approximately 30% of patients (more men than women) said that they wanted to receive advice on this issue from their family physicians. Younger patients and patients with higher education were more confident that they could improve their lifestyle. Patients who planned to change their lifestyle and were more confident in the success wanted to receive advice from their family physicians.

Conclusion

Family physicians should regularly ask the patients about the intention of changing their lifestyle and offer them help in carrying out this intention.Unhealthy lifestyle, including unhealthy diet and physical inactivity, is still a considerable health problem all over the world. Despite publicly available evidence about the health risks of unhealthy lifestyle, people still find it hard to improve their unhealthy diet and increase physical activity. Previous studies have shown that attitudes toward lifestyle change depended on previous health behavior, awareness of unhealthy lifestyle, demographic characteristics, personality traits, social support, family functioning, ongoing contact with health care providers, and an individual’s social ecology or network (1-4).As community-based health education approaches have had a limited effect on health risk factors reduction (3,5), the readiness-to-change approach, based on two-way communication, has become increasingly used with patients who lead an unhealthy lifestyle (3,6,7). Family physicians are in a unique position to adopt this approach, since almost every patient visits his/hers family physician at least once in five years (8). Previous studies showed that patients highly appreciated their family physicians’ advice on lifestyle changes (9,10). Moreover, patients who received such advice were also more willing to change their unhealthy habits (3,7,11). The reason for this is probably that behavioral changes are made according to the patient’s stage of the motivational circle at the moment of consultation (12), which can be determined only by individual approach.Although family physicians are convinced that it is their task to give advice on health promotion and disease prevention, in practice they are less likely to do so (13). The factors that prevent them from giving advice are time (14,15), cost, availability, practice capacity (14), lack of knowledge and guidelines, poor counseling skills (16), and personal attitudes (17). It also seems that physicians’ assessment varies considerably according to the risk factor in question. For example, information on diet and physical activity are often inferred from patients’ appearance rather than from clinical measurements (14). Also, health care professionals seldom give advice on recommended aspects of intervention that could facilitate behavioral change (18). As a large proportion of primary care patients are ready to lose weight, improve diet, and increase exercise (19), it is even more important that their family physicians provide timely advice.So far, several studies have addressed patients’ willingness to make lifestyle change (2-5,20) and the provision of professional advice (3,5,7,10,11). However, none of these studies have investigated the relation between these factors. So, the aim of our study was to assess the relation between patients’ attitudes toward changing unhealthy lifestyle, confidence in success, and the desired involvement of their family physicians in facilitating the change.     

Why pulsatility still matters: a review of current knowledge

Continuous-flow left ventricular assist devices (LVAD) have become standard therapy option for patients with advanced heart failure. They offer several advantages over previously used pulsatile-flow LVADs, including improved durability, less surgical trauma, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients. However, mounting evidence shows unanticipated consequences of continuous-flow support, such as acquired aortic valve insufficiency and acquired von Willebrand syndrome. In this review article we discuss current evidence on differences between continuous and pulsatile mechanical circulatory support, with a focus on clinical implications and potential benefits of pulsatile flow.During the last few decades, mechanical circulatory support has evolved into a standard therapy for patients with advanced heart failure – as a bridge to cardiac transplantation (1-3), bridge to myocardial recovery (4-7), or as destination therapy (8-10). This success can in most part be attributed to the use of continuous-flow devices and their advantages over previously used pulsatile pumps: they offer improved durability, less surgical trauma due to their smaller size, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients (11-13).The debate on the importance of pulsatility began several decades ago with the research on the effects of nonpulsatile flow during the cardiopulmonary bypass (CPB) (14,15). It is still alive today, after nearly a decade of use of continuous-flow devices, especially after evidence has shown that this therapy is complicated by diminished pulsatility. In this review article we discuss current evidence on differences between continuous and pulsatile ventricular assist devices, with a focus on clinical implications and potential benefits of pulsatile flow.     

