Heterogeneity of posttraumatic stress disorder symptoms in Croatian war veterans: retrospective study

Aim

To determine the relationship between the intensity of combat-related posttraumatic stress disorder (PTSD) and the intensity of predominating symptoms.

Method

The study included 151 veterans from 1992-1995 war in Croatia with PTSD, aged 38.3 ± 7.3 years (mean ± standard deviation). The veterans were psychologically tested with the Mississippi Scale for Combat-related PTSD (M-PTSD), Questionnaire on Traumatic Combat and War Experiences (USTBI-M), and Minnesota Multiphasic Personality Inventory-version 201 (MMPI-201).

Results

The discriminative analysis of the data revealed that the group with lower PTSD intensity had the highest scores on MMPI scales D (depression, T-score 95.7 ± 5.6), Hs (hypochondriasis, 87.6 ± 5.1), and Hy (hysteria, 85.6 ± 4.9), whereas the group with higher PTSD intensity, besides these three scales (D = 98.3 ± 5.3; Hs = 90.1 ± 4.3; Hy = 89.5 ± 4.7), also had clinically significantly elevated Pt (psychastenia, 80.6 ± 5.6), Sc (schizophrenia, 79.6 ± 4.8), and Pa (paranoia, 85.6 ± 5.4) scales, with the highest Pa scale.

Conclusion

It was possible to differentiate study participants with different PTSD intensity on the basis of their MMPI profile. More intense PTSD was associated with externalized symptoms, such as aggression, acting-out, hostility, and mistrust, whereas less intensive PTSD was associated with mostly depressive symptoms. Our study showed that different intensity of PTSD has different symptom patterns.A person’s reaction to trauma depends on the traumatic situation itself, personality characteristics of the person exposed to trauma, and posttraumatic social environment. Most people develop some form of acute stress reaction to traumatic event, but in the majority of cases the stress-related difficulties spontaneously withdraw once the person is removed from the situation (1). Fewer people will develop chronic disorders which may evolve into a clinical picture of posttraumatic stress disorder (PTSD) (2). Symptoms that characterize PTSD include repeated re-experiencing of the trauma, emotional numbing, detachment, lack of affect, anhedonia, and avoidance of activities and situations reminiscent of the traumatic event (3).PTSD is often comorbid with other psychiatric disorders (4-7). Patients with PTSD often complain of psychosomatic disturbances, ranging from anxiety accompanied with tremor and restlessness to depressive problems with predominant cognitive aspects of depression (dark thoughts, shame, guilt, and suicidal thoughts and intentions) and to vegetative symptoms (insomnia and loss of appetite) (8). Comorbidity of PTSD with anxiety or depressive disorders is diagnosed in cases where anxiety or depressive symptoms are prevalent. Due to these psychiatric problems, patients with PTSD often resort to alcohol or drug abuse (4). Memory and concentration impairment, often present in PTSD, may seriously interfere with everyday functioning of these patients (9).Because PTSD symptoms are so heterogeneous, many researchers presume that there are different subtypes of the disorder. Previous attempts to determine different types of PTSD used different methodologic approaches (10-12). Some studies analyzed characteristics of PTSD with respect to predominant symptomatology (6,8), whereas others tried to associate PTSD symptoms with different types of stressors (12,13). Electrophysiological indicators of PTSD as well as the possibility to determine different types of PTSD on the basis of specific electrophysiological indicators were investigated (14,15).Further attempts to discern among different types of PTSD were based on personality tests, primarily Minnesota Multiphasic Personality Inventory (MMPI) (16), response to specific pharmacotherapy (17), and existing aggressive behavior (18-20). Recently, intensity of PTSD has been investigated as a factor that determines the type of the disorder (21-23).The aim of the present study was to determine the relationship between the intensity of PTSD and predominating symptoms in a sample of Croatian 1991-1995 war veterans.     

Short-term memory in Croatian war veterans with posttraumatic stress disorder

Aim

To assess short-term memory impairment in war veterans with combat-related posttraumatic stress disorder (PTSD).

Method

The study included 20 war veterans diagnosed with PTSD and 21 control subjects matched for age, sex, and education level. Both groups were tested with the Rey-Osterrieth Complex Figure Test (ROCFT), consisting of Copy, Immediate Recall, and Delayed Recall steps, and Benton Visual Retention Test (BVRT). Subjects with visuoperceptive and visuoconstructional deficits, as indicated by their ROCFT Copy scores were excluded from the analysis, because this type of cognitive deficit could interfere with the results of the next two ROCFT steps measuring short-term memory.

Results

Subjects with PTSD scored significantly lower than control subjects on both Immediate Recall (mean ± standard deviation [SD], 16.3 ± 6.4 vs 26.7 ± 4.5, respectively; P<0.001, t test for independent samples) and Delayed Recall tests (15.7 ± 6.1 vs 26.3 ± 4.6, respectively; P<0.001, t test for independent samples) on ROCFT test. Intragroup comparison showed that both groups scored significantly lower on Immediate Recall test in comparison with Copy test (19.3 ± 6.4 for veterans and 8.9 ± 4.5 for controls; P<0.001 for both, t test for dependent samples), whereas no significant score difference was found between Immediate and Delayed Recall scores in either group (0.7 ± 2.4 for veterans, P = 0.239, t test for dependent samples; and 0.5 ± 1.8 for controls, P = 0.248, t test for dependent samples), which indicated greater difficulties with acquiring new information than with recalling already memorized information. Subjects with PTSD made significantly more errors on the BVRT for visuoperceptive and visuoconstructional abilities than control subjects (7.8 ± 2.9 for veterans; 4.0 ± 1.88 for controls; P<0.001, t test for independent samples).

Conclusion

War veterans with PTSD had impaired short-term memory and visual retention, but these cognitive deficits could not be related to traumatic experiences with certainty.Chronic posttraumatic stress disorder (PTSD) is accompanied with pathophysiological and biological changes in the brain structures such as hippocampus, amygdale, cortex, nucleus accumbens, striatum, and midbrain (1). These changes may be caused by traumatic experience and responsible for the appearance of PTSD symptoms (1). According to the modern concept of PTSD, it is a psychobiological phenomenon that includes neurobiological dysregulation and psychological dysfunction (2). Studies using sophisticated methods for brain imaging found the dysfunction of the frontal-limbic system as the biological correlate of PTSD (3). Magnetic resonance imaging studies showed that in chronic PTSD patients the volume of the hippocampus was reduced, which affects the learning and memory processes (3-5). The hippocampus atrophy is suspected to result from oversensitivity of the glucocorticoid receptors and increased concentration of glucocorticoids in persons exposed to stress (3,5). However, these changes in hippocampus are not caused by the traumatic experience alone. The trauma is constantly reexperienced through flashbacks and dreams, which are characteristic elements of the clinical picture of PTSD (3). In many PTSD patients, other cognitive dysfunctions are also present, such as intellectual deterioration (3,6), impaired executive functions (3), decreased concentration (7-9), memory deficits (7-9), and forgetfulness (9,10).Due to the high prevalence of PTSD among veterans from 1991-1995 war in Croatia, the degree of PTSD symptoms in this population is frequently assessed (11). Improving our knowledge about memory deficits in PTSD patients would facilitate the severity assessment of the disorder for the purposes of work fitness evaluations and therapy planning (12,13).The aim of this study was to determine the short-term memory deficit in Croatian war veterans with PTSD by comparing their immediate and delayed recall and visual retention abilities with those of healthy controls.     

Surviving genocide in Srebrenica during the early childhood and adolescent personality

Aim

To examine how the experience of genocide in Srebrenica in the early childhood (ages 1-5) influences the psychological health in adolescence.

Methods

This study included 100 school-attending adolescents, age 15-16 (born in 1990-91) who were divided in two groups according to the place of residence from 1992-1995: the Srebrenica group – adolescents who lived in Srebrenica during the siege and the non-Srebrenica group who lived in the “free territory,” were not wounded, and experienced no losses. We used the socio-demographic questionnaire created for the purposes of our study and the War Trauma Questionnaire, Posttraumatic Stress Reactions Questionnaire, Self-report Depressive Scale (Zung), Freiburg Personality Inventory, and the Lifestyle Questionnaire.

Results

Srebrenica adolescents experienced significantly more traumatic experiences (14.26 ± 3.11 vs 4.86 ± 3.16, P < 0.001). Although there was no significant difference in the total score of posttraumatic stress reactions and intensity of depression between the two groups, significantly higher scores of posttraumatic stress reaction were noticed for several specific questions. The most prominent defense mechanisms in both groups were projection, intellectualization, and reactive formation. Srebrenica adolescents had higher sociability levels (34.7% vs 16.0%, χ² = 7.231, P = 0.020).

