Trombocitopenija u trudnoći

Thrombocytopenia is a common finding in pregnancy, occuring in approximately 7-10% of pregnancies. There are diverse etiologies for thrombocytopenia, some of which are unique to pregnancy. Overall, about 75% of cases are due to gestational thrombocytopenia, 15-20% secondary to hypertensive disorders, 3-4% due to an immune process, and the remaining 1-2% made up to rare constitutional thrombocytopenias, infections and malignancies. This review provides a discussion of the diagnosis and management of the various causes of thrombocytopenia in pregnancyTrombocitopenija se često susreće u trudnoći, pojavljuje se u oko 7-10% trudnoća. Etiologija u većini slučajeva ostaje nepoznata, ali neki od čimbenika su jedinstveni za trudnoću. Općenito, 75% slučajeva otpada na gestacijsku trombocitopeniju, 15-20% su sekundarne trombocitopenije u sklopu hipertenzivne bolesti, 3-4% zbog imunoloških bolesti, a preostalih 1-2% su rijetke konstitucionalne trombocitopenije, vezane uz infekcije i zloćudne bolesti. U ovom članaku raspravlja se o dijagnostičkim postupcima i terapijskom pristupu u trombocitopeniji u trudnoći obzirom na etiološke čimbenik

Trombocitopenija u trudnoći

Thrombocytopenia is a common finding in pregnancy, occuring in approximately 7-10% of pregnancies. There are diverse etiologies for thrombocytopenia, some of which are unique to pregnancy. Overall, about 75% of cases are due to gestational thrombocytopenia, 15-20% secondary to hypertensive disorders, 3-4% due to an immune process, and the remaining 1-2% made up to rare constitutional thrombocytopenias, infections and malignancies. This review provides a discussion of the diagnosis and management of the various causes of thrombocytopenia in pregnancyTrombocitopenija se često susreće u trudnoći, pojavljuje se u oko 7-10% trudnoća. Etiologija u većini slučajeva ostaje nepoznata, ali neki od čimbenika su jedinstveni za trudnoću. Općenito, 75% slučajeva otpada na gestacijsku trombocitopeniju, 15-20% su sekundarne trombocitopenije u sklopu hipertenzivne bolesti, 3-4% zbog imunoloških bolesti, a preostalih 1-2% su rijetke konstitucionalne trombocitopenije, vezane uz infekcije i zloćudne bolesti. U ovom članaku raspravlja se o dijagnostičkim postupcima i terapijskom pristupu u trombocitopeniji u trudnoći obzirom na etiološke čimbenik

Placebo in the Treatment of Pain

Placebo is the use of the substance or procedure without specific activity for the condition that is trying to be healed. In medicine, benefits of placebo effect are used since 1985 and 1978 placebo effect was first scientifically confirmed. It was found that placebo induced analgesia depends on the release of endogenous opiates in the brain and that the placebo effect can be undone using the opiates antagonist naloxone. Functional magnetic resonance imaging of the brain showed that placebo analgesia was obtained regarding the activation and increased functional relationship between ant. cingulate, prefrontal, orbitofrontal, and insular cortex, nucleus accumlens, amygdala, periaqueduktalne gray matter and spinal cord. Placebo also facilitates descending inhibition of nociceptive reflexes through periacvaeductal gray substance. Placebo effect can be achieved in several ways: by using pharmacological preparations or simulation of operating or other procedures. This phenomenon is associated with perception and expectation of the patient. To achieve the effect of placebo it is essential degree of the suggestions of the person who prescribe a placebo, and the degree of belief of the person receiving the placebo. Expected effect of placebo is to achieve the same effect as the right remedy. Achieved placebo effect depends on the way of presentation. If a substance is presented as harmful, it may cause harmful effects, called »nocebo« effect. Placebo effect is not equal in all patients, same as the real effect of the drug is not always equal in all patients. Application of placebo in terms of analgesia will cause a positive response in 35% of patients. Almost the same percentage (36%) of patients will respond to treatment with morphine in medium doses (6–8 mg). Therefore, one should remember that response to placebo does not mean that a person simulates the pain and then it is unethical to withhold the correct treatment especially in light of findings that the prefrontal cortex is activated expecting liberation of pain and how this action reduce activities in brain regions responsible for sensation of pain (thalamus, somatosensory cortex and other parts of the cortex). However, the use of placebos is ethically, legally and morally very dubious. The basis for the placebo effect is deception. It undermines honest relationship and trust between doctor and patient which is extremely important for successful treatment. Consciously giving placebos to patients for a condition that can be adequately treated, with prejudice the right of patients to the best care possible, opens up many bioethical issues. Despite all the current knowledge level, placebo effect remains still a scientific mystery