Patients with Combat-related and War-related Posttraumatic Stress Disorder 10 Years After Diagnosis

Aim

To establish how many patients diagnosed with posttraumatic stress disorder (PTSD) in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later, and assess their sociodemographic characteristics, comorbid disorders, and type of treatment.

Methods

Medical records of patients diagnosed with PTSD in 1996 were reviewed in the period 2007-2009 and the patients who contacted a psychiatrist in that period (n = 85) and those who did not (n = 158) were compared.

Results

There were 36.7% of men and 20% of women diagnosed with PTSD in 1996 who contacted a psychiatrist in the period 2007-2009. Patients who contacted a psychiatrist and those who did not did not differ in sex, age, the number of visits and hospitalizations in 1996, and employment status. The majority of patients still had PTSD and/or were enduring personality change in the period 2007-2009, and 54.8% had some comorbidity (mostly depression, alcohol-related disorders, and personality disorders). Patients were most often treated with anxiolytics and antidepressants.

Conclusion

Ten years after the traumatic experience, one third of patients with PTSD received psychiatric help, regardless of their sex, age, and employment status. Half of them had comorbid disorders and the majority of them were treated with anxiolytics and antidepressants.Posttraumatic stress disorder (PTSD) is a mental disorder that develops in 9-25% of war veterans (1-4), mainly in the first two years after the traumatic experience (5,6), but sometimes can develop years later (7,8). A similar prevalence was also found among Croatian war veterans (5-9). In the majority of cases (80-98%), PTSD is comorbid with other mental disorders: alcohol abuse, depression, anxiety disorders, and somatization (5,9-11).PTSD can also develop after a war-related trauma that is not necessarily combat-related, and the lifetime prevalence of PTSD in this population is 15-38% (12) and the prevalence of anxiety and depressive disorders is even higher (13,14).Many patients in Croatia had symptoms of PTSD and used health facilities for treatment years after the war (5-9). In the former Yugoslavia, 84% of untreated war-related PTSD patients still had PTSD symptoms years after the war (15). Resolution of PTSD is observed in 50-60% of cases (4,16).Combat-related PTSD causes more functional impairment and is less responsive to treatment than PTSD related to other traumas (17-19). It is unclear whether this happens because there is indeed a difference between the two types of PTSD or some of the patients aggravate their symptoms in order to get compensation (17,18,20). Some studies show that the use of health facilities decreases after obtaining war veteran status and compensation, but others show that the patients who had obtained the status and compensation used medical facilities more often than those who had not (20-23).The aim of this study was to establish how many patients diagnosed with PTSD in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later and assess their comorbidities, sociodemographic characteristics, and type of treatment.     

A comparative study of neurotoxic potential of synthesized polysaccharide-coated and native ferritin-based magnetic nanoparticles

Aim

To analyze the neurotoxic potential of synthesized magnetite nanoparticles coated by dextran, hydroxyethyl starch, oxidized hydroxyethyl starch, and chitosan, and magnetic nanoparticles combined with ferritin as a native protein.

Methods

The size of nanoparticles was analyzed using photon correlation spectroscopy, their effects on the conductance of planar lipid membrane by planar lipid bilayer technique, membrane potential and acidification of synaptic vesicles by spectrofluorimetry, and glutamate uptake and ambient level of glutamate in isolated rat brain nerve terminals (synaptosomes) by radiolabeled assay.

Results

Uncoated synthesized magnetite nanoparticles and nanoparticles coated by different polysaccharides had no significant effect on synaptic vesicle acidification, the initial velocity of L-[¹⁴C]glutamate uptake, ambient level of L-[¹⁴C]glutamate and the potential of the plasma membrane of synaptosomes, and conductance of planar lipid membrane. Native ferritin-based magnetic nanoparticles had no effect on the membrane potential but significantly reduced L-[¹⁴C]glutamate transport in synaptosomes and acidification of synaptic vesicles.

