Albanian Medical Journal

2

Authors: Vitorino Modesto dos Santos, Lister Arruda Modesto dos Santos

We read the interesting cross-sectional study done by Gjerazi et al. about risk factors of surgical site infections in a general surgery ward, which involved 678 patients with mean age of 52.7±14.5 years. Post-operative skin infections were observed in 41 patients (6%) and 22 of them (53.6%) were males. The authors adequately emphasized the role of these infections on the increased time of hospitalization, the postoperative morbidity and mortality, in addition to significant elevation of medical care costs.

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Authors: Caner ahin1, Ceyhun Varim2, Sena Budak3

Aim: We aimed to investigate body mass parameters using bioelectric impedance measurement in patients who encountered our dietary clinic and, in addition, we aimed to investigate the relationship between these parameters and Epworth Scale. Methods: 156 patients were enrolled in this study which was conducted in Akyazi State Hospital, Sakarya, Turkey, during October 2013 October 2014.Age, gender, height, weight, neck circumference, body mass index, waist circumference, and body mass analysis using Bioelectric Impedance measurement device were examined. Patients were asked to fill Epworth sleep index. Results: 18 of the cases were males and 138 were females. Mean anthropometric indices of the patients were as follows: height: 159.6±7.3 cm; weight: 91.7±63.6 kg; body mass index: 34.2±5.2 kg/m2; neck circumference: 37.3±3.1 cm; waist circumference: 111.3±13.3 cm, and; Epworth Scale: 6.5±5.1. Body mass index and body fat mass exhibited approximately the same magnitude of the correlation with Epworth scale (R=0.628 and R=0.626, respectively). Waist circumference, visceral fat ratio, body fat percentage, correlation values was assessed at the level of medium significance (0.588, 0.573 and 0.526, respectively). Conclusion: Obesity is one of the predisposing factors of Sleep Apnea syndrome. Biolectrical Impedance measurement provides practical, inexpensive method analysis of the body distribution. This can be thought of as a pre-screening test. Patients with excess weight who attend dietary clinics should be referred to the ENT services if body parameters are above certain values in order to prevent their potential morbidity.

6

Authors: Artid Duni, Vilson Ruci, Julian Ruci, Leonard Lazaj, Lorenc Murati, Erjon Sejati

Aim: Fractures of the femoral neck, femoral head and trochanteric region are among the most challenging pathologies every orthopedic surgeon has to deal with in the everyday practice, especially in a hectic tertiary trauma center. Their incidence is increasing with ageing of the population and lifestyle changes towards sedentary life and motor vehicle use. Methods: During 2004-2014 we investigated the total number of femoral neck and trochanteric fractures treated in our facility in Tirana, Albania, in order to describe the incidence by the type of fracture (femoral neck, femoral head, transtrochanteric), the annual trend of treatment modality, the age groups affected, the hospitalization, the operability, and the mortality rate. Results: A total number of 2180 femoral neck, femoral head and trochanteric fractures were treated in our facility during the last decade. About 49% were male patients and the mean age was 67.7 years. This constitutes 9.33% of the total number of patients treated for the same period. There were 828 (37.98%) trochanteric fracture cases, 1347 cases (61.79%) were femoral neck fractures and 5 cases (0.23%) were femoral head fractures. The modalities of treatment were as follows: 982 cases or 45% underwent partial prosthetic replacement, 704 cases or 32.29% had ostheosynthesis with different forms of plates and/or screws, 0.73% cases were treated with total hip replacement and 478 cases or 21.93% were treated conservatively. Overall, inpatient mortality was 1.33%. Conclusion: The incidence of femoral neck and trochanteric fractures in the older age groups is increasing every year. The modalities of treatment are oriented towards modern protocols and the operability is increasing year by year. Lower hospitalization and higher operability should be our future goals in Albania.

6

Authors: Mirko Zganjer, Ante Cizmic

In this article we present a rare pathology of the spleen, namely the wandering spleen. Wandering spleen is defined as a spleen without peritoneal attachments, only attached with its pedicle. Wandering spleen is a rare condition in which spleen is located anywhere in the abdomen. The syndrome may be diagnosed during infancy or childhood, but it is not infrequently an incidental finding in adults. In the international literature, there are two methods of treating ectopic spleen - splenopexy and splenectomy. If there are no associated anomalies, surgical treatment of excess spleen is necessary in case of complications, such as torsion or places where there is a possibility of common trauma. We report our three Croatian patients with wandering spleen, and in all of these patients we performed splenectomy. All the three patients had recurrent pains in the lower parts of abdomen. In all patients we found torsion of the ectopic spleen. In one of the patients we performed open splenectomy, in another one we conducted laparoscopy splenectomy, whereas in the other patient we tried to do laparoscopic surgery, which we completed with conversion. Wandering spleen is an uncommon problem with quite rare clinical presentations. Methods of treatment depend on clinical presentation and findings at operative surgery.