Conclusion

Srebrenica adolescents reported significantly more severe PTSD symptoms and significantly greater sociability. Our findings could be used for planning treatment and improving communication and overcoming traumas in war-affected areas.Stressful early life experiences of war have been shown to influence behavioral, emotional, and cognitive development of children and shape their brain morphology (1,2).During the 1992-95 war in Bosnia and Herzegovina, more than 100 000 people died or went missing (3). The town Srebrenica, United Nation’s “safe haven” area, was held siege by Serbian military forces for more than three years. After the fall of the town, over 8000 captured boys and men were premeditatedly and systematically killed, and 20 000 women, children and the elderly were forced to leave their homes. In 2008, the International Court of Justice declared the massacre genocide (4). The bodies of the victims are still being exhumed from the mass gravesites (5).The impact of trauma and coping skills vary according to maturity and experience of the child, especially according to the degree of reliance on parents, adult caretakers, siblings, and peers (6).Studies of children and adolescents from Bosnia and Herzegovina (7-13), Croatia (14,15), Cambodia (16), and Israel and Palestine (17) showed that growing up and living in war conditions increased anxiety, depression, and PTSD symptoms, but also most of children, in traumatic situations, enhanced the ways of active coping with intellectual and emotional focusing (18).Our aims were to examine the influence of war traumatic experiences from the early childhood (age 1-5) on psychological health during adolescence, and the relationship between traumatic experiences, development of personality, and psychological defense mechanisms that influence adaptation and growth.     

Emotional and physical abuse in family: survey among high school adolescents

Aim

To determine the prevalence of different forms of child abuse among high school pupils in Slavonski Brod, Croatia.

Method

The study included 2140 first and fourth-grade pupils aged between 14 and 18 years from all 10 high schools in Slavonski Brod and the area (4 grammar and 6 vocational schools). The pupils were asked to complete an anonymous structured questionnaire during a 45-minute class. The questionnaire, developed for the needs of this study, collected basic demographic data on family life and experience of emotional or physical abuse.

Results

First-grade pupils were more satisfied with their family life than fourth-grade pupils (96.9% vs 91.3%, P<0.001, χ² test). The feeling of being insufficiently loved or unloved was reported by 17.5% of the first-grade and 24.6% of the fourth-grade pupils and a greater percentage of pupils whose parents were divorced or who had a stepparent. Almost 80% of pupils had been verbally or nonverbally punished for disobedience. Emotional abuse was significantly associated with female sex (Nagelkerke R² = 0.87, β = 0.474, P = 0.028), younger age (β = 1.263, P<0.001), and alcoholism in the family (β = 2.037, P<0.001. Physical punishment for disobedience was reported significantly more often by first-grade than fourth-grade pupils (15.6% vs 12.9% P = 0.021, χ² test). Physical abuse was significantly associated (Nagelkerke R² = 0.69) with younger age (β = 0.379, P<0.012), emotional abuse (β = 0.665, P<0.002), alcoholism in the family (β = 1.791, P<0.001) and the lack of parental love (β = -0.645, P<0.001). Possible sexual molestation was admitted by 6.0% boys and 3.3% girls.

Conclusion

Most high school pupils in Slavonski Brod were satisfied with their life at home. Disobedience was usually punished verbally or by aggressive behavior of the parents. Physical punishment was less common and usually did not result in serious injuries.Unfit parents negatively affect the child’s emotional development, which leads to behavioral problems (1-4). Most parents have no intention to hurt their child on purpose, but sometimes they do it out of lack of experience or parenting skills (1). Unfit parents quite often acquired dysfunctional behavior patterns in their childhood (1).Main forms of child abuse include physical, emotional, and sexual harassment, and neglect (5,6). The signs of physical abuse are usually visible. Emotional abuse may take many forms, such as ignoring, belittling, or intimidation. It negatively affects the development, distorts the positive self-image of the child, leaves long-term consequences, and may lead to risky or aggressive behavior in adolescence or adulthood (5). Abuse is defined as a permanent type of behavior that “erodes and corrodes” the child’s integrity (7). In the strict sense, the term does not include occasional spanking, or “losing patience” with the child. Fit mothers react inadequately in 10% of total time spent with the child, as opposed to unfit mothers who do so in 80%-90% of the time (7).Long-term negative family conditions are predictive of aggressive behavior, anxiety, depression, delinquency, and social problems in adolescence or adult life (8), for example adolescent pregnancy (9,10), risky sexual behavior and drug addiction (11-13), emotional vulnerability (14), lower verbal intelligence quotient (15), alcoholism, suicidal behavior, and job abandonment (11,16-18). According to the US Department of Health and Human Services, the prevalence of abuse in the USA for the year 2000 was about 12.3/1000 children (19). More than 60% of children were neglected, 20% were physically, 10% sexually, and 7% emotionally abused. The highest percentage of victims were infants and children up to 3 years of age, more often girls than boys, and more than 80% of abusers were parents (19).According to a retrospective study from the United States that involved 1000 adults, about 30% of women and more than 40% men reported to have experienced some form of abuse in childhood; 5% reported to have been sexually and as many as 19% physically abused (20). In Thailand, as many as 77% of sixth graders in the elementary school were physically punished by whipping or lashing with a belt, and 95% were emotionally harassed by being yelled at or humiliated in various ways (21). In Croatia, the number of abused children has increased by 74% over the last 10 years, and the prevalence of sexual child abuse has tripled (22). According to the Croatian Ministry of Internal Affairs, 13 698 cases of child abuse were recorded in the period between 1991 and 1995, and only 10% of the abused children were physically examined and treated in health care institutions (22).A study among Croatian elementary school children in 2004 showed that 35% were victims of various forms of abuse and school violence, 19% were passive victims, 8% provocative victims, and 8% were bullies (23). In Sisačko-moslavačka County, 10%-20% of high school pupils experienced some form of harassment in childhood (24).According to the 2001 census, Slavonski Brod and its surroundings had 124 349 inhabitants and was the sixth largest town in Croatia. Before the war 1991-1995, it was a prosperous industrial and agro-industrial center with developed social services, but during the war it suffered considerable infrastructural damage and hosted many refugees from adjacent Bosnia, part of which took permanent residence. Post-war recession took its toll and nowadays Slavonski Brod has become one of the most impoverished towns in Croatia (25). Such socio-economic situation opens the possibility for increased violence and child abuse. The aim of this study was to determine the frequency of adolescent abuse in Slavonski Brod.     

Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case-control study

Aim

To determine the presence of disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans who suffer from combat-related posttraumatic stress disorder (PTSD).

Methods

The research included 247 veterans of the 1991-1995 war in Croatia who suffered from PTSD and were psychiatrically examined at four clinical centers in Croatia during a month in 2008. It was based on the following self-assessment instruments: The Harvard Trauma Questionnaire (HTQ): Croatian Version, the Structured Interview for Disorder of Extreme Stress (SIDES-SR), and the Mini International Neuropsychiatric Interview (MINI)

Results

Based on the SIDES-SR results, we formed two groups of participants: the group with PTSD (N = 140) and the group with both PTSD and DESNOS (N = 107). Forty three percent of participants met the criteria for DESNOS. There was a significant difference in the intensity of posttraumatic symptoms between the group with both PTSD and DESNOS and the group with PTSD only (U = 3733.5, P = 0.001). Respondents who suffered from both PTSD and DESNOS also reported a significantly larger number of comorbid mental disorders (U = 1123.5, P = 0.049) and twice more frequently reported comorbid depression with melancholic features (OR = 2.109, P = 0.043), social phobia (OR = 2.137, P = 0.036), or panic disorder (OR = 2.208, P = 0.015).

