Ana Ivkovic

Generalized anxiety disorder: diagnosis and treatment

#### Summary points Generalized anxiety disorder (GAD) is relatively common, with lifetime prevalence rates of 4-7%. It is a disorder of chronic uncontrollable worry, compounded by physiological symptoms such as disturbed sleep, muscle tension, and difficulty concentrating. The disorder is associated with seriously impaired social and occupational functioning, comorbidity with other disorders, and increased risk for suicide.1 GAD can go undiagnosed because of a focus on physical symptoms and because of the stigma of mental illness. However, the disorder can be treated. This article reviews current knowledge about the diagnosis and treatment of GAD, including pharmacotherapy and psychosocial therapies. #### Sources and selection criteria We based this review on articles found by searching PubMed and the Cochrane Database of Systematic Reviews using the terms “generalized anxiety disorder” and “generalised anxiety disorder”. Our search was limited to English language articles published between 2005 and 2012. Meta-analyses, reviews, and randomised controlled trials were prioritized. GAD is characterized by excessive worry and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension (box). To meet Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV) criteria for the disorder, the patient must have excessive and difficult to control anxiety about several different events or activities.2 For example, anxiety confined to concern about personal safety would not qualify (but should elicit inquiries about symptoms of post-traumatic stress disorder or agoraphobia, for example). In addition to worry, patients must have at least three of the six physiological arousal symptoms listed in the box. …

Pellagrous encephalopathy presenting as alcohol withdrawal delirium: a case series and literature review.

BackgroundAlcohol withdrawal delirium (AWD) is associated with significant morbidity and mortality. Pellagra (niacin deficiency) can be a cause of delirium during alcohol withdrawal that may often be overlooked.ObjectivesWe present a three-patient case series of pellagrous encephalopathy (delirium due to pellagra) presenting as AWD.MethodsWe provide a brief review of pellagra’s history, data on pellagra’s epidemiology, and discuss pellagra’s various manifestations, particularly as related to alcohol withdrawal. We conclude by providing a review of existing guidelines on the management of alcohol withdrawal, highlighting that they do not include pellagrous encephalopathy in the differential diagnosis for AWD.ResultsThough pellagra has been historically described as the triad of dementia, dermatitis, and diarrhea, it seldom presents with all three findings. The neurocognitive disturbance associated with pellagra is better characterized by delirium rather than dementia, and pellagra may present as an isolated delirium without any other aspects of the triad.DiscussionAlthough endemic pellagra is virtually eradicated in Western countries, it continues to present as pellagrous encephalopathy in patients with risk factors for malnutrition such as chronic alcohol intake, homelessness, or AIDS. It may often be mistaken for AWD. Whenever pellagra is suspected, treatment with oral nicotinamide (100 mg three times daily for 3–4 weeks) prior to laboratory confirmation is recommended as an inexpensive, safe, and potentially life-saving intervention.

Survey of mammography practice in Croatia: equipment performance, image quality and dose

A national audit of mammography equipment performance, image quality and dose has been conducted in Croatia. Film-processing parameters, optical density (OD), average glandular dose (AGD) to the standard breast, viewing conditions and image quality were examined using TOR(MAM) test object. Average film gradient ranged from 2.6 to 3.7, with a mean of 3.1. Tube voltage used for imaging of the standard 45 mm polymethylmethacrylate phantom ranged from 24 to 34 kV, and OD ranged from 0.75 to 1.94 with a mean of 1.26. AGD to the standard breast ranged from 0.4 to 2.3 mGy with a mean of 1.1 mGy. Besides clinical conditions, the authors have imaged the standard phantom in the referent conditions with 28 kV and OD as close as possible to 1.5. Then, AGD ranged from 0.5 to 2.6 mGy with a mean of 1.3 mGy. Image viewing conditions were generally unsatisfying with ambient light up to 500 lx and most of the viewing boxes with luminance between 1000 and 2000 cd per m(2). TOR(MAM) scoring of images taken in clinical and referent conditions was done by local radiologists in local image viewing conditions and by the referent radiologist in good image viewing conditions. Importance of OD and image viewing conditions for diagnostic information were analysed. The survey showed that the main problem in Croatia is the lack of written quality assurance/quality control (QA/QC) procedures. Consequently, equipment performance, image quality and dose are unstable and activities to improve image quality or to reduce the dose are not evidence-based. This survey also had an educational purpose, introducing in Croatia the QC based on European Commission Guidelines.

