Differences that hurt: self-perceived health inequalities in Croatia and the European Union

Aim

To investigate the differences in self-reported health status and access to health care according to different income groups, urbanization level, and regional distribution in Croatia and European Union (EU) countries.

Method

Data for the EU countries were taken from the European Quality of Life Survey database, which examines different aspects of quality of life including health and health care. The survey was conducted in 2003 and covered 28 countries, although not Croatia. The survey in Croatia was conducted in 2006 by the United Nations Development Program Croatia. EU countries were divided into two groups – 15 “old” EU member states which joined the EU before May 2004 (EU15) and 10 new member states which joined the EU in May 2004 (NMS). The samples were representative and comprised persons aged 18 and over. Statistical differences in health status and access to health care between categories and groups (income groups, urban-rural divide, and analytical regions in case of Croatia) were tested by χ² test or analysis of variance.

Results

Significant differences were found among 4 income quartiles in Croatia and two EU country groups in all indicators: self-perceived health status, satisfaction with health, having long-standing illness or disability, access to health care according to four indicators (distance to the nearest medical facility, delay in getting an appointment, waiting time to see the doctor on the day of the appointment, and the cost of seeing the doctor), and the quality of health services. Higher proportion of the Croatian citizens in the lowest income quartile reported poor health (27.8%) than their counterparts in the EU15 (9.2%) or NMS (18.6%). In Croatia, 26% respondents in the lowest quartile perceived the distance to the nearest medical facility as a very serious problem, compared with 5.4% in the EU15 and 9.4% in the NMS. Rural urban proportion ratio of those who reported poor health was about 80% higher in Croatia than in both EU country groups. Rural-urban proportion ratio of those who reported the cost of seeing the doctor as a very serious problem was almost 2-fold higher than in the two EU country groups.

Conclusion

Health inequalities were more marked in Croatia than in EU countries, which should be taken into serious consideration in shaping health care reforms in Croatia.The issue of health inequalities is certainly among widely researched areas in a number of European countries. Health inequalities are defined as differences in health and health care among different social groups as a result of their different social positions (1). They are mainly associated with socio-economic inequalities, but can also be related to ethnic and gender inequalities (2). Health inequalities attract an increasing interest not only from researchers but also from politicians and the general public, since health care is considered to be a social benefit that should be equally accessed by anyone. Accordingly, the social policy approach to the health area cannot ignore the issue of health inequalities (3,4). Obviously, health inequalities persist, but it remains to be answered which inequalities are perceived as inevitable or normal and which as unjust or immoral.The issue of health inequalities is of great interest for transitional countries, including Croatia, which has undergone deep changes in all aspects of health care system (5). In addition, transitional countries have faced challenges typical for the developed countries: rising costs connected with demographic aging, rising expectations concerning health care rights, as well as constraints in financing health care (6). It seems that in transition period health inequalities rise with rising social inequalities (7). Contrary to this, scientific research and articles about health inequalities in Croatia are very limited. The study conducted in 1994 confirmed that the burden of increasing out-of-pocket expenditures was not equally distributed among income groups, as low income groups were paying six times larger share of their income than high income groups (8). The existence of inequalities in different social groups was also confirmed by the studies from 1999/2000 and 2003 (9,10). However, health inequalities and rising dissatisfaction with the health care system are not taken seriously in designing reforms. Although these issues are indeed a subject of public discussion, the process of designing reforms is still excessively under the influence of financial difficulties and conflicting interests (11). In addition, health inequalities between different minorities or genders have not been investigated enough. The notable exception is the Human Development Report (UNDP) – Croatia 2006, which partly focuses on the access to health care of different groups at the risk of social exclusion (12).The aim of this report was to examine the self-reported health status and access to health services in Croatia and the European Union (EU). Countries of the EU were divided into the group of old member states (EU15) and the group of new member states (NMS). We wanted to assess the health status, prevalence of chronic illness and disability, as well as satisfaction with health in and between the above-mentioned countries. In addition, the intention was to assess some aspects of access to and quality of health services, as well as distrust in the health care system. The primary aim was to analyze self-reported health status and different aspects of access to health services by income groups. Health inequalities were also analyzed according to the urbanization level, and in the case of Croatia according to analytical regions.     

Emigration-related attitudes of the final year medical students in Croatia: a cross-sectional study at the dawn of the EU accession

Aim

To investigate the emigration-related attitudes of final year medical students in Croatia at the dawn of the EU accession in 2013.

Methods

All final-year medical students at four Croatian medical schools (Zagreb, Rijeka, Split, and Osijek) were invited to participate in a cross-sectional survey on emigration attitudes.

Results

Among 260 respondents (response rate 61%), 90 students (35%) reported readiness for permanent emigration, expecting better quality of life (N = 22, 31%), better health care organization (N = 17, 24%), more professional challenges (N = 10, 14%), or simply to get a job (N = 8, 11%), while the least common expectation were greater earnings (N = 7, 10%). The most common target countries were Germany (N = 36, 40%), USA and Canada (N = 15, 17%), and UK (N = 10, 11%). In a multivariate analysis, readiness for permanent emigration was associated with an interest in undertaking a temporary training abroad (odds ratio [OR] 6.87; 95% confidence interval [CI] 2.83-16.72), while the belief that the preferred specialty could be obtained in Croatia appeared protective against emigration (OR 0.26; 95% CI 0.12-0.59).