Conclusion

Our results demonstrate that PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria. A greater intensity of symptoms and a more frequent comorbidity with other psychiatric disorders, especially depression, panic disorder, and social phobia require additional therapy interventions in the treatment processes.Posttraumatic stress disorder (PTSD) is a common, but not the only disorder that develops as an effect of a traumatic experience. The prevalence of PTSD in general population is 1 to 14% (1-4). In case of war veterans, the rate ranges from 15 to 57% (3,5,6). As much as 79% of persons suffering from PTSD suffer from another mental disorder and 44% suffer from three or more mental disorders. This means that in case of a large number of traumatized persons, PTSD diagnosis covers only a few mental disturbances (7-11).Chronic or complex PTSD and DES or DESNOS (disorder of extreme stress not otherwise specified) have been investigated since the 1990s (12-15). DESNOS is defined and viewed as a group of symptoms within associated features of PTSD, and as such it may be included in future classifications (2,9). On the other hand, the ICD-10 introduced a diagnostic category of Enduring Personality Change After Catastrophic Events (F62.0), which includes features such as hostility and mistrustful attitude toward the world, social isolation, a feeling of emptiness and hopelessness, irritability, and estrangement. The diagnosis can be given only after two years of the illness duration and it excludes the diagnosis of concurrent PTSD because the enduring change is seen only as an adverse outcome of a long-lasting PTSD, not as a separate entity that can exist in comorbidity with PTSD (1). After its full development, enduring personality change cannot be treated that easily. The ICD-10 classification does not allow diagnosing the comorbidity of PTSD and Enduring Personality Change After Catastrophic Experience or DESNOS as a corresponding diagnostic category proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification (2).The correlation of DESNOS and PTSD is still not completely clear. It is not specified whether DESNOS is a separate clinical entity or a complication of PTSD. Potential factors are severity of traumatic experience, correlation with the severity of PTSD, comorbidity in Axes I and II of the DSM-IV classification system, and a range of personal and social factors that add to the development of the disorder (9,16,17). In spite of clinical experience and results speaking in favor of the presence of the entity that can be developed as an effect of trauma independently of PTSD or in comorbidity with PTSD, the DSM IV classification has not included this category (2,16-19).However, over the past 15 years a number of studies have discussed the possible inclusion of DESNOS in the DSM-V classification (16-19), many criteria have been defined, and even a specific questionnaire, Structured Interview for Disorder of Extreme Stress (SIDES), has been formed (9). Six clusters of symptoms have been proposed for establishing the DESNOS diagnosis: 1) alterations in regulation of affect and impulses (eg, extreme and unmodulated emotional states); 2) alterations in attention or consciousness (eg, dissociation); 3) alterations in self-perception (eg, image of self as fundamentally damaged); 4) alterations in interpersonal relations (eg, impaired relational boundaries); 5) alterations in biological self-regulation (eg, somatization), and 6) alterations in sustaining beliefs (eg, spiritual alienation) (18).[REMOVED HYPERLINK FIELD]DESNOS mostly occurs as a separate disorder, but also in comorbidity with PTSD. The prevalence of DESNOS is 1% in female student population (19), 2% in civil population exposed to war (18), and up to 57% in war veterans, 31% in comorbidity with PTSD and 26% as a separate diagnostic category (16). Furthermore, the prevalence of PTSD is the same in the general population and treatment-seeking population (17). Nearly a half of the treatment-seeking population meets the criteria for DESNOS, which suggests that symptoms of DESNOS, more likely than symptoms of PTSD, are the ones prompting patients to seek help (17).Clinical experience in working with war veterans in Croatia shows that there are patients suffering from chronic PTSD who report a range of symptoms meeting the criteria proposed for DESNOS (9). However, possible comorbidity of DESNOS and PTSD has not been assessed, probably to conform to the existing ICD classification (1). It may be assumed that DESNOS affects patients with severe clinical features of PTSD and that it also occurs in cases of Axis I comorbidity. These assumptions were the subject of our investigation.     

Blood lactate levels in patients receiving first- or second- generation antipsychotics

Aim

To compare the blood lactate levels between patients with psychotic disorder receiving first- and those receiving second-generation antipsychotics.

Methods

The study was conducted at the psychiatric inpatient and outpatient clinics of the Split Clinical Hospital from June 6, 2008 to October 10, 2009. Sixty patients with psychotic disorder who were assigned to 6-month treatment were divided in two groups: 30 received haloperidol (first generation antipsychotic) and 30 received olanzapine (second generation antipsychotic). Blood lactate levels, other metabolic parameters, and scores on the extrapyramidal symptom rating scale were assessed.

Results

Patients receiving haloperidol had significantly higher blood lactate levels than patients receiving olanzapine (P < 0.001). They also more frequently had parkinsonism, which was significantly correlated with both haloperidol treatment at 1 month (P < 0.001) and 6 months (P = 0.016) and olanzapine treatment at baseline (P = 0.016), 3 months (P = 0.019), and 6 months (P = 0.021). Also, patients receiving haloperidol had significant correlation between blood lactate and dystonia at 1 month (P < 0.001) and 6 months (P = 0.012) and tardive dyskinesia at 1 month (P = 0.032). There was a significant difference between the treatment groups in lactate levels at all points from baseline to month 6 (P < 0.001).

Conclusion

It is important to be aware of the potential effect of haloperidol treatment on increase in blood lactate levels and occurrence of extrapyramidal side effects. Therefore, alternative antipsychotics should be prescribed with lower risk of adverse side effects.

Trial identification number

NCT01139463Due to their heterogeneity, antipsychotics are difficult to classify, but they are frequently categorized as the first- and second-generation based on the incidence of extrapyramidal side effects, ie, antidopaminergic activity (1,2). First-generation antipsychotics have dominant antidopaminergic activity and pronounced extrapyramidal side effects (1), while second-generation antipsychotics have a pronounced effect on other neurotransmitter systems, as well as sporadic extrapyramidal side effects.Antipsychotics block numerous neurotransmitter receptors in a manner that induces therapeutic effects and side effects, which may vary in intensity and produce serious consequences (3-7). Extrapyramidal side effects (adverse cardiovascular, hematological, gastrointestinal, sexual, and urologic effects) are most frequently manifested in first-generation antipsychotics due to their non-selective dopaminergic block (1,8-10). The consequence of a dopaminergic effect on the tuberoinfundibular system causing dopamine to inhibit prolactin secretion is hyperprolactinemia (11,12), with possible consequences such as tissue hypoxia and mortality (13-15).Particular attention today is paid to the effects of first-generation antipsychotics on metabolic disorders. Numerous studies have shown that first-generation antipsychotic therapy may lead to metabolic changes, particularly changes in the regulation of glucose, lipid levels, and body weight (3-5,13-21). These side effects are associated with increased mortality and substantial morbidity including diabetes, hypertension, and cardiovascular disease (22,23). In many years of clinical practice, we have empirically observed that treatment with certain antipsychotics causes, along with recognized and described metabolic disorders, an increase in the blood lactate levels. Increased lactate levels are generally associated with increased morbidity and mortality in patients with chronic illnesses or critically ill patients (13,14,24-26). A review of the literature did not find any studies on the effect of antipsychotic therapy on lactate levels or such changes as a part of other antipsychotic side effects. Therefore, it is important to investigate this phenomenon in patients taking first- or second-generation antipsychotic medication.We hypothesized that a 6-month treatment with haloperidol or olanzapine would change blood lactate levels and cause extrapyramidal side effects in patients without prior antipsychotic treatment.     

Pharmacotherapy of treatment-resistant combat-related posttraumatic stress disorder with psychotic features

Aim

To assess retrospectively the clinical effects of typical (fluphenazine) or atypical (olanzapine, risperidone, quetiapine) antipsychotics in three open clinical trials in male Croatian war veterans with chronic combat-related posttraumatic stress disorder (PTSD) with psychotic features, resistant to previous antidepressant treatment.

Methods

Inpatients with combat-related PTSD were treated for 6 weeks with fluphenazine (n = 27), olanzapine (n = 28) risperidone (n = 26), or quetiapine (n = 53), as a monotherapy. Treatment response was assessed by the reduction in total and subscales scores in the clinical scales measuring PTSD (PTSD interview and Clinician-administered PTSD Scale) and psychotic symptoms (Positive and Negative Syndrome Scale).

Results

After 6 weeks of treatment, monotherapy with fluphenazine, olanzapine, risperidone, or quetiapine in patients with PTSD significantly decreased the scores listed in trauma reexperiencing, avoidance, and hyperarousal subscales in the clinical scales measuring PTSD, and total and subscales scores listed in positive, negative, general psychopathology, and supplementary items of the Positive and negative syndrome scale subscales, respectively (P<0.001).

