The COVID-19 Pandemic and Recent Earthquake in Zagreb Together Significantly Increased the Disease Severity of Patients with Atopic Dermatitis.

BACKGROUND/OBJECTIVE: Stress may affect patients with atopic dermatitis (AD). The aim of this study was to examine the impact of the COVID-19 pandemic and the earthquake in Zagreb, Croatia (March 2020), on AD patients and their disease severity, symptoms/itch, and perceived stress. METHODS: Our observational cross-sectional study included three groups of AD patients diagnosed by a physician: group 1 (n = 50), who experienced both the pandemic (quarantine) and the earthquake; group 2 (n = 50), who experienced only the pandemic; and group 3 (n = 50), the comparison group, who experienced neither disaster (patients examined 2018-2019). Groups 1 and 2 were examined May-June 2020, immediately after the national lockdown/quarantine. Disease severity (SCORAD), data from the Perceived Stress Scale (PSS), and information on patients' confirmed allergies were recorded for all groups, while groups 1 and 2 additionally completed a questionnaire concerning their disease, hand hygiene, and experience during the pandemic and/or earthquake. RESULTS: The patients exposed to both disasters reported more pronounced AD worsening (p < 0.001; r = 0.388) and more frequent itching (p < 0.001; r = 0.350) than those exposed to the pandemic only. Notably, we found certain differences by gender: during the pandemic, women significantly more frequently washed their hands (81% of women washed "very frequently," while 52% of men washed "quite often") and had significantly higher PSS levels than men (p < 0.05). Concerning allergies, present or absent, during the pandemic, there was no significant difference in SCORAD between groups 1 and 2, neither when analyzed separately for indoor nor for outdoor allergens. The most commonly reported psychological disturbances during the pandemic were concern (46%), anger (18%), anxiety (16%), depression (9%), and increased alcohol, cigarette, and opioid agent use (6%). CONCLUSION: The COVID-19 pandemic together with the earthquake significantly increased disease severity and influenced AD worsening, itching, and psychological disturbances. This indicates that stressful events meaningfully affect the course of AD.

Psychological Stress and Atopic Dermatitis Severity Following the COVID-19 Pandemic and an Earthquake.

BACKGROUND: The course of chronic diseases can be influenced by psychological stress, suggesting a potential influence of current/recent disasters on atopic dermatitis (AD) patients. The aim of the study was to examine effects of the COVID-19 pandemic and Zagreb earthquake on the psychological stress level and disease condition of AD patients. SUBJECTS AND METHODS: This cross-sectional study included 150 AD patients (three groups with 50 patients): 1) those not exposed to either the COVID-19 pandemic or the earthquake; 2) those who only experienced the COVID-19 pandemic; and 3) those who experienced both the pandemic and the earthquake. Patients' data from the Perceived Stress Scale (PSS), on AD severity (SCORAD), and their answers from our newly designed questionnaire on disease-related behaviors and AD condition during the pandemic and quarantine were examined and statistically analyzed. RESULTS: The subjects who experienced both disasters had a greater PSS than those experiencing only the COVID-19 pandemic, especially women, and they also had higher disease severity (SCORAD) than those in the other two groups. Also, 59% of patients reported psychological stress during the pandemic, mostly caused by: the possibility of infection (31%), a changed work life and possible loss of income (23%), general pandemic-related conditions (17%), worry about physical survival (11%) and other (6%). Concerning the earthquake, the PSS significantly positively correlated with the psychological experience of the earthquake and with the intensity of sleep disturbances. CONCLUSION: To the best of our knowledge, this is the first study to specifically confirm that the COVID-19 pandemic influenced AD patients' stress levels and that stress from two disasters affected skin disease. Further research and therapeutic measures are needed.

The Influence of Psychological Stress on HPV Infection Manifestations and Carcinogenesis.

