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Going back to the beginning of 90-ies of last century before the present STCW-78/95 Convention was established the shipping industry relied on Maritime Education and Training Institutions for welleducated and trained seafarers. Every shipowner simply employed seafarers that his ships needed and the relevant Minimum Safe Manning Certificate required. Generally speaking MET Institutions were the only Institutions responsible for initial and following education and training of seafarers. The last decade in the shipping industry has been marked by plenty changes and quick development in different directions. One of the directions is improving the quality of seafarer's education and training, knowledge and skills as well. The obligatory competences in STCW-78/95 Convention are not enough for shipowners and they try to extend the education process outside the Convention's requirements and recommendations. It is a well known and more and more spread practice for Shipowners to organize and perform meetings with officers and engineers working on board their vessels. Such meetings get publicity as Fleet Officer's Meetings (FOM) or Fleet Officer's Seminars (FOS). The meetings or seminars are performed at least on a yearly basis but it is the Owner's decision to establish the agenda and the scope of the topics. The usefulness of the above mentioned events is visible enough and it is easy to understand that the applied efforts are not time wasted. The question is whether the companies can perform such kind of training and whether their lecturers and instructors, who are usually part of the office staff, are ready to deliver their experience at an acceptable level. It has to be highlighted that it is not a rule that good professionals as Masters and Engineers are always good lecturers and trainers. This article describes the summary results of the authors' experience in participating as a fleet officer and as an assessor in fleet officers' seminars. The article makes a SWAT analysis of such events and shares experience as a conclusion. The author gives his personal collaboration to the lifelong learning process in the shipping industry. The article makes an attempt to open the door to the co-operation between the shipping industry and MET Institutions at a higher level after the seafarers' graduation in their MET Institutions. [ABSTRACT FROM AUTHOR]

Cancer cachexia is a syndrome characterized by weight and muscle loss and functional impairment, strongly influencing survival in cancer patients. In this study, we aimed to establish the role of saliva cytokine measurement in cancer cachexia investigation and define two potential independent salivary biomarkers of the condition., Methods: serum and saliva specimens were obtained from 78 patients. Forty-six patients were non-cachectic, and 32 patients were cachectic (per SCRINIO group criteria), all with metastatic solid tumors. Commercial ELISA kits were used to determine the salivary and serum concentrations of interleukin 13 (IL-13) and transforming growth factor beta (TGF-β) in two patient groups and healthy controls. Laboratory values were obtained from the hospital information system, and weight and height were measured at the time of sampling., Results: A statistically significant difference was observed between the groups in saliva IL-13 concentrations but no difference in serum concentrations. Statistically significant differences were also observed between the groups in saliva and serum concentrations of TGF-β. Logistic regression analysis has identified salivary IL-13 and TGF-β as independent factors for cancer cachexia., Conclusions: We demonstrated saliva as a valuable specimen for cachexia investigation and established IL-13 and TGF-β as potential cancer cachexia biomarkers. Further research is needed to evaluate these findings.

Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.

Owing to its frequent occurrence and severe clinical picture, bone metastasis is an important problem in the clinical course of tumor diseases. Bone metastasis develops when the physiological remodeling process is disrupted by tumor cells via the same molecular mechanisms used by native bone cells. The process includes molecular crosstalk between osteocytes and osteoblasts and osteoclasts. Osteolytic bone metastasis, most often seen in breast cancer, is characterized by promoted differentiation and function of osteoclasts and reduced osteoblast function. Tumor cells take advantage of factors released by bone tissue resorption, thus establishing a vicious cycle that promotes the metastatic process. In osteoblastic metastasis, most often seen in prostate cancer, osteoblast function and differentiation are promoted, while osteoclast activity is reduced, resulting in net gain of bone tissue. Mechanisms involved in the early stages of bone metastasis and cancer cell dormancy have been understudied, and their exploration may pave the way for potential therapeutic strategies. Tumor affects the bone marrow microenvironment via exosomes, soluble factors, and membrane-bound ligands. In this way, an initial lesion is established, which after a variable duration of disseminated tumor cells dormancy progresses to an overt condition. The current review deals with basic mechanisms involved in bone metastasis formation and propagation. We illustrated a disparity between the diversity and number of factors included in the disease pathophysiology and the number of available and developing therapeutic options. We also examined new therapeutic strategies affecting molecular pathways.

