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The paper reviews experiences and accomplishments in application of system dynamics modeling in education, training and research projects at the Andrija Stampar School of Public Health, a branch of the Zagreb University School of Medicine, Croatia. A number of simulation models developed over the past 40 years are briefly described with regard to real problems concerned, objectives and modeling methods and techniques used. Many of them have been developed as the individual students' projects as a part of their graduation, MSc or PhD theses and subsequently published in journals or conference proceedings. Some of them were later used in teaching and simulation training. System dynamics modeling proved to be not only powerful method for research and decision making but also a useful tool in medical and nursing education enabling better understanding of dynamic systems' behavior.

Medical and nursing students need to be trained in critical evaluation of mobile health applications (m-health apps) in order to see their potential and to understand the need for their validation and certification. Students should develop positive attitudes but also critical views on such apps in order to be prepared for responsible and ethical use of m-health in their future professional practice.

The Association of Institutions Responsible for Advanced Teaching in Public Health and of Schools of Public Health in Europe was established in 1966. It was in response to the initiative of the World Health Organization (WHO)Regional Office for Europe as part of a worldwide initiative to set up Regional Associations of Schools in every WHO region as a channel for initiating innovative policies. The Organisation’s name was later changed into Association of Schools of Public Health in the European Region(ASPHER). ASPHER has established atradition in terms ofan annual award named Andrija Stampar, whichhasbecome a prestigious European reward for merits in public health.A significant contribution to public health education has been made during half century and the Association is today stronger than ever before

Background: The epidemic pattern of respiratory syncytial virus (RSV) in Croatia is biennial. In order to determine if the circulation of different RSV subtypes affects the outbreak cycle, the aim of the present study was to analyze the epidemic pattern of RSV in children in Croatia (Zagreb region) over a period of 3 consecutive years. Methods: The study group consisted of 696 inpatients, aged 0–5 years, who were hospitalized with acute respiratory tract infections caused by RSV, in Zagreb, in the period 1 January 2006–31 December 2008. The virus was identified in nasopharyngeal secretions using direct immunofluorescence. The virus subtype was determined on real-time polymerase chain reaction. Results: Of 696 RSV infections identified in children, subtype A virus caused 374 infections, and subtype B, 318. Four patients had a dual RSV infection (subtypes A and B). The period of study was characterized by four epidemic waves of RSV infections: the first, smaller, in the spring of 2006; the second, larger, in December 2006/January 2007; the third in spring 2008, followed by a fourth outbreak beginning in November of 2008. The biennial virus cycles were persistent although the predominant RSV subtype in the first two epidemic waves was subtype B, and in the second two it was subtype A. Conclusion: Over a 3 year period of observation, the biennial RSV cycle in Croatia cannot be explained by a difference in the predominant circulating subtype of RSV. Other unknown factors account for the biennial cycle of RSV epidemics in Croatia.

South Eastern European Journal of Public Health (SEEJPH), Volume IV, 2015

We conducted a retrospective study at the Department of Paediatric Cardiology of the University Hospital Centre Rebro, Zagreb, over the period from 1988 to 1998, so as to assess the epidemiology of childhood cardiomyopathies. The patients were categorized according to the guidelines of the Task Force on Cardiomyopathies of the World Health Organization and the International Society and Federation of Cardiology. We identified 121 infants, children and adolescents as having cardiomyopathy, giving an average occurrence for all cardiomyopathies of 38.81 for each 10, 000 patients examined in our outpatient clinics for paediatric cardiology. Of the patients, 50 were female (41.3%) and 71 were male (58.7%). The cardiomyopathy was of the dilated variant in 52 patients (42.9%), with 43 patients (35.5%) having hypertrophic cardiomyopathy, and 6 patients (4.8%) identified with restrictive cardiomyopathy. We encountered no patients with arrhythmogenic right ventricular cardiomyopathy. In nine patients (7.4%), it proved impossible to classify the cardiomyopathy. We placed 11 patients (9.0%) in the group of specific cardiomyopathies. Most of those with dilated cardiomyopathy had been diagnosed prior to the age of 3 years (RR 1.9, 95% CI 1.4-2.47). There were no statistically significant differences in the incidences of dilated as compared to hypertrophic cardiomyopathy (Z 0.923, p = 0.1779), but we encountered a significantly lower occurrence of restrictive cardiomyopathy (Z 6.044, p < 0.001). Of those with hypertrophic cardiomyopathy, 15 patients (34.8%) had the asymmetric variant, while 28 patients (65.2%) exhibited the concentric form. During the period of follow-up, 10 patients died, 4 with dilated cardiomyopathy, 4 with hypertrophic cardiomyopathy, 1 with restrictive cardiomyopathy, and 1 with a specific cardiomyopathy. We encountered 12 (9.9%) patients who, besides cardiomyopathies, also suffered from neuromuscular disorders. Most of these had dilated cardiomyopathy. Mitochondrial disorders, in contrast, were more frequently found in patients with hypertrophic cardiomyopathy.

