Umijeće razlučivanja preklapanja psihičkih i somatskih simptoma u okviru anksioznog poremećaja

Anksiozni poremećaji često su prisutni u obiteljskoj medicini. Anksioznost odnosno strah, napetost normalna je reakcija u novonastalim i opasnim situacijama. Smatramo je patološkom ukoliko nam uobičajene životne situacije uzrokuju strah te nam ujedno i otežavaju normalno funkcioniranje. Manifestira se psihičkim i tjelesnim simptomima. U sklopu anksioznosti moguća je i pojava hipohondrije. Prikazan je slučaj pedesetjednogodišnjeg muškarca lošijeg socioekonomskog položaja koji se žalio na brojne tjelesne simptome svojoj liječnici obiteljske medicine te je podvrgnut brojnim dijagnostičkim pretragama. Čak i kada su nalazi bili uredni, pacijent se i dalje žalio na brojne tjelesne tegobe. Konačno, postavljena je dijagnoza generaliziranog anksioznog poremećaja. Kod anksioznih poremećaja ključna je temeljita anamneza kojoj je cilj diferencirati radi li se o simptomatici anksioznog spektra ili novonastalom somatskom poremećaju. Poželjan je i kontinuitet odnosa u kojemu liječnik obiteljske medicine dugo poznaje svoje pacijente te može prepoznati promjenu ponašanja u slučaju pojave akutno ugrožavajućeg (hitnog) stanja. U liječenju anksioznih pacijenata vrlo je važan odnos liječnik-bolesnik gdje liječnik (vrlo često liječnik obiteljske medicine) preuzima važnu suportivnu ulogu. Ovisno o procjeni težine kliničke slike treba razmotriti potrebu za uvođenjem psihofarmakoterapije ili pacijenta uputiti specijalistu psihijatrije u svrhu selekcije i titracije adekvatne psihofarmakoterapije, odnosno eventualnog provođenja psihoterapije

PREDICTORS OF HEALTH-RELATED QUALITY OF LIFE IN INFORMAL CAREGIVERS OF DEMENTIA PATIENTS IN ZAGREB, CROATIA, A CROSS SECTIONAL STUDY

We aimed to estimate health-related quality of life (HRQoL) in family-member caregivers of patients with dementia in Croatia and to assess relevant predictors. A cross-sectional study in family medicine practices in Zagreb (Health Care Center Zagreb-West) was performed in period 10/2017-9/2018 and included 131 dyads consisting of a patient with dementia and one dominant informal caregiver. Patient measures included Mini-mental-state-examination (MMSE), Barthel-index and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Caregiver measures included 36-Item Short-Form-Health-Survey (SF-36), Zarit-Burden-Interview (ZBI) and structured questionnaire regarding general information on caregiver and patient. SF-36 is a reliable instrument to estimate HRQoL . Caregiver HRQoL was higher than reported in Croatian population in physical functioning (PF), role physical (RP), general health (GH), social functioning (SF) and role emotional (RE) domains. More pronounced neuropsychiatric symptoms in patient with dementia were associated with caregiver\u27s lower HRQoL in vitality (VT) and mental health (MH) domains. Caregivers with higher caregiver burden assessed by ZBI had lower HRQoL in RP, bodily pain (BP), GH, VT, SF, RE and MH domains. In multivariate analyses, higher caregiver\u27s burden was independent predictor of lower HRQoL in RP, VT, RE and MH domains. Neuropsychiatric symptoms and use of daycare service were recognized as independent predictors of lower HRQoL (in PF, BP and GH, SF, RE domains, respectively). Neuropsychiatric symptoms and caregiver burden are associated with HRQoL in caregivers of patients with dementia. Interventions including psychological support and learning of skills necessary to tackle individual problems may help in improvement of HRQoL

PREDICTORS OF HEALTH-RELATED QUALITY OF LIFE IN INFORMAL CAREGIVERS OF DEMENTIA PATIENTS IN ZAGREB, CROATIA, A CROSS SECTIONAL STUDY