Psychological stress is an important factor involved in disease manifestations of human papillomavirus (HPV) infection, and it can participate in HPV-associated carcinogenesis. The impact or effect which stress can have (exert) depends on a person's genetic pool, experiences and behaviors. Due to inconsistencies in some study results, this issue remains a subject of research. Concerning the course of HPV manifestations, it has been observed that a higher number of life stressors in at least the previous 6 months, the absence of social support and the types of personal coping mechanisms employed, all influence HPV progression. In women with cervical dysplasia, a connection between greater stress experiences and dysregulation of specific immune responses has been observed. Once HPV enters a cell via the α6 integrin there are three possible sequences: latent infection, subclinical infection, and clinically manifest disease. HPV proliferation in differentiated epithelial cells induces morphologically cytopathic changes (koilocytosis, epidermal thickening, hyperplasia, hyperkeratosis). Oncogenic transformation requires the integration of the virus genome into the host genome. In doing so, DNA in the E1 region of E2 breaks down, leading to transcription disorders of E6 and E7. For the formation of irreversible malignancy, the following sequence is necessary: initial expression of E6 and E7 genes followed by suppression of apoptosis and the stabile expression of E6 and E7 proteins that protect transformed cells from apoptosis. A successful immune response is characterized by a strong, local cell-mediated immune response. Several factors are important for the regression of HPV manifestation/infection, among which is psychological stress which can prolong the duration and severity of HPV disease. Stress hormones may reactivate latent tumor viruses, stimulate viral oncogene expression, and inhibit antiviral host responses. In the regression of HPV infection, increased activity of Th1 cells was observed. However, during psychosocial stress, a decrease in the Th1 type of immune response is seen, and there is a shift towards a Th2 response. Understanding perceived stress and biological changes in stress, as well as the evaluation of immune parameters, gives researchers a better picture of how stress influences HPV infections and how to improve disease management and outcomes.

Determination of Psychological Stress, Serum Immune Parameters, and Cortisol Levels in Patients With Human Papilloma Virus.

PURPOSE: Because the results of studies investigating the relation between human papilloma virus (HPV) infection and the effects of psychological stress are inconsistent, this study was conducted to expand on previous research by analyzing patient stress levels, serum immune parameters, and cortisol levels in patients with clinical HPV manifestations. It also looked for differences in clinical manifestations of HPV depending on patient level of experienced stress. METHODS: This cross-sectional study included 213 subjects (94 women and 119 men aged ≥18 years; average age, 41 years) with clinical manifestations of HPV infection (165 subjects with extragenital manifestations and 48 with genital manifestations) who were treated at the Department of Dermatovenerology, Karlovac General Hospital, from January 1, 2012, to December 31, 2015. Psychological, neurohormonal and immune parameters (serum values of leukocytes, alpha2-globulins, beta-globulins, albumins, and proteins), and serum cortisol levels were analyzed. Questionnaires were used to determine patients' perception of stress: the Recent Life Changes Questionnaire, the Perceived Stress Scale, and the Brief Cope Test. One group of subjects had confirmed stressful experiences, defined by the Recent Life Changes Questionnaire as a period of 1 year with at least 500 life change units; the control group included patients with no significant stressful experiences. FINDINGS: Patients with confirmed significant stress experience had a statistically significant higher degree of perception of stress. There were no statistically significant differences in terms of the impact of stress on clinical HPV manifestations (genital and extragenital), sex, lesional duration, or recurrence. In patients with significant stress experience, significantly higher values of leukocytes (6.68 × 109/L), alpha2-globulins (6.85 g/L), and beta-globulins (7.33 g/L) were observed. Adaptive coping and a lower perception of stress significantly reduced the chances of having extragenital manifestations by 2.63 times. A higher perception of stress significantly increased the likelihood of genital manifestations. IMPLICATIONS: Although this study found that stress increased the values of leukocytes, alpha2-globulins, and beta-globulins, no evidence was found that it affected clinical manifestations of HPV infection. The redundancy of the immune system could account for this finding. This study is among the first to investigate the correlation between psychological, neurohormonal, and immune indicators of stress.

How to Cope with Psoriasis: Data from Patient Tests and Surveys.

There are a limited number of studies that have addressed coping strategies in patients with psoriasis, so the aim of this study was to examine how patients with psoriasis cope with their illness. We included 122 participants in the study: 56 patients with psoriasis vulgaris and 66 healthy subjects. They filled out the Recent Life Changes Questionnaire (RLCQ), blinded to their stress and clinical status, and the Brief COPE questionnaire with 28 questions measuring 14 coping strategies that are either adaptive or maladaptive. We statistically analyzed the self-reported magnitude of each stressful event in the participants' lives. Our results show patients with psoriasis most commonly used active coping, seeking emotional support, positive reframing, and acceptance, while their least used strategies were denial and substance use. Since patients with psoriasis often experience psychologically related problems/consequences, it is necessary to take into account their psychological state and try to provide appropriate help and support.

