Undiagnosed hypertension in Croatia.

AIM: To determine the prevalence of undiagnosed hypertension in Croatia, and to assess its association with various demographic, socioeconomic, lifestyle, and health care usage factors. METHODS: We used the data from European Health Interview Survey wave 3, conducted in Croatia in 2019. The representative sample consisted of 5461 individuals aged 15 years and older. The association of undiagnosed hypertension with various factors was assessed with simple and multiple logistic regression models. The factors that contribute to undiagnosed hypertension were identified by comparing undiagnosed hypertension with normotension in the first model and with diagnosed hypertension in the second model. RESULTS: In the multiple logistic regression model, women and older age groups had lower adjusted odds ratio (OR) for undiagnosed hypertension than men and the youngest age group. Respondents living in the Adriatic region had a higher adjusted OR for undiagnosed hypertension than those living in the Continental region. Respondents who did not consult their family doctor in the previous 12 months and those who did not have their blood pressure measured by a health professional in the previous 12 months had a higher adjusted OR for undiagnosed hypertension. CONCLUSION: Undiagnosed hypertension was significantly associated with male sex, age from 35 to 74, overweight, lack of consultation with a family doctor, and living in the Adriatic region. The results of this study should be used to inform preventive public health measures and activities.

Development of a model for predicting risk from breast interval cancer in the female population in the Republic of Croatia.

There are several risk prediction models for screen-detected breast cancer but to the best of our knowledge, none for predicting risk from the interval cancer in breast cancer screening. The challenge for developing such a model was that the risk factors for both cancers appear to be similar, but the effects of interval cancer on women's health are more severe due to its higher biological aggressiveness. Our model is based on risk factors identified in the female population in the Republic of Croatia. Anonymized data from 472,395 women who participated in the National Program for Early Detection of Breast Cancer during the first three cycles of the program (October 2006-May 2014) were used. Cancer data from the Breast Cancer Screening Registry were linked by the data linkage method with data from the Cancer Registry of the Republic of Croatia. A total of 789 women with interval cancer and 3,530 women with screen-detected cancer were identified. Multivariate logistic regression in R was used to model the difference between participants with screen-detected cancer and those with interval cancer, using the general linear model (glm) function. The variables used for the analysis were selected using the all subset regression analysis method. The criterion of the least complexity parameter, the Cp-Mallows index, was chosen. Three variables were found to be statistically significant in the model: breast tissue density (p=0.038), hormone replacement therapy (p=0.034), and a first-degree family history of breast cancer (p<0.001). The resulting model has a discriminant accuracy of 0.658 (95% CI 0.602-0.713). Although our model has poorer predictor reliability, its advantage is that it is based on real-world data and that the criteria for interval cancer were strictly followed. It is best suited for use in the Croatian population of women because we have identified the available risk factors for the development of interval cancer in our population, but with knowledge of a specific epidemiological environment, it can be more widely applied. The model can be used to make recommendations for individual screening participants. The variables of breast tissue density and first-degree family history of breast cancer increase the likelihood of interval cancer and indicate an increased risk of detecting interval cancer between mammograms. Consequently, individualized risk screening should be considered (modification of screening interval or additional screening by magnetic resonance or ultrasound). According to the model, hormone replacement therapy is positively related to screen-detected cancer, and participants who use hormone replacement therapy must be medically monitored due to the increased risk of screen-detected cancer. In addition, participants in the screening program who use hormone replacement therapy and have a higher density of breast tissue should be encouraged to have more frequent mammograms.

Disease characteristics and causes of early and late death in a group of Croatian patients with systemic lupus erythematosus deceased over a 10-year period.

