Diabetes mellitus – essential news for family medicine care

Šećerna bolest je kompleksna kronična bolest kod koje dobra kontrola glikemije rezultira smanjenjem nastanka i progresije mikro- i makrovaskularnih komplikacija. Pri odabriru terapije neophodna je procjena postojanja kardiovaskularne bolesti, utjecaja terapije na hipoglikemiju i tjelesnu masu, ali i cijena lijekova. Uz optimalnu regulaciju glikemije neophodno je agresivno liječenje kardiovaskularnih čimbenika rizika, posebno LDL kolesterola i arterijskog tlaka, čime se značajno poboljšavaju kardiovaskularni ishodi. Promjene životnih navika (smanjenje tjelesne mase, zdrave prehrambene navike i povećanje tjelesne aktivnosti) potrebno je preporučiti svima oboljelima od šećerne bolesti bez obzira na njihov kardiovaskularni rizik. Cilje terapije je prevencija kompilkacija uz optimalnu kvalitetu života. Specifičnost skrbi za ove bolesnike u obiteljskoj medicini jest kontrola glikemije, stalni nadzor postojanja komplikacija, postavljanje ciljeva i aktivno praćenje, prepoznavanje kliničkog konteksta i prognoze te edukacija pacijenta. Naglasak je na individualnom pristupu svakom pacijentu.Diabetes mellitus is a complex, chronic disease in which glycaemic control reduces the development of micro- and macro-vascular complications. In order to chose the adequate therapy it is necessary to establish the presence of cardiovascular diseases, its influence on hypoglycaemia and body mass as well as on the cost. Best cardiovascular outcomes are achieved with optimal glycaemic control, along with aggressive control of all cardiovascular risk factors (especially LDL cholesterol and blood pressure). Regardless of cardiovascular history, all patients should receive lifestyle management counselling (including weight loss, dietary habits, physical activity). Prevention of complications and optimal life quality is the main aim in diabetes care. Constant glycaemic control, complications monitoring, target setting and active monitoring, identification of clinical context and prognosis as well as patients` education are specific tasks set for the family medicine specialist. The emphasis is on the individual approach to the patient

Diabetes mellitus – essential news for family medicine care

Šećerna bolest je kompleksna kronična bolest kod koje dobra kontrola glikemije rezultira smanjenjem nastanka i progresije mikro- i makrovaskularnih komplikacija. Pri odabriru terapije neophodna je procjena postojanja kardiovaskularne bolesti, utjecaja terapije na hipoglikemiju i tjelesnu masu, ali i cijena lijekova. Uz optimalnu regulaciju glikemije neophodno je agresivno liječenje kardiovaskularnih čimbenika rizika, posebno LDL kolesterola i arterijskog tlaka, čime se značajno poboljšavaju kardiovaskularni ishodi. Promjene životnih navika (smanjenje tjelesne mase, zdrave prehrambene navike i povećanje tjelesne aktivnosti) potrebno je preporučiti svima oboljelima od šećerne bolesti bez obzira na njihov kardiovaskularni rizik. Cilje terapije je prevencija kompilkacija uz optimalnu kvalitetu života. Specifičnost skrbi za ove bolesnike u obiteljskoj medicini jest kontrola glikemije, stalni nadzor postojanja komplikacija, postavljanje ciljeva i aktivno praćenje, prepoznavanje kliničkog konteksta i prognoze te edukacija pacijenta. Naglasak je na individualnom pristupu svakom pacijentu.Diabetes mellitus is a complex, chronic disease in which glycaemic control reduces the development of micro- and macro-vascular complications. In order to chose the adequate therapy it is necessary to establish the presence of cardiovascular diseases, its influence on hypoglycaemia and body mass as well as on the cost. Best cardiovascular outcomes are achieved with optimal glycaemic control, along with aggressive control of all cardiovascular risk factors (especially LDL cholesterol and blood pressure). Regardless of cardiovascular history, all patients should receive lifestyle management counselling (including weight loss, dietary habits, physical activity). Prevention of complications and optimal life quality is the main aim in diabetes care. Constant glycaemic control, complications monitoring, target setting and active monitoring, identification of clinical context and prognosis as well as patients` education are specific tasks set for the family medicine specialist. The emphasis is on the individual approach to the patient

