Primary care obesity management in Hungary: evaluation of the knowledge, practice and attitudes of family physicians.

BACKGROUND: Obesity, a threatening pandemic, has an important public health implication. Before proper medication is available, primary care providers will have a distinguished role in prevention and management. Their performance may be influenced by many factors but their personal motivation is still an under-researched area. METHODS: The knowledge, attitudes and practice were reviewed in this questionnaire study involving a representative sample of 10% of all Hungarian family physicians. In different settings, 521 practitioners (448 GPs and 73 residents/vocational trainees) were questioned using a validated questionnaire. RESULTS: The knowledge about multimorbidity, a main consequence of obesity was balanced.Only 51% of the GPs were aware of the diagnostic threshold for obesity; awareness being higher in cities (60%) and the highest among residents (90%). They also considered obesity an illness rather than an aesthetic issue.There were wider differences regarding attitudes and practice, influenced by the the doctors' age, gender, known BMI, previous qualification, less by working location.GPs with qualification in family medicine alone considered obesity management as higher professional satisfaction, compared to physicians who had previously other board qualification (77% vs 68%). They measured their patients' waist circumference and waist/hip ratio (72% vs 62%) more frequently, provided the obese with dietary advice more often, while this service was less frequent among capital-based doctors who accepted the self-reported body weight dates by patients more commonly. Similar reduced activity and weight-measurement in outdoor clothing were more typical among older doctors.Diagnosis based on BMI alone was the highest in cities (85%). Consultations were significantly shorter in practices with a higher number of enrolled patients and were longer by female providers who consulted longer with patients about the suspected causes of developing obesity (65% vs 44%) and offered dietary records for patients significantly more frequently (65% vs 52%). Most of the younger doctors agreed that obesity management was a primary care issue.Doctors in the normal BMI range were unanimous that they should be a model for their patients (94% vs 81%). CONCLUSION: More education of primary care physicians, available practical guidelines and higher community involvement are needed to improve the obesity management in Hungary.

Differences in Anthropometric Parameters of Children in Six European Countries.

BACKGROUND: The databases of children's anthropometric parameters are often outdated, rarely representative and are not always available at an international level. OBJECTIVES: To present children's anthropometric parameters in six European countries that contributed to the Feel4Diabetes project and find country-specific differences. DESIGN/SETTING: The Feel4Diabetes study was performed between 2016 and 2018, targeting children in Belgium, Bulgaria, Finland, Greece, Hungary and Spain. The current study presents data from the baseline and the yearly follow-up anthropometric measurements. SUBJECTS: In total, 20,832 measurements of children (48.7% boys) between 6 and 10 years of age were conducted. MAIN OUTCOME MEASURE: weight, height, BMI. RESULTS: Belgian boys had the lowest body weight and height, while Greek boys had the highest body weight, and Finnish had the highest body height. The highest proportion of overweight (percentile above 85%) and obese boys (percentile above 95%) was in Greece, followed by Hungarian, Spanish, Bulgarian and Finnish boys. In contrast, Belgian boys had the lowest ratio in both categories. Among girls, Greece had the highest; Belgium had the lowest body weight; Finland was the highest in all age categories. The ratio in the overweight range was the highest in Greece, followed by Spanish, Bulgarian and Hungarian girls, who were second in the obese category. Finnish girls had lower and Belgian girls had the lowest ratio in both BMI categories. All the detailed data are presented in tables, and the trends are figures. CONCLUSIONS: Our study presents fresh and comparable anthropometric data of children between 6 and 10 years of age in six European countries, supporting the need for appropriate obesity prevention.

[Trends and current questions of cardiovascular prevention in primary health care]. / A cardiovascularis prevenció irányai és aktuális kérdései a háziorvoslásban.

