Do Informal Care Recipients Internalise Carer Burden? Examining the Impact of Informal Care Receipt on Health Behaviours.

BACKGROUND: Providing informal care has a negative effect on the caregiver's health and well-being, but little is known about how individuals respond to receiving informal care. Care recipients may improve their health behaviours to minimise the onerousness of caregiving and the stress faced by their carer from seeing a loved one in ill-health. OBJECTIVE: We aimed to examine whether informal care recipients internalise the potential for carer spillovers through changes in health behaviours. METHODS: We used data from 3250 older adults with care needs who took part in the UK Household Longitudinal Study between 2017 and 2019. We examined the response to informal care receipt in terms of the probability of engaging in four health behaviours: healthy diet, physical activity, smoking and alcohol consumption. We estimated average treatment effects using regression adjustment with inverse probability treatment weights, comparing individuals that received informal care to those receiving either formal or no care. RESULTS: We found that informal care receipt increased the probability of refraining from negative health behaviours (smoking and alcohol consumption) but reduced the probability of engaging in positive health behaviours (eating fruits and/or vegetables and physical activity). CONCLUSIONS: The asymmetric effects detected suggest that the underlying mechanisms are different, and care recipients may be engaging in risk and effort compensation between negative and positive health behaviours. Failure to account for the behavioural responses from informal care recipients may lead to under-estimation or over-estimation of the extent of caregiving burden and the effectiveness of interventions impacting informal carers.

The clinical use of bone morphogenetic proteins revisited: a novel biocompatible carrier device OSTEOGROW for bone healing.

PURPOSE: The purpose of this study was to revise the clinical use of commercial BMP2 (Infuse) and BMP7 (Osigraft) based bone devices and explore the mechanism of action and efficacy of low BMP6 doses in a novel whole blood biocompatible device OSTEOGROW. METHODS: Complications from the clinical use of BMP2 and BMP7 have been systemically reviewed in light of their role in bone remodeling. BMP6 function has been assessed in Bmp6-/- mice by µCT and skeletal histology, and has also been examined in mesenchymal stem cells (MSC), hematopoietic stem cells (HSC) and osteoclasts. Safety and efficacy of OSTEOGROW have been assessed in rats and rabbits. RESULTS: Clinical use issues of BMP2 and BMP7 have been ascribed to the limited understanding of their role in bone remodeling at the time of device development for clinical trials. BMP2 and BMP7 in bone devices significantly promote bone resorption leading to osteolysis at the endosteal surfaces, while in parallel stimulating exuberant bone formation in surrounding tissues. Unbound BMP2 and BMP7 in bone devices precipitate on the bovine collagen and cause inflammation and swelling. OSTEOGROW required small amounts of BMP6, applied in a biocompatible blood coagulum carrier, for stimulating differentiation of MSCs and accelerated healing of critical size bone defects in animals, without bone resorption and inflammation. BMP6 decreased the number of osteoclasts derived from HSC, while BMP2 and BMP7 increased their number. CONCLUSIONS: Current issues and challenges with commercial bone devices may be resolved by using novel BMP6 biocompatible device OSTEOGROW, which will be clinically tested in metaphyseal bone fractures, compartments where BMP2 and BMP7 have not been effective.

Online learning applied to a course on rational therapeutics: an international comparison between final year students of two medical schools.