We aimed to estimate health-related quality of life (HRQoL) in family-member caregivers of patients with dementia in Croatia and to assess relevant predictors. A cross-sectional study in family medicine practices in Zagreb (Health Care Center Zagreb-West) was performed in period 10/2017-9/2018 and included 131 dyads consisting of a patient with dementia and one dominant informal caregiver. Patient measures included Mini-mental-state-examination (MMSE), Barthel-index and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Caregiver measures included 36-Item Short-Form-Health-Survey (SF-36), Zarit-Burden-Interview (ZBI) and structured questionnaire regarding general information on caregiver and patient. SF-36 is a reliable instrument to estimate HRQoL . Caregiver HRQoL was higher than reported in Croatian population in physical functioning (PF), role physical (RP), general health (GH), social functioning (SF) and role emotional (RE) domains. More pronounced neuropsychiatric symptoms in patient with dementia were associated with caregiver\u27s lower HRQoL in vitality (VT) and mental health (MH) domains. Caregivers with higher caregiver burden assessed by ZBI had lower HRQoL in RP, bodily pain (BP), GH, VT, SF, RE and MH domains. In multivariate analyses, higher caregiver\u27s burden was independent predictor of lower HRQoL in RP, VT, RE and MH domains. Neuropsychiatric symptoms and use of daycare service were recognized as independent predictors of lower HRQoL (in PF, BP and GH, SF, RE domains, respectively). Neuropsychiatric symptoms and caregiver burden are associated with HRQoL in caregivers of patients with dementia. Interventions including psychological support and learning of skills necessary to tackle individual problems may help in improvement of HRQoL

Assessment of alcohol related disorders in family physician’s work – a pilot study

Uvod. Prema podacima Svjetske zdravstvene organizacije u Republici Hrvatskoj se godišnje u prosjeku popije 12,2 litara čistog alkohola po stanovniku starijem od 15 godina. Usprkos ovim podacima, poremećaji uzrokovani pijenjem alkohola rijetko se dijagnosticiraju u ordinacijama obiteljske medicine (OM). Cilj. Istražiti proporciju osoba u skrbi liječnika obiteljske medicine na području Općine Bednja koji ispunjavaju kriterije rizičnog pijenja, štetnog pijenja ili moguće ovisnosti o alkoholu. Metode i ispitanici. Pilot istraživanje je provedeno u dvije ordinacije OM u Općini Bednja u razdoblju ožujak-travanj 2013. godine na prigodnom uzorku ispitanika starijih od 18 godina (N=150). Upitnikom su prikupljeni podaci o ispitanicima (sociodemografski podaci, samoprocjena zdravlja, zadovoljstvo životom), podaci o rizičnom pijenju, štetnom pijenju te mogućoj ovisnosti o alkoholu (AUDIT upitnik). Rezultati. Od 150 upitnika, 75 je uključeno u statističku obradu (stopa odgovora 