7

Authors: Artan Bodeci, Agim Sallaku, Agim Karaj, Euglent Hoxha

Axillary dissection is of great importance in breast surgery. Since the Halsted or Fisher era, the concepts have significantly changed. In the 1990-ies, the concepts evolved considerably. Nowadays, the contemporary sentinel lymph node serves as a modern treatment approach, considering it as an indicator or predictor in the prognosis of breast cancer. This technique can predict the patient s prognosis and of course the radicalism of surgery treatment. It has been recently reported the outcome of this technique in the international literature, but in Albania several issues should be considered in this regard. Nevertheless, the contemporary sentinel lymph node is a worldwide accepted approach, and this review tends to be focused on it, in order to revitalize our surgery treatment. Keywords: breast surgery, complete axillary lymph node dissection, contemporary sentinel lymph node.

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Authors: Aneida Hodo Vevecka, Marinela Serban, Jola Klosi, Elizana Petrela, Ergita Nelaj, Mihal Tase, Carmen Ginghina

Aim: To assess the clinical, echocardiographic and laboratory characteristics of pulmonary hypertension (PH) due to left heart diseases (LHDs), and to assess the prognostic role of PH in patients with LHDs. Methods: This study was conducted at the University Hospital Center Mother Teresa in Tirana and the Institute of Cardiovascular Emergencies Prof. C.C Iliescu , Bucharest. The study population included 208 patients, 53.8% female, average age 63.04±11.26 years. Inclusion criteria consisted of pulmonary artery systolic pressure (PASP) >50 mmHg due to LHDs. Patients were divided into four major groups: patients with left ventricle (LV) systolic dysfunction (N=71), patients with LV diastolic dysfunction (N=35), patients with mitral (N=66) and aortic (N=36) valvulopathies. Anthropometric data, symptoms, blood tests, transthoracic echocardiography, six-minute walking test distance (6MWT), comorbidities and treatment were recorded. Data regarding death were taken from family if death occurred outside hospital. Patients were followed every six months. Average follow-up time was 1.8±1.2 years. Results: PASP correlated will the severity of heart failure (r=0.268, P<0.001) and 6MWT distances (r= - 0.313, P<0.001). There was no significant relationship between PASP and LV ejection fraction (r=0.107, P=0.126). PASP correlated with LV diastolic dysfunction (r=0.206, P=0.034). PASP directly influenced mortality (r=0.348, P<0.001): each unit increase of PASP, increased by 8.5% the probability of death. Conclusion: PH due to LHDs aggravates HF symptoms and reduces physical activity, indifferent of LVEF. PASP is influenced by LV diastolic dysfunction. With its powerful impact on mortality, PH may be considered a marker of primary disease which requires specific treatment.

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Authors: Adriana Ruseva, Lidia Georgieva, Diyan Tochev, Ilko Kosturkov, Zhivka Boneva, Stella Yordanova, Diana Nikolovska

Aim: Physical activity is a main component of energy balance and it is of great importance for the overall health prosperity. There is convincing evidence for the relationship between physical activity and some certain type of carcinomas. Colorectal cancer (CRC) is one of the most important neoplasms in association with physical activity. Our aim was to examine the relationship between recreational physical activity and the risk of developing CRC. Methods: We investigated 540 people, divided into two groups: 270 patients with CRC and 270 healthy controls. A questionnaire, including information about recreational physical activity, was completed from each participant. CRC was diagnosed by fibro-colonoscopy with biopsies. Because of the conflicting data about the risk of colon cancer and rectal cancer, we considered the association of recreational physical activity and colorectal cancer risk in men and women, generally and by sub-site in particular. We selected the last five years of life, as a period of impact. Collected data was statistically processed. Results: There was a relationship between some of the examined types of physical activity and CRC risk, and that performing none of the indicated activities in the questionnaire increased the risk of this carcinoma. Conclusion: Considering the positive role of physical activity in the overall health prosperity, and for the prevention of CRC in particular, we recommend employment of this healthy lifestyle characteristic in the general population.

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Authors: Edite Sadiku, Stela Taci, Arvin Dibra, Ergita Nela, Adriana Babameto

Cholestasis is defined both clinically and biochemically, with varying degrees of jaundice, pruritus, and elevated levels of conjugated bilirubin, alkaline phosphatase, -glutamyl transpeptidase, 5'-nucleotidase, bile acids, and cholesterol. A conventional categorization of cholestatic liver diseases has divided these factors into intrahepatic and extrahepatic causes. Intrahepatic cholestasis may result from hepatocellular functional defects or from obstructive lesions of the intrahepatic biliary tract distal from bile canaliculi. Cholestasis may also be related to mixed mechanisms in diseases such as lymphoma. By convention, cholestasis is considered chronic if it lasts more than months. Most chronic cholestatic diseases are purely intrahepatic, whereas sclerosing cholangitis may affect small and large intrahepatic and/or extrahepatic bile ducts. The differential diagnosis of cholestatic disorders can be wide. The first critical step is to differentiate intra-and extrahepatic cholestasis. A careful patient history and a detailed physical examination are essential in the diagnostic process. Keywords: extra-hepatic cholestasis, hepatology, intrahepatic cholestatic disorders.

2

Authors: Greg Evans

Substance abuse, particularly alcohol, is a major problem on college campuses. The United States National Institute on Alcohol Abuse and Alcoholism reports that approximately 60% of young American college students aged 18-22 years report drinking in the past month and 40% of students binge drink.

