S10-1. L a b or a to r ij sk a m edicina tem elj ena na d ok az i ma (e ngl.

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1 S10 Laboratorijska medicina temeljena na dokazima S10-1 Laboratorijska medicina temeljena na do ka zi ma: prin ci pi ra da Christenson RH Me di cin ski fa kul tet Sveu či li šta u Ma rylan du, Bal ti mo re, MD, SAD S10 Evidence based laboratory medicine S10-1 Evidence-based laboratory medicine: Principles to practice Christenson RH University of Maryland School of Medicine, Baltimore, MD, USA L a b or a to r ij sk a m edicina tem elj ena na d ok az i ma (e ngl. eviden ce ba sed la bo ra to ry me di ci ne, EBLM) osigurava najbo lje mo gu će informacije na temelju kojih se dono se od - luke. Tehnike EBLM postaju ključan dio rutinskog rada u la bo rato rij skoj medi cini te se temelje na ciklusu od 5 ko - raka tzv. A5 ciklus. Ciklus uključuje 5 važnih koraka: postavljanje pitanja (engl. ask), prikupljanje podataka (engl. acquire), kri tič ka proc je na (en gl. ap prai se), primjena (engl. ap ply) i prov je ra (en gl. audit). EBLM pri stup kroz cik lus omo gu ća va dje lo va nje u smis lu rje ša va nja sva kod nev nih prob le ma. Pro ces EB L M z ap očinj e p os t avljanj e m k liničko g p it anja. Z a o bli ko v a nj e p it anja p rep or uč a s e kor ištenj e t z v. PI CO su stava. PICO je akronim od engleskih riječi bolesnik (en - gl. Patient), intervencija ili pretraga (engl. Int er vent ion), usporedba (engl. Com pa ra tor) i is hod (en gl. Out co me). Na kon is prav no postavljenog pitanja, PICO sustav omo - gu ć av a p r i k up ljanj e d ok az a iz liter ature koji o dg o v ar aju na postav lje no pitanje. Prikupljanje se može provesti pri - stu pom ba za ma podataka poput Medline (PubMED), EM - BASE ili Coc hrane collaboration pomoću računala priklju čenog na internet. Ključni pojmovi iz pitanja oblikova - nog pre ma PICO su sta vu i po mo ću Boo leo vih ope ra to ra o lak š av a ju p re tr aživ anj e. N ako n š to s e k lju čna liter atur a i dru gi do ka zi pro na đu, proc je nju ju se po mo ću pod sjet nika. To je nuž no ka ko bi se ut vr di lo tre ba li pro na đe na inf o r maci ja b i ti uključena u o dg ov ar anj e na p it anj e. D ok az i s e m ogu p r i mj eniti u p r ak si p r ilag ođav anj e m inf o rmacij e svakodnevnoj rutinu. Ciklus završava provjerom učinka pri mje ne do ka za. Na primjeru B tipa natriuretskog peptida (BNP) opisat će se proces EBLM i pokazati korisnost A5 strategije u sva - kod nev nom ra du. Kraj nji cilj je bo lje ra zu mi je va nje primje ne EBLM u sva kod nev nom ra du. e-pošta: Eviden ce Ba sed Laboratory Medicine (EBLM) involves pro - v idin g th e b es t p ossibl e inf o rmati o n o n w hich d ecisi ons are based. EBLM techniques are becoming an essential p ar t of ro u ti n e p r a ctice in lab or ator y m edicin e an d are ba sed on the A5 cycle. The A5 cycle sig ni fies Ask, Aquire, Ap prai se, Ap ply and Au dit. This struc tu re wi ll be used to il lu stra te how the EBLM ap proa ch is ac tio nab le in everyday prob lem sol vi ng. T h e EB L M p ro cess b egins w ith A SK in g a clinic al qu es ti o n, For que stion for mu la tion use of PI CO, an ac ro nym which stan ds for Pa tient, Int er vent ion (test), Com pa ra tor, and Out co me, is re com men ded. Af ter the que stion is pro perly for mu la ted, the PICO for mat can be used to Aqui re the evidence for addressing the question. Acquisition can be per for med at any com pu ter con nec ted to the int er net throu gh use of da ta ba ses su ch as Med li ne (PubMED), EM- BASE or the Cochrane collaboration for searching. Using key ter ms ident i fied from the for mu la ted PICO que stion in B o ol ean s tr ategi es f acilit ates th e s earchin g p rocess. After key li te ra tu re and ot her evi den ce are lo ca ted, avai lable chec kli sts can be used for Apprai sal of the evi den ce. T his is n e ces