Conclusion

Despite shortages of health care workers in Croatia, the percentage of students with emigration propensity was rather high. Prevalent negative perception of the Croatian health care and recent Croatian accession to the EU pose a threat of losing newly graduated physicians to EU countries.Today, health workers market is negatively affected by insufficient production due to the high cost of training, attrition, and increasing demand in the aging population. Also, an important problem is migration, which remains high on policy and research agenda ever since one of the first reports published in 1978 (1). Migration is most commonly described as negative, since the main flow of health workers is from less developed countries to more developed ones (2). For instance, in 2000 the percentage of foreign-born doctors was highest in the most developed countries, like New Zealand (46.9%), Australia (42.9%), Ireland (35.3%), Canada (35.1%), UK (33.7%), and USA (24.4%) (3). Positive aspects of migration include gaining knowledge and professional experience. They can also be seen in the remittances that emigrants send to their families left behind (4) and diaspora formation in recipient countries, which serves as a source of support and expertise transfers (5).A considerable public concern has been raised in Croatia due to accession to the EU on July 1st 2013. Emigration waves were predicted, especially among highly educated young people, like physicians (6), although many EU countries have restricted the access to Croatian citizens by transitional arrangements until June 30, 2020 (7). At the same time, physicians’ unemployment rate in Croatia is extremely low. For example, 0.09% of the average number of all the unemployed in 2013 were doctors (8), while the unemployment among the population of medical doctors was 2.2% (9). In other EU countries similar expectations were formed upon joining the EU (10,11), but they turned out to be over-estimations, since the annual outflows from the new EU members (EU-12 countries) rarely exceeded 3% of the domestic health care workforce (12). The aim of this study was to assess the willingness and attitudes of the final year medical students from Croatia toward emigration and to compare the contemporary situation to the one a decade ago.     

Trends in lung cancer incidence and mortality in Croatia, 1988-2008

Aim

To describe and interpret lung cancer incidence and mortality trends in Croatia between 1988 and 2008.

Methods

Incidence data on lung cancer for the period 1988-2008 were obtained from the Croatian National Cancer Registry, while mortality data were obtained from the World Health Organization mortality database. Population estimates for Croatia were obtained from the Population Division of the Department of Economic and Social Affairs of the United Nations. We also calculated and analyzed age-standardized incidence and mortality rates. To describe time incidence and mortality trends, we used joinpoint regression analysis.

Results

Lung cancer incidence and mortality rates in men decreased significantly in all age groups younger than 70 years. Age-standardized incidence rates in men decreased significantly by -1.3% annually. Joinpoint analysis of mortality in men identified three trends, and average annual percent change (AAPC) decreased significantly by -1.1%. Lung cancer incidence and mortality rates in women increased significantly in all age groups older than 40 years and decreased in younger women (30-39- years). Age-standardized incidence rates increased significantly by 1.7% annually. Joinpoint analysis of age-standardized mortality rates in women identified two trends, and AAPC increased significantly by 1.9%.

Conclusion

Despite the overall decreasing trend, Croatia is still among the European countries with the highest male lung cancer incidence and mortality. Although the incidence trend in women is increasing, their age standardized incidence rates are still 5-fold lower than in men. These trends follow the observed decrease and increase in the prevalence of male and female smokers, respectively. These findings indicate the need for further introduction of smoking prevention and cessation policies targeting younger population, particularly women.Lung cancer is the most common malignancy worldwide, accounting for one fifth of all cancer-related deaths (1). There are different trends of lung cancer incidence and mortality throughout Europe, mostly reflecting different phases of smoking epidemic in individual countries. In many European countries, the rates in men have recently decreased or stabilized, while the rates in women increased (2-4). Because the majority of lung cancer deaths are attributed to tobacco smoking, any decline or deceleration in the lung cancer death rates could be attributed to the past antismoking interventions (5,6). Early indicators of progress in tobacco-smoking control are lung cancer trends in young adults (6).About 90% of lung cancers in men and 83% in women are caused by smoking (7). The risk of developing lung cancer is affected by the level of consumption and duration of smoking (8), as well as the level of exposure to environmental tobacco smoke (9). The second most important cause of lung cancer is radon, which was estimated to be responsible for 9% of lung cancer deaths in European countries (10). Other risk factors include exposure to asbestos (11), silica (12), nitrogen oxides (13), radiation to the chest as part of the treatment of malignant diseases (14-16), and scarring on the lungs due to tuberculosis or recurrent pneumonia (17).Currently in Croatia, lung cancer is the most common cancer in men and the fifth most common cancer in women, accounting for more than 2000 and 600 deaths per year, respectively (18,19). The aim of this study was to provide an overview of the temporal trends of lung cancer incidence and mortality in Croatia for the period 1988-2008.     

Vaccination intention among healthcare workers during the first wave of the coronavirus disease 2019 pandemic in relation to knowledge: a cross-sectional study in Croatia,Slovenia, Serbia,and Poland

AimTo analyze SARS-CoV-2 vaccination intention and acceptance in relation to the knowledge about coronavirus disease 2019 (COVID-19) among healthcare workers (HCWs) in Croatia, Slovenia, Serbia, and Poland.MethodsIn spring 2020, an online survey was distributed among HCWs by using snowball sampling. The questionnaire was fully completed by 623 respondents: 304 from Croatia, 86 from Slovenia, 90 from Serbia, and 143 from Poland. The survey collected data on demographic characteristics (age, gender, education), vaccination acceptance, and knowledge about COVID-19.ResultsA total of 31% of respondents declared their intention to be vaccinated when a vaccine against COVID-19 is available, and 45% were undecided. Vaccination intention was associated with age, educational level, and knowledge about the pandemic, and differed significantly among the countries. Younger HCWs (18-25 years) and those with higher education more frequently expressed vaccination acceptance. Vaccination acceptance score was not associated with gender.ConclusionsHCWs with higher knowledge were more likely to express vaccination intention. Improving the knowledge about COVID-19 and increasing HCWs'' education might also increase vaccination acceptance among HCWs, and consequently in the general population.

