A Questionnaire for Rating Health-related Quality of Life.

BACKGROUND: Translations of instruments for measuring quality of life developed in certain, mostly more developed, parts of the world usually do not cover regionally specific aspects of health-related quality of life, even after transcultural validation. The aim of this study was to develop and validate a reliable questionnaire in Serbian, Croatian, Bosnian, and Montenegrin languages suitable for measuring health-related quality of life in adults. METHODS: The study was of a cross-sectional type, assessing the reliability and validity of a newly developed questionnaire for measuring health-related quality of life (HRQoL) in adults residing in western Balkan states (WB-HRQoL). It was conducted on a sample of 489 adults from Serbia, Croatia, Bosnia & Herzegovina, and Montenegro, with a mean age of 52.2±14.4 years and a male/female ratio of 195/294 (39.9%/60.1%). RESULT: The definitive version of the WB-HRQoL scale with 19 items showed very good reliability, with Cronbach's alpha 0.905. The scale was temporally stable, and satisfactory results were obtained for divergent and convergent validity tests. Exploratory factorial analysis brought to the surface four domains of health-related quality of life, namely the physical, psychical, social, and environmental. CONCLUSION: The WB-HRQoL scale is a reliable and valid generic instrument for measuring HRQoL that takes into account the cultural specifics of the western Balkan region.

Anemia Is Correlated with Malnutrition and Inflammation in Croatian Peritoneal Dialysis Patients: A Multicenter Nationwide Study.

Malnutrition, inflammation, and anemia are common in peritoneal dialysis (PD) patients. In this study, correlations between Malnutrition Inflammation Score (MIS), laboratory and anthropometric parameters, and anemia indices in Croatian PD patients were analyzed. One hundred and one PD patients (males/females 54/47, age 58.71 ± 14.68 years, mean PD duration 21.82 ± 21.71 months) were included. Clinical, laboratory, and anthropometric parameters were measured. Statistically significant correlations between MIS and erythropoietin weekly dose per kg of body weight (ESA weekly dose), hemoglobin (Hb), and erythrocytes were found (r = 0.439, p < 0.001; r = -0.032, p < 0.001; r = -0.435, p < 0.001), respectively. Also, statistically significant correlations were found between MIS and mean corpuscular volume (r = 0.344, p < 0.001), iron (r = -0.229, p = 0.021), and total iron binding capacity (TIBC) (r = -0.362, p < 0.001), respectively. Furthermore, statistically significant correlations between ESA weekly dose and serum albumin level and body mass index (BMI) were found (r = -0.272, p = 0.006; r = -0.269, p = 0.006), respectively. When we divided PD patients into 2 groups according Hb level (Hb ≥ 110 [N = 60, 59.41 %]) and Hb < 110 [N = 41, 40.59%]), statistically significant differences were found in MIS score (3.02 ± 2.54 vs 4.54 ± 3.54, p = 0.014), C-reactive protein (CRP) (3.52 ± 6.36 vs 7.85 ± 7.96, p = 0.005), and serum albumin level (44.22 ± 8.54 vs 39.94 ± 8.56, p = 0.003), respectively. Our findings suggest that anemia is correlated with malnutrition and inflammation in Croatian PD patients. Further studies are needed to assess whether modulating inflammatory or nutritional processes can improve anemia management in PD patients.

Angiogenic and lymphangiogenic profiles in histological variants of papillary thyroid carcinoma.

