Radiološka tehnologija u dijagnostici i liječenju melanoma

Melanom je zloćudni tumor pigmentnih stanica kože i sluznica te je jedan od najagresivnijih tumora u čovjeka sa specifičnim biološkim ponašanjem. Uz kiruršku terapiju, kemoterapiju te ciljanu i imunoterapiju, svoje mjesto u liječenju melanoma ima i radioterapija gdje je posebno važno istaknuti ulogu radiokirurgije u liječenju metastaza, osobito čestih moždanih metastaza. Ovisno o stadiju bolesti, radioterapija se može primijeniti kao primaran način liječenja, kao adjuvantna radioterapija melanoma ili adjuvantna radioterapija regionalnih limfnih čvorova te kao palijativna radioterapija kod inoperabilnih pacijenata. Budući da su rana dijagnostika i pravovremeno liječenje od neprocjenjive važnosti za bolesnika, prijeko je potreban timski pristup svih liječnika i zdravstvenih djelatnika koji sudjeluju u dijagnostici, terapiji i praćenju bolesnika. Radiološki tehnolog igra važnu ulogu, kako u dijagnostici, tako i u terapiji oboljelih od melanoma te se očekuje odgovoran i kvalitetan pristup u svakoj fazi susreta s pacijentom

Utjecaj pušenja na aktivnost bolesti u bolesnika s reumatoidnim artritisom - naša iskustva

The aim of this study was to investigate the association of smoking with disease activity, seropositivity, age and gender in patients with rheumatoid arthritis. We included 89 rheumatoid arthritis patients. All patients fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism rheumatoid arthritis classification criteria. Activity of the disease was measured by Disease Activity Score 28-joint count C-reactive protein (DAS28CRP). The subjects were stratified into smoking and non-smoking groups and cross-sectionally analyzed. There were 24 (27%) smokers and 65 (73%) nonsmokers. The mean age of patients was 57.1±8.8 years. The mean DAS28CRP was 5.81 in the smoking group and 5.57 in the non-smoking group, without statistically significant difference between the two groups (p=0.148). Similarly, smokers did not differ significantly from non-smokers according to age (p=0.443), gender (p=0.274), rheumatoid factor positivity (p=0.231), anti-citrullinated protein antibody positivity (p=0.754) or seropositivity (p=0.163). In this study, we found no association between smoking status and disease activity, seropositivity, age or gender in rheumatoid arthritis patients. Furthermore, disease activity was not related to age, gender or seropositivity. Additional studies on the effects of smoking on rheumatoid arthritis activity are needed.Cilj ovoga istraživanja bio je ispitati povezanost pušenja s aktivnošću bolesti, pozitivnim biokemijskim biljezima, dobi i spolom kod bolesnika s reumatoidnim artritisom. U istraživanju je sudjelovalo 89 ispitanika koji su bolovali od reumatoidnog artritisa. Svi ispitanici su ispunjavali klasifikacijske kriterije za postavljanje dijagnoze reumatoidnog artritisa Američkog reumatološkog društva i Europske reumatološke udruge (engl. European League Against Rheumatism, EULAR). Aktivnost bolesti mjerena je prema indeksu aktivnosti bolesti (engl. Disease Activity Score, DAS) koja se procjenjuje na 28 zglobova. Ispitanici su podijeljeni u dvije skupine (pušači i nepušači) koje su presječno analizirane. U ispitivanju je sudjelovalo 24 (27%) pušača i 65 (73%) nepušača. Srednja dob ispitanika bila je 57,1±8,8 godina. Srednje vrijednosti DAS28CRP u skupini pušača iznosile su 5,81, a u skupini nepušača 5,57, odnosno nije bilo statistički značajne razlike između dviju skupina (p=0,148). Također, skupina u kojoj su bili pušači nije se značajno razlikovala u parametrima dobi (p=0,443), spola (p=0,274), pozitivnog reumatoidnog faktora (p=0,231), pozitivnih anti-citrulinskih protutijela (p=0,754) ili seropozitivnosti (p=0,163) od skupine nepušača. U ovom istraživanju nismo pronašli povezanost između pušenja i aktivnosti bolesti, seropozitivnosti, dobi i spola kod bolesnika s reumatoidnim artritisom. Nadalje, aktivnost bolesti nije bila povezana s dobi, spolom i seropozitivnošću. Potrebna su daljnja istraživanja utjecaja pušenja na aktivnost reumatoidnog artritisa