The objective of this study is to determine the prevalence of blood donors positive for herpes simplex virus type 2 (HSV-2), to identify the patterns of sexual risk behavior responsible for HSV-2 positivity and to assess the reliability of HSV-2 positivity as a marker of sexual risk behavior in the study population.This cross-sectional study included 423 blood donors of both sexes from eastern Croatia. Their blood samples were tested by ELISA IgG test kit for HSV-2 IgG and Western blot. Data on sexual risk behavior were collected by use of an anonymous questionnaire.Western blot testing showed HSV-2 IgG antibodies in 14 of 423 (3.3%) donor blood samples. The most common patterns of sexual risk behavior potentially associated with test positivity were irregular condom use during sexual intercourse with new partners (294/423; 69.5%) andor = 5 sexual partners during lifetime (213/423; 50.4%).The population of blood donors from eastern Croatia included subgroups of subjects characterized by sexual risk behavior. Study results pointed to a relationship between various forms of sexual risk behavior and HSV-2 positivity, which could therefore serve as a reliable marker of sexual risk behavior in the study population.

The epidemic pattern of respiratory syncytial virus (RSV) in Croatia is biennial. In order to determine if the circulation of different RSV subtypes affects the outbreak cycle, the aim of the present study was to analyze the epidemic pattern of RSV in children in Croatia (Zagreb region) over a period of 3 consecutive years.The study group consisted of 696 inpatients, aged 0-5 years, who were hospitalized with acute respiratory tract infections caused by RSV, in Zagreb, in the period 1 January 2006-31 December 2008. The virus was identified in nasopharyngeal secretions using direct immunofluorescence. The virus subtype was determined on real-time polymerase chain reaction.Of 696 RSV infections identified in children, subtype A virus caused 374 infections, and subtype B, 318. Four patients had a dual RSV infection (subtypes A and B). The period of study was characterized by four epidemic waves of RSV infections: the first, smaller, in the spring of 2006; the second, larger, in December 2006/January 2007; the third in spring 2008, followed by a fourth outbreak beginning in November of 2008. The biennial virus cycles were persistent although the predominant RSV subtype in the first two epidemic waves was subtype B, and in the second two it was subtype A.Over a 3 year period of observation, the biennial RSV cycle in Croatia cannot be explained by a difference in the predominant circulating subtype of RSV. Other unknown factors account for the biennial cycle of RSV epidemics in Croatia.

Objective: The biennial epidemic pattern of respiratory syncytial virus (RSV) circulation in Croatia has been preserved and could not be related to climatic factors and the predominant RSV subtypes. The possibility that the circulation of different RSV genotypes affect the outbreak cycle in children in Croatia (Zagreb region) over a period of 3 consecutive years was explored in the paper. Methods: The study group consisted of inpatients, aged 0 - 10 years, who were hospitalized with acute respiratory tract infections caused by RSV, in Zagreb, over the period from 1 January 2006 to 31 December 2008. The virus was identified in the nasopharyngeal secretion using direct immunofluorescence method. The virus subtype and genotype was determined by real-time PCR and sequence analysis, respectively. Results: RSV infections identified in 731 children. RSV subtype A caused 399 infections, and subtype B 332. Two subtype A genotypes (NA1 and GA5) and three subtype B genotypes (BA7, BA9 and BA10) were found. During persistent RSV biennial cycles namely four succeeding outbreaks, the new genotype from the previous smaller outbreak persevered into the upcoming larger outbreak. Conclusion: Our molecular-epidemiology study of RSV subtypes and genotypes during calendar months demonstrates that the biennial RSV cycle cannot be fully explained by the dynamic of the predominant circulating genotype of RSV. Other unknown factors account for the biennial cycle of RSV epidemics in Croatia.

