Strict Standards: call_user_func_array() expects parameter 1 to be a valid callback, non-static method JModuleHelper::renderModule() should not be called statically in /home/vasginek/public_html/libraries/joomla/cache/handler/callback.php on line 99

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/modulehelper.php on line 143

Strict Standards: Non-static method JRequest::getCmd() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/modulehelper.php on line 144

Strict Standards: Non-static method JRequest::getVar() should not be called statically in /home/vasginek/public_html/libraries/joomla/environment/request.php on line 255

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JFactory::getLanguage() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/modulehelper.php on line 188

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRequest::getBool() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/modulehelper.php on line 219

Strict Standards: Non-static method JRequest::getVar() should not be called statically in /home/vasginek/public_html/libraries/joomla/environment/request.php on line 217

Strict Standards: Non-static method JRequest::_cleanVar() should not be called statically in /home/vasginek/public_html/libraries/joomla/environment/request.php on line 151

Strict Standards: Non-static method JFilterInput::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/environment/request.php on line 577

Strict Standards: Non-static method JDispatcher::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 511

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/advancedmodules.php on line 132
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Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JLoader::register() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 71

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JLoader::load() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 161

Strict Standards: Non-static method JLoader::register() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 138

Strict Standards: Non-static method JModuleHelper::getLayoutPath() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/mod_mainmenu.php on line 42

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/plugins/system/advancedmodules/modulehelper.php on line 266

Strict Standards: Non-static method JDispatcher::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 511

Strict Standards: Non-static method modMainMenuHelper::render() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/tmpl/default.php on line 82

Strict Standards: Non-static method JSite::getMenu() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 345

Strict Standards: Non-static method JApplication::getMenu() should not be called statically in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getUser() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 346

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JFactory::getSession() should not be called statically in /home/vasginek/public_html/libraries/joomla/factory.php on line 163

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRoute::_() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 107

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/libraries/joomla/methods.php on line 41

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 372

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JRouter::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 674

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 675

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 419

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 401

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 295

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JSite::getMenu() should not be called statically in /home/vasginek/public_html/components/com_content/router.php on line 19

Strict Standards: Non-static method JApplication::getMenu() should not be called statically in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 90

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JURI::base() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 109

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRoute::_() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 107

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/libraries/joomla/methods.php on line 41

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 372

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JRouter::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 674

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 675

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 419

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 401

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 295

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JComponentHelper::getComponent() should not be called statically in /home/vasginek/public_html/components/com_contact/router.php on line 23

Strict Standards: Non-static method JComponentHelper::_load() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/component/helper.php on line 39

Strict Standards: Non-static method JSite::getMenu() should not be called statically in /home/vasginek/public_html/components/com_contact/router.php on line 24

Strict Standards: Non-static method JApplication::getMenu() should not be called statically in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 90

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JURI::base() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 109

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRoute::_() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 107

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/libraries/joomla/methods.php on line 41

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 372

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JRouter::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 674

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 675

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 419

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 401

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 295

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JSite::getMenu() should not be called statically in /home/vasginek/public_html/components/com_content/router.php on line 19

Strict Standards: Non-static method JApplication::getMenu() should not be called statically in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 90

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JURI::base() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 109

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRoute::_() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 107

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/libraries/joomla/methods.php on line 41

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 372

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JRouter::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 674

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 675

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 419

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 401

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 295

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JSite::getMenu() should not be called statically in /home/vasginek/public_html/components/com_content/router.php on line 19

Strict Standards: Non-static method JApplication::getMenu() should not be called statically in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

Strict Standards: Non-static method JFactory::getApplication() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 90

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 394

Strict Standards: Non-static method JURI::base() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 109

Strict Standards: Non-static method JRegistryFormat::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/registry.php on line 373

Strict Standards: Non-static method JFilterInput::clean() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/registry/format.php on line 45

Strict Standards: Non-static method JRoute::_() should not be called statically in /home/vasginek/public_html/modules/mod_mainmenu/legacy.php on line 107

Strict Standards: Non-static method JFactory::getApplication() should not be called statically in /home/vasginek/public_html/libraries/joomla/methods.php on line 41

Strict Standards: Non-static method JFactory::getConfig() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 372

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JRouter::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 674

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 675

Strict Standards: Non-static method JSite::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/router.php on line 419

Strict Standards: Non-static method JApplication::getMenu() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/includes/application.php on line 345

Strict Standards: Non-static method JLoader::import() should not be called statically in /home/vasginek/public_html/libraries/loader.php on line 186

Strict Standards: Non-static method JMenu::getInstance() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 720

Strict Standards: Non-static method JError::isError() should not be called statically, assuming $this from incompatible context in /home/vasginek/public_html/libraries/joomla/application/application.php on line 721