s ar y to d ete rmin e i f th e inf o rmati o n f o un d shou ld be in clu ded in an swe ri ng the que stion. Ap plying the evidence into practice is possible by adapting the information into the practice environment. An Audit of how use of the evi den ce per for med as expec ted com pletes the A5 cycle. The theme throughout this lecture will involve a clinical problem in volving B- type natriuretic peptide to illustra - te the EBLM pro ce ss and de mon stra te to at ten dees how hel pful the A5 stra te gy can be uti li zed in eve ryday practi ce. The ove ra ll ob jec ti ve of the ses sion is to ha ve at tendees bet ter un der sta nd the use of EBLM in their eve ryday prac ti ce. S77

2 S10-2 Me di ci na te me lje na na do ka zi ma kli nič ka per spek ti va Mat ije v ic R Me di cin ski fa kul tet, Sveu či liš te u Zag re bu, Op ća bol ni ca Sve ti Duh, Zagreb M e dicin sk a p r ak s a z asn ov ana na d ok az ima (e ngl. Evidence b ase d m e di ci n e, EBM) se de finira kao trajni proces učenja koji ujedinjuje moderna medicinska znanja s procesom pružanja zdravsvenih usluga, a sve na dobrobit bolesnika. EBM objedinjuje mogućnost postavljanja kliničkog pita nja u for ma tu na ko ji se mo že na ći od go vor u do stupnoj lite ra tu ri, znanje pretraživanja literature te adekvatnu p ro c j e nu d ob ivenih inf o rmacija. Imp l em e ntacija EBM u svakodnevnom kliničkom radu korisna je i značajna na vi še na či na. Ona poboljšava njegu bolesnika osi guravaju - ći k v ali te t nu i p rovj erenu sk r b i o m o gućuj e izbj egav anj e po greša ka ko je mogu biti utužive i pri donosi unaprijeđe - nju primjenjenih kliničkih postupaka. Čitav postupak primjene principa EBM sastoji se od 5 kora ka: 1) Postavljanje pitanja - PICO. Prvi korak u rješavanju klinič kog prob le ma je nje go vo de fi ni ra nje i to pre ma načelu: P pacijent: entitet koji predstavlja ili ima problem I intervencija: govori što je učinjeno u pristupu pacijent u C usporedba: govori o načinu provođenja istraživanja u svr hu rje ša va nja prob le ma O ishod: rezultat intervencije 2) Traže nje najboljih dokaza 3) Kri tič ka proc je na do ka za 4) Integ ra ci ja dokaza i kliničke situacije 5) Pro c j e na u činkov itos ti, p o h r anjiv anj e p odat ak a i re - zul ta ta Proble ma ti ku medicine zasnovane na dokazi ma nemo - gu će je ob ra đivati bez spomena Cochrane baze podata - ka. Ona tre nut no djje lu je u 91 zem lji a sa či nja va ju je: Cochrane Da ta ba se of Systematic Reviews, Database of Ab - strac ts of Re views of Effec ts DARE, CENTRAL, Coc hra ne Da ta ba se of Methodology Reviews, NHS Economic Evaluation Database i Health Technology Assessment Reports. Co c hr a n e R e v i ew p r už a uslug e f o rmulir anja i d efinir anja pi ta nja, pre poznavanja i odabira studije, procjenjuje zna - čaj stu di je, pri kup lja in for ma ci je ko je za tim ana li zi ra, prezent i ra i int er pre ti ra kao re zul ta te. Od izu zet ne je važ no sti z a o drž a v a nj e nivo a k v alitete inf o rmacij e činj enic a da s e p o datci re d o v i to o bnavljaju. e-pošta: S78 S10-2 Evidence based medicine - clinical perspective Ma t i je v ic R Me di cal School, Uni ver si ty of Zag reb, Sve ti Duh Ge ne ral Hos pi tal, Zagreb, Croatia Evi den ce ba sed me di ci ne EBM is de fined as continuous lear ni ng pro ce ss used in or der to int eg ra te cur rent medical knowledge into an everyday process of healthcare, bo th for the be ne fit of our pa tient s. EBM int eg ra tes the process and ability to define clinical question and puts it in the for mat bei ng sui tab le to fi nd an an swer on it in the av ailabl e li te r a ture. A s well as that, EBM co ncept includ es knowled ge of the literature search, precise and selective assessment and judgment of information find in the literature. Implementation of EBM into everyday clinical practice is impor tant and use ful. It im pro ves