WHY DID ALL FAMILY MEMBERS ABANDON THIS MAN?

Danas je alkoholizam treća bolest suvremenog čovječanstva, u Hrvatskoj ima 6% ovisnika o alkoholu, a oko 15% muškaraca starijih od 20 godina prekomjerno uzima alkoholna pića. Prikazan je 65-godišnji pacijent, mjesec dana u mirovini, s teškim, neliječenim mnogostrukim psihičkim, fizičkim i socijalnim problemima uzrokovanim alkoholom. Tjelesne posljedice su često ozljeđivanje, prijelomi nadlaktice i kuka. Psihosocijalne posljedice su gubitak obiteljske kuće, odvojen život od žene koja živi povremeno kod kćerke, sin je razveden, često hospitaliziran na psihijatriji zbog PTSP-a i nije voljan primiti oca, troje unučadi od kojih su dvoje krenula „krivim“ putem i smješteni su u učenički dom, a unuka od 17 godina odustala je od škole. Njegov brat, sa senzomotornom afazijom nakon moždanog udara ga također ne može primiti u prigradsku kuću, koju iznajmljuje. Pacijent je prošlog ljeta zapušten spavao ispred ambulante te je uz insistiranje liječnika i prisilno hospitaliziran, zadržan „iz socijalnih razloga“ petnaestak dana na psihijatrijskom odjelu i potom udomljen. Obiteljska medicina je idealna za liječenje poremećaja uzrokovanih alkoholom i barem jednako efikasna kao specijalizirana zdravstvena skrb. Još uvijek je prisutna stigmatizacija alkoholičara i posljedična društvena diskriminacija, što valja suzbijati antistigma programima.Alcoholism is a major public health problem in modern society. There is 6% of alcoholics in Croatia while 15% of adult men drink excessively. A patient, 65-year-old alcoholic with severe, untreated multiple mental, physical and social problems is presented. Injuries such as fractures of upper arm and hip were frequent physical consequences. He lost his family home, separated from his wife, his son is divorced, frequently hospitalized for PTSD, and is not willing to accept his father to live with him. Three of his grandchildren undertook the wrong way in their lives (two of them were institutionalized, and a 17-year-old granddaughter abandoned school). His brother, with sensomotor aphasia after a stroke, refused to accept him in his suburban house, which is currently rented. Last summer the patient was found asleep in front of the dispensery in a poor condition, and compulsorily hospitalized. After he spent 15 days in a psychiatric ward for “social reasons” the patient was placed in foster care. Family medicine is ideal for the management of alcoholism. Interventions in reduction/cessation of heavy drinking in primary care are as effective as in specialized institutions. Stigmatization and consequential social discrimination of alcoholics is still present what is the reason for family doctors to implement antistigmatic programs

