Changes in family practice work management in Zagreb due to the COVID-19 pandemic.

BACKGROUND: Since the COVID-19 pandemic has impacted family medicine practice (FMP) workload, we aimed to determine changes in the structure of work of FMPs in the number and type of consultations, check-ups, administrative, preventive, and other diagnostic-therapeutic procedures (DTPs) during the COVID-19 pandemic (2021 and 2022) compared to 2019. METHODS: In this cross-sectional study, 172 FMPs from Zagreb (39%) were analysed based on monthly work reports for March and April of 2019, 2021, and 2022. Before being analysed, all noted DTPs were divided into 5 main groups (administration, telephone and e-mail consultations, check-ups, face-to-face consultations, preventive work, and other DTPs). RESULTS: In 2021 the number of check-ups and face-to-face consultations dropped by 36.20%, whereas the total number of telephone and e-mail consultations, patients per day, and DTPs done per day increased by 120.12%, 6.67%, and 13.76%, respectively. The amount of administrative work rose only in 2022 by 17.58% along with other procedures which significantly impacted the share of medical work: 42.84% in 2019, 49.58% in 2021, and 46.79% in 2022. Around two-thirds of FMPs made home visits (3 to 4 visits monthly) and performed electrocardiography (6 to 7 tests monthly) independently of the analysed year. CONCLUSION: Analysing 39% of FMPs in Zagreb we found a significant workload change during the COVID pandemic, especially in the excessive increase of telephone and e-mail consultations. The already small number of examinations, diagnostic, preventive procedures, and home visits, further decreased with the arrival of the pandemic and did not significantly recover in 2022, as was expected.

ARTERIAL HYPERTENSION FOLLOWING COVID-19: A RETROSPECTIVE STUDY OF PATIENTS IN A CENTRAL EUROPEAN TERTIARY CARE CENTER.

The aim of this study was to determine the frequency of newly verified or worsened existing hypertension in patients who had coronavirus 2019 (COVID-19). To be categorized as a COVID-19 patient, a positive reverse-transcription polymerase chain reaction test at a single point in time was required. The patients' age, history, laboratory values and antihypertensive therapy of patients were recorded. In one year, 32 of 199 patients studied had either newly verified (15) or worsened existing (17) arterial hypertension. Among those patients, the median time from a verified infection to the onset of symptoms was 3 months. When the patients were divided into groups, 4 were in the acute, 11 in the sub-acute, 8 in the chronic and 9 in the "long COVID" group. Compared to the rest of the study population, patients presenting with arterial hypertension had significantly higher systolic (median 141 mmHg vs 130 mmHg, p<0.001) and diastolic (median 93 mmHg vs 80 mmHg, p<0.001) blood pressure and were significantly younger (median 51 vs 59 years, p 0.032). Arterial hypertension following COVID-19, either newly verified or worsened existing, is a relatively common occurrence (16% of our patient pool), indicating that more effort should be directed at evaluating the blood pressure values of patients following COVID-19.

The Role of Anxiolytics in Hypertensive Urgency Management.

Current guidelines do not cover hypertensive urgency management in out-of-hospital setting. Main goal of this study was to evaluate the value of anxiolytic therapy in hypertensive urgencies. We analyzed data gathered by out-of-hospital unit set up during one year. Arterial hypertension was the primary diagnosis in 178 (6.11%) patients, of whom 144 had hypertensive urgency with mean SBP reduction 19.5±7.2%; control group 10.1±6.9%. Anxiolytic therapy was administered in 60% of patients in hypertensive urgency group, and they had a statistically significant greater SBP reduction (p=0.03) than patients who did not receive anxiolytic therapy. There is a place for anxiolytic therapy in hypertensive urgency management.

Prediabetes, Non-Dipping Profile and Hypertension-A Recipe for Increased Arterial Stiffness.

BACKGROUND: Pulse wave velocity (PWV) is a known predictor of target organ damage, cardiovascular disease and overall mortality. The aim of this study was to compare the PWV values in subjects with prediabetes, a non-dipper profile and arterial hypertension with their values in healthy subjects. METHODS: A total of 301 subjects, aged 40-70 years, without diabetes mellitus were included in this cross-sectional study (150 with prediabetes). They underwent a 24 h ambulatory blood pressure monitoring (ABPM). Subjects were divided into three hypertension groups (A = healthy, B = controlled hypertension, C = uncontrolled hypertension). Dipping status was determined according to ABPM results, and PWV was measured by an oscillometric device. Prediabetes was defined as having 2 separate fasting plasma glucose (FPG) measurements between 5.6 and 6.9 mmol/L. RESULTS: The highest PWV values were found in group C (9.60 ± 1.34 vs. 8.46 ± 1.01 in group B vs. 7.79 ± 1.10 in group A; p < 0.001), in subjects with prediabetes (8.98 ± 1.31 m/s vs. 8.26 ± 1.22 m/s; p < 0.001) and in prediabetic non-dippers among age groups (p = 0.05). In the multivariate regression model age, blood pressure, nocturnal indices and FPG were shown as independent predictors of PWV values. CONCLUSION: Significantly higher PWV values were found in subjects with prediabetes and non-dipping profiles in all three examined hypertension groups.