Conclusion

PTSD and psychotic symptoms were significantly reduced after monotherapy with typical or atypical antipsychotics. As psychotic symptoms commonly occur in combat-related PTSD, the use of antipsychotic medication seems to offer another approach to treat a psychotic subtype of combat-related PTSD resistant to previous antidepressant treatment.In a world in which terrorism and conflicts are constant threats, and these threats are becoming global, posttraumatic stress disorder (PTSD) is a serious and global illness. According to the criteria from the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (1), exposure to a life-threatening or horrifying event, such as combat trauma, rape, sexual molestation, abuse, child maltreatment, natural disasters, motor vehicle accidents, violent crimes, hostage situations, or terrorism, can lead to the development of PTSD (1,2). The disorder may also be precipitated if a person experienced, saw, or learned of an event or events that involved actual or threatened death, serious injury, or violation of the body of self or others (3,4). In such an event, a person’s response can involve intense fear, helplessness, or horror (3,4). However, not all persons who are exposed to a traumatic event will develop PTSD. Although the stress reaction is a normal response to an abnormal situation, some extremely stressful situations will in some individuals overwhelm their ability to cope with stress (5).PTSD is a chronic psychiatric illness. The essential features of PTSD are the development of three characteristic symptom clusters in the aftermath of a traumatic event: re-experiencing the trauma, avoidance and numbing, and hyperarousal (1,6). The core PTSD symptoms in the re-experiencing cluster are intrusive memories, images, or perceptions; recurring nightmares; intrusive daydreams or flashbacks; exaggerated emotional and physical reactions; and dissociative experiences (1,6,7). These symptoms intensify or re-occur upon exposure to reminders of the trauma, and various visual, auditory, or olfactory cues might trigger traumatic memories (3,4). The avoidance and numbing cluster of symptoms includes efforts to avoid thoughts, feelings, activities, or situations associated with the trauma; feelings of detachment or alienation; inability to have loving feelings; restricted range of affect; loss of interest; and avoidance of activity. The hyperarousal cluster includes exaggerated startle response, hyper-vigilance, insomnia and other sleep disturbances, difficulties in concentrating, and irritability or outbursts of anger. PTSD criteria include functional impairment, which can be seen in occupational instability, marital problems, discord with family and friends, and difficulties in parenting (3,4,8). In addition to this social and occupational dysfunction, PTSD is often accompanied by substance abuse (9) and by various comorbid diagnoses, such as major depression (10), other anxiety disorders, somatization, personality disorders, dissociative disorders (7,11), and frequently with suicidal behavior (12). Combat exposure can precipitate a more severe clinical picture of PTSD, which may be complicated with psychotic features and resistance to treatment. War veterans with PTSD have a high risk of suicide, and military experience, guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD are significantly associated with suicide attempts (12).The pharmacotherapy treatment of PTSD includes the use of antidepressants, such as selective serotonin reuptake inhibitors (fluvoxamine, fluoxetine, sertraline, or paroxetine) as a first choice of treatment, tricyclic antidepressants (desipramine, amitriptyline, imipramine), monoamine oxidase inhibitors (phenelzine, brofaromine), buspirone, and other antianxiety agents, benzodiazepines (alprazolam), and mood stabilizers (lithium) (13-16). Although the pharmacotherapy of PTSD starts with antidepressants, in treatment-refractory patients a new pharmacological approach is required to obtain a response. In treatment-resistant patients, pharmacotherapy strategies reported to be effective include anticonvulsants, such as carbamazepine, gabapentine, topiramate, tiagabine, divalproex, lamotrigine (14,17); anti-adrenergic agents, such as clonidine (although presynaptic α2-adrenoceptor agonist, clonidine blocks central noradrenergic outflow from the locus ceruleus), propranolol, and prazosin (13,14), opiate antagonists (13), and neuroleptics and antipsychotics (14,17,18).Combat exposure frequently induces PTSD, and combat-related PTSD might progress to a severe form of PTSD, which is often refractory to treatment (19-21). Combat-related PTSD is frequently associated with comorbid psychotic features (11,14,17,19-21), while psychotic features add to the severity of symptoms in combat-related PTSD patients (19,22-24). These cases of a more severe subtype of PTSD, complicated with psychotic symptoms, require the use of neuroleptics or atypical antipsychotic drugs (14,17,25-27).After the war in Croatia (1991-1995), an estimated million people were exposed to war trauma and about 10 000 of the Homeland War veterans (15% prevalence) have developed PTSD, with an alarmingly high suicide rate (28). The war in Croatia brought tremendous suffering, not only to combat-exposed veterans and prisoners of war (29), but also to different groups of traumatized civilians in the combat zones, displaced persons and refugees, victims of terrorist attacks, civilian relatives of traumatized war veterans and terrorist attacks victims, and traumatized children and adolescents (30). Among Croatian war veterans with combat-related PTSD, 57-62% of combat soldiers with PTSD met criteria for comorbid diagnoses (8-11), such as alcohol abuse, major depressive disorder, anxiety disorders, panic disorder and phobia, psychosomatic disorder, psychotic disorders, drug abuse, and dementia. In addition to different comorbid psychiatric disorders, a great proportion of war veterans with combat-related PTSD developed psychotic features (8,11,25,26), which consisted of psychotic depressive and schizophrenia-like symptoms (suggesting prominent symptoms of thought disturbances and psychosis). Psychotic symptoms were accompanied by auditory or visual hallucinations and delusional thinking in over two-thirds of patients (25,26). Delusional paranoid symptoms occurred in 32% of patients (25,26). The hallucinations were not associated exclusively with the traumatic experience, while the delusions were generally paranoid or persecutory in nature (25,26). Although psychotic PTSD and schizophrenia share some similar symptoms, there are clear differences between these two entities, since PTSD patients still retain some insight into reality and usually do not have complete disturbances of affect (eg, constricted or inappropriate) or thought disorder (eg, loose associations or disorganized responses).This proportion of veterans with combat-related PTSD refractory to treatment (18-20) and with co-occurring psychotic symptoms requires additional pharmacological strategies, such as the use of neuroleptics (25) or atypical antipsychotics (14,17,26). Studies evaluating the use of antipsychotics in combat-related PTSD with psychotic features are scarce, and antipsychotics were frequently added to existing medication in the treatment of PTSD.In this study, we compared retrospectively the clinical effects of four antipsychotic drugs – a neuroleptic drug (fluphenazine) and three atypical antipsychotics (olanzapine, risperidone and quetiapine) – in treatment-resistant male war veterans with combat-related PTSD with psychotic features.     

Sexual functioning in war veterans with posttraumatic stress disorder

Aim

To assess the sexual dysfunction among Croatian war veterans with combat-related posttraumatic stress disorder (PTSD).

Method

The study included two groups – 101 war veterans with PTSD and 55 healthy control volunteers receiving outpatient general health care in several outpatient clinics in Split. tructured interviews on different aspects of sexual functioning were conducted from April to October 2007 by trained interviewers.

Results

Respondents with PTSD reported significantly less sexual activity during the previous month than controls (sexual fantasies 2.5 ± 1.6 vs 3.7 ± 1.7, P<0.001; foreplay 2.4 ± 1.6 vs 3.5 ± 1.6, P<0.001; oral sex 1.6 ± 1.2 vs 2.6 ± 1.5, P<0.001; and sexual intercourse 2.4 ± 1.6 vs 3.8 ± 1.5, P<0.001) on a 7-point Likert type scale (from 1 – not a single time to 7 – more times a day). As reasons for reduced sexual activities, respondents with PTSD more frequently than controls reported their own health problems (3.2 ± 1.2 vs 1.5 ± 0.8; P<0.001) or health problems of their partner (2.4 ± 1.1 vs 1.9 ± 1.1; P = 0.004), whereas controls more frequently reported overwork than respondents with PTSD (2.6 ± 1.1 vs 2.1 ± 1.0; P = 0.007) on a 5-point Likert type scale (from 1 – not a single time to 5 – always). Respondents with PTSD reported antidepressant (n = 52, 51%) or anxyolitics use (n = 73, 72.3%). In a subgroup analysis, respondents with PTSD who were taking antidepressants masturbated less frequently than those who were not taking them (1.9 ± 1.3 vs 2.5 ± 1.6; P = 0.039), whereas premature ejaculation was more often experienced by respondents with PTSD who were not taking antidepressants than by those who were taking them (3.5 ± 1.8 vs 2.7 ± 1.5; P<0.049) both on a 7-point Likert type scale (from1 – not a single time to 7 – more times a day).

Conclusion

War veterans with PTSD had less sexual activity, hypoactive sexual desire, and erectile difficulties. Antidepressant therapy in veterans with PTSD may be associated with hypoactive sexual desire.Posttraumatic stress disorder (PTSD) is a complex phenomenon that develops as a response to a psychological trauma and affects several levels of personality, causing changes in both mental and physical functioning (1-3). It is often associated with problems in interpersonal relationships and difficulties with attachment, intimacy, and sexuality (1,2). Problems in the realm of sexuality arise from the individual’s inability to establish an adequate emotional-physical relationship with the partner, as well as from the disturbances in mental and physical health (4). Several studies found that the prevalence of sexual dysfunctions among patients with PTSD was higher than in general population (5-7). Dysfunctions can occur in almost all domains of sexuality – activity, desire, arousal, orgasm, and satisfaction with sexual life (5). The most frequent difficulties are erectile dysfunction and premature ejaculation (6,7). Antidepressant therapy is an additional factor that can aggravate difficulties in sexual functioning (8).Sexual dysfunctions in Croatia have rarely been explored (4,9). A national study that explored the prevalence and risk factors of erectile and ejaculatory difficulties pointed out the role of anxiety and stress in the occurrence of premature ejaculation (4). The significance of sexuality for one’s perception of quality of life, a high prevalence of PTSD in a post-war society such as Croatia, and a lack of relevant studies all point to the importance of studying this domain of veterans’ life (10,11). Our aim was to assess the impact of PTSD on the occurrence of sexual dysfunctions.     

