Albanian Medical Journal

4

Authors: Brunilda Hysaj (Vila), Lila Shundi, Mimoza Basho, Ela Ali, Erjona Abazaj, Silva Bino, Tefta Rexha

Aim: The aim of this study was to determine the prevalence of active infection (presence of HCV-RNA) among injecting drug users (IDUs) in Albania, in order to establish the current prevalence of HCV genotypes in this group. Methods: During the period 2012-2013, we analyzed 96 IDUs (95 male and 1 female) in Albania. Mean age was 26.6 years (range from 19 to 42 years). All samples were tested for anti-HCV positivity by enzyme-linked immunoassay (ELISA). The samples that resulted positive by ELISA were analyzed for presence of HCV-RNA (active infection of HCV) and HCV genotypes. Results: The prevalence of anti-HCV was 55.2%. The positivity for HCV-RNA was 79.2%. Genotypes 1 (85.7%) and 3 (9.5%) were detected in the IDUs group. Conclusion: The predominance of genotype 3 makes the situation in Albania similar to that among IDUs in Europe. Nonetheless, more detailed studies with a larger number of patients are necessary to understand the HCV dynamics in this population sub-group in transitional Albania.

5

Authors: Suzanne M. Babich

Health leadership training for mid- to senior-level public health professionals was identified as an urgent need more than 25 years ago in a landmark report published by the United States Institute of Medicine and repeated in a follow up report 15 years later. Worldwide, similar calls for action have been stressed. The need persists.

5

Authors: Jan Chalany

Aim: The aim of this paper was to evaluate nurses' attitudes to hypodermoclysis used for rehydration in older people with terminal phase of dementia. Methods: A qualitative study was carried out among 16 nurses of the psychogeriatric ward in Mental Hospital of Kromeriz, Czech Republic, from January 2013 to January 2014. Unstructured interviews were used to collect information about nurses' attitudes toward hypodermoclysis in elderlies with terminal phase dementia. Content analysis was used to analyze the provided answers. Results: All nurses appreciated spare of time and effortlessness of subcutaneous application compared to intravenous application. All of them reported a highly comfort of such application for the patients. Twelve nurses (75%) reported initial disbelief in effectiveness of hypodermoclysis. Hypodermoclysis complications such as local edema, local infection, and local erythema were rare and at case report level. Conclusion: Hypodermoclysis is welcomed by nurses and it has been well-tolerated by patients with terminal phase of dementia with low rate of complications. We recommend this method for palliative care rehydration.

6

Authors: Margarita Prifti-Kurti, Zamira Ylli, Elizana Petrela, Genc Sulcebe

Aim: Anti-citrullinated peptide antibodies (ACPA) represent a valid marker for rheumatoid arthritis (RA). The aim of this study was to evaluate the diagnostic parameters of ACPA versus the rheumatoid factor (RF) among Albanian patients with RA. Methods: This prospective study was conducted from November 2010 to November 2012. Serum samples analyses were performed in patients with RA (N=126), patients with other non-RA systemic rheumatic disorders (NRA-SRD; N=78), as well as in normal control individuals (N=105). Both ACPA and RF were measured through an ELISA method in both patient group and the control group. Results: ACPA positivity was detected in 54% and RF in 44.4% of the patients with RA. The diagnostic specificity related to the normal control group was 96.2% for ACPA and 86.7% for RF. In relation to the NRA-SRD patients, the specificity was 84.6% for ACPA and 32.1% for RF. The presence of both RF and ACPA positivity decreased the sensitivity for the diagnosis of RA up to 35%, but provided a substantial increase in specificity (100%). Conclusions: In our RA patients, the ACPA positivity resulted significantly higher compared to RF. The detection of ACPA provides also a higher specificity than RF for the RA diagnosis. The ACPA testing provides a better marker in order to differentiate RA from NRA-SRD. We also showed that the ACPA and RF prevalence in the Albanian RA patients is lower than in the Western European populations and this finding is probably related to the different immunogenetic background of the studied populations.

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Authors: Erkena Shyti, Jonila Pasholli, Genc Sulcebe

Aim: The purpose of this study was to determine the actions that should be taken to improve the situation of Hematopoietic Stem Cell (HSC) donation in Albania. Methods: In this study there were included 813 individuals (patients and donors), that have been examined at our laboratory for allogeneic stem cell transplantation purposes and for the definition of normal Human Leukocyte Antigens (HLA) allele frequency distribution in the Albanian population. HLA-A, -B, -DRB1 genotyping was performed by polymerase chain reaction sequence specific methods. The statistical analysis was conducted using Fisher's (two-tailed) exact test. Results: Overall, there were included 70 patients and 233 related donors. The age of the patients ranged from 1 year to 62 years (mean: 23 years). Of these, 44 (62.9%) were males and 26 (37.1%) were females. The age of the donors ranged up to 78 years (mean: 33.8 years). In the donor group, 108 (46.4%) were males and 125 (53.6%) were females. An HLA identical sibling donor has been found in 27 (38.6%) of our patients. HLA-A, -B and DRB1 profile of 43 (61.4%) patients that lacked a full HLA matched sibling was compared with HLA genotyping data of 510 normal Albanian unrelated individuals. Fifteen unrelated potential donors were HLA compatible with 10 out of the 43 patients. Conclusions: The data reported in this preliminary study underline the actual necessity of organizing an Albanian national unrelated donor registry which can withstand the needs of Albanian patients for allogeneic HSCT.