Opioids are considered the cornerstone of pain management in palliative care. Available data suggest that older patients use different analgesics and lower opioid doses compared to younger patients. However, it has not been elucidated yet whether such dosing is associated with worse pain levels or shorter survival in the palliative care setting. We evaluated the relationship among pain scores, quality of life, opioid dose, and survival in palliative care cancer patients in a hospice setting. A total of 137 palliative care cancer patients were analyzed prospectively. We divided patients into two groups using the age of 65 as a cut-off value. Younger patients exhibited significantly higher pain ratings (5.14 vs. 3.59, p=0.01), although older patients used almost 20 mg less oral morphine equivalent (OME) on arrival (p=0.36) and 55 mg OME/day less during the last week (p=0.03). There were no differences in survival between the two groups (17.36 vs. 17.58 days). The elderly patients also used nonsteroidal analgesics less often and paracetamol more often. Hence, using lower opioid doses in older palliative care cancer patients does not result in worse pain rating, and could be a plausible approach for pain management in this patient group.

Although most patients with thyroid cancer have a favorable clinical course, some patients develop a more aggressive type of cancer and exhibit more rapid disease progression with worse prognosis. Those patients usually exhibit mutations of proteins such as tyrosine kinase enzymes that play a significant role in regulation of tumor proliferation and spreading. Development of targeted therapies is based on the inhibition of mutated kinases which are involved in the MAPK signaling pathway. The aim of this study was to present the initial results of clinical experience with kinase inhibitors in patients with metastatic differentiated thyroid cancer (DTC), poorly differentiated thyroid cancer (PDTC), and medullary thyroid cancer (MTC) who exhibited rapid disease progression. A total of 17 adult patients (11 women, mean age 53.3 years) managed for progressive, metastatic disease were included in the study. Twelve patients with DTC and PDTC were previously tested for BRAF mutations, of whom nine that had tumor tissue negative for the BRAF V600E mutation received sorafenib, while three patients with tumors harboring the BRAF V600E mutation were treated with vemurafenib. Patients with MTC were treated with sunitinib, vandetanib, and sorafenib. Two patients with tumors harboring the BRAF mutation treated with vemurafenib showed restoration of radioiodine uptake. Most of patients showed significant improvement in disease status but of limited duration until disease progression. Although there was an improvement in progression-free survival, future research has to achieve a greater and longer-lasting response, probably by utilizing combined targeted therapy.

Treatment of oncological patients must be based upon multidisciplinary approach, and takes place in specialized oncological centers. By the end of a specific oncological treatment further follow-up is being managed mostly by the oncologists, but the role of the general practitioners becomes more important every day and therefore should be precisely defined. Nowadays, most of the existing follow-up guidelines are not being based on prospective studies, yet on the expert’s opinion of a precise oncological center or specialists. The aim of the Croatian Society of Medical Oncology (CSMO) with these recommendations is to standardize and rationalize the diagnostic procedures’ algorithm in follow–up of oncological patients after primary treatment, in patients with planocellular head and neck cancer, oesophageal cancer, gastric cancer and colorectal cancer.

The treatment of oncological patients must be based upon multidisciplinary approach, and takes place in specialized oncological centers. By the end of a specific oncological treatment further follow-up is being managed mostly by the oncologists, but the role of the general practitioners becomes more important every day and therefore should be precisely defined. Nowadays, most of the existing follow-up guidelines are not based on prospective studies, but on the experts opinion of individual oncological centers or specialists. The aim of the Croatian Society of Medical Oncology (CSMO) with these recommendations is to standardize and rationalize the diagnostic procedures algorithm in the follow–up of ­oncological patients after primary treatment, in patients with renal cell cancer, urinary bladder cancer, prostate cancer and testicular cancer.

