Showing papers in "Vnitr̆ní lékar̆ství in 2007"

Diabetes mellitus and cognitive impairments

Abstract: Patients with diabetes have an at increased risk of developing cognitive impairment in comparison with the general population Cognitive dysfunction comprises impairments of executive functions, memory, attention, and psychomotor efficiency The question of whether recurrent exposure to severe hypoglycaemia promotes long-term cognitive dysfunction is unresolved The main risk factors for cognitive impairment in diabetes are considered to be chronological age, duration of diabetes, and coexistent microvascular and macrovascular complications Diabetes should be treated as a risk factor for cognitive impairment Cognitive dysfunction is associated with poorer ability in diabetes self-care and decreased adherence to antidiabetic treatment

[Thyroid diseases, dyslipidemia and cardiovascular risk].

Abstract: By affecting the metabolism of lipids, hypothyroidism accelerates the process of atherogenesis and increases cardiovascular risk. In manifest hypothyroidism the number of LDL receptors in the liver decreases and there is an increase in levels of overall cholesterol, LDL-cholesterol and apolipoprotein B in the blood. Levels of HDL particles remain normal or even rise slightly as a result of reduced activity of the Cholesterol ester transfer protein (CETP) and hepatic lipase. This leads to a reduction in the transport of cholesterol esters from HDL-(2) to VLDL and IDL. Subclinical hypothyroidism also has a negative effect on the lipid profile, but is more likely to lead to pro-atherogenic changes in the proportion of lipid particles than to a reduction in overall cholesterol. Subclinical hypothyroidism leads to the manifestation of certain risk factors of atherosclerosis. Although studies of overall mortality and cardiovascular morbidity have not been completely unanimous in their conclusions, increased cardiovascular risk can be considered likely in subclinical hypothyroidism. It remains an open question whether the treatment of subclinical hypothyroidism with levothyroxine. At present we have only indirect proof from studies that assessed the effect of levothyroxine treatment on risk factors of atherosclerosis. Starting treatment with lipid lowering agents (especially statins) for (sub)clinical hypothyroidism is extremely risky though due to the risk of the development or worsening of myopathy, which is a further cogent argument for the active screening and treatment of(sub)clinical hypothyroidism for all patients with dyslipidemia.

Glucocorticoids and osteoporosis

Abstract: Treatment with glucocorticoids (GC) has no alternative in many medical disciplines for their anti-inflammatory and immunosuppressive effect However, osteoporosis and the related fractures are a serious complication brought about by long-term GC therapy The risk of fractures, especially of the vertebras and the ribs, becomes higher as early as in the first months of oral GC therapy It grows in proportion to the daily dose of GC, and is present even if low doses are administered (25-75 mg of prednisone per day) Decreasing bone density (BMD) is not accountable for the higher risk of fractures in GC therapy and fractures occur with higher values of BMD than in primary osteoporosis There is still no tool that we could use to quantify the changes in the bone quality and the increased risk of fracture in clinical practice The principal mechanism by which GC induces osteoporosis is inhibition of bone formation caused by the suppression of osteoblastogenesis as well as the activity of functional osteoblasts, with accelerated osteocyte and osteoblast apoptosis There are significant differences between individuals in terms of GC sensitivity, the reasons of which have not yet been explained Prior to planned long-term GC therapy (> 3 months) with daily doses higher than 25 mg of prednisone po (or higher doses of inhaled GC), it is recommended to perform a densitometry exam using dual-energy X-ray absorptiometry (DXA) in the lumbar region of the spine and femoral collum to evaluate additional risk factors of osteoporosis and fractures for a more precise estimate of the risk of fracture in the specific patient Sufficient intake of calcium (1,000-1,500 mg of elementary calcium per day) and of the vitamin D (800 IU per day) should be assured in all patients treated by GC Endogenous production of sexagens should be evaluated and possible substitution therapy should be considered in premenopausal women and younger men Today, bisphosphonates can be given to patients with a high risk of fracture, the effects of which in preventing the decrease of BMD and vertebral fractures have been documented in randomised clinical studies, even though the evaluation of the risk of fractures was not the primary endpoint of those studies However, in view of the antiremodelling effect of bisphosphonates, it is clear that this therapy does not eliminate the cause of GC induced osteoporosis and drugs with stimulating effect on osteoblasts will certainly be preferred in the future Very promising are the first clinical studies of injection parathormone (PTH 1-34) which stimulated bone formation in a continuing GC treatment

[Paradoxical embolization and patent foramen ovale in scuba divers: screening possibilities].

