Teaching evidence based medicine in family medicine

The concept of evidence based medicine (EBM) as the integrationof clinical expertise, patient values and the best evidence was introduced by David Sackett in the 1980’s. Scientific literature in medicine is often marked by expansion, acummulation and quick expiration. Reading all important articles to keep in touch with relevant information is impossible. Finding the best evidence that answers a clinical question in general practice (GP) in a short time is not easy. Five useful steps are described –represented by the acronym “5A+E”: assess, ask, acquire, appraise, apply and evaluate.The habit of conducting an evidence search “on the spot’’ is proposed. Although students of medicine at University of Split School of Medicine are taught EBM from the first day of their study and in all courses, their experience of evidence-searching and critical appraisal of the evidence, in real time with real patient is inadequate. Teaching the final-year students the practical use of EBM in a GP’s office is different and can have an important role in their professional development. It can positively impact on quality of their future work in family practice (or some other medical specialty) by acquiring this habit of constant evidence-checking to ensure that best practice becomes a mechanism for life-long learning. Conclusion. EBM is a foundation stone of every branch of medicine and important part of Family Medicine as scientific and professional discipline. To have an EB answer resulting from GP’s everyday work is becoming a part of everyday practice

COCHRANE SYSTEMATIC REVIEWS ON PROSTATE CANCER

Karcinom prostate je česti maligni tumor osoba starije dobi, koji zauzima značajan udio u ukupnom morbiditetu, ali vrlo malen u mortalitetu. U Republici Hrvatskoj je prema učestalosti drugi najčešći tumor u muškaraca. Oko probira, ranog otkrivanja i liječenja karcinoma prostate postoje mnoge dvojbe. Zato su u članku prikazani rezultati svih Cochrane sustavnih preglednih članaka (SR) s temom karcinoma prostate, koji su objavljeni u posljednjih osam godina. U lipnju 2016.pretražena je Cochrane baza sustavnih preglednih članaka prema ključnim riječima: Systematic Reviews, Prostate Cancer (Malignancy, Neoplasm). Uključni kriterij bio je objava Cochrane SR-a ili njihovih nadopuna u posljednjih osam godina. Učinjen je inicijalni probir sažetaka s uključenjem i/ili isključenjem iz daljnje analize i pribavljeni su cjeloviti tekstovi svih uključenih SR-a. Razvrstani su u četiri tematske cjeline: SR o prevenciji, probiru, liječenju i psihosocijalnim aspektima. Pretraživanjem je pronađeno ukupno 19 Cochrane SR s temom karcinoma prostate. Isključena su četiri članka koja nisu odgovarala specifi čnoj temi, a za preostalih 15 pribavljeni su cjeloviti tekstovi. Od toga je jedan SR bio o probiru, dva o prevenciji, većina odnosno jedanaest o liječenju, a jedan o psihosocijalnim aspektima vezanim uz karcinom prostate. Zaključak: Utemeljeno na rezultatima Cochrane SR o karcinomu prostate, nije opravdan masovni/populacijski probir na ovu bolest. Treba provoditi individualizirani/oportunistički probir u muškaraca dobi 55-69 godina, uvijek potpuno informirajući bolesnika i vodeći računa o mogućim koristima i štetnostima toga postupka.Prostate cancer is a common malignant tumor of the elderly, which accounts for a signifi cant proportion of total morbidity but very low of mortality. In Croatia, it is the second most common cancer in men. Currently, there are many doubts concerning screening, early detection and treatment of prostate cancer. Therefore, this article brings results of Cochrane systematic reviews (SRs) on the topic of prostate cancer published in the last eight years. In June 2016, Cochrane database of systematic reviews was searched using the following keywords: Systematic Reviews, and Prostate Cancer (Malignancy, Neoplasm). Inclusion criterion was publication date of the Cochrane SR or its update in the last eight years. The abstracts were initially screened and those that matched the topic were included in further analysis. Then full texts of all SRs involved were obtained. SRs were classifi ed into four topics: prevention, screening, treatment and psychosocial aspects. Our search retrieved a total of 19 Cochrane SRs on the topic of prostate cancer. Excluded were four articles that did not match the specifi c topic, and the remaining 15 full texts were obtained. One of these was on screening, two on prevention, the majority, i.e. eleven were on treatment, and one on the psychosocial aspects related to prostate cancer. Based on the results of the Cochrane SRs on prostate cancer, instead of mass/population screening, the individualized/opportunistic screening approach should be applied in men aged 55-69, always providing full information to the patient and taking into account the potential benefi ts and harms of this procedure

