Nutritivna potpora onkoloških bolesnika

The incidence of malnutrition in cancer patients treated in the intensive care unit (ICU) is significantly higher than in other patient groups. Hypermetabolism and increased energy requirements resulting from surgery further aggravate nutritional status in malnourished patients and increase the incidence of adverse events including infections, sepsis, wound dehiscence, tissue edema, decubitus and death. The estimation of nutritional status and nutritional needs, compensation for all energy requirements, including vitamin and mineral supplementation using parenteral, enteral or combination of both feeding techniques should become everyday practice in the ICU. Monitoring the success of treatment through laboratory test results and clinical status as well as early recognition of adverse effects of nutritional support minimize the frequency of complications resulting from nutritional therapy.Pojavnost pothranjenosti u bolesnika oboljelih od malignih bolesti koji se liječe u jedinicama intenzivnog liječenja (JIL) je znatno veća nego u drugim skupinama bolesnika. Hipermetabolizam i povećane energetske potrebe koji su posljedica operacijskog zahvata dodatno pogoršavaju nutritivni status u pothranjenih bolesnika i povećavaju učestalost neželjenih posljedica u vidu infekcija, sepse, dehiscijencije rana, edema tkiva, dekubitusa kao i smrtnost. Procjena nutritivnog statusa i nutritivnih potreba, nadoknada svih energetskih potreba, uz suplementaciju vitamina i minerala primjenom parenteralne, enteralne ili kombinacijom obaju tehnika prehrane nužno treba postati svakodnevna praksa u JIL-u. Praćenje uspješnosti liječenja kontrolom laboratorijskih nalaza i kliničkog statusa kao i rano prepoznavanje neželjenih učinaka nutritivne potpore minimaliziraju učestalost komplikacija koje su posljedica nutritivnog liječenja

Nutritivna potpora onkoloških bolesnika

The incidence of malnutrition in cancer patients treated in the intensive care unit (ICU) is significantly higher than in other patient groups. Hypermetabolism and increased energy requirements resulting from surgery further aggravate nutritional status in malnourished patients and increase the incidence of adverse events including infections, sepsis, wound dehiscence, tissue edema, decubitus and death. The estimation of nutritional status and nutritional needs, compensation for all energy requirements, including vitamin and mineral supplementation using parenteral, enteral or combination of both feeding techniques should become everyday practice in the ICU. Monitoring the success of treatment through laboratory test results and clinical status as well as early recognition of adverse effects of nutritional support minimize the frequency of complications resulting from nutritional therapy.Pojavnost pothranjenosti u bolesnika oboljelih od malignih bolesti koji se liječe u jedinicama intenzivnog liječenja (JIL) je znatno veća nego u drugim skupinama bolesnika. Hipermetabolizam i povećane energetske potrebe koji su posljedica operacijskog zahvata dodatno pogoršavaju nutritivni status u pothranjenih bolesnika i povećavaju učestalost neželjenih posljedica u vidu infekcija, sepse, dehiscijencije rana, edema tkiva, dekubitusa kao i smrtnost. Procjena nutritivnog statusa i nutritivnih potreba, nadoknada svih energetskih potreba, uz suplementaciju vitamina i minerala primjenom parenteralne, enteralne ili kombinacijom obaju tehnika prehrane nužno treba postati svakodnevna praksa u JIL-u. Praćenje uspješnosti liječenja kontrolom laboratorijskih nalaza i kliničkog statusa kao i rano prepoznavanje neželjenih učinaka nutritivne potpore minimaliziraju učestalost komplikacija koje su posljedica nutritivnog liječenja

