»Clinical significance of mutations in the calreticulin gene (CALR) in patients with myeloproliferative neoplasms«

Uvod: V septembru 2013 je bila pri večini bolnikov, ki nimajo mutacije v genu JAK2 V61F in MPL (JAK2 V617F- in MPL-negativni bolniki) z esencialno trombocitemijo (ET) ugotovljena somatska mutacija v genu za kalretikulin (CALR). Prepoznana je bila tudi pri nekaterih bolnikih z drugimi podvrstami mieloproliferativnih novotvorb (MPN). Do sedaj je bilo prepoznanih več kot 50 različnih mutacij CALR, skoraj izključno gre za mutacije, ki povzročajo premik bralnega okvirja, in vodijo v nastanek novega C-terminalnega peptida. Glede na sodobne smernice Svetovne zdravstvene organizacije ima mutacija CALR pri ugotovitvi bolezni ET pomembno diagnostično vlogo. Diferencialna diagnoza ET je široka in poleg nekaterih drugih hematoloških bolezni vključuje različne bolezni in stanja, kot so pomanjkanje železa, okužba, vnetje, stanja po kirurških posegih ali splenektomiji. Takšna trombocitoza je sekundarna in za razliko od ET ni povezana s povečanim tveganjem za trombotično-hemoragične zaplete. Ločevanje med ET in sekundarno trombocitozo je pogosto težavno, saj ne poznamo patognomoničnega pokazatelja ET, z znanimi molekularno-genetskimi kazalci bolezni pa bolezen ugotovimo le pri približno 90 % bolnikov. V Sloveniji je določanje mutacije CALR pri bolniki s sumom na MPN v rutinski rabi šele zadnjih nekaj let, zato prisotnost mutacije CALR pri vseh naših bolnikih, ki smo jih v preteklosti obravnavali zaradi suma na MPN, ni poznana. Namen: Retrospektivno potrditi diagnostično vrednost določanja mutacije CALR pri bolnikih s sumom na MPN. Oblikovati temelje za izdelavo diagnostičnega algoritma obravnave bolnikov s trombocitozo in sumom na ET. Materiali in metode: Vključili smo JAK2 V617F-negativne bolnike, ki so bili zaradi suma na MPN napoteni v Hematološko ambulanto Univerzitetnega kliničnega centra Ljubljana med letoma 2011 in 2016. Pri vseh bolnikih smo določali prisotnost mutacij v genu CALR iz periferne krvi ali kostnega mozga. Pri tem smo uporabili presejalno metodo visokoločljivostne talilne analize, rezultate smo potrdili z elektroforezo na gelu. Tip mutacije smo natančno opredelili, pri čemer smo pri bolnikih brez najpogostejših mutacij uporabili metodo sekvenciranja po Sangerju. Po potrditvi mutacij v genu CALR smo pri bolnikih glede na razpoložljive klinične in laboratorijske podatke ponovno ugotavljali in določali bolezen. Po izvedbi preverjanja prisotnosti mutacij CALR smo med vsemi vključenimi bolniki opredelili bolnike, ki so bili v Hematološko ambulanto napoteni zaradi trombocitoze, in ob tem suma na ET. Glede na razpoložljive podatke z obravnav v Hematološki ambulanti smo bolnike razvrstili na bolnike s primarno in bolnike s sekundarno trombocitozo. Bolnike, ki imajo mutacijo CALR (CALR-pozitivne bolnike), in bolnike, ki nimajo mutacije CALR (CALR-negativne bolnike) z domnevno ET smo primerjali po pogostnosti trombotičnih zapletov. Pri bolnikih, napotenih v Hematološko ambulanto zaradi trombocitoze, smo opredelili bolnike, pri katerih je ekspertni sistem »Smart Blood Analytics« (SBA) ugotavljal bolezen s šifro D47 po Mednarodni klasifikaciji bolezni (MKB) (druge neoplazme negotovega ali neznanega značaja limfatičnega, krvotvornega in sorodnega tkiva), kamor sodi tudi ET, kot najverjetnejšo diagnozo. Ugotavljali smo občutljivost, specifičnost, pozitivno in negativno napovedno vrednost SBA pri napovedovanju ET pri bolnikih, napotenih v Hematološko ambulanto zaradi trombocitoze. Rezultati: Med 524 JAK2 V617F- negativnimi bolniki, ki so bili napoteni v Hematološko ambulanto zaradi suma na MPN, smo prepoznali 23 CALR-pozitivnih bolnikov (23/524 = 4,4 %). Pri devetih bolnikih smo retrospektivno potrdili ET. Pri dveh bolnikih smo odkrili prisotnost mutacije CALR brez premika bralnega okvirjapri nobenem od obeh bolnikov nismo diagnosticirali ET. Štiri mutacije, ki smo jih potrdili v naši raziskavi, doslej v literaturi še niso bile opisane, in so novo-ugotovljene. 