Lithium-Induced Neurotoxicity: Clinical Presentations, Pathophysiology, and Treatment

IntroductionLithium carbonateisahighlyeffectiveandcommonlyprescribed treatment for bipolar illness, but its use—owing toanarrow therapeuticindex—risksiatrogenic(andsometimesirreversible)neurotoxicity.Wepresentacaseof“acute-on-chronic”lithiumneurotoxicityanduse it to highlight the clinical features, pathophysiol-ogy, and treatment of lithium-induced neurotoxicity.In addition, current guidelines for the management oflithium toxicity are examined critically and futuredirections are presented.Case Vignette“Mr. T,” a 56-year-old man with bipolar disorderstabilized on lithium carbonate for several years, wasbroughttotheemergencydepartmentbyhisfamilyforevaluation of confusion, worsening tremor, and diar-rheaofseveraldaysduration. Hismedical history wasnotable for chronic renal impairment and hyperten-sion. Mr. Ts medication regimen included lithiumcarbonate (1200 mg/d in divided doses), lisinopril(20 mg/d),quetiapine(300 mgatbedtime),andrisper-idone (1 mg b.i.d.). In the emergency department, hisvital signs revealed a heart rate of 105 beats perminute;histemperatureandbloodpressurewereinthereferencerange.Onphysicalexamination,hewasalertbut disoriented and distractible. His spontaneousrecall of recent events was poor. He was dysarthric,ataxic,anddysmetriconfinger-to-nosetesting,andhehadacoarsetremor.Laboratorystudieswereremark-ableforaserumlithiumlevelof2.65 mmol/L(upfromhis usual 0.8 mmol/L, last checked eight monthsearlier), a creatinine level of 2.28 mg/dL (up fromhis baseline of 1.7 mg/dL), a blood urea nitrogen of49 g/dL, and a mild leukocytosis. Calcium and potas-sium levels were in the reference range. A computedtomography of the brain was notable for periventric-ular white matter disease (consistent with chronicmicroangiopathic changes) with no acute intracranialprocess. His chest x-ray showed clear lung fields.Immediate management consisted of discontinu-ing lithium and starting intravenous fluids. He wasadmitted to the medical service with a diagnosis oflithium toxicity. Mr. Ts serial lithium levels normal-ized over the next 5 days with fluids and supportivecare. On hospital day 5, his lithium level was0.82 mmol/L, and he was no longer confused. How-ever, his short-term recall remained poor, and hisdysarthria and ataxia persisted until after discharge(hospital day 10). Further discussion with his familyrevealed that he had been complaining of worseningkneepainintheweeksbeforehisadmissionandthathehad been taking ibuprofen for symptomatic relief.There was notably no history of suicide attempts,depression (to address the possibility of intentionaloverdose), recent gastrointestinal tract illness (thatcould have led to dehydration and with increasedlithium levels), cognitive impairment (for the

Rotation of the Sacrum During Bellyboard Pelvic Radiotherapy

Patients with cervical, uterine, and rectal carcinomas are usually treated in the prone position using the bellyboard positioning device. Specific and uncomfortable prone position gives rise to uncertainties in the daily set-up of patients during the treatment. During investigation of translational movements, rotational movements of the pelvis are observed and investigated. The film portal imaging is used to discover patient positioning errors during treatment. We defined the rotational set-up errors by angle deviations of the sacrum. Thirty-six patients were included in the study; 15 patients were followed during the whole treatment and 21 during the first 5 consecutive treatment days. The image acquisitions were completed in 84%. Systematic and random positioning errors were analyzed in 725 images. Approximately half of the patients had adjusted to the bellyboard in the first few fractions, with sacrum angles remaining the same for the rest of the treatment. The other half had drifts of the sacrum angle during the whole treatment. The rotation of the sacrum during treatment ranged up to 14 degrees , causing the usual set-up verification and correction procedure to result in errors up to 15 mm. Rotational movements of the patient pelvis during bellyboard pelvis radiotherapy can introduce considerable patient position error.

