On aging and aged care in Serbia.

Serbia is a demographically old nation, with 17.4 % of its residents being aged 65 years and older in 2011. The previous two decades of turbulent history have significantly affected the demographic picture of this country, and their ramifications remain visible in Serbia's economic, political, cultural, and health spheres. Major demographic forces behind population aging in Serbia can be attributed to lower fertility rates, migrations, and declining mortality (reflecting improvements in overall health leading to a longer life expectancy). In Serbia, low fertility and migrations appear to play major roles, although the relative contribution of recent migrations cannot be measured with accuracy. Patterns of demographic aging vary considerably across different geographic, socioeconomic, and cultural settings. The common denominator throughout present day Serbia is extensive political and economic transition. One would expect that, given sufficient time, this process will result in improved population health, and yet, at this stage outcomes of major health care reform in Serbia are somewhat perplexing. For the second consecutive year, Serbia's health care system has been ranked at the very bottom of the scale among 34 European countries. It is then no surprise that the elderly represent particularly vulnerable population segment. This paper discusses some of the issues relevant to these demographic patterns of aging and aged care in contemporary Serbia, focusing on the period after 2000.

Nonsteroidal anti-inflammatory drugs: as inappropriate pharmacotherapy in the elderly?

Nonsteroidal anti-inflammatory drugs (NSAID) are one of the most used groups of drugs in elderly population. The aim of this study was to establish the frequency of reported disorders while using NSAID in elderly patients. A multi-centric study was conducted with a standard questionnaire for all geriatrician outpatients who were using NSAID. It has been found that out of 421 patients, 320 reported some kind of disorder; 287 of them used other drugs beside NSAID, 33 used only NSAID during the study. It has been concluded that frequency of reported disorders was significantly higher among patients who used another drug beside NSAID, and statistically most frequent reported disorders were gastrointestinal.

Acute geriatric units.

Together with increase of population of elderly people, there is an increase of the number of hospital admission for emergencies, especially for elderly people. Serbia shares this need for Acute Geriatric Units (AGU). The National Programme of Health Care of Elderly People Improvement is planning to open the Geriatric Ward in every regional general hospital in Serbia. But in cities with several hospitals, there is a waste need for geriatric ward capable of taking acute care. So, there is a need for geriatric wards in Serbia nowadays. The main targerts for AGU should be: the comprehensive geriatric assessment, prevention of development of worsening of delirium, decubital wounds, incontinence, improving mobility and early planning of discharge. The multidisciplinary team, which includes physicians, nurses, physiatrist and social worker, is the best solution for getting this target day by day. Thus, one of the distinctive features of Acute Geriatric Units should be comprehensive geriatric assessment, the prevention of geriatric syndrome and early planning of discharging the elderly patient.

Self-perception of health (SPH) in the oldest-old subjects.

SPH is a subjective and objective assessment of personal health. It is important in evaluation of health status in the elderly as it has capacity to predict mortality, functional declining, and health-care demands. A lot of research has been published about SPH in the elderly, but little is known about SPH in the very old, especially in comparison with the "younger-old" (YO) population. The study has aimed to investigate SPH in 240 elderly patients and compare the data between the "oldest-old" (OO) (aged >or= 90 years; n=52) and the YO (aged 60-74 years; n=188) subjects. Results have shown that the OO group of patients had better SPH than their YO counterparts. Our findings implicate that very old persons belong to a special sub-group of elderly, the "successfully aged", probably due to their genetic stability, distinctive lifestyle, or both.

Aging in Serbia.

Serbia has one of the largest elderly population segments in the World, with 17.2% of its citizens estimated to be 65 years and older in 2007. In the period of last 50 years, important demographic changes had occurred in Serbia. In 2002, Serbian demographic situation for the first time reached the point where the number of the older exceeded the number of the youngest. In 2007 this tendency continues to persist, with 22.1% of Serbians estimated to be 60 years or older, and 21.7% to be 20 years or younger. For the same year, life expectancy at birth was estimated to 70.7 years for the male, and 76.2 years for the female Serbian newborns. Elderly represent major consumers of health services, and yet, not always do they receive the quality of care they are entitled to. Family still holds a predominant role in providing social support and care for their elderly members. During the last 30 years, number of long term care facilities (primarily aimed at old people not competent of independent living) has gone up in Serbia from 35 to 43. Yet, they provide accommodation and care to only a small number of residents, ranging from 5996 in 1976 to 12,160 in 2005. Such institutions are named "Homes for the elderly" or "Geronto centers". The aims of aged care reform in Serbia include not only better education for the medical and other affiliated stuff, but, also, improvements in intersectoral collaboration, structural reforms of the social and health care systems, innovative capacity building, and the promotion of concepts that would replace, or at least ease the burden off the traditional family.

