These opening remarks were made by Max Sherman, Dean of the Lyndon B. Johnson School of Public Affairs, Austin, Texas, on May 6, 1996, as an introduction to the proceedings of the Symposium "Medicare: Advancing Towards the 21st Century."
Renal tissue is sensitive to the effect of potentially nephrotoxic drugs and other substances that are available over-the-counteror can be purchased at healthy food stores or elsewhere, and harmful substances from the environment. Theharmful effects of these substances lead to the development of recognizable clinical syndromes, including acute or chronicrenal failure, tubulopathy, and proteinuria. Risk factors that influence the development of kidney disease induced by drugsare divided into those related to patient characteristics, drug characteristics, and renal function. Drugs that commonlyexhibit nephrotoxic effects are analgesics, antimicrobials, chemotherapeutics, contrast agents, immunosuppressants,herbal preparations and substances containing heavy metals. Family physician must carefully observe their patients,nurturing individual approach to drug selection and determining the dose. Renal function can quickly return to normal if thedamage is recognized on time. Recent research yields insights into the identification of new biomarkers that will contributeto early detection of drug induced kidney damage.
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 accordancewith national guidelines. The PubMed and Cochrane systematic reviews databases were searched for the 1996-2015 periodusing the following key words: anemia, chronic renal failure, erythropoietin, and primary health care. In addition, all relevantarticles and textbooks available were manually searched to suggest the following conclusions. The use of erythropoiesis-stimulatingagents (ESA) slows down the progression of CKD, reduces the need for blood transfusions and improves thepatient quality of life. Target hemoglobin (Hb) concentration to be permanently maintained is 110-120 g/L. Higher Hb levelsare associated with higher mortality and major cardiovascular events in dialysis patients. Target hemoglobin level shouldbe strictly individualized depending on CKD stage (both non-dialyzed and dialyzed population), age, other risks, initial andmaintenance treatment. Early recognition and appropriate correction of anemia using ESA is of utmost importance in CKDpatients. Systematic primary and secondary prevention measures along with education and professional implementationof national guidelines in daily work of family practitioners can improve medical care of patients with CKD.
According to consensus definition, chronic kidney disease (CKD) includes urinary excretion of albumin >30 mg/day and/or reduction in kidney function defined as a decrease in estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2for a period longer than three months, in the presence of kidney tissue damage verified by imaging or histologic methods.In developed world, the first cause of CKD is diabetes, followed by arterial hypertension, and the less frequent causesare inflammatory disease (glomerulonephritis, interstitial nephritis) and congenital condition (polycystic kidney disease).Currently, there is valid classification under the acronym CGA, where C stands for the cause, G for glomerular filtration rate(GFR category) and A for the level of albuminuria category. In early stages, patients usually have no symptoms but there arechanges in creatinine values, estimated GFR (eGFR) reduction and presence of albuminuria, especially in patients at risk.Determining the grade of renal impairment is important because of different approaches to treatment, monitoring, expectedcomplications, and patient education. Due to improved diagnostic methods and population aging, CKD is diagnosed evermore increasingly. Family physicians should be familiar with the basic principles of screening and diagnosis of CKD toprovide them with appropriate care in collaboration with secondary and tertiary health care.