IMPROVING WOMENS’ HEALTH: EVIDENCE BASED RECOMENDATIONS FOR HORMONAL REPLACEMENT THERAPY

Cilj ovog rada je prikazati spoznaje o hormonskom nadomjesnom liječenju (HNL) žena u peri i postmenopauzi temeljene na znanstvenim dokazima i usporediti s našom aktualnom situacijom. Metode. Provedeno je pretraživanja literature koja se odnosi na HNL, istraživanja i preporuka nezavisnih ekspertnih skupina. Za procjenu aktualne situacije u RH povezane uz menopauzu i HNL korištene su javno dostupne baze podataka. Na temelju Hrvatskih zdravstveno-statističkih ljetopisa (1995.-2012.) prikupljani su podaci o menopauznim poremećajima zabilježenim u djelatnostima zaštite zdravlja žena (DZŽ) i obiteljske medicine (OM). Na temelju Izvještaja o potrošnji lijekova Hrvatske agencije za lijekove i medicinske proizvode prikupljeni su podaci o potrošnji spolnih hormona i ostalih pripravaka koji djeluju na spolni sustav za period 2004.-2012. (podaci o prethodnim godinama nisu dostupni). Rezultati. Činjenice u preporukama kanadske i američke radne skupine, u Cochrane bazi podataka i u drugim izvorima upućuju da rizici od uporabe HNL premašuju koristi. Povećan je rizik od infarkta miokarda i moždanog udara, venske tromboembolije, plućne embolije, raka dojke, demencije, kolecistitisa i pogoršanja inkontinencije. Nešto je smanjen rizik od osteporotičnih fraktura, dijabetesa tipa 2 i karcinoma debelog crijeva. Što se tiče naše situacije, menopauzni problemi su bili često prisutni u DZŽ (6-12% pobola), ali i u djelatnosti OM. Dok je u OM opaženo izrazito opadanje broja registriranih menopauznih problema, u DZŽ je taj broj do 2011. godine rastao. Zaključak. Rizik od razvoja mnogih kroničnih bolesti se izrazito povećava u žena koje koriste HNL. Jedina indikacija za primjenu HNL su izraziti peri- i postmenopauzni simptomi, ako ih se na drugi način ne može umanjiti.The aim of this article is to present the evidence based conclusions and recommendation on hormonal replacement therapy (HRT) in peri- and postmenopausal women and to explore the Croatian situation. Methods. First, we did a literature search (predominantly the independent resources, such as The Canadian Task Force on Preventive Health Service, the US Preventive Services Task Force and The Cochrane library). To investigate the Croatian situation, we extracted morbidity data related to the menopausal problems, N97 diagnoses (ICD-10), registered in family medicine (FM) and in women health service (WHC) from the Croatian Health Statistics Yearbooks (1995-2012). From the Reports on pharmaceuticals’ usage (Croatian Agency for Pharmaceuticals and Medical Substances) we extracted data on usage of sexual hormones and related substances (2004-2012). Results. According to the literature, the risk of HRT overcomes the benefits. A rise in myocardial infarction, stroke, venous thromboembolism, breast cancer, gallbladder diseases and urine incontinence has benn documented. Lowered was the risk of osteoporotic fractures (significantly), and of diabetes type 2 and colorectal cancer (insignificantly). In Croatia some 6-12% of morbidity registered in WHC and in FM was due to menopausal problems (N97, ICD-10). Up to 38% of all menopausal problems were registered in FM. This trend was continuously decreasing in FM, but not in the WHC. Conclusion. HRT has a strong unfavorable impact on many chronic conditions, and it should be applied in cases of severe hot flushes and sweats only. This should be implemented in Croatia, especially in the WHC

Patient with advanced prostate cancer: What to do when a patient refuses the recommended therapy?

