Assessment of the Antidepressant Side Effects Occurrence in Patients Treated in Primary Care

INTRODUCTION

It is an undeniable fact that antidepressants can cause side effects. Antidepressants generally have a similar effect but they differ in their application safety, as well as their side effects.

AIM

To determine differences in the frequency and intensity of antidepressant induced side effects in patients treated in primary care.

METHODS

The research was designed as a prospective, cross-sectional study, conducted on a voluntary and anonymous basis, and it included depression patients treated with antidepressant medications during 2013-2015 in Zenica-Doboj Canton using the Hamilton Depression Rating Scale and Toronto Side Effects Scale.

RESULTS

The total sample included 508 subjects. As a significant problem, abdominal pain was felt by 14% of subjects, indigestion by 19% of subjects, nausea by 15% of subjects, diarrhea by 9% of subjects, and constipation by 11% of subjects. 29% of subjects suffered from sweating, 20% suffered from a sudden heat stroke, 10% suffered from swelling, and 23% of them reported suffering from dry mouth as a significant problem. The prevalence of side effects in relation to how do they affect life and daily activities of subjects is statistically significant (P <0.000). Statistically significant side effects of SSRI antidepressants correlate with the duration of our subject's treatment: perception of increased sleep (0.039) as well as decreased sleep (P = 0.009), sweating (P <0.001), sudden heat stroke (P <0.001), being without orgasm (P = 0.004), decreased libido (P <0.001), weight loss (P = 0.045).

CONCLUSION

It is necessary to educate the patients about the nature and features of the depressive disorder, and to notify the patients of the expected course of recovery, as well as the need to adhere to the recommended therapy and the possible side effects of the medication.

Geriatric Depression in Family Medicine

INTRODUCTION

Elderly persons often suffer from depression, without anyone around them noticing. Depression is more common at physically ill elderly person then at their physically healthy contemporary. It is important mental health problem of developed society, because it is still faintly revealed thus insufficiently treated.

OBJECTIVE

To explore the existence of geriatric depression in elderly persons living on their own and those who live in family environment.

MATERIALS AND METHODS

The research included 200 elderly respondents, experimental group made of elderly persons (>65 years) living alone. Control group included elderly persons living in a family environment. Universal geriatric questionnaire was made for this research. To assess the presence of depression at respondents we used "The scale of geriatric depression".

RESULTS

The average age (±SD) was 75,4±6,2 years in the experimental group, while in the control group the average age was 74,9±5,6 years. In the experimental group there is significantly larger number of elderly persons that are neglected (p=0,001). Elderly respondents surrounded by loneliness are more depressive than elderly living in the family environment. Statistically geriatric depression is significantly connected with inability for everyday activities, with decreased result of cognitive abilities and indicated result of dementia (P=0.001).

CONCLUSION

Depression is an important mental health problem of the developed society, because it is still faintly discovered and by that insufficiently treated. Organizing approach to different aspects of geriatric health, doctors of the primary protection can improve care of their elderly patients.

The Frequency of Multifactorial Syndromes in Geriatrics of Tuzla Canton Population

Introduction:

There are four main multifactorial syndromes in geriatrics the so-called “4N”, which specifically occur at elderly patients. Listed syndromes often occur related, and they can be the cause and the result of many other syndromes at geriatric patients.

Objective:

determine the difference in the assessment of the level of immobility, instability, dependence, urinary incontinence (“4N”) in elderly groups.

Materials and methods:

The research included total 200 elderly respondents experimental group made of elderly persons (>65 years) living alone. Control group included elderly persons living in a family environment. Universal geriatric questionnaire was made for this research. For fast orientation the redone questionnaire was used for our conditions: examination in clinics for usual elderly problems “Short list for examination”. For the assessment of the mental abilities reduction at elderly we used “Short portable mental status questionnaire” (SPMSQ).

