Implementation of the action plan for human resources in the health system of Serbia--facing inherited problems.

It is through an objective insight into the situation of the health system, in the period of a ten-year isolation of the country, that the policy of planning staff has been defined. The Ministry of Health of the Republic of Serbia has produced an Action Plan for Human Resources for 2005-2010, after having performed the analysis of the situation. It is based on the evaluation of the health status of the inhabitants and its internal migrations. The Action Plan is focused on the efforts to meet international standards with respect to the building of human resources in the health sector. The consistent implementation of defined norms is an important issue for further development of the health system and the maintenance of its sustainability.

Risk factors related to the failure of venous leg ulcers to heal with compression treatment.

BACKGROUND: Compression therapy is the most widely used treatment for venous leg ulcers and it was used in different forms for more than 400 years. Published healing rates of venous ulcers obtained with compression therapy vary widely from 40-95%. According to numerous studies, it has been suggested that the application of external pressure to the calf muscle raises the interstitial pressure resulting in improved venous return and reduction in the venous hypertension. Several risk factors have been identified to be correlated with the failure of venous leg ulcers to heal with compression therapy (longer ulcer duration; large surface area; fibrinous deposition present on >50% of the wound surface and an Ankle Brachial Pressure Index (ABPI) of <0.85. METHODS: An open prospective single-center study was performed in order to determine possible risk factors associated with the failure of venous ulcers to heal when treated with multi-layer high compression bandaging system for 52 weeks. In the study, 189 patients (101 women, 88 men; mean age 61 years) with venous leg ulcers (ulcer surface >5 cm(2); duration >3 months) were included. The study excluded patients with arterial disease (ABPI <0.8), heart insufficiency with ejection fraction (EF) <35, pregnancy, cancer disease, rheumatoid arthritis, and diabetes. Based on clinical opinion and available literature, the following were considered as potential risk factors: sex, age, ulceration surface, time since ulcer onset, previous operations, history of deep vein thrombosis, body mass index (BMI), reduction in calf circumference >3 cm during the first 50 days of treatment, walking distance during the day <200 meters, calf:ankle circumference ratio <1.3, fixed ankle joint, history of surgical wound debridement, >50% of wound covered with fibrin, depth of the wound >2 cm. RESULTS: Within 52 weeks of limb-compression therapy, 24 (12.7%) venous ulcers had failed to heal. A small ulceration surface (<20 cm(2)), the duration of the venous ulcer <12 months, a decrease in calf circumference of more than 3 cm, and emergence of new skin islets on >10% of wound surface during the first 50 days of treatment were favorable prognostic factors for ulcer healing. A large BMI (>33 kg/m(2)), short walking distance during the day (<200 m), a history of wound debridement, and ulcers with deepest presentation (>2 cm) were indicators of slow healing. Calf:ankle circumference ratio <1.3, fixed ankle joint, and reduced ankle range of motion were the only independent parameters associated with non-healing (P < .001). CONCLUSION: The results obtained in this study suggest that non-healing venous ulcers are related to the impairment of the calf muscle pump.

The pharmacokinetics of Biolimus A9 after elution from the Nobori stent in patients with coronary artery disease: the NOBORI PK study.

OBJECTIVES: The aim of this study was to assess the pharmacokinetics and tolerability of Biolimus A9 eluted from Nobori coronary stents. BACKGROUND: : The release kinetics and pharmacokinetics of drugs delivered via coronary stents have been shown to play an essential role in the efficacy and safety of drug eluting stents. METHODS: Twenty patients with coronary artery disease were treated with single 14-mm (10 patients) or 28-mm long stent (10 patients). Blood samples were drawn at 16 time points to determine the pharmacokinetics of Biolimus A9. At seven time points, complete laboratory and toxicology panels were assessed to screen for potential Biolimus A9 toxicity. The primary endpoint of the study was the systemic blood concentrations of Biolimus A9 after 28 days and 6 months as measured using highly specific and sensitive liquid chromatography- tandem mass spectrometry assay. RESULTS: At 28 days, 6 patients (30%) had quantifiable Biolimus A9 concentrations in blood. The highest Biolimus A9 blood concentration measured in any sample was 32.2 pg/mL. The median time to maximum concentration was 2 hr, ranging from 0.05 hr to 3 months. Six months after stent implantation, only 1 of 20 patients had measurable Biolimus A9 concentrations at the lowest level of quantification, while at 9 months no sample had quantifiable Biolimus A9 concentrations. Laboratory and toxicology assessments did not indicate any impact of Biolimus A9 on the evaluated parameters. CONCLUSION: Results of this study suggest that systemic exposure to Biolimus A9 was very low and that Biolimus A9 was well tolerated.

Upper extremity function and quality of life in patients with breast cancer related lymphedema.

