Croatian guidelines for the pharmacotherapy of type 2 diabetes

INTRODUCTION: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. PARTICIPANTS: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. EVIDENCE: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. CONCLUSIONS: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

Does cryostripping add anything to the treatment of the ascending thrombophlebitis of the great saphenous vein?

OBJECTIVE: To analyse the differences of outcome between cryostripping and conservative therapy in the treatment of superficial vein thrombosis. PATIENTS AND METHODS: A retrospective analysis was performed between the October of 2001 and the October of 2014. In all, 246 cases were eligible for the study. High ligation, cryostripping and local thrombectomy was carried out on 94 patients with thrombophlebitis of the proximal part of the great saphenous vein. Thromboembolic events, the presence of residual varices and time for recovery were compared to 152 cases treated conservatively because of superficial vein thrombosis. RESULTS: Thromboembolic events were found without significant difference (mean ± SD for surgery: 1.11 ± 0.60 and conservative therapy: 1.11 ± 0.55; p = 0.988) in each group. The presence of residual varices (mean ± SD for surgery: 1.03 ± 0.52 and conservative therapy: 1.42 ± 0.99; p = 0.001) and the time for recovery (mean ± SD for surgery: 15 ± 10.50 and conservative therapy: 26 ± 12.32; p < 0.001) were more favourable in the cryostripping group. CONCLUSION: Our analysis confirmed that cryostripping does not result in a lower risk for thromboembolic complications due to superficial vein thrombosis but can be an alternative method to treat the ascending thrombophlebitis of the great saphenous vein because it has some advantages over conservative treatment on the short term.

[DIAGNOSTIC APPROACH TO PATIENTS WITH CHRONIC KIDNEY DISEASE].

According to consensus definition, chronic kidney disease (CKD) includes urinary excretion of albumin >30 mg/day and/ or reduction in kidney function defined as a decrease in estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 for a period longer than three months, in the presence of kidney tissue damage verified by imaging or histologic methods. In developed world, the first cause of CKD is diabetes, followed by arterial hypertension, and the less frequent causes are inflammatory disease (glomerulonephritis, interstitial nephritis) and congenital condition (polycystic kidney disease). Currently, there is valid classification under the acronym CGA, where C stands for the cause, G for glomerular filtration rate (GFR category) and A for the level of albuminuria category. In early stages, patients usually have no symptoms but there are changes in creatinine values, estimated GFR (eGFR) reduction and presence of albuminuria, especially in patients at risk. Determining the grade of renal impairment is important because of different approaches to treatment, monitoring, expected complications, and patient education. Due to improved diagnostic methods and population aging, CKD is diagnosed ever more increasingly. Family physicians should be familiar with the basic principles of screening and diagnosis of CKD to provide them with appropriate care in collaboration with secondary and tertiary health care.

[PATHOPHYSIOLOGY OF THE CARDIORENAL SYNDROME].

Cardiorenal syndrome, a complex pathophysiological disorder of both the heart and kidneys, is a condition in which acute or chronic damage to one organ can lead to acute or chronic dysfunction of the other organ. Depending on primary organ dysfunction and disease duration, there are five different types of cardiorenal syndrome. Type 1 cardiorenal syndrome (acute cardiorenal syndrome) is defined as acute kidney injury caused by sudden decrease in heart function. Type 2 cardiorenal syndrome (chronic cardiorenal syndrome) refers to chronic kidney disease linked to chronic heart failure. Type 3 cardiorenal syndrome (acute renocardial syndrome) is caused by acute kidney injury that leads to heart failure. Type 4 cardiorenal syndrome (chronic renocardial syndrome) includes chronic heart failure due to chronic kidney disease. Type 5 cardiorenal syndrome (secondary cardiorenal syndrome) is reversible or irreversible condition marked by simultaneous heart and kidney insufficiency, as a result of multiorgan disease such as sepsis, diabetes mellitus, sarcoidosis, amyloidosis, etc. The pathophysiological patterns of cardiorenal syndrome are extremely complicated. Despite numerous publications, perplexed physiological, biochemical and hormonal disturbances as parts of the main pathogenic mechanisms of cardiorenal syndrome remain obscure. Even though there are guidelines for the treatment of patients with heart failure and chronic kidney disease, similar guidelines for the treatment of cardiorenal syndrome are lacking. In everyday practice, it is crucial to diagnose cardiorenal syndrome and use all diagnostic and therapeutic procedures available to prevent or alleviate kidney and heart failure.