Psycho-social model of depression within the elderly population in the institutional and non-institutional life conditions.

The aged people are often in need of other people's help available at their home or in institutions for long term care. On the other hand depression is one of the most prevalent psychiatric disorders and a common cause of disability in the elderly. The study included N=100 participants. Subjects are individuals in the age of 65 or more, 39 men and 61 women. Fifty subjects have been accommodated in the Elderly Centres (homes for retirees), and fifty have been using gerontology centre services at their homes. Depression, functional capability, psychosomatic disorders and subjective estimate of health have been investigated. It has occurred that depression in general was more present among the subjects who lived in the institutional life conditions, namely that depression major (major, regarding severity of the disease) is more frequently present in this group. Depression minor is more frequent among those subjects who live in the non-institutional conditions. Psychosomatic disorders, decreased functional capability and lack of contacts outside homes are in larger correlation to depression among subjects living in the non-institutional life conditions. Depression and subjective health estimate are highly correlated in both groups. Depression is more widely present among women and subjects with higher education levels.

Progression of polyvascular disease--is there any rule?

The polyvascular disease (PVD) is presented by coexistence of ischemic heart disease (IHD),carotid disease (CD) and peripheral arterial disease (PAD). In the essence of this disease is atherosclerosis. The aim of the research was to learn what is the course of the worsening multiple arterial diseases during the two-year period considering the new cardiac, cerebrovascular and peripheral vascular events. Among 150 patients with clinical manifestations of obliterate vascular disease of at least two aforementioned vascular diseases, we investigated the incidence of new coronary, carotid and peripheral vascular events during the two-year period. New coronary events were the most common in PVD patients with preexisted IHD (88 persons, 58.7%, p < 0.01), in PVD patients with preexisted CD (51 persons, 34.0%, p < 0.01) and in PVD patients with preexisted PAD (61 persons, 40.7%, p < 0.01) as well. The second most common event is the worsening of the preexisting dominating vascular disease. Thus, whatever the predominant vascular disease was, in the further two-year course of polyvascular disease, the new coronary events are the most frequent.

Cross-sectional study on health and social status of the oldest old patients at home care in Belgrade.

In the period of the last 50 years important changes in the age structure of the population in Serbia occurred. There was a very pronounced tendency of the total demographic aging of the population. The main aim of the Study is evaluation of basic health, functional and social status of the elderly patients (N = 645) admitted in Institute of Gerontology, Home Treatment and Care (IGHTC) Belgrade in 2001. Particular attention has been paid to the health and social status of the "oldest old" (90+ age) patients in comparing to the group of the "young old" (60-74 age). The purpose is to explore specific health and social need of the oldest old patients, which determine requirements for home care and could present risk factors for their institutionalization. Results can help in health promotion and preventive health care of the oldest old. The results show significantly smaller degree of utilization of health care services in the population of age 90+. We may raise the question of reason for this: the discrimination of the "oldest old" patients in the health security system, unavailability because of functional dependence and non-adjusted system of health care to the oldest patients. This fact confirms the importance of home care services. Home care services, not only contribute to the maintaining quality of life in the old age, but delay and/or prevent institutionalization of patients who are under greatest risk of this. This is for sure one step towards the rationalization of health care costs.

[Echosonography in diagnostics of carotid artery disease].