7

Authors: Payam Behzadi, Elham Behzadi, Reza Ranjbar

Aim: Inspite of significant progressions in microarray techniques and accurate management, the analysis and interpretation of raw data is a big challenge for the majority of researchers on global scale. In this mini-review the authors have described general parameters to overcome current errors and drawbacks occurred in management, analysis and interpretation of microarray raw data. Methods: Visualization of correct data is related to researchers' knowledge about methodologies, experimental designing, appropriate platforms, upgrade softwares, suitable statistical tests and valuable databases. Hence, being up to date and skillful is considered a key factor for ensuring accurate data management, analysis and interpretation. Results: Application of correlated methodologies, experimental designs, platforms, softwares, statistical tests and virtual databases, guarantees high quality management, analysis and interpretation of microarray raw data. Conclusion: In accordance with new efforts in the field of databases and softwares, microarray data management, analysis and interpretation have been improved. The rise of microarray technology applications may lead to a significant decrease of the costs in the future.

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Authors: Indrit Këlliçi, Bledar Kraja

The aim of this article was to review how the behavioral factors such as smoking, alcohol and physical activity are involved in gastroesophageal reflux diseases (GERD) pathogenesis. Different pathogenic mechanisms for the association between these behavioral factors and GERD development have been suggested. Smoking decreases the lower esophageal sphincter (LES) pressure, may reduce salivary bicarbonate secretion and affects the esophageal epithelium due to direct effect of smoke products. Alcohol consumption facilitates hydrogen ion penetration into esophageal mucosa, causes dysfunction of LES, abnormal esophagus peristalsis, motility disorder, and may increase the acid secretion through gastrin stimulation. Physical exercise reduces gastrointestinal blood flow, alters the motor function of the esophagus and increases inspiratory thoraco-abdominal pressure gradient leading to reflux of gastric content into the esophagus. On the other hand, physical exercise may increase the inspiratory striated muscle tone, a key component of the antireflux barrier. However, there is sufficient evidence to show that modulation of these agents is either effective or ineffective in GERD symptoms. Further prospective studies are warranted to investigate the impact of these modifiable behavioral factors which, with prevention mechanisms, can help to reduce the burden of GERD in the general population. Keywords: alcohol, gastroesophageal reflux disease (GERD), physical activity, smoking.

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Authors: Valentina Semanaj, Teuta Curaj, Genc Sulcebe

Aim: Our aim was to determine the diagnostic relevance of flow cytometry multiparametric immunophenotyping (FCMI) in acute leukemias (AL) of all ages in Albania. Methods: A total of 300 bone marrow or peripheral blood samples of patients suspected for AL were examined in Tirana, Albania. The applied methodology consisted of a four color FCMI method. Results: Of the overall 300 patients studied, 128 (42.52%) were females and 172 (57.47%) were males. There were 103 (34.55%) children aged 0-16 years, whereas further 197 (65.44%) were adult patients. After the FCMI examination, 78 (75.7%) of the pediatric patients were diagnosed with acute lymphoid leukemia (ALL). In this group, 78.2% of the patients showed a malignant proliferation of B-cell line (ALL-B) and 21.8% of T-cell line (ALL-T). About 21% of the pediatric patients resulted with acute myeloid leukemia (AML). One patient displayed acute bilineal leukemia (BLL) and another patient biphenotypic acute leukemia (BAL). Only one patient displayed undifferentiated immunophenotypic cells. From the 197 adult patients with AL studied, we established the following immunophenotypic diagnosis: 139 (70.5%) of them were diagnosed with AML and 53 (26.9%) with ALL. In the latter group, 77.5% of the patients showed an ALL-B and 22.6% presented an ALL-T cell proliferation. Three adult patients were classified as BAL, while two of them displayed an undifferentiated immunophenotypic profile because of the expression of only non-specific cell line markers CD45, CD34 and CD117. Conclusion: Flow cytometry immunophenotyping is a very important examination for the final diagnosis and subtype differentiation of AL also in Albanian patients.

2

Authors: Suzanne Havala Hobbs

Our global health care systems face an enduring challenge: The urgent need for increased leadership capacity within the senior health services workforce. This call for leadership training is not new. It has been repeated for decades by diverse groups within the public health professional community as well as in the clinical health services.

5

Authors: Toni Yonkov Vekov

In healthcare, the value which a patient receives is usually defined as the result of the healthcare activities, achieved per a financial unit. Measuring this value should be the basis of the model for reimbursement of health products (therapeutic and diagnostic activities, medicines, prevention and prophylaxis and the like). When the reimbursement policy is bound to the value for the patient, then the medical providers are rewarded for their effectiveness in achieving good health results, while enabling to locate the responsibility for poor health results. The current health reforms in the economically developed EU countries are oriented precisely to such individualized long-term care policies. Keywords: approach, healthcare costs, management, reimbursement, value for patients.

