Comprehensive geriatric assessment in primary care practices: a multi-centered, cross-sectional study in Krakow, Poland.

BACKGROUND: Comprehensive geriatric assessment (CGA), as a complex diagnostic process, allows medical specialists to recognize the capabilities and limitations of the patient in older age. This study aimed to evaluate the prevalence and severity of deficits typical of seniors and find relationships between CGA results and selected factors. METHODS: A cross-sectional questionnaire study was performed in Krakow among patients aged 65 years and over visiting their general practitioners (GPs). CGA was conducted using eight scales: the Activities of Daily Living (ADL), Mini-Mental State Examination, Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, Timed Up and Go Test, Mini Nutritional Assessment Short Form, Clinical Frailty Scale, and Athens Insomnia Scale. RESULTS: Four hundred and thirty-eight patients, aged between 65 and 96 years, were examined. Most of them received high scores in the assessed aspects. The most common abnormalities were sleep disorders (42 %), symptoms of frailty (33 %), and depressive tendency (32 %). Age correlated with every aspect assessed in CGA and worsened as patients grew older (in all cases p <0.05). Male gender reduced the chance of depressive disorders [odds ratio (OR) =0.6 (0.39-0.92); p =0.02]. The strongest association was found between ADL and IADL scales [OR =153.56 (34.86-676.48); p <0.001]. CONCLUSIONS: Even though patients who attended general practices were functioning well in everyday life, after analysis, they manifested deficits in some areas of CGA. The most widespread problems in the geriatric population were depressive symptoms, frailty, and insomnia, and that is why GPs should ask about sleep and mood disorders during visits and assess the occurrence of frailty. HIPPOKRATIA 2020, 24(4): 173-181.

KIF5A de novo mutation associated with myoclonic seizures and neonatal onset progressive leukoencephalopathy.

The KIF5A gene (OMIM 602821) encodes a neuron-specific kinesin heavy chain involved in intracellular transport of mitochondria and other cargoes. KIF5A protein comprises the N terminal motor domain, the stalk domain and the C-terminal cargo binding domain. The binding between KIF5A and its cargoes is mediated by kinesin adaptor proteins such as TRAK1 and TRAK2. Numerous missense KIF5A mutations in the motor and stalk domains cause spastic paraplegia type 10 (SPG10, OMIM 604187). Conversely, the role of loss-of-function mutations, especially those affecting the cargo binding domain, is unclear. We describe a novel de novo KIF5A p.Ser974fs/c.2921delC mutation found by whole exome sequencing in a patient with a congenital severe disease characterized by myoclonic seizures and progressive leukoencephalopathy. Since this phenotype differs considerably from the KIF5A/SPG10 disease spectrum we propose that the KIF5A p.Ser974fs and possibly other mutations which lead to truncation of the C-terminal tail of the protein cause a novel disorder. We speculate that the unique effect of the C-terminal truncating KIF5A mutations may result from the previously described complex role of this protein domain in binding of the TRAK2 and possibly other kinesin adaptor protein(s).

Transient ischaemic attacks: desired diagnosis and management by Polish primary care physicians.

OBJECTIVE: The aim of this study was to assess the competence of Polish primary care physicians in diagnosing and managing patients with transient ischaemic attacks (TIAs) in the carotid territory. METHOD: A written questionnaire was distributed to all first-contact physicians (n = 100) in one of the seven health care districts of Warsaw (response rate 89%). The questionnaire included three pairs of TIA cases. In each of the pairs, only the age and type varied. Three cases were characterized by transient monocular blindness and the other three by symptoms of hemispheral ischaemia. RESULTS: Physicians confronted with TIA cases had difficulties in diagnosing it. In the cases of monocular blindness, only 20-44% of cases were diagnosed correctly, and hemispheral ischaemia was diagnosed correctly in 46-78% of cases. Patients with no history of non-specific symptoms and with the first attack would have a higher percentage of correct diagnoses in comparison with those with recurrent attacks and a history of non-specific symptoms. Patients with hemispheral ischaemia frequently would be referred to neurologists, and about two-thirds of doctors would refer patients with monocular blindness to ophthalmologists, and fewer than half to neurologists. Antiplatelet therapy would be prescribed by <22% of physicians, while peripheral vasodilatators would be prescribed by up to 60% of them. CONCLUSION: The results of this study indicate that Polish primary care physicians when confronted with TIA cases would have basic difficulties, especially in diagnosis and management. These results underline the need for changes in the vocational training of primary care physicians, with special attention to frequent family medicine problems.

