The aim is to present data on the treatment and follow-up in a cohort of patients with pediatric thyroid cancer who underwent total thyroidectomy and received postoperative radioactive iodine (I-131) ...therapy. The study was conducted in a tertiary high-volume thyroid center, in pediatric patients with differentiated thyroid cancer who were consecutively treated during the 1965-2015 period. A total of 45 patients aged less than or equal to18 years having undergone total thyroidectomy with or without selective neck dissection were included in the study. Decision on postoperative I-131 ablation was based on tumor characteristics, postoperative thyroglobulin level, preablative whole body scintigraphy, and/or neck ultrasound. Median age at diagnosis was 15 years. The presence of cervical lymph node metastases was significantly associated with papillary thyroid cancer, larger tumor size, involvement of two thyroid lobes, and multifocal disease. The presence of distant metastases was significantly associated with larger tumor size. None of the patients died during follow-up period, and the 5-year and 10-year overall survival rates were 100%. The 5-year and 10-year progression-free survival (PFS) rates were 87% and 73%, respectively. Male gender (p=0.046), age less than or equal to15 years (p=0.029) and tumor size >15 mm (p=0.042) were significantly associated with inferior PFS. A significant positive trend of increase in the number of newly diagnosed patients was observed over time (p=0.011). Clinical management of pediatric thyroid cancer is challenging, especially in the light of increasing incidence in this population. Male patients younger than 15 years and with tumors of more than 15 mm in size require additional caution due to lower PFS observed. Key words: Iodine; Tyroid cancer, papillary; Adenocarcinoma, follicular; Survival rate; Child; Follow-up studies
We compared characteristics of patients with hyperglycemic hyperosmolar state (HHS) and patients with severe hyperglycemia without the signs of hyperosmolarity and ketoacidosis; analyzed long-term ...all-cause mortality and potential prognostic factors.
The studied population included 261 749 adults. HHS was diagnosed in patients with plasma glucose >33.0 mmol/L, ketonuria <1+, and serum osmolarity >320 mmol/L. Patients with plasma glucose >33.0 mmol/L, ketonuria <1+ and serum osmolarity <320 mmol/L were considered as controls (nHHS).
During the 5-year period, we observed 68 episodes of HHS in 66 patients and 51 patients with nHHS. Patients with HHS were significantly older, had lower BMI, higher serum C-reactive protein and used diuretics and benzodiazepines more frequently. Mortality rates one, three and 12 months after admission were 19.0, 32.1 and 35.7% in the HHS group, and 4.8, 6.3 and 9.4% in the nHHS group (P<0.001). However, after adjustment for patient age, these differences were not statistically significant. In multivariate Cox regression in HHS group, mortality was positively associated with age, male gender, leukocyte count, amylase, presence of dyspnea and altered mental status, and the use of benzodiazepines, ACE inhibitors and sulphonylureas, while it was inversely associated with plasma glucose, bicarbonate, and the use of thiazides and statins. A nomogram derived from these variables had an accuracy of 89% in predicting lethal outcome.
Infection, use of furosemide and benzodiazepines may be important precipitating factors of HHS. Prospective clinical trials are mandatory to analyze the safety of ACE-inhibitors and benzodiazepines in elderly patients with diabetes.
Background
Chromogranin A (CgA) is a valuable biomarker for detection and follow-up of patients with neuroendocrine neoplasms (NENs). However, various comorbidities may influence serum CgA, which ...decreases its diagnostic accuracy. We aimed to investigate which laboratory parameters are independently associated with increased CgA in real-life setting and to develop a scoring system, which could improve the diagnostic accuracy of CgA in detecting patients with NENs.
Methods
This retrospective study included 55 treatment naïve patients with NENs and160 patients with various comorbidities but without NEN (nonNENs). Scoring system (CgA-score) was developed based on
z
-scores obtained from receiver operating curve analysis for each parameter that was associated with elevated serum CgA in nonNENs.
