Historical review: Towards the 50th anniversary of the last major smallpox outbreak (Yugoslavia, 1972).

In 1972, Yugoslavia experienced the largest outbreak of smallpox in the history of Europe following the Second World War and its first smallpox outbreak after 1930. The origin of the infection is believed to be a pilgrim who visited countries in the Middle East. In this epidemic in Yugoslavia, from 16th February to 11th April 1972, a total of 175 people fell ill, 35 (20%) of whom died. Measures against the outbreak were based on the strategy that was common in the final phase of the smallpox eradication program. It started with active surveillance and rapid identification of new cases. Measures, such as mass vaccination and quarantine of direct contacts, were promptly taken. In a few weeks, 18 million people had been vaccinated and approximately 15,000 had been quarantined. Yugoslavia was declared free of smallpox on 9th May 1972. The global community today is confronted with serious threats from infectious diseases, which can appear as outbreaks and pandemics.

Trend analyses of breast cancer incidence and mortality in Vojvodina.

PURPOSE: Breast cancer is the most common type of malignant tumor in women and one of the most significant public health problems in the world. The purpose of this work was to determine breast cancer epidemiology in the Autonomous Province of Vojvodina in a 20-year period (1993 to 2012) by determining breast cancer incidence and mortality in female population and analyzing the trend in the specified period. METHODS: The research involved the population of women in Vojvodina in the period from 1993 to 2012. Data were obtained from the Register for malignant neoplasms of Vojvodina. Incidence and mortality trends were analyzed by a joinpoint regression analysis. RESULTS: A total of 20,242 cases of breast cancer were registered in the observed period. Standardized incidence ratio in 2012 was 71.2/100,000. The trend of incidence increased with an average annual percentage of growth of 2.10. A total 10,062 deaths due to breast cancer were documented. Standardized incidence ratio in 2012 was 28.6/100,000. An increase of mortality rate by 1.70% per year was recorded in the period from 1992 to 2006 and a decline in the mortality rate by 1.56% was noticed afterwards. The highest percentage of deaths due to breast cancer was recorded in a group aged 60-69 years (26.7%).

A Forgotten Episode of Marburg Virus Disease: Belgrade, Yugoslavia, 1967.

In 1967, several workers involved in poliomyelitis vaccine development and production fell ill at three different locations in Europe with a severe and often lethal novel disease associated with grivets (Chlorocebus aethiops) imported from Uganda. This disease was named Marburg virus disease (MVD) after the West German town of Marburg an der Lahn, where most human infections and deaths had been recorded. Consequently, the Marburg episode received the most scientific and media attention. Cases that occurred in Frankfurt am Main, West Germany, were also described in commonly accessible scientific literature, although they were less frequently cited than those pertaining to the Marburg infections. However, two infections occurring in a third location, in Belgrade, Yugoslavia, have seemingly been all but forgotten. Due in part to their absence in commonly used databases and in part to the fact that they were written in languages other than English, the important articles describing this part of the outbreak are very rarely cited. Here, we summarize this literature and correct published inaccuracies to remind a younger generation of scientists focusing on Marburg virus and its closest filoviral relatives of this important historical context. Importantly, and unfortunately, the three episodes of infection of 1967 still represent the best in-depth clinical look at MVD in general and in the context of "modern" medicine (fully resourced versus less-resourced capacity) in particular. Hence, each individual case of these episodes holds crucial information for health care providers who may be confronted with MVD today.

Assessment of climate change impact on the malaria vector Anopheles hyrcanus, West Nile disease, and incidence of melanoma in the Vojvodina Province (Serbia) using data from a regional climate model.

