Predictive Impact of Coronary Risk Factors in Southern Croatia: A Case Control Study

The aim of study was to compare the impact of coronary risk factors on the incidence of acute myocardial infarction (MI) between Croatia, Central and Eastern Europe, and the rest of the world. As a part of the large international INTERHEART case-control study of acute MI in 52 countries (15,152 cases and 14,820 controls) we have investigated the relationship between several known risk factors (smoking, history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apolipoproteins, and psychosocial factors) and MI among patients without previously known coronary heart disease in Southern Croatia. The main identified MI risk factors in Southern Croatia were heavy smoking (>20 cig/day; OR 3.86; 95% CI 2.31–6.46), diabetes mellitus (OR 2.83; 95% CI 1.58–5.23), abnormal ratio of B-100 and A-1 apolipoproteins (OR 2.23; 95% CI 1.28–3.89), elevated waist to hip ratio (OR 1.96; 95% CI 1.21–3.18), and arterial hypertension (OR 1.68; 95% CI 1.15–2.45). Protective was moderate alcohol consumption (OR 0.63; 95% CI 0.40–0.99). The prevalence of major MI risk factors in Croatia is similar to that in the surrounding countries and in the world, accounting for over 90% of the population attributable risk. However, physical activity, dietary and psychosocial factors are seemingly less important in this country, while moderate alcohol consumption is more protective than regionally or globally

MERITS OF PARACETAMOL IN OSTEOARTHRITIC HYPERTENSIVE PATIENTS

Cilj ispitivanja bio je odrediti mjesto paracetamola u liječenju hipertoničara s artrozom, i utvrditi najpovoljniju kombinaciju antihipertenziva i antireumatika za te pacijente. U prospektivno ispitivanje provedeno u ordinaciji obiteljske medicine uključeno je 110 liječenih hipertoničara starijih od 55 godina; 50 u kontrolnu i 60 u interventnu skupinu (uzimali su i nesteroidne antireumatike zbog osteoartritisa). U tromjesečnom su razdoblju uspoređivana dva antihipertenziva, lizinopril/hidroklorotiazid i amlodipin s dva nesteroidna anrireumatika (NSAR): ibuprofenom i piroksikamom, te s paracetamolom. Nakon svakog jednomjesečnog razdoblja mjeren je arterijski tlak, učinak ispitivanih lijekova na intenzitet boli i kvalitetu života ispitanika. Ibuprofen i piroksikam pokazali su značajno prohipertenzivno djelovanje, a u razdoblju uzimanja paracetamola ono je bilo neznatno i klinički zanemarivo. U podskupini amlodipin ± ibuprofen, prosječni rezultat na ljestvici boli statistički se značajno smanjivao tijekom pokusa. U podskupini lizinopril/hidroklorotiazid ± piroksikam prosječna procijenjena kvaliteta života značajno se mijenjala. Paracetamol je pokazao podjednaku analgetsku učinkovitost kao ibuprofen, a tek nešto slabiju od piroksikama. Kvaliteta života je u NSAR fazama bila lošija nego tijekom uzimanja paracetamola. Samo paracetamol nije utjecao na antihipertenzivno djelovanje lizinopril/ hidroklorotiazid kombinacije. U hipertoničara s artrozom paracetamol je analgetik prvog izbora, dok je antihipertenziv izbora jedan antagonist kalcija, navlastito amlodipin.Background: Nonsteroidal anti-inflammatory drug (NSAID) side effects can impair quality of life in patients with osteoarthritis. Due to its particular mechanism of action, paracetamol might bypass these negative effects. Objectives: To determine both the role of paracetamol in the treatment of osteoarthritis patients and optimal combination of antihypertensives