Showing papers in "Croatian Medical Journal in 2002"

Encouraging the use of generic medicines: implications for transition economies.

Abstract: Generic drugs have a key role to play in the efficient allocation of financial resources for pharmaceutical medicines. Policies implemented in the countries with a high rate of generic drug use, such as Canada, Denmark, Germany, the Netherlands, the United Kingdom, and the United States, are reviewed, with consideration of the market structures that facilitate strong competition. Savings in these countries are realized through increases in the volume of generic drugs used and the frequently significant differences in the price between generic medicines and branded originator medicines. Their policy tools include the mix of supply-side measures and demand-side measures that are relevant for generic promotion and higher generic use. On the supply-side, key policy measures include generic drug marketing regulation that facilitates market entry soon after patent expiration, reference pricing, the pricing of branded originator products, and the degree of price competition in pharmaceutical markets. On the demand-side, measures typically encompass influencing prescribing and dispensing patterns as well as introducing a co-payment structure for consumers/patients that takes into consideration the difference in cost between branded and generic medicines. Quality of generic medicines is a pre-condition for all other measures discussed to take effect. The paper concludes by offering a list of policy options for decision-makers in Central and Eastern European economies in transition.

Malondialdehyde, superoxide dismutase, melatonin, iron, copper, and zinc blood concentrations in patients with Alzheimer disease: cross-sectional study.

Abstract: Aim. To investigate the oxidative stress hypothesis in patients with Alzheimer type dementia. Method. Serum melatonin, Zn, Cu, Fe, and malondialdehyde (MDA) concentrations and erythrocyte superoxide dismutase (SOD) activity were measured in patients with Alzheimer disease. Mini-Mental State Examination (MMSE) scores were obtained for the patients and their age- and sex-matched healthy controls. Results. MMSE score was 16.8±1.3 in patients with Alzheimer disease, and 28.2±2.4 in control group. Melatonin levels were lower in the Alzheimer disease group (170.5±5.2 pg/mL) than in the control group (205.2±5.8 pg/mL) (p<0.001). Fe, SOD, and MDA levels were higher in Alzheimer disease group (131.7±4.8 µg/dL, 1,510±90 U/g Hb, and 38.1±4.7 nmol/mL; respectively) than in the control group (97.1±4.1 µg/dL, 1,120±50 U/g Hb, and 17.2±1.6 nmol/mL; respectively) (p<0.001 for all comparisons). A statistically significant negative correlation between melatonin and SOD (r=-0.421, p=0.014) and a positive correlation between age and Fe (r=0.325, p=0.049) were found only in the Alzheimer disease group. Correlation between age and melatonin was positive (r=0.481, p=0.006) in Alzheimer disease group and negative (r=-0.472, p=0.009) in the control group. Conclusion. Melatonin blood concentration was significantly decreased, and Fe and MDA levels were increased in the patients with Alzheimer disease. We believe that low level of melatonin, especially if there is a simultaneous increase in Fe level, is associated with the development of Alzheimer disease.

Superoxide dismutase and glutathione peroxidase in erythrocytes of patients with iron deficiency anemia: effects of different treatment modalities.

Abstract: Aim To test whether the activities of erythrocyte superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) can be affected by oral iron (OI) treatment, parenteral iron (PI) treatment, and parenteral iron treatment with vitamin E supplementation (PIE) in iron deficiency anemia. Methods Twenty-eight patients with iron deficiency anemia and 18 healthy controls were included in the study. Anemic patients were systematically allocated into 3 treatment groups. The first group (n=8) received OI, the second group (n=10) PI, and the third group (n=10) PIE. SOD and GSH-Px activities were determined using commercial kits. Results Before the treatment, SOD activity was significantly lower in anemic patients than in the control group (Kruskal-Wallis test, p 0.05). Although there was no significant decrease in GSH-Px activity after OI treatment, both PI and PIE treatments significantly decreased GSH-Px activity (Wilcoxon signed-ranks test, p=0.007 for PI and p=0.005 for PIE). PIE was more effective than PI treatment in maintaining GSH-PX activity. Conclusion Oral iron treatment improved the iron deficiency anemia and recovered antioxidant defense system by increasing SOD activity and maintaining GSH-Px activity at normal level. When parenteral iron treatment is inevitable, vitamin E supplementation together with PI treatment may be effective in partially restoring the antioxidant status in this type of anemia.

Elevated serum lipids in veterans with combat-related chronic posttraumatic stress disorder.