ENTHESITIS AND DACTYLITIS – MANIFESTATIONS OF PSORIATIC ARTHRITIS

Entezitis i daktilitis važna su obilježja psorijatičnog artritisa (PsA) i negativno utječu na funkciju i kvalitetu života bolesnika sa PsA. Jaki biomehanički stres i citokini (interleukin 23/Th 17-put) uključeni su u patogenezu entezitisa i daktilitisa. Entezitis je rana lezija u PsA i može prethoditi sinovitisu. Dijagnoza entezitisa i daktilitisa zasniva se na kliničkom pregledu. Pri detekciji entezitisa senzitivniji od kliničkog pregleda jest pregled dijagnostičkim ultrazvukom uz uporabu Power Dopplera. Lijekovi usmjereni na TNF, IL-12/23, IL-17, IL-17R i PDE4 pokazuju učinkovitost pri liječenju entezitisa i daktilitisa u bolesnika sa PsA.Enthesitis and dactylitis are important manifestations of psoriatic arthritis (PsA) and have a negative impact on function and quality of life of PsA patients. High biomechanical stress and cytokines (interleukin-23/Th 17 pathway) are implicated in the pathogenesis of enthesitis and dactylitis. Enthesitis is an early lesion in PsA that may precede synovitis. Diagnosis of enthesitis and dactylitis is based on clinical assessment. Power Doppler ultrasound is more sensitive than physical exam for the detection of enthesitis. Drugs that target TNF, interleukin-17, interleukin-17R, interleukin-12/23, and PDE4 are eff ective for enthesitis and dactylitis

RAYNAUD’S PHENOMENON – FIRST SIGN OF MALIGNANCY: CASE REPORT

Raynaudov fenomen (RyF) je česti fenomen u općoj populaciji. Najčešće se javlja u zdravih pojedinaca u kojih se ne nalazi pridruženu bolest ili neki drugi uzrok RyF (primarni ili idiopatski RyF). Sekundarni RyF je čest uz reumatske bolesti (sistemsku sklerozu, sistemski eritemski lupus, primarni Sjogrenov sindrom, miješanu bolest vezivnog tkiva i dr.), okluzivne vaskularne bolesti, hematološke poremećaje, pri korištenju vibrirajućih alata te pri primjeni nekih lijekova, a rijetko uz maligne bolesti. Prikazujemo bolesnicu u koje je bolni RyF u trajanju od tri tjedna bio razlogom traženja pomoći u hitnoj internističkoj ambulanti, a nakon prijma u Kliniku dijagnostičkom je obradom utvrđen adenokarcinom pluća. U bolesnice su, u nižem titru, bila prisutna ANA i anti dsDNA protutijela te antikardiolipinska IgM i IgG protutijela. Poznato je da su u bolesnika s paraneoplastičkim reumatskim sindromima često prisutna antitijela, reumatoidni faktor ili antinuklearna antitijela (ANA) karakteristična za reumatske bolesti, što može navesti na krivi zaključak o eventualnoj sistemskoj bolesti vezivnog tkiva i u konačnici rezultirati kašnjenjem u postavljanju ispravne dijagnoze. Prva pojava RyF kao izoliranog simptoma u osoba starijih od 50 godina uz izrazite bolne znake ishemije tkiva, što je bio slučaj u naše bolesnice, ili kod pojave asimetričnog zahvaćanja prstiju, a posebice u muškaraca, bez obzira na prisutnost RF, ANA, anti dsDNA ili drugih autoantitijela, zahtijeva širu dijagnostičku obradu zbog moguće maligne bolesti.Raynaud’s phenomenon is a common phenomenon in the general population. It most commonly occurs in healthy individuals, in whom there is no associated illness or any other cause of Raynaud’s phenomenon (primary or idiopathic Raynaud’s phenomenon). Secondary Raynaud’s phenomenon is common with rheumatic diseases (systemic sclerosis, systemic lupus erythematosus, primary Sjögren’s syndrome, mixed connective tissue disease, etc.), occlusive vascular diseases, hematologic disorders, use of vibrating tools and use of some medications, and rarely with malignancy. We report on a patient who presented with a three-week history of painful Raynaud’s attacks, which was the reason for seeking assistance of internists in emergency clinic. Upon admission to the hospital and diagnostic work-up, adenocarcinoma of the lung was found. Antinuclear antibodies (ANA), anti-dsDNA antibodies, anticardiolipin IgM and IgG antibodies were present in a lower titer. It is known that rheumatoid factor or ANA characteristic of rheumatic disease are often present in patients with paraneoplastic rheumatic syndromes, which can lead to wrong conclusions about the possible systemic connective tissue diseases and ultimately delay the correct diagnosis. The first appearance of Raynaud’s phenomenon as an isolated symptom in people older than 50, with painful signs of ischemia, as in our patient, or the occurrence of asymmetric grasping fingers, especially in men, regardless of the presence of RF, ANA, anti-dsDNA or other autoantibodies, requires broader diagnostic evaluation for malignancy

