The Croatian physician Klara Dajčeva (1897–1984) is analyzed in this paper as an incentive for the identification of women within the medical corps and the introduction of a female perspective into research into the history of medicine and society in our region. Her article “On the Influence of Adrenaline on Tissue Regeneration”, published in Liječnički vjesnik in 1921, omitted in all previously published sources, is identified in this paper as the first experimental and visual publication by a woman. The feminist narrative of Klara Dajčeva, as the only feminist known so far from the Croatian medical ranks, is presented, which has been determined to function as a link between medical observation and social criticism.
Lysosomal acid lipase deficiency (LAL-D) is an ultra-rare inherited metabolic disease causing lipid accumulation in lysosomes. LAL-D is often unrecognized because clinical signs and symptoms of this disease overlap with some common liver diseases and not so rare dyslipidemias. Familial hypercholesterolemia (FH) is an inherited metabolic disorder causing elevated serum LDL-cholesterol levels which cause premature atherosclerosis and an increased risk of cardiovascular disease. As part of the universal screening of preschool children for FH which has been performed in Croatia for already three years, there is a possibility of detecting patients with LAL-D. The dyslipidemia panel is a genetic test which is a part of the screening for FH and which also tests the LIPA gene responsible for LAL-D. Therefore, the expert group proposes to determine also LAL activity in children with elevated levels of LDL-cholesterol and, if necessary, LIPA gene in the framework of FH screening to diagnose children with LAL-D. In this paper clinical signs and symptoms are described that should encourage physicians to test LAL activity in children who will not be genetically tested and do not have significantly elevated LDL-cholesterol values. The main criteria by which LAL-D can be clinically distinguished from other dyslipidemias are elevated activities of transaminases.
Rheumatoid arthritis (RA) is one of the most common chronic inflammatory rheumatic diseases primarily characterized by joint destruction, though it may also present with extra-articular manifestations. Despite current American College of Rheumatology/European Alliance of Associations for Rheumatology recommendations on the use of diagnostic ultrasound (US) as an additional tool in the diagnostic workup of RA, US has not yet been incorporated into standard disease activity indices or remission criteria. This review summarizes the latest published consensuses of professional societies for the quantification of US changes in rheumatology, as well as scoring systems for the quantification of synovitis, tenosynovitis, erosions and cartilage damage, with the aim of achieving US standardization. US aids in monitoring RA patients by enabling more objective assessment of disease activity, through detecting subclinical activity and differentiating between inflammatory and noninflammatory causes of elevated scores obtained using standard clinical indices. We believe that US in RA should find it’s main application in clinically doubtful cases exhibiting elevated disease activity scores using standard clinical indices, in screening of patients with arthralgia or undifferentiated arthritis, and especially in patients with stable remission in whom therapy reduction is being considered.
Cutaneous mastocytosis is a rare disorder characterized by the proliferation and accumulation of abnormal mast cells in the skin, without evidence of internal organ involvement. It represents the most common form of mastocytosis in childhood, whereas in adult patients cutaneous manifestations often indicate the presence of systemic disease. According to current classifications, three main clinical variants of cutaneous mastocytosis are distinguished: maculopapular cutaneous mastocytosis, diffuse cutaneous mastocytosis, and cutaneous mastocytoma. The pathogenesis of the disease is most commonly associated with activating mutations of the KIT proto-oncogene, leading to constitutive activation of the KIT receptor and increased mast cell proliferation. The clinical presentation is highly heterogeneous and encompasses a broad spectrum of cutaneous manifestations, frequently accompanied by symptoms mediated by mast cell mediator release, such as pruritus, flushing, gastrointestinal complaints, and anaphylactic reactions. Diagnosis is based on clinical examination, a positive Darier’s sign, dermatohistopathological analysis, and assessment of baseline serum tryptase levels and KIT mutational status. Therapeutic management focuses on avoidance of triggering factors and symptomatic treatment, as causal therapy is currently not available. Cutaneous mastocytosis represents an important clinical sign that may indicate systemic disease and enables assessment of the risk of potentially life-threatening manifestations, including anaphylaxis.