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Authors: Ramadan Halimi, Nazife Sylejmani-Hulaj, Hidajete Halimi, Sevdie Jashari-Ramadani

Aim: To assess the prevalence of Posttraumatic Stress Disorder (PTSD) and other comorbid disorders and also to assess the impact of demographic and social factors in deterioration of existing psychological problems in Kosovo War Veterans. Methods: Data were gathered from a representative sample of 215 Kosovo War Veterans. Subjects were assessed for the presence of lifetime and current DSM-IV TR psychiatric disorders with the following questionnaires: Harvard trauma questionnaire (HTQ), Beck's Depression Inventory and Mini International Neuropsychiatric Interview, Albanian version 5.0.0 (MINI 5.0). Results: All subjects under study were males (100%), with a mean age of 42.9±7.8. Criteria for PTSD were met by 113, or 52.6% of the subjects; criteria for PTSD in co-morbidity with Major Depressive Disorders were met by 70, or 32.6% of the subjects, and; criteria for Major Depressive Disorder were met by 77, or 35.8% of subjects. The study has confirmed a significant impact of education, unemployment and poverty in the deterioration of PTSD and other psychological disorders. Conclusion: Fourteen years after the war, our study has shown that psychological problems among War Veterans should still be considered as a very serious issue. Meanwhile, the demographic and social factors also have had a high impact in the deterioration of the PTSD symptomatology, in the symptomatology of Major Depressive Disorder and other Comorbid Disorders.

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Authors: Veronika Duci, Juliana Ajdini

Aim: This study aims to explore the quality of life of cancer caregivers and the impact of socio-demographic factors. Methods: A quantitative approach was used to conduct the study. The sample selection was based on a quota strategy and resulted to a total number of N=377 cancer caregivers. The study took place in the Oncology Hospital, at the "Mother Teresa" University Hospital of Tirana. The research tool was a questionnaire starting with socio-demoghraphic questions for the caregivers followed by the Quality of Life Scale of Flanagan (1982). Data analysis was conducted using SPSS 16. Validity of the QoLS was satisfying (Cronbach alpha=0.882). Results: Findings indicated that the caregivers were mainly women, unenmployed, of different ages and different types of families. Most of them offered care for more than five hours per day. QoL of the participants were at most low to medium. Age had a negative correlation with QoL (rs = -0.362, P<0.001). Participants with secondary education reported lower levels of quality of life (U=3334.5, P<0.001, r = -0.33). The married participants had higher levels of QoL, compared to the widowed (U=1117, P<0.001, r = -0.23). The mean values were m=169.07 for the caregivers with children and m=244.20 for the ones without children. Conclusion: Quality of Life can be influenced by certain life stressors like having a family member with cancer and being a caregiver. Further research with a cancer caregiver focus is needed in the Albanian context.

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Authors: Elia Krasimirova Georgieva, Peshka Angelova Pesheva, Lidia Mladenova Georgieva

Aim: To assess the prevalence of depression among medical students in Bulgaria. Gender and other associated factors were taken into account. Methods: A cross-sectional study was carried out in 2013 at Medical University-Sofia. A specially designed questionnaire was administered. The Beck Depression Inventory was used to study depression. The study was carried out at the Department of Social Medicine, Faculty of Public Health-Sofia. One hundred and fifty medical students in the second course and 128 students in the sixth course took part in the study. Descriptive analysis was performed. Relation between variables was assessed with chi-square test with a significance level P≤0.05. Results: Symptoms of depression were found in 54.7% of all medical students (mild depression in 41.7%, moderate in 11.5%, severe in 1.4%). There was no significant difference in depression rates for second and sixth course students (P=0.1613) and for males and females (P=0.85). The analysis showed that possible risk factors for developing depressive symptoms are not having a parent physician and the lack of an intimate partner. Conclusion: There was a high prevalence of depressive symptoms among medical students, with no significant difference by sex and course of education. It is important to identify students suffering from depression and to develop programs for addressing mental health problems.

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Authors: Erjola Piluri Ziu, Eris Mesonjesi, Maria Zoto, Blerina Bregu, Alfred Priftanji

The ALB-ISAAC 2011 study forms a part of a series of population surveys carried out in Tirana, using the internationally recognized procedures of the International Study of Asthma and Allergies in Childhood (ISAAC). ISAAC initiative was designed to study the aetiology of asthma, allergic rhinoconjunctivitis, and atopic eczema in children in different populations using standardized methodology. In Albania, all of the three phases were carried out; Phase One (1995), Phase Two (1999-2000) and Phase Three (2001). ALB-ISAAC specific aims are: 1) to describe the prevalence and severity of asthma, rhinitis and atopic dermatitis in children living in Tirana, Albania in 2011-2012; 2) to estimate the risk factors of asthma, allergic rhinitis and atopic dermatitis and the correlation between this risk factors and the allergic diseases; 3) to estimate to what extent the variation in the prevalence and severity of asthma and allergies in children can be explained by differences in known or suspected risk factors or by differences in disease management; 4) to examine time trends in the prevalence of asthma, allergic rhino-conjunctivitis and atopic eczema in Tirana compared to 16 years earlier (ISAAC Phase One, 1995) and also the risk factors in developing asthma. The ALB-ISAAC 2011 repeated both the ISAAC Phase Two survey among 10-11-year-olds, and the ISAAC Phase One and Three surveys among 6-7-year-olds and 13-14-year-olds, during the school year 2011-2012. In combination with the earlier surveys, it offers both a current and a historical perspective on childhood asthma and allergy extending over 16 years. Keywords: allergic disorders, ISAAC, prevalence.

