Can I Leave? Perspectives on Parental Leave and Parenthood in Medical Training Among Program Directors and Trainees in Oncologic Specialties

Purpose: Peak fertility commonly occurs during medical training, and delaying parenthood can complicate pregnancies. Trainee parental leave policies are varied and lack transparency. Research on the impacts of parenthood on trainee education is limited. Methods: A Qualtrics-based survey was distributed via e-mail/social media to program directors (PDs) within oncologic specialties with a request to forward a parallel survey to trainees. Questions assessed awareness of parental leave policies, supportiveness of parenthood, and impacts on trainee education. Statistical analyses included descriptive frequencies and bivariable comparisons by key groups. Results: A total of 195 PDs and 286 trainees responded. Twelve percent and 29% of PDs were unsure of maternity/paternity leave options, respectively. PDs felt they were more supportive of trainee parenthood than trainees perceived they were. Thirty-nine percent of nonparent trainees (NPTs) would have children already if not in medicine, and >80% of women trainees were concerned about declining fertility. Perceived impacts of parenthood on trainee overall education and academic productivity were more negative for women trainees when rated by PDs and NPTs; however, men/women parents self-reported equal impacts. Leave burden was perceived as higher for women trainees. Conclusions: A significant portion of PDs lack awareness of parental leave policies, highlighting needs for increased transparency. Trainees' perception of PD support for parenthood is less than PD self-reported support. Alongside significant rates of delayed parenthood and fertility concerns, this poses a problem for trainees seeking to start a family, particularly women who are perceived more negatively. Further work is needed to create a supportive culture for trainee parenthood.

The impact of the COVID-19 pandemic on the trend of prescribing long-acting injections of paliperidone and risperidone in Central Serbia

Since the end of 2019, the global spread of COVID-19 has represented a historic event that changed our way of treating patients globally. The use of long-acting injections (LAI) antipsychotics was emphasized. Our goal was to investigate the impact of COVID-19 on the frequency of prescribing LAI and compare it with a period before. All patients (198) who started LAI-risperidone or LAI-paliperidone for the period 2017-2022, in Kragujevac, the city in Central Serbia, were considered. The frequency of prescribing LAI before and during COVID-19 and the total number of prescribed LAI per year were compared. Separately, the frequency of prescribing LAI-R and the frequency of prescribing LAI-P were compared. The significant (p < 0,05) increase in the use of LAI risperidone and paliperidone was in 2020 and 2021 [per year 2017(3), 2018(6), 2019(26), 2020(75), 2021(55), and 2022(33)]. The significant (p < 0,05) increase in monthly and quarterly preparations of LAI paliperidone was in 2020 and 2021 relative to the years before the pandemic. As the pandemic weakened, the inclusion of LAI paliperidone therapy weakened during 2022. A significant increase in usage of LAI risperidone was in 2022, and in 2020 and 2021 was as it was in the period 2017-2019. During COVID-19, especially in years when COVID-19 restriction measures were stricter, there was a significant change in the application method of antipsychotic therapy in favor of LAI. Regardless of the increase in treatment costs, patients' interests and protection were prioritized in the treatment process.

Early aortic valve replacement improves exercise capacity in truly asymptomatic patients with severe aortic stenosis

Background

Exercise capacity is a strong predictor of morbidity and mortality overall. In severe aortic stenosis (AS) ustained pressure overload during watchful waiting is associated with LV structural and functional deterioration and impaired clinical outcome both pre- and post aortic valve replacement (AVR). The effect of early surgical aortic valve replacement (SAVR) in asymptomatic patients with severe AS and normal left ventricular function on exercise capacity in unknown.

Aim

We investigated whether the early surgical AVR in truly asymptomatic patients with severe aortic stenosis and normal LVEF improves the exercise capacity.

Methods

This is a sub-analysis or the AVATAR trial (NCT02436655), which is international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity &gt;4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Patients underwent cardiopulmonary exercise testing (supine bicycle, ramp protocol, 15 W/min) at the baseline and 12 months following the randomization. Patients who had positive exercise testing at baseline visit were excluded. We compared the value of workload (in WATs), VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope at the inclusion and at 12 months.

Results

Total of 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Mean LVEF and Vmax in early surgery and conservative treatment group were 70% and 4.5m/s and 69% and 4.5m/s, respectively. After 12 months in patients with conservative treatment there was a slight decrease in the values of workload, VO2 max, VO2 AT, VE/VCO2 and PETCO2 slope, but without statistical significance. However operated patients showed a significant increase in workload (115.4±38.4 watts at 12 months vs 104.8±42.2 at inclusion, p=0.038) and VO2 max (19.7±6.8 at 12 months vs 16.2±5.4 at the inclusion, p=0.048), while there was slight increase in the values of VO2 AT, VEVCO2 and PETCO2 but without statistical significance.

Conclusion

Early SAVR improve the functional capacity in asymptomatic patients with severe aortic stenosis and normal left ventricular ejection fraction

Funding Acknowledgement

Type of funding sources: None.