and antirheumatics for these patients. Methods: A prospective clinical trial in a family practice included 110 treated hypertensives aged over 55 years: 50 controls and 60 also taking NSAIDs for osteoarthritis. This 3-month study compared two antihypertensives, lisinopril/hydrochlorothiazide fixed combination and amlodipine, with two NSAIDs, ibuprofen and piroxicam, and with paracetamol. Following clinical work-up and NSAID discontinuation for at least 3 days (run-in period of only 3-7 days), osteoarthritis subjects were randomized to 1-month periods of ibuprofen (400-600 mg t.i.d.) or piroxicam (10-20 mg o.d.) with one month of paracetamol (1000 mg t.i.d.) in the middle as a “wash-out” interval, continuing the prescribed amlodipine (5-10 mg o.d.) or lisinopril/hydrochlorothiazide fixed drug combination (10/6.25-20/12.5 mg o.d.), while control subjects (hypertensives with no osteoarthritis) were just keeping their antihypertensive therapy. Blood pressure was measured with standard mercury sphygmomanometer and with an automatic device, in standing, sitting and supine position. The intensity of arthritic pain (on a visual analogue scale from 1 to 10, where 0 means “no pain” and 10 “the worst pain you may imagine”) and the patient’s quality of life estimate (on a visual analogue scale from 1 to 10, where 0 means “general condition excellent” and 10 “the worst possible”) were recorded. Results: Blood pressure control was unchanged in the amlodipine group across the study periods and impaired in the lisinopril/ hydrochlorothiazide group during either ibuprofen or piroxicam, but not during paracetamol. In the amlodipine ± ibuprofen subgroup, the reduction of the average pain intensity score throughout the study was significant (2=8.250; df 3; P=0.037). In the lisinopril/hydrochlorothiazide ± piroxicam subgroup, the assessed quality of life differed significantly (2=9.716; df 3; P=0.018), while in the amlodipine ± ibuprofen and amlodipine ± piroxicam subgroups the changes were marginal (2=6.936; df 3; P=0.072 and 2=7.146; df 3; P=0.065, respectively). Discussion: In our trial, paracetamol had analgesic efficacy similar to ibuprofen and only marginally inferior to piroxicam. The analgesic effect of ibuprofen, piroxicam and paracetamol was more pronounced in amlodipine than in the lisinopril/hydrochlorothiazide subgroups. The quality of life was reported to be worse with NSAIDs than with paracetamol, presumably due to dyspeptic problems. Although during the paracetamol phases, the quality of life was slightly improved, the difference was statistically nonsignificant because of the small samples and insufficiently sensitive scale. Conclusion: Analgesic efficiency of paracetamol is comparable to that of ibuprofen and is marginally inferior to piroxicam. Only paracetamol did not interfere with the antihypertensive effects of lisinopril/ hydrochlorothiazide combination. Piroxicam and ibuprofen markedly blunt the effects of antihypertensive drugs while paracetamol is almost inert in this sense. Lisinopril/hydrochlorothiazide combination is much more affected by this interaction than amlodipine. Because of less side effects and better tolerability, paracetamol is the analgesic of choice for hypertensive patients with osteoarthritis, needed prolonged pain relief. The second choice drugs are narcotic analgesics (e.g., tramadol). Small doses of NSAIDs can eventually be added with concomitant prescription of gastroprotective agents