Color duplex scanning is important method in diagnostics of carotid stenosis disease (CSD). This method is accurate in estimation of stenosis degree and plaque quality characteristics as potential source of embolus. It enable the approach to extracranial as mostly affected segments of carotid arteries, frequent follow up of asymptomatic clinical course of the disease and inspection in local chemodynamic flow parameters. Beside numerous advantages, in cases of severe degree stenosis of echolucent or heterogeneous calcificant plaques, estimation of stenosis degree is inaccurate and than the use maximal flow velocities for stenosis degree estimation is better. Unfortunately in this situation some local carotid changes like multiple carotid plaques, significant proximal or distal concomitant stenosis as well as some disease like arterial hypertension, aortic valve disease, arrhythmia absoluta etc. may over or underestimate the stenosis degree, and thus make impossible the right diagnosis.

The principles of chemotherapy of colorectal cancer in elderly.

The prevalence of colorectal cancer (CRC) increases significantly with age, with 40% of patients in Europe being older than 74 years of age at the time of initial diagnosis. The individualized management of the older-aged patient with cancer is based on the answers to the following questions: 1) will the patient die of cancer or with cancer; 2) will the patient suffer cancer-related morbidity; and 3) is the patient able to handle the toxicity of treatment? More than chronological age, the following parameters are important when elderly patients are to be treated with antineoplastic agents: general condition, liver function, kidney function and bone marrow status. Frail elderly with malignant disease should not be treated with cytostatic therapy. In the case of fit elderly, the standard chemotherapy (i.e. FOLFOX) regimen could be administered. In elderly ineligible for combination chemotherapy, the capecitabine used orally, as a single-agent therapy, is an important therapeutic option for colorectal cancer.

Is there such thing as "vaccine against aging"?

Problem could be found in the fact that very often we look for one deciding, definitive reason for the process of aging. It is a sort of search for a big discovery, like a fountain of youth or such. More and more authors are trying to explain the unknowns in the understanding of these observations about ageing, by adding the statement that there are two subgroups in the general population. This acknowledgement of two subpopulations explains why there are numerous cases that can not be explained or defined or fitted in these basic observations about caloric restrictions and the delay of reproduction. The identification of those two groups would allow us to find more realistic results in studies, and therefore a more efficient therapy of certain diseases. This hypothesis does not contradict theories of aging that we have accepted (at least not the majority of accepted theories), and this hypothesis also does not contradict the fact that there is a large interindividual variability. This hypothesis doubts, and claims there are exceptions to the starting assumption of geriatrics and gerontology's that: "parallel to the aging process the functions of all organs and organ systems lessen". In future we could use one of these screening tools to detect genetic instable population: the cytokinesis-block micronucleus assay, expression of hTERT, the component of the enzyme telomerase, identification of the "longevity" genes like daf-16, p53, THO, HSP70 or the level of insulin-growth factor-I. This would enable us to correct genetic instability in this population with "vaccine of youth", making the human race living 30 years longer with excellent life quality.

[Melkersson's-Rosenthal's syndrome]. / Melkerson-Rozentalov sindrom.

We examined a patient with Melkersson's-Rosenthal's syndrome who was admitted to the Department of Clinical Neurology for acute cerebral hemispheric ischaemic infarction. The patient presented the typical triad of features that include facial oedema, facial palsy, and fissure of the tongue. He had also manifestations unusual for that age (a 33 year-old man): hypertension, permanent haematuria and advanced cerebral stenoocclusive vascular disease. Immunological measurements have shown sligthly increased levels of both serum immunoglobulin and B lymphocytes, and high levels of histamine in blood. The patient was hypersensitive to certain external antigens (exhaust, fumes, Coca-Cola, fungicide--T.M.T.D.). This case demonstates the complexity of this syndrome and illustrates the necessity of long-term follow-up of such patients.

[Atopy and drug allergy]. / Odnos atopije i alergije na lekove.

