Challenges and improvement needs in the care of patients with central diabetes insipidus.

Central diabetes insipidus (CDI) is a rare condition, with significant impact on patient health and well-being. It is a chronic condition which usually requires meticulous long-term care. It can affect both children and adults. There is limited literature considering the needs and challenges inherent in providing high quality care to patients with CDI, across the care pathway. This paper seeks to address this gap by providing a unique and well-rounded understanding of clinical and healthcare systems-related challenges. It draws on insights from the literature, from direct clinical experience contributed by five clinicians as co-authors (providing insights from France, Ireland, Italy, Spain and the United Kingdom), and from patient perspectives provided through interviews with patient representatives from three patient organisations. We identify clinical challenges related to the diagnosis of CDI, including differentiating between other similar conditions and determining the underlying aetiology. Treatment is challenging, given the need to tailor medication to each patient's needs and ongoing management is required to ensure that patients continue to respond adequately to treatment. Ongoing support is required when patients switch between formulations. We also identify healthcare systems challenges related to limited awareness of CDI amongst primary care physicians and general paediatricians, and the need for highly skilled specialist care and appropriate workforce capacity. There is also a significant need for raising awareness and for the education of both healthcare professionals and patients about different aspects of CDI, with the aim of supporting improved care and effective patient engagement with healthcare professionals. We reflect on this information and highlight improvement opportunities. These relate to developing guidance to support patients, carers, primary care physicians and general paediatricians to identify clinical features earlier, and to consider CDI as a possible diagnosis when a patient presents with suggestive symptoms.

Nonsteroidal anti-inflammatory drugs: as inappropriate pharmacotherapy in the elderly?

Nonsteroidal anti-inflammatory drugs (NSAID) are one of the most used groups of drugs in elderly population. The aim of this study was to establish the frequency of reported disorders while using NSAID in elderly patients. A multi-centric study was conducted with a standard questionnaire for all geriatrician outpatients who were using NSAID. It has been found that out of 421 patients, 320 reported some kind of disorder; 287 of them used other drugs beside NSAID, 33 used only NSAID during the study. It has been concluded that frequency of reported disorders was significantly higher among patients who used another drug beside NSAID, and statistically most frequent reported disorders were gastrointestinal.

Mycobacterium caprae in cattle and humans in Croatia.

SETTING: This paper describes an outbreak of human and related bovine tuberculosis (TB) caused by Mycobacterium caprae in Croatia. A 13-year-old boy clinically presented enlargement of cervical lymph node with consecutive isolation of M. caprae. His 7-year-old sister, who had no clinical signs of disease, hyper-reacted to the purified protein derivative (PPD) test (>25 mm) and peribronchial infiltration was found by radiology. The children came from a family that ran a small-sized cattle dairy farm. DESIGN: All cattle on the farm were subjected to cutaneous TB testing: six of the 14 reacted positive, while three were suspicious. The entire herd was slaughtered, their carcasses examined and collected material subjected to pertinent diagnostic procedures. RESULTS: Gross examination findings consistent with TB were observed in the PPD-positive cows. Mycobacteria isolated from the boy and cattle were identified by classical and molecular methods, confirming M. caprae as the causative agent. CONCLUSION: Although not bacteriologically proven, consumption of raw milk or non-pasteurised milk products from infected dairy cattle was suspected as the source of infection in humans. Our findings confirm the domination of M. caprae among cattle in Croatia and represent the first evidence of M. caprae infection in humans in Croatia.

Anticardiolipin antibodies in women with unexplained infertility.

Concept of autoimmune basis of infertility is still controversial, particularly regarding the presence of non-organ specific autoantibodies. Non-organ specific anticardiolipin (aCL) and antithyroglobulin (TgAt) antibodies were detected in infertile women. Both partners were evaluated according to the criteria of The American Society for Reproductive Medicine. All the results were normal in cases of unexplained infertility. Antisperm antibodies (ASA) were determined by a mixed antiglobulin reaction (MAR) and the Kibrick agglutination assay, aCL by commercial ELISA, TgAt by commercial RIA. Fertile women had children. Subjects were grouped in fertile (n=27), infertile (n=65), and cases of unexplained infertility (n=42). In fertile women, aCL was below the negative cut-off value (100 %), while women with unexplained infertility were positive in 23.8 %. Anticardiolipin (aCL) antibodies were detected in 21.5 % of infertile patients, most of them with unexplained infertility (15.4 %). Other positive women had partners with ASA (4.6 %), or exhibited a negative postcoital test (1.5 %). In this study aCL were not detected in women with ASA. TgAt incidence was increased in infertile (20 %) and unexplained infertility group (21.4 %) compared to the fertile controls (18.5 %). Increased incidence of aCL and TgAt in infertile women supports the contention that these autoantibodies contribute to the infertility

[Treatment of Hodgkin's disease with high-dose chemotherapy and autologous stem cell transplantation]. / Lecenje Hodgkin-ove bolesti visokim dozama hemioterapeutike uz autologu transplantaciju maticnih celija hematopoeze.

