Eleonora Dubljanin

Epidemiology of onychomycosis in Serbia: a laboratory-based survey and risk factor identification

Onychomycosis is a fungal infection of the fingernails and/or toenails caused by dermatophytes, yeasts and non‐dermatophyte moulds. The epidemiology of onychomycosis in Serbia is yet to be fully established. This epidemiological study was aimed at evaluating the epidemiology of onychomycosis in a sample of the Serbian patients at risk of onychomycosis, to determine the fungal aetiological agents and to identify the possible risk factors. The study population included 374 patients from six centres in Serbia with suspected onychomycosis. Demographic data, data about comorbidities, lifestyle, clinical aspects of onychomycosis, trauma, excessive perspiration and personal and family history of previous onychomycosis were studied. Laboratory confirmation of diagnosis was done by direct microscopy, fungal culture and PCR. Diagnosis of onychomycosis was confirmed in 50.8% of patients, who tested positive to at least one laboratory test (direct microscopy, fungal culture or PCR). Trichophyton rubrum was predominant both on toenails (85.98%) and on fingernails (38.46%). Independent risk factors for onychomycosis were: old age (OR = 2.285; P < 0.001), family history of previous onychomycosis and/or tinea pedis (OR = 2.452; P = 0.005), excessive perspiration (OR = 2.165; P = 0.002) and higher degree of hyperkeratosis (OR = 1.755; P = 0.020). This is a first epidemiological study of onychomycosis from Serbia.

Clinical evaluation of a T. rubrum-specific polymerase chain reaction and pandermatophyte polymerase chain reaction in the diagnosis of suspected onychomycosis in 183 Serbian patients

DEAR EDITOR, In most European countries the prevalence of onychomycosis varies between 3% and 22%, with Trichophyton rubrum accounting for 60–90% of infections. The combination of microscopy with culture is still the most commonly employed test in routine laboratory practice worldwide. Direct microscopy is rapid, inexpensive and has good sensitivity but does not allow for the discrimination of different fungal species. However, culture allows fungal species identification but has a low sensitivity, particularly for nail specimens, and is time consuming. A few recent studies describe diagnostic molecular methods for the direct detection of dermatophytes in patient samples thereby providing a rapid and accurate diagnosis, including species identification. The aim of this study was to compare a conventional polymerase chain reaction (PCR)-based approach with traditional diagnostic methods using clinical nail specimens from Serbian patients with suspected onychomycosis. The study included 183 patients with suspected toe onychomycosis. All patients were examined by dermatovenerology specialists. We excluded patients who had used topical or systemic antifungal drugs within the previous 6 months. The entire nail surface was first cleansed with 70% alcohol, and nail samples were collected by scraping or clipping the clinically affected area. Every nail sample was subjected to direct microscopy, fungal culture and PCR. Two types of direct microscopic preparations (at 109 and 409 magnifications) were undertaken using (i) 10% potassium hydroxide and light microscopy; and (ii) fluorescent dye Blankophor and fluorescent microscopy. Nail samples were cultured and incubated for 3 weeks on two fungal media: Sabouraud dextrose agar (at 28 and 37 °C) and dermatophyte test medium (at 28 °C). Organisms were identified by macroand microscopic examination. Nail specimens were initially tested by two in-house PCRs: a pandermatophyte PCR (single-copy gene target) and a T. rubrum-specific PCR (multicopy gene target). In brief, DNA from nail samples was extracted by a patented method involving a 10-min sample incubation in 100 lL of extraction buffer [60 mmol L 1 sodium bicarbonate, 250 mmol L 1 potassium chloride and 50 mmol L 1 Tris (pH 9 5)] at 95 °C and the subsequent addition of 100 lL anti-inhibition buffer (2% bovine serum albumin). After vortex mixing, the solution was used for PCR. Pandermatophyte-positive and T. rubrum-negative samples were run in a subsequent PCR specific for the Trichophyton interdigitale complex. All PCR reactions were run with an internal control. Negative samples without a positive internal control amplicon were considered inhibited. They were then diluted (twofold) and a repeat PCR was performed; the samples either turned positive, negative or remained inhibited. Forty-two of the 90 samples found to be positive by traditional diagnostics (47%) were positive only by direct microscopy; hence, genus or species identification could not be performed (Table 1). Ninety-eight of 183 (53 5%) samples were found to be dermatophyte-positive by PCR: T. rubrum (n = 83), T. interdigitale (n = 5) and pandermatophyte (n = 10) (Fig. 1). Fortyfour microscopy and culture positive samples [T. rubrum (n = 42), T. interdigitale (n = 2)] were also identified as such by PCR, whereas one sample (T. rubrum) was found to be negative by PCR. Of 93 samples found to be negative by conventional methods, eight (8 6%) were found to be positive by PCR [T. rubrum (n = 4), T. interdigitale (n = 2), nonrubrum interdigitale dermatophyte (n = 2)]. Three samples that were nonrubrum interdigitale dermatophyte-positive by conventional methods [Trichophyton tonsurans (n = 2), Trichophyton verrucosum (n = 1)] were found to be pandermatophyte-positive by PCR. One PCR-negative but direct microscopy and culturepositive sample yielded Aspergillus flavus in culture. This is the first report of the diagnosis of onychomycosis in Serbian patients by molecular methods. Traditionally, in Serbia, onychomycoses are diagnosed using conventional techniques, which, owing to poor sensitivity, has resulted in many underdiagnosed patients. Despite clear evidence of the presence of fungal elements in direct microscopy, culture in almost half of the samples (53 3%) was negative, requiring additional samples and another approximately 3–4 weeks for additional diagnostics; however, these had questionable out-

Trends in mortality rates from coronary heart disease in Belgrade (Serbia) during the period 1990-2010: a joinpoint regression analysis.

