ZAGREB, November 25, 2018 - A third of Croatian school-age children are smokers, and Croatia ranks third in Europe according to the prevalence of this problem in society, said participants in a roundtable discussion organised by the Croatian Institute of Public Health (HZJZ) on smoking and drinking among youngsters.

During the discussion held in Zagreb, doctors supported the planned rise in excise taxes on alcoholic beverages and cigarettes, as they believe that higher prices will make those products less available to pupils.

On the other hand, the Croatian Employers' Association (HUP) insists that the higher prices of alcohol and cigarettes, the more prevalent illegal sale of such products.

Ivana Pavić Šimetin of the HZJZ presented some of the alarming statistics such as the fact that 4% of boys and 1% of girls have got drunk at least twice so far in their life. Pavić Šimetin spoke about the importance of making cigarettes and alcoholic drinks less available to underage buyers. "The HZJZ is not focused on a rise in income but on safeguarding public health against smoking and alcohol, having in mind the fact that the availability of alcohol and cigarettes to young people is 10% higher in Croatia than in other EU member-states," she said.

The ESPAD European survey on smoking and alcohol and drugs consumption among the youth in 2015 shows that every one in three Croatians below the age of 16 is a smoker, and 54.7% of those in this age cohort drank alcohol in the previous 30 days.

Danijela Štimac of the HZJZ warned that in Croatian cafes a shot of brandy costs 6 kuna and a glass of freshly squeezed juice 25 kuna.

Of all EU member-states, Croatia has the second lowest tobacco prices after Bulgaria, HZJZ director-general Krunoslav Capak noted.

Furthermore, in Croatia 25% of the population smokes on a daily basis, twice as much as in Finland, for instance, said Ivana Brkić Biloš of the HZJZ department for epidemiology and prevention of non-communicable chronic diseases.

"Alcohol as a risk factor has been identified in more than 200 different diseases, and in the world 3.3. million of deaths are believed to be linked to alcohol consumption, and in Croatia 3,000 deaths annually. Smoking is believed to be the cause of seven million deaths in the world annually, and in Croatia every fifth death is linked to smoking," she said.

HUP officials said that in principle they are opposed to increasing prices of such products as they usually lead to the creation of the grey market.

For more on health in Croatia, click here.

ZAGREB, November 17, 2018 - After a pharmacist in Zagreb refused to issue contraceptive pills to a patient, citing conscientious objection, Health Minister Milan Kujundžić said on Friday that the pharmacist's behaviour was impermissible, while the Social Democratic Party (SDP) called for urgent regulations regarding conscientious objection so as to prevent recurrence of similar cases of denying someone medication or health protection.

There is nothing that a pharmacist has the right to deny a patient based on conscious objection, Kujundžić said after a government meeting when asked about the incident. "Every patient has the right to be issued with a prescribed medication in any pharmacy. The pharmacist has the right to freedom of conscience but not in the workplace, in the pharmacy," the minister explained.

In response to the incident the opposition SDP called on the Croatian Medical Chamber to finally present its official stance on the issue of the conscientious objection and said that that it expected the Health Ministry and Minister Kujundžić to regulate acts when conscientious objection can be cited.

SDP expects the authorities to draw up registers of pharmacists, physicians and other health personnel citing conscientious objection because citizens have the right to that information.

"We don't have to point out that actually (non)regulation of conscientious objection is usually at the expense of women in exercising their right to terminate pregnancy," SDP said in a press release.

In light of the fact that a month ago a very large number of women decided to break their silence and talk about violations of their rights regarding reproductive health, and also about the treatment in hospitals with gynaecological wards, we consider this to be yet another attack on women's rights in Croatia, SDP said.

For more on the position of women in Croatia and attempts to deny them their rights, click here.

ZAGREB, November 16, 2018 - The government on Friday accepted a draft framework agreement on cooperation with the City of Zagreb in the preparation of a project for the construction of a national children's hospital within the compounds of what was supposed to be a hospital in Zagreb's Blato suburb.

"This is a historic opportunity for this government to do something that this nation and state badly need. We can now, in partnership with the City of Zagreb, build a new university hospital with its first stage being a children's hospital, instead of just adapting and refurbishing the existing hospitals," Health Minister Milan Kujundžić said.