Metabolic syndrome in type 2 diabetics

Cilj. Utvrditi ucestalost metabolickog sindroma (MS) u dijabeticara tipa 2 i razlike u njegovoj prevalenciji po kriterijima Svjetske zdravstvene organizacije (SZO) i Americkog nacionalnog programa edukacije o kolesterolu (NCEP-ATP III). Ispitanici i metode. Ukljuceni su svi dijabeticari tipa 2 stari 18 godina, u skrbi cetiri obiteljska lijecnika (LOM) koji medicinsku dokumentaciju vode elektronskim putem. Prireden je anketni upitnik s pitanjima o sociodemografskim podacima, životnim navikama, komorbiditetu, trajnoj medikamentnoj terapiji, antropometrijskim mjerenjima i cimbenicima kardiovaskularnog rizika. Svi podaci, osim antropometrijskih mjerenja (visina, težina, opseg struka), prikupljeni su retrospektivno. Rezultati. Analizirana su 243 dijabeticara tipa 2, što cini 3,79% od 6400 osiguranika u skrbi. Od toga je bilo 120 (49,4%) žena i 123 (50,6%) muškarca, prosjecne dobi 66,68 ± 9,23 godine. Prema definiciji SZO metabolicki sindrom ima 62 (25,2%), a po kriterijima NCEP-ATP III 117 (48,1%), ispitanika što je statisticki znacajna razlika (2 = 31,80; P < 0,001). MS je bio znacajno cešci u skupini ispitanika koji prekomjerno piju (2 = 13,56; P = 0,001), kao i tjelesno neaktivnih dijabeticara (2 = 10,52; P = 0,005). Zakljucak. Rezultati ovog istraživanja pokazuju relevantno vecu ucestalost MS-a u dijabeticara tipa 2 po kriterijima NCEP-ATP III, nego po kriteriju SZO o cemu treba voditi racuna pri usporedivanju razlicitih podataka. Mjerenje opsega struka trebalo bi implementirati u svakodnevni rad LOM-a. Temelj lijecenja MS su nefarmakološke mjere (gubitak težine i tjelovježba). Specificni odnos lijecnik – bolesnik omogucuje utjecaj na mijenjanje navika i ponašanja bolesnika. Zbog slabe percepcije odgodenog rizika to je najteže provediva, a najucinkovitija mjera lijecenja MS-a.Aim. The aim of this study was to determine the frequency of the metabolic syndrome (MS) in type 2 diabetics and to investigate the possible difference in frequency, calculated according to the World Health Organisation (WHO) and The Third Report of The National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III) criteria. Subjects and methods. Enrolled were all type 2 diabetics aged 18, enlisted in four computorised family physician\u27s offices. The questionnaire created for the purpose of this study included sociodemographic and anthropometric data, data on life habits, comorbidity, medication and cardiovascular risk factors. Data were collected from medical records retrospectively, while anthropometric data on body height, weight and waist measurement were collected by additional measurements. Results. Data on 243 type 2 diabetics were collected (3.79% of 6440 patients enlisted), 120 (46.4%) female and 123 (50.6%) male. The average age was 66.68 ± 9.23. According to WHO criteria 62 (25.2%) examinees in our sample met the metabolic syndrome criteria, while according to NCEP-ATP III criteria that number was significantly higher 117 (48.1%), ( = 31.8, P < 0.001). In our sample MS occurred more often in heavy alcohol drinkers ( = 13.56, P = 0.001) and in diabetics who lacked regular physical activity ( = 10.52, P = 0.005). Conclusion. There are several MS definitions, those by WHO and NCEP-ATP III are the most often used. In this study a markedly higher prevalence of the metabolic syndrome among type 2 diabetics was observed when assessed according to NCEP-ATP III criteria, which must be kept in mind while comparing different data. Taking waist measurements is an easy and sensitive method of detecting MS and should be implemented in the family physician\u27s daily practice. Nonpharmacological measures (weight loss and exercise) are fundamental for MS treatment. The family physician has an unique opportunity to influence MS patients\u27 lifestyle modifications, which is the most effective and the most difficult measure to carry out because of the patients\u27 inadequate perception of delayed risk

Job Satisfaction among Medical Doctors in One of the Countries in Transition: Experience from Croatia

Our aim was to explore and compare the job satisfaction between family physicians and hospital specialists in Split, Croatia. The survey was carried out in 2005 and 2006. A validated questionnaire was composed of two parts: 92 statements and questions about job satisfaction in the form of a Lickert scale (range 1–5) and eight questions concerning demographic issues. The questionnaire was completed and returned by 165 hospital specialists from the University Hospital and by 131 family physicians from the Split County. Response rate for family physicians was 39.81% and 41.46% for hospital specialists. Hospital doctors were divided in two groups: internal and surgical. There were no significant differences between family physicians and hospital specialists in total job satisfaction (F=1.02; p=0.41). Family physicians were more satisfied with their workplace conditions than internal medicine specialists (19.37±4.23 vs. 17.37±4.59; F=5.93; p=0.003), and less satisfied with the possibilities for postgraduate training than surgeons (5.27±1.90 vs. 6.59±2.07; F=9.26; p<0.001). Global job satisfaction was rather low but does not differ between the three medical groups. Disparities were observed in some segments (opportunity for further training and academic advancement, vacation, and salary). The reason for the family physician\u27s relative satisfaction may be due to stable working conditions, independence in organizing work schedules and personal responsibility

