Marijana Gulin, Lada Zibar, Željko Huljev, Ksenija Vučur, Mario Laganović

Human papillomavirus (HPV) infection is common in general population. Persistent infection caused by a high-risk oncogenic HPV increases the risk of developing cancer unless body’s immune system resolves infection. Although there is no specific treatment, HPV infection can be prevented by vaccination. Kidney transplant recipients are at increased risk for HPV persistent infection and developing complications due to lifelong immunosuppression, as compared with general population. In line with recommendations from different scientific societies, herein we present the Croatian guidelines for HPV vaccination in kidney transplant recipients.

Ivan Kovačić, Marijan Kovačić, Marija Kera, Tamara Tačigin

Giant basal cell carcinoma (GBCC) is a rare skin tumor with the longest diameter greater than five cm. The main factors for its occurrence are considered to be the neglect of conventional basal cell carcinoma (BCC) by patients and the biological aggressiveness of the tumor. With its slow infiltrative growth it disrupts the structural and functional integrity of the affected area. There are no guidelines for its treatment regardless of localization and it still poses a therapeutic problem. In this study, we analyzed patient and tumor characteristics and response to GBCC surgical treatment. Of the total number of patients with BCC over a period of 11 years we isolated 24 cases with GBCC. All patients were in the third age range, from 65 to 86 years old, mostly poor, prone to
alcohol and depression. The size and area of the tumor in the central part of the face were slightly smaller than in the lateral part. Male gender predominated (1.4:1). All patients underwent surgical resection of the tumor with histologically confirmed free margins, as the only method of treatment. Reconstruction of the resulting defect was performed in the same procedure . During the follow-up of 36 months on average no recurrence of the disease or metastasis in any of the patients was observed. Histological processing also defined the subtype of these tumors. Most were non-aggressive, nodular form tumors. Due to the duration of the disease, an average of 5.9 years, we believe that the greatest responsibility for the development of this subtype of BCC is the indolent attitude of the patient. Facial GBCC can be successfully treated surgically in such a demanding area as the face, and regardless of the patient’s age.

Marija Šćepović-Ljucović, Miroslav Mayer, Ivan Padjen, Branimir Anić

Longitudinal extensive transverse myelitis (LETM) is rather rare life threatening complication of systemic lupus erythematosus (SLE). It is defined as an inflammatory spinal cord lesion that extends over three or more adjacent vertebral segments. Clinical presentation can consist of paraparesis or tetraparesis, sensory disturbances and vegetative dysfunction, and respiratory failure may follow in severe cases. A female patient aged 28 years, diagnosed with SLE 11 years ago, has been herein presented, whose disease was complicated by LETM affecting cervical and thoracic spinal cord. LETM occurred after the period of stable remission, and was followed
by clinical, as well as previously serologically active disease. In the context of LETM the patient developed tetraparesis and high hypoesthesia, while respiratory muscle paralysis and consecutive respiratory failure required mechanical ventilation. After the exclusion of underlying intracranial infection, combined immunosuppressive therapy has been used resulting in a gradual but partial neurological recovery, and an overall neuroradiological improvement. LETM is an uncommon but severe complication of SLE leading to serious neurological sequelae, and often resulting even in fatal otcome. Along with herein presented case report, current available findings on pathogenesis, diagnosis and therapheutic approach in the context of neuropsychiatric lupus have been depicted through the review of the literature.

Mislav Mokos, Željko Kaštelan, Marijana Ćorić, Nikolina Bašić-Jukić

Kidney transplantation ensures not only the improvement of the patient’s quality of life but also extends life expectancy. A significant disproportion between the numbers of available and needed organs for transplantation has led to prolonged wait time for a kidney transplant. Since mortality rates for hemodialysis patients are manifold higher when compared to general population of the same age, organs from older donors are increasingly being accepted. We report the case of kidney transplantation in a 72-year-old recipient who received kidney from an 83-year-old deceased donor. Proper care of deceased donor in the intensive care unit, preimplantation
biopsy and short cold ischemia time were crucial for organ acceptance and resulted in immediate graft function. Adequately prepared older recipient, with short period on hemodialysis, appropriate postoperative monitoring and immunosuppressive therapy resulted in quick recovery of the patient, without intraoperative or early postoperative complications, and a short inpatient stay.