On 13 September, the Zagreb City Assembly adopted a decision on the conclusion of the framework agreement regulating cooperation in the preparation of the project to build a national children's hospital as the first stage of the establishment of a national university hospital within the compounds of the Blato hospital, whose construction was never completed.

The cooperation refers to the elaboration of a feasibility study and other documents as the basis for applying for project funding from the EU, the minister said.

The 2012-2020 national public healthcare development strategy envisages changes in the organisation and activities of hospitals and the establishment of a national university hospital as an umbrella healthcare institution offering medical services of the highest quality to citizens of Croatia, reads the government decision on endorsing the draft framework agreement.

For more on hospitals in Croatia, click here.

A pharmacy in the Jordanovac neighbourhood in Zagreb has recently refused to issue a women contraceptive pills, invoking the right to conscientious objection, reports Faktograf.hr on November 16, 2018.

“The pharmacist has refused to issue a gynaecologically prescribed contraceptive pill that I use because of a menstrual bleeding issue, as well as a method of contraception. She invoked the conscientious objection principle because she does ‘not support the use of contraceptive pills as a contraceptive method.’ She was the only one working at the pharmacy and there was no one else who could issue me the pills. The employee said I should come in the morning when she is not there. How can she decide this? First, it was the gynaecologists, now the pharmacists, where it will all end?” asked the woman.

Sandra Čelina, the owner of the pharmacy, confirmed that the controversial incident had occurred. “Of course I know about this, I am the head of the pharmacy. It happened because the other employee was sick, but I do not have to answer anything to you,” said Čelina, adding that she had sent her statement to the Croatian Chamber of Pharmacists.

The Chamber said they had received two complaints this month. These two are the only complaints this year. “In the period from January 1 to November 12, one complaint was received concerning an invocation of the conscientious objection by a pharmacist. We are currently in the process of resolving the case before the competent Ethics and Deontology Commission. In addition, we have received a query which does not make it clear whether the drug was not issued due to the conscientious objection or for some other reason in line with the rules (expert opinion that the medicine could endanger the patient’s health, improper medical records, threat or violent behaviour of a patient),” said the Croatian Chamber of Pharmacists.

The conscientious objection by pharmacy employees is defined by the Code of Pharmacy Ethics and Deontology. According to the third paragraph of Article 12, “pharmacists have the right to the conscientious objection only if it does not endanger the health and life of the patient.”

Višnja Ljubičić, the Gender Equality Ombudsperson, noted that the right to conscientious objection was individual. In cases where a worker or a pharmacist in a pharmacy invoke conscientious objection, pharmacies are “obliged to organize their operations in such a way that the use of the right to conscientious objection does not interfere with the work of the health institution or the pharmacy as a whole, which would prevent the provision of specific services.”

Since in the last week’s case the pharmacy in question did not reorganise its work, the gender equality ombudsperson says that the code of pharmacy ethics and deontology has been violated.

“In this particular case, if a pharmacy as an institution as a whole is unable to issue a medicine due to the conscientious objection of its employees, I consider this to be a threat to the user’s health,” concluded Ljubičić.

For more on the conservative movement in Croatia, click here.

Translated from Faktograf.hr (reported by Ana Brakus).

ZAGREB, November 14, 2018 - Diabetes has become the fourth most frequent cause of death in Croatia, moving up in the ranking from fifth position last year, and the main reason for this is chronic complications arising from late detection of the disease, the Croatian Federation of Diabetes Associations said at a press conference in Zagreb on Wednesday, marking World Diabetes Day.

Last year, 2,331 Croatians died from the disease, and it is estimated that 40 percent of people with diabetes are not even aware of it. As a result, costs of diabetes treatment have increased by 2 billion kuna over the last ten years to 4.6 billion kuna annually. This is 19.8 percent of the Croatian Health Insurance Fund's budget and 88 percent of the amount goes towards the treatment of complications, mostly those of a cardiovascular nature.

Both patients and specialists believe that urgent changes are necessary within the healthcare system to ensure better prevention, faster detection and treatment, and better treatment outcomes.