Citologija u dijagnozi raka jajnika

Cytology has so far been underutilized as a modality for the primary diagnosis of ovarian cancer. Lately the outlookon fi ne needle aspiration cytology (FNAC) has greatly shifted. With the availability of modern techniques, USG and CT guided FNAC is becoming an optimum modality for the diagnosis of primary and metastatic ovarian neoplasms and evaluation of recurrent malignant tumors, which consequently has a great impact on patient management. The most common indication for peritoneal washing cytology is staging or upstaging of ovarian carcinomas (First - look). Second - look procedures nare performed in patients previously treated by surgery, radiotherapy and/or chemotherapy to determine the presence of residual or recurrent ovarian cancer. In both procedures cytology has proven itself as a useful diagnostic method.Kao dijagnostička metoda, citologija je do nedavno bila nedovoljno uključena u primarnu dijagnostiku raka jajnika. No, u novije se vrijeme stav prema aspiracijskoj citologiji tankom iglom jasno mijenja. Uz dostupne suvremene tehnologije, ultrazvukom i CT-om vođena citološka punkcija postaje optimalna metoda za dijagnozu primarnih i metastatskih novotvorina jajnika, te za rano otkrivanje relapsa maligne bolesti. Time se citologija izravno upliće i u management liječenja pacijenta. Citološka pretraga ispirka trbušne šupljine najčešće je indicirana u određivanju stadija karcinoma jajnika (tz v. „prvi pogled“). Zahvati tz v. „drugog pogleda“ izvode se na bolesnicima koji su prethodno tretirani kirurški, zračenjem i/ili kemoterapijom da bi se odredila ostatna bolest ili recidiv karcinoma jajnika. U oba navedena slučaja („prvi i drugi pogled“) citologija se dokazala kao korisna dijagnostička metoda

Karcinomska bol i terapija

Cancer pain is not a homogenous and clearly understood pathological process. The best treatment is a combination of drug and non-drug measures. Pain is divided into visceral, bone or neuropathic pain and has characteristics of continuous or intermittent pain. Cancer bone pain therapy remains centered on strong opioid, radiotherapy and bisphosphonates. Invasive procedures are aimed to improve neurological function, ambulation and pain relief. Solid tumors often demand surgery. Treatment of acute postoperative pain is crucial for the prevention of chronic pain. Chemotherapy and radiation sometimes also cause pain. The management of cancer pain has improved because of rapid diagnosis and treatment, understanding of analgesics and the cooperation of patients and their family. The presence of special pain centers in hospitals also raise standard of cancer pain management. Drug therapy with non-opioid, opioid and adjuvant drugs is the base of such management. The side effects must be monitored and timely treated. Methods of regional nerve blockade in pain control are numerous. Placement of epidural, intrathecal and subcutaneous catheters, conductive nerve blocks with continuous delivery of mixed local anesthetics are very successful for selected patients. Conventional physical therapy involving lymphatic drainage is useful. Acupuncture, psychotherapy and similar methods are also applicable.Karcinomska bol nije homogen i potpuno razjašnjen patološki proces. Najbolja terapija je kombinacija medikamentozne terapije i nemedikametoznih postupaka. Možemo je podijeliti na visceralnu, koštanu i neuropatsku bol i ima karakteristike kontinuirane ili povremene boli. Terapija koštane boli fokusirana je na jake opioide, radioterapiju i bifosfonate. Cilj invazivnih metoda liječenja boli je poboljšati neurološku funkciju, pokretljivost i olakšanje boli. Solidni tumori često zahtjevaju operaciju. Liječenje akutne poslijeoperacijske boli je od iznimne važnosti u prevenciji nastanka kronične boli. Kemoterapija i radioterapija ponekad također uzrokuju bol. Liječenje karcinomske boli je poboljšano bržom dijagnostikom i terapijom, boljim poznavanjem analgetika i suradnjom s pacijentom i njegovom obitelji. Postojanje specijaliziranih centara za bol u bolnicama također je podiglo standard u liječenju boli. Liječenje boli medikamentozno neopioidima, opioidima i drugim pomoćnim lijekovima je osnova liječenja boli. Nuspojave lijekova moraju se neprestano pratiti i na vrijeme liječiti. Metode regionalne nervne blokade u liječenju boli su brojne. Plasiranje epiduralnih, intratekalnih i supkutanih katetera s kontinuiranom isporukom mješavine lokalnih anestetika veoma su uspješne kod određenih bolesnika. Fizikalna terapija s limfnom drenažom je korisna. Akupunktura, psihoterapija i slične metode su također primjenjive

