Gergely Fürjes

Mice deficient in pituitary adenylate cyclase activating polypeptide display increased sensitivity to renal oxidative stress in vitro.

Pituitary adenylate cyclase activating polypeptide (PACAP) is a multifunctional neuropeptide, showing widespread occurrence in the nervous system and also in peripheral organs. The neuroprotective effects of PACAP are well-established in different neuronal systems against noxious stimuli in vitro and in vivo. Recently, its general cytoprotective actions have been recognized, including renoprotective effects. However, the effect of endogenous PACAP in the kidneys is not known. The main aim of the present study was to investigate whether the lack of this endogenous neuropeptide influences survival of kidney cells against oxidative stress. First, we determined the presence of endogenous PACAP from mouse kidney homogenates by mass spectrometry and PACAP-like immunoreactivity by radioimmunoassay. Second, primary cultures were isolated from wild type and PACAP deficient mice and cell viability was assessed following oxidative stress induced by 0.5, 1.5 and 3mM H(2)O(2). Our mass spectrometry and radioimmunoassay results show that PACAP is endogenously present in the kidney. The main part of our study revealed that the sensitivity of cells from PACAP deficient mice was increased to oxidative stress: both after 2 or 4h of exposure, cell viability was significantly reduced compared to that from control wild type mice. This increased sensitivity of kidneys from PACAP deficient mice could be counteracted by exogenously given PACAP38. These results show, for the first time, that endogenous PACAP protects against oxidative stress in the kidney, and that PACAP may act as a stress sensor in renal cells. These findings further support the general cytoprotective nature of this neuropeptide.

General practitioners' cluster: A model to reorient primary health care to public health services

ARTICLE ARTICLE ‘Why a renewal of primary health care (PHC), and why now, more than ever?’ is the question by which the World Health Report 2008 is introduced.1 A primary care system in which health professionals are just simply entry points into the health system can respond neither to the challenges of a changing world nor to the growing expectations of people for better performance. The question of how to renew PHC is answered in the Report by ‘putting people first’, that is, by visioning a people-centred PHC service ‘delivered by teams that focus on health needs, create enduring personal relationships, take responsibility for the health of all in the community along the life cycle, as well as for tackling determinants of ill-health, and in which people are partners in managing their own health and that of their community’. The vision has remained a vision until now,2 and it will remain a vision forever if its implementation is considered just a health care system reform. A definitive link between PHC and public health services has to be formed to transform the vision into reality, in line with the Health 2020,3 the new World Health Organization European health policy framework and strategy, which indicates as one of its four priority areas ‘the strengthening of people-centred health systems along with public health capacity’. Lacking preventive services is one of the many previously identified anomalies of the Hungarian primary care system that needs to be corrected.4 Primary care presently is provided by one general practitioner (GP) and one nurse per practice, assisted by an …

Changes in Pituitary Adenylate Cyclase-Activating Polypeptide Following Renal Ischemia-Reperfusion in Rats

PACAP (pituitary adenylate cyclase-activating polypeptide) occurs in two biologically active forms, with 38 and 37 amino acid residues (PACAP38 and PACAP27). In mammalian tissues, PACAP38 is the dominant form. Diverse effects have been described in the cardiovascular, respiratory, gastrointestinal, and urogenital systems. PACAP is known for its strong cytoprotective effects, which are present endogenously as well, as proven by knockout studies and results showing that PACAP is up-regulated following diverse injuries. Little is known about such effects in the kidney. We have previously shown that PACAP is protective in renal ischemia-reperfusion injury. Therefore, the aim of the present study was to investigate the changes of endogenous PACAP following 60-minute renal ischemia using radioimmunoassay. Changes were observed within 24 hours following renal vessel clamping. In the cortex, an acute decrease was followed by an increase on the intact side, and levels returned to original ones on the operated side. In the medulla, changes were only observed on the clamped side: a marked up-regulation was detected in PACAP38-like immunoreactivity within the first 24 hours. The present study showed that PACAP38- and PACAP27-like immunoreactivities sensitively react to renal ischemia-reperfusion, the physiological importance of which awaits further investigation.