Comparison of peritonsillar infiltration effects of ketamine and tramadol on post tonsillectomy pain: a double-blinded randomized placebo-controlled clinical trial

Aim

To assess the effect of peritonsillar infiltration of ketamine and tramadol on post tonsillectomy pain and compare the side effects.

Methods

The double-blind randomized clinical trial was performed on 126 patients aged 5-12 years who had been scheduled for elective tonsillectomy. The patients were randomly divided into 3 groups to receive either ketamine, tramadol, or placebo. They had American Society of Anesthesiologists physical status class I and II. All patients underwent the same method of anesthesia and surgical procedure. The three groups did not differ according to their age, sex, and duration of anesthesia and surgery. Post operative pain was evaluated using CHEOPS score. Other parameters such as the time to the first request for analgesic, hemodynamic elements, sedation score, nausea, vomiting, and hallucination were also assessed during 12 hours after surgery.

Results

Tramadol group had significantly lower pain scores (P = 0.005), significantly longer time to the first request for analgesic (P = 0.001), significantly shorter time to the beginning of liquid regimen (P = 0.001), and lower hemodynamic parameters such as blood pressure (P = 0.001) and heart rate (P = 0.001) than other two groups. Ketamine group had significantly greater presence of hallucinations and negative behavior than tramadol and placebo groups. The groups did not differ significantly in the presence of nausea and vomiting.

Conclusion

Preoperative peritonsillar infiltration of tramadol can decrease post-tonsillectomy pain, analgesic consumption, and the time to recovery without significant side effects.Registration No: IRCT201103255764N2Postoperative pain has not only a pathophysiologic impact but also affects the quality of patients’ lives. Improved pain management might therefore speed up recovery and rehabilitation and consequently decrease the time of hospitalization (1). Surgery causes tissue damage and subsequent release of biochemical agents such as prostaglandins and histamine. These agents can then stimulate nociceptors, which will send the pain message to the central nervous system to generate the sensation of pain (2-4). Neuroendocrine responses to pain can also cause hypercoagulation state and immune suppression, leading to hypoglycemia, which can delay wound healing (5).Tonsillectomy is a common surgery in children and post-tonsillectomy pain is an important concern. Duration and severity of pain depend on the surgical technique, antibiotic and corticosteroid use, preemptive and postoperative pain management, and patient’s perception of pain (6-9). There are many studies that investigated the control of post tonsillectomy pain using different drugs such as intravenous opioids, non-steroidal anti-inflammatory drugs, steroids, ketamine, as well as peritonsillar injection of local anesthetic, opioid, and ketamine (6,7,10-14).Ketamine is an intravenous anesthetic from phencyclidin family, which because of its antagonist effects on N methyl-D-aspartate receptors (that are involved in central pain sensitization) has regulatory influence on central sensitization and opium resistance. It can also band with mu receptors in the spinal cord and brain and cause analgesia. Ketamine can be utilized intravenously, intramuscularly, epidurally, rectally, and nasaly (15,16). Several studies have shown the effects of sub-analgesic doses of ketamine on postoperative pain and opioid consumption (7,13,15-17). Its side effects are hallucination, delirium, agitation, nausea, vomiting, airways hyper-secretion, and increased intra cerebral pressure and intra ocular pressure (10,11,15,16).Tramadol is an opium agonist that mostly effects mu receptors, and in smaller extent kappa and sigma receptors, and like anti depressant drugs can inhibit serotonin and norepinephrine reuptake and cause analgesia (6,12,18). Its potency is 5 times lower than morphine (6,12), but it has lower risk of dependency and respiratory depression, without any reported serious toxicity (6,12). However, it has some side effects such as nausea, vomiting, dizziness, sweating, anaphylactic reactions, and increased intra-cerebral pressure. It can also lower the seizure threshold (6,12,18,19).Several studies have confirmed the efficacy of tramadol and ketamine on post-tonsillectomy pain (6,10-12,20). In previous studies, effects of peritonsillar/ IV or IM infiltration of tramadol and ketamine were compared to each other and to placebo, and ketamine and tramadol were suggested as appropriate drugs for pain management (6,7,10-19,21). Therefore, in this study we directly compared the effect of peritonsillar infiltration of either tramadol or ketamine with each other and with placebo.     

Tuberculosis Incidence in Elderly in Serbia: Key Trends in Socioeconomic Transition

Aim

To examine tuberculosis incidence rates among the elderly in Central Serbia in 1992-2006 period, which was characterized by socioeconomic crisis and migration of population.

Methods

We analyzed all reported active tuberculosis cases in a 15-year period, especially among patients aged ≥65, according to the Annual Reports of the Institute of Lung Diseases and Tuberculosis in Belgrade and Central Tuberculosis Register. Population estimates with extrapolations were based on 1991 and 2002 census data.

Results

Total tuberculosis incidence rates showed a slight but non-significant decreasing trend (P = 0.535), and no significant increase was found in patients aged ≥65 years (P = 0.064), with an average age-specific incidence rate for the elderly of 64.0 (95% confidence interval, 60.7-67.4). The increase was significant in patients aged ≥70 years (y = 49.3549 + 2.1186x; P = 0.001), both in men (y = 62.8666 + 2.3977x; P = 0.005) and even more prominently in women (y = 39.8240 + 1.9150x; P < 0.001). The proportion of tuberculosis cases in the elderly peaked in 2005, with 35% of all tuberculosis cases.

Conclusion

High incidence rates and increasing time trend of tuberculosis in the elderly in Central Serbia is a serious problem, especially among those aged 70 years and over, who might present a target group for active case-finding of the disease.Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis complex. It can affect persons of any age and involve any site in the body. The risk of developing tuberculosis depends both on the risk of being infected and the risk of developing the active form of the disease. The former depends on the tuberculosis prevalence in the community, whereas the latter depends on many genetic and environmental factors (1-3). A total of 8-10 million people worldwide develop active tuberculosis per year, while at least 1.7 million people die from this disease (4,5). In 1993, the World Health Organization declared tuberculosis a global problem. The main reasons for this are the dramatically increasing number of immune-deficient people in the world and the problem of multi-drug resistant tuberculosis (5,6). In Europe, two tuberculosis trends can be observed, one being a declining epidemic in the west and the other an increasing one in the east (4).While human immunodeficiency virus (HIV) infection presents the greatest single risk factor for developing active tuberculosis, in countries with low HIV prevalence, other factors that decrease human immunity are of higher importance. All tuberculosis risk factors are more pronounced and even multiplied in patients belonging to tuberculosis risk groups, such as immigrants/refugees, prisoners, elderly in old-age homes, people with disabilities in asylums, and Roma populations in slums (3,7-9). Tuberculosis in the elderly is an increasing problem in many countries (4), because of age-related decline in immunity (1) and increasing longevity (10). While the latter happens predominantly in developed countries, the elderly in developing countries suffer from poverty, malnutrition and tobacco smoking, which are proven risk factors for tuberculosis (1,11,12). Thus, tuberculosis in the elderly is likely to be a lasting and even an increasing problem worldwide.Serbia is a country with intermediate tuberculosis incidence rate (4,13,14). A molecular epidemiologic analysis, performed in Belgrade, showed a recent frequent transmission of tuberculosis (15). The national tuberculosis mortality data show peak numbers in the elderly (16,17). In the 1990s, Serbia faced socio-economic crisis, civil war, and mass migration of population following disintegration of former Yugoslavia. We investigated whether tuberculosis in the elderly in Serbia increased in the 1992-2006 period.     

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.     

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.     

Factors associated with posttraumatic stress disorder and depression in war-survivors displaced in Croatia

Aim

To examine the role of perceived stressfulness of trauma exposure and economic, social, occupational, educational, and familial adaptation after trauma in posttraumatic stress disorder (PTSD) and depression in displaced war survivors.

Methods

A cross-sectional survey was conducted between March 2000 and July 2002 with a sample of 173 internally displaced persons or refugees and 167 matched controls in Croatia. Clinical measures included Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale.

Results

Displaced war survivors reported the exposure to a mean ± standard deviation of 13.1 ± 8.3 war stressors, including combat, torture, serious injury, death of close persons, and loss of property. Compared to controls, they reported higher rates of marked to severe impact of war on family (16.2% vs 51.6%), social (7.2% vs 43.5%), economic (12.6% vs 55.4%), occupational (1.8% vs 15.9%), and educational (2.4% vs 8.8%) adaptation. In two logistic regression analyses, the strongest predictor of PTSD and depression was high level of perceived distress during trauma exposure. PTSD but not depression was associated with economic, social, occupational, educational, and familial adaptation after trauma.