Abstract: Aim. To assess possible differences in serum cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides, arteriosclerosis index, established risk factor (ERF) of arteriosclerosis, and 10-year risk for coronary disease according to the Adult Treatment Panel III (ATP-III) between veterans with combat-related posttraumatic stress disorder (PTSD) and a control group consisting of patients with major depressive disorder. Method. We determined serum cholesterol, LDL-C, HDL-C, and triglycerides in the patients with PTSD (n=103) and patients with major depressive disorder (n=92), using the enzyme-assay method. AI, ERF, and ATP-III were calculated from cholesterol, LDL-C, and HDL-C levels. The groups were matched in age and body mass index (BMI). Patients with major depressive disorder were chosen as a control group because they do not have changes in serum lipids. Results. Patients with combat-related PTSD had higher cholesterol (6.21.1 mmol/L vs 5.30.9 mmol/L; p0.001), LDL-C (3.90.7 mmol/L vs 3.51.0 mmol/L; p=0.005), and triglycerides (2.92.3 mmol/L vs 1.50.5 mmol/L; p0.001), and lower HDL-C (1.00.3 mmol/L vs 1.30.2 mmol/L; p0.001) than the control group. Arteriosclerosis index (4.21.2 vs 3.71.7; p =0.050), ERF (6.41.9 vs 5.52.4; p=0.010), and ATP-III (12.13.3 vs 10.23.8; p0.001) were higher in PTSD than in the control group.

Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis

Abstract: AIM To assess the survival of the primary arteriovenous fistula created for dialysis in 463 chronic hemodialysis patients, because the main causes of morbidity among such patients are associated with vascular access-related complications. METHOD We analyzed 269 (58%) men and 194 (42%) women with median age of 58 years (range 12-83), who underwent 0-14,784 (median 1,584) hours of hemodialysis. Data analyzed were age, gender, body weight loss during hemodialysis session, smoking habits, cause of renal failure, diabetes, myocardial infarction, stroke, malignant neoplasm, arterial hypertension or hypotension, drugs (salicylates, dipyridamole, coumarin anticoagulants, heparin, oral antidiabetics, insulin), number of hemodialysis sessions and hours of hemodialysis per week, fistula location, platelet count, hematocrit, institution in which the fistula had been created, and dialysis center where the fistula had been used. Kaplan-Meier and univariate analysis (Mantel-Cox and generalized Wilcoxon test) with 0.05 statistical significance were used for data analysis, and the outcome of the fistula survival was determined with logistic regression. RESULTS Out of 597 patients with primary arteriovenous fistula, 134 patients were lost to follow-up. In the remaining 463 patients the fistula survival was 73%, 63%, 52%, 44%, 36%, 10%, 3%, and <1% after 1, 2, 3, 4, 5, 10, 15, and 20 years, respectively. Factors affecting the survival of arteriovenous fistula were administration of heparin (p=0.004) and dipyridamole (p=0.012), hemodialysis-dependent hypotension (p=0.045), diabetes (p=0.009), presence of malignant neoplasm (p=0.003), institution in which the fistula had been created (p<0.001) or used (p=0.037), hours of hemodialysis per week (p=0.023), and number of hemodialysis sessions per week (p=0.007). CONCLUSION Primary arteriovenous fistula survival was shorter in end-stage renal disease patients with diabetes, hypotension, who underwent less than 3 hemodialysis sessions (<12 h) per week without heparin administration. Insufficient surgical experience, dipyridamole administration, and concomitant neoplasm contributed to arteriovenous fistula failure.

Carpal tunnel release by limited palmar incision vs traditional open technique: randomized controlled trial.

Abstract: Aim. To compare a limited palmar incision for carpal tunnel release (CTR) with a traditional open technique, which is still considered the gold standard. Methods. Seventy-two patients with a carpal tunnel syndrome were individually randomized into the trial (limited incision CTR) (n=36) and control group (traditional technique CTR) (n=36). In the trial group, skin incision parallel to the thenar crease was made up to 2.5 cm in length, under an operating microscope and endoscopic transillumination. Skin incision in the control group began at the distal border of the carpal ligament, followed the longitudinal crease of the palm, and crossed the base of the palm in a zigzag fashion. Three months after surgery, the patients were asked about symptomatic relief and intervals between the operation and return to their daily activities and work, and examined for scar tenderness and esthetic outcome. Distal motor latency, conduction velocity, scar length, scar width, and operation time were measured. Results. There were no differences between the two groups in symptomatic relief and electrophysiological parameters. Intervals between the operation and return to daily activities (median 5 days, range 2-15) were shorter in the trial group than in the control group (median 10 days, range 2-21 ; p<0.001), as well as the intervals between the operation and return to work (median 15 days, range 5-45 vs median 30 days, range 10-60 ; p<0.001). Scar/pillar tenderness, scar length and width, esthetic outcome, and operation time were significantly better in the trial group. Conclusion. Limited palmar incision CTR is as effective and safe as traditional CTR technique, but with better postoperative recovery and cosmetic results.

Comparative approaches to pharmaceutical price regulation in the European Union.

