PREVENTION AND EARLY DETECTION OF COLORECTAL CANCER

Karcinom debelog crijeva je globalni svjetski problem zbog svoje pojavnosti i smrtnosti. Stoga su prevencija i rano otkrivanje bolesti od iznimne važnosti. U Hrvatskoj se od 2007. provodi nacionalni program za prevenciju karcinoma debelog crijeva, međutim odaziv stanovnika je oko 18 posto, ovisno o regiji. Takav veliki javnozdravstveni i socijalni problem zahtijeva multidisciplinarni pristup u kojem imaju svoje mjesto i liječnici obiteljske medicine. Bogatstvo dobro razvijene mreže primarne zdravstvene zaštite i dostupnost liječnika obiteljske medicine svakom stanovniku Hrvatske nisu još u dovoljnoj mjeri iskorišteni, pogotovo za ovakve preventivne aktivnosti u kojima bi liječnik obiteljske medicine bio nadzor nad provedbom.Colorectal cancer is a global problem worldwide because of its very high prevalence and mortality. Therefore, prevention of colorectal cancer and its early diagnosis is of great importance. In Croatia, the National Program for Colorectal Cancer has been carried out since 2007; however, the rate of response was about 18 percent, depending on the region. Such a great public health and social and economic problem requires multidisciplinary approach in which family physicians have an important role. The well spread and developed network of primary health care and the availability of family physicians to each inhabitant have not been suffi ciently exploited, especially for such preventive activities where family physicians could supervise program implementation

CARDIORENAL SYNDROME: CLINICAL FEATURES, EARLY DIAGNOSIS AND TREATMENT AT FAMILY MEDICINE

Međuzavisnost oštećenja organskih sustava srca i bubrega defi nirana je kao kardiorenalni sindrom (KRS), složeni patofi ziološki poremećaj i srca i bubrega u kojem akutna ili kronična disfunkcija jednog organa može dovesti do akutnog ili kroničnog oštećenja drugog organa. Prepoznavanje i pravovremena dijagnostika nekih od podtipova KRS-a vrlo često počinje u ordinaciji obiteljskog liječnika. Upotreba jednostavnih i pouzdanih dijagnostičkih postupaka, primjerice skora MICE (engl. Male, Infarction, Crepitations, Edema) uz upotrebu EKG-a i biomarkera nije u potpunosti zaživjela. Cilj rada bio je prikazati najnovije spoznaje i razlike u kliničkoj slici, dijagnostici i liječenju 5 različitih podtipova KRS. Racionalna dijagnostika zatajenja srca (ZS) u obiteljskoj medicini trebala bi uključiti biomarkere (moždani natriuretski peptid, engl. brain natriuretic peptide BNP i N-terminalni pro-moždani natriuretski peptid, engl. N-terminal pro-brain natriuretic peptide, NT – proBNP) prije upućivanja na ultrazvuk srca. Za dijagnostiku oštećenja bubrega još uvijek se upotrebljava kreatinin i procijenjena stopa glomerularne fi ltracije (engl. estimated glomerular filtration rate, pGFR, ali ne i cistatin C i lipokalin povezan s neutrofi lnom gelatinazom (engl. Neutrophil Gelatinase-Associated Lipocalin - NGAL). LOM bi u dijagnostičkom postupku pri sumnji na zatajenje srca trebao obuhvatiti i funkciju bubrega, ali i obratno. Pristup liječenju KRS-a je različit ovisno o kliničkom specijalistu kojemu je pacijent prvo upućen na konzilijarni pregled: kardiologu ili nefrologu. Multidisciplinarni pristup liječenju KRS-a je nužan, ali u praksi još uvijek izostaje.The interdependent damage to the heart and kidney organ systems is defi ned as cardiorenal syndrome, a complex pathophysiological disorder of the heart and kidney in which acute or chronic dysfunction of one organ can lead to acute or chronic damage to the other. Identifi cation and early diagnosis of some subtypes of cardiorenal syndrome very often begin at family physician offi ce, however, the use of simple and reliable diagnostic procedures such as MICE score using ECG and biomarkers has not been implemented yet. The clinical picture, diagnosis and treatment vary according to the 5 cardiorenal syndrome subtypes, as described herein. Rational diagnosis of heart failure at family medicine offi ce should include biomarkers (BNP and NT-pro BNP) before performing ultrasound of the heart, while for kidneys creatinine and estimated glomerular filtration rate are still in use, but not cysteine C and NGAL. Diagnostic procedure for suspected heart failure at family medicine offi ce should include kidney function estimate and vice versa. Access to treatment of cardiorenal syndrome differs depending on the specialty to which the patient is referred fi rst, i.e. consultant examination, cardiologist or nephrologist. A multidisciplinary approach to treatment of cardiorenal syndrome is still lacking

Statin Prescription by Croatian Family Doctors – Lack of Systematic Proactive Approach to Cardiovascular Disease Prevention