HEPATOCELLULAR CARCINOMA – NEWS IN DIAGNOSIS, FOLLOW UP AND TREATMENT AND ROLE OF FAMILY PHYSICIAN

Cilj ovoga preglednog rada je upoznati liječnika obiteljske medicine (LOM) s novostima u načinima probira, dijagnosticiranja, praćenja i liječenja oboljelih od hepatocelularnog karcinoma (HCC), najčešće primarne maligne bolesti jetre. Prikazani su epidemiologija, etiologija, klinička slika, dijagnostika te maligne bolesti, ukazano je na porast incidencije koji se prati i u Republici Hrvatskoj, u kojoj su hepatitis B i C i nadalje važan javnozdravstveni problem. Navedene su smjernice nekoliko stručnih društava za dijagnostiku HCC-a koja se zasniva na tipičnom slikovnom prikazu CT-om ili MR te biopsijom. Posebno je obrađeno praćenje visokorizične populacije uz navod da je prema NCCN najprikladniji test za praćenje osoba s visokim rizikom uz ultrazvučnu pretragu jetre i određivanje alfa fetoproteina. Detaljno je opisano stupnjevanje i prognoza HCC-a uz navod da su glavne prognostičke varijable stadij tumora, funkcija jetre i ukupno stanje pacijenta. Istaknuta je uloga LOM-a kao osobe prvog kontakta u prevenciji HCC-a prepoznavanjem, probirom i praćenjem visokorizičnih pojedinaca, posebno intravenskih ovisnika o drogama koje treba testirati na prisutnost anti HCV protutijela i na HBsAg.Hepatocellular carcinoma (HCC) is the most common malignancy of the liver, the sixth most common cause of cancer and the third leading cause of cancer-related deaths worldwide. Its incidence has increased dramatically throughout the world mainly driven by the increasing numbers of persons with long-standing chronic hepatitis C virus (HCV) infection who develop cirrhosis. Although 90% of HCV-associated HCC cases occur concurrently with cirrhosis, 30% to 50% of liver cancers associated with chronic HBV occur in the absence of cirrhosis. Since most people with chronic hepatitis are asymptomatic until cirrhosis or HCC is established, initial diagnosis and management of chronic hepatitis rely on primary care physicians to identify and screen high risk individuals. Studies show that family physicians have inadequate knowledge about screening and counseling for chronic hepatitis and HCC. There is evidence of advances in surgical and nonsurgical therapies in the treatment of HCC, thus different associations have updated their recommendations following these clinical and scientifi c advances. The aim of this review is to make family physicians familiar with novelties in identifying high-risk patients, implementing an appropriate screening strategy, diagnosis and treatment, and to assist them in the decision-making process according to evidence based data

Poremećaji spavanja - kako dijagnosticirati i liječiti nesanicu u obiteljskoj medicini?

Poremećaji spavanja učestali su i nedovoljno prepoznat zdravstveni problem, a najčešći je nesanica. Karakterizira ju postojanje poteškoća s uspavljivanjem, održavanjem sna i/ili sklonost preranom buđenju s posljedičnim teškoćama u dnevnom funkcioniranju. Učestalost nesanice varira među ispitivanim stanovništvom različitih država, no najčešće se tumači kao simptom neke druge bolesti ili mentalnog stanja. Postaviti pravovremeno dijagnozu nesanice vrlo je bitno u svakodnevnoj praksi jer ima izravan utjecaj na svakodnevno funkcioniranje i posljedično na kvalitetu života pacijenata, a prema nekim autorima ima jednak utjecaj na kvalitetu života kao i veliki depresivni poremećaj ili kronične bolesti. Postoje različite podjele nesanica i podtipovi, no u praksi su najčešće prisutni preklapajući simptomi tih podtipova, što predstavlja veliki problem i još veći izazov u liječenju za svakog liječnika. Vrlo je korisno u svakodnevnom radu poslužiti se alatima koji nam pomažu u procjeni težine i opisu problema nesanice, kao što su dnevnik spavanja i razni upitnici. Liječenje poremećaja spavanja, uključujući liječenje nesanice, kompleksno je i sastoji se od higijene spavanja, psihoterapijskih metoda, psihofarmakoterapije i ostalih postupaka

GLYCEMIC CONTROL IN DIABETES MELLITUS PATIENTS WITH CHRONIC KIDNEY DISEASE – HOW TO CHOOSE HYPOGLYCEMIC AGENT?