Permanent central venous catheters (CVCs) are the least desirable form of access for chronic hemodialysis. However, they are acceptable when all other forms of long-term vascular access have been exhausted. In patients with thrombosis of the major veins of the shoulder girdle and pelvis, CVC placement and subsequent replacement are technically demanding procedures. We present the case of a 32-year-old patient in whom, due to thrombosis of both subclavian and iliac veins, a permanent dialysis CVC was placed directly into the inferior vena cava via a retroperitoneal approach. To reduce the risk of accidental catheter dislodgement and to facilitate future replacement, the catheter was inserted through a synthetic graft anastomosed to the inferior vena cava. The procedure was completed without complications, and after 18 months the catheter remains patent and fully functional. In patients with thrombosis of the central veins of the shoulder region and subclavian veins, permanent dialysis CVCs can be placed thoracoscopically into the superior vena cava or directly into the right atrium or inferior vena cava. In the present case, due to thoracic deformity, access to the inferior vena cava was selected and successfully achieved.
Introduction: Exposure of a synthetic vascular graft in the groin is a serious complication following vascular surgery, associated with a high risk of infection, potential graft explantation, and possible limb loss. Prompt soft tissue coverage is crucial to minimize the risk of infection and reduce overall morbidity. The success of vascular reconstruction is primarily determined by graft patency and preservation of adequate distal perfusion. Case report: We report the case of a 61-year-old woman who developed a skin and subcutaneous tissue defect with exposure of a Dacron vascular graft following multiple vascular procedures in the right groin region. After isolation of Staphylococcus epidermidis from the wound, targeted antibiotic therapy was initiated, followed by negative pressure wound therapy (NPWT). Despite these measures, a residual soft tissue defect measuring approximately 12×4 cm, persisted. Definitive reconstruction was therefore performed using a gracilis muscle flap combined with split-thickness skin grafting (Thiersch graft). The postoperative course was uneventful, with no evidence of flap-related complications, and complete wound healing was achieved by primary intention. Conclusion: In the management of groin defects with exposed synthetic vascular grafts, the gracilis muscle flap represents a reliable and well-established reconstructive option, particularly in patients with compromised local tissue conditions.
One of the most common sexually transmitted infections is human papillomavirus (HPV) infection, which has great public health significance due to its epidemiological and clinical characteristics. In most people it resolves spontaneously without clinical symptoms or consequences, but in some infected people it may cause anogenital warts, while persistent infection with high-risk types may result in serious health complications and certain types of cancers. There is no specific cure for HPV infection, but vaccination against HPV provides effective and long-term protection against infection with the most common types of HPV, including oncogenic types. Therefore, HPV immunization is an important biomedical intervention for the prevention of HPV-related diseases. In accordance with international recommendations, national professional societies and institutions have developed Croatian recommendations for HPV vaccination for routine vaccination of adolescents and young people, and vaccination of adults based on medical indications.
Aim: The authors present the results of an analysis of the causes of death of U.S. presidents. Material and methods: In this paper, we analyzed biographical data on 45 presidents (of whom 40 are deceased), including gender, age at death, and party affiliation. We classified the causes of death and analyzed detected comorbidities and rare diseases. We presented cases of assassinations and assassination attempts on U.S. presidents and compared the collected data with the data on assassinations of presidents and prime ministers of other countries. The cases in which the vice presidents assumed the presidency due to the death or resignation of the president were analyzed. Results: To date exclusively men have held the office of U.S. president, with an average age at death of 72.2 years. The highest age at death was 46 years, and the lowest was 100 years. The most common causes of death were cardiological (11), neurological (9), multicausal (5), infectious (4), violent death (4), gastroenterological (2), oncological (2), pulmonological (2), and otorhinolaryngological (1). Heart attack was diagnosed as the cause of death in five presidents and stroke in eight. The association of smoking with the cause of death was established in 13 of the 16 presidents. Comorbidities from rare diseases were identified in four presidents. Four U.S. presidents were assassinated, and eight have survived one or more assassination attempts. The number of assassinations of state leaders was higher in the U.S. than in France, Great Britain, Germany, Italy, and Israel. Due to the death or resignation of U.S. presidents during their term, the vice presidents took over the presidency in nine cases. Conclusion: The findings of this study provide an affirmative response to the question posed in the title of the publication. U.S. presidents experience similar health outcomes as the general population, most commonly dying from cardiovascular and cerebrovascular diseases; during the 18th and 19th centuries, they also frequently succumbed to infectious diseases that were widespread at that time. What distinguishes them from the general population is a higher risk of violent death.