About 300,000 diabetes patients are currently registered in Croatia, but their actual number is believed to be about 500,000.

All medicines for diabetes treatment are available in Croatia, and new treatment guidelines should also improve the quality of treatment. The biggest problem is the late detection of the disease, because by the time of diagnosis most patients have already developed certain complications, the most frequent being a stroke and a heart attack.

"The number of these patients in Croatia is growing steadily. Right now more than nine percent of the adult population have diabetes, compared to six percent ten years ago. The fact that the death rate is growing shows that we are unsuccessful in treatment," general practitioner Tereza Šarić said.

She presented the results of a survey conducted among diabetes patients, according to which 62 percent of patients had undergone only one or no examinations at all in the past year, and half of them had not taken any of the basic tests. A third did not receive any information about the disease and a fifth said they knew nothing about cardiovascular complications, although half of the patients had such complications.

For more on Croatia’s healthcare sector, click here.

October 25, 2018 - A new pharmacogenetic test called RightMed from OneOme has come to Europe, offering the possibility of eradicating the high number of deaths from Adverse Drug Reactions (ADR), as well as saving billions of dollars in the prescribing of drugs which have no effect. Co-founded by Mayo Clinic, the leading hospital in the United States, a European partnership was announced in Zagreb last week, with Leading Hospitals of the World member, St Catherine Speciality Hospital in Croatia the chosen European partner for the introduction of the OneOne RightMed test in Europe. After the press conference at St Catherine's, Professor dr. sc. Dragan Primorac kindly agreed to an interview with TCN to tell us more.  

1. Last week, St Catherine Specialty Hospital in Croatia announced a partnership with OneOme, co-founded by Mayo Clinic, to increase pharmacogenetic testing in Europe. Explain firstly what pharmacogenetic testing is, and why it is important?

Individualized (personalized) medicine can add tremendous value to health care. The United States Food and Drug Administration views personalized medicine as an innovative approach to disease prevention and treatment that takes into account differences in patients’ genes, environments and lifestyles. Pharmacogenetics is a critical component of personalized medicine. With the advances in molecular biology and genetics, pathogenesis of many diseases has been traced to variations in the genome. 

The ultimate goal of pharmacogenetics is to understand how genetic makeup determines drug action and adverse reactions. Most drugs are broken down (metabolized) by enzymes. In some cases, metabolism deactivates an active drug fully or partially. In other cases, metabolism activates an inactive (or less active) drug. Different genetic variants of a particular enzyme can metabolise a particular drug or group of drugs differently; hence, understanding the particular variant in the particular patient can directly affect the decision on the drug choice and dosage. To avoid drug-drug interactions, the decision on which drug to prescribe may also be influenced by other drugs taken. Understanding the genetic basis of patient’s metabolic differences (i.e., patient’s pharmacogenetics), clinicians can select the most effective drugs while keeping the likelihood of adverse reactions at the minimum. The likelihood of drug overdose can be decreased, as the dosage is based on the genetic constitution of the patient rather than on his/her body weight and age, as in the conventional approach. Pharmacogenetics will surely become part of standard considerations in the use of pharmaceuticals.  

2. Two interesting facts from the press conference for me were that Adverse Drug Reaction (ADR) was the fourth biggest killer in the United States and that about 50% of administered drugs have no effect, two statistics which are costly in terms of loss of life and money. Let’s fantasise - if the OneOme RightMed test was standard practice in the United States, what impact would that have in a reduction of ADR deaths and dollar savings annually?

The first article addressing your question was published in JAMA in 1998 estimated that in 1994 overall 2 216 000  hospitalised patients had serious ADRs and 106 000 had fatal Adverse Drug Reaction (ADRs), making these reactions between the fourth and sixth leading cause of death. However in a recent article published by Light it is estimated that in the United States, adverse drug reaction (ADRs) is the fourth leading cause of death, and it is estimated that prescription drugs are responsible for 2.74 million ADRs and 128,000 deaths annually. Some other publications emphasising that ADRs cost $136 billion yearly—more than the total costs of cardiovascular and diabetes care—and cause one out of five injuries or deaths per year to hospitalised patients.

3. This is very new technology. Can you give us a real-life case study where the PGx has been used to improve a patient’s health and change medication?

