Efekat upotrebe fitaze na proizvodne rezultate i čvrstinu tibije brojlera

The effect of microbial phytase in corn/soybean meal diets for broilers on performances and tibia characteristics were investigated. The trial was carried out on 200 Arbor Acres broilers of both sexes divided into four groups. The broilers were fed with complete mixtures with different levels of P (0.80 and 0.57% total P and 0.46 and 0.25% available P), with or without phytase. Reduction of the dietary total and available P levels for experimental broilers induced lower body mass and gain as well as higher fed conversion. However, by introduction phytase into diets negative effects of phosphorus reduction were, to some extent alleviated. Addition of phytase into diets decreased serum Ca and increased serum P. Reduction of the dietary P level had no significant effect on serum Ca, but had negative effects on serum P (p (lt) 0.01). The obtained results of bone analysis show that phytase was effective in increasing investigated parameters, but no significant differences were found among groups.Ispitivan je uticaj mikrobijalne fitaze dodate smešama na bazi kukuruza i sojine sačme na proizvodne rezultate i čvrstinu tibije brojlera. Brojleri podeljeni u 4 grupe, su hranjeni obrocima sa različitim količinama P (0,80 i 0,57% ukupnog P i 0,46 i 0,25% iskoristivog P), bez ili sa dodatkom fitaze. Smanjivanje sadržaja P u smešama izazvalo je proporcionalno smanjivanje telesne mase, dnevnog prirasta i pogoršanje konverzije hrane, dok je dodatak fitaze doprineo poboljšanju vrednosti ispitivanih parametara. Dodatkom fitaze uočeno je smanjivanje koncentracije Ca, odnosno povećanje koncentracije P u krvi. Smanjivanje sadržaja P u smešama, nije imalo značajan uticaj na koncentraciju Ca, ali je značajno negativno uticalo na koncentraciju P u krvi (p (lt) 0,01). Dodatak fitaze u smeše sa smanjenom količinom P nije značajno uticao na koncentraciju Ca i P u krvi. Dodatak fitaze u smeše sa adekvatnim i smanjenim sadržajem P doprineo je povećanju čvrstine tibije, sadržaj pepela i Ca u tibiji. Dodatak fitaze nije imao posebno izražene efekte na sadržaj fosfora u tibiji

Ectopic parathyroid tumor in thorax – case report

Cilj: Prikazati pacijenticu s primarnim hiperparatireoidizmom zbog ektopičnog smještenog tumora doštitne žlijezde u toraksu. Prikaz slučaja: 64-godišnja pacijentica s od ranije poznatom hipotireozom i hipertenzijom manifestirala se slikom normocitne anemije, bubrežne insuficijencije i smetnjama gutanja. Zbog navedenih simptoma učinjena je višeslojna kompjutorizirana tomografija (MSCT) toraksa koja je pokazala tvorbu u stražnjem gornjem medijastinumu, uz promjene na kostima i sumnju na sekundarizme. U sklopu nefrološke obrade uočene su izrazito visoke vrijednosti serumskog kalcija (> 3 mmol/L) i paratireoidnog hormona (PTH) (200 pmol/L), što je ukazalo da se najvjerojatnije radi o primarnom hiperparatireoidizmu. Učinjena je dodatna obrada: scintigrafija doštitnih žlijezda, punkcija navedene tvorbe i citološka analiza. Navedene dijagnostičke metode potvrdile su da se radi o primarnom hiperparatireoidizmu najvjerojatnije adenoma ektopično smještene doštitne žlijezde. Pacijentica je podvrgnuta operativnom zahvatu, torakotomiji te odstranjenju navedene tvorbe. Postoperativni kirurški tijek bio je uredan. U laboratorijskim nalazima javila se očekivana hipokalcemija, zbog sindroma „gladne kosti” koja je medikamentozno tretirana. Naknadno prispjeli patohistološki nalaz ukazao je na to da se radi o novotvorini doštitne žlijezde nesigurnog malignog potencijala. S obzirom na to da je jedini potpuno pouzdani pokazatelj zloćudne prirode bolesti nalaz metastaza, dijagnoza karcinoma nije se mogla postaviti. Vrijednosti PTH-a postoperativno su bile unutar referentnih vrijednosti. Tijekom praćenja pacijentice u razdoblju od pola godine nakon operativnog zahvata nije došlo do povrata bolesti. Zaključak: Primarni hiperparatireoidizam čest je endokrinološki poremećaj i o njemu treba razmišljati u svakodnevnom radu. Osim povećanih doštitnih žlijezda na tipičnom mjestu u vratu, moguć je razvoj i ektopčno smještenih doštitnih žlijezda.Introduction: The aim was to present a case of primary hyperparathyroidism due to ectopic parathyroid adenoma localized in thorax. Case report: We report a case of a 64-yearold female patient with hypothyroidism and hypertension in her medical history, presented to us with normocytic anemia, renal insufficiency and dysphagia. Due to swallowing disorder multi-slice computed tomography of thorax was performed and mass in upper-back mediastinum with ossification changes suspicious for metastatic process was found. Within the nephrology examination, hypercalcemia (>3 mmol/L) and elevated parathyroid hormone (PTH) value (200 pmol/L) were noticed, which pointed to the possibility of primary hyperparathyroidism. Consequentially, parathyroid scintigraphy, aspiration biopsy and cytological analysis were performed. Primary hyperparathyroidism was affirmed and ectopic parathyroid adenoma was suggested as possible etiology. The patient has undergone surgical procedure based on thoracotomy with extirpation of the mass. Surgical postoperative course was regular. Postoperative laboratory findings showed hypocalcemia, which was expected due to “hungry bone” syndrome, so medication treatment was necessary. Subsequently, histopathological analysis showed parathyroid tumor with insecure malignant potential. Since metastases were the only satisfied criteria for the malignancy, the diagnosis of parathyroid carcinoma couldn’t be allocated. PTH values after surgery were within the reference range. During a 6-month postoperative follow-up no signs of the disease recurrence were detected. Conclusion: Primary hyperparathyroidism is a very common endocrinology disorder, hence it has to be on a differential diagnosis list in every day clinical practice Except increased parathyroid glands in the typical site in the neck, it is possible to develop ectopic parathyroid glands

