Albanian Medical Journal

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Authors: Theodhore H. Tulchinsky

Classical public health is a strong tradition which goes back several centuries with many governmental activities to ensure health protection of the population from many hazards causing premature deaths of uncounted millions in epidemics, food borne disease, poor maternal and child health and unsafe workplaces. Public health systems evolved in keeping with traditions of various societies. In western countries local governmental authorities were the primary agencies for public health including sanitation, food control, business licensing vital records and other facets of public health. State and national governments began to assist and develop services beyond the financial and professional capacities of local authorities. Gradually national governments became the overarching agency responsible to protect the health protection of the nation’s population.

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Authors: Albana Adhami, Llukan Rrumbullaku

Aim: Our aim was to describe the level of primary health care visits conducted by family physicians in Albania in the past decade. Methods: We reviewed the number of primary health care visits conducted in each of the 36 districts of Albania separately for urban areas and rural areas for the period 2005-2012. The information was collected from the files of the Institute of Health Insurance. Results: For both urban areas and rural areas, there was evidence of a significant increase in the number of the overall primary health care visits performed by family physicians in Albania. In urban areas of Albania, the overall number of primary health care visits increased from 2436314 in 2005 to 3767941 in 2012 (linear trend: P<0.01). Conversely, in rural areas of Albania, the overall number of primary health care visits increased from 1001990 in 2005 to 1863592 in 2012 (linear trend: P<0.01). Conclusion: There has been a considerable and consistent increase in the overall number of health visits conducted by general practitioners and family physicians in Albania over the past decade. Future studies should explore the putative link between the frequency of health visits and the quality of health care services provided by primary health care professionals in Albania.

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Authors: Teuta Bare, Nikita Manoku

Aim: Preterm birth still remains a major cause of perinatal morbidity and mortality and its rate has not declined over the last two decades despite the improvement in perinatal management. The aim of our study was to assess the use of fetal fibronectin (fFN) testing and cervical length (CL) measurement to predict preterm delivery. Methods: This was a prospective study including all patients admitted between November 2009 and June 2011 to the UniversityObstetric-Gynecologic Hospital “Mbretëresha Geraldinë” in Tirana, with the diagnosis of increased preterm uterine contractility and intact membranes between 22 and 34 weeks of gestation (N=254). Results: Among 245 women with complete data, the mean gestational age at recruitment was 29.4±2.5 weeks. Six women (9.6%) delivered within two weeks of assessment and 14 (22.5%) women delivered before 34 weeks. A positive fFN test resulted in a sensitivity of 83%, a specificity of 84%, a positive predictive value of 36%, and a negative predictive value of 98% for delivery within two weeks. For CL <25 mm, these figures were: 50%, 52%, 10%, and 91%, respectively. Conclusion: In our study conducted in the capital city of Albania, fFN screening provided the best predictive capacity for preterm delivery. Cervical ultrasound after fFN triage appears to be an acceptable option, depending on the resources available.

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Authors: Artur Zoto, Hasan Hafizi, Elizana Petrela, Teuta Backa, Renato Osmenaj, Zamira Ylli

Aim: The purpose of our study was the identification of pulmonary manifestations in patients with scleroderma, their assessment in relations to immunological alterations, their relations to gender, andtheassessment of the sensitivity in the examinations that are used to detect lung injuries. Methods: This is a cross-sectional study including 58 patients with scleroderma during January-September 2011. Patients’ history of disease was carefully extracted and recorded. Patients were underwent immunological tests such as anti-nuclear antibody test, anti-topoisomeraseand anti-centromere tests. Furthermore, chest X-ray, pulmonary high-resolution computed tomography, pulmonary function tests and echocardiography Doppler were also performed. Chi-square test was used to assess potentially statistically significant associations. Results: Mean age of the patients (86.2% females) was 49.38±8.92 years. Mean duration of the disease was 7.29±4.5 years. Pulmonary involvements were found in 42 (72%) patients. Interstitial lung diseases were found in 42 (72%) patients, pulmonary arterial hypertensions in 6 (10%) patients and restrictive ventilator insufficiency in 32 (55%) patients. The proportion of individuals with pulmonary injuries was significantly higher among patients with immunological alterations compared with patient without immunological alterations and among females (both P<0.001). Conclusions: In our study, pulmonary manifestations were common in patients with scleroderma. These injuries are anatomical and functional. Our findings confirm that immunological alterations are an important factor in pulmonary injuries. Sex was also associated with pulmonary injuries in this sample of Albanian patients. High-resolution computed tomography is the most sensitive examination for the detection of pulmonary injuries in scleroderma.