[Overview of the Development of Psychiatric Care in Karlovac - Due to the 50th Anniversary Since the Establishment of the Department of Neuropsychiatry in the General Hospital Karlovac (1969 - 2019)] / Pregled razvoja psihijatrijske sluzbe u Karlovcu ­ U povodu 50. godisnjice osnivanja Odjela za neuropsihijatriju Opce bolnice Karlovac (1969. ­ 2019.)

The newly established Department of neuropsychiatry of the Medical Center of Karlovac opened on November 3rd, 1969, thus enabling a comprehensive and modern approach to people with mental disorders. Prior to its opening, the first stage of the hospital in Svarca was completed. Up until that point, psychiatric care had been inadequate despite the enthusiasm of individuals, such as Dr. Andrija Stampar who worked in Karlovac in 1912 and 1913. The first decade of the Department's work marked the overload of "mixing" psychiatric and neurological cases, as well as the leadership of the scholar, Prim. Dr. Drazen Neimarevic. The establishment of separate departments in 1980 showed improvement in the working conditions, and further steps were made with the formation of day hospitals for alcoholism and psychotherapy. Better access to patients was achieved due to the independence of psychiatric care in 1994. The start of the 21st century saw innovative breakthroughs with the opening of the first unit for treating sexual disorders in Croatia and the establishment of one of the first mobile psychiatric teams within the national implementation of Community-based psychiatry model. In honor of the 50th anniversary of the establishment of the Department of neuropsychiatry in the General Hospital Karlovac, it is important to give thanks to everyone who contributed to the development of psychiatric care. Following the foundations that were laid, it is necessary to adapt and improve the approaches to those with mental disorders, with the aim to provide recovery and destigmatization. Finally, following the development in Croatian psychiatry and parallel activities in similar institutions, the overview of "psychiatry in Karlovac" can be used as a representative sample of the development in other institutions and similar county/regional centers.

Stress and Coping in Patients with Clinical Manifestations of Human Papillomavirus.

Stressful life events in response to a psychosocial trigger have been reported to negatively affect the course of infections. This study was based on patients with clinical manifestations of human papillomavirus (HPV) infection and a control group of patients with psoriasis who were admitted over a period of one year to the Dermatology Department of Karlovac General Hospital. A total of 122 patients participated in the study, either with a confirmed diagnosis of clinical manifestations of HPV infection (n=66) or in a psoriasis control group (n=56). The aim of this study was to determine which coping strategies are used in patients with clinical manifestations of HPV infection. We used the Recent Life Changes Questionnaire and Brief COPE test for stress evaluation. There were no statically significant differences between adaptive and maladaptive coping strategies comparing patients with HPV and a control group. The difference in specific coping strategies between HPV and control groups showed that self-blame and planning strategies were statistically significantly more common in the HPV group. Patients with HPV with genital warts used maladaptive coping statistically significantly more than patients with non-genital localization of HPV. Patients with HPV who had a higher score of life stress events used maladaptive coping statistically significantly more than patients with a lower life stress events score. The results point to the need for patients with HPV with genital localization and high numbers of stress events to learn how to cope with stress, enabling them to take action and change their ways of coping. There is also a need to integrate psychological intervention into standard care protocols of dermatologic diseases.

QUALITY OF LIFE AND PERCEPTION OF DISEASE IN PATIENTS WITH CHRONIC LEG ULCER.

