[CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES]. / HRVATSKE SMJERNICE ZA FARMAKOLOSKO LIJECENJE SECERNE BOLESTI TIPA 2.

INTRODUCTION: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. PARTICIPANTS: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. EVIDENCE: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. CONCLUSIONS: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

[Quaternary prevention as a basis for rational approach to the patient in family practice]. / Kvartarna prevencija kao temelj racionalnog pristupa pacijentu u obiteljskoj medicini.

Quaternary prevention is an action taken to identify a patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions which are ethically acceptable. It belongs mostly to family medicine because of the family physician's position who is the first contact to the patient and "leader" of patient through health care system. Family physician must have a skill to locate the patient's symptom to the proper organ system and also to find the appropriate procedure for the patient. This is very complex in a situation when the patient has symptoms and complaints and the physician doesn't find the disease. In these situations individual approach to the patient, good communication, balance between finding appropriate procedures and defining neccessary procedures together with evidence based medicine make quaternary prevention, which becomes a neccessity in the process of leading the patient through modern health care system.

Antibiotic prescription rate for upper respiratory tract infections and risks for unnecessary prescription in Croatia.

Overprescribing of antibiotics in primary care has been recognized as public health problem. We investigated visits prescription rate of antibiotics to patients with upper respiratory tract infections (URTI) and unnecessary prescription for tonsillopharyngitis, in Croatia. In prospective observational study in November 2007. 25 GPs in Croatia recorded all patients' visits with URTI episode according ICPC-2. Clinical status of patients with tonsillopharyngitis were categorized according to Centor Criteria. 689 visits were analysed, 82% of visits were initial. Antibiotics were prescribed in 44.7% visits with URTI. There were no significant differences in antibiotic prescription rates regarding non-clinical factors. Antibiotics were prescribed to patients with tonsillopharyngitis in 62.2% visits. Unnecessary antibiotics were prescribed (Centor 1,2) in 49.6% visits with tonsillopharyngitis. Logistic regression analysis showed significant differences in unnecessary antibiotic prescription rates only with respect to the workday--Wednesday, CI (1.117-2.671), p = 0.0139. Leading antibiotic was amoxicillin + clavulonic acid, second was amoxicillin, the third were macrolides, the fourth was narrow spectrum penicillin and fifth were cephalosporins. This study shows over prescription for URTI. Unnecessary prescription for tonsillopharyngitis depend on non clinical factor--day of the week. This should be further explored and help to improved prescribe antibiotics.

Problem of substance misuse and lack of national strategy in Kosovo.

UNLABELLED: The aim of this project was to explore the problem of substance misuse among adolescent town dwellers in Kosovo, as a result of lack of a national strategy related to this problem. DESIGN: 261 students from 4 secondary schools took part in cross sectional survey performed in October 2005. The survey was carried out in Gjilan town in south-east of Kosovo. MAIN RESULTS: From all questioned students, 36% smoked cigarettes every day, 12.6% consumed alcohol occasionally and 1.4% consumed all kind of drugs regularly. Girls consumed more cigarettes, whereas boys consumed more alcohol and other drugs. The prevalence of substance misuse was higher among students in their last year of high school attendance. Students in Gjilan continue to smoke, consume alcohol and drugs despite their knowledge about the adverse health consequences of substance misuse, but in the same time, most of them consider information and counselling the best way of substance misuse prevention. CONCLUSIONS: The prevalence and trends of substance misuse among students in our survey indicates that it is time to start acting. It is assumed that results of survey may be a very useful source of information for policy-makers, government and ministry of health in developing and implementing national strategy that would address the most important issues in connection with addiction among adolescents.

Antibiotic prescription rate for upper respiratory tract infections in general practice - a Croatian study.