Results
CgA correlated positively with serum BUN, creatinine, α2-globulin, red-cell distribution width, erythrocyte sedimentation rate, plasma glucose and correlated inversely with hemoglobin, thrombocytes and serum albumin. Serum CgA was also associated with the presence of chronic renal failure, arterial hypertension and diabetes and the use of PPI. In the entire study population, CgA showed an area under the curve of 0.656. Aforementioned parameters were used to develop a CgA-score. In a cohort of patients with CgA-score <12.0 (
N
= 87), serum CgA >156.5 ng/ml had 77.8% sensitivity and 91.5% specificity for detecting NENs (AUC 0.841, 95% CI 0.713–0.969,
P
< 0.001). Serum CgA had no diagnostic value in detecting NENs in patients with CgA-score >12.0 (AUC 0.554, 95% CI 0.405–0.702,
P
= 0.430).
Conclusions
CgA-score encompasses a wide range of comorbidities and represents a promising tool that could improve diagnostic performance of CgA in everyday clinical practice.
Broj raspoloživih lijekova u svijetu, pa tako i u Republici Hrvatskoj, u stalnom je porastu. S obzirom na ograničena financijska sredstva u proračunu za zdravstvo, tijekom vremena na tržištu su ...ponuđeni i generički lijekovi, koji su u pravilu jeftiniji od originalnih. Objašnjenje za navedeno nalazi se u činjenici da je stvaranje novog originalnog lijeka dugotrajan (dugogodišnji) i skup proces, koji uključuje ulaganje u istraživanje i razvoj novih lijekova, provođenje kliničkih studija kroz više faza radi potvrde učinkovitosti i neškodljivosti, te kontinuirano praćenje podataka o lijeku nakon dolaska na tržište. U skladu s navedenim, proizvođač originalnog lijeka određeno vrijeme ima pravo na patentnu zaštitu, koja u pravilu traje 20 godina kako bi se proizvođaču osigurao povrat dijela sredstava uloženih u razvoj lijeka. Nakon isteka vremena patentne zaštite, aktivnu tvar, osim tvrtke koja je nositelj originalnog patenta, mogu proizvoditi i prodavati i druge tvrtke, uz uvjet da se poštuju zakonske norme proizvođačke i kliničke prakse. Prema definiciji, generički lijekovi trebali bi biti istovjetni originalnom lijeku u dozi, neškodljivosti, načinu primjene, kvaliteti, obliku i indikacijama, obzirom da posjeduju istu aktivnu (djelatnu) tvar. Međutim, potrebno je napomenuti da razlika postoji, jer generički lijek sadrži drugačije pomoćne tvari (služe u oblikovanju lijeka) nego što je to u originalnom lijeku. Upravo stoga, generički lijek može imati nešto drugačiji izgled, boju ili okus u odnosu na originalni lijek. Pomoćne tvari zakonski su regulirane i trebale bi biti neškodljive, no bitno je napomenuti da generički lijekovi ipak ne prolaze strogu istraživačku fazu kontrole kao originalni lijekovi. Neke od posljedica do kojih može doći zbog promijenjenog sastava pomoćnih tvari je reakcija zbog preosjetljivosti na neku od pomoćnih tvari (direktno) te utjecaj pomoćne tvari na brzinu i stupanj resorpcije aktivne tvari (indirektno). U skladu s time, u praksi se u određenog broja bolesnika može primijetiti povećana učestalost nuspojava prilikom provođenja terapije generičkim lijekovima, u odnosu na primjenu originalnog lijeka. Nuspojave čine jedan od dva glavna stupa pri procjeni isplativosti primjene terapije u bolesnika; drugi stup čini učinkovitost lijeka. Dakle, da bi primjena lijeka bila opravdana, on mora biti učinkovit za stanje za koje ga primjenjujemo, te mora biti dobro podnošljiv. U onkologiji je to posebno značajno iz više razloga. Nuspojave su jedan od najvažnijih razloga odgoda i prekida onkološke terapije, što u konačnici zbog manje izloženosti lijeku može dovesti do slabijeg učinka lijeka i napredovanja bolesti. Nadalje, nuspojave većeg stupnja mogu dovesti do trajnih posljedica za bolesnika, a u najtežim slučajevima i do smrti. Osim za bolesnike, razvoj nuspojava predstavlja opterećenje i za zdravstvene djelatnike te cjelokupan zdravstveni sustav. Zbrinjavanje nuspojava onkološke terapije ponekad je vrlo zahtjevno i iziskujevisok stupanj edukacije, kao i ulaganje dodatnog vremena kojeg u onkologiji nikad nema dovoljno. Često se spominje manja cijena generičkih lijekova kao glavni argument njihove primjene. Međutim, u tu cijenu nikada nisu uračunati i svi daljnji postupci koji slijede nakon primjene lijeka, poput zbrinjavanja nuspojava, troška medicinskog osoblja, bolničkih kreveta i cjelokupne opreme koja se koristi u slučaju razvoja neželjenih reakcija. Zaključno, iako bi po definiciji originalni i generički lijekovi trebali biti istovjetni po učinku i podnošljivosti, u praksi nije uvijek tako. Jedan od praktičnih problema u Republici Hrvatskoj jest nedovoljna komunikacija liječnika zaposlenih u bolničkim ustanovama s onima u obiteljskoj medicini, što u pojedinim slučajevima dovodi do situacije u kojoj bolesnik prima generički lijek usprkos preskripciji originalnog lijeka od strane nadležnog liječnika iz bilo kojeg razloga
The tyrosine kinase inhibitor (TKI) sunitinib malate is nowadays a standard first-line treatment option for patients with metastatic clear-cell renal cell carcinoma (mRCC). The aim of this study was ...to evaluate the incidence and clinical course of thyrotoxicosis in our cohort of patients treated with sunitinib.