PART I: CURRENT ISSUES IN HEALTH REFORMS Health Reforms in South East Europe: an Introduction W.Bartlett, J.Bozikov & B.Rechel Health Reforms in Croatia From the User Perspective M.Mastilica Health Reform in Bulgaria A.Dimova , M.Rohova , M.Popov & B.Rechel Decentralization in Croatia's Health System A.Dzakula, S.Sogoric & L.Voncina Health Workforce Mobility and Policy Responses in South East Europe D.Ognyanova & R.Busse PART II: PRIMARY HEALTH CARE REFORMS Primary Health Care Reform in Serbia: Driven by Whom? S.Simic, J.Marinkovic & G.Boulton Primary Health Care in Romania after 20 years of Reforms S.G.Scintee & C.Vladescu PART III: GOVERNANCE AND MANAGEMENT OF HOSPITALS The Public Hospital System in Macedonia V.Lazarevik & D.Donev Hospital Infrastructure Development in Serbia: Modernizing the Four University Clinical Centres I.M.Jekic, A.Katrava, G.Boulton, N.Koumpis, M.Obrovack i, & A.Milojkovic Hospital Performance Measurement in Bulgaria M.Georgieva & E.Moutafova PART IV: HEALTH FINANCE REFORMS The Combined Way of Paying Family Medicine in Croatia M.Katic, D.Jurkovic & V.Juresa Reforms of the Organization and Financing of Primary Health Care in Montenegro D.Ostojic & R.Andric The National Tender for Prospective Programmes in Slovenia V.P.Rupel, D.Marusic, J.Ceglar & T.Mate

Development of journal collection in the Andrija Stampar library is presented. Research of loaned and photocopied journals was performed in order to evaluate circulation of journals in 2001. There were 1057 titles of journals in the Library, 77 were secondary journals and they were excluded from the study. 346 different titles were used 5204 times, out of which 236 were current titles. There were 11 titles used more than 100 times. Journal of Clinical Microbiology was the highest ranking journal. The greatest number of users were from the School of Public Health Andrija Stampar. Most important users of the Library were hospitals, universities, institutions, institutes of public health from Zagreb and all parts of Croatia. More recent journals were used more frequently than the old ones. Decrease of journal usage in the Library has been noticed in recent years. The reason for that are the possibilities of using full text electronic journals either through free access, or through combined subscriptions. The access to electronic journals is possible through more and more affordable subscriptions from the big publishers.

Medical informatics began to develop in Croatia in 1966 when medicine was recognized as a field in which the use of computers is important and widespread, and will be necessary in the future. Andrija Stampar School of Public Health, Medical School in Zagreb, was a pioneer in this new field in our country. Medical informatics contents were then introduced into postgraduate education with the aim to introduce future medical/health professionals to the possibilities of using computers in their fields of work and in health care in general. At the same time, computer processing of notification sheets started, as well as disease registries development and pilot processing of primary care data. In 1970/71, medical informatics contents were introduced in education of medical students at the Medical School in Zagreb. The opening of the Zagreb University Computing Center terminal station at the Andrija Stampar School of Public Health in 1973, and later, the establishment of a computer laboratory and including equipment and networking of the Medical School's workplaces gave the students, teachers and researchers the opportunity for intensive use of new technologies. The teachers from the School helped in spreading medical informatics education to other medical schools and colleges. Medical informatics research and the national and international cooperation was a logical continuation of the professional development, and the postgraduate education in Medical Informatics was a step further in spreading of knowledge among medical and health personnel as well as among other professions working in the health field.