The aim of this study was to investigate statin prescription by family doctors (GP) in primary (PP) and secondary (SP) prevention of cardiovascular diseases (CVDs). Patients’ socio-demographic data, total cholesterol (TC) and LDL-cholesterol (LDL-C) thresholds for statin prescription, indications, data on GP and practices were registred. Statins were prescribed in 11.2% enlisted patients (64.11% PP, 35.88% SP), mostly aged 70+. In PP, thresholds were TC 6.2±1.09 mmol/L, LDL-C 3.6 mmol/L, in SP 5.4±1.26 mmol/L, 2,7mmol/L, respectively. Most frequently prescribed statin in PP was 10 mg atorvastatin (49.28%), in SP it was 20 mg simvastatin (48.36%). Participating GPs were women, aged 39±5.49, working for 13±6 years, the average number of enlisted patients per GP 1562±299. There was statisticaly significant difference in statin prescription in PP (c2=752.9; p<0.001) and SP (c2=64; p<0.001). Statin prescription in PP is due to pharmaceutical marketing and lack of independent continuing medical education. The fact that statins are most frequently prescribed in patients aged 70+ (35.28% in PP, 49.35% SP) reveals lack of preventive proactive CVDs approach in younger age groups, which is concerning

DO WE CORRECTLY MANAGE ADULT ASTHMA PATIENTS IN FAMILY MEDICINE?

Iako je učestalost astme u porastu, pogotovo u djece, astma je danas nedovoljno dijagnosticirana, ali i nedovoljno dobro i neadekvatno liječena bolest. Najveći broj bolesnika zbrinjava i prati liječnik obiteljske medicine (LOM). Prema smjernicama Global Initiative For Asthma (GINA) iz 2006. liječenje se određuje prema stupnju kontrole bolesti, umjesto dosad preporučene klasifikacije prema težini bolesti. Temelj liječenja trajne astme, bilo kojeg stupnja u odraslih i djece su inhalacijski kortikosteroidi (ICS) u monoterapiji, a dugodjelujući β2-agonist (LABA), montelukast (LTRA) ili teofilin su dodatna terapija ako se s ICS ne postigne zadovoljavajuća kontrola bolesti. Fiksne kombinacije (ICS + LABA) mogu se rabiti u liječenju samo umjerene i teške trajne astme, ne i kod blage astme, ili kada se s ICS u monoterapiji ne postigne kontrola bolesti. Postoji neopravdani trend sve većeg propisivanja fiksnih kombinacija. Iako postoje jasne smjernice profesionalnih i nacionalnih stručnih drštava, javlja se razmimoilaženje između smjernica i prakse.Although prevalence of asthma has increased particularly among children, asthma is still underdiagnosed and undertreated or inappropriately treated disease. Most of the health care for patients with asthma is provided by family physicians in primary health care. Nowadays recommendations (GINA 2006) are based on assessing asthma control levels, the cornerstone of therapy for persistent asthma of all degrees of severity, both in adults and children, are inhaled corticosteroids (ICS) as monotherapy, while long-acting β2-agonists (LABA), leukotriene modifiers (LTRA) or theophylline are add-on therapy if the control of disease is not successfully achieved. Fixed combination (ICS + LABA) could be used only for moderate to severe persistent asthma and in cases when satisfactory control is not achieved using ICS alone. Unjustified trend towards initial fixed combination prescribing has become more and more popular, but with potential of overuse

Prescribing antibiotics to preschool children in primary health care in Croatia

The use of antibiotics depends on cultural and socioeconomic factors, physician's characteristics as well as on microbiological considerations. Aim of our study was to asses antibiotic prescription among preschool children in primary health care in Croatia in relation to socioeconomic factors, symptoms and diagnoses, and type of health care provider. Retrospective longitudinal survey was conducted in 7 teaching primary health care offices in the Croatian capital of Zagreb during 2004, among 1700 preschool children. Antibiotics were prescribed to 611 (46%) children. Significantly more antibiotics were prescribed to boys (66.7%, P = 0.024) and to children whose parents had lower educational level. Most frequently antibiotics were prescribed for the symptoms such as fever (32%), cough (32.5%), nasal discharge (12%), and for the diagnoses such as respiratory diseases (J00-J99) (40%), infectious and parasitic diseases (A00-A99) (31%), and diseases of the middle ear and mastoid (H60-H95) (15%). Logistic regression analyses also predicted correlation of antibiotic prescriptions with socioeconomic factors, symptoms and diagnoses and health care of pediatrician. Prescription of antibiotics for preschool children in primary health care in Croatia related to socioeconomic factors, type of health care provider, certain symptoms and diagnosis groups which should be taken into account when assessing and planning primary health care for preschool children

