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Prikaz Slučaja Delija I Sadržaj Metabolički sindrom danas Rumboldt M ...................................................................................................... 5 Metabolički sindrom Bekić S, Pribić S, Samardžić Ilić M, Gmajnić R .............................................. 13 Polifarmacija u obiteljskoj medicini – rastući problem u 21.stoljeću Kašuba Lazić Đ ................................................................................................ 28 Puno lijekova (polifarmacija) i/ili previše je lijekova (overtreatment)? Vrcić Keglević M .............................................................................................. 47 Prehrambene navike unazad deset godina u oboljelih od arterijske hipertenzije Pribić S, Bekić S, Samardžić Ilić M, Samardžić-Ilić V, Gmajnić R .................. 58 Uloga liječnika obiteljske medicine u prepoznavanju i praćenju autoimunih oboljenja u obitelji Haralović D....................................................................................................... 67 Antikoagulantna terapija i metabolički sindrom Došen Janković S ............................................................................................. 75 Akutni pankreatitis - prikaz slučaja Delija I ............................................................................................................. 85 Kretanje hipertenzije registrirane u obiteljskoj medicini i potrošnja antihi- pertenziva: longitudinalni trendovi, 2004.-2013. Rapić M, Maćešić B, Vrcić Keglević M ............................................................ 94 Psorijaza i metabolički sindrom Tiljak A, Čeović R ............................................................................................ 112 Metabolički sindrom i depresija Tudorić-Gemo D, Benzon T, Šerić N ................................................................122 Razlika propisivanja antibiotika u ordinaciji obiteljske medicine između Varaždina i Amsterdama Cikač T, Vučetić M, Sambol K ..........................................................................135 Povezanost padova u starih ljudi sa upotrebom lijekova Kumbrija S ........................................................................................................144 Polipragmazija u starijoj životnoj dobi Begić N, Mosorović N, Kovačević S, Bećarević M, Dautović A .......................153 Propisivanje antibiotika: izazov za liječnike obiteljske medicine Cikač T, Sambol K, Bosak T, Škvorc B .............................................................163 Problemi u provođenju probira na kronične bolesti u obiteljskoj medicini. Poboljšanje u medicinskoj dokumentaciji Vrca Botica M, Zelić I ......................................................................................174 Male žlijezde u vratu – gigantski poremećaji u organizmu Ferenčak V, Prusac B, Ivandić Lončar M, Lončar J .......................................182 Statini u ordinaciji obiteljske medicine Dubravica M, Vinter-Repalust N .....................................................................190 O epidemiološkim i farmakoekonomskim aspektima šećerne bolesti Depolo T, Džono-Boban A .............................................................................. 201 Zdrava, lijepa i uspješna. Metabolički sindrom i mediteranska prehrana - prikaz slučaja Tudorić-Gemo D, Roguljić S ...........................................................................209 Fibrilacija atrija i ambulantno uvođenje varfarina u ordinaciji obiteljske medicine – prikaz slučaja Knez LJ, Fijačko B ..........................................................................................218 Bullyng (vršnjačko nasilje) u osnovnoj školi Benčić M, Vrcić-Keglević M ............................................................................232 Prekomjerna tjelesna težina i pretilost u djece Tkalec J, Golek Mikulić M ..............................................................................240 Hipotireoza i metabolički sindrom Toplak-Hranić S, Perčinlić Ž, Carević D ........................................................249 Prikaz slučaja oštećenja sluha u ambulanti izabranog doktora. Kadić, M, Kljajević M, Kontonar G, Kadić B, Ćatić S ...................................259 Racionalna farmakoterapija i polipragmazi- j a – v i đ e n j e H r v a t s k o g z a v o d a z a z d r a v s t v e n o o s i g u r a n j e Bekić T .............................................................................................................262 RADIONICE: Napredno održavanje života odraslih /ALS/ u ordinaciji obiteljske medicine Bosak T, Ognjanović Z .....................................................................................267 Pristup pacijentu s boli Čop R, Sambol K .............................................................................................269 