Pregled kirurškog liječenja raka želuca prema broju operacija u pojedinim bolnicama u Hrvatskoj

Gastric is considered neglected cancer in terms of stage at diagnosis and success of treatment worldwide. Early detection and quality of gastric cancer surgery remain the most important for successful treatment in terms of overall survival. In this paper, we focus on the overview of hospitals and volume of gastric cancer in Croatia as a possible baseline for quality assessment and implementation of existing quality guidelines. We accessed publicly available data from the Croatian Insurance Fund for the period between 1st January 2013 to 31st December 2018. For background information on gastric cancer incidence and mortality, we used Croatian Cancer Registry data available online. We obtained both the number of resected gastric cancer in all Croatian hospitals as well as the length of stay. Data analysis discovered that there is a clear volume difference between teaching hospitals and non-teaching hospitals; only the first have sufficient volume for quality audit. This overview stresses one of the most critical points in cancer surgery, volume of surgery as a quality indicator.Rak želuca smatra se zanemarenim tumorom zbog kasne dijagnoze i ishoda liječenja. Rano otkrivanje i kvaliteta operacijskog liječenja najvažniji su za uspješno liječenje i ukupno preživljenje. U radu predstavljamo pregled bolnica i broj operiranih bolesnika s rakom želuca u Hrvatskoj kao moguću osnovu za ocjenu i provedbu postojećih smjernica kvalitete. Korišteni su javno dostupni podatci Hrvatskog zavoda za zdravstveno osiguranje od 1. siječnja 2013. do 31. prosinca 2018. Podatci o učestalosti i smrtnosti od raka želuca su sa internetskih stranica Hrvatskog registra za rak pri Hrvatskom zavodu za javno zdravstvo. Prikazan je broj operiranih od raka želuca i duljina boravka u svim hrvatskim bolnicama. Ustanovljena je jasna razlika u broju operiranih bolesnika s rakom želuca između nastavnih i nenastavnih bolnica. Samo nastavne imaju dovoljan broj za reviziju kvalitete. Broj operacija je najvažnija mjera kvalitete u onkološkoj kirurgiji