Although an impressive progress has been achieved in the treatment of cardiovascular diseases, they are at the top of the mortality statistics in Hungary. Prevention of these diseases is an essential task of the primary health care. Cardiovascular prevention is carried out at primary, secondary and tertiary levels using risk group and population preventive strategies. The two main tasks of primary cardiovascular prevention are health promotion and cardiovascular disease prevention, and its main programs are ensuring healthy nutrition, improving physical training and accomplishing an anti-smoking program. The essential form of secondary prevention is the screening activity of the primary health care. The majority of cardiovascular risk factors can be discovered during the doctor-patient consultation, but laboratory screening is needed for assessing metabolic risks. The official screening rules of the cardiovascular risk factors and diseases are based on diagnostic criteria of the metabolic syndrome; however, nowadays revealing of global cardiometabolic risks is also necessary. In patients without cardiovascular diseases but with risk factors, a cardiovascular risk estimation has to be performed. In primary care, there is a possibility for long term follow-up and continuous care of patients with chronic diseases, which is the main form of the tertiary prevention. In patients with cardiovascular diseases, ranking to cardiovascular risk groups is a very important task since target values of continuous care depend on which risk group they belong to. The methods used during continuous care are lifestyle therapy, specific pharmacotherapy and organ protection with drugs. Combined health education and counselling is the next element of the primary health care prevention; it is a tool that helps primary, secondary and tertiary prevention. Changes needed for improving cardiovascular prevention in primary care are the following: appropriate evaluation of primary prevention, health education and counselling, renewal of the cardiovascular screening system based on the notion of global cardiometabolic risk, creating a unified cardiovascular prevention guideline, and operating primary care cardiovascular prevention within the framework of an integrated prevention system.

Knowledge, motivation, and attitudes of Hungarian family physicians toward pandemic influenza vaccination in the 2009/10 influenza season: questionnaire study.

AIM: To evaluate the knowledge, motivation, and attitudes of Hungarian family physicians toward pandemic influenza vaccination in the 2009/10 influenza season. METHOD: A questionnaire with 20 questions was developed and sent to 232 family physicians in 3 largest Hungarian cities: Budapest, Debrecen, and Miskolc. The study was conducted in December 2009 and January 2010. RESULTS: A hundred and ninety eight (85%) physicians answered the questionnaire adequately. Respondents believed that the influenza outbreak represented less of a threat to their practices than to Hungary or the world as a whole. They mostly agreed that vaccination was important and were frequently dissatisfied with the support from health authorities. The proportion of vaccinated patients ranged between 2% and 53%, without differences according to geographical region, age, sex, and duration of physicians' employment in family practice. Physicians who were satisfied with the payment for procedures and underwent vaccination themselves were more active in vaccination. CONCLUSION: Health authorities should provide clear and evidence-based professional support to family physicians and should encourage them to get vaccinated against pandemic influenza, while insurance funds have to establish appropriate reimbursement system.

[Current questions of thyroid diseases in childhood]. / A gyermekkori pajzsmirigybetegségek aktuális kérdései.

In recent years our knowledge on thyroid diseases in childhood has been increased. Several forms of congenital hypothyroidism (dysgenesis, dyshormongenesis, thyrotropin resistance and some central forms) are consequences of gene mutations. Maternal hypothyroxinemia due to severe iodine deficiency leads to early neurological damage and congenital hypothyroidism. Neonatal screening of congenital hypothyroidism and early treatment with l-thyroxin ensure good prognosis. Differential diagnosis of the various forms of congenital hypothyroidism in newborns is not an easy task. The need for treatment of transient hypothyroxinemia is still controversial. Diagnosis of juvenile lymphocytic thyroiditis can be ascertained by the clinical status, ultrasound examination, detection of anti-peroxydase antibodies, evaluation of thyroid function, and fine needle aspiration cytology. L-thyroxin therapy is recommended in cases of subclinical and manifest hypothyroidism. The transient form of the rare newborn hyperthyroidism is the consequence of maternal Graves-Basedow disease. It can be a sever condition and its permanent form is caused by TSH-receptor gene mutation. In the pathogenesis of autonomic thyroid adenoma mutations of the TSH-receptor and the alpha subunit of the stimulatory G-protein are involved. Treatment of Graves-Basedow disease in childhood is a debated question. The first choice is medical treatment with antithyroid and beta-blocking drugs. However, remission rate is low under this therapy, and the disease is characterised by frequent relapses. For this reason, the necessity of definitive therapy frequently arises. In Europe subtotal thyroidectomy is used as second choice of therapy, but clinical experience in the United States showed that radioiodine treatment is a safe and effective therapy for children and adolescents. Iodine deficient goitre in childhood is a form of iodine deficiency disorder. It is the consequence of adaptation to iodine deficiency. It can be treated by iodine or/and l-thyroxin, and its development can be prevented by iodinated salt. In childhood, thyroid nodule needs for a detailed investigation because of the possibility of thyroid cancer. Medullar thyroid carcinoma indicates genetic screening in the patients and their family, and the presence of disease-causing RET-proto-oncogene mutation confirms the need for total thyroidectomy already in childhood.