Large vessel vasculitides

U vaskulitise velikih krvnih žila ubrajamo gigantocelularni i Takayasuov arteritis. Gigantocelularni arteritis najčešći je oblik vaskulitisa u odraslih na koji treba pomišljati u starijih osoba s novonastalom glavoboljom, poremećajima vida, polimijalgijom reumatikom i/ili vrućicom nejasnog uzroka. Glukokortikoidi su osnova liječenja. Takayasuov arteritis je kronični panarteritis aorte i njezinih glavnih grana koji se javlja u mladih osoba. Premda sve velike arterije mogu biti zahvaćene, najčešće su zahvaćene aorta, arterije subklavije i karotidne arterije. Najčešći simptomi su klaudikacije gornjih udova, hipertenzija, bol u području karotida (karotidinija), omaglice i poremećaji vida. Rana dijagnoza i liječenje značajno poboljšavaju ishod bolesti.Large vessel vasculitis includes Giant cell arteritis and Takayasu arteritis. Giant cell arteritis is the most common form of vasculitis affect patients aged 50 years or over. The diagnosis should be considered in older patients who present with new onset of headache, visual disturbance, polymyalgia rheumatica and/or fever unknown cause. Glucocorticoides remain the cornerstone of therapy. Takayasu arteritis is a chronic panarteritis of the aorta ant its major branches presenting commonly in young ages. Although all large arteries can be affected, the aorta, subclavian and carotid arteries are most commonly involved. The most common symptoms included upper extremity claudication, hypertension, pain over the carotid arteries (carotidynia), dizziness and visual disturbances. Early diagnosis and treatment has improved the outcome in patients with TA