Background The epidemic pattern of respiratory syncytial virus (RSV) is quite different in regions of Europe (biennial epidemics in alternating cycles of approximately 9 and 15 months) than in the Western Hemisphere (annual epidemics). In order to determine if these differences are accounted for by the circulation of different RSV subtypes, we studied the prevalence of RSV subtype A and B strains in Zagreb County from 1 January 2006 to 31 December 2007. Results RSV was identified in the nasopharyngeal secretions of 368 inpatients using direct fluorescence assays and/or by virus isolation in cell culture. The subtype of recovered strains was determined by real-time PCR. Of 368 RSV infections identified in children during this interval, subtype A virus caused 94 infections, and subtype B 270. Four patients had a dual RSV infection (subtypes A and B). The period of study was characterized by two epidemic waves of RSV infections-one, smaller, in the spring of 2006 (peaking in March), the second, larger, in December 2006/January 2007 (peaking in January). The predominant subtype in both outbreaks was RSV subtype B. Not until November 2007 did RSV subtype A predominate, while initiating a new outbreak continuing into the following calendar year. Conclusion Though only two calendar years were monitored, we believe that the biennial RSV cycle in Croatia occurs independently of the dominant viral subtype.

ESH/ECS guidelines for diagnostics and treatment of arterial hypertension 2007 is a basic paper for all physicians who treat hypertensive patients. Since publishing, this article has been the most cited medical paper. According to ESH/ECS guidelines some local peculiarities in each country should be considered when diagnosing and treating hypertensive patients. Practical recommendations of the Croatian working group for the diagnostics and treatment of hypertension are in agreement with ESH/ECS guidelines. However, few additional issues are added and further discussed in this paper (hypertensive crisis, treatment of hypertension in patients undergoing dialysis and in renal transplanted patients, role of family physicians, role of nurse). We believe that this paper will contribute better control of hypertension in Croatia. All medical societies and institutions that took part in writing this document, have to consider this paper as an official statement.

To determine whether there are any differences in the prevalence of risk factors between survivors and nonsurvivors among acute myocardial infarction (AMI) patients hospitalized in a county hospital.Case histories of AMI patients treated at Department of Medicine, Bjelovar General Hospital from July 1, 1996 until December 31, 2000 were retrospectively analyzed. AMI was diagnosed using the World Health Organization definition. Demographic factors (age and sex), smoking habits, clinical and laboratory results (hypertension, diabetes, blood lipids--total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides), personal history of angina pectoris, myocardial infarction and stroke and family history of atherothrombotic disease were considered as potential risk factors. Comparisons were made between survivors and nonsurvivors during hospital treatment. On group comparisons Student's t-test and chi2-test were used. Statistical significance was set at p0.05.In a total of 396 study patients, there were 316 (79.8%) survivors, showing male predominance (87.1% vs 67.3% of women; p0.011). The patients aged under 65 were mainly male (79.6%), and among those older than 65 both sexes were equally represented (male 50.7% vs female 49.3%). Hypertension was more common in women (55.1% vs 42.6%; p=0.016), and smoking in men (31.7% vs 5.4%; p0.001). The group survivors showed a higher prevalence of hypertension (50.3% vs 35.0% in nonsurvivors; p=0.014) and smoking (25.9% vs 6.3%; p0.001). The prevalence of diabetes, previous myocardial infarction, angina pectoris, previous stroke and family history of atherothrombotic disease showed no statistically significant differences between survivors and nonsurvivors. Furthermore, a greater number of patients with increased levels of total cholesterol (or =5.0 mmol/L) and LDL-cholesterol (or =3.0 mmol/L) were found in the group of survivors than among nonsurvivors. The latter were 8 years older than survivors (71.0+/-9.3 vs 63.0+/-11.9 years; p0.001). Analysis according to age groups also showed a rise of hospital mortality with age group in both sexes (men: 4.6% in55 age group vs 22.6% inor =75 age group; women: 7.1% in55 age group vs 43.7% inor =75 age group). A higher percentage of men nonsurvivors were smokers in comparison to female nonsurvivors that also had a lower level of total cholesterol. The prevalence of hypertension showed no significant sex difference.The prevalence of risk factors, especially the most important ones, i. e. hypertension, smoking and abnormal lipid values in AMI patients should be considered according to sex and age. The impact of these factors on patient outcome, i. e. survival rate during hospital treatment, can only be analyzed taking into account sex and age.

