Telephone Problem-Solving Treatment Improves Sleep Quality in Service Members With Combat-Related Mild Traumatic Brain Injury: Results From a Randomized Clinical Trial.

OBJECTIVE: Evaluate sleep quality, its correlates, and the effect of telephone-based problem-solving treatment (PST) in active duty postdeployment service members with mild traumatic brain injury (mTBI) SETTING:: Randomized clinical trial. PARTICIPANTS: Active duty service members with combat-related mTBI. STUDY DESIGN: Education-only (EO) and PST groups (N = 178 each) received printed study materials and 12 educational brochures. The PST group additionally received up to 12 PST telephone calls addressing participant-selected issues. Outcomes were evaluated postintervention (6 months) and at 12 months. MAIN MEASURE: Pittsburgh Sleep Quality Index. RESULTS: Sleep quality was manifestly poor in both groups at baseline (Pittsburgh Sleep Quality Index = 12.5 ± 4). Overall sleep quality was significantly different between the PST and EO groups at 6 months (P = .003) but not at 12 months. Longitudinally, PST significantly improved sleep quality at 6 months (P = .001) but not over the follow-up. Low sleep quality was associated with concussion symptoms, pain, depression, and posttraumatic stress disorder at all time points (P < .0001). CONCLUSIONS: Sleep disorders, common in postdeployment service members with mTBI, are strongly associated with the presence of pain, posttraumatic stress disorder, and depression. Telephone-based PST may be an effective therapeutic approach for reducing sleep disorders in this population. Research should focus on maintenance of treatment gains.

PLTP regulates STAT3 and NFκB in differentiated THP1 cells and human monocyte-derived macrophages.

Phospholipid transfer protein (PLTP) plays an important role in regulation of inflammation. Previously published studies have shown that PLTP binds, transfers and neutralizes bacterial lipopolysaccharides. In the current study we tested the hypothesis that PLTP can also regulate anti-inflammatory pathways in macrophages. Incubation of macrophage-like differentiated THP1 cells and human monocyte-derived macrophages with wild-type PLTP in the presence or absence of tumor necrosis factor alpha (TNFα) or interferon gamma (IFNγ) significantly increased nuclear levels of active signal transducer and activator of transcription 3, pSTAT3(Tyr705) (p<0.01). Similar results were obtained in the presence of a PLTP mutant without lipid transfer activity (PLTP(M159E)), suggesting that PLTP-mediated lipid transfer is not required for activation of the STAT3 pathway. Inhibition of ABCA1 by chemical inhibitor, glyburide, as well as ABCA1 RNA inhibition, reversed the observed PLTP-mediated activation of STAT3. In addition, PLTP reduced nuclear levels of active nuclear factor kappa-B (NFκB) p65 and secretion of pro-inflammatory cytokines in conditioned media of differentiated THP1 cells and human monocyte-derived macrophages. Our data suggest that PLTP has anti-inflammatory capabilities in macrophages.

SAA and PLTP activity in plasma of periodontal patients before and after full-mouth tooth extraction.

OBJECTIVE: To assess whether treatment of advanced periodontal disease affects plasma levels of serum amyloid A (SAA) and phospholipid transfer protein (PLTP) activity. DESIGN: We measured the levels of SAA and PLTP activity in plasma of 66 patients with advanced periodontal disease before and after treatment by full-mouth tooth extraction (FME). RESULTS: At baseline, median SAA levels in our study population were within the normal range (2.7 microg ml(-1)) but SAA was elevated (>5 microg ml(-1)) in 18% of periodontitis patients. Three months after FME, SAA levels were significantly reduced (P = 0.04). SAA did not correlate with any of the periodontal disease parameters. PLTP activity was elevated in patients with periodontitis, compared to the PLTP activity reference group (age-matched systemically healthy adults, n = 29; 18 micromol ml(-1) h(-1)vs 13 micromol ml(-1) h(-1), respectively, P = 0.002). PLTP activity inversely correlated with average periodontal pocket depth (PPD) per tooth (r(s) = -0.372; P = 0.002). Three months after FME, median PLTP activity did not change significantly. CONCLUSIONS: Full-mouth tooth extraction significantly reduces SAA, a marker of inflammation, while it does not affect plasma PLTP activity. However, the inverse correlation between PLTP activity and average PPD suggests that increased PLTP activity may limit periodontal tissue damage.

Breast, colon, and prostate screening in the adult population of Croatia: does rural origin matter?