Liječenje hiperglikemije kod bolesnika s kroničnom bubrežnom bolešću je kompleksno, a ciljevi i načini postizanja glikemijske kontrole nisu jasno definirani. Iako je agresivno sniženje hiperglikemije korisno u ranim stadijima dijabetičke nefropatije, podatci o jasnoj koristi ovakvog liječenja u uznapredovaloj bubrežnoj bolesti nedostaju. Poseban izazov u liječenju ovih bolesnika su zahtjevne i učestale kontrole koje su neophodne kod ovih bolesnika, ali i kompleksnost dostupnih metoda liječenja. U ovom osvrtu učinjen je pregled svih trenutno dostupnih hipoglikemijskih lijekova, opisan je njihov mehanizam djelovanja s osvrtom na indikacije i kontraindikacije s obzirom na stadij bubrežnog oštećenja. Cilj rada je pomoći liječniku obiteljske medicine u donošenju ispravne terapijske odluke sukladno postavljenom glikemijskom cilju i stanju bubrežne funkcije.The management of hyperglycemia in patients with chronic kidney disease (CKD) is complex, and the goals and methods regarding glycemic control are not clearly defined. Although aggressive glycemic control seems to be advantageous in early diabetic nephropathy, outcome data supporting tight glycemic control in patients with advanced CKD are lacking. Challenges in the management of such patients include monitoring diffi culties and the complexity of available treatments. In this article, we review the current treatment options for patients with diabetes and CKD discussing all hypoglycemic agents that currently are available, as well as insulin, along with their indications and contraindications. The aim is to provide useful information to family physicians when deciding on individualized glycemic goals and appropriate therapy for patients with early or end stages of CKD

Prevalencija i značajke nesanice među odraslima u središnjoj Istri

Aim: We sought to examine the frequency and characteristics of insomnia among adults in central Istria, as well as to analyse sociodemographic characteristics and explore whether there is an association between symptoms of insomnia and sociodemographic parameters. Methods: This research included 685 participants that visited family medicine offices (FMOs) in Central Istria from September till December 2016. Mean age of the sample was 52.73 ± 17.93 years. Participants were randomly selected and interviewed and all gave their informed consent. Participants with sleep disturbances and insomnia lasting one year prior to study enrolment were assessed using the questionnaire designed for the study; along with gathering of sociodemographic data. Results: More than half of the participants had insomnia, 30% of them each night or several times a week, mostly older participants and women. Regardless of the frequency of insomnia symptoms, all participants reported great impairment in all areas of daytime functioning. The most frequent incidence of insomnia was associated with more frequent sleep apnoea and less frequent bruxism. Frequent night awakenings and restless legs syndrome were not related to a greater incidence of insomnia. Conclusion: Insomnia is a common problem among patients treated in primary care. Family physicians are therefore in an ideal position to identify, evaluate and treat insomnia. The high prevalence of insomnia highlights the need for a more adequate recognition and treatment of this psychiatric illness.Cilj: Istražiti učestalost i obilježja problema spavanja među odraslim ispitanicima centralne Istre, analizirati sociodemografske karakteristike ispitanika i ispitati postoji li povezanost između pojedinih simptoma nesanice i sociodemografskih karakteristika ispitanika. Metode: 685 ispitanika prosječne dobi 52.73±17.93 (± standardna devijacija), posjetilo je ordinacije obiteljske medicine u centralnoj Istri, u razdoblju od rujna do prosinca 2016. Ukupno je 14% odraslih ispitanika nasumično izabrano i anketirano. Svi ispitanici su potpisali informativni pristanak. Ispitivani su anketnim upitnikom koji se odnosio na razdoblje od godine dana prije istraživanja i napravljen je posebno za ovo istraživanje; također su prikupljeni sociodemografski podaci ispitanika. Rezultati: Više od polovice ispitanika imalo je probleme spavanja, no 30% ispitanika imalo je probleme spavanja svaku noć ili nekoliko puta tjedno, a najčešće su to bili stariji ispitanici i žene. Problemi spavanja, neovisno o učestalosti, jednako su ometali svakodnevicu ispitanika. Češća pojavnost problema spavanja bila je povezana s češćom apnejom u snu i manjom učestalosti škrgutanja zubima. Češća buđenja tijekom noći i nemirnost nogu kod ispitanika nisu bili povezani s većom učestalošću problema spavanja. Zaključak: Problemi spavanja su učestali među bolesnicima liječenim u primarnoj zdravstvenoj zaštiti stoga su liječnici obiteljske medicine idealno pozicionirani za njihovo pravodobno prepoznavanje, evaluaciju i liječenje. Velika učestalost problema spavanja naglašava potrebu za daljnjim edukacijama i istraživanjima, a zdravstvenu skrb obvezuje na rano prepoznavanje i liječenje ovih problema