There are numerous of publications precisely describing how PGx could improve a patient’s health and how it could help in reducing ADR and loss of money. I will mention just a few studies: A Mayo Clinic study involving 3,600 subjects showed that  hospitalisation of heart patients was reduced by 30 percent when doctors were made aware of the pharmacogenetics data prior to treatment with warfarin. Another study has shown that the breast cancer therapy guided by a commercially available PGx test was able to achieve a cost savings of $2,256 per patient, as a result of the reduction in the use of chemotherapy. 

Mrazek and colleagues recently published that patients with treatment-resistant depression have been estimated to cost the United States close to $50 billion more per year than if those same patients were to respond to first-line antidepressants. The FDA-approved drug label for codeine states in a black box warning that respiratory depression and death have occurred in children who received codeine following a tonsillectomy and/or adenoidectomy and who had evidence of being CYP2D6 ultra-rapid metabolizers. The label also states that deaths have occurred in nursing infants who were exposed to high levels of morphine in breast milk because their mothers were CYP2D6 ultra-rapid metabolisers, etc…

4. Take us through the practical process. I make an appointment at your clinic to take the test. What does the test actually entail and what happens next? The RightMed comprehensive test, co-developed with Mayo Clinic, determines how the patient may respond to medications, based on patients' DNA. How does the RightMed test work? 

First you make an appointment at St. Catherine’s and after a short conversation with a clinical representative at St. Catherine Hospital  a physician orders the OneOme RightMed test. Then your sample is collected by using a buccal swab collection procedure. 

Immediately afterwards, OneOme processes your sample and generates your RightMed test report. Finally, you visit a clinical representative at St. Catherine Hospital who helps you understand the test results. Depending on your genes, your body may break down a drug too slowly or too quickly. If you metabolise a drug too slowly, you may be exposed to too much of it, which may result in an adverse drug reaction (ADR). If you metabolize a drug too quickly, you may not get enough to have any effect at all. A OneOme RightMed test helps to identify this for your doctors.

5. Our bodies are constantly changing. Is the RightMed test a 'snapshot' of the current situation, or something that is valid for a longer time and/or other conditions? In other words, is it something you would recommend repeating in a few years for people seeking medication again?

PGx testing using the RightMed platform can benefit everyone, as it provides life-long information about how an individual metabolises more than 350 medications. What we like about the RightMed platform is that test reports are automatically updated as clinical guidelines change or as new evidence emerges in the future. That being said, the RightMed test will be highly recommended for polypharmacy patients (those on >5 medications) as well as those taking medications for pain management. 

6. Coming from such a leading health source as Mayo Clinic, the OneOme product cannot be cheap. What does it cost, and what is included in that price?

Back in 2001, the first copy of the human genome was published sequencing a single human genome came with a $100 million price tag, making the cost of genome sequencing one of the biggest barriers to incorporate it into routine medical care. Than geneticists, physicians, agreed that we should achieve $1,000 as the magic number in order to make genetic tests affordable enough to be a part of routine health care. We believe, we achieve it and the cost of OneOme RightMed test is 4 900 kunas (approx $750).

7. The long-term goal must be to have the OneOme RightMed test as part of national health strategies. While the benefits financially are clear from the numbers mentioned above, getting countries to proactively use (and pay for) the service will be a challenge to get established. What is your strategy in this regard?

It’s only a matter of time before pharmacogenomic testing becomes standard of care so now is the time to consider how we will implement it: from educating our clinical teams, to integrating PGx information into electronic health records. There is mounting clinical evidence supporting the clinical utility of pharmacogenomic testing across multiple indications, so choose a platform that will provide clinical benefit to as many patients as possible. Most importantly, choose a PGx testing provider who has a credible clinical development team and a product that is rooted in sound clinical evidence. 

In order to help those leaders to understand a great benefit of pharmacogenetic, recently I was editing (together with Prof. Hoppner) a book entitled Pharmacogenetics in clinical practice where we underline how pharmacogenomics as a critical component of personalized medicine will help in optimal treatment that takes into account differences in patients genes, environments and lifestyles.

