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Background Recently published paediatric guidelines for diagnosing coeliac disease do not include recommendations on the follow-up of coeliac disease patients. Goal The aim of this study was to assess the management practices and experience of coeliac disease patients with their follow-up appointments in Central Europe. Study Gastroenterologists and coeliac disease patients in five Central European countries were asked to complete the web-based questionnaire focusing on coeliac disease management practices. Results Answers from 147 gastroenterologists and 2041 coeliac disease patients were available for the analysis. More than half of the gastroenterologists (58.5%) schedule the first follow-up visit within 3 months after the diagnosis. At follow-up, tissue transglutaminase antibodies are checked in almost all patients (95.9%). Approximately two-thirds (60.7%) of gastroenterologists refer all of their patients to the dietitian at diagnosis. Similarly, 42.8% of coeliac disease patients reported that they had not been appointed to a dietitian. Almost one-third of coeliac disease patients (30.8%) reported that they had no follow-up appointments with gastroenterologist at all. Conclusions Follow-up of coeliac disease patients is suboptimal in Central Europe. Many patients are not followed regularly. A lot of patients are not referred to a dietitian. The recommendations on the optimal follow-up of coeliac disease patients are needed in order to improve patient care.

The influence of vegetarian and vegan diet on children’s health has been discussed not only by pediatricians but also by other professionals who take care of children. Therefore, the aim of this recommendations, based on presented and summarized scientific evidences on the effect of vegetarian and vegan diet on children’s and adolescents’ health, was to state the instructions of the Croatian Society for Pediatric Gastroenterology, Hepatology and Nutrition of the Croatian Medical Association. Vegetarian, and especially vegan diet, is not only the omission of meat and other food of animal origin, but has to represent balanced nutrition adjusted for children. Such a child requires continuous supervision not only by primary health physician but also by pediatric nutritionist, who both have to be specially educated in the field. As restrictions in diet significantly increase the risk for nutritional deficiencies, parents who decide to follow such a diet, and all professionals who take care of such children, have to be aware of possible nutritional risks that are much bigger than in adulthood.

OBJECTIVES: Celiac disease (CD) remains undiagnosed for a long time in many adult and pediatric patients. We assessed the knowledge about CD among healthcare professionals (HCPs) and CD patients in Central Europe (CE). METHODS: HCPs and CD patients from 5 CE countries were asked to complete the web-based questionnaire about CD. The questions were divided into subsections on epidemiology, clinical presentation, diagnostics, treatment, and follow-up. Achieved scores of different specialists managing patients with CD were compared and regional differences in patients' knowledge were analyzed. RESULTS: Questionnaire was completed by 1381 HCPs and 2262 CD patients or their caregivers from Croatia, Hungary, Germany, Italy, and Slovenia. Mean score achieved by HCPs was 50.9%, and by CD patients 56.4%. Pediatric gastroenterologists scored the highest (69.4%; P

Cilj: Osvijestiti o mogućnosti postojanja sindroma Rapunzel u adolescentica s akutnim pankreatitisom. Prikaz slučaja: U hitnu pedijatrijsku ambulantu javila se petnaestogodišnja djevojka zbog povremenih bolova u gornjem dijelu abdomena koji su se intenzivirali par dana pred dolazak. Prilikom fizikalnog pregleda nađena je u epigastriju i lijevom hipohondriju bolna rezistencija veličine otprilike 10 cm u promjeru. Opsežnom laboratorijskom analizom našle su se povišene koncentracije enzima gušterače te se postavila dijagnoza akutnog pankreatitisa. Daljnjom obradom indicirala se gastroskopija kojom se prikazala masa kose na ulazu u želudac. Kompjutoriziranom tomografijom uočilo se da ona seže sve do bulbusa duodenuma. Nakon provedenog konzervativnog liječenja pankreatitisa abdominalni bolovi su regredirali, došlo je do normalizacije enzima gušterače te je bilo indicirano operativno liječenje. Učinila se eksplorativna laparotomija i gastrotomija. Ekstirpirao se trihobezoar težine 1 kg i dužine 25 cm oblika odljeva lumena želuca i početnog dijela duodenuma. Postavila se dijagnoza sindroma Rapunzel. Dječji psihijatar potvrdio je prisutnu trihotilomaniju i trihofagiju te se djevojku uključilo u psihoterapijski tretman. Zaključak: Sindrom Rapunzel vrlo je rijetko stanje, ali treba biti uključeno u diferencijalnu dijagnozu akutnog pankreatitisa u adolescenata. Specifični simptomi trihotilomanije i trihofagije u kombinaciji s nespecifičnim simptomima, poput dugotrajnog bola u abdomenu, trebali bi pobuditi sumnju na razvoj trihobezoara., Aim: To raise awareness about the existence of Rapunzel syndrome in female adolescents with acute pancreatitis. Case report: A 15-year-old girl came to the emergency pediatric clinic due to the occasional pain in the upper abdomen, which had intensified a few days before her arrival. During physical examination, a painful resistance of approximately 10 cm in diameter was palpated in the epigastrium and the right hypochondrium. Extensive laboratory analysis revealed raised concentrations of pancreatic enzymes so a diagnosis of acute pancreatitis was made. Further examination indicated gastroscopy, which showed a mass of hair at the entrance to the stomach. Computed tomography revealed that the mass reached all the way to the duodenal bulbus. After the conservative treatment of pancreatitis, the abdominal pain regresses and the pancreatic enzymes returned to normal so the operative treatment was indicated. Exploratory laparotomy and gastrotomy were performed. A kilogram heavy and 25 cm long trichobezoar in the shape of the gastric lumen and the initial part of the duodenum were exploited. Rapunzel syndrome was diagnosed. The child psychiatrist confirmed the presence of trichotillomania and trichophagia, so the girl was referred to the psychotherapy treatment. Conclusion: Rapunzel syndrome is a very rare condition but should be included in the differential diagnosis of acute pancreatitis in adolescents. Specific symptoms of trichotillomania and trichophagia in combination with non-specific symptoms such as prolonged abdominal pain should raise the suspicion of the development of trichobezoars.

