Uspješnost liječenja ovisnika o opijatima zamjenskom terapijom metadonom u obiteljskoj medicini u Hrvatskoj [The efficacy of tretment of patients with opioid dependence treated with methadone in a family medicine setting in Croatia]

Patients with opioid dependence are chronic patients represented in a family physician's everyday work. The aim of this study was to evaluate efficacy of treatment of patients with opioid dependence treated with methadone in a family medicine setting in Croatia. The study was carried out from January 31, 1995 to January 31, 2007 in Novi Zagreb. Data were collected through personal interviews with family physicians, as well as by examing personal medical information sheets and included sociodemographic data about patients and data about treatment characteristics. The data collected at the annual check-up included the data about treatment outcomes. There were 256(82.05%) male and 56(17.95%) female patients with opioid dependence, average aged 26 years at the beginning of the treatment. During the present study, 225(72,1%) patients with opioid dependence treated with methadone in a family medicine setting achieved continuity of care and better outcomes in a treatment and 229(73,4%) patients with opioid dependence treated with methadone in a family medicine setting achieved retention in a treatment and better outcomes in a treatment. Treatment of the patients with opioid dependence with methadone in a family medicine setting provides accessibility of treatment, continuity of care and retention in a treatment

Sideropenic anemia as a predictor of celiac disease - case report

Celijakija ili glutenska enteropatija je imunološka reakcija na gluten, protein koji nalazimo u pšenici, ječmu i raži. Epidemiološki gledano, učestalost celijakije u SAD-u iznosi oko 1%. Slična situacija se bilježi i u većini europskih zemalja, iako se njena prevalencija u sjevernoj Europi kreće i do 3%. Unošenje glutena izaziva imunološki odgovor u tankom crijevu koji s vremenom oštećuje njegovu sluznicu, odnosno crijevne resice i time sprečava apsorpciju nužnih nutrijenata (malapsorpcija). Posljedica uništenih crijevnih resica je pojava simptoma kao što su proljev, mučnina, nadutost te gubitak tjelesne težine. Sve navedeno može dovesti do ozbiljnih komplikacija. Znakovi i simptomi bolesti se razlikuju ovisno o dobi pa tako odrasle osobe često imaju simptome i znakove koji nisu nužno neposredno povezani s intestinalnim traktom, a anemija uzrokovana nedostatkom željeza se uobičajeno ubraja u tu skupinu znakova. Cilj ovog prikaza slučaja je opisati tijek bolesti i dijagnostike kod mladog pacijenta kojemu je sideropenična anemija bila prediktor bolesti. Također je bitno istaknuti širok spektar simptoma i varijacije u njihovoj ekspresiji što čini menadžment bolesti također vrlo raznolikim te je osim primjene zadanih smjernica nužan individualan pristup pacijentu, konstantno praćenje bolesti u čemu liječnik obiteljske medicine ima izuzetnu i nezamjenjivu ulogu.Celiac disease or gluten - sensitive enteropathy is an immune reaction to eating gluten, the protein found in wheat, barley and rye. Epidemiologically, the average frequency of celiac disease in the United States is about 1%. Similar situation is observed in most European countries, although its prevalence in northern Europe is up to 3%. Gluten intake triggers immune response in the small intestine. Over time, this reaction damages small intestine’s lining thereby preventing the absorption of necessary nutrients (malabsorption). The result of intestinal damage is the onset of signs such as diarrhea, fatigue, bloating and weight loss. All of this can lead to severe complications. Signs and symptoms of the celiac disease can vary greatly according to age. Adults often have symptoms and signs that are not necessarily directly related to the intestinal tract. Anemia caused by iron deficiency is commonly considered in that group of signs. The goal of this case report is to provide insight into diagnosis and the course of disease in a young patient with sideropenic anemia as a predictor of the celiac disease. It is also important to highlight a wide spectrum of symptoms and variations in their expression, which makes the management of the disease also very diverse. Individual access to the patient, apart from the application of the given guidelines, is necessary as well as constant monitoring of the disease in which the family medicine physician has an exeptional and irreplaceable role