50%). Temeljem ukupnog broja bodova ostvarenog na AUDIT upitniku, kod 9 od 75 ispitanika utvrđeno je prekomjerno i štetno pijenje te postojanje moguće ovisnosti o alkoholu. Za većinu tih ispitanika (8 od 9) utvrđena je umjerena razina problema povezanih s alkoholom (AUDIT zbroj 8-15), dok je kod 1 od 9 ispitanika utvrđena visoka razina problema povezanih s alkoholom (AUDIT zbroj 16-19). Analizom pojedinačnih cjelina AUDIT upitnika, 11-27 od 75 ispitanika ispunjavalo je kriterij rizičnog pijenja, 3-10 od 75 ispitanika kriterij moguće ovisnosti o alkoholu, a 4-12 od 75 ispitanika ispunjavalo je kriterij postojanja štetnih posljedica pijenja alkohola. Zaključak. Značajan udio osoba u skrbi liječnika OM na području Općine Bednja ispunjava kriterije rizičnog pijenja, štetnog pijenja ili moguće ovisnosti o alkoholu. Analizom pojedinačnih cjelina upitnika (rizično pijenje; ovisnost o alkoholu; štetne posljedice pijenja) detektiran je još veći broj ispitanika koji ispunjavaju kriterije unutar pojedinačnih cjelina, što omogućuje rano prepoznavanje i ranu intervenciju liječnika OM.Introduction. According to WHO data, the average yearly alcohol consumption in the Republic of Croatia per capita resembles 12.2 L of pure alcohol in the age group >15 years. Despite these data, alcohol related disorders are rarely diagnosed in family medicine (FM) practices. Aim. Proportion of patients in care of family physicians in Bednja District that fulfill criteria of hazardous drinking, harmful drinking or possible alcohol dependence is investigated. Methods. A pilot study was conducted in two FM practices in Bednja District on an appropriate sample of respondents aged 18+ years (N=150) from March to April 2013. Data on respondents’ characteristics (sociodemographic data, health self-assessment, life satisfaction) and hazardous drinking, harmful drinking or possible alcohol dependence (AUDIT questionnaire) was collected. Results. There were 75 out of 150 questionnaires (response rate 50%) included in the analysis. According to total AUDIT score, 9 of 75 respondents fulfilled criteria of hazardous drinking, harmful drinking or possible alcohol dependence. Majority of these respondents (8 out of 9) had moderate level of alcohol related problems while in 1 respondent high level of alcohol related problems was detected. Analysis of 75 individual responses revealed that 11-27 fulfilled criteria of hazardous drinking, 3-10 of possible alcohol dependence and 4-12 of harmful drinking. Conclusion. A significant proportion of FM patients in Bednja District fulfilled criteria of hazardous drinking, harmful drinking or possible alcohol dependence. Analysis of individual responses revealed even higher rates of respondents that fulfilled those criteria in separate domains, enabling family physicians early detection and intervention in those patients