Abstract: Introduction The cause of decompression sickness (DCS) in scuba-divers is bubble formation in tissues and in venous blood during ascent. Divers with patent foramen ovale (PFO) have an increased risk of paradoxical embolization to the brain or other vital organs. The aim of our study was to assess the incidence of PFO in scuba-divers with DCS, to compare the group with asymptomatic controls, and to evaluate ultrasound contrast methods suitable for screening. Methodology We examined 28 scuba-divers (more than 100 dives). The right-to-left shunt detection was performed by bubble contrast transthoracic echocardiographic examination (TTE) and transcranial Doppler sonography over arteria cerebri media (TCD) in all divers. In divers with shunting, transoesophageal echocardiography (TEE) was performed to prove PFO. Results 15 divers had DCS associated with the ascent. In this group, PFO was diagnosed in 53% (8/15). The symptoms of all of them retrospectively were of paradoxical embolization (neurological form of DCS). In the group of asymptomatic divers, PFO was proven on the basis of right-to-left shunt screening in 1 diver (8% 1/13). TCD proved right-to-left shunt in all divers with PFO. Conclusion DCS can unmask a so far asymptomatic intracardiac right-to-left shunting. PFO is a risk factor for paradoxical embolization in divers. TCD is suitable for screening; TEE is a gold standard in PFO detection. Our results showed that PFO detection is a useful clinical tool after repeated DCS and in all frequent divers and instructors.

[Basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) are elevated in peripheral blood plasma of patients with chronic lymphocytic leukemia and decrease after intensive fludarabine-based treatment].

Abstract: Chronic lymphocytic leukemia (CLL) is characterized by extraordinary heterogeneity in terms of clinical course with overall survival ranging from several months to dozens of years. It is currently not possible to accurately predict the future clinical course in an individual patient. Angiogenesis has been recently reported as a potential prognostic factor in various hematological malignancies including CLL. The objective of the present study was to quantify plasma levels of key angiogenic activators vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in patients with CLL and determine their potential change after intensive fludarabine-based treatment. Peripheral blood EDTA plasma concentrations of bFGF and VEGF were measured using comercially available enzyme-linked immunosorbent assay in 73 patients with untreated CLL (43 males, 30 females, median age, 65 years, range 31-88) and 80 healthy donors serving as control group. We found statistically significant increase in concentrations in patients with chronic lymphocytic leukemia compared to the control group (p < 0.0001 for both cytokines). No differences in angiogenic factors were noted between subgroups with low vs. intermediate vs. high-risk stage according to modified Rai staging or males vs. females. In twelve patients who achieved at least partial response after intensive fludarabine-based treatment, levels of bFGF as well as VEGF decreased significantly (bFGF, p = 0.0005; VEGF, p = 0.0068); in addition, they were no more significantly different from controls (bFGF, p = 0.524; VEGF, p = 0.728). Our data showed that key angiogenic activators bFGF and VEGF were elevated in plasma ofCLL patients. Furthemore, treatment with intensive fludarabine-containing regimens resulted in significant decrease of both cytokines. These data suggest that angiogenic cytokines may indeed play a significant role in CLL biology and that treatment with combination of fludarabine, cyclophosphamide +/- rituximab may exhibit antiangiogenic properties. Further studies with longer follow-up are necessary for evaluation of a possible association between angiogenic markers and progression-free survival or overall survival.

Differences in ulcer location in diabetic foot syndrome

Abstract: UNLABELLED The foot ulcerations are among the most debilitating complications in diabetic patients. The main risk factors leading to the ulcer development are diabetic neuropathy (sensoric, autonomic), limb ischemia (angiopathy), limited joint mobility and teh plantar pressure; the infection plays a role in difficulty of ulcer healing. The aim of our study was to assess the possible differences in location of diabetic ulcers with regard to their origin. In 502 patients during 5 year interval 835 new diabetic ulcers were diagnosed. METHODS Ulcers were divided into 3 groups according to their origin: neuropathic, neuroischemic and ischemic. RESULTS In the neuropathic group most ulcers were found in the plantar surface of toes (40.4%) and in the plantar metatarsal heads region (39.1%); in contrast, the ischemic group had the most frequent location in the toe tips (63.6%), while the neuroischemic group had most ulcers distributed in both plantar surface and tips of the toes (51.8%). The ulcer distribution was statistically significant different in all groups and depended on the etiology of ulcers (p < 0.0001; Fisher's exact test, modification Monte Carlo). Totally more than 75% of all ulcer were located in the toe and forefoot area. The patients in the neuroischaemic group had more often revascularisation procedures. The patients in ischaemic group were more often after high amputation. These patients had always less microvascular diabetic complication (all p < 0.01; ANOVA chi2). CONCLUSION The location of diabetic foot ulcers differs significantly according to their cause. In addition more than 75% of all ulcerations were localisated in toes and forefoot area. This fact could change focus of the preventive strategy in the diabetic foot.