237 bolnikov je bilo napotenih v Hematološko ambulanto zaradi trombocitoze, zaradi manjkajočih podatkov smo jih razvrstili 231. Primarno trombocitozo smo ugotovili pri 51 bolnikih. 42 bolnikov smo opredelili kot bolnike z domnevno ET. Pri 9 bolnikih so bile v ozadju druge hematološke bolezni, pri katerih je lahko prisotna trombocitoza. Pri 180 bolnikih je bila ugotovljena sekundarna trombocitoza. Najpogostejši vzrok sekundarne trombocitoze je bilo pomanjkanje železa. CALR-pozitivni bolniki z domnevno ET niso imeli značilno manj pogostih trombotičnih zapletov kot CALR-negativni bolniki z domnevno ET (p=0,374). Med slednjimi so bili, z izjemo enega bolnika, bolniki brez mutacij JAK2 V617F, CALR in MPL (trojno negativni bolniki). Pozitivna napovedna vrednost ekspertnega sistema SBA pri ugotavljanju ET pri bolnikih s trombocitozo je bila 23,7 %, negativna napovedna vrednost je bila 88,1 %. Občutljivost testa je bila 69 %, specifičnost je bila 50,7 %. Pri tem smo kot bolnike z ET upoštevali vse bolnike z domnevno ET. Ob upoštevanju le bolnikov s potrjeno ET po kriterijih SZO 2008 ali modificiranih kriterijih SZO je bila pozitivna napovedna vrednost ekspertnega sistema pri ugotovitvi bolezni D47 po MKB 14,8 %, negativna napovedna vrednost je bila 96,3 %. Občutljivost testa je bila 81,8 %, specifičnost je bila 50,2 %. Zaključek: Molekularno-genetska diagnostika je smiselna pri bolnikih, pri katerih je glede na anamnezo, klinični pregled in laboratorijske preiskave sum na MPN visok. V naši raziskavi smo odkrili štiri doslej še neprepoznane mutacije CALR. Večina napotitev v Hematološko ambulanto zaradi suma na ET je neustreznih. Pred napotitvijo v Hematološko ambulanto je potrebno izključiti najpogostejša stanja, ki lahko povzročajo trombocitozo. Glede na našo raziskavo je v naši populaciji najpogosteje spregledano pomanjkanje železa, ki je lahko prisotno kljub odsotnosti anemije. Trojno negativne bolnike z vztrajajočim sumom na ET bi morali zaradi primerljivega tveganja za trombotične zaplete v primerjavi s CALR-pozitivnimi bolniki obravnavati, kot da imajo ET. Te bolnike bi morali obravnavati individualno in glede na tveganje za trombotične zaplete zaščititi vsaj z acetilsalicilno kislino. SBA je manj učinkovit pri ugotavljanju ET kot hematolog.Introduction: In September 2013 somatic mutations in the calreticulin gene (CALR) were recognised in most JAK2 V617F- and MPL-negative patients with ET. CALR mutations have also been recognised in patients with other myeloproliferative neoplasm (MPN) subtypes. Up to this date, more than 50 CALR mutations have been confirmed, almost all are frameshift mutations that result in a novel C-terminal peptide. Based on the renewed World Health Organisation (WHO) criteria, CALR mutations are an important diagnostic hallmark of MPN. The differential diagnosis of ET is broad and apart from other haematological diseases includes different diseases and states such as iron deficiency, infection, inflammation, postsurgical period, hyposplenism. Thrombocytosis that results from other diseases and states is called secondary thrombocytosis and does not represent an increased risk for thrombo-haemorrhagic complications. The distinction between primary and secondary thrombocytosis is often difficult as there are no specific markers of ET. Today we can recognise the disease based on molecular-genetic markers in about 90% of all patients. In Slovenia, CALR mutations have only routinely been searched for in patients with suspected MPN in the past few years. Therefore, CALR genetic status in all patients with suspected MPN in our population in the past is unknown. Aim: To retrospectively confirm the diagnostic importance of CALR mutation confirmation in patients with suspected MPN. To form a scientific basis for the diagnostic approach to