Novel sequence variation of AIRE and detection of interferon-omega antibodies in early infancy.

OBJECTIVE: Autoimmune polyendocrine syndrome type I (APS I) is a rare primary immunodeficiency disorder characterized by chronic mucocutaneous candidiasis, multi-organ autoimmunity and ectodermal dysplasia. Autoantibodies to parathyroid and adrenal glands and type I interferons (IFN) are hallmarks of APS I, which results from mutations in the autoimmune regulator (AIRE) gene. We wished to study clinical, immunological and genetic features of APS I in Hungarian patients, and to correlate anti-IFN-omega serum concentration with APS I and other multi-organ autoimmune diseases. DESIGN: Detailed analysis of patients with APS I and multi-organ autoimmune diseases. PATIENTS: Seven patients with APS I and 11 patients with multi-organ autoimmune diseases were studied. MEASUREMENTS: Mutational analysis was performed by bidirectional sequencing of AIRE. Antibodies against IFN-omega and endocrine organ-specific autoantigens were studied with radioimmunoassay. RFLP was performed by digestion of DNA with Hin6I restriction enzyme. RESULTS: AIRE sequence analysis revealed homozygous c.769C>T mutations in three patients and compound heterozygous sequence variants (c.769C>T/c.44_66dup26bp; c.769C>T/c.965_977del13bp; c.769C>T/c.1344delC) in four patients with APS I. All the six live patients tested had markedly elevated IFN-omega antibodies, which were not found in heterozygous siblings or parents. One of the identified patients was negative for antibodies against IFN-omega at 6 weeks of age, but became positive at 7 months. At age 1, he is still without symptoms of the disease. In contrast to patients with APS I, no AIRE mutation or elevation of IFN-omega antibodies were detected in patients with multi-organ autoimmune diseases. CONCLUSION: This is the first overview of patients diagnosed with APS I in Hungary. A novel c.1344delC mutation in AIRE was detected. Anti-IFN-omega antibodies seem to appear very early in life and are helpful to differentiate APS I from other multi-organ autoimmune diseases.

[Prevalence of microalbuminuria and its clinical correlation with other risk factors of cardiovascular diseases]. / A microalbuminuria prevalenciája és klinikai összefüggése a szív- és érrendszeri betegségek egyéb kockázati tényezoivel. Háziorvosi szurovizsgálati lehetoségek.

Degree of albuminuria is a sensitive parameter to estimate cardiovascular risk and endothelial dysfunction. Large epidemiological studies proved higher amount of protein in the urine in diabetic and hypertensive patients. Measurement of albuminuria is not a part of the daily routine in Hungarian primary care nowadays. Authors used a simple screening tests and confirmed higher incidence of microalbuminuria in patients with diabetes, hypertension, as well in patients with increased waist circumference, especially in women. Authors suggest this screening test to general practitioners and family physicians to use in their daily cardiovascular care and preventive practice.

[Continuing care of patients with cardiovascular risk in general practice: patients with dyslipidemia and their care]. / Cardiovascularis kockázattal rendelkezo páciensek gondozása háziorvosi praxisokban: dyslipidaemiás páciensek es gondozásuk.

INTRODUCTION: The role of dyslipidemia is essential in the development of atherosclerosis, therefore continuing care of dyslipidemic patients is an extremely important task in cardiovascular prevention. AIMS: This study was aimed to investigate continuing care of dyslipidemic patients in general practices. Method of the study was a questionnaire survey, 397 patients of 39 general practices were involved into the study. RESULTS: The cause of their continuing care was hypercholesterolemia in 91.7%, hypertriglyceridemia in 69%, decreased HDL-C in 18.4%, and these alterations frequently occurred together. Hypertension in 77%, disturbances of carbohydrate metabolism in 41.7%, increased BMI in 43.2% were found. Patients were smokers in 26.5%, given up smoking in 13.2%. They had cardiovascular problems in 56.5%, cerebrovascular problems in 18.6% and peripheral vascular ones in 20.3%. Patients were treated with lipid lowering drugs in 87.7%, statins were used in 81.7%, fibrates in 29.6% and both of them in 11.5%. The main results of continuing care were: in the whole group frequency of cholesterol level > 5.2 mmol/l decreased by 13%, frequency of triglyceride level >1.7 mmol/l decreased by 4%; cholesterol target values were reached in 3% of patients with high cardiovascular risk, in 22.2% of patients with medium risk, and in 66.7% of patients with mild risk. CONCLUSIONS: These results suggest that there is a need for more intensive drug treatment of dyslipidemic patients to reach the target lipid levels, and for regular assessment of continuing care of these patients.