AIM: To assess the causes of early death (ED) and late death (LD) in patients with systemic lupus erythematosus (SLE) and determine the features of deceased SLE patients followed-up in a single Croatian tertiary hospital center, because little if any data on causes of death (CODs) in SLE patients are available for Croatia. METHOD: We identified SLE patients regularly followed-up at the Division of Clinical Immunology and Rheumatology, University Hospital Center Zagreb, who died from 2002 to 2011. Death was ascertained by matching our institutional records with the Croatian National Death Database. Patients were grouped according to their disease duration to ED and LD and compared by demographic characteristics, classification criteria, organ damage, and CODs. RESULTS: We identified 90 patients (68 women), who died at the age of 58±15 years. The most frequent COD category was cardiovascular diseases (40%), followed by infections (33%), active SLE (29%), and malignancies (17%). No significant difference was found between the frequencies of causes of ED and LD, except for stroke, which caused only LD≥10 years after the diagnosis. SLE was reported in death certificates of only 41 of 90 patients. CONCLUSION: Although stroke occurred both in the early and late disease course, it was primarily associated with LD. Given the low proportion of SLE recorded in death certificates of deceased SLE patients, matching of institutional and vital statistics records may be required to assess the true impact of SLE on mortality.

Dengue virus infection in Croatia: seroprevalence and entomological study.

During 2011-2012, a total of 1,180 sera samples were collected from residents of seven Croatian counties located on the Adriatic Coast and four counties in northeastern Croatia and tested for the presence of dengue virus (DENV) IgG antibodies using ELISA. Reactive samples were further tested by IFA. Seven samples (0.59%) tested positive for DENV antibodies. Seroprevalence rates by county varied from 0-2.21%. The highest seropositivity rate (2.21%) was found in the Dubrovnik-Neretva County where autochthonous dengue cases were recorded in 2010. Additionally,3,699 mosquitoes were collected from 126 localities along the Adriatic coast in August-September, 2011. Aedes albopictus was the most prevalent species (81.37%). No evidence of DENV RNA was detected by RT-PCR among 1,748 female mosquitoes.

Excess Mortality Stratified by Age and Sex for Croatia and Croatian Counties during the 2020-2021 COVID-19 Pandemic.

Excess mortality is often used to estimate the effect of a certain crisis on the population. It is defined as the number of deaths during a crisis exceeding the expected number based on historical trends. Here, we calculated excess mortality due to the COVID-19 pandemic for Croatia in the 2020-2021 period. The excess was calculated on the national and county level for different age and sex categories. In addition to the absolute number, the excess mortality was also expressed as a ratio of excess deaths to the predicted baseline and excess mortality rate. We showed that using both measures is necessary to avoid incorrect conclusions. The estimated excess mortality on the national level was 14,963, corresponding to an excess percentage of 14.3%. With respect to sex, there was a higher excess mortality rate for men compared to women. An exponential relationship was observed between age and the excess mortality rate.These trends wee representative of most counties as well, with large variations in the magnitude of the effect. However, there were also exceptions to the general rule. The reasons for these deviations were discussed in terms of between-county differences in demographic structure, population density and special events that took place during the pandemic.

Five-year cumulative incidence of hypertension in adult Croatian population: the CroHort study.

The aim of this study was to establish a five-year cumulative incidence of arterial hypertension (hereinafter 5-CIAH) and its dependence on initial prehypertension, body weight, age and gender "Croatian Adult Health Cohort Study (CroHort)" data collected during 2003 and 2008 for the 1383 subjects aged 18 + with initially normal blood pressure (systolic < 140 mmHg and diastolic < 90 mmHg, and not taking medication) was analised. Methods of descriptive statistics, Student's t-test, chi2-test and logistic regression were used. The recorded 5-CIAH in male cohort was 36.9% [32.1 to 41.6] and 33.0% [30.1 to 36.0] in women and was higher in subjects with initial prehypertension (men 43.3% [37.5 to 49.0] versus 9.6% [12.1 to 27.2]; women (42 3% [38.1 to 46.6] versus 22.3% [18.5 to 26.1]). The development of arterial hypertension was affected by age (OR = 2.2168), initial prehypertension (OR = 2.1987) and overweight (OR = 1.9399).

Is there any association between blood pressure and education level? The CroHort study.

The aim of this study was to explore how the association of 5-year cumulative incidence of arterial hypertension (further 5-CIAH) and education varies according to body weight, age and sex. The study was conducted on cohort of 1383 subjects aged 18+ with initially normal blood pressure (systolic < 140 mmHg and diastolic < 90 mmHg, and not taking medication). Data were collected in 2003 and repeated in 2008. Methods of descriptive statistics, chi2 test and logistic regression were used. No association between education level and hypertension development was recorded in the group of men and in the group of woman aged 65+. In the group of women with normal body weight, younger than 65 years, significantly higher 5-CIAH values were recorded in those with less than 12 years of education (32.5% [22.0 to 42.9]) compared to those with 12 or more years of education (9.6% [6.1 to 13.1]).

