Attitudes of Roma toward smoking: qualitative study in Slovenia

Aim

To understand the reasons for widespread smoking behavior among Roma in Slovenia for the purpose of developing successful smoking cessation interventions.

Method

A qualitative focus group approach using a combination of pre-structured and open-ended questions was applied to collect the data from the representative members of the Roma community in southern Slovenia. The discussions were audiotaped and transcribed, and the collected data analyzed according to qualitative content analysis theory.

Results

The content analysis revealed that smoking was a strong part of the cultural, ethnic, and individual identity of the Roma. Even children smoked. Doctor’s advice to quit smoking was usually not followed and the attempts to quit were usually unsuccessful. Difficult financial situation was never mentioned as a possible motive to quit. Roma held a tenacious belief that the harmful effects of smoking were in the hands of destiny and did not associate the smoking-related illness with the habit.

Conclusions

Traditional strategies for smoking cessation are largely ineffective among the Roma because of their different attitudes toward smoking. Therefore, innovative and culturally acceptable methods need to be developed.According to the 2002 Census, 0.2% of inhabitants in Slovenia are Roma. However, on the basis of reports of social centers and schools, their real number could be up to four times higher than this (1). The socio-economic status, education level, and employment rate among Roma are considerably worse than among other Slovenian population, which places many of them into the category of poor people and thereby, at increased health risk.From the cultural point of view, the Roma are a highly specific ethnic minority. These once nomadic people now mostly live in poor accommodation and have difficult housing situation. The health culture of the Roma and their use of health care are low despite the fact that most of them can obtain full state-provided medical insurance irrespective of their employment status (2). Due to low hygienic and microclimatic conditions, low health education, and excessive smoking, diseases of the respiratory system seem to be among their most important health problems (3-5). Although epidemiologic data hardly exist, the Roma are known to be heavy smokers. The Roma trust in traditional folk medicine and do not believe smoking is a health-threatening habit (2). The percentage of smokers among the Roma in Slovenia is unknown. Studies from other countries show that, similar to other cardiovascular risk factors, smoking is by far more frequent in Roma than in other populations (5,6).Countries with a Roma population, whose health status is usually poor and socioeconomic position the lowest in the country (7-10), realized that research into the health status of the Roma people is needed for the planning of health intervention strategies, such as antismoking campaign (11,12). From everyday practice we know that the Roma never stop smoking and that they smoke heavily. We performed a qualitative study to understand the reasons for widespread and heavy smoking among the Roma in Slovenia for the purpose of developing more successful public health actions against smoking in their community.     

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

Aim

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

Methods

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

Results

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

Conclusion

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

Physician labor market in Croatia

Aim

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

Methods

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

Results

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

Conclusion

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

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.     

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

Aim

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

Methods

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

Results

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

Conclusion

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

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.     

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

Aim

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

Method

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

Results

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

Conclusion

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

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

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

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

Structural variation on the human Y chromosome from population-scale resequencing

Aim

To investigate the information about Y-structural variants (SVs) in the general population that could be obtained by low-coverage whole-genome sequencing.

Methods

We investigated SVs on the male-specific portion of the Y chromosome in the 70 individuals from Africa, Europe, or East Asia sequenced as part of the 1000 Genomes Pilot project, using data from this project and from additional studies on the same samples. We applied a combination of read-depth and read-pair methods to discover candidate Y-SVs, followed by validation using information from the literature, independent sequence and single nucleotide polymorphism-chip data sets, and polymerase chain reaction experiments.

Results

We validated 19 Y-SVs, 2 of which were novel. Non-reference allele counts ranged from 1 to 64. The regions richest in variation were the heterochromatic segments near the centromere or the DYZ19 locus, followed by the ampliconic regions, but some Y-SVs were also present in the X-transposed and X-degenerate regions. In all, 5 of the 27 protein-coding gene families on the Y chromosome varied in copy number.