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BMI Kalkulator

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Kalkulator kalorija

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Unesite datum poslednjeg ciklusa:
PAPA test
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PAPA test je deo ginekološkog pregleda čiji je cilj što ranije otkrivanje prekanceroznih i kanceroznih stanja grlića materice. Tokom pregleda uzima se material za citološki pregled sa prednje i zadnje usne grlića materice i iz kanala grlića materice. Od uzorka se napravi citološki razmaz ( ćelije grlića materice se razmažu po predmetnom staklu ) u kojem se pod mikroskopom gledaju znaci zapaljenja grlića, uzročnici infekcije, dobroćudne i zloćudne ćelije i promene. Dijagnostičku metodu je izmislio George Papanicolau 1953., pa se po njemu zove PAPA ili Papanicolau test.

Ko i kada treba uraditi PAPA test?

Test se obavezno preporučuje seksualno aktivnim ženama ili starijim od 18 godina života jednom godišnje. Ukoliko to vaš ginekolog preporuči po potrebi i češće. Najbolje vreme za uzimanje uzorka je sredina ciklusa tj. 10-20 dana nakon prvog dana poslednje menstruacije. Obavezno 2 dana pre odlaska na pregled treba izbegavati tuširanje vagine ili umetanje vaginalnih lekova, spermacidnih pena, krema ili tableta jer navedeni postupci mogu isprati ili sakriti izmenjene ćelije. Smatra se da se redovnom godišnjom PAPA kontrolom smanjuje rizik umiranja od raka grlića materice za 90%!

Tumačenje nalaza PAPA testa

Nalaz može biti 1. uredan; 2. pokazivati zapaljenske i eventualno uzroke zapaljenja, ali bez promena u epitelnim ćelijama; 3. biti abnormalan jer su nađene izmenjene ćelije. Abnormalan nalaz ne znači karcinom, kao ni da takvo stanje bezuslovno prelazi u karcinom, mada neke od tako promenjenih tzv. displastičnih ćelija imaju veću verovatnoću da postanu maligne.
Displazija je stanje u kojem se epitelne ćelije grlića materice svojom veličinom, izgledom i sazrevanjem razlikuju od normalnih epitelnih ćelija ali još nisu maligne. One sadrže potencijal da postanu maligne (prekancerozno stanje). Displazije se nalaze u oko 2-5% žena, a rizik prelaza u karcinom iznosi 10-15% odnosno 30-50% ako se radi o CIS. Naime, displastične ćelije mogu biti više ili manje promenjene, pa se tako razlikuju tri nivoa displazije: blaga, umerena i teška. Često se kao sinonimi koriste i termin CIN (cervikalna intraepitelna neoplazija), pri čemu u zavisnosti o debljini zahvaćenog epitela postoji CIN I (blaga displazija), CIN II (umerena displazija) i CIN III (teška displazija odnosno CIS tj. carcinoma in situ). CIS, za razliku od invazivnog karcinoma, nije probio bazalnu membranu (koja razdvaja epitel od vezivnog tkiva s krvnim i limfnim sudovima koje se nalazi ispod epitela), pa je još uvek ograničen samo na epitel.
U nalazu PAPA testa moguće je naići i na termin SIL (skvamozna intraepitelna lezija), koji se takođe odnosi na displastične ćelije grlića materice, pri čemu SIL niskog nivoa (LGSIL od eng. low grade) odgovara CIN-u 1, a SIL visokog nivoa (HGSIL od eng. high grade) uključuje CIN II i CIN III.

Postoji i nalaz atipičnih skvamoznih, odnosno glandularnih (žlezdanih) ćelija neodređenoga značenja (ASCUS odnosno AGCUS) u stanjima kada abnormalnosti ne ispunjavaju kriterijume za CIN, SIL ili displaziju. Kod prosečno 5-10% pacijentkinja s ovakvim nalazom se nakon daljnjih pretraga otkriva SIL visokog nivoa ili, retko, invazivni karcinom.

Karcinom grlića materice (cervikalni karcinom; invazivni cervikalni karcinom) nastaje kada tumorske ćelije probiju bazalnu membranu i prošire se dublje u tkivo materice ili u druga tkiva i organe.

Papanicolau klasifikacija je uvedena 1954. i godinama se koristila u interpretaciji nalaza.

Papa I - uredan nalaz

Papa II - netipične upalne promene

Papa III - displazija: blaga, srednje teška ili teška

Papa IV - carcinoma in situ

Papa V - sumnja na invazivni karcinom.

