Davorka Vrdoljak

Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population

Aim To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in achieving treatment goals by the general practitioners (GP) in different settings. Methods A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid. Results Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P < 0.001), obesity (P = 0.001), increased waist circumference (P < 0.001), and more intense physical activity (P = 0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference. Conclusion Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.

Association between hyperuricemia, prediabetes, and prehypertension in the Croatian adult population--a cross-sectional study.

BackgroundThe association between hyperuricemia, hypertension, and diabetes has been proved to have strong association with the risk for cardiovascular diseases, but it is not clear whether hyperuricemia is related to the early stages of hypertension and diabetes. Therefore, in this study we investigated the association between hyperuricemia, prediabetes, and prehypertension in Croatian adults, as well as that between purine-rich diet and hyperuricemia, prediabetes, or prehypertension.MethodsA stratified random representative sample of 64 general practitioners (GP) was selected. Each GP systematically chose participants aged ≥ 40 year (up to 55 subjects) . Recruitment occurred between May and September 2008. The medical history, anthropometric, and laboratory measures were obtained for each participant.Results59 physicians agreed to participate and recruited 2485 subjects (response rate 77%; average age (± standard deviation) 59.2 ±10.6; 61.9% women. In bivariate analysis we found a positive association between hyperuricemia and prediabetes (OR 1.66, 95% CI 1.09–2.53), but not for prehypertension (OR 1.68, 95% CI 0.76–3.72). After controlling for known confounders for cardiovascular disease (age, gender, body mass index, alcohol intake, diet, physical activity, waist to hip ratio, total cholesterol, low density lipoprotein, high density lipoprotein, and triglycerides), in multivariate analysis HU ceased to be an independent predictor(OR 1.33, CI 0.98–1.82, p = 0.069) for PreDM. An association between purine-rich food and hyperuricemia was found (p<0.001) and also for prediabetes (p=0.002), but not for prehypertension (p=0.41). The prevalence of hyperuricemia was 10.7% (15.4% male, 7.8% female), 32.5% for prediabetes (35.4% male, 30.8% female), and 26.6% for prehypertension (27.2% male, 26.2% female).ConclusionHyperuricemia seems to be associated with prediabetes but not with prehypertension. Both, hyperuricemia and prediabetes were associated with purine-rich food and patients need to be advised on appropriate diet.Trial registrationCurrent Controlled Trials ISRCTN31857696

How well do anthropometric indices correlate with cardiovascular risk factors? A cross-sectional study in Croati.

Summary Background Usefulness of anthropometric indices (AI) as predictors of CV risk is unclear and remains controversial. Material/Methods To evaluate the correlation between AI and CV risk factors in the Croatian adult population and to observe possible differences between coastal and inland regions and urban and rural settlements. CRISIC-fm (ISRCTN31857696) is a prospective, randomized cohort study conducted in GP (general practitioner) practices in Croatia. Between May and July 2008, 59 GPs each recruited 55 participants aged ≥40 years, who visited a practice for any reason. Height, weight, waist and hip circumference and blood pressure were measured. Blood samples were analyzed in accredited laboratories. Results Out of 2467 participants (61.9% women, 38.1% men), 36.3% were obese, with fewer in coastal than inland areas. More obese people were in rural areas. Logistic regression showed BMI was the most important predictor of hypertension, diabetes and dyslipidemia in both regions (except for diabetes in the coastal area), and for urban and rural settlements (except for diabetes in rural areas). WtHR was a significant predictor for hypertension and dyslipidemia in the coastal (but only for hypertension in the inland area), and in urban settlements (in rural only for hypertension). None of the AI showed significant correlation with total CV risk, but WC and BMI did with stroke risk. Receiver operating curve (ROC) analyses showed that WtHR was a better predictor than all other AI for hypertension and dyslipidemia. Conclusions Results encourage the use of BMI and WtHR as important tools in predicting CV risk in GP’s practice.

Teaching evidence based medicine in family medicine.