COMMUNICATION AND HEALTH OUTCOMES IN PATIENTS SUFFERING FROM GASTROINTESTINAL DISEASES

Unatoč rezultatima istraživanja koji ukazuju na jasnu povezanost komunikacije liječnika i pacijenta i zdravstvenog ishoda, nedovoljno su jasni mehanizmi njihova djelovanja. Iako razgovor sam po sebi može biti terapijski (umanjenjem pacijentove tjeskobe, pružanjem nade i utjehe), komunikacija između liječnika i pacijenta većinom utječe na zdravstvene ishode neizravnim putem. Proksimalni ishodi interakcije uključuju razumijevanje, povjerenje i dogovor liječnika i pacijenta. Navedeno utječe na intermedijarne ishode (povećanje adherentnosti, bolju vještinu samokontrole i samoliječenja) te u konačnici na zdravlje i blagostanje pacijenta. Sedam je domena putem kojih komunikacija može dovesti do unaprjeđenja zdravlja: povećanjem dostupnosti skrbi, povećanjem pacijentova poznavanja karakteristika bolesti i liječenja, zajedničkim razumijevanjem problema, donošenjem kvalitetnih medicinskih odluka, unaprjeđenjem terapijskog saveza, jačanjem socijalne podrške, jačanjem osnaženosti i zastupanja pacijenta, te povećanjem pacijentove sposobnosti nošenja s emocijama. Iako su ove domene utvrđene temeljem potreba onkološkog pacijenta, one su svakako primjenjive i u drugim zdravstvenim stanjima, pa tako i u skrbi bolesnika koji boluju od gastrointestinalnih bolesti.Although survey results indicate clear connection between the physician-patient communication and health outcomes, mechanisms of their action are still insuffi ciently clear. The aim was to investigate the specifi city of communication with patients suffering from gastrointestinal diseases and the impact of good communication on measurable outcomes. We performed PubMed (Medline) search using the following key words: communication, health outcomes, and gastrointestinal diseases. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. Although these pathways were explored with respect to cancer care, they are certainly applicable to other health conditions as well, including the care of patients suffering from gastrointestinal diseases. Although proposing a number of pathways through which communication can lead to improved health, it should be emphasized that the relative importance of a particular pathway will depend on the outcome of interest, the health condition, where the patient is in the illness trajectory, and the patient’s life circumstances. Besides, research increasingly points to the importance of placebo effect, and it is recommended that health professionals encourage placebo effect by applying precisely targeted communication skills, as the unquestionable and successful part of many treatments. It is important that the clinician knows the possible positive and negative effects of communication on health outcomes, and in daily work consciously maximizes therapeutic effects of communication, reaching its proximal (understanding, satisfaction, clinician-patient agreement, trust, feeling known, rapport, motivation) and intermediate outcomes (access to care, quality medical decision, commitment to treatment, trust in the system, social support, self-care skills, emotional management) to improve the health of patients he cares for

