Sisters of Charity Hospital (Zagreb)

Abstract Background Alpelisib is the first approved phosphatidylinositol-3-kinase alpha (PI3Kα) inhibitor for hormone receptor (HR)–positive, human epidermal growth factor receptor 2 (HER2)–negative, PIK3CA-mutated advanced breast cancer. Although it improves progression-free survival, hyperglycaemia is a common adverse effect, with diabetic ketoacidosis (DKA) being a rare but serious complication. PI3Kα inhibition increases hepatic gluconeogenesis, reduces peripheral glucose uptake, and induces compensatory hyperinsulinaemia, resulting in acute iatrogenic insulin resistance and hyperglycaemia. Current guidelines recommend metformin as first-line therapy, followed by sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) or pioglitazone as second-line agents. Case presentation A 64-year-old woman with metastatic HR-positive, HER2-negative, PIK3CA-mutated breast cancer developed DKA two months after commencing alpelisib. Baseline investigations demonstrated previously undiagnosed diabetes (HbA1c 5.8%, fasting plasma glucose 8.1 mmol/L, 2-hour OGTT 11.4 mmol/L), normal renal function, and a BMI of 22 kg/m2. She had a family history of type 2 diabetes. Metformin and sitagliptin were initiated pre-emptively. Following alpelisib commencement, she developed grade 2 hyperglycaemia, requiring the addition of dapagliflozin. Two months later, she presented to the emergency department with dyspnoea, nausea, and altered mental status. Imaging revealed left-sided lobar pneumonia. Biochemical investigations demonstrated severe hyperglycaemia (19.6 mmol/L), metabolic acidosis (arterial pH 7.00, base excess −26.9), normal lactate, and ketonuria (+++), consistent with severe DKA. Alpelisib and dapagliflozin were discontinued. She was admitted to the intensive care unit and treated with intravenous fluids, insulin infusion, and electrolyte replacement, with rapid clinical and glycaemic improvement. Further testing showed low-normal C-peptide (0.78 nmol/L), negative diabetes autoantibodies, and an HbA1c of 9.0%. She was discharged 12 days later on basal insulin, sitagliptin, and pioglitazone. Given the severity of DKA, alpelisib and SGLT2 inhibitors were permanently discontinued. At one-month follow-up, HbA1c had improved to 7.0%; however, due to disease progression with leptomeningeal spread, alpelisib was not reinitiated. Unfortunately, she died two months later. Conclusions This case demonstrates the rare but serious risk of DKA associated with alpelisib therapy. Despite guideline recommendations supporting SGLT2 inhibitors for glycaemic management, their use may potentiate ketoacidosis, particularly during acute illness. Enhanced surveillance, proactive patient education, close glucose and ketone monitoring, and individualized risk assessment are essential to optimize patient safety.

Mucosal healing is an important therapeutic target in ulcerative colitis (UC) because it is associated with improved clinical outcomes and sustained remission. Conventional white-light endoscopy has limitations, including subjective interpretation, interobserver variability, and difficulty detecting residual microscopic inflammation despite an apparently healed mucosa. Image-enhanced endoscopy (IEE) techniques improve visualization of mucosal and vascular patterns, potentially enhancing the assessment of inflammation and healing in UC. Modalities such as narrow-band imaging, linked-color imaging, blue laser imaging, dual-red imaging, texture and color enhancement imaging, and iSCAN accentuate vascular structures and subtle color differences, allowing more precise differentiation between complete and partial healing. These methods correlate strongly with histological inflammation and better predict clinical relapse compared with conventional scoring systems such as the Mayo Endoscopic Subscore. Quantitative IEE-based indices, including the linked-color imaging index, Paddington International virtual ChromoendoScopy ScOre, and Mucosal Analysis of Inflammatory Gravity by iScan TE-c Image score, provide reproducible and objective measurements that reduce subjective variability. Next-generation endoscopic platforms combining advanced IEE technologies enable real-time, high-resolution evaluation of mucosal microarchitecture and vascular regeneration. This facilitates personalized management by detecting residual inflammation earlier, improving monitoring, optimizing treatment decisions, and ultimately enhancing long-term outcomes while lowering relapse rates in UC patients.