Conclusions

Our study indicates that synthesized magnetite nanoparticles in contrast to ferritin have no effects on the functional state and glutamate transport of nerve terminals, and so ferritin cannot be used as a prototype, analogue, or model of polysaccharide-coated magnetic nanoparticle in toxicity risk assessment and manipulation of nerve terminals by external magnetic fields. Still, the ability of ferritin to change the functional state of nerve terminals in combination with its magnetic properties suggests its biotechnological potential.Superparamagnetic iron oxide nanoparticles are a promising candidate for increasing the efficiency of targeted drug delivery and therapy due to external magnetic guidance. Nanomaterials differ from those in bulk forms because they often show unexpected physical and chemical properties. They may produce potential functional and toxicity effects on human nerve cells due to their ability to pass through biological membranes and increase the risk of the development of neurodegenerative diseases (1-3). They can penetrate the blood-brain barrier (3-5) and kill nervous cells in vitro (6-8). Surface modification of iron oxide is a key issue for enhancing its interaction with the cell membrane. By using iron oxide nanoparticles coated by dextran, it was shown that labeled cells could be tracked by magnetic resonance imaging in vivo (9,10). Dextran occupies a special place among polysaccharides because of its wide application. Contrast agents based on dextran-coated iron oxides, eg, Endorem (Guerbet, Roissy, France) and Resovist (Bayer Schering Pharma AG, Berlin-Wedding, Germany), have been commercially available for human use as blood pool agents. Similarly, immortalized cells from the MHP36 hippocampal cell line labeled in vitro with gadolinium rhodamine dextran were tracked in ischemia-damaged rat hippocampus in perfused brains ex vivo (11).Taking into account that all nanoparticles are more or less toxic and the brain can be a target for their neurotoxic action (3,8,12,13), it is crucial to know their neurotoxic potential. Estimation of neurotoxic risks of nanoparticles can be assessed at various levels of nervous system organization. This research was conducted at the neurochemical level according to the Guidelines for Neurotoxicity Risk Assessment of US Environmental Protection Agency (14), assessing the uptake and release of the neurotransmitters in nerve terminals (15,16). It has been suggested that a possible target for nanoparticles, beyond the already established microglial cells, are presynaptic terminals of neurons (12). Presynaptic nerve terminals contain vesicular pool of neurotransmitters that can be released by exocytosis to the synaptic cleft in response to stimulation (17,18). A key excitatory neurotransmitter in the mammalian central nervous system is glutamate, which is implicated in many aspects of normal brain functioning. Abnormal glutamate homeostasis contributes to neuronal dysfunction and is involved in the pathogenesis of major neurological disorders (19,20). Under normal physiological conditions, extracellular glutamate between episodes of exocytotic release is kept at a low level, thereby preventing continual activation of glutamate receptors and protecting neurons from excitotoxic injury. Low extracellular glutamate concentration is maintained through its uptake by high-affinity Na⁺-dependent glutamate transporters located in the plasma membrane of neurons and glial cells.Prototypic nanoparticles have been shown to be useful for investigation of synaptic mechanisms underlying the development of neurotoxicity (8,12). Ferritin may be considered as a model nanoparticle (8,12) because it is composed of 24 subunits, which form a spherical shell with a large cavity where up to 4500 ions Fe³⁺ can be deposited as compact mineral crystallites resembling ferrihydrite (21-25). Ferritin stores cellular iron in a dynamic manner allowing the release of the metal on demand (24). Its cores exhibit superparamagnetic properties, which are inherent to magnetic nanoparticles, and vary in diameter from 3.5 nm to 7.5 nm in different tissues (26,27). This protein can penetrate blood-brain barrier (28) and be transported in different cells using clathrin-mediated endocytosis, similarly to many artificial nanoparticles that use the same mechanism (8,29,30).Recently, there has started an examination of ferritin from the biotechnological point of view. The hypothesis was that ferritin might be considered a good tool and prototypical nanoparticle for investigation of possible toxic properties of metal nanoparticles coated by dextran/polymer shells and possible causes of neurodegeneration associated with exposure to nanoparticles (8,12). Ferritin has been suggested as a label for high-gradient magnetic separation (31) and magnetic force microscopy imaging (32). Recently, it has been shown that the avascular microscopic breast and brain tumors could be noninvasively detected by designing nanoparticles that contained human ferritin as molecular probes for near-infrared fluorescence and magnetic resonance imaging (33).This research was focused on two aspects – the first was the assessment of neurotoxic potential of synthesized nanoparticles of magnetite (MNP) coated by dextran, hydroxyethyl starch, oxidized hydroxyethyl starch, chitosan as well as uncoated nanoparticles, studying their effects on: 1) the uptake of L-[¹⁴C]glutamate by rat brain nerve terminals via specific high-affinity Na⁺-dependent plasma membrane transporters; 2) the ambient level of L-[¹⁴C]glutamate in nerve terminals; 3) the membrane potential (Em) of the plasma membrane of nerve terminals using potential-sensitive fluorescent dye Rhodamine 6G; 4) transmembrane current across the planar lipid membrane using planar lipid bilayer technique; 5) acidification of synaptic vesicles in nerve terminals using pH-sensitive fluorescent dye acridine orange. The second aspect was a comparative analysis of neurotoxic potential of these synthesized polysaccharide-coated nanoparticles and ferritin, which could bring new insight into a possible usage of ferritin as an analogue of polymer-coated magnetic nanoparticle in toxicity risk assessment.     