Cardiorenal syndrome, a complex pathophysiological disorder of both the heart and kidneys, is a condition in which acuteor chronic damage to one organ can lead to acute or chronic dysfunction of the other organ. Depending on primary organdysfunction and disease duration, there are five different types of cardiorenal syndrome. Type 1 cardiorenal syndrome(acute cardiorenal syndrome) is defined as acute kidney injury caused by sudden decrease in heart function. Type 2cardiorenal syndrome (chronic cardiorenal syndrome) refers to chronic kidney disease linked to chronic heart failure. Type3 cardiorenal syndrome (acute renocardial syndrome) is caused by acute kidney injury that leads to heart failure. Type 4cardiorenal syndrome (chronic renocardial syndrome) includes chronic heart failure due to chronic kidney disease. Type5 cardiorenal syndrome (secondary cardiorenal syndrome) is reversible or irreversible condition marked by simultaneousheart and kidney insufficiency, as a result of multiorgan disease such as sepsis, diabetes mellitus, sarcoidosis, amyloidosis,etc. The pathophysiological patterns of cardiorenal syndrome are extremely complicated. Despite numerous publications,perplexed physiological, biochemical and hormonal disturbances as parts of the main pathogenic mechanisms ofcardiorenal syndrome remain obscure. Even though there are guidelines for the treatment of patients with heart failureand chronic kidney disease, similar guidelines for the treatment of cardiorenal syndrome are lacking. In everyday practice,it is crucial to diagnose cardiorenal syndrome and use all diagnostic and therapeutic procedures available to prevent oralleviate kidney and heart failure.
Results of this clinical study on surgical treatment of pressure ulcers at Department of Plastic, Reconstructive and Aesthetic Surgery, Dubrava University Hospital showed that there was no difference between the 2011-2016 and 2003-2008 periods, indicating continuation of good surgical treatment planning and appropriate postoperative care. Despite the smaller number of hospitalized patients in the 2011-2016 period (31 patients and 42 reconstructive procedures), the number of reconstructive procedure was similar to the recent 2003-2008 period (47 patients and 57 reconstructive procedures). The best results of reconstruction of sacral region pressure ulcer were achieved with fasciocutaneous and musculocutaneous flaps. Whenever possible, depending on the extent of the defect, musculocutaneous flaps should be preferred for reconstruction. It is especially suitable for pressure ulcer recurrence. For ischial region reconstruction, good results can be obtained by mobilizing the semimembranosus and/or semitendinosus in defect gap. For trochanteric region, the tensor fascia lata flap is a good choice. For maximal functional and reconstructive results, a multidisciplinary approach in pressure ulcer treatment has the leading role in the modern concept of wound healing. Surgical treatment should always include radical debridement, ostectomy and well planned defect reconstruction. Conservative treatment should be support to surgical treatment with a focus on patient health care and high hygiene measures. In recent years (2011-2016), the usage of better conservative treatment led to reduction of patient hospital stay and surgical treatment of pressure ulcer. Further ‘wound care’ nurses training in Croatia can lead the trend towards advanced practice nursing in pressure ulcer prevention and conservative treatment.
A venous ulcer is area of discontinuity of the skin, usually localised in distal parts of the lower legs. The aetiology is associated with chronic venous disease-venous hypertension. The size and shape of venous ulcer can be different and it may even cover all circumferential of extremity. Additionally, along with basic therapy possibilities, there are many different dressings. Therefore the knowledge of each characteristic of dressing on process of epithelisation is essential as well as treating the biofilm that is responsible for complications and persistence of ulcer. One of additional therapy possibility is platelet-rich plasma.
Current knowledge and proofs of biofilm, interactions between various bacterial species and overall virulence of microbes play a role in delayed healing of wound and development of infection. High quality description of clinical symptoms and current knowledge of microbes provide an excellent guideline for creating the strategy of wound treatment. Owing to better understanding of the role of biofilm in prolongation of healing time and facts about biofilm system and structure, scientists have developed the Ag+ technology. This technology has strong synergistic effects of the general and antimicrobial activity of ionic silver and specific compounds, which have proved efficient in biofilm obstruction and removal.
