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Grubić Rotkvić P, Ćelap I, Bralić Lang V, Jug J, Snagić A, Huljev Šipoš I, Cigrovski Berković M. Impact of SGLT2 inhibitors on the mechanisms of myocardial dysfunction in type 2 diabetes: A prospective non-randomized observational study in patients with type 2 diabetes mellitus without overt heart disease. J Diabetes Complications 2023; 37:108541. [PMID: 37329705 DOI: 10.1016/j.jdiacomp.2023.108541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/29/2023] [Accepted: 06/07/2023] [Indexed: 06/19/2023]
Abstract
AIMS This prospective observational study evaluated the possible mechanisms of action of SGLT2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) without overt heart disease. METHODS The study was designed to verify whether SGLT2i impact biomarkers of: myocardial stress-NT-proBNP, inflammation-high sensitivity C-reactive protein, oxidative stress -myeloperoxidase, functional and structural echocardiographic parameters, in patients with T2DM on metformin (heart failure stages A and B) who needed treatment intensification with a second antidiabetic agent. The patients were divided in two groups - the ones planned to receive SGLT2i or DPP-4 inhibitor (except saxagliptin). At baseline, and after six months of therapy, 64 patients underwent blood analysis, physical and echocardiography examination. RESULTS There were no significant differences between the two groups in terms of biomarkers of myocyte and oxidative stress, inflammation and blood pressure. Body mass index, triglycerides, aspartate aminotransferase, uric acid, E/E', deceleration time and systolic pressure in the pulmonary artery significantly decreased, while stroke volume, indexed stroke volume, high-density lipoprotein, hematocrit and hemoglobin significantly increased in the group on SGLT2i. CONCLUSIONS According to the results, SGLT2i mechanisms of action comprise rapid changes in body composition and metabolic parameters, reduced cardiac load and improvement in diastolic and systolic parameters.
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Affiliation(s)
- Petra Grubić Rotkvić
- The Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Croatia.
| | - Ivana Ćelap
- Department of Clinical Chemistry, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia; Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Valerija Bralić Lang
- Department of Family Medicine, Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Croatia
| | - Juraj Jug
- Health Center Zagreb-West, Zagreb, Croatia
| | - Andrea Snagić
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
| | - Ivana Huljev Šipoš
- Department of Internal Medicine, University Hospital Dubrava, Zagreb, Croatia
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Jug J, Delalić Đ, Bralić Lang V, Bulum T, Prkačin I. Prediabetes, Non-Dipping Profile and Hypertension—A Recipe for Increased Arterial Stiffness. Biomedicines 2023; 11:biomedicines11041065. [PMID: 37189683 DOI: 10.3390/biomedicines11041065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Pulse wave velocity (PWV) is a known predictor of target organ damage, cardiovascular disease and overall mortality. The aim of this study was to compare the PWV values in subjects with prediabetes, a non-dipper profile and arterial hypertension with their values in healthy subjects. Methods: A total of 301 subjects, aged 40–70 years, without diabetes mellitus were included in this cross-sectional study (150 with prediabetes). They underwent a 24 h ambulatory blood pressure monitoring (ABPM). Subjects were divided into three hypertension groups (A = healthy, B = controlled hypertension, C = uncontrolled hypertension). Dipping status was determined according to ABPM results, and PWV was measured by an oscillometric device. Prediabetes was defined as having 2 separate fasting plasma glucose (FPG) measurements between 5.6 and 6.9 mmol/L. Results: The highest PWV values were found in group C (9.60 ± 1.34 vs. 8.46 ± 1.01 in group B vs. 7.79 ± 1.10 in group A; p < 0.001), in subjects with prediabetes (8.98 ± 1.31 m/s vs. 8.26 ± 1.22 m/s; p < 0.001) and in prediabetic non-dippers among age groups (p = 0.05). In the multivariate regression model age, blood pressure, nocturnal indices and FPG were shown as independent predictors of PWV values. Conclusion: Significantly higher PWV values were found in subjects with prediabetes and non-dipping profiles in all three examined hypertension groups.