Efficacy of Healthy Weight Loss Program in Obesity Treatment: Croatian Experience

We evaluated the efficiency of a six-month outpatient weight loss treatment program combining healthy diet, fat reduction, psychological counseling, exercise, and orlistat treatment, by measuring body weight and levels of cardiovascular risk factors in 476 subjects with BMI over 30 or 28 with increased blood pressure, cholesterol, and sugar at the baseline and at the end of program. After four weeks of adjustment to a mild low-calorie diet (1600 kcal/day) and counseling, subjects started receiving orlistat (120 mg TID). The mean weight loss after 6 months was 10.9%. Systolic pressure dropped by 6.7%, diastolic by 4.2%, fasting blood glucose by 10.1%, and total cholesterol by 9.8%. Only 9 subjects (7.8%) poorly tolerated the treatment. More men than women were able to maintain the achieved weight loss six months after the program (70.6% vs. 58.3%, respectively). The healthy weight loss program was an efficient approach to obesity treatment

Cholesterol homeostasis is dysregulated in women with preeclampsia

Introduction The link between preeclampsia and dyslipidemia has been established. Even though lipid profile parameters have been intensively investigated in the pathology of preeclampsia, their accurate molecular mechanisms of action have not been fully decoded. Objectives We aimed to identify the specifics of cholesterol metabolism in women affected by late‑onset preeclampsia and single out potential biomarkers associated with late‑onset syndrome. Patient s and methods A total of 90 pregnant women with a priori risk for preeclampsia were monitored at 4 time points during gestation and, based on the outcome of pregnancy, they were classified into the high‑risk group (70 women) and the preeclampsia group (20 women). Cholesterol metabolic profiling was done using liquid chromatography‑tandem mass spectrometry. Result s The only significant change in the preeclampsia group was an increase in the lathosterol level (P = 0.001). The first‑trimester lathosterol level was higher in the preeclampsia group compared with the high‑risk group (P = 0.02). Further, in the preeclampsia group, positive correlations were found between desmosterol and β‑sitosterol (ρ = 0.474; P = 0.03) in the third trimester, desmosterol and campesterol changes between the second and the first (ρ = 0.546; P = 0.02), and the third and first trimesters (ρ = 0.754; P <0.001), as well as between the desmosterol and β‑sitosterol differences between the third and first trimesters (ρ = 0.568; P = 0.01). No similar correlations were found in the high‑risk group. Conclusions Late‑onset preeclampsia could be associated with an altered lipid profile. By studying the quantitative metabolic signatures of cholesterol, we might assume that both cholesterol synthesis and absorption are increased, that is, there is an imbalance in the cholesterol homeostasis regulation in women affected by the disease