Conclusion

Displaced survivors who experienced multiple war events perceived greater negative impact of war on their life domains compared to individuals who lived in a war setting but had no trauma exposure. The most important determinant of psychological outcomes was perceived stressfulness of war stressors. Although post-trauma adaptation in different life spheres had an impact, its effect was not robust and consistent across disorders. These findings suggest that it would be effective to use a trauma-focused approach in rehabilitation of war survivors.Armed conflicts, wars, and associated displacement affect large numbers of people in the world (1). According to the United Nations High Commissioner of Refugees (UNHCR) (2), at the end of 2010 the number of forcibly displaced people in the world was 43.7 million. Some war survivors are displaced within the borders of their countries as internally displaced persons, while others are displaced to other countries as refugees. In addition to war-related stressor events they have been through, such displaced war survivors are believed to experience enduring contextual stressors, including socioeconomic disadvantage and poverty, changes in family structure and functioning, loss of social support, lack of access to education, overcrowded housing, hostility and racism, acculturation difficulties, marginalization and isolation, and cultural bereavement (3-7). These stressors are claimed to cause general psychological distress (8), but there are few studies that examined their contribution to mental health while controlling for the impact of other potentially important variables.The most common mental health outcome of exposure to war-related traumatic stressors is posttraumatic stress disorder (PTSD) and depression (9). In a meta-analysis of 181 surveys comprising 81 866 refugees and other conflict-affected persons from 40 countries, the prevalence rate of PTSD across all surveys was 30.6% and that of depression was 30.8% (1). In this study, the factors that showed strong association with PTSD were cumulative exposure to traumatic events, time since conflict, and assessed level of political terror, while the factors associated with depression were cumulative exposure to traumatic events, time since trauma, torture, and residency status. An important factor that this meta-analysis did not control for (due to lack of data) was psychological processes during trauma exposure, including emotional reactions, perception of life threat, or dissociation during trauma, which have been determined to be the strongest predictors of PTSD (10-14). Indeed, in a series of studies involving war and torture survivors, distress and loss of control during exposure to traumatic stressors (9,15-19) emerged as the strongest predictors of PTSD when the effects of the number of trauma events (cumulative exposure) were statistically controlled for in a regression analysis.Some studies identified older age (20,21), female gender (3,21), and psychiatric history and current illness (22) as predictors of traumatic stress reactions but it is not possible to reach a conclusion about these associations because these studies rarely took into account the effects of trauma exposure characteristics.Political violence and terror during the 1991-1995 war in Croatia and the 1992-1995 war in Bosnia and Herzegovina were categorized as the highest level on the Political Terror Scale (23). Four years of conflict resulted in the displacement of almost 900 000 Croatian citizens of all ethnicities inside and outside the country. Serb secession in central and eastern parts of the country caused an internal displacement in Croatia of over 550 000 ethnic Croats. The war that erupted in Bosnia and Herzegovina in April 1992 resulted in a large population movement. Over the course of the conflict, Croatia accepted 403 000 refugees from the neighboring country (24). The total number of displaced war survivors in Croatia at the end of 1992 was more than 10% of the total Croatian population (25). In this study, we examined the factors associated with PTSD and depression in displaced war survivors in Croatia. Our aim was to determine the role of economic, social, occupational, educational, and familial adaptation after trauma on PTSD and depression while controlling for the effects of psychological processes during trauma exposure as well as demographic and personal history characteristics. Specifically, we hypothesized that 1) displaced war survivors who experienced multiple war-related potentially traumatic events would report greater negative impact on economic, social, occupational, educational, and familial adaptation compared to a control group of individuals who, despite living in a war setting, had no personal exposure to potentially traumatic events; 2) PTSD and depression would be most strongly associated with perceived stressfulness or uncontrollability of war-related traumatic stressors; and 3) economic, social, occupational, educational, and family adaptation in the aftermath of exposure to traumatic incidents would be an independent but weaker predictor of PTSD and depression.     

Quality of Life After Stroke in Old Age: Comparison of Persons Living in Nursing Home and Those Living in Their Own Home

Aim

To determine the differences in subjective quality of life between elderly people living in a nursing home and those living in their own homes after brain stroke, and to determine the contribution of demographic variables and different quality of life domains to the explanation of self-assessed quality of life.

Methods

The study included 60 elderly men and women, 30 living in their own homes (median age, 81; range, 72-90) and 30 living in a nursing home (median age, 81; range, 72-86). Both groups received care (stationary or ambulatory) from the same nursing home. World Health Organization Quality of Life Questionnaire – short version, self-assessed quality of life questionnaire, and demographic questionnaire were used to collect data on subjective quality of life. The participants completed self-report questionnaires individually.

Results

Quality of life scores were significantly higher in the elderly living in a nursing home than in the elderly living in their own home (mean ± standard deviation, 78.7 ± 12.8 vs 59.3 ± 17.3 out of maximum 100, P < 0.001). Also, the elderly living in the nursing home scored significantly higher than those living in their own home on all 4 quality of life domains (maximum 100 for each domain): physical (28.5 ± 3.3 vs 17.2 ± 5.0), psychological (22.3 ± 3.7 vs 16.3 ± 4.0), social relationships (11.4 ± 1.6 vs 8.3 ± 1.7), and environment (32.8 ± 4.6 vs 24.0 ± 6.1) domain (P < 0.001 for all). All predictive variables together explained 51.9% of quality of life variance, with self-assessed health being the most significant predictor.

Conclusion

Quality of life of the elderly in a nursing home was significantly higher than that of their peers living in their own home, which may be related to better care in specially organized settings.Quality of life is influenced by a wide range of different factors. Although material status is one of these factors, it is neither an essential nor sufficient precondition for the feeling of satisfaction with life (1). Objective factors, such as social, economic, and political situation influence subjective assessment of the quality of life, but the association between objective and subjective aspects is not linear, ie, a change in objective aspects does not automatically imply a change in subjective aspects (2). If poor social living conditions are improved, subjective perception of satisfaction with life improves, but after a certain point, this association disappears (1,2). If all basic life needs are met, increase in material well-being will not significantly influence the subjective assessment of quality of life (1).The World Health Organization (WHO) defines quality of life as an individual’s perception of his or her position in life in specific cultural, social, and environmental context (3). Quality of life consists of the following main areas: objective environment, environment, behavioral competence (including health), perceived quality of life, and psychological well-being (including life satisfaction) (4). Beside the objective factors, quality of life is influenced by subjective perception and assessment of physical, material, social, and emotional well-being, personal development, and purposeful activity. All these domains are influenced by an individual’s personal value system (5).It has been shown that individuals with serious and persistent disabilities and objectively poor quality of life report having good or satisfactory quality of life, which is also known as the disability paradox (6,7). This is explained by theory of balance, which says that an individual perceives the quality of life as a balance between body and mind (6). On the other hand, the explanation may lie in establishing supportive social relationships during illness (7,8) and developing effective coping strategies (9). Health is the most often reported factor influencing quality of life of elderly people (10-12). However, objective health problems are not always associated with subjective perception of poor health (13). Paying attention to individual context (14,15) could help us to understand this paradox. For example, Browne et al (16) found that self-reported quality of life was higher among very old study participants than among younger ones. Philp (17) holds that the most important aspect of care for the elderly is to increase and maintain quality of life and that, therefore, all factors that increase the quality of life should be identified. As human life is extended, there is a greater number of diseases that make adequate functioning more difficult (18-20), and the association between symptoms, disorders, and everyday activities has not been completely explained. For example, depression in persons without physical disabilities significantly contributes to the decrease in their daily activities and increases their dependence on others (21). Bowling and Brown (22) reported that persons aged over 85 who lived in their own homes in London assessed their health status as an important predictor of emotional well-being, more influential than social network. Persons with poorer social support had lower satisfaction with life (23), and dependence on help from others elicited the feelings of insecurity and anxiety about future and especially about continued availability of persons that provide help (24). Quality of life is influenced by socio-demographic factors, level of help, variety of activities, and social and environmental factors (23,25-27). Socio-economic indicators contribute relatively little to the model (28).The aim of our study was to determine the differences in self-assessed quality of life between elderly people living in the nursing home and elderly people living in their own homes after stroke and to determine predictive contribution of demographic variables and different quality of life domains to the explanation of subjective quality of life.     

Secondary traumatization of wives of war veterans with posttraumatic stress disorder

Aim

To determine the symptoms of secondary traumatic stress and possible influences of demographic and socioeconomic factors on the occurrence of secondary traumatic stress in wives of war veterans with posttraumatic stress disorder (PTSD).

Method

The study included 56 wives of war veterans diagnosed with PTSD and treated at the Center for Psychotrauma in Rijeka, Croatia. A short structured interview was conducted with each woman to collect demographic and socioeconomic data. The women independently completed an adapted 16-item version of Indirect Traumatization Questionnaire to determine the presence of secondary traumatic stress symptoms, which corresponded with PTSD symptoms as defined by the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders.