Balintova metoda i rad u Balintovoj grupi Vuković H, Kumbrija S ....................................................................................272 Spirometrija Fijačko B, Marinić T .......................................................................................275 Savjetovalište za dijabetičare u ordinaciji obiteljske medicine Cikač T, Sambol K ...........................................................................................277 Oftalmoskopija Kotur G................. ...........................................................................................286 Fibrilacija atrija i profilaksa tromboembolije varfarinom Knez Lj, Car S, Cikač T ...................................................................................288 Metabolički sindrom danas Metabolic syndrome today Mirjana Rumboldt Sažetak. Epidemijsko širenje metaboličkog sindroma uz pretilost i niz drugih otklona u mijeni tvari predstavlja prvorazredni javnozdravstveni problem i važno područje djelovanja liječnika obiteljske medicine. U ovom kratkom pregledu ukazano je na povijesne, dijagnostičke, epidemiološke i terapijske osobitosti pristupa ovoj rastućoj pošasti suvremenog svijeta. Ključne riječi: metabolički sindrom, obiteljska medicina Summary. Metabolic syndrome, with obesity and a number of other metabolic derangements, is reaching epidemic proportions, becoming a paramount public health problem and an important goal in family medicine. This brief overview summarizes historical, diagnostics epidemiologic and therapeutic peculiarities of this contemporary world plague. Key words: metabolic syndrome, family medicine Metabolički sindrom (MetS) postaje sve važniji javnozdravstveni problem jer utrostručuje rizik srčanožilnih bolesti, upeterostručuje rizik šećerne bolesti tipa 2 (DM2), a povezan je i s nizom malignih bolesti, poput raka dojke, debelog crijeva, jetre i gušterače1. 5 Definicija Premda se zadnjih desetak i više godina taj izraz široko rabi u medicinskim krugovima, već je sama definicija MetS-a prijeporna. Još uvijek se ne može postići čvrsti dogovor vodećih organizacija i ustanova. Naime, svjetski autoriteti, kao što su International Diabetes Federation (IDF), European Group for the study of Insulin Resistance (EGIR), National Heart, Lung, and Blood Institute (NHLBI), American Heart Association (AHA), World Heart Federation (WHF), International Atherosclerosis Society (IAS), National Cholesterol Education Program (NCEP) i World Health Organization (WHO) postavljaju slična, ali ipak različita mjerila za dijagnozu MetS-a, pa su i definicije različite2. Većina primjerice preporuča kao ključni kriterij abdominalnu gojaznost, koja je ujedno i vanjska manifestacija MetS-a, dok su za WHO to u prvom redu pokazatelji inzulinske rezistencije, posebno povišena glikemija natašte. Postoje i razilaženja u procjeni gojaznosti. Prema IDF-u je to indeks tjelesne mase (ITM, engl. Body Mass Index, BMI) veći od 30, koji podrazumijeva centralnu debljinu pa nije potrebno mjerenje opsega struka. Na taj se način isključuju sve osobe s BMI < 30, što ipak ne znači da sigurno nemaju abdominalnu pretilost. Nasuprot tome, NCEP i većina drugih uzimaju za procjenu abdominalne pretilosti obujam struka, što opet može biti sporno kako zbog tehnike mjerenja (različite trake, različite visine postavljanja, različita zatezanje), tako i zbog antropometrijskih razlika između etničkih skupina. Ni vrijednosti glikemije niti arterijskog tlaka nisu usuglašene (tab. 1). Nadalje, za djecu i adolescente još nema široko prihvaćenih mjerila. Vrlo je izgledno da će se definicija MetS-a i dalje dorađivati. Sigurno je međutim da MetS predstavlja skup (engl. cluster) ili grupiranje više metaboličkih poremećaja, uključujući abdominalnu pretilost, intoleranciju glukoze, arterijsku hipertenziju i dizlipidemiju, koji su povezani s porastom žilnih komplikacija, naročito na srcu, mozgu, bubrezima i drugim organima. Uz gojaznost, koja je gotovo neizbježna, bez obzira na koji se način MetS određuje, potrebna su još bar dva čimbenika: arterijska hipertenzija, dislipidemija (povišene koncentracije triglicerida, snižene koncentracije HDL kolesterola), inzulinska rezistencija/ hiperglikemija, odnosno mikroalbuminurija1,2. 6 Tablica 1. Osobitosti pojedinih definicija metaboličkog sindroma (prema2) WHO EGIR NCEP AHA IDF Temeljni Inzulin natašte: Inzulin - Ako je BMI kriterij gornji kvartil; GUK natašte: >30 , opseg ≥6,1; oGTT 2h gornji kvartil trbuha ne ≥7,8 treba mjeriti Broj otklona Gornji + ≥2 Gornji + ≥2 ≥3 ≥3 Gornji + ≥2 GUK - ≥6,1 ≥6,1 ≥5,6 ≥5,6 natašte HDL ≤ 0,9 M, ≤1,0 Z <1,0 ili pod <1,03 M, <1,03 M, <1,03 M, (mmol/l) terapijiom <1,29 Ž <1,29 Ž <1,29 Ž TG (mmol/l) ≥1,7 >2,0 >1,7 >1,7 >1,7 Pretilost WHR >0,9 M, Opseg >0,85 Ž; BMI ≥30 struka ≥94 cm M, ≥80 cm Ž Opseg
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