OBJECTIVES: During the past decades, there has been a shift in the clinical presentation of coeliac disease (CD) to nonclassical, oligosymptomatic, and asymptomatic forms. We assessed clinical presentation of CD in children and adolescents in Central Europe. METHODS: Paediatric gastroenterologists in 5 countries retrospectively reported data of their patients diagnosed with CD. Clinical presentation was analyzed and the differences among very young (

Pediatric inflammatory bowel disease (IBD) presents with extensive phenotype. The aim of this study was to determine the phenotype of pediatric IBD patients in Croatia at diagnosis and follow-up.Children were prospectively recruited into Croatian IBD national registry. Data on diagnostic evaluation, therapy and 1-year follow-up were collected.A total of 51 newly diagnosed patients were recruited (19 Crohn's disease (CD), 28 ulcerative colitis (UC) and 4 IBD-unclassified (IBD-U)). Most common location in CD was ileocolonic disease (52.6%), and pancolitis in UC (53.6%). The recommended complete diagnostic algorithm was performed only in 29.4% of patients. First-line therapy used in CD was exclusive enteral nutrition for remission induction (84.2%) and azathioprine for maintenance (73.7%). In patients with UC, aminosalicylates were the most common drug used (89.3%). By the end of the first year 41.2% of CD and 53.9% of UC patients had one or more relapses and required treatment escalation.Our data confirm extensive intestinal involvement in pediatric IBD and relatively high relapse rate during the first year of follow-up. More effort should be invested on the national level to implement more stringent adherence to the current European guidelines.The key message of our article is that pediatric IBD in Croatia shows extensive intestinal involvement with high relapse rates in first year of follow-up. It is the first cohort study reporting on the phenotype of pediatric IBD in Croatia, but also investigates adherence to diagnostic and therapeutic European guidelines which is not commonly reported. The study is national based, thus having the greatest impact on Croatian health care,stressing out that more effort should be invested on the national level to implement more stringent adherence to the current European guidelines.

Background: Pediatric inflammatory bowel disease (IBD) presents with extensive phenotype. The aim of this study was to determine the phenotype of pediatric IBD patients in Croatia at diagnosis and follow-up. Methods: Children were prospectively recruited into Croatian IBD national registry. Data on diagnostic evaluation, therapy and 1-year follow-up were collected. Results: A total of 51 newly diagnosed patients were recruited (19 Crohn's disease (CD), 28 ulcerative colitis (UC) and 4 IBD-unclassified (IBD-U)). Most common location in CD was ileocolonic disease (52.6%), and pancolitis in UC (53.6%). The recommended complete diagnostic algorithm was performed only in 29.4% of patients. First-line therapy used in CD was exclusive enteral nutrition for remission induction (84.2%) and azathioprine for maintenance (73.7%). In patients with UC, aminosalicylates were the most common drug used (89.3%). By the end of the first year 41.2% of CD and 53.9% of UC patients had one or more relapses and required treatment escalation. Conclusion: Our data confirm extensive intestinal involvement in pediatric IBD and relatively high relapse rate during the first year of follow-up. More effort should be invested on the national level to implement more stringent adherence to the current European guidelines. Impact: The key message of our article is that pediatric IBD in Croatia shows extensive intestinal involvement with high relapse rates in first year of follow-up. It is the first cohort study reporting on the phenotype of pediatric IBD in Croatia, but also investigates adherence to diagnostic and therapeutic European guidelines which is not commonly reported. The study is national based, thus having the greatest impact on Croatian health care,stressing out that more effort should be invested on the national level to implement more stringent adherence to the current European guidelines.

The aim of this study was to determine the annual incidence and geographic distribution of pediatric inflammatory bowel disease (IBD) in Croatia. This is a prospective, cohort, multicenter observational study based on the data obtained from the Croatian national registry for children with IBD. Children and adolescents younger than 18 years diagnosed with IBD, in time period between June 1, 2016, and May 31, 2017, were recruited. In total, 51 new cases were identified; 19 Crohn’s disease, 28 ulcerative colitis, and 8 IBD-unclassified. Male preponderance of all 3 types of the disease was noticed. The median age at diagnosis was 14.8 years. The calculated annual incidence of pediatric IBD per 100 000 persons per year was 7.05 (2.63 for Crohn’s disease, 3.87 for ulcerative colitis, and 0.55 for IBD-unclassified). A north to south gradient was observed with almost 2 times higher incidence in the northern region of the country.

