Intensive Rehabilitation in Children with Cerebral Palsy: Our View on the Neuronal Group Selection Theory

Cerebral palsy (CP) is one of the major forms of developmental disorders. There are different approaches and controversies in rehabilitation treatment. The Neuronal Group Selection theory could provide theoretical explanation for Stoj~evi} Polovina rehabilitation method. The aim of the study was to evaluate long-term impact of intensive and continuously performed rehabilitation on the motor autonomy level children with CP. Motor autonomy levels, defined according to the Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM), were analyzed in 24 children with CP at the beginning of the study and at the last visit. During rehabilitation, GMFM scores increased above the expected value of initial GMFCS level in the majority of patients. Intensive rehabilitation had significant influence on motor improvement in children with CP

Management of patients with adrenal incidentaloma – 2019 update

Zadnjih desetak godina došlo je do značajnih promjena u zdravstvenom zbrinjavanju bolesnika s incidentalomima nadbubrežne žlijezde koje su rezultirale novim preporukama za dijagnostiku i liječenje ovih bolesnika napravljenim u suradnji Europskoga endokrinološkog društva i Europske mreže za istraživanje tumora nadbubrežne žlijezde. Na temelju navedenih preporuka i višegodišnjega vlastitog iskustva Referentni centar Ministarstva zdravstva Republike Hrvatske za bolesti nadbubrežne žlijezde predlaže izmjene i dopune preporuka za dijagnostiku i liječenje ovih bolesnika objavljenih u Liječničkom vjesniku 2010. godine.In the last decade, the clinical care of patients with adrenal incidentaloma has been significantly changed which prompted the European Society of Endocrinology and European Network for the Study of Adrenal Tumors to develop an updated clinical practice guideline for the management of these patients. In accordance with the aforementioned recommendations and based on its own experience, the Croatian Referral Center for adrenal gland disorders provides an update of the previous guideline for the clinical management of patients with adrenal incidentaloma published in Liječnički vjesnik in 2010

A Diagnostic Approach to Patients with Osteoporosis

Osteoporozu karakteriziraju niska koštana masa, poremećaj mikroarhitekture kosti i fragilnost skeleta koji rezultiraju smanjenom jačinom kosti i povišenim rizikom prijeloma. Mjerenje koštane mineralne gustoće (BMD-a) korištenjem denzitometrije kosti standard je u dijagnostici osteoporoze. Denzitometrija je dobro dijagnostičko sredstvo, ali klinički čimbenici rizika također značajno utječu na rizik od prijeloma kod pojedinih bolesnika. Stoga se danas preporučuje da odluka o liječenju osteoporoze uključuje razmatranja o vjerojatnosti prijeloma. Rezultati BMD-a trebaju se kombinirati s ostalim kliničkim čimbenicima za rizik prijeloma kako bi se pravilno procijenio rizik te donijela odluka o terapiji. Osim denzitometrijom, klinička dijagnoza osteoporoze može se postaviti kod visokog rizika prijeloma procijenjenog prema FRAX-u (engl. Fracture Risk Assessment Tool) specifičnim za pojedinu zemljopisnu regiju/državu. Također, klinička dijagnoza osteoporoze može se postaviti kod prijeloma kuka, kralježaka, podlaktice, nadlaktice, rebara i zdjelice koji se javljaju spontano ili nakon minimalne traume, neovisno o BMD-u. Nakon što se postavi dijagnoza osteoporoze, potrebno je učiniti obradu radi isključenja sekundarnih uzroka osteoporoze.Osteoporosis is characterized by low bone mass, disruption of bone microarchitecture, and skeletal fragility, resulting in reduced bone strength and increased risk of fractures. Measurement of bone mineral density (BMD) using bone densitometry is the standard in the diagnosis of osteoporosis. Densitometry is an excellent diagnostic tool, but clinical risk factors also significantly affect fracture risk. Therefore, it is recommended that the decision to treat osteoporosis includes considerations about the likelihood of fracture. BMD results should be combined with other clinical factors to assess fracture risk and make proper decisions about therapy. In addition to densitometry, a clinical diagnosis of osteoporosis can be made at high fracture risk as set by FRAX (Fracture Risk Assessment Tool) specific to a particular geographic region/country. Also, a clinical diagnosis of osteoporosis can be made for fractures of the hip, vertebrae, forearm, upper arm, ribs, and pelvis, that occur spontaneously or after minimal trauma, regardless of BMD. After diagnosing osteoporosis, it is necessary to rule out secondary causes of osteoporosis before treatment is initiated

Challenges in Diagnosing Osteoporosis: What Limitations Do We Face?