ABPM – Ambulatory Blood Pressure Monitoring in Family Medicine Office

Kontinuirano mjerenje arterijskog tlaka (KMAT) ili holter tlaka, neinvazivna je metoda mjerenja arterijskog tlaka. Tlak se mjeri kontinuirano, u točno određenim vremenskim intervalima kroz 24 sata, čime se donosi ispravnija vrijednost kretanja arterijskog tlaka tijekom dana, ali i noću, pri obavljanju svakodnevnih aktivnosti u pacijentu poznatom okruženju. Mnogobrojne studije i smjernice potvrđuju kako je upravo KMAT najznačajniji prediktor budućih srčanožilnih događaja i oštećenja ciljnih organa. Njegova je korist višestruka. Omogućuje snimanje i prikaz kretanja arterijskog tlaka u 24 sata, što je daleko značajnije od jednokratnog povremenog ambulantnog mjerenja tlaka. Omogućuje identifikaciju pacijenata sa “sindromom bijele kute”, pacijente s maskiranom hipertenzijom. Pomaže u otkrivanju hipotenzivne krize u pacijenata na antihipertenzivnoj terapiji. Pokazuje kakav je odgovor na liječenje antihipertenzivima. Može davati uvid u prognozu bolesti jer su više vrijednosti arterijskog tlaka izmjerene KMAT-om povezane s povećanim mortalitetom. Koristi se i u istraživačke svrhe te je dugotrajno isplativiji u odnosu na ambulantno mjerenje arterijskog tlaka. Studije su pokazale kako su vrijednosti KMAT-a jače povezane s ciljnim oštećenjem ograna u odnosu na jednokratno mjerenje (hipertrofija lijeve klijetke, proteinurija, porast kreatinina, smanjenje glomerularne filtracije, aterosklerotski plakovi, okluzija retinalnih arterija, krutost arterija i smanjena rastezljivost). Aktualne smjernice svih značajnih stručnih društava kako Hrvatske tako i Europe i svijeta naglašavaju njegovu uporabu u primarnoj zdravstvenoj zaštiti te je trenutno najispravniji alat u postavljanju i zbrinjavanju dijagnoze arterijske hipertenzije.Ambulatory blood pressure monitoring (ABPM) is non invasive method for obtaining blood pressure readings continuously over a 24-hour period giving information about blood pressure during the day and night, while performing usual daily activities in the patient’s known environment. Many studies and guidelines showed that this was the most significant predictor of future cardiovascular events and damages of the target organs. ABPM has multiple value. It enables recording and displaying arterial pressure during 24 hours, what is far more important than occasional ambulatory blood pressure measurement. It identifies patients with “white coat syndrome” and patients with masked hypertension. It also helps detecting a hypotensive crisis in patients on antihypertensive therapy and shows the response to antihypertensive treatment. It can give an insight into the prognosis of the disease because higher values of arterial pressure measured by ABPM are associated with increased mortality. It is also used for research purposes, and has higher costeffective impact than ambulatory measurement of arterial pressure. The studies showed that ABPM findings are more closely related to target organs damage such as: left ventricular hypertrophy, proteinuria, creatinine increase, glomerular filtration reduction, atherosclerotic plaques, retinal artery occlusion, arterial stiffness, and reduced stretchability. Current guidelines of today’s relevant professional societies, both Croatian and European, emphasize its use in primary health care, and is currently the most advanced tool in setting up and managing the diagnosis of arterial hypertension

Recognition and treatment of depression in patients with chronic physical diseases in family practice

U svakodnevnom radu obiteljskog liječnika, depresija je česta i još uvijek nedovoljno prepoznata bolest. Cilj ovoga rada je pregledom literature istražiti značajke prepoznavanja (dijagnosticiranja) i liječenja depresije u bolesnika s kroničnom tjelesnom bolešću (KTB) u ordinaciji obiteljskoga liječnika. Pretraživana je baza podataka PubMed, a kriterijima uključivanja udovoljavali su radovi pisani na hrvatskom ili engleskom jeziku, objavljeni između 2000. i 2018. godine. Postupnim sužavanjem pretraživane tematike definirane su 93 publikacije. Uočeno je da simptomi depresije mogu biti maskirani simptomima KTB. Povećan broj posjeta bolesnika s KTB obiteljskom liječniku prepoznaje se kao čimbenik koji je unaprijedio prepoznavanje simptoma depresije. Publikacije koje su sadržajem analizirale liječenje depresije ukazuju na potrebu da se, uz farmakološko liječenje antidepresivima, trebaju provoditi i učinkovite psihoterapijske tehnike. Prepoznavanje i liječenje depresije veliki je izazov za zdravstveni sustav današnjice, ali i veliki izazov u svakodnevnom radu obiteljskih liječnika.Depression is a common disease in a family physician\u27s daily work but is still not sufficiently recognized. The aim of this paper is to examine the characteristics of diagnosis and treatment of depressed patients without chronic physical disease (CPD) compared to those with depression and one or more CPDs. The PubMed database was searched. The inclusion criteria met the articles written in Croatian or English, published between 2000 and 2018. By gradual filtration of the searched topics, 93 publications were selected. It was found that symptoms of depression can be masked by the symptoms of CPD. An increased number of visits to family physician was recognized as a factor that improved the recognition of depression. Publications that analyzed the treatment of depression indicate the need for effective psychotherapy techniques along the pharmacological treatment with antidepressants. Recognizing and treating depression is a major burden to today\u27s healthcare system and a major challenge in the family physician\u27s daily work

Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia

Aim To determine the risk factors for fatal outcome in patients with opioid dependence treated with methadone at the primary care level. Methods A group of 287 patients with opioid dependence was monitored prospectively from 1995 to 2007. At the beginning of the study, we collected the data on patient baseline characteristics, treatment characteristics, and living environment. At the annual check-up, we collected the data on daily methadone dose, method of methadone therapy administration, and family physician’s assessment of the patient’s drug use status. Results Out of 287 patients, 8% died. Logistic regression analysis showed that the predictors of fatal outcome were continuation of drug use during previous therapeutic attempts (odds ratio [OR], 19.402; 95% confidence interval [CI], 1.659-226.873), maintenance therapy as the planned treatment modality (OR, 3.738; 95% CI, 1.045-13.370), living in an unstable relationship (OR, 9.275; 95% CI, 2.207- 38.984), and loss of continuity of care (OR, 12.643; 95% CI, 3.001-53.253). Conclusion The patients presenting these risk factors require special attention. It is important for family physicians to insist on compliance with the treatment protocol and intervene when they lose contact with the patient to prevent the fatal outcome

“Grandma’s Old Tricks“- A Qualitative Study of Lay People’s Experiences in Treatment and Prevention of Common Cold and Influenza

We aimed to explore lay people’s perception of common cold and influenza as well as their experience in treatment and prevention of those conditions, with emphasis on the reasons impacting their decision towards influenza vaccination. 24 semi-structured, individual interviews were conducted, then transcribed and analysed to find emerging themes and sub-themes. Textual data were explored inductively using content analysis to generate categories and explanations. Five major themes and explanatory models of lay people’s perspective emerged from the data. The participants expressed satisfying knowledge regarding influenza and common cold symptoms, length, transfer and treatment options as well as described a clear distinction between those two diseases. On the other hand, they emphasized the same general preventative measures for both common cold and influenza, considering influenza vaccination primarily an option for chronic, old or bedridden patients and health workers. Facilitators in the vaccination decision making process were health professionals’ (mostly general practitioners’) recommendation, anxiety regarding influenza and possible complications, existence of chronic diseases and positive vaccination experience. As main reasons against vaccination participants stated perception of being at low risk for influenza, opinion that vaccination is necessary only for bedridden and old people, chronic patients or health workers and questionable effectiveness of the vaccine. Participants’ influenza vaccination knowledge was insufficient, which should direct further interventions, especially having in mind low vaccination rates. Since participants perceived general practitioner’s recommendation as a crucial facilitator in forming their positive attitude towards vaccination, practitioners are invited to assess and, when needed, modify inappropriate perception towards influenza prevention when leading person centred consultations

