Application of a system dynamics model in forecasting the supply and age distribution of physicians.

AIM: To predict the future supply and age distribution of physicians with a simulation model, which can be used as an advising tool for policymakers who decide on enrollment and specialization training (ST) quotas at the national level. METHODS: A simulation model was created using the system dynamics (SD) method. Changes in the number of physicians and their age distribution were projected in the context of the expected future changes of the Croatian population under different scenarios covering the period from 2017 to 2041. RESULTS: The two scenarios showed that Croatia would not face physician shortage in the future. The scenario 1 projected that Croatia would certainly reach the current European Union (EU) average of 360 physicians per 100 000 inhabitants by 2021, and that this figure would increase to 430 per 100 000 inhabitants by 2041. The scenario 2 suggested a similar trend, with Croatia reaching the current EU average by 2021 and the number of physicians increasing to 451 per 100 000 inhabitants by 2041. Both scenarios indicated that the Croatian physicians' age distribution will recover in favor of younger age groups of specialists. CONCLUSION: There is no need to increase the enrollment into the medical schools to ensure sufficient number of physicians per capita in Croatia, but it is necessary to keep the recently reached level of 550 licenses for ST per year. The developed dynamic model is available online and can be adapted to the analysis of different scenarios in different health care systems.

[Anxiety and depression in elderly - prevalence and association with health care]. / Anksioznost i depresivnost u starijih osoba - pojavnost i povezanost s koristenjem zdravstvene zastite.

OBJECTIVE: To investigate the prevalence of anxiety and depression in the elderly inhabiting Koprivnica-Kri evci, Istria and Dubrovnik-Neretva Counties and their association with socio-demographic characteristics and healthcare utilisation. METHODS: A cross-sectional cluster survey carried out in 2006, encompassing a total of 1,469 examinees aged 70+. The Hospital Anxiety and Depression (HAD) Scale was used to screen for self-reported symptoms of anxiety and depression, which were further associated with socio-demographic characteristics and healthcare utilisation. RESULTS: The elderly have shown a high prevalence of borderline and probable anxiety (43%) and depression (53%), and regional differences (p<0.001). The level of anxiety was higher in women than men (p<0.001); as for depression, no statistically significant gender-based differences were found. The prevalence of probable depression increases (p=0.034) and that of probable anxiety decreases (p=0.028) with age. Anxiety and depression are associated with increased use of specialist health care and more frequent hospitalizations. CONCLUSION: High prevalence of anxiety and depression in elderly is associated with sociodemographic characteristics and frequent use of health care.

Objective identification of sexual risk behavior among blood donors in Croatia: is it reality?

BACKGROUND: The objective of this study is to determine the prevalence of blood donors positive for herpes simplex virus type 2 (HSV-2), to identify the patterns of sexual risk behavior responsible for HSV-2 positivity and to assess the reliability of HSV-2 positivity as a marker of sexual risk behavior in the study population. METHODS: This cross-sectional study included 423 blood donors of both sexes from eastern Croatia. Their blood samples were tested by ELISA IgG test kit for HSV-2 IgG and Western blot. Data on sexual risk behavior were collected by use of an anonymous questionnaire. RESULTS: Western blot testing showed HSV-2 IgG antibodies in 14 of 423 (3.3%) donor blood samples. The most common patterns of sexual risk behavior potentially associated with test positivity were irregular condom use during sexual intercourse with new partners (294/423; 69.5%) and > or = 5 sexual partners during lifetime (213/423; 50.4%). CONCLUSIONS: The population of blood donors from eastern Croatia included subgroups of subjects characterized by sexual risk behavior. Study results pointed to a relationship between various forms of sexual risk behavior and HSV-2 positivity, which could therefore serve as a reliable marker of sexual risk behavior in the study population.

Analysis of biennial outbreak pattern of respiratory syncytial virus according to subtype (A and B) in the Zagreb region.