8. The RightMed test will be available in Europe initially in Croatia via your hospital, before expanding to Germany and Switzerland, according to the press conference. Can you tell us more about that?

St-Catherine Hospital sees more than 35,000 patients per year, so we wanted to implement a test that could be applied to a number of specialty areas, including pain, cardiology, psychiatry and cancer. The comprehensive nature of the RightMed panel was therefore also a critical factor in our decision. In addition, we chose to work with OneOme because of the scientific rigor which was applied to the development of the RightMed platform. Their PGx interpretation is supported by the highest level of clinical evidence, making their test the most clinically actionable one on the market. 9. Some people may be surprised that a Croatian hospital was chosen as the European partner for such a highly specialised medical initiative. St Catherine Speciality Hosptial is a member of the Leading Hospitals of the World, as well as the hospital for, among others, Croatia's World Cup heroes. For those international readers who have not come across your hospital, tell us about St Catherine Specialty Hospital, your long association with Mayo Clinic, and how this partnership came about. 

St. Catherine Hospital is a European center of excellence for advanced diagnostics, orthopedic procedures and spine surgery, pain management, sport medicine as well as in the implementation of innovative diagnostics methods and personalized treatment strategies. In addition, St. Catherine is the official medical institution of the Croatian Olympic Committee and of the Croatian Football Federation. Therefore, many of the top-level athletes from variety of sports have been either diagnosed or treated at the hospital, including: Garry Kasparov (former World Chess Champion), Marin Čilić (Winner of the US Open 2014), Aleksandr Viktorovich Khoroshilov (the first Russian male to win a World Cup race (Schladming, 2015) since 1981) Gordan Giriček (NBA player: Memphis Grizzlies, Orlando Magic, Utal Jazz), Bojan Bogdanović (NBA player: Brooklyn Nets), Ivica Kostelić (former World Cup alpine ski racer and two-time Olympic gold medalist),  Janica Kostelić (former World Cup alpine ski racer and four-time Olympic gold medalist), Blanka Vlašić (a high jump indoor World Champion), Niko Kranjčar (football player: Queens Park Rangers and Croatian National Soccer Team), Maria Clara Salgado Rufino (member of Brazilian Volleyball Team), Mathieu Carle (Canadian Ice Hockey player), Ivano Balić (one of the best handball players of all time.), Mirko Filipović (K-1 champion).Last but certainly not least, many football players have been either diagnosed or treated in our hospital as well, out of which some include: Burak Yilmaz (Beijing Guoan, China and The Turkey National Football Team), Mario Mandžukić (Juventus, Italy and The Croatian National Football Team), Luka Modrić (Real Madrid, Spain and The Croatian National Football Team), Ivan Rakitić (Barcelona, Spain and The Croatian National Football Team),  Ivica Olić (Wolfsburg, Germany and The Croatian National Football Team), Mateo Kovačić (Real Madrid, Spain and The Croatian National Football Team), Šime Vrsaljko (Atletico Madrid, Spain and The Croatian National Football Team), Stipe Pletikosa (Real Club Deportivo de La Coruña, and The Croatian National Football Team), Niko Kranjčar (Glasgow Rengers and The Croatian National Football Team), Andrej Kramarić (Hoffenheim 1899, Germany and The Croatian National Football Team), Dejan Lovren (Liverpool, England and The Croatian National Football Team), Alen Halilović (HSV and The Croatian National Football Team), Ibanez Luis Ezequiel (Trabzonspor, Turkey), Josip Pivarić (DInamo, Zagreb, Croatia and The Croatian National Football Team), Tin Jedvaj (Bayer 04 Leverkusen, Germany  and  The Croatian National Football Team), Marko Pjaca (Juventus, Italy and The Croatian National Football Team, Nikola Kalinić (Fiorentina, Italy and The Croatian National Football Team), Marcelo Brzović (Internacionale Milano, Italy and The Croatian National Football Team), Domagoj Vida (FC Dinamo Kyiv, Ukraine, and The Croatian National Football Team),  and dozens of others.

