Acta Medica Croatica最新文献

Esophageal tumors are relatively rare. They present with typical symptoms in patients that consume spicy food, alcohol, enjoycigarette smoking, and after alkaline solution ingestion. Considering their accessibility, they can be diagnosed in early stages.In recent years, the incidence of adenocarcinoma has increased in comparison to squamous cell carcinoma. This surge in theincidence is associated with gastroesophageal reflux disease and Barrett’s esophagus. Using better algorithms in the diagnosisand follow up of patients at risk, in the years to come we should diagnose patients at earlier stages of the disease.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver, the sixth most common cause of cancer and thethird leading cause of cancer-related deaths worldwide. Its incidence has increased dramatically throughout the world mainlydriven by the increasing numbers of persons with long-standing chronic hepatitis C virus (HCV) infection who develop cirrhosis.Although 90% of HCV-associated HCC cases occur concurrently with cirrhosis, 30% to 50% of liver cancers associated withchronic HBV occur in the absence of cirrhosis. Since most people with chronic hepatitis are asymptomatic until cirrhosis or HCCis established, initial diagnosis and management of chronic hepatitis rely on primary care physicians to identify and screen high-riskindividuals. Studies show that family physicians have inadequate knowledge about screening and counseling for chronichepatitis and HCC. There is evidence of advances in surgical and nonsurgical therapies in the treatment of HCC, thus differentassociations have updated their recommendations following these clinical and scientific advances. The aim of this review is tomake family physicians familiar with novelties in identifying high-risk patients, implementing an appropriate screening strategy,diagnosis and treatment, and to assist them in the decision-making process according to evidence based data.

Gastric cancer is the second most common cause of cancer-related death in the world. Gastric cancer mostly affects older people.The incidence increases with age and more than 75% of people are older than 50 years. Due to the relatively late detection,long-term survival is poor, except for patients with localized disease and it remains difficult to cure. There are many known riskfactors for stomach cancer, but it is not known exactly how these factors cause cells of the stomach lining to become cancerous.But it is known that a certain kind of diet can contribute to its development such as a diet high in salty and smoked foods andlow in fruits and vegetables. Long-term infection with H. pylori increases the risk of gastric cancer and the World Health Organizationdeclared H. pylori as carcinogenic for some types of the gastric cancers. About 90% to 95% of cancers of the stomach areadenocarcinomas, the others are Lymphomas, Gastrointestinal stromal tumor (GIST) and MALT lymphoma. Early gastric cancerhas no associated symptoms; however, some patients complain of indigestion, nausea or vomiting, dysphagia or postprandialfullness. When there is a suspicion of the gastric it is necessary to do an endoscopy with multiple biopsies. Many treatments maybe used such as surgery, radiation therapy, chemotherapy, targeted drugs or a combination of these methods, and the choicedepends on the stage of the disease and the condition of the patient. Family physician should determine all patients who are atincreased risk and regularly control them.

The prevalence of malnutrition in elderly is high. Malnutrition or risk of malnutrition can be detected by use of nutritional screeningor assessment tools. This systematic review aimed to identify tools that would be reliable, valid, sensitive and specific for nutritionalstatus screening in patients older than 65 at family medicine. The review was performed following the Preferred ReportingItems for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were retrieved using MEDLINE (via Ovid), PubMedand Cochrane Library electronic databases and by manual searching of relevant articles listed in reference list of key publications.The electronic databases were searched using defined key words adapted to each database and using MESH terms. Manual revisionof reviews and original articles was performed using Electronic Journals Library. Included studies involved development andvalidation of screening tools in the community-dwelling elderly population. The tools, subjected to validity and reliability testingfor use in the community-dwelling elderly population were Mini Nutritional Assessment (MNA), Mini Nutritional Assessment-ShortForm (MNA-SF), Nutrition Screening Initiative (NSI), which includes DETERMINE list, Level I and II Screen, Seniors in the Community:Risk Evaluation for Eating, and Nutrition (SCREEN I and SCREEN II), Subjective Global Assessment (SGA), Nutritional RiskIndex (NRI), and Malaysian and South African tool. MNA and MNA-SF appear to have highest reliability and validity for screeningof community-dwelling elderly, while the reliability and validity of SCREEN II are good. The authors conclude that whilst severaltools have been developed, most have not undergone extensive testing to demonstrate their ability to identify nutritional risk.MNA and MNA-SF have the highest reliability and validity for screening of nutritional status in the community-dwelling elderly, andthe reliability and validity of SCREEN II are satisfactory. These instruments also contain all three nutritional status indicators andare practical for use in family medicine. However, the gold standard for screening cannot be set because testing of reliability andcontinuous validation in the study with a higher level of evidence need to be conducted in family medicine.