TRANSLATION AND ADAPTATION OF COMPUTER ASSISTED SMOKING PREVENTION PROGRAM IN ROMANIA (ASPIRA).

ASPIRA smoking prevention online program consists in studying five modules that include tests, videos and interactive games. It was tested on a group of schoolchildren and students from Tîrgu Mures by completing a questionnaire with reference to the opinions of the young people and the functionality of the software. The vast majority of those questioned reported a good or very good impression about the ASPIRA program and believed that the information presented was suitable. High school pupils and boys were more critical.

[ESOPHAGEAL TUMORS IN FAMILY PHYSICIAN PRACT].

Esophageal tumors are relatively rare. They present with typical symptoms in patients that consume spicy food, alcohol, enjoy cigarette smoking, and after alkaline solution ingestion. Considering their accessibility, they can be diagnosed in early stages. In recent years, the incidence of adenocarcinoma has increased in comparison to squamous cell carcinoma. This surge in the incidence is associated with gastroesophageal reflux disease and Barrett's esophagus. Using better algorithms in the diagnosis and follow up of patients at risk, in the years to come we should diagnose patients at earlier stages of the disease.

Cryosclerosis. A forgotten endovenous procedure for treating the incompetence of the great saphenous vein. Short term results.

AIM: The aim of the present study was to prove the effectiveness, reliability and minimal invasiveness of cryosclerosis. METHODS: A prospective non-randomized study had been performed. The study enrolled 96 patients; 48 patients were treated by cryosclerosis and the other 48 by conventional stripping. Every time high ligation and phlebectomy of varices were done, in 1 patient the incompentence of the small saphenous vein was treated also by cryosclerosis. During the follow-up visits the obliteration of the great saphenous saphenous vein (GSV) was investigated; as primary objective of the study, secondary outcome measures were the most frequent complications of the conventional surgery, postoperative pain and recovery. Color-Duplex scan of the operated lower extremity was performed into 30 patients of the study group. Additionally, the vein wall (unhandled and frozen) was analyzed by transmission electron microscope in one case. All of the involved patients were examined at a follow-up visit (7 days after surgery) and sent back a questionnaire (6-8 weeks after surgery). RESULTS: Recanalization was observed only in 2 patients (success rate after 6 weeks: 93.3%). Thromboembolic events occurred only in the control group (1 patient, minor pulmonary embolism). Regarding mild wound healing disorder and lymphorrhea there were no significant differences between the groups. Concerning postoperative pain, bruising and recovery the cryosclerosis was found significantly favorable. The incidence of limb swelling after surgery was the same in each group. Temporary sensory abnormalities seem to be frequent in the study group, but the results show that the rate of permanent saphenous nerve injury is higher in the patients operated with the conventional method. The histological examination showed changes in the frozen vein wall. CONCLUSION: Lacking long-term results, we can only consider that cryosclerosis allows the occlusion of the great saphenous vein, is minimal invasive and should be considered among endovenous procedures for treating GSV incompetence.

Trisomy 7 and 17 mark papillary renal cell tumours irrespectively of variation of the phenotype.