[Serum level of retinol-binding protein 4 in obese patients with insulin resistance and in patients with type 2 diabetes treated with metformin].

Abstract: OBJECTIVE Is there a difference between the retinol-binding protein 4 (RBP4) levels in obese patients with insulin resistance (IR) without diabetes, in obese patients with type 2 diabetes mellitus (DM2T) treated with metformin and in nonobese healthy individuals? METHOD 28 obese individuals with insulin resistance, 11 type 2 diabetes patients treated with metformin and 17 control individuals were examined for serum level of retinol-binding protein 4 using the RIA method. The results were compared within the groups and RBP4 was correlated with insulin in the IR group and the control group. OUTCOME The highest and the lowest RBP4 levels (561.6 +/- 209 ng/ml) were recorded, respectively, for obese individuals with IR (IR HOMA 3.9) and for obese type 2 diabetics treated with metformin (391.1 +/- 133,5 ng/ml) (P < 0.01). The RBP4 level of the control group was significantly lower as compared with the obese individuals with IR (452.8 +/- 104.6 ng/ml) (P < 0.05), but insignificantly higher as compared with the obese individuals with DM2T treated with metformin (391,1 +/- 133.5 ng/ml). RBP4 in the monitored group correlated with insulin r = 0.46 (p < 0.03). CONCLUSION The increase in RBP4 in obese individuals by GLUT4 regulation in adipocytes contributes to the development and aggravation of systemic IR. Through its effect on RBP4 expression in adipocytes, metformin may improve total insulin sensitivity in obese individuals including those with MS and delay the onset of manifest DM. RBP4 could by used as a marker of deteriorating glucose tolerance in obese individuals.

The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study

Abstract: Abdominal obesity represents an independent risk factor for subsequent severe cardiovascular events. It is one of the important diagnostic criteria for Metabolic Syndrome whose predictive value for severe cardiovascular events is similar to that of elevated LDL-cholesterol levels. The prevalence of abdominal obesity in the context of Metabolic Syndrome still has not been systematically monitored in Slovakia. The IDEA program evaluated a sample of 4183 patients in 103 centres in Slovakia. It has shown that only one in three adult inhabitants of Slovakia has a normal body weight. Almost every second inhabitant of Slovakia has intraabdominal obesity (by ATP III criteria). Obesity was recorded in every third woman (34.7 %) and in every fourth man (27.0 %). The prevalence of the principal risk factors (hypertension, hyperlipoproteinemia and diabetes mellitus) grew in proportion to the increase in waist circumference.

Olfaction and gustation in diabetes

Abstract: Dysfunction of olfactory and gustatory functions can occur in diabetes. Gustatory dysfunction correlates with specific complications of diabetes. Olfactory dysfunction correlates with diabetic macronagiopathy. Gustatory sweating is the most important olfactory and gustatory dysfunction in diabetes. Pathology of olfaction and gustation can play a role in the pathogenesis of diabetes and its complications. Olfaction and gustation could be also a target of diabetes therapy in the future.

Adiponectin and atherosclerosis

Abstract: Obesity combined with other components of the insulin resistance syndrome is an important risk factor for atherosclerosis and its complications. The exact mechanisms through which the above diseases are linked have not yet been fully elucidated. One of the possible links may be a disturbance of the endocrine function of the adipose tissue of obese persons which produces an increased amount of proinflammatory and proatherogenic hormones and a lower amount of factors protecting against such pathologies. Adiponectin is the only hormone produced by the adipose tissue with a proven antiinflammatory and antiatherosclerotic effect. This hormone is predominantly produced by adipocytes and its concentrations are decreased in patients with obesity, insulin resistance and atherosclerosis. The objective of the article is to summarize current experimental and clinical knowledge of the links between adiponectin and atherosclerosis and to discuss possible utilization of adiponectin as a marker for atherosclerosis, and the potential for its exploitation in the prevention and/or treatment of atherosclerosis.