Association of hypertension with long-term overweight status and weight gain: the CroHort study.

Overweight is associated with hypertension, but longitudinal studies on the effect of weight gain on blood pressure are relatively rare. Aim of this study was to investigate association of long-term overweight status as well as of becoming overweight with hypertension. Odds of hypertension in 2008 were calculated for 1,383 respondents from Croatian Adult Health Cohort Study (CroHort) who had normal blood pressure in 2003. The results showed that for women both long-term overweight status and recently becoming overweight (in the last 5 years) were significantly associated with development of hypertension, while for men this was true only for long-term overweight. Prevention activities aimed at maintenance of normal body weight should be important part of primary prevention of hypertension.

Risk of angina pectoris, non-fatal myocardial infarction and non-fatal stroke among hypertensives: the CroHort study.

Aim of this study was to investigate association of controlled and uncontrolled hypertension with angina pectoris, non-fatal myocardial infarction and non-fatal cerebrovascular insult on a cohort from Croatian Adult Health Cohort Study (CroHort). Odds for angina pectoris, non-fatal myocardial infarction and non-fatal cerebrovascular insult were calculated for 227 respondents with controlled hypertension and 1,287 respondents with uncontrolled hypertension compared to 1,353 normotensive respondents. The results showed that among men uncontrolled hypertension was significantly associated with risk of non-fatal stroke, while among women no significant associations were recorded. Primary and secondary prevention of hypertension should be public health priority and would contribute to reducing the risk of stroke in Croatian population.

The Croatian Adult Health Cohort Study (CroHort) --background, methodology & perspectives.

Health interview surveys are important source of health information. All previous adult population-based health interview surveys in Croatia until CroHort, were one-off projects with very limited possibility of data comparison. CroHort enabled repeated survey of CAHS 2003 respondents with almost identical questionnaire, thus providing comparable data on trends of different risk factors as well as their relation to the specific outcomes. Next follow-up survey of the CroHort cohort is foreseen for 2013. Health interview survey according to Eurostat methodology (EHIS) on the new representative sample of adult Croatian population is planned for 2014. As the data from health interview surveys are valuable in health policy, efforts should be made to increase their use by policymakers in Croatia.

Acute Occlusion of the Infarct-Related Artery as a Predictor of Very Long-Term Mortality in Patients with Acute Myocardial Infarction.

AIM: The survey's aim was to examine the significance of infarct-related artery (IRA) occlusion (verified angiographically) on very long-term outcomes of patients with acute myocardial infarction, within the STEMI and NSTEMI diagnosis. METHODS: A single-center, nonrandomized, registry-based study on patients treated for acute coronary syndrome with percutaneous coronary intervention between June 2011 and December 2016 was conducted. Patients with angiographically proven IRA occlusion (100% stenosis with TIMI flow 0 distal to occlusion) were categorized as occlusive myocardial infarction (OMI) and patients with patent IRA (50-99% stenosis with TIMI 1-3 flow) were categorized as nonocclusive myocardial infarction (NOMI) and very long-term outcomes were analyzed. Data were collected prospectively from the hospital's PCI registry and the database of the Croatian Institute of Public Health. RESULTS: A total of 2450 patients were included in the study. 796 (32.5%) patients had NOMI and 1654 patients (67.5%) had OMI. According to ECG changes, 1534 patients presented with STEMI (62,6%) and 916 with NSTEMI (37,8%). 88% of STEMI patients presented with OMI and 12% with NOMI, while patients with NSTEMI in 33,8% presented with OMI and in 66,81% with NOMI. A median follow-up was 4.7 years. There was no significant difference in cardiovascular mortality between the groups (14.8% vs 13.1%; OMI vs NOMI, respectively; p=0.374) neither in all-cause mortality (19% vs 21.5%; OMI vs NOMI, respectively; p=0.374). Patients with NSTEMI had a significantly higher very long-term mortality (21.6% vs 18.1%; NSTEMI vs STEMI, respectively; p=0.029). CONCLUSION: The main findings of the study are as follows: (1) total IRA occlusion was not associated with higher long-term mortality; (2) NSTEMI was associated with a higher mortality rate compared with STEMI, independent of angiographic presentation (OMI/NOMI); (3) IRA occlusion was not associated with significantly higher mortality rates in patients with STEMI and NSTEMI, respectively.