patients with suspected ET. Materials and methods: JAK2 V617F-negative patients with suspected MPN that were referred to the Department of Haematology between 2011 and 2016 were included in the study. CALR mutations were tested in all patients from blood or bone marrow samples. The screening method was »high resolution melting« analysis. All results were confirmed by gel electrophoresis. Types of CALR mutations were defined. Sanger sequencing was used in all patients’ samples with non-typical mutations. Based on CALR mutation confirmation all patients were re-diagnosed based on the available clinical and laboratory data. After CALR mutation confirmation we further analysed only patients with thrombocytosis and suspected ET. Based on the available clinical and laboratory data patients with primary and secondary thrombocytosis were defined. The number of thrombotic complications were compared in CALR-positive and CALR-negative patients with suspected ET. Artificial intelligence programme »Smart Blood Analytics« (SBA) was used to define patients with thrombocytosis whose most probable diagnosis after the initial presentation at the Department of Haematology was D47 based on International Classification of Diseases (ICD) (Other neoplasms of uncertain or unknown behaviour of lymphoid, haematopoietic and related tissue). D47 includes the diagnosis of ET. Sensitivity, specificity, positive and negative predictive values of SBA programme in diagnosing D47 in patients with thrombocytosis were defined. Results: 23 (23/524 = 4.4%) CALR-positive patients with suspected MPN were discovered. In nine patients ET was retrospectively confirmed according to modified WHO criteria. In two patients in-frame CALR mutations were confirmed, none of these patients were diagnosed with ET. We discovered four novel mutations in our study that have previously not been described. 237 patients were referred to the Department of Haematology due to thrombocytosis, due to missing data 231 patients were analysed. Primary haematological disease was confirmed in 51 patients. 42 patients were diagnosed with suspected ET and 9 patients were diagnosed with other haematological diseases. In 180 patients secondary thrombocytosis was confirmed. The most common cause of secondary thrombocytosis was iron deficiency. Thrombotic complications were not significantly less common in CALR-positive patients compared to CALR-negative patients with suspected ET (p=0.374). CALR-negative patients with suspected ET were triple negative patients (JAK2 V617F, CALR and MPL- negative) with the exception of one patient. Positive predictive value of SBA in D47 prediction was 23.7%, negative predictive value was 88.1%. The sensitivity of the test was 69% and the specificity was 50.7%. As patients with ET we included all patients with suspected ET. By including only patients with WHO 2008 or modified WHO criteria confirmed disease the positive predictive value was 14.8% and negative predictive value 96.3%. The sensitivity of the test was 81.8% and the specificity was 50.2%. Conclusion: Molecular-genetic testing should be reserved for patients with suspected MPN based on patient’s history, clinical examination and blood results. In our study, four novel CALR mutations were discovered that have yet not been presented in the literature. Before referral to the Department of Haematology patients should be screened for the most common causes of thrombocytosis. Based on our results iron deficiency is most commonly unrecognized as it can be present even in the absence of anaemia. Triple negative patients with suspected MPN should be considered as patients with ET as their thrombotic risk can be compared to the risk of CALR-positive patients. These patients should be treated at least with acetylsalicylic acid based on their individual risk for thrombotic complications. SBA is not as efficient in diagnosing ET as a haematologist

