Assessment of health-related quality of life in patients treated with hemodialysis in Serbia: influence of comorbidity, age, and income

The importance of measuring health-related quality of life (HRQoL) in patients on maintenance hemodialysis (HD) is being increasingly recognized, but few studies, especially from the Balkan region, have addressed this issue. The aims of this study were (i) to evaluate HRQoL in an outpatient university-affiliated dialysis facility in South Serbia; (ii) to determine the effects of age, presence of comorbidity, primary kidney disease, dose of HD, and family income; and (iii) to make comparisons of the HRQoL in Serbian patients on chronic HD with that reported by others previously. The study enrolled 192 patients on HD for more than 3 months. Comorbidity was assessed using the index of coexistent diseases (ICED), including two subindexes: index of disease severity (IDS) and index of physical impairment (IPI). Patient's self-assessment of HRQoL was measured by the 36-item short form health survey questionnaire (SF-36), encompassing eight summary scales and two summary dimensions. Ten of the baseline variables had significant associations with parameters of HRQoL. Fitting these variables in linear regression models resulted in 41.9% variance for physical dimension of HRQoL (physical component summary score [PCS]), and 32.5% for mental dimension of HRQoL (mental component summary score [MCS]). However, statistically significant effect had only IDS, IPI, and age for PCS, and income of patients for MCS. We found that an increase in IDS score for one unit is associated with a decrease of PCS by 13.2%, and SF-36 score (total quality of life) by 15.2%. The increase of IPI score by one unit decreases PCS by 16.1% and SF-36 score by 17.5%. A 5-year increase in age is associated with a decrease of PCS by 3.1%, and SF-36 score by 3.8%. The monthly income increase of 10 euros per family member increases MCS by 5.2% and SF-36 score by 3.0%. HRQoL in patients on HD was found markedly impaired. Comorbid conditions have negative and statistically significant correlation with parameters of HRQoL, and could explain poor HRQoL to a remarkable extent. Older age and poor income substantially reduce HRQoL in HD patients.     

Health-related quality of life in patients on peritoneal dialysis in Serbia: comparison with hemodialysis

Abstract:  Patients' health-related quality of life (HRQoL) is an important indicator of the effectiveness of the medical care they receive. Patients who reach end-stage renal disease are older and have a considerable extent of comorbidity. The objectives of this study were (i) to evaluate HRQoL in patients at the initiation of continuous ambulatory peritoneal dialysis (CAPD) treatment (incident cohort) and in patients on long-term CAPD therapy (prevalent cohort), and (ii) to compare influence of comorbidity on HRQoL in CAPD and hemodialysis (HD) patients. In a cross-sectional study we enrolled 99 CAPD and 192 HD patients. HRQoL was assessed with the 36-item Short Form Health Survey Questionnaire (SF-36). HRQoL summary scales in both incident and prevalent groups of CAPD patients were similar for physical component summary score (PCS) and for mental component summary score (MCS). Generally, higher values were found in mental health domains in comparison to PCS. In the incident group of patients, 1 year of peritoneal dialysis treatment was associated with a slight improvement in both PCS and MCS, but statistical significance ( P  < 0.05) was found in the role-physical limitation (RP), bodily pain (BP), and vitality (VT) scales only. CAPD patients with the highest disease severity (Index of Disease Severity [IDS]-3) and physical impairment (Index of Physical Impairment [IPI]-2) scored significantly higher parameters of HRQoL than HD patients. Comorbidity had negative influence on HRQoL, but statistically significant correlation has been found in HD patients only. In conclusion, comorbid conditions had negative correlation with parameters of HRQoL in both CAPD and HD patients. One year after starting CAPD, patients reported better scores in some domains, especially in RP, BP, and VT scales. Assessment of HRQoL and comorbidity might be useful in clinical practice in the follow-up of patients treated with both CAPD and HD.     