Palliative care is defined as the care for patients whose disease is not responsive to curative treatment. The goals of palliativecare are symptom control, life prolongation and enabling the best possible quality of life for patients and their families. For mostpatients with an advanced progressive incurable disease, 90% of care in their last year of life is provided at home by family physicianand his team and patient family. Patients suffering from cancer have a mean of of 11.9 symptoms in the last three monthsof life. The most common symptoms are digestive tract symptoms and pain. The growth and spread of cancer, as well as thetherapeutic procedures applied are the most important causes of symptoms. The most common symptoms in patients with cancerof digestive system are nausea, vomiting, constipation, pain, cachexia, anorexia, and psychological problems. These mostcommon symptoms and many others will be of varying intensity and appearance depending on localization and aggressivenessof digestive system cancer, modality of treatment and patient condition. Patients with advanced cancer have longer survivaland all health care professionals involved in the care of patients should have more knowledge and skills necessary to effectivelytreat various symptoms. Coordination, organization and implementation of palliative care in family medicine, when large part ofcare is provided at patient home, are one of the most complex tasks of family physician. This task requires a family practitionerwith specific knowledge and skills to know how effectively control a number of symptoms and to provide adequate support tothe patient and his family. Communication between doctor and patient suffering from advanced cancer of digestive system is afundamental aspect of care. The quality of communication significantly affects the course of treatment, the benefit to patientsand their families, the choice of treatment and adherence to treatment, as well as care planning. In the management of patientswith advanced cancer of the digestive system, family physician should use holistic approach and respect the patient as a personand his decision.

Dyspepsia is a common symptom among patients in family medicine practice. The prevalence in adult population is about 40%.Two-thirds of patients have functional dyspepsia. Clinical assessment, diagnostic procedures and treatment of patients dependon the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impactof other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommendedin patients with newly detected dyspepsia older than 50 and presenting with alarming symptoms. In persons younger than 50,the recommended strategy is ‘test and treat’. In some patients, treatment is carried out by acid suppression. In patients failingto achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantlycontribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presentingwith symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment ofpatients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits andpsychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychologicalmorbidity, as well as his efforts in healthy behavior.

Cholestasis indicates stagnation of bile, a disorder in the synthesis, secretion and/or outflow of bile. Cholestasis is classifiedas intrahepatic or extrahepatic. Intrahepatic cholestasis may occur as a result of hepatocellular disorders or due to obstructionof the intrahepatic bile ducts. Extrahepatic cholestasis is caused by obstruction of the bile ducts outside the liver. Cholestasismanifests as acute or chronic (>6 months). Early biochemical markers of cholestasis include increased alkaline phosphatase,γ-glutamyltransferase, and conjugated hyperbilirubinemia. Clinically, the most common presenting symptoms are jaundice, itchyskin and fatigue. A key element in diagnosis is visual presentation of the biliary system. New insights into the pathophysiologicalmechanisms of cholestasis at the molecular level will contribute to the development of new treatments. Pancreatitis is aninflammatory process in the tissue of the pancreas caused by prematurely activated pancreatic enzymes. The course of acutepancreatitis is in most cases mild, with minimal organ dysfunction and full recovery, while the severe form of the disease is characterizedby complications and high mortality. Chronic pancreatitis is characterized by persistent inflammation of the pancreaswith permanent damage to glandular tissue in the presence of fibrosis and narrowed pancreatic ducts. Treatment of pancreatitisis supportive and directed to maintaining the basic physiological functions. The role of family physicians is very important in earlydetection of liver diseases, which can significantly affect the success of treatment and improve the quality of life in these patients.