Cilj: prikaz 15-godišnjeg pacijenta upućenog u našu Kliniku radi kroničnog kašlja i ezofagitisa. Prikaz slučaja: Petnaestogodišnji mladić patio je od dugotrajnog kašlja uz koji su se javljale i poteškoće gutanja. Dijagnostičkom obradom postavljena je dijagnoza gastroezofagealne refluksne bolesti (engl. gastroesophageal reflux disease, GERD) i patohistološki dokazanog ezofagitisa koji se na provedeno liječenje značajno smanjuju, ali kašalj ostaje nepromijenjen. Pulmološkom i psihijatrijskom obradom postavljena je dijagnoza psihogenog kašlja te je započeto psihoterapijsko liječenje na što dolazi do smanjenja mladićevih tegoba. Zaključak: GERD se prezentira širokim spektrom ezofagealnih i ekstraezofagealnih simptoma od kojih je značajan i kronični kašalj. Međutim, kašalj druge etiologije poput psihogenog kašlja može biti i uzrok GERD-u što diferencijalnodijagnostički moramo razmotriti kod bolesnika u kojih medikamentozna terapija nije dovela do poboljšanja., Aim: Presentation of 15-year-old patient admitted to our Clinic because of chronic cough and esophagitis. Case report: A 15-year-old boy suffers from chronic cough along with swallowing difficulties. Diagnostic workup has been performed and a diagnosis of gastroesophageal reflux disease (GERD) with pathohistologically proven esophagitis has been made with significant improvement after completion of therapy, but cough stayed unchanged. The boy was examined by pulmologist and psychiatrist and they made a diagnosis of habitual cough; psychotherapy was started and resulted in improvement of symptoms. Conclusion: GERD presents with a broad spectrum of esophageal and extraeosphageal symptoms with chronic cough as an important one. Nevertheless, a cough from different origin, such as habitual cough, may cause GERD which must be included in differential diagnosis of patients to whom pharmacological treatment failed to help.

Komplementarne i alternativne metode (KAM) liječenja koriste se kao zamjena ili kao nadopuna metoda medicine zasnovane na dokazima. One prolaze provjeru sigurnosti i djelotvornosti, ali, za razliku od konvencionalnih metoda, u nedostatno kvalitetno dizajniranim istraživanjima. Sve je više pacijenata koji se odlučuju za KAM, posebice onih koji boluju od kroničnih, rekurirajućih ili fatalnih bolesti. Incidencija upalnih bolesti crijeva (UBC) u stalnom je porastu, a patogeneza i, posljedično, terapija ostaju nedovoljno spoznate. U liječenju UBC-a nastoji se koristiti sigurne i jeftine lijekove koji se primijenjuju samostalno ili kombinirano. Konvencionalni lijekovi za UBC umanjuju simptome, ali su često nedostatni za uspješno liječenje ili pak imaju značajne nuspojave. U današnjoj kliničkoj praksi nameće se potreba edukacije liječnika o primjeni KAM-a, posebice u kroničnih bolesti kao što je UBC. Najčešće spominjani oblici KAM-a u djece oboljele od UBC-a su: ljekovite biljke (kurkuma, kanabis), probiotici, riblja ulja, hiperbarična oksigenoterapija, akunpunktura, dijetne prehrane te multivitaminske terapije., Complementary and alternative treatment methods (CAM) are used instead of, or as a supplement to, methods of evidence based medicine. CAM treatments undergo verification of safety and efficacy, but in not sufficiently well-designed studies. Increasing number of patients is opting for CAM, especially those suffering from chronic, recurrent or fatal diseases. The incidence of inflammatory bowel disease (IBD) has been growing steadily and pathogenesis and, consequently, the therapy remains insufficiently defined. In the treatment of IBD there is a tendency towards using safe and cheap drugs, which may be applied independently or combined. Conventional medications for IBD reduce symptoms, but are often insufficient for successful treatment or have significant side effects. In everyday's clinical practice, there is a need for educating physicians on the use of CAM, especially in chronic diseases, such as IBD. The most commonly reported forms of CAM in children with IBD are: herbs (turmeric, cannabis), probiotics, fish oils, hyperbaric oxygen therapy, acupuncture, diet nutrition and multivitamin therapy.

Objectives. The current European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines introduced the option to diagnose coeliac disease (CD) in children and adolescents without upper endoscopy if the defined criteria are met. The aim of our study was to evaluate how frequently paediatric gastroenterologists in Central Europe used the “no-biopsy” approach and how often the duodenal biopsy could have been omitted. Methods. Medical records of patients aged<19 years diagnosed with CD in 2016 from five European countries were analysed, focusing on levels of transglutaminase antibodies (TGA) at the time of diagnosis and on whether the diagnosis was confirmed using duodenal biopsy or “no-biopsy” approach. Clinical presentation and delays until final diagnosis were analysed according to diagnostic approach. Results. Data from 653 children (63.9% female, median age: 7 years, range: 7 months-18.5 years) from Croatia, Hungary, Germany, Italy, and Slovenia were analysed. One fifth (n=134) of included children were asymptomatic at diagnosis. Of 519 symptomatic children, 107 (20.6%) were diagnosed by the “no-biopsy” approach. Out of the remaining 412 children who underwent duodenal biopsies, 214 (51.9%) had TGA≥10 times upper level of normal (ULN) and would have been eligible for the “no-biopsy” approach. Signs and symptoms of malabsorption were more frequent in children diagnosed without duodenal biopsies. There were no differences in diagnostic delays with respect to the diagnostic approach. Conclusion. In this cohort, about 60% of symptomatic CD patients could have been diagnosed without duodenal biopsies. The aim of the “no-biopsy” approach was to make the diagnostic procedure less challenging without compromising its reliability. However, this option was applied only in 20%, in spite of fewer burdens to the family and reduced costs. The reasons for this discrepancy are unknown. Physicians should be made more aware about the reliability of CD diagnosis without biopsies when the ESPGHAN guidelines for CD diagnosis are followed.

