HRONIČNA RENALNA INSUFICIJENCIJA KOD PACIJENTA NA SUPSTITUCIONOJ TERAPIJI METADONOM

Uvod. Zavisnost od opijata je hronično stanje povezano s različitim morbiditetima. Metadonska supstituciona terapija opijatskog zavisnika u kombinaciji sa socijalnim, zdravstvenim i psihološkim uslugama, zlatni je standard u lečenju. Svi opioidi ispoljavaju brojna neželjena dejstva. Oštećenje bubrega kod opijatskih zavisnika može nastati zbog sepse, rabdomiolize, pada glomerularne filtracije, hipotenzije, edema pluća, renalne lipidoze ili amiloidoze.Prikaz slučaja. Pacijent, 40 godina, na metadonskoj supstitucionoj terapiji, oseća slabost, znojenje, bol u mišićima i visoko je febrilan. U laboratorijskim analizama: kaliemija 9.87 mmol/L, urea 18.3 mmol/L, kreatinin 268 µmol/L, klirens uree 0,20 ml/s klirens kreatinina 0,81 ml/s, eGFR 23 ml/ min/1,73m2, kreatin fosfokinaza 1180 IU/L, Hgb 79 g/L, Er 2.81x1012/L, C-reaktivni protein 13.2 µg/mL, Le 7.41x109/L, PCO2 41 mmHg, 22 HCO3 mmol/L i acidoza pH 7.21. Krvni pritisak 130/80 mmHg i srčana frekvencija 64/min, na EKG produžen PR interval i visoki T-talasi. Lečen je infuzijama kristaloidnih rastvora, 8.4% rastvorom bikarbonata, diureticima, kalcijum glukonatom, kratkodelujućim insulinom, antibioticima i antikoagulansima. Dolazi do normalizacijekalijemije, diureze i regresije promena na elektrokardiogramu. Nakon 24 dana bolničkog lečenja, pacijent je otpušten na kučno lečenje.Zaključak. Pacijenti na metadonskoj supstitucionoj terapiji imaju povećan rizik od multiplog oštećenja funkcije svih organa. Posebno je ugrožena renalna funkcija. Od izuzetne važnosti je da se među lekarima poveća svest o opasnosti nastanka rabdomiolize kod ovih pacijenata. Redovne laboratorijske analize kod pacijenata na supstitucionoj terapiji metadonom, mogu na vreme da otkriju postojanje akutne i hronične bubrežne komplikacije i omoguće blagovremeno sprovođenje terapije.

Prehospitalno kašnjenje pacijenata sa znacima akutnog moždanog udara

Uvod. Akutni moždani udar je drugi vodeći uzrok smrti i treći vodeći uzrok invaliditeta u svetu. Osnovni cilj u lečenju je da pacijent u prva 4,5h od pojave simptoma dobije trombolitičku terapiju. Većina pacijenata prve simptome doživi izvan zdravstvenih ustanova, tako da je važno prepoznavanje oboljenja od strane prisutnih osoba. Teži moždani udari, korišćenje vozila Hitne medicinske pomoći i mlađe životno doba udruženi su sa smanjenjem prehospitalnog kašnjenja.Cilj rada. Prikazati koliko je prehospitalno kašnjenje pacijenata koji imaju tegobe koje ukazuju na moždani udar, i taj uticaj na lečenje.Metod. Istraživanje je studija preseka rada ambulante Hitne medicinske pomoći Beograd u periodu od 1.1.2015. do 31.12.2018 god. sa pacijentima kojima je postavljena dijagnoza Cerebrovaskularni insult CVI, sumnja na CVI, Tranzitorni ishemični atak. Prehospitalno kašnjenje je vreme od pojave tegoba do trenutka javljanja lekaru. Pacijenti su podeljeni u grupe prema kašnjenju: do 3h, 3-24h i više od 24h. Statistička obrada je izvršena u programu SPSS 11, a statistička značajnost je definisana na nivou p<0,05.Rezultati. U istraživanju je učestvovalo 119 ispitanika prosečne starosti 65,53±14,24 godina, muškog pola 46,22%, ženskog pola 53,78%. U prva tri sata od početka tegoba u ambulantu je stiglo 44,54%, u vremenu od 3-24h - 31,93%, a preko 24h - 23,53% pacijenata.Zaključak. Više od polovine pacijenata se javlja u vremenu kada savremena trombolitička terapija nije efikasna.