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Authors: Monika Cenameri

Aim: This research is an exploratory and descriptive study on the way the Internet use influences the child development. It has three objectives: i) to provide an overview about the spread of the Internet in Albania; ii) to indicate how adolescents’ online activities affect their well-being, and; iii) to suggest the efficient ways used by parents to assist children on the problems created by such addictive behaviors. Methods: The most recent studies of the intersection between technology and development as young people confront and deal with the challenges and issues that are present in their lives were reviewed. Results were presented based on the data from seven countries that are part of the World Internet Project (WIP; see at: www.worldinternetproject.net). The WIP is a global international survey on the impact of the Internet on individuals and societies, coordinated by the Center for the Digital Future at the USC Annenberg School for Communication. Results: Digital media, such as computers, the Internet, video games, and mobile phones, have come to occupy a central place in the lives of today’s youth. It is important to consider the implications of young people’s online living, especially for their development and well-being. The Internet is a fundamental tool and, therefore, the particular ways that teens employ the Internet will ultimately determine the effects on their well-being. Conclusion: Te current review of the literature supports the conclusion that Internet use during childhood is associated with both positive and negative developmental outcomes.

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Authors: Rudina Cakraj, Donika Prifti

Aim: The olive oil industry generates big amounts of by-products: pomace and waste water that may result in very negative environmental impacts if there are no accu­rate management strategies. The Cleaner Production (CP) is a continuous application of an inte­grated preventive environmental strategy applied to processes and prod­ucts to increase efficiency and reduce risks to humans and the envi­ronment. This study was carried out to demonstrate the application of Cleaner Production Technology in the olive oil industry. Methods: The CP demonstration was carried out during the period 2011-2012, in an olive oil mill. The methodology used for conducting on-site evaluation of the CP included: i) pre-assessment of the company (description of the company and the processes, input-output analysis through in­terviewing staff of the company); ii) material and energy flow analysis, with the aim to identify pollution sources and the related pollution causes; iii) option generation and feasibility study from technical, economic and environmental view, identification of feasible measures, and; iv) implementation of feasible measures by the company and monitoring of the achieved effects. Results: The identified CP measures included the following: development of the information system, monitoring and saving of water consumption, improvement of the quality of olives, process modification: installation of the sec­ond centrifuge in the oil cleaning process, processing the pomace to be used as fuel (drying and pressing of the pomace), treatment of waste waters before discharging into municipal sewage system (op­tional treatment system “reed bed system” or “constructed wet­land”). Conclusion: This study demonstrates how CP can be implemented successfully in the olive oil industry using efficiently the available resources.

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Authors: Elinda Gjata, Ervin Toçi

Aim: The aim of this study was to retrieve information regarding the results of in-vitro fertilization procedures (IVF) and factors associated with pregnancy and live birth after IVF procedures in order to shed light into this under-researched topic in Albania. Methods: We included 246 infertile couples who showed up at the “Iakentro” IVF clinic during 2006-2012. Estradiol level, endometrium thickness and the number of embryos transferred were measured in all cases. In addition, basic socio-demographic information was collected. Binary logistic regression was used to assess the association of socio-demographic and laboratory parameters with pregnancy and live birth after IVF. Results: The rate of pregnancy after IVF was 45%. Among these, 67.3% of pregnancies resulted in live births. In our total sample, the rate of live births was 30.3% whereas the abortion rate after IVF was 14.7%. Upon multivariable adjustment, the higher number of embryos transferred was significantly associated with higher odds of pregnancy and live birth after IVF. Conclusions: Our findings indicate that pregnancy and live birth rates after IVF in Albania are comparable to those in developed countries. In the future, information regarding IVF procedures and their results in Albania should be more complete and accurate in order to ensure the quality of IVF services and improve the regulation of this sector.