Breast and gynecological cancers in Croatia, 1988-2008

Aim

To analyze and interpret incidence and mortality trends of breast and ovarian cancers and incidence trends of cervical and endometrial cancers in Croatia for the period 1988-2008.

Methods

Incidence data were obtained from the Croatian National Cancer Registry. The mortality data were obtained from the World Health Organization (WHO) mortality database. Trends of incidence and mortality were analyzed by joinpoint regression analysis.

Results

Joinpoint analysis showed an increase in the incidence of breast cancer with estimated annual percent of change (EAPC) of 2.6% (95% confidence interval [CI], 1.9 to 3.4). The mortality rate was stable, with the EAPC of 0.3% (95% CI, -0.6 to 0.0). Endometrial cancer showed an increasing incidence trend, with EAPC of 0.8% (95% CI, 0.2 to 1.4), while cervical cancer showed a decreasing incidence trend, with EAPC of -1.0 (95% CI, -1.6 to -0.4). Ovarian cancer incidence showed three trends, but the average annual percent change (AAPC) for the overall period was not significant, with a stable trend of 0.1%. Ovarian cancer mortality was increasing since 1992, with EAPC of 1.2% (95% CI, 0.4 to 1.9), while the trend for overall period was stable with AAPC 0.1%.

Conclusion

Incidence trends of breast, endometrial, and ovarian cancers in Croatia 1988-2008 are similar to the trends observed in most of the European countries, while the modest decline in cervical cancer incidence and lack of decline in breast cancer mortality suggest suboptimal cancer prevention and control.Breast and gynecological cancers are among the seven most common female cancers in Croatia: in 2008 breast cancer was the most common cancer with the proportion of 26% of all cancer sites, endometrial cancer ranked fourth (6%), ovarian cancer (with fallopian tubes cancer) sixth (5%), and cervical cancer seventh (4%) (1).Breast, endometrial, and ovarian cancers share some similar risk factors like early menarche, late menopause, obesity, and low parity (2-5). Also, breast cancer in personal history increases the risk of endometrial and ovarian cancer (6). Delayed childbearing increases the risk of breast cancer but seems to have no impact on the development of ovarian and endometrial cancer (3-5). Diabetes mellitus increases the risk of endometrial and breast cancer (7,8). Use of tamoxifen or other selective estrogen receptor modulators increases the risk of endometrial and ovarian cancer, while the use of combined oral contraceptives is a protective factor (2,9,10). Also, tobacco smoking and alcohol intake reduce the risk of endometrial cancer (2,11,12). Alcohol intake and both oral contraceptives and hormonal replacement therapy are risk factors for breast cancer (2,13,14). Multiparty and physical activity are protective factors for all three cancers (2,4,15,16). Low socioeconomic status, sexually transmitted diseases, promiscuity, unprotected sexual behavior, earlier age of first intercourse, and smoking are risk factors for cervical cancer (2,17-23). Infection with human papillomavirus is considered as a necessary cause of cervical cancer (24).The aim of this study was to report the incidence and mortality of breast and ovarian cancers and incidence of endometrial and cervical cancers, analyze the trends in the period 1988-2008, and compare them to other European countries.     