Results:

In total sample the research included 200 elderly respondents, 45% in experimental group and 55% in control group. The average age (±SD) was 75,4±6,2 years in the experimental group, while in the control group the average age was 74,9±5,6 years. We notice nearly equal distribution of falling risk according to groups (50%, 47%). In total sample there were 62% mobile, 22,5% limited mobility, and 4% immobile. Dependence frequency was more represented at examination group respondents (p=0,002). Dependence chances (OR) were 2,05 times larger (95 %CI=1,12-3,75) in examination group than in control group respondents. Frequency of urinary incontinence problem is significantly represented at all our respondents (42,2% v.s. 35%).

Conclusion:

Permanent gerontology and geriatrics training is needed both family medicine doctors and other experts in the field of elderly health protection and preventive health measures, pharmacotherapy, palliative care, especially about four main geriatrics syndromes at elderly.

Influence of Unemployment on Mental Health of the Working Age Population

Introduction:

Bosnia and Herzegovina has one of the highest unemployment rates in the Balkan region (43.2%), so unemployment is one of the most serious public concerns in our country.

Aim:

To analyze the influence of unemployment on mental health of the working age population who attend primary care center.

Material and Methods:

The study was carried out in the municipality of Bosanska Krupa, which has the highest unemployment rate in the Federation of Bosnia and Herzegovina (56%), and included 510 randomly selected working age patients (aged 23-65 years). We used the General Health Questionnaire-28 (GHQ-28) to evaluate mental health of the working age population.

Results:

There were significantly more women than men (53.5% vs. 46.5%; p=0.02). The mean age of participants was 51.04±12.84 years. The experimental group included 318 (62.35%) unemployed working age participants: 160 (50.3%) had been unemployed for more than 5 years and had had no work experience, while 158 (49.7%) unemployed participants had had a previous work experience of more than five years. The control group included 192 (37.65%) employed working age participants. Unemployment had a significant influence on mental health of the working age population. The unemployed participants had a significantly poorer mental health compared to the employed (p=0.0003). A predictor of impaired mental health was a job loss. A significantly greater mental health impairment occured in the group of unemployed participants with previous work experience of more than five years compared to the unemployed participants who had had no work experience (p=0.001) and employed (p=0.000).

Conclusion:

Unemployment has a negative impact and leads to impaired mental health of the working age population in Bosnia and Herzegovina. A job loss has a predictive role. It indicates that social and health policies must be developed in order to improve well-being of the working age population.

DISTRESS AND PTSD IN PATIENTS WITH CANCER: COHORT STUDY CASE

INTRODUCTION

embarrassed emotional experience may affect the ability to oncology patient effectively cope with cancer, symptoms and treatment. Distress extends a long period, from common, normal feelings of vulnerability, sadness and fears to problems of PTSD, depression, anxiety, panic, social isolation and the perception of spiritual crisis. The aim of the research is to determine the level of distress and PTSD in cancer patients.

PATIENTS AND METHODS

In a prospective, cohort study cases from 2011- 2014 were included patients with cancer who are treated under the supervision of his chosen family medicine doctor. Including a factor for the participation of patients in the study is that from the moment of diagnosis of malignant disease passed <12 months. The total sample was 174 of the planned 200 (response rate=87%). The subjects were divided into three groups. A key factor in the creation of the group was the time elapsed from the moment of acknowledgment and confirmation of the diagnosis: T1 <14 days, n=56 patients; T2>14 days-<6 months, n=79 patients; T3>6 months n=39 patients. To achieve the set goals of the research was used instruments of 3 questionnaires: Questionnaire on the clinical characteristics of patients with malignant disease, demographic and individual characteristics; questionnaire distress oncology patient-hospital scales of depression and anxiety, HADS scale (Hospital Anxiety and Depression Scale - HADS) and a rapid test for self-assessment of the symptoms of PTSD.

RESULTS

Age of patients was 54.63 ± 11:46 years, and the age of the respondents when they were diagnosed with cancer 54.34 ± 11.26 years. The prevalence of distress was a high 76% 82x higher than expected), and PTSD 55%. Predictors of burnout syndrome in cancer patients are all important determinants of malignant disease: the time elapsed since the diagnosis of the disease which determines the clinical status of malignant disease (β=0.280; P=0.001; 95% CI, 0742-2259), discovered metastases (β=0.304; P=0.001; 95% CI -2621 to 0978) and treatments (β=0.160; P=0.031, 95% CI 0050 to 1.060).