INTRODUCTION: Papillary thyroid carcinoma (PTC) is a well­differentiated tumor that occurs in several histological variants whose biological behaviors remain unclear. Angiogenesis and lymphangiogenesis are critical processes that enable tumor progression. OBJECTIVES: The aim of this study was to evaluate the angiogenic and lymphangiogenic phenotypes of PTC, considering the differences between histological variants. PATIENTS AND METHODS: Angiogenic and lymphangiogenic profiles were analyzed by determining microvascular density (MVD) and lymphatic vessel density (LVD) in 73 cases of PTC, using immunohistochemistry. To assess the biological markers involved in blood and lymph vessel formation, the expression of vascular endothelial growth factor (VEGF), cyclooxygenase 2 (COX­2), and p27kip1 (p27) was determined. RESULTS: MVD was significantly higher in patients with high­risk PTC and in those with local extrathyroidal and vascular invasion. Positive VEGF expression was strongly associated with high MVD and age­related tumor enlargement. The presence of lymph vessel invasion was associated with the expression of either VEGF or COX­2. The analysis of angiogenesis and lymphangiogenesis in different histological variants of PTC revealed elevated LVD rather than MVD in the follicular variant of PTC (FV­PTC).Lower MVD was observed in FV­PTC relative to the classic variant of PTC (CV­PTC). The frequency of VEGF­positive tumors was higher in CV­PTC than in FV­PTC. A significant association between COX­2 and p27 expression was observed in FV­PTC but not in CV­PTC. CONCLUSIONS: These results suggest that VEGF, COX­2, and p27 may be important biological markers that determine the angiogenic and lymphangiogenic potentials of PTC, particularly between the follicular and classic variants.

Circulating and tissue galectin-1 and galectin-3 in colorectal carcinoma: association with clinicopathological parameters, serum CEA, IL-17 and IL23.

PURPOSE: Galectins are modulators of many processes critical for tumor progression and metastasis but their clinical significance is still unclear. The objective of this study was to analyze the clinical significance of Galectin-1 and Galectin-3 in the tissue and sera of patients with colorectal carcinoma (CRC). Examined were also their association with serum CEA, IL-17 and IL-23 in CRC patients. METHODS: One hundred and twenty patients with CRC were included in this study. The expression of Galectin-1 and Galectin-3 in biopsy samples of CRC was determined using immunohistochemistry (N=120). The concentrations of Galectin-1, Galectin-3, IL-17 and IL-23 in the sera of CRC patients (N=38) were determined by Enzyme Linked Immunosorbent Assay (ELISA). RESULTS: Serum Galectin-1 concentrations positively correlated with parameters of malignancy including perineural invasion (p=0.016), lymph node involvement and distant metastases (p=0.029). Higher expression of peritumoral Galectin-1 was associated with both presence of perineural invasion and poor differentiation of CRC. Serum CEA levels positively correlated with circulating Galectin-1, but inversely correlated with peritumoral Galectin-1 expression. There was no correlation between Galectin-3 and clinicopathological parameters of CRC, but it was found that Galectin-3 expression in the tumor tissue positively correlated with serum IL-17 and IL-23. Circulating Galectin-3 levels significantly correlated with IL-17 (p=0.042), but not with IL-23 in the sera of CRC patients. CONCLUSIONS: This study suggests that Galectin-1 and Galectin-3 exhibit protumorigenic activity in CRC by affecting different aspects of tumor progression. Galectin-1 facilitates tumor invasion and metastasis while Galectin-3 preferentially modulates tumor-associated inflammatory processes.

Do Health Reforms Impact Cost Consciousness of Health Care Professionals? Results from a Nation-Wide Survey in the Balkans.