Postoperative Hyperuricemia-A Risk Factor in Elective Cardiosurgical Patients.

Hyperuricemia is a well-known cardiovascular risk factor. The aim of our study was to investigate the connection between postoperative hyperuricemia and poor outcomes after elective cardiac surgery compared to patients without postoperative hyperuricemia. In this retrospective study, a total of 227 patients after elective cardiac surgery were divided into two groups: 42 patients with postoperative hyperuricemia (mean age 65.14 ± 8.9 years) and a second group of 185 patients without it (mean age 62.67 ± 7.45 years). The time spent on mechanical ventilation (hours) and in the intensive care unit (days) were taken as the primary outcome measures while the secondary measure comprised postoperative complications. The preoperative patient characteristics were similar. Most of the patients were men. The EuroSCORE value of assessing the risk was not different between the groups nor the comorbidities. Among the most common comorbidities was hypertension, seen in 66% of all patients (69% in patients with postoperative hyperuricemia and 63.7% in those without it). A group of patients with postoperative hyperuricemia had a prolonged time of treatment in the intensive care unit (p = 0.03), as well as a prolonged duration of mechanical ventilation (p < 0.01) and a significantly higher incidence of the following postoperative complications: circulatory instability and/or low cardiac output syndrome (LCOS) (χ2 = 4486, p < 0.01), renal failure and/or continuous venovenous hemodiafiltration (CVVHDF's) (χ2 = 10,241, p < 0.001), and mortality (χ2 = 5.22, p < 0.01). Compared to patients without postoperative hyperuricemia, elective cardiac patients with postoperative hyperuricemia have prolonged postoperative treatment in intensive care units, extended durations of mechanically assisted ventilation, and a higher incidence of postoperative circulatory instability, renal failure, and death.

Effects of trastuzumab and trastuzumab emtansine on corrected QT interval and left ventricular ejection fraction in patients with metastatic (HER2+) breast cancer.

BACKGROUND: Trastuzumab and trastuzumab emtansine are specific antibody and antibody-drug conjugates used in the treatment of human epidermal growth factor receptor 2 (HER2) positive metastatic breast cancer. The aim of this study was to test their effect on the QTc interval duration and left ventricular ejection fraction (LVEF) in our patients, two parameters used in evaluation of cardiotoxicity. From May 2015 to October 2017, 26 patients with preserved LVEF were included in the study. All of them were previously treated with standard paclitaxel and cisplatin-based chemotherapy regimens. Electrocardiogram (ECG) was recorded just before each trastuzumab dose application and six months after the last dose. Echocardiography with LVEF measurement was performed several days before the application of the initial dose, and six months after the last cycle. Later, 24 patients with metastatic disease received additional treatment with trastuzumab emtansine after six months and the same ECG and echocardiography protocol was performed again. Due to reduction in LVEF, two patients were discontinued from additional treatment. RESULTS: A statistically significant QTc prolongation was found after each drug dose application, with an increase in mean QTc duration with every successive application, reaching the peak QTc values just before the fifth cycle of treatment. The QTc interval returned to its initial value six months after the last cycle (p < 0.001). These results were similar for both drugs. Mean LVEF before both treatment protocols was significantly higher compared to LVEF value after the treatment. LVEF before trastuzumab emtansine treatment was non-significantly higher than LVEF after trastuzumab treatment. CONCLUSION: Trastuzumab and trastuzumab emtansine cardiotoxicity manifested as a significant and progressive QTc prolongation after successive drug applications, reaching the peak value just before the fifth cycle of both drugs. Both medications also caused statistically significant but asymptomatic LVEF reduction. Complete reversibility of cardiotoxic effects of both drugs was confirmed by QTc interval and LVEF normalisation after the treatment discontinuation.

Impact of SGLT2 inhibitors on the mechanisms of myocardial dysfunction in type 2 diabetes: A prospective non-randomized observational study in patients with type 2 diabetes mellitus without overt heart disease.