 

 

 

 

 

Sada je zamenjena klasifikacijom koja veću pažnju poklanja histološkim kriterijumima u dijagnostici i razlikujemo:

Displazija lakog stepena (CIN I, LGSIL): promene slabo izražene i to u površinskim ćelijama, čije su citoplazme uredne, jezgra blago povećana, nepravilnog oblika, jače obojena. Jezgro zauzima više od trećine površine ćelije. Kod blage displazije može se očekivati spontano povlačenje u oko 50-80% slučajeva tokom 1 godine, čak i uz pozitivan nalaz visokorizičnog HPV.

Displazija srednje teškoga stepena (CIN II, HGSIL): promene površinskih i dubokih ćelija do 2/3 debljine epitela, pri čemu je sloj bazalnih ćelija jasno proširen s većim brojem mitoza (umnožavanje ćelija), kao i većim brojem ćelija s netipičnim jezgrama, odnosno netipičnog izgleda. Jezgra zauzima polovinu površine ćelije.

Displazija teškoga stepena (CIN III,CIS, HGSIL): više od 2/3 debljine epitela je zahvaćeno displastičnim promenama, promenjena jezgra nalaze se u svim slojevima ćelija. Kod karcinoma 'in situ' (CIS) znakovi normalne građe epitela i sazrevanja ćelija u potpunosti nedostaju.

Uzimanje uzorka nije povezano s bilo kakvim komplikacijama ili rizicima.

Savet: Nemojte uzimati vaginalete ili tablete samo na osnovu nalaza Papa testa bez prethodno učinjenih molekularnih ili mikrobioloških testova za tačno utvrđivanje uzročnika upale. Ženama kod kojih je nađen povećani broj upalnih celija u Papa testu bez drugih smetnji ili znakova upale, preporučuje se  preventivni DNK PCR test na Chamidiu trachomatis, kao i svim zdravim polno aktivnim osobama oba pola barem jednom godišnje. Ženama koje imaju smetnje i znakove upale, bez obzira na broj zapaljenskih ćelija ili prisustvo vidljivih uzročnika u Papa testu, preporučuje se  testiranje na hlamidiju, mikoplazmu i ureaplazmu, aerobe i anaerobe iz brisa grlića maternice. Nije retkost istovremena infekcija s dva ili više uzročnika, od kojih svaki može zahtevati primenu različitog leka. Lečenje je opravdano i daće rezultate isključivo na temelju pozitivnog nalaza tačno određenog uzročnika posebnim laboratorijskim testovima.

HPV DNK test zajedno sa  PAPA testom

Prema podacima Svetske zdravstvene organizacije (WHO), rak grlića maternice je na drugom mestu po učestalosti kao uzrok smrti žena u svetu. Do 40% žena obolelih od raka grlića maternice imalo je normalan nalaz Papa testa unazad 3 - 5 godina pre pojave bolesti. Preko 99 % karcinoma grlića maternice povezano je s infekcijom humanim papiloma virusima (HPV) iz grupe visokog rizika. Do sada je istraženo 13 HPV genotipova visokog rizika, ali se i dalje otkrivaju novi tipovi i podtipovi. Procenjuje se da se kod 1 % inficiranih žena tokom godina razvije rak grlića maternice.

Infekcija HPV virusom je najraširenija polna bolest na svetu. Procenjuje se da je oko 80 % polno aktivnih ljudi tokom života izloženo zarazi HPV čije širenje za sada nije moguće sprečiti.

Kod muškaraca ova infekcija ne uzrokuje ozbiljnije poteškoće. Danas u svetu ne postoje pouzdani dijagnostički testovi za dokazivanje HPV infekcije kod muškaraca.

Jedini način zaštite žena od karcinoma grlića maternice je rano otkrivanje onih žena koje imaju rizik za nastanak bolesti.

Do sada se u ranom otkrivanju raka grlića maternice koristio samo Papa test kojim se otkrivaju abnormalne promene na ćelijama.Papa test je značajno smanjio smrtnost žena od raka grlića maternice. Test ima nedostataka i tehničkih ograničenja zbog kojih njegova najveća osetljivost ne prelazi 80%. To znači da u najboljem slučaju svaka peta žena koja ima predstadijum karcinoma ili rani karcinom (CIN) dobije lažno negativan (uredan) nalaz Papa testa.

Kod blažih promena u Papa testu (CIN I i CIN II) i kod nejasnih sumnjivih nalaza (ASCUS) nije moguće na temelju izgleda ćelije proceniti da li se radi o dobroćudnim promenama ili o početnom karcinomu. Različite kliničke studije su pokazale da HPV DNK test otkriva više žena s CIN nego Papa test. HPV DNK test treba uraditi uz Papa test kod redovnog ginekološkog godišnjeg pregleda žena uzrasta od 25 i više godina. Kod svih žena, uključujući i mlađe od 25 godina, HPV DNK test treba uraditi odmah nakon prvog abnormalnog nalaza Papa testa.

 
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