Objective: Despite significant improvement in survival of gastrointestinal stromal tumors (GIST) due to use of tyrosine kinase inhibitors, surgery still represents the important part of clinical management. The aim of our study was to retrospectively analyze prognosis of GIST depending on the success of surgical treatments and utilization of chemotherapy in transitional country with relatively limited resources., Methods: cohort of consecutive patients operated for GIST in tertiary medical center, within time frame 1999-2012., Results: 54 patients, in age range 20-85 years (63.3 ± 14.7), male to female ratio 28 (51.9%):26 (48.1%), respectively. Complete excision with clean resection margins (R0) was obtained in 44 (81.5%)of total patients i.e. 44/47 (93.6%) of localized GISTs. Mean follow up was 3.9 ± 3.3 years and 19 patients (35.2%) received imatinib. Rate of overall survival was 40 (74.1%), disease-free survival 31 (57.4%) and 20 (37.0%) experienced recidivism. Follow-up parameters showed significant difference in connection with utilization of imatinib, completeness of resection and existence of metastatic disease (all p < 0.05). ROC analyzes revealed critical value of Ki-67 > 9% as significant predictor of long-term mortality; sensitivity 64.3% [95%CI = 35.1-87.2]; specificity 75.0% [58.8-87.3]; (AUC = 0.693; p = 0.049)., Conclusion: Rate of complete resections in studied sample of patients from transitional background was overall peer comparable with reports from the developed countries. On the other hand, relatively dominant prognostic position of surgical treatments might be consequence of limited utilization of adjuvant treatment with tyrosine kinase inhibitors., (Copyright © 2014. Published by Elsevier Ltd.)

Aim: To investigate primarily the prognostic value of Ki-67, as well as other parameters, in gastrointestinal stromal tumors (GISTs)., Methods: Ki-67, c-KIT, platelet-derived growth factor receptor-alpha (PDGFRα), smooth muscle actin (SMA), CD34, S100 were stained for immunohistochemistry which was performed on formalin-fixed, paraffin-embeded sections on representative block from each case. Proliferation index counted by Ki-67 antibody was calculated as a number of positive nuclear reaction over 100 cells. Immunoreactivity for c-KIT and PDGFRα was evaluated semiquantitatively (weak, intermediate, strong) and for c-KIT type of reactivity was analyzed (cytoplasmic, membrane and "dot-like" staining). Immunoreactivity for SMA, CD34 and S100 were was evaluated as positive or negative antigen expression. Pathologic parameters investigated in this study included tumor size, cell type (pure spindle, pured epitheloid mixed spindle and epitheloid), mitotic count, hemorrhage, necrosis, mucosal ulceration. Clinical data included age, gender, primary tumor location and spread of disease. χ² test and Student's t-test were used for comparisons of baseline characteristics. The Cox's proportional hazard model was used for univariable and multivariable analyses. Survival rates were calculated by Kaplan-Meier method and statistical significance was determined by the log-rank test., Results: According to the stage of disease, there were 36 patients with localized disease, 29 patients with initially localized disease but with its recurrence in the period of follow up, and finally, 35 patients had metastatic disease from the very beginning of disease. Tumor originated most commonly in the stomach (41%), small intestine was the second most common location (36%). The mean size of primary tumors was 6.5 cm. The mean duration of follow-up was 60 mo. Multiple parameters were analyzed for their effect on overall survival, but no one reached statistical significance (P = 0.06). Analysis of time to progression/relapse in initially localized disease (univariate analysis), tumor size, mitotic count, Ki-67 and type of d-KIT distribution (cytoplasmic vs membrane/"dot-like") showed statistically significant correlation. In multivariate analysis in the group of patients with localized disease, there were only 2 parameters that have impact on relapse, Ki-67 and SMA (P < 0.0001 and P < 0.034, respectively). Furthermore, Ki-67 was analyzed in localized disease vs localized with recurrence and metastatic disease. It was shown that there is a strict difference between these 2 groups of patients (median value was 2.5 for localized disease vs 10.0 for recurrent/metastatic disease, P < 0.0001). It was also shown that the cut-off value which is still statistically significant in terms of relapse on the level of 6%. The curves for survival on that cut-off level are significantly different (P < 0.04, Cox F)., Conclusion: Ki-67 presents a significant prognostic factor for GIST recurrence which could be of great importance in evaluating malignant potential of disease.

Clear cell renal carcinoma is the most common kidney cancer. It is generally asymptomatic. A small percentage of patients present with hematuria, flank pain and abdominal mass. It is usually detected accidentally during radiologic examination. The diagnosis of kidney cancer is confirmed by pathohistological findings after completion of the diagnostic process. The decision about treatment is made based on clinical assessment of disease stage and other risk factors. Depending on that, treatment options include surgery, and considering high resistance of kidney cancer on chemotherapy and hormone therapy, use of targeted therapies (immunotherapy, tyrosine kinase inhibitors) and palliative radiotherapy. The following text presents the clinical guidelines in order to standardize procedures and criteria for the diagnosis, management, treatment and monitoring of patients with kidney cancer in the Republic of Croatia.