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Affiliation(s)
- Juraj Jug
- Health Center Zagreb-West, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Điđi Delalić
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Valerija Bralić Lang
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Family medicine practice Valerija Bralić Lang, 10000 Zagreb, Croatia
| | - Tomislav Bulum
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, 10000 Zagreb, Croatia
| | - Ingrid Prkačin
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Internal E.R., Merkur University Hospital, 10000 Zagreb, Croatia
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Vellinga A, Luke-Currier A, Garzón-Orjuela N, Aabenhus R, Anastasaki M, Balan A, Böhmer F, Lang VB, Chlabicz S, Coenen S, García-Sangenís A, Kowalczyk A, Malania L, Tomacinschii A, van der Linde SR, Bongard E, Butler CC, Goossens H, van der Velden AW. Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries. Antibiotics (Basel) 2023; 12:antibiotics12030572. [PMID: 36978439 PMCID: PMC10044809 DOI: 10.3390/antibiotics12030572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.
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Affiliation(s)
- Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Addiena Luke-Currier
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Rune Aabenhus
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marilena Anastasaki
- Department of Social Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anca Balan
- Balan Medfam Srl, 400064 Cluj Napoca, Romania
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany
| | - Valerija Bralić Lang
- Department of Family Medicine, “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, 10020 Zagreb, Croatia
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Samuel Coenen
- Department of Family Medicine & Population Health, University of Antwerp, 2610 Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 08007 Barcelona, Spain
- Centro de investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, 92-213 Lodz, Poland
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, 0190 Tbilisi, Georgia
| | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine and Pharmacy “Nicolae Testemițanu”, MD-2004 Chişinǎu, Moldova
| | - Sanne R. van der Linde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
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Bralić Lang V, Baretić M. Continuous glucose monitoring in primary care practice: Beside numbers. Prim Care Diabetes 2021; 15:1113. [PMID: 34593346 DOI: 10.1016/j.pcd.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Valerija Bralić Lang
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - Maja Baretić
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
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Bainrauch A, Šisl D, Markotić A, Ostojić A, Gašparov S, Bralić Lang V, Kovačić N, Grčević D, Mrzljak A, Kelava T. NOTCH3 rs1043996 Polymorphism Is Associated with the Occurrence of Alcoholic Liver Cirrhosis Independently of PNPLA3 and TM6SF2 Polymorphisms. J Clin Med 2021; 10:jcm10194621. [PMID: 34640639 PMCID: PMC8509578 DOI: 10.3390/jcm10194621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/22/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023] Open
Abstract
Alcoholic liver cirrhosis (ALC) is the most common indication for liver transplantation (LT) in Croatia and presents a risk factor for the development of hepatocellular carcinoma (HCC). However, genetic susceptibility has not yet been systematically studied. We aimed to investigate the contribution of the risk polymorphisms PNPLA3 rs738409, EGF rs4444903, TM6SF2 rs58542926, MTHFR rs1801133, previously identified in other populations and, additionally, the contribution of Notch-related polymorphisms (NOTCH1 rs3124591, NOTCH3 rs1043996 and rs1044116, NOTCH4 rs422951). The study included 401 patients. The ALC group consisted of 260 LT candidates, 128 of whom had histopathologically confirmed HCC, and 132 of whom were without HCC. The control group included 141 patients without liver disease. Genotyping was performed by PCR using Taqman assays. The patients' susceptibility to ALC was significantly associated with PNPLA3 rs738409, TM6SF2 rs58542926, and NOTCH3 rs1043996 polymorphisms. These polymorphisms remained significantly associated with ALC occurrence in a logistic regression model, even after additional model adjustment for sex and age. Cirrhotic patients with the PNPLA3 GG genotype demonstrated higher activity of ALT aminotransferases than patients with CC or CG genotypes. The susceptibility to the development of HCC in ALC was significantly associated with PNPLA3 rs738409 and EGF rs4444903 polymorphisms, and logistic regression confirmed these polymorphisms as independent predictors.
