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Synchronous Adie's syndrome and type 1 antineuronal nuclear antibody (anti-Hu)-related paraneoplastic neurological syndromes as predictors of complete response in limited-stage small-cell lung cancer: A case report
No full textAdie's syndrome (AS) and paraneoplastic sensorimotor neuropathy with cerebellar ataxia (PSN CA) are extremely rare, rapidly progressive, autoimmune diseases associated with the development of antibodies against neuronal-specific Hu proteins that are abnormally expressed in small-cell lung cancer (SCLC). We herein present the unique case of a 55-year-old obese woman, previous heavy smoker, who, during treatment with standard cisplatin-etoposide chemotherapy for limited-stage SCLC, developed simultaneous AS and worsening symptoms consistent with PSN CA that led to significant neurological disability and severe axonal electrophysiological pattern on nerve conduction studies. Serology confirmed the presence of low-titre type 1 antineuronal nuclear antibodies (ANNA-1), previously referred to as anti-Hu antibodies. Following plasmapheresis, immunosuppressive therapy and physical rehabilitation, the neurological symptoms progressively improved. The tumour completely regressed, with no recurrence detected on subsequent radiological examinations. The aim of this case was to highlight the importance of a multidisciplinary team approach for early recognition and rapid treatment of paraneoplastic neurological syndromes (PNS) as key to achieving significant recovery and marked improvement of the neurological deficit. This report extends the literature by confirming earlier studies showing that the presence of serum ANNA-1 in SCLC, an aggressive type of pulmonary carcinoma that is challenging to treat, may portend a more favourable prognosis and response to chemotherapy. Thus, patients with SCLC and new-onset neurological symptoms should be tested for ANNA-1. The role of a multimodality approach to treating PNS is also emphasized
How to give and receive feedback effectively
No full textIn most European countries, feedback is embedded in education, training and daily professional activities. It is a valuable tool for indicating whether things are going in the right direction or whether redirection is required. In the world of healthcare professionals, it is intended to provide doctors with information about their practice through the eyes of their peers. Feedback is a valuable tool for doctors to gather information, consolidate their awareness of strengths and areas to improve, and aims to support effective behaviour. Doctors of all levels may be approached by peers or juniors to give feedback, or they may ask others to give feedback on their own performance. Giving and receiving feedback is not an easy task and poses significant challenges for both sides. In this article, we will discuss pragmatic feedback models, how to overcome barriers to an effective feedback and tips for giving effective feedback, as well as how to receive feedback and make the most out of it
Successful factor XIII treatment of refractory chylothorax in tuberous sclerosis complex-associated lymphangioleiomyomatosis, multifocal multinodular pneumocyte hyperplasia and mediastinal lymphadenopathy
No full textTuberous sclerosis complex (TSC) or Bourneville disease is a rare autosomal dominant neurocutaneous disorder that affects various organs. Pulmonary involvement in TSC may consist of lymphangioleiomyomatosis (LAM) and multifocal micronodular pneumocyte hyperplasia (MMPH), occurring together or alone. In patients with TSC-LAM, chylous pleural effusion (CPE) is a rare, though well-recognized, complication with an unpredictable clinical course. In refractory or persistent CPE, optimal management remains a clinical challenge. We report the unique case of a 29-year-old Caucasian female, neversmoker, with definite TSC since infancy, characterized by seizures, facial angiofibromas ("adenoma sebaceum"), bilateral renal angiomyolipomas, hepatic angiomyolipomas, subcortical/cortical tubers, and subependymal nodules. At 27 years old, due to bleeding from the renal angiomyolipomas, she underwent nephrectomy, first of the right, and then a year and 9 months later, of the left kidney. She was hemodialysis dependent for the next five years until cadaveric kidney transplantation. The medical history was also remarkable for recurrent exudative lymphocytic PE despite repeated therapeutic thoracenteses, with first presentation at 23.5 years of age. Chylothorax was initially diagnosed at 24 years and 8 months old (PE triglycerides 