MALNUTRITION SCREENING TOOLS FOR ELDERLY IN GENERAL PRACTICE

Malnutricija starijih je nedovoljno prepoznato stanje koje je moguće učinkovito liječiti. Povezana je s povećanim pobolom, hospitalizacijama, manjom kvalitetom života, povećanom smrtnošću i značajnim troškovima. Indeks tjelesne mase (BMI) nije dovoljna mjera uhranjenosti starijih, jer ne uvažava promjene građe i sastava tijela nastale starenjem. Za probir malnutricije starijih preporuča se korištenje validiranih alata. Starije osobe koje žive u zajednici u skrbi su obiteljskog liječnika, pa je on u idealnoj prilici načiniti probir malnutricije te populacije. Cilj rada je prikazati alate za probir malnutricije starijih s naglaskom na one zadovoljavajuće osjetljivosti i specifi čnosti, prikladne za primjenu u obiteljskoj medicini. Pregledane su baze podataka Medline, Library of Congress i Web of Science po odabranim ključnim riječima. Pretraživanje je ograničeno na članke objavljene u posljednjih 20 godina, bez jezičnog ograničenja. Ukupno je pronađeno 37 članaka, inicijalnim probirom isključeno 20, čime ih je preostalo 17. Pregledom cjelovitih tekstova isključen je jedan članak, te ih je konačno analizirano 16. U istraživanjima probira malnutricije starijih u obiteljskoj medicini korišteni su alati: Gerijatrijski indeks procjene nutritivnog rizika, Geriatric Nutritional Risk Index (GNRI), Alat probira malnutricije, Malnutrition Screening Tool (MST); Procjenska mini ljestvica za malnutriciju-kratki oblik, Mini Nutritional Assesment-Short Form (MNA-SF); Ljestvica probira nutritivnog rizika 2002, Nutritional Risk Screening 2002 (NRS 2002); Univerzalni alat za probir malnutricije, Malnutrition Universal Screening Tool (MUST); Kratki upitnik za nutritivnu procjenu 65+, Short Nutritional Assessment Questionnaire 65+ (SNAQ65+) i Australska inicijativa nutritivnog probira, Australian Nutrition Screening Initiative (ANSI). Najučestalije (u devet članaka) je korišten alat MNA-SF zbog njegove praktičnosti i jednostavnosti uz dostatnu osjetljivost i specifi čnost. Prvi korak nutritivne skrbi za starije je probir malnutricije. Obiteljski liječnik ima na raspolaganju mnoge alate za probir malnutricije starijih. Valjalo bi odabrati jednostavan alat dovoljne osjetljivosti i specifi čnosti, koji je lako ugraditi u tijek konzultacije sa starijim bolesnikom. Čini se da je takav alat za obiteljskog liječnika MNA-SF.Malnutrition of elderly is an unrecognized condition, which can be effectively treated. It is associated with increased morbidity, hospitalizations, lower quality of life, increased mortality and signifi cant costs. Body mass index (BMI) is not a suffi cient measure of nutritional status of the elderly as it does not take into account changes in body structure and composition caused by aging. Various validated screening tools are recommended to use in elderly. General practitioner (GP) provides health care for all the elderly living in the community and therefore has an ideal opportunity to screen them for malnutrition. The objective of the article is to show malnutrition screening tools for elderly, with an emphasis on those with sufficient sensitivity and specificity, applicable in family medicine. We searched databases Medline, Library of Congress and the Web of Science using selected keywords. The search was limited to articles published in the last 20 years, with no language restrictions. We found 37 articles: in initial screening we excluded 20 and 17 articles remained. After retrieving all 17 full texts, one more was excluded so that the final number of analyzed articles was 16. Among reviewed studies, following malnutrition screening tools were used for elderly: Geriatric Nutritional Risk Index (GNRI), Malnutrition Screening Tool (MST), Mini Nutritional Assessment-Short Form (MNA-SF), Nutritional Risk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), Short Nutritional Assessment Questionnaire 65+(SNAQ 65+) and Australian Nutrition Screening Initiative (ANSI). The most frequently used tool (in nine articles) was MNA-SF, for its convenience, simplicity, sufficient sensitivity and specificity. Screening for malnutrition is the fi rst step in nutritional care for the elderly. For the purpose of screening, GP has many tools available and should choose a simple one with suffi cient sensitivity and specifi city and easy to incorporate in the course of consultation with an elderly patient. It seems that such a tool for GP is MNA-SF

Statin Prescription by Croatian Family Doctors – Lack of Systematic Proactive Approach to Cardiovascular Disease Prevention