When in early March 2020, the SARS-CoV-2 virus began to spread in Europe, the governments of Croatia, Slovenia, Serbia, and Poland relatively quickly imposed containment measures, including a closure of kindergartens and schools, and a ban on public life. The measures seemed to be successful, as in the first wave of the pandemic these countries had lower COVID-19 infection and death rates than some Western European countries such as Italy, France, Spain, and the United Kingdom (1). It soon became clear that, in addition to prevention, diagnosis, and treatment, the pandemic can be limited globally only by the introduction of vaccines against COVID-19 (2). The success of a vaccination program depends on the uptake rates in the population, especially among health care workers (HCWs) (3). Better knowledge about the disease and higher perceived severity of COVID-19 have been shown to increase vaccine acceptance (4).HCWs play an important role as health educators and can help in disease control by disseminating accurate information in communities. According to the theory of knowledge, attitude, and practice, successful disease control requires good knowledge of the disease (5). HCWs'' lack of such knowledge can delay treatment and lead to rapid spread of infection (6,7). Indeed, HCWs were shown to have inadequate knowledge about COVID-19 (8).HCWs have a higher risk of becoming infected with COVID-19 than the general population (3,9,10) and are potential transmitters of the virus in the clinical setting. However, they can also help the lay population understand and accept vaccination. In Southeast Asia, HCWs had higher acceptance of COVID-19 vaccination than the general population, due to a higher perceived risk of COVID-19 infection (11). Chinese HCWs had higher willingness to receive future vaccination compared with lay population (12). Because HCWs are the most important sources of information and the strongest authority when it comes to vaccination decisions (13-15), their opinions and vaccination intentions should be assessed, and the relation between key sociodemographic factors and vaccination intentions should be investigated.Due to the importance of HCWs'' vaccination uptake during the COVID-19 pandemic in Central and Eastern Europe, this study analyzed HCWs'' vaccination acceptance in Croatia, Slovenia, Serbia, and Poland in relation to their knowledge about COVID-19. Based on the findings of previous research on influenza vaccination uptake (17), we hypothesized that the countries would significantly differ in COVID-19 vaccination intention and acceptance among HCWs and that vaccination acceptance would be influenced by gender, education, knowledge, and attitudes.     

Frequency of tuberculosis at autopsies in a large hospital in Zagreb, Croatia: a 10-year retrospective study

Aim

To assess the frequency and forms of pulmonary tuberculosis at autopsy in a high-traffic hospital in the capital city of a country with a low tuberculosis incidence.

Methods

We performed a retrospective search of autopsy data from the period 2000 to 2009 at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia. We also examined patients’ records and histological slides.

Results

Of 3479 autopsies, we identified 61 tuberculosis cases, corresponding to a frequency of 1.8%. Active tuberculosis was found in 33 cases (54%), 23 of which (70%) were male. Of the 33 active cases, 25 (76%) were clinically unrecognized and 19 (76%) of these were male.

Conclusion

Clinically undiagnosed tuberculosis accounted for a substantial proportion of active tuberculosis cases diagnosed at autopsy. Autopsy data may be an important complement to epidemiological data on tuberculosis frequency.Each year, there are nearly 9 million new tuberculosis cases globally and nearly 2 million tuberculosis-related deaths (1,2). Tuberculosis occurs throughout the world, but its incidence varies greatly (3). Preventing infection through contact between healthy individuals and patients is the best measure to fight tuberculosis. The new World Health Organization strategy to fight tuberculosis, Stop TB Strategy (2006-2015), deals with the human immunodeficiency virus epidemic that has increased the incidence of tuberculosis (4). The European Centre for Disease Prevention and Control in 2008 created a strategy against tuberculosis called the “Framework Action Plan to Fight Tuberculosis in the European Union” (5). The long-term goal of the Stop TB Strategy and TB Framework Action Plan is to control and ultimately eliminate tuberculosis in the world based on four basic principles: ensure prompt and quality care for all; strengthen the capacity of health systems; develop new tools; and build partnerships and collaboration with countries and stakeholders (4,5).Croatia has a low incidence of tuberculosis, which has been steadily decreasing for the last five decades (6). The peak of the epidemic was at the turn of the 19th and 20th century, when more than 400 deaths per 100 000 people occurred as a direct result of tuberculosis (6). In the mid-20th century, the incidence of new tuberculosis cases was 20 000 per 100 000 people (6). In 2009, the incidence of new tuberculosis cases was 20 per 100 000 people (7) and in 2006 nearly all reported cases showed low levels of multidrug resistance (2,6,7). In accordance with international and European efforts, Croatia has its own guidelines for the fight against tuberculosis, with the following goals: to cure at least 85% of cases; to detect at least 70% of tuberculosis patients, and to decrease the incidence of the disease to 10 per 100 000 people (6-8).Although tuberculosis can affect any organ, 70%-80% of cases suffer from pulmonary tuberculosis (2). Generally, it is possible to detect tuberculosis infection 8-10 weeks after exposure based on a positive tuberculin skin test or an interferon-gamma release assay (9). The rest of the cases have latent tuberculosis infection (LTBI), which is an asymptomatic condition, and cannot transmit the disease (1,2). However, transmission becomes possible under certain conditions such as stress or immune suppression (6,10,11). It is believed that individuals with LTBI account for most infections in low-incidence countries like Croatia, and that this problem is compounded by migration and increasing numbers of homeless persons, alcoholics, and drug addicts (6,10,12).Statistics about tuberculosis prevalence may underestimate the number of infected people, since as many as half of the cases of pulmonary tuberculosis seen at autopsy were previously undiagnosed (12,13). In fact, few studies have examined the relationship between tuberculosis diagnoses at autopsy and reported tuberculosis prevalence in the population (14). This information may help assess whether clinically unrecognized tuberculosis poses a significant public health threat. The present study examined 3479 autopsies performed from 2000 through 2009, to assess the frequency and forms of pulmonary tuberculosis in a country with a low tuberculosis incidence. The results were compared with the number of tuberculosis patients in Croatia recorded in the Croatian Health Service Yearbook for the same period (7,8).     

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).     

Breast and gynecological cancers in Croatia, 1988-2008

Aim

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

Methods

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

Results

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

Conclusion

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

Incidence and mortality trends of leukemia and lymphoma in Croatia, 1988-2009

Aim

To investigate the time trends of leukemia and lymphoma in Croatia from 1988-2009, compare them with trends in other populations, and identify possible changes.

Methods

The data sources were the Croatian National Cancer Registry for incidence data, Croatian Bureau of Statistics for the numbers of deaths, and United Nations population estimates. Joinpoint regression analysis using the age-standardized rates was used to analyze incidence and mortality trends.