VIDEO SURVEILLANCE

Optične oči video kamer so postale del naših vsakodnevnih življenj. Jemljemo jih kot nekaj skorajda samoumevnega povsod, kjer se kažejo interesi lastnine, zaščite, nadzora, umetnosti, zabave, navigacije. Vendar video kamere niso naravna in samoumevna entiteta naših življenj. Tako kot vsaka tehnologija, je tudi video nadzor zaznamovan z vrednotami, prilagojen institucijam in družbenim dogodkom. Hipoteza diplomske naloge je, da opazovanje spremeni opazovano (predvsem, kadar ne vemo, kdo nas opazuje in kdaj) in da posledično do nadzornih video kamer ne moremo biti ravnodušni. Danes postaja video nadzor sporen predvsem zaradi baz osebnih podatkov, ki se tvorijo z njihovimi posnetki. Ker video kamere posegajo v spolzek teren meje med zasebnim in javnim, je namen naloge (preko orisa zgodovinskega loka, ki je pripeljal do nadzora množic, kot ga poznamo danes) osvetliti področja, na/v katerih se s posluževanjem video nadzora intenzivneje zbirajo osebni podatki, ter se premika meja razumevanja zasebnega prostora. Rezultat raziskave je zemljevid pokritosti javno dostopnih površin mestnega centra Maribora z video kamerami, z namenom označiti predele oz. entitete, ki se Mariborčanom zdijo ustrezne posluževanja nadzornih oči video kamer in hkrati označiti področja, kjer se o mimoidočih intenzivneje zbirajo osebni podatki.Optical eyes of video cameras have become a part of our everyday lives. We grasp them as something almost self-evident where there are interests of property, protection, surveillance, art, leisure, navigation at hand. Nevertheless, video cameras are not a natural and self-evident entity of our lives. As any technology video surveillance is denoted with values, adapted to institutions and social events. Hypothesis of this paper is that observing changes what is being observed (above all when we don\u27t know who is watching us and when) and hence we cannot be indifferent to surveillance cameras. Video surveillance is considered to be disputable mostly because of databases, which can be made from its usage. Taking into account that surveillance cameras shift borders between public and private, the purpose of this paper is (through outline of historical arch, which has led to mass surveillance as we know it today) to highlight the areas in which the collection of personal data is more intensive and the understanding of public and private is being shifted. Result of the research is a map of publicly accessible areas of Maribor\u27s city center, showing the coverage with video surveillance cameras. The purpose was to mark the areas, which the citizens of Maribor consider to be suitable for the control from eyes of cameras and at the same time marking the areas in which personal data is more intensively collected

Independent investigative mechanisms and the usefulness of their reports before the International criminal court

