Health workers labor market before and during the Covid-19 pandemic: Health sector capacity of Serbia

Background

During the COVID-19 pandemic surges, healthcare stakeholders were concerned with the sufficiency of available health workforce capacity. In this study we examined the changes in the supply and demand of physicians, nurses and care workers in Serbia over the period 2011-2021.

Methods

The National Employment Service (NES) data on total number of unemployed physicians, nurses and care workers, and vacancy data in health sector were described using the annualized % change for the period 2011-2021. The long-term duration of unemployed female physicians and nurses was further analyzed.

Results

In 2021, NES has registered total of 13,332 unemployed physicians, nurses and care workers, out of which the majority were females (79%), and nurses and care workers (88%). 2021 data on vacancies showed that only 16% of unemployed workers were needed. The peak of health workers unemployment was in 2016, highlighting the period of unemployment rise (2011-2016) at an annualized rate of 3.7% for medical doctors’ specialists, 6.4% for medical doctors without specialization, and 3.2% for nurses and care workers, and the period of unemployment decline (2017-2021) at an annualized rate of -7.9% for medical doctors’ specialists, -10.9% for medical doctors without specialization, and -5.9% for nurses and care workers. The annualized rate of decline was the lowest for female nurses and care workers. On average 53% of all long term unemployed medical doctors, nurses and care workers were women. In comparison to 2019, during the COVID-19 epidemic in 2020 and 2021 the number of vacancies for specialists and nurses and care workers has increased by one-third.

Conclusions

The study indicated a continuous mismatch between the supply and demand of physicians and nurses in Serbia (a surplus of some categories of nurse-specialists versus a shortage of some doctor specialists). The Serbian stakeholders need to urgently intervene regarding the long-term unemployment of female health workers.

Key messages

• NES data imply a low capacity of the Serbian health sector to absorb the huge numbers of (long-term) unemployed health workers.

• It is necessary to thoroughly examine and counteract the causes of the dramatic number of unemployed health workers on the NES records in Serbia.

Burden of alcohol use disorder in Balkan countries

Background

Alcohol use is recognized as an important risk factor for more than 200 different diseases and injuries. In the Diagnostic statistic Manual- 5 (DSM-5) it is defined as ‘impaired control over alcohol consumption with chronic, heavy and often escalating pattern of alcohol use despite significant detrimental consequences to their overall health, the lives of their family members and friends and society in general’. The aim of this study was to describe the disability adjusted life years (DALY) associated with the alcohol use disorder in the Balkan countries in the period between 1990 and 2019.

Methods

The study included the data on age-standardized DALY rate per 100,000 for alcohol use disorder in the period between 1990 and 2019 for ten Balkan countries (Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Montenegro, North Macedonia, Romania, Serbia and Slovenia) from the Institute of Health Metrics and Evaluation. We acknowledge the support from the COST Action 18218 - European Burden of Disease Network.

Results

The highest age-standardized DALY rate in 1990 was in Romania 484.03 per 100,000 (95% CI: 394.68-594.99), while the highest age-standardized DALY rate per 100,000 in 2019 was in Slovenia 427.75 (95% CI: 332.28-543.83). Along with Slovenia, only country that recorded the increase in the age-standardized DALY rates in the period between 1990 and 2019 was Albania, but the increase was only marginal (DALY per 100,000 increased from 174.24, 95% CI: 115.07-244.76 to 187.92, 95% CI: 127.26-262.41). The lowest burden measured in age-standardized DALY rates per 100,000 in 1990 was in Albania, and in 2019 was in Greece- 174.68, 95% CI: 113.66-251.34.

Conclusions

In the majority of the Balkan countries the age-standardized DALY rates per 100,000 for alcohol use disorder decreased in the observed period. The increase is observed for Slovenia and Albania, with the more apparent increase in Slovenia.

Key messages

What influences the intention to get vaccinated against COVID-19 in the Western Balkans?

Background

Although effective vaccines against COVID-19 have been developed with the unprecedented speed, insufficient vaccine uptake suggests that many people are unwilling to get vaccinated worldwide. The aim of this study was to assess factors influencing intention to get vaccinated against COVID-19 in five Western Balkans countries.