Introduction. Celiac disease (CD) is an autoimmune disease triggered by gluten in genetically predisposed individuals. Despite the increasing prevalence of CD, many patients remain undiagnosed. Standard serology tests are expensive and invasive, so several point-of-care tests (POC) for CD have been developed. We aimed to determine the prevalence of CD in first-grade pupils in Primorje-Gorski Kotar County, Croatia, using a POC test. Methods. A Biocard celiac test that detects IgA antibodies to tissue transglutaminase in whole blood was used to screen for celiac disease in healthy first-grade children born in 2011 and 2012 who consumed gluten without restrictions. Results. 1478 children were tested, and none of them were tested positive with a rapid test. In 10 children (0,6%), IgA deficiency has been suspected; only 4 of them agreed to be tested further for total IgA, anti-tTG, and anti-DGP antibodies. IgA deficiency was confirmed in 3 patients, and in all 4 children, CD has been excluded. Conclusion. Our results have not confirmed the usefulness of the POC test in screening the general population of first-grade schoolchildren. Further research is needed to establish the true epidemiology of CD in Primorje-Gorski Kotar County and to confirm the value of the rapid test in comparison with standard antibody CD testing.

Objectives: Coeliac disease (CD) is a systemic autoimmune disorder affecting about 1% of the population. Many patients remain undiagnosed or are diagnosed with substantial delay. We assessed diagnostic delays in symptomatic CD children in Central Europe (CE). Methods: Paediatric gastroenterologists in 5 CE countries retrospectively reported data of their patients diagnosed in 2016. Age at first CD-related symptom(s), first visit to paediatric gastroenterologist and confirmed diagnosis were used to determine diagnostic delays. Results: Data from 393 children (65% girls, median age 7 years, range 7 months to 18.5 years) from Croatia, Hungary, Germany, Italy, and Slovenia were analysed. Median duration from first symptom(s) to visit to paediatric gastroenterologist was 5 months (range 0–10 years ; preschool 4 months, school-aged 5 months), and further duration until final diagnosis was 1 month (range 0–5 years) with significant regional differences (P < 0.001). Median diagnostic delay was 6 months (range 0–10 years ; preschool 5 months, school-aged 7 months). Type of clinical presentation had little, however, significant effect on delays. Reduced body mass in delays longer than 3 years compared with delays shorter than 1 year was found (z score −0.93 vs −0.39, P < 0.05). Conclusions: Time from first symptoms to CD diagnosis in children in 5 CE countries is slightly shorter compared with few other small paediatric studies, and significantly shorter than reported for adults. Nevertheless, delays of more than 3 years in 6.6% of children are worrisome. Raising awareness about the variable symptoms and implementation of reliable diagnostic tools will further reduce diagnostic delays

Hereditary spherocytosis is the most frequent congenital hemolytic anemia and is characterized with variable degree of anemia, jaundice, and splenomegaly. In the case of severe hyperbilirubinemia out of proportion with hemolysis, other causes of hyperbilirubinemia must be considered. Gilbert syndrome (GS) is an autosomal dominant disorder characterized with intermittent hyperbilirubinemia without any other sign and symptom of liver disease as a result of reduced activity of uridine diphosphate-glucuronyl transferase 1A1. The calculated rate of coexistence of these 2 diseases is 15 to 35/million births. Here we present a 21-month-old girl with hereditary spherocytosis diagnosed at the age of 40 days with hyperbilirubinemia out of proportion of hemolysis which led to diagnosis of GS. Thereby, the diagnosis of GS should be considered in unexplained unconjugated hyperbilirubinemia in different age groups, including infants and toddlers.

Edema is defi ned as abnormal accumulation of fl uid in the interstitium. Differential diagnosis of generalized edema is very broad. Most often, renal and cardiac causes lead to generalized edema. The potential gastrointestinal causes of edema are liver failure and protein losing enteropathy including celiac disease and protein malnutrition. Generalized edema is rarely an initial manifestat ion of celiac disease. Hereby, we present a case of a 3-year-old boy with celiac disease, initially presented with generalized edema and hypoproteinemia.

Edema is defi ned as abnormal accumulation of fl uid in the interstitium. Diff erential diagnosis of generalized edema is very broad. Most often, renal and cardiac causes lead to generalized edema. The potential gastrointestinal causes of edema are liver failure and protein losing enteropathy including celiac disease and protein malnutrition. Generalized edema is rarely an initial manifestation of celiac disease. Hereby, we present a case of a 3-year-old boy with celiac disease, initially presented with generalized edema and hypoproteinemia., Edemi nastaju zbog abnormalnog nakupljanja tekućine u intersticiju. Diferencijalna dijagnoza edema je vrlo široka. Bubrežni i srčani uzroci su najčešći uzroci generaliziranih edema. Mogući gastrointestinalni uzroci edema su zatajenje jetre, enteropatija uzrokovana gubitkom proteina, uključujući celijakiju i proteinsku neishranjenost. Generalizirani edemi su rijetka prva manifestacija celijakije. Prikazujemo slučaj trogodišnjeg dječaka s celijakijom koji se inicijalno prezentirao generaliziranim edemima i hipoproteinemijom.

