Experiences, knowledge, and opinions on palliative care among Romanian general practitioners

Aim

To assess experience, knowledge, and opinions of Romanian general practitioners (GPs) on palliative health care in Romania.

Methods

A questionnaire survey was performed among 1283 GPs in five districts of Romania in 2004. The data were collected on the GPs’ self-assessed experience in, knowledge of, and opinion on palliative care, entered into a database, and analyzed. The GPs were also asked to indicate if they needed to improve their knowledge about palliative care.

Results

The response rate was 71%. GPs mostly reported having limited experience in providing palliative care, with 24% reporting to have provided palliative care frequently, and 55% reporting to have it provided sometimes. Significant correlations were found between the GPs’ experience in palliative care provision and their age, sex, and place of work. The majority of Romanian GPs reported that their medical knowledge was inadequate for the provision of care to terminal patients at home. Over 80% of GPs agreed to develop palliative care services and to participate in a training program.

Conclusion

GPs in Romania reported to recognize the need for improvement of palliative care delivery in their country. They expressed the need for better knowledge of palliative care and agreed that multidisciplinary teams to provide palliative care at home would be the best form of delivering this type of health care.Palliative care is a relatively new form of health care provision in Central-Eastern European (CEE) countries unlike in Western Europe, where it has been an established health care specialty for decades (1,2). The most widely used model of palliative care provision in CEE countries is the hospice model. However, the number and availability of hospices and financial means allocated to these institutions have been insufficient, and the population in need of palliative care has been increasing. Palliative care professionals are less focused on the needs of patients and possible development of a new model for palliative care provision than they are on the “vested interests” of the model, ie, preventing the hospices in which they work from being closed down.With aging of the population, the morbidity profile in CEE countries has changed and so have the health care needs. The need for nursing and care, including palliative care, is increasing and largely uneven distribution of medical care facilities between urban and rural areas only aggravates the problem. All these factors bring the palliative care issues to focus (3).Until recently, palliative care in Romania and many CEE countries was primarily associated with terminal care of patients with cancer and the hospice movement (4,5). In the last few years, however, the hospice model as a preferred model of palliative care has been reevaluated and questioned by many (3). Because of the over-institutionalization of health care and the decrease in the number of hospital beds, health care policymakers are increasingly thinking about promoting palliative care at home, which would be supported by a palliative care team (1). Furthermore, people in most CEE countries prefer to die at home, as there is still a strong tradition of family care (6).The expectation of the Romanian primary health care system, which includes general practitioners (GPs) and nurses, to play an important role in palliative care at home is relatively far from realization. Not only that this aspect of health care provision is new and partly unknown to great majority of GPs, but the complementary services and expertise in home care and pain management are not well developed either. This problem is also present in Croatia, Hungary, and Slovakia (1), where various initiatives are being taken to develop palliative care as the need for it increases. As Doyle et al (7) have stated, palliative care at home is dependent on the attitudes and perceptions of family physicians and wider socio-cultural attitudes. Also, the lack of information on the latest techniques and developments in palliative care may prohibit the development of that health care area (8).The first hospices in Romania were established in Oradea and Brasov (9); by 2004, five hospices had been opened. Although a government policy from 1998 tried to strengthen the role of the GP in the health care delivery system (10), no systematic attention had been given to palliative care in general practice or hospitals until 2002 (4). Thereafter, family physicians have increasingly started to provide palliative care, but they have not been reimbursed for the service. Thus, it may be said that the efforts to develop a system of palliative care provision in Romania are still not organized.We asked GPs in five districts in Romania to self-assess their experience in palliative care provision, their knowledge and need for better education in palliative care, and their opinion on the best way to deliver this type of care.     

Reliability and validity of the Croatian version of Consultation and Relational Empathy (CARE) Measure in primary care setting

AimTo translate the Consultation and Relational Empathy (CARE) Measure into Croatian and validate the Croatian version of the questionnaire.MethodsA cross-sectional study was conducted in July 2011 in 8 general practices (GP) in Croatia. Following two stages of translation, back-translation, and pilot testing, the Croatian version of the CARE was tested on 568 consecutive patients.ResultsFace validity was high, the number of missing values was low (9%), and the internal consistency (Cronbach’s alpha) was 0.77. A principal component analysis of 10 CARE Measure items extracted two components with eigenvalues >1. These two components explained 43.6% of the total instrument variance.ConclusionThe Croatian version of the CARE Measure had acceptable reliability and face validity, but its intended component structure was not reproduced and further research is needed to understand its dimensionality.Physician empathy is widely regarded as an essential component of primary health care consultations and is central to the physician-patient relationship (1,2). In the clinical context, it is usually defined as the physician’s ability to understand the patient''s situation, perspective, and feelings; to communicate that understanding to the patient, check its accuracy, and to act upon it in a helpful therapeutic way (3). Empathy has been linked to a number of benefits in health care encounters including patient satisfaction, patient enablement, and better health outcomes (3-5). It may have both immediate and long-term effects on the patient (6). Attempts to measure empathy from a neurobiological perspective, although promising, will not be applicable in health care consultation settings in the near future. Several psychometric tools have been developed to measure physician’s empathy, with the Jefferson Scale of Empathy being the most referenced one (7). However, none of these scales have been designed specifically for the primary care setting and the majority of them is administered by physicians rather than self-administered (8-10). This is the reason why we chose the Consultation and Relational Empathy (CARE) Measure, which is widely used for the patient-rated assessment of physician empathy in the primary health care setting and which requires only 5-10 minutes to complete (11,12). Like many other physician empathy scales, the CARE measures situational empathy and ignores dispositional empathy, which is understood as physician’s character trait. The CARE measure has been validated in English, German, and Chinese (4,11,12). The aim of this study was to translate the questionnaire into Croatian and validate the Croatian version, determining its face validity, reliability, and dimensionality.     

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

Aim

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

Methods

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

Results

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

Conclusion

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

Emotion work and burnout: cross-sectional study of nurses and physicians in Hungary

Aim

To investigate predictors of occupational burnout, such as emotion work, among health care workers and compare the frequencies of burnout and emotion work in nurses and physicians.