INTRODUCTION: Poor prescribing is probably the most common cause of preventable medication errors and many of these events involve junior doctors. In 2009, an electronic problem-based therapeutics course developed at the University of Michigan Medical School (UMMS) was translated and adapted for use at the University of Zagreb Medical School (UZMS). METHODS: After students from both schools took the course in 2010, we compared their responses with an online questionnaire addressing the course quality and its effectiveness. RESULTS: There were no statistically significant differences in the overall average grades awarded for the course (UZMS 4.11 ± 0.86 vs. UMMS 3.96 ± 0.93; 95% CI mean difference (MD) -0.36, 0.07; P = 0.175) with both student groups expressing high satisfaction rates with its quality, accessibility and overall design. UZMS students reported spending less time working through the course than their American colleagues (2.14 ± 1.01 vs. 2.89 ± 1.02 on a five point Likert scale; 95% CI MD 0.51, 0.99; P < 0.05). Furthermore, Croatian students indicated greater difficulty with course materials (3.54 ± 0.59 vs. 3.25 ± 0.59; 95% CI MD -0.42, -0.15; P < 0,05) and weekly multiple choice questions (3.83 ± 0.62 vs. 3.4 ± 0.61; 95% CI MD -0.58, -0.29; P < 0,05) compared with the UMMS students. CONCLUSION: It is possible to adapt and translate successfully whole online teaching resources and implement them internationally in different countries and health care systems, achieving similar, high student satisfaction rates while decreasing administrative and cost burdens. Web based learning may have great potential to offer a cost effective and safe environment in which prescribing skills can be improved.

Pain relief in medical patients: does clinical judgment and prescribing knowledge suffice?

The aim of this study was to evaluate the quality of pain management in hospitalised patients. A cross-sectional study design that included all medical patients experiencing pain was used. Out of 167 patients hospitalized at the Department of Medicine at the University Hospital Zagreb, 41 patients were experiencing pain and 40 out of them received analgesics. Twenty-two out of 38 patients were treated for malignant pain, 16 for non-malignant pain, and 2 patients could not be classified. Adequate pain relief was reported in less than 25% of patients in both groups. Our study revealed under-prescribing of combination therapy, low utilization rates of strong opioids and prevailing "as needed" prescribing practice. In conclusion, unsatisfactory pain management in medical patients is often present if left solely to the clinical judgement and knowledge of the prescribing physician. Regular pain assessment, evidence-based guidelines, education and regular audits of implementation of these measures are a prerequisite for effective pain treatment, and should all be employed in patients experiencing pain.

[ISKRA guidelines for antimicrobial prophylaxis in surgery--Croatian National Guidelines]. / Smjernice ISKRA za antimikrobnu profilaksu u kirurgiji--Hrvatske Nacionalne Smjernice.

Summary. The development of the Guidelines for perioperative prophylactic use of antimicrobial agents (further on Guidelines) was initiated by the Interdisciplinary Section for Antibiotic Resistance Control (ISKRA) of the Croatian Ministry of Health and Social Welfare in accordance with the principles of AGREE (Appraisal of Guidelines for Research and Evaluation) methodology which means that the guidelines are the result of a consensus between all involved professional societies. Guidelines were composed in order to improve antibiotic use in surgical professions. Data obtained from observational studies have shown that the use of antimicrobials in surgical professions is unsatisfactory, and since around 50% of all prescribed drugs in surgical professions refer to perioperative prophylaxis, such guidelines could significantly improve current negative trend and reduce the occurrence of infections in surgical patients as well as slow down the selection of resistant bacteria. In the introductory part of the guidelines, principles of perioperative prophylaxis are presented. The advantages and risks of prophylaxis are listed as well as factors that determine prophylaxis effectiveness. For easier orientation, surgical professions have been divided into basic surgical fields. In each field, the specificity of the field has been described followed by uniform structured tables and with every listed surgical procedure there is the most probable cause of infection, the drug of choice for prophylaxis, alternative drug, remark for particular surgical procedure and finally the grade of recommendation. The Guidelines do not cover perioperative prophylaxis in immunocompromised patients nor perioperative prophylaxis in children. The Guidelines do not cover all possible surgical interventions, but can be used as a basis for most surgical procedures performed in our hospitals. At the very end of these Guidelines, a comprehensive list of references enables all those interested to find further information and details about this topic. The revision of the Guidelines is planned in three years' time.

[Three-year-old boy--a homozygote for familiar hypercholesterolemia]. / Trogodisnji djecak--homozigot za porodicnu hiperkolesterolemiju.