Vse več oboroženim konfliktom v svetu sledi ustanavljanje preiskovalnih komisij in neodvisnih preiskovalnih mehanizmov, da bi ugotovili dejstva in ukrepali proti nekaznovanosti storilcev. Mednarodne organizacije, kot npr. Organizacija združenih narodov (OZN) in njeni organi - Varnostni svet, Generalna skupščina in Svet za človekove pravice, ter Organizacija za varnost in sodelovanje v Evropi (OVSE), s pomočjo preiskovalnih komisij, misij za ugotavljanje dejstev in neodvisnih preiskovalnih mehanizmov, obravnavata resne kršitve človekovih pravic v državah. Neodvisni preiskovalni mehanizmi so izjemno pomembni zaradi svoje večplastne vloge pri spodbujanju odgovornosti storilcev kaznivih dejanj, preprečevanju nekaznovanosti in podpiranju pravne države in pravičnosti ter imajo ključno vlogo pri obravnavi kršitev človekovih pravic in spodbujanju zaupanja javnosti v institucije, kar posledično krepi zaupanje v upravljanje in pravni sistem. Neodvisna preiskovalna mehanizma za Sirijo in Mjanmar, na primer, na različne načine zagotavljata ključno podporo Mednarodnemu kazenskemu sodišču (MKS). Zbirajo in dokumentirajo dokaze v zvezi z vojnimi hudodelstvi in hudodelstvi zoper človečnost, s čimer lahko prispevajo k preiskavam MKS, ki deluje na podlagi načela komplementarnosti, kadar nacionalni sistemi ne morejo ali nočejo preganjati storilcev kaznivih dejanj. Hipoteza tega magistrskega diplomskega dela je: Poročila mednarodnih neodvisnih preiskovalnih mehanizmov so, odvisno od načina ustanovitve samega organa in njegovega delovanja, predvsem ob upoštevanju dokaznih standardov mednarodnega kazenskega pravosodja pri zbiranju dokazov, lahko sprejeta kot dokaz v postopkih pred MKS. Po uvodnem delu sledi analiza delovanja treh neodvisnih preiskovalnih mehanizmov – dveh mehanizmov OZN, to sta mehanizma za Sirijo in Mjanmar, ter mehanizma OVSE, to je Moskovskega mehanizma. Analizirana je njihova ustanovitev, njihovi mandati ter sodelovanje z drugimi mednarodnimi akterji. Sledi predstavitev faze potrditve obtožnice pred MKS in analiza njegove sodne prakse, da bi se potrdila hipoteza, da bodo poročila neodvisnih preiskovalnih mehanizmov lahko uporabljena kot dokaz v fazi potrditve obtožnice.More and more armed conflicts around the world are being followed by the establishment of commissions of inquiry and independent investigative mechanisms to establish the facts and act against impunity for perpetrators. International organisations such as the United Nations (UN) and its organs - the Security Council, the General Assembly and the Human Rights Council, as well as the Organisation for Security and Cooperation in Europe (OSCE) - are addressing serious human rights violations in countries through commissions of inquiry, fact-finding missions and independent investigative mechanisms. Independent investigative mechanisms are extremely important because of their multifaceted role in promoting accountability of perpetrators, preventing impunity, upholding the rule of law and justice, as well as playing a key role in addressing human rights violations and promoting public confidence in institutions, which in turn strengthens trust in governance and the legal system. The Independent Investigative Mechanisms for Syria and Myanmar, for example, provide crucial support to the International Criminal Court (ICC) in a variety of ways. They collect and document evidence relating to war crimes and crimes against humanity, and can thus contribute to the ICC\u27s investigations, which operate on the basis of the principle of complementarity when national systems are unable or unwilling to prosecute perpetrators. The hypothesis of this Master\u27s thesis is: Depending on how the body itself is established and how it operates, and in particular taking into account the evidentiary standards of international criminal law in the collection of evidence, reports of international independent investigative mechanisms may be admissible as evidence in proceedings before the ICC. After the introduction, an analysis of the functioning of the three independent investigative mechanisms follows - the two UN mechanisms, i.e. the Syria and Myanmar mechanisms, and the OSCE mechanism, i.e. the Moscow Mechanism. Their establishment, their mandates and their cooperation with other international actors are analysed. This is followed by a presentation of the ICC\u27s confirmation of charges phase and an analysis of its jurisprudence in order to confirm the hypothesis that the reports of the independent investigative mechanisms can be used as evidence in the confirmation of charges phase

