Hiperglikemijske krize u bolesnika sa šećernom bolesti u Republici Hrvatskoj

Aim. The main aim of this study was to estimate the incidence of diabetic ketosis (DK) and ketoacidosis (DKA) in a well defiend population in Croatia. Secondary aims were: to detect antropomenthric and laboratory parameters which could serve as predictors of DK and DKA; to estimate the incidence of diabetic hyperosmolar syndrome (DHS) in type 2 diabetes mellitus (ŠBT2); to analyze the differences in antropomethric and laboratory parameters between the NKH, DK and DKA groups; to analyze the differences in antropomethric and laboratory parameters between ŠBT1 and ŠBT2; to analyze mortality rates after each hyperglycemic crisis and to search for prognostic factors. Methods. Studied population comprised of 261,749 adults with a residency in City of Zagreb and Zagreb county. Patients admitted to emergency departement in the period between January 1st 2010 and December 31st 2014 with plasma glucose > 13.9 mmol/L were enrolled. Based on their acid-base analysis, urinary ketones and plasma osmolarity, they were classified into one of the following groups: non-ketotic hyperglycemia (NKH), DK, DKA or DHS. Incidence was expressed as the number of episodes per 100,000 person-years. Analysis of mortality was performed in all patients with ŠBT2 with DHS, DKA and DK, and in NKH patients who were age- and gender-matched with DK group in 1:1 fashion. Results. We observed 630 episodes of DK in 520 patients, 215 episodes of DKA in 165 patients and 68 episodes of DHS in 66 patients. Only 8.6% of DK episodes and 34.4% of DKA were attributed to ŠBT1, while all patients with DHS had ŠBT2. Stadardized incidence ratios were as follows: 48.1 (95% CI 44.5 - 52.1) for DK, 17.0 (95% CI 14.9 - 19.4) for DKA and 6.2 (95% CI 5.1 – 7.2) for DHS. Patients with ŠBT1 were younger, leaner, majority had newly diagnosed disease and hyperglycemia was the main cause of admission. During a median follow-up of 33.4 months, mortality rate in NKH patients was 40.9%, 30.2% in DK patients, 44.5% in DKA patients and 46.4% in DHS patients. Patients with DK had lower moratlity when compared with NKH patients (HR 0.63, 95% CI, 0.48 - 0.82; P = 0.0005). Patients with DKA had higher mortality than DK patients (HR 1.92, 95% CI 1.41 - 2.61, P<0.001). When compared with DK and DKA group, patients with NKH were older, had higher prevalence of heart, renal and liver failure, had impaired renal function and used less metformin and alcohol. Heart and renal failure were main negative prognostic factors, while the use of metformin and alcohol were main positive prognostic factors. Conclusion. The majority of patiets with DK and DKA have ŠBT2. DK and DKA are more common complications in patients with ŠBT2, when compared with DHS. Use of metformin and alcohol was associated with DK, which was assosciated with decreased all-cause mortality when compared with NKH and DKA. Lower prevalence of heart and renal failure in patients with DK may explain lower mortality rates. Prognostic factors associated with increased mortality in patients with DKA remain unknown

Endocrinological outcomes of pure endoscopic transsphenoidal surgery: a Croatian Referral Pituitary Center experience

AIM: To analyze early remission, complications, and pituitary function recovery after pure endoscopic endonasal transsphenoidal surgery (PEETS), a novel method in pituitary adenoma treatment. ----- METHODS: Testing of all basal hormone values and magnetic resonance imaging (MRI) were performed preoperatively and postoperatively (postoperative MRI only in nonfunctioning adenomas) in 117 consecutive patients who underwent PEETS in the period between 2007 and 2010. The series consisted of 21 somatotroph adenomas, 61 prolactinomas, and 4 corticotroph and 31 nonfunctioning adenomas. Sixty-three were macroadenomas and 54 were microadenomas. Remission was defined as hormonal excess normalization on the seventh postoperative day in functioning adenomas and as normal MRI findings approximately four months postoperatively in nonfunctioning adenomas. The presence of hypogonadism, growth hormone deficiency, and hypothyroidism was assessed on the seventh postoperative day. Hypocortisolism was assessed through necessity for replacement therapy within 18 months postoperatively. ----- RESULTS: Remission was achieved in 84% of patients: in 100% of microadenoma and 70% of macroadenoma patients (P<0.001, odds ratio [OR], 28.16, 95% confidence interval [CI], 1.61-491.36), respectively. Endocrinological complications occurred in 17.1% of patients: in 9% of microadenoma and 24% of macroadenoma patients (P=0.049, OR, 3.06; 95% CI, 1.03-9.08). Duration of empirical hydrocortisone replacement therapy was significantly shorter in microadenoma patients (P<0.001). Thirty-five percent of preoperatively present hormonal deficiencies improved after the surgery. Between tumor types there were no significant differences in remission, complications, and normal pituitary function recovery. ----- CONCLUSION: Patients with microadenomas had higher remission and lower complication rates following PEETS, emphasizing the necessity for early detection and treatment of pituitary adenomas. PEETS is a discussion-worthy method for microprolactinoma treatment