APPROACH TO PATIENTS WITH GASTROINTESTINAL BLEEDING

U razvijenim zemljama zapadnog svijeta unatoč akumulaciji znanja o uzrocima i načinu liječenja gastrointestinalnog krvarenja, iskustvu gastroenterologa endoskopičara, upotrebi sofi sticiranih endoskopskih uređaja, broj hospitalizacija i stopa smrtnosti nisu se očekivano smanjili. Moguća objašnjenja su starenje populacije, povećanje prevalencije gastroezofagealne refl usne bolesti, debljina, antibiotska rezistencija Helicobacter pylori, upotreba antiagregacijskih, antikoagulantnih lijekova te ekscesivno korištenje nesteroidnih antireumatika. Cilj ovog preglednog rada je prikazati incidenciju, defi nirati najčešće znakove i simptome krvarenja, pokazati inicijalnu kliničku evaluaciju, dijagnostičke metode, osnovne uzroke krvarenja i endoskopske metode zaustavljanja krvarenja te algoritme liječenja krvarenja iz gornjeg i donjeg gastrointestinalnog sustava. Koristeći baze podataka MEDLINE i Ovid tražili smo meta analize i sistemske preglede objavljene na engleskom jeziku u razdoblju od 2005.-2015. godine. Meta analize su uključivale rezultate randomiziranih, dvostruko slijepih istraživanja na odraslim bolesnicimaliječenima zbog gastrointestinalnog krvarenja. Uključene su smjernice Europskog i Američkog društva za gastroenterološku endoskopiju kao i recentni radovi stručnjaka. Donosimo najaktualnije spoznaje o krvarenju iz gastrointestinalnog sustava, novu podjelu na krvarenja iz gornjeg, srednjeg i donjeg dijela gastrointestinalnog trakta, kontroverze o plasmanu nazogastrične sonde, upotrebi prokinetika i inhibitora protonske pumpe u akutnim krvarenjima iz gornjeg dijela gastrointestinalnog trakta, restriktivnoj transfuzijskoj strategiji, boljoj kliničkoj stratifi kaciji težine krvarenja, hospitalizaciji te kliničkom ishodu na osnovi upotrebe dijagnostičkih zbrojeva, gastroprotekciji u bolesnika s visokim rizikom nastanka peptičnih ulkusa, važnosti inicijalne ezofagogastroduodenoskopije u procjeni variksa u bolesnika s novootkrivenom cirozom jetre, primarnoj i sekundarnoj profi laksi varicealnog krvarenja, novim endoskopskim metodama hemostaze (Hemospray), radiološkom i kirurškom zaustavljanju krvarenja. Smatramo da bi edukativna narav ovog teksta mogla poslužiti kao temelj stvaranju hrvatskih smjernica za krvarenja iz gastrointestinalnog sustava.In the developed Western countries, despite the accumulation of knowledge about the causes and treatment of gastrointestinal bleeding, as well as the experience of gastroenterologists-endoscopists using sophisticated endoscopic devices, the number of hospitalizations and mortality rates has not declined as expected. The most likely explanations are the following: aging population, increased prevalence of alcoholic liver cirrhosis, gastroesophageal refl ux disease and obesity, Helicobacter pylori antibiotic resistance, using dual anti-aggregation therapy, anticoagulants, and excessive use of nonsteroidal anti-infl ammatory drugs. The aim of this paper is to show the incidence and the most common signs and symptoms of gastrointestinal bleeding. The aim is also to present initial clinical evaluation, diagnostic methods, the main causes of gastrointestinal bleeding, endoscopic hemostatic modalities and treatment of bleeding from the upper and lower gastrointestinal tract. Using the MEDLINE and Ovid databases, we searched the meta-analyses and systematic reviews published in English during the 2005-2015 period. Meta-analyses included results of randomized, double-blind studies on adults treated for gastrointestinal bleeding. Included were guidelines of the European and American Society of Gastroenterological Endoscopy, as well as recent expert work. In this review, we bring the state-of-the-art on gastrointestinal bleeding, new classifi cation of gastrointestinal bleeding from the upper, mid and lower gut, controversy of nasogastric tube placement, use of prokinetic agents and inhibitor proton pumps in acute gastrointestinal bleeding from the upper tract, restrictive transfusion strategy, useful clinical stratifi cation of the severity of bleeding, indications for hospitalization and outcome of using the clinical bleeding score, proper use of gastroprotection in patients at a high risk of peptic ulcer, the need of initial endoscopy, variceal assessment in newly diagnosed liver cirrhosis, primary and secondary prophylaxis of variceal bleeding, new endoscopic hemostatic modality, and radiological and surgical treatment of gastrointestinal bleeding. The educational nature of this review could serve for establishing Croatian guideline for the management of gastrointestinal bleeding