Aim Acute upper respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The frequency of antibiotics prescribed to patients with upper respiratory tract infections has been studied. Methods A cross-sectional survey has been conducted from October to December 2017 with participation of 17 General Practices in Croatia. Visits of patients with symptoms of upper respiratory tract infections made the survey framework. A specially structured questionnaire was a tool for the assessment of reasons for encounters, clinical statuses and practitioners' decisions. According to the registered clinical status, two independent doctors classified patients using Centor criteria, which were used to evaluate appropriate indication for antibiotic prescription. Results The survey analysed 709 patients' visits. Seventy three percent of general practice visits due to acute respiratory tract infection were initial. Antibiotics had been prescribed in the total of 32.6% of cases. Analysing upper respiratory tract infections with Centor score 1 and 2, antibiotics had been prescribed in 22.8% cases of the first visit and in 31.7% of the second visit, and with the Centor score 3 and 4 antibiotics had been prescribed in 85.1% of cases during the initial visit, and 66.7% of cases during the second visit. Logistic regression analysis about the contribution of nonclinical variables to antibiotic prescribing showed that most often antibiotics had been prescribed on Mondays. The most prescribed group of antibiotics was the penicillin group (74.8%), followed by macrolides (17.6%) and cephalosporins (4.0%). Conclusion General practitioners prescribe antibiotics for acute respiratory tract infections more than recommended by evidence based medicine and professional criteria.

Treatment of hypertension by general practitioners and antihypertensive drugs expenditure in an urban environment.

Aim of our study was to determine the treatment habits of hypertension by general practitioners (GPs) as well as the monthly costs of prescribed antihypertensive drugs and their share in the total prescription drug expenditure approved by the Croatian Institute for Health Insurance (CIHI), the compulsory health insurance system. The study was performed in six GPs offices in Zagreb, serving 8,866 patients, in December 2005. The monthly costs of antihypertensive drugs prescribed by the GPs was obtained by summarizing the prices of all antihypertensive drugs prescribed in one month and then comparing the sum with total monthly prescription drug expenditure approved by the CIHI. The type and dosage of prescribed antihypertensive drugs were also analyzed. Hypertension was diagnosed in 2,342 (26.4%) patients. The monthly costs of prescribed antihypertensive drugs accounted for 52.33% of the total amount approved for medications by the CIHI. 945 (40.0%) hypertensive patients were taking antihypertensive monotherapy. The most frequently prescribed drugs as monotherapy were ACE inhibitors (38.3%), calcium-channel blockers (26.7%), beta blockers (18.6%), and diuretics (10.3%). a antagonists (3.6%). Angiotensin receptor blockers (2.5%) were rarely prescribed. As combination therapy, ACE inhibitors and diuretics (30.4%) were most frequently used. More than 50% of the funds allocated to GPs for medications were spent for the treatment of only one disease. The most used antihypertensive drugs were ACE inhibitors.

Prescribing antibiotics to preschool children in primary health care in Croatia.

The use of antibiotics depends on cultural and socioeconomic factors, physician's characteristics as well as on microbiological considerations. Aim of our study was to asses antibiotic prescription among preschool children in primary health care in Croatia in relation to socioeconomic factors, symptoms and diagnoses, and type of health care provider. Retrospective longitudinal survey was conducted in 7 teaching primary health care offices in the Croatian capital of Zagreb during 2004, among 1700 preschool children. Antibiotics were prescribed to 611 (46%) children. Significantly more antibiotics were prescribed to boys (66.7%, P = 0.024) and to children whose parents had lower educational level. Most frequently antibiotics were prescribed for the symptoms such as fever (32%), cough (32.5%), nasal discharge (12%), and for the diagnoses such as respiratory diseases (J00-J99) (40%), infectious and parasitic diseases (A00-A99) (31%), and diseases of the middle ear and mastoid (H60-H95) (15%). Logistic regression analyses also predicted correlation of antibiotic prescriptions with socioeconomic factors, symptoms and diagnoses and health care of pediatrician. Prescription of antibiotics for preschool children in primary health care in Croatia related to socioeconomic factors, type of health care provider, certain symptoms and diagnosis groups which should be taken into account when assessing and planning primary health care for preschool children.

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.

[CroDiab GP--follow up of diabetics protection in general medicine]. / CroDiab GP--pracenje zastite dijabetickih bolesnika u obiteljskoj medicini.