Family medicine team administrative and medical scale of work

Analizom strukture rada liječnika obiteljske medicine (LOM) i medicinske sestre (MS), u vrijeme i neposredno nakon obveze naplate administrativne pristojbe (AP), opserviran je rad u šest ordinacija LOM (tri u Zagrebu, tri u Varaždinu), registracijom vrste i vremenskoga trajanja svakog pojedinoga postupka. LOM su 67,2% radnog vremena obavljali medicinske, a 32,7% administrativne poslove prije, a 68,9%, odnosno 31,1% nakon ukidanja AP (t = 0,125, df = 5, p > 0,05). MS su 84,9% radnoga vremena obavljali administrativne, a 15,1% medicinske poslove prije, u odnosu na 69,8% odnosno 30,2% nakon ukidanja AP (t = 3,021, df = 5, p = 0,01). LOM i posebice MS znatan dio svoga radnog vremena troše na obavljanje administrativnih poslova, manjujući udio vremena za medicinske poslove, posebice za zdravstveno savjetovanje. Nužne su temeljite strukturalne promjene u radu MS (smanjenje administrativnog bremena, uz povećanje udjela medicinskih poslova, otvorivši LOM-u prostor i vrijeme za provođenje drugih aktivnosti, uključujući i sustavnu prevenciju, koja u sadašnjem trenutku izostaje.Six general practitioners\u27 (GP) practices (three of them located in Zagreb and three in Varaždin) were observed by analysing the work structure of the GP and nurse (N) during the period of charging administrative fee (AF) and right after its annulment, noting the kind and time duration of each procedure. GPs spent 67.2% of their workday on medical activities and 32.7% on paperwork during the period of charging administrative fee. After the AF annulment, the time used attending to administrative and medical activities accounted for 68.9% and 31.1% of the total workday (t = 0.125, df = 5, p > 0.05). Nurses spent 84.9% of their workday on paperwork, and 15.1% on medical activities before the AF. After the AF annulment, they spent 69.8% and 30.2% of their working hours on paperwork and medical activities (t = 3.021, df = 5, p = 0.01). GPs, and Ns particularly, spent a large portion of their time on paperwork, reducing their time for medical procedures, in particular for health care counselling. It is necessary to make fundamental structural changes in N\u27s work (reducing the administrative burden while increasing the share of medical activities, thus creating time and space for GPs to implement other activities including systemic prevention, which is missing at the moment)

How well do family physicians record cardiovascular risk factors?

Pozadina. Kardiovaskularne bolesti (KVB) su prema podacima WHO vodeći uzrok smrtnosti u suvremenom svijetu pa i u Hrvatskoj, gdje čine 49,6% ukupnog mortaliteta. Cilj. Istražiti bilježenje čimbenika rizika KVB u hipertoničara u skrbi liječnika obiteljske medicine dviju ordinacija grada Splita, kao i postizanje ciljnih vrijednosti arterijskoga tlaka i glikemije u istih. Ispitanici i metode. Napravljeno je retrospektivno pilot-istraživanje pregledom elektroničke baze podataka. Iz uzorka hipertoničara svake ordinacije, generatorom slučajnih brojeva odabrana je po polovina, te su ispitanici razvrstani u skupinu primarne (PP) i sekundarne prevencije (SP). Zabilježeni su: dob, rod, postojanje podataka o indeksu tjelesne mase (BMI), pušačkom statusu, kolesterolemiji, glikemiji natašte (GUK) i arterijskom tlaku (RR), te postizanje ciljnih vrijednosti arterijskoga tlaka i glikemije. Rezultati. U ukupnom broju ispitanika (N = 445), BMI je zabilježen u njih 19,8%, pušački status u 19,8%, kolesterolemija u 71,9%, GUK u 72,1%, te RR u 80,9% slučajeva. Glikemija i kolesterolemija su češće zabilježene u uzorku SP, nego PP. Kod ispitanika koji su imali zabilježen arterijski tlak, ciljna vrijednost u PP je postignuta u 63,8%, a u SP u 40,4% njih. U uzorku SP, od 115 ispitanika kod koji je zabilježena glikemija ciljna vrijednost je postignuta u 53,9% slučajeva. Zaključak. Naše istraživanje je pokazalo kako je bilježenje i praćenje čimbenika KV rizika, te postizanje ciljnih vrijednosti RR i glikemije u istraživanim ordinacijama bilo neadekvatno.Background. Cardiovascular diseases (CVD), according to the World Health Organization (WHO), are the leading cause of death in the modern world, and Croatia is no exception. Aim. To investigate the recording of CVD risk factors in hypertensive patients enlisted for family physicians in two practices in the city of Split, as well as to achieve their target blood pressure and glycemia levels. Respondents and methods. A retrospective pilot study was performed by reviewing the electronic database of two family practices. From the sample of all hypertensive patients, half (50%) of them were selected in each practice by using a random number generator. The participants were classified in the group of primary (PP) and secondary prevention (SP). We have recorded: age, gender, existence of data on body mass index (BMI), smoking status, cholesterolaemia, fasting blood glycemia (FBG) and blood pressure (BP) as well as the achievement of target levels of BP and FBG. Results. Out of the total of 445 respondents, BMI and smoking status were recorded in 19.8%, cholesterolaemia in 71.9%, FBG 72.1%, and BP in 80.9%. Data on FBG and cholesterolaemia were more often observed in the sample of SP than in PP. In participants with recorded BP, target values in PP were achieved in 63.8%, while in SP in 40.4%. In SP sample, in 115 participants with recorded glycemia, the target value was achieved in 53.9%. Conclusion. Our research in two practices has shown that CVD prevention in terms of recording and monitoring of risk factors and achieving target values of BP and FBG was inadequate