THE USE OF ORAL HYPOGLYCEMIC AGENTS IN CHRONIC KIDNEY DISEASE

Procjenjuje se da danas u svijetu oko 200 milijuna ljudi boluje od kronične bolesti bubrega (KBB). Najčešći uzrok nastanka KBB je šećerna bolest i njeni prateći komorbiditeti: povišeni krvni tlak te arterioskleroza. Dobra glukoregulacija može odgoditi nastanak KBB ili usporiti njegovu progresiju. U takvih se bolesnika često vrlo rano pribjegava prelasku na inzulinsku terapiju koja je učinkovita i sigurna, no dozu je potrebno redovito i adekvatno titrirati. Nasuprot tome, danas je na tržištu dostupan širok spektar peroralnih hipoglikemizantnih lijekova koji se mogu upotrebljavati u različitim stupnjevima KBB.It is estimated that 200 million people suffer from chronic kidney disease (CKD) worldwide. Diabetes mellitus and associated disorders of hypertension and arteriosclerosis are the most common causes. Appropriate glucoregulation may postpone its onset and/or progression. Although insulin is the most commonly used antidiabetic agent in CKD patients, nowadays there is a wide spectrum of oral antidiabetic agents that can be used safely and effectively across different stages of CKD

Initial weight loss after restrictive bariatric procedures may predict mid-term weight maintenance: results from a 12-month pilot trial

Background: Bariatric procedures are effective options for weight loss (WL) in the morbidly obese. However, some patients fail to lose any weight after bariatric surgery, and mid-term weight maintenance is variable. The aim of this study was to investigate whether initial WL could predict mid-term weight maintenance. ----- Methods: Eighty patients were enrolled, of whom 44 were treated with the BioEnterics Intragastric Balloon (BIB), 21 with laparoscopic adjustable gastric lap-banding (LAGB), and 15 with laparoscopic sleeve gastrectomy (LSG). Percentage of body WL and percentage of excess weight loss (EWL) were calculated at baseline and after 1, 3, 6, and 12 months. Successful WL was defined as EWL >20% for patients treated with BIB and >50% for patients treated with LAGB and SG. ----- Results: Success in the 6th and 12th month was achieved in 80% and 58% of patients in the BIB group, 33% and 40% in the LAGB group, and 60% and 73% in the LSG group. In the BIB group, WL in the 1st month correlated positively with WL at the 6th and 12th month, and an initial WL >6.5% best predicted success (sensitivity 50%, specificity 80%). A similar association was observed in the LAGB group at the 6th and 12th month and an initial WL >9.4% best predicted success (sensitivity 90.0%, specificity 81.2%). In patients treated with LSG, WL in the 3rd month correlated positively with EWL at the 6th and 12th month, with a cutoff value of 17% (sensitivity 66.7%, specificity 100%). ----- Conclusions: WL in the 1st month in patients treated with BIB and LAGB and WL in the 3rd month in patients treated with LSG could be used as a prognostic factor to predict mid-term weight maintenance

Validation of diabetes knowledge questionnaire in Croatian with assessment of diabetes knowledge and quality of life in patients with type 2 diabetes mellitus