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Affiliation(s)
- Ana Bainrauch
- Department of Internal Medicine, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Dino Šisl
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, 10000 Zagreb, Croatia; (D.Š.); (N.K.); (D.G.)
- Department of Physiology and Immunology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Antonio Markotić
- Department of Physiology, School of Medicine, University of Mostar, 88000 Mostar, Bosnia and Herzegovina;
- Center for Clinical Pharmacology, University Clinical Hospital Mostar, 88000 Mostar, Bosnia and Herzegovina
| | - Ana Ostojić
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, University of Zagreb, 10000 Zagreb, Croatia;
| | - Slavko Gašparov
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
- Department of Pathology and Cytology, Merkur University Hospital, 10000 Zagreb, Croatia
| | | | - Nataša Kovačić
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, 10000 Zagreb, Croatia; (D.Š.); (N.K.); (D.G.)
- Department of Anatomy, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Danka Grčević
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, 10000 Zagreb, Croatia; (D.Š.); (N.K.); (D.G.)
- Department of Physiology and Immunology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, University of Zagreb, 10000 Zagreb, Croatia;
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
- Correspondence: (A.M.); (T.K.); Tel.: +385-1-238-8888 (A.M.); +385-1-456-6945 (T.K.)
| | - Tomislav Kelava
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, 10000 Zagreb, Croatia; (D.Š.); (N.K.); (D.G.)
- Department of Physiology and Immunology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Correspondence: (A.M.); (T.K.); Tel.: +385-1-238-8888 (A.M.); +385-1-456-6945 (T.K.)
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Vlah Tomičević S, Lang VB. Psychological outcomes amongst family medicine healthcare professionals during COVID-19 outbreak: A cross-sectional study in Croatia. Eur J Gen Pract 2021; 27:184-190. [PMID: 34328376 PMCID: PMC8330718 DOI: 10.1080/13814788.2021.1954154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Healthcare professionals (HCPs) in family medicine (FM) in Croatia work in a demanding environment caused by the SARS-CoV-2 pandemic. Besides particular circumstances in healthcare, an unknown virus, social distancing, and homeschooling, the capital was hit with the earthquake during the lockdown. Objectives To assess the prevalence of stress, anxiety, depression, posttraumatic stress disorder (PTSD) and the influence of demographic characteristics, professional differences, medical history, and specific stressors on the psychological outcomes. Methods A cross-sectional study with the online questionnaire containing the Depression, Anxiety and Stress Scale (DASS-21) and the Impact of Event Scale-Revised (IES-R) was conducted from 1st to 15 May 2020 in FM. Results HCPs (534, 35% response rate), predominantly female (84.5%), participated in the research. High prevalence of stress (30.9%), anxiety (33.1%), depression (30.7%), and PTSD (33.0%) were found. Female participants had higher results in the anxiety subscale of DASS-21 and IES-R scores. Pre-existing conditions were associated with higher levels of stress, anxiety, depression, and PTSD. The IES-R score for PTSD showed borderline correlation (p = 0.053) with working in regions with the highest incidence of COVID-19. Having schoolchildren made a difference on a stress subscale in DASS-21 (p < 0.043), but the earthquake did not have an impact. Conclusion Family physicians and nurses in FM in Croatia are under a great mental load during the COVID-19 outbreak. Results suggest that HCPs of the female sex, with pre-existing chronic conditions, work in regions with a high incidence of SARS-CoV-2 or have schoolchildren at greater risk of the poor psychological outcome.