Methods

Total of 700 unvaccinated respondents aged 18-75 participated in the study. Intention was assessed by a single item gauging the likelihood of getting vaccinated on a 5-points Likert scale. Multiple linear regression was used to determine whether socio-demographics (gender, age, religiousness, educational level, employment status, presence of chronic diseases) and attitudes towards vaccination predict intention to get vaccinated.

Results

Proportion of respondents willing to get vaccinated against COVID-19 ranged from 22.6% in Serbia to 40.4% in Montenegro. In Bosnia and Herzegovina and Albania stronger intention to get vaccinated in the future was associated with confidence in vaccine safety (β=.24, p<.01 and β=.20, p<.01 respectively) and efficacy (β=.28, p<.01 and β=.26, p<.001), higher feeling of danger of the disease (β=.21, p<.05 and β=.17, p<.05) and higher social responsibility (β=.35, p<.001 and β=.18, p<.01). Confidence in vaccine efficacy (β=.34, p<.001) and social responsibility (β=.24, p<.01), accompanied with higher sense of susceptibility to the disease (β=.13, p<.05), were significant predictors of intention in Serbia. In North Macedonia willingness to get the vaccine was significantly associated only with social responsibility (β=.09, p<.001), while in Montenegro age was the single predictor (β=-.32, p<.001);

Conclusions

Results of this study suggest that vaccination campaigns should focus on specific set of socio-psychological factors in each country, enhancing confidence in vaccine efficacy and appealing to collective responsibility as most prevalent determinants of vaccination intention in Western Balkans.

Key messages

• Specific set of socio-psychological factors influenced vaccination intention in each country.

• Most prevalent factors influencing intention to get vaccinated against COVID-19 were confidence in vaccine efficacy and social responsibility.

Sex related difference in heart failure development in patients after first myocardial infarction; role of galectine-3

 

Cardiac remodeling after the first myocardial infarction (MI) appears to be more successful in women than in men, but more frequently associated with heart failure (HF) development. Galectin-3 expression is upregulated in remodeling and failing myocardium and circulatory level is activated in hypertrophy, fibrosis and inflammation.

This study aimed to investigate the potential role of sex differences in the following: risk factors, structural and functional left ventricle (LV) changes, coronary angiography, expression of Galectin-3 and it's circulating level for HF occurrence during 6 months in patients after first MI.

Material and methods

The prospective study included patients with the first MI treated with the primary percutaneous coronary intervention (p PCI) who underwent Doppler echocardiography within 2±1 days of MI and after 6 months. Relative LGALS-3 mRNA expression in peripheral blood were detected by TaqMan® technology. Expression and concentration of Galectin-3 was obtained by ELISA method. Presence of HF was confirmed by clinical examination and Doppler echocardiography. Assessment of p PCI and description of coronary angiography was performed at the patient's admission time.

Results

The study included 137 men and 44 women, who were significantly older (57.8 vs. 54.4, p=0.034), with higher LDL cholesterol (3.54±0.93 vs. 4.03±1.27, p=0.027) without differences among angiographic characteristics and medications. In the acute phase of MI, the significantly lower indexed LV volumes were found in women compared to men (EDLVI: 58.3 vs. 49.6, p<0.001, ESLVI: 33.84 vs. 26.83, p<0.001), but the grade of LV remodeling (delta LVDVI, delta LVESVI) during 6 months and changes in LV ejection fraction (deltaLVEF) were similar (p=ns). Incidence of LV hypertrophy and HF development was significantly higher in women 70% vs. 44.6%, p=0.034, 37.5% vs.19.3%, p=0.02). Females have had a higher degree of LV diastolic dysfunction (DD) in the early and late phase after MI (p=0.038, p=0.027). There were significant correlations between grade of DD and level of Gal-3 expression (p=0.001). The relative expression of LGALS-3 mRNA in peripheral blood was higher in females (p=0.007) with upregulation of circulating Gal-3 in females (44.66 vs. 16.30, p<0.001) and in HF patients (31.1 vs. 21.2, p=0.025).

Conclusion

Sex specific actions such as LV hypertrophy, diastolic dysfunction, upregulation of Galectin-3 expression and higher circulating level may explain more incidence of HF in female. Difference in model and determinants of HF between men and women can be important for further therapy including Gelectin-3 inhibition.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Left atrial function in patients with heart failure with mid-range and preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction Little is known about the left atrial (LA) function in patients with heart failure with mid-range and preserved ejection fraction (EF). We explored LA function in patients with heart failure with mid-range ejection fraction (HFmrEF) and compared to that in patients heart failure with preserved ejection fraction (HFpEF).