Gastrointestinal stromal tumors are the most common mesenchymal tumors in gastrointestinal tract. They are often asymptomatic and discovered incidentally during endoscopic or barium studies. About 80% GISTs have a KIT (CD 117 antigen) gene mutation. Most affect exon 11, less commonly exon 9,13 or 17, that results in uncontrolled KIT signaling. This led to effective systemic therapies in the form of small molecule inhibitors of the receptor tyrosine kinase such as imatinib mesylat. With the purpose of providing standardized approach to rational and effective diagnostic and treatment algorithm in Croatia, a multidisciplinary session was organized. Results of the session are given in the form of Consensus guidelines.

Pancreatic neuroendocrine tumors (PETs) are increasingly recognized. In order to assure an optimal treatment of patients and to propose an efficient diagnostic algorithm we were prompted to organize meetings, with participating experts, specialists in different fields of expertise. The idea for the meetings was to try to give a standardized approach, which would in future help in stratification of PET patients. Results of meetings are given in a form of Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic neuroendocrine tumors.

Gastrointestinal stromal tumours (GIST) may be defined as intraabdominal mesenchymal tumours that express KIT protein or have an activating mutation in class III receptor tyrosine kinase gene (KIT or PDGFRalpha). Most GISTs respond to imatinib mesylate, which selectively inhibits both KIT and PDGFRalpha, and is now considered standard systemic therapy for advanced GIST. We assessed the antitumour response of patients treated with imatinib mesylate who had advanced and/or metastatic (GIST). In the Department of Medical Oncology fourteen (14) patients with advanced GIST were treated in the period from year 2002 to 2004. Imatinib mesylate was applied at the dose of 400 mg daily. Only two patients required dose enlargement up to 800 mg. All tumours had positive immunohystochemical expression of KIT. Median age of patients was 56 years. 12 male patients and 2 female patient was treated. Considering primary site of tumour we had 6 small intestine, 4 mesenterium and 4 gastric tumours. Mean duration of the treatment was 14 months (5 to 30 months). Six patients had partial remission, six had stable disease and two progression. Complete remission has not been achieved in any patient. Side-effects were mild and no patient required dose reduction or treatment discontinuation. Our results show the effectivness of targeted antitumour therapy with imatinib mesylate in advanced and/or metastatic GIST, and correspond to those in literature.

One of prognostic factors known as Nottingham Prognostic Index (NPI), which is combination of known prognostic factors such as tumor size, grade and axillary node status, is recently in usage in some European countries in clinical practice in prediction of breast carcinoma patients' survival. Therefore, the aim of this study was to verify, according to our experience, the prognostic significance of Nottingham Prognostic Index (NPI) in breast carcinoma patients in association with other new prognostic factors. In this study 148 consecutive specimens of breast carcinoma patients were analyzed. The following data for each patient were collected: age, tumor size, histological grade, axillary lymph node status, overall survival, estrogen (ER), progesterone (PR) receptor expression as well as expression of bcl-2, Ki-67, nm23, HER-2/neu, and p53. The Nottingham Prognostic Index (NPI) was calculated from the pathological information and patients were grouped according to the standard NPI index into: good prognostic group (GPG), moderate prognostic group (MPG), and poor prognostic group (PPG). The correlation of prognostic groups according to the NPI with other prognostic and predictive factors such as age, ER, PR, p53, bcl-2, Ki-67, nm23, Ki-67, Cathepsin D and HER-2/neu on overall survival was analyzed. The results of univariate analysis showed statistically significant correlation between patients' age, NPI prognostic groups and stage of disease with patients survival. When other prognostic factors were correlated with NPI prognostic groups there was not additional prognostic discrimination in given prognostic groups. Only marginally statistically significant influence of p53 expression was found on patient survival between MPG and PPG. It seems that other prognostic factors in combination with NPI prognostic groups do not have in our group of patients practical clinical relevance for the management of patients with breast carcinoma.