Relationship of Glucose, C-peptide, Leptin, and BDNF in Maternal and Umbilical Vein Blood in Type-1 Diabetes

The study aimed to determine the relationship between glucose, C-peptide, brain-derived neurotrophic factor (BDNF), and leptin between mother and fetus and neonatal weight.

METHODS

In the prospective observational cohort study, we included 66 women with type-1 diabetes mellitus (T1DM). According to the z-score for neonatal weight, patients were divided into healthy-weight neonates (n = 42) and overweight neonates (n = 24). The maternal blood samples were taken during pregnancy and cesarean section when the umbilical vein blood sample was also withdrawn. The maternal vein sera were analyzed for fasting glucose, C-reactive protein (CRP), leptin, BDNF, TSH, FT3, and FT4. The umbilical vein sera were analyzed for glucose, C-peptide, leptin, TSH, thyroid-stimulating protein (FT3), free thyroxine (FT4), and BDNF concentration. The neonatologist measured the skinfold thickness on the third day of neonatal life.

RESULTS

A strong correlation was confirmed between maternal and umbilical vein glucose concentration and maternal glucose and C-peptide in umbilical vein blood. A negative correlation was found between the concentration of BDNF in the umbilical vein and glucose in maternal blood. A strong correlation was seen between BMI and maternal blood leptin concentration, neonatal fat body mass, and umbilical vein blood leptin concentration. Higher BMI elevated BDNF, and TSH increase the odds for overweight neonates in the first trimester of pregnancy. Maternal higher leptin concentration in the first trimester decrease the odds of overweight neonates.

CONCLUSIONS

Maternal glucose concentrations affect the fetus's glucose, C-peptide, and BDNF concentrations. Leptin levels increase in maternal blood due to increased body mass index, and in the neonate, fat body mass is responsible for increased leptin concentrations.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases

Background

Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder.

Methods

Literature search of all full-text articles included PubMed (1946–2021), PubMed Central (1900–2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied.

Results

Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17–48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival.

Conclusion

The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival.

Level of evidence

Level V

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00444-w.

Projected all-cause deaths attributable to COVID-19-related unemployment in Croatia in 2020

Objectives

In 2020, Croatia reported the first increase in the unemployment rate after six consecutive years of reduction in the number of unemployed persons. Unemployment is associated with an increase in morbidity and mortality among unemployed persons. We estimated the number of potential excess deaths that could be associated with an increase in unemployment seen after the beginning of the COVID-19 pandemic in 2020.

Study design

This was a cross-sectional analytic study.

Methods

We used previously published meta-analyzed hazard ratios for the unemployment–mortality association and unemployment and mortality data from the Croatian Bureau of Statistics to estimate 1-year age-standardized deaths potentially attributable to COVID-19–related unemployment for persons aged 20–64 in Croatia.

Results

In January 2021, we observed a 19% increase in unemployment among persons aged 20–64 years compared with February 2020 (prepandemic). This increase in unemployment could lead to 23 excess deaths among newly unemployed persons. This would constitute a 42% increase in the number of deaths and 29% of all deaths among this group. Deaths were disproportionately higher among men and those aged >40 years.

Conclusions

To mitigate the negative impact of COVID-19–related unemployment on population health, interventions that will reduce the further spread of SARS-CoV-2 and policies that will ensure economic recovery and reduction of unemployment are needed. Job skills training and provision of legal and welfare advice programs for unemployed persons should be integrated with health interventions.

Prevalence of Gestational Diabetes Mellitus and Perinatal Outcomes According to the Old Who Criteria and IADPSG Criteria

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common metabolic disorder in pregnancy. Pregnancies with GDM have worse outcomes compared to pregnancies with normal glucose tolerance. The objectives of the study were to determine the prevalence of GDM and perinatal outcomes according to the old WHO criteria and IADPSG criteria.

SUBJECTS AND METHODS

A retrospective study included 2,405 pregnant women who delivered between January 2009 and December 2010. According to the OGTT results, pregnant women were divided into 4 groups. We analyzed the prevalence of GDM, characteristics of pregnant women and their newborns and perinatal outcomes.