Method

A cross-sectional survey was conducted in 2007 and 2008 among 80 physicians and 76 nurses working in a variety of health care settings in Hungary. The survey contained sociodemographic questions and work- and health-related questions from, respectively, the Maslach Burnout Inventory-Human Services Survey and the Hungarian version of the Frankfurt Emotion Work Scale. To identify the dimensions of emotion work associated with burnout, linear regression analyses were carried out. To analyze differences in burnout and emotion work between nurses and physicians, independent t tests were used.

Results

Nurses reported significantly higher emotional dissonance and fewer regulation possibilities, such as interaction and emotion control, than physicians. However, no differences were found in the level or frequency of burnout. Nurses had fewer regulation requirements regarding sensitivity and sympathy. Linear regression analyses showed that emotional dissonance for emotional exhaustion (β = 0.401) and display of negative emotions for depersonalization (β = 0.332) were the strongest predictors of burnout.

Conclusion

The factors that should be taken into account when developing prevention and intervention programs differ for nurses and physicians. In nurses, the focus should be on stressors and emotional dissonance, while in physicians it should be on work requirements and display and regulation of negative emotions.During the last decade, the topic of emotion work has gained a much greater significance in organizational and health psychology. As defined by Zapf et al, emotion work occurs when employees are required by the employer to regulate their emotions in order to display appropriate emotions to the client (1). Emotion work determines the quality of social interaction between the caregiver and client. Action theory distinguishes 3 aspects of emotion work requirements: regulation requirements, regulation possibilities, and regulation problems. Regulation requirements (display of emotions) are related to properties of the hierarchical-sequential organization of action and constitute the complexity of decision. Regulation possibilities refer to the concept of control. Regulation problems, also known as emotional dissonance, are the discord between felt and expressed emotions and occur when stressors disturb the regulation of action (1,2). Current burnout research is greatly facilitated by theories explaining work stress (3-6). Using Karasek’s job demands control model, the research group of LeBlanc and DeJonge investigated emotional job demands (3-5). It was also found that health care workers are at high risk for emotional exhaustion resulting from interaction with clients (6,7).Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment occurring in people-oriented and service work (8). Emotional exhaustion refers to feelings of being depleted of one’s emotional resources. Depersonalization is a negative and cynical attitude and behavior toward clients. Reduced personal accomplishment is the self-perception of a decline in one’s own competence and self-efficacy. Burnout has most often been studied in caregiving professionals, such as clinicians, psychologists, social workers, and nurses (9-17). Indeed, several studies have directly measured the emotional aspects of job demands dealing either with emotion work (18-20) or burnout (21-24). However, few studies investigating the relationship between burnout and emotion work have been conducted in the nursing and health care profession, particularly in Hungary and Eastern Europe (25). The differences in burnout and emotion work between nurses and physicians have been studied in the Netherlands, Germany, and Spain (3-5,14,26). Some studies have suggested that physicians experience more burnout than nurses (14,16), while others have suggested the opposite (17).Recently, burnout has been conceptualized as a psychological syndrome that takes place in response to chronic interpersonal stressors on the job (6). According to Zapf, burnout makes individuals no longer able to adequately manage their emotions while interacting with clients (27). According to the model of emotion work by Grandey (28), antecedents of emotion regulation are the situational variables, eg, interaction between the caregiver and client.A relationship between burnout and emotion work has recently been found in the health care setting in Western European countries (3,4,29-31). Health care professionals, especially nurses, are at high risk of burnout because their job requires a high level of emotion work (18-20,32,33). Most studies have found a positive relationship between emotion work and burnout, suggesting that emotional dissonance may predict emotional exhaustion and depersonalization (25,34). Demerouti (35) argues that contribution of job demands and resources to explaining burnout may vary across occupations because these features differ across occupations. Burnout literature usually focuses on general variables that predict burnout and does not distinguish between predictors across health professions (6,8). Thus, we hypothesized that differences in emotion work can be detected between nurses and physicians, although the predictors of the syndrome do not vary.This study assesses the relationships between burnout and emotion work in a sample of Hungarian health care professionals and investigates how emotional job demands relate to the frequency of burnout.     

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

Aim

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

Methods

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

Results

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

Conclusion

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

Relation between burnout syndrome and job satisfaction among mental health workers

Aim

To identify predictors of burnout syndrome, such as job satisfaction and manifestations of occupational stress, in mental health workers.

Method

The study included a snowball sample of 174 mental health workers in Croatia. The following measurement instruments were used: Maslach Burnout Inventory, Manifestations of Occupational Stress Survey, and Job Satisfaction Survey. We correlated dimensions of burnout syndrome with job satisfaction and manifestations of occupational stress dimensions. We also performed multiple regression analysis using three dimensions of burnout syndrome – emotional exhaustion, depersonalization, and personal accomplishment.

Results

Stepwise multiple regression analysis showed that pay and rewards satisfaction (β = -0.37), work climate (β = -0.18), advancement opportunities (β = 0.17), the degree of psychological (β = 0.41), and physical manifestations of occupational stress (β = 0.29) were significant predictors of emotional exhaustion (R = 0.76; F = 30.02; P<0.001). The frequency of negative emotional and behavioral reactions toward patients and colleagues (β = 0.48), psychological (β = 0.27) and physical manifestations of occupational stress (β = 0.24), and pay and rewards satisfaction (β = 0.22) were significant predictors of depersonalization (R = 0.57; F = 13.01; P<0.001). Satisfaction with the work climate (β = -0.20) was a significant predictor of lower levels of personal accomplishment (R = 0.20; F = 5.06; P<0.005).

