István Ilyés

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

BackgroundObesity, 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.MethodsThe 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.ResultsThe 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%).ConclusionMore education of primary care physicians, available practical guidelines and higher community involvement are needed to improve the obesity management in Hungary.

Urinary Homogentisic Acid in Alkaptonuric and Healthy Children

Abstract To detect and follow-up the metabolic status of patients with alkaptonuria (AKU), urinary homogentisic acid (HGA) was measured by gas chromatography. These results were close to values we obtained by colorimetric method (linearity: up to 700 mg/l, detection limit: 1 mg/l, within-run imprecision (CV): 1.2% at 100 mg/l HGA, 4.9% at 10 mg/l, between-run CV: 6.8% at 100 mg/l). To determine urinary reference ranges of HGA, 84 healthy children (age: 2months–18 years) were divided into five age groups. HGA and creatinine were measured in their morning urine. Statistical analysis proved that urinary HGA/creatinine ratio is age-dependent. The ratio is relatively high between 1 and 6 years of age, with large scatter (upper limit of reference ranges given as mean + 2 SD: 5.5–7.2 mg/mmol = 0.03–0.04 mmol/mmol creatinine), and it decreases with age. Approximately at the age of 7 years, HGA/creatinine ratio becomes constant, and later it is similar to the adult value (upper limit: 2.8 mg/mmol = 0.017 mmol/mmol creatinine). We monitored a patient during her 1–5th year of life, and her urinary HGA was 80–200 times higher than the upper limit of the age-matched reference ranges. The measurement of HGA supports the decision for starting restricted protein diet and is useful for the evaluation of the effectiveness of therapy.

Alterations of carbohydrate and lipoprotein metabolism in childhood obesity--impact of insulin resistance and acanthosis nigricans

AIM To study the prevalence of alterations of glucose and lipoprotein metabolism and the impact of acanthosis nigricans (AN) in childhood obesity. PATIENTS AND METHODS 113 obese children, 57 with simple obesity (SO) and 58 with obesity and AN (OAN). Oral glucose tolerance test was performed, serum glucose, insulin and lipoprotein parameters were determined, and insulin resistance/sensitivity indices were calculated. RESULTS Insulin resistance, basal and reactive hyperinsulinemia, impaired glucose tolerance (IGT) and dyslipidemia were found to be frequent conditions in children with OS as well as OAN. Reactive insulinemia was more pronounced in OAN than in SO, and insulin resistance was more frequent when AN was more prominent. Triglycerides were higher and HDL-C was lower, and atherogenic dyslipidemia was more frequent in OAN compared to SO. CONCLUSION Children with obesity form a risk population. AN is a factor which can be used in metabolic risk factor clustering estimation in childhood obesity.

Correlations between obesity and asthma control in children: Hungarian primary care pilot study