The aim of this study was to investigate statin prescription by family doctors (GP) in primary (PP) and secondary (SP) prevention of cardiovascular diseases (CVDs). Patients’ socio-demographic data, total cholesterol (TC) and LDL-cholesterol (LDL-C) thresholds for statin prescription, indications, data on GP and practices were registred. Statins were prescribed in 11.2% enlisted patients (64.11% PP, 35.88% SP), mostly aged 70+. In PP, thresholds were TC 6.2±1.09 mmol/L, LDL-C 3.6 mmol/L, in SP 5.4±1.26 mmol/L, 2,7mmol/L, respectively. Most frequently prescribed statin in PP was 10 mg atorvastatin (49.28%), in SP it was 20 mg simvastatin (48.36%). Participating GPs were women, aged 39±5.49, working for 13±6 years, the average number of enlisted patients per GP 1562±299. There was statisticaly significant difference in statin prescription in PP (c2=752.9; p<0.001) and SP (c2=64; p<0.001). Statin prescription in PP is due to pharmaceutical marketing and lack of independent continuing medical education. The fact that statins are most frequently prescribed in patients aged 70+ (35.28% in PP, 49.35% SP) reveals lack of preventive proactive CVDs approach in younger age groups, which is concerning

Quality of Life after Stroke in Croatian Patients

In order to evaluate the microsocial factors affecting quality of life in stroke victims, 100 survivors of ischemic stroke and the same number of their relevant family members (key persons, controls) were interviewed using Stroke Specific Quality of Life Scale (SS-QOL)1 questionnaire. Total SS-QOL score did not differ significantly between post-stroke patients and key persons (z=0.64, P=0.524). Relevant family members ranked the patients’ family (P=0.022) and social role (P=0.08), and their mobility (P=0.09) slightly higher than the patients themselves. However, male patients rated their »family role« (z=–2.82, P=0.005), »mobility« (z=–2.28, P=0.023) and »social role« (z=–1.86, P=0.063) higher than their female peers. Recent ( 33 months) and remote (>33 months after the ischemic accident) stroke patients did not differ substantially in total SS-QOL score, social role and hand function assessment but in mobility (z=–1.90, P= 0.057) and family role estimation (z=–2.47, P=0.014) the difference was in favor of recent stroke patients. The domain scores and total SS-QOL score did not differ by gender between recent stroke patients and their controls either. It is concluded that assessment of general functioning and global quality of life among post-stroke patients provided by relevant patients’ family members could be accepted with confidence. Male patients slightly overestimate their mobility and social role. No significant impact of post-stroke time span on quality of life estimation was observed

Diabetes in Elderly

Diabetes is a major public health problem in the world and one of the leading causes of morbidity and mortality from cardiovascular and chronic kidney disease. Aging of the population is expected to further increase the prevalence of type 2 diabetes, particularly in the age group over 65. According to the 2011 census, in Croatia, 17.7% of the population were elderly, and the estimated prevalence of diabetes in this age group is 15–20%. Taking care of elderly diabetics has its own characteristics compared to other age groups, and a particular challenge for the family physician due to comorbidity and polymedication, as well as more frequent complications of the disease and more common side effects of treatment. The aim of this article is to show the treatment of diabetes in elderly, in the light of new studies (ACCORD, ADVANCE and VADT), and to present revised professional societies (ADA, AHA, ACC) recommendations, focusing on the individualized approach

DO WE CORRECTLY MANAGE ADULT ASTHMA PATIENTS IN FAMILY MEDICINE?

Iako je učestalost astme u porastu, pogotovo u djece, astma je danas nedovoljno dijagnosticirana, ali i nedovoljno dobro i neadekvatno liječena bolest. Najveći broj bolesnika zbrinjava i prati liječnik obiteljske medicine (LOM). Prema smjernicama Global Initiative For Asthma (GINA) iz 2006. liječenje se određuje prema stupnju kontrole bolesti, umjesto dosad preporučene klasifikacije prema težini bolesti. Temelj liječenja trajne astme, bilo kojeg stupnja u odraslih i djece su inhalacijski kortikosteroidi (ICS) u monoterapiji, a dugodjelujući β2-agonist (LABA), montelukast (LTRA) ili teofilin su dodatna terapija ako se s ICS ne postigne zadovoljavajuća kontrola bolesti. Fiksne kombinacije (ICS + LABA) mogu se rabiti u liječenju samo umjerene i teške trajne astme, ne i kod blage astme, ili kada se s ICS u monoterapiji ne postigne kontrola bolesti. Postoji neopravdani trend sve većeg propisivanja fiksnih kombinacija. Iako postoje jasne smjernice profesionalnih i nacionalnih stručnih drštava, javlja se razmimoilaženje između smjernica i prakse.Although prevalence of asthma has increased particularly among children, asthma is still underdiagnosed and undertreated or inappropriately treated disease. Most of the health care for patients with asthma is provided by family physicians in primary health care. Nowadays recommendations (GINA 2006) are based on assessing asthma control levels, the cornerstone of therapy for persistent asthma of all degrees of severity, both in adults and children, are inhaled corticosteroids (ICS) as monotherapy, while long-acting β2-agonists (LABA), leukotriene modifiers (LTRA) or theophylline are add-on therapy if the control of disease is not successfully achieved. Fixed combination (ICS + LABA) could be used only for moderate to severe persistent asthma and in cases when satisfactory control is not achieved using ICS alone. Unjustified trend towards initial fixed combination prescribing has become more and more popular, but with potential of overuse