Trainee and program director perspectives of parental leave and parenthood in oncologic specialties

11051

Background: Delays in pregnancy exacerbate infertility. Thus, trainees are forced to make complex family planning decisions while juggling all aspects of training. In addition to a lack of parental leave and financial constraints, trainees are often concerned with the perceptions of leave and parenthood. Two single specialty surveys found that most program directors (PDs) felt parenthood negatively impacted trainee performance, disproportionately for women. We aim to understand PD and trainee perspectives of parental leave and parenthood in oncologic trainees. Methods: Contact information for PDs in oncologic specialties was gathered from FRIEDA. Surveys were distributed to all eligible PDs with a request to forward a parallel survey to their trainees. Social media links for both surveys were shared on Twitter. Tests of association for descriptive analyses included Fisher's exact test, Chi-square test, or the Mantel-Haenszel Chi-Square test, as appropriate. All computations were performed using SAS version 9.4. Results: 195 PDs and 286 trainees completed the survey with 49% and 56% female and 89% and 41% parent respondents, respectively. Per PDs, 73% of programs have a maternity leave policy, 48% have a paternity leave policy, and 5% have a fertility services policy. PDs and non-parent trainees (NPTs) rated the negative impact of parenthood on overall education (p < 0.001 for PDs, p < 0.001 for NPTs) and academic productivity (p < 0.001 for PDs, p < 0.001 for NPTs) as higher for women trainees than men trainees. PDs and NPTs also rated the burden of parental leave on co-trainees as greater for women trainees as compared to men trainees (p < 0.001 for PDs, p < 0.001 for NPTs). Among PDs, no significant differences by gender or specialty were found in advising for or against parenthood in training, but PDs in surgical specialties reported providing less support for trainees starting a family (p < 0.001) and trainees in surgical specialties reported being less supported (p < 0.001). Women trainees were more likely than men trainees to indicate that they would have started a family sooner if not in medicine (p < 0.001). 89% of parent trainees would choose to have children in training again, and 84% would recommend parenthood in training. Conclusions: Although many programs have parental leave policies, a substantial number continue to lack them. Concerns about negative perceptions of parenthood by trainees are valid, particularly for women who are significantly more likely to be seen as having their education and academic productivity impacted by parenthood. In addition, specialty choice impacts the support given to trainees as they start families. Despite these barriers, the vast majority of parent trainees would still choose to have children in training and recommend this path to fellow trainees. Additional initiatives to normalize and support family planning in medical training for interested trainees are warranted.

Risperidone Induced Hyperprolactinemia: From Basic to Clinical Studies

Risperidone is one of the most commonly used antipsychotics (AP), due to its safety and efficacy in reducing psychotic symptoms. Despite the favorable side effect profile, the therapy is accompanied by side effects due to the non-selectivity of this medicine. This review will briefly highlight the most important basic and clinical findings in this area, consider the clinical effects of AP-induced hyperprolactinemia (HPL), and suggest different approaches to the treatment.The route of application of this drug primarily affects the daily variation and the total concentration of drug levels in the blood, which consequently affects the appearance of side effects, either worsening or even reducing them. Our attention has been drawn to HPL, a frequent but neglected adverse effect observed in cases treated with Risperidone and its secondary manifestations. An increase in prolactin levels above the reference values result in impairment of other somatic functions (lactation, irregular menses, fertility) as well as a significant reduction in quality of life. It has been frequently shown that the side effects of the Risperidone are the most common cause of non-compliance with therapy, resulting in worsening of psychiatric symptoms and hospitalization. However, the mechanism of Risperidone-induced HPL is complicated and still far from fully understood. Most of the preclinical and clinical studies described in this study show that hyperprolactinemia is one of the most common if not the leading side effect of Risperidone therefore to improve the quality of life of these patients, clinicians must recognize and treat HPL associated with the use of these drugs.

Posttraumatic stress disorder symptoms among trauma-exposed adolescents from low- and middle-income countries

BACKGROUND

Exposure to traumatic events in childhood is associated with the development and maintenance of various psychiatric disorders, but most frequently with posttraumatic stress disorder (PTSD). The aim of this study was to evaluate the types of traumatic events experienced and the presence and predictors of PTSD symptoms among adolescents from the general population from ten low- and middle-income countries (LMICs).

METHODS

Data were simultaneously collected from 3370 trauma-exposed adolescents (mean age = 15.41 [SD = 1.65] years, range 12-18; 1465 (43.5%) males and 1905 (56.5%) females) in Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, the Palestinian Territories, the Philippines, Romania, and Serbia, with Portugal, a high-income country, as a reference point. The UCLA PTSD Reaction Index for the DSM-5 (PTSD-RI-5) was used for the assessment of traumatic events and PTSD symptoms.

RESULTS

The most frequently reported traumatic events were death of a close person (69.7%), witnessing violence other than domestic (40.5%), being in a natural disaster (34.4%) and witnessing violent death or serious injury of a close person (33.9%). In total, 28.5% adolescents endorsed two to three DSM-5 PTSD criteria symptoms. The rates of adolescents with symptoms from all four DSM-5 criteria for PTSD were 6.2-8.1% in Indonesia, Serbia, Bulgaria, and Montenegro, and 9.2-10.5% in Philippines, Croatia and Brazil. From Portugal, 10.7% adolescents fall into this category, while 13.2% and 15.3% for the Palestinian Territories and Nigeria, respectively. A logistic regression model showed that younger age, experiencing war, being forced to have sex, and greater severity of symptoms (persistent avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity) were significant predictors of fulfilling full PTSD criteria.

CONCLUSIONS

Nearly every third adolescent living in LMICs might have some PTSD symptoms after experiencing a traumatic event, while nearly one in ten might have sufficient symptoms for full DSM-5 PTSD diagnosis. The findings can inform the generation of PTSD burden estimates, allocation of health resources, and designing and implementing psychosocial interventions for PTSD in LMICs.