U članku je prikazan bolesnik s uznapredovalim stadijem karcinoma prostate koji je odbio predloženi način aktivnog onkološkog, a prihvatio samo palijativno liječenje. Radilo se o 77-godišnjem bolesniku s lokalno proširenom i invazivnom (Gleason score 9) bolešću i koštanim metastazama u centralnom skeletu i oba femura. Preporuke urologa o liječenju, orhidektomiji i uzimanju antiandrogena, je odbio, kao i nastojanja obiteljskoga liječnika da ga nagovori. Prihvatiti ili ne prihvatiti bolesnikovu odluku, te razmišljanja je li se moglo učiniti više, dileme su s kojima se susreću liječnici u skrbi za ovakvog ili slične bolesnike. Zakon o zdravstvenoj zaštiti i Kodeks medicinske etike i deontologije nas obvezuju da uvažimo pravo bolesnika na prihvaćanje ili odbijanje predloženog dijagnostičkog ili terapijskog postupka Osim toga, sve je više rasprava u literaturi o učinkovitosti onkološkog liječenja pacijenata koji se nalaze u terminalnoj fazi bolesti i sve više dokaza o pogoršanju kvalitete života, najčešće uzrokovane neželjenim učincima kemoterapije, povećanim brojem hospitalizacija i drugim oblicima agresivnih intervencija u osoba koje primaju palijativnu kemoterapiju. Međutim, bez obzira na racionalnost donesenih odluka, u zdravstvenim radnicima koji rade s ovakvim bolesnicima ostaje „gorak okus“, pod većim su stresom i skloniji razvoju sindroma izgorjelosti na poslu. Stoga bi valjalo razmišljati o potrebi sustavnog ulaganja u pružanje podrške zdravstvenim radnicima koji rade s teškim bolesnicima kroz antistres treninge, odjelne sastanke, vršnjačke skupine ili Balintove grupe.This article describes the case of a patient with metastatic prostate cancer who refused recommended active oncologic treatment. The patient was a 77-year-old man, with advanced local cancer status, very high PSA level and bone metastases, to whom castration and antiadrogen therapy were recommended. In spite of the intention of his family doctor to accept the recommendations, the patient and his family remained persistent. He only accepted a palliative home care. Taking care for this patient was not an easy task for his family doctor because many dilemmas arose; to accept or not his decision, or if the medical decisions were evidence-based , have I done enough for this patient? But, from the rational point of view, family doctors should accept their patients’ decisions, because they are in accordance to the Croatian Law on Patient’s Rights and in accordance to the Doctor\u27s Ethical Code. Moreover, the patient\u27s decision seemed rational from the medical point of view. There is a lot of evidence based (EBM) literature questioning the effectiveness of chemotherapy near the end of life. But, something irrational in family doctor\u27s thoughts and feelings still remains bringing him a certain sort of stress. This was solved through discussion in peer-groups, because other methods do not exist in practice. In conclusion, it could be said that this situation is very common in health care and that further resources, human and material, should be invested in helping the health care professional to deal with the possibility of the burn-out syndrome

Differences in the organizational structure and functioning of family practice in Brodsko-posavska county and republic of Croatia

S promjenama zdravstvenog sustava u Hrvatskoj(RH) u proteklih 20 godina došlo je do promjenau organizaciji i funkcioniranju obiteljske medicine(OM) uz regionalne razlike. Cilj je opažajnom (povijesno prospektivnom) analizom utvrditi postoje li i kakve su razlike u organizaciji i funkcioniranju OM između Brodsko-posavske županije (BPŽ) i RH. Izvori podataka su bili Hrvatski zdravstvenostatistički ljetopisi od 1995. do 2014. godine, Mreža planiranih i ugovorenih ordinacija OM te Popis stanovništva 2011. godine. Rezultati. Broj LOM-a u RH povećao se u ovih 20 godina za 11,2%, a u BPŽ za 28,4%. U BPŽ je nedostajalo 16 ili 17,4% liječnika u 2013. a u Hrvatskoj 5,5 %. BPŽ ima prosječno više specijalista OM nego RH (52,6% : 49,3%). U BPŽ je broj osiguranika na listi liječnika 2.035, u RH 1.849. Dio pacijenata koji koriste OM u BPŽ je manji od državnoga (44.0%-8.1% : 74.9%-80,5%). U RH godišnji prosječan broj posjeta / LOM je manji nego u BPŽ (8.515-15.283 : 9.063 - 15.483). Broj kućnih posjeta u BPŽ kreće se od 88 do 180, u RH od 140 do180. Zaključak. Nedvojbeno je potreban veći broj LOM-a u BPŽ, posebno u ruralnim područjima radi bolje dostupnosti populaciji i manjeg opterećenja, tj. kvalitetnije zdravstvene zaštite.Frequent “health care reforms” in the last 20 years led to changes in organization, structure and function of family practice (FP), with regional differences in outcomes. The aim of this study was to investigate the differences in the organization and functioning of FP between a county [Brodskoposavska County (BPC)] and the Croatian mean. It was an observational, longitudinal study, using the Croatian Health Service Yearbooks, 1995-2014, the Croatian Network of planned and contracted FPs, and national census. Results. The number of FPs in Croatia increased by 11.2% while in BPC it increased by 28.4%, but still 16 family doctors (FDs) are missing there (17.4% in BPC vs. 5.5% in Croatia). However, in BPC there were more FD specialist than in Croatia (52.6 % vs. 49.3 %), and more enlisted patients (2,035 vs 1,849), while the number of annual visits o FP was less (44.0%-78.1% vs. 74.9-80,5%). The annual number of office visits per FD was similar and varied from 8,515 to 15,283 in Croatia vs. 9,063-15,483 in BPC, as well as the number of home visits (140-180 per FD in Croatia vs. 88-180 in BPC). Conclusion. FPs in BPC are understaffed; the FDs are overburdened by office visits and referrals, performing less home visits and preventive activities, which should be accounted for in any FP service planning, particularly concerning the rural regions