Complicated diverticulitis remains a relatively commonly encountered surgical emergency in Croatia. Eventhough early stages of complicated diverticulitis can benefit from a conservative management, large abscesses, diffuse purulent or stercoral peritonitis usually require colonic resection. In Western countries, such scenarios commonly involve sigmoid colon resection with or without end colostomy formation. We report a rare presentation of complicated sigmoid diverticulitis manifesting as an abdominal wall abscess without signs of peritonitis in a 60-year-old female, with a significant medical history including type 2 diabetes, hypertension, dyslipidemia, extreme obesity, and prior laparotomy for complicated diverticulitis. The patient presented with localized lower abdominal pain, erythema, and tenderness consistent with cellulitis, alongside elevated CRP but normal white cell count. Imaging via CT scan revealed a large purulent collection in the lower abdominal wall, suggesting a contained perforation. Emergency surgical exploration confirmed a firm adhesion of the sigmoid colon to the abdominal wall and a large abscess cavity containing feculent material. There was no sign of free fluid or peritonitis in the abdominal cavity. Hartmann’s procedure was performed, including resection of the diseased colon and formation of a colostomy. Postoperative recovery was initially favorable but complicated by colostomy retraction due to the patient’s obesity. A revision surgery was successfully performed on day 11, restoring bowel continuity. We opted for the latter due to the absence of peritonitis. Further recovery was uneventful, with a complete resolution of the abdominal wall cellulitis and drainage. This case reports of an unusual route of perforation in diverticulitis leading to an abdominal wall abscess without intraabdominal contamination and highlights the importance of individualized surgical planning in complex recurrences.
This paper explores mediation as a modern, effective, and economical form of alternative dispute resolution in the Republic of Croatia. The study aims to analyze the legislative framework, principles, and practical application of mediation, with particular emphasis on its role in damages proceedings and within the healthcare system. Using a desk-based research approach, relevant legislation, professional literature, and practice from 2010 to 2025 were examined. The paper provides a detailed overview of the fundamental principles of mediation, including voluntariness, confidentiality, and impartiality, and compares its cost and duration with often lengthy and expensive court proceedings. Special attention is devoted to healthcare, where mediation is proposed as a key tool for resolving conflicts between patients and medical staff. The authors highlight that inadequate communication is frequently the primary trigger of malpractice claims, while empathy, apology, and dialogue in mediation may prevent escalation of disputes and restore damaged trust. The paper also examines damages proceedings in the insurance sector, where mediation enables faster settlement and helps preserve business reputation. In conclusion, the study confirms that mediation alleviates the burden on the judicial system and reduces financial losses for the parties, and proposes guidelines to strengthen the implementation of this mechanism in Croatian hospitals to improve healthcare quality and interpersonal relations.