Motivated by the One Health paradigm, we found the expected changes in temperature and UV radiation (UVR) to be a common trigger for enhancing the risk that viruses, vectors, and diseases pose to human and animal health. We compared data from the mosquito field collections and medical studies with regional climate model projections to examine the impact of climate change on the spreading of one malaria vector, the circulation of West Nile virus (WNV), and the incidence of melanoma. We analysed data obtained from ten selected years of standardised mosquito vector sampling with 219 unique location-year combinations, and 10 years of melanoma incidence. Trends in the observed data were compared to the climatic variables obtained by the coupled regional Eta Belgrade University and Princeton Ocean Model for the period 1961-2015 using the A1B scenario, and the expected changes up to 2030 were presented. Spreading and relative abundance of Anopheles hyrcanus was positively correlated with the trend of the mean annual temperature. We anticipated a nearly twofold increase in the number of invaded sites up to 2030. The frequency of WNV detections in Culex pipiens was significantly correlated to overwintering temperature averages and seasonal relative humidity at the sampling sites. Regression model projects a twofold increase in the incidence of WNV positive Cx. pipiens for a rise of 0.5°C in overwintering TOctober-April temperatures. The projected increase of 56% in the number of days with Tmax ≥ 30°C (Hot Days-HD) and UVR doses (up to 1.2%) corresponds to an increasing trend in melanoma incidence. Simulations of the Pannonian countries climate anticipate warmer and drier conditions with possible dominance of temperature and number of HD over other ecological factors. These signal the importance of monitoring the changes to the preparedness of mitigating the risk of vector-borne diseases and melanoma.

Smallpox as an actual biothreat: lessons learned from its outbreak in ex-Yugoslavia in 1972.

Variola (smallpox) virus is classified as class A of potential biological weapons, due to its microbiological, genetic, antigenic and epidemiological characteristics. The potential danger is more real because vaccination against smallpox has stopped since disease eradication in 1979. That is why we want to share our unique, rich experience and acquired knowledge in the fight against this highly contagious and deadly disease during the smallpox outbreak in ex-Yugoslavia in 1972. It was the largest postwar outbreak in Europe when there were officially registered 175 ill patients, 35 of them with lethal outcome. This outbreak was specific by the time of its occurrence, the affected territory, dimensions and some epidemiological characteristics, but also by the well-organized, synchronized and efficient reaction of the competent state services in the fight against it.

Anthrax of domestic animals in Vrbas Banate: from traditional beliefs to the first scientific views on the ancient disease.

From 1929 to 1941, the Vrbas Banate was one of nine provinces of the Kingdom Yugoslavia, and according to historical data, the poorest one, without well-organized and sustainable agriculture production. Naturalistic production and poor animal health control in the Vrbas Banate were the most important risk factors for infectious disease spreading. Anthrax was very prevalent infectious disease in domestic animals and humans in that period, but some data on this disease remain scarce. In this paper epidemiology and clinical investigation of anthrax in the Vrbas Banate are reviewed. Apart from many aggravating factors that influenced the control of anthrax, the veterinary service of Banate contributed to the development of animal husbandry, animal health and public health in that period.

Influenza B Viruses in the Population of Province of Vojvodina during the 2012/2013 Season: Differentiation of B/Yamagata and B/Victoria Lineages by Real-time RT-PCR, Antigenic and Phylogenetic Characterization.