INTRODUCTION: The aim of this study was to investigate the utilization of breast, colon and prostate cancer screening in the adult Croatian population in a period without national cancer screening programs, with a special interest in respondents' rural versus urban origin. METHODS: Self-reported screening utilization was investigated in the Croatian Adult Health Survey, which collected health-related information from a representative sample of the adult Croatian population. Breast cancer screening was investigated in women aged over 40 years, while colon and prostate screening was investigated in respondents aged over 50 years. The data were analysed using binary logistic regression. RESULTS: One in five women reported breast cancer screening uptake in the year preceding the survey (22.5%), while only 4.5% reported a colon screening. A total of 6.1% men reported colon screening, while 13.7% of men reported having a prostate cancer screening. Respondents with rural origin reported all sites screening utilization less frequently than those of urban origin (breast: 14.5% vs 27.4%; prostate: 9.6% vs 16.3%; colon-men: 5.7% vs 6.3%; colon-women: 3.6% vs 5.1%; respectively). Multivariable models indicated that people with higher socio-economic status more commonly reported breast and prostate cancer screening uptake. Access to health care was the only independent variable associated with colon cancer screening in men, and the strongest variable associated with colon cancer screening in women. Rural origin was associated only with lower odds of breast screening (adjusted odds ratio 0.60 [95% confidence interval 0.48-0.74]), while in the remaining models, rural origin was not a significant predictor for cancer screening uptake. CONCLUSIONS: Opportunistic cancer screening uptake is low in the Croatian adult population, with existing socio-economic differences in breast and prostate screening, and their absence in colon cancer screening. Rural origin was significantly associated with breast screening, even after adjustment to socioeconomic status and problems in access to health care. Lack of rural origin significance in the other screening sites could be related to small sample sizes of people who reported opportunistic utilization. Overall, access to health care is the strongest cancer screening predictor, and this should have a prominent role in the development of a systematic cancer screening program on a national level.

Teleradiology in Croatia.

A teleradiology system connecting 35 workstations in 27 hospitals was established in Croatia. In two years of operation, 2071 consultations were conducted using the system at an average rate of four neurosurgical teleconsultations per day. Eighty patients required urgent transfer to the tertiary hospital and 181 required non-urgent transfer. An additional 181 patients remained in their local hospital and were treated under the supervision of the tertiary hospital. The avoidance of unnecessary patient transfer led to significant cost savings.

Genealogical structuring of a population.

The study observed population of 484 generation restrictive genealogies collected in four Croatian regions during 1970/71 within "The study of fat and carbohydrate metabolism indicators correlated with the occurrence of diabetes in animal fat and oil consuming population groups". The genealogies were collected on two islands (Brac and Hvar) and in two continental regions (Sinjska Krajina and Srijem). Genealogy Structure Index (GSI) was defined as quantitative indicator of genealogy structure. GSI was continuos variable which, by its extreme, describes vertical and horizontal type of genealogy structure, independently of the way genealogies were collected. Genealogy structure of surveyed population was described on the basis of participation of different genealogy types. Populations of the island Hvar and Brac showed to have horizontal genealogy type, continental population of Sinjska Krajina showed to have mixed type and continental population of Srijem showed to have vertical type of genealogy structure.

Geographical distribution of elderly people in Croatia.

The authors outlined the geographical distribution of individuals displaying longevity in the Republic of Croatia. Elderly people, aged 80 years and older, have been the subject of this study and were viewed in several aspects including the number of elderly people and age-specific mortality rate by districts. Data for the years 1981 and 1991 were reviewed. In 1981 there were 73,052 (1.6%) persons aged 80 or older. Ten years later in 1991 their number had increased to 107,256, which was 2.2% of the whole population. Most of the elderly people live on the islands, in the district of Dubrovnik and in Lika, which is in the continental part of Croatia. There are more women than men among those aged 80 years and older Age-specific mortality rate in 1981 in Croatia was 170 and in 1991 151 per 1,000 elderly people. In women the rate was 162 in 1981 and 141 in 1991, per 1,000 elderly people. The death rate was higher in men; in 1981 it was 201 and in 1991, 172 per 1,000 elderly people. We can see that the specific mortality rate had fallen in 1991 compared to 1981. The age specific mortality rate varies from district to district. In 1991 the lowest, 110 per 1,000, was in Lika, and the highest in the districts of Varazdin (182 per 1,000), Bjelovar (178 per 1,000) and Zagorje (175 per 1,000). The death rate was higher amongst elderly men (172.31 per 1,000) than elderly women (141.65 per 1,000). The smallest number of those aged 80 years and older with a high death rate is found in Slavonia. The opposite--a high number of elderly people and a low specific mortality rate--can be seen in the district of Lika. On the islands the number of elderly people is high, especially women, and surprisingly, the specific mortality rate is relatively high as well.