High dose chemotherapy (HDC) with autologous stem cell transplantation (SCT) was applied for the treatment of 13 patients (pts) with Hodgkin's disease (HD) (10 with relapsed form and 3 with conventional chemotherapy resistant form) in the Clinic for Hematology, Military Medical Academy, from May 1997 to October 1999. After the initial treatment for the reduction of tumor, burden stem cells were mobilized by cyclophosphamide 2.5-7.0 g/m2 with G-CSF 5-12 micrograms/kg body mass (BM). The average number of colected mobilized mononuclear cells (MNC) was 2.99 (1.66-5.9) x 10(8)/kg BM by the apheresis large volume from peripheral blood. All patients received BEAM (BCNU, etoposide, Cyto-Ara, and melfalan) conditioning regimen with adequate supportive therapy. Good engraftment (100%) was observed at postransplantation period: number of polymorphonuclear cells was > 0.5 x 10(9)/l, on day 13th (10-21) and number of platelets > 20 x 10(9)/l, on day 17th (11-28). One patient (7.6%) died due to infective complications at day 98th after transplantation, 9 (69.2%) patients achieved complete and 3 (23.1%) patients partial remission of the disease. Out of three patients with partial remission, one relapsed, seven months after autologous SCT, with conventional chemotherapy resistant form and two, after the applied conventional locoregional radiotherapy reached remission. One patient (7.6%) developed secondary malignancy of acute myeloid leukemia form with threelinage displasy 27 months after autologous SCT. HDC with autologous SCT contributes to more successful treatment of early relapsed and standard chemotherapy resistant forms of HD and gives the opportunity for successful quality of living for those patients.

[Secondary myelodysplastic syndrome after autologous transplantation of hematopoietic stem cells in a female patient with Hodgkin's disease]. / Sekundarnih mijelodisplazni sindrom nakon autologe transplantacije maticnih celija hematopoeze kod bolesnice sa Hodgkin-ovom bolesti.

Secondary acute myeloid leukemia with threelineage displasy (sAML/MDS) has been described as a complication of therapeutic approach with high-dose chemotherapy and autologous stem cell transplantation (SCT) in the patients with Hodgkin's disease (HD). It is not yet clear whether the sAML/MDS is a consequence of a standard therapeutic regimen, applied before transplantation, or a high-dose chemotherapy. In a female patient with initially resistant form of HD at III-B-b clinical stadium (bulky disease in neck and mediastinum) after the initial treatment (MOPPx4; ABVDx3; BEA-COPPx2), high-dose chemotherapy has been applied according to BEAM protocol with autologous SCT. In a period after transplantation, radiotherapy (RT) has been applied at initial region of the disease and a patient reached complete remission (CR), which lasted for a 27 months. After that period sAML/MDS has been observed. Application of more standard therapeutic cycles and characteristic cytogenetic findings are the facts that support the opinion that sAML/MDS is a consequence of standard treatment before transplantation, rather than high-dose chemotherapy. That finding implies the need for correct choice of the HD patients suitable for early SCT therapeutic approach.

[Second allogenic bone marrow transplantation after late graft rejection in a patient with severe aplastic anemia]. / Sekundarna alogena transplantacija kostne srzi kod bolesnika sa teskom aplastickom anemijom nakon kasnog odbacivanja primarnog kalema.