Results

Acute lymphoblastic leukemia and chronic lymphocytic leukemia incidence did not significantly change. Acute myeloid leukemia incidence significantly increased in women, with estimated annual percentage change (EAPC) of 2.6% during the whole period, and in men since 1998, with EAPC of 3.2%. Chronic myeloid leukemia incidence significantly decreased in women (EAPC -3.7%) and remained stable in men. Mortality rates were stable for both lymphoid and myeloid leukemia in both sexes. Hodgkin lymphoma non-significantly increased in incidence and significantly decreased in mortality (EAPCs of -5.6% in men and -3.7% in women). Non-Hodgkin lymphoma significantly increased in incidence in women (EAPC 3.2%) and non-significantly in men and in mortality in both men (EAPC 1.6%) and women (EAPC 1.8%).

Conclusion

While Croatia had similar leukemia and lymphoma incidence trends as the other countries, the mortality trends were less favorable than in Western Europe. The lack of declines of leukemia incidence and non-Hodgkin lymphoma mortality could be attributed to late introduction of optimal therapies. As currently the most up-to-date diagnostics and treatments are available and covered by health insurance, we expect more favorable trends in the future.Leukemias and lymphomas contribute 5% to the overall cancer incidence in Croatia (1). They comprise disease entities diverse in etiology, incidence, prognosis, and treatment. The four major leukemia subtypes include acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myeloid leukemia (AML), and chronic myeloid leukemia (CML), while lymphomas include Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL).Estimated 5-year relative survival for patients diagnosed between 2000 and 2002 in Europe, according to EUROCARE-4 results, is 43.4% for the overall group of leukemias. CLL has the highest 5-year survival rate (70.2%), followed by CML (37.2%), ALL (28.8%), and AML (15.8%). Five-year survival rates for lymphomas were 81.9% for HL and 53.6% for NHL (2).Recognized environmental risk factors for leukemia are exposure to ionising radiation (3-5), chemicals such as benzene (6), pesticides (7), chemotherapy (8), cigarette smoking (9), genetic disorders (10,11), family history in case of CLL (12), infection with HTLV-I (13), socio-economic status (14), and obesity (15). However, those risk factors could explain only a minority of cases, and leukemia etiology remains largely unknown. Environmental risk factors for NHL are exposure to pesticides, solvents (16,17) and HIV infection (18), while those for HL include HIV (19) and Epstein-Barr virus infection (20).The last decades brought significant improvements in diagnosis and treatment of leukemias and lymphomas. The aim of our study was to investigate the time trends of leukemia and lymphoma in Croatia from 1988-2009, compare them with trends in other populations, and identify possible changes.     

Regional differences in incidence and clinical presentation of type 1 diabetes in children aged under 15 years in Croatia

Aim

To determine regional differences in the incidence, incidence trends, and clinical presentation of type 1 diabetes in children under the age of 15 years in Croatia in a 9-year period (1995-2003).

Methods

We included the patients who had been diagnosed with the disease and had started the insulin treatment before they were 15 years old. Regional differences between eastern, central, and southern Croatia were observed. The gross incidence was expressed by the number of newly diagnosed type 1 diabetes patients in 100 000 children of the same age and sex per year, ie, for the 0-14 age group, and for the 0-4, 5-9, and 10-14 subgroups.

Results

The highest incidence was observed in southern Croatia (10.91 per 100 000/y) and the lowest in central Croatia (8.64 per 100 000/y), and in eastern Croatia the incidence was 8.93 per 100 000/y. All three regions showed a growing incidence trend, which was significant only in eastern and southern Croatia. There was 35.9% of patients with diabetic ketoacidosis in eastern Croatia, 41.7% in central Croatia, and 31.3% in southern Croatia.

Conclusion

Croatian regions show differences in the incidence, incidence trends, and disease presentation of type 1 diabetes. A further follow-up is needed to establish whether the regional differences are a consequence of the population dynamics in the observed period or they will continue to exist, pointing to differences in environmental risk factors.The incidence of type 1 diabetes is highest in Finland, amounting to 40.9/100 000/y, and lowest in China and Venezuela, amounting to 0.1/100 000/y (1). It varies up to by 10 times among European countries, and as much as by 400 times globally (2). These variations are mainly caused by differences in the genetic makeup of specific ethnic groups and diverse environmental factors (3,4).Sometimes countries of a certain region have similar incidence patterns despite their genetic and long-standing socio-economic differences. A good example are Hungary (7.87/100 000/y), Austria (9.5/100 000/y), the Czech Republic (9.8/100 000/y), and Slovakia (9.2/100 000/y) (5,6). In contrast to this, certain bordering countries sharing the same genetic pool show considerable differences in their incidence rates, ie, Spain and Portugal, and Finland and the Russian province Karelia (7,8). Such cases have not only been recorded in Europe, but also in America. While the incidence for Puerto Rico is the same as for the majority of the US states (17/100 000/y), the neighboring Cuba has a considerably lower incidence, with fewer than 3 patients per 100 000/y (9).Differences in the incidence rates have been recorded even among the regions of the same country (5,10-14). In some cases, this may be explained by the presence of a certain ethnic minority (14) with a different genetic base than the majority population. However, variations are sometimes noted in genetically more homogeneous populations, which points to environmental factors as the possible cause of the differences (10,11). Some studies have shown that changes in the incidence in different regions do not necessarily follow the same pattern over a course of time (15).Establishing the regional distribution of a disease is an important epidemiological method, which may lead to certain etiological hypotheses (10). Since the national incidence and clinical presentation patterns of type 1 diabetes in Croatia had already been established (16,17), the aim of this study was to determine regional differences in the incidence, incidence trends, and clinical presentation of type 1 diabetes in children under the age of 15 years within a 9-year period.     

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.     

Association among education level, occupation status, and consanguinity in Tunisia and Croatia

Aim

To investigate the association between education level, occupation status (a proxy for socio-economic status), and consanguinity in 2 large data sets from Tunisia and Croatia countries with different attitudes toward consanguinity.