RESULTS

We found significantly higher prevalence of GDM according to the IADPSG criteria compared to the WHO criteria. Pregnant women with GDM were significantly older, had higher pre-pregnancy BMI, fasting and 2-h plasma glucose. Pregnant women with GDM had worse pregnancy outcomes compared to control group. The overall proportion of overweight and obese pregnant women was the highest in the group of untreated pregnant women with GDM according to the IADPSG criteria. In this group we found significantly higher rate of fetal macrosomia and LGA. The rate of caesarean section was significantly higher in comparison to control group. Pre-eclampsia was significantly more common in groups of pregnant women with GDM compared to control group.

CONCLUSION

IADPSG diagnostic criteria reveals more women with hyperglycemic disorders in pregnancy. A group of pregnant women who were normoglycemic according to the WHO criteria, but according to the IADPSG were diagnosed GDM, had adverse pregnancy outcomes. Lower values of glycemia, than those defined for diabetes in pregnancy, are associated with adverse pregnancy outcomes.

Higher Cord Blood Levels of Fatty Acids in Pregnant Women With Type 1 Diabetes Mellitus

CONTEXT

Type 1 diabetes mellitus (T1DM) is associated with a disturbance of carbohydrate and lipid metabolism.

OBJECTIVE

To determine whether T1DM alters maternal and neonatal fatty acid (FA) levels.

DESIGN

Observational study.

SETTING

Academic hospital.

PATIENTS

Sixty pregnant women (30 women with T1DM with good glycemic control and 30 healthy women) were included in the study. Maternal blood, umbilical vein, and artery blood samples were collected immediately upon delivery. Following lipid extraction, the FA profiles of the total FA pool of maternal serum and umbilical vein and artery serum were determined by gas chromatography.

RESULTS

Total FA concentration in maternal serum did not differ between the study groups; it was significantly higher in umbilical vein serum of the T1DM group compared with that in the control group [median (interquartile range)]: T1DM 2126.2 (1446.4 to 3181.3) and control 1073.8 (657.5 to 2226.0; P < 0.001), and in umbilical artery vein serum: T1DM 1805.7 (1393.1 to 2125.0) and control 990.0 (643.3 to 1668.0; P < 0.001). Composition of FAs in umbilical vein serum showed significantly higher concentrations of saturated, monounsaturated, and polyunsaturated FAs (SFAs, MUFAs, and PUFAs, respectively) in the T1DM group than compared with those in the control group (P = 0.001). Furthermore, cord blood levels of leptin (P < 0.001), C-peptide (P < 0.001), and insulin resistance (P = 0.015) were higher in the T1DM group compared with controls.

CONCLUSION

The neonates born to mothers with T1DM had higher concentrations of total FAs, SFAs and MUFAs, as well as PUFAs, compared with control newborns.

Intermittent epidural TOP-UPS vs. patient control epidural analgesia during labor

Pain during labor and delivery is often very unpleasant and stressful for the parturients. Patient controlled epidural analgesia (PCEA) has been found to be both safe and effective, providing optimal pain relief and allowing women to participate in their own analgesia). Compared to other epidural techniques, intermittent epidural top-ups and continuous epidural analgesia (CEA), PCEA uses diluted local anesthetic solutions with less motor block and less unscheduled clinician interventions. The purpose of our study was to compare intermittent bolus epidural top-ups and PCEA in labor. Sixty ASA I patients who requested epidural analgesia for labor and had written consent were included in the study. 30 patients in the first group received intermittent bolus epidural top-ups, while patients in the second group received PCEA. We evaluated duration of labor, maternal sense of pain using VAS scale and maternal satisfaction during fetal descent in both groups. We found that the duration of labor was significantly shorter and maternal sense of pain was lower in the PCEA group than in the group receiving epidural bolus top-ups. There were no differences between groups in maternal satisfaction during fetal descent.