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Authors: Ahmet Kamberi

Despite criticisms of shortcomings, the World Health Organization s definition of health remains unamended since its adoption in 1948. Subsequent interpretations of the definition have sought to address some of the shortcomings. This paper argues about a new understanding of health. According to this understanding, health is perceived as the quality of being, emanating from satisfying the obligations and responsibilities toward self and others, in proportion with the shape, size and quality of a functioning life structure, as well as economic and social status, at a certain time and a given physical and social environment. Its source is cellular biologic potential energy, sufficiency and efficiency of which make us act, interact, cooperate or refrain, and adapt. Such an understanding has important implications. Individuals, communities and governments can improve their role in the assessment, preservation, protection, upholding, development, measurement and management of both individual and population health, which are fundamental to human wellbeing, progress and prosperity. Keywords: biological mechanisms, health definition, health measurement, life structure, potential biological energy.

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Authors: Dritan Todhe, Gjergji Çaushi, Eliziana Petrela

Aim: Our aim was to evaluate the surgical treatment of the tibial plateau fracture. The main objective was to offer statistical proofs whether the chosen treatment is the right one and to test if the use of medicaments in postoperative patients has improved their performance in Albanian patients. Methods: This study included a group of 126 patients operated at the Orthopedic and Trauma University Service in Tirana during 2005-2012. The average follow-up was four years. All patients were operated using screws or plate and screws as synthesis for the fracture. Patients were grouped according to the Schatzker classification and the surgical treatment technique in relation to the classification was investigated. The objective evaluation of the results was performed according to Iowa Knee Score, a clinical evaluation system. A questionnaire was conducted each year for the patients. The outcomes were compared for each patient during four years. Results: The chi-square test used to check the difference in treatment provided the following results: x2= 7.423, df =55, P=0.001. The use of hyaluronic acid improved the performance of the patients (r=0.887, P=0.003). Conclusions: Our findings indicate that improving the treatment of tibial plateau fractures through the right diagnosis, the surgical treatment technique and the postoperative period, followed by medical treatment and physiotherapy, is the key-point in getting the best results.

6

Authors: Patricia Brownell

Legislative developments at the national level reflect the division among conceptual frameworks for abuse of older women: whether it is an older adult protective program, a form of elder mistreatment, or reflect intimate partner violence. Most, but not all, national legislation passed is bifurcated, addressing women as part of domestic violence laws, older adults as part of family violence legislation if at all, and older care dependent adults in need of protection residing in nursing homes and sometimes in the community as part of laws to protect the vulnerable in need of protection. Domestic violence legislation is generally not specifically inclusive of older women and vulnerable older adult legislation assumes some degree of care dependency on the part of the older adult victim; gender is not usually specified. There is a growing awareness of older women victims of family mistreatment both in terms of prevalence and in terms of commonalities and differences when compared to younger battered women. Both quantitative and qualitative research studies have begun to identify salient factors in cultural differences, age related needs, and service needs and gaps for older women victims. In addition, gender-based scholarship has begun to examine the application of frameworks for practicing effectively with older women who are victims of abuse. Gerontologists are beginning to focus more research attention on older women and abuse, and human rights experts are beginning to recognize the special vulnerabilities of older women who are care dependent and may lack the ability to protect themselves from undue harm without special protections that go beyond those needed by women of all ages who are not care dependent. Keywords: abuse, neglect, older women, violence.

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Authors: Sebastian Schee genannt Halfmann

Aim: The European region is facing major health challenges attributable to noncommunicable diseases. Non-communicable diseases are the leading cause of premature mortality in Europe. This paper aims to indicate how Disability-Adjusted Life Years (DALYs) attributable to tobacco smoking, alcohol use and diet have changed over the past 20 years in Albania and Greece. Moreover, the paper discusses the impact of policies and preventions to reduce the burden of diseases attributable to lifestyle. Methods: Review by using statistics of the Institute for Health Metrics and Evaluation (IHME). In order to compare the burden of disease (BoD) attributable to lifestyle, the health indicator DALY was used. Statistics were retrieved from the IHME database. Results: Greece and Albania differ in DALYs attributable to tobacco use, alcohol use and diet. Whereas DALYs related to all the three risk factors are decreasing in Greece, Albania experienced increasing DALYs until 2005. Since 2005, DALYs are slightly decreasing in Albania. The greatest gap in DALYs between the countries can be seen for nutritional deficiencies. DALYs attributable to nutritional deficiencies are almost 12 higher in Albania than in Greece. Conclusion: The countries differ in their policies and strategies on the prevention of lifestyle risk factors. Albania is facing changes in lifestyle behaviour since the opening to the West in 1990. The BoD increased in Albania due to lacking policies and health programs on lifestyle characteristics. The awareness about prevention is increasing, but policies are still lacking and are ineffective. Improvements of preventions and policies are needed to tackle the BoD, especially in Albania.