Kombinovano prisustvo genskih polimorfizma faktora koagulacije XIII V34L i inhibitora plazminogen aktivatora 1 4G/5G značajno utiče na rizik od spontanog pobačaja u srpskoj populaciji

Background:Recurrent pregnancy loss (RPL) is a heterogeneous condition affecting up to 5% of women of reproductive age. Inherited thrombophilia have been postulated as one of the causes of RPL. Here we examined the prevalence of nine thrombophilic gene polymorphisms among women with history of recurrent miscarriages and fertile controls.Methods:The study included 70 women with history of at least three early pregnancy losses and 31 fertile controls with no miscarriages. We investigated mutations in genes responsible for clotting and fibrinolysis, including factor V(FV) Leiden, FV H1299R, factor II (FII) G20210A, methyl-ene tetrahydrofolate reductase (MTHFR) C677T and A1298C, factor XIII (FXIII) V34L, plasminogen activator inhibitor-1 (PAI-1) 4G/5G and endothelial protein C receptor (EPCR) H1 and H3 haplotypes using reverse polymerase chain reaction ViennaLab cardiovascular disease StrippAssays. Results:Our results showed no significant increase inprevalence of tested polymorphisms in women with RPL. However, relative risk for PRL among women heterozygousfor FXIII V34L was 2.81 times increased (OR 2.81, 95% CI1.15–6.87, P=0.023). Haplotype analysis showed that combined presence of high-risk genotypes for FXIII andPAI-1 significantly increases risk for RPL (OR 13.98, CI95% 1.11–17.46, P=0.044).Conclusions:This is the first study in Serbian population that investigated prevalence of FVR2, A1298C, FXIII V34Land EPCR gene variants. Compound heterozygosity forFXIII V34L and PAI-1 4G is significant risk factor for recur-rent miscarriage. Our results should be viewed in context of small case-control study, so further large prospective studies are need for confirmation of our findings.Uvod: Ponavljani spontani pobačaji (PSP) su etiološki heterogeni i javljaju se kod 5% parova u reproduktivnom period. Jedan od mogućih uzroka PSP su i nasledne trombofilije. U okviru ove studije analizirali smo učestalost devet trombofilnih polimorfizama kod pacijentkinja sa ponavljanim spontanim pobačajima. Metode: Ispitanici su u studiji podeljeni u dve grupe na osnovu anamnestičkih podataka o broju spontanih pobačaja (70 u grupi sa PSP i 31 u kontrolnoj grupi). Ispitivani su sledeći genski polimorfizmi: faktor V Lajden (FVL), FVR2, faktor II (FII) G21210A, metilentetrahidrofolat reduktaza (MTHFR) C677T i A1298C polimorfizmi, inhibitor aktivatora plazminogena 1 (PAI-1) 4G/5G, faktor XIII (FXIII) V34L i endotelni protein C receptor (EPRC) H1, H2 i H3 haplotipovi. Za detekciju navedenih polimorfizama je korišćena metoda multipleks reakcije lančanog umnožavanja i reverzne hibridizacije na ViennaLab stripovima. Rezultati: Dobijeni rezultati nisu pokazali povećanu učestalost ispitivanih polimorfizama u grupi sa PSP. Posmatrajući uticaj pojedinačnih polimorfizama na ishod trudnoće pokazano je da polimorfizam FXIII V34L povećava rizik za ponavljane spontane pobačaje (OR 2,81, 95%CI 1,15-6,87, P=0,023). Analizom haplotipova ustanovljeno je da kombinovano prisustvo V34L i PAI-1 4G varijanti značajno povećava rizik za PSP (OR 13,98, CI 95% 1,11-17,46, P=0,044). Zaključak: Ovo je prva studija koja je ispitivala prevalencu FVR2, A1298C, FXIII V34L and EPCR polimorfizama u populaciji žena iz Srbije. Složeni heterozigoti za FXIII V34L i PAI-1 4G polimorfizme imaju značajno povišen rizik sa ponavljane gubitke trudnoće. Radi potvrde dobijenih rezultata potrebne su veće prospektivne studije