Methods

A total of 66 HF patients (35 HFpEF and 31 HFmrEF) were included in the study. Left venticular EF, global longitudinal strain (GLS) and the mitral E/e" ratio were measured in all patients. LA function was assesed by measuring phasic changes in LA volume - maximal LA volume, pre-atrial contraction volume and minimal LA volume. All volumes were indexed to body surface area before calculating the indices of LA function: LA total emtying fraction (reservoir function), LA passive emptying fraction (conduit function) and LA active emptying fraction (pump function).

Peak LA strain during ventricular systole (S-LAs) and peak LA strain during atrial systole (S-LAa) were measured also as LA functional parameters (reservoir and pump function). Conduit function of LA was derived as difference of S-LAs and S-LAa.

LA deformation was also assessed by strain rate at different phases of the cardiac cycle. Strain rate analysis was used to measure peak LA strain rate during ventricular systole (SR-LAs), during early LV filling (SR-LAe) and during atrial contraction (SR-LAa).

Results

There were no significant differences in GLS and the mitral E/e’ between patients with HFmrEF and HFpEF (p > 0.05 for all). Significantly lower values of LA total emptyng fraction (47.6 ± 13.0 vs 38.9 ± 11.8, p = 0.006), LA passive emptyng fraction (26.6 ± 13,2 vs 20.9 ± 9.4, p = 0.049) and LA active emptyng fraction (33.0 ± 10.0  vs. 26.0 ± 9.7, p = 0.005) were observed  in HFmrEF tham HFpEF patients, respectively.

Significantly lower values of S-LAs (27,3 ± 5,8 vs 22,3 ± 8,0, p = 0,004), S-LAa (12,8 ± 4,0 vs  10,3 ± 3,7, p = 0,01) (Figure 1), SR-LAs (1,40 ± 0,42 vs 1,18 ± 0,43, p = 0,045), SR-Lae (-1,47 ± 0,56 vs -1,13 ± 0,51, p = 0,012) and SR-LAa (-1,90 ± 0,50 vs -1,64 ± 0,55, p = 0,044) were obtained in group of HFmrEF patients.

Conclusions

All components of left atrial function were worse in patients with HFmrEF than in those with HFpEF, despite similar GLS and mitral E/e" ratio. Clinical and prognostic implications of these observations warrant futher research. Abstract Figure.

P279 Subclinical left ventricular dysfunction in patients with insulin resistence and hypovitaminosis D

Introduction

Patients with subclinical left ventricular diastolic and systolic dysfunction are at risc of future cardiac events.

Insulin resistance (IR) has been reported to be a strong risk factor for cardiovascular disease (CVD). Hypovitaminosis D is associated with insulin resistance and beta cell dysfunction and vitamin D deficiency is also associated with increased risk of CVD, including hypertension, heart failure, and ischemic heart disease.

Aim

The aim has been to explore association of IR and vitamin D deficiency with subclinical left ventricular disfunction.

Method

The study consisted of 79 patients divided into two groups according IR, evaluated at baseline by the homeostasis model assessment method (HOMA-IR). v The HOMA1-IR index was calculated by the formula: HOMA1-IR = fasting plasma insulin (µU/ml) x fasting plasma glucose (mmol/L). The HOMA2-IR index was obtained by the program HOMA Calculator (free) download Windows version.

The cut-off values for IR were: HOMA1-IR > 2.7 and HOMA2-IR > 1.8; group of 41 patients, and group od 38 patients without of IR.

Parameters of left atrial and ventricular geometry were estimated by echocardiography. Tissue Doppler velocities were measured from medial and lateral annulus (e, a, s) including isovolumic contraction velocity (IVCv) and E/e Global longitudinal strain (GLS) was derived from two-dimensional speckle-tracking.

Results

In IR group level of 25-OH-D was deficient in 25 (61.2%), insufficient in 10 (25%) and sufficient in 6 (13.8%) patients and significantly lower compared to control group (46.8 ± 25.5 vs 61.5 ± 33.8, p < 0.001).