the me di cal ca re of all patient s and it is de sig ned for a spe ci fic pa tient by the pro ce ss of quali ty ca re. It minimizes the risk of medical mistake po - tentially opening a field of litigation process and finally, improves the use of clinical protocols and guidelines. The who le pro ce ss of EBM can be sim pli fied in five steps: 1) Asking and defining a clinically important question - PICO. This is a first step in sol vi ng a cli ni cal prob lem. It is ba sed on: P - pa tient or ent i ty who had a prob lem I int er vent ion: or what had been do ne in or der to sol ve the prob lem in pa tient or prob lem ap proa ch C com pa ri son: de fi nes the way of sol vi ng the prob lem, the way of in ve sti ga tion per for med or de fi ned for the pur po se of sol vi ng a prob lem O out co me: is a re su lt of int er vent ion used in or der to assess the benefit or otherwise for specific intervention in or der to sol ve the prob lem 2) Fin di ng the best evi den ce 3) Critical assessment of the evidence found 4) Integration of the evidence found and setting the clinical situa tion and defining a guideline 5) Assessment of clinical usefulness, data storage and results assessment EBM ap proa ch and cli ni cal prac ti ce ba sed on EBM ro les is im pos sib le to explain wit hout ment io ni ng Coc hra ne collaboration and Cochrane database of systematic reviews. Cur rent ly it is pre sent in 91 count ries and it in clu des: Cochrane Da ta ba se of Systematic Reviews, Database of Abstracts of Re views of Effects DARE, CENTRAL, Cochrane Database of Methodology Reviews, NHS Economic Evaluation Database and Health Technology Assessment Reports. Coc hra ne Re view hel ps in de finin g an d f o rmulatin g cli - ni cal im por tant que stion, hel ps to find and evaluate the stu dies used for the fur ther as ses sment, as ses ses the quality of the studies, collect in for ma tion for the fur ther ana lysis and finally, analyses, presents and interprets the re sul ts. It is cru cial ly im por tant for the EBM and for maintaining a quality assessment and control. e -mail: rma ti

3 S10-3 Prenatalni probir sindroma Down - dometi i og ra ni če nja Kralik Oguić S Klinički zavod za laboratorijsku dijagnostiku, Klinički bolnički centar Zagreb, Zagreb S10-3 Prenatal screening of Down syndrome Kralik Oguić S Clinical Institute for Laboratory Diagnostics, Zagreb Clinical Hospital Centre, Zagreb, Croatia Downov sin drom je naj češ ći ge net ski uz rok ment al ne zaostalosti. U otprilike 92% svih slučajeva prisutna je trisomija 21. Kad govorimo o prenatalnoj dijagnostici sindroma Down mislimo na invazivne postupke kao što je am ni oce nt e z a i b i o psija kor i o n sk ih re sic a, a koj e n os e s a s ob o m r i z ik r a znih ko mp lik acija uključujući i p ob ač aj. Po če tko m d e ved es etih g odina p rošl o g s tolj eć a p očinj e raz voj me to da pro bi ra ko je slu že u ident i fik aciji tr u dn o - ća s po ve ća nim ri zi kom sin dro ma Down ko je je pot reb no uputiti na invazivnu dijagnostiku. I stov re me no opa ža mo ve li ki na pre dak u pro bi ru sin droma Down, ali i sve ve ći broj že na ko je ra đa ju u sta ri joj do bi ka da se i ri zik ovog sin dro ma po ve ća va. To ote ža va pra vu proc je nu ko li ko su no ve me to de zai sta do ve le do napretka. Pr ve m e to d e p rob ir a koj e i danas kor is tim o su d vos tr uk i (h CG i AFP), tros tr uk i (d odatni b ilj e g n ekonjugir ani es tr i o l) i če t vero s tr u k i (d odatni b ilj e g inhib in A) tes tov i u dr ug o m tro mj es e č ju tr u dn oće (15-22 tj e dna). N ešto k asnij e p ojav ili su se kom bi ni rani te stovi u prvom tromjesečju (11-14 tje - da na). Raz nim kombinacijama probira postiže se sve ve - ća os jet lji vost (do 95%) i sve ma nja sto pa laž no po zi tiv nih re z ult at a (2%). M eđutim smj e rnice s e u veliko r a zlik uju o d zemlje do zemlje, a u primjeni