BACKGROUND: The epidemic pattern of respiratory syncytial virus (RSV) in Croatia is biennial. In order to determine if the circulation of different RSV subtypes affects the outbreak cycle, the aim of the present study was to analyze the epidemic pattern of RSV in children in Croatia (Zagreb region) over a period of 3 consecutive years. METHODS: The study group consisted of 696 inpatients, aged 0-5 years, who were hospitalized with acute respiratory tract infections caused by RSV, in Zagreb, in the period 1 January 2006-31 December 2008. The virus was identified in nasopharyngeal secretions using direct immunofluorescence. The virus subtype was determined on real-time polymerase chain reaction. RESULTS: Of 696 RSV infections identified in children, subtype A virus caused 374 infections, and subtype B, 318. Four patients had a dual RSV infection (subtypes A and B). The period of study was characterized by four epidemic waves of RSV infections: the first, smaller, in the spring of 2006; the second, larger, in December 2006/January 2007; the third in spring 2008, followed by a fourth outbreak beginning in November of 2008. The biennial virus cycles were persistent although the predominant RSV subtype in the first two epidemic waves was subtype B, and in the second two it was subtype A. CONCLUSION: Over a 3 year period of observation, the biennial RSV cycle in Croatia cannot be explained by a difference in the predominant circulating subtype of RSV. Other unknown factors account for the biennial cycle of RSV epidemics in Croatia.

Differences in healthcare service utilisation in elderly, registered in eight districts of five European countries.

AIMS: The aim of the study was to compare and analyse the differences in self-reported frequencies of visits paid to physicians and hospitalisation rates, as well as their association with socio-demographic factors and health status self-rated by elderly. METHODS: A cross-sectional study was performed in eight districts of five European countries (Finland, Sweden, Ireland, Croatia, and Greece). A total of 3540 persons aged 70 or more were interviewed by trained interviewers. Healthcare service utilisation and its association with demographic characteristics and self-rated health were analysed using descriptive statistical methods, chi-square test, and logistic regression. RESULTS: Almost 90% of elderly visited a physician in the past year; 50% visited a specialist, while 24% were hospitalised. A visit to a specialist was paid by 70% of the Greek, 50% to 60% of the Croatian, and around 40% of the Irish, the Finnish, and the Swedish elderly. The highest proportion of hospitalisations (32%) was encountered in Greece and the lowest one (20%) in Sweden. Self-rated poor health appears to be the only common denominator associated with increased healthcare utilisation. Younger age stood out as a statistically significant predictor of the likelihood of specialist consults, while older age, male gender, and the synergy of male gender and current single life were disclosed as the predictors of hospitalisation frequency. CONCLUSIONS: Healthcare service utilisation exercised by the elderly across European districts was found to be highly variable and showed a clear distinction between north-western and south-eastern Europe; this is in line with differences in self-rated health.

Digital morphometry of cytologic aspirate endometrial samples.

Unlike cervical cytology, morphological cytology criteria in the differential diagnosis of endometrium have not yet been clearly defined, and methods to allow for more precise evaluation of endometrium status have been searched for. The aim of the present study was to assess the value of morphometric nucleus analysis of cytologic aspirate endometrial samples in proliferative, hyperplastic and malignant endometrium by use of digital image analysis. Morphometric analysis was performed on archival cytologic aspirate endometrial samples (at least 10 per group) stained according to Papanicolaou (n = 77) and May-Grünwald-Giemsa (MGG; n = 80) with the following histopathologic diagnoses: proliferative endometrium, hyperplasia simplex, hyperplasia complex, hyperplasia complex atypica, and adenocarcinoma endometriodes endometrii (grade I, II and III). Interactive image analysis (nuclear area, convex area, perimeter, maximum and minimum radius, length and breadth, as well as nucleus form factor and elongation factor) was performed by use of the SFORM software (VAMSTEC, Zagreb) on at least 50 (Papanicolaou stain) and 100 (MGG stain) well preserved endometrial epithelial cell nuclei without overlapping, at magnification of x1000. Statistical data analysis was done by use of the Statistica Ver. 6 statistical package. Multivariate analysis (ANOVA) distinguished malignant, hyperplastic and proliferative endometrium according to all morphometric variables with both staining methods (p < 0.05). However, on interactive testing of the groups (Kruskal-Wallis test), hyperplasias without atypia yielded no significant differences (p > 0.05) from atypical hyperplasia, adenocarcinoma and proliferative endometrium only according to the nucleus form factor and elongation factor (Papanicolaou stain), whereas malignant and atypical hyperplastic endometrium (MGG stain) differed statistically significantly (p < 0.05) from proliferative and hyperplastic endometrium without atypia according to all study parameters except for the nucleus form factor (p > 0.05). According to the cytologic staining method, morphometric parameters were considerably higher in MGG stained endometrial samples, reaching the level of statistical significance (p < 0.05) except for the nucleus form factor and elongation factor (p > 0.05) in the groups of hyperplasia simplex and complex, well differentiated adenocarcinoma (form factor) and atypical hyperplasia (elongation factor). A combination of cytomorphology and the morphometric variables assessed in this study can yield useful information on the cytologic state of endometrium, with special reference to the possible differentiation of the group of hyperplasia without atypia from the group of adenocarcinoma and atypical hyperplasia.