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Authors: Vjollca Koko, Ana Ndrepepa, Skënder Skënderaj

Aim: We aimed to assess the severity of disease in patients with rheumatoid arthritis (RA) and to investigate the association of various risk factors for rheumatic diseases with the RA severity. Methods: This is an observational study that included 194 patients with RA living in the southern Albania during the years 1995-2011. The data collection was achieved in two phases: the retrospective phase (years 1995-2009) and the prospective phase (years 2010-2011). The main study endpoint was RA disability. Results: During 1995-2011, 194 patients with RA were identified. Eighty-nine patients were in RA stages III or IV and more than 1/3 of patients (n=69) had disabilities: three in stage II, 57 in stage III and nine in stage IV. Variables that showed a significant association with disability were age at the onset of disease, duration of disease, stages, male gender, occupation, smoking and alcohol consumption. Age at the onset of disease, disease duration, disability, alcohol and familial history showed a significant association with the RA stages. In the multivariate analysis, male gender, delay in diagnosis, occupation, age and RA stages were independently associated with disability, whereas alcohol consumption, age and age at the onset of disease were independently associated with the advanced RA stages. Conclusion: This study shows that nearly half of the patients with RA in the southern Albania are in the RA stages III and IV and 35.6% of them have disabilities. A series of predisposing factors for rheumatic diseases were independently associated with the RA severity.

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Authors: Ditila Doracaj, Edi Grabocka, Elda Hallkaj

Aims: Infant and child feeding index (ICFI), which translates the multidimensional child feeding practices into one age-specific summary index, has proven to be a useful tool for examining the association between childcare and nutritional status. We examined this relationship in Diber, Albania using an adapted version of the ICFI developed by Ruel and Menon. Methods: A cross-sectional survey including 464 mothers of children aged 6-23 months was conducted in three districts of Diber during June-July 2012. The variables used for the ICFI were current breastfeeding, bottle feeding, use of complementary foods in the past 24 hours, frequency of use of food groups over the past week and feeding frequency. The index was calculated according to age distribution for children 6-8 months, 9-11 months and 12-23 months and was categorized into tertiles. The associations between ICFI and anthropometric indices including length-for-age (LAZ), weight-for-length (WLZ) and weight-for-age (WAZ) Z-scores were examined separately for each age group. Linear regression models were used to adjust for potential socio-demographic confounders. Results: The ICFI was positively associated with children's LAZ. Adjusted mean LAZ in low, medium and high tertiles of ICFI were, respectively, -1.34, 0.22, and 0.4 (P<0.01) among children aged 6-8 months; -1.01, 0.009, and 0.013 (P<0.01) among children aged 9-11 months; and -1.16, -0.69, and 0.51 (P<0.01) among children aged 12-23 months. Among the components of ICFI, dietary diversity, food-group frequency and frequency of feeding were positively associated with anthropometric indices. Conclusion: ICFI and its components could be used to assess the effect of complementary feeding practices in child growth.

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Authors: Konstantinos H. Katsanos, Vasileios Grammeniatis, Nikoletta Karavasili, Dimitrios Christodoulou, Epameinondas V. Tsianos

Many of the varying manifestations of celiac disease can occur without the enteric involvement, thus medical specialties should be familiar with the ways of diagnosing and treating the disease. The resolution to the problem of celiac disease is the gluten free diet which restores the damage of the mucosa and relieves from symptoms. Celiac disease can appear with classical symptoms of malabsorption while it can arise with extraintestinal symptoms like fatigue, anorexia, arthralgy, osteoporosis, osteomalacia, short stature, gingival disorders, sidiropenic anemia, dermatitis herpetiformis and neurological disorders. During the last decade, sensitive and specific methods have been developed for the identification of specific antibodies at the serum of patients with celiac disease which had a tremendous impact on clinical expression, epidemiology and diagnostic approach of the disease. Nonetheless biopsy of small intestine remains the gold standard for the diagnosis of celiac disease. It is interesting to say that while once celiac disease was considered to be a rare disease, recent studies have shown that the prevalence reached 1/250 of the general population or 0.5% to 1.0% percent in Europe. Taken this into consideration, it is clear that celiac disease is a disease whose prevalence is continuously revised with a raising tendency. Keywords: celiac disease, epidemiologic features, Greece.

3

Authors: Tony Smith

Modern societies are afflicted with what has been described by broad range of health problems, including epidemics of over consumption and rising rates of mental distress and disorder diminishing levels of well-being and increasing health and social inequalities.

4

Authors: Drita Jaka, Enver Roshi

Aim: The objective of this study was to assess the association of anthropometric indices with the health status among adult prisoners in Albania. Methods: A cross-sectional study was conducted in 2013 including 401 prisoners in Albania: 290 (72%) males and 111 (28%) females. All participants were measured height and weight and waist and hip circumferences, based on which the anthropometric indices were calculated (body mass index [BMI] and waist-to-hip ratio [W/H]). In addition, an anonymous and structured questionnaire was administered including data on self-perceived health status, health-related problems, lifestyle factors (smoking, alcohol intake and drug use) and demographic and socioeconomic characteristics (age, sex, educational attainment and income level). Binary logistic regression was used to assess the association between self-reported health status and anthropometric indices. Results: Mean BMI was 27.84±3.91 among participants who reported a poor health vs. 26.16±3.62 in individuals who did not report a poor health status. Conversely, mean W/H was 0.92±0.07 and 0.89±0.06, respectively. In age-adjusted analysis, poor self-reported health status was positively related to the overall obesity (OR=1.59, 95%CI=1.14-2.18, P<0.01) and abdominal obesity (OR=1.72, 95%CI=1.23-2.34, P<0.01). Conclusion: Findings from this study point to a strong positive association between anthropometric indices and poor health status among Albanian adult prisoners. These findings should raise the awareness of policymakers and health care providers in Albania dealing with this marginalized segment of the population.