The Hedgehog signaling pathway in ovarian teratoma is stimulated by Sonic Hedgehog which induces internalization of Patched

The Hedgehog-Gli (Hh-Gli) signaling pathway was examined in ovarian dermoids, which show characteristics of both tumors and developmental malformations. Dermoids are classified as mature teratomas that present differentiation into various tissues, mostly epidermal elements such as glands, multilayered epithelium, hair follicles and occasionally bone and cartilage. Their development is attributed to aberrant meiosis of germinal cells within the ovary. We showed activation of the Hh-Gli signaling in ovarian dermoid primary cultures. Cyclopamine treatment slows down cell proliferation, while the Sonic Hedgehog (Shh) protein stimulates cell proliferation and induces internalization of the Patched (Ptch) protein, which accumulates in the form of granules in the cytoplasm, colocalized with the Shh protein. Cyclopamine treatment decreases Gli1 localization in the nucleus compared to non-treated cells. Based on our observations, the mechanism of Hedgehog activation in the ovarian dermoids could be the ligand-dependent autocrine pathway, which can also be stimulated by paracrine signals.

Macroprolactinemia: new insights in hyperprolactinemia

Hypersecretion of prolactin by lactotroph cells of the anterior pituitary may lead to hyperprolactinemia in physiological, pathological and idiopathic conditions. Most patients with idiopathic hyperprolactinemia may have radiologically undetected microprolactinomas, but some may present other causes of hyperprolactinemia described as macroprolactinemia. This condition corresponds to the predominance of higher molecular mass prolactin forms (big-big prolactin, MW > 150 kDa), that have been postulated to represent prolactin monomer complexed with anti-prolactin immunoglobulins or autoantibodies. The prevalence of macroprolactinemia in hyperprolactinemic populations between 15–46% has been reported. In the pathophysiology of macroprolactinemia it seems that pituitary prolactin has antigenicity, leading to the production of anti-prolactin autoantibodies, and these antibodies reduce prolactin bioactivity and delay prolactin clearance. Antibody-bound prolactin is big enough to be confined to vascular spaces, and therefore macroprolactinemia develops due to the delayed clearance of prolactin rather than increased production. Although the clinical symptoms are less frequent in macroprolactinemic patients, they could not be diff erentiated from true hyperprolactinemic patients, on the basis of clinical features alone. Although gel filtration chromatography (GFC) is known to be the gold standard for detecting macroprolactin, the polyethylene glycol precipitation (PEG) method has off ered a simple, cheap, and highly suitable alternative. In conclusion, macroprolactinemia can be considered a benign condition with low incidence of clinical symptoms and therefore hormonal and imaging investigations as well as medical or surgical treatment and prolonged follow-up are not necessary.

A low-grade ovarian carcinoma case with coincident LOH of PTCH1 and BRCA1, and a mutation in BRCA1

We report a case of a 53-year-old woman with Grade 1 serous cystadenocarcinoma on her left ovary and metastatic serous adenocarcinoma on her right ovary. Serous carcinoma is the most common type of ovarian cancer, representing approximately half of all cases. Because of positive family history, the patient was referred for BRCA1/2 screening. Germline BRCA1 mutation c.676delT (p.C226VfsX8) was found, and in tumor tissue the normal allele was lost. Tumor tissue also had loss of heterozygosity in the PTCH1 gene, one of the major members of the Hedgehog-Gli (Hh-Gli) pathway. Gene expression analysis showed upregulation of the Hh-Gli pathway in both ovaries compared with healthy ovarian tissue. Primary cell culture was developed from the patient's tissue and showed downregulation of gene expression in response to cyclopamine, a Hh-Gli pathway inhibitor. The Hh-Gli signaling pathway may play a role in malignant transformation and metastasis of ovarian cancer.

LOH of PTCH1 region in BCC and ovarian carcinoma: microsatellite vs. HRM analysis

Loss of heterozygosity (LOH) of tumor suppressor genes is a frequent event in tumorigenesis. LOH is most often analyzed by microsatellite typing, but here we offer a fast and efficient method for simultaneous SNP genotyping and mutation scanning, which can also be used for LOH detection. High resolution melting (HRM) provides simple variant detection, and can be adopted for a wide range of applications. When a melting profile for a specific SNP is determined, the screening can be done without the need for sequencing, and only the melting profiles differing from the established melting profiles should be sequenced. LOH of PTCH1 gene is often found in a series of different tumors, for example basal cell carcinoma (BCC) and ovarian carcinoma (OC). In this study LOH was detected in 50 % of BCC and 27.27 % of OC, and the detection rates of microsatellite typing and HRM were comparable. Both methods depended only on the heterozygosity of the loci analyzed, but HRM offers an additional advantage of detection of all sequence variants in the gene of interest.