Differences in the organizational structure and functioning of family practice in Brodsko-posavska county and republic of Croatia

S promjenama zdravstvenog sustava u Hrvatskoj(RH) u proteklih 20 godina došlo je do promjenau organizaciji i funkcioniranju obiteljske medicine(OM) uz regionalne razlike. Cilj je opažajnom (povijesno prospektivnom) analizom utvrditi postoje li i kakve su razlike u organizaciji i funkcioniranju OM između Brodsko-posavske županije (BPŽ) i RH. Izvori podataka su bili Hrvatski zdravstvenostatistički ljetopisi od 1995. do 2014. godine, Mreža planiranih i ugovorenih ordinacija OM te Popis stanovništva 2011. godine. Rezultati. Broj LOM-a u RH povećao se u ovih 20 godina za 11,2%, a u BPŽ za 28,4%. U BPŽ je nedostajalo 16 ili 17,4% liječnika u 2013. a u Hrvatskoj 5,5 %. BPŽ ima prosječno više specijalista OM nego RH (52,6% : 49,3%). U BPŽ je broj osiguranika na listi liječnika 2.035, u RH 1.849. Dio pacijenata koji koriste OM u BPŽ je manji od državnoga (44.0%-8.1% : 74.9%-80,5%). U RH godišnji prosječan broj posjeta / LOM je manji nego u BPŽ (8.515-15.283 : 9.063 - 15.483). Broj kućnih posjeta u BPŽ kreće se od 88 do 180, u RH od 140 do180. Zaključak. Nedvojbeno je potreban veći broj LOM-a u BPŽ, posebno u ruralnim područjima radi bolje dostupnosti populaciji i manjeg opterećenja, tj. kvalitetnije zdravstvene zaštite.Frequent “health care reforms” in the last 20 years led to changes in organization, structure and function of family practice (FP), with regional differences in outcomes. The aim of this study was to investigate the differences in the organization and functioning of FP between a county [Brodskoposavska County (BPC)] and the Croatian mean. It was an observational, longitudinal study, using the Croatian Health Service Yearbooks, 1995-2014, the Croatian Network of planned and contracted FPs, and national census. Results. The number of FPs in Croatia increased by 11.2% while in BPC it increased by 28.4%, but still 16 family doctors (FDs) are missing there (17.4% in BPC vs. 5.5% in Croatia). However, in BPC there were more FD specialist than in Croatia (52.6 % vs. 49.3 %), and more enlisted patients (2,035 vs 1,849), while the number of annual visits o FP was less (44.0%-78.1% vs. 74.9-80,5%). The annual number of office visits per FD was similar and varied from 8,515 to 15,283 in Croatia vs. 9,063-15,483 in BPC, as well as the number of home visits (140-180 per FD in Croatia vs. 88-180 in BPC). Conclusion. FPs in BPC are understaffed; the FDs are overburdened by office visits and referrals, performing less home visits and preventive activities, which should be accounted for in any FP service planning, particularly concerning the rural regions