BackgroundCoronary heart disease (CHD) causes an estimated 7 million deaths worldwide each year. In the last few decades, mortality from CHD has been decreasing in many countries. The aim of this study was to analyze the trends of mortality from CHD and myocardial infarction (MI) in the population of Belgrade during the period 1990–2010.MethodsMortality data for CHD and MI were obtained from the Municipal Institute of Statistics in Belgrade and used to calculate age- and sex-specific and age-adjusted mortality rates. Joinpoint regression analysis was used to estimate annual percent changes (APCs) in mortality and to identify points in time where significant changes in trend occur.ResultsTrends in CHD mortality rates showed significant decline in men during the period studied (APC -0.5%, no joinpoints detected), but no significant change among women (APC +0.4%, no joinpoints detected). While we observed significant declines in CHD mortality in men aged 35–44, 55–64 and 65–74 and women aged 55–64, there was a significant increase in mortality in men aged ≥85 and women aged 75–84 and ≥85. Trends in MI mortality rates showed similar patterns in both genders, with a significant decline from the mid-1990s. Significant decline in MI mortality was observed in almost all age groups, except the two oldest (75–84 and ≥85) in women population.ConclusionsGiven that CHD and MI mortality trends showed different patterns during the period studied, especially in women, our results imply that further observation of trend is needed.

Low Back Pain among Medical Students in Belgrade (Serbia): A Cross-Sectional Study

Aim To examine the prevalence of low back pain, to identify self-perceived triggers of low back pain, and to investigate the impact of perceived pain on the daily activities and mood among medical students. Methods This cross-sectional study enrolled 459 fourth year students at the Faculty of Medicine in Belgrade during December 2014. The anonymous questionnaire was used for data collection. In data analysis, the chi-square test and t-test were used. Results The lifetime prevalence of low back pain was 75.8%, 12-month prevalence 59.5%, and point prevalence 17.2%. Chronic low back pain was experienced by 12.4% of the students. Both the lifetime (p=0.001) and the 12-month (p=0.001) low back pain prevalence rates were significantly higher among female medical students. Mental stress during an exam period (p=0.001), sitting at the university (p=0.002), fatigue (p=0.043), improper body posture (p=0.005), and lack of exercise (p=0.001) as self-perceived triggers of low back pain were significantly more often reported by female students, compared to males. Regarding daily functioning, the experience of low back pain mostly affects students sleeping (14.6%) and walking (12.0%). Conclusions The prevalence of LBP is high among Belgrade medical students and significantly affects their everyday functioning.

Serbian medical students’ fertility awareness and attitudes towards future parenthood

Abstract Objectives: Medical students represent a group particularly at risk of involuntary childlessness due to their highly demanding careers and university curriculum. The aim of this study was to investigate Serbian medical students’ attitudes towards future parenthood and their awareness of fertility issues. Methods: A cross-sectional study was conducted among fourth year students at the Faculty of Medicine, University of Belgrade, Serbia, between 12 and 16 December 2016. Data were collected through an anonymous 56-item validated questionnaire, translated into the Serbian language. The participation rate was 87.1%. Results: More than 95% of students, regardless of gender, wanted to have children in the future; most indicated three as the desired number of children. Both genders equally rated the importance of having children. Women rated significantly higher the likelihood of IVF treatment or child adoption if faced with infertility (both p = .001). All students wanted to have their first child before the age of 35 years. Knowledge about the age-related decline in female fertility was not satisfactory. Women found it more important to have children when they felt sufficiently mature, were in a stable relationship, were financially secure, had completed their studies, were not too old to have children, and had access to childcare, although these prerequisites were rated highly by both genders. Conclusion: Serbian medical students greatly value and have a positive perception of future parenthood. Appropriate education is needed, however, because of their inadequate knowledge of the age-related decline in female fertility.

Psychosocial Stress and Risk of Myocardial Infarction: A Case-Control Study in Belgrade (Serbia)

BACKGROUND The purpose of this study was to investigate which psychosocial risk factors show the strongest association with occurrence of myocardial infarction (MI) in the population of Belgrade in peacetime, after the big political changes in Serbia. METHODS A case-control study was conducted involving 154 consecutive newly diagnosed patients with MI, and 308 controls matched by gender, age, and place of residence. RESULTS According to conditional logistic regression analysis, after adjustment for conventional coronary risk factors, the odds ratios (95% confidence intervals) for work-related stressful events, financial stress, deaths and diseases, and general stress were 3.78 (1.83-7.81), 3.80 (1.96-7.38), 1.69 (1.03-2.78), and 3.54 (2.01-6.22), respectively. Among individual stressful life events, the following were independently related to MI: death of a close family member, 2.21 (1.01-4.84); death of a close friend, 42.20 (3.70-481.29); major financial problems, 8.94 (1.83-43.63); minor financial problems, 4.74 (2.02-11.14); changes in working hours, 4.99 (1.64-15.22); and changes in working conditions, 30.94 (5.43-176.31). CONCLUSIONS During this political transition period , stress at work, financial stress, and stress in general as they impacted the population of Belgrade, Serbia were strongly associated with occurence of MI.