The effect of a compulsory curriculum on ethical attitudes of medical students.

The purpose of the present study was to assess the influence of a compulsory curriculum on first-year medical students. The ethical attitude study was performed at the School of Medicine, University of Rijeka, Croatia. The samples consisted of 171 medical students (68 males and 103 females) interviewed at the beginning of the first year of studies. Some of them, namely 143 (56 males and 87 females) were interviewed again at the end of the same academic year. Data were analysed by applying factor analysis under principal component model and varimax criterion as the rotation model. The results clearly show that the current compulsory curriculum without formal ethical education has a limited influence on first-year medical students. That points to the obvious necessity to implement the medical ethics in the course of medical education.

Albuminuria, cardiovascular morbidity and mortality in diabetic and non-diabetic subjects in a rural general practice.

OBJECTIVES: The aim of this study was to estimate the frequency of albuminuria in patients with and without diabetes mellitus, answering the question: 'How relevant for general practice are epidemiological findings that albuminuria is a significant risk indicator for the development of cardiovascular syndromes?'. METHOD: The relationship between albuminuria and vascular disease was studied in two groups of subjects: one group consisted of 138 patients with diabetes mellitus and the other of 160 patients without diabetes, randomly selected from a stratified sample comparable with known diabetics by age, sex and profession. The groups were examined in the same way and mortality was followed over 5 years (1994-1998). RESULTS: Albuminuria was significantly more often present in diabetics (P < 0.0001). Peripheral arterial occlusive disease was diagnosed in 27.3% of patients with diabetes mellitus, and in 8.8% of the control group (P < 0.001). In the diabetic group 40 (29%) had microalbuminuria, but only 20 (12.5%) of the other group had the condition. In the presence of albuminuria, the incidence of arterial occlusive disease was 53.6%, but in those without it was only 9.8%. CONCLUSIONS: Our study has demonstrated that albuminuria is frequently present with diabetes mellitus, peripheral arterial occlusive disease, hypertension, coronary heart disease, hyperlipidaemia and in cases with increased concentration of blood fibrinogen. The albuminuria was significantly more frequent in those who died in the observed 5-year period after first examination. Although albuminuria indicates higher risks of cardiovascular morbidity and mortality in diabetics and in non-diabetics, it is necessary to study further how useful is this evidence for general practice.

Cancer incidence in eastern Adriatic isolates, Croatia: examples from the islands of Krk, Cres, Losinj, Rab and Pag.

As an extension of previous research this study investigates the incidence of cancer in five genetic isolate island populations of the Eastern Adriatic, Croatia. Thorough anthropological research over the past three decades has established some of those populations as outstanding examples of genetic isolates. A previous study which found higher cancer incidence in 5 Eastern Adriatic islands than in a control population supported a hypothesis that among the founders of these populations there were genetic variants (especially with recessive inheritance) responsible for genetic susceptibility to certain types of cancer. This study sought to investigate cancer incidence in 5 further island populations. All cancer cases in five island populations (Krk, Cres, Losinj, Rab and Pag) over the 20-year period (1971 to 1990) was extracted from the data of the Croatian Cancer Registry. The mainland populations of Istrian and Primorsko-Goranska County, characterized by similar environmental factors but an outbred genetic structure, represented a control population. After standardization by by sex and age, cancer incidence was higher in the island populations than in the control population in both sexes. The cancer sites primarily responsible for the excess incidence were prostate, stomach and pancreatic cancer in males, and ovarian, breast, stomach, bowel, and brain cancer in females. The reasons for the increased cancer incidence are uncertain and may be due to different environmental exposure between the two populations. However, it is possible that genetic isolation and inbreeding are important factors. Further investigations of cancer in these isolate populations are warranted to explore these findings further.

Surname as 'cancer risk' in extreme isolates: example from the island of Lastovo, Croatia.

The aim of this study was to analyze whether there are surnames which appear more frequently among the ancestors of cancer cases in a small isolate, in comparison to the ancestral surnames of the healthy controls, using the classic case-control design. The chosen setting was the island of Lastovo, Croatia, located more than 100 kilometers from the nearest coastal region. The period of study was 1970-1995, during which a total of 76 cancer cases were recorded in a population of approximately 800. The comparison of surname frequencies was performed in current and in five ancestral generations. The leading hypothesis was that, if inbreeding and common ancestry contributed to the development of the disease, then those phenomena should be reflected in increasing frequency of some surnames among ancestors, identifying the 'hidden' consanguinity, or 'following' cancer-promoting genes on the Y-chromosome. The results imply that there are surnames representing a classic "risk" for cancer, but also those "protecting" from its development, which all underscores the importance of founder effect and genetic predisposition to the disease in a small, reproductively isolated population. All of the results become more evident and increasingly significant when analyzed in more distant ancestral generations.