CONCLUSION

The problem of distress in cancer patients is widespread and has a high prevalence of 76% in our environment, while still absent intervention and treatment.

METABOLIC SYNDROME - THEORY AND PRACTICE

Introduction:

Due to sedentary lifestyles and excessive calorie intake, metabolic syndrome is becoming increasingly common health problem in the world, as well as in our country, and it is estimated to occur in 30% of the population of middle and older age. The metabolic syndrome is a combination of disorders that include: obesity, insulin resistance, glucose intolerance, impaired regulation of body fat and high blood pressure. Complications resulting from metabolic syndrome significantly reduces quality of patient’s life and represents a huge socio-economic burden. Metabolic syndrome therapy is directed to reduce all risk factors, and that means the change of lifestyle, which includes a reduction of body weight, physical activity, antiatherogenic diet and smoking cessation. Medical therapy is aimed to the individual risk factors.

Case report:

In case of our patient, despite the optimal standard therapy, including drugs for the regulation of LDL and HDL cholesterol and triglycerides, an intensive control of blood pressure and glucose, failure to implement the recommended treatment led to a myocardial infarction.

Conclusion:

The fundamental problem is not the lack of efficacy of available therapeutic measures, medications and procedures, but in insufficient implementation.

Atherogenic Dyslipidemia and Residual Vascular Risk in Practice of Family Doctor

Objective:

Timely recognition and optimal management of atherogenic dyslipidemia (AD) and residual vascular risk (RVR) in family medicine.

Background:

The global increase of the incidence of obesity is accompanied by an increase in the incidence of many metabolic and lipoprotein disorders, in particular AD, as an typical feature of obesity, metabolic syndrome, insulin resistance and diabetes type 2. AD is an important factor in cardio metabolic risk, and is characterized by a lipoprotein profile with low levels of high-density lipoprotein (HDL), high levels of triglycerides (TG) and high levels of low-density lipoprotein (LDL) cholesterol. Standard cardiometabolic risk assessment using the Framingham risk score and standard treatment with statins is usually sufficient, but not always that effective, because it does not reduce RVR that is attributed to elevated TG and reduced HDL cholesterol. RVR is subject to reduction through lifestyle changes or by pharmacological interventions. In some studies it was concluded that dietary interventions should aim to reduce the intake of calories, simple carbohydrates and saturated fats, with the goal of reaching cardiometabolic suitability, rather than weight reduction. Other studies have found that the reduction of carbohydrates in the diet or weight loss can alleviate AD changes, while changes in intake of total or saturated fat had no significant influence. In our presented case, a lifestyle change was advised as a suitable diet with reduced intake of carbohydrates and a moderate physical activity of walking for at least 180 minutes per week, with an recommendation for daily intake of calories alignment with the total daily (24-hour) energy expenditure (24-EE), depending on the degree of physical activity, type of food and the current health condition. Such lifestyle changes together with combined medical therapy with Statins, Fibrates and Omega-3 fatty acids, resulted in significant improvement in atherogenic lipid parameters.

Conclusion:

Unsuitable atherogenic nutrition and insufficient physical activity are the new risk factors characteristic for AD. Nutritional interventions such as diet with reduced intake of carbohydrates and calories, moderate physical activity, combined with pharmacotherapy can improve atherogenic dyslipidemic profile and lead to loss of weight. Although one gram of fat release twice more kilo calories compared to carbohydrates, carbohydrates seems to have a greater atherogenic potential, which should be explored in future.

Screening for depression patients in family medicine

GOAL

The aims are to establish the prevalence of newfound, unidentified cases of depressive disorder by screening with the Becks Depression scale; To establish a comparative relationship with self-identified cases of depression in the patients in the family medicine; To assess the significance of the BDI in screening practice of family medicine.