BACKGROUND: Serbia, as the largest market of the Western Balkans, has entered socioeconomic transition with substantial delay compared to most of Eastern Europe. Its health system reform efforts were bold during the past 15 years, but their results were inconsistent in various areas. The two waves of global recession that hit Balkan economies ultimately reflected to the financial situation of healthcare. Serious difficulties in providing accessible medical care to the citizens became a reality. A large part of the unbearable expenses actually belongs to the overt prescription of pharmaceuticals and various laboratory and imaging diagnostic procedures requested by physicians. Therefore, a broad national survey was conducted at all levels of the healthcare system hierarchy to distinguish the ability of cost containment strategies to reshape clinician's mindsets and decision-making in practice. AIMS: Assessment of healthcare professionals' judgment on economic consequences of prescribed medical interventions and evaluation of responsiveness of healthcare professionals to policy measures targeted at increasing cost-consciousness. STUDY DESIGN: Cross-sectional study. METHODS: A nationwide cross-sectional survey was conducted through a hierarchy of medical facilities across diverse geographical regions before and after policy action, from January 2010 to April 2013. In the middle of the observed period, the National Health Insurance Fund (RFZO) adopted severe cost-containment measures. Independently, pharmacoeconomic guidelines targeted at prescribers were disseminated. Administration in large hospitals and community pharmacies was forced to restrict access to high budget-impact medical care. Economic Awareness of Healthcare Professionals Questionnaire-29 (EAHPQ-29), developed in Serbian language, was used in face-to-face interviews. The questionnaire documented clinician's attitudes on: Clinical-Decision-Making-between-Alternative-Interventions (CDMAI), Quality-of-Health-Care (QHC), and Cost-Containment-Policy (CCP). The authors randomly and anonymously recruited 2000 healthcare experts, with a total of 1487 responding; after eliminating incomplete surveys, 649 participants were considered before and 651 after policy intervention. RESULTS: Dentists (1.195±0.560) had a higher mean CDMAI score compared to physicians (1.017±0.453). The surgical group compared to the internist group had a higher total EAHPQ-29 score, CCP score and CDMAI score. Policy intervention had a statistically significant negative impact on the QHC score (F=4.958; df=1; p=0.027). There was no substantial impact of policy interventions on professional behavior and judgment with regard to the CDMAI, CCP, and total EAHPQ-29 scores. CONCLUSION: Although cost savings were forcibly imposed in practice, the effects on clinical decision-making were modest. Clinicians' perceptions of quality of medical care were explained in a less effective manner due to the severely constrained resources allocated to the providers. This pioneering effort in the Balkans exposes the inefficiency of current policies to expand clinicians' cost consciousness.

[Thirty years experience of treatment with peritoneal dialysis in University Hospital "Sveti Duh"]. / 30-godisnje iskustvo lijecenja peritonejskom dijalizom u KB Sveti Duh.

Peritoneal dialysis (PD) is a treatment for patients with severe chronic kidney disease (CKD) which uses the patient's peritoneum as a membrane across which fluids and dissolved substances are exchanged from the blood. Implementation of this method begun in the seventies, with approximately 7000 patients treated in the year 1981. That same year, we started using this method in our center and to date we have a total of 167 patients. Years of experience and improvement of the technique made this method equivalent to hemodialysis and often even a first method of choice when treating patients with CKD. Data from all patients treated in our center were prospectively collected from year 1981 to 2010. A total of 167 patients (83 women and 84 men) between the ages 28 and 79 (median of 59) were treated by this method. The number of patients enrolled in the program of PD decreased from 64 in the first 10 year period (1981-1990) to 40 in the last 10 year period (2001-2010). 30-year average of PD treatment was 34 months (range from 1 to 110 months). Average duration of treatment per patient increased during the years up to 42 months per patient. The most common reason for termination of PD treatment was fatal outcome (48%), failure of peritoneal membrane (35%) and kidney transplantation (2.4%). Overall rate of peritonitis during the observed peritonitis was 1 every 15 months of treatment. Comparing the rates of peritonitis between the first and the last ten year period, a significant decrease from 1 every 10 months to 1 every 39 months was observed. Overall share of patients with diabetes was 19%. The total number of diabetic patients increased during years according to the increasing rates of diabetic patients worldwide. The decrease in number of patients enrolled in the program in our center is probably due to further development of transplantation program and opening of new dialysis centers in Croatia. The decrease of the peritonitis rate and consequent increase of duration of PD treatment per patient is explained by the improvement of techniques, solutions and better education of the patients and medical staff. 30 years of existence the Centre enabled us to gain experience in treating patients with CKD. Along with experience came the improvement of quality of life of our patients. Our goal is to further develop PD as it is the method of choice in terms of better physical and psychical rehabilitation of the patient with CKD waiting for the transplantation treatment.

Obstruction of left ventricular outflow tract by a calcified mass at mitral valve.

A case of an unusual left ventricular outflow tract obstruction by mitral valve pathology in a 35-year old female with diabetes and end-stage renal disease is presented in the study. The patient suffered from fever of an unknown origin after lower-leg amputation. Although the wound healed well, fever persisted for three weeks despite a triple antibiotic treatment until the infection was resolved with vancomycin. Three months later echocardiography displayed a floating mass attached to mitral valve, producing a newly developed systolic murmur and a mild haemodynamic obstruction of the left ventricular outflow tract. The calcified vegetation was probably formed during an unrecognized subacute infective endocarditis.