The contemporary approach to CALR-positive myeloproliferative neoplasms

CALR mutations are a revolutionary discovery and represent an important hallmark of myeloproliferative neoplasms (MPN), especially essential thrombocythemia and primary myelofibrosis. To date, several CALR mutations were identified, with only frameshift mutations linked to the diseased phenotype. It is of diagnostic and prognostic importance to properly define the type of CALR mutation and subclassify it according to its structural similarities to the classical mutations, a 52-bp deletion (type 1 mutation) and a 5-bp insertion (type 2 mutation), using a statistical approximation algorithm (AGADIR). Today, the knowledge on the pathogenesis of CALR-positive MPN is expanding and several cellular mechanisms have been recognized that finally cause a clonal hematopoietic expansion. In this review, we discuss the current basis of the cellular effects of CALR mutants and the understanding of its implementation in the current diagnostic laboratorial and medical practice. Different methods of CALR detection are explained and a diagnostic algorithm is shown that aids in the approach to CALR-positive MPN. Finally, contemporary methods joining artificial intelligence in accordance with molecular-genetic biomarkers in the approach to MPN are presented

Cirkuška pedagogika

Cirkuška pedagogika je en od medijev socialnopedagoškega dela. Elementi, ki sestavljajo to dejavnosti oz. so zanjo pomembni, so: gibanje, skupinska dejavnost, interaktivne igre, vse skupaj pa vodi velika mera ustvarjalnosti ter odprtost za raznolike naravnanosti vsakokratne skupine

Management of anticoagulant-related nephropathy

Background: Anticoagulant-related nephropathy (ARN) is a form of acute kidney injury that mainly occurs in patients with previously unrecognized glomerular disease in addition to excessive anticoagulation. Since a renal biopsy is not performed in most cases, the diagnosis is often presumptive. Methods: Here, we present the characteristics of a national Slovenian patient cohort with histologically verified ARN, from the first case in 2014 to December 2020, and a review of the current literature (Pubmed database). Results: In Slovenia, ARN has been detected in 13 patients, seven of whom were treated with coumarins, and others with direct oral anticoagulants. In seven patients, ARN appeared after excessive anticoagulation. As many as 11 patients had underlying IgA nephropathy. Similar to the global data presented here, the pathohistological impairment associated with pre-existing glomerulopathy was mild and disproportionate to the degree of functional renal impairment. The majority of our patients with ARN experienced severe deterioration of renal function associated with histological signs of accompanying acute tubular injury, interstitial edema, and occlusive red blood cell casts. These patients were treated with corticosteroids, which (in addition to supportive treatment and discontinuation of the anticoagulant drug) led to a further improvement in renal function. Conclusions: Anticoagulant therapy combined with a pre-existing glomerular injury may lead to ARN. In addition to discontinuation of the anticoagulant and supportive care, corticosteroids, which are currently listed in only a few cases in the world literature, may have a positive influence on the course of treatment. However, the benefits of steroid treatment must be weighed against the risk of complications, especially life-threatening infections

Transmission of pancreatic adenocarcinoma by a single multiorgan donor to two kidney transplant recipients: A case report

We present two cases of transmission of a pancreatic adenocarcinoma from a single donor to two kidney transplant recipients. Autopsy of the donor revealed a pancreatic adenocarcinoma that had already spread locally to the regional lymph nodes and had not been detected at the time of organ procurement. Both recipients were carefully monitored, as neither consented to graft nephrectomy. In one patient, the tumor was discovered on surveillance biopsy of the graft approximately 14 months after transplantation, and in the second patient, ultrasound-guided aspiration needle biopsy of a growing formation in the lower pole of the graft revealed poorly differentiated metastatic adenocarcinoma. Both patients were successfully treated with graft nephrectomy and complete discontinuation of immunosuppression. None of the follow-up imaging showed persistent or recurrent malignancy, and both patients were candidates for re-transplantation. These exceptional cases of donor-derived pancreatic adenocarcinoma suggest that removal of the donor organ and restoration of immunity may lead to complete recovery