The Association Between Family Violence, Depression and Anxiety Among Women Whose Partners Have Been Treated for Alcohol Dependence

The negative effects of men's excessive alcohol consumption on family members are well known. However, less is known about how men's alcohol dependence is associated with the mental health of their female spouses residing with them. Therefore, the aim of this study was to investigate the prevalence and factors associated with depression, anxiety, and intimate partner violence against women (IPVAW) whose male spouses are undergoing treatment for alcohol dependence. We hypothesize that men with alcohol dependency, who are also violent, present a serious threat to women's mental health. We conducted a cross-sectional study among 104 women whose male partners had been admitted for inpatient treatment for alcohol dependence. Women's depression was measured by the Beck Depression Inventory (BDI-II); anxiety was measured by the Beck Anxiety Inventory (BAI), and exposure to physical and sexual IPVAW was measured by the Conflict Tactics Scale (CTS-2). Multinomial logistic regression analyses were conducted in order to analyze factors associated with depression and anxiety. The prevalence of moderate/severe depression and anxiety among the women was 34.6% and 25.2%, respectively, while almost half (48.1%) experienced IPV during the past 12 months. After adjustments for age, exposure to IPV increased the chances of experiencing moderate/severe depression by 37.5 times (95% CI 7.91-177.76), and 8.15 times for moderate/severe anxiety (95% CI 2.45-27.14). The mental health of women whose partners have alcohol dependence is significantly threatened and should be considered, especially when it is associated with exposure to spousal violence.

Prevalence and risk factors for thyroid cancer in patients with multinodular goitre

BACKGROUND

Rates of thyroid cancer in patients with multinodular goitre (MNG) vary widely, from 3 per cent in older studies to 35 per cent in more recent studies. The purpose of the present study was to evaluate the prevalence of thyroid cancer in patients operated on for MNG, and to determine risk factors for incidental thyroid malignancy.

METHODS

A prospectively developed database of all patients who underwent thyroidectomy for a benign MNG at the high-volume endocrine surgery unit of a tertiary referral university hospital was interrogated.

RESULTS

A total of 3233 patients were analysed, separated into three groups according to their functional thyroid status (hypothyroid, hyperthyroid or euthyroid). There were 2788 women (86.2 per cent); the mean patient age was 56.4 years and mean preoperative disease duration was 106.2 months. Incidental thyroid cancer was identified in 1026 patients (31.7 per cent), of which 917 (89.4 per cent) were papillary cancers. Multivariable regression analysis identified functional thyroid status, younger age, male sex, smaller adenoma size, smaller thyroid glands, Hashimoto's thyroiditis and chronic non-specific thyroiditis as independent risk factors for thyroid cancer.

CONCLUSION

MNG was associated with a considerable rate of incidental thyroid cancer, which has been underestimated. A variety of factors should be taken into account when considering the malignant potential of a presumed benign MNG.

Use of dietary supplements among male fitness club members in Nis, Serbia

Background

Dietary supplements use continues to increase in many countries. They are often used without a full understanding of the potential benefits and risks associated with their use, and without consultation with a health care professional. This study aimed to explore health beliefs and patterns of dietary supplement usage among fitness club participants.

Methods

This cross-sectional study was conducted in fitness clubs of the city of Nis, Serbia. Male adults, age 18-45 years, participated. Data from participants were collected through an original structured, self-administered questionnaire describes the prevalence and type of supplements used, the reasons for using and the information source.

Results

The prevalence of dietary supplement intake among participants was 85.86%. Most participants were between the age of 20 and 40 years, had a college degree (57.1%), non-smokers (80.5%), without chronic disease (86%), perform exercise at least thrice weekly (76.2%) and 63% had at least1 hour. The percentage of participants who had favorable health views on dietary supplements was significantly higher among the supplement users than among the non-users (P &lt; 0.0001). Most participants (76.19%) perform exercise from 3 to 5 times weekly and 82.85% had from 1 to 2 hours exercise duration. The percentage of subjects who think supplements have side effects was significantly higher among the supplement non-users than among the users (p &lt; 0 .05). Proteins (83.33%), amino acids (63.09%) and creatine (52.38%) were the most commonly reported supplements used. The places of buying dietary supplements most mentioned were specialized supplement store (78.57%), online (11.9%) and pharmacy (9.52%).

Conclusions

Male fitness club member are large consumers of dietary supplements. Public health campaigns could be useful to educate Serbian population regarding using dietary supplements during fitness activities.

Key messages

Male fitness club members are large consumers of dietary supplements in Serbia. Public health campaigns are needed to educate fitness participants about using dietary supplements.