A constrained independent component analysis technique for artery-vein separation of two-photon laser scanning microscopy images of the cerebral microvasculature

Understanding brain hemodynamics as well as the coupling between microvascular hemodynamics and neural activity is important in pathophysiology of cerebral microvasculature. When local increases in neuronal activity occur, the blood volume changes in the surrounding brain vasculature. Dynamic contrast enhanced imaging (DCE) is a powerful technique that quantifies these changes in the blood flow by repeatedly imaging the vasculature over time. Separating artery, vein and capillaries in the images and extracting their intensity-time curves from the DCE image sequence is an important first step in understanding vascular function. A constrained independent component analysis (ICA) technique is developed to analyze the two photon laser scanning microscopy (2PLSM) images of rat brain microvasculature, where a bolus of fluorescent dye is administered to the vascular system as the contrast agent. A priori information inferred from the gamma variate model of cerebral microvasculature is incorporated with the data driven technique in temporal and spatial domains using two constraints. The constraints are: no independent component (IC) is allowed to have negative contribution in forming the images (positivity constraint) and the component curves follow a gamma variate function (model fitting constraint). Experimental and simulation studies are conducted to demonstrate the improved performance of the proposed constrained ICA (CICA) technique over the most commonly used classical ICA algorithm (fast-ICA) in providing physiologically meaningful ICs and its ability to separate the model following factors from other factors are shown. The efficiency of CICA in handling noise is compared to model based techniques. Its capability in providing improved separation between artery, vein and capillaries compared to the other two techniques is also demonstrated.     

Pregnancy-associated recurrent liver necrosis in patient with antiphospholipid syndrome

The presence of antiphospholipid antibodies is associated with thromboembolic events, thrombocytopenia and numerous pregnancy complications such as recurrent miscarriage, preeclampsia and HELLP syndrome. This condition is known as the antiphospholipid syndrome (APS). We describe a rare case of recurrent liver necrosis postpartum in two consecutive pregnancies of woman with systemic lupus erythematosus (SLE) and positive antiphospholipid antibodies (aPL) who underwent complete recovery.     

Predictors of patient compliance during Class II division 1 malocclusion functional orthodontic treatment

ObjectivesTo determine factors that could predict Class II/1 malocclusion patient compliance during functional treatment.Materials and MethodsThe sample consisted of 77 subjects (aged 11–13 years; 47% girls) presenting with Class II/1 malocclusion. Inclusion criteria were distal molar relationship, overjet greater than 5 mm, and confirmed pubertal growth spurt. Removable functional appliances (62% Twin Block [TB], 38% Sander Bite Jumping [BJ]) with built-in maxillary expansion screws were used. Follow-up period was 1 year. Patients and parents independently filled out the Child Perception Questionnaire, Parental/Caregiver Perception Questionnaire, and Family Impact Scale to assess emotional and social well-being, oral symptoms, functional limitations, parental emotions, family activities, conflicts, and financial burden as possible predictors of compliance during treatment. Sex, overjet, and appliance type were also analyzed.ResultsThere were more noncompliant than compliant patients (55% vs 45%). Parental perception of altered emotional well-being of their children was the strongest predictor, increasing compliance odds 3.4 times (95% confidence interval [CI], 1.2–9.4; P = .017). Patients were 3.2 times (95% CI, 1.1–9.3; P = .033) more likely to cooperate with TB compared with BJ appliance. OJ ≥ 8 mm increased compliance odds 3.1 times (95% CI, 1.0–9.4; P = .044).ConclusionsParental perception of child''s emotional well-being alteration, severity of malocclusion, and type of appliance are major predictors of compliance. Psychosocial issues and oral function limitations reported by children and family impact are of negligible influence.     