4

Authors: Sadet Gjata, Elizana Petrela, Altin Gjata

Aim: Similar to other regions of Albania, congenital malformations are leading causes of childhood mortality and chronic illness in Elbasan region, too. Nevertheless, to date, the evidence on the magnitude and determinants of congenital malformations for Elbasan region is scarce. The aim of this study was do describe the frequency of congenital malformations for the period 2007-2012, as recorded by the active screening procedures conducted in primary health care services in Elbasan region. Methods: An active screening for congenital malformations was undertaken by primary health care physicians in the region of Elbasan during 2007-2012. Hence, the information on congenital malformations was extracted from the health records pertinent to primary health care services in Elbasan region. On the other hand, the information about live births and infant deaths was collected from the Albanian Ministry of Health. Results: Overall, there was evidence of an increase in the rate of birth defects in Elbasan region from 18.4/1000 live births (in 2007) to 21.2/1000 live births (in 2012). However, the trend over time was inconsistent, with the highest peak noticed in 2010 (24.6/1000 live births). As a matter of fact, there was no evidence of a statistically significant linear trend in the increase of birth defects in Elbasan region for the period 2007-2012 (Cox-Stuart test for linear trend: P=0.25). On the other hand, there was evidence of a decreasing trend in infant mortality rate in the past few years in Elbasan region. Hence, infant mortality rate declined from 12.3/1000 live births in 2010 to 5.2/1000 live births in 2012. Conclusion: In Elbasan region, congenital malformations may have a negative health impact similar to the other regions of Albania. Health professionals and policymakers in Elbasan and other regions of Albania should be aware of the means of prevention and treatment of congenital malformations.

4

Authors: Altin Gjata, Teuta Backa, Sadet Gjata

Osteoporosis is a progressive bone disease that is characterized by a decrease in bone mass and density which can lead to an increased risk of fracture. Furthermore, osteoporosis is a recognized complication in several specific diseases and medical disorders. Risk factors for the fractures resulting from osteoporosis are categorized into non-modifiable and (potentially) modifiable risk factors. The presence of osteoporosis can be established by use of conventional radiography and by measuring the bone mineral density. Medication use is theoretically modifiable, although in many cases, the use of medication that increases osteoporosis risk may be unavoidable. The international literature recommends screening by bone densitometry for all women aged 65 years or older. In addition, it is recommended to provide screening for women with increased risk factors. On the other hand, in men, the harm versus benefit of screening for osteoporosis is unknown. The information about the magnitude and distribution of osteoporosis in population-based studies from Albania including Elbasan region is scarce. Therefore, there is a need to conduct epidemiological studies in order to assess the prevalence and distribution of osteoporosis in Elbasan region and other regions of Albania. Keywords: bone densitometry, Elbasan, fractures, osteoporosis, screening.

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Authors: Elham Behzadi, Payam Behzadi, Reza Ranjbar

Aim: Klebsiella pneumoniae is an opportunistic pathogenic bacterium which may lead to colonization and infection of burn wounds. The objective of this survey wasto examine the triggering effect of UVB light for probable induction of programmed cell death (apoptosis) in irradiated colonies of Klebsiella pneumoniae. Methods: The samples were categorized into control and three irradiated groups. The well grown colonies of Klebsiella pneumoniae were irradiated by UVB beams during ten minutes at the wavelength of 302 nm. 10µl of purified total genomic DNA belonging to control and radiated colonies were extracted by DNP kit and were running on 1% agarose gel electrophoresis up to 30 minutes. Results: The pattern of DNA bands including both control and UV-irradiated colonies was completely normal. Neither deformity nor unusual patterns like laddering band nor smear was observed. Conclusion: There are different genetic and biophysical mechanisms which may inhibit the process of apoptosis in irradiated colonies of Klebsiella pneumoniae. That is why the current UV-irradiation protocol is not able to induce the apoptotic reaction in irradiated colonies.

5

Authors: Arben Haxhihyseni, Vangjel Tavo, Daniela Haxhihyseni, Migena Prifti

Aim: There are many studies to support the idea that hysteroscopic metroplastic procedure improves reproductive result in primary infertility in women with a history of obstetric problems. However, the role of uterine septum in patients with inexplicable infertility is still not clear because of lack of information. Our aim was to assess whether the hysteroscopic metroplastic procedure impacts the inexplicable infertility in women with uterine septum. Methods: In this study, 28 women with uterine septum and inexplicable infertility were included. All patients underwent hysteroscopic septal resection. The reproductive outcome in these patients was studied and analyzed within the first year of metroplastic procedure. Results: All cases (N=28) got pregnant within a year after the metroplastic procedure. Twenty-three of them had children at normal birth weight on the due date of delivery. Only two cases resulted in spontaneous abortion, losing their children; only three women had premature live birth. All women had pregnancies with one foetus. Eleven of them had cerclage. Conclusion: Hysteroscopic metroplastic procedure, in women with uterine septum, significantly improves the reproductive outcome.

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Authors: Fitim Alidema, Majlinda Kryeziu-Alidema

Aim: Micronuclei analysis (MN) in exfoliative human cells presents an opportunity to study genomic changes in the target organs affected by cancer. The aim of this study was to analyze the extent of changes in the nuclei of epithelial exfoliated cells of oral buccal mucosa of patients with breast cancer treated with chemotherapy. Methods: This study lasted for four months and, during this time period, 22 patients became part of the study. The patients were diagnosed with breast cancer (22.7% male) with an average age of 48.7±11.0 years. Taking the epithelial cells from oral cavity of those 22 patients, we analyzed the degree of nuclei alteration in exfoliated cells of buccal mucosa. The statistical parameters were tested with the t-test. Results: The mean of degenerative changes in exfoliated epithelial cells of the buccal mucosa in patients with breast carcinoma increased significantly after chemotherapy (17.7±27.2 vs. 29.8±33.6, P<0.0001). The data indicates significant increase for all types of nuclei alterations. The frequency of various acute nuclei alterations and the total number of such alterations was similar in both genders. Conclusion: The results have shown that chemotherapy induced cell cytotoxicity, but it did not induce chromosomal changes and micronuclei formation.