Allogeneic bone marrow transplantation (BMT) is the treatment of choice in young patients (pts) with severe aplastic anemia (SAA) who have an HLA identical sibling donor. Late graft rejection to following allogeneic BMT for SAA is a significant clinical problem and is associated with a high risk of mortality. The optimal treatment strategy for patients with late graft rejection after first BMT is still an open question. We report 12-year-old patient with acquired SAA who underwent BMT from his HLA identical sister. BMT was first-line treatment within 3 months of diagnosis. Preparative therapy was Cyclophosphamide (Cy) 200 mg/kg body mass (BM) during 4 days. Graft versus host disease (GVHD) was prevented with Methotrexate (MTX), Methylprednisolone (MPDN) and Cyclosporin A (CsA). After 17 months, during which patient was with normal blood counts and full donor chimaerism, graft rejection occurred. The patient was re-engrafted from the same donor after conditioning with Cy 200 mg/kg BM plus horse antithymocyte globulin (ATG)--2 vials (á 25 mg)/10 kg BM over 4 days. Before the collection, donor's bone marrow was activated with low dose rhGM-CSF (3 micrograms/kg one day). Following a secondary BMT engraftment has sustained. The patient is alive with full donor chimaerism 26 months from secondary transplantation, without acute or chronic GVHD.

[In vivo study of spontaneous and therapy-induced apoptosis in patients with chronic lymphocytic leukemia treated with chlorambucil]. / In vivo pracenje spontane i terapijom indukovane apoptoze kod bolesnika sa HLL lecenih hlorambucilom.

The efficiency of Chlorambucil in the induction of apoptosis was investigated in the study, and measurable apoptosis parameters were compared to the other prognostic factors with the aim of possible prediction of clinical response to the therapy in the patients with CD5 + B-cell chronic lymphocytic leukemia (B-CLL). Seven newly diagnosed patients, initially treated with daily high-doses of Chlorambucil (HD-CLB) were analyzed. Quantitative analysis of apoptosis parameters on semi-fine sections obtained from peripheral blood was performed prior and during the first five days of therapy. The level of spontaneous apoptosis (SA) was determined, as well as the maximal response by apoptosis (MAR), and the time needed to establish maximal response by apoptosis (TMAR), respectively. The results revealed that the level of SA in the studied group of patients was 11.39%-20.50%. In three patients with achieved criteria for complete remission (CR) was observed high level of SA, TMAR 2-4 days and MAR 23.42-26.36%, respectively. All patients with CR were with negative LDT, non-diffuse involvement of bone marrow and clinical stage B. Criteria for partial remission (PR) were achieved in 4 patients. Within this group, all three measurable parameters of apoptosis could have been determined in only one patient, while in the rest was noticed the increased percentage of apoptotic cells on the last day of follow-up. In all patients was observed negative LDT, diffuse bone marrow involvement, and 2 out of 4 patients had CLPL of cytomorphological type and clinical stage B. By comparing the obtained values of measurable apoptotic parameters with the clinical response to the applied therapy with HD-CLB, it is possible to divide our patients into two groups: patients who have achieved CR have the highest percentage of cells dying due to the therapy-induced apoptosis, as well as the higher values of measurable parameters compared to the certain parameters of the patients with the criteria for PR. Our preliminary results of therapeutic response to the apoptosis might be useful for the timely decision upon the duration of therapy and change of modality of treatment for every patient during the follow-up period.

Evaluation of cryopreserved murine and human hematopoietic stem and progenitor cells designated for transplantation.

The influence of five different cryopreservation protocols on the quality and/or quantity of frozen cells was investigated on mouse bone marrow cells and human peripheral blood mononuclear cells (MNC). The efficiency of the protocols was evaluated on the basis of the recovery of very primitive pluripotent hematopoietic stem cells (MRA), pluripotent progenitors (CFU-Sd12), committed granulocyte-monocyte progenitors (CFU-GM) of mouse cells after thawing. The recovery of MRA, CFU-Sd12 and CFU-GM varied depending on the type of freezing procedure and cryoprotector (DMSO) concentrations used. It was shown that the controlled-rate protocol was more efficient, enabling better recovery of all categories of progenitor cells in frozen samples. The most efficient was the controlled-rate protocol of the cryopreservation designed to compensate for the release of fusion heat, which enabled the best recovery of CFU-GM (73.0 +/- 8.8%) and CFU-Sd12 (90.0 +/- 15.9%) when combined with 5% DMSO concentration (protocol 4). On the contrary, a better recovery (79.8 +/- 13.5%) of very primitive stem cells (MRA) was achieved only when the higher concentration (10%) DMSO was used in combination with a five-step protocol of cryopreservation (protocol 1). These results pointed out the adequately used controlled-rate freezing to be essential for a highly efficient cryopreservation of some of the categories of hematopoietic stem and progenitor cells. At the same time, it was obvious that a higher DMSO concentration was necessary for the cryopreservation of MRA, but not for more mature progenitor cells (CFU-S, CFU-GM). These results imply the existence of a mechanism that decreases the intracellular concentration of DMSO in MRA cells, which is not the case in less primitive progenitors. For human MNC, the recovery and viability of the cells, as well as the engraftment potential of cryopreserved cells after thawing were investigated. Cryopreservation protocol 1 resulted in better MNC recovery (82.7 +/- 10.4%) than protocol 3 (49.9 +/- 15.1%). The mean recovery of MNCs (collected from patients for autologous transplantation) was 78.5 +/- 7.3% (protocol 1) and 53.1 +/- 26.2% (protocol 3). The obtained favorable recovery of thawed cells and rapid reconstitution of hematopoiesis (on the day 11th following the transplantation) in patients confirmed that the controlled-rate freezing in combination with optimal DMSO concentration was able to obtain sufficient progenitor cryoprotection.