Placebo in the Treatment of Pain

Placebo is the use of the substance or procedure without specific activity for the condition that is trying to be healed. In medicine, benefits of placebo effect are used since 1985 and 1978 placebo effect was first scientifically confirmed. It was found that placebo induced analgesia depends on the release of endogenous opiates in the brain and that the placebo effect can be undone using the opiates antagonist naloxone. Functional magnetic resonance imaging of the brain showed that placebo analgesia was obtained regarding the activation and increased functional relationship between ant. cingulate, prefrontal, orbitofrontal, and insular cortex, nucleus accumlens, amygdala, periaqueduktalne gray matter and spinal cord. Placebo also facilitates descending inhibition of nociceptive reflexes through periacvaeductal gray substance. Placebo effect can be achieved in several ways: by using pharmacological preparations or simulation of operating or other procedures. This phenomenon is associated with perception and expectation of the patient. To achieve the effect of placebo it is essential degree of the suggestions of the person who prescribe a placebo, and the degree of belief of the person receiving the placebo. Expected effect of placebo is to achieve the same effect as the right remedy. Achieved placebo effect depends on the way of presentation. If a substance is presented as harmful, it may cause harmful effects, called »nocebo« effect. Placebo effect is not equal in all patients, same as the real effect of the drug is not always equal in all patients. Application of placebo in terms of analgesia will cause a positive response in 35% of patients. Almost the same percentage (36%) of patients will respond to treatment with morphine in medium doses (6–8 mg). Therefore, one should remember that response to placebo does not mean that a person simulates the pain and then it is unethical to withhold the correct treatment especially in light of findings that the prefrontal cortex is activated expecting liberation of pain and how this action reduce activities in brain regions responsible for sensation of pain (thalamus, somatosensory cortex and other parts of the cortex). However, the use of placebos is ethically, legally and morally very dubious. The basis for the placebo effect is deception. It undermines honest relationship and trust between doctor and patient which is extremely important for successful treatment. Consciously giving placebos to patients for a condition that can be adequately treated, with prejudice the right of patients to the best care possible, opens up many bioethical issues. Despite all the current knowledge level, placebo effect remains still a scientific mystery

Iron overload as a consequence of red blood cell transfusions in patients with hematological diseases

Preopterećenje željezom česta je i ozbiljna komplikacija višestrukih transfuzija deplazmatiziranih eritrocita koja pridonosi oštećenju organa te utječe na preživljenje bolesnika s hematološkim bolestima. U ruti nskoj praksi koristi se više metoda za procjenu preopterećenja željezom. Liječenje kelatorima željeza preporučuje se kada serumski feriti n premaši 1.000 ug/L i/ili ako je bolesnik primio više od 20 jedinica deplazmati ziranih eritrocita. Učinkoviti kelatori željeza neprocjenjivo su važni u liječenju preopterećenja željezom bolesnika s hematološkim bolesti ma koji zahti jevaju višestruke transfuzije krvi te dokazano smanjuju njihov morbiditet i poboljšavaju kvalitetu života.Iron overload is a very common and serious complicati on of repeated red blood cell transfusions which contributes to organ dysfuncti on and influences survival in patients with hematological diseases. Several methods for measuring ti ssue iron content are used in every-day practice. Iron chelation therapy is recommanded when serum ferriti n levels reach 1000 ug/L and/or in pati ents who have previously received more then 20 units of red blood cell. Effective iron chelators are essenti al in the management of iron overload of hematological patients that require repeted blood transfusions with proved reducti on of morbidity and improvement of their quality of life