Methods

The sample of 1016 students, attending 5 university institutions in Monastir, Tunisia, were interviewed about the educational level and occupation status of their parents and the degree of parental relatedness. In Croatia, a sample of 1001 examinees from 9 isolated island populations was interviewed about their own educational level, occupation status, and consanguinity.

Results

Prevalence of consanguinity (offspring of second cousins or closer) among 1016 Tunisian students was 20.1%, and 9.3% among 1001 Croatian isolates. In Tunisia, the association between consanguinity and both parental degree of education and parental occupation status was highly significant in women (P<0.001), but not significant in men. In Croatia, no statistically significant associations were noted, although there was a consistent trend of increased prevalence of consanguinity with lower education level or occupation status in both genders, but more pronounced in women.

Conclusion

Association between education level, socio-economic status, and consanguinity needs to be taken into account in inbreeding studies in human populations. The relationship may be specific for each studied population and highly dependent on the cultural context. It is generally more pronounced among women in most settings.Consanguineous marriages are unions between two persons who share at least one recent common ancestor (1). In clinical genetics, a consanguineous marriage is commonly defined as union between subjects related as second cousin or closer, equivalent to an inbreeding coefficient in their progeny of F≥0.0156 (2). This kind of union was known to increase the risk of homozygous recurrence of deleterious recessive genes (3,4), and this could explain the increase of polygenic or multifactorially determined diseases in populations with high prevalence of consanguinity (1,5,6). A number of studies reported that offsprings of consanguineous parents had higher rates of neonatal, post-neonatal, child, and infant mortality than those of non-consanguineous parents (7-11).It is widely perceived that consanguinity is more prevalent among the underprivileged in the society (12-14). However, it is possible that factors that are not genetically determined, such as education level and socio-economic status of the subjects, have a confounding effect in the studies on consanguinity. To explore this, we investigated the association between education level, occupation status (a proxy for socio-economic status), and consanguinity in 2 large data sets available from Tunisia and Croatia. The analysis in these two countries with different attitudes toward consanguinity and causes and prevalence of inbreeding could reveal whether the presumed associations between education, occupation, and inbreeding could be generalized, or whether they are more complex and context-specific.     

Delinquency in incarcerated male adolescents is associated with single parenthood,exposure to more violence at home and in the community,and poorer self-image

Aim

To assess the relationships between delinquency and demographic and family variables, academic performance, war stressors, home/community, school, and media violence exposure, self-image, and psychopathology.

Methods

This cross-sectional study included 100 delinquent, incarcerated male adolescents and 100 matched schoolchildren from Croatia. It lasted from January 2008 to June 2009, and used socio-demographic questionnaire, questionnaire on children’s stressful and traumatic war experiences, exposure to violence scale, the Offer Self-Image Questionnaire, and Youth Self-Report Questionnaire.

Results

Logistic regression analysis showed that delinquency in incarcerated adolescents was more likely related to having parents who did not live together (odds ratio [OR] 2.40; confidence interval [CI] 1.18-4.90, P = 0.015), being more exposed to violence at home/community (OR 3.84; CI 1.58-9.34, P = 0.003), and having poorer self-image (OR 1.09; CI = 1.03-1.16, P < 0.002).

Conclusion

Preventive and therapeutic interventions in incarcerated delinquents should be specifically targeted toward single parenthood, family factors, trauma oriented interventions, and focused on multiple dimensions of self-concept of adolescents.Delinquency is associated with many risk factors, including demographic, genetic, and family characteristics (single parenthood) or academic performance. Many studies have focused on exposure to various forms of violence – in the family or home; community and neighborhood; in school and peer groups; and the media, but other risk factors have also found to be important, such as poorer self-image, various forms of psychopathology, and social characteristics (neighborhoods characterized by poverty) (1-15). Most of the studies dealing with delinquency aim to develop therapeutic interventions in relation to the obtained factors or mediators (9,11,16).There are relatively few studies on incarcerated adolescents. Many report on delinquents’ traumatic experiences, posttraumatic stress disorder, and importance of developmental tasks of adolescence and parental monitoring (14,17,18). Therapeutic interventions are specifically directed toward assessment and intervention of trauma and psychopathology, and family interventions are used very often.There are not many studies on delinquents in Croatia and most of them deal with a model that takes into account the interplay between protective and risk factors (19-21). Factors that are often mentioned are parental distrust and punishment, and family dysfunctionality (22-24). The prevalence of delinquency in the last few years has not been reducing (25), which suggests that the current preventive and therapeutic efforts have not been sufficient (25). Another important factor that has to be considered when studying delinquency in Croatia is the influence of Croatian War for Independence 1991-1995. The relationship between war experiences (direct or indirect) and the development of delinquency in adolescents has been relatively rarely described, with contradictory findings. Some studies found no association between the impact of war and bullying (26), whereas others found a relationship between aggressiveness in child refugees and their past war experiences (27) or experiences of their parents, war veterans (28). Besides war-related violence, we expected that delinquency was related to the exposure to other types of violence, eg, violence at home (29). Finally, we also expected an association with poorer self-image (8) and the presence of significant psychopathological syndromes (7).Our aim was therefore to examine the relationship between demographic, family factors, academic performance, exposure to violence in different contexts (home, community, school, media, war related stress), psychopathology, and delinquency.     

Body image and weight control among adolescents in Lithuania, Croatia, and the United States in the context of global obesity

Aim

To compare body image and weight control behavior among adolescents in Lithuania, Croatia, and the United States (US), the countries with striking contrasts in the prevalence of overweight among adolescents.

Method

The study was carried out according to the methodology of the Health Behavior in School-aged Children collaborative survey. Nationally-representative samples of students, aged 13 and 15, were surveyed in Lithuania (3778 respondents), Croatia (2946 respondents), and the US (3546 respondents) in the 2001/2002 school year.