Conclusion

Mental health workers exhibited a moderate degree of burnout syndrome, but there were no significant differences regarding their occupation. Generally, both dimensions of job satisfaction and manifestations of occupational stress proved to be relevant predictors of burnout syndrome.Burnout syndrome is a subject of the interdisciplinary area of occupational stress research (1). It is defined as a sustained response to chronic work stress and includes emotional exhaustion, negative attitudes, and feelings toward the recipients of the service (depersonalization), and a feeling of low accomplishment and professional failure. Emotional exhaustion involves feelings of being emotionally overextended and exhausted by one’s work, resulting in a loss of energy and general weakness. Depersonalization refers to the development of impersonal and unfeeling attitudes toward patients and loss of idealism at work. The feeling of reduced personal accomplishment refers to a feeling of lack of competence and personal achievement (2).Burnout syndrome was most often studied among helping professionals (nurses, physicians, psychologists, and social workers), education, and human resources professionals (3,4). In mental health workers, sources of occupational stress are mostly related to the difficulties in the functioning of health care system (5,6), such as time pressure, chronic fatigue, uncertainties in patient care, demanding chronic patients, poor interpersonal relations at work, and role ambiguity (7-9). Moreover, working with patients is considered to be one of the most important factors leading to burnout syndrome (6,10).In the 1990, in Croatia, a number of studies was conducted on the occupational stress in the helping profession (1,11,12) and burnout syndrome (2,13-16), showing their negative effect on the workers’ health and economic losses induced by absence from work and decreased working productivity. Also, some recent studies have identified personal, interpersonal, and organization factors related to job satisfaction, occupational stress, and burnout syndrome in health care (17-21) and have confirmed a correlation between low job satisfaction and burnout syndrome (22,23).Low job satisfaction can lead to increased job mobility and more frequent absenteeism, which may reduce the efficiency of health care services (24). In the previous research (25), the relationship between job satisfaction and burnout syndrome was viewed from two perspectives – the perspective of causes and the perspective of consequences and their effect on attitudes, mental and physical health, productivity, absence from work, fluctuation, and other different forms of work behavior. Some of recent studies have shown that social workers (26-28) and nurses (29) express lower job satisfaction than other professions in mental health care.Low job satisfaction among mental health workers has also been confirmed by some studies conducted in United Kingdom (30) and Canada (31), while several studies have shown exactly the opposite, ie, that there is a high degree of job satisfaction among employees in these professions (6,20,21). Exposure to occupational stress leads to psychological and physical reactions, the intensity and form of manifestation of which depends on personality traits and environmental factors. The most widespread manifestations of occupational stress in helping professions include emotional exhaustion, depersonalization and dehumanized perception of the patient, absenteeism, damaged physical health, and reduced personal satisfaction. Studies have shown that, compared with general population and other professions, social workers suffer from relatively high level of anxiety and depression related to their profession (32,33).The aims of this study were to examine the relation between burnout syndrome and job satisfaction and to identify independent predictors, such as job satisfaction and manifestations of occupational stress, of burnout syndrome among mental health workers.     

Why pulsatility still matters: a review of current knowledge

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

Care-seeking and quality of care for outpatient sick children in rural Hebei,China: a cross-sectional study

Aim

To assess the quality of outpatient pediatric care provided by township and village doctors, prevalence of common childhood diseases, care-seeking behavior, and coverage of key interventions in Zhao County in China.

Methods

We conducted two cross-sectional surveys: 1) maternal, newborn, and child health household survey including1601 caregivers of children younger than two years; 2) health facility survey on case management of 348 sick children younger than five years by local health workers and assessment of the availability of drugs and supplies in health facility.

Results

Our household survey showed that the prevalence of fever, cough, and diarrhea was 16.8%, 9.2%, and 15.6% respectively. Caregivers of children with fever, cough, and diarrhea sought care primarily in village clinics and township hospitals. Only 41.2% of children with suspected pneumonia received antibiotics, and very few children with diarrhea received oral rehydration solutions (1.2%) and zinc (4.4%). Our facility survey indicated that very few sick children were fully assessed, and only 43.8% were correctly classified by health workers when compared with the gold standard. Use of antibiotics for sick children was high and not according to guidelines.

Conclusion

We showed poor quality of services for outpatient sick children in Zhao County. Since Integrated Management of Childhood Illness strategy has shown positive effects on child health in some areas of China, it is advisable to implement it in other areas as well.Globally the number of deaths of children younger than five years decreased from 9.6 million to 7.6 million between 2000 and 2010, despite increases in the number of live births (1-3). During the past 20 years China made great achievements concerning child survival. Between 1990 and 2006, under-five mortality rate decreased from 64.6 to 20.6 per 1000 live births, and Millennium Development Goal 4 (MDG4) was achieved nine years ahead of the target set for 2015 (4-6). In 2011, under-five mortality rate was further reduced to 15.6 per 1000 live births (7). While this progress is remarkable, there remains the challenge of urban-rural mortality rate differences. Under-five mortality rate in rural areas was 2.7 times higher than in urban areas, 19.1 and 7.1 per 1000 live births, respectively (7).Under-five mortality decrease was achieved by focusing on social development and sustained economic growth and investments in health system, including expansion of health intervention coverage (8-10). However, these were much lower in rural areas. In 2010, rural residents’ net income per capita was 5919 Yuan, which was less than one third of urban residents’ income (19 109 Yuan) (11), and the health expenditure per capita in urban areas was 3.5 times lower than in rural areas, 2316 Yuan vs 666 Yuan (7). In 2009, the number of health professionals per 1000 population was 6.03 in urban and 2.46 in rural areas, respectively (12). These factors reduce overall rural health care quality as well as the quality of pediatric care, which in rural China is often less than desirable (13-15).To improve child survival, in the mid-1990s the World Health Organization (WHO) and United Nation’s Children Funds (UNICEF) jointly developed the Integrated Management of Childhood Illness (IMCI) strategy (16,17). The IMCI strategy has reduced the number of deaths due to diarrhea, pneumonia, malaria, measles, and malnutrition, which was estimated to 70% of all global deaths of children younger than 5 years at that time (18). IMCI has already been introduced into more than 100 countries (WHO 2005). In China it was introduced in 1998 and since 2003 has been expanded to 46 counties in 11 provinces, considerably improving health workers’ skills (19,20). Although IMCI has been in force in China for more than 10 years, training coverage remains very low for township and village doctors (21).In 2010, the Ministry of Health of China launched a research project aiming to explore the use of appropriate medical techniques in rural areas, and IMCI was selected as a key component of the project. We carried out a household survey and a health facility survey in Zhao County, Hebei Province before IMCI implementation. The household survey aimed to assess the prevalence of common childhood diseases, care-seeking behaviors, and population coverage of key interventions, and the health facility survey aimed to assess the quality of outpatient pediatric care by township and village doctors.     

Awareness,knowledge, use,and attitudes toward evidence based medicine in a developing country: survey of physicians in a canton in Bosnia and Herzegovina

Aim

To assess awareness, knowledge, use, and attitudes toward evidence-based medicine (EBM) and The Cochrane Library (CL) among physicians from Zenica-Doboj Canton (ZDC), Bosnia and Herzegovina.