Possibilities of See5 software in forecasting of life expectancy not achieving.

Results of application of See5 to epidemiological domain were presented. The aim of this paper is to find out if See5 can be used for forecasting whether life expectancy will be achieved or not. The basis for forecasting are data-attributes, predictors (anthropological data, living habits, laboratory data, blood pressure measured in years 1970/71, and the status of examinee--class (alive or dead) in 1990. Data were split at random into 10 blocks with approximately the same number of cases and the same distribution of classes. Results were given in the form of decision trees and rulesets, and tested through crossvalidation. The most interesting question--what are prediction-candidates for not achieving life expectancy estimated in the year of examination--did not give a satisfactory result: the accuracy of classification was about 70%. However, a very interesting fact is that each rule consists of at least one candidate predictor, usually considered as risk factor (e.g. high diastolic blood pressure and animal fat consumption).

ILLM--inductive learning algorithm as a method for prediction of life expectancy achieving.

The aim of the paper was to use inductive learning algorithm ILLM in the field of epidemiology, for prediction the life expectancy achieving. Data base comprised results of epidemiological investigation in some regions of Croatia. Overall accuracies for different samples and corresponding rules produced by ILLM algorithm, showed some interesting results. Algorithm can be seen as having the capacity to forecast 'achieving the life expectancy'. In the same time algorithm was not able to make a good forecast for 'not achieving the life expectancy'.

[Patterns of referring patients by general practitioners to specialist consultation--an international comparison]. / Obrasci upucivanja bolesnika iz opce medicine na konzultativne preglede--medunarodna usporedba.

The prospective study of referrals from 46 general practices in the Republic of Croatia to specialist consultation was carried out in the course of 1989 and 1990. A total of 39 specialists in GP, 3 trainees and 4 general practitioners were involved. Each GP marked period required for referral of 30 patients. The data collected included 1375 referrals and 22740 examined patients. The results from our study were compared with the analogous data collected in other 14 countries within the European Study of Referrals from Primary Care. In European countries the observed range of referral rates was almost fourfold (81.7 in Norway, 26.0 in France). The referral rate for the Republic of Croatia is 60.7 ranking Croatia fourth in the European comparison. The re-referral make 55.3% of all referrals in Croatia thus ranking Croatia first in the European comparison. Croatian GPs consult the following specialists (in order of importance): ophthalmologist (11.9%), surgeon (10.8%), internist (7.8%), otolaryngologist (7.6%), cardiologist (6.7%) and orthopedist (6.0%). A considerable variability of individual referral rates was noticed in the studied group of Croatian GPs (from 23.4 to 461.5). The value of determination coefficient R2 = 0.3233 was obtained using the classical multiple linear regression based on the system of predictors, which included 12 referral characteristics. This explained 32% of referral variability of the studied group. The ratio of routine referred patients (having the largest ratio of re-referrals), and the median age of referred patients had the most significant contribution to the coefficient of determination.(ABSTRACT TRUNCATED AT 250 WORDS)

[Respiratory symptoms and pulmonary ventilatory function in greenhouse workers]. / Respiracijski simptomi i ventilacijske funkcije pluca radnica u staklenicima.

Respiratory symptoms and ventilatory capacity were studied in a group of 135 women employed in greenhouses. In addition, a control group of 51 unexposed women were studied. Greenhouse workers had significantly higher prevalence of chronic cough, dyspnea, chest tightness and rhinitis (p < 0.01) than the controls. Smokers had significantly higher prevalence of chronic cough (p < 0.01) and rhinitis (p < 0.05) than nonsmokers. There was a high prevalence of acute symptoms during work shift. In greenhouse workers there was a statistically significant decrease of measured ventilatory capacity tests (except FVC) as compared to the predicted normal values, especially for FEF25. Smokers and nonsmokers had similar changes of ventilatory capacity as percentage of the predicted normals. Greenhouse workers exposed for more than 10 years had considerably lower FEF50 and FEF25 as percentage of the predicted values than those exposed for less than 10 years. Our data indicate that longer exposure in greenhouses may be associated with the development of acute and chronic respiratory impairment.

Medical decision making based on inductive learning method.

