Migration of BPA from Food Packaging and Household Products on the Croatian Market.

BPA is a plasticizer for the production of polycarbonate plastics and epoxy resins and is widely used in the production of household goods, including food packaging. Free BPA is known to migrate from packaging to food, and its uptake has been associated with adverse health effect, particularly the disruption of endocrine activity. The presence and migration of BPA from plastic consumer products are subject to strict regulation in the EU. The aim of this study is to analyse the migration of BPA from different packaging items and household products sold on the Croatian market. To simulate real life exposure, we treated samples with a food simulant. The analytical performance was confirmed with the EU requirements. BPA levels were assessed in 61 samples by HPLC-FLD and the LOQ of the method was 0.005 mg kg-1 for the food simulant. These results showed that the levels of BPA that migrated to the food simulant were below LOQ and in accordance with the specific migration limit into food, which was defined as 0.05 mg kg-1 for all samples. None of the analysed products presented a health hazard. However, these regulations do not refer to products intended for children's use, in which BPA is banned. Furthermore, regulations require testing before putting products on the market, and previous research shows that possible BPA migration occurs due to various uses, along with a cumulative effect of exposure from even very small concentrations. Therefore, for accurate BPA consumer exposure evaluation and possible health risks, a comprehensive approach is needed.

Informed Patient Is Satisfied Patient - Qualitative Study of Patients' Experience after Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty is "gold standard" in surgical treatment of hip osteoarthritis but we still lack quality information on patients' perspective. Preoperative narrative approach as instrument of patient-centered paradigm that provide detailed information tailored to the patients' needs, might give patient control over the whole process and better outcomes. The aim of this article is to explore the lived experience of patients from onset of disease to final treatment. SUBJECTS AND METHODS: This is a qualitative study using direct content analysis. Data were collected through semi-structured interviews with 33 patients who undergone total hip arthroplasty in Special hospital for orthopedics in Biograd na Moru, Croatia, 6 to 9 months after surgery. Interviews were coded and organized to themes. RESULTS: Three main themes emerged and all themes were closely related to information available: 1) Pre-operation information (information about disease and coping with it, pain management, exercise for muscle and joint function maintenance), 2) Information about operation and technical information (waiting list transparency, type of implant, possible complications and risks), 3) After operation information (early rehabilitation, stationary rehabilitation, quality of life after operation). CONCLUSION: Our findings reveal that patients experience lack of information prior to referral to our hospital. Involving patients in the process through good communication with doctor and providing extensive information on what to expect before and after surgery, and how surgery will affect quality of life, make them feel that they progress better. Identifying hidden barriers and enablers might help in patients' healing process. Our results indicate that preoperative narrative approach was a worthy time investment that contributed to patient general satisfaction.

Health Status, Lifestyle, Use of Health Services, Social Capital and Life Satisfaction As Predictors of Mental Health - Comparative Analysis of Women that Receive and Do not Receive Public Assistance in Croatia.

BACKGROUND: The connection between socio-economic status and health is documented, yet not fully understood. The goal of this research was to analyze the relationship between socio-economic status, lifestyle and health status, availability of health-care, social capital, and satisfaction with life. SUBJECTS AND METHODS: Subjects were 1117 women aged 25-65 years divided in two groups. Group 1 consisted of women who receive public assistance (N1=591), while Group 2 consisted of women who do not (N2=526). The sample was stratified by random choice into multiple stages based on six regions of Croatia, residential area size, and the age of respondents. Visiting nurses surveyed the deprived population, while in Group 2 self-interviewing was conducted. A questionnaire entitled "Inequalities in health" was used. The respondents participated in this research voluntarily and anonymously. RESULTS: Socially deprived women consume spirits and wine more often (p<0.001). There is no difference between groups regarding tobacco consummation. Working women perform significantly less strenuous physical tasks (p<0.001). Deprived women are significantly less engaged in physical activities (p<0.001). Health conditions in deprived women more commonly limit their physical activity (p<0.001). There is a significant difference in utilization of health-care among groups (p<0.001). Younger women who are married, with a higher number of household members, a larger income, and with higher education are generally more satisfied with life (p<0.001). Although deprived women are significantly less satisfied with their lives, feel less free, are less physically active, and less likely to consume spirits or beer, they are significantly happier than working women (p<0.001). CONCLUSIONS: Personal health status and lifestyle, access to health-care services, and life satisfaction have a high importance as predictors and protective factors of mental health in women - recipients of state-provided financial welfare.