Methods

In this cross-sectional study, a self-administered anonymous questionnaire was sent by post to all state owned health institutions (2 hospitals and 11 Primary Health Care Institutions) in ZDC. The main outcome measures were physicians’ awareness of the Cochrane, awareness and use of CL, access to EBM databases, and access to internet at work. 358 of 559 physicians responded (63.69%).

Results

23.18% of respondents stated they had access to EBM databases, but only 3.91% named the actual EBM databases they used. The question on the highest level of evidence in EBM was correctly answered by 35.7% respondents, 34.64% heard about Cochrane and 32.68% heard about CL. They obtained information about CL mostly on the internet and from colleagues, whereas the information about EBM was obtained mainly during continuous medical education.

Conclusion

Although the attitudes toward EBM are positive, there is a low awareness of EBM among physicians in ZDC. Open access to the CL should be used more. Educational interventions in popularizing EBM and Cochrane are needed to raise awareness both among students and practicing physicians, and finally among lay audience.Evidence based medicine (EBM) is described as an integration of individual clinical expertise, the best available external clinical evidence from systematic research, and individual patients’ predicaments, rights, and preferences, in making clinical decisions about their care (1,2). However in many settings there are still barriers to its implementation (3-6).Awareness, knowledge, use, and attitudes toward EBM have been assessed worldwide (6,7). Attitudes toward EBM were mostly positive and participants welcomed the promotion of EBM (6-11). Barriers to practicing EBM differed between developing and developed countries. For example, respondents from Iran (8) reported that a major barrier was the lack of EBM training courses, while those from the Netherlands and Belgium reported limited time, attitudes, knowledge, and skills (5,12-14).Systematic reviews with or without meta-analysis produced by The Cochrane Library (CL) are considered as the “gold standard” in EBM (15-18). Cochrane systematic reviews (CSRs) can raise the quality of health care, especially in developing countries with scarce resources. For example, CSRs have been shown to provide invaluable evidence in creating national reimbursement lists (19).A nation-wide study among physicians in Croatia concluded that there was low awareness about EBM and the CL (30%), and additional educational interventions were required (6). Unlike Croatia, Bosnia and Herzegovina (BH) has no organized Cochrane activity (20). Our study aimed to assess the awareness, knowledge, use, and attitudes toward EBM and the CL (as the only available EBM database in BH with unrestricted access) among physicians in Zenica-Doboj Canton (ZDC), to help in the implementation of educational activities that would improve the use of EBM and the CL.     

Experience with comprehensive pharmacogenomic multi-gene panel in clinical practice: a retrospective single-center study

AimTo assess the prevalence of actionable pharmacogenetic interventions in patients who underwent pharmacogenetic testing with a multi-gene panel.MethodsWe retrospectively reviewed single-center electronic health records. A total of 319 patients were enrolled who underwent pharmacogenomic testing with the RightMed test panel using TaqMan quantitative real-time PCR method and copy number variation analysis to determine the SNPs in the 27 target genes.ResultsActionable drug-gene pairs were found in 235 (73.7%) patients. Relevant guidelines on genotype-based prescribing were available for 133 (56.7%) patients at the time of testing. Based on the patients’ genotype, 139 (43.6%) patients were using at least one drug with significant pharmacogenetic interactions.ConclusionTwo out of three patients had at least one drug-gene pair in their therapy. Further studies should assess the clinical effectiveness of integrating pharmacogenomic data into patients’ electronic health records.

The field of pharmacogenetics has been booming in the past decades, with research being focused on studying novel genetic variants that impact drug metabolism or pharmacological effect, which ultimately affects the patient’s response to a given dose of medication. Pharmacogenetics examines gene-drug interactions that change pharmacokinetic and/or pharmacodynamic properties of a drug (1). It is impossible to implement any of the principles of personalized medicine without determining the patients'' pharmacogenetic profile before starting a new therapy (2).Several professional organizations, namely, Clinical Pharmacogenetics Implementation Consortium (CPIC) and Dutch Pharmacogenetics Working Group (DPWG), provide comprehensive and understandable guidelines on genotype-based drug prescribing (3,4). Pharmacogenomic prescribing guidelines are growing in number and are available for various drug classes including the cardiovascular drugs, drugs affecting the central nervous system, gastrointestinal drugs, drugs that treat infectious and malignant diseases, immunosuppressives, analgesics, and other (5,6).Several companies specialize in pharmacogenetic panels, making it easily accessible for patients and clinicians of various specialties to obtain the test results in a matter of days or weeks. These commercial tests are developed by industry stakeholders and can be implemented in various settings during the diagnostic or treatment process (7,8). They are comprehensive and include a number of genes that are important for the pharmacologic profile across drug groups, or targeted for a certain category of drugs, ie, psychiatric, analgesics, oncologic drugs, etc. Data on the rate of utilization and clinical utility of such tests are lacking. A recent study found that from 2013 until 2017 only 5712 insured US patients performed pharmacogenetic testing of at least one gene (9). The field of pharmacogenomics is still in its early stages. One of the principal problems is the education of health care providers responsible for ordering and interpreting the test results. In a recent survey, 84.3% of doctors from seven European countries deemed pharmacogenomics relevant for their practice, however 65.7% did not order a pharmacogenomic test in the last year (10). Potential implementation of pharmacogenomics in the clinical practice should be complemented with a clinical decision support tool integrated into the patient’s electronic health record (11,12). In Croatia, pharmacogenomic testing has been available for over a decade, with multiple studies examining population genetics and cost-effectiveness of pharmacogenomic guided therapies (13,14). However, commercial panel-based tests targeting multiple genes known to influence drug response is a new concept that was implemented in 2018 at St. Catherine Hospital in Zagreb (8,15,16).The aim of this retrospective study was to assess the proportion of patients with actionable pharmacogenetic interventions in a single center from 2018 to 2021 who had undergone pharmacogenetic testing of 27 genes by using a commercial gene panel.     

Physician labor market in Croatia

Aim

To analyze the physician labor market in Croatia with respect to the internship and employment opportunities, Croatian needs for physicians and specialists, and trends in physician labor market in the European Union (EU) in the context of EU enlargement.

