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Background: Publication and implementation of clinical guidelines is an important educational measure that considerably helps physicians in choosing appropriate antimicrobial drug., Objectives: To evaluate long-term changes in antimicrobial prescribing habits before and after publishing the guidelines and to determine the factors that influence physician's decision to prescribe an antimicrobial drug., Methods: The study among general practitioners in Primorsko-Goranska County was conducted in three periods (January 2009, January 2011 and April 2019) by using a structured questionnaire that included general data about the physician, questions about their habits in antibiotic prescribing, criteria that influenced decision to prescribe antibiotics and antimicrobial agent(s) preferred in treating common infections., Results: Concomitant chronic (non-pulmonary) disease was the most important factor influencing decision to prescribe an antimicrobial drug. Over 88% of physicians that completed the survey declared themselves as rational prescribers of antimicrobials but more than half of them (53.3%) sometimes prescribed an antibiotic even though it was not indicated compared to 75% of self-reported non-rational prescribers (P ˂ 0.05). Self-reported adherence to the guidelines increased from 34.6% in 2011 to 51.8% in 2019., Conclusion: The research showed improvement in physicians' knowledge in choosing the right antibiotic based on the analysis of answers but indicated the necessity for improving communication skills and empowering physicians not to prescribe antibiotics 'just in case' because of diagnostic uncertainty or patient demand. Further qualitative research is needed to understand physicians' prescribing behaviour and decision-making processes in order to develop interventions that will effectively improve the use of antibiotics., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To determine the use of evidence-based medicine (EBM) information and the level of awareness and knowledge of EBM among patients in Croatia., Methods: A cross-sectional study was conducted among 987 patients in 10 family medicine practices in Croatia. Patients from both urban (n=496) and rural (n=482) areas were surveyed. A 27-item questionnaire was used to collect data about sources that patients searched for medical information, patient awareness and use of Cochrane systematic reviews and other EBM resources, and their demographic characteristics., Results: Half of the patients searched for medical information from sources other than physician. Internet was the most common place they searched for information. Very few patients indicated using EBM sources for medical information; one fifth of patients heard of EBM and 4% of the patients heard of the Cochrane Collaboration. Patients considered physician's opinion as the most reliable source of medical information. A logistic regression model showed that educational level and urban vs rural residence were the predictors of awareness about EBM and systematic reviews (P<0.001 for both)., Conclusion: Our finding that patients consider a physician's opinion to be the most reliable source of health-related information could be used for promotion of high-quality health information among patients. More effort should be devoted to the education of patients in rural areas and those with less formal education. New avenues for knowledge translation and dissemination of high-quality health information among patients are necessary.

Renal anemia develops secondary to chronic kidney disease (CKD) and its incidence increases with the progression of CKD. The aim is to inform family physicians about the latest developments and ways of approaching the issue, in accordance with national guidelines. The PubMed and Cochrane systematic reviews databases were searched for the 1996-2015 period using the following key words: anemia, chronic renal failure, erythropoietin, and primary health care. In addition, all relevant articles and textbooks available were manually searched to suggest the following conclusions. The use of erythropoiesis-stimulating agents (ESA) slows down the progression of CKD, reduces the need for blood transfusions and improves the patient quality of life. Target hemoglobin (Hb) concentration to be permanently maintained is 110-120 g/L. Higher Hb levels are associated with higher mortality and major cardiovascular events in dialysis patients. Target hemoglobin level should be strictly individualized depending on CKD stage (both non-dialyzed and dialyzed population), age, other risks, initial and maintenance treatment. Early recognition and appropriate correction of anemia using ESA is of utmost importance in CKD patients. Systematic primary and secondary prevention measures along with education and professional implementation of national guidelines in daily work of family practitioners can improve medical care of patients with CKD.

