To help general practitioners (GPs) in early identification of patients with palliative care (PC) needs, this pilot study aimed to determine the potential of the combined original surprise question ...(SQ1) ('Would I be surprised if this patient died within the next 12 months?') and the second surprise question (SQ2) ('Would I be surprised if this patient was still alive after 12 months?'). We hypothesized that answering these SQs would trigger them to make a multidimensional care plan.
26 Slovenian GPs, randomized into 4 groups, were invited to write a care plan for each of the four patients described in case vignettes (2 oncologic, 1 organ failure and 1 frailty case). GPs in group 1 were only asked to write a care plan for each patient. GPs in group 2 answered SQ1 and GPs in groups 3 and 4 answered SQ1 and SQ2 before writing the care plan. The type and number of PC aspects mentioned in the respective care plans were quantified into a numeric RADboud ANTicipatory (RADIANT) score.
Mean RADIANT scores in groups 1-4 were 2.2, 3.6, 2.5 and 3.1, respectively. When comparing the different vignettes, vignette B (terminal oncologic patient) scored best (3.6). Mean RADIANT scores in groups 3 and 4 were slightly higher for GPs who would be surprised compared to GPs who would not be surprised if the patient was still alive in 12 months.
The combined SQs were considered helpful in the early identification of patients in need of PC in Slovenian general practice.
As copper sulphate pentahydrate (CSP) is a common compound used in agriculture and industry, chronic occupational exposures to CSP are well known, but acute poisoning is rare in the Western world. ...This case report describes acute poisoning of a 33-year-old woman who attempted suicide by ingesting an unknown amount of CSP. On admission to the hospital, she had symptoms and signs of severe hemorrhagic gastroenteritis, dehydration, renal dysfunction and methaemoglobinaemia with normal serum copper level. Therapy included early gastric lavage, fluid replacement, vasoactive drugs, furosemide, antiemetic drugs, ranitidine, and antidotes methylene blue and 2,3-dimercaptopropane-1-sulphonate (DMPS). However, the patient developed severe intravascular haemolysis, acute severe hepatic and renal failure, as well as adrenal insufficiency. After prolonged, but successful hospital treatment, including haemodialysis and IV hydrocortisone, the patient was discharged with signs of mild renal and liver impairment. Our conclusion is that in severe cases of copper poisoning early supportive measures are essential. In addition, antidotes such as methylene blue for methaemoglobinaemia and chelating agent such as DMPS improve morbidity and survival of severely poisoned victims.
Bakrov sulfat pentahidrat (BSP) se pogosto uporablja v kmetijstvu in industriji, zato so kronične poklicne zastrupitve dobro poznane, akutne zastrupitve pa so v razvitem svetu redke. Opisujemo primer akutne zastrupitve zaradi poskusa samomora pri 33-letni ženski zaradi zaužitja neznane količine BSP. Ob sprejemu so bili prisotni simptomi in znaki težkega hemoragičnega gastroenteritisa, izsušitve, razvijajoče se ledvične odpovedi in methemoglobinemije z normalno vrednostjo bakra v serumu. Takoj smo sprali želodec in začeli iv. dajati tekočine, kateholamine, furosemid, antiemetik, ranitidin in antidota metilensko modrilo in 2,3-dimerkaptopropan-1-sulfonat (DMPS). Kljub zgodnjim ukrepom se je razvila težka znotrajžilna hemoliza, težka akutna jetrna in ledvična odpoved ter odpoved nadledvičnice. Po dolgem, vendar uspešnem zdravljenju, vključno z zdravljenjem s hemodializo in iv. steroidi, je bila bolnica odpuščena z znaki blage ledvične in jetrne okvare. Zaključujemo, da je pri težkih zastrupitvah z bakrom zgodnje simptomatsko zdravljenje prvi najpomembnejši ukrep. Uporaba antidotov, kot je metilensko modrilo pri methemoglobinemiji, in ionskih izmenjevalcev, kot je DMPS, pa dodatno zmanjša obolevnost in izboljša preživetje težko zastrupljenih.