Up-regulation of Synaptotagmin IV within amyloid plaque-associated dystrophic neurons in Tg2576 mouse model of Alzheimer’s disease

Aim

To investigate the involvement of the vesicular membrane trafficking regulator Synaptotagmin IV (Syt IV) in Alzheimer’s disease pathogenesis and to define the cell types containing increased levels of Syt IV in the β-amyloid plaque vicinity.

Methods

Syt IV protein levels in wild type (WT) and Tg2576 mice cortex were determined by Western blot analysis and immunohistochemistry. Co-localization studies using double immunofluorescence staining for Syt IV and markers for astrocytes (glial fibrillary acidic protein), microglia (major histocompatibility complex class II), neurons (neuronal specific nuclear protein), and neurites (neurofilaments) were performed in WT and Tg2576 mouse cerebral cortex.

Results

Western blot analysis showed higher Syt IV levels in Tg2576 mice cortex than in WT cortex. Syt IV was found only in neurons. In plaque vicinity, Syt IV was up-regulated in dystrophic neurons. The Syt IV signal was not up-regulated in the neurons of Tg2576 mice cortex without plaques (resembling the pre-symptomatic conditions).

Conclusions

Syt IV up-regulation within dystrophic neurons probably reflects disrupted vesicular transport or/and impaired protein degradation occurring in Alzheimer’s disease and is probably a consequence but not the cause of neuronal degeneration. Hence, Syt IV up-regulation and/or its accumulation in dystrophic neurons may have adverse effects on the survival of the affected neuron.The main pathological hallmarks of Alzheimer’s disease (AD) are the formation of amyloid plaques, neurofibrillary tangles, dystrophic neurites, and sometimes activation of glial cells in the brain (1,2). In the vicinity of amyloid plaques, neurons undergo dramatic neuropathological changes including metabolic disturbances such as altered energy metabolism, dysfunction of vesicular trafficking, neurite breakage, and disruption of neuronal connections (3-8).Synaptotagmin IV (Syt IV) is a protein involved in the regulation of membrane trafficking in neurons and astrocytes (9,10). In hippocampal neurons, it regulates brain-derived neurotrophic factor release (11) and is involved in hippocampus-dependent memory and learning (12,13). In astrocytes, it is implicated in glutamate release (10). Recent data show that Syt IV plays an important role in neurodegenerative processes (14). Syt IV expression could be induced by seizures, drugs, and brain injury. Its changes have been shown in several animal models of neurodegeneration (Parkinson’s disease, brain ischemia, AD) (14-25). However, the exact role of Syt IV in neurodegeneration is unknown.Our previous study showed that the expression of Syt IV mRNA and its protein in the hippocampus and cortex of Tg2576 mouse model for AD was increased in the tissue surrounding β-amyloid plaques (14). It is not clear whether Syt IV is expressed in astrocytes (10,26,27) or/and in neurons (28,29), ie, whether it regulates the release of pro- or anti-inflammatory cytokines from β-amyloid associated astrocytes or is involved in neuronal vesicular pathogenesis (5,30). Therefore, the present study aimed to determine the type of cells in which Syt IV up-regulation occurs.     

Laser-Doppler flowmetry and Horner's syndrome in patients with complete unilateral damage to the parasellar sympathetic fibers during cavernous sinus surgery

Aim

To determine ocular, sudomotor, and vasomotor components of Horner’s syndrome resulting from complete unilateral intraoperative damage to the parasellar sympathetic fibers during cavernous sinus surgery.