The effects of implementation WHO/UNICEF Breastfeeding Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates were examined during and after the breastfeeding promotion campaign in one county of Croatia. Comparison with a control group indicated increase of breastfeeding prevalence in a period of BFHI implementation (1994-1998) - 68% vs. 87% at infant age 1 mo., 30% vs. 54% at 3 mo., 11.5% vs. 28% at 6 mo., and 2% vs. 3.5% at infant age 11-12 mo. (chi-square test, p0.05). More considerable increase has been noticed in period 1999-2000 which is characterized by breastfeeding support groups activity: 68% vs. 87% at infant age 1 mo., 30% vs. 66% at 3 mo., 11.5% vs. 49% at 6 mo., and 2% vs. 23% at infant age 11-12 mo. (chi-square test, p0.05). Our conclusion is that activities aiming to promote breastfeeding in maternity hospitals have had limited success. They have resulted in satisfactory increase of breastfeeding prevalence in early infant's period, but for far-reaching effect postnatal support is also required.

The Electronic Health Center (eHC) is aimed as an Internet service for continuing medical education of general practitioners (GPs) at the national level. It integrates education, access to relevant and trusted information sources and group communication in order to meet the needs of both daily work and continuing education at home.

To analyze a five-year publication output of the Zagreb University Medical School in scientific journals, especially in the journals covered by the Current Contents (CC), bibliographic database of the Institute for Scientific Information.Medical School of the Zagreb University is organized in 10 preclinical, 6 public health, and 17 clinical departments, with 359 faculty members. Research activity is important for the academic promotion, with the number of publications (especially in journals covered by CC) and their impact as a key element. Bibliographic data on the published papers by the authors affiliated to the Zagreb University Medical School in the 1995-1999 period were searched in the CC and Biomedicina Croatica databases, according to the official faculty name list. The collected data were classified into three groups according to the source journals: papers published in international journals covered by the CC, Croatian journals covered by the CC, and Croatian journals not covered by the CC. The publication production was measured on individual and departmental levels by using two counting schemes: a) full publication to each author/department; and b) an equal fraction of a publication (1/n) to each author/department.In the 1995-1999 period, the faculty published 578 papers in the journals covered by the CC, 22.6% of them in the subset of Croatian journals. The differences among departments were considerable, with publishing activity per faculty member varying from 0.25 to 6.23 papers in CC journals and from 0.0 to 15.8 in Croatian non-CC journals. Preclinical departments published significantly less in the Croatian journals indexed in the CC then public health and clinical departments. There was a high variance in the number of publications on the individual level, with the 15.4% of the faculty in the professor rank and 45% in the assistant rank who did not publish a single paper in journals covered by the CC in the analyzed period. On the contrary, 10.1% of professors and 6.0% of assistants published more than 10 and more than 4 CC-indexed papers, respectively. A number of authors who have been very productive in international journals indexed in the CC (11 or more papers) did not publish in Croatian journals indexed in the same database, and vice versa.Publication output of the Zagreb University Medical School shows imbalances characteristic of a small scientific community: productivity with extreme values, relatively unsatisfactory number of papers published in the international journals covered by the CC database as compared to their importance in the process of the academic promotion, and disproportional role of certain domestic journals covered by the CC.

To examine the role of the genetic component in the quantitative dermatoglyphic traits of autistic patients and their families, and the transmission of the autism.Finger and palm prints were taken from 120 autistic patients (92 males and 28 females), their parents (92 mothers and 70 fathers), 32 healthy brothers and 28 sisters, as well as 400 healthy controls (200 males and 200 females). An analysis of quantitative traits of dermatoglyphs on the fingers (FRC - finger ridge count) and palms (a-b, b-c, and c-d ridge count, and atd angle) was performed. Descriptive statistics, multivariate analysis of variance (MANOVA) with Tukey HSD post hoc test, and discriminant analysis were used to determine the differences among the groups. In addition, correlations among family members were analyzed.Multivariate analysis showed significant differences among examined groups of autistic patients and their family members and healthy volunteers regarding both group membership and sex. Autistic male patients differed significantly from the healthy controls in the ridge count (RC) on the fourth and fifth finger, and in a-b RC and atd angle of both hands. Healthy fathers of autistic patients differed in atd angle, and brothers of autistic patients differed in all palmar variables from the healthy control group. Mothers of autistic patients differed significantly from the healthy female controls in the RC of the first, fourth, and fifth finger, in a-b and c-d RC on the palms, and atd angle of both hands. The first two discriminant functions explained 85.4% of variance and separated groups clearly in two ways: the first function separated healthy controls from family members of autistic patients, and the second one males from females. Interfamilial analysis showed significant interclass correlations between autistic sons and their mothers or fathers in practically all variables. However, the correlation between parents and their autistic daughters was lower. Both mothers and fathers of autistic patients correlated with their healthy children only in palmar variables.We found significant differences in ridge counts on the fingers and palms between the affected patients and their healthy controls, but these differences also existed between family members of autistic patients and healthy controls. Particularly pronounced were the differences between healthy female controls and female family members, including not only autistic female patients, but also their healthy mothers and sisters. Since the mothers and their autistic sons showed higher statistically significant correlation in most of the examined variables, unlike the mothers and their autistic or healthy daughters, it is possible that there is a connection between a recessive X-chromosome linkage, as a genetic component in the etiology of autistic disorders, and the influence of the inactivation of the affected X-chromosome in the females.