UNLABELLED: The aim of our study is to show possible correlation between atopy and drug allergy, and the clinical manifestations of drug allergy that may have predictive value. There were 150 patients with positive history of drug allergy, ages 18-73 years. Cutaneous anr/or dose provocative testing was done, depending on the drug. Drug allergy was found in 58 patients (40%). There were 18 patients (12%) with atopic diathesis of which 9 (50%) were found to have drug allergy. Of 17 patients diagnosed as anaphylaxis, 13 (76%) had drug allergy, penicillin being the most common offending drug (7 parients). Of 75 patients diagnosed as urticaria, drug allergy was prouded in 36 (47%) patients. Positive drug allergy was found as follows (percentage wise): trimetoprim-sulfometoksazol 46% (13 tested, 6 positive); penicillin 35,8% (54 tested, 19 positive); noraminophenazone 31% (22 tested, 6 positive); muscle relaxants and general anaesthetics 26% (23 tested, 6 single positive). CONCLUSIONS: Athophy is not predisposing factor for drug allergy; 60% of patients did not have drug allergy although stated in medical documents; anaphylaxis has the highest predictive value, followed by urticardia and fixed drug eruption (when trimetoprim-sulfometoxasol is concerned).

[Significance of monitoring histamine serum levels, cryoglobulins and complement titers during cold tests in patients with cold allergy and Raynaud's phenomenon]. / Znacaj pracenja vrednosti histaminemije, krioglobulina i titra komplementa u toku testa hladjenja u pacijenata sa alergijom na hladnocu i Raynaud fenomenom.

The aim of our investigations is to evaluate blood histamine, complement titer and cryoglobulins before and after cold stimulation (extremity water immersion test) in patients with cold urticaria and Raynaud phenomenon. In our investigations patients were put into five groups according to the following diagnoses: cold urticaria (40 patients), chronic urticaria (15 patients), Urticaria-Vasculitis Syndrome (15 patients), Raynauds Disease (16 patients), and Raynauds phenomenon (15 patients). The investigations demonstrated that the test was always positive in cold urticaria and that a high percentage of patients had a rise in blood histamine. This was found in 50% of the patients while cryoglobulins were found in one third of the patients. Consequently they can be grouped in secondary cold urticarias. A number of patients with chronic urticaria and Urticaria-Vasculitis Syndrome gave a positive history of cold sensitivity. Positive tests were accompanied by a rise in histamine, although (less frequently) there was a decrease in the complement titer and the occurence of cryoglobulins. Raynauds Disease was accompanied by a positive test in 94% of the patients, while patients with Raynauds Phenomenon (whose etiology was Thoracic Outlet Syndrome) had a negative test (60% of the patients). Significant changes were not found in the remaining groups. Positive tests were accompanied by abnormal values of cryoglobulins and of complement titer as well as an increase in histamine. The rise in histamine was not significant in Raynauds Phenomenon, while one patient had a decrease in the complement titer and the appearance of cryoglobulins.

[Histologic manifestations in the skin in alpha-lactoalbumin intradermal tests in patients with chronic urticaria]. / Histoloske pojave u kozi u toku intradermnog testa alfa-laktoalbuminom kod bolesnika s hronicnom urtikarijom.

Intradermal injection with alpha-lactoalbumine, 2000 PNU/ml was carried out in seven patients (1 male, 6 females, mean age 32.4 years) suffering from milk intolerance. None of the patients had a positive allergen-specific IgE antibodies in the sera (RAST). Skin test was performed on the volar part of the forearms at the same time. The area of skin reaction was estimated and measured within 36 hours on the right arm. Skin biopsy was done with a 4 mm punch after 8 hours from site of antigen injection on the left arm. Various cells infiltrating the site of antigen instillation were present. Leukocytoclastic vasculitis was only found in patients with dual intradermal reaction (immediate and late onset of response; 8 12 hours). These results indicate that local skin reaction to alpha-lactoal-bumine is mediated by diverse immune mechanisms, and that it may be of clinical significance for the diagnosis of cow milk allergy in adults.

[Clinico-laboratory characteristics of physical urticaria]. / Klinicko-laboratorijske karakteristike fizickih urtikarija.

Physical urticarias represent a specific reaction of the skin, which is characterised by local erythema, edema and pruritus at the site where the physical stimulus has been applied. However, local changes can be associated with various systemic manifestations. Specific cutaneous reactions due to physical factors may be the first manifestation of a systemic and/or infectious disease, which should be taken into account as physical urticarias generally occur in young patients. In view of the above mentioned, as well as unpredictable course of the disease and relatively limited therapeutic effects, the etiology and pathogenesis of the physical urticarias are one of the most interesting fields of investigation in contemporary medicine.