INTRODUCTION: At present, two phylogenetically distinct influenza B virus lineages, B/Yamagata and B/ Victoria, co-circulate worldwide and can cause significant morbidity and mortality. OBJECTIVE: The aim of this study was to determine the prevalences of two influenza B virus lineages in the population of Vojvodina and to identify their antigenic and phylogenetic properties. METHODS: A total of 369 and 334 nasopharyngeal, or nasal/throat swab samples, collected during the 2012/2013 and 2013/2014 seasons, respectively, were tested using specific singleplex influenza A, influenza B, influenza B/Yamagata and influenza B/Victoria real-time reverse transcription polymerase chain reaction (RT-PCR) assays. Antigenic and genetic testing were done by hemagglutination inhibition assay and hemagglutinin and neuraminidase gene sequence analysis, respectively. RESULTS: During the 2012/2013 season, influenza B viruses were present in 53.4% (101/189) of influenza positive samples.The B/Yamagata-like viruses (81.2%) significantly predominated over the B/Victoria-like viruses (18.8%). Comparing to B/Victoria-like positive patients, among B/Yamagata-like positive patients, children 5-14 years of age were significantly more represented (5.3% vs. 35.4%, respectively), as well as patients with mild form of illness (15.8% vs. 45.1%, respectively). The results of sequence analysis and antigenic testing showed that tested viruses were not closely related to B/Wisconsin/1/2010, the vaccine virus for 2012/2013. During the 2013/2014 season influenza B viruses were not detected. CONCLUSION: The results of this study confirmed the health significance of influenza B viruses and indicated that B/Yamagata-like viruses were significantly more prevalent than B/Victoria lineage viruses, during the 2012/2013 season. They also showed a sub-optimal match between the tested viruses and the vaccine virus for season 2012/2013.

Blood lead concentration and thyroid function during pregnancy: results from the Yugoslavia Prospective Study of Environmental Lead Exposure.

BACKGROUND: Although maternal hypothyroidism increases the risk of adverse neonatal and obstetric outcomes as well as lower IQ in children, the environmental determinants of maternal thyroid dysfunction have yet to be fully explored. OBJECTIVES: We aimed to examine associations between mid-pregnancy blood lead (BPb) and concomitant measures of thyroid function among participants in the Yugoslavia Prospective Study of Environmental Lead Exposure. METHODS: As part of a population-based prospective study of two towns in Kosovo-one with high levels of environmental lead and one with low-women were recruited during the second trimester of pregnancy, at which time blood samples and questionnaire data were collected. We measured concentrations of BPb, free thyroxine (FT4), thyroid-stimulating hormone (TSH), and thyroid peroxidase antibodies (TPOAb) in archived serum samples. RESULTS: Compared with women from the unexposed town, women from the exposed town had lower mean FT4 (0.91 ± 0.17 vs. 1.03 ± 0.16 ng/dL), higher mean TPOAb (15.45 ± 33.08 vs. 5.12 ± 6.38 IU/mL), and higher mean BPb (20.00 ± 6.99 vs. 5.57 ± 2.01 µg/dL). No differences in TSH levels were found. After adjustment for potential confounders, for each natural log unit increase in BPb, FT4 decreased by 0.074 ng/dL (95% CI: -0.10, -0.046 ng/dL), and the odds ratio for testing positive to TPOAb was 2.41 (95% CI: 1.53, 3.82). We found no association between BPb and TSH. CONCLUSIONS: Prolonged lead exposure may contribute to maternal thyroid dysfunction by stimulating autoimmunity to the thyroid gland.

Mechanisms of psychological distress following war in the former Yugoslavia: the role of interpersonal sensitivity.

While high prevalence rates of psychological symptoms have been documented in civilian survivors of war, little is known about the mechanisms by which trauma exposure might lead to poor psychological outcomes in these populations. One potential mechanism that may underpin the association between war-related traumatic experiences and psychopathology is interpersonal sensitivity. In the current study, we applied structural equation modeling to investigate the impact of interpersonal sensitivity on posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and anger responses following exposure to war trauma. 3313 survivors of the war in the former Yugoslavia were identified and selected using a multistage, probabilistic sampling frame and random walk technique. Participants were interviewed regarding trauma exposure, interpersonal sensitivity, and PTSD symptoms, depression symptoms, and anger responses. Structural equation modeling analyses revealed that the relationship between trauma and PTSD symptoms and depression symptoms was partly statistically mediated by interpersonal sensitivity. Further, findings indicated that the relationship between trauma and anger responses was fully statistically mediated by interpersonal sensitivity. These results suggest that interpersonal sensitivity may function as a key mechanism that contributes to psychopathology following trauma.

Epidemiology of pancreatic cancer in vojvodina province in Serbia.