Methods

Data were collected from the Ministry of Health and Social Welfare, the Croatian Employment Service, and the Croatian Institute for Public Health. We compared the number of physicians waiting for internship before and 14 months after the implementation of the State Program for Intern Employment Stimulation. Also, the number of employed specialists in internal medicine, general surgery, gynecology and obstetrics, and pediatrics was compared with estimated number of specialists that will have been needed by the end of 2007. Average age of hospital physicians in the four specialties was determined and the number of Croatian physicians compared with the number of physicians in EU countries.

Results

The number of unemployed physicians waiting for internship decreased from 335 in 2003 to 82 in 2004, while a total number of unemployed physicians decreased from 436 to 379 (χ² = 338, P<0.001). In October 2004, 79.3% of unemployed physicians waited for internship <6 months; of them, 89.2% waited for internship <3 months. In February 2005, 365 unemployed physicians were registered at the Croatian Employment Service and that number has been decreasing in the last couple of years. The number of employed specialists was lower than the estimated number of specialists needed in the analyzed specialists, as defined by the prescribed standards. A shortage of 328 internists, 319 surgeons, 209 gynecologists, and 69 pediatricians in Croatian hospitals is expected in 2007.

Conclusion

The lack of employment incentive seems to be the main reason for the large number of unemployed physicians waiting for internship before the implementation of the Employment Stimulation Program. According to the number of physicians per 100 000 population, Croatia is below the EU average. Croatian labor market will not be able to meet the needs of the health system for physicians by the end of 2007.Physicians (medical doctors, MDs), as defined by law, are university-qualified health professionals with the medical school degree. After they graduate from medical school, physicians are registered in the Registry of Health Professionals of the Croatian Institute for Public Health and in the Croatian Medical Chamber (1,2). However, to become independent physicians with a license to practice, medical graduates first have to complete their internship, which they can do either in health care institutions or in private practice (1-4), and then pass the Medical Licensure Exam (MLE) (1,2). Health care institutions and health professionals in private practice are expected to determine the minimum number of intern positions they can provide and thus allow young physicians to complete the internship according to the specified program, as defined by the Rules and Regulations on Internship of Health Care Providers (1-4). After completing the internship and passing the MLE, physicians are granted a license to practice medicine by the Croatian Medical Chamber, which also keeps records of all issued medical licenses (2,5,6). Licensed physicians then enter the Croatian labor market and seek employment. They can either practice medicine in primary health care as general practitioners or continue their education through a specialist (or subspecialist) training. The availability of specializations is determined according to the National Plan for Specializations and Subspecializations issued annually by the Minister of Health on the basis of estimated needs of health care institutions, Croatian Institute for Public Health, and Croatian Medical Chamber.Before 2003, medical graduates had waited for intern position for several months on average, and the percentage of unemployed physicians who had not completed the internship had been 73.1% (5,7-10), although the minimum number of intern positions for physicians that health care institutions had to provide, as defined by the Rules and Regulations on Internship Criteria for Health Care Providers (Regulations on Criteria), had already exceeded the Croatian annual needs only in university and general hospitals (5,7-10).In September 2003, the State Program for Intern Employment Stimulation (Program) was introduced to stimulate financially health care institutions to employ interns and thus decrease the share of unemployed physicians who had not completed internship in the total number of unemployed physicians (11-13).The number of physicians per 100 000 population in the European transition and European Union (EU) countries varies from over 500 in Italy, to 400 in Byelorussia, Norway, Spain, and Georgia, to over 300 in Belgium, Czech Republic, Hungary, Slovakia, and Lithuania (14,15). Several extremely wealthy countries, such as the Netherlands and the USA, have <300 physicians per 100 000 population, whereas UK and Japan have <200 physicians per 100 000 population. In Croatia, there were 227 physicians per 100 000 population in 2002, which is below the EU average (14,15).For the UK to reach the German standard with respect to the number of health care professionals, another 100 000 physicians should be employed. In other words, the UK’s National Health Care System is worried by the lack of health professionals, which bears a negative impact on the accessibility and quality of health care (16-18). France, which had 334 physicians per 100 000 population in 2002 (a total of 200 800 physician), notes a 15-year-long decreasing trend in the number of physicians and such a trend is expected to continue. For that reason, the French Government decided to take an active role in managing the number of physicians on the labor market by implementing a series of short-term and long-term measures, one of them being the “import” of foreign-trained physicians (19). Also, physicians from “new” EU-member countries are interested in moving to “old” EU countries. For example, of 408 immigrant physicians interviewed for over 500 physician job openings in Norway, 20% came from Eastern Europe (20). A 2002 survey among Lithuanian physicians showed that 60.7% of MD interns wanted to emigrate to EU or other foreign countries; the reasons were better salary, professional opportunities, and quality of life (21).Besides the shortage in numbers of physicians, the age structure of health care professionals is another problem. Average age of physicians in New Zealand is 44 years, 43 for nurses and over 40 for support workers (22). In 1985, 55% of French physicians were aged <40 years, while by 2000, the number of physicians in this age group had decreased to only 23%. UK Census data for 2001 showed that only 19% of specialists were under the age of 40, whereas around 40% of those aged over 50 were likely to retire during the following 10-15 years (22,23).The present study had several aims. The first aim was to determine how long it takes for physicians to complete their internship after graduating from medical school and establish the effects of the Employment Stimulation Program until October 2004. The second aim was to compare the number of Croatian physicians with their numbers in EU countries, trends in supply and demand for physicians in EU countries, and possible impact of the EU expansion on physician labor market in new EU-member countries and Croatia. The third aim was to assess the needs for specialists in university and general hospitals and the potential of Croatian labor market to satisfy the needs of Croatian health care system for physicians from the pool of domestic-trained physicians and with respect to the expected number of medical graduates from four medical schools in Croatia by 2007 (8,14,15).     

Stress among Croatian physicians: comparison between physicians working in emergency medical service and health centers: pilot study

Aim

To determine the sources of stress, its intensity, frequency, and psychophysical and behavioral reactions in physicians working in emergency medical service and those working in health centers.

Methods

To a convenience sample of primary care physicians employed in emergency medical service (n = 79) and health centers (n = 81), we administered the list of demographic questions, Scale of Sources of Stress, Scale of Intentions of Leaving the Job, and Scale of Psychosomatic Symptoms.