[Continuing care of patients with cardiovascular risk in general practice: diabetic patients and their care]. / Cardiovascularis kockázattal rendelkezo betegek gondozása háziorvosi praxisokban: diabeteses betegek és gondozásuk.

INTRODUCTION: Both types of diabetes mellitus are conditions with high cardiovascular risk. AIMS: This work was aimed to study the frequency of cardiovascular risk factors, macrovascular and microvascular complications and to assess the results of continuous diabetes care in an adult population with type 1 and type 2 diabetes. Method of the study was a questionnaire survey, altogether 400 patients, 49 with type 1 and 351 with type 2 diabetes, were enrolled to it. RESULTS: Frequency of cardiovascular complications, obesity, hypertension and dyslipidemia was higher in type 2 diabetes, smoking and microvascular complications were more frequent in type 1 diabetes. The ratio of conservative intensive and conventional insulin therapy in type 1 diabetes was 70% and 30%, respectively. Treatment methods used in type 2 diabetes were: diet only: 8%, oral antidiabetic therapy: 78%, antidiabetic agent and insulin: 7%, insulin therapy 7%. Ratios of the patients having at least three laboratory results were: fasting blood glucose: 50%, postprandial blood glucose: 30%, haemoglobin A(1C): 10%. Ratios of patients reached the target results were in type 1 and type 2 diabetes were: fasting blood glucose: 27% vs. 14%, postprandial blood glucose: 26% vs. 18%, haemoglobin-A: 29% vs. 34%. Ratios of the patients in micro- and macrovascular risk category were: fasting blood glucose: 59% vs. 68%, postprandial blood glucose: 54% and 53%, haemoglobin-A(1C): 40% vs. 27%. CONCLUSIONS: Frequency of investigations to estimate glycemic control as well as ratio of patients reached target values were rather low, ratio of patients in micro- and macrovascular risk category was high. For these reasons there is a need for a more intensive continuous diabetes care to reach better results.

[Cardiovascular risk among patients of general practices, who are not in current acute care]. / Cardiovascularis kockázat háziorvosi praxisok gondozásban nem álló páciensei körében.

INTRODUCTION: Cardiovascular diseases are the first in the Hungarian mortality statistics. Numerous factors are known that may be involved as risk factors in the development of these diseases, and the risk is multiplied when they occur simultaneously. The recommendations of the European and Hungarian professional societies regard the early exploration of these risk factors and the estimation of cardiovascular risk as extremely important, since the intervention to be introduced depends on the extent of the risk. METHODS: The study was aimed to assess, by using a professionally accepted risk estimation method, the extent of cardiovascular risk in the adult population aged between 18 and 60 years and previously not treated for cardiovascular risk(s) or diseases. 48 family doctors' practices of four counties participated in the study; a total of 1320 individuals were enrolled. During the study targeted recording of medical history, physical examination and the determination of certain parameters of carbohydrate and lipid metabolism were performed. Afterwards the participants' cardiovascular risk was calculated for 10 years, based on the parameters obtained (age, sex, smoking habits, systolic blood pressure, total cholesterol level, status of carbohydrate metabolism). RESULTS: Frequency of high and very high cardiovascular risk was 12.44% in the population (22.59% in men and 4.89% in women, 17.72% in middle-aged and 0.75% in younger patients). Distribution of cardiovascular risk levels was less favourable in men than in woman (p < 0.001), and in middle-aged patients than in younger ones (p < 0.001). The distributions of each risk factors were similar: significant differences were demonstrated in smoking habit, systolic blood pressure and plasma cholesterol between men and women as well as between middle and younger aged patients, however significant difference in alterations of carbohydrate metabolism was found just between middle- and younger aged groups. CONCLUSIONS: Cardiovascular risk is reasonably high in adult population previously not treated with cardiovascular risks or disease. Distribution of risk levels is less favourable in men than in women, and middle-aged patients compared to younger aged patients. These results show that there is a need for the increase of the frequency of patients' preventive visits to physicians, since this can allow the identification of risk factors as early as possible, the recognition of increased cardiovascular risk and the use of the necessary and adequate intervention.