Adrenocortical carcinoma is a rare entity. However, it is the most common type of cancerous adrenal gland tumor with poor prognosis. Approximately 4 to 12 per 1 million people develop this type of tumor, which begins in the adrenal cortex. Adrenocortical carcinoma can occur at any age. Women tend to be diagnosed slightly more often than men. In most cases, the cause of cancerous adrenal gland tumor remains unknown. However, people with certain hereditary conditions have a higher risk. Adrenocortical carcinoma can be a functional or nonfunctional tumor. If the tumor is functional, it may produce hormones causing symptoms such as high blood pressure, low potassium level, heart palpitations, nervousness, feelings of anxiety or panic attacks, excessive perspiration, diabetes, Cushing syndrome, unexplained weight gain or weight loss, weakness, abdominal stretch marks, excessive hair growth, changes in genitalia, change in libido, etc. If the tumor is nonfunctional, symptoms occur because the tumor has grown so large that it exerts pressure on the nearby organs, causing abdominal pain or a feeling of fullness. To diagnose adrenocortical carcinoma, in addition to thorough physical examination, the following tests are used: blood and urine tests to help determine whether the tumor is functional or nonfunctional, and imaging tests (computed tomography scan or magnetic resonance imaging). The treatment depends on cancer stage. Two major staging systems are used: the American Joint Committee on Cancer (AJCC) TNM staging system and the ENSAT (European Network for the Study of Adrenal Tumors) staging system. Both are based on the same TNM categories. The main types of treatment for adrenal cancer are surgery (the main treatment), chemotherapy and targeted therapy. Radiation therapy is not used often as the main initial treatment for adrenal cancer because the cancer cells are not easy to kill with x-rays. Radiation may be used as adjuvant therapy. By definition, adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctional adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g., adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma, or metastasis).
Psychodermatologic disorders are conditions involving an interaction between the mind and the skin. Correlation between psychiatric and dermatological disorders is a highly complex relation considering etiology, diagnostic procedures and treatment. There are three major groups of psychodermatological disorders: psychosomatic (psychophysiologic) disorders, primary psychiatric disorders and secondary psychiatric disorders. Psychosomatic disorders are dermatological diseases which can be exacerbated or worsened by emotional stress, but are not caused directly by stress. Emotional stress can exacerbate many chronic dermatoses like urticaria, eczema, psoriasis, acne, seborrheic dermatitis, atopic dermatitis, alopecia areata, psychogenic purpura, rosacea, atypical pain syndromes and hyperhidrosis. The treatment of patients with the resistant chronic dermatosis can be difficult when stress is not recognized as a provoking factor. Primary psychiatric disorders are psychiatric conditions which induce development of various skin changes, e.g trichotillomania, factitial dermatitis, neurotic excoriations, delusions of parasitosis and dysmorphophobia. They include psychiatric disorders with anxiety, compulsive- opsessive and depressive symptoms and pathologic delusional ideas or hallucinations regarding the skin. Secondary psychiatric disorders appear as a result of a certain disfiguring skin disease that induces psychologic suffering such as loss of self-confidence, anxiety and social phobia. This category includes diseases like psoriasis, chronic eczema, various ichthyosiform syndromes, rhinophyma, multiple neurofibromas, severe acne, and other cosmetically disfiguring cutaneous lesions. The therapeutic approach of psychodermatological disorders should be multidisciplinary including primary care physicians, dermatologist, psychiatrist and psychologist. It is very important to educate dermatologists in the diagnostic procedures and therapy of psychiatric disorders which sometimes coexist with the skin disease. Majority of psychodermatological disorders can be treated with cognitive-bihevioral psychotherapy, psychotherapeutic stress-and-anxiety-management techniques and psychotropic drugs. Psychopharmacologic treatment includes anxiolytics, antidepressants, antipsychotics and mood stabilizer.
Recognition of the existence of biofilm in chronic wounds is increasing among wound care practitioners, and a growing body of evidence indicates that biofilm contributes significantly to wound recalcitrance. While clinical guidelines regarding the involvement of biofilm in human bacterial infections have been proposed, there remains uncertainty and lack of guidance towards biofilm presence in wounds. The intention of this report is to collate knowledge and evidence of the visual and indirect clinical indicators of wound biofilm, and propose an algorithm designed to facilitate clinical recognition of biofilm and subsequent wound management practices.