Conclusions

We confirmed that Y-SVs were readily detected from low-coverage sequence data and were abundant on the chromosome. We also reported both common and rare Y-SVs that are novel.Structural variation, here considered as genetic variation that affects more than a single base pair of DNA, accounts for the majority of the nucleotide differences between individuals (1). Furthermore, structural variants (SVs) have substantial functional impact. For example, individual SVs are more likely than individual single nucleotide polymorphisms (SNPs) to lead to phenotypic differences such as changes in gene expression (2), are responsible for more loss-of-function in protein-coding genes (3), and underlie many disorders, indeed leading to the recognition of a novel class of “genomic disorder” (4). There has therefore been considerable interest among human geneticists in cataloguing SVs in both patients and samples from the general population. Technological advances have allowed the resolution of genome surveys to increase from ~ 5 Mb in cytogenetic studies, via ~ 100 kb in comparative genomic hybridization (CGH) experiments based on bacterial artificial chromosome clones (5) to ~ 0.5 kb using high-resolution oligonucleotide arrays (6) and finally to base-pair resolution in sequence-based studies (7).The Y chromosome (here, “Y chromosome” always refers to the male-specific portion excluding the pseudoautosomal regions) stands out in SV studies for two reasons. First, it is unusually rich in SVs (8). Cytogeneticists reported visible variation in the length of the Y long arm, pericentric inversions, and translocations of nucleolus organizer regions (NORs, containing ribosomal RNA gene clusters) to the Y in the general population (9). Early molecular studies focusing mainly on individual loci identified variable microsatellites (10), minisatellites (11,12), major satellites (13,14), tandemly-arranged genes (15), and also large duplications, deletions, and inversions (16,17) in the general population. The enrichment of copy number variants (CNVs) on the Y was confirmed by genome-wide surveys (5). More recently, however, the second reason for the Y standing out has come to the fore: it has been neglected in high-resolution studies, either because these are focused on women (6) or, in the most comprehensive sequence-based study (7), because of a combination of lower depth of coverage of the sequence reads (ie, less sequence information because of its haploid status), the use of SV discovery algorithms optimized for autosomes, and the complexities of mapping the short sequence reads produced by next-generation sequencing to the repeated regions that make up most of the Y.There are, nevertheless, good reasons to study Y-SVs at high resolution. Several independent >100 kb deletions on Yq (18), and variation of the copy number of the TSPY array on Yp (19), contribute to spermatogenic variation and failure, but together account for only a small proportion of male infertility. Do smaller Y-SVs account for additional cases of male infertility? In forensic genetics, the AMELY locus forms the basis for the most commonly-used sex test, but is unreliable in a minority of men (20) because of deletions of this locus, which make men difficult to distinguish from women, and have several independent origins (21). More generally, the absence of recombination over most of the length of the Y provides an opportunity to investigate the density, size distribution, and mutational origins of SVs in this different environment, aided by a well-established phylogeny (22).We therefore used a previously-generated population-scale resequencing data set to investigate Y-SVs at high resolution. We chose the 70 male samples used in the 1000 Genomes Pilot Project (23) because, despite their potential, only three validated Y-SVs have been reported in them (7), leaving scope for further discoveries, and additional high-coverage sequence data from 8 of these men have been released. We performed further Y-SV discovery in both the original low-coverage and newer high-coverage sequence data, combined these Y-SVs with those reported by Mills et al, Complete Genomics, and Phase 1 of the 1000 Genomes project in the same samples (7,24), and performed extensive validation and functional prediction on the combined set.     

The construction of the Split Sleep Questionnaire on sleep habits during the COVID-19 pandemic in the general population

AimTo construct a single-format questionnaire on sleep habits and mood before and during the COVID-19 pandemic in the general population.MethodsWe constructed the Split Sleep Questionnaire (SSQ) after a literature search of sleep, mood, and lifestyle questionnaires, and after a group of sleep medicine experts proposed and assessed questionnaire items as relevant/irrelevant. The study was performed during 2021 in 326 respondents distributed equally in all age categories. Respondents filled out the SSQ, the Pittsburgh Sleep Quality Index (PSQI), and State Trait Anxiety Inventory (STAI), and kept a seven-day sleep diary.ResultsWorkday and work-free day bedtime during the COVID-19 pandemic assessed with SSQ were comparable to the sleep diary assessment (P = 0.632 and P = 0.203, respectively), as was the workday waketime (P = 0.139). Work-free day waketime was significantly later than assessed in sleep diary (8:19 ± 1:52 vs 7:45 ± 1:20; P < 0.001). No difference in sleep latency was found between the SSQ and PSQI (P = 0.066). Cronbach alpha for Sleep Habits section was 0.819, and 0.89 for Mood section. Test-retest reliability ranged from 0.45 (P = 0.036) for work-free day bedtime during the pandemic to 0.779 (P < 0.001) for sleep latency before the pandemic.ConclusionThe SSQ provides a valid, reliable, and efficient screening tool for the assessment of sleep habits and associated factors in the general population during the COVID-19 pandemic.