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Authors: Enriketa Kroi, Roland Hasa, Nikita Manoku

Aim: Shear-wave (SW) elastography is a new method of obtaining quantitative tissue elasticity data during breast ultrasound (US) examinations. The aim of this study was to correlate the maximum elasticity and standard deviation values of breast masses with histological findings, and to compare the validity of these procedures. Methods: This is a cross-sectional study among 76 consecutive patients conducted in the “Evangelism” medical center from January 2012 to April 2013. Patients underwent standard breast US supplemented by quantitative SW elastography using the Aixplorer® ultrasound system. SW elastographic evaluation (maximum elasticity of stiffest portion of mass and surrounding tissue and standard deviation [SD]) was calculated for each lesion. Elastography measurements were correlated with histology results. Maximum elasticity and standard deviation cut-off values of <60 kilopascals (kPa) and ≤10, respectively, were used for benign/malignant differentiation. Results: Mean age of participants was 51 years (range 25-65 years). In total, 79 lesions were noticed. Mean ultrasound mass diameter was 16.7 mm, while mean elastography mass diameter was 17.2 mm. Histologic results detected 36 benign lesions and 43 malignant ones. Maximum elasticity vs. SD sensitivity, specificity, positive predictive value, negative predictive value, misclassification rate and accuracy rate were respectively 95.3% vs. 83.8%; 86.1% vs. 88.9%; 89.1% vs. 90%; 93.9% vs 82.1%; 8.9% vs. 13.9% and 91.1% vs 86.1%. Conclusion: SW elastography yields useful quantitative information on breast masses. The performance of maximum elasticity is comparable with that of standard deviation.

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Authors: Elia Krasimirova Georgieva, Lidia Mladenova Georgieva, Vili Slavchev Zahariev, Peshka A. Pesheva

Aim: To assess the stress levels and the sources of stress among medical students in Medical University-Sofia. Gender and other differences were taken into account. Methods: A cross-sectional study with a specially designed questionnaire was carried out. For studying the stressors, it was used an inventory called Medical Student Stressor Questionnaire. The study was carried out in 2013 at the Department of Social Medicine, Faculty of Public Health-Sofia. In the study took part 150 medical students in the second course and 128 students in the sixth course. Descriptive analysis was performed. Relation between variables was assessed with chi-square test with a significance level of P≤0.05. Results: Moderate to severe stress was experienced by 78.4% of the medical students. High and severe stress was declared by 20.1% of the students. High to severe stress was reported by 21.4% of the females and 18.2% of the males. Academic related stressors caused high to severe stress in 59.7% of the students. Conclusion: Academic related stressors were the main cause of stress both for the second and the sixth year students. A gender difference regarding stress levels was observed, where women reported higher levels of stress than men. There was no statistically significant difference in stress between second and sixth year students. We recommend more detailed future investigation of stress factors in Bulgarian medical students in order to introduce stress management programs.

10

Authors: Ailsa Baker

Cervical cancer is a prominent public health problem in Europe. In 2012 it caused an estimated 12,977 deaths in the European Union (EU). Incidence and mortality from cervical cancer vary across Europe, with Romania having the highest estimated incidence and mortality rate in the EU in 2012. The significant health threat caused by this disease highlights the need for a comprehensive cervical cancer prevention programme to be fully developed and implemented throughout the EU. Collecting and analysing data on risk factors associated with cervical cancer is a crucial first step to developing a prevention programme. The following risk factors for cervical cancer are discussed in the literature: Human papillomavirus (HPV) infection; smoking; having human immunodeficiency virus (HIV) or another condition that makes it difficult to fight infection; using birth control pills for a long time (five or more years); giving birth to three or more children and having several sexual partners.The goal of this paper is to assess the availability of data in the form of indicators, on risk factors associated with cervical cancer. The first research question addressed is: “What indicators are available in international health databases?” Using Romania as an example, the second research question is: “Do the identified indicators provide data on Romania?” The European Health for All Database (HFA-DB), The Organisation for Economic Co-operation and Development (OECD) and Eurostat are three core international health databases that were used to address the research questions. The results showed indicators were available on smoking, having HIV and giving birth to three or more children. However, not every indicator that was available provided data on Romania. No indicators were available on HPV infection, contraceptive use or having several sexual partners. These results indicate a lack of available indicators related to risk factors associated with cervical cancer in HFA-DB, OECD and Eurostat. In addition, the identified gaps in the availability of data, with regards to Romania, could be detrimental to the development of a comprehensive national cancer prevention programme. Keywords: cervical cancer, data availability, health for all database, Romania.

2

Authors: Helmut Brand

What do we, here in Maastricht, know about the Balkans? What do we really know about this part in the centre of Europe? Do we understand what happened when former Yugoslavia broke up? Why could a war start in Europe again?