Correlations between obesity and asthma control in children: Hungarian primary care pilot study Introduction: Asthma is often associated with overweight and obesity. The aim of this study was to find associations between asthma control, obesity and different levels of physical activity. Methods: Using a questionnaire, 117 asthmatic patients between 6-18 years of age were interviewed. Two groups of children, normal vs. overweight, at different levels of physical activity (sport, school-based proper or light activity and full physical exemption) were compared. Asthma control was evaluated in two groups (controlled vs. non or partially controlled). Results: The asthmatic status was generally controlled in 78%; in 81% and 72% of patients with a normal weight and overweight, respectively. Being overweight was more common among girls than boys (43.2% vs. 30.3%). A positive family history of asthma was revealed in many cases; the prevalence of asthma was found at 63% (P=0.0074) among the parents. Weight was significantly higher when the parents themselves were overweight. A lightened workload in physical education lessons at school doubled the risk of obesity (P=0.25), while full exemption increased it by six times (P=0.06). High bodyweight was found in 37% and 31% of children who had received steroid medication and other treatment, respectively (P=0.57). Conclusion: High bodyweight and physical inactivity worsened the chances of effective asthma treatment, while sport improved it. The rates of physical activity among the surveyed patients were lower than recommended. More focus is needed; paediatricians, school-teachers and parents should pay more attention to the issue when establishing a proper family background for healthier lifestyles. Korelacije Med Prekomerno Telesno Težo in Nadzorom nad Astmo Pri Otrocih: Madžarska Pilotna Študija V Osnovnem Zdravstvenem Varstvu Uvod: Astmo se pogosto povezuje s prekomerno telesno težo in debelostjo. Namen te študije je bil ugotoviti povezave med nadzorom nad astmo, debelostjo in različnimi stopnjami telesne aktivnosti. Metode: S pomočjo vprašalnika je bilo anketiranih 117 astmatičnih bolnikov v starosti od 6 do 18 let. Primerjani sta bili dve skupini otrok, z normalno in prekomerno telesno težo, na različnih stopnjah telesne aktivnosti (šport, običajna ali lažja aktivnost in popolna oprostitev od telesne aktivnosti v šoli). Nadzor nad astmo je bil ocenjen v dveh skupinah (nadzorovana vs nenadzorovana ali delno nadzorovana). Rezultati: Astmatični status je bil na splošno nadzorovan pri 78 %; pri 81 % bolnikov z normalno telesno težo in 72 % bolnikov s prekomerno telesno težo. Prekomerna telesna teža je bila pogostejša pri dekletih kot pri fantih (43,2 % vs 30,3 %). V številnih primerih je bila odkrita pozitivna družinska zgodovina astme; obolevnost za astmo je bila ugotovljena pri 63 % (P=0,0074) staršev. Prekomerna telesna teža je bila precej večja, če so imeli prekomerno težo tudi starši. Manjša delovna obremenitev pri urah športne vzgoje v šoli je podvojila tveganje za debelost (P=0,25 %), medtem ko je popolna oprostitev od telesne aktivnosti to tveganje povečala za šestkrat (P=0,06). Prekomerna telesna teža je bila ugotovljena pri 37 % otrok, ki so prejemali steroidna zdravila, in 31 % otrok, ki so bile deležni drugačnega zdravljenja (P=0,57). Zaključek: Prekomerna telesna teža in telesna neaktivnost sta poslabšali možnosti učinkovitega zdravljenja astme, medtem ko je športna aktivnost te možnosti povečala. Stopnje telesne aktivnosti med anketiranimi bolniki so bile nižje od priporočenih. Potrebna je večja osredotočenost; pediatri, učitelji in starši bi morali več pozornosti namenjati vprašanju, kdaj vzpostaviti ustrezno družinsko podlago za bolj zdrav življenjski slog.

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.

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.

Trends and current questions of cardiovascular prevention in primary health care

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.

Current questions of thyroid diseases in childhood

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.

Prevalence of microalbuminuria and its clinical correlation with other risk factors of cardiovascular diseases

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.

Atherogenic factors in childhood obesity

The aim of the study was to investigate insulin resistance, dyslipidemia and other atherogenic factors influencing HDL functions in symple obesity (SO) and obesity with acanthosis nigricans (OAN). Altogether 37 children with obesity, 17 girls and 20 boys, 19 with SO and 18 with OAN, were included into the study. Parameters investigated were the following: fasting glucose (FG), insulin (INS), HOMA-IR index, total cholesterol (T-C), HDL-C, triglycerid (TG), LDL-C, paraoxonase (PON1), arylesterase (ARYL), lecitin-cholesterol acyltransferase (LCAT), cholesterol-ester transfer protein (CEPT), intracellular adhesion molecule-1 (ICAM-1) and vascular adhesion molecule (VCAM-1). FG was normal in all obese patients, and hyperinsulinemia was detected in 27, insulin resistance in 31 cases of 37 children. Among parameters investigated the frequencies of abnormal INS, TG and HDL-C values were higher in OAN than in SO. PON1, ARYL, LCAT and CEPT activities as well as ICAM-1 and VCAM-1 levels didnotdifferaccordingtopresenceofAN.ICAM-1levelswerehigher in patients with low HDL-C than in cases with normal HDL-C. A significant negative correlation was found between PON1 and ICAM-1. These results demonstrate that hyperinsulinemia and atherogenic dyslipidemia are more frequent conditions in OAN than in SO, and they also suggest that atherogenic dyslipidemia in childhood obesity has a complex influence to the parameters to related HDL-function. European Abstracts