General practitioners' attitudes towards research in general medicine

Introduction: General medicine is a specific scientific discipline and research is a constituting part of each medical discipline. Objective: We reviewed general physicians` (GPs) attitudes towards scientific research and their reasons for participating or not participating in them. Method: We made a specific questionnaire for the sake of this research. We got the data on age, gender, service periods, place of work (city/country), and specialty: GP or specialist in general medicine, as well as their opinions on research. We forwarded the questionnaire to 550 physicians' email addresses in November 2016. The acquired data were statistically processed using SPSS 20.0 for Windows. Results: The questionnaire was filled out by 233 physicians, of whom 83,3% were women, 67% specialists in general medicine, 68,7% physicians worked in city clinics; the average age of the participants was 46.46±10.29, the average service period 17.85±10.99 years. Out of the total number, 67.8% of the participants thought research was important and useful, even more so by specialists in general medicine, which was statistically significant (p=0.000). There were 71.2% of the physicians who already participated in the research projects, mostly working in the cities (p=0.008), physicians older than 50 (p=0.000), and physicians with service period >20 years (p=0,000). Physicians 30 or younger (p=0.017) and physicians with ≤ 10 years of service (p=0.002) thought research improved work quality. The most frequent reason for not participating in the research projects was lack of time due to a patient and administration overload. The most frequent reason for participating, for physicians with 11-20 and over 20 years of service, was improving work quality (p=0.007). Conclusion: Physicians think research is necessary and useful in general medicine and it improves work quality. The most frequent reason for not participating in the research projects was lack of time due to a patient and administration overload.

Eosinophilic esophagitis: A potential complication of sublingual immunotherapy

Introduction. Eosinophilic esophagitis (EoE) represents chronic, a local immune-mediated disease with symptoms of esophageal dysfunction and histologically eosinophil-predominant inflammation and requires immediate endoscopy. Male gender is a strong risk factor. Case report. We presented a case of a 25-year-old young man with a history of allergic rhino-conjunctivitis, asthma, and intermittent severe feeding disturbance. The patient had begun sublingual immunotherapy therapy, containing specific soluble allergens for ambrosia. Six weeks after starting the ambrosia sublingual immunotherapy he developed burning epigastric pain, dysphagia, and odynophagia. Six days later, he was admitted to an emergency department due to choking on a solid of food. Esophageal histopathological findings were in favor of EoE. Sublingual immunotherapy was discontinued. He feels well now. Conclusion. The majority of cases of Eosinophilic esophagitis are diagnosed in spring or fall, 1-2 months following the peak of pollen season. Dysphagia, chest pain, food sticking, and bolus obstruction are the most common symptoms. Endoscopic findings are Schatzki ring, edema, exudates, furrows, and strictures. Six biopsies should be taken from areas with endoscopic mucosal abnormalities, and infiltration of eosinophils (more than 15 eosinophils/HRI) (HRI - high resolution imaging) is necessary for the diagnosis confirmation. Treatment options are proton pump inhibitors - oral dispersible tablets of budesonide or fluticasone propionate, an elimination diet. Sublingual immunotherapy should be discontinued. Family physicians should be aware of this complication in evaluating patients with dysphagia.

Social skills inventory in health care workers in the city of Loznica

Introduction: Social skills inventory is a measure used to evaluate two dimensions of communicational skills: emotional (non-verbal), and social (verbal). Each dimension evaluates three categories: expressiveness, sensibility, and control. Objective: We wanted to find out if there was a statistically significant difference in social skills, in health workers, in the city of Loznica. We hypothesized there weren't any differences in social skills inventories of men and women working in primary and secondary healthcare levels. Method: The participants were given the SSI (Social skills inventory) questionnaire. It contained 90 questions, divided into 6 categories. The total number of the participants (employees of the primary and secondary health care institutions in the city of Loznica) was 76, of whom 51 were women and 25 men, and their age ranged from 25 to 65. A university level of education had 47 participants, 4 had a college degree, and 25 had a high school degree. The inferential statistics (t-test) was used for data analysis. Results: After data analysis, based on statistical data handling (t-test of independent categories for singular samples) we got a p<0.05 for expressiveness, and it was more prominent in male participants and behavioral control in female participants. The p-value for the total score for social skills was p>0.05, which bore no statistical significance. There was no statistically significant difference in the total score of the inventory of social skills between male and female health care workers. Though, there was a statistically significant gender difference in expressiveness, in favor of men, and social control, in favor of women. Conclusion: The total score, after testing the inventory of social skills of health workers in Loznica, showed there was no statistically significant difference between men and women, but the level of expressiveness and behavioral control showed a statistically significant difference.