[Anemia treatment in peritoneal dialysis patients]. / Znacajke lijecenja bubrezne anemije u bolesnika na peritonejskoj dijalizi.

Anemia is highly prevalent among chronic kidney disease (CKD) patients and patients receiving renal replacement therapy. In this paper we will outline the prevention and treatment of anemia in patients treated with peritoneal dialysis (PD). PD patients are less anemic and more sensitive to erythropoesis-stimulating agent (ESA) than their hemodialysis (HD) counterparts and, in general, dosages required for achieving similar hemoglobin levels to those achieved in HD patients are remarkably less. Before starting with ESA treatment we have to evaluate the degree of anemia and excluded other causes which are not connected with CKD and method of treatment. Patient's compliance is crucial for a successful therapy and it can be improved by decreasing frequency of administration of ESA. Since ESAare expensive, "cost-effectivnes" studies represent an important factor in choosing a distinct drug. Subcutaneous administration provides better long-term utilization of ESA in comparison to intravenous administration and is therefore preferred in PD patients. Intraperitoneal administration is not recommended due to poor bioavailability. In some patients we can observe the reduced response to ESA therapy. The definition of reduced response is generally regarded as a failure to achieve target hemoglobin concentration of >11 g/dL. Identification of underlying cause is not always easy but every attempt should be made to investigate every patient with resistance to therapy because some causes are easily corrected. Since 2005 particular ESA drugs have been approved by Croatian Institute for Health Insurance and registered for use in Croatia. For PD patients the ESAcan be prescribed by general practitioner. The list of available drugs is available in the official government newspaper Nardone novine No.27, March 2nd, 2009.

[Long-terme outcome of peritoneal dialysis treatment--27 years of single centre experience]. / Ishod dugogodisnjeg lijecenja peritonejskom dijalizom--27 godina iskustva u jednom centru.

By the end of 2007 we had 160 patients on CAPD treatment in our centre (44% male, 56% female) aged between 29-78 years. Till 1994 13% of our patients were diabetics. In the last 10 years (1997-2007) the percentage of diabetics increased to 36%. During the 27 years period 44% of our patients died, 35% switched to haemodialysis and 3% have undergone renal transplantation. The survival rate after three years of treatment was 75%, after five years 63% and after 10 years 44%. Technique survival was 77%, 65% and 48% respectively. There were 309 episodes of peritonitis as the main complication of treatment (one episode on every 9, 4 months of treatment till 1994 and one episode on every 25, 8 months in the last ten years), out of which 58% was caused by Gram positive bacteria, 18% by Gram negative, 4% were fungal infections while the remaining 20% were culture negative. Regarding other complications we had 42 exit-site infections and 8 episodes of sclerosing peritonitis with 4 deaths. We found peritonitis to be the main reason of switching to haemodialysis (71%) and the main reason of death (39%) among the patients on CAPD. In the last 10 years (1997-2007) we analyzed the diabetics group separately and we found that the rate of CAPD dropout was not significantly different between diabetics and non-diabetics group. However, when analysing the causes of CAPD dropout, we found significant difference in mortality ate (50% among diabetics versus 26% among non-diabetics) and the rate of switching to haemodialysis (37% versus 55% respectively). In addition we established that the rate of CAPD survival was better after 1994 and we speculate that the main reason is the diminished peritonitis rate.

[Prevention and treatment of hepatitis B in patients on hemodialysis and vaccination of hemodialysis health personnel against hepatitis B]. / Smjernice za sprjecavanje, kontrolu i lijecenje hepatisa B na dijalizi, kao i za cijepljenje zdravstvenih radnika na dijalizi protiv hepatitisa B.