4.53 mmol/L), and reconfirmed at age 29 (PE triglycerides 12.46-15.30 mmol/L). Computerized tomography scan of the thorax showed a large encapsulated PE in the left lung field, multiple thin walled cysts (≤ 5 mm in diameter) in the lung parenchyma bilaterally, and mediastinal lymphadenopathy - all prominent features of LAM - as well as nodular pulmonary lesions (≤ 3 mm in diameter) consistent with MMPH. Given the persistent nature of the CPE, a five-day course of recombinant human factor XIII (FXIII) was administered intravenously. The chylothorax completely resolved within three months. There has been no recurrence of CPE on follow-up chest X-rays (i.e., total follow-up period of 53 months). This report suggests that the transglutaminase FXIII, a blood coagulation factor, may have an important clinical benefit in treating recurrent or thoracentesis-refractory CPE in TSC-LAM. To our knowledge, this is the first known case in the literature describing the successful treatment of CPE with FXIII in TSC-LAM. Because CPE is rare and there is currently no gold standard for its management, regardless of etiology, further research is warranted to investigate the potential clinical use of FXIII as an effective and safe treatment strategy in selected patients
Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation
No full textMaternal brain death during pregnancy remains an exceedingly complex situation that requires not only a well-considered medical management plan, but also careful decision-making in a legally and ethically delicate situation. Management of brain dead pregnant patients needs to adhere to special strategies that support the mother in a way that she can deliver a viable and healthy child. Brain death in pregnant women is very rare, with only a few published cases. We present a case of a pregnant woman with previously diagnosed multiple brain cavernomas that led to intracranial hemorrhage and brain stem death during the 21st week of pregnancy. The condition that can be proven unequivocally, using tests that do not endanger viability of the fetus, is brain stem death, diagnosed through absence of cranial reflexes. The patient was successfully treated until delivery of a healthy female child at 29 weeks of gestation. The patient received continuous hormone substitution therapy, fetal monitoring and extrinsic regulation of maternal homeostasis over 64 days. After delivery, the final diagnosis of brain death was established through multi-slice computerized tomography pan-angiography. This challenging case discusses ethical and medical circumstances arising from a diagnosis of maternal brain death, while showing that prolongation of somatic life support in a multidisciplinary setting can result
in a successful pregnancy outcome
Uspoređivanje koncentracije litija u serumu, plazmi i eritrocitima
No full textThe use of lithium in medicine began in the mid-19th century, when the solubility of uric acid salts in the solution of lithium carbonate was demonstrated in vitro, which meant that lithium could be used in the treatment of gout. The use of lithium in psychiatry starts in 1949, when the effect of lithium in the treatment of mania was demonstrated. The mechanism of action of lithium is not yet completely understood. In parallel with the use of lithium in the treatment of psychiatric disorders, different methods for the determination of lithium in human samples have been developed. The first aim of the study was to determine the amount of lithium in serum samples using electrochemical methods, flame photometry and spectrophotometry and use the results to compare the results obtained using these methods. Because of the possibility of determining lithium in various media, the second aim of the study was to evaluate the clinical value of determining the concentration of lithium in erythrocytes in relation to the concentration of lithium in plasma. The third aim was to investigate the extent to which a therapeutic dose of lithium correlates with the measured concentrations of lithium in serum, plasma and erythrocytes. It was concluded that statistically there was no significant difference between the three test laboratory methods (P = 0.507). Investigating the correlation between the concentration of lithium in various media measured by different methods and the daily therapeutic dose of lithium, it was concluded that statistically a significant correlation was found only in serum lithium concentrations measured with electrochemical method (P = 0.009; r = 0.47). There was statistically a significant moderate correlation between the