Homozygous familial hypercholesterolemia (FH) is a rare autosomal dominant disorder caused by mutations in the low-density-lipoprotein (LDL) receptor gene. It occurs with a frequency of approximately 1 per million persons world-wide. Clinically, homozygous FH is associated with extremely elevated levels of LDL cholesterol and cutaneous xanthomas that develop in early childhood. These children are at risk of extremely early coronary events and death from myocardial infarction caused by premature generalized atherosclerosis. Their medical treatment is very complex, associated with various problems and complications. We describe a 3-year-old boy with clinical signs of homozygous FH (elevated LDL-cholesterol levels and xanthomas). Heterozygous hypercholesterolemia was found in his parents and some other family members. The boy has been treated with simvastatin and atorvastatin, but without reaching the treatment goals. LDL apheresis is planned as the treatment of choice for homozygous children with FH.

Requirement of a bone morphogenetic protein for the maintenance and stimulation of osteoblast differentiation.

The requirement of a bone morphogenetic protein for the maintenance and stimulation of an osteoblast phenotype was examined using mouse MC3T3-E1 cell cultures. Cells expressed BMP-4 mRNA, which correlated with the stimulation of the osteoblast phenotype. The addition of a BMP-4 specific antibody reduced bone nodules, suggesting that BMP-4 is required for the osteogenic activity of osteoblasts in an autocrine manner. Exogenously added BMP-7 gradually decreased the expression of BMP-4 with a concurrent stimulation of the osteoblast phenotype. Exogenous BMP-7 can therefore substitute for endogenously produced BMP-4 acting as a paracrine factor on osteoblasts. The addition of 17beta estradiol decreased BMP-4 expression but initiated synthesis of BMP-6 mRNA, an endocrine signal for osteoblasts, which also substituted for the lack of endogenous BMP-4, as evidenced by normal bone nodule formation. The addition of dexamethasone and parathyroid hormone did not affect the BMP-4 expression but induced transcripts for BMP-2 and BMP-3, respectively, suggesting that their effects on bone can be in part achieved via the BMP signaling. These experiments support the requirement of a BMP for osteoblast differentiation and function, demonstrating for the first time that a BMP can functionally substitute for another BMP in an autocrine/paracrine manner or mediate a response to an endocrine action on osteoblasts.

[Guidelines for antimicrobial treatment and prophylaxis of urinary tract infections]. / Smjernice antimikrobnog lijecenja i profilakse infekcija mokracnog sustava.

Recommendations for antimicrobial treatment and prophylaxis of urinary tract infections (UTI) have been made according to the results of investigation of resistance of the most frequent causative agents of UTI to antimicrobial drugs. This investigation has been conducted for the past seven years by the Committee for monitoring bacterial resistance to antibiotics in the Republic of Croatia, with consensus of eight professional societies of the Croatian Medical Association. Uncomplicated cystitis is treated 1, 3, or 7 days, complicated 7 days, pyelonephritis 10-14 days, and complicated UTI 7 to 14 days, rarely longer. For the treatment of cystitis fluorokinolons, nitrofurantoin, betalactam antibiotics, and in the fields of lower resistance trimethoprim/sulfamethoxazol are being used. Single treatment with fluorokinolons is administered to otherwise healthy young women with normal urinary tract in whom cystitis symptoms have been present for less than 7 days. Empiric antimicrobial treatment of pyelonephritis, recurrent and all complicated UTI must be reviewed after urine culture finding is obtained. In the treatment of bacterial prostatitis and febrile UTI in males, the drug of first choice is ciprofloxacin. Asymptomatic bacteriuria (AB) is treated in pregnant women, newborns, preschool children with urinary tract abnormalities, before invasive urologic and gynecologic procedures, in kidney transplant recipients, and in the first days of short term urinary bladder catheterization. Recommendations for the treatment of AB in patients with diabetes mellitus have been controversial in the past two years. Antimicrobial prophylaxis is administered mostly one hour prior to the diagnostic or therapeutic invasive urological procedure, using selected antimicrobial agents.