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Authors: Manika Kreka, Eleni Nastas, Gentiana Qirjako, Bledi Kreka, Vjollca Hajro, Floreta Kurti, Anila Godo

Aim: Although the frequency of the painful sickle cell crisis, which is an important marker of sickle cell disease related complication, is considered a parameter of this disease’s severity, most patients do not frequently experience such crisis that can require always medical assistance. Methods: We studied 64 patients with sickle cell disease from December 2011 to December 2012 at the University Hospital Center, Tirana, Albania. About 63% of the patients were female. Pain rate was assessed by calculating the cumulative number of admissions for painful crisis (like articular, muscular, abdominal pain). The patients were categorized into three groups: 0, 1, or ≥1 crises per year. Painful crises that did not require medical assistance were excluded. Results: Sixteen patients did not have crisis, and 15 patients had more than one crisis per year. Avascular necrosis, acute chest syndrome, cholelithiasis and iron overload were significantly related to pain rate. Cholelithiasis was the prominent clinical manifestation amongst this group of patients. There was no significant change in laboratory findings. Pain was evaluated as an important marker and was present (one or more per year) in 15 patients with Sickle Cell Disease and Thalassaemia Sickle Cell Disease. Conclusion: The association between iron overload and the pain rate is probably the result of many blood transfusions used for treating painful crisis. Our data shows that several major diseases which are complications of sickle cell disease are not strictly related to pain rate and occur in a very significant number of patients that seem clinically well. Hence, we have to evaluate systematically these complications, even in patients which represent a mild-to-moderate clinical panorama of disease in order to prevent the severe complications.

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Authors: Brunilda Hysaj (Vila), Lila Shundi, Mimoza Basho, Silva Bino, Eriona Abazaj, Tefta Rexha

Aim: To determine the prevalence and HCV genotype among high risk groups in Albania. Methods: In this study we analyzed 172 blood samples collected from various high risk groups for the presence and genotype of HCV virus with HCV-RNA (Cobas Amplicor HCV Test v2.0, Roche), HCV genotype (Line Probe Assay-LiPA, Bayer). The data analysis was done using SPSS, version 16.0. Results: A total of 172 blood samples were screened including thalasemic patients, dialysis patients, and injecting drug users (IDUs). Initial screening was done for anti-HCV using ELISA-test. Confirmation of active HCV infection was carried out with the help of Cobas Amplicor test V 2.0. Out of 172 samples, 121 (70.34%) were both HCV positive for anti-HCV and HCV RNA. Prevalence of active HCV-RNA infection in individual risk groups was: 20 (41.66%) for 48 thalasemics patients, 74 (88%) for 84 cases with dialysis and 27 (67.5%) for 40 cases in injection drug users, respectively. Four major genotypes (1, 2, 3, 4) and their subtypes (1a, 1b, 1a/b, 3a, 4a, 4e) were identified. The most frequent HCV genotypes were 1 and 3. There was no significant relationship between virus genotypes and sex, age and risk-group. Conclusions: The prevalence of HCV-RNA was higher in these population groups. Genotype 1, subtype 1b was the most prevalent in dialysis patients and genotype 3 was the most prevalent between the IDUs group, but more detailed studies with a larger number of patients are necessary to understand the HCV dynamics in this population subgroup of Albania.

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Authors: Eralda Mariani, Polikron Pulluqi, Enver Roshi, Doriana Frashëri, Entela Buzali

Aim: Human brucellosis is a serious disease that can result in disabling complications. Brucellosis is still one of the most challenging issues of both health and economy. This study was designed to determine the epidemiological features of brucellosis in Korça prefecture, as this is one of the endemic areas in Albania. Methods: This is a retrospective descriptive study. Data on socioeconomic and occupational factors and history of exposure to animals and animal products over a 7-year period 2005–2012 were collected in Korça prefecture by using a structured questionnaire. Results: In total, 737 cases of brucellosis were reported. The incidence rate of brucellosis decreased from 95/100,000 in 2005 to 11/100,000 in 2012. The male-to-female ratio was 1.6 and the disease was most common in individuals aged 40-49 years. 62.8% of cases were from rural areas. Cases occurred throughout the year, with the highest incidence rate between May and August. Among the occupations identified, 37.3% were housewives, 22.6% farmers, 21.3% students, 6.1% shepherds and 12.7% of the patients had other occupations. Conclusions: Exposure and contact to home-owned animals and consumption of homemade milk and dairy products were identified as probable sources of human brucellosis infection in the districts included in this study conducted in Albania.

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Authors: Nikolin Filipi, Kozeta Filipi, Blerim Saraçi

Aim: Cardiac surgery interventions can often be associated with complications. One of the most important of them is postoperative acute kidney injury (AKI) that can significantly contribute in a higher postoperative morbidity and mortality. The risk and prevention of acute kidney injury (AKI) following cardiac surgical interventions is less well understood and still remains a challenge. By conducting the study, we evaluated the factors that may predispose the appearance of AKI in terms of cardiac surgery. Methods: The study was based on the recorded clinical and demographic data of 72 adult patients (age ≥18 years) who underwent coronary artery bypass graft (CABG) surgery and valve surgery (with or without concomitant CABG) at the Hygeia Hospital Tirana, Albania, in cardiac surgery department during September 2011 – May 2012. According to RIFLE/AKIN classifications, risk factors such as patient’s condition, lowest mean arterial pressure during intervention, aortic clamp time, bypass time, intubation total time and hemorrhage and creatinine levels were studied during the first five postoperative days. Results: 72 patients were included in the study. Mean age was 61.3±9.7 years; 76.4% were men and 23.6% were women. About 78% were intervened of cardiopulmonary bypass, 11% underwent valvular replacement surgeries and 7% combined surgeries. Around 14% of patients developed signs of AKI within the fifth postoperative day. Pre, intra- and postoperative risk factors for acute renal failure were evaluated. By studying the variables’ correlation with AKI, we found a highly significant association (P<0.001) for values like total intubation time and ICU (intensive care unit) stay time as well as mean value of urea and creatinine within five days. A less significant association was found with lactate values taken 24 hours after cardiac interventions (P=0.05). Conclusion: In patients that undergo surgical procedures in cardiac surgery, the postoperative renal function tests, as well as intubated and ICU time, play a very important role in development of the postoperative AKI. Reducing these factors to their lowest limits, can directly help in minimizing the postoperative development of AKI and will surely reduce the treatment costs of the postoperative patient. Quality improvement strategies should be incorporated at all institutions in order to identify and track quality indicators relevant to the prevention of postoperative renal dysfunction during the index admission for cardiac surgery. Once identified, clinicians can implement preventative measures for high-risk patients.