PEER EDUCATION AS AN INNOVATIVE APPROACH IN IMPROVEMENT OF YOUTH MENTAL HEALTH CARE

Uvod: Vršnjačka edukacija postaje sve važnija u praksi kao snažan alat za promociju zdravlja. Promocijom mentalnog zdravlja adolescentima se pomaže u izgradnji otpornosti kako bi se mogli dobro snalaziti u teškim situacijama i nepovoljnim okolnostima u životu. Kako bi preuzeli aktivniju ulogu u poboljšanju zaštite mentalnog zdravlja među mladima, Međunarodna udruga studenata medicine Hrvatska u suradnji s Gradskim uredom za zdravstvo Grada Zagreba i Domom zdravlja Zagreb-Zapad pokrenuli su projekt o mentalnom zdravlju mladih. Projekt je baziran na vršnjačkoj edukaciji na način da prethodno educirani studenti medicine provode radionice u srednjim školama s ciljem promocije mentalnog zdravlja i rane prevencije. Cilj ove studije je procijeniti učinkovitost vršnjačke edukacije kao dobrog modela za promociju mentalnog zdravlja među mladima. Metode: Provedeno je 7 radionica u 17 razreda, s ukupnim obuhvatom od 390 srednjoškolaca. Svaka radionica je evaluirana s Evaluacijskim obrascem propitujući mišljenje srednjoškolaca o korisnosti, zadovoljstvu, sadržaju, itd. Srednjoškolci su također ispunjavali Skalu svijesti o sebi (Fenigstein, Scheier, Buss, 1975) i Privatnu skalu svijesti o sebi (Huić, 2009) prije i nakon provođenja projekta kako bi objektivno procijenili učinak provedenih radionica na svijest o sebi. Rezultati: Preliminarni rezultati su pokazali statistički značajnu promjenu u svim aspektima skale Svijesti o sebi na kraju projektu u usporedbi s upitnicima prije početka projekta. Najveći napredak se vidi na varijabli privatne svijesti o sebi (t = -3,474; p<.01), ali također se vidi napredak na varijablama koji procjenjuju svijest o svojim emocijama (t= -3,320; p<.01), svijest o svojoj kogniciji (t= -2,336; p<.05) i svijesti o svojem tijelu (t= -2,580; p<.01). Izvješća srednjoškolaca su pokazala i subjektivni napredak na njihovom mentalnom zdravlju i veliko zadovoljstvo projektom. Zaključak: Vršnjačka edukacija bi se češće trebala uzeti u obzir kao snažan alat za aktivniji rad na poboljšanju mentalnog zdravlja među mladima, u suradnji sa službama za zaštitu mentalnog zdravlja te aktivnim angažmanom učitelja i roditelja.Introduction: Peer education is growing in popularity and practice as a powerful tool for health promotion. Promotion of mental health helps adolescents in building resilience so that they can cope well in difficult situations or adversities. In order to take a more active role in improvement of youth mental health care Croatian Medical Students\u27 Association in collaboration with City Office for Health in Zagreb and Regional Health Center Zagreb - West started a project on mental health promotion. Project is based on peer education, with previously educated medical students conducting workshops in high schools, in order to emphasize the importance of early prevention and mental health promotion. The aim of this study was to evaluate whether peer education is a good framework for mental health promotion among youth, with physicians actively involved as educators and supervisors. Methods: There were 7 workshops conducted in 17 classes, with 390 high school students participating. Every workshop was evaluated with Evaluation form, questioning students\u27 opinion on usefulness, satisfaction, content etc. High school students were also given Self-Consciousness Scale (Fenigstein, Scheier, Buss, 1975) and Private Self-Consciousness Scale (Huić, 2009) before and after the project to objectively evaluate benefits on their self-consciousness. Results: Preliminary results showed a statistically relevant change in all aspects of the Self-Consciousness Scale in the post, compared to prequestionnaires. The biggest improvement is seen in the private self-consciousness part (t = -3,474; p<.01), but there were also improvements in the parts evaluating emotions (t= -3,320; p<.01), cognition (t= -2,336; p<.05), and body image (t= -2,580; p<.01). Students reported subjective improvement of their mental health and high satisfaction with project. Conclusion: Peer education should be considered as a powerful framework for active involvement in improvement of youth mental health care, in collaboration with mental health services and efforts from teachers and parents

Reliability and validity of the Croatian version of Consultation and Relational Empathy (CARE) Measure in primary care setting

Aim To translate the Consultation and Relational Empathy (CARE) Measure into Croatian and validate the Croatian version of the questionnaire. Methods A cross-sectional study was conducted in July 2011 in 8 general practices (GP) in Croatia. Following two stages of translation, back-translation, and pilot testing, the Croatian version of the CARE was tested on 568 consecutive patients. Results Face validity was high, the number of missing values was low (9%), and the internal consistency (Cronbach’s alpha) was 0.77. A principal component analysis of 10 CARE Measure items extracted two components with eigenvalues >1. These two components explained 43.6% of the total instrument variance. Conclusion The Croatian version of the CARE Measure had acceptable reliability and face validity, but its intended component structure was not reproduced and further research is needed to understand its dimensionality. Receive