[Efficacy of public health surveillance systems]. / Ucinkovitost javnozdravstvenih nadzornih sustava.

Public health surveillance system (PHSS) serves for continuous and systematic data collection, analysis and interpretation, in order to enable planning, implementation and evaluation of public health practice. PHSS should alert to events (usually unwanted), assist to create public health policy and strategies, document effects and achieving the goals as well as setting public health priorities. Surveillance systems monitor communicable and non-communicable diseases, health resources and public health programs and interventions. The main drawback of the existing PHSS is fragmentation and delay of information, usually not up-to-date. Modern information and communication technology enables getting data from hospitals and other health information systems directly, and use them for surveillance. Our model of surveillance system appeared as not standalone but an integrated system getting data that are by-product of frontline workers. Therefore, the electronic health records should be the source of data for disease surveillance. Medical, nurse and similar schools as well as the Ministry of Health and health institutions could be data sources for health personnel surveillance. Medical devices can be monitored by data coming from institutions and bodies dealing with such devices. Public health programs defined by institutions and bodies can be monitored by them and others taking part in implementation. Therefore, they all can be the source of data for surveillance of public health programs and interventions. Without such systems, any rationalization in health care and better quality is not possible. Therefore, the present public health surveillance system should be improved, as we have suggested, by using current information and communication technology and integrating the data that are by-product of the frontline worker, and by including the end users in system development at the very beginning.

Regional differences in the prevalence of arterial hypertension in Croatia.

This paper analyzes the Croatian Adult Health Survey data, collected in 2003 with a total of 9,070 respondents aged 18+. Based on an average of two measurements, respondents with the mean systolic arterial pressure > or = 140 mmHg or mean diastolic pressure > or = 90 mmHg were classified as hypertensive. The data for men and women were analyzed separately, according to regions. Prevalence of hypertension in men was 40.5% (95% confidence interval CI 37.9-43.01; coefficient of variability CV = 3.2), women 34.9% (95% CI 33.2-36.7; CV 2.5). There were no significant differences in regional prevalence in men, except in the Northern and Eastern region. In women we did not detect any significant regional difference. Non-controlled arterial hypertension is an important public health problem in all monitored regions of Croatia. Raising awareness about the problem, early detection and encouraging the population to adhere to the therapy for elevated arterial pressure, in addition to a healthy life style, are important for successful control and harm reduction.

[Incidence and prevalence of asbestos-related diseases in Croatia]. / Pojavnost bolesti uzrokovanih azbestom u Republici Hrvatskoj u razdoblju od 2002. do 2007.

The aim of this study was to identify the incidence and prevalence of asbestos-related diseases in Croatia, based on the Hospital Morbidity Database and General Mortality Database of the Croatian National Institute of Public Health. Both databases cover a period from 2002 to 2007), and include information from the Register of Occupational Diseases. Diagnoses in focus were mesothelioma (C45), asbestosis, and pleural plaque (J61 and J92). Yearly rates of inpatients treated for mesothelioma, asbestosis, or pleural plaque that were higher than the Croatian average (2.1) were recorded in the Counties of Split-Dalmatia (5.0), Dubrovnik-Neretva (3.9), Istria (3.7), and Primorje-Gorski kotar (3.1 per 100,000 people). From 2002 to 2007, 649 occupational diseases were reported, out of which 11.7% were asbestos-related. The most frequent were pleural plaque with asbestosis (38 cases, 50.0%), pleural plaque (23 cases, 30.3%), and mesothelioma (6 cases, 7.9%). Mortality attributable to asbestos was assessed using official Croatian National Statistics Bureau reports for 2002 to 2007 at the county and national level. During that period, Croatia recorded 312 deaths with the average yearly rate of 1.2 per 100.000 people. Four counties had higher rates than the national average: Primorje-Gorski kotar (3.4), Split-Dalmatia (2.8), Istria (2.8), and S1. Brod-Posavina (1.5). The number of inpatients treated for asbestos-related diseases was higher than the national average in the counties of Split-Dalmatia, Dubrovnik-Neretva, and Primorje-Gorski Kotar. Mesothelioma incidence was above the national average in the counties of Split-Dalmatia, Primorje-Gorski Kotar, and Istria. The rates of occupational, asbestos-related diseases were higher than the national average in the counties of Split-Dalmatia and Primorje-Gorski Kotar. We were aware that the interpretation of data is somewhat limited by the relatively small absolute number of treated persons and deaths for the observed period, by the fact that crude rates have not been adjusted for total numbers and for regional differences in population distribution by age and gender. The real extent of asbestos-related burden in Croatian general population remains unknown, because only occupational exposure has been monitored. Therefore, the National Public Health Institute and county public health institutes should implement a specific monitoring programme in collaboration with government environmental bodies to assess asbestos exposure of the population living in the vicinity of asbestos plants. It is also necessary to establish the number of exposed persons who have developed an asbestos-related disease. Their health should be monitored and their environment inspected on a regular basis.