Aim: To validate the Croatian version of the Patient-Practitioner Orientation scale (PPOS). Materials and Methods: The used PPOS questionnaire contains 18 statements assessing whether the respondent prefers patient-centered or disease-centered approach. It also measures two dimensions of person-centered care: sharing and caring. The questionnaire was translated from English to Croatian using the translation forward-backward procedure and an online survey was created using the REDCap platform. Data were collected from November 2022 to January 2024 from a convenience sample of family medicine physicians in Croatia – members of the Croatian Medical Chamber, employees of Zagreb-West Health Center and Health Center of the Split-Dalmatia County. Statistical processing and data analysis were conducted using IBM SPSS Statistics, version 21.0 on a sample of 198 respondents. Results: Results indicated an acceptable level of reliability (Cronbach’s α = 0.65) for the overall PPOS questionnaire score, while the reliability was low for the dimensions sharing (α = 0.56) and caring (α = 0.52). The construct validity of the questionnaire was examined using exploratory factor analysis with the principal component analysis extraction method. According to the Guttman-Kaiser criterion, seven factors were identified, explaining 60.05% of the variance of the construct measured by the questionnaire. The PPOS questionnaire is based on a two-factor model, and when two factors are specified, only 27% of the variance of the construct is explained. Four out of 18 items do not align with the factor corresponding to them according to the assumed distribution of the items into the sharing and caring subscales. Conclusions: The PPOS could be used in Croatia to assess patients’ orientation toward physicians as well as physicians’ and other healthcare professionals’ orientation toward patients. A higher level of reliability could potentially be achieved by modifying the questionnaire and its items based on the results of the factor analysis.
Gastrointestinal (GI) disorders are a common problem among patients in the intensive care units (ICUs). They include a wide range of pathological conditions resulting from impaired GI motility, imbalance of gut microbiome, disrupted mucosal barrier integrity, compromised mesenteric perfusion, and altered bile homeostasis. During the stay in the ICU, almost 60% of patients develop some form of GI dysfunction. Clinical evaluation is difficult because of the lack of uniform guidelines, standardized diagnostic protocols, and a universal tool for GI function monitoring. A newly proposed scoring system for quantification of GI dysfunction in this patient population, known as the gastrointestinal dysfunction score (GIDS), is still undergoing validation. Therefore, the assessment of GI insufficiency in the ICU is based on data obtained from a detailed clinical examination, laboratory measurements, and some of the radiological imaging techniques. Information on enteral feeding intolerance, gastric residual volume, values of intra-abdominal pressure, possible GI bleeding, and blood lactate concentration are of key importance. Patients with GI dysfunction have a high risk of developing complications that are associated with prolonged ICU stays and higher mortality. The most severe include bowel ischemia, sepsis due to bacterial translocation, perforation of the digestive tube, GI hemorrhage, and abdominal compartment syndrome. At this moment, there is a continuous need for finding new methods and defining clear diagnostic criteria for detection and quantification of this group of disorders. Timely determination of the underlying pathophysiological process with appropriate therapy and individualized nutritional support aimed at preventing malnutrition, dehydration, and micronutrient deficit effectively improves clinical outcomes in critically ill patients.
Etiology of chronic liver diseases in children differs from adults, with up to 20-30% of rare genetic and metabolic disorders. A child with elevated liver enzymes needs to be cautiously followed, blood tests need to be repeated within 2-3 week interval and further diagnostics should be done in case of persistence of elevated transaminases. After exclusion of muscular origin of aminotransferases initial evaluation should include serology to hepatotropic viruses, liver synthetic function tests, and abdominal ultrasound. In the case of clinical suspicion further specific investigations should be done as well. Viral infections are the most frequent causes of transient aminotransferase elevation in children. When evaluating persisting pathologic liver tests treatable diseases (with pharmaco- or dietotherapy) should always be excluded and chronic viral hepatitis, autoimmune liver disease, celiac disease and Wilson’s disease should be searched for. In infancy differential diagnosis should always include inherited metabolic diseases. They should also be considered beyond infancy, especially if hypertransaminasemia is episodic, or if there is a history of metabolic crises accompanied by hypoglycemia, ketoacidosis, lactic acidosis and hyperammonemia or the course is recurrent. Although metabolic dysfunction-associated fatty liver disease is the most common cause of prolonged elevation of aminotransferases in children, concomitant chronic liver disease should be excluded in overweight children as well (autoimmune liver disease, celiac disease, Wilson’s disease, alpha-1 antitrypsin deficiency).