RAYNAUD’S PHENOMENON – FIRST SIGN OF MALIGNANCY: CASE REPORT

Raynaudov fenomen (RyF) je česti fenomen u općoj populaciji. Najčešće se javlja u zdravih pojedinaca u kojih se ne nalazi pridruženu bolest ili neki drugi uzrok RyF (primarni ili idiopatski RyF). Sekundarni RyF je čest uz reumatske bolesti (sistemsku sklerozu, sistemski eritemski lupus, primarni Sjogrenov sindrom, miješanu bolest vezivnog tkiva i dr.), okluzivne vaskularne bolesti, hematološke poremećaje, pri korištenju vibrirajućih alata te pri primjeni nekih lijekova, a rijetko uz maligne bolesti. Prikazujemo bolesnicu u koje je bolni RyF u trajanju od tri tjedna bio razlogom traženja pomoći u hitnoj internističkoj ambulanti, a nakon prijma u Kliniku dijagnostičkom je obradom utvrđen adenokarcinom pluća. U bolesnice su, u nižem titru, bila prisutna ANA i anti dsDNA protutijela te antikardiolipinska IgM i IgG protutijela. Poznato je da su u bolesnika s paraneoplastičkim reumatskim sindromima često prisutna antitijela, reumatoidni faktor ili antinuklearna antitijela (ANA) karakteristična za reumatske bolesti, što može navesti na krivi zaključak o eventualnoj sistemskoj bolesti vezivnog tkiva i u konačnici rezultirati kašnjenjem u postavljanju ispravne dijagnoze. Prva pojava RyF kao izoliranog simptoma u osoba starijih od 50 godina uz izrazite bolne znake ishemije tkiva, što je bio slučaj u naše bolesnice, ili kod pojave asimetričnog zahvaćanja prstiju, a posebice u muškaraca, bez obzira na prisutnost RF, ANA, anti dsDNA ili drugih autoantitijela, zahtijeva širu dijagnostičku obradu zbog moguće maligne bolesti.Raynaud’s phenomenon is a common phenomenon in the general population. It most commonly occurs in healthy individuals, in whom there is no associated illness or any other cause of Raynaud’s phenomenon (primary or idiopathic Raynaud’s phenomenon). Secondary Raynaud’s phenomenon is common with rheumatic diseases (systemic sclerosis, systemic lupus erythematosus, primary Sjögren’s syndrome, mixed connective tissue disease, etc.), occlusive vascular diseases, hematologic disorders, use of vibrating tools and use of some medications, and rarely with malignancy. We report on a patient who presented with a three-week history of painful Raynaud’s attacks, which was the reason for seeking assistance of internists in emergency clinic. Upon admission to the hospital and diagnostic work-up, adenocarcinoma of the lung was found. Antinuclear antibodies (ANA), anti-dsDNA antibodies, anticardiolipin IgM and IgG antibodies were present in a lower titer. It is known that rheumatoid factor or ANA characteristic of rheumatic disease are often present in patients with paraneoplastic rheumatic syndromes, which can lead to wrong conclusions about the possible systemic connective tissue diseases and ultimately delay the correct diagnosis. The first appearance of Raynaud’s phenomenon as an isolated symptom in people older than 50, with painful signs of ischemia, as in our patient, or the occurrence of asymmetric grasping fingers, especially in men, regardless of the presence of RF, ANA, anti-dsDNA or other autoantibodies, requires broader diagnostic evaluation for malignancy

INFLUENCE OF BIOLOGICAL THERAPEUTICS ON PATIENT-REPORTED QUALITY-OF-LIFE OUTCOMES (WHOQOL-BREF), FUNCTIONAL SCORES AND DISEASE ACTIVITY AMONG CROATIAN PATIENTS WITH RHEUMATOID ARTHRITIS: OUR EXPERIENCE

Background: Rheumatoid arthritis (RA) is a chronic and disabling disease with a great impact on the quality of life (QOL). The aim of this study was to assess QOL and health in RA patients treated with biological disease-modifying drugs (bDMARDs) as opposed to those treated with conventional synthetic DMARDs (csDMARDs). We analysed four domains of QOL: physical health (D1), mental health (D2), social relationships (D3) and one\u27s surroundings (D4); as well as general quality of life (W1), general state of health (W2), and disease activity and physical disability. Subjects and methods: Seventy-seven RA patients (group A=29 on bDMARDs, group B= 48 on csDMARDs) were enrolled in the study. QOL was evaluated using WHO questionnaire (WHOQOL-BREF), disease activity using Disease ActivityScore28C-reactive protein (DAS28CRP) and functional status using Health Assessment Questionnaire (HAQ). Results: There was no statistically significant difference of mean values in the four domains of QOL, nor in the general QOL, between groups A and B. There was also no statistically significant difference regarding RA activity (3.51 vrs 3.54, p=0.56). However, we have found that the variable of the general state of health domain was statistically significantly higher in group B (2.66 vrs 2.89, p=0.001), while HAQ was statistically significantly higher in group A (1.19 vrs 1.07, p=0.018), as well as the duration of RA (6.25vrs 3.75 years, p=0.0006). Statistically significant correlation was found between HAQ and W2, disease duration and D3 in group A and DAS28CRP and D1, D2, W2 and HAQ and D1 and D2 in group B. Conclusion: These findings suggest that the inclusion of bDMARDs in the treatment regimen was overdue, with RA already advancing with developed functional disability, which prevented the achievement of the primary goals of treatment: low disease activity or remission and the improvement of patient\u27s QOL