Abstract: Aim To review pharmaceutical price regulation methods in countries of the European Union (EU), in terms of the anticipated impact of regulation on pharmaceutical expenditures and evidence of actual outcomes. Method An extensive search was performed of medical and economic studies on regulatory interventions specifically targeting pharmaceutical prices in EU countries, published between January 1990 and April 2002. Both peer-reviewed and "gray" literature were systematically reviewed. Results Four principle approaches to pharmaceutical price regulation with some methodological differences were identified in EU countries, as follows: fixed pricing, cost-effectiveness pricing, profit controls, and reference pricing. Actual evidence of the impact of price regulation was limited in many of these countries. Cross-country comparisons suggested that limiting the rise of pharmaceutical prices did not equate to controlling the rise of pharmaceutical expenditures because of the volume effect of utilization. Conclusions Supply-side regulation without the simultaneous use of demand-side incentives and volume controls does little to control the rise in pharmaceutical expenditures. The types of needed demand-side controls depend on the context of the individual country, on political priorities, and on the type of supply-side regulation in place.

Knowledge about and attitude towards science of first year medical students.

Abstract: Atotalof193(82%)studentswhoenrolledattheZagrebUniversitySchoolofMedicinein2001filledoutananonymousquestionnaireattheirfirstlecture.Thequestionnaireconsistedofdemographicdata,20statementsonsci -ence adapted to a 1-5 Likert scale, and 8 multiple-choice test questions on knowledge of scientific research.

Mechanisms of action and potential therapeutic uses of thalidomide.

Abstract: Thalidomide was first introduced to the market in Germany under the brand name of Contergan in 1956, as a non-barbiturate hypnotic, advocated to ensure a good nights sleep and to prevent morning sickness in pregnancy. It was advertised for its prompt action, lack of hangover, and apparent safety. It has been banned from the market since 1963 after it caused the worldwide teratogenic disaster: babies exposed to thalidomide in utero during the first 34-50 days of pregnancy were born with severe life-threatening birth defects. Despite its unfortunate history, thalidomide has attracted scientific interest again because of its recently discovered action against inflammatory diseases and cancer. Its broad range of biological activities stems from its ability to moderate cytokine action in cancer and inflammatory diseases. Early studies examined its anxiolytic, mild hypnotic, antiemetic, and adjuvant analgesic properties. Subsequently, thalidomide was found to be highly effective in managing the cutaneous manifestations of leprosy, being superior to Aspirin in controlling leprosy-associated fever. Recent research has shown promising results with thalidomide in patients with myeloma, myelodysplastic syndrome, a variety of infectious diseases, autoimmune diseases, cancer, and progressive body weight loss related to advanced cancer and AIDS. Here we review the history of its development, pharmacokinetics, metabolism, biologic effects, and the results of clinical trials conducted thus far. Further research in this field should be directed towards better understanding of thalidomide metabolism, its mechanism of action, and the development of less toxic and more active analogs.

Reforms of health care system in Romania.

Abstract: Aim. To describe health care reforms and analyze the transition of the health care system in Romania in the 1989-2001 period. Method. We analyzed policy documents, political intentions and objectives of health care reform, described new legislation, and presented changes in financial resources of the health care system. Results. The reforms of the health care system in Romania have been realized in a rather difficult context of scarcity of financial and human resources. The Gross Domestic Product spent on health care in 2000 was 4% and the number of physicians in 1999 was 42,975. The main changes due to the legislative reforms have been the introduction of a new social health insurance and strengthening of the position of family physicians. Negative effects of the reforms have been the decrease in health care accessibility and growing inequity in utilization of health care services. Health care users still pay physicians under-the-table, and have more out-of-pocket health care expenses. Conclusion. Future reforms in Romania should encourage the positive effects of current reforms: free choice of physician, autonomy of the primary health care system, and increasing financial resources for the health care system.

Kipling's guide to writing a scientific paper.

Abstract: The generally accepted structure of a scientific paper is four sections, an introduction, a methods section, the results, and a discussion. This so-called IMRaD format is, with a few small variations, found in most research articles in biomedical journals. However, as a guide for someone writing up research data for the first time, it is far from complete – for example, there is no T for title or even S for summary. Nor does IMRaD explain what belongs in which section and how much should be included in or excluded from any section. As a supplement to, but not a replacement for, IMRaD research-workers could bear in mind the “six honest serving-men” of the poet Rudyard Kipling. These writer’s servants are called What, Why, When, How, Where, and Who, and they can be applied to all parts of the paper from its title down to the tables.

Temporal trends in demographic profiles and stress levels in medieval (6th-13th century) population samples from continental Croatia

Abstract: Aim. To analyze and compare the demographic profiles and disease frequencies of early (6th-9th century) and late (10th-13th century) medieval skeletal series from continental Croatia. Methods. Age and sex distributions in three early (n=277) and six late (n=175) medieval skeletal series were compared. All skeletons were analyzed for the presence of dental enamel hypoplasia, periostitis, trauma, and presence of Schmorl’s depressions in vertebral bodies. Results. Data collected from the skeletal series suggested significantly higher stress in the late medieval period. This stress may have affected mortality, as evidenced by significantly higher subadult mortality and shorter adult average life span. Men in the late medieval series, in particular, seem to have been under greater stress. They exhibited significantly higher mortality in the 21-25 years age category, and significantly higher frequencies of periosteal lesions, cranial and postcranial trauma, and Schmorl’s depressions. Conclusion. The frequencies of all skeletal indicators of stress increased significantly during the late medieval period. This was accompanied by a significant increase in subadult mortality and shortening of the average life span of adult men and women.