Background. Diabetes mellitus (DM) is one of the biggest challenges in global healthcare and society in general. Assessment of the patient’s level of knowledge regarding diabetes is an important step in adapting group education programs to achieve better treatment outcomes. The aim of this study was to validate Diabetes Knowledge Questionnaire (DKQ) in Croatian language, to evaluate knowledge about diabetes and examine the relationship between knowledge and quality of life among type 2 DM patient’s in Croatia.Methods. The study was conducted as a cross-sectional study on 500 subjects. Validation of DKQ questionnaire in Croatian language was done using forward-backward method and internal consistency was examined using Cronbach’s Alpha. Quality of life was assessed using WHOQOL-BREF Questionnaire.Results. Good reliability and internal consistency of DKQ was confirmed (a = 0,740). Overall knowledge about diabetes was satisfactory (average DKQ score was 12,13). Longer duration of disease and previous education about diabetes were observed as predictive factors of better knowledge. No association was found between diabetes knowledge and quality of life.Conclusions. Our study confirms that DKQ is a good tool for assessing diabetes knowledge in Croatian language. Patients with DM demonstrated good diabetes knowledge but education in areas of self-care and nutrition needs to be improved which may increase quality of life

Ishemijska apopleksija hipofize, hipopituitarizam i dijabetes insipidus: trijada specifična za nekrotizirajući hipofizitis

A rare case of necrotizing hypophysitis (NH) in a 52-year-old man presenting with pituitary apoplexy and sterile meningitis is described. This case indicates that the diagnosis of NH could be made without biopsy, based on concomitant presence of diabetes insipidus, hypopituitarism and radiologic features of ischemic pituitary apoplexy. Conservative management of pituitary apoplexy should be advised in NH. Additionally, this is the first report of a case of sterile meningitis caused by ischemic pituitary apoplexy.Autori prikazuju rijedak slučaj nekrotizirajućeg hipofizitisa u 52-godišnjeg muškarca koji se inicijalno prezentirao apopleksijom hipofize i sterilnim meningitisom. Ovaj slučaj ukazuje na mogućnost da je dijagnozu nekrotizirajućeg hipofizitisa moguće postaviti i bez biopsije ako postoji patognomonična trijada ovoga sindroma: dijabetes insipidus, hipopituitarizam i radiološki znakovi ishemijske apopleksije hipofize. Dodatno, ovo je prvi opisani slučaj sterilnog meningitisa uzrokovanog ishemijskom apopleksijom hipofize

Hipopituitarizam uzrokovan metastazom supraglotičnog karcinoma larinksa u hipofizu: prikaz slučaja

Intracranial metastases from laryngeal carcinoma are rarely clinically diagnosed. To our knowledge, this is the first report of hypopituitarism due to pituitary metastasis from laryngeal carcinoma. We report on a 70-year-old man who had a supraglottic squamous cell carcinoma, which was resected surgically followed by local full dose radiation therapy. Four months later, he presented with a sudden onset of diplopia, syncope, headache, general malaise and loss of appetite. Magnetic resonance imaging of the brain revealed a tumorous process of the sellar region. Endocrinological tests disclosed the presence of hypopituitarism. The tumor was subtotally resected endoscopically via endonasal transsphenoidal approach. Histopathology of tumor specimens indicated squamous cell carcinoma. Tumors of the sellar and parasellar region as in the case presented may easily be confused with pituitary adenoma. Pituitary metastases should be considered on differential diagnosis of unusual pituitary tumors, especially in patients with as well as in those without a history of malignant disease.Intrakranijske metastaze karcinoma larinksa se rijetko dijagnosticiraju. Prema našim spoznajama, ovo je prvi zabilježeni slučaj hipopituitarizma uzrokovanog metastazom karcinoma larinksa u hipofizu. Prikazujemo slučaj muškarca u dobi od 70 godina kojemu je dijagnosticiran supraglotički planocelularni karcinom larinksa koji je kirurški uklonjen te je provedena lokalna radioterapija u punoj dozi. Četiri mjeseca kasnije javljaju se naglo nastale dvoslike, glavobolja, sinkopa, opća slabost i gubitak apetita. Učinjena je MR mozga te je otkriven tumorski proces selarne i paraselarne regije. Endokrinološkim testovima otkriveno je postojanje hipopituitarizma. Tumor je djelomice odstranjen endonazalnim transsfenoidnim pristupom. Patohistološki nalaz pokazao je planocelularni karcinom. Tumori selarne i paraselarne regije, kao u ovom slučaju, lako se zamijene za adenom hipofize. Metastaze u hipofizu bi trebalo razmotriti u diferencijalnoj dijagnozi neobičnih tumora hipofize, pogotovo u bolesnika s poviješću maligne bolesti, ali također i u onih bez nje