Akutni pankreatitis je bolest koja se sve češće dijagnosticira u dječjoj dobi. Postoje značajne razlike između akutnog pankreatitisa u djece i odraslih; bolesti se razlikuju u etiologiji,prirodnom tijeku i prognozi. Ipak, današnji pristup bolesti i njenom liječenju zasniva se uglavnom na istraživanjima u odraslih osoba. U tijeku su brojna istraživanja koja za cilj imaju rasvijetliti značajke bolesti dječje dobi. U ovom članku donosimo današnje spoznaje o etiopatogenezi, dijagnostici, liječenju i prognozi akutne upale gušterače u dječjoj dobi., Acute pancreatitis is a disease that is becoming increasingly recognized in the pediatric population. There are numerous differences between the pediatric and adult disease, including etiology, natural history and prognosis. Nevertheless, the current approach to the disease and its treatment is mostly based on adult studies. Currently, many studies are aimed at finding the characteristics of the pediatric type of the disease. In this review we summarize the current concepts on the etiopathogenesis, diagnosis, treatment and prognosis of pediatric acute pancreatitis.

Purpose To compare the utilisation of systemic antimicrobials at the paediatric units of the university hospitals in Marburg (Germany) and Rijeka (Croatia). Methods A prospective, observational analysis of hospital records from 300 incident users of antimicrobials in each study centre that were younger than 19 years. Antimicrobial utilisation was analysed in six gender-specific age groups with respect to drug choice, duration of treatment and hospital stay, indication and route of administration. The extent of antimicrobial drug use was assessed by the number of treatment courses. Results In each hospital, more than 1/3 of the patients were younger than 1 year. The duration of hospital stay was about two-fold longer in Rijeka (18.5 ± 5.8 days) than in Marburg (8.6 ± 3.8 days). Pneumonia and other respiratory tract infections were the most common indications in Marburg (38.6%) and Rijeka (58.7%). The cumulative percentage of patients treated with an equal number of different antimicrobials was lower in Rijeka than in Marburg. The most commonly used antimicrobials were ampicillin (40.3%) and cefuroxim (35.9%) in Marburg, but ceftriaxone (43.3%) and cefotaxim (14.0%) in Rijeka. Conclusions A shorter treatment duration, less variation in the prescribing pattern and a greater adherence to the use of recommended antimicrobials argue for a more rational antimicrobial drug use in Marburg than in Rijeka. However, a further identification of drug choice determinants is warranted. Copyright © 2005 John Wiley & Sons, Ltd.

In this study the extent and pattern of inpatient and outpatient antimicrobial drug use was investigated in Rijeka Croatia and the impact of control measures was evaluated. Consumption of antibacterials for the years 2000 and 2001 was monitored using the ATC/DDD methodology. During the investigation period the antimicrobial utilization at the University Hospital Center (UHC) Rijeka has decreased by 14%. In the outpatient setting of the County of Primorje and Gorski kotar the antimicrobial utilization was similar during both years. At the UHC Rijeka not only the amount but the pattern of antibacterial utilization also has changed in contrast to the outpatient setting where the pattern of antimicrobial prescribing remained the same. The control measures for antibiotic use that were introduced in the outpatient setting did not influence the prescribing habit of primary care physicians while the impact of hospital antibiotic use control measures was satisfactory. Further investigation is needed to evaluate the impact of these measures on bacterial resistance patterns. (authors)

In this study we evaluated antibiotic utilisation pattern at two paediatric clinics in different European (transitional) countries: Croatia (Rijeka) and Russia (Smolensk). Antibiotic utilisation during the year 2000 was observed using the ATC/defined daily doses (DDD) methodology (ATC code-J01). Drug-usage data was expressed in numbers of DDD/100 bed-days and the DU 90% profile. In Rijeka 35 different systemic antibiotics were used and in Smolensk 22. The overall consumption of antibiotic drugs in Rijeka was more than three times higher than in Smolensk (28.96 vs 8.3 DDD/100 bed-days). The top five antibiotic drugs used in Smolensk were amoxicillin mydecamicin ampicilin doxycylin gentamicin; and in Rijeka cefuroxime axetil ceftriaxone azytromycin ceftibuten and amoxicillin. Differences in antibiotic prescribing patterns are greater than expected. The pattern of antibiotic utilisation in both countries implies that regional control measures and guidelines for antibiotic use in children should be urgently established. (authors)