Indicators of Cellular and Developmental Disorders in Multiple Primary Cancers

In human organism development is a very complex and highly regulated system that enables the functional balance of each organ in a whole body. Disorders and tumor micro-environment weaken host immune system that is not able to recognize the tumor as a unknown body and fight against its uncontrollable forces. Tumor avoids the immune system in a way that promotes imunosuppression and orientation cytokine production towards Th2 immune responses which are responsible for infection appearances. Some of infectious agents (viruses) can cause oncogene activation and inhibition of tumor suppressor genes. It is also known that oncology treatment can be detrimental to the host immune system. The drugs or radiation can activate different signaling pathways which lead to a vicious circle from which there is no return. Experimental models of tumor biology and molecular events in vivo are patients who have multiple primary cancers (MPC) diagnosed during life. Such patients confirm the complexity of disorders that occur in the cell and explain all the influences and contributions to developmental tumor cascad

DIFFICULTIES IN DIFERENTIAL DIAGNOSIS OF ANEMIA CAUSED BY CHRONIC DISEASE AND IRON DEFICIENCY ANEMIA · CASE REPORT

Diferencijalna dijagnoza sideropenične anemije i anemije kronične bolesti ne bi trebala biti teška, no u ponekim slučajevima razlikovanje ta dva tipa anemije stvara velike dijagnostičke teškoće, osobito pri planiranju terapije. U radu opisujemo slučaj 53-godi¹nje bolesnice upućene hematologu zbog anemije (Hb 87 g/L). Prethodno učinjene pretrage nisu bile dovoljne za postavljanje jasne dijagnoze, a nadomjesna terapija željezom započeta je šest mjeseci prije hematološke obrade. Istodobno vaginalno krvarenje u postmenopauzi, upalni proces i moguć ginekološki maligni tumor, dodatno su otežavali točnu dijagnozu primarnog uzroka mikrocitne anemije. Nakon histerektomije, dobiveni je patohistološki nalaz isključio malignu bolest pa je provedeno antibiotsko liječenje upalne bolesti male zdjelice i zapaženo je postupno poboljšanje laboratorijskih nalaza bez dodatne terapije željezom, kao i opće poboljšanje stanja pacijentice tijekom tromjesečnog praćenja. Zaključčli smo da rutinski laboratorijski nalazi katkad nisu dovoljni za postavljanje definitivne dijagnoze anemije. Kada vrijednost feritina nije vjerodostojna zbog mogućeg povišenja uzrokovanog životnom dobi, kroničnim poremećajima ili malignom bolesti, te ako postoji značajna sumnja na sideropeničnu anemiju, potrebno je odrediti transferinske receptore u serumu na koje kronična bolest nema utjecaja.The differential diagnosis of iron deficiency anemia and anemia caused by chronic disease should not be difficult despite the fact that distinguishing these two types may be a major clinical dillema in certain cases, especialy regarding the following treatment planning phase. We report a case of 53 year old woman who was sent to our Department of Hematology with a registered anemia (Hb 87 g/L). Although previous tests were not sufficient for establishing a clear diagnosis, iron replacement therapy had been started by general practitioner six months prior to the patients admittance to our ward. Concomitant postmenopausal vaginal bleeding, inflamatory process and possible gynecologic malignant tumor recorded in the same patient, made the diagnosing process of the primary cause of microcitic anemia quite complex. After hysterectomy which revealed no pathohystological evidence of any malignant gynecological tumor and antibiotic treatment for pelvic inflamatory disease, routine blood tests slowly normalized without iron replacement therapy and patient was in much better condition after three months follow up. We emphasize that routine laboratory analyses are not always sufficient for establishing a definitive diagnosis of the iron deficiency anemia. In cases where serum feritin level is not reliable due to its increase with age, chronic disorders and malignancy, considering a strong suspicion of iron deficiency, it is necessary to use serum transferrin receptor assay, which is not affected by chronic diseases