PATIENTS AND METHODS

A prospective study was conducted anonymously by Beck's Depression scale (Beck Depression Questionnaire org.-BDI) and specially created short questionnaire. The study included 250 randomly selected patients (20-60 years), users of services in family medicine in "Dom Zdravlja" Zenica, and the final number of respondents with included in the study was 126 (51 male, 75 female; response or response rate 50.4%). Exclusion factor was previously diagnosed and treated mental disorder. Participation was voluntary and respondents acknowledge the validity of completing the questionnaire. BDI consists of 21 items. Answers to questions about symptoms were ranked according to the Likert type scale responses from 0-4 (from irrelevant to very much). Respondents expressed themselves on personal perception of depression, whether are or not depressed.

RESULTS

Depression was observed in 48% of patients compared to 31% in self estimate depression analyzed the questionnaires. The negative trend in the misrecognition of depression is -17% (48:31). Depression was significantly more frequent in unemployed compared to employed respondents (p = 0.001). The leading symptom in both sexes is the perception of lost hope (59% of cases).

CONCLUSION

All respondents in family medicine care in Zenica showed a high percentage of newly detected (17%) patients with previously unrecognized depression. BDI is a really simple and effective screening tool for the detection and identification of persons with symptoms of depression.

Assessment of osteoporosis in family medicine obtained by ultrasound densitometry

Introduction:

Osteoporosis is a disease characterized by a decrease in bone mineral density, making bones become less rigid, and therefore susceptible to fractures, either spontaneously or with force, which is lower than otherwise needed for healthy bones fractured. Nearly 10% of the world population and 30% of women after menopause, suffer from osteoporosis. Clinical assessment of osteoporosis in family medicine is key to prevention, early detection and treatment of osteoporosis.

Objective:

To investigate the possibility of early detection and diagnosis of osteoporosis by analyzing the risk factors for osteoporosis and to compare the results with the parameters obtained by ultrasound densitometry of calcaneus, and determine the relationship of calcaneus densitometry with DXA findings, as the gold standard for the diagnosis of osteoporosis.

Patients and methods:

The study included all patients of Family Medicine Kalesija Team 1, aged 50 years and over, a total of 711 patients, of whom 425 were women and 286 men. In all patients we assessed the existence of the following risk factors for osteoporosis: Constitutional: gender, age, weight, constitution, menarche and menopause, loss of height and stooped posture; Living habits: smoking, alcohol consumption, coffee, physical activity, and medications: long-term use corticosteroids, anticonvulsants, antacids, thyroid hormones. Comorbidity: history of fractures, hyperthyroidism, COPD, Chussing’s disease, diabetes. In the group of high-risk patients determined by the clinical assessment, quantitative ultrasound densitometry screening was carried out. Monitoring parameters derived with densitometry: the value of T-score, BUA (Broadband Ultrasound Attenuation), SOS (Speed of Sound), QUI (Quantitative Ultrasound Index). To confirm the diagnosis of osteoporosis, in all patients with positive findings using ultrasound densitometry (T score lower than 2.5), another densitometry was performed by standard DXA method.

Results:

The incidence of osteoporosis was 96% in women and 4% in men. Differences in prevalence between men and women are statistically significant. People with and without osteoporosis significantly differ in gender, age, weight, constitution (BMI-Body Mass Index). The parameters that distinguish those with and without osteoporosis: age, weight, height, BMI, gender. Out of the total of 711 patients, in 11% of patients the clinical evaluation showed the existence of high risk of osteoporosis. In 9.8% patients, the values were determined by ultrasound densitometry, where T score was lower than 2.5 what induces a high risk of fractures, and for 8.8% patients the DXA confirmed the diagnosis of osteoporosis.

Conclusion:

Clinical assessment of osteoporosis in the family medicine clinic performed in timely and focused history of risk factors for osteoporosis, with additional findings from quantitative densitometry of calcaneus, was sufficient for the early detection and screening of patients with high risk for osteoporosis. With good clinical assessment of osteoporosis it will be necessary to send all patients who enter the high-risk group to undergo ultrasound densitometry of calcaneus, to make it possible to determine the risk of bone fractures and osteoporosis in time, and then refer patients for further processing and DXA measurements according to the guidelines by the WHO.

Prevention of diabetes in family medicine

Conflict of interest: none declared.