PURPOSE: Analysis of descriptive epidemiological characteristics of pancreatic cancer in Vojvodina, Serbia. MATERIALS AND METHODS: The study covers population of Vojvodina in the period from 2000 to 2009. The method used for data processing was the descriptive. The data, referring to a specified period of time, were analyzed from chronological and demographic aspects and according to histological diagnosis. RESULTS: In the period from 2000 to 2009, there were 2,108 registered cases of pancreatic cancer of which 1,886 had a fatal outcome. Standardized incidence rates varied between 5.7 and 9.1 per 100,000 population in males and between 4.2 and 5.3 in females. Linear incidence trends in males in the specified period of time, based on crude (r=0.7883, p<0.05) and standardized (r=0,6373, p<0,05) incidence rates, demonstrated increase. Annual percent increase in the crude incidence rate was 4.5% in males, and 2.8% in females. Age-standardized mortality rates varied between 5.2 and 7.5 per 100,000 population in males and 3.6 and 4.7 in females. Linear mortality trends in males in the specified period of time, based on crude (r=0.8795, p<0.05) and standardized (r=0.7669, p<0.05) mortality rates, also demonstrated annual percent increase. CONCLUSIONS: Data analysis shows unfavorable onco-epidemiological situation related to pancreatic cancer in Vojvodina, in aspects of both incidence and mortality. Absence of primary and secondary prevention does not allow medical institutions to successfully fight against this disease.

Secular trends and latitude gradients in the male-female ratio at birth in Yugoslavia and the ex-Yugoslavian States.

BACKGROUND: Latitude gradients and secular trends in Europe and North America have been found in the male-female ratio at birth (M/F: male births divided by total births) which approximates 0.515. METHODS: Annual national data for Yugoslavia and the post-Yugoslavia States for male and female live births were obtained from the World Health Organisation and analysed with contingency tables. RESULTS: This study analysed 22,020,729 live births. There was a increasing trend in M/F prior to the breakup of the former Yugoslavia (1950-1990, p = 0.002), followed by a decreasing trend after 1990 (p = 0.02). A latitude gradient was also noted, with more males being born in southern, warmer latitudes (p < 0.0001). There was an overall excess of 42,753 male births based on an anticipated M/F of 0.515. CONCLUSION: M/F is decreasing in this region, similar to the rest of Europe and North America. A latitude gradient is also present with more males being born in warmer (more Southern) latitudes (p < 0.0001), even in this small region and over the short time-frame studied.

Prevalence and socioeconomic correlates of chronic morbidity among elderly people in Kosovo: a population-based survey.

BACKGROUND: Our aim was to assess the prevalence and demographic and socioeconomic correlates of chronic morbidity in the elderly population of transitional Kosovo. METHODS: A cross-sectional study was conducted in Kosovo in 2011 including a representative sample of 1890 individuals aged ≥ 65 years (949 men, mean age 73 ± 6 years; 941 women, mean age 74 ± 7 years; response rate: 83%). A structured questionnaire inquired about the presence and the number of self-reported chronic diseases among elderly people, and their access to medical care. Demographic and socioeconomic data were also collected. Binary logistic regression was used to assess the association of demographic and socioeconomic characteristics with chronic conditions. RESULTS: In this nationwide population-based sample in Kosovo, 42% of elderly people were unable to access medical care, of whom 88% due to unaffordable costs. About 83% of the elderly people reported at least one chronic condition (63% cardiovascular diseases), and 45% had at least two chronic diseases. In multivariable-adjusted models, factors associated with the presence of chronic conditions and/or multimorbidity were female sex, older age, self-perceived poverty and the inability to access medical care. CONCLUSION: This study provides important evidence on the magnitude and distribution of chronic conditions among the elderly population of Kosovo. Our findings suggest that, in this sample of elderly people from Kosovo, the oldest-old (especially women) and the poor endure the vast majority of chronic conditions. These findings point to the urgent need to establish a social health insurance scheme including the marginalized segments of elderly people in this transitional country.