Željka Laksar Klarić , Ana Đanić Hadžibegović, Andrijana Včeva, Tamara Živković Ivanović, Darija Birtić, Ratko Prstačić, Željko Zubčić

Total laryngectomy is surgical removal of the entire larynx and is performed in cases of advanced larynx cancer. There are three methods of restoring voice after total laryngectomy: electrolaryngeal voice, esophageal voice, or tracheoesophageal voice with voice prosthesis where mucosa of pharyngoesophageal segment is the source of voice production. The acoustic analysis of alaryngeal voice is gold standard in assessing the voice quality in patients after total laryngectomy. Unfortunately, by using videostroboscopy, standard diagnostic procedure for visual analysis of vocal mucosa vibratory behavior, it is not possible to visualize and measure vibrations of
pharyngoesophageal segment. High-speed videoendoscopy has proven to be the optimal method for visual recording of vibratory movement of the mucosa of pharyngoesophageal segment. By reviewing the current literature we provided a detailed insight into application of high-speed videoendoscopy in the analysis of phonatory behavior of pharyngoesophageal segment in laryngectomized patients.

Nina Milutin Gašperov, Ivan Sabol , Vjekoslav Tomaić, Magdalena Grce

Despite continuous efforts to identify molecular markers for the early detection of head and neck cancer (HNC), and improved therapy, the overall survival and prognosis of HNC patients still remain poor. Scientific evidences suggest that HPV-associated HNC had better prognosis and survival. Furthermore, epigenetic alterations are generally frequently involved in carcinogenesis, tumor progression and resistance to therapy. Thus, understanding and characterization of epigenetic modifications associated with head and neck carcinogenesis promise the identification of epigenetic markers for the early detection of cancer and improvement of therapeutic approaches to fight cancer. In this review, the focus is on the current knowledge on epigenetic modifications regarding DNA methylation and microRNAs observed in HNC, particularly in HPV-positive oropharyngeal cancer.

Vjekoslav Tomaić, Nina Milutin Gašperov, Ivan Sabol, Magdalena Grce

More than 200 human papillomaviruses (HPVs) infect human epithelial cells, and out of them alpha and beta types have been the most extensively investigated and analysed. Alpha HPVs primarily infect mucosal epithelia and only a small proportion of them is associated with more than 600,000 cancers per year worldwide at various anatomical sites, especially anogenital and head-and-neck region. Of these the central disease is cervical cancer, which is the leading cause of cancer-related deaths in women in numerous parts of the world. HPVs encode two oncoproteins, E6 and E7, which are directly involved in the development of HPV-mediated malignancies. They do this in cooperation by targeting various cellular pathways involved in the regulation of cell cycle control, of apoptosis and of cell polarity control networks. In this review, the biological consequences of HPV manipulating of various cellular proteins at diverse anatomical sites in the development of HPV-induced carcinogenesis are depicted, with focus on head and neck cancer.

Marko Barešić, Branimir Anić

Systemic sclerosis is a multisystem autoimmune disorder characterized by widespread fibrosis, primarily of the skin but also of the lung parenchyma. Interstitial lung disease is one of the most severe manifestations of the disease and a leading cause of death among patients with systemic sclerosis. This article presents and summarizes therapeutic options for interstitial lung disease – predominantely immunosuppressives and biologics (cyclophosphamide, mycophenolate mofetil, rituximab and tocilizumab) and the drugs which remodel fibrotic tissue (antifibrotics). There is increasing evidence for a beneficial effect of combination therapy (immunosuppressive + antifibrotic) on the lung parenchyma. Recently, autologous hematopoietic stem cell transplantation seems
to be a therapeutic method reserved for the treatment of progressive forms of systemic sclerosis and should be performed in medical centers with experience in transplantation medicine.

Darija Birtić, Matej Rezo, Jasminka Grigić, Željka Laksar Klarić, Mirjana Grebenar Čerkez