The COVID-19 pandemic, along with its multiple adverse effects on various aspects of mental health, has significantly affected sleep. Sleep habits alterations and newly developed sleep disturbances during the COVID-19 pandemic may influence the overall well-being and health (1). Since the beginning of the pandemic, several studies reported a delay in bedtimes and waketimes, and an associated shift in chronotype toward eveningness (2-5).Even though actigraphy and sleep diaries provide a valid and reliable assessment of sleep habits (6,7), to achieve the highest reliability and validity, these methods require an assessment during seven consecutive days including weekends (8). Daily reporting may be perceived by the respondents as an additional burden (6,9), a limitation that may be overcome by the use of single-administration questionnaires (9,10). Since sleep disturbances recognized in the first pandemic outbreak remained stable during new waves of the COVID-19 pandemic (5), single-administration questionnaires may enable screening of large population groups and an extended assessment of sleep disturbances during the pandemic.So far, validated sleep questionnaires have most often aimed at sleep disorders or symptoms associated with sleep disorders (9). Studies commonly report the Pittsburgh sleep Quality Index (PSQI) (11), which provides data on sleep duration, sleep disturbances, and sleep latency during the previous month. However, PSQI reflects mainly sleep quality on workdays (12), while not collecting information on sleep habits on weekends. The Sleep Timing Questionnaire (STQ) has been developed as an alternative to the sleep diary for the healthy adult population, showing good reliability and validity (10). Still, although sleep habits are associated with mood (13), social media use (14-16), learning time in students (17-19), sports or exercise (20), and symptoms of insomnia (21), the STQ does not assess variables such as mood and lifestyle habits.Large studies objectively assessing sleep with wearable devices have recognized sleep timing and sleep duration to be modifiable risk factors for adverse mental health during the current pandemic (22). Young adults are especially at risk for increased mood disorder symptoms, higher levels of perceived stress, and more common alcohol use during the pandemic (23). Even though mood disorders are often reported in pandemic studies on sleep habits, mood itself has been less commonly measured and associated with sleep parameters (24). A review of the literature showed a transactional relationship between mood and emotion (25), indicating that mood is characterized by longer duration than emotion (26). Mood is often assessed with the Brief Mood Introspection Scale (27), the Profile of Mood States (28), or the Visual Analogue Mood Scale (29). A relevant aspect of mood measurement is a hierarchical structure with two broad dimensions in positive and negative affect, and multiple specific states (30). Commonly used mood assessment scales evaluate the basic negative mood of fear/anxiety, sadness/depression, and anger/hostility, as well as at least one positive mood. Therefore, it has been strongly recommended that mood researchers assess a broad range of both positive and negative emotions (30).Linking mood changes and lifestyle habits during the pandemic has been relevant in order to recognize possible predictors of mood changes, especially due to a reported increase in depression (31). Since sleep is often intertwined with mood and lifestyle changes (31), we assumed that a single-format questionnaire comprehensively assessing these variables and sleep may be applicable and timely.The aim of this study was to construct a single-format Split Sleep Questionnaire (SSQ) comprehensively assessing sleep habits, lifestyle habits, and mood changes, as well as to evaluate its reliability and validity in the general population. Sleep habits were validated by using standard instruments such as sleep diary, PSQI, and STAI questionnaires as the measures of construct validity. Additionally, we aimed to assess the psychometric properties of the Mood section and to explore the effects of the COVID-19 pandemic on sleep habits and mood alterations in the general population of Croatia.     

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

Aim

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

Method

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

Results

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

Conclusion

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

The vicious interplay between disrupted sleep and malignant brain tumors: a narrative review

Malignant brain tumors are among the most aggressive human neoplasms. One of the most common and severe symptoms that patients with these malignancies experience is sleep disruption. Disrupted sleep is known to have significant systemic pro-tumor effects, both in patients with other types of cancer and those with malignant brain lesions. We therefore provide a review of the current knowledge on disrupted sleep in malignant diseases, with an emphasis on malignant brain tumors. More specifically, we review the known ways in which disrupted sleep enables further malignant progression. In the second part of the article, we also provide a theoretical framework of the reverse process. Namely, we argue that due to the several possible pathophysiological mechanisms, patients with malignant brain tumors are especially susceptible to their sleep being disrupted and compromised. Thus, we further argue that addressing the issue of disrupted sleep in patients with malignant brain tumors can, not just improve their quality of life, but also have at least some potential of actively suppressing the devastating disease, especially when other treatment modalities have been exhausted. Future research is therefore desperately needed.

The annual incidence of tumors of the central nervous system (CNS) is little over 22 per 100 000 in the general population (1). Around a third of these lesions are malignant. Among the malignant tumors, gliomas are by far the most common type, constituting over 80% of the number. Among gliomas, the most aggressive type (glioblastoma) is the most common one, making up over a half of all newly diagnosed gliomas (2,3). The five-year survival of patients with malignant CNS tumors is around 30%, with patients being diagnosed a glioblastoma having a five-year survival rate of less than 5%. All this goes to show how malignant CNS tumors are some of the most aggressive human malignancies today. It also shows how the vast accumulated knowledge on the disease origin and progression still has not translated into significant improvement of the overall survival of these patients. New treatment modalities are therefore desperately needed.Besides the devastating diagnosis of a malignant brain tumor, these patients often experience a wide variety of severe symptoms, which significantly diminish their quality of life (4). There has been an increasing awareness of the importance of supportive and palliative care in patients suffering from malignant brain tumors, especially those in whom other treatment modalities have been exhausted (5-7). One of the most commonly reported symptoms is sleep disturbance (4,8-12).Sleep is a recurrent, physiological phenomenon, which consists of many measurable factors (12) and is ubiquitous throughout the natural world (13-16). It is a highly active, easily reversible process, which is crucial not only for the physical and mental well-being of all living organisms, but also for the very concepts we as humans have of ourselves and the world around us (17). There are many theories regarding the possible function of sleep, ranging from the physiological explanations such as rest of individual cells (18) to behavioral explanations of why a biological system needs periodic inactivity (19). There is a growing understanding of how the modern lifestyle disrupts the natural circadian rhythm in humans, consequences of which are still not sufficiently explored (20).Sleep disruption has a well known detrimental role for an organism. Indeed, patients with disrupted sleep have been found to have a higher prevalence of several diseases, such as cardiovascular disorders (21), cognitive impairment (22), various metabolic disorders and obesity (23,24), and systemic and local inflammation (25,26). Furthermore, sleep can be impaired in many ways. The current classification of sleep disorders consists of several clinical entities such as insomnia, parasomnia, hyper-somnolence, sleep-related movement disorders, etc (27). However, this article refers to all of this broad pathology as “sleep disturbance,” primarily for clarity and simplicity sake. In addition, research on disrupted sleeping patterns in patients with malignant lesions usually also encompasses all of these entities into this broader term (28,29).     