Successful breastfeeding is not an automatism. Like other behavioral models, breastfeeding experience is forwarded from generation to generation. To analyze the influence of previous generation on offspring's breastfeeding. Research was carried out in three general pediatric offices in Croatian towns: Sibenik, Varazdin and Zagreb. Examinees were mothers of preschoolers older than 1 year, and totally 300 mothers were comprised by the questionnaires. Mothers who had been breastfed for longer period (more than 6 mo.) statistically significantly more frequently breastfeed their children over 6 months (chi 2 = 10.4; p = 0.0013), in comparison with mothers who had been breastfed for shorter period (up to 6 mo.). There is no significant difference in children breastfeeding duration (up to 6 mo. vs more than 6 mo.) with regard to whether the mothers lived in autonomous housekeeping, or if they lived in common housekeeping with their mothers, or mothers-in-law (chi 2 = 0.303; p = 0.86; d. f. = 2). The influence of examinees' mothers on decision to breastfeed is more frequently positive (63%) than neutral or negative, while, at the same time, positive influence on decision to breastfeed was exerted by significantly smaller number (40%) of mothers-in-law (chi 2 = 27.87; p0.001). The strongest influence on mother's decision to breastfeed was exerted by mass media. In the age of nuclear families, health workers should offer more support to breastfeeding mothers with the aim of achieving successful lactation.

Introduction The aggressive biological behavior of invasive and metastatic cancer is considered to be the most insidious and life-threatening aspect for breast cancer patients. It is mostly the result of changes in many molecular characteristics of tumor cells, including alterations in the mechanisms controlling cell growth and proliferation. Aim The aim of this retrospective study was to identify predictors of aggressive biological behavior and metastatic potential in breast carcinoma among a number of intrinsic bio-markers of tumor cells such as steroid receptors and oncogene and tumor suppressor gene products. Methods Routine formalin-fixed, paraffin-embedded tumor samples were used and sections were stained immunohistochemically with the DAKO Strept ABC method to determine the expression of estrogen receptors (ER), progesterone receptors (PgR), HER-2/neu, bcl-2, Ki-67, p53 and nm23 in 192 consecutive breast carcinoma patients. The results of the quantitative immunohistochemical assays were correlated with clinical and histological data such as patient age, overall survival, tumor size, axillary lymph node status, hystological type, tumor grade, Nottingham prognostic index (NPI) and therapeutic regimens. Results Univariate analysis revealed that survival was significantly longer for patients with small tumors (P = 0.007), lower tumor grade (P = 0.021), negative axillary lymph nodes (P = 0.002), presence of nm23 protein (P = 0.002), and for patients treated with adjuvant hormonal therapy (P = 0.010). In multivariate analysis the independent factors positively affecting survival were absence of axillary lymph node metastases (P = 0.002), nm23 expression (P = 0.009) and hormonal therapy (P = 0.050). Among patients with positive axillary nodes there was a significantly higher survival rate in patients with nm23 expression compared with nm23-negative patients (P Conclusion Identification of a subset of node-positive breast cancer patients with a more favorable prognosis according to nm23 expression might be clinically useful.