Results

Emergency medicine physicians experienced significantly more intense and more frequent uncontrollable working situations, conflict between work and family roles, and unfavorable relationships with coworkers than physicians working in health centers. They were also more likely to leave the job during the next few years and/or change jobs within the profession (scores 2.2 ± 0.9 vs 1.7 ± 0.9 out of maximum 5.0, F = 12.2, P = 0.001) and they had a poorer physical health status (scores 1.8 ± 0.5 vs 1.7 ± 0.5 out of maximum 4.0, F = 5.3, P = 0.023).

Conclusion

Physicians working in emergency medical service experience more stress in almost all aspects of their work than physicians working in health centers. They also have a stronger intention of leaving the job, which decreases with years of experience.It has been shown that health workers are highly susceptible to stress at work and experience more negative outcomes of stress than other professions (1-8). For example, a survey conducted in Irish hospitals indicated that work stress caused dissatisfaction in 79% of physicians, 56% evaluated their job as stressful or extremely stressful, and as many as 68% considered leaving the profession, half of them very seriously (9). Work stress in physicians is associated with an array of other negative outcomes: adverse psychological well-being (6), job burnout (10), significantly larger number of suicide attempts (11,12), alcohol dependence, and other psychosocial problems (11). Stress in physicians affects not only their private lives and health but also the quality of medical care that they provide, patient’s satisfaction with the physician, and patient’s adherence to treatment (13).Some of the most important sources of stress for general practitioners and hospital physicians of different specializations were identified as intrinsic factors of work, administration, stressors related to financial opportunities, contact with patients, relationships with coworkers, organizational structure and climate, and interference of private and work life (4-6). One of the most stressful areas of medicine is emergency medicine, in which physicians and other medical personnel are frequently exposed to unexpected and serious medical conditions, trauma, and life or death situations. Important sources of stress specific to work in emergency medicine were found to be time pressure and the need to make critical decisions (8), with numerous negative effects of stress, particularly the intention of leaving the job and deteriorated psychological well-being (11,14-16).The activities of emergency medical service in Croatia include the treatment of severe acute and urgent conditions at the site of the incident, at the dispensary in which the patient arrived, and during transport to the nearest hospital or other health care institution (17,18).The aim of this pilot case study was to identify specific sources of stress in emergency medicine physicians in Croatia, since we assumed that, due to the unpredictable nature of their job, they have different perception of sources of stress, health status, and intent of leaving the job than physicians working in health care centers.     

Posttraumatic stress disorder symptoms and coping with the lockdown among help-seeking veterans before and during the COVID-19 pandemic

AimsTo compare the severity of posttraumatic stress disorder (PTSD) symptoms and of particular PTSD clusters among help-seeking veterans before and during the COVID-19 lockdown. The second aim was to identify the main coping strategies used.MethodsMale war veterans (N = 176) receiving outpatient treatment at the Referral Center for PTSD were assessed at baseline (12-18 months before the pandemic declaration in March 2020) and during the COVID-19 pandemic lockdown (March-June 2020). The Life Events Checklist for DSM-5, PTSD Checklist for DSM-5, and The Brief COPE were used.ResultsDirect exposure to the virus in our sample was low, and the majority of participants followed the preventive measures. The severity of the overall PTSD symptoms and of clusters of symptoms significantly decreased compared with the first assessment. At the second assessment, all participants still fulfilled the PTSD diagnosis criteria. During the lockdown, the participants used emotion-focused and problem-focused coping rather than dysfunctional coping.ConclusionThe severity of PTSD symptoms decreased during the lockdown. Further research is needed to study the trajectories of long-term psychopathology.

The COVID-19 pandemic has severely threatened the physical and mental health of individuals around the world. Stressors have included isolation, self-isolation or quarantine, restricted movement and physical contact, infection fears, loss of loved ones, lack of supplies, inadequate information (“infodemic”), financial loss, and social stigma (1-3). During emergencies, mental health requires special consideration due to increased rates of stress-related mental health problems and limited availability of mental health services (2-5).Depending on the emergency context, particular groups of people are at an increased risk of experiencing social and psychological problems (6), and ex-combatants have been repeatedly shown to be one of them (7).Exposure to a new traumatic or stressful life event might affect posttraumatic stress disorder (PTSD) symptoms. A growing body of research shows that such exposure is a risk factor for worsening of the condition in various groups of PTSD patients (8,9). This mainly happens if the subsequent event is of the same type as the initial stressors, serving as a reminder and as an additional traumatic factor with a “wear and tear” effect on the exposed person (10-13).Regarding the coping strategies used among PTSD patients, combat veterans with PTSD report a more ineffective and dysfunctional coping style, with the avoidance coping style as a predictive factor of the overall PTSD symptom severity (14-16). PTSD patients try to avoid confrontation with trauma-reminders, intrusive memories, and trauma-related thoughts and emotions (17,18). Some authors emphasize the importance of differentiating between coping strategies with PTSD symptoms and coping strategies with actual traumatic or stressful events as they depend on various factors related to the specific traumatic exposure (19).Twenty-five years after the Homeland War in Croatia (1991–1995), veterans still suffer from numerous health problems and have been highly prevalent among the users of the health facilities for PTSD treatment (20-22). The same is true for PTSD patients treated in the Referral Center of the Ministry of Health of the Republic of Croatia (RCPTSD) at the Clinical Hospital Center (CHC) Rijeka. A recent study revealed high rates of overall symptoms and severe posttraumatic symptoms (ie, complex PTSD) in this population years after the war ended (23).The COVID-19 pandemic lockdown in Croatia started on March 19, 2020. According to Oxford University, Croatia introduced the world''s strictest restrictions in relation to the number of the infected (24,25). On March 21, 2020, mental health experts from RCPTSD recommended self-help strategies for staying in good mental health and advice for front-liners on how to deliver psychological first aid (26,27). On the same day, the Croatian Psychiatric Association Expert Group released recommendations for the organization of psychiatric care, psychiatric interventions, and psychopharmacological treatment of mental conditions during the COVID-19 pandemic, and for de-escalation and appropriate communication techniques with aggressive patients (28-30). In RCPTSD, mental health service was restructured to be delivered via the internet or hotlines during the pandemic, with a possibility for urgent outpatient and inpatient treatment. On April 27, 2020, the lifting of restrictions began.To our knowledge, no study worldwide has examined the psycho-social correlates of the COVID-19 pandemic lockdown in veterans with PTSD. Therefore, we aimed to compare the severity of PTSD symptoms and of particular PTSD symptom clusters before and during the COVID-19 pandemic lockdown. Second, we identified the main coping strategies that veterans used during the lockdown.     