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Authors: Ermira Muco, Arjan Harxhi, Loreta Kuneshka, Erjona Abazaj, Arsilda Gjataj, Mario Pipero, Dhimiter Kraja, Pellumb Pipero

Aim: Toxoplasmosis is a worldwide infectious disease, caused by a parasite most often found in cats and farm animals. Humans can get this disease from contacts with feces of infectious cats, eating raw or undercooked meat and contaminated vegetables or being born with it. Once a person is infected, the infection remains in the body for life. The aim of this study was to highlight selected epidemiological aspects of Lymphoglandulary Toxoplasmosis in immunocompetent adults in Albania. Methods: 291 patients admitted at the University Hospital Center Mother Teresa in Tirana over the years 1984-2012 and diagnosed with Lymphoglandulary Toxoplasmosis were included in this study (age range: 15 to 60 years). Socio-demographic data included sex, age group, place of residence (urban or rural area), educational level and profession. In addition, clinical information was collected including month of onset of illness, behavioral data characteristics such as contacts with cats, meat consumption and the quality of water consumed. Results: Male-female ratio was 1:1.8. The ages affected most included individuals 26-55 years old. Regarding the educational level, 17.2% of individuals had completed university studies, 32.3% the high school and the remaining 50.5% of participants had completed only the elementary school. Toxoplasmosis was present in 18 regions of the country, whereas contacts with cats were reported in 40.9% of the cases. Conclusions: Toxoplasmosis is a widespread disease in Albania and Lymphoglandulary Toxoplasmosis in immunocompetent adults is present as well. Incidence and prevalence of this disease is cross-linked with age, education level, season, personal hygiene, contact with cats and way of feeding. Education of the general population and continuous education of health professionals are important means for an effective control and prevention of this disease.

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Authors: Xhiliola Doci, Agim Sallaku, Sonela Xinxo, Ermira Vasili, Irena Savo, Helidon Nina

Aim: Non-melanoma skin cancers (NMSC) represent a burden to health services all over the world and their frequency is rising. The epidemiology of these tumors in Albania is poorly documented. The aim of this study was to describe selected epidemiological features of NMSC in Albania for the period 2005-2013. Methods: This was a cross-sectional study of non-melanoma skin cancer cases during 2005-2013. The information was retrieved from the Service of Statistics at the premises of the University Hospital Centre Mother Theresa during 2014 and consisted of the following variables: age at the moment of diagnosis, sex, residence, type of work environment, type of NMCS and anatomic localization of the lesion. Information about the number of the population was retrieved from the Institute of Statistics. SPSS, version 16 was used for data analysis. Results: 5289 patients were diagnosed with NMSC for the first time during 2005-2013, of whom 63.7% were males. Basal cell carcinoma was the most frequent tumor and the ratio with squamous cell carcinoma was 2.42 : 1.00. The mean age of NMSC patients was higher for males than females (67.57 years vs. 66.64 years, respectively, P<0.05). NCMS was more frequent among outdoor than indoor working individuals. The incidence has increased steadily over the years in Albania. Conclusion: The incidence of NMSC in Albania shows an increasing trend over the past decade, with males and individuals working outdoors being more often affected by such health conditions. These data should guide early detection and prevention strategies in order to lower the increasing burden on NMSC in Albania.

7

Authors: Dorina Xhani, Fatlinda Tahiri

Aim: Sex selection is becoming of increasing concern not only in China, India, Pakistan and the Caucasus, but even in transitional Albania. In addition, the situations where abortion is restricted for sex-selection purposes, terminating a pregnancy for this reason is likely to involve an unsafe procedure carrying high risks. Our aim was to gain more understanding regarding this phenomenon, by explaining the situation in the context of women s mental health. Methods: We reviewed the latest documents concerning sex-selection based on the international literature and the databases of major organizations dealing with sex-selection. Social literature is used to analyze theoretical perspective in terms of the implications on mothers mental health after experiencing sex-selection. Results: The majority of the literature shows that in the case of sex-selection there are complex reasons and implications that occur in women s life. The findings indicate that a woman can experience a range of often contradictory emotions after having a sex-selective abortion. Conclusion: Our conclusion based on this literature review is that sex selective abortion represents a concerning issue. In some cultures, the failure of the wife to bear a male child leads to sex-selection, which has shown a negative influence on women s health. In theAlbanian context, further research is needed given the lack of information and data on this issue.

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Authors: Eno Gaçe, Herion Prifti, Rovena Dulli

Aim: The aim of this study was to determine the prevalence of malocclusion and dental anomalies in children with different disabilities attending different schools for disabled people in Albania. Methods: This study was carried out in nine special schools for children with disabilities in Albania. Participants were grouped according to disability type as follows: Autistic Spectrum Disorder, Down syndrome, Cerebral Palsy, Mental Retardation, Blind, Deaf-Mute. Malocclusion and dental anomalies were examined and assessed according to the World Health Organization 1997 criteria. Results: Overall, the prevalence of malocclusion for all groups of children was 51.2%. Of these, 21.9% of the children had slight malocclusion and 28.3% had severe malocclusion. Down syndrome had the highest value of malocclusion prevalence (69%), whereas cerebral palsy had the lowest (28.6%). Compared to boys, girls had slightly higher malocclusion prevalence (50.7%). Conclusions: Our findings indicate a high prevalence of malocclusions in Albanian children with disabilities. Health professionals and policymakers should be aware of the poor oral health conditions among vulnerable children in transitional Albania.