Medical decision making based on inductive learning has been studied in order to collect experience necessary for practical use of such methods in clinical and epidemiological work. The decision trees have been constructed by using the modified Quinlan's approach based on choosing relevant attributes according to their informativity. An inductive learning software tool, ASSISTANT Professional, has been used for experimenting. The variability in results has been studied under varying learning conditions. Two sets of data have been chosen for learning experiments: from a study on rheumatoid factors in patients with rheumatoid arthritis, and from an epidemiological investigation of aging. The results of this study indicate the necessity to determine inductive learning parameters for each particular problem. The pruning procedure is always recommended as it eliminates redundant elements in the tree. In problems with greater number of attributes, however, pruning itself is not guaranteeing satisfactory solutions. Interventions like the change of the minimal weight threshold might improve the situation. If these precautions are met, the method of inductive learning seems to be a useful guide in practical clinical and epidemiological decisions.

Genealogy data design appropriate for family relationship retrieving.

Data structure representing a genealogy or genealogies as a stand-alone date structure is presented. Genealogy is considered as a finite, connected graph with nodes ni representing individuals, arcs (ni, nj), ordered pairs of nodes as parent-offspring relationships and edges (ni, nj), unordered pairs of nodes as twinships. Such structure enables storage of the minimum of family relationships and recognition of them and others like 'ancestor-descendant', 'sibs', 'twins', 'cousins', 'uncle/aunt-nephew/niece' or 'spouses'. Algorithms for genealogy retrieval are classified as vertical, lateral and parallel. In certain combinations, vertical and lateral algorithms become capable of finding any relatives, no matter if they are in a direct 'ancestor-descendant' relationship or if they have only the same ancestor(s). A parallel algorithm is designed in order to search for twins, triplets etc.

[A comprehensive program for prevention of chronic non-infectious diseases in basic population groups--the Belec Study. V. Changes in mortality and causes of death after intervention]. / Cjeloviti program borbe protiv kronicnih nezaraznih bolesti u osnovnim populacijskim skupinama--studija Belec. V. Promjene mortaliteta i strukture uzroka smrti nakon intervencije.

After an earlier analysis of mortality and causes of death in the rural community Belec for the period from 1977 to 1981, analysis was repeated for the period from 1983 to 1987. In the meantime, in 1984, the Health Committee and the Guidance Clinic for Hypertension were founded, as important elements of Comprehensive Programme for Fighting Non-infectious Chronic Diseases in Basic Population Groups of Belec Study, started in 1981. The order of causes of death did not change significantly in the period analyzed. However, 12% decrease of the crude death rate was noted, as well as the decrease of both cardiovascular diseases death rate (33%) and malignant neoplasms death rate (17%). Cerebrovascular diseases death rate increased for 3%. At the same time, data for the Republic of Croatia show an increase of 16% of crude death rate, as well as an increase of cardiovascular diseases death rate (20%), cerebrovascular diseases death rate (24%) and malignant neoplasms death rate (11%). Results suggest positive impact of the Programme.

Analysis of data as information: quality assurance approach.

Describes a prototype module for data analysis of the healthcare delivery system. It consists of three main parts: data/variable selection; algorithms for the analysis of quantitative and qualitative changes in the system; and interpretation and explanation of the results. Such a module designed for primary health care has been installed on a PC in the health manager's office. Data enter the information system through the standard DBMS procedures, followed by calculating a number of different indicators and the time series, as the ordered sequences of indicators, according to demands of the manager. The last procedure is "the change analysis" with estimation of unexpected differences between and within some units, e.g. health-care teams, as well as some unexpected variabilities and trends. As an example, presents and discusses the diagnostic pattern of neurotic cases, referral patterns and preventive behaviour of GP's teams as well.

[A comprehensive program in the fight against chronic non-infectious diseases in a basic population group--the Belec Study. IV. The interventional model]. / Cjeloviti program borbe protiv kronicnih nezaraznih bolesti u osnovnim populacijskim skupinama--studija Belec. IV. model intervencije.

As part of a comprehensive programme aimed at the struggle against chronic non-infectious diseases in basic population groups, an intervention model in the rural community Belec has been set up. The development, application and evaluation of this intervention model with an emphasis on positive experiences and difficulties connected with such a model have been described. The role of important parts of the programme has been emphasized--the work of the Health Committee and Guidance Clinic of Elevated Blood Pressure. The results show that there is necessary and possible to efficaciously involve the population of the community into the priority assessment, planning, application and follow-up of such a programme. However, the close cooperation with the local health service and other community sectors and their support is indispensible. It is also stressed that the economic and social development of the rural community is the prerequisite for the continuous intervention measures to be carried out and health care system promoted.