Patient expectations from consultation with family physician

Aim

To assess patient expectations from a consultation with a family physician and determine the level and area of patient involvement in the communication process.

Method

We videotaped 403 consecutive patient-physician consultations in the offices of 27 Estonian family physicians. All videotaped patients completed a questionnaire about their expectations before and after the consultation. Patient assessment of expected and obtained psychosocial support and biomedical information during the consultation with physician were compared. Two investigators independently assessed patient involvement in the consultation process on the basis of videotaped consultations, using a 5-point scale.

Results

Receiving an explanation of biomedical information and discussing psychosocial aspects was assessed as important by 57.4-66.8% and 17.8-36.1% patients, respectively. The physicians did not meet patient expectations in the case of three biomedical aspects of consultation: cause of symptoms, severity of symptoms, and test results. Younger patients evaluated the importance of discussing psychological problems higher than older patients. The involvement of the patients was high in the problem defining process, in the physicians'' overall responsiveness to the patients, and in their picking up of the patient''s cues. The patients were involved less in the decision making process.

Conclusion

Discussing biomedical issues was more important for the patients than discussing psychological issues. The patients wanted to hear more about the cause and seriousness of their symptoms and about test results. The family physicians provided more psychosocial care than the patients had expected. Considering high patient involvement in the consultation process and the overall responsiveness of the family physicians to the patients during the consultation, Estonian physicians provide patient-centered consultations.The quality of physician consultation depends on the relationship between the patient and the physician, on the ability of the physician to understand patient’s expectations, and on the agreement between the patient and the physician on the problem (1-3). Traditionally, physicians in family practice and their patients have always known each other well and have shared previous experience (4). However, reorganization of health care systems, development of medical and information technology, and other recent changes in society have influenced the patient-physician relationship and new consultation styles have emerged (5). The traditional physician-oriented approach in health care has shifted to a patient-oriented approach (1,6-8), which includes patient satisfaction and compliance in addition to the outcomes of medical treatment (9,10).The importance of different aspects of patient-physician consultation and its association with the physician’s performance have been studied mostly in countries with a long tradition of comprehensive primary health care (1,9). Estonia belongs to the countries where a traditional, centralized health care system was transformed into a new patient-oriented system only 15 years ago (11,12). The new system today requires professionally trained family physicians and fixed lists of patients, which ensure patient access to the primary health care physician (11,12). It also requires a new format of patient-physician relationship and consultations.The aim of our study was twofold. First, we aimed to determine if and to what level patient expectations from the consultation with a family physician were met with respect to various biomedical and psychosocial aspects of the visit. The second aim was to assess the degree of patients’ involvement in the consultation process with family physicians.     

Can laboratory evaluation differentiate between coronavirus disease-2019, influenza,and respiratory syncytial virus infections? A retrospective cohort study

AimTo identify clinical and laboratory parameters that can assist in the differential diagnosis of coronavirus disease 2019 (COVID-19), influenza, and respiratory syncytial virus (RSV) infections.MethodsIn this retrospective cohort study, we obtained basic demographics and laboratory data from all 685 hospitalized patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza virus, or RSV from 2018 to 2020. A multiple logistic regression was employed to investigate the relationship between COVID-19 and laboratory parameters.ResultsSARS-CoV-2 patients were significantly younger than RSV (P = 0.001) and influenza virus (P = 0.022) patients. SARS-CoV-2 patients also displayed a significant male predominance over influenza virus patients (P = 0.047). They also had significantly lower white blood cell count (median 6.3 × 10⁶ cells/μ) compared with influenza virus (P < 0.001) and RSV (P = 0.001) patients. Differences were also observed in other laboratory values but were insignificant in a multivariate analysis.ConclusionsMale sex, younger age, and low white blood cell count can assist in the diagnosis of COVID-19 over other viral infections. However, the differences between the groups were not substantial enough and would probably not suffice to distinguish between the viral illnesses in the emergency department.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an RNA virus causing coronavirus disease 2019 (COVID-19). First identified in the Chinese province of Hubei in late 2019, COVID-19 was declared a global pandemic by the World Health Organization in March 2020 (1).As of July 2021, there were more than 180 million confirmed COVID-19 cases and more than four million patients who died due to the disease complications (2). Moreover, the disease caused a substantial economic and social burden (3), and affected health care quality (4-7).The diagnosis of COVID-19 is currently determined primarily by molecular methods and antigen tests (8,9). Radiographic diagnosis is possible as well (10,11). This practice often consumes valuable time and expensive equipment (12). There is a growing need to accelerate the diagnostic process by enabling point-of care diagnosis in various ambulatory settings, while keeping it accurate to ensure the necessary precautionary measures (13).The clinical presentation of SARS-CoV-2 infection resembles that of other respiratory viruses, with predominant symptoms of fever, cough, fatigue, and dyspnea (14-17). Hematological abnormalities, including leukopenia, lymphopenia, and thrombocytopenia, are common among COVID-19 patients, as well as elevated levels of C-reactive protein (CRP), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and ferritin (14,15,18-21). Some of these inflammatory markers correlated with disease severity and mortality (22,23).The influenza season of 2021 in the Northern hemisphere was relatively weak in contrast with predictions. Low to zero rates of influenza were detected in several countries. This was attributed to social distancing, masks wearing, and a reduced number of air travelers (24). Despite a growing number of vaccinated individuals (25), the emergence of new SARS-CoV-2 variants suggest that COVID-19 is here to stay. Seasonal viruses such as influenza virus and respiratory syncytial virus (RSV) could rebound in the following winter, with the loosening of restrictions.Differentiating between COVID-19 and other respiratory viral illnesses on clinical grounds alone can be very challenging. These viral infections share similarities in the transmission route and symptoms (26-28). Several small studies attempted to delineate the differences in the clinical presentation of SARS-CoV-2 and influenza infections (29-31). In this study, we aimed to identify demographic and laboratory parameters that can assist in the early differentiation between SARS-CoV-2, influenza, and RSV infections in the emergency department.     

