[Reconstruction of mental health services in Bosnia and Herzegovina]. / Rekonstrukcija sluzbe za zastitu mentalnog zdravlja u Federaciji Bosne i Hercegovine.

Psychiatric services in Bosnia-Herzegovina before the war disaster was fairly developed and one of the best organized services amongst the republics of the former Yugoslavia. The psychiatric care system was based on psychiatric hospitals and small neuropsychiatric wards within general hospitals, accompanied by psychiatric services in health centers. The onset of war in B&H brought devastation and destruction in all domains of life, including the demolition and closing of numerous traditional psychiatric institutions, together with massive psychological suffering of the whole civilian population. Already during the war, and even more so after the war, the reconstruction and reorganization of the mental health services was undertaken. The basis of mental health care for the future is designed as a system where majority of services is located in the community, as close as possible to the habitat of the patients. The key aspect of the system of the comprehensive health care is primary health care and the main role is assigned to family practitioners and mental health professionals working in the community. Large psychiatric institutions were either closed or devastated, or have their capacities extensively reduced. There will be no reconstructions or reopening of the old psychiatric facilities, nor the new ones will be built. The most integrated part of the psychiatric system are the Community based mental health centers. Each of these centers will serve a particular geographic area. The centers will be responsible for prevention and treatment of psychiatric disorders, as well as for the mental health well being. Chronic mental health patients without families and are not able to independently live in the community will be accommodated in designated homes and other forms of protected accommodation within their communities. The principal change in mental health policy in B&H was a decision to transfer psychiatric services from traditional facilities into community, much closer to the patients. Basic elements of the mental health policy in B&H are: Decentralization and sectorization of mental health services; Intersectorial activity; Comprehensiveness of services; Equality in access and utilization of psychiatric service resources; Nationwide accessibility of mental health services; Continuity of services and care, together with the active participation of the community. This overview discusses the primary health care as the basic component of the comprehensive mental health care in greater detail, including tasks for family medicine teams and each individual member. 1. Comprehensive psychiatric care is implemented by primary health care physicians, specialized Centers for community-based mental health care, psychiatric wards of general hospitals and clinical centers in charge of brief, "acute" inpatient care; 2. Primary mental health care is implemented by family practitioners (primary care physicians) and their teams; 3. Specialized psychiatric care in community is performed professional teams specialized mental health issues' within Mental health centers in corresponding sectors; 4. A great deal of relevance is given to development of confidence and utilization of links between primary health care teams and specialized teams in Mental health centers and psychiatric in patient institutions; 5. Psychiatric wards within general cantonal hospitals, departments of psychiatric clinics in Sarajevo, Tuzla, and Mostar, and Cantonal Psychiatric hospital in Sarajevo (Jagomir) shall admit acute patients as well as chronic (with each new relapse). Treatment in these facilities is brief an patients are discharged to return to their homes, with further treatment referral to their family practitioner or designated Mental health center; 6. Chronic mental patients with severe residual impairment in social, psychological, and somatic functioning, shall live in the community with their families or independently. Those chronic patients without families and economic and other resources to live independently shall be placed in supervised Homes in the communities where they live. The above delineated strategy of mental health care program in B&H has several fundamental and specific objectives, among which the most important are: Reduction of incidence and prevalence of some mental disorders, particularly war stress-related disorders and suicide; Reduction of level of functional disability caused by mental disorders through improvement of treatment and care of individuals with mental health problems; Improvement of psychosocial well being of people with mental health problems, through implementation of comprehensive and accessible service for community mental health care; and Respect of basic human rights of individuals with mental health disabilities. The program has been updated since 1996, after the two-year pilot program. The main goals for current two- and five-year period are: Implement the mental health care reform program by launching all 38 Mental health centers in the Federation of BiH by 2002; Complete the 10-day education and re-education of at least 50% of all professionals employed in mental health services in FB&H by 2002; and Achieve that 80 percent of all mental health problems are treated by family medicine teams (primary care practitioners) and specialized mental health services (Community mental health care centers) by 2005.

Influence of left ventricular function on survival after coronary artery bypass grafting.

BACKGROUND: Preoperative left ventricular function is a most important predictor for survival in patients with ischemic heart disease. To elucidate the optimal timing of recommended coronary artery bypass grafting, we investigated the influence of different aspects of preoperative left ventricular function on relative survival. METHODS: To calculate the relative survival and estimate the disease-specific survival, we compared 6,514 patients who survived the first month after primary coronary artery bypass grafting with the general Swedish population stratified by age, sex, and 5-year calendar period. In particular we studied the relation between relative survival and different aspects of left ventricular performance, namely left ventricular function at rest, New York Heart Association functional class, and number of previous myocardial infarctions. RESULTS: The three variables (left ventricular function at rest, New York Heart Association functional class, and number of previous myocardial infarctions) as well as age and follow-up year gave independent information concerning relative survival. The results from this multivariate analysis were used to define a risk score for each patient. Patients were categorized into different risk groups. Patients in the low-risk group (30% of the total) showed a survival better than that of the population at large for 9 years after operation. The medium-risk group had no or low excess mortality for about 7 years, and the high-risk group (25%) showed increased excess mortality immediately after operation. CONCLUSIONS: If primary coronary artery bypass grafting is performed before the left ventricular function and physical performance deteriorate, survival is excellent.

The antiarrhythmic and hemodynamic actions of alpha, alpha-dimethyl-4-(alpha, alpha, beta, beta-tetrafluorophenethyl) benzylamine (MK-251).

Alpha,alpha-Dimethyl-4-(alpha,alpha,beta,beta-tetrafluorophenethyl)benzylamine (MK-251) has been found to prevent certain types of experimentally induced ventricular arrhythmias and at maximally effective doses possesses substantial hemodynamic safety in contrast to standard antiarrhythmic agents. MK-251 prevented or modified ventricular arrhythmias produced by injection of tetrafluorohexachlorobutane into the coronary artery of dogs and baboons. In dogs, the dose estimated to prevent 80% of the arrhythmic impulses (ED80) was 0.5 mg/kg i.v. and 5.0 mg/kg p.o. The duration of action after oral administration of 5.0 mg/kg to the dog or baboon exceeded 5 to 6 hours. MK-251 delayed the onset of arrhythmias resulting from coronary artery ligation, reduced their severity and permitted a conversion back to normal sinus rhythm earlier than in control dogs. In cats, the doses of digoxin required to induce ventricular ectopic activity, ventricular tachycardia and ventricular fibrillation were elevated by MK-251. In anesthetized dogs, 4 times the i.v. ED80 produced no change in blood pressure, cardiac contractility or output, or in ventricular conduction. The only effect after 8 times the ED80 was a slight decrease in contractility. In contrast. lidocaine at its ED80 (0.21 mg/kg/min), decreased blood pressure and contractility; there was no change in ventricular conduction. Quinidine at the ED80 (8.8 mg/kg i.v.) and above produced hypotension, decreased contractility and prolonged conduction in a dose-related manner.