Prescribing pattern of benzodiazepines in outpatients without a diagnosis of mental disorders: Retrospective study

Introduction: Benzodiazepines (BZD) are efficient drugs used to reduce anxiety, treat insomnia, or used as myorelaxants. BZDs are generally recommended for short-term use due to numerous side-effects and addiction. Objective: To investigate the prescribing pattern in family medicine outpatient clinics, in patients without the diagnosis of a mental disorder, and the influence of sociodemographic characteristics on BZD use. Method: A retrospective study of BZDs use, in a tenyear period (2009-2019), was conducted in patients treated in five family medicine teams of three primary health care centers in the Republic of Srpska. The study was carried out by reviewing electronic health records (EHRs) of patients above 18 years of age. The patients with the diagnosis of mental disorders were not recruited in the study. The study included 8560 EHRs, and 259 patients with the diagnosis of the mental disorders were excluded from the study. Results: Out of a total of 8301 analyzed EHRs, in 1044 (12.58%) patients at least one prescription for BZDs was found in a ten-year period. Females used BZDs in a greater percentage (71.07%), persons older than 65 years (44.54%), patients with secondary school education (60.44%), patients with chronic diseases (88.60%), patients living in an urban environment (75.96%). The most prescribed BZD was bromazepam (80.17%). Conclusion: The use of BZDs in our patients is quite considerable when compared to recommendations. The strategies to reduce BZD prescribing are necessary to reduce the chronic use of these drugs.

Chronic lymphocytic leukemia in general practice

Introduction: Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults, rarely affecting children. It is more common in males over 60. Etiopathogenetically, it represents an abnormal proliferation of lymphocytes in the bone marrow, which are dysfunctional although morphologically similar to mature ones. Case report: Female patient, 66, a housewife, comes for an examination due to fatigue lasting about a month and weight loss of 3-4 kg. She denies other health problems. On the examination, she is alert, oriented to time, space, and persons, eupnoeic, lymphadenopathy on the neck, axillae and groins. She gives away the impression of a patient with mild clinical symptoms. Clinical examination: clear breath sounds in all lung fields, regular heartbeat, clear tones, BP 140/80 mmHg, abdomen at chest level, painless to palpation, liver not palpable, and spleen palpated 2 cm below the costal arch. CBC (complete blood count) showed an increased number of leukocytes 181.30x109 /L and lymphocytosis 92.2%, other parameters were normal. She was referred to the hematologist in the Kraljevo General Hospital, where further diagnostics were performed. Blood count was repeated, Chest X-ray was performed, ultrasound (US) of the abdomen neck, axillae, groins, and heart, virology tests, ENT examination. Abdominal US showed a pathological finding with enlarged liver, spleen, lymph nodes (LN). ENT examination: enlarged tonsils, other findings unremarkable. Since chronic lymphocytic leukemia was suspected, she was referred to the Clinical Center of Serbia. Immunophenotyping (IF) and computed tomography (CT) of the neck, chest, and abdomen were performed. The diagnosis of CLL was confirmed. A Medical Council decided to perform immunochemotherapy (IHT) with fludarabine and rituximab. After 6 received cycles, the patient feels well and the CBC parameters are normal. Conclusion: CLL may be asymptomatic or nonspecific and with mild symptoms in a large number of patients. Therefore, blood tests with leukocytosis and absolute lymphocytosis findings are crucial to suspect the disease and perform further diagnostics.

D-dimer rise in outpatients with COVID 19 and comorbidities

Introduction: COVID-19 is an infectious disease caused by a newly discovered Coronavirus. Most of the infected people will go through it with mild to moderate respiratory symptoms and recover without any specific treatment. Older people and people with medical issues, such as cardiovascular diseases, diabetes, chronic pulmonary diseases, malignant diseases are at higher risk for the severe form of the disease. Case report: Female patient, 57, physician, presents with symptoms of Sars-Cov-2 virus infection. Her personal history is significant for pulmonary thromboembolism (PTE). This is a disease which should be paid special attention to. Conclusion: A new Coronavirus infection, which struck the world a year ago, presents a great challenge for general physicians (GPs) and the health system as a whole. The scientific and medical community and the general public must lean on verified facts in this fight against the COVID-19 pandemic. They should be ready to change their treatment protocols, as new information appears from properly designed, implemented, and presented basic and clinical studies. Each patient should be approached with special care, using up-todate facts and proofs from clinical practice, and guided by the newest treatment protocols thus reducing complications in COVID-19 patients with comorbidities.