Objective: To present the impact of national lockdown due to COVID-19 pandemic on the incidence of persistent secretory otitis media in children. Patients: Children aged from four to 13 years who were surgically treated from 1st January 2017 to 31th December 2020 at the University Department of Otolaryngology, Head and Neck Surgery, University Hospital Center Osijek. Methods: Patients underwent otomicroscopy, tympanometry, tone audiometry and fiberendoscopy of the epipharynx. After confirmation of the existence of secretory otitis the children were treated surgically, using adenotomy and myringotomy by inserting ventilation tubes in the equilateral
ear. Results: This study included 107 children who were surgically treated with adenotomy and myringotomy by inserting ventilation tubes. The results showed a significant decline in the number of operations in 2020 compared to the previous three years, presumably due to national lockdown closures. We recorded the largest difference comparing 2018 and 2020, when the number of operations decreased by 87%. Conclusions: Drastic reduction of activities during the national lockdown closure, schooling from home and emphasizing the proper and regular implementation of personal hygiene have contributed to reducing the incidence of one of the most common infections in children. Lower frequency of acute otitis media has a positive effect on reducing the frequency of development of secretory otitis in children. Compared to the previous three years, there has been a significant decline in the number of children requiring surgical treatment. This is the first retrospective study on the impact of national lockdown on reducing the need for surgical treatment of persistent secretory otitis in children.

Karmela Šentija

Danijela Tomić

Branka Aukst Margetić

Maja Prutki, Marko Petrovečki, Petra Valković Zujić, Gordana Ivanac, Tade Tadić, Damir Štimac, Karolina Bolanča Čulo, Boris Brkljačić, Paula Podolski, Damir Miletić

Breast carcinoma is the most common neoplasm in the female population of Croatia. The main imaging breast diagnostic modalities are mammography, ultrasound, and magnetic resonance. This paper reviews radiological guidelines for breast diagnostic and interventional procedures, and monitoring of breast cancer patients in the Republic of Croatia. An algorithm for radiological assessment is presented for symptomatic patients, pregnant and lactating women, patients with average and increased risk of developing breast cancer, and patients with radiological findings of mastitis.

Marija Milićević, Pave Markoš, Darija Vranešić Bender, Damir Aličić, Marko Banić, Neven Baršić6, Ivan Bogadi, Mirjana Kalauz, Goran Poropat, Rosana Troskot Perić, Željko Krznarić

Eosinophilic esophagitis is a chronic, Th2-mediated disease characterized by the presence of predominantly eosinophilic inflammation in the esophagus. The disease is mediated by an immune or antigenic pathophysiological background, and the definition of the disease requires the presence of clinical symptoms and histological elements of the disease. Over the past ten years, there has been an increase in the incidence and prevalence of EoE, where the prevalence of EoE varies, and in the general population is 0.2–4 / 1000 in asymptomatic patients, while in symptomatic patients it is 5–6%. The prevalence in the general population is considered to be 43 to 52/100000. Pathophysiologically, it is a polygenic disease in which certain cytokines (IL-4, IL-5, IL-13, IL-14 and TGF-β) play a key role by activating eotaxin-3 in the esophageal mucosa. Eotaxin-3 strongly attracts eosinophils into the esophageal mucosa, and thus activated eosinophils lead to the attraction of other inflammatory cells, the release of mediators and the onset of disease. The histological criterion for the diagnosis of EoE is the presence of more than 15 eosinophils present in the visual field of esophageal mucosal biopsies. Clinically, the disease can manifest itself by a spectrum of symptoms, from acute food impaction, dysphagia, epigastric pain and heartburn, and nonspecific symptoms such as incontinence or vomiting also occur in these patients. The basis of treatment of these patients is based on drug therapy, dietary recommendations and endoscopic dilatation. Thea im of these clinical recommendations is to present the pathway of diagnosis and therapy of eosinophilic esophagitis.

Anja Benšić, Mirta Arlović, Patricia Orlić, Diana Maržić

Introduction: Spasmodic dysphonia (SD) and muscle tension dysphonia (MTD ) are two different disorders with different etiology that influence the quality of voice, characterized by similar perceptual and acoustic features. It is known that the emergence of compensatory mechanisms can lead to problems in the differential diagnosis of adductor spasmodic dysphonia (ADSD) and primary hyperkinetic dysphonia (MTD) by fiberoptic video laryngoscopy (FLS). So, the goal of this paper is to determine acoustic objective differential diagnostic criteria for distinguishing between SD and MTD and confirm clinical laryngeal findings by FLS and diagnosis.
Patients and methods: Eight women with MTD and eight women with SD diagnosed at the Department of Audiology and Phoniatrics of the Clinical Hospital Center Rijeka participated in this study. A phoniatrician and a speech language pathologist (SLP) participated in the diagnostic procedure. FLS and SLP assessment were performed. Samples of extended phonation of the vowel /a/ and reading were collected. The samples were analyzed in the computer program Praat, which was used to measure the duration of words and sentences, the percentage of brakes in phonation and words, and cepstral peak prominence (CPPS). Results: This study found that four acoustic
parameters (word duration, sentence duration, percentage of brakes /a/, percentage of brakes (word)) separate SD and MTD well. CPPS does not separate these two groups of patients. Furthermore, it was confirmed that by analyzing the phonation pattern of the vowel /a/ in the computer program Praat it is possible to classify these two disorders with a cut-off value of 5%. If the percentage of delay in the phonation pattern of the vowel /a/ is greater than or equal to 5%, it is very likely that it is a voice sample of a person with SD. Conclusion: Acoustic measures applicable in clinical conditions were determined. It has been shown that acoustic analysis of voice samples can provide valuable differential diagnostic data. This suggests that acoustic analysis of voice samples should be an integral part of the standard diagnostic protocol for voice disorders besides FLS.