MERITS OF PARACETAMOL IN OSTEOARTHRITIC HYPERTENSIVE PATIENTS

Cilj ispitivanja bio je odrediti mjesto paracetamola u liječenju hipertoničara s artrozom, i utvrditi najpovoljniju kombinaciju antihipertenziva i antireumatika za te pacijente. U prospektivno ispitivanje provedeno u ordinaciji obiteljske medicine uključeno je 110 liječenih hipertoničara starijih od 55 godina; 50 u kontrolnu i 60 u interventnu skupinu (uzimali su i nesteroidne antireumatike zbog osteoartritisa). U tromjesečnom su razdoblju uspoređivana dva antihipertenziva, lizinopril/hidroklorotiazid i amlodipin s dva nesteroidna anrireumatika (NSAR): ibuprofenom i piroksikamom, te s paracetamolom. Nakon svakog jednomjesečnog razdoblja mjeren je arterijski tlak, učinak ispitivanih lijekova na intenzitet boli i kvalitetu života ispitanika. Ibuprofen i piroksikam pokazali su značajno prohipertenzivno djelovanje, a u razdoblju uzimanja paracetamola ono je bilo neznatno i klinički zanemarivo. U podskupini amlodipin ± ibuprofen, prosječni rezultat na ljestvici boli statistički se značajno smanjivao tijekom pokusa. U podskupini lizinopril/hidroklorotiazid ± piroksikam prosječna procijenjena kvaliteta života značajno se mijenjala. Paracetamol je pokazao podjednaku analgetsku učinkovitost kao ibuprofen, a tek nešto slabiju od piroksikama. Kvaliteta života je u NSAR fazama bila lošija nego tijekom uzimanja paracetamola. Samo paracetamol nije utjecao na antihipertenzivno djelovanje lizinopril/ hidroklorotiazid kombinacije. U hipertoničara s artrozom paracetamol je analgetik prvog izbora, dok je antihipertenziv izbora jedan antagonist kalcija, navlastito amlodipin.Background: Nonsteroidal anti-inflammatory drug (NSAID) side effects can impair quality of life in patients with osteoarthritis. Due to its particular mechanism of action, paracetamol might bypass these negative effects. Objectives: To determine both the role of paracetamol in the treatment of osteoarthritis patients and optimal combination of antihypertensives and antirheumatics for these patients. Methods: A prospective clinical trial in a family practice included 110 treated hypertensives aged over 55 years: 50 controls and 60 also taking NSAIDs for osteoarthritis. This 3-month study compared two antihypertensives, lisinopril/hydrochlorothiazide fixed combination and amlodipine, with two NSAIDs, ibuprofen and piroxicam, and with paracetamol. Following clinical work-up and NSAID discontinuation for at least 3 days (run-in period of only 3-7 days), osteoarthritis subjects were randomized to 1-month periods of ibuprofen (400-600 mg t.i.d.) or piroxicam (10-20 mg o.d.) with one month of paracetamol (1000 mg t.i.d.) in the middle as a “wash-out” interval, continuing the prescribed amlodipine (5-10 mg o.d.) or lisinopril/hydrochlorothiazide fixed drug combination (10/6.25-20/12.5 mg o.d.), while control subjects (hypertensives with no osteoarthritis) were just keeping their antihypertensive therapy. Blood pressure was measured with standard mercury sphygmomanometer and with an automatic device, in standing, sitting and supine position. The intensity of arthritic pain (on a visual analogue scale from 1 to 10, where 0 means “no pain” and 10 “the worst pain you may imagine”) and the patient’s quality of life estimate (on a visual analogue scale from 1 to 10, where 0 means “general condition excellent” and 10 “the worst possible”) were recorded. Results: Blood pressure control was unchanged in the amlodipine group across the study periods and impaired in the lisinopril/ hydrochlorothiazide group during either ibuprofen or piroxicam, but not during paracetamol. In the amlodipine ± ibuprofen subgroup, the reduction of the average pain intensity score throughout the study was significant (2=8.250; df 3; P=0.037). In the lisinopril/hydrochlorothiazide ± piroxicam subgroup, the assessed quality of life differed significantly (2=9.716; df 3; P=0.018), while in the amlodipine ± ibuprofen and amlodipine ± piroxicam subgroups the changes were marginal (2=6.936; df 3; P=0.072 and 2=7.146; df 3; P=0.065, respectively). Discussion: In our trial, paracetamol had analgesic efficacy similar to ibuprofen and only marginally inferior to piroxicam. The analgesic effect of ibuprofen, piroxicam and paracetamol was more pronounced in amlodipine than in the lisinopril/hydrochlorothiazide subgroups. The quality of life was reported to be worse with NSAIDs than with paracetamol, presumably due to dyspeptic problems. Although during the paracetamol phases, the quality of life was slightly improved, the difference was statistically nonsignificant because of the small samples and insufficiently sensitive scale. Conclusion: Analgesic efficiency of paracetamol is comparable to that of ibuprofen and is marginally inferior to piroxicam. Only paracetamol did not interfere with the antihypertensive effects of lisinopril/ hydrochlorothiazide combination. Piroxicam and ibuprofen markedly blunt the effects of antihypertensive drugs while paracetamol is almost inert in this sense. Lisinopril/hydrochlorothiazide combination is much more affected by this interaction than amlodipine. Because of less side effects and better tolerability, paracetamol is the analgesic of choice for hypertensive patients with osteoarthritis, needed prolonged pain relief. The second choice drugs are narcotic analgesics (e.g., tramadol). Small doses of NSAIDs can eventually be added with concomitant prescription of gastroprotective agents