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

OBJECTIVE: To analyse the frequency of nonrecreational prescription analgesic sharing, associated factors and differences between lenders and borrowers. METHODS: A cross-sectional study was conducted in 10 outpatient family medicine practices in Croatia amongst 1000 patients to whom their physicians have prescribed analgesics at least once in their lives. A questionnaire was used to collect data about patients' pain intensity, prescription analgesic sharing habits, factors associated with this behaviour, perception of risks associated with the conduct and demographic data. Logistic regression was conducted to analyse independent factors associated with lending and borrowing prescription analgesics. RESULTS: We found that 61% of patients in family medicine practices engage in sharing prescription analgesics, whether it was lending (42%) and/or borrowing (54%). Independent predictors of lending prescription analgesics were as follows: history of sharing prescription medication other than analgesics, providing information regarding the medication alongside the prescription medication itself, not reading package insert that accompanies medication, subjective perception of personal health and decreased awareness of personal harm associated with prescription analgesic sharing. Independent predictors of prescription analgesic borrowing were as follows: younger age, communicating details regarding the medication that was given, scanning of package insert accompanying the medication, biased subjective perception of personal health and perceiving alternative medicine as a safer option over conventional medicine. CONCLUSIONS: Sharing prescription analgesics is highly prevalent amongst patients in family medicine. Healthcare providers should remain alert by routinely questioning patients regarding such behaviours. Preventive interventions should be conceived and established. SIGNIFICANCE: Sharing of prescription analgesics is a highly prevalent behaviour amongst pain patients, and there exist independent factors associated with such conduct. This information can be useful in the design of interventions aimed at mitigating analgesic sharing behaviour in the future.

[ANEMIA IN CHRONIC KIDNEY DISEASE].

Renal anemia develops secondary to chronic kidney disease (CKD) and its incidence increases with the progression of CKD. The aim is to inform family physicians about the latest developments and ways of approaching the issue, in accordance with national guidelines. The PubMed and Cochrane systematic reviews databases were searched for the 1996-2015 period using the following key words: anemia, chronic renal failure, erythropoietin, and primary health care. In addition, all relevant articles and textbooks available were manually searched to suggest the following conclusions. The use of erythropoiesis-stimulating agents (ESA) slows down the progression of CKD, reduces the need for blood transfusions and improves the patient quality of life. Target hemoglobin (Hb) concentration to be permanently maintained is 110-120 g/L. Higher Hb levels are associated with higher mortality and major cardiovascular events in dialysis patients. Target hemoglobin level should be strictly individualized depending on CKD stage (both non-dialyzed and dialyzed population), age, other risks, initial and maintenance treatment. Early recognition and appropriate correction of anemia using ESA is of utmost importance in CKD patients. Systematic primary and secondary prevention measures along with education and professional implementation of national guidelines in daily work of family practitioners can improve medical care of patients with CKD.

[RESISTANT ARTERIAL HYPERTENSION ­ APPROACH TO PATIENT IN FAMILY MEDICINE].

Increasing the proportion of patients with controlled hypertension implies understanding and systematic approach to patients with resistant hypertension. In the past decades, an increase in the prevalence of resistant arterial hypertension (RAH) has been observed and the incidence of this problem is becoming greater in the practice of family physicians. Patients with RAH have a higher prevalence of target organ damage as compared with patients having achieved target blood pressure values, and their risk of an adverse cardiovascular event is tripled. RAH is defined as hypertension in which there is no satisfactory control of blood pressure despite compliance to lifestyle changes and taking at least three drugs in full doses, one of which has to be a diuretic. The most important risk factors for resistance to treatment are older age, obesity, smoking, excessive intake of salt and alcohol, the presence of left ventricular hypertrophy, chronic renal failure, diabetes, inadequate baroreflex pathway, chronic stress and associated mental states, use of some drugs, and all forms of secondary hypertension. One-fifth of patients with RAH have primary aldosteronism. Obstructive sleep apnea is a common cause of RAH, and literature reports point to its increasing frequency. Optimal treatment involves a combination of three drugs, one of which is a diuretic. Use of mineralocorticoid antagonist as the fourth drug has shown significant efficacy even in patients who do not have elevated levels of aldosterone. New invasive methods of treatment include renal denervation and permanent electrical stimulation of the carotid sinus. The aim of this paper is to emphasize the importance of RAH as a cardiovascular risk factor, along with early detection and treatment at the family medicine level and timely referral to additional procedures to treat the specific forms of RAH.

[APPROACH TO A PATIENT WITH DYSPEPSIA IN FAMILY MEDICINE PRACTICE].