[Effect of ranitidine on the pharmacokinetics of theophylline in patients with obstructive pulmonary disease]. / Moguci uticaj ranitidina na farmakokinetiku teofilina u bolesnika sa opstruktivnim bolestima pluca.

Investigations were performed on 20 patients with mild and moderately severe forms of bronchiale asthma or chronic obstructive bronchitis. Theophylline for oral use (sustained release form) and Ranitidine (second generation H2-blocker) were used in the first group of patients (7 females and 3 males, average age 37.9). Dosage of theophylline from patients sera was monitored at 3, 6 and 12 hours, beginning with the initial morning dose. The second group of patients (9 females and 1 male, average age 46.3) were on Ranitidine therapy, along with 250 mg intravenous theophylline-ethylene-diamine. Fractionated dosage of theophylline was done within 12 hours. Pharmacokinetic parameters were calculated according to the concentration of theophylline in the sera of patients in the second group. Significant differences were not found by statistical analysis (T-test) in the pharmacokinetic parameters of theophylline although significantly higher concentrations of theophylline were found in the sera of patients in the first group. This indicated that there are individual differences on the metabolism of theophylline drugs with concomitant use of Ranitidine.

[Laboratory study of patients with endemic nephropathy]. / Prilog laboratorijskim ispitivanjima bolesnika sa endemskom nefropatijom.

The introduction deals with the main characteristics of two representatives of high risk pregnancies: diabetes mellitus and EPH gestoses. Particular interest was shown in risks that may occur in pregnant diabetics, with which they must be acquainted. Some theories are given on the pathogenesis of EPH gestoses. The aim of our investigation was to determine the concentration at which immunoglobulins G, M and A pass in cord blood, amniotic fluid and urine, and whether there is a significant difference between control group and among pregnant diabetics or those with EPH gestoses. The investigation was performed by the nephelometric technique on the Immunochemistry Analyzer. Each group consisted of 20 women, with a total of 60. Immunoglobulins A, M and G were determined in the mothers' sera, cord blood or amniotic fluid. IgG was obtained in urine in measurable concentrations. A significant increase of IgG was found in the urine of pregnant diabetics. IgM was significantly increased in the sera of diabetic mothers. IgA was significantly increased in pregnant diabetics, while both high risk pregnancy groups had an increased IgA in cord blood. The values of IgA in amniotic fluid were decreased in the EPH gestoses group in comparison to the group of diabetics. The authors find these variations interesting and feel they should be followed in other high risk pregnancy groups.

[The effect of ranitidine on theophylline pharmacokinetics in patients with obstructive lung disease]. / Uticaj ranitidina na farmakokinetiku teofilina u bolesnika sa opstrukcionim bolestima pluca.

The study was performed in 20 patients with mild and moderately severe forms of bronchial asthma or chronic obstructive bronchitis. Theophylline for oral use (sustained release form) and ranitidine was used in the first group of patients (7 females and 3 males, mean years of age 37.9). Dosage of theophylline from patients' sera was monitored prior and at 3, 6, and 12 hours beginning with the initial morning dose. The second group of patients (9 females and 1 male, mean age 46.3 years) were on ranitidine therapy along with 250 mg intravenous theophylline-ethylene-diamine. Fractionated dosage of theophylline was made within 12 hours. Pharmacokinetic parameters were calculated according to the concentration of theophylline in the sera of patients in the second group. In the sera of patients in the first group significantly higher concentrations of theophylline were found at 3 and 6 hour of the initial morning dose (p less than 0.05). In the second group a significant difference was not registered for the assessed pharmacokinetic parameters. This investigation indicates that there are individual differences of the metabolism of theophylline drugs with concommitant use of ranitidine.

[The oral milk provocation test in patients with chronic urticaria]. / Oralni provokacioni test mlekom u bolesnika sa hronicnom urtikarijom.

Histamine and sera complement were followed-up in patients with chronic urticaria during oral provoking test to cow milk. Three patients with a positive history to cow milk sensitisation showed a significant decrease in C3 concentration within 180 minutes of the test. This was followed by increased histamine and skin eruption. According to our results (skin test reactivity and clinical evaluation of the provoking test) several mechanisms were involved in the sensitisation to cow milk in our patients.