Results

In all three countries, girls perceived themselves as being “too fat” more frequently than boys (37.0% vs 19.7%, P<0.001, z test). The prevalence of this perception increased with age among girls (32.7% vs 41.1%, P<0.001, z test) and decreased among boys (21.4% vs 17.9%, P = 0.005, z test). Lithuanian adolescents were least likely to perceive themselves as “too fat;” this perception was significantly more frequent in Croatia and the US (24.2%, 27.5%, and 34.3%, respectively; P<0.001, χ² test). With the exception of 15-year-old Lithuanian boys, in all respondents the proportion of adolescents with body mass index (BMI) ≥85th percentile who perceived themselves as “too fat” was significantly higher (up to 3.13 times among 15-year-old US girls) than the proportion of adolescents with BMI ≤15th percentile who perceived themselves as “too thin.” The highest proportion of overweight boys and girls on a diet or doing something else to lose weight was found in the US. Boys in Lithuania were most likely to be satisfied with their weight regardless of their weight status.

Conclusion

Perceived body image and weight control behavior differ among adolescents in Lithuania, Croatia, and the US. Cross-cultural, age, and sex influences moderate body image and weight control behavior in underweight and overweight adolescents.The prevalence of overweight and obesity among adolescents is rising rapidly in many countries around the world, including Europe (1). Parallel to the rise in obesity, there is an increase in body dissatisfaction among adolescents (2,3). Previous studies have found that body dissatisfaction is a strong predictor of unhealthy weight control practices (4,5), and restrictive dieting and unhealthy or extreme weight control methods are frequently used by adolescents attempting to achieve an internalized image of ideal body (6). Longitudinal studies have indicated that dieting also predicts weight gain and obesity (7,8). Furthermore, weight control behavior is associated with a wide range of health risk behaviors and psychological problems (9). Thus, frequent weight control associated with poor body image can lead to significant health risks or has potentially serious medical and social consequences.Psychologists define adolescence as a critical period with respect to psychological development of self-image. The association between self-image and mental health is particularly important, since during this period these newly developed cognitive abilities facilitate self-reflection (10,11). Sociocultural theories of body image and empirical research pertinent to them suggest that unrealistic cultural standards of beauty contribute to adolescents’ body dissatisfaction (12). Body dissatisfaction has serious physical and psychological consequences, so further study is needed on cultural and sex differences in these attitudes.Body dissatisfaction problems, which are prevalent in adolescents worldwide, can be incorporated into discussions on perceptions of physical appearance and suggest new hypotheses. Recent international data suggest that of the 34 countries, which conducted the Health Behavior in School-age Children (HBSC) study in 2001/2002, the US had the highest and Lithuania had the lowest prevalence of overweight and obesity in adolescents (13,14).The aim of this article is to compare body image and weight control behavior among adolescents of Lithuania, Croatia, and the US, selected as the countries with different cultural context and a striking contrast in the prevalence of overweight among adolescents. We hypothesize that body weight perceptions among adolescents and weight control behavior pertinent to them differ across countries. Moreover, cross-cultural comparisons may indicate whether the influence of being underweight or overweight on body image and dieting is a universal characteristic of adolescence or if there are cultural, age, or sex influences that moderate this relationship (9).     

Venous thromboembolism in Croatia – Croatian Cooperative Group for Hematologic Diseases (CROHEM) study

Aim

To analyze the incidence and characteristics of venous thromboembolism (VTE) in Croatia.

Methods

The Croatian Cooperative Group for Hematologic Diseases conducted an observational non-interventional study in 2011. Medical records of patients with newly diagnosed VTE hospitalized in general hospitals in 4 Croatian counties (Šibenik-Knin, Koprivnica-Križevci, Brod-Posavina, and Varaždin County) were reviewed. According to 2011 Census, the population of these counties comprises 13.1% of the Croatian population.

Results

There were 663 patients with VTE; 408 (61.54%) had deep vein thrombosis, 219 (33.03%) had pulmonary embolism, and 36 (5.43%) had both conditions. Median age was 71 years, 290 (43.7%) were men and 373 (56.3%) women. Secondary VTE was found in 57.3% of participants, idiopathic VTE in 42.7%, and recurrent VTE in 11.9%. There were no differences between patients with secondary VTE and patients with idiopathic VTE in disease recurrence and sex. The most frequent causes of secondary VTE were cancer (40.8%), and trauma, surgery, and immobilization (38.2%), while 42.9% patients with secondary VTE had ≥2 causes. There were 8.9% patients ≤45 years; 3.3% with idiopathic or recurrent VTE. Seventy patients (10.6%) died, more of whom had secondary (81.4%) than idiopathic (18.6%) VTE (P < 0.001), and in 50.0% VTE was the main cause of death. Estimated incidence of VTE in Croatia was 1.185 per 1000 people.

Conclusion

Characteristics of VTE in Croatia are similar to those reported in large international studies. Improved thromboprophylaxis during the presence of risk factors for secondary VTE might substantially lower the VTE burden.Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major health problem in the world, associated with significant morbidity and mortality (1-9). Incidence rates for VTE mostly vary from 1 to 2 in 1000 individuals per year (1-5,7,9). PE, the most serious manifestation of VTE, has a mortality rate of more than 15% in the first 3 months after diagnosis, with short-term survival of less than 60% (10,11). Cohen et al estimated that the number of VTE-related deaths across the European Union (EU) was 543 454 per year, which was more than double the number of combined deaths in EU due to AIDS, breast and prostate cancer, and traffic accidents (8).VTE in survivors is associated with several chronic consequences of the disease that can severely impair the patients’ quality of life, including post-thrombotic syndrome (PTS) and pulmonary hypertension (PH), as well as recurrent VTE. PTS affects at least one-third of patients after DVT (8,12-15) and PH affects 4%-5% of patients after PE (8,16,17). VTE has significant incidence of recurrence: 10.1% at 6 months, 12.9% after 1 year, and 30.4% after 10 years (18).Total VTE-related costs to health care system are enormous. For example, the total cost of VTE to the UK National Health Service in 1993 was £235-£257 million (€349-€382 million), and the combined direct and indirect costs in 2004/2005 were approximately £640 million (€950 million), and are even higher when PTS is taken into account (8,19,20).VTE is a multifactorial disease, resulting from a complex interaction of genetic and acquired factors. Although some studies estimated that genetics was related to up to 60% of the risk of VTE (including FV Leiden and prothrombin G20210A mutations, deficiencies of protein C, S and antithrombin, and elevations of some procoagulant factors) (21), there is also a large number of acquired risk factors for VTE such as immobilization, surgery, trauma, cancer, pregnancy and puerperium, oral contraceptives, autoimmune diseases, and other disorders (1-8,21).In spite of the importance of VTE, there is not enough data on its incidence and characteristics in transitional countries. Also, although several studies analyzed the epidemiology of VTE in different study settings (1-9), there is still not much information on conditions present at the diagnosis of thrombosis, comparing idiopathic and secondary (provoked) VTE. Therefore, the Croatian Cooperative Group for Hematologic Diseases (CROHEM) analyzed the incidence and characteristics of idiopathic and secondary newly diagnosed VTE in Croatia in 2011, the year of the most recent national population census.     