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Affiliation(s)
| | - Valerija Bralić Lang
- Private Family Physician Office, Department of Family Medicine, Zagreb University School of Medicine, School of Public Health 'Andrija Štampar', Zagreb, Croatia
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Zavidić T, Bralić Lang V. Prevalence and Characteristics of Insomnia Problems Among Adults in Central Istria. Arch Psychiatry Res 2021. [DOI: 10.20471/dec.2021.57.02.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: We sought to examine the frequency and characteristics of insomnia among adults in central Istria, as well as to analyse sociodemographic characteristics and explore whether there is an association between symptoms of insomnia and sociodemographic parameters. Methods: This research included 685 participants that visited family medicine offices (FMOs) in Central Istria from September till December 2016. Mean age of the sample was 52.73 ± 17.93 years. Participants were randomly selected and interviewed and all gave their informed consent. Participants with sleep disturbances and insomnia lasting one year prior to study enrolment were assessed using the questionnaire designed for the study; along with gathering of sociodemographic data. Results: More than half of the participants had insomnia, 30% of them each night or several times a week, mostly older participants and women. Regardless of the frequency of insomnia symptoms, all participants reported great impairment in all areas of daytime functioning. The most frequent incidence of insomnia was associated with more frequent sleep apnoea and less frequent bruxism. Frequent night awakenings and restless legs syndrome were not related to a greater incidence of insomnia. Conclusion: Insomnia is a common problem among patients treated in primary care. Family physicians are therefore in an ideal position to identify, evaluate and treat insomnia. The high prevalence of insomnia highlights the need for a more adequate recognition and treatment of this psychiatric illness.
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Marjanović M, Bralić Lang V, Đido V. Total and partial clinical inertia of general physicians with type 2 diabetes mellitus patients in Central Bosnia Canton. Prim Care Diabetes 2020; 14:622-627. [PMID: 32173293 DOI: 10.1016/j.pcd.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The goal of this study was to determine the frequency and predictive factors of partial (PCI) and total clinical inertia (TCI) of general physicians (GPs) in Central Bosnia Canton in the care of type 2 diabetes mellitus patients. MATERIAL AND METHODS A longitudinal study was conducted with a prospective data collection. Total of 541 subjects of over 40 years of age with type 2 diabetes mellitus of both genders were included in the study. Total of 532 subjects completed the study. Questionnaires for physicians and patients and the Perceived Stress Scale were used, as well as anthropometric measurements and measurements of the glucose level in plasma, HbA1c, triglycerides, AST, ALT, creatinine and eGFR, which were examined on the day of study entry, after 6 months and after one year. RESULTS TCI was 5.8% and PCI was 25.6%. Patients with poorly regulated glycaemia and elevated triglyceride levels had the highest probability of PCI and TCI. Patients with an unaccomplished targeted level of blood pressure were more likely to experience PCI. Patients treated by both an internist and a general physician were more likely to have TCI as compared to patients treated only by an internist. CONCLUSIONS Patients with poor glycemic control experience PCI and TCI more often. In our study, referring to a diabetologist was observed as a non-inert procedure, which resulted in lower PCI and TCI, compared to studies where clinical inertia was defined only as non-intensification of medication therapy.
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Affiliation(s)
- Marijan Marjanović
- Faculty of Health Care, University "Vitez "in Vitez, Bosnia and Herzegovina.