INTRODUCTION: There is an increasing number of diabetics in the population. Care of diabetes mellitus type 2 has been transferred from specialist care to the level of general practice. Collecting data and making database of diabetic care are set as quality indicators of diabetic care. AIM: The aim is to present the electronic CroDiab GP program as a tool for collecting data on diabetics in family practice in Croatia. Another aim is to track diabetic quality care and include patients in the national registry of diabetics. METHODS: The program was demonstrated on a sample of 10 family practice units with approximately 18,000 patients from four districts in north Croatia. These units are involved in the project of tracking diabetic care quality in family medicine. The core population for data collection is set by the basic diagnostic unit according to ICD-10: E10-E14. The program mainframe is the CroDiab NET computer system. The central module of CroDiab NET is BIS (Basic Information Sheet). It is set as optimal data collection that allows tracking diabetic care quality. Sixteen diabetic variables were analyzed. These variables refer to the type of disease, duration, treatment, and procedure for early detection of complications. RESULTS: In the population of 18,0000 patients there were 822 (4.6%) diabetics. There were 6.3% of patients with type 1 diabetes and 87.4% with type 2 diabetes; 6.3% were unknown. There were 16.0% diabetics on diet therapy, 60.7% on oral medication (1 to 3 medications), and 13.4% on insulin therapy, 8.4 diabetics were on both insulin and oral medication. CONCLUSION: Family medicine should present parameters of the quality of diabetic care. It is possible to collect data in electronic media, make statistical analysis and present data. The next step is entering patient data in the national registry of diabetics.

Missing risks in opportunistic screening for type 2 diabetes - CroDiabGP study.

Aim To examine two methods of extracting risks for undetected type 2 diabetes (T2D): derived from electronic medical record(EMR) and family medicine (FM) assessment during pre-consultation phase. All risks were structured in three lists of patients' data using Wonca International Classification Committee(WICC). Missing data were detected in each list. Methods A prospective study included a group of 1883 patients(aged 45-70) identified with risks. Risks were assessed based on EMR for continuity variables and FM's assessment for episodes of disease and personal related information. Patients were categorized with final diagnostic test in normoglycaemia, impaired fasting glycaemia and undetected T2D. Results Total prevalence of diabetes was 10.9% (new 1.4%), of which 59.3% were females; mean age was 57.4. The EMR risks were hypertension in 1274 patients (yes 67.6%, no 27.9%, missing 4.4%), hypolipemic treatment in 690 (yes 36.6%, no 30.9%, miss 32.5%). In the episodes of disease: gestational diabetes mellitus in 31 women (yes 2.8%, missing 97.2%). Personal information: family history of diabetes in 649 (yes 34.5%, no 12.4%, missing 53.1%), overweight in 1412 (yes 75.0%, no 8.4%, missing 16.6%), giving birth to babies >4000g in 11 women (yes 0.9%, missing 99.1%). Overweight alone was the best predictor for undiagnosed type 2 diabetes, OR: 2.11 (CI: 1.41-3.15) (p<.001). Conclusion Two methods of extraction could not detect data for episodes of the disease. In the list of personal information, FMs could not assess overweight for one in six patients and family history for every other patient. The study can stimulate improving coded and structured data in EMR.

Structure of visits persons with diabetes in Croatian family practice--analysis of reasons for encounter and treatment procedures using the ICPC-2.