At War Within Clark, William R
1995, 19951130
eBook, Book
In the seventeenth century, smallpox reigned as the world’s worst killer. Luck, more than anything else, decided who would live and who would die. That is, until Lady Mary Wortley Montagu, an English ...aristocrat, moved to Constantinople and noticed the Turkish practice of “ingrafting” or inoculation, which, she wrote, made “the small-pox … entirely harmless.” Convinced by what she witnessed, she allowed her six-year-old son to be ingrafted, and the treatment was a complete success--the young Montagu enjoyed lifelong immunity from smallpox. Lady Montagu’s discovery would, however, remain a quiet one; it would be almost 150 years before inoculation (in the more modern form of vaccination) would become widely accepted while the medical community struggled to understand the way our bodies defend themselves against disease. William Clark’s At War Within takes us on a fascinating tour through the immune system, examining the history of its discovery, the ways in which it protects us, and how it may bring its full force to bear at the wrong time or in the wrong place. Scientists have only gradually come to realize that this elegant defence system not only has the potential to help, as in the case of smallpox, but also the potential to do profound harm in health problems ranging from allergies to AIDS, and from organ transplants to cancer. Dr. Clark discusses the myriad of medical problems involving the immune system, and he systematically explains each one. For example, in both tuberculosis and AIDS, the underlying pathogens take up residence within the immune system itself, something Clark compares to having a prowler take up residence in your house, crawling around through the walls and ceilings while waiting to do you in. He discusses organ transplants, showing how the immune system can work far too well, and touching on the heated ethical debate over the use of both primate and human organs. He explores the mind’s powerful ability to influence the performance of the immune system; and the speculation that women, because they have developed more powerful immune systems in connection with childbearing, are more prone than men to contract certain diseases such as lupus. In a fascinating chapter on AIDS, arguably the most deadly epidemic seen on Earth since the smallpox, Clark explains how the disease originated and the ways in which it operates. And, in each section, we learn about the most recent medical breakthroughs. At first glance, it may appear that our immune system faces daunting odds; it must learn to successfully fend off, not thousands, but millions of different types of microbes. Fortunately, according to Clark, it would be almost impossible to imagine a more elegant strategy for our protection than the one chosen by our immune system, and his At War Within provides a thorough and engaging explanation of this most complex and delicately balanced mechanism.
Carnosine is a dipeptide formed of the amino acids β-alanine and histidine. Only a limited number of studies have examined the effects of carnosine on sympathetic nerve activation and anxiety. The ...present study was undertaken to determine the dose-related effects of carnosine on anxiety in the elevated T-maze test (ETM) with electrodermal activity (EDA). Carnosine was injected in three groups of rats with doses of 10 (low dose), 100 (medium dose) and 1000 (high dose) mg/kg i.p. Physiological saline was injected in the sham group. The anxiety scores of the rats were measured with ETM 20 minutes after injection. Then, SCL was measured. The decreased number of entries into the open arm (NEOA), the percentage of time spent in the open arm (% TSOA) and higher EDA shown by skin conductance level (SCL) indicate higher anxiety. The NEOA and % TSOA were lower in the high-dose group than in the other groups. SCL was lower in the medium-dose carnosine group than in the high-dose carnosine and sham groups. SCL was higher in the high-dose group than in the medium-dose and sham groups. Our results suggest that high-dose carnosine produced anxiety-like effects as assessed in the SCL and ETM. Medium-dose carnosine acted as an anxiolytic. The anxiety-related responses of carnosine depend on its dose-related effect.
N. Dolu, H. Acer, A. Y. Kara
Úvod: Sympatická kožní odpověď (SSR) je jednoduchý a široce dostupný test sudomotorických funkcí. Jedná se o polysynaptický reflex s variabilní aferentací a eferentní částí, zprostředkovanou tenkými ...nemyelinizovanými vlákny typu C. Cílem práce bylo zhodnocení validity SSR v diagnostice neuropatie s postižením tenkých senzitivních nervových vláken. Metodika: SSR byla vyšetřena na horních a dolních končetinách u 69 pacientů s bolestivou periferní neuropatií. U 33 pacientů této skupiny šlo o izolovanou neuropatii tenkých nervových vláken (NTV). Třicet šest pacientů mělo kombinované postižení vláken tenkých a silných. Nálezy byly srovnány se souborem 89 zdravých kontrol. Hodnocena byla výbavnost odpovědí elektrickým proudem a prudkým inspiriem a jejich reprodukovatelnost, amplituda a latence. Výsledky: Hodnocení latencí ani amplitud odpovědí neprokázalo jasný přínos pro diagnostiku postižení tenkých nervových vláken. Nejspolehlivější typ SSR abnormity je tedy nevýbavnost odpovědí. Postižení tenkých autonomních vláken však bylo v našem souboru pomocí SSR prokazatelné pouze u malé části pacientů se senzitivní neuropatií – senzitivita dosáhla necelých 10 % u pacientů s čistou NTV a 33 % u pacientů s kombinovaným postižením vláken tenkých a silných (u nichž je současně pravděpodobnější těžší stupeň postižení vláken tenkých). Závěr: Při zohlednění nízké senzitivity není SSR optimální metoda využitelná jako jediný diagnostický test neuropatie tenkých vláken.