Effects of treatment adherence on clinical and economic outcomes in patients with psoriasis.

AIM: To compare clinical and cost outcomes of psoriasis in non-biological treatment of adherent and non-adherent patients in a developing Balkans country going through socio-economic transition. METHODS: The study was designed as a retrospective cohort study involving patients with psoriasis adherent and non-adherent to the prescribed treatment regimen. The patients were followed for a period of one year, through four visits with intervals of three months. The adherence to the prescribed regimen was measured at the end of the follow-up period by the medication possession ratio. Clinical outcomes of the treatment were estimated by the Psoriasis Area Severity Index (PASI) at each visit and the treatment costs were collected from patients' files at each visit. RESULTS: The study enrolled 108 patients, 61 (56.5%) were adherent to the prescribed treatment, and 47 (43.5%) were non-adherent. A signiicant decrease of PASI score was noted in the patients adherent to prescribed therapy (p < 0.001). The costs also decreased significantly in the group of adherent patients (p=0.001), and the drop of costs was the highest from the visit 3. The decrease in PASI score and costs were less rapid in non-adherent patients. CONCLUSION: Better treatment adherence leads to faster clinical improvement and a more rapid decrease in costs of treatment, which diminish overall expenditure of the health system and society, leaving room for treatment of other diseases more efficiently. Therefore, health systems of developing countries should support additional research of causes of treatment non-adherence in patients with psoriasis, in order to minimize this fenomenon more efficiently, and make significant savings.

Early neurologic complications and long-term sequelae of childhood bacterial meningitis in a limited-resource country (Kosovo).

PURPOSE: Since neurologic complications of childhood bacterial meningitis are encountered frequently despite antibiotic treatments, the purpose of this study was to analyze early neurologic complications and long-term sequelae of bacterial meningitis in children in a limited-resource country (Kosovo) METHODS: This study uses a retrospective chart review of children treated for bacterial meningitis in two study periods: 277 treated during years 1997-2002 and 77 children treated during years 2009-2010. RESULTS: Of the 277 vs 77 children treated for bacterial meningitis, 60 (22%) vs 33 (43%) patients developed early neurologic complications, while there were 15 (5.4%) vs 2 (2.6%) deaths. The most frequent early neurologic complications were the following: subdural effusions (13 vs 29%), recurrent seizures (11 vs 8%), and hydrocephalus (3 vs 3%). The relative risk (95% confidence interval) for neurologic complications was the highest in infants (3.56 (2.17-5.92) vs 2.69 (1.62-4.59)) and in cases caused by Haemophilus influenzae 1.94 (1.09-3.18) vs Streptococcus pneumoniae 2.57(1.26-4.47). Long-term sequelae were observed in 10 vs 12% of children, predominantly in infants. The most frequent long-term sequelae were late seizures 9 vs 1%, neuropsychological impairment 1 vs 5%, and deafness 1 vs 3%. CONCLUSIONS: In both study periods, the most frequent early neurologic complications of childhood bacterial meningitis were subdural effusions. Long-term sequelae were observed in 10% of children, with late seizures, neuropsychological impairment, and deafness being the most common one. Age prior to 12 months was risk factor for both early neurologic complications and long-term sequelae of bacterial meningitis in children.

Epidemiological and clinical features of erythema infectiosum in children in Novi Sad from 2000 to 2009.