Capitation-Based Financing Hampers the Provision of Preventive Services in Primary Health Care

Mortality caused by non-communicable diseases has been extremely high in Hungary, which can largely be attributed to not performed preventive examinations (PEs) at the level of primary health care (PHC). Both structures and financial incentives are lacking, which could support the provision of legally defined PEs. A Model Programme was launched in Hungary in 2012 to adapt the recommendations for PHC of the World Health Organization. A baseline survey was carried out to describe the occurrence of not performed PEs. A sample of 4320 adults representative for Hungary by age and gender was surveyed. Twelve PEs to be performed in PHC as specified by a governmental decree were investigated and quantified. Not performed PEs per person per year with 95% confidence intervals were computed for age, gender, and education strata. The number of not performed PEs for the entire adult population of Hungary was estimated and converted into expenses according to the official reimbursement costs of the National Health Insurance Fund. The rate of service use varied between 16.7 and 70.2%. There was no correlation between the unit price of examinations and service use (r = 0.356; p = 0.267). The rate of not performed PEs was not related to gender, but older age and lower education proved to be risk factors. The total number of not performed PEs was over 17 million in the country. Of the 31 million euros saved by not paying for PEs, the largest share was not spent on those in the lowest educational category. New preventive services offered in the reoriented PHC model program include systematic and scheduled health examination health promotion programs at community settings, risk assessment followed by individual or group care, and/or referral and chronic care. The Model Programme has created a pressure for collaborative work, consultation, and engagement at each level, from the GPs and health mediators up to the decision-making level. It channeled the population into preventive health services shown by the fact that more than 80% of the population in the intervention area has already participated in the health status assessment.

Public health services provided in the framework of general practitioners’ clusters

ARTICLE ARTICLE The public health focused operation of primary health care (PHC) is impeded by its reactive approach and old fashioned treatment-oriented organization in many countries, including Hungary. Our general practitioners’ (GPs’) cluster model, to solve the presently existing organizational problems, builds a new structure described by Adany et al. 1 The lack of adequate education in public health of the current PHC staff2 represents another crucial obstacle of the improvement of PHC performance, which is also handled by the Programme.3 An additional obstacle is that guidelines for PHC preventive services are generally lacking. Although certain countries have developed such kind of guidelines, their proposals are adopted by other countries to a limited extent. The Decree No. 51/1997 of the Minister of Welfare (on the compulsory health insurance-based health services, aimed to prevent and timely detect the diseases and the certification of screenings) defines the preventive tasks of GPs and health visitors. Although, the listed tasks are almost entirely in harmony with the international recommendations, due to the lack of organizational base, financing incentives, relevant training, detailed protocols and auditing, the interventions/screenings prescribed by the decree are hardly implemented. The performance indicators obtained in the preliminary studies in connection with the Swiss Contribution Programme are unacceptably low: 1. Assessment of family history, 36.2% 2. Assessment of dietary habit, 24.7% 3. Screening for alcohol misuse, 16.3% 4. Assessment of smoking …

Delivery of cardio-metabolic preventive services to Hungarian Roma of different socio-economic strata.

Background. Because the cardiovascular mortality in Hungary is high, particularly among the socio-economically deprived and the Roma, it is implied that primary health care (PHC) has a limited ability to exploit the opportunities of evidence-based preventions, and it may contribute to social health inequalities. Objectives. Our study investigated the underuse of PHC preventive services. Methods. Random samples of adults aged 21–64 years free of hypertension and diabetes mellitus were surveyed with participation rate of 97.7% in a cross-sectional study. Data from 2199 adults were collected on socio-demographic status, ethnicity, lifestyle and history of cardio-metabolic preventive service use. Delivery rates were calculated for those aged 21–44 years and those aged 45–64 years, and the influence of socio-demographic variables was determined using multivariate logistic regression. Results. Delivery rates varied between 12.79% and 99.06%, and the majority was far from 100%. Although most preventive service use was independent of education, younger participants with vocational educations underutilized problematic drinking (P = 0.011) and smoking (P = 0.027) assessments, and primary or less educated underutilized blood glucose (P = 0.001) and serum cholesterol (P = 0.005) checks. Health care measures of each lifestyle assessment (P nutrition = 0.032; P smoking = 0.021; P alcohol = 0.029) and waist circumference measurement (P = 0.047) were much less frequently used among older Roma. The blood glucose check (P = 0.001) and family history assessment (P = 0.043) were less utilized among Roma. Conclusions. The Hungarian PHC underutilizes the cardio-metabolic prevention contributing to the avoidable mortality, not generating considerably health inequalities by level of education, but contributing to the bad health status among the Roma.