Damage to the central nervous system leads to the loss of motor control, loss of consciousness, sensory, cognitive andperceptive dysfunction. Patients are immobile in the early phase of recovery, therefore therapeutic approach demandsappropriate methods of patient positioning in bed. The positioning has to ensure conditions that will stimulate and promotefunctional rehabilitation and prevent complications of immobility. The positioning has to rely on functional assessment ofthe patient problem, while it should also be therapeutic and individually adjusted to the patient needs. In the methods ofpositioning an immobile patient, all medical team members take part, especially nurses, physical therapists and occupationaltherapists. Results of positioning are better if mobilization and integration of the abilities regained by the patient are included.
Pressure ulcer develops as a result of many factors, primarily pressure, tensile forces and ischemia with immobility andincontinence. Targeted and properly designed preventive measures reduce the incidence and complications of pressureulcers, among which the most common are infections. An important preventive measure is protection of the surroundingskin before the application of wound dressings. Skin changes dictate the use of emollients and topical therapy according todermatological status.
The ever improving health standards in terms of quality and more efficient health care result in an increase in life expectancy,thus increasing the number of elderly people in the population. A higher level of activity in elderly population leads to greaterincidence of injuries, and on the other hand, there is an increasing number of comorbidities. Circulatory disorders, diabetesmellitus, metabolic imbalances, etc. and a reduced biological potential of tissue regeneration result in an increased numberof chronic wounds that pose a significant health, social and economic burden on the society. These conditions require significantinvolvement of medical and non-medical staff in pre-hospital institutions. Significant material and other health careresources are allocated for the treatment of chronic wounds. These conditions result in a lower quality of life of patients andtheir families and caregivers. Debridement is a crucial medical procedure for the treatment of acute and chronic wounds.The result of debridement is removal of all barriers within and around the wound that obstruct physiological processes ofwound healing. Debridement is a repeating process when indicated. There are several types of debridement, each with itsadvantages and disadvantages. The method of debridement should be determined by the physician or other professionaltrained person on the basis of wound characteristics and in accordance with their expertise and capabilities. In the samewound, we can combine different types of debridement, all with the goal of faster and better wound healing.
This review article describes the occurrence of painful sensation with special reference to the occurrence of pain in chronicwounds, and presents recommendations for medical treatment of pain. Treatment is focused on pharmacotherapy. The recommendedbasis for rational use of analgesics is the WHO ‘three-degree’ scale. The need for combining pharmacotherapywith non-pharmacological treatment is also stressed. The positive effect of Visible Incoherent Polarized (VIP) light on theacceleration of chronic wound healing is highlighted.
Pressure ulcer is an undesired event for patient, frequently used in quality monitoring as an indicator of healthcare quality and patient safety. According to legal regulations in the Republic of Croatia, pressure ulcer is included in the group of indicators of other undesired events (patient safety) and healthcare institutions are obliged to monitor the applicable indicator and submit report to the Agency every six months. Annual reports on the patient safety indicators are available on the Agency website. The article presents the descriptive list of indicators and descriptive list for the Pressure Ulcer indicator.
This introduction has highlighted both the complex nature of the aetiology of pressure ulcer development and the complex nature of the assessment process intended to identify those patients who are or might be at an enhanced risk of pressure ulcer development. The latter statement assumes that all patients cared for in any healthcare setting are vulnerable to pressure ulcer development. Whilst it is acknowledged that the use of a risk assessment tool can be important in an overall pressure ulcer prevention strategy, it is important that the limitations of these tools are acknowledged and that they are not an finite assessment in themselves and that they should be used by a practitioner with a fundamental breadth of relevant knowledge and an appreciation of the range of appropriate preventative equipment/techniques available and the role of the multi-disciplinary team in the prevention of all avoidable pressure ulcers.