BACKGROUND/AIM: Erythema infectiosum (EI) is a common childhood illness, caused by human parvovirus B19. It occurs sporadically or in epidemics and is characterized by mild constitutional symptoms and a blotchy or maculopapular lacy rash on the cheeks (slapped-cheek) spreading primarily to the extremities and trunk. The aim of our study was to analyse the epidemiological and clinical characteristics of erythema infectiosum in children. METHODS: This study included 88 children observed in the Department of Dermatology of the Institute for Child and Youth Health Care of Vojvodina, in Novi Sad, during the period January 2000-December 2009. We compared the data about the clinical characteristics during and after the outbreak of EI observed from December 2001 to September 2002. The data were retrieved from the hospital database. RESULTS: During the study period, EI was detected in 88 children (44 females and 44 males), 0.213% of the total number of 41,345 children observed in the Department of Dermatology. An outbreak of erythema infectiosum was observed from December 2001 to September 2002, with the peak frequency in April and May 2002 and 39 diagnosed cases, and stable number of cases from 2005 to 2009 (a total of 49 diagnosed cases). The average age of infected children was 7.59 +/- 3.339. Eleven (12.5%) children were referred from primary care pediatricians with the diagnosis of urticaria or rash of allergic origin. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of the cases, followed by 89.77% of cheek erythema. Pruritus was present in 9.09% of the children, mild constitutional symptoms in 5.68% and palpable lymph glands in 3.41% of the children. In all the cases the course of the disease was without complications. CONCLUSION: The results of this study confirm the presence of EI (the fifth disease) in our area with a mild course in the majority of patients. Since the diagnosis of EI is usually based on clinical findings, continuing medical education of primary health care pediatricians is essential for reducing the number of misdiagnosed cases.

Prevalence of left chamber cardiac thrombi in patients with dilated left ventricle at sinus rhythm: the role of transesophageal echocardiography.

BACKGROUND: Left atrial appendage (LAA) may be a source of thrombi in patients with dilated cardiomyopathy at sinus rhythm. The objectives of our study were to assess the prevalence of intracardiac left chamber thrombus and/or spontaneous echo contrast and to identify clinical and echocardiographic predictors for left ventricle (LV), left atrium (LA), and/or LAA thrombus formation, particularly as regard to LV, LA, and LAA size, in heart failure patients at sinus rhythm. METHODS: We included 45 patients with dilated cardiomyopathy of ischemic or idiopathic origin with mild to moderate systolic dysfunction, who were at sinus rhythm and without anticoagulation therapy. RESULTS: Mean left ventricular end diastolic diameter was 64.9 ± 6.1 mm, and mean LV ejection fraction was 39.9 ± 7.3%. LV thrombus was found in 13.3% of patients and LAA thrombus in 68. 9%. Left ventricular end diastolic diameter was correlated with LA volume (r = 0.59, p < 0.0001) and LV thrombus (r = 0.38, p = 0.005). LA volume was correlated with LAA maximal area (r = 0.34, p = 0.01), which was an independent predictor for LAA thrombus formation (p = 0.003). CONCLUSIONS: Dilation of left cardiac chambers offers a suitable terrain for thrombus formation. The high probability of LAA thrombosis should be kept in mind when designing the treatment strategy for patients with dilated cardiomyopathy at sinus rhythm.

Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction.

BACKGROUND: The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional capacity assessed by 6 min walk test (6-MWT) in patients with heart failure (HF), irrespective of ejection fraction (EF). METHODS: In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and an echo-Doppler study were performed in the same day. Global LV dyssynchrony was indirectly assessed by total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time + total filling time)], and Tei index (t-IVT/ejection time). Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m), and also in two groups according to EF (Group A: LVEF ≥ 45% and Group B: LVEF < 45%). RESULTS: In the cohort of patients as a whole, the 6-MWT correlated with t-IVT (r = -0.49, p < 0.001) and Tei index (r = -0.43, p < 0.001) but not with any of the other clinical or echocardiographic parameters. Group I had lower hemoglobin level (p = 0.02), lower EF (p = 0.003), larger left atrium (p = 0.02), thicker interventricular septum (p = 0.02), lower A wave (p = 0.01) and lateral wall late diastolic myocardial velocity a' (p = 0.047), longer isovolumic relaxation time (r = 0.003) and longer t-IVT (p = 0.03), compared with Group II. In the patients cohort as a whole, only t-IVT ratio [1.257 (1.071-1.476), p = 0.005], LV EF [0.947 (0.903-0.993), p = 0.02], and E/A ratio [0.553 (0.315-0.972), p = 0.04] independently predicted poor 6-MWT performance (<300 m) in multivariate analysis. None of the echocardiographic measurements predicted exercise tolerance in HFpEF. CONCLUSION: In patients with HF, the limited exercise capacity, assessed by 6-MWT, is related mostly to severity of global LV dyssynchrony, more than EF or raised filling pressures. The lack of exercise predictors in HFpEF reflects its multifactorial pathophysiology.