Marijan Kovačić, Ivan Kovačić, Ivica Francišković, Maja Grgec Dragičević

Objective: In this paper, we present a rare case of transorbital intracranial penetrating injury, our diagnostic procedures, treatment, and final outcome. Patient and methods: A 38-year-old patient on triage examination had right periorbital injury, bruising and swelling of the upper eyelid, minor skin laceration, and joint prolapse. He had no loss of consciousness, vision or neurological deficit. Based on the data that he had suffered an orbital injury when mowing the plants, in addition to clinical examination we performed radiological processing. As the first method of radiological diagnostics we performed computed tomography. A metal artifact was found stuck in the medial part of the roof of the orbit with a partial penetration into the intracranium. After tetanus prophylaxis and antibiotic administration we proceeded to remove the foreign body. External transorbital pathway above the entrance wound was selected. We exposed the orbital part of the foreign body, and without applying brute force removed a piece of wire. The resulting perforated bone defect was closed with bone wax. Results: The patient’s recovery was rapid, with no neurological or ocular outbursts. We did not notice the presence of early and late complications of the operation. Conclusion: This serious, sometimes life threatening injury, can have a successful outcome if a multidisciplinary approach is used to diagnose early, perform targeted diagnostic imaging, quality surgical planning and postoperative treatment.

Ana Marija Valetić, Joško Mitrović, Marija Jelušić, Branimir Anić, Jadranka Morović Vergles

Episodic angioedema with eosinophilia, also known as Gleich syndrome, is an extremely rare disorder characterized by recurrent occurrence of angioedema, urticaria, fever, increased body weight, elevated serum values of immunoglobulin M, and leukocytosis with significant eosinophilia. The cause and pathogenesis of the disease are not fully clarified. It occurs mostly in children or adults of younger age. The first choice of treatment are glucocorticoids, and the prognosis is mostly good. We report a case of a patient who was diagnosed with Gleich syndrome based on recurrent episodes of angioedema and fever in the presence of leukocytosis with eosinophilia and elevated immunoglobulin M values. The patient has been in stabile remission for four years since the administration of glucocorticoids.

Ludvig Letica, Ilija Perutina

Aim: The aim of this study is to compare hemorrhoid laser procedure with Morgan-Milligan surgical procedure for short-term outcome. Methods: The research sample included patients with verified 3rd or 4th stage hemorrhoidal disease. Twenty-five of them were provided surgical Morgan-Milligan treatment at the Clinic for Surgery at the University Clinical Hospital Mostar, and 25 underwent laser hemorrhoidoplasty treatment in a private polyclinic in Mostar. The part of the data collected from the hospital network system and medical history from the polyclinic supplied information about gender, operative technique, duration of hospitalization, and surgical treatment price. The other part of the data is composed of phone answers of patients about postoperative pain on the 1st, 7th, and 14th day after the procedure, pain duration, and recovery time duration. Results: The study has shown that more men (74%) were surgically treated for hemorrhoidal disease than women (26%). Hospitalization time was two hours after laser procedure, but about seven days after Morgan-Milligan procedure. There was a statistically significant difference between classic Morgan-Milligan hemorrhoidectomy (CHE) group and laser hemorrhoidoplasty (LHP) group regarding the short-term outcome. Pain intensity, measured by numerical rating scale, during the first day was 6.20 in CHE, and 3.48 in LHP group, after seven days 3.44 in CHE and 1.12 in LHP, and after 14 days 1.52 in CHE and 0.44 in LHP group. Pain duration after procedures was 14 days in CHE group compared to three in LHP. Recovery time duration was about 30 days in CHE group and five in LHP. Conclusion: Minimally invasive laser hemorrhoidoplasty procedure results in better short-term outcome than open surgical hemorrhoidectomy, but is more expensive. Our results suggest that intrahemorrhoidal diode laser treatment, if available, is preferred to open hemorrhoidectomy due to lower postoperative pain intensity, pain duration time, recovery time period, and hospitalization of two hours.