DIFFICULTIES IN DIFERENTIAL DIAGNOSIS OF ANEMIA CAUSED BY CHRONIC DISEASE AND IRON DEFICIENCY ANEMIA · CASE REPORT

Diferencijalna dijagnoza sideropenične anemije i anemije kronične bolesti ne bi trebala biti teška, no u ponekim slučajevima razlikovanje ta dva tipa anemije stvara velike dijagnostičke teškoće, osobito pri planiranju terapije. U radu opisujemo slučaj 53-godi¹nje bolesnice upućene hematologu zbog anemije (Hb 87 g/L). Prethodno učinjene pretrage nisu bile dovoljne za postavljanje jasne dijagnoze, a nadomjesna terapija željezom započeta je šest mjeseci prije hematološke obrade. Istodobno vaginalno krvarenje u postmenopauzi, upalni proces i moguć ginekološki maligni tumor, dodatno su otežavali točnu dijagnozu primarnog uzroka mikrocitne anemije. Nakon histerektomije, dobiveni je patohistološki nalaz isključio malignu bolest pa je provedeno antibiotsko liječenje upalne bolesti male zdjelice i zapaženo je postupno poboljšanje laboratorijskih nalaza bez dodatne terapije željezom, kao i opće poboljšanje stanja pacijentice tijekom tromjesečnog praćenja. Zaključčli smo da rutinski laboratorijski nalazi katkad nisu dovoljni za postavljanje definitivne dijagnoze anemije. Kada vrijednost feritina nije vjerodostojna zbog mogućeg povišenja uzrokovanog životnom dobi, kroničnim poremećajima ili malignom bolesti, te ako postoji značajna sumnja na sideropeničnu anemiju, potrebno je odrediti transferinske receptore u serumu na koje kronična bolest nema utjecaja.The differential diagnosis of iron deficiency anemia and anemia caused by chronic disease should not be difficult despite the fact that distinguishing these two types may be a major clinical dillema in certain cases, especialy regarding the following treatment planning phase. We report a case of 53 year old woman who was sent to our Department of Hematology with a registered anemia (Hb 87 g/L). Although previous tests were not sufficient for establishing a clear diagnosis, iron replacement therapy had been started by general practitioner six months prior to the patients admittance to our ward. Concomitant postmenopausal vaginal bleeding, inflamatory process and possible gynecologic malignant tumor recorded in the same patient, made the diagnosing process of the primary cause of microcitic anemia quite complex. After hysterectomy which revealed no pathohystological evidence of any malignant gynecological tumor and antibiotic treatment for pelvic inflamatory disease, routine blood tests slowly normalized without iron replacement therapy and patient was in much better condition after three months follow up. We emphasize that routine laboratory analyses are not always sufficient for establishing a definitive diagnosis of the iron deficiency anemia. In cases where serum feritin level is not reliable due to its increase with age, chronic disorders and malignancy, considering a strong suspicion of iron deficiency, it is necessary to use serum transferrin receptor assay, which is not affected by chronic diseases

Aggressive Multifocal Form of Epithelioid Hemangioendothelioma – Case Report

Epithelioid hemangioendothelioma (EHE) is a rare tumor of the vascular origin. It was first described in its pulmonary form by Dail and Leibow in 1975. and named »intravascular bronhioalveolar tumor« (IVBAT). Since then, reports of occurences of the tumor have been made for number of locations, but most often tumor can be found in soft tissues, liver, lungs, bone and skin. It is considered to be a low or borderline malignant tumor with, usually, slow progression, but aggressive forms have been descrided.We here report a case of a 46-year old female patient with multifocalmalignant tumor spreading to lungs, liver, spleen and with synchronous involvement of lumbal vertebrae, illiac bones and central nervous system dissemination. To the best of the authors knowledge, no case of malignant EHE with multiorgan involvement of this proportions and synchronous central nervous system and bone involvement in one patient has been reported to this date in English-speaking literature