Die Rolle des Hausarztes bei der Vorbeugung gegen Geschlechtskrankheiten und ihrer Behandlung

Primarni zadaci liječnika opće/obiteljske medicine u prevenciji spolno prenosivih bolesti (Sexually transmitted diseases – STD) odnose se na edukaciju pučanstva o učestalosti, načinu prenošenja, mogućnostima zaštite, simptomima, ranom otkrivanju, liječenju te rizicima neliječenih infekcija. Liječnik opće/obiteljske medicine treba osigurati primjereno liječenje bolesnika i spolnog partnera bolesnika što je najveća prepreka uspješnom liječenju. Umješnost je liječnika da nagovori bolesnika da se u liječenje STD moraju uključiti i drugi partneri te da pri tom sačuva povjerljiv odnos s bolesnikom. U opisu rada liječnika opće/obiteljske medicine u liječenju STD opisano je nekoliko primjera iz prakse koji ukazuju na specifičnosti postupaka te potrebe individualnog pristupa svakom bolesniku. Iako je, prema dostupnim podacima, učestalost STD u populaciji u skrbi liječnika opće/obiteljske medicine u našoj sredini još uvijek relativno malo, prema podacima iz razvijenih zemalja za očekivati je u budućnosti da se te bolesti mnogo češće javljaju i primjerenije dijagnosticiraju u našoj praksi. Pri tome je nužno povećati znanje i liječnika i drugih zdravstvenih djelatnika u primarnoj zaštiti, ali i populacije u tom području.Primary tasks of general practitioner/family physician in the prevention of STD (Sexually transmitted diseases) are related to population education on STD, their frequency, channels of infection, possible protection, symptoms, early detection, treatment, and risks of untreated infections. General practitioner/ family physician should provide an adequate treatment for the patient and his/her partner(s), which is the most difficult obstacle to successful treatment. It is up to the physician and his skills to convince the patient that the treatment of STD should involve also all his/her other partners, at the same time preserving confidentiality and close relationship with the patient. The description of general practitioner’s/family physician’s work in the treatment of STD gives several examples from practice which indicate the specificity of the problem and the need for individual approach to each patient. Although the available data have shown that the frequency of STD in the Croatian population in care of general practitioners/family physicians is still relatively low, according to data from developed countries a rise in the frequency of STD may be expected in the near future, which asks for a more adequate diagnostics in our practices. Furthermore, it is necessary to expand knowledge in this field not only of physicians and other primary health care workers but also of the population at large.Die primären Aufgaben des allgemeinbehandelnden Hausarztes bei der Vorbeugung gegen Geschlechtskrankheiten (Sexually Transmitted Diseases – STD) bestehen in der Aufklärung der Bevölkerung über die Häufigkeit dieser Krankheiten, über die Art ihrer Übertragung, über Schutzmaßnahmen, Symptome, Früherkennung, Behandlung und Risiken nicht ausgeheilter Infektionen. Der allgemeinbehandelnde Hausarzt muß auf angemessene Weise sowohl den Erkrankten als auch dessen Geschlechtspartner behandeln, doch ist gerade dies das größte Hindernis bei der Bekämpfung von Geschlechtskrankheiten. Das Geschick des Arztes offenbart sich darin, seinen Patienten von der Notwendigkeit der Behandlung seiner Geschlechtspartner zu überzeugen, ohne dabei das Vertrauensverhältnis zwischen ihm und dem Patienten zu beeinträchtigen. Der vorliegende Artikel beschreibt die Arbeit des allgemeinbehandelnden Hausarztes und zeigt anhand mehrerer Beispiele, daß im Falle von Geschlechtskrankheiten eine spezifische Vorgangsweise des Arztes erforderlich ist und er nach Bedarf auch einen jeweils individuellen Ansatz anwenden muß. Auch wenn in Kroatien, gemäß den zur Verfügung stehenden Angaben, in Patientenkreisen, die bei einem Facharzt für Allgemeinmedizin in Behandlung sind, Geschlechtskrankheiten relativ selten auftreten, so sprechen Angaben aus den Industrieländern für eine in der Zukunft zu erwartende Ausbreitung von Geschlechtskrankheiten sowie für angemessenere Diagnostizierungsverfahren in kroatischen Arztpraxen. Eine notwendige Voraussetzung dafür ist die Vertiefung von Kenntnissen sowohl auf seiten der Ärzte als auch des im primären Gesundheitswesen tätigen Personals, ebenso aber der Bevölkerung in diesem Raum