Impact of war on health related quality of life in Croatia: population study.

Abstract: The aim was to present health-related quality of life in post-war Croatia focusing on the population as a whole rather than on the specific group of people. The study was conducted in six Croatian counties in the 1997-1999 period. Three of those counties had been directly affected by the 1991-1995 war. The sample consisted of 1297 randomly selected respondents aged 18 years and older. The questionnaire was anonymous consisting of questions on sociodemographic characteristics of respondents and Medical Outcome Study 36-item short-form health survey (SF-36). SF-36 comprised the following nine subscales: physical functioning (PF) role-physical (RP) bodily pain (BP) general health (GH) vitality (VT) social functioning (SF) role-emotional (RE) mental health (MH) and health transition (HT). Mean subscale scores for the areas directly affected by war were PF 64.21; RP 52.70; BP 59.35;GH 49.02; VT 49.52; SF 68.29; RE 63.02; MH 57.95; HT 41.28; and for the areas not affected by war were PF 65.35; RP 62.01; BP 61.79; GH 50.45; VT 49.40; SF 71.41; RE 74.11; MH 60.33; HT 45.14. The two areas differed significantly in RP (p < 0.001) SF (p = 0.035) RE (p < 0.001)MH(p = 0.038) and HT (p = 0.003). Respondents living in the areas directly affected by war achieved lower total health-related quality of life scores. Younger respondents respondents with secondary education and those with lower income were the groups mostly affected by war. War affects self-perceived health physical ability and emotional and mental health of the entire population affected by war especially younger age groups those with lower education and lower income. (authors)

Educatione ad excelentiam--ten years of the Croatian medical journal.

Abstract: Although the earliest memories fade first, those of the CMJ remain vivid, perhaps because they coincided with the tragic aggression against Croatia in 1991. Actually, the life of the Journal began before it was officially born. Preparation of the first issue, planned for March 1992 (Fig. 1), was well under way when the first attacks on Croatian cities began in the early autumn of 1991 (1). We witnessed enormous suffering of the civilian population: refuge, killings and wounding, and siege and destruction of many Croatian towns. Health care professionals, although without formal training in war medicine, managed to adapt to the war situation and provide adequate care for the war casualties (2). We wanted to document the experience and knowledge Croatian physicians had gained in war medicine and decided to produce a special supplement to the first journal issue (Fig. 2). It required a huge amount of work and efforts, especially in the circumstances when it was too complicated to get even the simplest task done, such as prepare the cover page. We worked on the supplement’s covers at a printing house in Zagreb during a blackout. Under the dim light, the printers could not see well which colors they mixed and the red cross on the front page picture came out green. Nevertheless, we could still laugh and make jokes, despite all the problems.

Are medical savings accounts a viable option for funding health care

Abstract: Aim To summarize the international experience of medical savings accounts (MSAs), make a preliminary evaluation of the impact of MSAs, and assess their feasibility in other countries, particularly Central and Eastern Europe. Method A review of published literature in academic journals, books, Internet sources, and other "gray" literature. Results Most published studies were theoretical. Advocates argued that MSAs improved the efficiency of insurance, increased consumer choice, and reduced health care expenditures. Critics argued that MSAs led to adverse selection, reduced equity, resulted in cost inflation, and deterred necessary utilization. MSAs have been implemented in China, Singapore, the United States of America, and South Africa. The organization of MSAs varied between countries. MSAs were combined with either a public or private insurance element to cover catastrophic expenses. Few empirical studies of MSAs have been conducted and, therefore, the evidence on their impact is limited. Conclusion More empirical evaluations are needed on the impact of MSAs. Results of empirical evaluations cannot be easily generalized but depend on the complementary systems of financing and the extent of state regulation. MSAs are not likely to be feasible in countries where the unemployment rate is high, savings rates and average earnings low, and the state weak.

Psychiatric help to psychotraumatized persons during and after war in Croatia.

Abstract: Aim. To present organization of psychosocial support and treatment of traumatized persons during and after the 1991-1995 war in Croatia. Method. Description of application and results of community-based National Program of Psychosocial Help to War Victims, and retrospective analysis of hospitalizations for psychotrauma at the National Center for Psychotrauma, Dubrava University Hospital. Results. During the 1991-1995 war in Croatia, the population faced severe traumatic events, and the need for organized psychosocial help to traumatized persons was great. Government has established the network of psychosocial help in 1994. This was the beginning of the National Program of Psychosocial Help to War Victims. As a strategy in building a social support, the pyramidal model consisting of five levels of psychosocial help was used. The levels were the following: 1) preventive programs in mental health, 2) nonspecific psychological help in community, 3) basic psychological help, 4) psychiatric institutionalized help and specific psychological help, and 5) national coordination and operative planning. During the war, the work primarily centered around community-based approach, satisfying the current needs of the traumatized people, such as food, medication, and clothes, and providing crisis psychological interventions and urgent psychiatric help. In 1999, this organizational scheme was replaced by the establishment of the National Center for Psychotrauma and four Regional Centers for Psychotrauma in Zagreb, Rijeka, Osijek, and Split. In the post-war period, the emphasis was on psychological and social help in the community and on institutionalized approach to treatment of psychotrauma. According to the data of the Croatian Institute of Public Health, in the 1998 and 1999 there were 1, 744 and 2, 415 hospitalizations due to PTSD and related disorders, respectively. Conclusion. The community-based approach remained central in dealing with psychotraumatized persons during and after the war. In the post-war period, the emphasis was put on non-specific and specific psychological and social help in the community, with institutionalized approach to the treatment of PTSD and related disorders, whereas satisfying the current needs (food, medication, clothing), intervention in the crisis situations and urgent psychiatric interventions were of prime importance during the war.