Obesity as a risk factor for artherial hypertension

Introduction:

Today’s lifestyle is characterized by increased intake of calories with reduced physical activity, which benefits a real epidemic of obesity in the population. The increase in the prevalence of hypertension in the population follows a significant increase in the prevalence of obesity. Parallel to the trend of increasing the number of older population with increased cardiovascular disease.

The aim:

The aim of our study was to determine the value of body mass index and determine the correlation of obesity and arterial hypertension.

Material and methods:

The study was conducted in family medicine Clinic of the Primary Health Care Center Zenica. Out of 600 patients of both sexes aged over 18 years, randomly are formed groups of 188 patients with hypertension and 189 patients without hypertension of the same gender and same age. The study included patients with primary or essential hypertension, and excluded patients with secondary hypertension, hypertension due to renal disease, pheochromocytoma, coarctation of the aorta, as a result of taking oral contraceptives, corticosteroids, and cocaine. We used the method of anthropometric measurements (body weight, body height from which is calculated the body mass index) measurement of blood pressure with the statistical data processing at the significance level of p <0.05.

Results and discussion:

The increased value of BMI in the sample with hypertension are present in much higher percentage (87.23%), compared to the tested sample without hypertension (60.10%). In patients with hypertension, the highest percentage (51.06%) of the respondents has the BMI in range between 25 and 30, then BMI in the range between 30 and 35 (25%). BMI of 35-40 have 6.38% of patients, and 3.72 patients BMI over 40. In patients without hypertension was significantly smaller percentage of respondents in the previous group (39.15%) with a BMI in the range 25-30, then BMI in the range between 30 and 35 (18.51%). BMI of 35-40 had 3.17% of respondents, and 1.05% of patients had BMI over 40. Correlation between groups of patients with and without hypertension compared to the value of BMI indicate the presence of strong positive correlation (Rho = 0.737). Correlation between groups of subjects with hypertension and without hypertension compared to triglycerides was statistically significant (Rho = 0.123).

Stress at work and burnout syndrome in hospital doctors

INTRODUCTION

Reforming the health care system in Bosnia and Herzegovina began in 1998 through various forms of amendments to existing health plans and programs. There has been the introduction of new technologies, flow of new information from the profession, excessive demands on employers, financial constraints, etc. The hospital doctors in the workplace suffer from too many stressors. Burnout syndrome at work is a form of chronic stress reactions to stressors, and develops as a result of inefficient coping with and solving every day, demanding stressful situations related to professional duties.

GOAL

The goals of this study were: to identify the specific stressors of high intensity in the hospital physicians work environment, to discover whether and how certain stressors can affect the appearance of burnout syndrome at work in a hospital physician, to determine whether certain individual factors influence the occurrence of burnout syndrome at work.

METHODS AND SUBJECTS

We made the intersection study involving the use of questionnaires, in order to assess the stressors and burnout syndrome in hospital among doctors of the University Clinical Center in Tuzla.

RESULTS

The study comprised 34.7% hospital doctors (specialists and doctors on specialization) of a total 423 employees in various departments of the University Hospital Clinical Center in Tuzla. High level of emotional exhaustion was recorded in 37.4%, a high level of depersonalization in 45.6%, and a low level in perceptions of personal accomplishments in 50.3% of respondents.

CONCLUSIONS

Continuous exposure to stressors at the workplace, such as work at shifts, excessive workload, poor communication with superiors, and lack of continuous education of hospital physicians can lead to mental and physical exhaustion, professional burnout. Management of the University Clinical Center Tuzla should in the future address the structural reorganization of workplaces, as well as ongoing prevention interventions in other domains of risk factors or stressors, that this study identified.

Polypharmacy and decreased cognitive abilities in elderly patients

GOAL

To estimate the prevalence of poly pharmacy and poly pharmacy effect on decline in cognitive abilities of randomly selected group of people over 65.

METHODOLOGY

A preliminary pilot study was based on the results of other researchers. 54 patients over 65 were randomly interviewed. Poly pharmacy was defined as using 23 drugs. "A short portable mental status questionnaire" was used in estimating decline of cognitive abilities.