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

Aim

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

Methods

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

Results

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

Conclusion

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

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

Aim

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

Methods

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

Results

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

Conclusion

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

Prevalence of erectile and ejaculatory difficulties among men in Croatia

Aim

To determine the prevalence and risk factors of erectile difficulties and rapid ejaculation in men in Croatia.

Method

We surveyed 615 of 888 contacted men aged 35-84 years. The mean age of participants was 54 ± 12 years. College-educated respondents and the respondents from large cities were slightly overrepresented in the sample. Structured face-to-face interviews were conducted in June and July 2004 by 63 trained interviewers. The questionnaire used in interviews was created for commercial purposes and had not been validated before.

Results

Out of 615 men who were sexually active in the preceding month and gave the valid answers to the questions on erectile difficulties and rapid ejaculation, 130 suffered from erectile or ejaculatory difficulties. Men who had been sexually active the month before the interview and gave the valid answers to the questions on sexual difficulties reported having erectile difficulties more often (77 out of 615) than rapid ejaculation (57 out of 601). Additional 26.8% (165 out of 615) and 26.3% (158 out of 601) men were classified as being at risk for erectile difficulties and rapid ejaculation, respectively. The prevalence of erectile difficulties varied from 5.8% in the 35-39 age group to 30% in the 70-79 age group. The association between age and rapid ejaculation was curvilinear, ie, U-shaped. Rates of rapid ejaculation were highest in the youngest (15.7%) and the oldest (12.5%) age groups. Older age (odds ratios [OR], 6.2-10.3), overweight (OR, 3.3-4.2), alcohol (OR, 0.3-0.4), intense physical activity (OR, 0.3), traditional attitudes about sexuality (OR, 2.8), and discussing sex with one’s partner (OR, 0.1-0.3) were associated with erectile difficulties. Education (OR, 0.1-0.3), being overweight (OR, 22.0) or obese (OR, 20.1), alcohol consumption (OR, 0.2-0.3), stress and anxiety (OR, 10.8-12.5), holding traditional attitudes (OR, 2.8) and moderate physical activity (OR, 0.1) were factors associated with rapid ejaculation.

Conclusion

The prevalence of erectile difficulties was higher than the prevalence of rapid ejaculation in men in Croatia. The odds of having these sexual difficulties increased with older age, overweight, traditional attitudes toward sex, and higher level of stress and anxiety.A growing number of international studies on sexual health issues suggest that many women and men worldwide have sexual health problems (1-4). According to surveys based on community samples, the prevalence of male sex disturbances ranges between 10% and 50% (2,4). The most frequent male sexual disturbance seems to be premature or rapid ejaculation (5,6), reported to range from 4% to 29% (6). The Global Study of Sexual Attitudes and Behaviors estimated the prevalence of rapid ejaculation at approximately 30% across all age groups (7). Actually, it seems to be the most common of all male sexual disturbances (5-9). However, when objective definition of rapid ejaculation is attempted, problems arise (9,10). According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), rapid ejaculation is a persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it (11). It results in pronounced distress or interpersonal difficulties and is not exclusively due to the direct effects of a substance used (11). Although useful for clinical practice, this definition does not offer precise guidelines for epidemiological research. As indicated by large discrepancies in the prevalence rates (6), epidemiological analyses of rapid ejaculation are characterized by definition and measurement inconsistencies (1,10,12).In spite of the lack of agreement as to what constitutes rapid ejaculation (12) and the fact that it is not a well-understood problem (5,13), the consequences are well known. Chronic rapid ejaculation is accompanied by an array of psychological problems, including a psychogenic erectile dysfunction (14). Rapid ejaculation can seriously burden interpersonal dynamics and decrease sexual satisfaction (15) and sometimes the overall quality of intimate relationship (16,17). In addition to frustrations, withdrawal (including the lack of desire and cessation of sexual contacts), and strained relationship, rapid ejaculation causes changes in self-image and one’s sense of masculinity. It has been shown that rapid ejaculation has similar psychological impact as erectile problems, especially in terms of self-confidence and worries over the relationship, both the present and the future ones (14).Psychologically and culturally, erectile difficulties are the most dreaded male sexual problem (16,18,19), which not only result in deep frustration, but often lead to a crisis of masculine identity (19). Recent pharmacological breakthrough has initiated a rapid growth of interest in the epidemiology of erectile difficulties. Current studies suggest that a sizeable proportion of adult men suffer from erectile difficulties and that the likelihood of erectile difficulties increases with age (1-4). According to a recently published systematic review, the prevalence of erectile difficulties ranges from 2% in men younger than 40 years to over 80% in men aged 80 years or more (4). Due to the aging of population, the number of men with erectile difficulties is expected to be rising (20,21). The projection based on the results of the Massachusetts Male Aging Study (MMAS) from 1995 is that the number of men with the condition will more than double by 2025 (22).How do we explain considerable variations in reported prevalence rates of erectile difficulties? Methodological and conceptual differences between the studies (1,3,4,23) seem to be the main reason, although the effect of culture-specific perception of sexual problems should not be underestimated (24). In spite of a large number of population or community sample studies (18,20,25-38), inconsistent definitions and operationalization seriously hamper the analysis of the role of culture in perception and reporting of erectile difficulties in men.In transitional countries, sexual health is a rather neglected research area. The main reason for that is the lack of education and research training of possible investigators in the field of sexology. In Croatia, sexual health issues have only recently gained attention as a topic worthy of clinical (39) and non-clinical research (40,41). Our aim was to determine the prevalence of and risk factors for erectile difficulties and rapid ejaculation in a national sample of Croatian men.     