With the increasing prevalence of obesity and metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) has become themost common liver disease in adults and children. Despite the increasing prevalence, NAFLD remains largely undiagnosed anduntreated in routine medical practice. Most patients with NAFLD have no symptoms, while only a few feel discomfort in the upperright quadrant of the abdomen or increased fatigue. The diagnosis is usually set during abdominal ultrasound examination,which is done for some other reason, or by elevated liver biochemical test findings. Early recognition is very important for correctand successful treatment. In primary health care, little is known about the processes related to the identification, diagnosis andreferral of patients to specialists. Differentiation between steatosis and steatohepatitis by assessing the severity of fibrosis withinsteatohepatitis is extremely important. Histopathologic analysis of tissue obtained by biopsy remains the gold standard in thisfield. For family physician, guidelines that should be combined can be of great help in treating patients with suspected NAFLD.The serious consequences of late recognition of NAFLD could be reduced by such guidelines. Recent studies have shown thatNAFLD is associated with an increased prevalence and incidence of cardiovascular complications. Because of their complexity,hepatic and extrahepatic complications, heterogeneity in clinical presentation, histologic severity, prognosis and therapeuticoutcome, NAFLD requires a multidisciplinary approach with the active role of family physicians in preventive care, diagnosis andtreatment, especially in individuals and groups at risk. Greater attention should be focused on lifestyle modifications (reduction inbody weight and physical activity) and their practical implementation.Key words: non-alcoholic fatty liver disease, liver biopsy

The paper gives a short presentation of 40 years of experience of Osijek Health Center family physicians in colorectal cancer(CRC) prevention and early detection. Systematic work in the prevention and early detection of cancer includes raising publicawareness and knowledge of healthcare issues, educating health professionals, conducting scientific research and contributingto the development and implementation of the National Program for Early Detection of Cancer. Cooperation of the Ministryof Health and Osijek Health Center resulted in issuing brochures entitled Men and Cancer and Women and Cancer in 100,000copies, and later 20,000 copies of a book entitled Smoking Induced Diseases. Analysis of patients undergoing surgery for CRCat Department of Surgery, Osijek General Hospital during the 1973-1984 period showed a low 5-year and 10-year survival rate.A study of early CRC detection by using fecal occult blood test (FOBT), conducted in Osijek between 1980 and 1984, included11,431 subjects. Results of the study confirmed FOBT to be an acceptable and reliable method for early CRC detection becauseof its simple use, general level of acceptance by the population and relatively low cost. Physical examinations aimed at detectingCRC by using FOBT were to be implemented in a planned, systematic manner in high-risk persons (those older than 50). Basedon the results of this study, guidelines on cancer control were published in 1993 by teams of primary care physicians, especiallyfamily physicians. The Osijek Health Center, specifically its Family Medicine Department, participated in the development andimplementation of the National Program for Colorectal Cancer Prevention and Early Detection, which started in 2007. Responseto the National Program for Early Detection of Colorectal Cancer in individual counties was under 37%. A project called EarlyCancer Detection Model Integrated in Family Medicine Practice, which was implemented in Osijek and included subjects fromthe 45-49 and 75-84 age groups at risk, revealed that teams of family physicians were motivated to join the national programs forearly detection of cancer in Croatia. Experiences of the Osijek Health Center Family Medicine Department in the prevention andearly detection of CRC indicated that family physicians were pioneers in activities that had ultimately led to the establishment ofa National Program for Colorectal Cancer Prevention and Early Detection in Croatia.

Diagnosing irritable bowel syndrome (IBS) is often a problem for general practitioners (GPs) because they rely on symptomswithout specific biological markers. The objective was to examine the attitudes and knowledge of GPs in identifying and treatingpatients with IBS. The study included 51 GPs who take care of 87,000 patients, approximately 1,530 of them with IBS, on thebasis of a questionnaire developed for this study in two health centers in Zagreb. The questionnaire contained questions with acase vignette on GP attitudes and knowledge about IBS. In comparison with other pain conditions, GPs were found to have leastconfidence and pleasure, while spending a lot of time and finding it most difficult to diagnose and treat patients suffering fromIBS. In the case vignette, GPs answered correctly that it was IBS (84%) and most of them would give dietary advice and followup the patient (67%). For the diagnosis of IBS, most physicians considered necessary to take diagnostic criteria into account,exclude alarming symptoms and do basic laboratory tests (39%). Most GPs considered IBS to be a functional bowel disorder(92%), 63% used diagnostic criteria for IBS, and 61% were familiar with the Rome III criteria for IBS. Gastroenterologists would beconsulted by 53% of GPs in case of uncertain diagnosis and 35% of GPs for therapeutic inefficiency. In the treatment of IBS, mostGPs (51%) prescribe pharmacotherapy for functional bowel disorders. The authors conclude that GPs showed great knowledgein recognizing and diagnosing IBS, but compared to other painful conditions they have little self-confidence and pleasure. Theyspend a lot of time and find it most difficult to diagnose and treat patients suffering from IBS. Additional education is needed witha more proactive approach in the form of workshops, which may bring change in their attitudes and improve their knowledge.