The development and appraisal of a tool designed to find patients harmed by falsely labelled, falsified (counterfeit) medicines.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked FilesFalsely labelled, falsified (counterfeit) medicines (FFCm's) are produced or distributed illegally and can harm patients. Although the occurrence of FFCm's is increasing in Europe, harm is rarely reported. The European Directorate for the Quality of Medicines & Health-Care (EDQM) has therefore coordinated the development and validation of a screening tool.The tool consists of a questionnaire referring to a watch-list of FFCm's identified in Europe, including symptoms of their use and individual risk factors, and a scoring form. To refine the questionnaire and reference method, a pilot-study was performed in 105 self-reported users of watch-list medicines. Subsequently, the tool was validated under "real-life conditions" in 371 patients in 5 ambulatory and in-patient care sites ("sub-studies"). The physicians participating in the study scored the patients and classified their risk of harm as "unlikely" or "probable" (cut-off level: presence of ≥2 of 5 risk factors). They assessed all medical records retrospectively (independent reference method) to validate the risk classification and documented their perception of the tool's value.In 3 ambulatory care sites (180 patients), the tool correctly classified 5 patients as harmed by FFCm's. The positive and negative likelihood ratios (LR+/LR-) and the discrimination power were calculated for two cut-off levels: a) 1 site (50 patients): presence of two risk factors (at 10% estimated health care system contamination with FFCm's): LR + 4.9/LR-0, post-test probability: 35%; b) 2 sites (130 patients): presence of three risk factors (at 5% estimated prevalence of use of non-prescribed medicines (FFCm's) by certain risk groups): LR + 9.7/LR-0, post-test probability: 33%. In 2 in-patient care sites (191 patients), no patient was confirmed as harmed by FFCm's. The physicians perceived the tool as valuable for finding harm, and as an information source regarding risk factors.This "decision aid" is a systematic tool which helps find in medical practice patients harmed by FFCm's. This study supports its value in ambulatory care in regions with health care system contamination and in certain risk groups. The establishment of systematic communication between authorities and the medical community concerning FFCm's, current patterns of use and case reports may sustain positive public health impacts.EDQ

IMPROVEMENT OF NON-INSTITUTIONAL TREATMENT AND CARE FOR WOMEN WITH POSTPARTUM DEPRESSION

Cilj: Prikazati tijek i rezultate projekta unaprjeđenja kompetencija, vezano uz duševno zdravlje, zdravstvenih djelatnika - primarno patronažnih sestara i liječnika obiteljske medicine. Očekivani doprinos unaprijeđenih kompetencija bio bi povećani broj rodilja s poslijeporođajnom depresijom koje traže liječničku pomoć te unaprijeđena dostupnost intenzivnog ambulantnog tretmana (poslijeporođajne depresije) na razini primarne zdravstvene zaštite. Metode: Patronažne medicinske sestre u sklopu usluga obveznog zdravstvenog osiguranja posjećuju sve rodilje u prvom mjesecu poslije poroda pa ovaj oblik pristupa korisnicama koje možda imaju smetnje duševnog zdravlja ima minimalne troškove i lako je održiv. U sklopu projekta provedena je dodatna edukacija i supervizija patronažnih sestara. Praćen je broj pacijentica, specifi čnost odabrane metode povećanja upućivanja, te ishod liječenja (CGI-I) i zadovoljstvo korisnica koje su se na pregled javile po preporuci patronažnih sestara. Statistička značajnost određivana je primjenomThe aim is to present implementation and results of the project intended to increase primary health care worker (family doctors and visiting nurses) competencies related to mental health. The expected outcome of the project was twofold, i.e. an increased number of referrals of women suffering from postpartum depression to medical care facilities and better accessibility of appropriate services (user-friendly provision of intensive treatment in primary care setting). Obligatory health insurance in Croatia covers services of visiting nurses for women during the fi rst month after childbirth. We considered this to be a comprehensive, low cost and sustainable way of approaching omen who might have mood disorders. Subjects and Methods: Visiting nurses were additionally trained and supervised during the project. The number of referred patients, specifi city of the referral method, clinical global improvement and client satisfaction were recorded. Statistical significance was determined wit