Bolesnik sa srčanom insuficijencijom – izazov za lekara porodične medicine

Srčana insuficijencija (SI) predstavlja veliki problem javnog zdravlja. Učestalostse, za razliku od drugih kardiovaskularnih bolesti, povećava. Tome doprinosistarenje stanovništva i efikasnost lečenja etioloških činilaca kardiovaskularnihbolesti, naročito ishemijske bolesti srca. Pacijenti sa SI najčešće traže pomoćkod svog izabranog doktora, pa su tako oni česti posetioci ambulanti porodičnemedicine. Njihovo stanje je ozbiljno, sa lošom prognozom i kvalitetomživota, sa potrebom za čestim hospitalizacijama, a prosečno preživljavanjenakon postavljanja dijagnoze je pet godina. Vođenje bolesnika sa SI predstavljaizazov za svakog lekara porodične medicine. Pažljivo uzimanje anamneze je odvelike važnosti, jer simptomi upozoravaju lekara na mogućnost postojanja SI.Ipak, oni su relativno česti u opštoj populaciji i ponekad ih je teško objasniti,posebno kod starih osoba, gojaznih i kod žena. Njihova prediktivna vrednostje niska, zato ih treba tumačiti oprezno i sprovoditi detaljnu dijagnostikupomoću metoda koje su dostupne i na raspolaganju lekaru porodične medicineu svakodnevnoj praksi. Pacijentima sa SI potreban je pregled kardiologa kojiće dopunskim pretragama potvrditi dijagnozu SI. U lečenju SI, lekar porodičnemedicine ima važnu ulogu ne samo u pružanju savremene terapije nego i usavetovanju i podsticanju pacijenta da provodi nefarmakološke mere, kaoi da odgovori na pitanja pacijenta koja se ne odnose samo na bolest, negoi na kvalitet života. Na kraju života, u terminalnoj fazi SI, lekar porodičnemedicine je često jedini koji ostaje na raspolaganju pacijentima i porodicamau palijativnom zbrinjavanju

Difference in end-tidal CO(2 )between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting

INTRODUCTION: There has been increased interest in the use of capnometry in recent years. During cardiopulmonary resuscitation (CPR), the partial pressure of end-tidal carbon dioxide (PetCO(2)) correlates with cardiac output and, consequently, it has a prognostic value in CPR. This study was undertaken to compare the initial PetCO(2 )and the PetCO(2 )after 1 min during CPR in asphyxial cardiac arrest versus primary cardiac arrest. METHODS: The prospective observational study included two groups of patients: cardiac arrest due to asphyxia with initial rhythm asystole or pulseless electrical activity, and cardiac arrest due to acute myocardial infarction or malignant arrhythmias with initial rhythm ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). The PetCO(2 )was measured for both groups immediately after intubation and then repeatedly every minute, both for patients with and without return of spontaneous circulation (ROSC). RESULTS: We analyzed 44 patients with asphyxial cardiac arrest and 141 patients with primary cardiac arrest. The first group showed no significant difference in the initial value of the PetCO(2), even when we compared those with and without ROSC. There was a significant difference in the PetCO(2 )after 1 min of CPR between those patients with ROSC and those without ROSC. The mean value for all patients was significantly higher in the group with asphyxial arrest. In the group with VF/VT arrest there was a significant difference in the initial PetCO(2 )between patients without and with ROSC. In all patients with ROSC the initial PetCO(2 )was higher than 10 mmHg. CONCLUSIONS: The initial PetCO(2 )is significantly higher in asphyxial arrest than in VT/VF cardiac arrest. Regarding asphyxial arrest there is also no difference in values of initial PetCO(2 )between patients with and without ROSC. On the contrary, there is a significant difference in values of the initial PetCO(2 )in the VF/VT cardiac arrest between patients with and without ROSC. This difference could prove to be useful as one of the methods in prehospital diagnostic procedures and attendance of cardiac arrest. For this reason we should always include other clinical and laboratory tests