Medical records of all patients treated with first-line sunitinib for mRCC at our Institution between November 2008 and March 2014 were retrospectively reviewed. Thyroid function was assessed after every 2 cycles of therapy, during the 2 weeks off period.
Out of the 62 included patients, hypothyroidism has developed during therapy in 12 patients (19%) and it was preceded by thyrotoxicosis in 2 (3.2%).
Sunitinib-induced thyrotoxicosis (SIT), a not so rare entity, was followed by hypothyroidism. The patterns of occurrence and possible significance of SIT, as predictive marker of better treatment response to sunitinib, need to be validated in further studies.
Sifilis je spolno prenosiva, sistemska bolest uzrokovana spirohetnom bakterijom Treponema pallidum. Najčešći način prijenosa bolesti je spolni odnos. Iako ima više hipoteza, točno podrijetlo bolesti ...još je uvijek nepoznato. Nedavno objavljeni podaci pokazuju da je najvjerojatnije točna hipoteza koja podupire teoriju američkog podrijetla bolesti. Među 1500 analiziranih patografi ja skladatelja i glazbenika za ovaj prikaz izdvojeni su podaci o deset angloameričkih skladatelja i jazz glazbenika koji su bolovali od neurosifi lisa (tercijarni stadij bolesti). U analiziranoj skupini angloameričkih skladatelja i glazbenika većina ih je umrla od progresivne paralize dok su još uvijek bili u kreativnoj fazi života. Dodatno, ukratko su prikazane dijagnoze jedanaestorice drugih slavnih skladatelja neurosifi litičara te također osnovni biografski podaci desetorice manje poznatih skladatelja koji su umrli od neurosifi lisa odnosno progresivne paralize. U zaključku, neurosifi lis može uzrokovati značajno neurološko oštećenje, a u težim slučajevima također dovesti do trajnog invaliditeta ili smrti i time spriječiti daljnji rad i profesionalni razvoj.
To investigate the prevalence of burnout syndrome among physicians of all specialties, including residents and non-specialists, on a national level in Croatia.
This cross-sectional study, conducted ...in October 2017, used anonymous online survey based on the Maslach Burnout Inventory Human Services Survey. The Croatian version of the inventory was assessed for acceptability, factorial validity, and reliability. Key dimensions of burnout - emotional exhaustion, depersonalization, and lack of personal accomplishment were assessed. Respondents scoring high for emotional exhaustion or depersonalization were defined as burned-out.
The response rate was 18% (2557/14 427). Respondents' median age was 41 years (range 25-80), and 68% (1737/2557) were women. Good sampling adequacy and scale reliability were confirmed. Factorial validity suggested the presence of three overall factors, and no items were eliminated. Sixty-three percent of physicians were burned-out. High score on emotional exhaustion, depersonalization, and reduced personal accomplishment were found in 58%, 29%, and 52% of respondents, respectively. As many as 16% of the respondents simultaneously experienced high levels of all three burnout dimensions. Multivariate logistic regression analysis revealed that residents and physicians in tertiary or primary care were at an increased risk of burnout, while physicians working in institutes were at a decreased risk.
Active national measures are needed to reduce the high prevalence of burnout among Croatian physicians.
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