Enrolment procedures and self-selection by patients: evidence from a Polish family practice.

This paper examines the consequences of patient enrollment procedures in a capitation-based family practice in Krakow (Poland), where the local city government used two different methods for preparation of patient lists. In the first, the city gave the individuals living within the practice area the option of withdrawing from being enrolled in the practice; in the second, individuals were given the option of enrolling in the practice. These two enrollment procedures, identified as 'active-negative' and 'active-positive' respectively, provide a natural experiment for investigating the effects of an enrollment methodology on the economics of a physician's practice. An examination of the data indicates that self-selecting enrollees utilize significantly greater quantities of health care compared to others, and university educated individuals and individuals more likely to fall ill are more likely to self-select into a practice. The study suggests that in order to reduce demand-side adverse selection, either the system of active-positive enrollment should be modified, or capitation rates should be risk-adjusted by health status rather than by demographic variables only. The policy implications of this study become even more significant as more and more physicians leave their salaried jobs to start state-financed independent practices.

The Polish experience of quality improvement in primary care.

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.

Are antibiotics over-prescribed in Poland? Management of upper respiratory tract infections in primary health care region of Warszawa, Wola.

BACKGROUND: Concern about the increasing numbers of multiple resistant strains resulting from over- and misuse of antibiotics is growing world-wide. METHOD: A questionnaire based on two cases related to respiratory tract infections for which antibiotic prescription was disputable was sent to primary care physicians in the health care district of Warszawa, Wola, Poland. RESULTS: The prescription percentage for both cases was high, with a large variety in choice of antibiotic therapy made by the doctors. This finding was striking when compared with the more restrictive prescription behaviour of Dutch general practitioners. Moreover, this high prescription percentage was combined with other abundant activities. In the case of the patient with acute tonsillitis, 53% of the primary care physicians would have ordered additional tests, 94% would have advised bed-rest and 9% would have referred. In the sinusitis case, these figures were 88, 74 and 54% respectively. No correlations were found between choice of antibiotics and characteristics of the physicians such as age, gender, experience with working in primary health care or degree of specialization. CONCLUSIONS: In conclusion, the results of this small pilot study indicate that Polish first-contact doctors have an inadequate prescription behaviour in cases with upper respiratory tract infections. Our results underline the need for courses in pharmacotherapy within the postgraduate education course in family medicine recently introduced in Poland.

Hepatic insulin resistance during canine sepsis.

Glucose dyshomeostasis and insulin resistance are well-documented characteristics of sepsis. The insulin resistance could be manifested in a decreased peripheral glucose uptake and/or an increased hepatic glucose output. To investigate the hepatic and peripheral responses to insulin in a three-day model of sepsis, 14 mongrel dogs were studied. Animals were randomly assigned to a SEPTIC (n = 5), SHAM (n = 4), or CONTROL (n = 5) group. Sepsis was induced in anesthetized dogs via a midline laparotomy with subsequent placement of a fecal-soaked gauze sponge around intestines. SHAM and CONTROL dogs were pair-fed with the SEPTIC dogs. On the third day, animals were anesthetized, intubated, and ventilated. Via a left-side laparotomy, electromagnetic flow probes were placed to measure hepatic arterial and portal venous blood flows. Cannulas were placed in femoral, portal, and hepatic veins and femoral artery to measure hepatic outputs of glucose, lactate, and oxygen during hyperinsulinemic-euglycemic clamps ranging from 0.4 to 4,000 mU insulin/min. Portal venous insulin concentrations in SEPTIC animals were significantly increased compared to CONTROL animals during 0.4 and 4 mU insulin/min infusions. An insulin infusion rate of 40 mU/min significantly decreased net hepatic glucose output (NHGO) in CONTROL animals but did not affect NHGO in SHAM or SEPTIC animals. An insulin infusion rate of 4,000 mU/min significantly decreased NHGO in all groups. An attempt to analyze the ED50 of the three dose-response curves was inconclusive. Glucose infusion rates (GIR) increased during insulin infusion but the GIR were not different between groups at any insulin infusion rate.(ABSTRACT TRUNCATED AT 250 WORDS)