[Blood pressure measurement--do not sweat the small stuff and it is all small stuff?! Position paper of the Croatian national referral center for hypertension, center of excellence of the European Society of Hypertension]. / Mjerenje arterijskoga tlaka--ne mari za male stvari i ostat ce male stvari?! Preporuke Hrvatskoga referalnog centra za hipertenziju centra izvrsnosti Europskog drustva za hipertenziju.

Office blood pressure measurement using mercury sphygmomanometer is the gold standard for making diagnoses of hypertension, evaluation of cardiovascular risk and estimation of obtained control of treated hypertensives. The vast majority of epidemiologic data are based on this method. However, the importance of blood pressure variability, white coat effect as well as availability of simple devices, home and ambulatory blood pressure measurements became routine parts in routine clinical work. As mercury will be soon forbidden in clinical work such devices and methodology will be even more important. In everyday clinical practice all three techniques should be implemented and in this paper advantages and drawbacks of all techniques are discussed. In the end, based on recent data and recommendations of international societies, diagnostic algorithm was proposed. Additionally, we described the technique of non-invasive central blood pressure measurement, determination of pulse wave velocity and calculation of augmentation index, new proposed risk factors.

Issues around household pharmaceutical waste disposal through community pharmacies in Croatia.

BACKGROUND: Croatian regulations mandate pharmacies to receive unused medicines from households. Pharmacies are considered as producers and holders of pharmaceutical waste and are obliged to finance this service. Model where pharmacies are responsible for financing disposal of unused medicines without reimbursement is not common in Europe. Present service was not tested before implementation. OBJECTIVE: To investigate the elements of the pharmaceutical waste disposal service provided by pharmacies, and to gain insight into the factors that might influence the effectiveness of the service. Setting All pharmacies in the city of Zagreb. METHOD: Each pharmacy was asked to weigh the collected waste from the public during a period of 30 days, between June 1st and July 10th of 2011, absent from any media advertisement and answer a specifically designed questionnaire that was exploring possible connections between the amount of collected waste, type of pharmacy ownership, discretion while disposing, location of the container, appropriate labeling and to compare the amount of collected waste between neighborhoods. MAIN OUTCOME MEASURE: Quantity of collected unused medicines from the public. RESULTS: Of 210 pharmacies, 91 participated completing the questionnaire (43 % response rate). The total amount of collected waste was 505 kg. Pharmacies owned by the city of Zagreb had higher response rate (74 %) than privately owned pharmacies (36 %), and collected significantly higher amount of waste. Anonymity when disposing influenced collected quantity, while labelling and location of the container did not. There were differences in the amount of collected waste between neighborhoods due to the demographic characteristics and number of pharmacies per capita. CONCLUSION: The effectiveness of the pharmacy service of collecting unused medicines in Croatia shows a number of weaknesses. The amount of collected medicines is below the European average. Functioning of the service seems to be negatively influenced by the type of pharmacy ownership, distribution of pharmacies and lack of anonymity when disposing unused medicines. Additionally, type of ownership is connected with financial burden for pharmacies. Governmental bodies should examine current legislation regulating pharmaceutical waste disposal, particularly financial responsibility for providing the service, in order to increase pharmacies' compliance. Advertising of the service may increase awareness of the importance of proper disposal of unused medicines.

[USE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE AMONG FAMILY MEDICINE PATIENTS--EXAMPLE OF THE TOWN OF CAKOVEC]. / UPOTREBA KOMPLEMENTARNE I ALTERNATIVNE MEDICINE KOD PACIJENATA U OBITELJSKOJ MEDICINI--PRIMJER GRADA CAKOVCA.