su višestruke kombinacije s r a z li čitim is h o dima. Poj edini s tr u čnjaci smatr aju da s e nij e bit no sma njio broj po ro da dje ce sa sin dro mom Down, a da s e b roj p o b ač aja iz a zv anih dijagn os tičk im z ahv atima p o ve ć a o. O t v a r a s e i p it anj e o dn os a cij en e i kor isn os ti n o - vih strategija probira. O b r a di v ši p o datke većin e velik ih s tudija p rob ir a sindroma Down mo že se sa si gur noš ću re ći da se uvo đe njem kombi ni ra nog pro bi ra u pr vom trom je seč ju i nje go vom int egr a ci j o m s re z ult atima iz dr ug o g tro mj es e čja smanji o b roj po ro da dje ce sa sin dro mom Down i uku pan broj am nioce nt ez a i b i o p sija ko r i o nsk ih resic a. D o danas j e d ok az an o da op ti ma lan test pro bi ra u pr vom trom je seč ju mo ra uklju či v ati ko m b inaciju rez ult at a ultr a zv uko m izmj eren o g nuhalnog nabora i plazmatskog proteina A pridruženog trud no ći (PAPP -A), a da je pot pu no sve jed no da li će se kao tre ći bi ljeg koristiti inhibin A, slobodna beta podje - di ni ca hcg -a ili ukup ni hcg. U dru gom trom je seč ju opti malno je ko ristiti 4 ili eventualno 3 biljega (bez inhibi - na - A). U us p o re db i s tr ategija ko mb inir anja tes tov a p rvo g i dru gog trom je seč ja naj bo lji om jer ci je ne i ko ris no sti pok a z a o j e ko nt ing e ntni p r is tup u o dn osu na inte gr ir ani i Down s syndro me is the most com mon ge ne tic cau se of ment al re tar da tion. Tryso my 21 is pre sent in ap proximately 92% of all cases. Prenatal diagnostics of Down s syndro me in cludes only invasive procedures as amnio - centesis and chorionic villus sampling which carrie proce du re -re la ted ri sk wi th mis car ria ges as the wor se. In the ear ly 90 s in the last cent u ry the de ve lop ment of scree ning met ho ds star ted whi ch pro vi ded ident i fi ca tion of pregnan cies wi th in crea sed ri sk of Down syndro me ne ces sary to offer pre na tal diag no sis. At the sa me ti me a great prog re ss in Down s syndro me scree ni ng is de tec ted but al so a pro por tion of wo men givi ng bir th at ol der ages. It ma kes the e sti ma tion of effi cacy of new scree ni ng me to ds mo re difficult. First scree ni ng met ho ds in se co nd tri me ster of pre gnancy (15-22 wee ks) are sti ll in use: doub le test (AFP and hcg), trip le test (ad di tion of un co nju ga ted e striol) and quad test (addition of inhibin-a). Combined screening test in first tri me ster (11-14 wee ks) ca me la ter. Wi th different combinations of screening tests better sensitivity (95%) and lower fal se po si ti ve ra te (2%) is ac hie ved. Nevertheless the recommendations are various from country to count ry and effic as y is di ff e rent de pen di ng on metho ds used. So me aut ho rs claim that the num ber of bir ths of chil dren wi th Down s syndro me is not sig ni fi cant ly redu ced and that even the num ber of misscarriages induced with in va sive diagnostic procedures is growing. The - re is al so a que stion of co st -be ne fit ra tio of diffe rent strategies. Comparing the data from large population studies we can con clu de that the int ro duc tion of a com bi ned ri sk as ses ment in the first trimester and its integration with s econ d tr i m e s te r result s reduce d th e numb e r of inf ants bo rn wi th Down s syndro me and al so the num ber of chorionic vilus samplings and amniocentesis. It is also proved that optimal first trimester screening test combines nuchal translucency and pregnancy associated plasma protei n -A (PAPP -A) wi th the thi rd mar ker but it is ir re le vant whet her is it to tal hcg, free be ta -hcg or in hi bin A, the re is no difference in screening performance. Quad or triple test is the op ti mal choi ce for se co nd tri me ster screeni ng. When com pa ri ng cost effe ctiven ess of thre e di ff e- rent strategies in combining results from first and se co nd trimester screening (integrated test, sequential screening and contingent screening) contingent screening is the S79