KIDNEY DISEASE IN DIABETIC PATIENTS – THE ROLE OF FAMILY MEDICINE PHYSICIAN

Unatoč svim dostupnim modalitetima liječenja incidencija i progresija šećerne bolesti je u stalnom porastu. Bubrežno oštećenje kod ovih bolesnika je posebno devastirajuća komplikacija budući da je povezana i s kraćim trajanjem života i sa smanjenom kvalitetom života. Uz dijabetičku nefropatiju, kod oboljelih od šećerne bolesti prisutni su i drugi oblici bubrežnog oštećenja kao što je ishemijsko oštećenje povezano s oštećenjem krvnih žila i hipertenzijom, ali i drugi oblici oštećenja koji nisu povezani s dijabetesom. Nakon detaljnog pretraživanja literature dostupne na PubMed-u u ovom članku ukratko opisujemo ključne trenutke u kojima je posebno bitna uloga liječnika obiteljske medicine (LOM). Tijekom skrbi za oboljele od šećerne bolesti posebnu pozornost zahtijeva probir bubrežnog oštećenja, ispravno praćenje i liječenje i pravodobno upućivanje nefrologu. Na osobu usmjeren holistički pristup karakterističan za rad LOM prepoznat je kao poseban izazov u praćenju ovih bolesnika.The alarming rates of diabetes mellitus incidence and progression continue despite deployment of all current treatments. Kidney disease can be a particularly devastating complication, as it is associated with signifi cant reductions in both length and quality of life. A variety of forms of kidney disease can be seen in people with diabetes, including diabetic nephropathy, ischemic damage related to vascular disease and hypertension, as well as other renal diseases that are unrelated to diabetes. Following an extensive PubMed search, this review provides a brief view on the screening for chronic kidney disease (CKD) in people with diabetes, how to treat them to slow down the progression of CKD and when to refer them to specialist care. This review also emphasizes the basic challenge in treating diabetic patients, which is to shift the main criterion from the disease-oriented to person-centered approach in the context of treating the patient as a whole

The association of lifestyle and stress with poor glycemic control in patients with diabetes mellitus type 2: a Croatian nationwide primary care cross-sectional study

Aim To assess lifestyle habits and self-reported stress levels among type 2 diabetes mellitus (T2DM) patients and their association with hemoglobin A1c (HbA1c) in general practitioners’ (GP) offices in Croatia. Methods 449 GPs from all Croatian regions from 2008 to 2010 consecutively recruited up to 20-25 participants diagnosed with T2DM at least 3 years prior to the study, aged ≥40 years, and scheduled for diabetes control check-ups. The recruitment period lasted six months. Lifestyle habits and self-reported stress were assessed using the questionnaire from the Croatian Adult Health Survey. Results The study included 10 285 patients with T2DM with mean (±standard deviation) age of 65.7 ± 10.05 years (48.1% men). Mean HbA1c level was 7.57 ± 1.58%. 79% of participants reported insufficient physical activity, 24% reported inappropriate dietary patterns, 56% reported current alcohol consumption, 19% were current smokers, and 85% reported at least medium level of stress. Multivariate analysis showed that having received advice to stop drinking alcohol, inadequate physical activity, consumption of milk and dairy products, adding extra salt, and high level of stress were significantly associated with increased HbA1c (P < 0.05). Conclusion Poor glycemic control was more frequent in patients who had several “unhealthy” lifestyle habits. These results suggest that diabetes patients in Croatia require more specific recommendations on diet, smoking cessation, exercise, and stress control

CARE QUALITY FOR PATIENTS WITH CORONARY ARTERY DISEASE IN FAMILY MEDICINE - GUIDELINE IMPLEMENTATION BY TAKING A GLANCE AT THE RISK FACTORS