The use of complementary and alternative medicine (CAM) is widespread around the world including Croatia. The number of studies that investigate both quantitative and qualitative use of CAM in Croatia is limited. The aim of this study was to investigate the use of CAM among family medicine patients in the town of Cakovec and the rate they report it to their family doctor. This was a cross-sectional study in a sample of 300 patients that visited primary health center for any reason. We used anonymous questionnaire already employed in a previous investigation (Cizmesija et al. 2008), which describes socioeconomic characteristics, modalities of CAM use, and reasons for use. We also added questions on the type of herbs used and use of over-the-counter vitamin and mineral supplements. On data analysis we used descriptive statistics, χ2-test and Fisher's exact test, while the level of statistical significance was set at p ≤ 0.05. The response rate was 76%. Out of the total number of patients, 82% used some modality of CAM. Women, patients with secondary school education, employed and retired persons used CAM more often. Students and pupils reported least use of CAM. The most commonly used were herbs (87%), bioenergy (29%), diet therapy (28%), chiropractics (22%), and homeopathy and acupuncture (11% each). Vitamin and mineral supplements were used by 77% of study subjects. CAM was most frequently used for respiratory, urinary and musculoskeletal problems, as well as to improve overall health condition. Of the respondents that reported CAM use, 55% believed it would help them, 43% used it because they wanted to try something new, while only 2% indicated dissatisfaction with their physician as the reason for using CAM. Statistically, there were more subjects that used CAM and did not notify their family doctor about it, which could indicate poor communication between family doctors and health care users. Our results are consistent with a previous quantitative study conducted in Croatia and with literature data on the countries with a predominant use of western medicine. Qualitative data from previous studies in Croatia could explain the cultural and socioeconomic context of CAM use. Dissatisfaction with their physician as the reason for using CAM was rarely indicated, suggesting that CAM most probably fills the gap between successful and unsuccessful treatment, and perception that evidence based medicine has its own limitations. The arguments to turn to CAM therapy could involve poor doctor to patient ratio, i.e. 1750 patients per family medicine doctor on average, and the 20% increase in the number of diseases and conditions diagnosed by family medicine units. In conclusion, these results suggest that the use of CAM is common among patients in family medicine. When taking patient history, doctors should ask about CAM use and be aware of the patient beliefs and lifestyle. When patients strongly believe in CAM methods, there is the need of making compromise in therapy, with explanation of the possible side effects and at the same time continuous follow up. There is the need of additional education of family doctors and population about good and bad effects of CAM. In Croatia, accent should be on herbalism because this modality is most widespread.

Health facilities safety in natural disasters: experiences and challenges from South East Europe.

The United Nations named 2010 as a year of natural disasters, and launched a worldwide campaign to improve the safety of schools and hospitals from natural disasters. In the region of South East Europe, Croatia and Serbia have suffered the greatest impacts of natural disasters on their communities and health facilities. In this paper the disaster management approaches of the two countries are compared, with a special emphasis on the existing technological and legislative systems for safety and protection of health facilities and people. Strategic measures that should be taken in future to provide better safety for health facilities and populations, based on the best practices and positive experiences in other countries are recommended. Due to the expected consequences of global climate change in the region and the increased different environmental risks both countries need to refine their disaster preparedness strategies. Also, in the South East Europe, the effects of a natural disaster are amplified in the health sector due to its critical medical infrastructure. Therefore, the principles of environmental security should be implemented in public health policies in the described region, along with principles of disaster management through regional collaborations.

Five-years cumulative incidence of alcohol consumption in Croatian adult population: the CroHort study.

Alcohol consumption is traditionally part of most human cultures, and with the onset of industrial revolution it was recognized as a health and social problem. The aim of this article is to investigate cumulative incidence of alcohol consumption in Croatia. Data were obtained from the Croatian Adult health Survey in 2003 followed by 2008. The cohort consisted of 3229 participants. Questions regarding alcohol consumption were calculated into two factors describing existence or non-existence of risk behavior. Results revealed higher incidence of risk alcohol consumption in man than in women and highest in the 35-65, age group. Due to the some study limitations results might be underestimated. Present problem of alcohol is alarming, even more so, in women's population it might be only the tip of the iceberg. Cultural and regional differences should be taken into account when educational programs are constructed, especially due to the different type of alcohol consumed.