Years of potential life lost and valued years of potential life lost in assessing premature mortality in Slovenia.

Abstract: Aim To determine the leading causes of death that contribute most to premature mortality in Slovenia; to classify premature mortality according to the cause of death, age, and sex; and to determine the age point before which premature mortality becomes a potential loss to the society. Method Potential economic losses to society were estimated by use of years of potential life lost (YPLL), with a cut-off point at 65 years, and valued years of potential life lost (VYPLL) methods. We calculated the sex-, age-, and underlying causes of death-specific YPLL and VYPLL for residents of Slovenia who died at age younger than 65 years, using Slovene sex-specific life expectancy for 1998/1999 and age-specific weights of investment-producer-consumer model. Results In 1998, 4,558 YPLL per 100,000 population were lost to Slovenia. We found bimodal age distribution of YPLL, with the first peak in the 20-24 year age group and the second in the 45-49 year age group. Men to women rate ratio was 2.5. The leading causes of YPLL were external causes of death, followed by malignant neoplasms, and cardiovascular diseases. External causes, including suicides and traffic accidents, were the leading causes of death in men, whereas malignant neoplasms, including breast cancer and digestive cancer, were top-ranking causes in women. Among those, only external causes of death produced positive VYPLL, indicating a net loss to the society. Conclusion In Slovenia, YPLL peaked in the 20-24 and 45-49 year age groups. Only external causes of death, most of which were preventable, accounted for the net economic loss to Slovenian society. We believe that YPLL and VYPLL, as specific mortality measures, can be reliably used in the evaluation of leading causes of death before age 65 and potential economic loss to the society caused by those deaths, and that they should be taken into account when setting public health priorities.

Surgical resection in the treatment of primary gastrointestinal non-Hodgkin's lymphoma: retrospective study.

Abstract: Aim. To evaluate the role of surgical resection in the treatment of patients with primary gastrointestinal non-Hodgkin’s lymphoma in our institution. Method. The retrospective study included 79 patients with a histologically confirmed primary gastrointestinal lymphoma, who were diagnosed and treated for the disease in the 1978-1997 period. According to the treatment modality, the patients were divided into surgically treated and surgically non-treated group. Data were analyzed with Fisher’s exact test, long-rank test, and Kaplan-Meier method. Results. The stomach was the primary site of non-Hodgkin’s lymphoma in 45 (57%) patients, small intestine in 19 (24%), and colon in 9 (11%) patients. Six patients (8%) had multifocal disease. There were 56 (71%) patients with stages IE and IIE, and 23 (29%) with stages III and IV. Aggressive histology was found in 51 cases (65%), and low grade mucosa-associated lymphoid tissue (MALT) lymphoma in 28 (35%). Helicobacter pylori infection was registered in 20 out of 45 patients with gastric lymphoma. Twenty-six (33%) patients underwent surgical resection followed by chemotherapy, 47 (59%) were treated with chemotherapy alone, and 6 (8%) received antibiotics plus chemotherapy. Fifteen patients needed urgent surgical intervention. The overall response rate was 77%. Complete remission was achieved in 54 (68%) patients and partial remission in 7 (9%). Eighteen patients (23%) experienced progressive disease. A 10-year overall survival (OS) was 63% and event-free survival (EFS) was 52% for all patients. Patients with gastric lymphoma had better OS and EFS than patients with primary lymphoma at other sites (65% vs 42%, and 62 vs 28%, respectively) (p=0.005). A 10-year EFS rates were 58% and 52% for surgically treated and non-treated group, respectively. There was no significant difference between patients with resected and non-resected tumors (p=0.855). Patients with early-stage disease had significantly better OS and PFS than patients with advanced-stage disease (p=0.048). Conclusion. Primary gastrointestinal lymphoma can be successfully treated with chemotherapy alone but surgery remains an important therapeutic option for emergency problems. The main prognostic factors were primary tumor site and extent of the disease.

Assessment of ecologic and biologic factors leading to hantavirus pulmonary syndrome, Colorado, U.S.A.