Results

Out of 56 veterans’ wives included in the study, 32 had six or more symptoms of secondary traumatic stress, whereas only 3 had none of the symptoms. Twenty-two women met the diagnostic criteria for secondary traumatic stress. Women with secondary traumatic stress were married longer than those without it (mean ± standard deviation, 19.1 ± 9.1 vs 13.2 ± 7.8 years, respectively; P = 0.016). Eleven of 22 women with secondary traumatic stress and 8 of 34 women without secondary traumatic stress were unemployed (P = 0.05).

Conclusion

As more than a third of war veterans wives met the criteria for secondary traumatic stress, any treatment offered to veterans with PTSD must address the traumatization of their family.The Croatian 1991-1995 war caused a wide range of psychological and psychosocial difficulties in war veterans (1). Many of them were diagnosed with posttraumatic stress disorder (PTSD), which has considerably disrupted their social and emotional functioning (2,3). The veteran’s difficulties in everyday life mostly affect his family, while the family is expected to provide all the support that he needs (2). The wife and children witness his sleepless nights, restless dreams, and absentmindedness that sometimes lasts for hours or even days, and avoid upsetting him as much as possible (2,4-6). His low frustration threshold, lack of patience with children, inability to carry on with his family role, great expectations, and verbal and physical aggressiveness heavily influence the relationship with his spouse, children, parents, and the rest of the family (4,7-10).Previous research showed that close and long-term contact with an emotionally disturbed person may cause chronic stress, which in time in persons providing help leads to various emotional problems, such as higher levels of depressive symptoms and anxiety, problems in concentration, emotional exhaustion, pain syndromes, and sleeping problems (2,3,6). One third of wives of Croatian veterans treated for PTSD met the criteria for secondary traumatization (2). In case of posttraumatic disorders, Figley (10,11) believes that empathy toward the traumatized person may induce significant emotional agitation in other family members and calls this phenomenon the secondary stress reaction to catastrophe. Other authors used different terms for this phenomenon, such as compassion fatigue, secondary traumatic stress, and vicarious trauma (11-13). However, the mechanism of transmission of posttraumatic stress onto persons who witnessed or learned about the trauma exposure of the close ones is still rather unknown (11).Secondary traumatic stress is defined as natural emotional reaction to the traumatic experience of a significant other (10,14). Secondary traumatization is the stress caused by providing help, or wishing to help, and offering emotional support to a traumatized person. Secondary stress disorder as a syndrome is almost identical to PTSD except that indirect exposure to the traumatic event through close contact with the primary victim of trauma becomes the criterion A (10). The symptoms of secondary traumatization are similar to those present in directly traumatized persons: nightmares about the person who was directly traumatized, insomnia, loss of interest, irritability, chronic fatigue, and changes in self-perception, perception of one''s own life, and of other people (10). Physical symptoms may also be present, including headaches, indigestion, susceptibility to infections, and increased use of alcohol, drugs, or tobacco (2,12).A few studies investigated the effects that PTSD in war veterans had on their spouses (5,15,16). Dekel et al (5) in their qualitative study on the marital perceptions of 9 wives of veterans with PTSD found that being employed and having known their husbands before the war was very important to the wives of PTSD-diagnosed veterans. Various demographic variables, such as age, ethnicity, education level, or social support, were not found to influence the perceived burden and psychological distress in partners of veterans with PTSD (16). Apart from qualitative study by Dekel et al (5), our literature search of the PILOTS and EPNET bibliographical databases with the key words secondary traumatization, wives, PTSD, war trauma, sociodemographics, socio economics, education level, employment, income, and several others did not find any studies that specifically investigated the relationship between the socioeconomic status and the level of secondary traumatization symptoms or the association between the duration of marriage and the occurrence of secondary traumatization in veterans’ wives.Due to the exposure to stress, caused by the husband’s PTSD symptoms or other psychiatric and health conditions, often combined with his insufficient social and emotional support and increased demands, the veterans’ wives are at an increased risk of specific mental problems related to the life with mentally disturbed husband (3,17-19). Given the recent war in Croatia and relatively high percentage of war veterans with combat-related PTSD, we expected secondary traumatic stress in their wives and female partners to be relatively frequent and that the duration of their life together, number of children, economic situation, and (un)employment would influence the occurrence of secondary traumatic stress.The aim of this study was to determine whether the wives of war veterans with PTSD had symptoms of secondary traumatic stress and to evaluate the possible influence of demographic and socioeconomic factors on the occurrence of secondary trauma stress in these women.     

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.     

Psychiatric heredity and posttraumatic stress disorder: survey study of war veterans

Aim

To explore the prevalence of psychiatric heredity (family history of psychiatric illness, alcohol dependence disorder, and suicidality) and its association with the diagnosis of stress-related disorders in Croatian war veterans established during psychiatric examination.

Methods

The study included 415 war veterans who were psychiatrically assessed and diagnosed by the same psychiatrist during an expert examination conducted for the purposes of compensation seeking. Data were collected by a structured diagnostic procedure.

Results

There was no significant correlation between psychiatric heredity of psychiatric illness, alcohol dependence, or suicidality and diagnosis of posttraumatic stress disorder (PTSD) or PTSD with psychiatric comorbidity. Diagnoses of psychosis or psychosis with comorbidity significantly correlated with psychiatric heredity (φ = 0.111; P = 0.023). There was a statistically significant correlation between maternal psychiatric illness and the patients’ diagnoses of partial PTSD or partial PTSD with comorbidity (φ = 0.104; P = 0.035) and psychosis or psychosis with comorbidity (φ = 0.113; P = 0.022); paternal psychiatric illness and the patients’ diagnoses of psychosis or psychosis with comorbidity (φ = 0.130; P = 0.008), alcohol dependence or alcohol dependence with comorbidity (φ = 0.166; P = 0.001); psychiatric illness in the primary family with the patients’ psychosis or psychosis with comorbidity (φ = 0.115; P = 0.019); alcohol dependence in the primary family with the patients’ personality disorder or personality disorder with comorbidity (φ = 0.099; P = 0.044); and suicidality in the primary family and a diagnosis of personality disorder or personality disorder with comorbidity (φ = 0.128; P = 0.009).

Conclusion

The study confirmed that parental and familial positive history of psychiatric disorders puts the individual at higher risk for developing psychiatric illness or alcohol or drug dependence disorder. Psychiatric heredity might not be necessary for the individual who was exposed to severe combat-related events to develop symptoms of PTSD.There are several risk factors associated with the development of posttraumatic stress disorder (PTSD), such as factors related to cognitive and biological systems and genetic and familial risk (1), environmental and demographic factors (2), and personality and psychiatric anamnesis (3).They are usually grouped into three categories: factors that preceded the exposure to trauma or pre-trauma factors; factors associated with trauma exposure itself; and post-trauma factors that are associated with the recovery environment (2,4).There are many studies which support the hypothesis that pre-trauma factors, such as ongoing life stress, psychiatric history, female sex (3), childhood abuse, low economic status, lack of education, low intelligence, lack of social support (5), belonging to racial and ethnic minority, previous traumatic events, psychiatric heredity, and a history of perceived life threat, influence the development of stress related disorders (6). Many findings suggest that ongoing life stress or prior trauma history sensitizes a person to a new stressor (2,7-9). The same is true for the lack of social support, particularly the loss of support from significant others (2,9-11), as well as from friends and community (12-14). If the community does not have an elaborated plan for providing socioeconomic support to the victims, then the low socioeconomic status can also be an important predictor of a psychological outcome such as PTSD (2,10,15). Unemployment was recognized as a risk factor for developing PTSD in a survey of 374 trauma survivors (16). It is known that PTSD commonly occurs in patients with a previous psychiatric history of mental disorders, such as affective disorders, other anxiety disorders, somatization, substance abuse, or dissociative disorders (17-21). Epidemiological studies showed that pre-existing psychiatric problems are one of the three factors that can predict the development of PTSD (2,22). Pre-existing anxiety disorders, somatoform disorders, and depressive disorders can significantly increase the risk of PTSD (23). Women have a higher vulnerability for PTSD than men if they experienced sexually motivated violence or had pre-existing anxiety disorders (23,24). A number of studies have examined the effects of gender differences on the predisposition for developing PTSD, with the explanation that women generally have higher rates of depression and anxiety disorders (3,25,26). War-zone stressors were described as more important for PTSD in men, whereas post-trauma resilience-recovery factors as more important for women (27).Lower levels of education and poorer cognitive abilities also appear to be risk factors (25). Golier et al (25) reported that low levels of education and low IQ were associated with poorer recall on words memorization tasks. In addition, this study found that the PTSD group with lower Wechsler Adult Intelligence Scale-Revised (WAIS-R) scores had fewer years of education (25). Nevertheless, some experts provided evidence for poorer cognitive ability in PTSD patients as a result or consequence rather than the cause of stress-related symptoms (28-31). Studies of war veterans showed that belonging to racial and ethnic minority could influence higher rates of developing PTSD even after the adjustment for combat exposure (32,33). Many findings suggest that early trauma in childhood, such as physical or sexual abuse or even neglect, can be associated with adult psychopathology and lead to the development of PTSD (2,5,26,34,35). Surveys on animal models confirm the findings of lifelong influences of early experience on stress hormone reactivity (36).Along with the reports on the effects of childhood adversity as a risk factor for the later development of PTSD, there is also evidence for the influence of previous exposure to trauma related events on PTSD (9,26,28). Breslau et al (36) reported that previous trauma experience substantially increased the risk for chronic PTSD.Perceived life threats and coping strategies carry a high risk for developing PTSD (9,26). For instance, Ozer et al (9) reported that dissociation during trauma exposure has high predictive value for later development of PTSD. Along with that, the way in which people process and interpret perceived threats has a great impact on the development or maintenance of PTSD (37,38).Brewin et al (2) reported that individual and family psychiatric history had more uniform predictive effects than other risk factors. Still, this kind of influence has not been examined yet.Keeping in mind the lack of investigation of parental psychiatric heredity on the development of stress-related disorders, the aim of our study was to explore the prevalence and correlation between the heredity of psychiatric illness, alcohol dependence, suicidality, and the established diagnosis of stress-related disorders in Croatian 1991-1995 war veterans.     