Mislav Mokos, Suzana Ljubojević Hadžavdić

The use of personal protective equipment (PPE) and hand hygiene belong to essential preventive measures against the spread of the COVID-19 pandemic. Several professions, particularly health care workers, are exposed to prolonged contact with PPE, which may result in numerous skin changes, including new skin lesions and aggravations of the pre-existing skin diseases. Occlusive effects of protective masks, together with pressure and friction, may lead to the dryness of the facial skin and the appearance or flair-ups of preexisting acne (maskne). Frequent hand washing with soaps and detergents may result in both dryness of hands and irritant contact dermatitis since detergents and hot water represent the combination of mechanic and chemical irritants. Talcum powder in the gloves may have an additional irritative effect. Protective masks, goggles, and clothing impair the skin barrier due to their occlusive effect, leading to irritant contact dermatitis. Allergic contact dermatitis, which occurs less frequently than irritant contact dermatitis, is a delayed-type hypersensitivity reaction provoked by allergens present in PPE (particularly in masks and gloves) and disinfectants. Contact urticaria is a rare consequence of PPE, and the most common cause of contact urticaria is latex in protective gloves. Prolonged use of protective masks, goggles and face shields may also lead to mechanical injuries to the skin, which range from the mildest forms, such as skin redness and linear marks, to blisters, erosions and ulcerations. The results of up-todate studies concerning skin changes caused by PPE are presented in this review article.

Iva Pažur, Josipa Kovačić, Ognjen Ožegić

Majority of mechanically ventilated patients in intensive care units (ICU) suffer from diaphragm dysfunction. It occurs in approximately 60 to 80 % of such patients. Early after the initiation of mechanical ventilation pathophysiological processes leading to diaphragm dysfunction are triggered. Inadequate diaphragm function significantly contributes to difficult weaning, prolonged mechanical ventilation as well as increased morbidity and mortality. Etiology of ventilation induced diaphragm dysfunction (VIDD) is complex and multifactorial. Metabolic and inflammatory changes in muscular tissue are one of the hallmarks of critical illness and together with patient-ventilator asynchrony and prolonged vasopressor support play a key role in VIDD pathophysiology. Treatment of primary cause of respiratory insufficiency is of utmost importance, but besides this, adequate titration of sedatives and muscle relaxants, monitoring of respiratory mechanics and deployment of proportional modes of ventilation are of great significance in prevention and treatment of VIDD. Proportional modes offer support to spontaneous breathing. However, unlike the conventional modes, this support is not constant, it changes with every breath, offering assistance that is proportional to activity of respiratory muscles. The aim of this article was to offer an insight into latest data from scientific literature to healthcare providers. The electronic search of Pubmed, Medline and Google Scholar was conducted by using MeSH (Medical Subject Headings) terms. Our search was limited to randomized controlled trials and review articles written in English, which were published from 2016 to 2021 and conducted on adult patients. Conclusion: During the pandemic of SARS-CoV-2, the importance of mechanical ventilation with all its aspects came into the focus of medical community. Mechanical ventilation is considered as a life saving method of treatment, but serious adverse effects such as dysfunction of diaphragm can be encountered. There are ongoing developments of new strategies and modes of mechanical ventilation aiming at protection of lungs and diaphragm. Diaphragm protective mechanical ventilation reduces the duration of mechanical ventilator support, decreases the incidence of severe complications such as multiple organ failure and consequntely mortality.

Robert Trotić


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ISSN 0024-3477 (Tisak)
ISSN 1849-2177 (Online)
UDK: 61(061.231)=862=20

Liječnički vjesnik (LV), the official peer-reviewed journal of the Croatian Medical Association, publishes editorials, professional and research articles, review articles, case reports, drugs and methods reviews, preliminary scientific and professional communications, commentaries, letters to the editor, book reviews, and other contributions, provided they have not been published in the same format in another journal or book. The journal is published six times a year.
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