An estimate of asthma prevalence in Africa: a systematic analysis

Aim

To estimate and compare asthma prevalence in Africa in 1990, 2000, and 2010 in order to provide information that will help inform the planning of the public health response to the disease.

Methods

We conducted a systematic search of Medline, EMBASE, and Global Health for studies on asthma published between 1990 and 2012. We included cross-sectional population based studies providing numerical estimates on the prevalence of asthma. We calculated weighted mean prevalence and applied an epidemiological model linking age with the prevalence of asthma. The UN population figures for Africa for 1990, 2000, and 2010 were used to estimate the cases of asthma, each for the respective year.

Results

Our search returned 790 studies. We retained 45 studies that met our selection criteria. In Africa in 1990, we estimated 34.1 million asthma cases (12.1%; 95% confidence interval [CI] 7.2-16.9) among children <15 years, 64.9 million (11.8%; 95% CI 7.9-15.8) among people aged <45 years, and 74.4 million (11.7%; 95% CI 8.2-15.3) in the total population. In 2000, we estimated 41.3 million cases (12.9%; 95% CI 8.7-17.0) among children <15 years, 82.4 million (12.5%; 95% CI 5.9-19.1) among people aged <45 years, and 94.8 million (12.0%; 95% CI 5.0-18.8) in the total population. This increased to 49.7 million (13.9%; 95% CI 9.6-18.3) among children <15 years, 102.9 million (13.8%; 95% CI 6.2-21.4) among people aged <45 years, and 119.3 million (12.8%; 95% CI 8.2-17.1) in the total population in 2010. There were no significant differences between asthma prevalence in studies which ascertained cases by written and video questionnaires. Crude prevalences of asthma were, however, consistently higher among urban than rural dwellers.