Treatment approach to type 2 diabetes: past, present and future

Type 2 diabetes mellitus (DM) is a lifelong metabolic disease, characterized by hyperglycaemia which gradually leads to the development and progression of vascular complications. It is recognized as a global burden disease, with substantial consequences on human health (fatality) as well as on health-care system costs. This review focuses on the topic of historical discovery and understanding the complexity of the disease in the field of pathophysiology, as well as development of the pharmacotherapy beyond insulin. The complex interplay of insulin secretion and insulin resistance developed from previously known "ominous triumvirate" to "ominous octet" indicate the implication of multiple organs in glucose metabolism. The pharmacological approach has progressed from biguanides to a wide spectrum of medications that seem to provide a beneficial effect on the cardiovascular system. Despite this, we are still not achieving the target treatment goals. Thus, the future should bring novel antidiabetic drug classes capable of acting on several levels simultaneously. In conclusion, given the raising burden of type 2 DM, the best present strategy that could contribute the most to the reduction of morbidity and mortality should be focused on primary prevention

Ilealna hernijacija kroz foramen Winslow: prejedanje kao rizični čimbenik unutarnje hernije

Internal hernias have an overall incidence of less than 1% and are difficult to diagnose clinically due to their nonspecific presentation. Most internal hernias present as strangulating closed-loop obstruction and delay in surgical intervention is responsible for a high mortality rate (49%). We present a case of ileal herniation through the foramen of Winslow. A 29-year-old previously healthy female presented with acute onset right upper quadrant pain, abdominal fullness, and nausea. The pain was sudden in onset and began shortly after a dinner party where she consumed larger portions of food. Laboratory investigations revealed mild leukocytosis with left shift. Dual-phase multi-detector computed tomography disclosed herniation of the small bowel into the lesser sac. The patient underwent an emergency median laparotomy that revealed ileal herniation through the foramen of Winslow. Adhesiolysis and manual reduction of the bowel was performed, and the reduced bowel showed only congestive changes. The postoperative recovery was uneventful and the patient was discharged on the third postoperative day. Risk factors for internal herniation still remain unclear, although excessively mobile bowel loops and an enlarged foramen of Winslow have been described. Our case demonstrated that overeating could be an additional risk factor for internal herniation. We describe our clinical and radiology findings, as well as surgical management. Due to the high rates of morbidity and mortality, it is imperative that clinicians be aware of the possible risks factors for internal herniation. Internal hernias should be included in the differential diagnosis of small bowel obstruction so that appropriate steps can be made in the work-up of these patients, followed by timely surgical intervention.Ukupna incidencija unutarnjih hernija manja je od 1%, a zbog njihove nespecifične prezentacije otežano je postavljanje kliničke dijagnoze. Većina unutarnjih hernija prezentira se kao strangulirajuće opstrukcije zatvorene petlje, a nepravodobna kirurška intervencija odgovorna je za visoku stopu smrtnosti (49%). U našem radu predstavljamo slučaj ilealne hernijacije kroz foramen Winslow. Dvadesetdevetgodišnja prethodno zdrava žena primljena je zbog akutnog nastupa boli locirane u desnom gornjem trbušnom kvadrantu praćene mučninom i osjećajem nadutosti. Bol je nastupila iznenadno, nedugo nakon večere gdje je konzumirala veću količinu hrane. Laboratorijske pretrage pokazale su blagu leukocitozu sa skretanjem ulijevo. Nativnim abdomenom vizualizirani su aerolikvidni nivoi, a višeslojnom kompjutorskom tomografijom prikazana je hernijacija tankog crijeva u omentalnu bursu. Bolesnica je podvrguta hitnoj medijanoj laparotomiji kojom je vizualizirana ilealna hernijacija kroz foramen Winslow. Odstranjene su priraslice s tankoga crijeva koje je pokazivalo promjene kongestivnog tipa. Poslijeoperacijski tijek protekao je uredno te je bolesnica otpuštena kući trećeg dana poslije operacije. Međutim, čimbenici rizika za unutarnje hernijacije još uvijek ostaju nepoznati. Neki od mogućih čimbenika rizika su povećana mobilnost crijevnih vijuga i povećan foramen Winslow. Naš slučaj pokazuje da i prejedanje može biti potencijalni dodatni rizični čimbenik za unutarnje hernijacije. U radu prikazujemo kliničke i radiološke pokazatelje, kao i samu kiruršku intervenciju. Zbog visoke stope pobola i smrtnosti veoma je važno da liječnici budu svjesni mogućih rizičnih čimbenika za pojavu unutarnje hernijacije. U diferencijalnu dijagnostiku opstrukcija tankog crijeva svakako bi trebalo uključiti i unutarnje hernije kako bi se mogle provesti odgovarajuće mjere pri obradi bolesnika te pravodobna kirurška intervencija