BACKGROUND: Papillary renal cell tumours (RCTs) have been described as a genetic entity. Recently, papillary RCTs have been divided into small (type 1) and large (type 2) cell tumours. Subsequent DNA analyses have resulted in controversial data regarding putative genetic changes marking type 1 and type 2 tumours. AIM: The aim of this study was to improve the original description that papillary RCT is a genetic entity regardless of the phenotypic variation. METHODS: DNA from 163 papillary RCTs, including 82 multiplex tumours from eight hereditary cases, was analysed for copy number changes by chromosomal comparative genomic hybridisation (CGH) and/or for allelic changes at chromosomes 7 and 17 by microsatellite analysis. The results of the genetic analysis were compared with the cytological characteristics of the tumours. RESULTS: The results showed alterations of chromosomes 7 and 17 at similar frequencies in papillary RCTs with characteristics ranging from small to large cell, nuclear grade 1 to 3, and 3 mm to 16 cm diameter. CONCLUSION: Trisomies of chromosomes 7 and 17 are specific genetic alterations in papillary RCTs irrespective of their size, grade and cellular differentiation.

Construction of a perfectly N-representable two-electron density matrix carrying full information on an interacting system.

The two-particle density matrix contains all information, which is "readable" by one- and two-particle operators. The report discusses the building of a two-electron density matrix, which is perfectly N-representable by construction. The 2-matrix of a pure quantum state is obtained without the intermediate determination of the wave function. The procedure is illustrated by computations on atomic and small molecular systems.

Mapping the papillary renal cell carcinoma gene between loci D17S787 and D17S1799 on chromosome 17q21.32.

Trisomy of chromosome 17 is associated with the development of papillary renal cell tumors (RCT). We have analyzed 37 papillary RCT by applying 25 polymorphic microsatellite markers and found an overlapping duplication including loci D17S1795 and D17S1306 on chromosome 17q21. This region was then analyzed in additional 118 sporadic and hereditary papillary RCT. Overlapping partial duplications at the chromosome 17q21.32 region localized the papillary RCT gene to an approximately 300 kb genomic sequences flanked by loci D17S787 and D17S1799. Altogether, 92% of the 100 papillary RCT showed allelic duplication at this region. We did not find mutation in coding sequences or altered expression of the hepatic leukemia factor gene, which is mapped the smallest duplicated interval, in any type of RCT. Therefore, another gene within the 300 kb region might be responsible for the development of papillary RCT.

[The incidence of emergency thoracotomy in thoracic trauma. 7000 cases of thoracic trauma (T.T.) treated in the period of 1978-1995]. / Incidenta toracotomiei de urgenta în traumatismele toracice. Observatii pe marginea a 7000 de traumatisme toracice (T.T.) tratate în intervalul 1978-1995.

With intensive care, pleural drainage and judicious physiotherapy most thoracic injuries can be treated adequately. We reviewed the experience with urgent thoracotomy, to compare the relative indications and injury pattern after blunt versus penetrating trauma. Among 7000 patients with thoracic trauma (T.T.), excluding 319 resuscitative thoracotomy, 83 required urgent thoracotomy. A thoracotomy was necessary in 14% of the patients with blunt thoracic trauma, and 33% with penetrating trauma. Thoracotomy for penetrating trauma was performed earlier and had better results than thoracotomy for blunt trauma. Seventy-five percent of penetrating trauma were operated in the first hour after admission against 29% of blunt trauma. Postoperative mortality for penetrating trauma was three times lower than for blunt trauma (18% versus 56%). Surgical procedure depends on the type and extend of the thoracic and general injuries and on the patients general condition.

[Biliary lithiasis complicated by cholecystocholedocal fistula and prolonged mechanical jaundice]. / Litiaza biliara complicata cu fistula colecistocoledociana si icter mecanic prelungit.

A case is presented, of a patient with biliary lithiasis complicated by cholecystocholedocian fistula, and prolonged mechanical jaundice. The low frequency of such cases is stressed and the difficulties encountered in making a correct diagnosis. Particularities of the observation are analysed, and the therapeutical attitude is discussed.