LOH of PTCH1 region in BCC and ovarian carcinoma: microsatellite vs. HRM analysis

Loss of heterozygosity (LOH) of tumor suppressor genes is a frequent event in tumorigenesis. LOH is most often analyzed by microsatellite typing, but here we offer a fast and efficient method for simultaneous SNP genotyping and mutation scanning, which can also be used for LOH detection. High resolution melting (HRM) provides simple variant detection, and can be adopted for a wide range of applications. When a melting profile for a specific SNP is determined, the screening can be done without the need for sequencing, and only the melting profiles differing from the established melting profiles should be sequenced. LOH of PTCH1 gene is often found in a series of different tumors, for example basal cell carcinoma (BCC) and ovarian carcinoma (OC). In this study LOH was detected in 50 % of BCC and 27.27 % of OC, and the detection rates of microsatellite typing and HRM were comparable. Both methods depended only on the heterozygosity of the loci analyzed, but HRM offers an additional advantage of detection of all sequence variants in the gene of interest.

Use of complementary and alternative medicine in departments of obstetrics in croatia and a comparison to Germany

BACKGROUND

This nationwide study assessed the use of complementary and alternative medicine (CAM) methods in departments of obstetrics in Croatia and compared it with an identical assessment carried out in Germany.

METHODS

All Croatian obstetrics departments were sent a questionnaire already tested in Germany which assessed the use of CAM methods: whether any were used during childbirth and if so how frequently, and the reasons behind their application.

RESULTS

Questionnaires were returned by 100% (36/36) of departments identified. The only used CAM therapy was acupuncture, which was available in 5.6% (2/36) of the departments. All other methods (homeopathy, aromatherapy, massage etc.) were not used at all. Furthermore, acupuncture was only administered by physicians. These findings were found to strongly contrast with the findings from Germany.

CONCLUSIONS

Among the main CAM methods only acupuncture is used to a small extent in the field of obstetrics in Croatia. Thus, the impression from the literature that shows a considerable use of CAM in this area definitely does not apply for all parts of the world. Future studies should seek to identify the reasons behind the intensive use of CAM in Germany and its virtual non-use in Croatia. This also means that analyses of CAM use are required with respect to perinatal outcome, the results of which could finally help decide about the reasonability of CAM.

Minimally invasive therapy of cervical intraepithelial neoplasia for fertility preservation

The aim of this study was to determine the extension of cervical intraepithelial neoplasia grade III (CIN III) into endocervical canal and depth of endocervical crypts involvement by CIN with the regard to patients' age and parity. Correlation between the area of CIN involvement and the extension into endocervical canal was estimated. A total of 218 cervical cone specimens with histologically proven CIN III were included in this study. Extension of CIN into the endocervical canal, depth of involved crypts and ectocervical area affected by CIN were histologically analyzed. The average endocervical crypt involvement was at 1.2 mm of depth. The excision of >4 mm (1.2 mm x 3S.D.) in depth removes >99% of CIN. With the cone length of 15 mm (nulliparous patients) and 18 mm (multiparous patients), no endocervical cone margins were affected with CIN. Since the cone length is the most important determining factor for fertility preservation, the measurement of cervical cone could be essential for future pregnancies.

The Patched gene is epigenetically regulated in ovarian dermoids and fibromas, but not in basocellular carcinomas

The Hedgehog/Patched signaling pathway plays a prominent role during mammalian development but it is also involved in oncogenic transformation. We investigated the methylation status of the Patched promotor in a set of basocellular carcinomas of the skin and ovarian tumors as an alternative to mutational causes of the pathway deregulation. Our aim was to define a possible role of genetic and/or epigenetic mechanisms of Hedgehog/Patched signal transduction in the development of these tumors. Bisulfite-converted DNA from tumors and from matched healthy tissue was amplified by a specific PCR and the CpG-rich regions of the Patched promoter were sequenced. Two promoter regions showed statistically significant hypermethylation compared to healthy controls in ovarian tumors; more significantly in the region in the vicinity of Gli1-binding sites and less significantly in the region containing the ATG codon. But, in basocellular carcinomas of the skin we observed no difference in methylation, suggesting different mechanisms of neoplasia in these tumors.