| | - Valerija Bralić Lang
- Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Vedran Đido
- Faculty of Health Studies, University of Sarajevo, Bosnia and Herzegovina
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Baretić M, Lang VB. Professional Continuous Glucose Monitoring Reveals Nocturnal Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease Treated with Oral Antidiabetics. Korean J Fam Med 2020; 42:185-186. [PMID: 32526818 PMCID: PMC8010433 DOI: 10.4082/kjfm.19.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Maja Baretić
- Department of Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Valerija Bralić Lang
- Private Family Physician Office Affiliated to University of Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
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Bralić Lang V, Baretić M. Letter to the Editor Regarding: Continuous Glucose Monitoring in Type 2 Diabetes Mellitus Patients in Primary Care. Adv Ther 2020; 37:1276-1278. [PMID: 31997240 PMCID: PMC7089726 DOI: 10.1007/s12325-020-01234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Valerija Bralić Lang
- Private Family Physician Office Affiliated to the Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - Maja Baretić
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
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Marjanović M, Vrdoljak D, Bralić Lang V, Polašek O, Đido V, Kašćel Fišić M, Mađar Šimić I, Dodig D, Radoš Perić M. Clinical Inertia in Type 2 Diabetes Patients in Primary Health Care Clinics in Central Bosnia. Med Sci Monit 2018; 24:8141-8149. [PMID: 30421728 PMCID: PMC6243831 DOI: 10.12659/msm.911286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The goal of this research was to determine the frequency of clinical inertia of general practice physicians in the region of Central Bosnia in healthcare for type 2 diabetes patients, to analyze characteristics of patients and physicians, as well as glucose regulation during clinical inertia, and, on the basis of these indicators, give recommendations for reducing clinical inertia. MATERIAL AND METHODS This study included 29 doctors, family physicians, or general practitioners, who collected data in a total sample of 541 type 2 diabetes mellitus patients from July to November 2017. The research was conducted using 2 questionnaires. The glucose concentration in plasma and the percentage of glycosylated hemoglobin (HbA1c) were determined. Concertation of cholesterol, triglycerides, AST, and ALT were also measured. After the collection, new data were processed and the degree of clinical inertia was determined. RESULTS Levels of HbA1c ranged from 4.3% to 13.0%, and 38.4% of all patients had HbA1c level higher than 7.5%, while 8.3% of them had HbA1c level 9.0% or higher. Clinical inertia in our research was 12.6% out of all patients and 48.2% were referred to a specialist by their doctor. CONCLUSIONS For better regulation of glycemia and reduction of clinical inertia with type 2 diabetes patients, more specialized training is needed for selected physicians. Strengthening of primary healthcare and encouraging doctors to perform procedures can contribute to better outcomes of treatment, lower clinical inertia, and better education of patients.
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Affiliation(s)
- Marijan Marjanović
- Faculty of Health Care, University "Vitez", Vitez, Bosnia and Herzegovina
| | - Davorka Vrdoljak
- Department of Family Medicine, University of Split School of Medicine, Split, Croatia
| | - Valerija Bralić Lang
- Private Family Physician Office Affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Ozren Polašek
- Department of Global Health, University of Split School of Medicine, Split, Croatia
| | - Vedran Đido
- Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Marinka Kašćel Fišić
- Department of Internal Medicine, Health Centre Novi Travnik, Novi Travnik, Bosnia and Herzegovina
| | - Ivanka Mađar Šimić
- Department of Surgery, Health Centre Novi Travnik, Novi Travnik, Bosnia and Herzegovina
| | - Danijela Dodig
- Department of Family Medicine, Health Centre Novi Travnik, Novi Travnik, Bosnia and Herzegovina
| | - Marina Radoš Perić
- Department of Family Medicine, Health Centre Novi Travnik, Novi Travnik, Bosnia and Herzegovina
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Bralić Lang V, Bergman Marković B, Vrdoljak D. The association of lifestyle and stress with poor glycemic control in patients with diabetes mellitus type 2: a Croatian nationwide primary care cross-sectional study. Croat Med J 2016; 56:357-65. [PMID: 26321029 PMCID: PMC4576750 DOI: 10.3325/cmj.2015.56.357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To assess lifestyle habits and self-reported stress levels among type 2 diabetes mellitus (T2DM) patients and their association with hemoglobin A1c (HbA1c) in general practitioners' (GP) offices in Croatia. METHODS 449 GPs from all Croatian regions from 2008 to 2010 consecutively recruited up to 20-25 participants diagnosed with T2DM at least 3 years prior to the study, aged ≥40 years, and scheduled for diabetes control check-ups. The recruitment period lasted six months. Lifestyle habits and self-reported stress were assessed using the questionnaire from the Croatian Adult Health Survey. RESULTS The study included 10285 patients with T2DM with mean (±standard deviation) age of 65.7±10.05 years (48.1% men). Mean HbA1c level was 7.57±1.58%. 79% of participants reported insufficient physical activity, 24% reported inappropriate dietary patterns, 56% reported current alcohol consumption, 19% were current smokers, and 85% reported at least medium level of stress. Multivariate analysis showed that having received advice to stop drinking alcohol, inadequate physical activity, consumption of milk and dairy products, adding extra salt, and high level of stress were significantly associated with increased HbA1c (P < 0.05). CONCLUSION Poor glycemic control was more frequent in patients who had several "unhealthy" lifestyle habits. These results suggest that diabetes patients in Croatia require more specific recommendations on diet, smoking cessation, exercise, and stress control.