Ocular melanoma: an overview of the current status

Ocular melanoma is the second most common type of melanoma after cutaneous and the most common primary intraocular malignant tumor in adults. Large majority of ocular melanomas originate from uvea, while conjunctival melanomas are far less frequent. Incidence of uveal melanoma has remained stable over last three decades. Diagnosis is in most cases established by clinical examination with great accuracy. Local treatment of uveal melanoma has improved, with increased use of conservative methods and preservation of the eye, but survival rates have remained unchanged. Recent advances in cytogenetics and genetics enhanced prognostication and enabled to determine tumors with high metastatic potential. However, due to lack of effective systemic therapy, prognosis of patients with metastasis remains poor and metastatic disease remains the leading cause of death among patients with uveal melanoma. Conjunctival melanoma is rare, but its incidence is increasing. It mostly occurs among white adults. In majority of cases it originates from preceding primary acquired melanosis. Current standard treatment for conjunctival melanoma is wide local excision with adjuvant therapy, including brachytherapy, cryotherapy and topical application of chemotherapeutic agent. Rarity of this tumor limits conduction of controlled trials to define the best treatment modality. As well as for uveal melanoma, prognosis of patients with metastasis is poor because there is no effective systemic therapy. Better understanding of underlying genetic and molecular abnormalities implicated in development and progression of ocular melanomas provides a great opportunity for development of targeted therapy, which will hopefully improve prognosis of patients with metastatic disease.     

Robust quantification of microvascular transit times via linear dynamical systems using two-photon fluorescence microscopy data

Vascular transit time is an important indicator of microcirculatory health. We present a second-order-plus-dead-time (SOPDT) model for robust estimation of kinetic parameters characterizing microvascular bolus passage using two-photon fluorescence microscopy (2PFM) in anesthetized rats receiving somatosensory stimulation. This methodology enables quantification of transit time, time-to-peak, overshoot, and rate of bolus passage through the microvascular network. The overall transit time during stimulation, of 2.2±0.1 seconds, was shorter (P∼0.0008) than that at rest (2.7±0.2 seconds). When compared with conventional γ-variate modeling, the SOPDT modeling yielded better quality of fit both at rest (P<0.0001) and on activation (P<0.001).     

Balkan endemic nephropathy: a need for novel aetiological approaches

Aetiology remains the main unanswered problem in Balkan endemic nephropathy (BEN) despite investigations into the roles of genetic factors, environmental agents and immune mechanisms. Evidence has accumulated that BEN is an environmentally-induced disease. Weathering of low-rank coals near to the villages where BEN is endemic produces water-soluble polycyclic aromatic hydrocarbons and aromatic amines, similar to metabolic products of acetaminophen that cause analgesic nephropathy. Many of these compounds are known to be carcinogenic and could also cause urothelial cancer. Genetic studies have supported genetic predisposition to BEN. The candidate genes have been localized to a region between 3q25 and 3q26, the 3q BEN marker being detected in both BEN patients and in some healthy relatives with initial morphological changes peculiar to BEN. Three bands with increased frequencies of spontaneous and induced aberrations contain oncogenes. The frequent association of BEN and urinary tract tumours (UTT) can be explained by the chromosomal hypothesis of oncogenesis. The results of molecular biological investigations will allow the identification of genetic markers of BEN, permitting early detection of BEN-predisposing mutations and identification of susceptible individuals who may be at risk of exposure to the environmental agents. An increased incidence of tumours of renal pelvis and ureter in patients with BEN and in population from endemic settlements has been observed. Familial clustering of the UTT was also reported. The frequency of urinary bladder tumours in BEN-endemic settlements is also increased compared with the non-endemic villages and cities. The geographic correlation between BEN and UTT supports the speculation that these diseases share a common aetiology.      