Role of the hedgehog/patched signaling pathway in oncogenesis: a new polymorphism in the PTCH gene in ovarian fibroma

We compared the expression of target genes of Hedgehog/Patched signaling in ovarian fibromas and ovarian dermoids. We noted that high levels of SHH appear almost regularly, especially in dermoids, usually accompanied by increased expression of SMO. GLI overexpression does not coincide with that of PTCH. Loss of heterozygosity findings in the PTCH locus and increased expression of several genes in the pathway strongly suggest that the pathway is involved in both ovarian fibroma and dermoids.

Analysis of the PTCH1 signaling pathway in ovarian dermoids

Dermoids belong to the group of developmental cysts and arise from germ cells. Studies on these tumors may therefore increase our understanding of normal germ cell development within different environments and cell lines derived from these lesions may also constitute an important vehicle for studying neoplasia and differentiation. Recently, we investigated the status of the PTCH1 locus in a large set of sporadic non-inflammatory, developmental cystic lesions. Our data showed allelic loss of microsatellite markers in close vicinity to the PTCH1 locus in both odontogenic keratocysts and dentigerous cysts as well as in ovarian dermoid cysts (ODC). In this study, we closely examined the status of the PTCH1 gene in ODCs. Although about 25% of cysts demonstrated LOH at the PTCH1 locus, no nonsense or missense mutations in the coding region of PTCH1 were detected in genomic DNA isolated from any of the ODCs examined by direct sequencing. Staining with PTCH1 and GLI1 antibodies showed that proteins were present in virtually all epithelial linings, with variable staining intensity not correlated with LOH and generally weaker for GLI1. However, cDNA microarray analysis performed on cell lines derived from ODCs did not show any significant alteration in the expression of the analyzed target genes of PTCH1 signaling in any of the cell lines examined, except for CyclinD1 (and several other genes generally not associated with PTCH1 signaling).

A significance of immunohistochemical determination of steroid receptors, cell proliferation factor Ki-67 and protein p53 in endometrial carcinoma

OBJECTIVES

The aim of the study was to preoperatively predict the biologic behavior of the endometrial carcinoma using immunohistochemical analysis of the p53 protein and Ki-67 expression, and estrogen receptor (ER) and progesterone receptor (PR) status, in the material obtained by fractional curettage.

METHODS

One hundred and thirty-six patients with primary endometrial carcinoma were included in the study. In all 136 patients, the fractional curettage was performed before the hysterectomy, and the diagnosis of endometrial carcinoma was confirmed pathohistologically after the surgical procedure on the hysterectomy specimens. The significance of the prognostic factors was assessed using univariate and multivariate analyses. The cutoff values of the percentage of ER, PR, p53, and Ki-67 positive cells in terms of survival probability determination were obtained as the values of the highest chi-square test, using proportional-risk regression method. A multivariate Cox regression analysis was performed to estimate the influence of several clinical, pathohistologic, and immunohistochemical covariates to patients' survival. Survival curves were determined by the Kaplan-Meier product-limit method based on the most recent clinical status.

RESULTS

According to the histologic type of the tumor, fractional curettage specimens revealed 111 histologically favorable types (81.6%) and 25 unfavorable types (18.4%). The data indicate that ER, PR, Ki-67, and p53 levels of the hysterectomy specimens and those of the preoperative specimens were in fairly good agreement. The patients with the most favorable tumor grade (G I) had significantly better prognosis when the percentage of p53 positive cells was less than 15%. In the group of patients with histologic grade II, the survival was affected by ER expression (more than 30% of positive cells) and p53 levels (less than 15% of positive cells). None of the parameters was predictive in the group of patients with histologic grade III.

CONCLUSIONS

We found that determination of immunohistochemical parameters (ER, PR, and p53) on well-differentiated and moderately differentiated endometrial carcinoma of favorable histologic type obtained by curettage enables the recognition of the patients with favorable prognosis, who should not be treated by radical surgery.