Conclusion

Our findings suggest an increasing prevalence of asthma in Africa over the past two decades. Due to the paucity of data, we believe that the true prevalence of asthma may still be under-estimated. There is a need for national governments in Africa to consider the implications of this increasing disease burden and to investigate the relative importance of underlying risk factors such as rising urbanization and population aging in their policy and health planning responses to this challenge.Chronic respiratory diseases (CRDs) are among the leading causes of death worldwide, with asthma rated the most common chronic disease affecting children (1). Globally, about 300 million people have asthma, and current trends suggest that an additional 100 million people may be living with asthma by 2025 (1,2). The World Health Organization (WHO) estimates about 250 000 deaths from asthma every year, mainly in low- and middle-income countries (LMIC) (3,4). Just like with many other chronic diseases in Africa, the fast rate of urbanization has been linked to the increase in the burden of asthma and other allergic diseases (3,5,6). The prevalence of these conditions may, in theory, have the potential to reach levels higher than those observed in high-income countries (HIC) due to priming effects of parasitic helminthic infections on the immune system, as these infections are common in many African settings (5). The International Study of Asthma and Allergies (ISAAC) reported that asthma prevalence among children was increasing in Africa and has contributed most to the burden of disease through its effects on quality of life (3). In-patient admissions and purchase of medications account for most of the direct costs on government, while loss of productivity, due to absenteeism from work and school, are responsible for most of the indirect costs (7,8).Asthma is widely known as a multifactorial respiratory disorder with both genetic and environmental underlying risk factors (3). Exposure to common allergens (including pollens, dust mites, and animal furs) and indoor and outdoor air pollution from various sources (eg, traffic pollution, combustion of fossils and biomass fuels, workplace dust) have all been implicated as triggers of the disease (9). Second hand tobacco smoking is a confirmed risk factor in pediatric patients (5,10). Viral infections, a major cause of upper respiratory tract infections and “common cold,” are also a common risk factor in children (11,12). As noted, helminthic infections are relatively common in Africa and are associated with bronchial hyper-responsiveness and asthma (5,13); this is perhaps due to the presence of related raised immunoglobulin E (IgE) and a prominent Th2 immune response (5,14).Studies on asthma are few in Africa, with most publications mainly from South African and Nigerian populations (14). One main factor affecting research output is the diagnosis of asthma, which still remains a challenging issue (15,16). The WHO has emphasized that this has limited on-going research efforts globally (4,16). The International Union against Tuberculosis and Lung Diseases (IUATLD) published one of the first diagnostic and survey guidelines for asthma in 1984, but experts subsequently reported concerns about its precision and reliability (17). According to the Global Initiative for Asthma (GINA), detailed history, physical examination and spirometric lung function tests are vital to the diagnosis and management of asthma (10,18). Generally, a reduction in forced expiratory volume in one second (FEV₁) and peak expiratory flow (PEF) may be indicative of asthma, with the amount of reduction proportional to the severity of asthma (4). GINA proposed that an increase in FEV₁ of >12% and 200 mL in about 15-20 minutes following the inhalation of 200-400 μg of salbutamol or a 20% increase in PEF from baseline can be employed as standardized criteria in diagnosis of asthma (10). This, however, lacks sensitivity, as many asthmatics, especially those on treatment, may not exhibit an increase in FEV₁ and PEF when assessed (16,19). Thus, although asthma is characterized by significant reversibility of airway obstruction, an absence of reversibility may not always exclude the presence of asthma (20). The ISAAC established in 1991, remains the largest epidemiological study among children globally (1). ISAAC methodologies and scoring are currently the most widely employed by researchers in Africa (1,4). This involves both video and written questionnaires, as there were reports that video and pictorial representations of asthma symptoms may contribute to improved case recognition in younger children (1). However, this is still a subject of debate among experts (21). The European Community Respiratory Health Survey (ECRHS), which assessed the prevalence of atopy and symptoms of airway disease among older age groups in Western Europe, has been widely implemented and has reported significant geographic variations in the prevalence of asthma and atopy (9). Despite these revised guidelines, both ISAAC and ECRHS research groups have reported challenges in achieving high sensitivity and specificity in case ascertainment with the symptom “wheeze at rest in the last 12 months” (also regarded as current wheeze, or active wheeze), yielding the highest sensitivity and specificity (1).In Africa, problems including those arising from the over-utilization of health services, lack of trained staff and diagnostic apparatus, and non-availability and unaffordability of inhaled medications have hindered efforts to improve the management of asthma (22,23). The lack of organized health promotion programs, such as effective control strategies for environmental triggers, air pollutants, and occupational dusts have also contributed to the growing burden (24). The WHO has reported that the levels of asthma control and health responses in the continent have been below recommended standards, and that these have contributed to the size of the disease burden (3,4). In addition, although many African countries have national guidelines for the management of asthma and other CRDs, these guidelines have not been implemented in most rural areas (25,26). Economic analyses in many African settings have shown that direct costs from asthma are usually greater than the indirect costs. However, indirect costs represent a relatively higher proportion of total costs among pediatric than adult patients (8). Moreover, the wider economic burden on individuals, families, employers, and society, due to loss of future potential source of livelihood, has also been devastating in many resource-poor settings (22). It is believed that many children with asthma in Africa may fail to achieve their full potential if proper management and control measures are not put in place (1). It has been suggested that education of health care providers and the public is a vital element of the response to the challenge posed by asthma in Africa (4,27).By 2015, it is expected that world’s urban population will increase from 45% to 59%, with over half of this occurring in Africa (8). It is also expected that the prevalence of asthma and many chronic diseases in Africa will increase due to this growing population size and from effects of accompanying urbanization and adoption of western lifestyles (28). In light of this and of the low research output and poor availability of health services data on the burden of asthma in Africa, it is important to analyze the available data through a systematic review of the literature in order to attempt to quantify the burden, guide health priority settings, and inform the formulation of an appropriate health policy response.     

Patients with Combat-related and War-related Posttraumatic Stress Disorder 10 Years After Diagnosis

Aim

To establish how many patients diagnosed with posttraumatic stress disorder (PTSD) in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later, and assess their sociodemographic characteristics, comorbid disorders, and type of treatment.

Methods

Medical records of patients diagnosed with PTSD in 1996 were reviewed in the period 2007-2009 and the patients who contacted a psychiatrist in that period (n = 85) and those who did not (n = 158) were compared.