Predictors of High Prescribing Rates in Family Practice during Actual Consultation: A Cross-sectional Study from Slovenia

With a cross-sectional survey wich was held on in Slovenia we would like to define the predictors of high prescribing rates in family practice. 42 involved family doctors reported 300 office contacts, i.e. a total of 12,596 contacts. The participants were asked to fulfil the questionnaire for each patient-doctor encounter in one day. In 12,596 recorded contacts, 14.485 prescriptions were issued to the patients. The patients got from 0 to 10 prescriptions per visit (X±SD: 1.2±1.4). Among 7,363 (58.5%) patients, who got at least one prescription, the mean number of prescriptions was 2.0±1.4. The majority of prescribed drugs were for cardiovascular system. The multivariate model for higher number of prescribed drugs explained 20.2% of the variation. Independent predictors for higher prescribing rates during a consultation were female sex, older age, higher number of problems dealt within the consultation (comorbidity), longer consultation times, lower education grade, higher patient quota on the list, higher prescribing quota indexed by NHII for the past year, being a specialist in family medicine, male doctor and age of doctor more than 44 years. Practice characteristics did not show any correlations with high prescribing volumes. The results of this survey show that some patients’ and doctors’ characteristics and also some consultations’ characteristics affect the prescribing rate. Additional analyses should be performed to identify reasons for that and to propose proper actions

Validation of the Slovenian Version of Patient Assessment of Chronic Illness Care (PACIC) in Patients with Coronary Heart Disease

The Chronic Care Model (CCM) is a conceptual framework that supports the evidence-based proactive and planned care of chronic diseases. Our aim was to validate a Slovenian translation of Patient Assessment of Chronic Illness Care (PACIC) – a self-reported instrument designed to measure the extent to which patients with chronic illnesses receive care congruent with CCM – on a sample of patients with coronary heart disease. Secondary analysis of patients’ evaluation of general practice care (EPA Cardio study) was done in patients with coronary heart disease in Slovenia. Patients completed a written questionnaire, which included the instrument for assessing chronic illness care (PACIC), the EUROPEP questionnaire and demographical data. Internal consistency was expressed in terms of Cronbach’s á. Reliability was expressed as the intra class correlation coefficient (ICC). Correlation between PACIC and EUROPEP was considered as a measure of construct validity. Factor analysis was done to identify number and types of domains in the instrument. Questionnaires of 843 patients were analysed. The mean age was 68.2 (SD 11.1) years, 34.6% of participants were female. 32.7% of PACIC questionnaires were not completely fulfilled. The internal consistency of the entire questionnaire assessed by Cronbach’s á was 0.953 and reliability was 0.937. Construct validity was confirmed with important and significant correlation between PACIC and EUROPEP questionnaire (Spearman’s correlation coefficient =0.60, p<0.001). Principal component factor analysis identifies two major factors which we labeled according to the PACIC domains as »Patient activation, decision support and problem solving« and »Goal settings and coordination«. A translated and validated Slovenian version of PACIC questionnaire is now available. Further research on its validity in other groups of chronically ill patients and the use of instrument for monitoring changes of chronic care over time is recommended

Selective Portal Vein Embolization as Introduction in Major Surgery

In the period between the December 2000 and September 2004, altogether 13 patients underwent preoperative portal vein embolization (PPVE); 9 patients with colorectal metastases and 4 patients with hepatocellular carcinoma. The indirect splenic portography was performed after catheter was introduced into superior mesenteric artery via femoral artery approach. The portal vein was punctured percutaneously transhepatic under fluoroscopy. Following portography, selected portal vein segments were embolized by injecting polyvinil alcohol (PVA) particles until stasis of blood flow was achieved. Proximal parts of branches and the channel in the liver parenchyma were occluded with Gelfoam particles. The increase of the remnant liver parenchyma was measured by magnetic resonance imaging. Two patients experienced post-embolization syndrome and another one had subcapsular hematoma. The volume of the liver parenchyma increased minimally for 8% and maximally for 109%. Altogether, 10 patients underwent surgical resection. In two patients, the disease progressed and carcinoma spread to the previously healthy liver lobe and in one there was no hypertrophy and we decided for artery chemoembolization (AC). The results show that PPVE triggers a strong regenerative response resulting in hypertrophy of normal liver parenchyma and expand possibilities of curative surgery for patients who would not otherwise have been candidates for extended resection