IMPROVING WOMENS’ HEALTH: EVIDENCE BASED RECOMENDATIONS FOR HORMONAL REPLACEMENT THERAPY

Cilj ovog rada je prikazati spoznaje o hormonskom nadomjesnom liječenju (HNL) žena u peri i postmenopauzi temeljene na znanstvenim dokazima i usporediti s našom aktualnom situacijom. Metode. Provedeno je pretraživanja literature koja se odnosi na HNL, istraživanja i preporuka nezavisnih ekspertnih skupina. Za procjenu aktualne situacije u RH povezane uz menopauzu i HNL korištene su javno dostupne baze podataka. Na temelju Hrvatskih zdravstveno-statističkih ljetopisa (1995.-2012.) prikupljani su podaci o menopauznim poremećajima zabilježenim u djelatnostima zaštite zdravlja žena (DZŽ) i obiteljske medicine (OM). Na temelju Izvještaja o potrošnji lijekova Hrvatske agencije za lijekove i medicinske proizvode prikupljeni su podaci o potrošnji spolnih hormona i ostalih pripravaka koji djeluju na spolni sustav za period 2004.-2012. (podaci o prethodnim godinama nisu dostupni). Rezultati. Činjenice u preporukama kanadske i američke radne skupine, u Cochrane bazi podataka i u drugim izvorima upućuju da rizici od uporabe HNL premašuju koristi. Povećan je rizik od infarkta miokarda i moždanog udara, venske tromboembolije, plućne embolije, raka dojke, demencije, kolecistitisa i pogoršanja inkontinencije. Nešto je smanjen rizik od osteporotičnih fraktura, dijabetesa tipa 2 i karcinoma debelog crijeva. Što se tiče naše situacije, menopauzni problemi su bili često prisutni u DZŽ (6-12% pobola), ali i u djelatnosti OM. Dok je u OM opaženo izrazito opadanje broja registriranih menopauznih problema, u DZŽ je taj broj do 2011. godine rastao. Zaključak. Rizik od razvoja mnogih kroničnih bolesti se izrazito povećava u žena koje koriste HNL. Jedina indikacija za primjenu HNL su izraziti peri- i postmenopauzni simptomi, ako ih se na drugi način ne može umanjiti.The aim of this article is to present the evidence based conclusions and recommendation on hormonal replacement therapy (HRT) in peri- and postmenopausal women and to explore the Croatian situation. Methods. First, we did a literature search (predominantly the independent resources, such as The Canadian Task Force on Preventive Health Service, the US Preventive Services Task Force and The Cochrane library). To investigate the Croatian situation, we extracted morbidity data related to the menopausal problems, N97 diagnoses (ICD-10), registered in family medicine (FM) and in women health service (WHC) from the Croatian Health Statistics Yearbooks (1995-2012). From the Reports on pharmaceuticals’ usage (Croatian Agency for Pharmaceuticals and Medical Substances) we extracted data on usage of sexual hormones and related substances (2004-2012). Results. According to the literature, the risk of HRT overcomes the benefits. A rise in myocardial infarction, stroke, venous thromboembolism, breast cancer, gallbladder diseases and urine incontinence has benn documented. Lowered was the risk of osteoporotic fractures (significantly), and of diabetes type 2 and colorectal cancer (insignificantly). In Croatia some 6-12% of morbidity registered in WHC and in FM was due to menopausal problems (N97, ICD-10). Up to 38% of all menopausal problems were registered in FM. This trend was continuously decreasing in FM, but not in the WHC. Conclusion. HRT has a strong unfavorable impact on many chronic conditions, and it should be applied in cases of severe hot flushes and sweats only. This should be implemented in Croatia, especially in the WHC