Uvod: Bolesnici s koronarnom bolešću su velik izazov u skrbi liječnika obiteljske medicine (LOM) zbog brojnih komorbiditeta te primjene mjera sekundarne prevencije kojima se prate i istovremeno korigiraju rizični čimbenici koji se odnose na bolesnika, njegovu okolinu i stil života. Cilj: Istražiti uspješnost LOM-a u primjeni mjera sekundarne prevencije kardiovaskularnih bolesti i pronaći moguće rješenje za poboljšanje kvalitete skrbi. Ispitanici i metode: Opservacijsko istraživanje provedeno je 2017. godine u devet specijalističkih ordinacija obiteljske medicine diljem Hrvatske, a uključivalo je 169 bolesnika koji su ili preboljeli infarkt miokarda i/ili su bili podvrgnuti perkutanoj koronarnoj intervenciji i/ili operaciji aortokoronarnog premoštenja. Praćene su vrijednosti krvnog tlaka, LDL kolesterola i indeksa tjelesne mase, a ispitivano je pridržavanje poželjnih oblika ponašanja (nepušenje, tjelesna aktivnost, pravilna prehrana, redovno uzimanje dokazano djelotvornih lijekova) te prilagodba novom stilu života koja je mjerena Likertovom ljestvicom (1-5) kao i zadovoljstvo liječnika preglednošću elektroničkog zdravstvenog zapisa. Rezultati: Zadovoljavajuće vrijednosti arterijskog tlaka postignute su u 63,2 % ispitanika, razinu LDL kolesterola prema smjernicama imalo je 19,4 %, dok je 25,3 % ispitanika imalo uredan indeks tjelesne mase; 25,1 % ispitanika je i dalje pušilo, dok je 43,2 % ispitanika konzumiralo alkohol. Prehrambene navike promijenilo je 63,7 % ispitanika, a 63,4 % je povećalo svoju tjelesnu aktivnost. LOM je u većini slučajeva proveo savjetovanje oko promjene životnog stila nakon koronarnog incidenta. Liječnici su većinom bili zadovoljni sadržajem i količinom podataka u elektroničkom zdravstvenom zapisu, ali ne i njihove upotrebljivosti u svakodnevnoj, vremenski ograničenoj konzultaciji s bolesnikom. Osmišljeno rješenje u programu Adobe Illustrator® omogućilo bi i olakšalo bolju preglednost rizičnih čimbenika i time bi moglo imati utjecaja na učinkovitiju kontrolu provođenja mjera sekundarne prevencije. Zaključak: Skrb za bolesnike s koronarnom bolešću u obiteljskoj medicini je vrlo kompleksna, a dio kompleksnosti se odnosi na primjenu mjera sekundarne prevencije koje su od vitalne važnosti. Zbog toga je potrebno planirati i osigurati dovoljno vremena za konzultaciju s takvim bolesnicima kako bi se dobio uvid u kontrolu rizičnih čimbenika i pravovremeno učinile promjene sukladno važećim smjernicama. Rezultati istraživanja pokazali su da se u bolesnika svi rizični čimbenici ne nalaze unutar preporučenih vrijednosti te da je jedan od mogućih razloga tome što ne postoji njihov pregledan prikaz u elektroničkom zdravstvenom zapisu. Kvalitetnija skrb mogla bi se postići kada bi postojalo jasno vizualno rješenje stanja rizičnih čimbenika koje je u ovom radu osmišljeno i predloženo u obliku slika koje bi LOM-u dale brzi uvid u “profi l” bolesnika te poboljšale učinkovitost svake konzultacije s obzirom na njeno kratko vremensko ograničenje u svakodnevnim uvjetima rada u ordinacijama obiteljske medicine.Introduction: Patients with coronary artery disease represent a challenge in each family medicine practice because of many comorbidities and the application of secondary prevention measures which represent a tool for tracking and simultaneously correcting risk factors related to the patient, his surroundings and lifestyle. Objective: Explore the effectiveness of family medicine specialists in applying secondary prevention measures in cardiovascular diseases and to find a solution for improving quality of care. Participants and Methods: This observational study, was conducted in 2017. under nine specialised family medicine practices throughout Croatia and included 169 patients who suffered from myocardial infarction and/or underwent percutaneous coronary intervention and/or bypass surgery. Blood pressure, LDL cholesterol and body mass index were measured and it was examined whether the participants were abiding to the advised healthy habits (nonsmoking, physically active, good diet, regular use of medicaments according to the guidelines). Adjustment to the new lifestyle was measured with Likert scale (1-5) and the same scale was used to asses physicians satisfaction with transparency of electronic health record data. Results: 63.2% of participants had recommended values for blood pressure, 19.4% for LDL cholesterol and 25.3% had a normal body mass index according to the guidelines. 25.1% of participants continued to smoke and 43.2% continued alcohol consumption. In terms of diet, a change was observed in 63.7% and physical activity increase in 63.4% of participants. In most cases, after coronary incident, physician consulted them regarding lifestyle changes. Family medicine specialists were mostly pleased with the content and the amount of data in electronic health records, but not with their transparency and ease of use in everyday, usually time constrained, patient - doctor consultations. A software application Adobe Illustrator® was used to visually represent the relevant risk factors which could provide more effective control for conducting secondary prevention measures. Conclusion: The care for coronary artery disease patients in family medicine is very complex, and a part of it is related to providing effective measures of secondary prevention which are of crucial importance. Therefore it is imperative to plan ahead and allow sufficient consultation time to obtain control over the risk factors and make timely changes according to the guidelines. Research results have shown that not all risk factors are within recommended values and one of the reasons could be the lack of clear presentation in the electronic health record. Better quality of care could be achieved with the proposed visual solution using pictures that allows the family physician fast access to the patient’s “profile” and improves efficiency of every consultation despite its constrained duration in everyday conditions