It has been generally recognized that the prevalence of bacterial resistance among bacteria is an unavoidable consequence of antibiotic use and is positively linked to the overall use of antibacterial drugs. The purpose of this study was to investigate the extent of antimicrobial usage and to evaluate the antimicrobial resistance at three different hospital settings in Croatia: a clinical hospital, a general hospital and a specialized clinic for infectious diseases. In this survey the antimicrobial drug consumption and antimicrobial susceptibility test results were analyzed for the first 6 months of 1997 in three different hospitals in Croatia: the University Hospital Center (UHC), Rijeka, the Clinic for Infectious Diseases 'Dr Fran Mihaljevic', Zagreb and the Dubrovnik General Hospital. The data were collected from corresponding hospital pharmacy records and microbiology laboratories. Antimicrobial drug utilization was expressed in number of defined daily doses (DDDs) per 100 bed days. High antimicrobial utilization and high resistance rates were found in all three hospitals. At the Clinic for Infectious Diseases, the most frequently used antimicrobials where those of narrow spectrum while at the UHC Rijeka and the Dubrovnik General Hospital the broad spectrum antimicrobials were mostly used. The highest antimicrobial consumption was noted at the Susak locality of the UHC, Rijeka, where the highest resistance rates of bacteria to antimicrobials were also found. Results of this observational study indicate that attempts should be made to reduce the influence of factors that may lead to emergent resistance. The most effective approach to the prevention of transmission of multidrug-resistant pathogens is preventing the initial emergence of resistance. A rational and strict antibiotic policy is thus of great importance for the optimal use of these agents.

Objective. Antibiotic formulary restrictions are among the most popular methods to control antibiotic utilization in hospitals. The aim of the present survey was to investigate the influence of “ reserve antibiotic” on antimicrobial utilization at the University Hospital Center (UHC) Rijeka. Methods. At the UHC Rijeka “ reserve antibiotic” was implemented in July 1997. The antimicrobial drug consumption was monitored 6 months prior and 6 months after the introduction of the method. Antimicrobial consumption was measured in defined daily doses (DDDs) according the major clinics. Results. “ Reserve antibiotic” has led to a decrease in total antibiotic consumption at the UHC Rijeka (45, 9 DDDs/100 bed days vs. 32, 9 DDDs/100 bed days). Antibiotic utilization decreased in the second semester at most clinics: at the Clinic for Infectious diseases 41%, at the Anesthesiology and Intensive Care Unit 30%, at the Clinic for Internal medicine 18%, and at the Surgical Clinic 12%. At the Clinic for Gynecology and Obstetrics the antibiotic utilization remained the same while at the Pediatric Clinic an increase of 28% in antibiotic utilization was noted. Conclusion. Our study indicates that restriction of usage of some antibacterials is a successful method to decrease antibiotic consumption and a way to bring cost savings and helps prevent emergence of resistance in hospitals. Also, to improve antimicrobials prescribing additional methods such as education are required.

The purpose of the present study was to investigate the antibiotics utilization in the University Hospital Center of Rijeka (UHC), with capacity of 1566 beds, during the period of 4 years (1990-1994). The data concerning the antibiotics utilization were collected from a hospital pharmacy record and calculated as the defined daily dose (DDD) per 100 bed days. Total antibiotics use decreased continually from 1990 through 1994. According to our study, metronidazole became the most frequently prescribed antibiotic. Comparing the 1994 to the 1990 antibiotics utilization, we may notice an outstanding decrease in cotimoxazole, ampicillin and cefalexin utilization and an increase in amoxicillin + clavulanic acid, gentamycin and cefuroxime (there are no tetracyclines among the 10 most frequently prescribed antibiotics). The changes noticed in the use of antibiotics are partly caused by changes in therapeutic principles, but we consider drug donations as the most important factor. Drug donations have retained the treatment quality of our patients in very difficult conditions in Croatia during the war period.

The aim of this study was to determine the prevalence and pattern of unlicensed and off-label drugs prescribed to hospitalized children at the Department of Paediatrics, University Hospital Rijeka, Croatia. A prospective cross-sectional study was performed on 1 day each month during a 12 month period and included all hospitalized children and adolescents. A total of 1, 643 prescriptions for 198 different drugs were prescribed to 531 out of 691 (77%) hospitalized patients. Forty-six percent of the different drugs were prescribed in an unlicensed or off-label manner. Of all drug prescriptions, 25% were either unlicensed or off-label. Forty-eight percent of the patients received either an unlicensed or off-label drug. The most frequently prescribed off-label drugs were proton pump inhibitors. Unlicensed and off-label drug use is common. It is not illegal and may be clinically appropriate but is associated with a number of clinical, safety, and ethical issues. Regulatory authorities should use existing clinical evidence on the use of off-label and unlicensed drugs in decision making. Marketing authorization holders and national regulatory authorities should monitor for any safety concerns associated with unlicensed and off-label drug use and take appropriate measures as well as identify research priorities and mandate clinical studies to resolve important questions.

Chronic intussusception (CI) is defined as an intussusception lasting for 14 days or more. Because the clinical manifestations are non-specific, the diagnosis is usually delayed. Symptoms include intermittent abdominal pain, sometimes an abdominal mass is palpable and there is a marked weight loss. Diagnosis is based on typical features revealed by ultrasound or barium enema and CT investigations. Therapy is surgical with obligatory exclusion of possible underlying lesions. We report a case of a 3.5-year-old girl with chronic intussusception. Laboratory blood findings revealed sideropenic anemia and stools positive for Ascaris lumbricoides. Anti-parasitic therapy with mebendazole was repeatedly administered with early improvements but soon after symptoms relapsed. During surgery an ileocolic chronic intussusception extending to hepatic flexure was found. Postoperative control examinations proved complete healing. We suspected that Ascaris lumbricoides infestation was an etiologic factor for the development of chronic intussusception in the child.