Roma child participation in public health policy and practice across Europe

Roma teenagers are often excluded from participation opportunities, when they could be informing a wide range of law, policy and practice. CoE and EU recommendations make it clear that improvements in living conditions can only be achieved through active participation of Roma people. The 2018 Roma Civil Society Monitoring report reinforces that 'it is essential for Roma to be involved not only in narrowly defined 'Roma issues', but also in a wider range of topics and policies'. We address the question of what methods enable Roma children to become involved in influencing health policy and service design, focusing on the case of Bulgaria. A qualitative European survey (Feb - June 2020) in English, French, Spanish and Bulgarian identified professional perspectives on the impact of COVID-19 on children, with a focus on Roma families. Case studies of Roma children's experiences, and examples of their participation, were analysed of these case studies was conducted by the authors (combining sociological, public health and community perspectives). Accuracy of emergent findings were assessed through dialogue with survey participants. Preliminary results indicate that participatory practices that enable Roma children's participation in designing public health policy, services and responses are limited and pre-existing inequalities are deepening. However relevant isolated examples of inclusive participation were identified: information design, peer-administered questionnaires, arts-based activities, dialogue events, and campaigning in Bulgaria and beyond. Inclusive methods that enable Roma teenagers' engagement in health policy and service design are closely tied to methods used with other communities facing discrimination. However, significant structural barriers, related to economic inequalities and anti-gypsyism are additional barriers faced by some Roma children. International exchange of examples of such practices could inform future health promotion practice.

Participation of disadvantaged school age children (7-18) in health inequality projects

Results

The preliminary finding is that none of the ten selected projects have identified children 7-18 years old as a primary target group. Majority of the projects (4 out of 6) involve sort of relationship building with children, while storytelling is used by a smaller number of projects (2 out of 10). All projects (6 out of 6) involve children just in the implementation phase focusing on educating children and none of them in the project design phase. Moreover, children covered by the implementation are mainly included through schools (8 out of 10) due to a missing parent consent for interacting with most disadvantaged children that are not in schools.

Conclusions

There is a serious lack of awareness on the importance of meaningfully engaging disadvantaged children in health programming processes for decreasing existing health inequalities. Due to a significant lack of meaningful participation of disadvantaged children in majority projects tackling health inequalities of school-age children in Europe there is a serious risk of having these inequalities increased rather than overcome, despite significant financial and human investments.

Key messages

The most disadvantaged children should be meaningfully engaged in design, implementation and evaluation of health inequality projects that are of their immediate concern. There is a need for more in depth research on health inequalities faced by school age children (7-18) that are out of educational system.

Functional and pharmacological analysis of agmatine administration in different cerebral ischemia animal models

Agmatine (AgM, 100 mg/kg i.p.) effect was tested in parallel at two animal models of cerebral ischemia - rat MCAO model (60'/24 h, 60'/48 h, 90'/24 h, 90'/48 h) and gerbil global ischemia (10') model, administrated 5 min after reperfusion. Aim was to evaluate AgM effect on functional outcome 24 and 48 h after MCAO on neurological and sensor-motor function, and coordination in rats. AgM administration significantly reduced infarct volume, improved neurological score and improved post-ischemic oxidative status. Results of behavioral tests (cylinder test, beam walking test, and adhesive removal test) have shown very effective functional recovery after AgM administration. Efficiency of AgM administration in gerbils was observed in forebrain cortex, striatum, hippocampus, and cerebellum at the level of each examined oxidative stress parameter (nitric oxide level, superoxide production, superoxide dismutase activity, and index of lipid peroxidation) measured in four different time points starting at 3 h up to 48 h after reperfusion. The highest levels were obtained 6 h after the insult. The most sensitive oxidative stress parameter to AgM was nitric oxide. Additionally, we performed pharmacological analysis of AgM on rat isolated common carotid arteries. The findings imply that mixed population of potassium channels located on the smooth muscle cells was involved in common carotid artery response to AgM, with predominance of inward rectifying K⁺ channels. In our comparative experimental approach, judged by behavioral, biochemical, as well as pharmacological data, the AgM administration showed an effective reduction of ischemic neurological damage and oxidative stress, hence indicating a direction towards improving post-stroke recovery.

Surgical treatment of metastasis to the thyroid gland: a single center experience and literature review

BACKGROUND

Metastasis to the thyroid gland or nonthyroid malignancy (NTM) is rarely an indication for thyroidectomy and constitute 1-3 % of all thyroid carcinomas. NTM has a poor prognosis, due to the advanced stage of the primary tumor. This study aimed to present the incidence, clinical characteristics, and treatment outcome of NTM in a single, high volume center.

CASE SERIES

We retrospectively analyzed all patients who had undergone thyroidectomy at the Center for Endocrine Surgery in Belgrade, during the period from 1995 to 2015. Out of 13,385 patients who were submitted to thyroidectomy, 3,344 (24.2 %) patients had thyroid malignancy. The diagnosis of NTM, based on the histopathological findings, was found in ten patients (0.075 % of all patients who had thyroid surgery, i.e., in 0.3 % of patients with thyroid cancer), with a mean age of 59.5 years. The most frequent primary tumor location in NTM was kidney in four patients, esophagus in two patients, and pharynx, breast and lungs (one case each). Total thyroidectomy was performed in four patients and lobectomy in two patients. Mean survival time following thyroid surgery was 43.2 months.

CONCLUSION

NTM are uncommon, and their prognosis is generally poor and depends on the characteristics of the primary tumor. Nevertheless, in selected cases, surgical treatment of NTM should be considered. HIPPOKRATIA 2018, 22(3): 137-140.

ADIPONECTIN AS A POTENTIAL BIOMARKER OF LOW BONE MINERAL DENSITY IN POSTMENOPAUSAL WOMEN WITH METABOLIC SYNDROME

CONTEXT

Adiponectin is an abundant adipokine, which has antiinflammatory, anti-atherosclerotic and vasoprotective actions, and potential antiresorptive effects on bone metabolism. It seems to be directly involved in the improvement and control of energy homeostasis, protecting bone health and predicting osteoporotic fracture risk.