Effectiveness of biologics in patients with rheumatoid arthritis – a single-center experience

Pri neučinkovitosti sintetskih lijekova koji modificiraju tijek bolesti (engl. disease-modifying antirheumatic drugs – DMARD s; u tekstu DMARD -i) u liječenju bolesnika s aktivnim reumatoidnim artritisom (RA ) možemo primijeniti jedan od bioloških ili biosličnih lijekova prema smjernicama Hrvatskoga reumatološkog društva iz 2013. godine. Unatoč postignutoj remisiji i boljoj kontroli bolesti primarna ili sekundarna neučinkovitost lijeka razvije se, prema literaturnim podacima, čak u 60% bolesnika. Radi utvrđivanja primarne odnosno sekundarne neučinkovitosti lijeka retrospektivno smo analizirali podatke bolesnika liječenih biološkim lijekovima u Zavodu za kliničku imunologiju, alergologiju i reumatologiju Klinike za unutarnje bolesti Medicinskog fakulteta Sveučilišta u Zagrebu, Kliničke bolnice Dubrava, od 2008. do 2016. god. Aktivnost bolesti praćena je indeksom DAS 28-CRP. U ispitivanje je bilo uključeno 88 bolesnika, 25 muškaraca i 63 žene. U 39 bolesnika (44%), 10 muškaraca i 29 žena, prvi biološki lijek zamijenjen je drugime. Od 39 bolesnika, njih 30 (77%) postiglo je remisiju na primijenjeni drugi biološki lijek, a u sedam bolesnika (18%) zbog neučinkovitosti lijeka uveden je treći biološki lijek, dok je u dva bolesnika uveden i četvrti, odnosno peti lijek. Najčešći razlog prekida primjene lijeka bila je klinička neučinkovitost (visoka aktivnost bolesti). Nismo pronašli statistički značajnu razliku u titru reumatoidnog faktora, anticitrulinskih protutijela ni pušačkog status.In the case of ineffectiveness of synthetic disease-modifying anti rheumatic drugs (DMARD s) in the treatment of patients with active rheumatoid arthritis (RA ), we can use one of the biological or biosimilar drugs according to the Croatian Society for Rheumatology guidelines from 2013. Despite the achieved remission and better disease control, according to literature data up to 60% of patients develop primary or secondary ineffectiveness of the drug. In order to determine primary or secondary ineffectiveness of the drug in our patients, we retrospectively analyzed data from patients treated with biological drugs at the Division of Clinical Immunology, Allergology, and Rheumatology of the Department of Internal Medicine of the University of Zagreb School of Medicine, Clinical Hospital Dubrava, in the period 2008–2016. The study included 88 patients, 25 men and 63 women. The activity of the disease was monitored using the DAS 28(CRP) index. In 39 patients (44%), 10 men and 29 women, the first biological drug was replaced with another. Out of these 39 patients, 30 (77%) achieved remission on the second line of treatment. Seven (18%) patients had to be given a third biological drug because of the ineffectiveness of the second drug, while two patients had to be given a fourth or fifth biological drug. The most common cause of discontinuation of the drug was clinical ineffectiveness, which means that the high activity of the disease was maintained. We did not find a statistically significant difference in the titer of rheumatoid factor (RF) and/or anti-citrulatory peptide (anti-CC P) or smoking status in patients treated with a single biological agent and those in which two or more biological drugs had to be used