Hepatitis B and HIV/AIDS in Zagreb: a district level analysis

This study examines the presence of hepatitis B as a possible precursor marker for HIV/AIDS in 10 districts of Zagreb, Croatia. There were a total of 931 cases of hepatitis B in Zagreb in the period 1979-1995, the annual rate ranging from 3.1 to 15.4 per 10,000. The highest relative risk for hepatitis B for the 1979-1995 period was in the Pescenica district (Relative risk (RR): 1.4). There were 108 cases of HIV/AIDS diagnosed in Croatia in the period 1986-1996, with 34% from Zagreb. The highest relative risk for HIV/AIDS was within the Pescenica district (RR: 2.3). Pescenica had also a significantly higher incidence of hepatitis B when compared to other districts (p = 0.005). The cumulative incidence of hepatitis B in Zagreb was directly related to levels of neighborhood discomfort as determined by an index including unemployment, inflation and housing conditions (p = 0.005). This research demonstrates that the poor areas of the city with higher incidence of hepatitis B hold the greatest threat for the spread of HIV/AIDS.

Life expectancy in Central and Eastern European countries and newly independent states of the former Soviet Union: changes by gender

AIM

To examine changes in life expectancy at birth for countries in Central and Eastern Europe (CEE) and the Newly Independent States of the former Soviet Union (NIS) for the period 1989-1996. Differences in the change by gender were examined and several factors which likely bear on the changes were discussed. Methods. Data from the WHO Health for All European Data Base were used to determine changes in life expectancy and selected economic factors for CEE and NIS countries.

RESULTS

Changes in life expectancy varied by gender in both CEE and the NIS, with the difference increasing for the two groups during the period with the largest increase occurring in the NIS. Both male and female life expectancy declined, with male life expectancy dropping at a more rapid rate. In 1994, the year in which most, but not all countries, reached a low point, life expectancy for males had declined below 60 years for two countries.

CONCLUSIONS

The most striking point about the decline in life expectancies was the short period in which the declines occurred, especially in the NIS. It is not possible to determine the exact cause for the changes, but there are likely multiple reasons. It is not completely clear why the decline in life expectancy was greater for males, although the linkage between economic and behavioral and lifestyle factors appear to have some association. Further research is necessary to determine why effects by gender vary so greatly and whether the negative outcomes are a short-term anomaly or will persist.

New priorities for health sector reform in Central and Eastern Europe

After the breakdown of the state socialism, a number of changes have occurred in the legal framework, as well as governmental policy, ownership, production, financing, and reimbursement of health care in Central and Eastern Europe (CEE). However, the policy context in CEE makes priority setting a necessary step to ensure the efficient use of public funds for health. The problems with prioritizing of health services in the Central and Eastern Europe are, in essence, related to the general position of health care within broad national priorities. The percentage of gross domestic product spent on health is insufficient and many cost-effective interventions are currently neglected, under-funded or provided with low quality standards. If the health status is to be improved, such interventions should be granted a greater priority. The experience from the established market economies indicate that: (a) overall future system of priorities setting in health care in the CEE should be driven by new democratic values; (b) new systems must be people-centered, more oriented to the needs of individual patient and specific groups, and sensitive to inequalities, unemployment, and social poverty; (c) they should be health-focused; and (d) they should be evidence-based and oriented towards primary health care.

Back to Europe: back to Bismarck?

Since 1989 there have been enormous changes in all aspects of health policy, and the Former Socialist Economies (FSEs) are facing similar challenges. The general restructuring of politics and economies has resulted in two leading orientations in the transformation of health care systems: the separation of funding and service provision from the state, and the separation of funding and service provision from each other. Many FSEs have already passed legislation establishing a sickness insurance system under a single national funding institution, or a combination of compulsory and voluntary insurance, or a system involving private sector insurance companies in generating compulsory or voluntary health care funding. Due to the peculiarities and specific features of the German health care system, the uncritical intention to implement the "Bismarck model" in the FSEs faces several problems. These can be summarized in one main point: the relative stability of the German health care system, which may be attractive to the FSEs, is based on economic prosperity and on a strong ability to assert the will of the central state institutions: these preconditions are not present in the FSEs.