concentration of lithium in plasma and erythrocytes (P = 0.002; r = - 0.54), and the lithium concentration erythrocytes are higher than lithium concentrations in plasma (P = 0,043). The range of the ratio of the concentration of lithium in erythrocytes and plasma is wide (13.25 to 111.15), and is not in correlation with the therapeutic daily dose and therefore is not a better indicator in the control of the treatment.Primjena litija u medicini započela je sredinom 19. stoljeća kada je in vitro prikazana topljivost soli mokraćne kiseline u otopini litijeva karbonata što je ukazalo na činjenicu da se litij može koristiti u liječenju gihta. Korištenje litija u psihijatriji započinje 1949. godine kada je dokazan njegov učinak u liječenju manije. Njegov mehanizam djelovanja još nije u potpunosti razjašnjen. Paralelno s korištenjem litija u liječenju psihijatrijskih poremećaja razvile su se različite metode za određivanje koncentracije litija u ljudskim uzorcima. Prvi cilj studije bio je odrediti razinu litija u uzorcima seruma koristeći elektrokemijske metode, plamenu fotometriju, spektrofometriju i usporediti rezultate s rezultatima dobivenim korištenjem ovih metoda. Zahvaljujući mogućnosti određivanja litija u raznim medijima, drugi cilj studije bio je procijeniti kliničke vrijednosti određivanja koncentracije litija u eritrocitima u odnosu na koncentraciju litija u plazmi. Treći cilj bio je istražiti u kojoj se mjeri terapijska doza litija podudara s izmjerenim koncentracijama litija u serumu, plazmi i eritrocitima. Zaključeno je da statistički ne postoji značajna razlika između tri laboratorijske metode (P.= 0.507). Istražujući povezanost između koncentracije litija u raznim medijima izmjerenim različitim metodama i dnevne terapeutske doze litija, zaključeno je da je statistički značajna poveznica pronađena jedino u izmjerenoj koncentraciji litija u serumu pomoću elektrokemijske metode (P 0 0.009; r = 0.47). Statistički je značajna umjerena povezanost između koncentracije litija u plazmi i eritrocitima (P = 0.002; r = - 0.54), i koncetracije litija u eritrocitima su veće od koncentracije litija u plazmi (P = 0,043). Raspon udjela koncentracije litija u eritrocitima i plazmi je širok (13.25 do 111.15) i nije povezan s terapeutskom dnevnom dozom i stoga nije bolji indikator u kontroli tretmana
Primarni maligni limfom tijela maternice: prikaz slučaja
No full textPrimary malignant lymphoma of the genital tract is a rare disease. It’s frequency has been reported to be less than 1% among extranodal lymphoma in women. The main symptoms are abnormal vaginal bleeding, unclear abdominal/pelvic pain, dyspareunia and/or urinary obstruction.
We present a 77-year old woman with a primary malignant lymphoma of the uterine corpus. Non-Hodgkin diffuse large B cell lymphoma was diagnosed in a curettage specimen. Positron emission tomography/ computed tomography (PET-CT) findings showed a lesion confined to the uterus without evidence of disease in the head, neck, chest or abdomen. There were no enlarged lymph nodes. The patient was treated by chemotherapy.Primarni maligni limfom genitalnog trakta je rijetka bolest. Učestalost je manja od 1% među limfomima izvan limfnih čvorova. Glavni simptomi su abnormalno vaginalno krvarenje, nejasna abdominalna/zdjelična bol, dispareunija i/ili urinarna opstrukcija.
Mi predstavljamo slučaj 77-godišnje pacijentice sa primarnim malignim limfomom tijela maternice. Non-Hodgkin difuzni velikostanični B limfom je dijagnosticiran u uzorku frakcionirane kiretaže. Imunohistokemijsko bojanje je potvrdilo dijagnozu. PET/CT je potvrdio bolest unutar maternice bez znakova bolesti u glavi, vratu, prsima ili trbuhu. Nije bilo uvećanih limfnih čvorova. Pacijentica je liječena kemoterapijom
The Use of Metformin and the Incidence of Metastases at the Time of Diagnosis in Patients with Lung Cancer and Type 2 Diabetes
No full textLung cancer is often insidious disease. It usually produces only a few symptoms until the disease is advanced. At initial diagnosis 20% of patients have localized disease, 25% of patients have regional metastasis and 55% of patients have distant spread of disease. Metastasis is a process by which a small number of cancer cells undergo numerous alterations, which enables them to form secondary tumors at another and often multiple sites in the host. Recently, studies have suggested that cancer stem cells are the originators of metastasis. Cancer stem cells are small populations of slowly dividing, treatment – resistant, undifferentiated cancer cells that are being discovered in a different cancers. Metformin has proved to be effective in the treatment of glioblastomas and neuroblastomas, in vitro, by targeting their cancer stem cell population. Recently, studies have shown that metformin use is not associated with a decreased risk of lung cancer in patients with type 2 diabetes, but it has been suggested that metformin use is associated with improved survival among patients with stage IV NSCLC patients