The prevalence and incidence of hepatitis B in hemodialysis patients in Croatia have been estimated to 1.3% and 0.03%, respectively. HBV infection in dialysis patients is usually asymptomatic, has a prolonged course, and progresses to chronic HBsAg hepatitis in 50% of cases. Some 15%-40% of HBsAg carriers on dialysis will develop cirrhosis, liver decompensation or hepatocellular carcinoma. Strict adherence to the standard infection prevention measures, continuous monitoring of HBV markers in patients on hemodialysis, patient and personnel immunization and hepatitis B treatment in hemodialyzed patients are mandatory. Each new patient in a dialysis center must be tested for HBV markers irrespective of prior immunization. All patients in the center should be routinely screened every 3-4 months. HBV immunization is mandatory for all patients on dialysis. In patients with uremia the anti-HBs antibody production is decreased (antibodies will develop in 50%-60% of cases after immunization). It is recommended to immunize all patients with progressive kidney disease, preferably in the preterminal stage. Hepatitis B therapy is recommended in all patients with biopsy proven chronic liver disease. Patients should be treated with standard interferon alpha and/or lamivudine, or peginterferon alpha monotherapy. Hepatitis B treatment is most important in kidney and/or liver transplant candidates. HBV immunization is obligatory for all hospital personnel who are in close contact with infected patients and infective materials.

[Adequacy of dialysis at the Department of Nephrology and Dialysis of the Sveti Duh General Hospital in Zagreb and the Dialysis Outcomes Quality Initiative (DOQI) guidelines--comparison of the years 1998 and 2002]. / Adekvatnost dijalize u Odjelu nefrologije i dijalize u Opcoj bolnici "Sveti duh" u Zagrebu i DOQI preporuke--usporedba 1998. i 2002. godine.

Every year ever more and more patients in our country receive some form of dialysis, which provides life-saving renal replacement therapy for end-stage renal disease. In an effort to improve the quality and outcomes of dialysis care, the National Kidney Foundation--Dialysis Outcomes Quality Initiative (NKF-DOQI) have developed clinical practice guidelines for care of dialysis patients regarding hemodialysis adequacy, peritoneal dialysis adequacy, treatment of anemia, and vascular access. The morbidity and mortality of patients is strongly connected with dialysis adequacy and degree of anemia. We compared 180 patients on hemodialysis (HD) in 1998 and 177 patients in 2002, who are regularly treated in our Center with the use of DOQI guidelines. Dialysis adequacy was assessed by use of urea reduction ratio URR = 1-(post. urea/pre. urea), and overall wellbeing according to the degree of anemia, number of blood transfusions, presence of elevated blood pressure, and number of antihypertensives in therapy. In year 2002, 50% of the patients had adequate dialysis compared with 30% in 1998. The average duration on dialysis and the age of patients did not change. We recorded a rise in hemoglobin from 80 g/L to 92 g/L, and in the use of EPO (from 18% to 30%). No case of hypoalbuminemia was observed. The aim of dialysis is to improve the overall wellbeing of uremic patients. Comparing our results with DOQI-guidelines, we demonstrated that dialysis therapy could be improved to prevent complications and early mortality in dialysis patients.

[Catheter placement for peritoneal dialysis using videoendoscopy]. / Postavljanje katetera za peritonejsku dijalizu videoendoskopskim nacinom.

From December 1993 to December 2000 at the Department of Surgery, General Hospital "Sveti Duh", and University, Hospitals Split and Osijek the catheter for peritoneal dialysis was placed in 128 patients, in 137 cases. Videoendoscopic procedure, with the trocar made precisely for that purpose, was used. All surgical procedures, performed in the completely equipped operation room and in general anesthesia, were done without any intraoperative or postoperative complications. The procedure showed to have all advantages of endoscopic or minimally invasive surgery. The patients recovered quickly with low consumption of analgesics, got out of the bed and started with feeding sooner. There were no wound complications. It was possible to start with the dialysis 2-3 days after the procedure. Most important, the results showed that using this approach in comparison to others, there were no more dialysis solution leakages, catheter drainage problems, or more tunnel, exit site or peritoneal infections. Along with placing the catheter, other surgical procedures could be also done without increasing the complication rate. Therefore, laparoscopic cholecystectomy was done in 12 cases, adhesiolysis in 25 cases, and right adnexectomy, open hernioplasty and umbilical hernioplasty in one case. Videoendoscopic approach of placing the catheter is a simple, short and patient convenient procedure, with quick recovery and without any increase in complication rate.