Increasing the proportion of patients with controlled hypertension implies understanding and systematic approach to patients with resistant hypertension. In the past decades, an increase in the prevalence of resistant arterial hypertension (RAH) has been observed and the incidence of this problem is becoming greater in the practice of family physicians. Patients with RAH have a higher prevalence of target organ damage as compared with patients having achieved target blood pressure values, and their risk of an adverse cardiovascular event is tripled. RAH is defined as hypertension in which there is no satisfactory control of blood pressure despite compliance to lifestyle changes and taking at least three drugs in full doses, one of which has to be a diuretic. The most important risk factors for resistance to treatment are older age, obesity, smoking, excessive intake of salt and alcohol, the presence of left ventricular hypertrophy, chronic renal failure, diabetes, inadequate baroreflex pathway, chronic stress and associated mental states, use of some drugs, and all forms of secondary hypertension. One-fifth of patients with RAH have primary aldosteronism. Obstructive sleep apnea is a common cause of RAH, and literature reports point to its increasing frequency. Optimal treatment involves a combination of three drugs, one of which is a diuretic. Use of mineralocorticoid antagonist as the fourth drug has shown significant efficacy even in patients who do not have elevated levels of aldosterone. New invasive methods of treatment include renal denervation and permanent electrical stimulation of the carotid sinus. The aim of this paper is to emphasize the importance of RAH as a cardiovascular risk factor, along with early detection and treatment at the family medicine level and timely referral to additional procedures to treat the specific forms of RAH.

Cholestasis indicates stagnation of bile, a disorder in the synthesis, secretion and/or outflow of bile. Cholestasis is classified as intrahepatic or extrahepatic. Intrahepatic cholestasis may occur as a result of hepatocellular disorders or due to obstruction of the intrahepatic bile ducts. Extrahepatic cholestasis is caused by obstruction of the bile ducts outside the liver. Cholestasis manifests as acute or chronic (>6 months). Early biochemical markers of cholestasis include increased alkaline phosphatase, γ-glutamyltransferase, and conjugated hyperbilirubinemia. Clinically, the most common presenting symptoms are jaundice, itchy skin and fatigue. A key element in diagnosis is visual presentation of the biliary system. New insights into the pathophysiological mechanisms of cholestasis at the molecular level will contribute to the development of new treatments. Pancreatitis is an inflammatory process in the tissue of the pancreas caused by prematurely activated pancreatic enzymes. The course of acute pancreatitis is in most cases mild, with minimal organ dysfunction and full recovery, while the severe form of the disease is characterized by complications and high mortality. Chronic pancreatitis is characterized by persistent inflammation of the pancreas with permanent damage to glandular tissue in the presence of fibrosis and narrowed pancreatic ducts. Treatment of pancreatitis is supportive and directed to maintaining the basic physiological functions. The role of family physicians is very important in early detection of liver diseases, which can significantly affect the success of treatment and improve the quality of life in these patients.

Gastric content reflux to the esophagus is a physiological phenomenon that occasionally occurs after meal. Gastroesophageal reflux disease (GERD) is a state that appears when the quantity of gastric content surpasses its physiological elimination from the esophagus and causes difficulties with or without associated esophageal mucosa damage, as well as alarming symptoms. The symptoms are defined as alarming if they disturb the patient’s well-being and are the reason for a visit to the physician. The prevalence of GERD in the Western world is 10%-20% and is based on the estimation of the heartburn incidence as the leading symptom. The dominant symptoms are heartburn and regurgitation, especially after a heavy meal, and are highly specific for GERD. Extraesophageal reflux disease represents a wide range of symptoms connected to the upper and lower respiratory system, such as cough, laryngitis, asthma, chronic obstructive pulmonary disease, hoarseness, sinusitis-postnasal drip syndrome, otitis media, recurrent pneumonia and laryngeal carcinoma. The following tests are used in the reflux differential diagnosis: esophagogastroscopy, laryngoscopy and 24-hour pH monitoring. Patients suspected to suffer from GERD are initially treated with empirical proton pump inhibitor therapy twice a day for one to two months.

Dyspepsia is a common symptom among patients in family medicine practice. The prevalence in adult population is about 40%. Two-thirds of patients have functional dyspepsia. Clinical assessment, diagnostic procedures and treatment of patients depend on the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impact of other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommended in patients with newly detected dyspepsia older than 50 and presenting with alarming symptoms. In persons younger than 50, the recommended strategy is ‘test and treat’. In some patients, treatment is carried out by acid suppression. In patients failing to achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantly contribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presenting with symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment of patients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits and psychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychological morbidity, as well as his efforts in healthy behavior.

Peptic ulcer disease is represented by a lesion in the mucosa of the digestive tract due to imbalance of its aggressive and protective mechanisms. The main external factors of the development of peptic ulcers are Helicobacter pylori infection and the use of non-steroidal anti inflammatory drugs (NSAIDs) and acetylsalicylic acid (ASA). Symptoms of peptic ulcer disease are a common reason for visiting the family physician. All patients with symptoms of dyspepsia under the age of 50 and without the alarm symptoms should be tested whether H. pylori is present by performing the Urea Breath Test or stool antigene testing, and infection, if found, should be treated. Endoscopic examination is obligatory in patients older than 50 years and those with alarm symptoms. „Sequential therapy“ is recommended in Croatia as the first-line treatment of H. pylori infection, or triple therapy that comprises applying a proton pump inhibitor (PPI) in combination with amoxicillin and metronidazole. Four weeks after eradication therapy the control testing for H. pylori should be performed.