Psihološki aspekti učenja u kliničkom okruženju pokazali su se jednako važnima kao i svladavanje medicinskih znanja i vještina. U radu se razmatraju emocionalna inteligencija, stres i otpornost, samoučinkovitost, anksioznost prije prakse, suočavanje s gubitkom te prevencija sagorijevanja, pri čemu se naglašava da navedeni čimbenici zajednički oblikuju iskustvo kliničkog učenja i profesionalnog sazrijevanja studenata. Razvijena emocionalna inteligencija olakšava komunikaciju, regulaciju emocija i sigurno djelovanje u timu, dok otpornost i učinkovite strategije suočavanja smanjuju negativne posljedice kroničnog stresa. Samoučinkovitost se pokazuje ključnom za aktivno uključivanje studenata u rad i za izgradnju kliničke kompetencije, a anksioznost prije prakse može se ublažiti pripremom, simulacijama i podržavajućom kulturom učenja. Posebno se ističe važnost strukturirane podrške studentima u suočavanju s patnjom i gubitkom te potrebe za ranim prepoznavanjem i prevencijom sagorijevanja. Uloga medicinskih sestara i tehničara, edukatora i mentora presudna je u oblikovanju sigurnog i poticajnog okruženja za učenje, kroz orijentaciju, konstruktivnu povratnu informaciju, refleksiju i njegovanje timske pripadnosti. Sustavno uključivanje psiholoških kompetencija u obrazovanje pridonosi dobrobiti studenata i dugoročno jača kvalitetu i održivost zdravstvene skrbi.

Rad se temelji na dosad neobrađenoj arhivskoj građi vezanoj uz djelovanje Branka Cvjetanovića, jednog od bitnih aktera hrvatske i svjetske epidemiologije druge polovice XX. stoljeća. Umjesto klasične biografske ili historiografske rekonstrukcije, istraživanje promatra arhiv kao autonomni izvor znanja, odnosno kao materijalni, vizualni i administrativni trag stručnoga djelovanja, institucionalnih odnosa i svakodnevnih praksi javnoga zdravstva. Polazeći od arhiva kao aktivnoga epistemološkog prostora, a ne pasivnoga spremišta činjenica, rad analizira fotografije, dokumente, radne zapise i kontekstualne artefakte nastale u okviru epidemiološkoga rada na terenu i unutar zdravstvenih institucija. Poseban naglasak stavlja se na »radni život« znanosti: terenski rad, organizaciju i provedbu javnozdravstvenih kampanja, vizualnu dokumentaciju bolesti, populacije i infrastrukture, kao i administrativne procedure koje su oblikovale proizvodnju i primjenu epidemiološkoga znanja. Arhiv se pritom sagledava kao dinamičan sustav u kojem se znanstvena praksa odvija kroz operativne, logističke i komunikacijske procese koji nadilaze okvire formalnih publikacija. Analiza pokazuje kako se stručni autoritet i znanstvena legitimnost ne konstituiraju isključivo kroz znanstvene radove, nego i kroz svakodnevne prakse, birokratske obrasce i vizualne strategije bilježenja i kontrole zdravstvenih rizika. U širem smislu, rad razmatra arhiv kao medij koji omogućuje uvid u odnose između znanosti, države i društva, osobito u kontekstu socijalističkoga i postsocijalističkoga javnozdravstvenog sustava. Time se arhiv Branka Cvjetanovića sagledava ne samo kao dokumentacija jednog profesionalnog života nego i kao vrijedan izvor za proučavanje institucionalne kulture javnoga zdravstva i načina na koji se znanstveno znanje operacionalizira u društvenoj praksi.

Rheumatoid arthritis (RA) is one of the most common chronic inflammatory rheumatic diseases primarily characterized by joint destruction, though it may also present with extra-articular manifestations. Despite current American College of Rheumatology/European Alliance of Associations for Rheumatology recommendations on the use of diagnostic ultrasound (US) as an additional tool in the diagnostic workup of RA, US has not yet been incorporated into standard disease activity indices or remission criteria. This review summarizes the latest published consensuses of professional societies for the quantification of US changes in rheumatology, as well as scoring systems for the quantification of synovitis, tenosynovitis, erosions and cartilage damage, with the aim of achieving US standardization. US aids in monitoring RA patients by enabling more objective assessment of disease activity, through detecting subclinical activity and differentiating between inflammatory and noninflammatory causes of elevated scores obtained using standard clinical indices. We believe that US in RA should find it’s main application in clinically doubtful cases exhibiting elevated disease activity scores using standard clinical indices, in screening of patients with arthralgia or undifferentiated arthritis, and especially in patients with stable remission in whom therapy reduction is being considered.