Effect of unilateral ureteral obstruction and anti-angiotensin II treatment on renal tubule and interstitial cell apoptosis in rats

Aim

To investigate the effects of angiotensin-converting enzyme inhibitor (cilazapril) and angiotensin II type I receptor antagonist (losartan) on tubular and interstitial cell apoptosis and caspase-3 activity in rats with obstructive nephropathy after unilateral ureteral obstruction.

Methods

Rats with unilateral obstructive nephropathy and sham-operated rats were treated with cilazapril, losartan, or the vehicle (water). Tubular and interstitial cell apoptosis was detected morphologically on hematoxylin and eosin-stained renal specimens and by the terminal deoxynucleotidyl transferase-mediated nick end-labeling. Caspase-3 activity in whole-kidney tissue homogenates was measured colorimetrically.

Results

After unilateral ureter ligation, there was a significant increase in the number of apoptotic tubular and interstitial cells in the obstructed kidney (13.17 ± 8.73 vs 3.00 ± 4.53 cells per high power field; P = 0.049 and 6.33 ± 3.27 vs 2.00 ± 2.35 cells per high power field; P = 0.036 vs sham-operated rats, 10 days after ligation). In rats with unilateral obstructive nephropathy, neither cilazapril nor losartan had an effect on tubular cell apoptosis. However, cilazapril caused a significant increase in the number of renal apoptotic interstitial cells (7.00 ± 9.74 vs 0.8 ± 1.41 cells per high power field, P = 0.019). Caspase-3 activity was not significantly different in rats with unilateral obstructive nephropathy than in sham-operated rats.

Conclusion

Rats with unilateral obstructive nephropathy had increased apoptosis of tubular and interstitial cells in comparison with sham-operated rats. Neither cilazapril nor losartan had an effect on tubular cell apoptosis, and cilazapril even increased interstitial cell apoptosis.Unilateral ureteral obstruction is a procedure that leads to a number of pathophysiological and morphological changes, including tubular atrophy, interstitial inflammation and fibrosis, and apoptosis of renal tubular and interstitial cells (1), which results in chronic obstructive nephropathy (2). Although apoptosis of renal tubule and interstitial cells is a prominent feature of unilateral obstructive nephropathy, the mechanisms involved in it have not been fully elucidated (3). Recent research has indicated that in unilateral obstructive nephropathy there is an association between the renin-angiotensin system and apoptotic alterations in the kidney (4).All the components of the renin-angiotensin system are present within the kidney (5), where both classic and alternate pathways are operational. The biological effect of angiotensin II is mediated by cell surface receptors, which can be divided into two main pharmacological classes, angiotensin II receptor subtypes I (AT1) (6) and angiotensin II receptor subtypes II (AT2) (7). The AT1 receptors are responsible for the major actions of angiotensin II, whereas the role of AT2 receptors is still not completely known (8,9). Angiotensin II may induce renal cell apoptosis by promoting oxidative stress, by causing vasoconstriction, and by enhancing the expression of adhesion molecules inducing chemotaxis and cytokine synthesis. In obstructive nephropathy, angiotensin II increases the expression of various factors, including transforming growth factor β1, tumor necrosis factor α (10), platelet derived growth factor, insulin-like growth factor, osteopontin, vascular cell adhesion molecule-1, monocyte chemotactic protein-1, intercellular adhesion molecule-1, and nuclear factor kappa-B (3).The process of apoptosis is a complex mechanism in which a major role is played by caspases (cysteinyl aspartate-specific proteinase) (11). Many apoptosis-inducing factors (12) transport the signals through the cytoplasm via mediating molecules. These signals are transduced through cytosol by an ever-increasing number of mediator molecules that belong to distinct families (13), each of which mediates a specific apoptotic pathway (14). These pathways, however, converge into a common arm, characterized by an orderly activation of caspases (15), which serve as effector molecules for apoptosis (16,17). One of the best studied effector caspases is caspase-3, the central molecule at the crossroad of all known apoptotic pathways (18).Although the role of angiotensin II in the pathophysiology of unilateral obstructive nephropathy is clear, there is a shortage of studies comparing the effects of angiotensin-converting enzyme (ACE) inhibition and AT1 antagonism on renal tubule and interstitial cell apoptosis. We hypothesized that both ACE inhibitor (cilazapril) and AT1 receptor antagonist (losartan) would decrease renal tubular and interstitial apoptosis. Also, we expected that cilazapril would have greater antiapoptotic effect than losartan, because of the well-known association between ACE inhibition and increased nitric oxide (NO) generation (9). The potential pharmacologic difference between the two classes of anti-angiotensin drugs with different effects on renal cell apoptosis may have clinical therapeutic implications for patients with obstructive nephropathy.     

The prevalence of domestic violence in primary care patients in Slovenia in a five-year period (2005-2009)

Aim

To estimate the prevalence of exposure to domestic violence in primary care patients in Slovenia and determine the associated factors.

Methods

In a systematic cross-sectional survey, 70 physicians from 70 family medicine practices from urban and rural settings conducted interviews with every fifth patient from January 15 to February 15, 2010.

Results

Of 2075 patients (98.8% response rate), 372 (17.9%) were exposed to psychological or physical violence in the family in the last five years. Factors that increased the chances of exposure to psychological and physical violence were female sex (odds ratio [OR], 3.27; 95% confidence interval [CI], 2.24-4.76; P < 0.001; OR, 4.52; 95% CI, 2.83-7.20; P < 0.001, respectively) and formal divorce (OR, 2.08; 95% CI, 1.35-3.21; P = 0.001; OR, 2.72; 95% CI, 1.73-4.29; P < 0.001, respectively). Factors that decreased the chances of exposure to psychological violence were age of 65 years or above (OR, 0.56; 95% CI, 0.33-0.96, P = 0.035) and single status (OR, 0.43; 95% CI 0.21-0.86, P = 0.016), while age of 65 years or above (OR, 0.43; 95% CI, 0.23-0.79, P = 0.007) and parenting of two children (OR, 0.51; 95% CI, 0.29-0.90, P = 0.020) decreased the chances of exposure to physical violence.

Conclusions

We found the rate of exposure to psychological and physical violence of 17.9%, which indicates that this problem is a serious public health issue that needs to be addressed by adequate measures. The identified risk and protective factors could serve as a valid guidance for family physicians dealing with physical violence.Domestic violence is a serious health issue, with consequences ranging from physical impairments to psychological symptoms, physical trauma, and death (1-3). Its prevalence is between 5% and 30% (4-6), and about 90% of the perpetrators are family members (1). The exposure to violence inevitably leads to more frequent use of health services, while unrecognized causes of health problems in victims of violence can lead to unnecessary consultations, unwarranted diagnostic procedures, and ineffective health care (5-10). Health services often miss the opportunity to prevent violence (11), probably because victims hesitate to disclose it and medical health providers hesitate to ask about it, even if a number of guidelines and recommendations has been published (12-17). A meta-analysis (18) has showed that 63% of female patients in primary health care would approve of screening on domestic violence, and the percentage is even higher among those who have experienced violence (18). However, despite the recommendations of professional organizations, only 10% of physicians actively ask their patients about violence (19). The aim of the study was to estimate the prevalence of domestic violence in family care settings in Slovenia and to identify the factors influencing it.