AIMS: This prospective observational study evaluated the possible mechanisms of action of SGLT2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) without overt heart disease. METHODS: The study was designed to verify whether SGLT2i impact biomarkers of: myocardial stress-NT-proBNP, inflammation-high sensitivity C-reactive protein, oxidative stress -myeloperoxidase, functional and structural echocardiographic parameters, in patients with T2DM on metformin (heart failure stages A and B) who needed treatment intensification with a second antidiabetic agent. The patients were divided in two groups - the ones planned to receive SGLT2i or DPP-4 inhibitor (except saxagliptin). At baseline, and after six months of therapy, 64 patients underwent blood analysis, physical and echocardiography examination. RESULTS: There were no significant differences between the two groups in terms of biomarkers of myocyte and oxidative stress, inflammation and blood pressure. Body mass index, triglycerides, aspartate aminotransferase, uric acid, E/E', deceleration time and systolic pressure in the pulmonary artery significantly decreased, while stroke volume, indexed stroke volume, high-density lipoprotein, hematocrit and hemoglobin significantly increased in the group on SGLT2i. CONCLUSIONS: According to the results, SGLT2i mechanisms of action comprise rapid changes in body composition and metabolic parameters, reduced cardiac load and improvement in diastolic and systolic parameters.

Continuity of care in patients with type 2 diabetes in Croatian primary care setting during COVID-19 pandemic: A retrospective observational study.

AIM: To examine the differences in the continuity of health care for type 2 diabetic patients before and during COVID pandemic in family medicine depending on whether the physician who provided care finished vocational training in family medicine or not. METHODS: This retrospective longitudinal research lasted from 2018 to 2020 in eight family medicine practices on 648 patients with type 2 diabetes diagnosed before 2018, and without Sars-Cov2 infection in previous medical history in Zagreb, Croatia. Follow-up parameters (HbA1c, LDL, eGFR, blood pressure, BMI, eye fundus and neurological findings, number of check-ups and vaccination against the flu) were noted before (2018, 2019), and in the COVID period (2020) in the care of family medicine specialists (FMPs) and without it (FMPws). RESULTS: No differences were found between the gender and age of patients. A decrease was seen in existing laboratory findings (64-47%, P < 0.001), eye fundus check-ups (39-37%, P = NS), neurologist check-ups (28-25%, P = NS) and FMP check-ups (382-321, P < 0.001) during the COVID period with significant differences between FMPs and FMPws. Significant changes were seen in LDL cholesterol (2.7-2.4 mmol/L, P < 0.001) and eGFR (83-80 ml/min/1.73 m2, P = 0.002), but BMI, blood pressure and HbA1c (>7% had 42% of patients) values did not differ during the COVID period. CONCLUSION: According to the observed parameters, the continuity of care for diabetic patients in Zagreb has worsened during the COVID pandemic but remained significantly better in care of FMPs than in FMPws, without differences in achieving target values of follow-up parameters.

PR interval as a predictor of syncope in tilt-up testing in adolescents and young adults.

BACKGROUND: Syncope, as the most frequent consciousness disorder, is very common in young individuals. The aim of this study was to analyze ECG parameters and clinical properties obtained during tilt-up testing in 12 to 30-year-old subjects. We enrolled a total of 142 patients from our outpatient clinic (39 males, 103 females) with a true positive tilt-up test and analyzed ECG records obtained during tilt-testing. Data were stratified according to the age, gender, and type of syncope. RESULTS: PR interval shortening preceding syncope was found in all syncope types, irrespective of the gender. All types of syncope were more frequent in women (72.5%). Mixed syncope type was found to be the most common (47.18%). Male and female subjects differed in initial heart rate (71.56 vs 76.23/min, p=0.05), as well as heart rate dynamics during tilt-up testing. A gender difference was also found in systolic blood pressure (116.92 vs 110.44 mmHg, p<0.01), time to syncope onset (20.77 vs. 16.44 min, p=0.03), and the total number of syncopal episodes in patient history (2.79 vs. 4.62, p<0.05). Subjects with cardioinhibitory syncope had the longest PR interval (average 154.3 ms). PR interval prolongation and loss of variability during tilt-up testing positively correlated with aging (r=0.22, p<0.05). Nodal rhythm was found in 8 patients. CONCLUSION: PR interval shortening on ECG tracings during a tilt-up test can be found in all subtypes of vasovagal syncope, thereby contrasting previous reports that these changes are a hallmark of the cardioinhibitory type of syncope. PR shortening, if observed during ECG monitoring, could be a potential predictor of syncope.