Background/Aim: Exposed to increasing needs of users for better and faster services, more medications and innovative health technologies, managers of healthcare services in the public sector need motivation, permanent updating of information and constant personal development. The aim of this paper was to evaluate, on the basis of experienced healthcare managers, the impact of their motivation, selected character traits, managerial skills and formal education in management on healthcare facilities performances in the public sector. Methods: For the purposes of this study, 97 experienced managers from public hospitals and primary health centers in Serbia answered to 30 questions on the motivation of managers, essential skills for successful management and formal education in management in health facilities. The obtained data about their motivation, governing experience, personal skills and formal education in management were systematized and processed by the Statistical Package for Social Sciences (SPSS). Healthcare facilities performances were expressed by the healthcare facilities ranks in the official annual rankings according to the quality improvement, conducted by the Institute of Public Health of Serbia. Pearson's or Spearman's correlation coefficients were used for proving the potential impact of selected factors on performances of healthcare facilities. Results: This study confirmed the association between the healthcare facilities ranks and managers' abilities to organize the working process (t = -2.453; p = 0.018); expressed high managers' motivation (ρS = 0.206; p = 0.048) and the length of governing experience (r = -0.198; p = 0.043). Within a 3-year follow-up, this study also confirmed a positive correlation between annual ranks of healthcare facilities and managers quality management courses (ρS = -0.238; p = 0.017) and managers education in human resources management (ρS = -0.234; p = 0.027). Conclusion: In addition to management education, permanent personal development and higher motivation of managers have positive influence on healthcare performances.

Health care economics in Serbia: current problems and changes.

One of the fundamental rights of every human being is to enjoy "the highest attainable standard of health". Achieving better health requires no only adequate medical knowledge and technologies, laws and social measures in the field of health care, but also sufficient funding for fulfilling people's right to health. However, economic crisis has left every community with limited possibility of investing in health care and forced them to use the available resources more efficiently. This is the reason why health financing policy represents an important and integral part of the health system concerned with how financial resources are generated, allocated and used. Development of new drugs and medical technologies, population aging, increased incidence of chronic diseases as well as the peoples' rising demands from health care providers lead to a constant increase of health system costs worldwide. In these circumstances, countries in transition, like Serbia, face difficult challenges in financing their health systems. Current economic crisis and budget constraints do not allow the Government to simply allocate more public revenues for health and solve the people's expectations by increasing the spending. Instead, Serbia is forced to start reforms to provide a more efficient health system. The reform processes are positioned within the wider context of European integration and public administration reforms. This paper provides a short description of the health care system in Serbia focusing on the healthcare economics and reforms and their influence on financial sustainability.

Coronary vasomotion one year after drug-eluting stent implantation: comparison of everolimus-eluting and paclitaxel-eluting coronary stents.

First-generation drug-eluting stents (DES) have been associated with impaired localized coronary vasomotion and delayed endothelialization. We aimed to compare coronary vasomotion after implantation of a newer-generation everolimus-eluting stent (EES), with a first-generation paclitaxel-eluting stent (PES). Coronary vasomotion was studied in 19 patients with EES and 13 with PES. Vasomotor response was measured proximally and distally to the stent and in a remote vessel (reference segment). Quantitative coronary angiography was performed offline. Endothelium independent vasomotion did not differ significantly between the two groups. EES showed significant vasodilatation while PES showed vasoconstriction at both proximal (+4.5 ± 3.6 vs -4.2 ± 6.9, p < 0.001) and distal (+4.6 ± 7.9 vs -4.8 ± 9.3, p = 0.003) segments. The reference segment did not show any significant difference in vasodilatation between the two groups (+9.8 ± 6.4 vs +7.2 ± 5.2, p = 0.17). Endothelium-dependent vasomotion at adjacent stent segments is relatively preserved after EES implantation while vasoconstriction was observed after PES implantation.

Mentality and organisational changes are key to developing primary angioplasty.

At the moment of signing the Stent for Life (SFL) Initiative on August 31st, 2009, it was shown that, in Serbia during 2008, 48% of patients with ST-elevation myocardial infarction (STEMI) did not receive any reperfusion and only 19% and 33% received primary percutaneous coronary intervention (p-PCI) or hospital thrombolysis, respectively. However, during 2009, there was a trend towards a substantial increase in p-PCI procedures. This was the result of the commitment of cardiologists, the contract signed by the Health Insurance Fund (HIF) for remuneration of catheterisation laboratory (cathlab) staff for each p-PCI procedure (2005), and the provision of new cathlabs by the Ministry of Health (MOH). The number of PCI centres and trained cardiologists has been rising simultaneously. Direct mobile telephone contact with interventional cardiologists has facilitated the transport of patients directly to cathlabs (from 7.5% before 2009 to 34.2% in 2010 and 2011). Although the number of patients treated with p-PCI is increasing (2006 - 647 p-PCIs; 2007 - 1,248 p-PCIs; 2008 -1,794 p-PCIs; 2009 - 2,468 p-PCIs; 2010 - 3,216 and 2011 - 3,498 p-PCIs), the percentage of patients who are treated within 120 minutes of establishing a diagnosis (first medical contact) is still not satisfactory (38%).