Osteoporotični prijelomi kuka i kralježaka povezani su s povećanjem mortaliteta od 10 do 20 % u žena i muškaraca. Mnoga su ispitivanja pokazala da je nizak BMD povezan s visokim rizikom prijeloma. Međutim, kako se veliki broj prijeloma događa kod osoba s T-scoreom boljim od –2,5, liječenje koje bi se temeljilo samo na BMD-u izostavilo bi mnoge bolesnike koji imaju visok rizik prijeloma i profitirali bi od liječenja. Stoga je evaluacija kliničkih čimbenika rizika prijeloma važna u odluci o liječenju. U kliničkom radu najčešće koristimo FRAX (engl. Fracture Risk Assessment Tool) kalkulator rizika za procjenu rizika prijeloma. Međutim, potrebno je uvijek uzeti u obzir ograničenja FRAX-a. Isto tako kliničari trebaju biti svjesni potencijalnih pogrešaka u snimanju i interpretaciji denzitometrijskog nalaza kako bi se izbjegle greške u dijagnosticiranju i praćenju bolesnika s osteoporozom. U dijagnosticiranju i odluci o terapiji također je potrebno uzeti u obzir dob i spol bolesnika te lijekove koji utječu na metabolizam kosti.Osteoporotic hip and vertebral fractures are associated with a 10 to 20% higher mortality rate in both women and men. Many studies have shown that low BMD is associated with increased fracture risk. However, as many fractures occur in individuals with a T-score better than -2.5, treatment based on BMD alone would miss many patients at high fracture risk who would benefit from treatment. Therefore, evaluating clinical fracture risk factors is essential in the treatment decision. We often use the FRAX risk calculator in clinical work to assess fracture risk. However, the limitations of FRAX should always be considered. Likewise, clinicians should be aware of potential errors in recording and interpreting densitometry to avoid mistakes in diagnosing and monitoring patients with osteoporosis. When analyzing and deciding on therapy, it is also necessary to consider the patient\u27s age and gender and medications that affect bone metabolism

Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery

Purpose The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery. ----- Methods We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up. ----- Results ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%. ----- Conclusion The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn

Open vs laparoscopic adrenalectomy for localized adrenocortical carcinoma

Objective: The purpose of the study was to compare the long-term outcomes of patients with localized adrenocortical carcinoma (ACC) subjected to open vs laparoscopic surgery. ----- Design: Retrospective study. ----- Patients: This retrospective study included 46 patients with the ACC ENSAT stage I-stage III of whom 23 underwent open surgery (OA group), whereas 23 were subjected to laparoscopic adrenalectomy (LA group). The main outcomes analysed in the study were differences between the OA and LA groups in recurrence-free survival (RFS) and overall survival (OS). ----- Results: Patients in OA group had larger tumours (120 [70-250] mm vs 75 [26-110] mm; P < .001), higher Ki-67 index (16 [1-65] % vs 10 [1-25] %; P = .04) and higher disease stage (P = .01) compared with the patients in the LA group. The median duration of follow-up for patients underwent OA and LA was 51 (12-174) and 53 (5-127) months, respectively. Eight patients (5 OA and 3 LA) experienced recurrent disease, whereas six patients (3 OA and 3 LA) died during follow-up. No differences in RFS and OS were found between patients who underwent open or laparoscopic surgery. ----- Conclusion: The study demonstrated that in patients with localized ACC and without invasion of extra-adrenal tissues, LA is a plausible treatment option in terms of RFS and OS. However, our results are limited to referral centres with large experience in the management of patients with ACC and may not necessarily apply to nonspecialized centres

Open vs laparoscopic adrenalectomy for localized adrenocortical carcinoma

Objective: The purpose of the study was to compare the long-term outcomes of patients with localized adrenocortical carcinoma (ACC) subjected to open vs laparoscopic surgery. ----- Design: Retrospective study. ----- Patients: This retrospective study included 46 patients with the ACC ENSAT stage I-stage III of whom 23 underwent open surgery (OA group), whereas 23 were subjected to laparoscopic adrenalectomy (LA group). The main outcomes analysed in the study were differences between the OA and LA groups in recurrence-free survival (RFS) and overall survival (OS). ----- Results: Patients in OA group had larger tumours (120 [70-250] mm vs 75 [26-110] mm; P < .001), higher Ki-67 index (16 [1-65] % vs 10 [1-25] %; P = .04) and higher disease stage (P = .01) compared with the patients in the LA group. The median duration of follow-up for patients underwent OA and LA was 51 (12-174) and 53 (5-127) months, respectively. Eight patients (5 OA and 3 LA) experienced recurrent disease, whereas six patients (3 OA and 3 LA) died during follow-up. No differences in RFS and OS were found between patients who underwent open or laparoscopic surgery. ----- Conclusion: The study demonstrated that in patients with localized ACC and without invasion of extra-adrenal tissues, LA is a plausible treatment option in terms of RFS and OS. However, our results are limited to referral centres with large experience in the management of patients with ACC and may not necessarily apply to nonspecialized centres