4 sekvencijalni. U kontingentnom pristupu kombinirani test u pr vom trom je seč ju di je li trud ni ce u tri gru pe: vi so kog, srednjeg i niskog rizika. Ženama s visokim rizikom predlaže se od mah invaziv na dijagnostika, nisko rizične se uop - će da lje ne te sti ra ju, a one sa sred njim ri zi kom se ša lje na tro stru ki ili čet ve ro stru ki test u dru gom trom je seč ju pa se iz r a čuna v a int e gr ir ani r iz ik s v ih b ilj ega. Zak ljuč no mo že mo re ći da su me to de pro bi ra sin dro ma Down da nas vr lo dje lot vor ne, ali ova ko ve li ka raz novr sn os t iz b o r a i njih ove ko mb i nacij e z b unjuj e i tr u dnice i liječnike, a i nas u kliničkom laboratoriju na kojima je odlu ka oda bi ra što od sve ga to ga mo že mo ili mo ra mo ponuditi. e- p oš ta: sk ra lik@kb c -za g reb. hr pre fer red op tion. In cont in gent scree ni ng the first tri mester re sul ts are used to ca te go ri se wo men as hi gh, int erme dia te or low ri sk. Hi gh ri sk wo men are offered early diag no sis, low ri sk wo men do not go se co nd tri me ster testing and intermediate risk women are offere d s econ d tri me ster te sti ng. We can con clu de that scree ni ng met ho ds of Down s syndro me pro vi ded to day are ve ry effe ctive b u t v ar i et y of choi ces is too big. It is con fu si ng for bo th pa tient s and doctors but also for us who work in clinical laboratory when we ha ve to de fi ne whi ch type of te sts wi ll be in cluded in scree ni ng we can offer. e -mail: skra lik@kbc -zag reb.hr S10-4 Racionalno korištenje metaboličkog laboratorija Fumić K Kli nič ki za vod za la bo ra to rij sku di ja gno sti ku Me di cin sko ga fa kul te ta Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb S10-4 Rational use of the metabolic laboratory Fumić K Clinical Institute of Laboratory Diagnosis, Zagreb University School of Medicine and Clinical Hospital Center, Zagreb, Croatia Po d r u čj e na slj e dnih m et ab oličk ih b ol es ti b rzo s e r a zv ija i po stavlja sve više zahtjeve pred liječnike, medicinske bio - ke mič a re, ro di te lj e, a i cj el ok upnu z aj e dnicu koja na njih tre ba od go vo riti. Za sada je poznat mehanizam nastan - k a v iš e o d 50 0 naslj e dnih m et ab oličk ih p orem eć aja ko d ko jih s e m o gu p rep oznati p romj en e na r az ini m et ab olit a, e n z i ma ili g e na. M et ab oličk i lab or ator iji z a p r imarn o i / ili se lek tiv no tra ganje za nasljednim metaboličkim bolesti - ma tre b a li b i o dg ovor iti izb oro m naj o ptimalnijih m etoda i p o s tu p a k a k ako z a otk r iv anj e, t ako i z a p r aćenj e tij ek a li je če nja ve li kog broja takvih rijetkih bolesti. Te osobito - sti odre đu ju metaboličke laboratorije neovisno o njiho - voj orga ni za ci ji. Kako bi se što racionalnije iskoristila la - b o r a tor ij sk a o prema i s tr u čni k adar, te t ako o m ogućila sav jes na pri mje na naj bo ljih do ka za za do no še nje od lu ka u di jagno sti ci i lije čenju određenog bolesnika s nasljed - nom me ta bo ličkom bolesti, preporuka je da jedan meta - bo lič ki la bo ra to rij pok ri va potre be sta nov niš tva od oko sta nov ni ka. Kont inui ra na edukacija treba olakšati manje upućenim li - ječnicima odabir metaboličkih pretraga sa svrhom što rani jeg ot kri va nja me ta bo lič kih bo le sti, što je pre duv jet njihovog uspješnog liječenja i smanjenje broja nepotrebnih pret raga ko je zna čaj no otežavaju rad metaboličkog labo - ratorija. Naime, iako je velik broj normalnih nalaza jedna od uobi ča je nih karakteristika takvih laboratorija, potreb - The area of he reditary metabolic diseases develops quickly and se ts even hig her de man ds to physi cia ns, me di cal biochemists, parents and the whole community that has to res po nd to them. Up