OBJECTIVE

To examine the relationship between adiponectin level and bone mineral density (BMD) in post-menopausal women with metabolic syndrome (MetS) and low BMD, and to estimate the prognostic significance of adiponectin in osteoporosis.

DESIGN

Clinical-laboratory cross-sectional study including 120 middle-aged and elder women (average 69.18±7.56 years).

SUBJECTS AND METHODS

The anthropometric parameters were measured for all examinees. Lumbar spine and hip BMD, as well as body fat percentage, were measured using a Hologic DEXA scanner. In all subjects serum adiponectin concentration was measured by ELISA method.

RESULTS

The level of adiponectin was significantly positively correlated with BMD-total, BMD of the lumbar spine and BMD of the femoral neck (r=0.618, r=0.521, r=0.567; p<0.01). Levels of adiponectin and BMD are significantly lower in post-menopausal women with MetS and osteoporosis compared to patients with osteopenia (856.87±453.43 vs. 1287.32±405.21 pg/mL, p<0.01; BMD, p<0.05), and the highest values in healthy examinees. A cut-off value of adiponectin level for osteoporosis/osteopenia was 1076.22/1392.74 pg/mL.

CONCLUSIONS

Post-menopausal women with MetS have significantly lower adiponectin level and low BMD compared to healthy examinees. Adiponectin may be an early, significant and independent predictor of developing osteoporosis in women with MetS, especially in post-menopausal period.

Oxidative Stress Intensity in Lens and Aqueous Depending on Age-Related Cataract Type and Brunescense

Purpose

Cataract formation represents a serious problem in the elderly, and has a large impact on healthcare budget. The oxidative stress form and intensity might determine the cataract type and pigmentation, making efforts in the cataract prevention challenge more complex.

Methods

This is a retrospective cross-sectional review of 80 samples of aqueous humor and lens corticonuclear blocks. Aqueous samples were analyzed by the method of antioxidant activity estimation (%iMDA), while lipid peroxides (LP) and total sulfhydryl groups (TSH) were determined in lenses.

Results

Mixed and brunescent cataracts have statistically significant lower values of antioxidative %iMDA and TSH (p<0.001 for both parameters) and higher values of lipid peroxidation (p<0.001). No correlation between LP and TSH with maturity of cortical cataract was found, but there was a significant correlation with the %iMDA (p<0.05).

Conclusions

The role of the oxidative stress in cataractogenesis could not be the same for all cataract types. High level of lipid peroxides in pigmented cataracts may point to the different nature of pigment source than proteins solely, whereas lipid peroxidation and SH groups consumption in cortical cataractogenesis might be of less importance.

Effects of antidepressants on serum concentrations of bone metabolism markers and major electrolytes in patients from routine psychiatric practice

Background/Aim. Data about effects of antidepressant on calcium, phosphorous and magnesium metabolisms are very scorce. The aim of this study was to investigate effects of antidepressants on serum concentration of bone metabolism markers and main electrolytes in patients from routine psychiatric practice. Methods. A prospective, before-and-after, time-series research included 9 males and 24 females, with average 53.3 ? 11.5 years-of-age, suffering from depression (n = 26) and neurotic disorders (n = 7), mostly taking selective serotonin reuptake inhibitors. We measured analytes at baseline, and 4th, 6th and 12th weeks during the treatment and tested the parameter changes from baseline and the trends with appropriate statistics at p ? 0.05 significance level. Results. The age above 60 years was a significant factor for appearance of negative cumulative changes (in percent) of 25-hydroxyvitamin D ? 25(OH)D concentrations from the base-line (OR = 11.4, 95% CI 1.2?113.1, p = 0.037). Serum concentrations of calcium significantly correlated with sodium (rs = 0.531, p < 0.001), with chloride (r = 0.496, p < 0.001), with magnesium (rs = 0.402, p < 0.001) and with osteocalcin (r = 0.240, p = 0.019). Significant correlations were among phosphorous with chloride (r = -0.218, p = 0.035); magnesium with sodium (r = 0.295, p = 0.004) and with potassium, (r = 0.273, p = 0.009); osteocalcin with C-telopeptide (r = 0.760, p < 0.001) with sodium (r = 0.215, p = 0.039) and with chloride (r = 0.209, p = 0.041); sodium with chloride (r = 0.722, p < 0.001). There were no statistically significant changes between antidepressant treatment and changes of absolute serum concentration of calcium, magnesium, phosphorous, 25(OH)D, osteocalcin, C-telopeptide, sodium, potassium and chloride. There were no statistically significant changes in frequency of disturbances in values of laboratory analytes (below/above lower/upper normal limits), too. Conclusion. Antidepressant treatment was not significantly associated with the changes in study analytes but some of them positively correlated with each other, suggesting the need for individual patient approach and further research in the field of bone metabolism in patients with mental disorders.