Drug prescribing – daily activity in the work of family physicians

Propisivanje lijekova je jedna od svakodnevnih aktivnosti u radu obiteljskog liječnika. Uloga liječnika obiteljske medicine kao čuvara ulaza u zdravstveni sustav, osobna, stručna i moralna odgovornost te obaveza racionalnog raspolaganja sredstvima u zdravstvenom sustavu utječu kako na donošenje svakodnevnih odluka u pružanju zdravstvene skrbi, tako i na propisivanje lijekova. Liječnik obiteljske medicine skrbi za čovjeka kao cjelovitu osobu u njenom okruženju, uvažavajući biološke, psihološke, socijalne i kulturne značajke. Kod pacijenata s multimorbiditetom gotovo je neizbježna istovremena uporaba velikog broja lijekova, što je povezano s većim rizikom razvoja nuspojava i interakcija te polipragmazije. Rast troškova vezanih uz propisivanje lijekova bilježi se u svim razvijenim zemljama Europe i svijeta, ali i u Republici Hrvatskoj. Posebni izazov u svakodnevnom radu obiteljskog liječnika je racionalno propisivanje lijekova u osoba koje istovremeno boluju od više kroničnih bolesti kao i osoba starije dobi. U navedenim skupinama bolesnik od velike je važnosti poznavanje bolesnika kroz dulje vrijeme kao i kontinuitet skrbi koji osigurava obiteljski liječnik. Obiteljski liječnik pri propisivanju lijekova treba se voditi medicinom zasnovanoj na dokazima, ali i principima bolesniku usmjerene skrbi koji će osigurati suradljivost bolesnika te posljedično postizanje željenih ishoda u liječenju.Drug prescribing is one of the daily activities in the work of family physicians. The role of family physicians as gate keepers of health care system, personal, professional and moral responsibility and obligation of rational allocation of resources in the health care system affect everyday decision-making in the delivery of health care and drug prescribing. Family physicians’ care for patient as a complete person, is taking into account his/her biological, psychological, social and cultural features. Patients with multimorbidity use more than one drug, what is associated with a higher risk for adverse reactions and interactions and poly pharmacy. The costs for drug prescription are increasing in all developed countries of Europe and world, in Croatia as well. A challenge in the daily work of family physicians is rational drug prescribing to people with multimorbidity and elderly people. Knowing the patient for a long time as well as continuity of care is essential to ensure the family physicians’ good care. In drug prescribing evidence-based medicine should be applied, but also the principles of patientcentered care that will ensure compliance and achievement of the desired outcomes

Stavovi obiteljskih liječnika o elektroničkim alatima i dostupnosti, uporabi i pridržavanju smjernica za prevenciju kardiovaskularnih bolesti u Hrvatskoj

Family physicians are burdened with a great number of guidelines considering different conditions they treat. We analyzed opinions of family physicians on electronic tools which help managing chronic conditions and their influence on patient care by cardiovascular disease (CVD) prevention guideline availability, usage and adherence. A descriptive study was performed on a convenient sample of 417 (response rate 56.0%) Croatian family physicians. Data on physician characteristics and availability, usage and adherence to CVD prevention guidelines were analyzed. The χ2-test was used for comparisons. Significance was defined as p<0.05. Family physicians who used additional electronic tools in Electronic Health Record software on more than 80% of their patients had CVD prevention guidelines more available (p<0.01) and used them more frequently (p<0.01). A group who used electronic tools on more than 80% of their patients had CVD prevention guidelines available to them frequently and used them on more than 60% of their patients, also strictly adhering to the guidelines (p<0.01). Physicians who used CVD prevention guidelines on more than 60% of their patients spent more time doing patient education (p=0.036). Using electronic tools helps Croatian family physicians in terms of availability, usage and adherence to the guidelines and quality improvement.Obiteljski liječnici su u radu opterećeni velikim brojem smjernica za različite bolesti. Analizirali smo njihovo mišljenje o elektroničkim alatima koji im pomažu u skrbi za bolesnike s kroničnim bolestima i njihovom utjecaju na dostupnost, uporabu i pridržavanje smjernica za prevenciju kardiovaskularnih bolesti (KVB). Provedeno je opisno istraživanje na uzorku od 417 (stopa odgovora 56,0%) hrvatskih obiteljskih liječnika. Analizirani su podaci o značajkama liječnika, dostupnosti, upotrebi i pridržavanju smjernica za prevenciju KVB. Za usporedbe je primijenjen χ2-test. Statistička značajnost je definirana kao p<0,05. Obiteljski liječnici koji su rabili dodatne elektroničke alate za više od 80% svojih bolesnika imali su dostupnije smjernice za prevenciju KVB (p<0,01) i više su ih upotrebljavali (p<0,01). Liječnici koji su istodobno rabili elektroničke alate na više od 80% svojih bolesnika često su imali na raspolaganju smjernice za prevenciju KVB i upotrebljavali su ih na više od 60% svojih bolesnika, a ujedno su se strogo pridržavali smjernica (p<0,01). Liječnici koji su rabili smjernice za prevenciju KVB na više od 60% svojih bolesnika proveli su i više vremena obrazujući svoje bolesnike (p=0,036). Primjena elektroničkih alata pomaže obiteljskim liječnicima u Hrvatskoj u pogledu dostupnosti, upotrebe i pridržavanja smjernica te unaprjeđenju kvalitete skrbi