Karcinoid želuca tipa 1 u bolesnika s autoimunim poliglandularnim sindromom zahtijeva dodatne endokrinološke pretrage

Autoimmune polyglandular syndrome by definition consists of two or more endocrinological insufficiencies or two organ specific autoimmune diseases. There are no stringent criteria for endocrinological evaluation of patients with one endocrine insufficiency. However, detailed endocrinological evaluation should be undertaken in patients with two autoimmune diseases. Additionally, follow up thereafter should be a must in these patients in order to avoid the possibility of not diagnosing subsequent autoimmune diseases that can occur. The aim of this case report is to point to the necessity of endocrinological screening to be made in patients presenting with gastric carcinoid type 1. We report on a 62-year-old woman who was diagnosed with primary hypothyroidism in 1993. In 2011, she was re-admitted to the hospital due to increasing fatigue. Macrocytic anemia, low vitamin B12 levels and positive parietal antibodies confirmed pernicious anemia. Furthermore, she underwent gastroscopy, which revealed two polyps in the corpus of the stomach and one in the fornix. Endoscopic mucosal resection was performed and histopathologic analysis confirmed three G1 gastric carcinoids (Ki67 2%). Additional endocrinological evaluation disclosed positive glutamic acid decarboxylase antibodies, but normal fasting and postprandial glucose and HbA1c. In 2013, she was diagnosed with glucose intolerance and subsequently with latent autoimmune diabetes of adulthood. Plasma glucose and HbA1c normalized after dietary intervention. Due to the increase of serum chromogranin A, prophylactic antrectomy was performed in 2014. The patient is still followed-up and has normal chromogranin A, gastrin and HbA1c levels.Autoimuni poliglandularni sindrom čine dvije ili više endokrinih insuficijencija ili najmanje dvije za organ specifične autoimmune bolesti. Ne postoje jasne smjernice za endokrinološko testiranje i praćenje bolesnika s jednom endokrinom insuficijencijom. Bolesnici s dvije endokrine insuficijencije ili za organ specifične autoimmune bolesti trebaju detaljnu endokrinološku obradu kako bi se isključila mogućnost postojanja treće autoimmune bolesti. Cilj ovoga prikaza slučaja jest naglasiti nužnost dodatne endokrinološke obrade u bolesnika s karcinoidom želuca tipa 1. Prikazujemo slučaj bolesnice kojoj je godine 1993. otkrivena primarna hipotireoza. Godine 2011. bolesnica je hospitalizirana zbog izražene opće slabosti i malaksalosti. Makrocitna anemija, nizak vitamin B12 i pozitivna protutijela na parijetalne stanice potvrdili su dijagnozu perniciozne anemije. Gornjom endoskopijom probavnog trakta otkrivena su dva polipa u korpusu i jedan u forniksu želuca. Nakon endoskopskog ultrazvuka učinjena je endoskopska mukozektomija svih triju polipa. Patohistološka analiza potvrdila je karcinoide gradusa 2 (Ki67 2%). Dodatnim endokrinološkim testiranjem otkrivena su povišena protutijela na dekarboksilazu glutamata uz uredne vrijednosti glukoze u plazmi i HbA1c. Godine 2013. otkrivena je intolerancija glukoze te je postavljena dijagnoza latentnog autoimunog dijabetesa odrasle dobi. Glukoza u plazmi se normalizirala nakon higijensko-dijetetskih mjera. Zbog porasta kromogranina A u serumu učinjena je antrektomija godine 2014. Bolesnica sad ima uredan kromogranin A, gastrin i HbA1c