Does the viral subtype influence the biennial cycle of respiratory syncytial virus?

BACKGROUND: The epidemic pattern of respiratory syncytial virus (RSV) is quite different in regions of Europe (biennial epidemics in alternating cycles of approximately 9 and 15 months) than in the Western Hemisphere (annual epidemics). In order to determine if these differences are accounted for by the circulation of different RSV subtypes, we studied the prevalence of RSV subtype A and B strains in Zagreb County from 1 January 2006 to 31 December 2007. RESULTS: RSV was identified in the nasopharyngeal secretions of 368 inpatients using direct fluorescence assays and/or by virus isolation in cell culture. The subtype of recovered strains was determined by real-time PCR. Of 368 RSV infections identified in children during this interval, subtype A virus caused 94 infections, and subtype B 270. Four patients had a dual RSV infection (subtypes A and B). The period of study was characterized by two epidemic waves of RSV infections-one, smaller, in the spring of 2006 (peaking in March), the second, larger, in December 2006/January 2007 (peaking in January). The predominant subtype in both outbreaks was RSV subtype B. Not until November 2007 did RSV subtype A predominate, while initiating a new outbreak continuing into the following calendar year. CONCLUSION: Though only two calendar years were monitored, we believe that the biennial RSV cycle in Croatia occurs independently of the dominant viral subtype.

Using Simulation Modeling to Inform Policy Makers for Planning Physician Workforce in Healthcare System in Croatia.

The objective of this paper is to show how a simple but powerful simulation model can be build up using standard spreadsheet program and used to simulate future, needs and supply of physicians in order to inform policy makers at national level when deciding on enrollment to medical schools and immigration quotas for physicians. The Republic of Croatia is facing a serious shortage of physicians in the healthcare system and simulation results have shown that the gap between needs and supply will even increase if current enrollment qoutas to medical schools would persist. Increasing enrollment quotas, adjusting immigration policy, re-directing physicians from other professions to the healthcare system, task shift and skill mix options are just some of the measures needed to be taken promptly in order to prevent a huge deficit of physicians in the future. Simulation modeling is certainly a method for predicting changes within healthcare systems with a possibility to examine multiple different scenarios and suggest interventions.

[Guidelines for diagnostics and treatment of arterial hypertension. Practical recommendations of the Croatian Working Group for Hypertension. Consideration on the ESH-ESC 2007 guidelines]. / Smjernice za dijagnosticiranje i lijecenje arterijske hipertenzije. Prakticne preporuke hrvatske radne skupine i osvrt na smjernice ESH/ESC 2007.

ESH/ECS guidelines for diagnostics and treatment of arterial hypertension 2007 is a basic paper for all physicians who treat hypertensive patients. Since publishing, this article has been the most cited medical paper. According to ESH/ECS guidelines some local peculiarities in each country should be considered when diagnosing and treating hypertensive patients. Practical recommendations of the Croatian working group for the diagnostics and treatment of hypertension are in agreement with ESH/ECS guidelines. However, few additional issues are added and further discussed in this paper (hypertensive crisis, treatment of hypertension in patients undergoing dialysis and in renal transplanted patients, role of family physicians, role of nurse). We believe that this paper will contribute better control of hypertension in Croatia. All medical societies and institutions that took part in writing this document, have to consider this paper as an official statement.