to now we are fa mi liar wi th the mecha ni sm of development of more than 500 heredita - r y m et a b o lic dis o rd er s w h ere o n e c an reco gnize chang es o n th e l e ve l of m et ab olites, e nz y m es o r g en es. M et ab olic laborato ries for primary and /or selective search for here - dit ar y m e t a b o lic dis eas es sh o ul d resp on d w ith an arr ay of the most op ti mal met ho ds and pro ce du res for de tecti ng a di sea se as we ll as for treat ment mo ni to ri ng of a great num ber of su ch ra re di sea ses. Tho se cha rac te ri sti cs determi ne me tabolic laboratories independently of the - ir or ga ni za tion. In or der to use the la bo ra to ry equip ment and professional staff as ra tio nal as po ssib le and thus to enab le con scient ious ap pli ca tion of the best evi den ce for d ecisi o n ma k i n g in dia gn os tic an d treatm e nt of a ce rt ain patient wi th a hereditary metabolic disease, it is recom - m e nd e d that o n e m et ab olic lab or ator y cove r s n e eds of 4,000,000 ci ti ze ns. Continuous education should ease a choice of metabo - lic te sts to le ss in for med physi cia ns wi th the aim of the earliest possible detection of a metabolic disease, what is al so a pre con di tion for a suc ces sful treat ment and a dec rea se in num ber of un ne ces sa ry te sts that ma ke the wor k of a m e t ab olic lab or ator y signifi cant ly com pli ca ted. S80

5 n o j e š to b o lj e p os t av iti indik acij e z a p oj edin e p re tr ag e. Jed no od na čela koje bi liječnici trebali usvojiti u sluča - jevima kad bolesnik nije ugrožen je odabir najprije onih p re t r aga ko j e m ogu otk r iti lj ečive ili češće b ol es ti, p a te k uko li ko se te ne ot kri ju, tra ži ti ri jet ke i ne li je či ve. Ta kav na čin rada podrazumijeva aktivnu suradnju liječni - ka s me di cin skim bio ke mi ča ri ma, što je pre duv jet ra cional n o g ko r iš tenja m et ab oličko g lab or ator ija. e-pošta: ksenija.fumic@zg.htnet.hr Al thou gh a great num ber of test re sul ts pre sent s one of the usual cha racteristics of such laboratories, it is necessa ry to set the in di ca tio ns for cer tain te sts as we ll as possib le. One of the prin cip les that shou ld be adop ted by physi cia ns in ca ses when pa tie nt s li fe is not in dan ger is first to choo se tho se te sts that can de te ct cu rab le and mo re com mon di sea ses. On ly af ter they are not de tec ted o n e sh o u l d s earch f o r r are an d incur abl e dis eas es. Such way of work requires and understands active physician s co op er a ti o n w ith m edic al b i o ch emis t s, w hat re pres e nts a prerequisite for rational utilization of metabolic laboratory. ksenija.fumic@zg.htnet.hr S10-5 U tra ga nju za ideal nim po ka za te ljem kontrole glikemije Vučić Lovrenčić M Sveu či liš na kli ni ka za di ja be tes, en dok ri no lo gi ju i bo le sti me ta bo liz ma Vuk Vrhovac, Zagreb S10-5 In sear ch of an ideal glyce mic cont rol in di ca tor Vučić Lovrenčić M Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Zagreb, Croatia N e p r ij e p o r n o j e d ok az an o da j e d o br a ko ntrola glikemij e ključni preduvjet za sprečavanje razvoja kroničnih komp li k acija š e će rn e b ol es ti. M eđutim, p r aćenj e i p ro cj ena kontrole glikemije još uvijek su predmetom brojnih kontroverzi. Unatoč tehnološkom napretku i dobroj edukaciji, re z ul t a ti s a m o mj e renja glukoze u p la zmi koj e p om oću glu kome ta ra provode oboljeli od šećerne bolesti još uvi - jek nisu do voljno pouzdani. Kontinuirano mjerenje glu - ko ze u plaz mi pomoću potkožnih senzora nije široko do - stup no ra di vi soke cijene, a interpretacija rezultata zahti - j e v a d o dat na i s tr a živ anja u tem elj ena na d ok az ima. Stoga je laboratorijsko mjerenje hemoglobina A1c i dalje nezaobilazni čimbenik kontrole i kliničkog praćenja še ćerne bo le sti. Potreba za