Dexmedetomidine in perioperative period

Deksmedetomidin je anestetik koji se svakodnevno koristi u kliničkoj praksi. Prema načinu djelovanja on je selektivni agonist α2-adrenergičkih receptora (α2-AR). Ciljna mjesta djelovanja su α2-AR locusa ceruleusa moždanog debla (sedacija i vagomimetički učinak) i leđne moždine (analgezija). Lijek se u potpunosti biotransformira u organizmu direktnom glukoronidacijom i jetrenim p450 enzimskim sustavom u inaktivne metabolite koji se izlučuju urinom. Njegovo djelovanje je povezano sa analgetskim učincima (inhibicija otpuštanja antinociceptivnih transmitera poput sustance P i glutamata) i sedacijskim učincima kojima se smanjuje potreba za korištenjem opioda u perioperativnom periodu, smanjenom pojavom delirija i agitacijom u jedinicama intenzivnog liječenja. Obzirom na brz početak i predvidljiv prestanak djelovanja, te postojanje antidota, sve češće se koristi u kliničkim uvjetima te se trenutno koristi kao premedikacija, intraoperativno tijekom indukcije i održavanja anestezije, u regionalnoj anesteziji te za sedaciju u jedinicama intenzivnog liječenja. Nadalje, pogodan je za korištenje tijekom kratkotrajnih ambulantnih zahvata poput kolonoskopije, transezofagealne ehokardiografije i litotripsije. Njegovo jedinstveno svojstvo oponašanja prirodnog stanja sna i mogućnosti lakog razbuđivanja te njegov neuroprotektivni učinak, čine ga pogodnim za korištenje kod neurokirurških bolesnika u jedinicama intenzivnog liječenja. Postoje i neželjeni učinci Deksmedetomidina poput izazivanja bradikardije i hemodinamske nestabilnosti zbog čega se preporuča izbjegavanje davanja bolus doza. Posljednje studije također upozoravaju na štetnost dugotrajnog davanja Deksmedetomidina te na povećanu smrtnost u odnosu na pacijente sedirane Propofolom ili Midazolamom.Dexmedetomidine is an anesthetic generally used in clinical practice during perioperative period. It is a selective α2-adrenergic receptor (α2-AR) agonist. The target sites of action are the α2-AR on locus ceruleus of the brainstem (sedation and vagomimetic effect) and the spinal cord (analgesia). The drug is completely biotransformed in the body by direct glucuronidation and the hepatic p450 enzyme system into an inactive metabolite that is excreted in the urine. Its action is associated with analgesic effects (inhibition of the release of antinociceptive transmitters such as substance P and glutamate) and sedation effects that reduce the need for the use of opioids in the perioperative period, reduced occurrence of delirium and agitation in intensive care units. Apparently due to its rapid onset and predictable cessation of action, and the existence of an antidote, it is increasingly used in clinical settings and is currently used as a premedication, during the induction and maintenance of anesthesia intraoperatively, in regional anesthesia and for sedation in intensive care units. Furthermore, it is suitable for use during short-term outpatient procedures such as colonoscopy, transesophageal echocardiography and lithotripsy. Its unique property of imitating the natural state of sleep and the possibility of easy awakening, as well as its neuroprotective effect, make it suitable for use in neurosurgical patients in intensive care units. There are also adverse effects of Dexmedetomidine such as bradycardia and hemodynamic instability, which is why it is recommended to avoid giving a loading dose. The latest studies also warn of the harmfulness of long-term administration of Dexmedtomidine and of increased mortality compared to patients sedated with Propofol or Midazolam