Abstract: Aim. To understand the ecologic parameters of Sin Nombre virus (SNV; family Bunyaviridae, genus Hantavirus) infections in the deer mouse (Peromyscus maniculatus), environmental variables impacting the rodent populations, and the conditions under which SNV is amplified. This may help us understand the antecedents of human risk for developing hantavirus pulmonary syndrome (HPS) as a consequence of SNV infection. Method. Each 6 weeks, we trapped, measured, tagged, bled, and released rodents at three widely spaced sites in Colorado, USA: Fort Lewis (1994-2001), Molina (1994-2001), and Pinyon Canyon Maneuver Site (1995-2001). The ELISA method was used to test rodent blood samples for IgG antibody to SNV antigen. Results. Where rodent species richness was high, the prevalence of infection of deer mice (as determined by the presence of antibody) with SNV was low, and vice versa. There was a higher prevalence of antibody to SNV in male than in female rodents, and seasonal differences were observed in acquisition of SNV between male and female deer mice. Long-lived infected deer mice served as transseasonal, over-winter reservoirs for the virus, providing the mechanism for its survival. Conclusion. Prevalence of rodent infection appears to be associated with fluctuations in deer mouse populations and, indirectly, with timing and amount of precipitation and the resulting biologic events (a “trophic cascade”). Together with information regarding transseasonal maintenance of SNV, seasonal differences in acquisition of SNV between sexes, group foraging, and various other factors may expand our understanding of the risk factors for acquiring HPS. Taken together and applied, we anticipate developing methods for preventing this disease as well as diseases caused by other rodent-borne viruses.

Satisfaction with family medicine training in Turkey: survey of residents.

Abstract: Aim To explore how satisfied family medicine residents are with their training in teaching hospitals and current postgraduate training program. Methods We surveyed 135 family medicine residents in 5 teaching hospitals in Ankara region. The residents were asked to fill out the questionnaire at their work place. The questionnaire consisted of 23 open- and closed-ended questions about general demographic data, training conditions, appropriateness of training, and quality of training delivered by clinical teachers in family medicine. The response rate was 75%. Results Seventy percent of respondents found the order of rotation important. Most residents were satisfied with the duration of rotation. Eighty two percent of residents found basic skills taught during the course of the training to be insufficient. Fifty five percent of the participants felt that training in teaching hospitals was not sufficient, and majority desired training in family practice settings. Ninety-nine respondents suggested establishing a coordinating center for family medicine training and training of clinical teachers in topics relevant to family practice. Conclusion Family medicine residents were generally dissatisfied with their training in major teaching hospitals in Turkey. Postgraduate family medicine curriculum needs to be changed and opinions of residents regarding their training should be taken into consideration.

Wasp venom is appropriate for immunotherapy of patients with allergic reaction to the European hornet sting.

Abstract: Aim To identify whether it is the yellow jacket (Vespula germanica) or European hornet (Vespa crabro) venom that induces sensitization in patients with IgE-mediated allergic reaction to the venom from the sting of a European hornet. Since these patients usually have positive skin tests and specific IgE to all vespid venoms, it would be useful to distinguish cross-reactors from non-cross-reactors to perform immunotherapy with the venom that induced the sensitization. Methods We performed inhibition tests in 24 patients who had experienced anaphylactic reaction after being stung by a European hornet. Results Of 24 patients with allergic reaction after Vespa crabro sting, 17 were sensitized only to epitopes of Vespula germanica venom. Only 4 out of 24 patients were sensitized to epitopes completely cross-reactive with Dolichovespula arenaria venom. Conclusion In Slovenia, the vast majority of patients with anaphylactic reaction to Vespa crabro sting seem to be sensitized to Vespula germanica venom. We consider wasp venom an appropriate immunotherapeutic agent for such patients, except for those with proven primary sensitization to specific epitopes of Vespa crabro venom. Fluorescence enzyme immunoassay inhibition should be considered a convenient tool for the identification of primary sensitization in patients allergic to vespid venoms.

The World Health Organization classification of lymphomas.

Abstract: The Revised European-American Classification of Lymphoid Neoplasms (REAL) classification has been validated by a multi-institutional study, and project data showed that it is both reproducible and clinically relevant. The new World Health Organization (WHO) Classification of Neoplastic Diseases of Hematopoietic and Lymphoid Tissues, as a joint project of the Society of Hematopathology and European Association of Hematopathologists, is an update of the REAL classification, with minor changes based on newly available information. We analyzed the incidence of different histological types of non-Hodgkin s lymphomas diagnosed in Zagreb University Hospital Center, which were reclassified according to the WHO classification. Furthermore, we present a conceptual grouping of lymphomas into four categories (indolent, aggressive, highly aggressive, and localized indolent).

Psychological status of Sarajevo children after war: 1999-2000 survey.