Use of System Dynamics Modeling in Medical Education and Research Projects.

The paper reviews experiences and accomplishments in application of system dynamics modeling in education, training and research projects at the Andrija Stampar School of Public Health, a branch of the Zagreb University School of Medicine, Croatia. A number of simulation models developed over the past 40 years are briefly described with regard to real problems concerned, objectives and modeling methods and techniques used. Many of them have been developed as the individual students' projects as a part of their graduation, MSc or PhD theses and subsequently published in journals or conference proceedings. Some of them were later used in teaching and simulation training. System dynamics modeling proved to be not only powerful method for research and decision making but also a useful tool in medical and nursing education enabling better understanding of dynamic systems' behavior.

[Risk factors as prognostic factors of hospital mortality in patients with acute myocardial infarction]. / Cimbenici rizika kao predskazatelji intrahospitalnog letaliteta u bolesnika s akutnim infarktom miokarda.

OBJECTIVE: To determine whether there are any differences in the prevalence of risk factors between survivors and nonsurvivors among acute myocardial infarction (AMI) patients hospitalized in a county hospital. METHODS: Case histories of AMI patients treated at Department of Medicine, Bjelovar General Hospital from July 1, 1996 until December 31, 2000 were retrospectively analyzed. AMI was diagnosed using the World Health Organization definition. Demographic factors (age and sex), smoking habits, clinical and laboratory results (hypertension, diabetes, blood lipids--total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides), personal history of angina pectoris, myocardial infarction and stroke and family history of atherothrombotic disease were considered as potential risk factors. Comparisons were made between survivors and nonsurvivors during hospital treatment. On group comparisons Student's t-test and chi2-test were used. Statistical significance was set at p<0.05. DISCUSSION: In a total of 396 study patients, there were 316 (79.8%) survivors, showing male predominance (87.1% vs 67.3% of women; p<0.011). The patients aged under 65 were mainly male (79.6%), and among those older than 65 both sexes were equally represented (male 50.7% vs female 49.3%). Hypertension was more common in women (55.1% vs 42.6%; p=0.016), and smoking in men (31.7% vs 5.4%; p<0.001). The group survivors showed a higher prevalence of hypertension (50.3% vs 35.0% in nonsurvivors; p=0.014) and smoking (25.9% vs 6.3%; p<0.001). The prevalence of diabetes, previous myocardial infarction, angina pectoris, previous stroke and family history of atherothrombotic disease showed no statistically significant differences between survivors and nonsurvivors. Furthermore, a greater number of patients with increased levels of total cholesterol (> or =5.0 mmol/L) and LDL-cholesterol (> or =3.0 mmol/L) were found in the group of survivors than among nonsurvivors. The latter were 8 years older than survivors (71.0+/-9.3 vs 63.0+/-11.9 years; p<0.001). Analysis according to age groups also showed a rise of hospital mortality with age group in both sexes (men: 4.6% in <55 age group vs 22.6% in > or =75 age group; women: 7.1% in <55 age group vs 43.7% in > or =75 age group). A higher percentage of men nonsurvivors were smokers in comparison to female nonsurvivors that also had a lower level of total cholesterol. The prevalence of hypertension showed no significant sex difference. CONCLUSION: The prevalence of risk factors, especially the most important ones, i. e. hypertension, smoking and abnormal lipid values in AMI patients should be considered according to sex and age. The impact of these factors on patient outcome, i. e. survival rate during hospital treatment, can only be analyzed taking into account sex and age.

Training of Students for Critical Evaluation of Mobile Health Applications.

Medical and nursing students need to be trained in critical evaluation of mobile health applications (m-health apps) in order to see their potential and to understand the need for their validation and certification. Students should develop positive attitudes but also critical views on such apps in order to be prepared for responsible and ethical use of m-health in their future professional practice.

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study.