Uloga citologije u otkrivanju i liječenju tumora dojke

Fine-needle aspiration cytology (FNAC) is an established, highly accurate, and cost-eff ective method for diagnosing lesions in the breast. The method is minimally invasive without unwanted side efect. FNAC forms part of the triple assessment of breast lesions and has a high accuracy and sensitivity in dedicated centres. Method as a part of triple assessment has provide its value in describing the fi ndings most accurately. The diagnostic impact depends on experience of the operator, quality of preparation and diagnostic skills of the cytopathologist. Inadequate sampling with FNAC is particulary seen in collagenous lesions and in submitt ed specimens sampled by physicians lacking experience with the FNAC procedure. The highest accuracy is achived at centres with multidisciplinary approach. The majority of European countries use similar reporting system for breast FNAC (C1-C5), in keeping with European guidelines for quality assurance in breast cancer screening and diagnosis. A clear reporting system ensures that an unequivocal cytological diagnosis of malignancy is reliable, and in cases where mammography/ultrasonography and clinical examination are in agreement with FNAC, frozen section examination is unnecessary. The issue of optimal sampling to obtain adequate cell material in suffi cient quantity is of paramount importance when assessing the accuracy of FNAC. The inadequate rates in FNAC from diff erent sources are lowest when FNAC is performed by a cytopathologist and highest when done by a non-cytopathologist. The multidisciplinary approach is necessary to amplify FNAC quality and to reduce its diagnostic limits. Only when this model of activity is not available, the role of FNAC is less eff ective and the addition of core biopsy (CB) to FNAC should be considered. CB as an alternative diagnostic modality should be used advisedly, in situations where it is more likely to yield diagnostic information, e.g., in the diagnosis of impalpable masses, microcalcifi cations or a clinically apparent malignancy where preoperative chemotherapy is planned. CB should not be used as a substitute for poor performance at FNAC. The methods are not mutually exclusive.Aspiracijska citologija tankom iglom (FNAC) je utemeljena, visoko pouzdana i jeftina metoda u dijagnostici lezija dojke. Metoda je minimalno invazivna bez neželjenih nuspojava. Sastavni je dio tzv. trojnog pristupa u dijagnostičkoj obradi lezija dojke, te u specijaliziranim centrima ima visoku pouzdanost i senzitivnost. Također je unutar trojnog pristupa dokazala svoju vrijednost mogućnošću da izrazito pouzdano okarakterizira promjene. Dijagnostički učinak ovisi o iskustvu liječnika koji izvodi postupak, kvaliteti obrade materijala te dijagnostičkim vještinama citopatologa. Neadekvatni uzorak se najčešće susreće u kolagenoznim lezijama,komplex sklerozirajućim promjenama te u oskudnosti primljenih materijalima od strane liječnika koji izvode punkciju, a nemaju dovoljno iskustva s procedurom. Najviša razina pouzdanosti postiže se u centrima s multidisciplinarnim pristupom. Većina europskih zemalja koristi isti sustav pisanja citoloških nalaza vezanih za dijagnostiku dojke (C1-C5), koristeći se smjernicama za osiguravanje kvalitete u probiru i dijagnostici karcinoma dojke. Jasni sustav pisanja nalaza time osigurava pouzdanost nedvojbene citološke dijagnoze maligniteta, te u slučajevima kada je ona u skladu s radiološkim nalazima (mamografijom/ultrazvukom), kao dio trojnog pristupa nije potrebna hitna, introperativna patohistološka dijagnostika. Optimalno prikupljanje materijala radi dobivanja adekvatno celularnog uzorka je od ključne važnosti za pouzdanost aspiracijske citologije ( FNA). Nivo neadekvatnog materijala je najniži kada postupak izvodi citopatolog, a najveći kada ga izvode liječnici drugih specijalnosti. Multidisciplinarni pristup je neophodan za povećanje kvalitete metode te za reduciranje njenih dijagnostičkih ograničenja. Samo u slučajevima kada ovakav model pristupa nije dostupan, uloga citologije (FNA) je manje učinkovita te se treba uzeti u obzir biopsija širokom iglom (CB). CB je alternativni dijagnostički modalitet, te se treba koristiti ciljano, u situacijama kada je izvjesnije da će omogućiti bolju dijagnostičku informaciju, npr. u slučajevima kada se radi o nepalpabilnim promjenama, mikrokalcifi katima, te u slučajevima klinički jasnog malignog procesa gdje se planira preoperativna kemoterapija. CB se ne treba koristiti kao alternativa slabo izvedenoj citološkoj punkciji, te se navedene dvije metode međusobno ne isključuju

Structure-Based Exploration and Exploitation of the S4 Subsite of Norovirus 3CL Protease in the Design of Potent and Permeable Inhibitors

Human noroviruses are the primary cause of epidemic and sporadic acute gastroenteritis. The worldwide high morbidity and mortality associated with norovirus infections, particularly among the elderly, immunocompromised patients and children, constitute a serious public health concern. There are currently no approved human vaccines or norovirus-specific small-molecule therapeutics or prophylactics. Norovirus 3CL protease has recently emerged as a potential therapeutic target for the development of anti-norovirus agents. We hypothesized that the S4 subsite of the enzyme may provide an effective means of designing potent and cell permeable inhibitors of the enzyme. We report herein the structure-guided exploration and exploitation of the S4 subsite of norovirus 3CL protease in the design and synthesis of effective inhibitors of the protease

SECOND LANGUAGE LEARNING DIFFICULTIES

Master Thesis. Mentor: Dr.Sc. Qatip ArifiThis research paper has its importance on analysing the main concerns related to the difficulties in understanding the English Language as an example by the pupils of the Primary School “Zekeria Rexha “ in Gjakova. It also shows an overview of diagnosis on how individuals differ from each other concerning the understanding of the foreign language as a second language. Of course this thesis gives a picture of how a teacher can facilitate or serve as a guide how language can be learned or absorbed in the shortest possible way by the pupils in this case by the pupils of primary school. The diagnosis of the teacher related to the differences between the learners is also an important issue stressed in this research paper. Different dimesions of how the second language can be learned and also the challenges that the learners face during learning proces is an important aspect of this thesis