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Authors: Izet Masič, Enes Kujundič

The revolution in information-communication technologies has led to the appearance of a “real tide” of different types of information sources that are offered in digital form. These new resources, far more than it was the case with traditional sources (books - handwritten and printed, contributions in scientific periodicals, archives and museums’ holdings, etc.), placed members of the scientific and research community at a serious dilemma: “Which sources to choose, how to evaluate and use them in a useful manner in scientific research?” This paper discusses aspects of the influence of modern information technology in scientific research. It also provides a review of the most important products and sources of knowledge necessary for scientific research, issues of information preservation, digital libraries, e-books, and information resources in the digital environment, databases and the use of sources of scientific information. Finally, it discusses how to validate the results of professional scientific work through the procedures of statistical processing, analysis, interpretation, technical and linguistic preparation and review, evaluation and impact of the dissemination of knowledge in various scientific publications. Keywords: ICT, IMRAD, publications, quoting literature, review of the articles.

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Authors: Peter Schröder-Bäck, Helmut Brand

In Europe we have more than four dozen countries and many different health systems. To look across borders and to see how public health and health care is organized in our neighbour countries and what policies and interventions they employ can be a worthwhile exercise. Maybe our neighbours have already found a solution for a pressing health issue we still do not have any idea how to tackle.

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Authors: Jolanda Hyska, Entela Bushi, Enkeleda Kadiu, Iris Mone

Aim: Iodine deficiency disorders (IDDs’) currently constitute a major global public health problem. IDDs’ remain a public health concern in Albania too. We undertook this survey in Albania to determine median urinary iodine concentration in a sample of school children, and asses the level of iodine in salt samples at the household level. Methods: A nationwide cross-sectional study was conducted in Albania in 2012 including a representative sample of 1027 school children aged 6-13 years. Urine and salt samples were examined for iodine concentration. Results: The median urinary iodine concentration was 100.4 μg/l, indicating no iodine shortage. Conversely, 49.6%of the examined urine samples indicated iodine deficiency. Iodine content was found to be adequate in 62.1% of salt samples. The median iodine concentration of salt samples was 18.5 mg/kg. Conclusion: Our findings indicate that IDDs’ are still an important public health problem in Albania. These results point to the need for strengthening the national IDD Control Program in Albania, and the need to ban production, trading and use of the non-iodized salt.

4

Authors: Xhevat Kurhasani, Hasan Hafizi

Aim: At a global level, there has been a significant progress towards reduction of tuberculosis morbidity and mortality in the past decades. Our objective was to describe the incidence and case notification rate of tuberculosis in Kosovo for the period 2000-2010. Methods: Data about all new cases of tuberculosis, incidence rate and case notification rate for the period 2000-2010 were obtained from the National Tuberculosis Control Program in Kosovo. Furthermore, selected indicators of tuberculosis in Kosovo were retrieved from the World Health Organization Global Tuberculosis Report 2012. Results: In the past decade, there has been a significant decrease in the incidence rate of tuberculosis in Kosovo. More specifically, the incidence of tuberculosis declined twice in the period 2000-2010: it was 89.9 per 100,000 population in 2000 vs. 43.7 per 100,000 population in 2010 (linear trend: P<0.01). Similarly, case notification rate declined from 78.2 per 100,000 population in 2001 to 43.7 per 100,000 population in 2010 (linear trend: P<0.01). Conclusion: Official statistics for Kosovo indicate a downward trend in tuberculosis incidence and case not ificat ion rate in the past decade. Nevertheless, the most significant decrease concerns the period from the year 2000 to the year 2003. Afterwards, there has been a fluctuation in the incidence rate and the case notification rate.