Cilj: Kronična upalna bolest crijeva (KUBC) spada među najteže kronične bolesti dječje i adolescentne dobi. KUBC je zajednički naziv za Crohnovu bolest (CB), ulcerozni kolitis (UK) i nediferencirani kolitis. Točan uzrok nije poznat, ali se smatra da su u nastanak kronične upalne crijevne reakcije uključeni i funkcionalno integrirani utjecaji okoline, bolesnikovo genetsko nasljeđe, bolesnikova crijevna mikrobiološka flora te imunološki sustav. Obilježena nepredvidljivim egzarcebacijama neujednačene jačine, bolest se najčešće manifestira probavnim smetnjama, ali nisu rijetke ni izvancrijevne tegobe. Izvancrijevne smetnje puno su izrazitije u CB. Psihičke smetnje u te su djece brojne, a učestalije su u aktivnim fazama bolesti. Prikaz slučaja: U prikazu je opisan dječak obolio od ulceroznog kolitisa s pridruženim psihičkim smetnjama. Osobita pažnja posvećena je obiteljskim odnosima. Rasprava: Iako su psihološki i tjelesni čimbenici povezani, prihvaćenije je mišljenje da su psihički poremećaji u KUBC posljedica, a ne uzrok bolesti. Uobičajeno funkcioniranje i kvaliteta života obitelji djece s KUBC mogu biti ozbiljno narušeni. Reakcija obitelji na bolest djeteta ovisi o dobi djeteta, prirodi, težini i prognozi bolesti. Cijela obitelj mora se udruženo suočiti s bolesti te na taj način ostaje zajedno. Otvoreno obiteljsko komuniciranje o simptomima i liječenju KUBC mora biti prilagođeno dobi bolesnika. Time se osnažuje bolesnikova percepcija o mogućnostima savladavanja svakodnevnih problema. Zaključak: Osnova liječenja KUBC mora biti holistički pristup kojim se uvažavaju sve posebnosti djetetova stanja., Aim: Inflammatory bowel diseases are considered to be amongst the most severe chronic diseases in childhood and adolescence. They are marked by unpredictable relaps with uneven intensity. The most recognizable are gastrointestinal disturbances, but extraintestinal ones are numerous as well. It’s not rare that those affected develop psychological disturbances which then can lead to further complications to the diseases course and treatment. Case report: We described a case of a boy with colitis ulcerosa and psychological disturbances. Special attention was paid to relationship with closed family. Discussion: Normal functioning and the quality of life of families with children with IBD can be seriously disturbed. Coping with the disease of the child depends on the child’s age, nature, severity and prognosis of the illness. Both, the individual and the whole family should face the disease united and in that way they remain together. Open family communication about symptoms and treatment of IBD must be adapted to the patient’s age. This reinforces the patient’s perception of the possibilities of overcoming everyday problems. Conclusion: The basis of treating IBD must be a holistic approach that takes into consideration all the specifics of the child’s condition.

Djeca koja boluju od recidivirajućih abdominalnih bolova vrlo su raznolika skupina bolesnika. Organski, psihogeni i funkcionalni uzroci poremećaja preklapaju se u većoj ili manjoj mjeri, otežavajući dijagnozu i liječenje. Doprinos Rimskih kriterija je u definiranju simptoma koji pomažu pri dijagnostici funkcionalnih poremećaja i na taj način smanjuju broj nepotrebnih pretraga. Svrha ovog postupnika je pomoći liječnicima u dijagnostici i liječenju djece s recidivirajućim abdominalnim bolovima., Children who suffer from recurrent abdominal pain are a very heterogeneous group of patients. The organic, psychological and functional causes of this disorder overlap, making both the diagnosis and the treatment more difficult. The contribution of Rome criteria is in defining symptoms that helps in diagnosing functional disorders and thus lessen the number of unnecessary diagnostic procedures. The purpose of this algorithm is to help physicians diagnose and treat children with recurrent abdominal pain.

Objective: To evaluate the quality of antimicrobial drug use at the Department of Medicine with 270 patient beds at the University Hospital Rijeka, Croatia. Methods: The appropriateness of antimicrobial treatment was assessed in a prospective, longitudinal survey, during a 21-week period using modified Kunin's criteria. Criteria were categorized as follows: I. Agree with the use of antimicrobial therapy, the protocol is appropriate ; II. Agree with the use of antimicrobial therapy, the protocol is probably appropriate ; III. Agree with the use of antimicrobial therapy, but a different antimicrobial is preferred ; IV. Agree with the use of antimicrobial therapy but a different mode of use is preferred ; and V. Disagree with the use of antimicrobial therapy, administration is unjustified. Categories I. and II. indicate "appropriate therapy", categories III. and IV. indicate some major deficiency in the choice or use of antimicrobials. Results: During the study period 438 patients were treated with antimicrobials at the Department of Medicine. Of these, 159 (36%) had received antimicrobials appropriately (category I and II), 180 (41%) needed antimicrobials (category III and IV) but they should have been prescribed differently. The main reason for inapproprite antimicrobial treatment was the wrong choice of animicrobials (broad-spectrum where a narrow spectrum would suffice). Ninty-nine patients (23%) did not need antimicrobials at all (category V). Conclusion: The main reason for suboptimal use of antimicrobials was over- prescribing of broad-spectrum antimicrobials, and its reduction should be a major goal of the stewardship program in the Department of medicine in our institution.