Introduction: Sympathetic skin response (SSR) is a simple and widely available test of sudomotor functions. Afferent part of this polysynaptic reflex is variable, while the efferent direction of the reflex arch is via thin unmyelinated C fibres. No reliable study of the SSR diagnostic validity in patients with sensory small fiber neuropathy (SFN) has so far been published. In clinical practice, however, we repeatedly meet patients, who have been diagnosed with SFN based solely on abnormal SSR. The aim of the study was to evaluate diagnostic validity of SSR in patients with sensory small fibre neuropathy. Methods: SSR was recorded from palms and soles of 69 patients with painful sensory neuropathy (33 of them with pure SFN and 36 with mixed small and large nerve fibre dysfunction) using electrical stimulation and inspiratory gasp stimuli. Small nerve fiber involvement was confirmed by reduced intraepidermal nerve fiber densities in skin biopsy samples of all cases. The results were compared with those of 89 healthy controls. The outcome for health controls were also used to establish age-stratified normative data. We assessed electric stimuli and sudden inspiration response recall end their reproducibility, amplitude and latency. Results: Both the SSR latencies and amplitudes showed very low diagnostic validity in small fibre neuropathy patients. The absence of SSR response represented the most reliable abnormality. However, using this parameter, dysfunction of small autonomic nerve fibres has only been found in a small part of our sensory neuropathy patients: sensitivity did not exceed 10% in pure SFN patients and 33% in those with mixed small and large nerve fibre dysfunction (where more pronounced small sensory nerve fibre involvement has previously been found). Conclusion: Considering its low sensitivity, SSR should not be used as the only test to confirm sensory small fibre neuropathy. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.
E. Vlčková, I. Šrotová, J. Bednařík
Karcinom prsu je morfologicky a geneticky velmi heterogenní onemocnění a k jeho léčbě je nutno přistupovat přísně individuálně. Jednou z možných léčebných strategií je zahájení terapie neoadjuvantní ...systémovou léčbou. Ta byla původně vyhrazena jen pro lokálně pokročilé formy onemocnění, u kterých byl primární chirurgický výkon kontraindikován, nicméně v posledních letech je možné ji s výhodou použít též u rizikových pacientek s časnějším stadiem onemocnění. Cílem této léčby byla změna inoperabilních tumorů na operabilní, event. konverze radikálních výkonů na výkony prs šetřící a dále předpoklad likvidace mikrometastáz a snaha dosažení lepšího přežití u žen s pokročilejší formou onemocnění. Tato hypotéza však nebyla dosud potvrzena (výsledky NSABP B18 studie). S podáním iniciační systémové léčby a jejím efektem na tumor (zejména primárně operabilní) je však spjata i řada otazníků, které se týkají především výběru vhodných pacientek k tomuto typu léčby, vhodných režimů a indikací následné adjuvantní terapie. V závěru práce jsou shrnuty výhody a nevýhody primárního podání systémové terapie a lze konstatovat, že u správně indikovaných nemocných převyšují benefity nad možnými riziky.
Being both morphologically and genetically very heterogenous disease, breast cancer requires strictly individulal treatment approach. One of possible treatment strategies is to start the therapy with neoadjuvant systemic treatment. This was originally designated only for locally advanced disease, in which primary surgery was excluded, it has been possible to use it also in high risk patients with early stage disease recently. The goal of this treatment was to turn inoperable tumors into operable or convert radical operation into breast saving surgery, to eliminate micrometastases and also to achieve longer survival in women with more advanced disease. This hypothesis hasn´t been confirmed yet (NSABP B18 study). There are nevertheless many question marks connected with the administration of initial systemic therapy and its effect on the tumour (mostly primarilly operable), dealing with the selection of suitable patients, appropriate chemotherapy regimen and the indication of subsequent adjuvant chemotherapy. At the end of the work there are summarised both advantages and disadvantages of primary systemic treatment administration and it is possible to conclude that in correctly indicated patients the benefits exceed possible risks. in adjuvant chemotherapy.