Awareness and use of evidence-based medicine information among patients in Croatia: a nation-wide crosssectional study

Aim To determine the use of evidence-based medicine (EBM) information and the level of awareness and knowledge of EBM among patients in Croatia. Methods A cross-sectional study was conducted among 987 patients in 10 family medicine practices in Croatia. Patients from both urban (n = 496) and rural (n = 482) areas were surveyed. A 27-item questionnaire was used to collect data about sources that patients searched for medical information, patient awareness and use of Cochrane systematic reviews and other EBM resources, and their demographic characteristics. Results Half of the patients searched for medical information from sources other than physician. Internet was the most common place they searched for information. Very few patients indicated using EBM sources for medical information; one fifth of patients heard of EBM and 4% of the patients heard of the Cochrane Collaboration. Patients considered physician’s opinion as the most reliable source of medical information. A logistic regression model showed that educational level and urban vs rural residence were the predictors of awareness about EBM and systematic reviews (P < 0.001 for both). Conclusion Our finding that patients consider a physician’s opinion to be the most reliable source of healthrelated information could be used for promotion of highquality health information among patients. More effort should be devoted to the education of patients in rural areas and those with less formal education. New avenues for knowledge translation and dissemination of high-quality health information among patients are necessary

How well do family physicians record cardiovascular risk factors?

Pozadina. Kardiovaskularne bolesti (KVB) su prema podacima WHO vodeći uzrok smrtnosti u suvremenom svijetu pa i u Hrvatskoj, gdje čine 49,6% ukupnog mortaliteta. Cilj. Istražiti bilježenje čimbenika rizika KVB u hipertoničara u skrbi liječnika obiteljske medicine dviju ordinacija grada Splita, kao i postizanje ciljnih vrijednosti arterijskoga tlaka i glikemije u istih. Ispitanici i metode. Napravljeno je retrospektivno pilot-istraživanje pregledom elektroničke baze podataka. Iz uzorka hipertoničara svake ordinacije, generatorom slučajnih brojeva odabrana je po polovina, te su ispitanici razvrstani u skupinu primarne (PP) i sekundarne prevencije (SP). Zabilježeni su: dob, rod, postojanje podataka o indeksu tjelesne mase (BMI), pušačkom statusu, kolesterolemiji, glikemiji natašte (GUK) i arterijskom tlaku (RR), te postizanje ciljnih vrijednosti arterijskoga tlaka i glikemije. Rezultati. U ukupnom broju ispitanika (N = 445), BMI je zabilježen u njih 19,8%, pušački status u 19,8%, kolesterolemija u 71,9%, GUK u 72,1%, te RR u 80,9% slučajeva. Glikemija i kolesterolemija su češće zabilježene u uzorku SP, nego PP. Kod ispitanika koji su imali zabilježen arterijski tlak, ciljna vrijednost u PP je postignuta u 63,8%, a u SP u 40,4% njih. U uzorku SP, od 115 ispitanika kod koji je zabilježena glikemija ciljna vrijednost je postignuta u 53,9% slučajeva. Zaključak. Naše istraživanje je pokazalo kako je bilježenje i praćenje čimbenika KV rizika, te postizanje ciljnih vrijednosti RR i glikemije u istraživanim ordinacijama bilo neadekvatno.Background. Cardiovascular diseases (CVD), according to the World Health Organization (WHO), are the leading cause of death in the modern world, and Croatia is no exception. Aim. To investigate the recording of CVD risk factors in hypertensive patients enlisted for family physicians in two practices in the city of Split, as well as to achieve their target blood pressure and glycemia levels. Respondents and methods. A retrospective pilot study was performed by reviewing the electronic database of two family practices. From the sample of all hypertensive patients, half (50%) of them were selected in each practice by using a random number generator. The participants were classified in the group of primary (PP) and secondary prevention (SP). We have recorded: age, gender, existence of data on body mass index (BMI), smoking status, cholesterolaemia, fasting blood glycemia (FBG) and blood pressure (BP) as well as the achievement of target levels of BP and FBG. Results. Out of the total of 445 respondents, BMI and smoking status were recorded in 19.8%, cholesterolaemia in 71.9%, FBG 72.1%, and BP in 80.9%. Data on FBG and cholesterolaemia were more often observed in the sample of SP than in PP. In participants with recorded BP, target values in PP were achieved in 63.8%, while in SP in 40.4%. In SP sample, in 115 participants with recorded glycemia, the target value was achieved in 53.9%. Conclusion. Our research in two practices has shown that CVD prevention in terms of recording and monitoring of risk factors and achieving target values of BP and FBG was inadequate