With the increasing prevalence of obesity and metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in adults and children. Despite the increasing prevalence, NAFLD remains largely undiagnosed and untreated in routine medical practice. Most patients with NAFLD have no symptoms, while only a few feel discomfort in the upper right quadrant of the abdomen or increased fatigue. The diagnosis is usually set during abdominal ultrasound examination, which is done for some other reason, or by elevated liver biochemical test findings. Early recognition is very important for correct and successful treatment. In primary health care, little is known about the processes related to the identification, diagnosis and referral of patients to specialists. Differentiation between steatosis and steatohepatitis by assessing the severity of fibrosis within steatohepatitis is extremely important. Histopathologic analysis of tissue obtained by biopsy remains the gold standard in this field. For family physician, guidelines that should be combined can be of great help in treating patients with suspected NAFLD. The serious consequences of late recognition of NAFLD could be reduced by such guidelines. Recent studies have shown that NAFLD is associated with an increased prevalence and incidence of cardiovascular complications. Because of their complexity, hepatic and extrahepatic complications, heterogeneity in clinical presentation, histologic severity, prognosis and therapeutic outcome, NAFLD requires a multidisciplinary approach with the active role of family physicians in preventive care, diagnosis and treatment, especially in individuals and groups at risk. Greater attention should be focused on lifestyle modifications (reduction in body weight and physical activity) and their practical implementation. Key words: non-alcoholic fatty liver disease, liver biopsy

Background: Regular use of evidence-based medicine (EBM) among general practitioners (GP) is insufficient., Objective: To analyse whether knowledge and attitudes about EBM can be improved among mentors in general practice by involving sixth-year medical students as academic detailers., Methods: An interventional non-randomized before-and-after study included 98 GPs (49 in the intervention group of mentors and 49 controls) and 174 medical students attending family medicine clinical rotations. A telephone survey on knowledge and attitudes towards EBM was conducted among participating physicians before, and six months after the rotation. During the rotation, each mentor chose two cases from real life, and the students' task was to form an answerable clinical question, find the evidence-based answer and to write a brief report. The mentor reviewed the report and discussed it with the student., Results: Students' EBM detailing intervention led to significant improvement in knowledge and attitudes about EBM in the intervention group of mentors in general practice compared to control GPs (relative increase in knowledge was 20 ± 46.9% vs 6 ± 12.1%, respectively; P = 0.042). Among participants with Ph.D. or specialization in family medicine, the observed effects of the intervention were similar as in the total sample, and statistically significant, but not in the group of participants with neither scientific degree nor specialization in family medicine., Conclusion: Knowledge and attitudes of GP mentors towards EBM can be improved by involving medical students as academic detailers. Further studies should explore the effectiveness of this method among GPs that are not mentors, and who do not have a specialization or research degree.

The role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this "healthcare continuum". The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care.

Introduction: Depression is one of the five most frequent disorders in primary care practice and often remains unrecognized. One of the reasons why depression often passes unnoticed is comorbidity - a number of different chronic diseases coexist with depression, especially in elderly patients., Aim: The aim of this research was to assess the difference between depressed and non-depressed patients regarding somatic and mental comorbidity. The differences in drug use were also examined., Subjects and Methods: Five hundred successive adult patients visiting family physicians in Rijeka, Croatia, were polled using the Beck Depression Inventory and a general questionnaire which was created for the purpose of the study. The existing medical records were also used., Results: Elevated depression level was determined in 48.1% of the examinees. These patients were suffering from larger number of chronic diseases (X=1.23) than non-depressed patients (X=0.70; t=5.07; p<0.001; z=4.93; p<0.001), especially cardiac, mental, renal and osteomuscular diseases. Depressed persons used significantly more drugs (X=1.28) than non-depressed patients (X=0.58; t=6.10; p<0.001; z=5.78; p<0.001), especially antirheumatics, analgesics, sedatives, antidepressants, antiallergics and diuretics., Conclusion: The research results point to a necessity of routine screening and early treatment of depression in patients with chronic diseases in primary care practice.