Medication, nocturnal dipping profile and hypertensive emergency / Medicación, perfil de inmersión nocturna y emergencia hipertensiva

INTRODUCTION: the aim of this study was to analyze the medication used by the patients with hypertensive crisis (blood pressure above 180/120mmHg) and its impact on the main risk factors for hypertensive emergency development. METHODS: a total of 233 patients (108 male, 125 female), 184 had hypertensive urgency/ 53 emergency (54.44% /50.95% in women) at the Emergency department during 11 months. Patients were divided in five age groups as decades starting from the age of 40 (mean 65.85 years) and a total ten groups depending on which type of hypertensive medication they were using (ACEi, ARB, BB, CCB, diuretics, moxonidine, and their combinations). RESULTS: by using antihypertensive monotherapy percentage of hypertensive emergencies were 100.00%, 50.00%, 41.66%, 33.33%, 21.05%. Using ACEi + CCB + diuretic significantly decreased the number of emergencies to 0%, 18.47%, 21.05%, 25.00%, 33.33%; but adding beta blocker additionally diminished the risk. Overall 53 patients had no medication (22.75%) and 68 of 233 patients were smokers (29.18%, 63.23% male) of which 36 patients had hypertensive emergency (52.94% of smokers). The biggest number of non-dippers was found in patients who took ARBs, diuretics and/or CCB but the smallest number was shown in patients who took ACEi in combination with moxonidine (-20.07%). 22.02% of smokers were non-dippers (-54.67% nonsmokers). Odds ratio for getting hypertensive emergency in case patient had a non-dipper profile was 4.18 (CI 1.02 ­ 18.89, p < 0.05). Patients taking different medication (or none) did not have increased chance for hypertensive emergency development (OR 1.21, p = NS). We didn't find any differences in the non-dipping profile incidence between genders (72.12% males, 72.83% females). CONCLUSION: combinations of all antihypertensive medication showed benefit over monotherapy. Higher 24-hour and nighttime blood pressure (non-dipping profile) was significantly associated with greater change for developing hypertensive emergency.

INTRODUCCIÓN: el objetivo de este estudio fue analizar la medicación utilizada por los pacientes con crisis hipertensiva (presión arterial superior a 180/120mmHg) y su impacto en los principales factores de riesgo para el desarrollo de la emergencia hipertensiva. MÉTODOS: un total de 233 pacientes (108 hombres, 125 mujeres), 184 tenían urgencia hipertensiva/ 53 emergencia (54,44% /50,95% en mujeres) en el servicio de Urgencias durante 11 meses. Los pacientes fueron divididos en cinco grupos de edad según décadas a partir de los 40 años (media de 65,85 años) y un total de diez grupos según el tipo de medicación hipertensiva que utilizaban (IECA, ARA, BB, BCC, diuréticos, moxonidina y sus combinaciones). RESULTADOS: utilizando monoterapia antihipertensiva el porcentaje de urgencias hipertensivas fue del 100,00%, 50,00%, 41,66%, 33,33%, 21,05%. El uso de IECA + BCC + diuréticos disminuyó significativamente el número de urgencias al 0%, 18,47%, 21,05%, 25,00%, 33,33%; pero la adición de betabloqueantes disminuyó el riesgo. En general, 53 pacientes no tenían medicación (22,75%) y 68 de 233 pacientes eran fumadores (29,18%, 63,23% hombres), de los cuales 36 pacientes tuvieron una urgencia hipertensiva (52,94% de los fumadores). El mayor número de hipertensos no inmersivos se encontró en los pacientes que tomaban ARA, diuréticos y/o BCC, pero el menor número se mostró en los pacientes que tomaban IECA en combinación con moxonidina (-20,07%). El 22,02% de los fumadores no eran hipertensos inmersivos (-54,67% de los no fumadores). El odds ratio para obtener una emergencia hipertensiva en caso de que el paciente tuviera un perfil no inmersivo fue de 4,18 (IC 1,02 - 18,89, p < 0,05). Los pacientes que tomaban una medicación diferente (o ninguna) no tenían mayor probabilidad de desarrollar una emergencia hipertensiva (OR 1,21, p = NS). No se encontraron diferencias en la incidencia de perfil no inmersivo entre géneros (72,12% varones, 72,83% mujeres). CONCLUSIÓN: las combinaciones de toda la medicación antihipertensiva mostraron beneficios sobre la monoterapia. Una mayor presión arterial de 24 horas y nocturna (perfil de hipertensión no inmersiva) se asoció significativamente con un mayor cambio para desarrollar una emergencia hipertensiva.