Effects of Obesity Reduction on Cardiovascular Risk Factors: Comparison of Individual and Group Treatment – Substudy of the Croatian Healthy Weight Loss Programme

Prevention of obesity may help reduce the morbidity and mortality from cardiovascular diseases. In Croatia, over half of adult population is overweight. Aldo the basic medical principles of healthy weight-loss programmes are well known, it is believed that mainly because of the leak of successful therapeutic approach obesity remains the most challenging changeable cardiovascular risk factor in nowadays clinical practice. Objective of this Croatian Healthy Weight Loss Programme substudy was to determine effects and differences between the intensive group and intensive individual weight-loss program on weight loss and cardiovascular risk factor. A clinical trial included 476 adults whose body mass index (BMI) was >30 or >28 accompanied by increased blood pressure, glucose, and cholesterol. The study participants completed either a group (n=243) or individually-based (n=233) 6-month weight-loss program consisting of education, low-fat diet, pharmacological treatment with orlistat, psychological counselling, and exercise. Body weight, body mass index, blood pressure, blood sugar, and blood cholesterol were measured in all participants after 3 and 6 months. The average weight loss was 12.2 (13%) kg and 7.6 (9%) kg in the group and individual program, respectively. Beside the weight reduction, the levels of blood cholesterol, glucose, and blood pressure were also significantly reduced in comparison with baseline, decreasing to normal values in all participants (P<0.001 for all). Decrease in the monitored parameters was greater in participants in the group program. The weight loss program provided a healthy loss of extra weight in the period of 6 months. The group program produced greater decrease in body weight, body mass index, blood pressure, glucose, and cholesterol than the individual program