Biomedical Informatics Workforce in Croatia: Qualitative Analysis of Teachers' Opinions on Needs and Employment Opportunities.

We report a qualitative analysis of higher education biomedical informatics (BMI) teachers' opinions on the needs for BMI workforce and employment opportunities in the Croatian health care system. Needs were perceived as considerable; however this was not coupled with adequate employment opportunities. Barriers were identified to correcting this imbalance, including the failure of the health care system planners to recognise BMI experts as an important part of the workforce and lack of adequate educational opportunities.

Educational Landscape of Biomedical Informatics in Croatia: Who Are the Teachers and What Are Their Attitudes.

Lack of experts with complementary competences in the field of information technology as well as medicine and health care has been recognised as an important obstacle to successful computerisation of the health care system. Using a questionnaire survey, we aimed to describe the current educational landscape of biomedical informatics in Croatia, focussing on teachers' profiles and attitudes about existing educational opportunities in the field. Our findings show that Croatian institutions of higher education should better recognise the need for education in biomedical informatics. Dedicated programs need to be established and teacher force strengthened. Joint efforts of existing teachers-institutionalised through a working group focussing on education within the Croatian Society for Medical Informatics, for which strong support exists-might contribute to recognition of the field and improvement of educational opportunities.

Physicians' strike and general mortality: Croatia's experience of 2003.

The aim of the study was to establish whether the physicians' strike, which took place in Croatia in 2003, had an impact on the mortality of the population. Mortality data from the National Bureau of Statistics relating to the strike period (15 January - 14 February 2003) were selected and compared with the previous and subsequent periods of the same duration in 2001, 2002 and 2004. Of the 52,575 deaths in 2003, Croatia recorded 4,682 (8.9%, 95% Confidence interval 8.4-9.4) in the strike period from the 15th of January to the 14th of February 2003 or 1.1 deaths per 1000. No deviations of the 15th of January to the 14th of February period's share of the death total in relation to other observation periods were noted. It is impossible to associate the strike based on the figures shown in this paper with either an increase or decrease in population mortality.

[Regional characteristics of arterial hypertension in adult population of Croatia]. / Regionalne znacajkev arterijske hipertenzije u odraslog stanovnistva republike Hrvatske.