Chronic wounds on lower extremities most commonly result from chronic venous insufficiency. Chronic leg ulcer impacts the quality of life in a number of ways such as reduced mobility, pain, unpleasant odor, sleep disturbances, social isolation, etc. This study included 100 patients with chronic wounds/lower leg ulcer (59% of women and 41% of men, aged 31 to 89) treated locally with special wound dressings for moist wound healing. Study results showed no age and sex correlation with the quality of life, and all participants evaluated their quality of life and health satisfaction as neither good nor bad, but it was found that the disease mostly affected social relationships and to a lesser extent patient satisfaction with their physical and mental health, and the environment. Results on the disease perception showed that the participants considered their disease to have a significant effect on their life and would last for a relatively long time, but they also believed they had good control of their disease. Also, they considered the disease to have many symptoms affecting them; they were worried about their disease which they understood relatively well; they were aware that treatment could be very helpful; and that the disease had moderate effect on their emotional health. According to sex, the disease was found to have greater effect on women (especially on their emotional condition) and women had more faith in successful treatment, while correlation with age was nonsignificant. This study confirmed the importance of the patient psychological condition and the need of due care of their psychological reactions to and facing with the disease.

Influence of stressful life events on coping in psoriasis.

Outbreaks of psoriasis usually can be linked with traumatic life stress events. Stressful life events in response to psychosocial trigger have been reported to negatively affect the course of psoriasis and are regarded as preventable causes of morbidity. Aims of this study were to determine which coping strategies are mostly used in psoriatic patients and to determine if there is a difference in coping according genders, clinical stages and stress level. The result shows that denial, active coping, seeking emotional support, positive reframing and acceptance are most frequently used among psoriatic patients. In adaptive coping psoriatic patients Psoriasis Area and Severity Index (PASI) score was 16.24, in maladaptive coping psoriatic patients PASI score was 19.6. Difference between adaptive and maladaptive coping strategies in psoriatic patients according clinical stage measured by PASI score was not statistically significant. Psoriatic patients who had higher score of life stress events (461.57) measured by Life change units (LCU) used maladaptive coping statistically significant more then patients with lower life stress events score (284.71). The results point to the need of psoriatic patients to learn how to cope with stress, enabling them to change ways of coping. There is need for integrating psychological intervention into standard care protocol of chronic dermatologic disease as psoriasis.

Epicutaneous patch test results in children and adults with allergic contact dermatitis in Karlovac county: a retrospective survey.

The aim of the study was to evaluate the results of epicutaneous patch testing with a standard series of contact allergens in children suspected to have allergic contact dermatitis (ACD), and to compare the results of patch testing between children and adults. Clinical records of children defined as patients aged ≤18 years and adults examined at Department of Dermatology and Venereology, Karlovac General Hospital, for suspicion of ACD during the 1994-2009 period were reviewed. Epicutaneous patch testing with a standard series of contact allergens, manufactured by the Institute of Immunology, Zagreb, Croatia, was performed in group 1 consisting of 412 children (274 female and 138 male, mean age 13.4 years, range 4-18 years) and group 2 consisting of 4440 adult patients (2918 female and 1522 male, mean age 40.3 years, range 19-81 years). The most common six allergens differed between the two groups. Adult subjects were divided into three age subgroups: 19-40 (n=1708), 41-60 (n=1570) and 61-81 (n=1162 subjects). The high sensitization rate in younger subgroup and lower sensitization rate in the oldest group compared to adult patient group as a whole was statistically significant (P<0.05). In children, the most common positive reactions were recorded to nickel sulfate (25.4%), thimerosal (17.8%), cobalt chloride (11.6%), fragrance mix (8.9%), white mercury precipitate (6.2%), formaldehyde (4.7%) and other allergens (25.4%). In adult patients, positive reactions were most common to nickel sulfate (32.6%), cobalt chloride (10.8%), fragrance mix (9.0%), wood tars (7.1%), potassium dichromate (6.6%), balsam of Peru (5.1%) and other allergens (28.8%). The group of children included 179 (43.4%) atopic subjects (according to Hanifin and Rajka criteria) and 233 (56.6%) non-atopic subjects. There was no statistically significant between-group difference and no statistically significant difference in nickel sulfate, cobalt chloride, fragrance mix and balsam of Peru sensitization between children and adult patients. A higher sensitization rate in children versus adults was recorded for thimerosal, white mercury precipitate and formaldehyde. Less frequent sensitization in children versus adults was found for wood tars and potassium dichromate. It is concluded that pediatric ACD exists and is more common than previously recognized. Sensitization to allergens differs between children and adults.

Epidemiology of central nervous system tumors in Karlovac area (Croatia), 1995-2010.