Surveillance of tularaemia in Kosovo, 2001 to 2010.

Tularaemia, caused by Francisella tularensis, had not been registered in Kosovo before an outbreak in 1999 and 2000. A national surveillance system has been implemented in Kosovo since 2000 to monitor a number of diseases, including tularaemia. Antibody detection in human sera was used for laboratory diagnosis of tularaemia and F. tularensis lipopolysaccharide antigen was used as a marker of infection. The purpose of this study is to describe the incidence of tularaemia in Kosovo after the 1999-00 outbreak. In 2001 and 2002, a second outbreak occurred, with 327 serologically confirmed cases. From 2001 to 2010, 25-327 cases were registered per year, giving a mean annual incidence of 5.2 per 100,000 population. The most likely sources of infection were contaminated drinking water and food. The dominant clinical manifestations were the glandular (79%) and ulcero-glandular (21%) forms. By 2010, the disease had spread throughout Kosovo. Presumably as a result of war and subsequent environmental disruption, mass population displacement and breakdown of sanitation and hygiene, the two major outbreaks of tularaemia resulted in the establishment of an active endemic area of tularaemia in Kosovo.

Long-term impact of war on healthcare costs: an eight-country study.

OBJECTIVE: Exposure to war can negatively affect health and may impact on healthcare costs. Estimating these costs and identifying their predictors is important for appropriate service planning. We aimed to measure use of health services in an adult population who had experienced war in the former-Yugoslavia on average 8 years previously, and to identify characteristics associated with the use and costs of healthcare. METHOD: War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, FYR Macedonia, and Serbia were recruited through a random walk technique. Refugees in Germany, Italy and the UK were contacted through registers, organisations and networking. Current service use was measured for the previous three months and combined with unit costs for each country for the year 2006/7. A two-part approach was used, to identify predictors of service use with a multiple logistic regression model and predictors of cost with a generalised linear regression model. RESULTS: 3,313 participants were interviewed in Balkan countries and 854 refugees in Western European countries. In the Balkan countries, traumatic events and mental health status were related to greater service use while in Western countries these associations were not found. Participants in Balkan countries with post traumatic stress disorder (PTSD) had costs that were 63% higher (p = 0.005) than those without PTSD. Distress experienced during the most traumatic war event was associated with higher costs (p = 0.013). In Western European countries costs were 76% higher if non-PTSD anxiety disorders were present (0.027) and 63% higher for mood disorders (p = 0.006). CONCLUSIONS: War experiences and their effects on mental health are associated with increased health care costs even many years later, especially for those who stayed in the area of conflict. Focussing on the mental health impact of war is important for many reasons including those of an economic nature.

Mental health outcomes of widowed and married mothers after war.

We assessed prevalence rates of mental disorders in 206 mothers who had experienced the Kosovo war 10 years previously: 100 lone mothers widowed by the war, 71 non-bereaved married mothers, and 35 married mothers bereaved since the war (loss of family other than husband). A total of 96% of widowed lone mothers reported a major depressive episode, an anxiety disorder or a substance use disorder as compared with 54.9% and 60% in the married groups. Furthermore, 45% of widowed lone mothers reported current suicide risk as compared with 16.9% and 22.9% in the married samples. War-related widowhood combined with lone motherhood constitutes a significant factor for elevated psychopathology.