The prehospital phase in patients with acute myocardial infarct in Slovakia. A challenge

Better management of patients with acute myocardial infarction during the prehospital phase is at present a challenge not only for health workers but for society as a whole. The authors pay attention to knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction which is a prerequisite for finding possible solutions for a favourable effect on their management. The authors analyzed 3,040 patients who were admitted to hospital alive within 96 hours after the development of complaints with suspicion of a first or repeated acute myocardial infarction. They focused attention in particular on prehospital time delay. They found that within a satisfactory time interval (within 2 hours) 29.8% patients were delivered and within a yet acceptable interval of 4 hours 51.6% patients (with respect to effectiveness of thrombolytic treatment). Similarly undesirable are also data on the patient time delay. Within the optimal first hour after development of complaints following the decision of the patient (subjects present) to ask for or seek medical assistance was the decision of 34% patients, during the first two hours 47.5% and within 4 hours 61.2% patients with acute myocardial infarction. The ratio of time delay of the patient in the total prehospital delay is 45.5% even in patients who were admitted during the first hour after development of acute myocardial infarction. In patients who were admitted 4 hours after development of complaints it is 79.5%. The patient is admitted to hospital most quickly if he calls the medical emergency service and latest when he decides to see a doctor. Physicians and other health workers contributed only in 16.4-20.9% patients with acute myocardial infarction to their early decision to seek medical assistance. Patients with an early decision (within one hour) call most frequently the medical emergency service and are taken to hospital by this service. The time delay due to transport is shortest in these patients. The late hospital admission of patients with acute myocardial infarction in Slovakia calls for reduction of the time interval from the development of complaints to hospital admission (total prehospital delay), in particular the time taken by the patient to make up his mind (patient time delay). Early calling of the emergency medical service and transport of the maximum possible number of patients with acute myocardial infarction to hospital by the emergency medical service will greatly improve the management of patients with acute myocardial infarction. Comprehensive implementation of the survival chain (24), the most comprehensive implementation of recommendations of the European Society of Cardiology and the European Resuscitation Council for in the management of patients with acute heart attacks during the prehospital phase (21) and early effective treatment which begins already in the prehospital phase has a favourable impact on the condition of patients with acute myocardial infarction and on their prognosis. Along with early and effective treatment of patients with acute myocardial infarction in hospital and their stratification these are the most important approaches to the development and control of sudden cardiac death. Knowledge of the complex problem of the prehospital phase in patients with acute myocardial infarction is the prerequisite for the elaboration of high standard prehospital management of patients with acute myocardial infarction.     

Prognostic significance of mucin expression in urothelial bladder cancer

Urothelial bladder cancer (UBC) is a common genitourinary malignancy, accounting for more than 160.000 deaths per year worldwide. Overexpression and aberrant glycosylation of mucins are frequent traits of many human cancers derived from epithelial cells, and are found to have prognostic significance in various carcinomas. The aim of this study was to further elucidate the features and significance of mucin expression in UBC. We investigated the relationship between mucin expression and clinicopathological characteristics in 539 cases of UBC by immunohistochemical analysis of MUC1, MUC2, MUC4, MUC5AC and MUC6 expression profiles. MUC1 stained 61.8% of the tumors and correlated with high tumor grade (P = 0.013). The expression of MUC2 and MUC6 was associated with low tumor grade (P < 0.000 and P < 0.022, respectively), and low pathologic stage (P < 0.001 and P = 0.001, respectively). MUC2 negative tumors were more frequently associated with the finding of carcinoma in situ in tumor surroundings (P = 0.019). UBC with divergent differentiation correlated with MUC1, MUC4 and MUC5AC staining. MUC4 expression was directly linked to cancer specific death (P = 0.027), while MUC2 and MUC6 showed inverse correlation to cancer-specific death (P < 0.001 and P = 0.005, respectively). Kaplan-Meier analyses showed that expression of MUC2 and MUC6 in UBC was significantly associated with better overall survival of the patients (P < 0.001, respectively). In Cox regression model, the absence of MUC6 expression emerged as independent predictor of death outcome. In conclusion, this study identifies MUC2 and MUC6 expression as markers of UBC with less aggressive behavior and useful predictors of better survival.