UNLABELLED The concept of evidence based medicine (EBM) as the integration of clinical expertise, patient values and the best evidence was introduced by David Sackett in the 1980s. Scientific literature in medicine is often marked by expansion, acummulation and quick expiration. Reading all important articles to keep in touch with relevant information is impossible. Finding the best evidence that answers a clinical question in general practice (GP) in a short time is not easy. Five useful steps are described- represented by the acronym 5A+E: assess, ask, acquire, appraise, apply and evaluate.The habit of conducting an evidence search on the spot is proposed. Although students of medicine at University of Split School of Medicine are taught EBM from the first day of their study and in all courses, their experience of evidence-searching and critical appraisal of the evidence, in real time with real patient is inadequate. Teaching the final-year students the practical use of EBM in a GPs office is different and can have an important role in their professional development. It can positively impact on quality of their future work in family practice (or some other medical specialty) by acquiring this habit of constant evidence-checking to ensure that best practice becomes a mechanism for life-long learning. CONCLUSION EBM is a foundation stone of every branch of medicine and important part of Family Medicine as scientific and professional discipline. To have an EB answer resulting from GPs everyday work is becoming a part of everyday practice.

Diversity of metabolic syndrome criteria in association with cardiovascular diseases--a family medicine-based investigation.

Background This study compared the association between the 3 definitions of metabolic syndrome (MetS) suggested by the World Health Organization (WHO), National Cholesterol Education Programme (NCEP ATP III), and International Diabetes Federation (IDF), and the risk of cardiovascular diseases (CVD) and shows the prevalence and characteristics of persons with MetS in continental vs. coastal regions and rural vs. urban residence in Croatia. Material/Methods A prospective multicenter study was conducted on 3245 participants ≥40 years, who visited general practices from May to July 2008 for any reason. This was a cross-sectional study of the Cardiovascular Risk and Intervention Study in Croatia-family medicine project (ISRCTN31857696). Results All analyzed MetS definitions showed an association with CVD, but the strongest was shown by NCEP ATP III; coronary disease OR 2.48 (95% CI 1.80–3.82), cerebrovascular disease OR 2.14 (1.19–3.86), and peripheral artery disease OR 1.55 (1.04–2.32), especially for age and male sex. According to the NCEP ATP III (IDF), the prevalence was 38.7% (45.9%) [15.9% (18.6%) in men, and 22.7% (27.3%) in women, and 28.4% (33.9%) in the continental region, 10.2% (10.9%) in the coastal region, 26.2% (31.5%) in urban areas, and 12.4% (14.4%) in rural areas. Older age, male sex, and residence in the continental area were positively associated with MetS diagnosis according to NCEP ATP III, and current smoking and Mediterranean diet adherence have protective effects. Conclusions The NCEP ATP III definition seems to provide the strongest association with CVD and should therefore be preferred for use in this population.

A proposal for enhancement of research capacities in Croatian general practice

UNLABELLED Research in family medicine contributes to the increase of knowledge, and its practical application improves the work of family physicians. Although research in family medicine in the Republic of Croatia has a long tradition, no sustainable research network exists as yet. Enhancing such a network is essential to efficaciously conduct research that is specific and important for family practice. This article describes the experiences of other countries and offers a proposal for a conceptual model for the development of a permanent research network in family medicine through three key elements: recognition of research as an indicator of quality of care that is specifically funded, introducing a continuing cycle of education for family physicians/researchers in the field of scientific research and building the capacity of academic family medicine and the success of their applications for domestic and international projects and funding sources. CONCLUSION The application of the conceptual model from Australian primary health care research, adjusted to our circumstances, could further enhance research capacity building in Croatian family medicine.

Sharing of prescription analgesics amongst patients in family practice: Frequency and associated factors

To analyse the frequency of nonrecreational prescription analgesic sharing, associated factors and differences between lenders and borrowers.