Communication in medicine is much more than the exchange of information. It is a bridge between people who find themselves in emotionally intense, life-critical, hierarchically sensitive, and time-pressured situations. Despite existing communication protocols, clinical practice still lacks a metaprinciple that encompasses all levels of communication within the healthcare system. The aim is to present and conceptually ground an integrative SOCRATES–YES communication model, based on Socrates’ method of guiding toward affirmative responses, and to consider its applicability across different forms of medical communication (physician–patient, physicianfamily, physician–student, interdisciplinary teams, and organizational management). The paper is structured as a narrative, theoretical, and professional overview, drawing on relevant literature from medical communication studies, psychology, and communication theory. It proposes an integrative model and analyzes its application in clinical and organizational practice. The SOCRATES–YES model synthesizes Socrates’ method of eliciting affirmative responses, validation, emotional intelligence, and relational communication theory. The model consists of six steps: initial alignment, validation, Socratic guidance, formulating information and recommendations, feedback, and the concluding “yes” with encouragement. Through examples, this approach is shown to reduce defensiveness, facilitate acceptance of medical information and decisions, and improve collaboration at all levels of the system. The SOCRATES–YES model represents an original, simple, and widely applicable communication framework in medicine. Its use can enhance relationships with patients and their families, support student education, increase the efficiency of consultations, and reduce resistance to organizational change. As a metaprinciple, the model can be integrated into educational programs and clinical protocols to improve healthcare quality.
Objectives. Patients with rheumatoid arthritis (RA) are at an increased risk of mortality and morbidity due to cardiovascular disease (CVD). RA patients are 50–60% more likely than the overall population to develop CVD. In this investigation, we examined how smoking affected RA patients’ CVD risk. Methods. An eight-year follow-up prospective, clinical cohort research was conducted, at the University Hospital Osijek through special outpatient visits to which participants were invited. The study included 201 participants, 124 with rheumatoid arthritis (RA) as investigation group and 77 with osteoarthritis (OA) as control group. The investigation was f inished for 137 participants, 82 with RA and 55 with OA. The average participants age at the beginning of the investigation for RA group was 59.78 years, while that of the OA group was 64.23 years. During the course of the investigation, 58 participants (41 with RA and 17 with OA) passed away. We compared the prevalence of smoking and how it relates to RA patients’ risk for cardiovascular disease. Results. In the RA group, smoking was more common than in the OA group (p=0.0001). During the follow-up period, trends in the prevalence of smoking in both groups did not significantly alter. Smoking was associated with an increased risk of CVD in the RA group for both current and former smokers (p=0.028 and p=0.016, respectively). Conclusion. Our findings imply that smokers are more likely to develop RA and CVD, the reason underlying the trend of continued cigarette smoking in patients with RA remains unclear. Further studies are needed to clarify the trend of continued smoking in patients with RA.
Introduction: Liver cirrhosis during pregnancy is an uncommon but increasingly recognized condition, largely due to advances in assisted reproductive technologies and improved management of chronic liver disease. It carries significant maternal and fetal risks, including variceal hemorrhage, coagulopathy, and preterm delivery. Case report: A 26-year-old primigravida with decompensated non-alcoholic fatty liver disease (NAFLD)- related cirrhosis was diagnosed during the fourth month of pregnancy. She developed portal hypertension, grade II esophageal varices, and severe thrombocytopenia refractory to intravenous immunoglobulin therapy. Following multidisciplinary consultation among gastroenterology, hematology, obstetrics, and anesthesiology teams, cesarean delivery was planned at 32 weeks’ gestation due to hepatic decompensation. Preoperative optimization included the administration of fibrinogen, factor XIII concentrate, platelet transfusions, and the use of remifentanil during induction of general anesthesia to maintain hemodynamic stability. A male infant weighing 1950 g (Apgar 7/9) was delivered with estimated blood loss of 700 mL during procedure. Postoperative recovery was uneventful, with significant improvement in liver function within four months after delivery. Discussion: Effective multidisciplinary collaboration and targeted hemostatic management were essential in minimizing perioperative bleeding risk. The use of remifentanil provided hemodynamic stability during induction. Conclusion: Even in decompensated cirrhosis, favorable maternal and neonatal outcomes are achievable with individualized perioperative planning, correction of coagulopathy, and coordinated multidisciplinary care.