A point-prevalence survey of five European university hospitals was performed to benchmark antimicrobial drug use in order to identify potential problem areas in prescribing practice and to aid in establishing appropriate and attainable goals. All inpatients at the university hospitals of Rijeka (Croatia), Tartu (Estonia), Riga (Latvia), Vilnius (Lithuania) and Karolinska-Huddinge (Sweden) were surveyed for antimicrobial drug use during a single day. The frequency of antimicrobial drug use was 24% in Rijeka, 30% in Tartu, 26% in Riga, 14% in Vilnius and 32% in Huddinge. Surgical patients were treated with antimicrobial agents more often than medical patients in Riga (53% vs. 31%), Tartu (39% vs. 26%) and Vilnius (54% vs. 25%). Two-thirds of patients in Rijeka, Tartu, Riga and Vilnius, and fewer than half of the patients in Huddinge, received antimicrobial agents intravenously. Broad-spectrum antimicrobial agents were used most commonly in Rijeka. The prevalence of nosocomial infections treated with antibiotics was 9% at Huddinge, and 3–5% at the other centres. Benchmarking antimicrobial drug use at five university hospitals identified differences and problem areas. The high rates of intravenous administration, poor compliance with guidelines, and prolonged surgical prophylaxis were general problems that deserved specific attention at all centres. A change in prescription practices may reduce unnecessary drug use and decrease antimicrobial resistance.

To analyse the consumption rate of new generation antiepileptic drugs (AEDs) compared with traditional AEDs at a university hospital in Croatia. Antiepileptic drugs use was analysed retrospectively for two consecutive years, 2001 and 2002 at Departments of Neurology, Paediatrics, Psychiatry and Neurosurgery at the University Hospital Centre (UHC) Rijeka. The results obtained are expressed as number of defined daily doses (DDDs) per 100 bed days, as proposed by the WHO. The use of new generation AEDs was represented by 2% in 2001 and 5% in 2002. Majority of AEDs administered was taken by the barbiturates in both years. A wide spectrum of AEDs has been used at the Department of Paediatrics. At the Department of Neurology and Psychiatry use of barbiturates and carbamazepine predominated. The use of new AEDs at UHC has increased during the investigation period but it is still rather low compared with traditional AEDs. The similarity of our results with the result of the leading Croatian university hospitals might represent general routine AED prescription in country. Nationally based guidelines may bring more appropriate and rational approach for usage of modern AED. This task should be supported and promoted by international and national neurology associations.

Background: Inappropriate use of antimicrobials in hospitals contributes to the emergence of resistant miocroorganisms, increased costs and unnecessary exposure of patients to drugs. There is a variety of methods that aim to improve their use. However, criteria for evaluation of appropriateness or quality of antimicrobial drug use have not been defined. Measurment of quality by using specific indicators has been suggested as an effective measure of performace. Objective. To evaluate the quality of antimicrobial drug prescribing at a department of medicine at a university hospital by using a new scoring system as a quality indicator. Design. A prospective, longitudinal survey, during a 21-week period. The necessity of antimicrobial treatment for all inpatients at the department of medicine for whom new antimicrobials were prescribed was asessed using a scoring system based on the presence of signs and symptoms of an infection. If the total score sum was 3 or more the antimicrobial treatment was deemed justified ; if the score was less than 3 the antimicrobial treatment was regarded as questionable. Setting. Department of medicine (279 patient-beds) at the University Hospital Center Rijeka, a 1200-bed teaching hospital in Croatia. Results. Antimicrobials were prescribed to 15% of the patients. They were given for tretment in 89% of the patients, of whom 67% empirically. According to the scoring system, 29% of the patients did not have justified indication for antimicrobial treatment. Conclusion. The proposed quality indicator (the scoring system) that we used is a simple method for assessment of the quality of antimicrobial use. It has pointed at areas that require in-depth analysis. We suggest futher validation of this key quality indicator.

Objective: A number of factors may influence antibiotics prescribing. The objective of this study was to identify trends in antimicrobial prescribing during a period of 11 years at the University Hospital Centre Rijeka (UHC), Croatia, and identify possible factors that might have influenced changes in prescribing patterns.This may help in establishing criteria for future intervention. Methods: Antimicrobial utilisation was evaluated retrospectively for 11 years: from 1990 to 2000. It was measured in defined daily doses (DDDs) per 100 bed days using ATC Index with DDDs 2000. Results: During the investigation period great differences were noted in total and individual antimicrobial consumption. In the first four years of this study, the utilisation of all groups of antimicrobials decreased, while in its second part (i.e., from 1995 to 1997) an increase in utilisation of all antimicrobial groups occured. Changes in utilisation of groups of antimicrobials did not coincide completely with the changes in total antimicrobial utilisation. The most prominent changes were a decrease in penicillin and cephalosporin utilisation, and an increase of macrolides and aminoglycosides utilisation from 1997 to 2000. Ampicillin and cefalexin were mostly prescribed as single antibiotics during a five year period (1990 to 1995) with the exception of one year (1994) when a great decline in antimicrobial utilisation was noted). In the following years amoxicillin and amoxicillin with enzyme inhibitor became the mostly used antimicrobials. Conclusion: Different factors were found to influence antimicrobial utilisation during the investigation period. There were factors that directly influenced prescribing: physician's prescribing habit, guidelines, policy and formulary, but also factors that directly influenced utilisation: availability of a drug through purchasing, dispensing, procurement, pricing etc.

We described the successful use of bronchopexy as a tretment for bronchogenic cyst in an infant.