Abstract: Aim. To make a survey of children’s health and psychosocial needs after the 1992-1995 war in Sarajevo, Bosnia and Herzegovina. Methods. Representative samples of school-age children (n=310) from 6 public schools in the Sarajevo Canton, their parents (n=280), and teachers (n=156) were surveyed by means of self-administered questionnaires and standardized psychometric scale (Ryan-Wenger’s Schoolagers Coping Strategies Inventory). The survey was conducted in October-November 1999, approximately four years after the war. Results. At the time of survey, well-being of children in Sarajevo was still heavily impacted by many various unhealthy life conditions and psychosocial stressors. Many school-age children lived in unhealthy and dangerous environment, including overcrowded living conditions (40%), unsafe playgrounds (68%), and no access to sports fields (52%). Most felt unsafe on streets (74%), many (73%) coped with one or more school problems, and even 84% were ill at least once during the past 12 months. General poverty was the prime stressor (common variance explained: 23.5%), followed by school- and health-related risks (common variance explained: 17.0%). At the third place were family-associated risk factors impacting children’s health and development, such as overcrowded living conditions and lack of social support within their own family (common variance explained: 10.5%). Parents and teachers also lived and worked in stressful life conditions and were concerned for both their children’s and their own well-being. Despite all that, most children tended to use healthy strategies in coping with stressful events in their everyday lives. Conclusion. The reinforcement of children with positive (healthy) coping skills and strengthening of their social support networks seems to be the most important intervention strategy to help the war-traumatized children in Bosnia and Herzegovina.

Knowledge and attitude regarding sleep medicine of medical students and physicians in Split, Croatia.

Abstract: AIM To assess the knowledge and attitudes regarding sleep medicine among second-year medical students and physicians. METHODS A total of 112 respondents were surveyed for their attitude and knowledge regarding sleep medicine and hypertension. The respondents were divided into three groups: 1) second-year medical students (46 or 41%); 2) physicians at postgraduate study program (26 or 23%); and 3) specialists in different fields (40 or 36%). The questionnaire was composed of the sleep medicine attitude test, sleep medicine knowledge test, and hypertension knowledge test. Differences among the groups were statistically analyzed with ANOVA, and differences within each group were analyzed with Wilcoxon test. RESULTS Postgraduate students and specialists showed better knowledge in hypertension than in sleep medicine (p=0.001 and p<0.001, respectively). In the student group, no difference was found between the knowledge in hypertension and sleep medicine (p=0.192). Differences in sleep medicine knowledge were not found between medical students and specialists (p=0.228) or between postgraduates and specialists (p=0.647). Sleep medicine attitude score was similar in all groups (p=0.470). In general, there was a positive correlation between sleep medicine knowledge and attitude (p=0.002), and between hypertension knowledge and sleep medicine attitude (p=0.019). CONCLUSION Medical students, postgraduate physicians, and specialists showed poor knowledge but positive attitude toward sleep medicine. This finding points to the need for better education in the field of sleep medicine in medical schools.

Management of guttate and generalized psoriasis vulgaris: prospective randomized study.

Abstract: AIM To assess the efficacy of betamethasone dipropionate 0.05% cream plus ultraviolet B (UVB) radiation with and without additional penicillin therapy in the treatment of guttate psoriasis, and to compare the efficacies of oral psoralen plus ultraviolet A (PUVA) therapy and systemic retinoids therapy for treatment of generalized psoriasis. METHODS Sixty patients with guttate (n = 20) and generalized psoriasis vulgaris (n = 40) of various intensity and duration treated at the Department of Dermatology, Medical School in Skopje, from February 2000 to January 2002, were included in this prospective, open-label, randomized, parallel group study. The clinical features of the patients were quantified according to the mean psoriasis area and severity index (PASI) values. Student s t-test for paired samples and two independent samples were used in statistical analysis. RESULTS The final PASI values were not significantly different for the patients receiving different treatments of guttate psoriasis or generalized psoriasis. The initial PASI values for guttate psoriasis patients treated with betamethasone dipropionate plus UVB with and without penicillin treatment (5.7 +/- 2.1 and 5.9 +/- 2.5, respectively) declined to 0.5 +/- 0.8 and 1.0 +/- 0.9, respectively, after the therapy. The initial PASI values in generalized psoriasis patients receiving PUVA dropped from 24.1 +/- 3.6 to 1.7 +/- 1.5 by the end of the therapy. Finally, pre-treatment PASI values in patients with generalized psoriasis receiving retinoids decreased from 24.6 +/- 3.5 to 0.9 +/- 1.1 after treatment. However, patients receiving systemic retinoids for generalized psoriasis had statistically higher incidence of side effects than patients receiving PUVA therapy (t = 6.458, df = 38, p < 0.001). CONCLUSION Penicillin should be applied in addition to local corticosteroids with UVB in the treatment of guttate psoriasis, since the disease may be triggered by a streptococcal infection. In cases of generalized psoriasis vulgaris, PUVA therapy caused fewer side effects than did systemic retinoids.

Burden of tuberculosis in Afghanistan: update on a war-stricken country.