Person- and People-Centered Integrated Health Care for Alcohol Dependence - Whether It Is Real in the Present Moment

Alcohol continues to occupy a leading position in Europe as a popular substance of abuse. According to WHO sources together with cigarette smoking and obesity, alcohol is a major cause of preventable diseases. Harmful use of alcohol is one of the main factors contributing to premature deaths and disability and has a major impact on public health. The consequences of alcohol use on human health are enormous. Additionally, alcohol use can have harmful effects that do not directly affect person who consumes alcohol (e.g., fetal alcohol syndrome violations that are related to alcohol use, etc.). It is well known that the harmful effects and consequences of alcohol use (e.g., acute and chronic illness, injuries in fights, at the workplace, in traffic, violent behavior, and death) create a great burden for the economic development of society. Persons who have been diagnosed with alcoholism and currently drinking have a less chance to achieve a life insurance cover. On the contrary, recovering alcoholic with a significant abstinent period can get a good life insurance quote. The abstinence of a year or 2 is usually enough for a person to get an average price of life insurance. Furthermore, new consequent relapses could also be considered as potential aggravating factor to accomplish this kind of financial benefits. So far, the research (and interventions) focused on the effects on the population level, such as the increase in taxes, advertising bans, and the implementation of laws that prevent the use of alcohol in traffic. However, it seems that the problem may be viewed at the individual level. The models of the treatment should be designed according to the needs of the individual. These models should incorporate not only the reduction of alcohol intake but also the path to abstinence. The plan should take into account the different (individual) needs for treatment, with regard to the degree of alcohol dependence and health status and also include the needs of the family, community, and broader society.

Legal Framework and Retirement Policies in Serbia from 1990 to 2016 - Gendered Perspective

Retirement policy is an unavoidable factor for the economic and social stability of the state. In our country, Serbia, the total number of pensioners in 2015 was almost 1.8 million, which is higher in comparison to the time period from 2002 to 2014. According to increased number of pensioners, pension reforms are a crucial step of economic stability for less developed country, such as Serbia. The first step in this question in Serbia was made in 2001, and this change was referred to the raise in the retirement age. Next step was made in 2003 and involved wider ranges of changes than the previous step. Another change in this field was followed by 2005, and it was related to age limit for retirement, which was supposed to increase for 6 months each year during the period from 2008 to 2011, while another change was a gradual pension adjustment. The last step in this road of pension reforms in Serbia has become with adopted Law on Pension and Disability Insurance that entered into force in January 2015, when age limit for retirement was extended for both genders, whereby it is clear that the aim of this measure is to equalize years of service for genders by 2023 and age limit by 2032 when 65 years will be the age limit.

The results of molecular genetic testing for RET proto-oncogene mutations in patients with medullary thyroid carcinoma in a referral center after the two decade period

BACKGROUND

Medullary thyroid carcinoma (MTC) is a type of thyroid neoplasm which originates from parafollicular cells, and it is commonly diagnosed by calcitonin screening. Besides the sporadic form, the heritable form of MTC is characterized by constitutive activation of the RET (REarranged during Transfection) proto-oncogene caused by different mutations.

METHOD

We collected data regarding RET genetic screening performed in the Center for Endocrine Surgery in Belgrade during a 20-year-period. The study group included 249 MTC patients who were genetically tested for RET mutations by Sanger's sequencing method.

RESULTS

Genetic screening of the study population revealed nine different mutations of the RET gene in 42 carriers. The most common mutation was C634F, and it has been detected in 31 % (13/42) of individuals, while C618R, L790F, and S904S were present in only 2 % (1/42) each in the study group. Detected mutations were unequally distributed in different RET gene exons. Among MTC patients, 67 % (28/42) had mutation harbored in exon 11, while the rarest mutation was located in exons 10 and 15, each present in only 2 % (1/42) of patients.

CONCLUSIONS

The RET gene mutation profile has a unique distribution in this study population when compared with the other European populations. The mutations in codon 634 are most common; therefore the cost-reducing genetic screening should primarily target this codon, and if the negative outcome appears, then other codons should be examined in the order that depends on their occurrence. Hippokratia 2016, 20(3): 187-191.

Child and Adolescent Online Mental Health Information: Parent and Adolescent Perspectives to Inform Development of Canadian Mental Health E-Resources for Paediatrics

BACKGROUND: Parents and adolescents are searching online for information about mental health. Google searches are frequently used, but do not always yield accurate and reliable information that is presented in a user-friendly manner. The first step toward the development of a useful online child mental health resource is to examine existing web content and understand parent and adolescent needs from online mental health material.

OBJECTIVES: The objectives of this study are two-fold (i) To conduct an environmental scan of existing online repositories of child and adolescent mental health information with respect to both parent and adolescent friendly content on three identified topic areas for the initial phase of the project (Anxiety, Eating Disorders, Suicide Prevention) (ii) To determine parent and adolescent needs from, and perspectives about, current web-based information with respect to site design, content and limitations to inform the creation of a pediatric hospital based web site with a broad range of information pertaining to child and adolescent mental health.

DESIGN/METHODS: An environmental scan was conducted to assess available online information about three identified topic areas as described above. As the project continues, the scan will be expanded to include other topic areas in child and adolescent mental health. Parallel parent needs assessment surveys were conducted. As our adolescent section was being developed, adolescents were surveyed for their feedback regarding illustrations and presentation of current content.

RESULTS: The environmental scan identified 17 hospital websites for in-depth review. Although some websites had information on diverse mental health topics, few contained comprehensive information on a broad range of topics. For example, only 9 had information about anxiety disorders. Additionally, an overall lack of adolescent specific content was noted. Parent surveys revealed significant interest in a strong stand-alone site where they could access mental health information. Parents also indicated that they would prefer separate parent and teen content areas.