EGFR mutations in lung adenocarcinoma and brain metastases: A Croatian single institution experience
No full textThe brain, bones and lungs are common sites of metastasis in non-small cell lung cancer. We aimed to investigate the metastatic pattern of epidermal growth factor receptor (EGFR) mutations by analyzing the incidence of different metastatic sites in EGFR positive (þ) lung adenocarcinoma patients with brain metastases (BM)
Prescribing practices in Southeastern Europe – focus on benzodiazepine prescription at discharge from nine university psychiatric hospitals
No full textThere is much concern about the widespread long-term use of benzodiazepines. Our manuscript addressed its use in the region of Southeastern Europe, which seems extensive, but insufficiently explored. At nine university psychiatric hospitals (Croatia, Macedonia and Serbia), we retrospectively analyzed discharge summary documents to find the prevalence of discharge benzodiazepine prescriptions and the prescribed benzodiazepine doses. This study included 1047 adult subjects and showed that 81.9% of them had benzodiazepines prescribed in the discharge summary document, with high mean daily dose of around 5 mg lorazepam equivalents. Factors associated with the prescriptions were exclusively clinical factors (diagnosis of schizophrenia spectrum disorders, more lifetime hospitalizations, psychiatric comorbidity, co-prescription of antidepressant or mood stabilizer, shorter duration of the hospitalization), while socio-demographic factors were not found to influence benzodiazepine discharge prescriptions. Similarly, factors which influenced the prescription of higher daily benzodiazepine dose were more lifetime psychiatric hospitalizations and co-prescription of antidepressant or mood stabilizer, as well as the diagnosis of mental/behavioral disorders due to substance use and co-prescribed antipsychotic. Our data are emphasizing an urgent need for guidelines and improved education of both health care professionals and patients, in order to prevent long term benzodiazepine (mis)use and related side-effects
Anxiety and How to Heal it
No full textAnksioznost se javlja u cijelom nizu psihičkih poremećaja te ju stoga kliničar uvijek mora ozbiljno razmotriti kako bi stekao cjelovit dojam prilikom postavljanja dijagnoze određenoga psihičkog poremećaja, ali ujedno diferencijalnodijagnostički isključio i druga stanja koja također mogu doći u obzir. Ključna obilježja anksioznih poremećaja jesu strah i zabrinutost, koji su prisutni u čitavom spektru anksioznih poremećaja. Amigdala ima središnju ulogu u reakciji straha. Brojni su neurotransmitori uključeni u reguliranje krugova koji sudjeluju u etiologiji anksioznih poremećaja. GABA (g-aminomaslacna kiselina) glavni je neurotransmitor kod anksioznosti, a benzodiazepinski anksiolitici ostvaruju učinak putem ovoga neurotransmitorskog sustava. Serotonin, noradrenalin, α2δ-ligandi, koji se vežu na naponske kalcijeve kanale, regulatori su krugova anksioznosti. Brojne su terapije na raspolaganju za liječenje anksioznih poremećaja, a većina njih se na sličan način primjenjuje u čitavom spektru anksioznih poremećaja, kao i u liječenju depresije.Anxiety occurs in a variety of mental disorders, and it needs to be seriously considered in order to create a complete impression when setting up a specific diagnosis of mental disorders, but also when ruling out other conditions that may also be considered. The key characteristic of anxiety disorders are fear and concern, which are present throughout a whole spectrum of anxiety disorders. The amygdala plays a central role in the reaction of fear. Numerous neurotransmitters are involved in regulation of pathways involved in the etiology of anxiety disorders. GABA (Ȗ-aminobutyric acid) is the major neurotransmitter in anxiety, and benzodiazepine anxiolytics have an effect through this neurotransmitter system. Serotonin, noradrenaline, α2δ-ligand binding to voltage-gated calcium channels are also regulators of anxiety circuits. Numerous therapies are available for the treatment of anxiety disorders, most of which are applied in a similar way throughout the spectrum of anxiety disorders, and also in the treatment of depression