Mjesto i uloga obiteljskog liječnika u sprečavanju i suzbijanju pušenja

Obiteljski je liječnik u povlaštenom položaju za provedbu preventivnih aktivnosti, zahvaljujući tome što bolesnici imaju trajan kontakt s liječnikom. Istraživanja pokazuju da 90% registriranih osoba na liječnikovoj listi posjete liječnika najmanje jedan puta u 3 godine. Prema podacima Hrvatskog zavoda za javno zdravstvo u 2005. godini 88,0% hrvatskog pučanstva bilo je registrirano u službi obiteljske medicine, i zabilježeno je prosječno po osobi 6,3 konzultacije kod obiteljskog liječnika godišnje. Mnogi od kontakata liječnika i bolesnika nude mogućnost primarne prevencije, kao što su primjerice: izobrazba o zdravim stilovima života, ili provedba cijepljenja, savjetovanje o reprodukcijskom zdravlju i drugo

National vs. international journals: views of medical professionals in Croatia

Scholarly journals, especially in non-English-speaking countries, may perform very different functions depending on whether they are published for national or international audiences. Four hundred and sixty-six academic physicians and non-academic general practitioners in Croatia were surveyed on their knowledge about two Croatian medical journals: Liječnički vjesnik (published in Croatian) and Croatian Medical Journal (published in English). The physicians were also surveyed about the importance of all national and international journals published in Croatia, and the types of articles they thought should be published in these journals. More respondents rated national (n = 329, 72.6%) than international journals (n = 275, 63.5%, P < 0.001, Wilcoxon test) as very important for the medical profession. On the other hand, publishing in international journals was more often rated as important than publishing in national journals (n = 184, 42.5% vs. n = 125, 27.8%; P < 0.001, Wilcoxon test). Guidelines for clinical practice were rated as the most important publication item in national journals, and original scientific articles in international journals

SIGNIFICANCE OF REFERRING PATIENTS TO PSYCHIATRISTS FROM FAMILY PRACTITIONER’S OFFICE

U zdravstvenom sustavu Republike Hrvatske liječnik obiteljske medicine (LOM) ima zadaću „čuvara ulaza“ u zdravstveni sustav te upućuje bolesnika u druge razine zdravstvene zaštite kad procijeni da mu na razini primarne zdravstvene zaštite ne može riješiti problem ili da postoji potreba za drugim mišljenjem. Najčešći psihički poremećaji u OM su neuroze, afektivni poremećaji povezani sa stresom i somatoformni otkloni, označeni šiframa F40-F48 u MKB-10. Cilj ovog istraživanja je utvrditi opseg i razlog te procijeniti opravdanost upućivanja bolesnika iz ordinacije LOM-a psihijatru. Retrospektivnim, presječnim istraživanjem prikupljeni su podaci iz elektronskog zdravstvenog kartona pacijenata registriranih u ordinaciji obiteljske medicine u Kaštel Sućurcu koji su u 2011. godini bili upućeni psihijatru iz bilo kojeg razloga. Iz elektronski vođenog zdravstvenog kartona prikupljani su podaci o bolesniku (matični broj, dob, spol, stručna sprema, status zaposlenja, mjesto stanovanja, bračno stanje, trajanje bolesti, stadij bolesti) te o upućivanju (prvo ili ponovno, tko je indicirao upućivanje, razlog upućivanja, dijagnoza, ishod, procjena opravdanosti, vrsta i količina terapije). Podaci su obrađeni metodama deskriptivne statistike, a opažene razlike provjeravane su χ2 testom. Od ukupno 1665 osiguranika u skrbi, njih 121 (7,26%) od toga 86 (71,07%) muškaraca i 35 (28,93%) žena, tijekom 2011. godine je upućeno psihijatru. Za te osobe je izdano ukupno 498 uputnica, u prosjeku 4,11 po pacijentu. Prema MKB-10 pacijenti su u većini slučajeva upućivani zbog bolesti i stanja označenih šiframa F40-F49 (47,49%) te F30-F39 (22,77%). Prosječno trajanje bolesti za sve ispitanike iznosilo je 4,36 godina. Većina uputnica (89,56%) izdana je za bolesnike koji su bili u kompenziranom stanju. Ponovna ili opetovana upućivanja su bila zastupljena u 467 (93,78%) upućivanja. Najveći broj, njih 343 (68,88%), inicirao je specijalist, većinom za kontrolni pregled, a samo 73 (14,6%) ih je LOM procijenio u potpunosti opravdanima. Na temelju dobivenih rezultata može se zaključiti da većina upućivanja nije bila stručno opravdana: to su mahom bili kompenzirani pacijenti, upućeni na kontrolni pregled ili zbog drugih, administrativnih razloga. Kako bi višom razinom stručnosti mogao zbrinjavati blaže psihičke otklone LOM-u je potrebna promjena društveno-političke paradigme, a vjerojatno i dodatna specijalistička naobrazba.In the Croatian health care system family physicians/ general practitioners (GPs) are supposed to be its “gate keepers”. They are obliged to refer patients to other health care levels when they assess that the patient’s problem could not be solved on primary care level or if there is a need for the second opinion. Neurotic and affective disorders associated with stress and somatoform disorders are highly prevalent in GPs’ among mental and behavioral disorders. The aim of this study was to determine the extent, reasons and justification for referring patients to psychiatric consultation. In this retrospective, cross-sectional study data were collected from electronic medical records of patients, registered at the GP in Kaštel Sućurac, referred to psychiatrist for any reason in 2011. A questionnaire was designed and data were extracted from the electronic medical records, about the patients (personal identification number, age, sex, education, employment status, place of residence, marital status, disease duration, disease stage) and about referrals (first or repeated, who indicated the referral, reason for referral, diagnosis, outcome, assessment of the justification, the type and amount of therapy). Data were analyzed by descriptive statistics with the χ2 test to assess the observed differences. Out of the 1665 registered patients in 2011, 121 (7.3%) were referred to psychiatrist 121 (7.3%); 86(71.1%) men and 35 (28.9%) women. There were altogether 498 referrals, averaging 4.11 per patient. According to the ICD-10, most referrals were coded as F40-F49 (47.49%) and F30-F39 (22.8%). The average duration of those mental and behavioral disorders was 4.36 years. Most consultations (89.6%) were issued for patients in a compensated state. Repeated referrals were highly prevalent: 467 or 93.8%, mostly instigated by the consultants (343 or 68.9%), as regular control or check-up visits. The GP estimated that only 73 referrals (14.6%) were justified. The conclusion is that most mental referrals were not professionally justified. The patients were mostly compensated patients referred for control check ups, often for administrative reasons. A change in sociopolitical paradigm, and possibly some additional psychiatric training for GPs are required In order to resolve less severe mental disorders at the primary care level