Association of behavioral cardiovascular risk factors with mortality in Croatian adult population: the CroHort study.

This study examined individual and combined influence of smoking, physical inactivity, alcohol drinking, and unhealthy diet on total mortality. Relationship between individual and combined poor health behaviours and total mortality were examined using Cox proportional hazards regression. Out of 7490 individuals included in the study, during 5 years follow up 808 died. Adjusted hazard ratios (HRs), and 95% confidence intervals (95% CIs) for men with health behaviour scores 1, 2, 3, and 4 compared with those with score 0 were 1.67 (1.24-2.24), 2.28 (1.64-3.18), 2.24 (1.32-3.84), and 2.86 (0.77-11.70), respectively (p value for trend < 0.001). Adjusted HRs (95% CIs) for women with health behaviour scores 1, 2, and 3 compared with those with score 0 were 1.17 (0.97-1.42), 1.37 (1.02-1.86), and 1.20 (0.37-3.61), respectively (p value for trend = 0.04). A unit of the health behaviour score increased mortality risk equivalent to being 5.9 and 2.9 years older, for man and woman respectively.

Could determinants of PCS and MCS serve for public health intervention regarding chronic diseases in Croatia?

The aim of this article was to identify parameters that determinate PCS and MCS values, and analyze 5-year changes in those values according to the age, sex and geographic region. Cohort of 3229 participants was obtained from the CAHS 2003-2008. Results revealed no statistically significant differences between same age group, sex, and different region regarding PCS and MCS. When chronic conditions were in the model difference was present, PCS being more influenced by all conditions but bronchial asthma. The strongest influence comes from musculoskeletal conditions; followed by weak heart. Values for PSC and MSC decreased in 2008 compared with 2003, but only in few cases decrease was statistically significant. Values of PCS and MCS are higher in men in all regions, but they show higher variability than woman. Our results support the findings that data obtained through SF-36 could be the useful for public health interventions regarding chronic diseases.

Distribution of changes in systolic blood pressure and waist circumference--indicators for primary prevention.

Eliminating or diminishing risk behaviors that lead to cardiovascular diseases could be achieved through primary prevention during the general practice visits. However, there is difference in effectiveness of preventive measure while there are no symptoms, and reactive response when burden of diseases start to show. We analyzed trends in gender and age--pattern changes of systolic blood pressure and waist circumference, as a reflection of primary prevention. Results show increase of values for both indicators in both genders, through youngest and middle age groups. In the oldest group stagnation and even decrease of values is evident. These results signal possible absence of primary prevention in younger age groups and some action when symptoms occur. It is hard to distinguish weather lower values is consequence of medication or lifestyle change. The absence of primary prevention is usually missed opportunity that is charged later both to the patient and health care system.

Counseling on cardiovascular behavioral risk factors within the healthcare system: the CroHort study.

Eliminating four behavioral risk factors (tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol) could contribute to a decrease of up to 80% in burden of non-communicable diseases, including cardiovascular diseases. Primary healthcare providers have a unique position within the healthcare system, which allows them to actively contribute to the prevention of cardiovascular behavioral risk factors (CVBRFs) by providing individual counseling. The aim of this article is to show the change in frequency and the effects of counseling on CVBRFs by healthcare providers between two periods: up until 2003 and between 2003 and 2008. Results, obtained within the CroHort study, show a low frequency and undesired effects of counseling within the healthcare system in both studied periods. This points to a lack of consistency with which the healthcare system tackles prevention of behavioral risk factors for cardiovascular diseases.

Is salt intake hidden risk for rural population: case study Village of Sjeverovac, County Sisacko-moslavacka?

Nutritional habits between urban and rural population differ as much as life style and socioeconomic standards of these populations. In Croatia, rural populations are mostly live stock producers. Their nutrition frequently depends on their own production, which includes high quantity of cured meat products, eggs and dairy products. Data were obtained from longitudinal the Croatian Adult health Survey and pilot cross-sectional survey in three villages in Sisacko-moslavacka county. Our findings show that there is no great difference between urban and rural population regarding salt intake. The difference is in the type of food and food preparation, as well as life style. We propose combination of more culturally and socially sensitive questionnaires along with analytical methods that include biological matrix, such as 24-hour urine collection.