Results

There were 36.7% of men and 20% of women diagnosed with PTSD in 1996 who contacted a psychiatrist in the period 2007-2009. Patients who contacted a psychiatrist and those who did not did not differ in sex, age, the number of visits and hospitalizations in 1996, and employment status. The majority of patients still had PTSD and/or were enduring personality change in the period 2007-2009, and 54.8% had some comorbidity (mostly depression, alcohol-related disorders, and personality disorders). Patients were most often treated with anxiolytics and antidepressants.

Conclusion

Ten years after the traumatic experience, one third of patients with PTSD received psychiatric help, regardless of their sex, age, and employment status. Half of them had comorbid disorders and the majority of them were treated with anxiolytics and antidepressants.Posttraumatic stress disorder (PTSD) is a mental disorder that develops in 9-25% of war veterans (1-4), mainly in the first two years after the traumatic experience (5,6), but sometimes can develop years later (7,8). A similar prevalence was also found among Croatian war veterans (5-9). In the majority of cases (80-98%), PTSD is comorbid with other mental disorders: alcohol abuse, depression, anxiety disorders, and somatization (5,9-11).PTSD can also develop after a war-related trauma that is not necessarily combat-related, and the lifetime prevalence of PTSD in this population is 15-38% (12) and the prevalence of anxiety and depressive disorders is even higher (13,14).Many patients in Croatia had symptoms of PTSD and used health facilities for treatment years after the war (5-9). In the former Yugoslavia, 84% of untreated war-related PTSD patients still had PTSD symptoms years after the war (15). Resolution of PTSD is observed in 50-60% of cases (4,16).Combat-related PTSD causes more functional impairment and is less responsive to treatment than PTSD related to other traumas (17-19). It is unclear whether this happens because there is indeed a difference between the two types of PTSD or some of the patients aggravate their symptoms in order to get compensation (17,18,20). Some studies show that the use of health facilities decreases after obtaining war veteran status and compensation, but others show that the patients who had obtained the status and compensation used medical facilities more often than those who had not (20-23).The aim of this study was to establish how many patients diagnosed with PTSD in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later and assess their comorbidities, sociodemographic characteristics, and type of treatment.     

Zagreb Amblyopia Preschool Screening Study: near and distance visual acuity testing increase the diagnostic accuracy of screening for amblyopia