TEN-YEAR TRENDS IN THE UTILIZATION OF ANTIBIOTICS IN CROATIA ON THE BASIS OF ROUTINELY COLLECTED DATA

Istraživanja potrošnje antibiotika od osobitog su interesa zbog dokazane povezanosti rezistencije bakterija s njihovom potrošnjom. Cilj ovog rada je istražiti je li došlo do promjene trendova potrošnje antibiotika u RH u odnosu na one prikazane u European Surveillance of Antimicrobial Consumption (ESAC) studiji. Pratila se farmakološka potrošnja antibiotika (J01AJ01X) na temelju podataka iz godišnjih Izvješća o potrošnji lijekova, Hrvatske agencije za lijekove i medicinske proizvode tijekom dva razdoblja, razdoblja trajanja ESAC studije (2005.-2009.) i razdoblja nakon završetka studije (2010.-2014.). U odnosu na ESAC studiju u kojoj je zabilježen stalni rast potrošnje antibiotika, nakon završetka studije potrošnja se stabilizirala na oko 23 defi nirane dnevne doze na 1000 stanovnika na dan. Iako se potrošnja stabilizirala, RH još uvijek spada u skupinu zemalja s većom potrošnjom antibiotika od sjevernoeuropskih zemalja, osobito s nepovoljnom strukturom potrošnje. Dok je u našoj studiji udio uskog spektra penicilina iznosio manje od 10 %, u nordijskim zemljama njegov udio je prelazio 50 % ukupne penicilinske potrošnje. Kod nas je zabilježena osobito velika potrošnja amoksicilina s klavulonskom kiselinom i azitromicina, pojava koja nije prisutna u zapadnoeuropskim zemljama. Iako se već primjenjuju mjere smanjenja potrošnje antibiotika u RH, dobiveni rezultati ukazuju na potrebu još sustavnijeg pristupa problemu njihove prekomjerne potrošnje.Introduction: Antibiotic resistance is a very important public health problem throughout the world, which is undoubtedly connected with the excessive use of antibiotics. According to monitoring of antibiotic consumption in Europe, Croatia as part of the European Surveillance of Antimicrobial Consumption (ESAC) project was among countries with stable high outpatient antibiotic consumption from 1997 to 2009 and consequently high rates of resistance to many antibiotics. Research on the use of antibiotics is especially important for family medicine; more than 90% of antibiotics were prescribed outside the hospital, mostly by family physicians (general practitioners). The main aim of this study was to investigate ten-year (2005-2014) trends in antibiotic consumption in Croatia divided into two periods, i.e. during (2005-2009) and after (2010-2014) ESAC study, and to compare the data obtained to those from other EU countries. Methods: The study was observational, based on routinely collected data from annual reports of the Croatian Agency for Medicinal Products and Medical Devices (HALMED) for the 2005-2014 period. Drug consumption in the reports was presented according to ATC/ DDD methodology and antibiotics were presented under the J code. Results: The results showed an increasing trend of antibiotic consumption until 2009, followed by a stable trend from 2010, with 22-23 daily doses per 1000 inhabitants per day. In comparison to other EU countries, Croatia is a country with high antibiotic consumption. Similar to other countries, penicillins were the most widely used antibiotics, accounting for 48%-55% of total pharmacological consumption. Cephalosporins ranked second with 34%-22%, showing a downward trend of consumption. Macrolides with an upward trend were on the third place and quinolones on the fourth place with a variable trend. However, the structure of consumption was not comparable to other EU countries. For instance, co-amoxiclav accounted for 53%-70% of the penicillin group, with an upward trend, and azithromycin for about 50% of macrolide consumption, with a varying trend. The increasing trend of consumption of third-generation cephalosporins and quinolones also differed from other EU countries. Consumption of ciprofl oxacin showed an upward trend, and norfl oxacin a downward trend. Conclusion: Although the trend has been stable since 2010, the consumption of antibiotics in Croatia is still higher than in many European countries. Special attention should be paid to the overuse of co-amoxiclav and azithromycin. These data are the reasons to think about introducing systematic interventions aimed at reducing the use of antibiotics

Outpatient antibiotic consumption for urinary infections in Croatia 2005 - 2014: What can be learned from utilization trends

The aim of this study was to determine quantities of antibiotics used mainly or exclusively for urinary tract infections in Croatia between 2005 and 2014, to describe utilisation trends, and general consequences of antibiotic consumption on antimicrobial resistance