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Authors: Afrim Pirraçi, Arben Mitrushi, Drita Totozani

In surgical settings, it is very important to know and understand the anatomy and different types of variations of the gall bladder and the biliary tract, because these structures are in close connection with the adjoining organs and may show various anomalies and anatomic variations. There exist several variations of the normal gall bladder including duplicat ions (ectopic cysts), septate cholecyst , agenesis and hypognesis of the gall bladder, variations of the form of the gall bladder including “Phrygian cap”, Hartmann’s pocket, as well as other types of anatomic variations. In this short report, we highlight some of these anatomic variations of the gall bladder which are also examined and documented among hospitalized patients at the University Hospital Center “Mother Theresa” in Tirana and in a large and representative sample of primary health care users in Tirana municipality, the Albanian capital. Keywords: anatomic anomaly, anatomic variation, biliary tract, ectopic gallbladder, gall bladder, multiseptate gall bladder, Phrygian cap.

4

Authors: Altina Xhaferi, Medien Xhaferi, Astrit Hoxhaj, Gentiana Qirjako

Introduction: Dissection of the carotid arteries can occur in the general population as a result of blunt trauma to the neck, such as a car accident or a fall, or from hyperextension of the neck in sportsor exercise. According to recent studies, the incidence of carotid artery dissection as a result of blunt injuries (mainly high-speed motor vehicle accidents) ranges from less than 1% to 3%. Methods: We present a case of dissection of the right common carotid artery in a 25 years old patient after blunt neck trauma at the workplace. Results: The patient complained of neck pain. The radiologic exam revealed a dissection of the right CCA associated with the stenosis of the lumen up to 75-78 %. The angiosurgeon of the case confirmed the radiologic diagnosis. Conclusion: During the traumas of the neck region, performing the right protocol of examinations will improve treatment and prognosis.

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Authors: Anri Troja, Orion Muçaj

Aims: Adverse effects associated with opioid use are numerous and can be treatment limiting, but a variety of management strategies and tactics exists. The aim of this study was to review opioid use adverse effects and their treatment options. Methods: We reviewed the recent literature and highlighted the most common adverse effects associated with opioid use and the suggested treatment options and tactics. Results: Adverse effects of opioids range from common ones (constipation, nausea) to the less common (hiccups, lower leg edema), from the relatively mild (dry skin, runny nose) to the severe (respiratory depression). The adverse effects of opioids may be classified into inhibitory and excitatory, although they somet imes occur simultaneously. Ultra-low doses of opioid antagonists can reduce excitatory effects which, in turn, can heighten the inhibitory response (and possibly potentiate analgesia). Conclusions: Patients on opioid therapy may benefit from a change in drugs (ideally to a non-opioid altogether, but possibly to a lower dose or different opioid) or combination therapy. Specific medications or therapies have been shown to be effective in managing some adverse effects of opioid therapy, but there is considerable intra-patient variability. Opioid therapy confers analgesic benefits to well-selected patients, but adverse effects of this therapy are common and may require physician management.

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Authors: Fitim Skeraj, Katarzyna Czabanowska, Gazmend Bojaj, Bajram Hysa, Elizana Petrela, Jolanda Hyska, Genc Burazeri