The reasons for encounter and the procedures conducted during the visit persons with diabetes to family practice have been investigated. Five family practitioners located in two Croatian counties took part in this study. In this study patients with diagnoses E10-E14 according to International Classification Disease-10 (ICD-10), were involved. There were 543 persons with diabetes (women 324) in the total population of 10,150 patients Data were registered according to the International Classification Primary Care-2 (ICPC-2) (components 1-7 for reasons of encounter, and components 2-6 for procedures during the visit), in period october till december 2005. 871 visits of persons with diabetes (average age 65.7 +/- 12.5 were registered. Patients presented in total 1921 reasons for encounter or 2.1 +/-1.1 per visit. Family practitioner made in total 2,341 procedures or 2.6 +/- 1.5 procedures per visit. 85.0% of patients had 1 to 3 reasons for encounter, 78.4% of patients had 1 to 3 procedures per visit. 64.4% of patients with diabetes presented at least one reason for encounter connected to diabetes. The most common reasons for encounter were prescriptions of medication 46.4 per 100 reasons for encounter, the second was dignostic procedure 19.9, request for analysis of findings 11.1, symptoms complaints 11, request for referrals to diagnostic procedures or specialist consultation 8.9 and administrative reuqests 1.6 per 100 reasons for encounter. Family practitioner performed procedure prescriptions of medication 47 per 100 procedures. The second was dignostic procedure 32.8 per 100 procedures, referrals to diagnostic procedures or specialist consultation 14.7 and administrative procedures 1.7 per 100 procedures. From the total number of 100 referrals to specialist, 23 were to diabetologist, 15 to ophtalmologist, 13 to cardiologist. The largest proportion of procedure belong to diabetics 33.8%, followed by the circulatory system 25.4%, musculosceletal 6.9%, symptoms 5.1%, respiratory 4.5%. The reasons for encounter and the procedures conducted during the visit have direct influence to the quality of care for persons with diabetes. It is necessery collecting the data and research in the field of reasons for encounter and procedures during the visit of person with diabetes. The results then can be compared to the results already found in literature.

A thin line between Meniere's disease and spontaneous intracranial hypotension syndrome.

AIM: To point out the similarity of Meniere disease and spontaneous intracranial hypotension and difference of their treatment. METHODS: A case of a 54-year-old male patient with previously diagnosed Meniere's disease and newly diagnosed spontaneous intracranial hypotension syndrome is presented. Additional neuroradiological examination, Brain contrast-enhanced MRI and MR myelography were used for diagnosis. RESULTS: Due to deterioration of vertigo, hearing loss and tinnitus in the right ear the patient was referred to the additional neuroradiological examination which confirmed the diagnosis of spontaneous intracranial hypotension syndrome. Brain contrast-enhanced MRI showed increased pachymeningeal contrast enhancement, and MR myelography identified the location of CSF leak. The patient was successfully treated conservatively. CONCLUSION: According to our knowledge this is the fifth case report of Meniere's disease and spontaneous intracranial hypotension coexistence. Both diseases have similar clinical presentation and initial treatment. We suggest procedures of additional examination when the treatment fails and initial diagnosis becomes questionable.

Frequent attenders in family practice in Croatia: retrospective study.

AIM: To determine the number of "frequent attenders" in family practice offices in Croatia according to the number and proportion of frequent attender visits in the total number of visits, and to follow up the frequent attenders and the number of visits they made over a period of three years. METHODS: The retrospective study involved 8 family practice offices in Northern Croatia. The number of visits to family practice was determined for 4,312 patients aged over 18 years. There were 1,826 men (42.3%) and 2,486 (57.7%) women. The follow up period lasted from January 1, 1997 to December 31, 1999. The borderline value that divided the frequent from non-frequent attenders was the value at the third quartile of the number of visits in a single age-sex group of patients. RESULTS: We recorded a total of 58,088 visits of patients older than 18 years to 8 family practice offices in the three-year period. In 1997, out of 4,312 patients who made a total of 17,938 visits, 944 (22%) frequent attenders made 11,257 (63%) visits. In 1998, there were a total of 20,350 visits made, with 966 (22%) frequent attenders making 12,145 (60%) visits. In 1999, a total of 20,725 visits were made, with 988 (23%) frequent attenders making 12,259 (59%) visits. The differences in the distribution of frequent vs non-frequent attenders according to age and sex were not statistically significant in any of the three study years (chi-square, p=0.727). Older men and older women were not more often frequent attenders than younger men and younger women, respectively. Out of 4,312 patients, 1,714 (40%) were frequent attenders in one of the three study years. Of these, 884 (21%) were frequent attenders in one year, 476 (11%) in two years, and 354 (8%) in all three subsequent study years. Out of 4,312 patients, 1,762 (41%) patients in 1997, 1,139 (26%) in 1998, and 1,116 (26%) patients in 1999 did not make a single visit to a family physician. CONCLUSION: Frequent attender visits make a great proportion of the total number of visits to family practice offices in Croatia, a country with a health care system in transition. Eight percent of patients remained being frequent attenders during all three study years.