3

Authors: Mindaugas Stankunas, Mark Avery, Richard Olley

Is it time that we revisit how we define and value what constitutes a health system? We use the term health system but consumers, government, health care providers, insurers and other funders want different things in terms of outputs and outcomes and even how to define an effective system really does mean different things to different people. There are intensive debates regarding the scope, roles and governance of health, aged and disability care services that enable us to challenge existing definitions of what is a health system.

5

Authors: Sonil Mone, Albana Zani, Pjerin Radovani

Aim: The aim of this study was to assess the treatment effectiveness of Group A Beta hemolytic streptococcus (GABHS) tonsillopharyngitis in Vlora, which is the main district in south Albania. Methods: A cross-sectional study was conducted in Vlora district during December 2013 - February 2014 including 63 children diagnosed with GABHS tonsillopharyngitis.All children were treated with antibiotics for ten days. Afterwards, all children were reexamined for the presence of GABHS and classified as GABHS negative versus GABHS positive(carriers). In both rounds, identification of GABHS was done through isolation of the microorganism by throat cultures. Binary logistic regression was used to assess the association of positive cultures after antibiotic treatment with demographic and socioeconomic characteristics of the children and their parents. Results: Of 63 children treated with antibiotics, 46 (73%) resulted negative, whereas the remaining 17 (27%) were positive (alias, GABHS carriers). There was evidence of positive association between GABHS carriers and male gender (OR=3.9, 95%CI=1.1-13.7), fathers lower educational level (OR=4.6, 95%CI=1.4-15.3), mothers unemployment (OR=6.8, 95%CI=2.0-23.4) and fathers unemployment (OR=5.0, 95%CI=1.5-16.7). Conclusion: Our study provides novel evidence about the treatment effectiveness of GABHS tonsillopharyngitis among children aged 5-15 years in the main region of south Albania.

5

Authors: Jorida Kuçaj, Sotiraq Lako, Etleva Gjoshe, Teuta Dedej

Methotrexate is one of the most effective and widely used medications for treating rheumatic diseases. Only a few cases of severe pancytopenia caused by low-dose methotrexate therapy have been reported to date. White blood cell counts of 100 000 mm3 or greater have been observed in 2% of patients receiving filgrastim. We present a case of a 39-year old woman with pancytopenia, requiring hemotransfusion, folinic acid, and filgrastim, as a result of a low dose of methotrexate for subacute cutaneous Lupus Erythematosus. After five days on filgrastim treatment, the leukocyte count increased to 115,000 mm3, and recovered completely within eight weeks. Patients receiving low-dose methotrexate therapy require regular monitoring though a complete blood count to identify myelosuppression and avoid pancytopenia. Hyperleukocytosis from filgrastim occurs occasionally, but there is the risk of leukostasis and monitoring of the complete blood count should also be done after treatment with growth factors. Keywords: filgrastim, methotrexate, pancytopenia.

6

Authors: Buzunesh Feyissa, Fanta Gashe

Aim: Drugs are one of the health care components needed to be used rationally and appropriately as the emergency of antibiotic resistance has become a major issue of health care delivery. Our aim was to assess the utilization pattern of antibiotics in urinary tract infection patients in Jimma University Specialized Teaching Hospital. Methods: A cross-sectional study was conducted during 2013-2014. Prescribed parameters related to patients, prescribers, the medications prescribed and errors associated with these parameters were compiled from patient record data. The parameters were matched against WHO prescribing recommendations. Results: A total of 282 cards of urinary tract infection patients were observed during the study period. Out of these, 170 (60.3%) were prescribed for females. From the total 282 prescriptions, 264 (93.6%) contained one drug, while 17 (6.0%) prescriptions had two drugs per encounter. All the antibiotics were prescribed in their generic name. Fluoroquinolones 189 (67.0%) were the most prescribed drugs, followed by penicillin 54 (19.1%), tetracycline 16 (5.7%) and sulfa drugs 14 (5.0%). Important information frequently overlooked by prescribers were physician signatures 34 (62.9%), dosage forms 10 (18.5%) and quantity of drugs 8 (14.8%). Average number of antibiotics prescribed per encounter and percentage of encounters with an injection prescribed were 1.07 and 15.25%, respectively. Conclusion: The prescribing patterns of antibiotics in urinary tract infection patients was found to be good as the drugs were prescribed from national treatment guidelines and in their generic name. However, some important information was frequently missing such as physician signature, dosage form and quantity of treatment.