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 depend on the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impact of other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommended in 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 failing to achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantly contribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presenting with symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment of patients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits and psychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychological morbidity, as well as his efforts in healthy behavior.

[GASTROESOPHAGEAL REFLUX DISEASE ­ A MULTIFACETED DISEASE].

Gastric content reflux to the esophagus is a physiological phenomenon that occasionally occurs after meal. Gastroesophageal reflux disease (GERD) is a state that appears when the quantity of gastric content surpasses its physiological elimination from the esophagus and causes difficulties with or without associated esophageal mucosa damage, as well as alarming symptoms. The symptoms are defined as alarming if they disturb the patient's well-being and are the reason for a visit to the physician. The prevalence of GERD in the Western world is 10%-20% and is based on the estimation of the heartburn incidence as the leading symptom. The dominant symptoms are heartburn and regurgitation, especially after a heavy meal, and are highly specific for GERD. Extraesophageal reflux disease represents a wide range of symptoms connected to the upper and lower respiratory system, such as cough, laryngitis, asthma, chronic obstructive pulmonary disease, hoarseness, sinusitis-postnasal drip syndrome, otitis media, recurrent pneumonia and laryngeal carcinoma. The following tests are used in the reflux differential diagnosis: esophagogastroscopy, laryngoscopy and 24-hour pH monitoring. Patients suspected to suffer from GERD are initially treated with empirical proton pump inhibitor therapy twice a day for one to two months.

[PATIENT WITH PEPTIC ULCER DISEASE].

Peptic ulcer disease is represented by a lesion in the mucosa of the digestive tract due to imbalance of its aggressive and protective mechanisms. The main external factors of the development of peptic ulcers are Helicobacter pylori infection and the use of non-steroidal anti inflammatory drugs (NSAIDs) and acetylsalicylic acid (ASA). Symptoms of peptic ulcer disease are a common reason for visiting the family physician. All patients with symptoms of dyspepsia under the age of 50 and without the alarm symptoms should be tested whether H. pylori is present by performing the Urea Breath Test or stool antigene testing, and infection, if found, should be treated. Endoscopic examination is obligatory in patients older than 50 years and those with alarm symptoms. "Sequential therapy" is recommended in Croatia as the first-line treatment of H. pylori infection, or triple therapy that comprises applying a proton pump inhibitor (PPI) in combination with amoxicillin and metronidazole. Four weeks after eradication therapy the control testing for H. pylori should be performed.

[NON-ALCOHOLIC FATTY LIVER DISEASE].

With the increasing prevalence of obesity and metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in adults and children. Despite the increasing prevalence, NAFLD remains largely undiagnosed and untreated in routine medical practice. Most patients with NAFLD have no symptoms, while only a few feel discomfort in the upper right 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 correct and successful treatment. In primary health care, little is known about the processes related to the identification, diagnosis and referral of patients to specialists. Differentiation between steatosis and steatohepatitis by assessing the severity of fibrosis within steatohepatitis is extremely important. Histopathologic analysis of tissue obtained by biopsy remains the gold standard in this field. 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 that NAFLD 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 therapeutic outcome, NAFLD requires a multidisciplinary approach with the active role of family physicians in preventive care, diagnosis and treatment, especially in individuals and groups at risk. Greater attention should be focused on lifestyle modifications (reduction in body weight and physical activity) and their practical implementation. Key words: non-alcoholic fatty liver disease, liver biopsy

[CHOLESTASIS AND INFLAMMATION OF THE PANCREAS IN FAMILY MEDICINE].

Cholestasis indicates stagnation of bile, a disorder in the synthesis, secretion and/or outflow of bile. Cholestasis is classified as intrahepatic or extrahepatic. Intrahepatic cholestasis may occur as a result of hepatocellular disorders or due to obstruction of the intrahepatic bile ducts. Extrahepatic cholestasis is caused by obstruction of the bile ducts outside the liver. Cholestasis manifests 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, itchy skin and fatigue. A key element in diagnosis is visual presentation of the biliary system. New insights into the pathophysiological mechanisms of cholestasis at the molecular level will contribute to the development of new treatments. Pancreatitis is an inflammatory process in the tissue of the pancreas caused by prematurely activated pancreatic enzymes. The course of acute pancreatitis is in most cases mild, with minimal organ dysfunction and full recovery, while the severe form of the disease is characterized by complications and high mortality. Chronic pancreatitis is characterized by persistent inflammation of the pancreas with permanent damage to glandular tissue in the presence of fibrosis and narrowed pancreatic ducts. Treatment of pancreatitis is supportive and directed to maintaining the basic physiological functions. The role of family physicians is very important in early detection of liver diseases, which can significantly affect the success of treatment and improve the quality of life in these patients.