Differential effects of drug-eluting stents on local endothelium-dependent coronary vasomotion.

OBJECTIVES: The aim of our study was to compare coronary vasomotion after implantation of a second-generation biolimus A9-eluting stent (BES) and of a sirolimus-eluting stent (SES). BACKGROUND: Drug-eluting stents (DES) have been associated with impaired local coronary vasomotion, delayed endothelialization, and increased late thrombotic risk. New DES with different drugs, pharmacokinetics, and polymers have been developed. METHODS: Nineteen patients with a BES and 15 patients with a SES were studied 9 months after stent implantation. Endothelium-dependent and -independent coronary vasomotion were tested proximally and distally to the stent as well as at a reference segment during right atrial pacing at increasing heart rates. Quantitative coronary angiographic measurements were performed offline. RESULTS: Of the patients with BES, 2 showed vasoconstriction with increased heart rate and 17 showed vasodilatation. Of the patients with a SES, 9 showed vasoconstriction while 6 showed vasodilatation. The SES showed significant vasoconstriction at both the proximal (-2.3 +/- 10% vs. 7.9 +/- 10%) and the distal (-5.4 +/- 9% vs. 6.1 +/- 8%) segments to the stent compared with the BES (p = 0.003 for proximal, p < 0.001 for distal segment). Endothelium-independent vasomotion after intracoronary nitrates did not differ significantly between the 2 groups (p = NS for proximal and distal segment). CONCLUSIONS: Unlike the case with the SES, endothelium-dependent vasomotion at adjacent stent segments seems to be preserved after BES implantation. This result may be explained by the different drug release kinetics, DES design, or characteristics of polymer used in the stent system.

Prevention of pocket related complications with fibrin sealant in patients undergoing pacemaker implantation who are receiving anticoagulant treatment.

AIM: The aim of our study was to establish the efficiency of fibrin sealant in the prevention of pocket related complications in patients undergoing pacemaker implantation who are receiving anticoagulant treatment. METHODS: The study was performed on 40 and 41 patients prospectively randomized into treatment and control groups who underwent pacemaker implantation procedure between January 2002 and July 2004 at the Pacemaker Center - Clinical Centre Nis, Serbia. Both groups of patients were receiving anticoagulant treatment with either heparin or warfarin. Surgical procedures between the groups differed only in the application of fibrin sealant prior to wound closure in the treatment group. RESULTS: In the treatment group, there were no pocket related complications while in the control group six patients (14.63%) had minor haematomas that required no treatment. Four patients (9.76%) had significant haematomas (two patients were treated conservatively while the other two needed reintervention). The INR in the treatment group was 2.76+/-0.85 and in the control group 2.65+/-0.79 (P=ns). In the follow-up period (2-27 months) no late complications were registered in either group. CONCLUSION: Fibrin sealant is an effective haemostatic agent. The results obtained in our study show that the administration of fibrin sealant in patients receiving anticoagulant treatment eliminates postoperative haematomas after pacemaker implantation.

[Predictive significance of residual ischemia detected by the dobutamine stress-echocardiography test soon after the first uncomplicated myocardial infarction]. / Prognosticki znacaj rezidualne ishemije procenjene dobutaminskim stresehokardiografskim testom rano posle nekoplikovanog infarkta miokarda.

BACKGROUND: To evaluate the long-term prognostic value of dobutamine stress-echocardiography (ECG) test for new coronary events (new episodes of angina pectoris, cardiac-related deaths, and reinfarctions) early after the first uncomplicated myocardial infarction. METHODS: Dobutamine stress-echocardiography tests were performed in all of 104 patients 10-20 days after the first myocardial infarction. Patients were followed-up for 36 (29 +/- 7) months. Kaplan-Meier cumulative survival curves were tested by Breslow test (Log Rank). RESULTS: Two cardiac deaths (1.92%), nine nonfatal myocardial infarctions (8.65%), and three cases of recurrent angina pectoris (2.88%) occurred during the prospective follow-up. Cumulative survival curves showed that in patients with negative findings of dobutamine stress-echocardiography test, survival time without significant events was 35.31 months, while in the group with positive findings of dobutamine stress-echocardiography test it was 30.91 months (log Rank 7.22; p<0.01). Prognostic value of dobutamine stress-echocardiography test was analyzed by Cox regression model and was 2.92, meaning that the risk of significant events was 2.92 times higher in the group of patients with positive findings of dobutamine stress-echocardiography test. CONCLUSION: Patients with negative findings of dobutamine stress-echocardiography test were with significantly higher possibility of surviving without significant events in comparison with the patients in whom the findings of dobutamine stress-echocardiography test were positive. In combination with clinical signs and ECG results, the results of dobutamine stress-echocardiography test improved prognostic value in the patients with the first uncomplicated myocardial infarction, and in that way influenced the strategy of their further treatment.