6

Authors: Ermira Demiraj, Ermira Vasili, Leonard Deda

Aim: Seborrheic dermatitis is a chronic and relapsing disease. The implication of Malassezia yeasts in the pathogenesis of seborrheic dermatitis provides the rational basis for the therapeutic use of systemic antifungal agents, including fluconazole. Our aim was to evaluate the efficacy of fluconazole in the treatment of scalp lesions in adult patients with seborrheic dermatitis in Albania. Methods: This pseudo-experimental study involved 49 patients with seborrheic dermatitis affecting the scalp. The treatment was initiated after a wash-out period of one month for topical treatments and six months for oral antifungals. Fluconazole 150 mg/day was administered twice weekly for two weeks in all patients. Erythema, scaling and itching were assessed using a 0 3 point scale. An overall clinical assessment (OCA) score was calculated as the sum of each separate sign or symptom s score. Based on clinical findings observed at week 0 (pretreatment visit), patients were categorized as having mild (OCA<3), moderate(OCA >3 to <6), or severe (OCA >6 to <9) form. Further evaluations were done at weeks 1, 2 and 6. Results: At the end of the treatment (week 2) a significant improvement versus baseline was reported in all three clinical parameters: erythema, scaling, and itching, in all OCA groups. No further significant improvement (week 6) was observed after the cessation of therapy, although the improvement was maintained up to the end of the study. No adverse events or blood test abnormalities were reported during the study. Conclusions: Oral fluconazole was safe and beneficial, especially in patients with moderate or severe forms of scalp seborrheic dermatitis.

6

Authors: Payam Behzadi, Elham Behzadi, Reza Ranjbar

Aim: In spite of improvements in microarray platforms, there are some uncertainties, biases and errors in data outcomes and ultimate data interpretations. One of the most considerable problems in microarray methodologies is the choice of probe sets. For selecting an appropriate probe set, designing and calibrating the related probes, there is an unavoidable need to microarray methodologies, bioinformatics, biophysics and their relationship. Therefore, cooperation and collaboration between biologists, bioinformaticians and biophysicists is a must. For this reason, the aim of this literature review is to show the multi-dimensional effects of probes in final analytical outcomes throughout array designing, probe sets, probe calibration, noise calculation, and hybridization. Methods: A good choice of probe set in association with accurate probe calibration and minimum noise production is needed as an acceptable and prompt methodology to decrease the erroneous of data analysis and biased interpretation. Results: The use of interdisciplinary sciences including bioinformatics, biophysics, and biology for designing an accurate probe set in microarray technology ensures the quality of data analysis and unbiased interpretation. Hence, a proper methodology for choosing an appropriate probe set improves the reliability of the results obtained via the microarray technique. Conclusion: The application of suitable probe sets results in precise and accurate protocols. The occurrence of this progression is related to an intense collaboration between biophysicists, bioinformaticians and biologists.

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Authors: Ervin Gjerazi, Arben Gjata, Elona Kureta

Aim: Surgical site infections (SSI) are among the most common complications in hospitalized patients and have serious consequences for treatment outcomes and costs. The aim of this study was to investigate the frequency of SSI in patients admitted at the general surgery ward of a tertiary hospital in Tirana, Albania. Methods: This was a cross-sectional study carried out at the general surgery ward of the University Hospital Centre Mother Theresa , a tertiary care hospital in Tirana during the period 2012-2013. Patients were followed for up to 30 days for development of surgical site infections. Socio-demographic data and information about SSI was collected for all the hospitalized patients undergoing surgery during the time period of the survey. Binary logistic regression was used to assess the association of SSI with several independent factors. Results: Of the 678 patients, 41 (6%) developed surgical site infection. The mean age of the patients was 52.7±14.5 years. The most common surgical procedures were the colon surgery and fistulectomy. The factors significantly associated with the occurrence of SSI were smoking, diabetes, hypertension, inadequate skin preparation, presence of drain and contaminated wounds. Conclusion: The prevalence of surgical site infections after surgical procedures in Albania is higher compared to the European average, even though the situation has improved compared to previous reports. Surgical site infections remain common and constitute a major cause of postoperative morbidity in Albania, a transitional country in the Western Balkans.

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Authors: Bledar Xhemali, Zija Ismaili, Sokrat Meksi, Linda Matua, Mirnela Cinije

Aim: Our aim was to describe the epidemiological aspects of homicide victims in Albania as well as means, mechanisms, reasons and manners of death due to homicide. Methods: This case-series study involved 383 victims of homicide during 2008-2013 examined through official forensic autopsy in the premises of the Institute of Forensic Medicine (IFM) in Tirana. Basic demographic and socioeconomic data as well as information on means and mechanisms of murder were collected. Absolute numbers and their respective percentages were reported. Results: In total, 2962 autopsies were carried out during 2008-2013 in the premises of IFM in Tirana, of which, 383 were due to homicide (12.9%). Around 38% of homicide victims were 30 years old or younger and the proportion of homicide victims declined steadily with increasing age of the victims. More than 70% of homicide victims were males, urban residents and around 70% of deaths due to homicide occurred in outdoor settings. In over 70% of the cases, homicide involved firearms and/or explosions. The cause of death was identified as traumatic-hemorrhagic shock in 62% of the cases and injuries of brain and meninges in 27% of cases. Conclusion: The total number of autopsies following murder suspicion during the last three years has been constantly increasing, reflecting an inadequate societal reaction against criminality and murder in Albania. The fact that firearms are the preferred instrument of homicide should alert policymakers and law enforcing entities towards their regulation and controlling.