Risk perception about medication sharing among patients: a focus group qualitative study on borrowing and lending of prescription analgesics

Background One form of self-medication is sharing of medications, defined as borrowing or lending medications in situations where the receiver of these drugs is not the individual to whom the medications were allocated. Objective To explore experiences and opinions of patients about sharing prescription analgesics, reasons for sharing prescription analgesics, the way in which patients choose to share those medications, their awareness of risk regarding sharing prescription analgesics, and how they estimated the potential risk. Methods This qualitative study was conducted by focus group discussions with 40 participants led by a moderator trained in focus group methodology using a semi-structured moderator guide. Adults aged ≥18 years who had received a prescription for an analgesic at least once in a lifetime were included. Six separate focus groups were conducted to discuss participants’ perception of risks associated with sharing of prescription analgesics among patients. Additionally, participants filled out two questionnaires on demographic data, their own behavior regarding sharing analgesics, and their attitudes about risks associated with sharing prescription analgesics. Results In a questionnaire, 55% of the participants indicated that they personally shared prescription analgesics, while subsequently in the focus group discussions, 76% confessed to such behavior. Participants recognized certain risks related to sharing of prescription analgesics, mentioned a number of reasons for engaging in such behavior, and indicated certain positive aspects of such behavior. Forty-five percent of the participants indicated that sharing prescription analgesics is riskier than sharing nonprescription analgesics. Conclusion There is a prevalent attitude among participants that sharing prescription analgesics is a positive behavior, where potential benefits outweigh risks.

Is a targeted and planned GP intervention effective in cardiovascular disease prevention? A randomized controlled trial

Background The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular (CV) risk still need to be established. The aim of this study was to evaluate the impact of general practitioner’s (GP’s) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors. Material/Methods This was a cluster-randomized trial (ISRCTN31857696) including 64 practices and 3245 patients aged ≥40. The participating GPs and their examinees were randomized into an intervention or to a control group (standard care). Intervention group practitioners followed up their examinees during 1, 3, 6, 12, and 18 months. The main outcome measures were change in proportion of patients with low, moderate, high, and very high CV risk, and change in individual CV risk factors from the first to the second registration. Results The proportion of patients with very high CV risk was lower in the intervention group, the same as of patients with high blood pressure, total and LDL cholesterol, and increased intake of alcohol. The mean systolic (−1.49 mmHg) and diastolic (−1.57 mmHg) blood pressure, triglycerides (−0.18 mmol/L), body mass index (−0.22), and waist (−0.4 cm) and hip circumference (−1.08 cm) was reduced significantly in the intervention group. There was no additional impact in the intervention group of other tested CV risk factors. Conclusions Systematic and planned GP’s intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits.

What can we learn from each other about undergraduate medical education in general practice/family medicine?

Abstract Introduction There is a dearth of published literature on the organisation of family medicine/general practice undergraduate teaching in the former Yugoslavia. Methods A semi-structured questionnaire was sent to the addresses of 19 medical schools in the region. Questions covered the structure of Departments of Family Medicine (DFM), organisation of teaching, assessment of students and their involvement in departmental activities. Results Thirteen medical schools responded, of which twelve have a formal DFM. Few DFM have full-time staff, with most relying upon external collaborators. Nine of 13 medical schools have family doctors teaching other subjects, covering an average of 2.4 years of the medical curriculum (range: 1-5). The total number of hours dedicated to teaching ranged from 30 - 420 (Md 180). Practice-based teaching prevails, which is conducted both in city and rural practices in over half of the respondent schools. Written exams are conducted at all but two medical schools, with the written grade contributing between 30 and 75 percent (Md=40%) of the total score. Nine medical schools have a formal method of practical skills assessment, five of which use Objective Structured Clinical Examinations. Student participation is actively sought at all but three medical schools, mainly through research. Conclusion Most medical schools of the former Yugoslavia recognise the importance of family medicine in undergraduate education, although considerable variations exist in the organisation of teaching. Where DFM do not exist, we hope our study will provide evidence to support their establishment and the employment of more GPs by medical schools.