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Affiliation(s)
- Valerija Bralić Lang
- Valerija Bralić Lang, Private General Practitioner's Office affiliated to University of Zagreb, School of Medicine, Zvonigradska 9, 10000 Zagreb, Croatia,
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Bralić Lang V, Bergman Marković B. Prevalence of comorbidity in primary care patients with type 2 diabetes and its association with elevated HbA1c: A cross-sectional study in Croatia. Scand J Prim Health Care 2016; 34:66-72. [PMID: 26853192 PMCID: PMC4911025 DOI: 10.3109/02813432.2015.1132886] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To the authors' knowledge, there are few valid data that describe the prevalence of comorbidity in type 2 diabetes mellitus (T2DM) patients seen in family practice. This study aimed to investigate the prevalence of comorbidities and their association with elevated (≥ 7.0%) haemoglobin A1c (HbA1c) using a large sample of T2DM patients from primary care practices. DESIGN A cross-sectional study in which multivariate logistic regression was applied to explore the association of comorbidities with elevated HbA1c. SETTING Primary care practices in Croatia. SUBJECTS Altogether, 10 264 patients with diabetes in 449 practices. MAIN OUTCOME MEASURES Comorbidities and elevated HbA1c. RESULTS In total 7979 (77.7%) participants had comorbidity. The mean number of comorbidities was 1.6 (SD 1.28). Diseases of the circulatory system were the most common (7157, 69.7%), followed by endocrine and metabolic diseases (3093, 30.1%), and diseases of the musculoskeletal system and connective tissue (1437, 14.0%). After adjustment for age and sex, the number of comorbidities was significantly associated with HbA1c. The higher the number of comorbidities, the lower the HbA1c. The prevalence of physicians' inertia was statistically significantly and negatively associated with the number of comorbidities (Mann-Whitney U test, Z = -12.34; p < 0.001; r = -0.12). CONCLUSION There is a high prevalence of comorbidity among T2DM patients in primary care. A negative association of number of comorbidities and HbA1c is probably moderated by physicians' inertia in treatment of T2DM strictly according to guidelines. KEY POINTS There is a high prevalence of comorbidity among T2DM patients in primary care. Patients with breast cancer, obese patients, and those with dyslipidaemia and ischaemic heart disease were more likely to have increased HbA1c. The higher the number of comorbidities, the lower the HbA1c.