EVALUATION OF VIRAL HEPATITIS IN SOLID ORGAN TRANSPLANTATION

Uspješna transplantacija bubrega je optimalna metoda liječenja bolesnika koji se nalaze u završnom stadiju kronične bubrežne bolesti. Za uspjeh same transplantacije, kao i dugoročnog preživljenja bolesnika i njegovog transplantata, nužna je detaljna evaluacija primatelja i potencijalnog darivatelja organa, bilo da se radi o kadaveričnom ili živom darivatelju. Poseban problem u sklopu infektivnih bolesti su virusi hepatitisa, osobito virus hepatitisa B (HBV) i C (HCV), a u novije vrijeme sve se više spominje i virus hepatitisa E (HEV) kao značajan uzrok kroničnog hepatitisa u populaciji bolesnika s transplantatom. Unatoč poboljšanju preventivnih mjera posljednjeg desetljeća incidencija virusnih hepatitisa je u bolesnika koji se liječe postupcima hemodijalize značajno smanjena. Međutim, njihova incidencija i dalje je veća u toj skupini bolesnika kao i u bolesnika kojima je transplantiran bubreg u odnosu na opću populaciju. Virusni hepatitisi su značajan čimbenik povećanog morbiditeta i mortaliteta u tim populacijama bolesnika, ali i prema većini studija značajan čimbenik disfunkcije bubrežnog transplantata. Naime, u bolesnika koji su podvrgnuti transplantaciji bubrega primarni cilj je očuvanje dobre funkcije transplantata, uz primjenu učinkovite, a što manje toksične imunosupresivne terapije. Osim toga, nužno je praćenje i adekvatna terapija virusnih hepatitisa, s obzirom na dobro poznatu činjenicu da te infekcije vode prema kroničnom hepatitisu, cirozi jetre i hepatocelularnom karcinomu. Nadalje, HBV i HCV mogu inducirati nastanak de novo membranskog glomerulonefritisa u bubrežnom transplantatu.Renal transplantation has significantly improved survival of patients with end-stage renal disease (ESRD). Transplantation is the best treatment in this population of patients. Despite the introduction of various preventive measures, viral hepatitis, i.e. hepa¬titis B virus (HBV) and hepatitis C virus (HCV) infections, are still a major problem because they are common in patients on re¬nal replacement therapy as well as in allograft recipients. They are a significant cause of morbidity and mortality in this patient population. In recent years, hepatitis E virus (HEV) infection has been added as an emergent cause of chronic hepatitis in solid organ transplantation, mainly in renal and liver allograft recipients. Most studies show higher mortality in renal transplant recipi¬ents (RTRs) infected with HBV, compared with RTRs without HBV infection, although this topic is still under debate. Furthermore, HCV infection in RTRs is associated with a significant reduction in patient and graft survival due to liver disease and septic com¬plications related to cirrhosis and immunosuppressive therapy. The immunosuppressive therapy prescribed after transplantation modifies the natural history of chronic HCV infection. Given the high prevalence of HCV and HBV infections in RTRs, a growing incidence of hepatocellular carcinoma and the possible contribution of immunosuppression might be expected in these patients. Therefore, after renal transplantation, early screening with abdominal ultrasound (every 3 months in cirrhotic patients and every 6-12 months in non-cirrhotic RTRs) is necessary when the risk factors such as HBV and HCV are present. The European Asso¬ciation for the Study of the Liver (EASL) recommends that all HbsAg-positive patients who are candidates for solid organ trans¬plantation should be treated with nucleoside analogs. The KDIGO guidelines recommend that all HbsAg-positive RTRs receive prophylaxis with tenofovir, entecavir or lamivudine; however, tenofovir and entecavir are preferable to lamivudin. Viral suppres¬sion by inhibiting necro-inflammation may result in reduced fibrosis, thereby improving transplant survival. Active HCV infection in a dialysis patient requires evaluation of liver fibrosis. Antiviral therapy should be given to all HCV-infected dialysis patients in order to achieve a sustained virologic response (SVR) not only to avoid subsequent hepatic deterioration but also to limit the risks of HCV-related posttransplant de novo glomerulonephritis. Systematic vaccination of all HbsAg-negative patients is the best preventive treatment of HBV infection. HbsAg positive donors are only used occasionally, whereas the use of hepatitis B core antibody (HbcAb)+, HbsAg negative donors is more common but remains somewhat controversial. The presence of antibody to HCV is indicative of HCV infection because antibody to HCV appears in peripheral blood within two months of HCV exposure. However, it is important to emphasize that detection of antibody to HCV by serologic screening of the donor is not predictive of HCV transmission. Approximately 50% of patients positive for antibody to HCV have detectable hepatitis C viremia by PCR analysis of peripheral blood. Therefore, all organ donors with PCR analysis positive for HCV will transmit HCV to RTRs. On the other hand, the risk of transmission from an organ donor with negative PCR analysis is unclear. Another problem in the evalua¬tion of the potential donors of solid organs is the fact that antibody testing by enzyme-linked immunosorbent assays (ELISAs) will not detect recent infections. The use of nucleid acid testing (NAT) could be useful because it involves amplification of viral gene products and thus is not dependent on antibody formation. Therefore, by using this method the period between the infection and detectability, which is known as the window period, could be reduced. However, this method is expensive and time consuming