3

Authors: Mari Pollari

Most of the countries in the world have developed effective health services based on universal health coverage. Albania, a transitional country in the Western Balkans, should also embark in this difficult journey towards universal health coverage. While there is no doubt for the need of such integrated attempts, there is a significant amount of ill-health which can be prevented effectively by investing in health promotion and disease prevention.

4

Authors: Mirlinda Likmeta, Artan Shkoza, Sokol Myftiu

Peg-interferon alpha is a molecule frequently used in the treatment of chronic hepatitis B, C, and D, with immunomodulatory and antiviral activity. It is also used in some cancer types. It has been widely claimed that interferon alpha triggers autoimmunity, with its broad adverse effect profile. Here we present the case of a 49-year-old male patient with chronic hepatitis B diagnosis, who developed type 1 diabetes mellitus and peripheral neuropathy during the treatment with peg-interferon alfa-2a. Within four months of initiation of treatment with peg-interferon alfa-2a, the patient presented to our clinic with tiredness, myalgia, arthralgia, and blood glucose level of 166 mg/dL. Four months later, on November 2013, his fasting blood glucose level was 287 mg/dL. The patient complained of thirst, decreased balance and gait changes; he was admitted to the gastro-hepatology clinic for a thorough evaluation. Endocrinology consultation was requested and the patient was diagnosed with type 1 diabetes mellitus. Insulin therapy and diabetic diet was started, and blood glucose and HbA1C levels were monitored regularly thereafter. The endocrinologist recommended the evaluation of nerve conduction. The results of this examination showed metabolically-induced axonal demyelinating sensitive neuropathy with subnormal evoked potential amplitude and conduction velocity of sural nerve. For patients who will receive treatment with interferon alpha, especially those individuals with chronic hepatitis, pancreatic autoantibodies should be checked; close monitoring of glucose levels, neurological signs and symptom, prior to and during the treatment, are also mandatory.

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Authors: Rubena Moisiu, Alketa Hoxha, Enkeleda Prifti, Ehadu Mersini, Jolanda Hyska, Eduard Tushe

Aim: Initiation of breastfeeding within the first hour can help prevent neonatal deaths caused by sepsis, pneumonia, and diarrhea and may also prevent hypothermia-related deaths, especially in preterm and low birth weight infants. The aim of this study was to assess the level of awareness and training of the maternity staff in Tirana, Albania, for performing, documenting and reporting indicators of breastfeeding within the first hour of life. Methods: This was a prospective study conducted at the Department of Obstetrics of the Maternity Koco Gliozheni in Tirana during the period July-October 2014. Overall, 80 infants were included in this study. Results: The average gestational ages was 39.4±0.9 weeks, whereas the average birth weight of the newborns was 3224±306 g. Evaluation based on physical development of infants was as follows: AGA: 59 (73%), LGA: 11 (13.7%), and SGA/IUGR: 10 (12.5%). Distribution by sex: 44 (55%) males and 36 (45%) females. Based on the parity, 21 (26.2%) were primiparous, 34 (42.5%) were secondiparous and 34 (42.5%) were tertiparous. About 49% of the babies were placed in the breast within the first hour of life. The medical charts, however, documented that 100% of infants were placed in the breast within the first hour of life. Conclusions: Nearly half of the babies were not put in the breast within the first hour of life in this study conducted in Tirana. Babies were put in the breast significantly more in the morning hours where the attention of the medical staff is usually much higher. Medical staff is aware of documenting breastfeeding within the first hour of life, but we noticed discrepancies between documentation and the exact time of initial breastfeeding of the newborns.

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Authors: Alma Barbullushi, Etleva Refatllari, Anyla Bulo, Anila Beqja, Jovan Basho

Aim: Anemia is one of the most important symptoms associated with several pathologies of the gastrointestinal tract. The aim of this study was to assess the level and types of anemia among patients with different diseases of the gastrointestinal system in Albania. Methods: This study included 100 patients with various pathologies of the gastrointestinal tract, who were admitted at the Gastroenterology and Hepatology Service of the University Hospital Center Mother Teresa in Tirana, Albania. All of the patients were examined and treated during the period February-June, 2012. Results: The infections/inflammation of the gastrointestinal tract accounted for 41% of the overall patients included in this study. In this group, 82% of the patients had erythropenia, 15% had normal values of erythrocytes and 3% had an increased number of erythrocytes. Based on hemoglobin levels, 60% of the patients had minor anemia, whereas moderate and severe anemia comprised 20% of cases each. Conclusion: In the Albanian context, we showed that the most common cause of chronic anemia consists of gastrointestinal diseases, and this fact explains why the majority of the patients with anemia are referred to gastroenterologists.