[Influence of daily set-up errors on dose distribution during pelvis radiotherapy].

Utjecaj pogreške u položaju bolesnika tijekom zračenja zdjelice na raspodjelu doze Radioterapija megavoltnim snopovima fotona linearnog akceleratora oblik je lokalnog onkološkog liječenja. Njezin je cilj predati propisanu apsorbiranu dozu ciljnom volumenu, uz što nižu dozu okolnomu zdravom tkivu. Proces se sastoji od niza koraka u kojima sudjeluje tim stručnjaka iz različitih područja. Veliki broj postupaka i ljudi uključenih u radioterapijski proces, nepouzdanosti uređaja te pomaci bolesnika i unutrašnjih organa tijekom terapije mogu uzrokovati odstupanja između planirane i stvarne raspodjele doze. U ovom radu procijenili smo utjecaj pogreške položaja bolesnika tijekom terapije na raspodjelu doze, te na veličine koje služe za procjenu kvalitete plana. Pogreške u položaju bolesnika ispitane su u skupini od 35 bolesnika. Te smo pogreške simulirali na pet bolesnika, koristeći se 3D programom za planiranje XiO (CMS Inc., St. Louis, MO, Elekta). Ispitali smo razlike u raspodjeli doze između planiranog i stvarnog položaja. Dodatno, utjecaj pogrešaka na odabir plana zračenja provjerili smo analizirajući promjene u dozno-volumnom histogramu (DVH), pokrivenost planiranog volumena (engl. PTV conformity index, CIPTV) i jednoličnost raspodjele doze u ciljnom volumenu (engl. homogeneity index, HI). Simulacije pokazuju da promjene u položaju bolesnika mogu uzrokovati značajne razlike između planirane i stvarne raspodjele doze. Kod nekih bolesnika ako se ne korigiraju pogreške, CIPTV postaje manji od 97% što znači da plan više nije prihvatljiv za zračenje. Iznenađuje da HI nije ovisan o pomacima bolesnika kao CIPTV. Rezultati pokazuju potrebu za smanjenjem pogrešaka, što se može postići provođenjem kontrole kvalitete u radioterapiji. Influence of Daily Set-Up Errors on Dose Distribution During Pelvis Radiotherapy An external beam radiotherapy (EBRT) using megavoltage beam of linear accelerator is usually the treatment of choice in cancer patients. The goal of EBRT is to deliver the prescribed dose to the target volume, with as low as possible dose to the surrounding healthy tissue. A large number of procedures and different professions involved in radiotherapy, uncertainty of equipment and daily patient set-up errors can cause a difference between the planned and delivered dose. We investigated a part of this difference caused by measuring daily patient set-up errors for 35 patients. These set-up errors were simulated on five patients, using 3D treatment planning software XiO. The simulation investigated differences in dose distributions between the planned and shifted geometry. Additionally, we investigated the influence of the error on treatment plan selection by analysing changes in dose volume histograms, planning target volume conformity index (CIPTV), and homogeneity index (HI). Simulations showed that patient daily set-up errors can cause significant differences between the planned and actual dose distributions. Moreover, for some patients, those errors could affect the choice of treatment plan since CIPTV fell under 97%. Surprisingly, HI was not as sensitive to set-up errors as CIPTV. Our results have confirmed the need to minimise daily set-up errors through quality assurance programmes.

Survey of equipment quality control in radiotherapy centres in croatia: first results.