Early detection of diabetes mellitus in family medicine

Incidencija dijabetesa melitusa danas zauzima epidemijske razmjere. 90-95% bolesnika cine pacijenti s Tipom 2 dijabetesa. Bolest se sporo razvija, i ima dugu asimptomatsku fazu. Klinicki se otkrije nakon 5-10 godina trajanja. Bolesnik s dijabetesom, zbog komplikacija bolesti, umire ranije od svojih vršnjaka bez dijabetesa. Poznati su pozitivni ucinci ranog otkrivanja bolesti – probiranjem (skriningom). Još nisu nadeni idealni modeli provodenja probiranja za rano otkrivanje bolesti, za otkrivanje stadija povecane glukoze natašte i stadija oštecene tolerancije glukoze. Nisu dobiveni efinitivni odgovori ni na pitanja: tko ce provoditi skrining, gdje ce se provoditi i kako? Kako odrediti rizicne skupine? Kako provoditi probiranje u tranzicijskoj obiteljskoj medicini? Znanost i struka se u jednome slažu: obiteljski lijecnik ima kljucnu ulogu u ranom otkrivanju bolesti.The incidence of diabetes mellitus today precedes epidemic dimensions. 90-95% of diabetic patients have type 2 diabetes. The disease develops slowly, and it has a long asymptomatic phase. Clinical detection comes after 5-10 years of disease duration. Due to disease complications, diabetic patients die earlier than their peers without diabetes. Positive effects of early disease detection (screening) are well known. The perfect models of screening for early diseases detection high level fasting glucose stage and the impaired glucose tolerance stage detection haven’t been found yet. Definitive answers to the following questions haven’t also been found yet – Who will conduct the screening, where and how? How to determine the risk groups? How to conduct the screening in transitional family medicine? Science and profession concur in one thing: the family practitioner has the key role in early disease etection

Chronic patients: persons with diabetes frequent attenders in Croatian family practice

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two group of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p = 0.0005), diet-only-treatment (p = 0.0062), treatment by secondary care (p = 0.0116), and if glycated hemoglobin test (HbA1c) is determined (p = 0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems

PERSONALIZED APPROACH TO PATIENT WITH CHRONIC WOUND IN FAMILY MEDICINE

Pojava rana, cijeljenje, odgođeno cijeljenje i pojam kronične rane možemo reći, osnovna su značajka svih živih bića. Kod čovjeka se u procesu cijeljenja događaju brojni procesi kojima se, čak i u idealnim prilikama, stvara funkcionalno manje vrijedno ožiljno tkivo uz strukturne i funkcionalne promjene. U području ožiljka na mjestima izloženosti većim silama može doći do stvaranja rana. Takve rane otežano cijele unatoč nepostojanju drugih mogućih razloga otežanog cijeljenja. Prisutnost rane kao i dugotrajnost liječenja utječu na sve sfere života bolesnika te dovode do pada kvalitete života. Prikazom bolesnika s posttraumatskom ranom u području ožiljka u našoj ustanovi opisan je model skrbi prema principu sveobuhvatne individualizirane skrbi uz biopsihosocijalni pristup. Dijagnostičko-terapijski postupci uključivali su procjenu rane, prepoznavanje biofi lma, limfedema, ocjenu psihosocijalnog statusa bolesnika, čimbenika rizika za cijeljenje te ultrazvučnu dijagnostiku, primjenu karboksiterapije kao specijalizirane adjuvantne terapije, korištenje suvremenih pokrivala za rane te primjenu kompresivne terapije. U pozitivnom okruženju tijekom liječenja provođena je suportivna psihoterapija. Partnerskim odnosom s bolesnikom utjecalo se ne samo na cijeljenje rane, što je bio primarni cilj, već i na podizanje ukupne kvalitete bolesnikova života kao i na naše profesionalno zadovoljstvo postignutim rezultatom. U skrbi za bolesnike s kroničnim ranama sudjeluju liječnici obiteljske medicine i dio su multidisciplinarnog tima stručnjaka. Za takvu skrb potrebna su dodatna specifi čna znanja i vještine kako bi se mogla pružiti sveobuhvatna kvalitetna skrb kao nadopuna postojećim znanjima, vještinama i iskustvu rada u obiteljskoj medicini.It can be said that the occurrence and development of wounds, healing, delayed healing, and the notion of chronic wound are some of the basic characteristics of all living beings. When it comes to people, there are a number of processes that take place during wound healing, and even under ideal circumstances, they create a functionally less valuable skin tissue, along with structural and functional changes. Fibrosis in the form of hypertrophic scars and keloids, contractures and adhesions are examples of excessive healing. Microcirculation is signifi cantly different from healthy skin circulation with consequential formation of local hypoxia and stagnation in lymph fl ow with edema. Poor functionality of the scar tissue, particularly in the areas exposed to stronger forces, can cause forming of wounds. Such wounds are hard to heal despite the inexistence of other possible reasons for delayed healing, precisely because of their poor functionality and placement. The presence of wound requiring long-term treatment affects all areas of patient life and leads to decline in the quality of life. Exemplifi ed by case presentation of a patient with post-traumatic wound in the scar area, in our offi ce we showed a model of care based on the principle of overall personalized care with the biopsychosocial approach. Diagnostic and therapeutic procedures included wound assessment, biofi lm and lymphedema detection, assessment of the patient’s psychosocial status, risk factors for wound healing, vascular ultrasound diagnostics, carboxytherapy as specialized adjuvant therapy, use of modern wound dressings, and compression therapy. Supportive psychotherapy was conducted in positive communication environment during treatment. In this way, in an atmosphere of cooperation with the patient, it was possible not only to infl uence the process of wound healing as the primary objective, but also to improve the quality of the patient’s life, as well as to infl uence our professional satisfaction with the results achieved. Family doctors are involved in the care of chronic wound patients as part of the multidisciplinary team of experts. Additional specifi c knowledge and skills are required for such care in order to ensure overall quality care as a supplement of the existing knowledge, skills and working experience in family medicine

Peripartal leukogram in cows with and without retained placenta

The aim of this study was to investigate whether prepartal leukogram in cows with retained placenta could indicate the presence of subclinical systemic inflammatory response before the onset of disease. After calving, sixteen highly pregnant Holstein cows, aged 3 to 9 years, without clinical signs of the disease prior to calving were divided into two groups: the first group (n=9) were animals without retained placenta, or any visible inflammation after birth; the second group (n=7) were cows with retained placenta. Blood was sampled three times before parturition, at intervals of one week, and once 24 hours after birth. The number of total leukocytes, segmented and non segmented neutrophilic granulocytes (NG), lymphocytes and monocytes were determined by standard laboratory techniques. The results have shown that in the group of cows with retained placenta the number of mature neutrophils was slightly elevated in the third, second and last week before calving, and equal number of non segmented neutrophils in regard to the group with no retention. The results have also shown that, in both groups of cows, 24 hours after calving, the number of total leukocytes and the number of segmented neutrophils decreased, but the number of the non segmented neutrophils increased. Based on this, we can conclude that cows with retained placenta had no systemic inflammatory response during three weeks prepartal period, but 24 hours after calving, systemic inflammatory response was documented in all the cows. Moreover, the intensity of inflammatory response in cows with retained placenta was not more pronounced in comparison to cows without retained placenta. [Projekat Ministarstva nauke Republike Srbije, br. 175061