The aim of this study was to provide an overview of the central nervous system (CNS) tumours epidemiology in Karlovac region, over the 1995-2010 period. We analyzed data on 359 patients (194 men and 165 women), diagnosed with CNS tumours according to the World Health Organization's diagnostic criteria, in period 1995-2010. The data were obtained from the Neurology and Neurosurgery Department, including other medical records. The data were analysed with t-test and chi-square test. A total of 359 cases of tumours in CNS were recorded for the period of 1995-2010, with slight predominance of men (194;54.0%) over women (165;46.0%). Under the assumption of gender equality, we did not detect a significant gender difference in tumour diagnosis (p = 0.279). Mean age at the diagnosis was 64.1 +/- 12.6 years, with significant gender difference: mean age at diagnosis for men was 62.8 +/- 11.6 years, while for women it was 65.7 +/- 13.5 (p = 0.029). The commonest type of all tumours was metastases (144;40.1%). When only primary tumours were analysed, the commonest type was glioblastoma (125;58.15%), followed by meningeoma (44;20.5%). The remaining types were much less frequent, with i.e. 5 recorded cases of the following three types: astrocytoma, ependimoma and oligodendroglyoma (2.3%). These results suggest a commonly encountered epidemiological profile in the region, with commonest metastases, and glioblastoma as the most common primary tumour. Due to difficulties related to patient gravitating hospitals admittance and overall small sample size for more detailed analyses, it remains for future studies to determine potential association of the Homeland war (1991-1995) and the occurrence of CNS tumours.

[War health care system in Karlovac area during war in Croatia 1991-1995]. / Ratino zdravstvo u karlovcu za vrijeme domovinskog rata 1991-1995.

Croatian military medicine developed with the Croatian State and Army. Severe war conditions called for a military medicine that would integrate civil and military components: General Hospital Karlovac, medical corps of the Croatian Army, and emergency, preventive, and general medicine care. The wounded from the entire battlefield of the Karlovac area were admitted to and treated at the General Hospital Karlovac, totalling 1475 wounded, 39 of whom died of wounds. 229 people killed in action were directly admitted to the Department of Pathology. Medical Corps of the Croatian Army provided only primary health care services and emergency care. Due to the vicinity of the battlefield the classic echelon structure could not be followed in the Karlovac area. The third component was civilian emergency, preventive, and general medical care. Concept of collaboration between civilian and military medical services was successfully implemented in the Karlovac area, resulting in effective health care.

[Eminent medical doctor from Karlovac Dr. Milan Nemicic (1884-1930)]. / Znameniti Karlovacki lijecnik Dr. Milan Nemicic (1844-1930).

Milan Nemicic was born in 1844 in Petrinja, Croatia. He was promoted as medical doctor at Vienna medical school (Jozefinum) in 1868. In 1873 he became chief medical officer in regiment. During occupation of Bosnia and Herzegovina in 1878 he was very active in war operations near Bihad. In 1883 he was elected city physician in Karlovac and head doctor in Karlovac city hospital. During 1886 he was in Pasteur Institute in Paris and together with Louis Pasteur studied vaccination process in rabies. His results were published in Liecnicki vjestnik. He undertook first biological experiment on rabbit with rabies in Croatia, and he was first to have vaccinated patients with Pasteur's antirabies vaccine. Lexicon medicorum (Ljekarski rjecnik) was his biggest accomplishment printed in Zagreb 1898. He was retired in 1904 and lived in Graz, last years of his life he spent in Merano and died in 1930 at the age of 86 years.

Skin disease in a geriatric patients group in outpatient dermatologic clinic Karlovac, Croatia.