Kontinuum u stjecanju kompetencija za rad u obiteljskoj medicini u Republici Hrvatskoj

Integriranje novih znanstvenih spoznaja u kurikule medicinskih fakulteta (MF) i programe specijalističkog usavršavanja doktora medicine te postizanje podudarnosti stečenih kompetencija sa stvarnom zdravstvenom potrebom pučanstva izazovi su obrazovanja doktora medicine 21. stoljeća. Kako je obiteljski liječnik temelj dobro organiziranoga zdravstvenog sustava, neophodno je osigurati njegovu dobro strukturiranu izobrazbu. Cilj ovoga rada jest opisati obrazovanje obiteljskih liječnika u Republici Hrvatskoj i usporediti ga sa standardima izobrazbe obiteljskih liječnika Europske unije. Europska akademija nastavnika opće/obiteljske medicine (EURACT) dala je preporuke za petnaest obveznih tema koje treba sadržavati predmet Obiteljska medicina u okviru studija medicine te preporuke za specijalističko usavršavanje iz obiteljske medicine koje treba biti više praktičnog nego teorijskog karaktera. U RH kurikuli svih četiriju MF imaju predmet Obiteljska medicina. Predmet Obiteljska medicina MF-a u Zagrebu uključuje svih petnaest tema sukladno preporukama EURACT-a, implementaciju instrumenta za neposredno nadgledanje proceduralnih vještina, izradu e-portfolija i poticanje učenja kroz stjecanje kliničkoga iskustva tijekom boravka u nastavnim praksama obiteljske medicine (OM). Predmet Obiteljska medicina MF-a u Splitu uključuje svih petnaest tema sukladno preporukama EURACT-a za diplomski studij medicine te organizaciju kliničke nastave koja uključuje boravak studenata i u gradskim i u otočkim nastavnim praksama OM. Nastava predmeta Obiteljska medicina na MF-u u Rijeci podrazumijeva teorijsku i praktičnu nastavu u nastavnim praksama OM te izradu pismenih odgovora na odabrano kliničko pitanje koje se temelji na iskustvu rada s bolesnikom. Nastava iz OM na MF-u u Osijeku izvodi se kroz integrirani program „Obiteljska medicina, školska medicina i medicinska sociologija” te uključuje kombinaciju kliničke nastave u nastavnim praksama OM i vježbi u kabinetu vještina. Četverogodišnji program specijalističkog usavršavanja iz OM temelji se na definiranim kompetencijama te podrazumijeva da specijalizant polovinu specijalističkog usavršavanja provodi u ordinaciji mentora koja je akreditirana za specijalističko usavršavanje iz OM. Slijedom navedenoga izobrazba obiteljskih liječnika u RH u skladu je s europskim i globalnim preporukama