AIM: To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy. METHODS: In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus (0.5-1.5 mg/kg). Arterial blood pressure (BP) was monitored at 3 min intervals and heart rate and oxygen saturation (SpO2) were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure. RESULTS: A statistically significant reduction in mean arterial pressure was demonstrated (P < 0.001) when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60 mmHg, was noted in only 5 patients (0.5%). Oxygen saturation decreased from 96.5% to 94.4 % (P < 0.001). A critical decrease in oxygen saturation (< 90%) was documented in 27 patients (2.4%). CONCLUSION: Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effects if carefully titrated. All the patients (and especially ASA III group) require monitoring and care of an anesthesiologist.

Genetic background of Huntington disease in Croatia: Molecular analysis of CAG, CCG, and Delta2642 (E2642del) polymorphisms.

This study presents the first molecular data on the basis and the origin of Huntington disease in Croatia and is the first such analysis performed among a Slavic population. We analyzed three trinucleotide polymorphisms in the HD gene: CAG, CCG and GAG Delta2642 (E2642del) triplets. Analysis of the CAG repeat size among 44 Huntington patients (39-66 CAGs) and 51 normal individuals (9-34 CAGs) showed that the range of the repeats was similar to previous findings. The frequency of the CCG and Delta2642 polymorphic alleles on N and HD chromosomes was found to correlate well with earlier reports for Western European populations. We found significance for both the CCG7 allele (p=0.004) and the Delta2642 allele (p<0.001) among HD chromosomes. The CCG7 allele was overpresented among affected chromosomes (94.6%), but was also the most frequent CCG allele among normal chromosomes (66.7%). Interestingly, the Delta2642 allele was present on 40.5% HD chromosomes compared to only 9.8% of control chromosomes. Our results indicate that HD mutations in Croatia could be of the same origin as in Western populations and also support the multi-step hypothesis for generating new HD alleles. Similar frequencies and distributions of both the CCG and the Delta2642 polymorphisms in Croatia and Western European normal chromosomes indicate that the prevalence rate of HD in Croatia may be as high as in Western populations. Since we estimated a lower prevalence rate (1 : 100,000), we assume that there are still many misdiagnosed and/or unrecognized cases of Huntington disease in Croatia.

Prognostic value of different factors in breast carcinoma.

INTRODUCTION: The aggressive biological behavior of invasive and metastatic cancer is considered to be the most insidious and life-threatening aspect for breast cancer patients. It is mostly the result of changes in many molecular characteristics of tumor cells, including alterations in the mechanisms controlling cell growth and proliferation. AIM: The aim of this retrospective study was to identify predictors of aggressive biological behavior and metastatic potential in breast carcinoma among a number of intrinsic biomarkers of tumor cells such as steroid receptors and oncogene and tumor suppressor gene products. METHODS: Routine formalin-fixed, paraffin-embedded tumor samples were used and sections were stained immunohistochemically with the DAKO Strept ABC method to determine the expression of estrogen receptors (ER), progesterone receptors (PgR), HER-2/neu, bcl-2, Ki-67, p53 and nm23 in 192 consecutive breast carcinoma patients. The results of the quantitative immunohistochemical assays were correlated with clinical and histological data such as patient age, overall survival, tumor size, axillary lymph node status, hystological type, tumor grade, Nottingham prognostic index (NPI) and therapeutic regimens. RESULTS: Univariate analysis revealed that survival was significantly longer for patients with small tumors (P = 0.007), lower tumor grade (P = 0.021), negative axillary lymph nodes (P = 0.002), presence of nm23 protein (P = 0.002), and for patients treated with adjuvant hormonal therapy (P = 0.010). In multivariate analysis the independent factors positively affecting survival were absence of axillary lymph node metastases (P = 0.002), nm23 expression (P = 0.009) and hormonal therapy (P = 0.050). Among patients with positive axillary nodes there was a significantly higher survival rate in patients with nm23 expression compared with nm23-negative patients (P < 0.001). CONCLUSION: Identification of a subset of node-positive breast cancer patients with a more favorable prognosis according to nm23 expression might be clinically useful.

Electronic health center (eHC): integration of continuing medical education, information and communication for general practitioners.