Abstract: The aim was to review Afghans Tuberculosis (TB) Control Program and assesses the impact of disruption induced by the war in Afghanistan. National TB control program of Afghanistan was reviewed in terms of its milestones achievement parameters and potential barriers. Information and data were collected by review visits to the Ministry of Health and health facility survey of nongovernmental organizations working for TB control in Afghanistan. Local and international literature was consulted. Mortality and morbidity figures due to tuberculosis remained alarmingly high in the last two decades especially among women. Current estimates show that the incidence of active TB cases is 278 per 100000 and mortality mounts to 15000 cases per year. The epidemiological profile reflecting the situation of Afghans inside and outside the country is extremely deplorable. The situation has worsened due to the cessation of TB control activities during the war. Compliance of patients and access to the treatment has become very difficult in an emergency situation. Similarly an increasing number of TB cases among Afghans refugees in Pakistan have also been observed. Overcrowded refugee camps and lack of treatment facilities increases many-fold the risk of further transmission. TB is a major public health threat inside and outside war-stricken Afghanistan. TB control activities need prompt attention of health authorities in reestablishing TB control network. World Health Organizations guidelines and nationwide Directly Observed Treatment Short Course strategy should be adopted and sufficient resources allocated. It is vital to build a peaceful environment with a viable and durable alliance of local and international donors in the fight against TB. (authors)

Primary health care in complex humanitarian emergencies: Rwanda and Kosovo experiences and their implications for public health training.

Abstract: In a complex humanitarian emergency, a catastrophic breakdown of political, economic, and social systems, often accompanied by violence, contributes to a long-lasting dependency of the affected communities on external service. Relief systems, such as the Emergency Response Units of the International Federation of Red Cross and Red Crescent Societies, have served as a sound foundation for fieldwork in humanitarian emergencies. The experience in emergencies gained in Rwanda in 1994 and Kosovo in 1999 clearly points to the need for individual adjustments of therapeutic standards to preexisting morbidity and health care levels within the affected population. In complex emergencies, public health activities have been shown to promote peace, prevent violence, and reconcile enemies. A truly democratic and multi-professional approach in all public health training for domestic or foreign service serves as good pattern for fieldwork. Beyond the technical and scientific skills required in the profession, political, ethical, and communicative competencies are critical in humanitarian assistance. Because of the manifold imperatives of further public health education for emergency assistance, a humanitarian assistance competence training center should be established. Competence training centers focus on the core competencies required to meet future needs, are client-oriented, connect regional and international networks, rely on their own system of quality control, and maintain a cooperative management of knowledge. Public health focusing on complex humanitarian emergencies will have to act in prevention not only of diseases and impairments but also of political tension and hatred.

Health and peace.

Abstract: Health and peace are closely linked. One cannot have one without the other. Although health and peace are desirable conditions, we human beings often thwart our best intentions to achieve and maintain them. War has profound impacts on human health. In addition to direct consequences, including the fact that 90% of all deaths related to recent wars were among civilians, war has several indirect consequences, including long-term physical and psychological adverse health effects, damage to the social fabric and infrastructure of society, displacement of people, damage to the environment, drainage of human, financial, and other resources away from public health and other socially productive activities, and fostering of a culture of violence. Many public health issues can be both a consequence and a cause of war, including infectious diseases, mental health disorders, vulnerability of population groups, disparities in health status within and among countries, and weakening of human rights. We, health professionals, can promote peace in many ways and facilitate this work by demonstrating our values, vision, and leadership.

Public health and peace.

Abstract: The modern concept of public health, the New Public Health, carries a great potential for healthy and therefore less aggressive societies. Its core disciplines are health promotion, environmental health, and health care management based on advanced epidemiological methodologies. The main principles of living together in healthy societies can be summarized as four ethical concepts of the New Public Health essential to violence reduction equity, participation, subsidiarity, and sustainability. The following issues are discussed as violence determinants: the process of urbanization; type of neighborhood and accommodation, and consequent stigmatization; level of education; employment status; socialization of the family; women's status; alcohol and drug consumption; availability of the firearms; religious, ethnic, and racial prejudices; and poverty. Development of the health systems has to contribute to peace, since aggression, violence, and warfare are among the greatest risks for health and the economic welfare. This contribution can be described as follows: 1) full and indiscriminate access to all necessary services, 2) monitoring of their quality, 3) providing special support to vulnerable groups, and 4) constant scientific and public accountability of the evaluation of the epidemiological outcome. Violence can also destroy solidarity and social cohesion of groups, such as family, team, neighborhood, or any other social organization. Durkheim coined the term anomie for a state in which social disruption of the community results in health risks for individuals. Health professionals can make a threefold contribution to peace by 1) analyzing the causal interrelationships of violence phenomena, 2) curbing the determinants of violence according to the professional standards, and 3) training professionals for this increasingly important task. Because tolerance is an essential part of an amended definition of health, monitoring of the early signs of public intolerance is important. The vital interplay between the informed public and efficient administration, however, can only exist in an open society. The link between democracy and health of the people, and between public health and economic welfare is real. The Public Health Collaboration in South Eastern Europe (PH-SEE) evolved just in time to reconnect and strengthen disrupted professional networks in the region as a prerequisite of effective public health action.