Aim: Our aim was to validate an international instrument measuring abilities, skills and competencies of family physicians from practitioners' and policymakers' perspective in Kosovo. Methods: A sample of 20 family physicians in primary health care services and 20 policymakers in the health sector was interviewed in December 2012 and subsequently re-interviewed in January 2013. A structured questionnaire, administered and subsequently re-administered after two weeks (test -retest) to all participants, assessed physicians level of abilities, skills and competencies regarding different domains of quality of health care. The questionnaire included 37 items grouped into 6 subscales/ omains. Answers for each item of the instrument ranged from one (novice physicians) to five (expert physicians). An overall summary score (range: 37-185) and a subscale score for each domain were calculated for the test and retest procedures. Cronbach’s alpha was employed to assess the reliability (internal consistency) for both the test and the retest procedures, whereas Spearman’s rho was used to assess the test-retest reliability (stability over time) of the tool. Results: Among policymakers, the instrument exhibited a higher internal consistency (Cronbach’s alpha was 0.97 for the test and 0.96 for the retest procedure) compared to family physicians (0.89 and 0.88, respectively). Subscale coefficients, however, were not very different in each group. In particular, the patient care and safety domain behaved similarly in both groups for the test and the retest procedure. Overall, stability over time of the instrument was slightly higher among policymakers (Spearman’s rho: 0.87, P<0.01) compared to practitioners (Spearman’s rho: 0.83, P<0.01). Except the continuing professional development domain, for all the other subscales, the test-retest reliability coefficients were higher among policymakers than practitioners. Conclusion: Our findings point to an adequate internal consistency (for both the test and retest procedures) and stability over time (test -retest reliability) in this sample of family physicians and policymakers in Kosovo. From this perspective, this validation study provides useful evidence on cross-cultural adaptation of an international instrument measuring the level of competencies of family physicians in Kosovo. Seemingly, the instrument indicates a good potential for wide scale application to policymakers and especially to nationally representative samples of family physicians in transitional Kosovo.

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Authors: Valbona Duraj, Argjent Tafaj, Teuta Backa

Rheumatoid arthritis is basically considered a clinical syndrome across several disease subsets characterized by systemic inflammation, persistent synovit is, and autoantibodies. Genetic factors account for 50%of the risk of developing rheumatoid arthritis. In population-based studies in developed countries, it has been reported that rheumatoid arthritis affects 0.5%-1.0% of adults. The condition is three times more frequent in women than men. In both sexes, the prevalence increases with age. The prevalence of rheumatoid arthritis has remarkable geographical variations. The disease is more prevalent in Northern Europe and North America compared with many parts of the developing world. Nonetheless, valid and reliable data about developing countries and/or transitional societies are scarce. The new classification criteria for rheumatoid arthritis, developed by the American College of Rheumatology and the European League Against Rheumatism, assess joint involvement, autoantibody status, and acute-phase response and symptom duration. Notwithstanding the unresolved difficulties and challenges related to management of rheumatoid arthritis, the ongoing introduction of ground-breaking treatments may turn out to be rather effective. In any case, it has been convincingly argued that the new direction of treatment and management of rheumatoid arthritis should be towards short intensive therapeutic courses that result in remission instead of the traditional approach that is long-term suppressive treatment strategies. Keywords: arthritis, rheumatoid arthritis, rheumatic conditions, rheumatology.

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Authors: Alketa Hoxha, Ermira Kola, Numila Kuneshka, Eduard Tushe

Aims: The aim of this study was to compare the efficacy and safety of oral versus intravenous ibuprofen for the pharmacological closure of patent ductus arteriosus (PDA) in low birth weight (LBW) preterm infants and assess the impact of perinatal infection to pharmacological closure of PDA in LBW preterm infants. Methods: A randomized, single-blinded, clinical trial included 68 premature infants with significant PDA confirmed through cardiac ultrasound at the Koço Gliozheni maternity hospital in Tirana, Albania, during January 2010-December 2012. Infants were randomly assigned to receive either intravenous (n=32) or oral ibuprofen (n=36) at an initial dose of 10 mg/kg, followed by 5 mg/kg after 24 hours and after 48 hours. The rate of ductal closure, reopening, the need for surgical ligation, and the patients’ clinical course were recorded. Results: After the first t reatment cycle, the PDA closed in 83.3% of the patients receiving oral vs. 71.8%of those receiving intravenous ibuprofen. 16.6%of the patients in the oral group required a second cycle of treatment, compared with 28.1%in the intravenous group; all these cases had clinical signs of infection and positive bloodculture. No reopening of the ductus after its closure was noticed. Furthermore, there were no patients with oliguria. Conclusions: Oral ibruprofen showed a similar rate of ductal closure and renal tolerance, but fewer adverse effects compared to intravenous ibuprofen. Association of PDA with perinatal infection has a negative impact in pharmacological closure of the ductus, increasing the need for a second treatment cycle and surgical ligation. Larger comparative studies are needed to replicate these findings.