Human resources development for the operation of general practitioners’ cluster

ARTICLE ARTICLE As it was detailed in previous Viewpoints, Hungary has launched a new primary health care model programme in four small areas of the most disadvantaged regions of the country, aiming to reorient primary health care towards prevention with the long-term hope of not only improving the health status of the general population but also reducing social inequalities in health. In addition to services that they are competent to provide as licensed health workers, professionals working in the clusters will carry out activities that they have not at all or have not regularly done so far such as planning and implementing health promotion projects in the community, assessing the health status according to specific guidelines, counselling on lifestyle issues, assisting chronic care with rehabilitation focus. They work in a novel cluster-team in which mutually supportive collaboration and communication skills and attitudes are required. Therefore, special training with varying emphasis is needed to prepare all participants for work in the cluster. The ‘core training’ introduces the basics of the Programme, its aims, participants, organization, activities and publicly available documents on the details of the Programme. This module covers the fundamentals of internal and external communication as well, providing a basic understanding of the concept of the Programme to all professional participants. The ‘health promotion’ module will cover details to all professionals working at the cluster level on the development and organization of health promotion programmes in community settings. Community participation is a vital element of these programmes on which much has been published in the health promotion literature. Of them, the scheme on the degree of participation and accompanying toolbox—providing a range of methods for …

Special Health Care Utilization Pattern with Elevated Costs and High Risk of Premature Death Among Adults Living in Segregated Roma Settlements

Roma is the largest ethnic minority of Europe with poor health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health-indicators for adults living in segregated Roma settlements (SRS) representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR=1.152, 95%CI: 1.136–1.167). The proportion of subjects hospitalized (RR=1.286, 1.177–1.405), and the reimbursement for inpatient care (RR=1.060, 1.057–1.064) were elevated for SRS. Premature mortality was significantly higher in SRSs (RR=1.711, 1.085-2.696). Our study demonstrated that it is possible to compute the SRS-specific version of the routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue to a non-sensitive small area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of premature death.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136–1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177–1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057–1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085–2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Influence of patient characteristics on preventive service delivery and general practitioners’ preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary

Abstract Background: Regular primary healthcare (PHC) performance monitoring to produce a set of performance indicators for provider effectiveness is a fundamental method for improving guideline adherence but there are potential negative impacts of the inadequate application of this approach. Since performance indicators can reflect patient characteristics and working environments, as well as PHC team contributions, inadequate monitoring practices can reduce their effectiveness in the prevention of cardiometabolic disorders. Objectives: To describe the influence of patients’ characteristics on performance indicators of PHC preventive practices in patients with hypertension or diabetes mellitus. Methods: This cross-sectional analysis was based on a network of 165 collaborating GPs. A random sample of 4320 adults was selected from GP’s patient lists. The response rate was 97.3% in this survey. Sociodemographic status, lifestyle, health attitudes and the use of recommended preventive PHC services were surveyed by questionnaire. The relationship between the use of preventive services and patient characteristics were analysed using hierarchical regression models in a subsample of 1659 survey participants with a known diagnosis of hypertension or diabetes mellitus. Results: Rates of PHC service utilization varied from 18.0% to 97.9%, and less than half (median: 44.4%; IQR: 30.8–62.5) of necessary services were used by patients. Patient attitude was as strong of an influencing factor as demographic properties but was remarkably weaker than patient socioeconomic status. Conclusion: These findings emphasize that PHC performance indicators have to be evaluated concerning patient characteristics.