OneOme® RightMed test was co-developed with Mayo Clinic, with whom International Society for Applied Biological Sciences that I am in charge of and St.Catherine Hospital has had a long-standing relationship. St-Catherine Hospital is pioneering the implementation of the personalised medicine concept in clinical practice and our Center for Individualised and Preventative Medicine is designed to bring the latest and greatest innovations in translational medicine to our patients, from glycomics to pharmacogenomics and beyond. Pharmacogenomic testing is a critical addition to our program, as we know that we can optimize health outcomes for our patients by tailoring their medications to their unique genetic makeup. Our collaboration with OneOme resulted with the introduction of the OneOme® RightMed test in Europe and you are completely right, we will be expanding shortly to several EU member states. 

10. And finally, for readers who are interested to take the RightMed pharmacogenetic test, what are the next steps, and where can they take it in Europe currently? 

Currently, your readers can take OneOme® RightMed test at the St. Catherine’s Hospital in Zagreb.  However,  OneOme, co-founded by Mayo Clinic and exclusively licensed from Mayo Clinic, is working to deliver the most comprehensive, cost-effective pharmacogenomic testing and tools for all providers across the globe to use in everyday patient care. St. Catherine’s is partnering with OneOme fulfilling that mission. 

(Paul Owen, CEO of OneOme, at the Zagreb press conference)

11. Two successful companies on a unique mission: the introduction of a personalised medicine concept to clinical practice worldwide. A difficult and challenging task?

OneOme and St. Catherine are creating effective strategic partnership based on performance excellence, innovation and visionary leadership in health care. OneOme is the company with incredibly professional and dedicated people. OneOme was named one of the World’s 50 most innovative companies for 2018 by Fast Company.  St. Catherine Hospital is a teaching hospital of 4 universities and the official hospital of the Croatian Olympic Committee and of the Croatian Football Federation. The Hospital is a member of the prestigious The Leading Hospitals of The World family and a first European recipient of U.S. Global Healthcare Accreditation.  In addition, St. Catherine Hospital is recipient of many national and international awards including “Croatia Super-brands 2016/2017 Award”, “National Champion for Republic of Croatia in The European Business Awards”, “Ruban d’Honneur Award for Customer Focus” and by overall rating is listed among the top 10 European Companies in its category during 2016. We strongly believe that our reputation, values, dedication and vision are essential to make our mission success.

12. OneOme and St. Catherine’s relationship seems to be very unique: a brilliant model of translational medicine concept with the goal of implementing recent scientific findings in a clinical practice.

You are right: This is not a vendor-client relationship; OneOme and St-Catherine are true partners in this program. There is a mutual commitment on both sides to make a positive impact on St-Catherine Hospital’s patients, first and foremost. We intend to continue working closely with OneOme to bring about enhancements to the platform and truly fulfill the promise of pharmacogenomics.   Finally, OneOme and St. Catherine’s will present the results of collaboration during the “11th ISABS Conference on Forensic and. Anthropologic Genetics and Mayo Clinic Lectures in Individualized Medicine” to be held on June 17-22, 2019 in Split. More than 650 participants with 60 invited speakers (including 4 Nobel prize laureates) all together from 50 different countries will learn more about our collaboration as well as about our unique approach of implementing the concept of personalized medicine in clinical practice.

To learn more about the OneOme RightMed test, visit the St Catherine Specialty Hospital website.

„15.3.2017, Vukovar Hospital. Curettage without anesthesia, even though I had asked for anasthesia for mental distress. My pregnancy was in its tenth week, its heart stopped...They held me by my hands, legs and head, the doctor said I was spoiled because I was crying. The complaint to the director was rejected without excuse, all that remained was the pain."

ZAGREB, October 15, 2018 - Representatives of the Roda parent association on Monday presented the Health Ministry with the testimonies of 400 women with unpleasant experiences in Croatian hospitals. "We bring you the testimonies of 400 women who have experienced some form of violent and painful treatment before, after or during labour," Daniela Drandic of the Roda association told the press outside the Health Ministry.

A former Croatian international has recently lost his daughter.

ZAGREB, September 30, 2018 - The number of sick leave days taken by employees in Croatia in the first half of 2018 increased by 682,357 compared with the same period in 2017, while the average number of people on sick leave on a daily basis increased by 4,051, the Croatian Health Insurance Fund (HZZO) said earlier this week.