Inflammatory bowel diseases are chronic disorders of the digestive system, the exact etiology of which is still unknown. Immunological, genetic, and environmental factors, along with changes in the gut microbiota and intestinal barrier, are the most likely pathogenetic mechanisms of disease development. Intestinal permeability is one of the essential factors in the onset of inflammation and is associated with dysbiosis, inflammatory response, and changes in the tight junctions of the intestinal epithelial barrier. Claudins, which are part of the family of proteins that form tight junctions, are crucial for maintaining the integrity of the intestinal barrier and participate in the regulation of paracellular permeability. Considering the multifactorial nature of the disease, the role of claudins in the development of inflammatory bowel disease has become the subject of numerous studies in light of recent findings suggesting that claudins not only serve as transmembrane proteins but also have various other functions, and that changes in the expression, spatial, and temporal distribution of certain claudins may imply previously unrecognized pathophysiological mechanisms responsible for the onset of inflammatory bowel diseases.
Adnexal torsion is a gynecological emergency that presents rarely in postmenopausal women. Its symptoms are often mistaken for other abdominal pathologies or gynecological disorders, leading to delayed diagnosis. This case report describes a 70-year-old postmenopausal woman who presented with an acute onset of intense abdominal and pelvic pain, which was found to be caused by unilateral adnexal torsion secondary to bilateral ovarian fibromas. Surgical intervention via Pfannenstiel laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy confirmed the diagnosis. Preoperative diagnostic tests, including transvaginal ultrasound, were inconclusive, suggesting a pelvic mass, possibly a myoma. Histopathological examination confirmed bilateral ovarian fibromas. This case highlights the importance of considering adnexal torsion in the differential diagnosis of abdominal or pelvic pain in postmenopausal patients
Background: Reactive arthritis (ReA) is an inflammatory rheumatic disease that belongs to the group of spondyloarthritis (SpA). Etiopathogenesis of ReA, as well as the majority of other SpA entities, is linked with the presence of HLA-B27. However, considerable uncertainty remains regarding the HLA-B27 positivity and its association with the source of infection, clinical, laboratory, and imaging features in ReA. Aim: To assess the prevalence of the HLA-B27 antigen and its relationship with gender and age at onset, source of infection, features of peripheral arthritis, presence of sacroiliitis, and inflammatory burden of ReA. Methods: Patients diagnosed with ReA, who were hospitalized for a work-up and treatment, were evaluated for HLA-B27 status. Demographic data (gender and age at onset), ESR and CRP, number and distribution of clinically affected joints, and presence of sacroiliitis imaging on MRI were obtained and analyzed towards HLA-B27 positivity. Statistical significance was set at P<0.05. Results: A total of 224 patients with a mean age of 32.2±6.9 years were included. The majority were males (135 patients, 60.3%) (P = 0.0021), and the disease mostly started in the age group of 30–39 years (P<0.00001). The overall prevalence of HLA-B27 was 70.5%, with no significant association with any gender (P=0.153). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were significantly higher in HLA-B27 positive patients (for both P =0.001). There was a tendency to observe sacroiliitis more frequently in HLA-B27 positive patients, although the result did not reach significance (P = 0.0517). Compared to other locations urogenital tract infection was associated with the highest prevalence of HLA-B27 positivity (P<0.00001). Conclusion: In our study of ReA patients, results indicate that profiling based on HLA-B27 status can be associated with a urogenital source of infection and is valuable for predicting a higher level of systemic inflammation, as well as a tendency to detect sacroiliitis.