Levels of self-reported depression and anxiety among HIV-positive patients in Albania: a cross-sectional study

Aim

To gain an initial perspective of mental health issues facing the Human Immunodeficiency Virus (HIV)-positive population at the University Hospital Center of Tirana (UHCT) HIV/AIDS Ambulatory Clinic.

Methods

From June-August 2009, we conducted semi-structured interviews with 79 patients (93% response rate) at the UHCT HIV/AIDS Ambulatory Clinic. The interviews assessed patient-reported histories of mental health diagnoses, patients’ demographics, and current emotional health status.

Results

The percentage of patients who reported a history of diagnosis of depression or anxiety was high – 62.3% and 82.3%, respectively. Factors associated with a history of depression included having been diagnosed with anxiety (P < 0.001), having a higher number of barriers to care (P < 0.001), having a higher number of current medical and social needs (P < 0.001), or having not obtained antiretroviral therapy (ART) abroad (P = 0.004). Factors associated with a history of anxiety included having been on first-line ART (P = 0.008), having been diagnosed with HIV for shorter periods of time (P = 0.043), having been diagnosed with depression (P < 0.001), having a higher number of current medical and social needs (P = 0.035), or having not obtained ART abroad (P = 0.003).

Conclusions

Mental health problems are widespread among the known HIV-positive patient population in Albania. The high prevalences of anxiety and depression and of dual diagnoses of these conditions suggest the need for more mental health care for HIV-positive patients in Albania.Mental health is one of the co-morbidities that is often overlooked in treating patients for Acquired Immune Deficiency Syndrome from Human Immunodeficiency Virus (HIV/AIDS) (1-3). In particular, the rates of depression and anxiety are higher than those in the general population (1-6). Depression is second only to substance abuse as the most prevalent psychiatric disorder among HIV-positive patients (5). In the context of HIV/AIDS, depression has also been shown to lead to more social isolation, lower antiretroviral medication adherence, and faster progression to AIDS (7-14). Anxiety, especially among those that have recently been diagnosed with HIV, has been shown to be more prevalent among patients with stress or excess social stigma related to their diagnosis (15-17). Anxiety can also correlate with lower adherence to antiretroviral therapy (ART) and medical recommendations (18,19).With mental health issues affecting medical treatment of HIV, mechanisms to reduce their burden among HIV-positive patients have been explored. Treatment of depression has been shown to improve adherence to ART along with the quality of life for HIV-positive patients (5,20,21). Community-based group therapy has also been shown to decrease psychiatric symptoms in HIV-positive patients or in regions with high prevalence of HIV, while treatment with ART may reduce both anxiety and depression (22,23). However, with all the advances in the field of mental health, there is still a paucity of data from developing countries (especially Eastern and Central Europe) on the relationship between HIV/AIDS and mental health (18).With the growing epidemic of HIV in Eastern Europe and possible spread to South Eastern Europe, an understanding of the mental health issues facing HIV-positive patients will be vital for the improvement of medical services and treatment for HIV (18,24-29). This is especially true in countries that have only recently initiated psychological services for HIV positive patients. Albania, which boasts a low prevalence of HIV, is one such country that initiated psychological services soon after the introduction of ART in 2004 (30,31). High levels of risky behavioral patterns (including low condom usage and high rates of needle sharing among injection drug users), the recent sociopolitical changes, and the under-resourced prevention and surveillance capabilities, have placed the Albanian population at risk for a rising local HIV epidemic (30-34). In fact, previous studies have suggested that the prevalence of HIV in Albania may be 150-fold the current Ministry of Health estimate (35,36). Thus, an initial patient-driven assessment of the mental health issues of patients under HIV/AIDS medical care in Albania is warranted. In this study, we examined the prevalence of HIV-positive patients’ self-reported histories of mental health diagnoses in Albania. This study also examined effects of ART on mental health and associations with depression and anxiety.     

Health care issues in Croatian elections 2005-2010: series of public opinion surveys

Aim

To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking.

Methods

The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers.

Results

Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively).

Conclusion

Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking.There are various predictors of citizens’ satisfaction with health care system, but there are two main political factors: patient participation and institutional influence of their representative organizations, and political party affiliations (1-4).Some authors concluded that socio-demographic characteristics were only a minor predictor of satisfaction with health care system, but older age appeared to be one of the most consistent positive determinants of health care satisfaction (5-13). Women were found to be less satisfied with care than men because they were more frequent users of care and had higher expectations (14,15).Studies in post-communist states provide mixed evidence in this regard. In a 1991 cross-country survey study, most of the respondents believed that, while the market system was essential to economic development, policies that promoted social and economic egalitarianism were important (16). They also found that women, those with lower educational level, and those with lower income were more likely to be supportive of socialist principles. On the other hand, a study conducted in 1999 showed a change in value systems, with a majority of respondents from Poland and Hungary not favoring further redistribution of income, even at the expense of welfare (17). Furthermore, there was a positive correlation between education and positive attitude to health care competition. Still, in Hungary the older generations were predominantly against increases in health care competition.Since the early 1990s, the public level of satisfaction with the health care system reforms in Croatia has not matched the apparent success of the reform goals. A 1994 consumer survey found that a vast majority of lower- and middle-income Croats was skeptical of health care reforms (18). They attributed this to the legacy of universal access to health care, the view of health care access as a universal right, negative consequences on the patients, and lack of public understanding of the reforms.The same study (18) found the distribution of out-of-pocket payments and co-payment for health care to represent a regressive burden on those in the lower income group. Patient satisfaction was also low: 44% were dissatisfied with the quality of health facilities and 48% with the equipment (18). Similar face-to-face interviews found that citizens of Croatia did not hold a positive view of the health insurance reform (19). Their primary concern were limitations of their rights and the increase in the financial burden related to medical care. A 2005 survey found that during the presidential election campaign period health care was the second most important issue on the voters’ minds, closely following economy (20).Finally, a national survey on patients’ satisfaction with hospital and primary health care in 2006 showed considerable concerns with relations between patients and medical professionals, hospital accommodation, communication between primary and secondary health care, and corruption (21,22).In this study, we present and compare the results of a series of public opinions surveys conducted between 2005 and 2009. This is the first study that targeted public experiences and voters’ opinion as an evaluation of the health care sector in Croatia.