AimTo present and evaluate a new screening protocol for amblyopia in preschool children.MethodsZagreb Amblyopia Preschool Screening (ZAPS) study protocol performed screening for amblyopia by near and distance visual acuity (VA) testing of 15 648 children aged 48-54 months attending kindergartens in the City of Zagreb County between September 2011 and June 2014 using Lea Symbols in lines test. If VA in either eye was >0.1 logMAR, the child was re-tested, if failed at re-test, the child was referred to comprehensive eye examination at the Eye Clinic.Results78.04% of children passed the screening test. Estimated prevalence of amblyopia was 8.08%. Testability, sensitivity, and specificity of the ZAPS study protocol were 99.19%, 100.00%, and 96.68% respectively.ConclusionThe ZAPS study used the most discriminative VA test with optotypes in lines as they do not underestimate amblyopia. The estimated prevalence of amblyopia was considerably higher than reported elsewhere. To the best of our knowledge, the ZAPS study protocol reached the highest sensitivity and specificity when evaluating diagnostic accuracy of VA tests for screening. The pass level defined at ≤0.1 logMAR for 4-year-old children, using Lea Symbols in lines missed no amblyopia cases, advocating that both near and distance VA testing should be performed when screening for amblyopia.Vision disorders in children represent important public health concern as they are acknowledged to be the leading cause of handicapping conditions in childhood (1). Amblyopia, a loss of visual acuity (VA) in one or both eyes (2) not immediately restored by refractive correction (3), is the most prevalent vision disorder in preschool population (4). The estimated prevalence of amblyopia among preschool children varies from 0.3% (4) to 5% (5). In addition, consequences of amblyopia include reduced contrast sensitivity and/or positional disorder (6). It develops due to abnormal binocular interaction and foveal pattern vision deprivation or a combination of both factors during a sensitive period of visual cortex development (7). Traversing through adulthood, it stands for the leading cause of monocular blindness in the 20-70 year age group (8). The main characteristic of amblyopia is crowding or spatial interference, referring to better VA when single optotypes are used compared to a line of optotypes, where objects surrounding the target object deliver a jumbled percept (9-12). Acuity is limited by letter size, crowding is limited by spacing, not size (12).Since amblyopia is predominantly defined as subnormal VA, a reliable instrument for detecting amblyopia is VA testing (13-15). Moreover, VA testing detects 97% of all ocular anomalies (13). The gold standard for diagnosing amblyopia is complete ophthalmological examination (4). There is a large body of evidence supporting the rationale for screening, as early treatment of amblyopia during the child’s first 5-7 years of life (8) is highly effective in habilitation of VA, while the treatment itself is among the most cost-effective interventions in ophthalmology (16). Preschool vision screening meets all the World Health Organization’s criteria for evaluation of screening programs (17). Literature search identified no studies reporting unhealthy and damaging effects of screening. The gold standard for screening for amblyopia has not been established (4). There is a large variety of screening methodologies and inconsistent protocols for referral of positives to complete ophthalmological examination. Lack of information on the validity (18,19) and accuracy (4) of such protocols probably intensifies the debate on determining the most effective method of vision screening (8,20-29). The unique definition of amblyopia accepted for research has not reached a consensus (4,5,30,31), further challenging the standardization of the screening protocols.Overall, two groups of screening methods exist: the traditional approach determines VA using VA tests, while the alternative approach identifies amblyogenic factors (27) based on photoscreening or automated refraction. The major difference between the two is that VA-based testing detects amblyopia directly, providing an explicit measure of visual function, while the latter, seeking for and determining only the level of refractive status does not evaluate visual function. In addition, the diagnosis and treatment of amblyopia is governed by the level of VA. On the other hand, amblyogenic factors represent risk factors for amblyopia to evolve. There are two major pitfalls in screening for amblyogenic factors. First, there is a lack of uniform cut-off values for referral and second, not all amblyogenic factors progress to amblyopia (19).Besides the issue of what should be detected, amblyopia or amblyogenic factors, a question is raised about who should be screened. Among literate children, both 3- and 4- year-old children can be reliably examined. However, 3-year-old children achieved testability rate of about 80% and positive predictive rate of 58% compared to >90% and 75%, respectively in the 4-year-old group (32). In addition, over-referrals are more common among 3-year-old children (32). These data determine the age of 4 years as the optimum age to screen for amblyopia. Hence, testability is a relevant contributor in designating the optimal screening test.If VA is to be tested in children, accepted standard tests should be used, with well-defined age-specific VA threshold determining normal monocular VA. For VA testing of preschool children Lea Symbols (33) and HOTV charts (22,32) are acknowledged as the best practice (34), while tumbling E (28,35,36) and Landolt C (28,37-39) are not appropriate as discernment of right-left laterality is still not a fully established skill (34,40). The Allen picture test is not standardized (34,41). Both Lea Symbols and HOTV optotypes can be presented as single optotypes, single optotypes surrounded with four flanking bars, single line of optotypes surrounded with rectangular crowding bars, or in lines of optotypes (22,33,34,41-53). The more the noise, the bigger the “crowding” effect. Isolated single optotypes without crowding overestimate VA (24), hence they are not used in clinical practice in Sweden (32). If presented in lines, which is recognized as the best composition to detect crowding, test charts can be assembled on Snellen or gold standard logMAR principle (34,42,51,54). Age-specific thresholds defining abnormal VA in preschool screening for amblyopia changed over time from <0.8 to <0.65 for four-year-old children due to overload of false positives (20).The outline of an effective screening test is conclusively demonstrated by both high sensitivity and high specificity. Vision screening tests predominately demonstrated higher specificity (4). Moreover, sensitivity evidently increased with age, whereas specificity remained evenly high (4). The criteria where to set the cut-off point if the confirmatory, diagnostic test is expensive or invasive, advocate to minimize false positives or use a cut-off point with high specificity.On the contrary, if the penalty for missing a case is high and treatment exists, the test should maximize true positives and use a cut-off point with high sensitivity (55). A screening test for amblyopia should target high sensitivity to identify children with visual impairment, while the specificity should be high enough not to put immense load on pediatric ophthalmologists (14). Complete ophthalmological examination as the diagnostic confirmatory gold standard test for amblyopia is neither invasive nor elaborate technology is needed, while the penalty for missing a case is a lifetime disability.In devising the Zagreb Amblyopia Preschool Screening (ZAPS) study protocol, we decided to use Lea Symbols in lines test and to screen preschool children aged 48-54 months to address the problems declared. Near VA testing was introduced in addition to commonly accepted distance VA testing (14,22,24,32,45,56-69) due to several reasons: first, hypermetropia is the most common refractive error in preschool children (70), hence near VA should more reliably detect the presence of hypermetropia; second, the larger the distance, the shorter the attention span is; and third, to increase the accuracy of the test.The pass cut-off level of ≤0.1 logMAR was defined because of particular arguments. Prior to 1992 Sweden used the pass cut-off level for screening of 0.8 (20). A change in the referral criteria to <0.65 for four-year-old children ensued, as many children referred did not require treatment (20). In addition, amblyopia treatment outcome of achieved VA>0.7 is considered as habilitation of normal vision (3,14). At last, the pass cut-off value ≤0.1 logMAR at four years can hardly mask serious visual problems, and even if they are present, we presume they are mild and can be successfully treated at six years when school-entry vision screening is performed. The aim of the ZAPS study is to present and evaluate new screening protocol for preschool children aged 48-54 months, established for testing near and distance VA using Lea Symbols in lines test. Furthermore, we aimed to determine the threshold of age-specific and chart-specific VA normative, testability of the ZAPS study protocol, and the prevalence of amblyopia in the City of Zagreb County. By delivering new evidence on amblyopia screening, guideline criteria defining optimal screening test for amblyopia in preschool children can be revised in favor of better visual impairment clarification.