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.     

Cancer epidemiology in Central, South and Eastern European countries

Aim

To collect cancer epidemiology data in South Eastern European countries as a basis for potential comparison of their performance in cancer care.

Methods

The South Eastern European Research Oncology Group (SEEROG) collected and analyzed epidemiological data on incidence and mortality that reflect cancer management in 8 countries – Croatia, Czech Republic, Hungary, Romania, Poland, Slovakia, and Serbia and Montenegro in the last 20-40 years.

Results

The most common cancer type in men in all countries was lung cancer, followed by colorectal and prostate cancer, with the exception of the Czech Republic, where prostate cancer and colorectal cancer were more common. The most frequent cancer in women was breast cancer followed by colorectal cancer, with the exceptions of Romania and Central Serbia where cervical cancer was the second most common. Cancer mortality data from the last 20-40 years revealed two different patterns in men. In Romania and in Serbia and Montenegro, there was a trend toward an increase, while in the other countries mortality was declining, after increasing for a number of years. In women, a steady decline was observed over many years in the Czech Republic, Hungary, and Slovakia, while in the other countries it remained unchanged.

Conclusions

There are striking variations in the risk of different cancers by geographic area. Most of the international variation is due to exposure to known or suspected risk factors which provides a clear challenge to prevention. There are some differences in incidence and mortality that cannot be explained by exposure to known risk factors or treatment availabilities.On a global scale, cancer has become a major public health problem and an increasingly important contributor to the burden of disease. Based on the most recent available international data, there were an estimated 12.7 million new cancer cases, 7.6 million deaths from cancer, and 28 million persons alive with cancer within five years from the initial diagnosis (1-3). The most common cancers in the world were lung (1.61 million cases), breast (1.38 million), and colorectal cancer (1.24 million) (3). Because of its poor prognosis, lung cancer was also the most common cause of death (1.38 million), followed by gastric (737 000 deaths), and liver cancer (695 000 deaths) (1-4).Priority setting for cancer control and cancer services in any region needs to be based on knowledge of the cancer burden and the local mix of predominant cancer types (5). According to estimates of global cancer burden made by the International Agency for Research on Cancer (IARC), the incidence and mortality rates from many specific types of cancer and all cancers combined vary widely by geographic locality (6). Moreover, the IARC also estimated that over half of newly diagnosed cases and two-thirds of cancer deaths occur in low and medium-income countries (6). There are striking variations in the pattern of cancer by site from region to region (7). The large differences in incidence and mortality in different countries may reflect a combination of differences in prevalence of underlying risk factors, differences in host susceptibility, and/or variations in cancer detection, reporting, classification systems, treatment, and follow-up. Among European countries, wide differences in the quality of cancer care are observed, especially when comparison is made between “old” and “new” EU members or between developed and developing countries (8). Cancer survival is significantly lower in Eastern European countries, including the new Member States, than in the EU 15 (9-12). Transitional countries and middle income countries are frequently left forgotten “in between” and the cancer problem in these countries is among the worst and fastest growing (8).In this report, we provide an analysis, which we propose as a foundation for detailed evaluation of cancer care in selected Central, Southern and Eastern European countries, represented by members of the South Eastern European Research Oncology Group (SEEROG). Our epidemiological analysis indicates the scale of the problem of oncological care in individual countries and shows current trends in the incidence of particular cancers. Comparison of status of oncology between countries in Eastern, Southern, and Central European region has never been undertaken before and key barriers to deliver appropriate quality of care have not previously been identified.     

Alcohol abuse as the strongest risk factor for violent offending in patients with paranoid schizophrenia

Aim

To determine predictive risk factors for violent offending in patients with paranoid schizophrenia in Croatia.

Method

The cross-sectional study including male in-patients with paranoid schizophrenia with (N = 104) and without (N = 102) history of physical violence and violent offending was conducted simultaneously in several hospitals in Croatia during one-year period (2010-2011). Data on their sociodemographic characteristics, duration of untreated illness phase (DUP), alcohol abuse, suicidal behavior, personality features, and insight into illness were collected and compared between the groups. Binary logistic regression model was used to determine the predictors of violent offending.

Results

Predictors of violent offending were older age, DUP before first contact with psychiatric services, and alcohol abuse. Regression model showed that the strongest positive predictive factor was harmful alcohol use, as determined by AUDIT test (odds ratio 37.01; 95% confidence interval 5.20-263.24). Psychopathy, emotional stability, and conscientiousness were significant positive predictive factors, while extroversion, pleasantness, and intellect were significant negative predictive factors for violent offending.