Angiotensin-converting enzyme gene polymorphism and N-Acetyl-ß-D-glucosaminidase excretion in endemic nephropathy.

BACKGROUND: Tubular proteinuria and enzymuria are hallmarks of endemic nephropathy (EN). The role of I/D angiotensin convertase (ACE) gene polymorphism has not yet been elucidated in this peculiar chronic tubulointerstitial nephritis, and our aim was to investigate the role of this polymorphism in EN focusing on the urinary N-acetyl-ß-D-glucosaminidase (NAG) excretion, a biomarker of proximal tubular damage. METHODS: ACE genotype and allele frequencies were determined in 229 farmers (147 women and 82 men) from an endemic Croatian village. The farmers were stratified according to the WHO criteria into the following subgroups: those 'at risk' for EN (n = 37), 'suspected of having EN' (n = 57), and 'others' (n = 135). RESULTS: There were 74 (32.3%) subjects homozygous for the D allele, 99 (43.2%) heterozygous (ID genotype) and 56 (24.4%) homozygous for the I allele. No differences in allele frequency were found between the established WHO subgroups (p > 0.05). In the whole group, DD subjects had significantly higher values of diastolic blood pressure (p = 0.003) and urinary NAG than subjects with ID and II genotype (5.5 ± 1.2 vs. 4.0 ± 3.0 vs. 3.8 ± 4.2, respectively; p = 0.023). The highest values of serum creatinine (p = 0.02), proteinuria (p = 0.03) and urinary NAG (6.0 ± 3.7 vs. 3.7 ± 2.1 vs. 3.0 ± 1.6, respectively; p = 0.008) were observed in those suspected of having EN group with the DD genotype. CONCLUSION: ACE gene polymorphism is not a risk factor for EN. However, it might influence the clinical course of EN, and increased excretion of NAG might be a prognostic marker of this chronic tubulointerstitial nephritis.

[Adverse health events and health hazards reflections of epidemiologists and environmentalists]. / Nezeljeni zdravstveni dogadaji--kako epidemiolozi i ekolozi razmislaju zajedno.

In this article we present management of water resources in Croatia as a model of integral approach in public health interventions. The links between provision of clean water, sanitation and good health are so strong that today management and water protection are deeply integrated in primary health care. This article is a follow up on topics presented on 2nd Croatian congress on preventive medicine and health promotion which gave us "state of art" in Croatian public health. We strongly believe that every system has its own advantages and downsides, and only by knowing the system well and continuous improvement we can protect ourselves in time of health, social or economic crisis. The model of water protection showed that to prevent and overcome the variety of water-related health risks, implementation of various activities that include general environmental protection, development of water management system, permanent water quality monitoring and control, and improvement of standards and legislative is needed. On the other hand if there is no holistic approach, to the public health problems, all the efforts in just one field will not result in health indicators improvement. Constant monitoring and uniform analysis of data could help to identify possible risks of adverse effects of various environmental factors and possible burden of disease as a consequence. That information could be a point of arguing with local governments and communities for public health interventions. It is important that epidemiological and environmental data do not remain in the domain of academic discussion or statistics, and never reach primary health care which could use them in direct health care providing. Information exchange in real time is important for the real time public health intervention. Primary health care is the front line in communication with patients and diagnostics of disease as well as prevention, and they need to have access to all relevant data.

Who empowers women towards healthier lifestyles? Example from western Croatia.

This article explores who among the doctors, other health care workers, family or somebody else most frequently advised women about their lifestyle changes related to cardiovascular health (including smoking, nutritional habits and physical activity). We analyzed who advised the most, in relation to the parameters important in the etiology of cardiovascular diseases: age, systolic blood pressure and body mass index (BMI). Sample was a part of comprehensive Croatian Adult Health Survey, comprised of women from Primorje-Goran, Istra and Lika-Senj Counties. Results indicated low frequency of advising on lifestyle changes in primary health care in all three counties, with most advice from general practitioners on nutritional habits. Family and other health care workers advised about smoking and nutrition and had strong influence in the youngest age groups. The GPs failure to counsel younger population and disease-free women could be regarded as the missed opportunity for avoidance of preventable risk factors that are associated with cardiovascular diseases. Other subjects in the health care process, as well as the family and media could fill the gaps between the patients and health care system messages. In order to create and develop such heterogeneous network approaches to training various programs and activities have to take into account all specific gender and regional characteristics.