Survey of Equipment Quality Control in Radiotherapy Centres in Croatia: First Results Implementation of advanced radiation therapy techniques in clinical practice can greatly improve tumour control and normal tissue sparing. An important part of this implementation is quality control (QC) of every part of the radiotherapy process, as it helps to detect errors and provides instant remedy. This increases the probability of successful radiation treatment and ensures patient radiation safety. Every radiotherapy quality assurance (QA) programme is based on quality control of radiotherapy equipment. The aim of our survey was to review QC practices in a number of radiotherapy centres in Croatia. As a first step, we defined a set of tests to check different parameters of linear accelerators and simulators in these centres. The tests were defined and performed according to protocols developed at two university hospitals. Test results varied largely between the centres. This calls for harmonisation of QC protocols. Utvrđivanje stanja kontrole kvalitete opreme radioterapijskih centara u Hrvatskoj: prvi rezultati Uvođenje naprednih radioterapijskih tehnika u kliničku praksu ima golem utjecaj na bolju kontrolu tumora i poštedu zdravog tkiva. Veliku ulogu u tome ima postojanje protokola za kontrolu kvalitete za svaki dio radioterapijskog procesa. Provođenje protokola ključno je za detektiranje pogrešaka i njihovo trenutačno ispravljanje. Time se povećava vjerojatnost za željeni ishod radioterapije i osigurava zaštita pacijenta od neželjenog zračenja. Osnova osiguranja kvalitete u radioterapiji jest kontrola kvalitete samog uređaja. U sklopu projekata financiranih od Međunarodne agencije za atomsku energiju, istraživali smo postojanje protokola za kontrolu kvalitete radioterapijske opreme. Pokazalo se da se testovi kontrole kvalitete provode u svim centrima u Hrvatskoj, no među njima postoje razlike. Također, pisani su protokoli bili rijetko prisutni. Pregled prakse u kontroli kvalitete i razmjena iskustva pomogli bi u razvoju protokola za kontrolu kvalitete na nacionalnom nivou. Kao prvi korak definirali smo niz testova za provjeru raznih parametara na linearnim akceleratorima i klasičnim simulatorima u radioterapijskim centrima u Hrvatskoj. Testovi su definirani i izvedeni u skladu s protokolima razvijenim u naše dvije bolnice. Sljedeći korak planiran je tijekom ove godine, a odnosi se na verifikaciju sustava za planiranje u kliničkim uvjetima prema protokolu izrađenom u KBC-u Rijeka. U radu iznosimo pregled provedenih testova, uređaja i računalnih programa za analizu kojima smo se koristili, kao i cjelokupne rezultate.

The Neutron Dose Equivalent Around High Energy Medical Electron Linear Accelerators

The measurement of neutron dose equivalent was made in four dual energy linear accelerator rooms. Two of the rooms were reconstructed after decommissioning of 60Co units, so the main limitation was the space. The measurements were performed by a nuclear track etched detectors LR-115 associated with the converter (radiator) that consist of 10B and with the ac - tive neutron detector Thermo BIOREM FHT 742. The detectors were set at several locations to evaluate the neutron ambient dose equivalent and/or neutron dose rate to which medical personnel could be exposed. Also, the neutron dose dependence on collimator aperture was analyzed. The obtained neutron dose rates outside the accelerator rooms were several times smaller than the neutron dose rates in side the accelerator rooms. Never the less, the measured neutron dose equivalent was not negligible from the aspect of the personal dosimetry with almost 2 mSv a year per person in the areas occupied by staff (conservative estimation). In rooms with 15 MV accelerators, the neutron exposure to the personnel was significantly lower than in the rooms having 18 MV accelerators installed. It was even more pronounced in the room reconstructed after the 60Co decommissioning. This study confirms that shielding from the neutron radiation should be considered when building vaults for high energy linear accelerators, especially when the space constraints exist.

Personal Viewpoint on Opioid Agonist Therapy and Transplantation

Opioid use disorder (OUD) is an increasing public health problem. Transplant centers worldwide are being confronted with increasing numbers of patients with opioid use disorder and end stage organ disease. Opioid agonist therapy (OAT; ie, methadone, buprenorphine, and buprenorphine/naloxone) is a scientifically proven, effective, physician‐prescribed treatment for OUD. Although data in transplant populations remain limited, studies suggest that OAT does not appear to negatively affect graft or patient survival. Policies that require discontinuation of OAT for purposes of listing or transplantation contradict the evidence base for efficacy of OAT. Additional prospective outcomes studies on OAT and transplantation are needed. In the meantime, centers should not be asking patients to come off these effective treatments.

International Trends in Health Science Librarianship Part 20: The Balkan States (Serbia and Slovenia)

This is the 20th in a series of articles exploring international trends in health science librarianship in the 21st century. The focus of the present issue is the Balkan region (Serbia and Slovenia). The next regular feature will look at Russia and the Ukraine. JM.