harmonizacijom hemoglobi - na A1c dove la je do kont ro ver znog is ho da: NGSP su stav stan dar di za ci je osigurava sljedivost rezultata prema ključnim kliničkim studijama utemeljenim na dokazima gdje j e u t v r đe na vez a izm eđu r az in e glikemij e izr ažen e p reko hemoglobina A1c i rizika za razvoj kroničnih komplikacija š eće r n e b o l es ti; I FCC sus t av s t andardiz acij e osigur av a sljedivost prema referentnoj analitičkoj metodi, ali su radi specifičnosti metode rezultati značajno niži, što bi prema int er pre ta ci ji kliničkih dijabetologa moglo dovesti do po - gre š ak a u li j e čenju i ozb iljn o u groz iti sk r b o o b o lj elima o d š e će rn e b o l e s ti. Ovaj pri je por do veo je do ide je jed ne te me lji te re va lo riz a ci j e h e m o g l ob ina A1c, na način da s e p r ib ave p rošireni The re is plent y of evi den ce im pli ca ti ng tig ht glyce mic control as a key-postulate for prevention of chronic diab etic co m p li c ati ons. H oweve r, m onitor in g an d ass essment of glycemic control is still controversial. Despite ad van ces in tec hno lo gy and pa tient edu ca tion, re sul ts of self- cont rol glucose monitoring performed by the diabe - tic patients are still uncertain. Continuous subcutaneous glu co se mo ni to ri ng by the use of ap prop ria te sen so rs is limite d in us e b ec aus e of high cos t s, an d a ccur ate result int er pre ta tion nee ds additio nal evi den ce -ba sed stu dies. Thus, la bo ra to ry measurement of hemoglobin A1c remai - ns an ine vi tab le fac tor in the cont rol and cli ni cal mo nitoring of diabetes mellitus. A need for harmonzation of he mog lo bin A1c lead to a cont ro ver sial out co me: NGSP - standardization system enabled traceability of results to the landmark clinical evidence-based studies with established correlation between glycemic control, expressed as he mog lo bin A1c and ri sk for de ve lop ment of chro nic dia be tic com pli ca tio ns; IF CC -re fe ren ce system enab les traceability to the analytical reference method, giving signifi cant ly lower re sul ts due to it s spe ci ficity which, according to the interpretation of clinical diabetologists mig ht lead to the treat ment er ro rs and se rious de te rio ration in the ca re for dia be tic pa tient s. This controversy resulted into idea of a complete revaloriza tion of he mog lo bin A1c in ter ms of ob tai ni ng exten ded evi den ce of it s cor re la tion wi th an ave ra ge glyce mia, wi- S81

6 d o k az i o nj e g ovoj korelaciji s p rosj e čn o m glikemij o m, koji bi u ko nač ni ci omogućili izražavanje rezultata hemoglo - b i na A1c u o b lik u e kv iv al enat a p rosj e čn e glikemij e. I ako su rez ul t a ti multice ntr ičn o g is tr aživ anja p otv rdili ko relaci - ju i osigu ra li dovoljno podataka za matematičku konverzi - ju h e m o g l o b i na A1c (%) u e kv iv al e nte p rosj e čn e glikemij e (mmol/l), značajan rasap vrijednosti uočen već u kontrolir a n oj p o p u la ci ji p acij enat a uključenih u is tr aživ anj e, čin e p r i mj e nu ovo g m od ela u o pćoj p op ulaciji up itn o m. Stoga će tek daljnja istraživanja omogućiti odabir idealnog pok a z a telja ko nt rol e glikemij e. e- p oš ta: v u d b. hr th an ul ti ma te goal of expressing hemoglobin A1c resul - ts as equivalents of average glycemia. Albeit respective multicentric study results confir med cor re la tion and ensured enough data for the mathematical conversion of he mog lo bin A1c (%) int o de ri ved ave ra ge glyce mia equiva lent s (mmol/l), a sig ni fi cant dis per sion of va lues in the co ntro l l e d s tud y p op ulati o n mad e e x tr ap olati o n of this mo del to the ge ne ral po pu la tion que stio nab le. Thus, further re sear ch is nee ded to pro vi de choi ce for an ideal indi ca tor of glyce mic cont rol. e -mail: vu db.hr S82

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