Respiratory function in wind instrument players.

BACKGROUND: The playing of wind instruments has been associated with changes in respiratory function. STUDY OBJECTIVES: To investigate the effect of playing wind instruments on lung function and respiratory symptoms. METHODS: The present study included 99 wind instrument players and a group of 41 string instrument players as a control from 3 major orchestras in Zagreb, Croatia. Data on chronic respiratory symptoms were recorded in all studied subjects. Lung function was measured in wind instrument players by recording maximum expiratory flow-volume curves. RESULTS: Wind instrument players demonstrated significantly higher prevalences of sinusitis, nasal catarrh and hoarseness compared to control musicians. One wind instrument player developed asthma associated with his work. Odds ratios for wind instrument players were significant for chronic cough, chronic phlegm and chronic bronchitis by smoking habit (p<0.05 or p<0.01) but not for length of employment. Ventilatory capacity data indicate that wind instrument players had significantly greater FEV1 (smokers and nonsmokers) as well as FEF50 (nonsmokers) (p<0.05) compared to predicted values. Regression analysis of pulmonary function tests in wind instrument players demonstrate a significant link between FEV1 and FEF50 and length of employment. Those wind instrument players with longer employment had the greatest increases in lung function. CONCLUSIONS: Our data suggest that musicians playing wind instruments may be susceptible to chronic upper airway symptoms. Interestingly wind instrument playing may be associated with higher than expected lung function parameters.

Women in medicine through the ages.

BACKGROUND: Female practitioners of the medical arts have been active since the ancient world The role of women in science, and particularly in medicine, has changed significantly over time. METHODS: We provide a chronological review of the growing knowledge in medicine related to women's activities through the ages with particular attention to occupational medicine. Throughout history hazards have been shaped by the forces that shape work itself social evolution, shifting economic powers and demographic changes. RESULTS: Mythical Greece, Egypt and ancient Rome were the cradle of ancient medicine. In the past century, women were allowed to enter the medical profession with increasing acceptance. Some of the most important women in ancient and modern medicine are recalled, such as Mother Peseshet in ancient Egypt, Artemisia of Caria and Phanostrate and Philista in the Greek period, Hildegard of Bingen, Marie Marguerite Biheron in England, Elisabeth Blackwell, Emily Jennings, Maude E. Abbott and others. Women in occupational medicine are described separately, such as Alice Hamilton, Harriet L. Hardy, Molly Newhouse and Olga Macek. CONCLUSIONS: Certainly, the first few women who iluminated the way for the generations that followed them into medicine, the women who made outstanding contributions to medicine, and the women who are currently finding success in medicine deserve our respect and admiration.

Management of hazardous medical waste in Croatia.

This article provides a review of hazardous medical waste production and its management in Croatia. Even though Croatian regulations define all steps in the waste management chain, implementation of those steps is one of the country's greatest issues. Improper practice is evident from the point of waste production to final disposal. The biggest producers of hazardous medical waste are hospitals that do not implement existing legislation, due to the lack of education and funds. Information on quantities, type and flow of medical waste are inadequate, as is sanitary control. We propose an integrated approach to medical waste management based on a hierarchical structure from the point of generation to its disposal. Priority is given to the reduction of the amounts and potential for harm. Where this is not possible, management includes reduction by sorting and separating, pretreatment on site, safe transportation, final treatment and sanitary disposal. Preferred methods should be the least harmful for human health and the environment. Integrated medical waste management could greatly reduce quantities and consequently financial strains. Landfilling is the predominant route of disposal in Croatia, although the authors believe that incineration is the most appropriate method. In a country such as Croatia, a number of small incinerators would be the most economical solution.