CONCLUSION: Current websites providing information regarding child and adolescent mental health, while plentiful, lack sufficient scope, adolescent-friendly content, and interactivity that limit their utility for parents and families. Development of a high-quality and accessible child and adolescent mental health website requires an interdisciplinary collaboration of experts in mental health, website design, and knowledge dissemination. This study has informed the development of a new online resource, interactive elements of which will be shared as part of the oral presentation.

Parameters of Calcium Metabolism Fluctuated during Initiation or Changing of Antipsychotic Drugs

OBJECTIVE

Serum parameters of calcium homeostasis were measured based on previously published evidence linking osteoporotic fractures and/or bone/mineral loss with antipsychotics.

METHODS

Prospective, four-week, time-series trial was conducted and study population consisted of patients of both genders, aged 35-85 years, admitted within the routine practice, with acute psychotic symptoms, to whom an antipsychotic drug was either introduced or substituted. Serial measurements of serum calcium, phosphorous, magnesium, 25(OH)D, parathyroid hormone, calcitonin, osteocalcin and C-telopeptide were made from patient venous blood samples.

RESULTS

Calcium serum concentrations significantly decreased from baseline to the fourth week (2.42±0.12 vs. 2.33±0.16 mmol/L, p=0.022, n=25). The mean of all calcemia changes from the baseline was -2.6±5.7% (-24.1 to 7.7) with more decreases than increases (78 vs. 49, p=0.010) and more patents having negative sum of calcemia changes from baseline (n=28) than positive ones (n=10) (p=0.004). There were simultaneous falls of calcium and magnesium from baseline (63/15 vs. 23/26, p<0.001; OR=4.75, 95% CI 2.14-10.51), phosphorous (45/33 vs. 9/40, p<0.001; 6.06, 2.59-14.20) and 25(OH)D concentrations (57/21 vs. 13/35, p<0.001; 7.31, 3.25-16.42), respectively. Calcemia positively correlated with magnesemia, phosphatemia and 25(OH)D values. Parathyroid hormone and C-telopeptide showed only subtle oscillations of their absolute concentrations or changes from baseline; calcitonin and osteocalcin did not change. Adjustment of final calcemia trend (depletion/accumulation) for relevant risk factors, generally, did not change the results.

CONCLUSION

In patients with psychotic disorders and several risks for bone metabolism disturbances antipsychotic treatment was associated with the decrease of calcemia and changes in levels of the associated ions.

Changes In QTc Interval Duration Among Heroin Addicts On Methadone Treatment

This paper aimed to collect and unite facts known about the effect of methadone treatment on QTc interval prolongation that could determine precipitating factors in the development of heart arrhythmias and their consequences (Torsade de Pointes and sudden cardiac death), and to raise the methadone treatment safety level.

Studies conducted up to now clearly demonstrate that methadone therapy evokes changes in the heart’s electrical conduction, but those studies also show that QTc interval prolongation could be precipitated by other factors. The most often present risk factors in our research were dose of methadone, co-medication, and co-morbidity, but other relevant risk factors were gender, age, misuse of illicit drugs, therapy length and tobacco use.

Active participation in modern treatment processes and implementation of knowledge acquired recently into daily practice, such as setting up reutilized questionnaires and diagnostic methods to expose higher risk for complications and providing broader therapeutic range for cases of drug replacement necessity, will enhance therapy safety level and bring us to the next step of resocialization of these patients, which needs to remain the final goal of treatment.

LAT software induced savings on medical costs of alcohol addicts' care--results from a matched-pairs case-control study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42 ± 0.90 vs. 0.70 ± 1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70 ± 1.74 vs. 0.97 ± 1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts' care (€ 54,660) were significantly reduced to € 36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: € 331 ± 381 vs. € 626 ± 795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was € 320 ± 330 (CI 95% 262-378) and among LAT € 197 ± 165 (CI 95% 168-226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were € 144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to € 295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.

Intermittent or continuous occlusion of hepatic inflow

THE AIM OF THE STUDY

The aim was to compare the effects of intermittent and continuous inflow occlusion on liver I/R injury in an experimental model.

METHOD

The experiment was done using the Wistar rats that underwent continuous and intermittent inflow liver vascular occlusion. Blood and liver tissue samples were taken and parameters of hepatic ischemia/reperfusion injury were analyzed and compared.

RESULTS

Serum activities of ALT, AST and LDH were significantly higher and ALP activity and albumin concentration were markedly lower in rats with continuous liver ischemia. Also, histopathological examination revealed more severe changes in animals with continuous liver vascular occlusion.

CONCLUSION

The results of biochemical assay and histopathological examination were concurrent, both indicating more serious parenchymatous damage caused by continuous hepatic pedicle clamping. Study results clearly demonstrated a better tolerance of the liver to intermittent Pringle maneuver (Tab. 1, Fig. 5, Ref. 9).

Assessment of viral genotype impact to the cost-effectiveness and overall costs of care for PEG-interferon-2α + ribavirine treated chronic hepatitis C patients

BACKGROUND

Pegylated interferon alfa plus ribavirin protocol is currently considered the most efficient hepatitis C treatment. However, no evidence of costs comparison among common viral genotypes has been published.

OBJECTIVES

We aimed to assess core drivers of hepatitis C medical care costs and compare cost effectiveness of this treatment among patients infected by hepatitis C virus with genotypes 1 or 4 (group I), and 2 or 3 (group II).