Radical surgical treatment of urinary bladder cancer: our experiences

Svrha rada je analiza bolesnika oboljelih od raka mokraćnoga mjehura, kod kojih je učinjena radikalna operacija. U razdoblju 1972.-2004. liječili smo 1708 bolesnika sa rakom mokraćnoga mjehura. Radikalnom kirurškom zahvatu podvrgnuto je 239 (14%) bolesnika. Muškaraca je bilo 188 (78,7%), a žena 51 (21,3%). Najviše bolesnika bilo je u dobi između 60. i 80. godine (171 - 71,5%). Anamnestički je najčešći i najvažniji simptom tumora mjehura hematurija 213 (89%). U naših bolesnika bilo je 220 (92%) karcinoma prijelaznoga epitela, 13 (5,4%) planocelularnih tumora i 6 (2,5%) adenokarcinoma. Prema TNM klasifikaciji prevladava T3 stadij 118 (49,3%) i T2 stadij 94 (39,3%). Prema histološkom kriteriju najčešći je G3 stadij 186 (77,8%). Radikalnu cistektomiju samu ili kombiniranu s uretrektomijom učinili smo kod 203 (85%) bolesnika. Nažalost u 13% bolesnika (T3b i T4 stadij) podvezali smo samo unutarnje ilijačne žile zbog uznapredovaloga tumora. Vanjsku supravezikalnu derivaciju urina (Bricker, U-tubing nefrostoma) učinili smo kod 188 (78,7%) bolesnika. Unutarnju derivaciju (Coffey, Ureteroileosigmoidostomia, Mainz-Pouch II) rabili smo u 23 (9,6%), a neovesiku (Hautmann, Studer) kod 28 (11,7%) bolesnika. Ranih poslijeoperacijskih komplikacija bilo je 83 (34,7%). Među njima prevladavaju kirurške 32 (13,4%) i komplikacije udaljenih organa 23 (9,6%). Među kasnim komplikacijama prevladava uroinfekt 11 (4,6%) i ileus 8 (3,3%), koji su liječeni uglavnom konzervativno. U bolesnika s negativnim čvorovima 72 (30%) preživjelost je nakon pet godina bila 62%. Kod bolesnika s pozitivnim čvorovima 59 (24,6%), preživjelost nakon pet godina bila je 44%. Najlošiju prognozu imala je skupinabolesnika (13%), gdje zbog opsežnoga procesa nismo uspjeli učiniti cistektomiju. Kod njih su podvezane ilijačne žile, a liječeni su radioterapijom i kemoterapijom. Nakon godine dana preživjelost je bila oko 9%.In the period from 1972-2004, 1708 patients with bladder cancer were treated. 239 (14 %) of them were treated by means of radical surgical procedures. There were 188 (78.7%) male and 51 (21.3%) female patients. The average age was between 60 and 80 (171 71.5%). The most frequent and the most important symptom of bladder cancer is hematuria 213 (89%). In our patients there were 220 (92%) epithelial cancers, 13 (5.4%) planocellular cancers and 6 (2.5%) adenocarcinomas. According to TNM classification, T3 stage (118 - 49.3%) and T2 stage (94- 39.3%) were predominant in our study. According to histological criteria, the most common was G3 stage (186 -77.8%). Radical cystectomy alone or combined with urethrectomy was done in 203 (85%) patients. Unfortunately, in 13% of patients (T3b and T4 stages) inner iliac blood vessels were tied off due to a progressive cancer. Outer supravesicular urine derivation (Bricker, U-tubing nephrostoma) was done in 188 (78.7%) patients. Inner derivation (Coffey, uretheroileosigmoidostomy, Mainz-Pouch II) was done in 23 (9.6%) and neovesica (Hautmann, Studer) in 28 (11.7%) patients. There were 83 (34.7 %) early postoperative complications. Among them the most dominant ones were surgical 32 (13.4%) and distant organ complications 23 (9.6%). Among late complications, predominant ones were uroinfection 11 (4.6%) and ileus 8 (3.3%), which were treated conservatively. In the patients with negative nodes 72 (30%), the survival rate after five years was 62%. In the patients with positive nodes 59 (24.6%), the survival rate after five years was 44%. The least favorable prognosis was for patients (13%) in whom cystectomy could not be done due to a progressive process. In these patients, iliac blood vessels were tied off and they were treated with radiotherapy and chemotherapy. The survival rate was 9% after one year

MANAGEMENT OF ADRENAL INCIDENTALOMA: THE POSITION STATEMENT OF THE CROATIAN REFERRAL CENTER FOR ADRENAL GLAND DISORDERS

Incidentalomi nadbubrežne žlijezde jesu tumori otkriveni tijekom dijagnostičke evaluacije nekoga drugog kliničkog stanja. Tehnološki napredak radioloških uređaja i njihova sve veća upotreba u svakodnevnoj kliničkoj praksi doveli su do češćeg otkrivanja ovih tumora čineći njihovu dijagnostiku i liječenje jednim od najvažnijih izazova moderne endokrinologije. Radi racionalnog pristupa ovim bolesnicima radna skupina koju su činili vodeći hrvatski stručnjaci iz područja bolesti nadbubrežne žlijezde, na temelju relevantne znanstvene literature i postojećih smjernica europskih i svjetskih društava, donijela je preporuke za dijagnostiku i liječenje incidentaloma nadbubrežne žlijezde.Adrenal incidentalomas are tumours of adrenal glands discovered during diagnostic workup for other clinical condition unrelated to adrenal glands. Improvement in imaging techniques and their widespread use in everyday practice have increased detection of adrenal incidentalomas making their management one of the most important challenges of modern endocrinology. Based on the relevant medical literature and guidelines of other international societies a panel of Croatian leading experts in adrenal gland disorders provide practical recommendations for the diagnostics and treatment of adrenal incidentaloma