Renata Neumanová
Literatura
Interferony b (IFN‑b) patří v léčbě pacientů s relaps‑remitentní formou roztroušené sklerózy mezi léky první volby. V návaznosti na podání IFN‑b dochází v lymfocytech k syntéze Myxovirus resistance ...proteinu A, který je vzhledem k následnému vzestupu hladiny považován za vhodný marker účinnosti IFN‑b in vivo. V průběhu léčby IFN‑b dochází u některých pacientů k tvorbě neutralizačních protilátek, jež mohou vést k poklesu či ztrátě biologické účinnosti tohoto léku. Jejich detekce, stejně jako měření hladiny mRNA Myxovirus resistance proteinu A, rozšiřuje možnosti sledování účinnosti léčby IFN‑b.
Interferon β is the first-line treatment for relapsing-remitting multiple sclerosis. Patients treated with interferon β may develop neutralizing antibodies that can reduce or abolish its efficacy. Interferon-inducible Myxovirus resistance protein A has been proven to be a sensitive marker of biological response to interferon β. Neutralizing antibodies and the levels of Myxovirus resistance protein A mRNA are sensitive measures of biological response to interferon β; their levels should be investigated in all interferon-treated patients.
J. Libertínová, E. Meluzínová, V. Maťoška, M. Zajac, E. Hynčicová, A. Tomek, M. Bojar
Nádory hlavy a krku jsou celosvětově 6. nejčastějším zhoubným nádorem. Histologicky se ve většině případů jedná o spinocelulární karcinomy s lokalizací dutiny ústní, orofaryngu, laryngu, hypofaryngu ...a dutiny nosní. Hlavním rizikovým faktorem je kouření a alkohol. Nově se diskutuje souvislost s infekcí lidského papilomaviru (HPV 16), zejména v oblasti orofaryngu. Pacienti mající infekci HPV 16 mají 15–50× vyšší riziko pro vznik karcinomu. Dle výsledků zkoumání se jedná o rozdílnou formu karcinomu s výskytem u mladších pacientů, lepšího sociálního stavu, nejčastěji v oblasti orofaryngu a báze jazyka, s pokročilým postižením uzlin, s lepší prognózou proti HPV negativním tumorům. Základem léčby je chirurgie a radioterapie, chemoterapie a nově cílená léčba. Ve většině případů (nad 50 %) se jedná o lokálně pokročilé onemocnění zasahující oblast polykání, mluvení – výrazně omezující denní aktivity. Chemoradioterapie s cisplatinou je standardem pro pacienty s pokročilým neresekabilním karcinomem hlavy a krku. Ve studiích fáze III byla srovnávána samostatná radioterapie proti přidání cetuximabu k radioterapii. Výsledky odpovědi pro kombinaci s cetuximabem 74 % vs. 64 %, s mediánem přežití 49 vs. 29,3 měs. (Bonner, 2006). Cetuximab je monoklonální protilátka třídy IgG1, blokující vazbu endogenních EGFR ligand, což vede k inhibici funkce receptoru. EGFR je exprimován u nádorů epiteliálního původu. U nádorů hlavy a krku se vyskytuje téměř u všech – nad 90 %.
Worldwide, head and neck tumours are the sixth leading malignant tumour. Histologically, the majority of cases are squamous cell carcinomas of the oral cavity, the oropharynx, the larynx, the hypopharynx, and the nasal cavity. Smoking and alcohol are the major risk factors. Recently, an association with the human papillomavirus (HPV 16) infection, particularly in the area of the oropharynx, has been discussed. Patients with the HPV 16 infection have a 15–50-fold higher risk of developing carcinoma. According to research results, it is a distinct form of carcinoma occurring in younger patients, of a higher social status, most frequently in the area of the oropharynx and the base of tongue, with advanced lymph involvement, and with a better prognosis compared to HPV-negative tumours. The mainstay of treatment is surgery and radiotherapy, chemotherapy, and, more recently, targeted therapy. In most cases (over 50%), there is locally advanced disease involving the area of swallowing and speaking, thus significantly limiting daily activities. Chemoradiotherapy with cisplatin is the standard treatment for patients with advanced unresectable head and neck cancer. Radiotherapy alone versus adding cetuximab to radiotherapy was compared in phase III trials. The response results for the combination with cetuximab were 74% vs. 64%, with a median survival of 49 vs. 29.3 months (Bonner 2006). Cetuximab is a monoclonal IgG1 antibody that blocks the binding of endogenous EGFR ligands, resulting in inhibition of receptor function. EGFR is expressed in tumours of epithelial origin. It occurs in nearly all (over 90%) head and neck tumours.
Michaela Zábojníková, Markéta Pospíšková, Milan Kohoutek
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