RESULTS

According to the study results it was concluded that prevalence of poly pharmacy by the elderly is significant--48.1%. Most present drugs are the ones treating cardiovascular disease, anti diabetic, anti-inflammatory drugs, long acting benzodiazepines, antihistamines. Of the total respondents 33.3% of them live alone and do not have adequate supervision. We have found that poly pharmacy resulted in decline of cognitive abilities in 23 of 54 patients tested in rapid mental status check.

CONCLUSION

It is necessary to conduct future research on this issue.

The effect of loneliness on malnutrition in elderly population

INTRODUCTION

The clinical and epidemiological data show that proper nutrition plays an important role in maintaining health and combating the danger of developing some chronic diseases in the elderly population. Nutrition is an important factor in many physiological and pathological changes that accompany the aging process. More than 50% of elderly patients are suffering from malnutrition which is information that concerns. Due to various factors, older people are potentially vulnerable groups at risk of malnutrition. Loneliness, isolation from society and neglect of parents by children is a big problem to many people in old age.

OBJECTIVE

To determine differences in nutritional status of elderly people living alone compared to those who live in family surroundings.

SUBJECT AND METHODS

The study was conducted in the municipality of Tuzla in 2009-2010, in outpatient family medicine Simin Han. The survey covered a total of 200 elderly subjects (age >65 years). Subject group consisted of 45% of people living alone, and 55% control group consisted of elderly patients who live in traditional family surroundings. Questionnaires used in this study are General geriatric assessment questionnaire and Mini nutritional status.

RESULTS

The average age (+/- SD) was 75.4 +/- 6.2 years in subject group, while the same in the control group was 74.9 +/- 5.6 years. In subject group significantly more patients are on the verge of poverty. There are significant differences in the classification of financial status, according to the groups (p = 0.043). Members of subject groups have significantly lower BMI categories (p = 0.03) compared with the control group. In our study, people who live alone are at increased risk of malnutrition (p = 0030), have reduced the number of daily meals, significantly lower daily intake of protein, fruits and vegetables in the diet in relation to persons living in a family environment. Significantly more patients with loss of appetite live alone. According to the existence of self-reported food problems significantly more people are in subject group. There is a difference value score "Small assessment of nutrition" between the two groups (p = 0.001). About 22% of the total number of respondents said they have not so good health status compared to others.

CONCLUSIONS

Loneliness is a significant predictor of anorexia nervosa, the risk of malnutrition and malnutrition. Results indicate that it is necessary to work on improving the status and protection of elderly.

Influence of lifestyle on overweight and obesity in school-age children

INTRODUCTION

Special attention needs to be given to resolution of obesity problem among children because many studies indicate that majority of persons that have suffered from obesity during their child age still have the same problems when they become adults. Incorrect nutritional habits cause health problems at later age. The purpose of this study is to determine the frequency of overweight and obesity occurrence among school-age children, as well as risk factors that certainly lead to obesity.

METHODS

This research was conducted on sample of 530 pupils from one elementary school from suburban area. Assessed children were from seven to fourteen years old. Anthropometric measurements were taken and questionnaires and general medical examinations followed with the statistical processing of collected data.

RESULTS

Based on the Body Mass Index (BMI) considering age and gender of examined subjects we have found that 14.7% subjects were overweight and 7.3% of children were obese. Also, we have determined that children often use food that is identified as risk factor for obesity. Overweight and obesity are directly related to amount of time spent in front of TV set or personal computer (p = 0.01). Children that were overweight in 57.1% cases would prefer to change their nutritional habits and 68.4% of obese children would like to do so as well. Children that were obese, in high percent would like to change habits regarding their physical activity (57.9% of them) and overweight children in 33.8% cases.

CONCLUSION

It is necessary to encourage young people to develop healthy nutritional habits, to promote physical activity and sports, and definitely to strongly advice against the sedentary lifestyle. It is crucial to educate parents on healthy nutritional habits and physical activity because they have the strongest influence on their children. Also, effort needs to be taken in schools by increasing number of physical education classes and to provide healthy food in school canteens in order to ensure improvement of physical activity and healthy nutritional habits among children.