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Authors: Leonard Simoni, Ervina Shirka, Artan Goda

Aim: We sought to investigate the impact of body mass index (BMI) on morbidity and all-cause mortality in patients following first-time elective percutaneous coronary intervention (PCI). Methods: We included in this study 334 patients who underwent for the first-time elective PCI from September 2011 to October 2012 at the Department of Cardiology and were followed for a period of one year. The impact of BMI on prognosis was examined. We excluded patients who had previously undergone revascularization. Patients were categorized according to BMI groups: BMI=18.5-24.9 kg/m2 (normal group); BMI=25-29.9 kg/m2 (overweight group) and; BMI>30 kg/m2 (obese group). Results: During the follow-up period there was only one death in each group. Compared with normal weight individuals, those overweight had more high risk for coronary anatomy (either three vessel disease or left main stem stenosis) (13.6% vs 1.6%, P=0.0241), length of stents per person higher (29.89±14.75 vs 35.17±18.23, P=0.042) and were older (60.56±9.94 years vs 57.37±10.26 years, P=0.042). The mean diameter of stents per person used in obese individuals was significantly larger compared to normal weight individuals (3.15±0.35 vs 2.95±0.29, P<0.001). Compared to normal weight individuals, those overweight had a significantly reduced number of hospitalizations for CVD (7.9% vs 24.2%, P=0.0008) and all cause death or hospitalizations for CVD (8.5% vs 25%, P<0.001). Also, compared to normal weight, obese individuals had a reduced number of hospitalizations for CVD (11.3% vs. 24.2%, P=0.09). Conclusion: Patients with increased BMI undergoing percutaneous coronary intervention have a more favorable clinical performance.We suggest that the obesity paradox partially can be explained with the existence of a large coronary damage, which may contribute to more favorable outcomes and with the inverse association between diameters of vessels treated and clinical outcomes.

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Authors: Philip Astaire Hines

Quality-adjusted life years (QALYs) have received a growing amount of criticisms. This paper sought to evaluate the future of QALYs though establishing and assessing common critical themes. Electronic searches of PubMed and Web of Science were conducted. The resulting papers were screened for their common critical themes. A total of 19 relevant studies were found, with six common critical themes: direct and indirect assessments report different disease weightings; patients and the public report different disease weightings; underreporting and lack of standardisation in generation of disease weightings; ageism of QALYs and equity vs. efficiency. The critical themes identified call into questions QALY s validity and reliability. However, they do not completely nullify QALYs as a pragmatic tool for Health Technology Assessments and health economics more broadly. They also highlight areas where QALYs can be improved such as standardisation and incorporating social welfare functions into the QALY construct.

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Authors: Indrit Kellici, Bledar Kraja, Rozana Aleksi, Marsela Sina, Skerdi Prifti

Aim: To compare the prevalence and severity of gastroesophageal and extraesophageal symptoms in patients with gastroesophageal reflux disease (GERD) in Albania. Methods: In this descriptive study, we investigated 248 patients (mean age: 46.5±16.3 years)diagnosed with erosive esophagitis by upper endoscopy. We assessed the severity of esophagitis by Los Angeles (LA) classification and the gastroesophageal and extraesophageal symptoms by a standard questionnaire. The prevalence of symptoms between mild erosive esophagitis(LA grade A/B: 230 patients) and severe erosive esophagitis (LA grade C/D: 18 patients) were described and reported. Results: The prevalence of severe gastroesophageal symptoms (heartburn, acid regurgitation, and dysphagia) was higher in patients with severe erosive esophagitis than in those with mild erosive esophagitis. Patients with severe erosive esophagitis also had a higher prevalence of extraesophageal symptoms (cough and sore throat) than patients with mild erosive esophagitis (44% vs. 19% and 28% vs. 16%, respectively). Conclusions: The prevalence of gastroesophageal and extraesophageal symptoms were higher among patients with severe erosive esophagitis. In the future, prospective clinical studies in multiple medical centers are warranted to generalize our findings in the overall Albanian population.

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Authors: Robert Qirko, Elton Koroveshi, Bledar Benja, Alojva Xhelilaj, Verona Beka

Aim: The aim of this study was to assess the cerebro-placental ratio and its influence on postnatal outcomes in pregnancies complicated with preeclampsia in Albania. Evaluation of this ratio and its values were determined based on fetal outcomes. Methods: In this study there were involved 106 patients diagnosed with preeclampsia or gestational hypertension hospitalized in the Queen Geraldine University Hospital in Tirana during the time period 1 October 2010 31 July 2012. For each patient, a Doppler flow velocity was performed and the result of the last examination conducted before labor was taken into consideration. The cerebro-placental ratio (PI ACM/PI AU) was considered abnormal or inverted when its value was lower than one. The fetal wellbeing was assessed immediately after delivery and in the first days after birth. The corresponding values were determined. Results: Patients were evaluated based on their mothers age, prematurity, Apgar in the first and the fifth minute, method of delivery, corresponding IUGR, or fetal weight. Mortality and morbidity of newborns were evaluated based on their ratio of cerebro-placental blood flow in utero. The same evaluation including amniotic fluid was the basis of evaluation for IUGR, preeclampsia severity and fetal outcomes. Conclusions: Cerebro-placental blood flow velocity can be used to decide the time of delivery for preeclamptic women. Fetal outcome is often compromised in cases with inverted flow velocity. Abnormal cerebro-placental blood flow velocity results in a higher rate of Cesarean section delivery. Morbidity and mortality indicators may be improved if the cerebro-placental ratio is considered.