Importantly, 25-OH-D was associated with global longitudinal strain (r= −0.21, <0.05). Values of GLS (-19.9 ± 2.8 vs -26.6 ± 2.9; p < 0.001) and IVCv (0.07 ± 0.02m/s vs 0.09 ± 0.03m/s; p < 0.05) were significantly lower and E/e (9.11 ± 2.24 vs 7.18 ± 1.65; p < 0.001) significantly higher in group of patients with IR.

Conclusion

The results showed that insulin resistence is asociated with subclinical LV diastolic and systolic dysfunction. Level of 25-OH-D was significantly lower in patients with insulin resistence suggests that vitamin D deficiency may have a certain contribution to the development of myocardial dysfunction in these patients.

Fortunately insulin resistance and vitamin D deficiency are a modifiable risk factors; the reduction of insulin resistance and increase the level of 25-OH-D may reduce CV risk in this group of patients.

Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review

: The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials.

CLINICAL TRIAL REGISTRATION

This systematic review was registered in the international prospective register of systematic reviews.

PROSPERO

CRD42015019817.

Personality traits and PTSD after experiencing civilian war-related trauma among women in Croatia

Introduction

Although many studies report that neuroticism and introversion predispose people to PTSD after exposure to traumatic event, the relationship between personality traits and PTSD is still vague. Also, little attention has been given to posttraumatic responses of civilians and especially women after war circumstances.

Objectives

To explore the relationships between basic personality traits and PTSD among female civilians who have experienced war- related trauma.

Aims

To investigate whether women with current PTSD, PTSD in remission, and those who did not develop PTSD differ in neuroticism, extroversion, openness to experience, agreeableness and conscientiousness.

Methods

The research is a part of a larger study „Psychobiology of PTSD”. CAPS and NEO PI-R were administrated to 395 female participants: 61 participants have current PTSD, 124 PTSD in remission and 108 never developed PTSD after experiencing at least one civilian war related traumatic event. The control group consisted of 101 women with no war related trauma.

Results

Four groups significantly differ on four out of five major domains of personality (one way ANOVA). Women with current PTSD and PTSD in remission have significantly higher scores on neuroticism (F = 25,170, p = ,000). Non PTSD group and controls show significantly higher scores on extroversion (F = 29,980, p = ,000) and on openness to experience (F = 18,421, p = ,000). Participants with current PTSD score have significantly lower scores on conscientiousness in comparison to the other three groups (5,672, p = ,001).

Conclusion

According to our results, personality traits are in significant relationship with PTSD development in female civilians with war related traumatization.

Xenon modulates neutrophil adhesion molecule expression in vitro

BACKGROUND AND OBJECTIVE

Xenon reduces the infarct size after regional ischaemia in the rabbit heart in vivo, but the underlying mechanisms are unknown. Since adhesion molecules on neutrophils are closely involved in the pathophysiology of ischaemia/reperfusion injury and modulation of neutrophil function, we investigated the effect of xenon on neutrophil adhesion molecule expression in vitro.

METHODS

Freshly isolated neutrophils were incubated with 30% or 60% xenon for 60 min. In unstimulated and after stimulation with either N-formyl-methionyl-leucyl-phenylalanine or phorbol-12-myristate-13-acetate neutrophil surface expression of PSGL-1, L-selectin, CD11a and CD11b were measured by flow cytometry.

RESULTS

At both concentrations, xenon reduced the surface expression of PSGL-1 by 10% (P < 0.05), and of L-selectin by 15% (P < 0.05) in the 60% xenon group. Furthermore, N-formyl-methionyl-leucyl-phenylalanine activated neutrophils showed an increased removal of L-selectin from the neutrophil surface following incubation with xenon (30% compared to controls, P < 0.05). Neutrophil beta2-integrin expression was not altered by xenon.

CONCLUSIONS

Xenon increases the removal of the selectins PSGL-1 and L-selectin from the neutrophil surface in vitro. Since both selectins are involved in the initial contact between neutrophils and endothelial cells, xenon may affect neutrophil adhesion to endothelium during ischaemia/reperfusion injury. However, because the beta2-integrin expression was unaffected by xenon, further investigations are required to clarify whether xenon may modulate neutrophil transmigration through endothelial cells in vivo.