Comorbidities and characteristics of coronary heart disease patients: their impact on health-related quality of life

Background: Patients with coronary heart disease (CHD) commonly present with more than one comorbid condition, contributing to poorer health-related quality of life (HRQoL). The aim of our study was to identify the associations between HRQoL and patient characteristics, vascular comorbidities and anxiety/depression disorders. Methods: This observational study was conducted in 36 family medicine practices selected by random stratified sampling from all regions of Slovenia. HRQoL was assessed using the European Quality of Life - 5 Dimensions (EQ-5D) questionnaire and EQ Visual Analogue Scale (EQ-VAS). The associations between HRQoL and patient characteristics stratified by demographics, vascular comorbidities, health services used, their assessment of chronic illness care, and anxiety/depression disorders were identified by ordinal logistic regression and linear regression models. Results: The final sample included 423 CHD patients with a mean age of 68.0 ± SD 10.8 years35.2% were female. Mean EQ-VAS score was 58.6 ± SD 19.9 (median: 60 with interquartile range of 45–75), and mean EQ-5D index was 0.60 ± SD 0.19 (median: 0.56 with interquartile range of 0.41–0.76). The statistically significant predictors of a lower EQ-VAS score were higher family physician visit frequency, heart failure (HF) and anxiety/depression disorders (R² 0.240F = 17.368p < 0.001). The statistically significant predictor of better HRQoL, according to EQ-5D was higher patient education, whereas higher family physician visit frequency, HF and peripheral artery disease (PAD) were predictors of poorer HRQoL (Nagelkerke R 2 = 0.298χ 2 = 148.151p < 0.001). Conclusions: Results of our study reveal that comorbid conditions (HF and PAD), family physician visit frequency and years in education are significant predictors of HRQoL in Slovenian CHD patients

Correlation of coronary heart disease patient assessments of chronic illness care and quality of care procedures

Purpose: Patient-centered assessment of chronic illness care is replacing the assessment of satisfaction, which does not cover all dimensions of care. Pa- tient assessments reflect both the qual- ity of chronic illness care and provide feedback to healthcare workers about their work. The study aim was to inves- tigate the patient-centered assessment of coronary heart disease (CHD) pa- tients and its correlation with the care that was delivered. Methods: This cross-sectional study evaluated data obtained from the patient medical records and surveyed patients using the Patient Assessment of Chronic Illness Care (PACIC) ques- tionnaire. A descriptive analysis of the overall and domain-specific responses to the PACIC questionnaire was con- ducted and the association of the results with delivery of care data in the patient records was determined by Pearson\u27s correlation coefficient. Results: The study sample included 768 of 1080 CHD patients (71,1%) at 36 family medicine practices who com- pleted the PACIC questionnaire. The mean age of the re- spondents was 68.3 +- 10.7 years and the overall PACIC score was 3.3 +- 0.9. The highest PACIC scores were deliv- ery system design (3.7), patient activation (3.7), and prob- lem solving (3.6). Follow-up received the lowest score (2.8). Quality of delivered care and PACIC scores were correlated (r = 0.10, p = 0.009). Conclusions: CHD patients highly rated all aspects of chronic care included in the PACIC questionnaire. They were least satisfied with the follow-up and coordination as- pects of chronic care. The process indicators of care were positively correlate with patient assessment of care