The Electronic Health Center (eHC) is aimed as an Internet service for continuing medical education of general practitioners (GPs) at the national level. It integrates education, access to relevant and trusted information sources and group communication in order to meet the needs of both daily work and continuing education at home.

The effect of baby friendly hospital initiative and postnatal support on breastfeeding rates--Croatian experience.

The effects of implementation WHO/UNICEF Breastfeeding Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates were examined during and after the breastfeeding promotion campaign in one county of Croatia. Comparison with a control group indicated increase of breastfeeding prevalence in a period of BFHI implementation (1994-1998) - 68% vs. 87% at infant age 1 mo., 30% vs. 54% at 3 mo., 11.5% vs. 28% at 6 mo., and 2% vs. 3.5% at infant age 11-12 mo. (chi-square test, p < 0.05). More considerable increase has been noticed in period 1999-2000 which is characterized by breastfeeding support groups activity: 68% vs. 87% at infant age 1 mo., 30% vs. 66% at 3 mo., 11.5% vs. 49% at 6 mo., and 2% vs. 23% at infant age 11-12 mo. (chi-square test, p < 0.05). Our conclusion is that activities aiming to promote breastfeeding in maternity hospitals have had limited success. They have resulted in satisfactory increase of breastfeeding prevalence in early infant's period, but for far-reaching effect postnatal support is also required.

Antioxidant enzymes activity in patients with peripheral vascular disease, with and without presence of diabetes mellitus.

The study evaluated antioxidant status in patients with peripheral vascular disease (PVD), with and without concomitant diabetes mellitus (DM). 211 participants were divided into standardized 4 groups: patients with PVD and DM (PVD+DM+), patients with PVD without DM (PVD+DM-), patients without PVD with DM (PVD-DM+) and patients without PVD and DM (PVD-DM-). The diagnosis of PVD was established by Doppler sonography analysis, including determination of the ankle brachial index (ABI), partial pressures along the leg, and CW Doppler sonography at typical locations. Antioxidant status has been evaluated through the colorimetrically assessed serum activity of key antioxidant enzymes: superoxide dismutase (SOD), catalase, and glutathione peroxidase (GLPX) as well as through total antioxidant status (TAS) determination. In PVD+DM- group, as well as PVD-DM+ group, a significantly lower activity of the GLPX, catalase and TAS was found, whereas activity of SOD was significantly higher. There was no statistically significant difference between PVD+DM+ and PVD-DM+ group. Likewise, there was no statistically significant difference between PVD+DM- and PVD-DM-group. This study has shown that there is statistically significant difference in activity of antioxidant enzymes between diabetic and non-diabetic patients, irrespectively of PVD presence. Furthermore, PVD present alone does not alter key antioxidant enzymes activity in comparison with healthy subjects.

[Medical informatics--contribution of the Andrija Stampar School of Public Health to Croatian medicine and health care for the transition to the 21st century]. / Medicinska informatika--doprinos Skole narodnog zdravlja Andrija Stampar hrvatskoj medicini i zdravstvu za prijelaz u XXI. stoljece.

Medical informatics began to develop in Croatia in 1966 when medicine was recognized as a field in which the use of computers is important and widespread, and will be necessary in the future. Andrija Stampar School of Public Health, Medical School in Zagreb, was a pioneer in this new field in our country. Medical informatics contents were then introduced into postgraduate education with the aim to introduce future medical/health professionals to the possibilities of using computers in their fields of work and in health care in general. At the same time, computer processing of notification sheets started, as well as disease registries development and pilot processing of primary care data. In 1970/71, medical informatics contents were introduced in education of medical students at the Medical School in Zagreb. The opening of the Zagreb University Computing Center terminal station at the Andrija Stampar School of Public Health in 1973, and later, the establishment of a computer laboratory and including equipment and networking of the Medical School's workplaces gave the students, teachers and researchers the opportunity for intensive use of new technologies. The teachers from the School helped in spreading medical informatics education to other medical schools and colleges. Medical informatics research and the national and international cooperation was a logical continuation of the professional development, and the postgraduate education in Medical Informatics was a step further in spreading of knowledge among medical and health personnel as well as among other professions working in the health field.