The effects of cAMP on the expression of glycolytic isozymes in activated peripheral human T lymphocytes.

Forskolin, an activator of adenylate cyclase, inhibits mitogen induction of glycolytic isozymes in human peripheral T cells. Inhibition of lactate dehydrogenase isozyme activity is correlated with lowered mRNA levels, suggesting a transcriptional block in the presence of increased cAMP. Forskolin added with the mitogen, or 12-24 h after the mitogen, strongly inhibits isozyme expression and DNA synthesis, and causes cells to accumulate in the G0 or early G1 phase of the cell cycle. The data suggest that DNA synthesis and isozyme expression are both inhibited by a cAMP-sensitive step(s) in the early activation or progression phase.

Expression of glycolytic isoenzymes in activated human peripheral lymphocytes: cell cycle analysis using flow cytometry.

Human peripheral lymphocytes activated with concanavalin A and phorbol myristate ester exhibit an increase in glycolysis on a time-course similar to that for DNA synthesis. Elevated glycolysis is accompanied by increased specific activities of the glycolytic enzymes. Increased enzyme activities are accounted for by the appearance of specific isoenzyme forms (muscle forms) normally expressed in rapidly growing tumor cells or in growth-stimulated cells. In the present study we analyzed the expression of the glycolytic isoenzymes during cell cycle progression of activated human lymphocytes using two-parameter (DNA and protein) flow cytometry. Time-course studies and analysis of subpopulations prepared by elutriation centrifugation showed that the inducible isoenzymes are expressed at low levels or not at all in G0 cells. They are expressed first during the G0 to G1 transition or in early G1. However, expression increases throughout G1, reaching a maximum in S-phase. Thus, induction of glycolytic isoenzymes provides an excellent marker of T-cell activation and progression toward DNA synthesis.

Expression of a new set of glycolytic isozymes in activated human peripheral lymphocytes.

The combination of phorbol 12-myristate 13-acetate (PMA) and concanavalin A induces the expression of a new set of glycolytic isozymes in human peripheral lymphocytes. The induced isozyme for each enzyme tested (hexokinase, phosphofructokinase, enolase, pyruvate kinase and lactate dehydrogenase) is usually the muscle form, which is often associated with rapidly dividing tumor cells. Increases in a specific isozyme can account for the 2-5-fold increase in specific activities of the enzyme induced by Con A plus PMA. Increased specific activities and the appearance of the new isozyme forms both occur relatively late, and are probably associated with the G1 or S phase of the cell cycle.

The application of hard contact lenses in patients with congenital nystagmus.

From 1973 to 1987, 210 contact lenses were fitted in 112 patients with nystagmus and a refraction anomaly. In 79%, it was possible to correct myopia or a myopic or mixed form of astigmatism. In these cases, the visual acuity improved significantly. The hard contact lenses were well tolerated in all patients, and the intensity of the nystagmus can be reduced through this treatment.

Effect of phorbol myristate acetate and concanavalin A on the glycolytic enzymes of human peripheral lymphocytes.

The effects of Concanavalin A and the tumor promoting agent, phorbol 12-myristate 13-acetate (PMA), on glycolytic enzymes in human peripheral lymphocytes have been studied. A combination of Concanavalin A plus PMA stimulates DNA and protein synthesis to a significantly greater extent than when each are added individually. PMA and concanavalin A together, but not individually, also increase the levels of the activity of the glycolytic enzymes in peripheral lymphocytes treated for 48 h. The increase in hexokinase activity induced by PMA plus concanavalin A appeared to be due to the expression of the isoenzyme form, hexokinase II. The results suggest that the expression of glycolytic enzymes in stimulated lymphocytes is a late event (perhaps associated with the S phase) which is regulated by a cellular signal system controlled by the combined action of PMA plus concanavalin A.