Conclusion

This study found an association between alcohol abuse and the risk for violent offending in paranoid schizophrenia. We hope that this finding will help improve public and mental health prevention strategies in this vulnerable patient group.Individuals with schizophrenia have an increased risk of violence (1), but different studies report different risks (1,2). Anglo-American studies commonly report higher prevalence rates than European studies (3,4). These patients have also been reported to have up to 4-6 times higher violent behavior rate than the general population (3-5). Nonetheless, less than 0.2% patients suffering from schizophrenia commit homicide (in 20-year period) and less than 10% of commit a violent act (3). Also, patients with schizophrenia contribute to 6%-11% of all homicides and homicide attempts (3-5).In general, aggressiveness is usually associated with anti-social personality features, juvenile delinquency, and psychoactive substance abuse (6). In patients with schizophrenia violence and violent offending is associated with a great number of risk factors, such as premorbid affinity to violent behavior, alcohol abuse, younger age, lower socioeconomic status (6,7), deinstitutionalization, longer duration of untreated psychosis, later onset of first episode of psychosis (1,4,8), lower social status, broken families, asocial behavior of parents, loss of father at an early age, a new marriage partner in the family, and growing up in an orphanage (9).Several studies (10-12) looked at four basic personality dimensions and their role in violence in patients with schizophrenic illness spectrum: impulse control, affect regulation, narcissism, and paranoid cognition. Impulsivity and immature affect regulation were associated with most neuropsychiatric disorders, and were particularly predictive of affinity for addictive disorders, while paranoid cognition and narcissism were predictive of violence acts (10-12).The causes of schizophrenia may be genetic, early environmental, and epigenetic risk factors (13,14), which may further modulate the risk of violent offending among individuals with this disease (1,15). Until recently, very little has been reported about the predictive factors of violence and violent offending in the patient population in Croatia. The Croatian population has during the last two decades been exposed to environmental and socio-demographic changes (eg, Croatian War 1991-1995 and post-war period), which might have had an impact on predictive risk factors. Therefore, we conducted a cross-sectional study of in-patients with paranoid schizophrenia with or without history of physical violence and violent offending (inclusive of homicide) in several hospitals in Croatia during one-year period.     

Life expectancy and mortality differences between populations on Croatian islands and the mainland

Aim

To examine the differences in life expectancy and mortality between the populations on Croatian islands and the mainland, and among the islands themselves.

Method

Data on population size and mortality collected in Croatia in 2001 were analyzed by life table and standardized mortality rates.

Results

Life expectancy at birth (95% confidence interval) of the population on Croatian islands was 76.4 yr (75.7-77.1) which was significantly higher than life expectancy at birth of general Croatian population which was 73.8 yr (73.5-73.9) or mainland Croatian population which was 73.7 yr (73.6-73.8). Island population had higher life expectancy until the age of 80 and again in the oldest age group, 95+. More than 10% of inhabited islands in Croatia had life expectancy at birth over 80 years. Two inhabited islands, Ilovik (Kvarner islands) and Lopud (South Dalmatian islands), had one of the highest life expectancy at birth recorded in the literature, with 95.0 and 90.6 years respectively. Mortality rates on islands were significantly lower for age groups 50-64 and 65-79 years, and this difference persisted for all island groups compared with general Croatian population.

Conclusion

Residents of Croatian islands had a higher life expectancy than general or mainland Croatian population. Life expectancy at birth on Croatian islands was lower than in other European Mediterranean countries, but it resembles that in the neighboring Slovenia, and it is considerably higher than in central and eastern Europe and Balkan countries.Life expectancy is one of the most important demographic indicators used to compare different population groups. It is defined as the mean number of years a cohort of people might expect to live according to the current age-specific mortality rates. Life expectancy is the main outcome measure of life table analysis. In general, it reflects differences in mortality, but is relatively resistant to differences in age structure and other population characteristics (1,2). It has mostly been applied for comparison of different countries (3,4), regions (5-7), and specific socio-economic groups (8,9) in terms of health and health care. Life expectancy is generally considered to reflect differences in mortality quite well, but also to be insensitive to age structure of the population, changes in birth rates, and other demographic phenomena (10,11).Low mortality and high life expectancy in European Mediterranean population prompted much interest and has been a focus of research in many studies (12-14). Low intake of saturated fats and high intake of monosaturated fats, as well as high consumption of fruit and vegetables have been proposed as the main factors underlying the low mortality in the Mediterranean (12-17).This study was the first attempt to investigate the differences in life expectancy and mortality between population on Croatian islands and the mainland, and among the islands themselves, as well as to compare the results on Croatian islands with life expectancy in Mediterranean population of European countries.     

Serosurvey of human metapneumovirus infection in Croatia

Aim

To assess the seroprevalence of human metapneumovirus (hMPV) in Croatia.

Methods

During 2005, a total of 137 serum specimens from Croatian patients aged from 6 days to 51 years, without respiratory symptoms, were collected at the Croatian National Institute of Public Health. The sera were examined using the indirect immunofluorescent assay.

Results

The overall hMPV seropositivity rate in the samples tested was 77.4% (106/137). The seropositivity rate increased from 18.7% in children aged between 6 months and 1 year to 100% in people older than 20 years of age. The highest proportion of titers ≥1:512 was found in children aged from 1 to 2 years.

Conclusion

Our results suggest that hMPV infection is present in Croatia, with primary infection occurring in early childhood. This is the first study that indicates the circulation of hMPV in Croatia.Human metapneumovirus (hMPV) is a newly discovered respiratory virus assigned to the Paramyxoviridae family, Pneumovirinae subfamily, Metapneumovirus genus. It was first isolated in 2001 from nasopharyngeal aspirates obtained from young children in the Netherlands (1). Sequence analysis of several isolates identified two major genetic lineages (subtypes A and B) that can be further divided into subgroups A1, A2, B1, and B2 (2). HMPV causes acute respiratory tract infections in all age groups (3,4). In hospitalized young children, hMPV infection is commonly present as bronchiolitis with or without pneumonitis (5,6), whereas bronchitis, bronchospasm, and pneumonitis are most commonly seen in elderly patients (3). Since the initial report, hMPV has been studied all over the world and it has been reported on all continents (7). Seroprevalence surveys from the Netherlands (1), Japan (8), and Israel (9) indicated that virtually all children are infected by 5-10 years of age. The aim of this study was to demonstrate the presence of hMPV infection in Croatia, by examining sera from Croatian people for specific anti-hMPV antibodies by an indirect immunofluorescent assay (IFA).