PATIENTS AND MATERIALS

Prospective bottom-up cost-effectiveness analysis from societal perspective was conducted at Infectious Diseases Clinic, University Clinic Kragujevac, Serbia, from 2007 to 2010. There were 81 participants with hepatitis C infection, treated with peg alpha-2a interferon plus ribavirin for 48 or 24 weeks. Economic data acquired were direct inpatient medical costs, outpatient drug acquisition costs, and indirect costs calculated through human capital approach.

RESULTS

Total costs were significantly higher (P = 0.035) in group I (mean ± SD: 12,751.54 ± 5,588.06) compared to group II (mean ± SD: 10,580.57 ± 3,973.02). In addition, both direct (P = 0.039) and indirect (P < 0.001) costs separately were significantly higher in group I compared to group II. Separate comparison within direct costs revealed higher total cost of medical care (P = 0.024) in first compared to second genotype group, while the similar tendency was observed for total drug acquisition (P = 0.072).

CONCLUSION

HCV genotypes 1 and 4 cause more severe clinical course require more care and thus incur higher expenses compared to HCV 2 and 3 genotypes. Policy makers should consider willingness to pay threshold differentially depending upon HCV viral genotype detected.

Serbian and Austrian alcohol-dependent patients: a comparison of two samples regarding therapeutically relevant clinical features

AIMS

To support the Serbian Expert Board in setting up reimbursement for modern pharmacotherapeutic support, we compared a Serbian sample of alcohol-dependent patients with an Austrian sample, in order to detect differences that might inhibit the introduction of anti-craving medications in Serbia.

METHODS

One hundred and twenty-seven (116 males) alcohol-dependent patients in Serbia and 136 in Austria (78 males) were enrolled consecutively from January 2011 to March 2012 and were assessed using the Lesch alcoholism typology instrument (LAT).

RESULTS

Age of onset was slightly higher in the Austrian sample (28.5 vs. 30.0; P = 0.10). The Serbian sample showed a higher rate of anxiety disorders than the Austrian sample (89.8 vs. 26.5%, P ≤ 0.0001). Suicidal tendencies, independent of alcohol intake or withdrawal syndrome, were higher in the Austrian sample (1.6 vs. 13.2% P ≤ 0.0001). There was no difference between the two samples in Lesch-Type IV (26 vs 28); there was a slight excess in the Serbian sample of Type I (15 vs. 10). In Austria, significantly more Type II patients (32 vs. 52) had been included, while the Serbian sample comprised significantly more Type III patients.

CONCLUSIONS

Austrian and Serbian patients are quite similar, without any showing any factor that would detract from the potential value of modern anti-craving medications in Serbia. The differences in anxiety disorders might be due to the 1990s war and should be investigated further.

Advantages of isolated application of fibrin glue over suture in preservation of second-grade spleen lesion

OBJECTIVES

The aim of this procedure was to assess the safety and efficiency of glue application in the treatment of lienal second-degree lesions, compared with traditional suture method of treatment.

BACKGROUND

The spleen is the most frequently injured intra-abdominal structure regardless of injury mechanisms. Fibrin glue is a useful bio-adhesive for safe and efficient treatment of diffuse parenchymatous spleen haemorrhages.

METHODS

Seventy dogs under intravenous anaesthesia were subdued to spleen incision in length of 5 cm and depth of 2 cm. Forty animals from the experimental group were treated with fibrin glue preservation, and 30 animals from the control group were treated with suture. Removed spleens were histologically analyzed. No animal was sacrificed.

RESULTS

The application of fibrin glue allowed reparation to be accomplished in all cases. The effectiveness of primary repair was registered in 95 %, with only 5 % of cases requiring an application of fibrin omentoplasty. Secondary bleeding was registered only in 1 (2.5 %) case. Preservation with suture is primarily effective only in 40 %, requires additional repair in 23 %, and even 37 % of cases are not feasible. This method is characterized by mortality of 21 %, secondary haemorrhage (32 %), appearance of focal necrosis (42 %) and abscess (11 %).

CONCLUSIONS

Application of FG is a method of choice in cases of second-degree transcapsular spleen lesions and it has a considerable advantage over suture (Tab. 4, Fig. 6, Ref. 24).

Prognostic value of survivin expression in Wilms tumor

PURPOSE

To determine survivin expression patterns in Wilms tumor (WT) and compare it with the expression in normal renal tissue. Also, to analyse cytoplasmic and nuclear survivin expression in relation to histological type, prognostic group and tumor stage.

METHODS

Immunohistochemical expression of survivin was analysed in 59 cases of primary WT and in 10 normal kidney specimens, taken from the same patients, but distant from the tumor.

RESULTS

51 out of 59 cases of WT (86.44%) showed decreased cytoplasmic survivin expression and 4 out of 59 cases of WT (6.78%) showed nuclear overexpression of survivin. There was statistically significant difference in the frequency of decreased cytoplasmic expression of survivin in individual components of WT (p=0.005). Decreased cytoplasmic expression of survivin in epithelial, blastemal and stromal component was found significantly more often in low stage WT compared to high stage WT (Fisher exact test, p=0.0002, p=0.002, p=0.002, respectively). There was no statistically significant difference in the frequency of survivin nuclear overexpression between different stages of WT (Fisher exact test, p=0.564), histological types (Fisher exact test, p=0.915), or between different prognostic groups (Fisher exact test, p=1).

CONCLUSION

Decreased survivin cytoplasmic expression or nuclear overexpression may be related to favorable prognosis of WT.