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Affiliation(s)
- Valerija Bralić Lang
- Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
- CONTACT Valerija Bralić Lang Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zvonigradska 9, 10000 Zagreb, Croatia
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Abstract
Background Many patients with diabetes do not achieve target values. One of the reasons for this is clinical inertia. The correct explanation of clinical inertia requires a conjunction of patient with physician and health care system factors. Our aim was to determine the rate of clinical inertia in treating diabetes in primary care and association of patient, physician, and health care setting factors with clinical inertia. Material/Methods This was a national, multicenter, observational, cross-sectional study in primary care in Croatia. Each family physician (FP) provided professional data and collected clinical data on 15–25 type 2 diabetes (T2DM) patients. Clinical inertia was defined as a consultation in which treatment change based on glycated hemoglobin (HbA1c) levels was indicated but did not occur. Results A total of 449 FPs (response rate 89.8%) collected data on 10275 patients. Mean clinical inertia per FP was 55.6% (SD ±26.17) of consultations. All of the FPs were clinically inert with some patients, and 9% of the FPs were clinically inert with all patients. The main factors associated with clinical inertia were: higher percentage of HbA1c, oral anti-diabetic drug initiated by diabetologist, increased postprandial glycemia and total cholesterol, physical inactivity of patient, and administration of drugs other than oral antidiabetics. Conclusions Clinical inertia in treating patients with T2DM is a serious problem. Patients with worse glycemic control and those whose therapy was initiated by a diabetologist experience more clinical inertia. More research on causes of clinical inertia in treating patients with T2DM should be conducted to help achieve more effective diabetes control.
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Affiliation(s)
- Valerija Bralić Lang
- Private Family Physician Office affiliated to University of Zagreb, School of Medicine, Zagreb, Croatia
| | | | - Ksenija Kranjčević
- General Practice Office, Zagreb-Zapad Health Care Center, Zagreb, Croatia
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Lang VB, Langguth P, Ottiger C, Wunderli-Allenspach H, Rognan D, Rothen-Rutishauser B, Perriard JC, Lang S, Biber J, Merkle HP. Structure-permeation relations of met-enkephalin peptide analogues on absorption and secretion mechanisms in Caco-2 monolayers. J Pharm Sci 1997; 86:846-53. [PMID: 9232527 DOI: 10.1021/js960387x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Due to the low effective permeabilities of peptides at many absorption sites, their structure-permeation relations are of high interest. In this work structure-permeation relations of Met-enkephalin analogues are presented using confluent Caco-2 cells as an in vitro permeation model. Four model peptides (Met-enkephalin, [D-Ala2]Met-enkephalin, [D-Ala2]Met-enkephalinamide, and metkephamid) were tested in terms of permeability, lipophilicity, charge, and molecular size. Permeability coefficients (P(eff)) across Caco-2 cells were low, 3.3 x 10(-8) to 9.5 x 10(-8) cm s-1, and were similar to typical paracellular markers. No correlation of permeability and the log(apparent octanol/buffer partition coefficient) was observed. A 40-fold increase of the permeability of metkephamid in the presence of 10 mM EDTA suggested a significant contribution of paracellular transport. Independent support for this conclusion was obtained by visualizing the pathway of the fluorescein isocyanate isomer I 1-metkephamid by confocal laser scanning microscopy (CLSM). The fluorophore-labeled peptide was observed in the intercallular space only. Metkephamid permeabilities were found to be direction-specific. Permeabilities from basolateral to apical (b-to-a) were significantly higher (ca. 4-fold) than in the opposite (a-to-b) direction. The addition of verapamil equalized the permeabilities in the a-to-b and b-to-a directions, suggesting the involvement of a P-glycoprotein-mediated secretion mechanism. Similar observations were obtained with [D-Ala2]Met-enkephalinamide, but not with Met-enkephalin and [D-Ala2]Met-enkephalin. In contrast to the other analogues, metkephamid and [D-Ala2]Met-enkephalinamide are positively charged at neutral pH, as demonstrated by their isoelectric points (pl = 8.6 for [D-Ala2]Met-enkephalinamide and metkephamid and 5.3 for [D-Ala2]Met-enkephalin and Met-enkephalin). The data is in agreement with the literature showing that most compounds secreted by the P-glycoprotein transporter carry a positive charge.
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Affiliation(s)
- V B Lang
- Department of Pharmacy, Swiss Federal Institute of Technology Zurich, Switzerland
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