Methods

Complete damage to the parasellar sympathetic fibers was found in four patients operated for central skull base lesions. Pupilometry, eyelid fissure measurement, Hertel’s exophthalmometry, starch iodine sweat test, and laser-Doppler perfusion assessment of bilaterally symmetrical forehead and cheek areas were performed.

Results

Pupil diameter was smaller and the eyelid fissure was >2 mm narrower on the affected side in all four patients. Exophthalmometry after the operation never revealed >1 mm difference. Anhydrosis was localized to the medial forehead in three and to the entire forehead in one patient. Average perfusion did not significantly differ between the affected and opposite side of the forehead or cheek.

Conclusions

The parasellar sympathetic fibers exclusively innervate the orbit and variably innervate the forehead sweat glands. No conclusion regarding their contribution to the facial vasomotor control could be established.The anatomical relationships of the cranial nerves III, IV, the first division of the cranial nerve V, and VI, internal carotid artery and its branches, venous compartments and tributaries, and related osseous structures with adjacent dural folds in the cavernous sinus or parasellar space are well described (1,2). The parasellar space contains distinct sympathetic fiber bundles (1,2), which originate from the superior cervical ganglion and travel along the internal and external carotid arteries. Sympathetic fibers around the external carotid artery accompany its branches to supply the majority of the facial blood vessels and sweat glands (3). Sympathetic fibers around the internal carotid artery form the internal carotid nerve, give off caroticotympanic fibers and deep petrosal nerve in the carotid canal, and divide into the larger anterosuperior and smaller posteroinferior group (3-5). Sympathetic fibers inside the parasellar space are distributed systematically rather than in a plexiform arrangement (2,6). Most parasellar sympathetic fibers adhere to the cranial nerve VI, but then leave it usually after a few millimeters to join the first division of the cranial nerve V before entering the superior orbital fissure (5-13).It has been postulated that the parasellar sympathetic fibers innervate the orbit and contribute to the innervation of blood vessels and sweat glands of an as yet unproven forehead area (3,7-11,13), which would be difficult to ascertain morphologically (2). However, evidence of the parasellar sympathetic fiber function might come from clinical observation.Our aim was to contribute to the understanding of the facial sympathetic innervation by analyzing the ocular, vasomotor and sudomotor features of Horner’s syndrome resulting from complete unilateral damage to the parasellar sympathetic fibers due to central skull base surgery in four patients.     

Association between total serum cholesterol and depression,aggression, and suicidal ideations in war veterans with posttraumatic stress disorder: a cross-sectional study

Aim

To investigate the relationship between total serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with posttraumatic stress disorder (PTSD) without psychiatric comorbidity.

Methods

A total of 203 male PTSD outpatients were assessed for the presence of depression, aggression, and suicidality using the 17-item Hamilton Depression Rating Scale (HAM-D₁₇), Corrigan Agitated Behavior Scale (CABS), and Scale for Suicide Ideation (SSI), respectively, followed by plasma lipid parameters determination (total cholesterol, high density lipoprotein [HDL]-cholesterol, low density lipoprotein [LDL]-cholesterol, and triglycerides). PTSD severity was assessed using the Clinician-Administered PTSD Scale for DSM-IV, Current and Lifetime Diagnostic Version (CAPS-DX) and the Clinical Global Impressions of Severity Scale (CGI-S), before which Mini-International Neuropsychiatric Interview (MINI) was administered to exclude psychiatric comorbidity and premorbidity.