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Authors: Vjollca Shpata, Xhensila Prendushi, Alma Nurçe, Alketa Hoxha, Floreta Kurti, Ilir Ohri

Aim: Malnutrition is a frequent concomitant of surgical illness, especially in gastrointestinal surgery. The purpose of the studywas to evaluate the prevalence of malnutrition for intensive care unit (ICU) patients, who underwent gastrointestinal surgery and to determine the correlation with post-operative outcome. Methods: We prospectively studied 313 post-surgical patients 18 years that stayed 4 days at the Intensive Care Unit (ICU) of the UniversityHospital Center Mother Teresa in Tirana, Albania. Patients were divided into well-nourished (NRS 2002 <3) and malnourished groups (NRS 2002 3) according to their nutritional status. All patients were followed up clinically until discharge from ICU or death and their outcomes were recorded. Univariate and multivariate logistic regression analysis were used to identify the relationship between malnutrition and the clinical outcome. Results: The prevalence of pre-operative malnutrition was 61.7% and for gastrointestinal cancer patients it was 80.2%. Malnutrition, as analyzed by a multivariate logistic regression model, was an independent risk factor for higher complications, higher nosocomial infections, increased mortality, and longer stay in the ventilator and ICU. Conclusion: This study shows that malnutrition is a significant problem in surgical patients, especially in patients with gastrointestinal cancer, staying for more than four days in the intensive care unit. Malnutrition in gastro-intestinal surgery patients is an independent risk factor on increased post-operative morbidity and mortality.

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Authors: Jeremy G. Guillory

Aim: The burden of disease among populations is not spread evenly across Europe. Some nations in Europe have the lowest disease burden in the world, while some lag far behind among industrialized nations. These differences make real-world impacts in the lives of the residents of Europe, and are thus important to investigate. The objective of this paper was, firstly, to examine the correlation between the geographic locations of nations in Europe and the amount of burden of disease accumulated by their populations. Looking further, to correlate the burden of disease with the amount spent on healthcare per capita in these nations. Finally, to investigate the question of how health system efficiency is affected by healthcare spending. Methods: Using data concerning burden of disease, healthcare spending and health system efficiency, correlations were made both visually and numerically in order to show the results. Results: There is a strong correlation between the high number of DALY’s accumulated by a population and living in Eastern Europe. This is related to low healthcare spending and lack of efficiency in the health systems of these nations. Conclusion: In order to reduce the burden of disease in Eastern Europe when compared to Western Europe, healthcare spending per capita must be increased to reach a minimum level where efficient practices can take place and DALY’s can be reduced.

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Authors: Shpëtim Doksani, Anila Kristo, Sokol Myftiu, Fatime Elezi

Aim: There has been an increase in the levels of alcohol intake in Albania, particularly among men. In recent years, the use of pharmacotherapy together with psychosocial interventions has enhanced the percentage of success in maintaining alcoholic patients in remission. The aim of this study was to describe an alcohol treatment program in Albania, as well as to assess the response to psychotherapeutic and pharmacologic treatment of alcohol-addicted patients in Albania. Methods: This is a prospective study including 51 consecutive subjects admitted to the Clinic for the Treatment of Alcohol Addiction at the University Hospital Center “Mother Teresa” in Tirana, Albania, over the period September 2010 – September 2011. After the three week period of hospitalization all patients were followed up for one year after discharge. Results: Mean age of the patients was 47.3± 9.8 years (range 31-60 years). About 96% of the patients were males. The most frequent disorders among patients were psychiatric disorders in 41 (80%) patients, followed by internal disorders in 36 (70%) patients and neurological disorders in 15 (30%) patients. Patients with high dependence were 3.2 times more likely to manifest anxiety and general depressive disorders than patients with low dependence without a significant difference between them (OR= 3.2, 95%CI=0.6-19.28, P=0.1). About 45% of the patients achieved one year abstinence (95%CI=33.2-58.6). About 55% (95%CI=41.3-67.7) of the patients relapsed to alcohol use. Divorced patients were 8.7 times more likely to relapse compared to the married counterparts (OR=8.7, 95%CI=1.7-66.4). Around 67% of married patients who relapsed manifested family/spouse relationship difficulties (P<0.01). Conclusion: The high rates of associated psychiatric disorders in patients with alcohol-use disorders require that alcoholic patients undergo careful psychiatric evaluation. Similarly, the treatment of alcohol-dependent patients with comorbid disorders is complex. The pharmacotherapy should not be considered as the only form of treatment, but as an integrated part of a multimodal approach including psychological and social support.