Data collected in the Croatian Health Survey launched in 2003 by the Ministry of Health and Social Welfare were analyzed. The survey included a regionally stratified random sample. Using the method of structured questionnaire and anthropometric measurements (blood pressure, height and weight), data were collected on 9,070 subjects aged >18. The mean systolic and diastolic blood pressure was calculated from two measurements. Inclusion criteria in the group of subjects with elevated blood pressure were the subject's reporting taking antihypertensive medication and/or mean systolic blood pressure > or =140 mm Hg, and/or mean diastolic blood pressure > or =90 mm Hg. Descriptive analysis was done on figures yielded by use of the SPSS software. Subjects with elevated blood pressure accounted for 44.2% (95%CI=42.61-45.85) of study population, with a h gher rate in male (45.6%; 95%= 43.14-48.06) and lower in female subjects (43.0%; 95%CI=41.46-44.55). Croatia was estimated to have 1,538,982 inhabitants with high blood pressure (748,072 males and 790,910 females). The proportion of individuals with elevated blood pressure was highest (78.9%; 95%CI=76.9-81.0; CV=1.32) in the 65 age group, followed by 35-64 age group 46.9% (95% CI=44.8-41.0; CV=2.3), and lowest rate (13.8%; 95%CI=11.1-16.6; CV=10.2) in the 18-34 age group. Regional distribution of high blood pressure was as follows: central Croatia 46.4% (95%CI=42.9-49.9; CV= 3.8), south 45.3% (95%CI= 40.9-49.7; CV=. 5.0), City of Zagreb 44.7% (95%CI= 40.9-48.5; CV= 4.3), east 44.2% (95%CI=40.5-47.8; CV=4.2), north 43.0% (95%CI=40.9-49.7; CV= 5.0), and west 40.5% (95%CI= 36.0-45.0; CV= 5.7). In the female group aged 35-64, regional distribution was as follows: east 52.3% (95%CI=46.0-58.7; CV=6.2), central Croatia 45.4% (95%CI=40.3-50.5; CV=5.7), City of Zagreb 43.5 (95%CI=38.1-48.9; CV=6.4), south 40.7% (95%CI=37.4-44, 0; CV=4.1), north 39.3% (95% CI=33.7-44.8; CV=7.2), and west 35.1% (95%CI=26.1-44.2; CV= 13.1). Differences between the east and south, west and City of Zagreb should be investigated. In the high blood pressure group, 76.5% of subjects had a body mass index greater than 25 and 48% ofthose with inadequate physical activity, both exceeding the rates recorded in persons with normal blood pressure. Whereas 58.6% of the subjects knew they had elevated blood pressure, 48.4% of them were taking their therapy, and only 14.8% kept their blood pressure under control (systolic <140 mm Hg and diastolic <90 mm Hg). Arterial hypertension is a major public health problem in all regions of Croatia. The available literature data suggest that the Croatia's share of individuals with high blood pressure is comparable to that in industrialized countries of continental Europe. The prevention of excessive body weight, also through increased physical activity of the population and changes in poor dietary habits, remains the essential element in planning primary prevention programs for high blood pressure. Raising the population's awareness of the problem, early detection of high blood pressure and encouraging the population to take regular therapy for high blood pressure, along with the adoption of healthy lifestyle are important factors in achieving effective control and alleviating the consequences of hypertension.

[National public health information system]. / Nacionalni javnozdravstveni informacijski sustav.

Information production and its communication being a key public health activity, developing modern information systems is a precondition for its fulfilling these assignments. A national public health information system (NPHIS) is a set of human resources combined with computing and communication technologies. It enables data linkage and data coverage as well as undertaking information production and dissemination in an effective, standardized and safe way. The Croatian Institute of Public Health LAN/WAN modules are under development. Health Safety System, Health Workers Registry, and Digital Library are among the Institute's developmental priorities. Communication between NPHIS participants would unfold over the Internet by using every relevant data protection method. Web technology-based applications would be run on special servers. Between individual applications, use would be made of the transaction module of communication through an exchange of the HL7 standard-based xml messages. In the conditions of transition, the health system must make an optimal use of the resources, which is not feasible without applying modern information and communication technologies.

Socioeconomic inequalities show remarkably poor association with health and disease in Southern Croatia.

OBJECTIVES: This study aimed at investigating the association of socioeconomic status and health outcomes in populations of the two remote Croatian islands and one coastal city. METHODS: Medical history and survey information were used to create 33 variables that were analysed using logistic regression. The population from the island of Vis was followed up and mortality data were used to calculate hazard ratios using Cox regression. RESULTS: Socioeconomic inequalities were poorly associated with health and disease indices. In the matrix of 33 outcome variables and 13 socioeconomic predictor classes, only 10 associations were significant at the level of P < 0.001. None of the associations was replicated across samples. We did not detect the association of any socioeconomic estimate with mortality data for the island of Vis. CONCLUSIONS: Homogenous island populations were expected to have greater levels of social homogeneity and consequently less expressed inequalities in health. The lack of stronger association in the urban population of Split is likely the result of the mechanisms that persisted from the former communist regime and high level of retained formal and informal social support.