Results

After adjustments for PTSD severity, age, body mass index, marital status, educational level, employment status, use of particular antidepressants, and other lipid parameters (LDL- and HDL- cholesterol and triglycerides), higher total cholesterol was significantly associated with lower odds for having higher suicidal ideation (SSI≥20) (odds ratio [OR] 0.09; 95% confidence interval [CI] 0.03-0.23], clinically significant aggression (CABS≥22) (OR 0.28; 95% CI 0.14-0.59), and at least moderate depressive symptoms (HAM-D₁₇≥17) (OR 0.20; 95% CI 0.08-0.48). Association of total cholesterol and HAM-D₁₇ scores was significantly moderated by the severity of PTSD symptoms (P < 0.001).

Conclusion

Our results indicate that higher total serum cholesterol is associated with lower scores on HAM-D₁₇, CABS, and SSI in patients with chronic PTSD.Posttraumatic stress disorder (PTSD) is one of the few mental disorders with a clearly identifiable cause. It is an anxiety disorder caused by exposure to a traumatic event that presented a threat to the physical integrity of persons themselves or other people in their surroundings (1). Key neurochemical PTSD features include altered catecholamines regulation, alterations in serotonergic system, and alterations in systems of aminoacids, peptides, and opioid neurotransmitters (2).Associations between serum lipids and various psychiatric disorders and some behavioral aspects (like aggressive behavior) and/or suicidality have been widely explored. Lower total cholesterol levels were predominantly found in patients with major depressive disorder (MDD) (3-9). Significantly higher high-density lipoprotein cholesterol (HDL-cholesterol) levels were found in depressive patients than in controls (7). Some studies found significantly lower HDL-cholesterol levels (10) and a lower HDL-cholesterol/total cholesterol ratio (5) in patients with MDD than in controls.A negative correlation (11-13) between serum cholesterol level and aggressive behavior was also found, confirming the cholesterol-serotonergic hypothesis of aggression (14,15). Inadequate cholesterol intake could lead to decreased central serotonin activity, which is associated with an increased risk for impulsive-aggressive behavior (14-18). Depression (19-21) and aggression are well-known suicidality risk factors (15,22).The correlation between hypocholesterolemia, decreased central serotonin activity, increased depressive potential, and increased suicidality risk (23-27) was confirmed, implicating that hypocholesterolemia might be indirectly, ie, through decreased central serotonin activity and increased depression potential (20,25,28), associated with an increased suicidality risk (15,19-24,26,27). In patients with anxiety disorders other than PTSD, like panic disorder (PD), lower HDL-cholesterol and higher very low density lipoprotein cholesterol (VLDL-cholesterol) levels were found to be associated with higher suicide ideations/risk (29). Significantly lower serum total cholesterol and LDL cholesterol levels were found in suicidal patients with PD than in control subjects (30).Hypercholesterolemia was found to be associated with chronic, war-related PTSD (31-34). In a study from Bosnia and Herzegovina, not only hypercholesterolemia but also increased VLDL- and HDL-cholesterol levels were found in war veterans with PTSD in comparison with war veterans without psychiatric disorders (35). A Croatian study found no significant differences in the total serum cholesterol level, LDL-, and HDL-cholesterol between war veterans with PTSD, war veterans without PTSD, and healthy volunteers (36).The aim of this study was to investigate the relationship between serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with PTSD free of other psychiatric premorbidity and comorbidity.     

Uric Acid and Antioxidant Effects of Wine

The aim of this article is to review the role of uric acid in the context of antioxidant effects of wine and its potential implication to human health. We described and discussed the mechanisms of increase in plasma antioxidant capacity after consumption of moderate amounts of wine. Because this effect is largely contributed by acute elevation in plasma uric acid, we paid special attention to wine constituents and metabolic processes that are likely to be involved in uric acid elevation.The association between light-to-moderate wine consumption and risk reduction of cardiovascular diseases and/or reduction of all-cause mortality was confirmed by numerous epidemiological studies (1-7). Among other beneficial biological effects, it has been shown that wine can increase antioxidant capacity in humans (8-12) and reduce susceptibility of human plasma to lipid peroxidation (11,13). These effects of wine attracted significant research interest, as oxidative stress is implicated in the pathogenesis of various diseases such as cancer and cardiovascular and neurodegenerative diseases (14-19).