Primary care of patients with high cardiovascular risk : Blood pressure, lipid and diabetic target levels and their achievement in Hungary.

Cardiovascular diseases are responsible for the majority of premature deaths in Hungary as well. Most of them could be prevented with healthy lifestyle of patients and adequate drug prescription of primary care physicians. Earlier European surveys found wide differences between the practices and achievements of different countries in this field. The study was based on and designed according to the framework of previous European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) studies and aimed presenting Hungarian results and comparing with the achievements of other countries and previous Hungarian surveys. Among rural and urban settings, 679 patients under continuous care (236 diabetics, 218 with dyslipidaemia, and 225 with hypertension) were consecutively selected by 20 experienced general practitioners. The mean age of patients was 60.3 years (men) and 64.0 years (women). Among diabetics, less than 7 % of glycated hemoglobin (HbA1c) values were found in 42.5 % patients, while only 11.4 % patients had fasting plasma sugar less than 6.0 mmol/L. Of the patients treated for dyslipidaemia, the target level of triglyceride was reached by 40.6 %, recommended total cholesterol by 14.2 % and the HDL-cholesterol by 71.8 %. The therapeutic control of total and HDL-cholesterol was better in men, although women had better triglyceride values. The achievement among patients with hypertension was 42.0 %. Significantly higher blood pressure was measured by patients who were treated with not recommended combinations of antihypertensive medication. A remarkable improvement could be observed in Hungary in the field of secondary prevention. It was greater among patients with hypertension and dyslipidaemia and smaller in diabetes care. Compared to the results of published European surveys, Hungary occupies a good position, but further improvement is still required.

Endocrine and anatomical findings in a case of Solitary Median Maxillary Central Incisor Syndrome.

Solitary Median Maxillary Central Incisor Syndrome (SMMCI) is a rare malformation syndrome consisting of multiple, mainly midline defects. Some authors suggest that it is a mild manifestation of the wide spectrum of holoprosencephaly, others classify it rather as a distinct entity. Authors report a case of SMMCI presenting with growth retardation, mild intellectual disability and absence of puberty. Cytogenetic and molecular cytogenetic investigations could identify no abnormalities. The presence of a single maxillary incisor called for further investigations to clarify hidden anomalies, these were empty sella, panhypopituitarism, hypothyroidism, and hypoplasia of the inner genitals. Based on the above findings, growth hormone, estrogen, and L-thyroxine substitution was introduced, which resulted in satisfactory longitudinal growth and onset of sexual maturation. We suggest genetic counselling and if needed, invasive investigations in female patients with short stature and absent/delayed puberty, with or without sex chromosomal anomalies, as the adequate therapy and even the quality of life of patient depends largely on the knowledge of their anatomical and endocrine status.

Relation between the socioeconomic status of the family and primary allergy prevention in infant feeding in Hajdu-Bihar County, Hungary.

BACKGROUND: The relationship between socioeconomic status and preventive care is an important issue in public health practice in Hungary. Our aim was to investigate the association between the socioeconomic status and the present practice of primary allergy prevention in infant feeding in Hajdú-Bihar County, Hungary. METHODS: A questionnaire-based cross-sectional survey was performed among 3076 infants aged 0-6 months. We studied how socioeconomic status, type of settlement, allergic background of the family and skin symptoms indicative for allergy were related to primary allergy prevention in infant feeding. Prevalence odds ratios (ORs) were calculated by multiple logistic regression. RESULTS: Independent determinants of breast feeding were age [OR corresponding to one month change 0.74; 95% confidence interval (CI) 0.70-0.77], the female gender (OR 1.24; 95% CI 1.06-1.46), the socioeconomic status of the family (OR comparing the worst with the best category 0.63; 95% CI 0.43-0.93), and birth weight (OR comparing <1500 g to >2500 g category 0.17; 95% CI 0.07-0.41). Among supplementary nutrient users independent determinants of the use of hydrolysed infant formulae were the socioeconomic status (OR comparing the worst with the best category 0.06; 95% CI 0.01-0.27), the type of settlement (OR comparing village with town 0.48; 95% CI 0.28-0.80), history of allergy in the family (OR 2.30; 95% CI 1.28-4.11), and skin symptoms indicative of allergy (OR 3.46; 95% CI 1.96-6.14). CONCLUSION: Socioeconomic status is related to the implementation of primary allergy prevention in infant feeding.