Although asymptomatic hyperuricemia is rather often in laboratory reports, it cannot be considered a disease. Despite the high prevalence of hyperuricemia in patients with arterial hypertension (AH), chronic kidney disease (CKD), cardiovascular disease (CVD) or metabolic syndrome, hyperuricemia is not confirmed as a causative factor of these disorders. The aim is to point to the latest studies of the importance of urate as a possible cardiorenal risk factor. The literature published in 2015 and 2016 was searched for the possible impact of urate level on the development of cardiorenal diseases. The PubMed, Cochrane, Medline, and UpToDate databases were searched for the literature published between November 2009 and October 2016 using the following key words: urate, hyperuricemia, cardiovascular disease, and chronic kidney disease. Causative correlation of hyperuricemia is confirmed only in disorders where deposits of monosodium urate crystals are present. Results of recent studies do not justify routine use of xanthine oxidase inhibitors in asymptomatic hyperuricemia. Some studies with small numbers of patients and short follow up report on endothelial function improvement on therapy with xanthine oxidase inhibitors. Nonpharmacological intervention by changing unhealthy lifestyle is preferred. Treatment of asymptomatic hyperuricemia in CKD is still debated, and additional studies are necessary to demonstrate the benefit of lowering urate level in CKD. Family doctors (general practitioners) should be familiar with the recommended approach to patients with asymptomatic hyperuricemia. Evidence based medicine still does not recommend target determination of serum urate level for identifying CVD and CKD risk factors. Recent studies suggest the possible effect of uric acid in cardiorenal diseases and that treatment of asymptomatic hyperuricemia with xanthine oxidase inhibitors may also be useful in CVD prevention. Additional studies are needed to prove this statement.
Urinary tract infections (UTI) are the most common bacterial infections involving lower (cystitis, prostatitis) or upper(pyelonephritis, renal abscess, perinephric abscess) urinary tract. Differentiation of complicated and uncomplicated UTIis usually based on the presence of structural or functional urinary tract abnormalities, which can increase the risk oftreatment failure and development of serious complications. Factors that increase the risk are foreign bodies, stones,obstruction, neurogenic bladder, kidney transplantation, immunosuppression, and pregnancy. Complicated UTI includes aspectrum of conditions that increase the risk of treatment failure, as well as of serious complications such as bacteremiaand sepsis, perinephric abscess, renal impairment and emphysematous pyelonephritis. To avoid the potentially devastatingoutcomes, appropriate diagnostic procedures, antibiotic and surgical treatment, and appropriate follow-up are required.The incidence of complicated UTI will grow in the future due to general aging of the population, increasing incidence ofdiabetes, and ever growing number of immunocompromised and immunosuppressed patients. It is of key importance torecognize complicated UTI on time, and treat it wisely and aggressively to reduce duration of the disease and the risk ofantibiotic resistance.
Prostate cancer is a common malignant tumor of the elderly, which accounts for a significant proportion of total morbiditybut very low of mortality. In Croatia, it is the second most common cancer in men. Currently, there are many doubtsconcerning screening, early detection and treatment of prostate cancer. Therefore, this article brings results of Cochranesystematic reviews (SRs) on the topic of prostate cancer published in the last eight years. In June 2016, Cochrane databaseof systematic reviews was searched using the following keywords: Systematic Reviews, and Prostate Cancer (Malignancy,Neoplasm). Inclusion criterion was publication date of the Cochrane SR or its update in the last eight years. The abstractswere initially screened and those that matched the topic were included in further analysis. Then full texts of all SRs involvedwere obtained. SRs were classified into four topics: prevention, screening, treatment and psychosocial aspects. Our searchretrieved a total of 19 Cochrane SRs on the topic of prostate cancer. Excluded were four articles that did not match thespecific topic, and the remaining 15 full texts were obtained. One of these was on screening, two on prevention, themajority, i.e. eleven were on treatment, and one on the psychosocial aspects related to prostate cancer. Based on theresults of the Cochrane SRs on prostate cancer, instead of mass/population screening, the individualized/opportunisticscreening approach should be applied in men aged 55-69, always providing full information to the patient and taking intoaccount the potential benefits and harms of this procedure.