To determine the characteristic pattern and frequency of dermatoses in dermatologic patients over 65 years we used electronic data base of General hospital Karlovac and conducted a retrospective cross sectional study evaluating age, sex and proportion of dermatoses. Total number of patients was 3200. There were 822 (25.69%) patients older than 65 years, and 2378 (74.31%) patients aged from 18-64 years. Ratio male/female in population over 65 years in our study was 0.76:1. Males had higher frequncy of verrucae vulgares 26 (7.3%) and dermatitis nummularis 47 (13.2%) then female and that difference was statistically significant. Female had higher frequency of keratosis acitinca 124 (26.61%) and fibroma 23 (4.94%), and that difference was statistically significant. The ten most common diagnosis in population over 65 years old were: keratosis actinica in 184 patients (22.38%) verrucae seborrhoicae in 156 (18.98%), dermatitits nummularis in 77 patients (9.37%), dermatitis allergica e contactu in 60 (7.30%) patients, mycosis in 56 (6.81%) patients, psoriasis in 51 (6.20%), verrucae vulgares in 39 (4.74%), fibromas in 27 (3.28%), naevi in 9 (1.09%) and acne in 1 (0.12%) patient. The number of patients with diagnosis of keratosis actinica, verrucae seborrhoicae and mycoses in population over 65 years old are greater then in younger subpopulation and that difference was statistically significant. There are specific pattern of frequency of dermatoses in elderly. Verrucae seborrhoica, keratosis actinica and mycoses are more common then in general population. In elderly risk for development of skin cancer is increased. Early detection of skin cancers and treatment of precanceroses is of utmost interest of health providers.

Epicutaneous patch test results in patients with allergic contact dermatitis in Karlovac county--a retrospective survey.

During the 1994-2003 study period, patch testing was carried out in 1102 subjects (740 female and 362 male, mean age 39.8, range 7-81 years) suspected to have allergic contact dermatitis (ACD). Epicutaneous patch test with a standard series of contact allergens was made by the Institute of Immunology, Zagreb, Croatia, according to the Internationational Contact Dermatitis Research Group (ICDRG) rules. During the study period, 399 (36.2%) subjects with one or more positive tests were recorded, and 640 positive tests were observed. The most frequent allergens were nickel sulfate identified in 214 (33.4%), cobalt chloride in 64 (10%), fragrance mix in 60 (9.4%), wood tar in 47 (7.3%), potassium dichromate in 39 (6.1%), balsam of Peru in 29 (4.6%) and other allergens in 187 (29.2%) cases. According to the localization of ACD, hands as the most common site were involved in 535 (48.5%) cases, followed by the face in 167 (15.2%) and other locations in 400 (36.3%) cases. It is concluded that nickel is the principal allergen as the cause of ACD, mostly affecting women. The areas most frequently involved by ACD were the hands and face.

Epicutaneous patch test reactions in atopic dermatitis patients.

During the 1998-2003 period, patch testing was carried out in 65 atopic dermatitis patients, 20 (31%) male and 45 (69%) female, mean age 34.7 (range 6-77) years. Twenty-six (40%) patients, 7 (27%) male and 19 (73%) female, showed positive reaction to one or more allergens. Allergic reactions were more common in women. The most common allergens were nickel (33.3%), cobalt (11.1%), fragrance mix (11.1%), white mercury precipitate (8.4%), and others (36.1%). There was a significant association between nickel allergy and cobalt allergy. It is concluded that contact hypersensitivity is not rare in patients with atopic dermatitis.

Search systems and medical data quoting from the internet.

The Internet as a new medium also has its use in medicine. Plenty of information which can be found on the world computer network, needs an efficient searching as well as an evaluation system and quoting of the information obtained. Twelve most popular search engines were chosen--9 general: Netscape, Altavista, HotBot, Goggle, Northern Light, Magellan, Infoseek, MSN; 2 specialized medical search engines: Medscape and Medline; and one Croatian search engine: Cross. The efficiency of searching was observed by analyzing the number of obtained pages, their contents and examples of the quoted references from the Internet. The searching was done using the mentioned search engines, and results varied from 2,189,793 network pages found on the Infoseek for the term 'skin cancer' to 0 pages with the search engine Cross for the term 'melanoma+therapy'. When comparing the results for a single term using various search engines, it is concluded that the number of pages varied because of different databases and specialized scooters that search and make indexes. It is possible to use logical operators and more advanced search systems with the majority of search engines. The quoting system is based on mentioning the names of the author and his work, the access date and url (uniform resource locator) addresses of the network pages. Permanent and reliable access to quotations could not be established with previous quotation systems. Dermatologic terms have been well dealt with concerning general population, whereas professionals are recommended to use Medline and reviewed web pages. There have been very few professional and professionally relevant and comprehensive pages on the Internet relative to the total of web pages.