Pathogenesis of diabetic retinopathy

Abstract: Diabetic retinopathy (DR) develops in patients with both type 1 and type 2 diabetes and is the major cause of vision loss and blindness in the working population. The main risk factor of DR is hyperglycemia accompanied by enhanced mitochondrial production of reactive oxygen species and oxidative stress, formation of advanced glycation end products (AGE) and hexosamines, increased polyol metabolism of glucose. The severity of vascular injury depends on the individual genetic background and is modified by other metabolic and haemodynamic factors influencing numbers of intracellular signalling molecules such as PKC, MAPK or NF-kappaB. In diabetes, damage to the retina occurs in the vasculature (endothelial cells and pericytes), neurons and glia, pigment epithelial cells and infiltrating immunocompetent cells: monocytes, granulocytes, lymfocytes. These activated cells change the production pattern of a number of mediators such as growth factors, vasoactive agents, coagulation factors and adhesion molecules resulting in increased blood flow, increased capillary permeability, proliferation of extracellular matrix and thickening of basal membranes, altered cell turnover (apoptosis, proliferation, hypertrophy), procoagulant and proaggregant patterns, and finally in angiogenesis and tissue remodelling. The insights into pathophysiological mechanisms responsible for DR that are presented here could help in the development of a more targeted approach to its prevention and treatment.

Pulmonary hypertension in Takayasu arteritis

Abstract: Takayasu arteritis (TA) is a rare chronic vasculitis primarily involving the aorta and its main branches. The disease affects women much more frequently than men, the ratio being 8:1. The onset occurs in the teenage years, always before age of 40. Aortic regurgitation is rare. The pulmonary artery stenosis may also rarely occur. We report the case of a 49-year old female patient with Takayasu arteritis who presented with severe left pulmonary trunk stenosis resulting in pulmonary hypertension, severe aortic regurgitation due to the dilatation of the ascending aorta, mitral insufficiency, critical left renal artery stenosis, and probably with left main coronary artery stenosis. No severe stenosis or occlusion in the mid portion of mid subclavian artery lesion were present. Because the patient presented with serious congestive heart failure, she underwent mitral valvuloplasty and aortic valve replacement. However, the patient died in early postoperative period due to pulmonary hypertension which failed to respond to pharmacotherapy.

Surgical treatment of diabetic retinopathy

Abstract: Laser treatment is effective for diabetic macular oedema and proliferative diabetic retinopathy. In focal diabetic macular oedema, laser coagulation of the microaneurisms prevents the leakage of liquid through their walls. In diffuse macular oedema, laser photocoagulation not only destroys the microaneurisms but probably also hereby causes stimulation of proliferation activity of endothelial cells in retinal capillaries and veins. For some patients with diabetic retinopathy there is a progression of retinal findings and complications arise that require surgery within the eye - pars plana vitrectomy (PPV). In general PPV is indicated in diabetic retinopathy in the following cases: vitreous opacity, traction disorders.

The impact of statin therapy on bone density changes in postmenopausal women

Abstract: Generalised use of statins in primary and secondary prevention of ischemic heart disease has led in recent years to the discovery ofa number of other "pleiotropic" effects ofstatins. One of them is the effect ofstatins on bone metabolism. The objective of the study was to monitor bone density, bone turnover markers and basic biochemical parameters in a group of postmenopausal women at regular intervals for a period of 2 years. The monitoring allowed for an assessment of the effect of statin therapy on those parameters. Statin therapy safety was also monitored. According to expectations, the group receiving active treatment recorded a decrease in the levels of total cholesterol, as well as LDL-cholesterol, and a mild decrease in the level of triacylglycerols. However, no significant difference in bone density in any of the measured regions (NECK, TROCH, SHAFT) was found when the trends in bone density parameters were compared for the two groups, nor there was a significant change in the respective T-scores. There was no significant difference with respect to the markers of bone formation or the markers of bone resorption between the group with active treatment and the control group. The results correspond to inconsistent data from the performed and quoted retrospective and prospective studies.

Tinnitus and diabetes

Abstract: Tinnitus is the perception of sound in the absence of corresponding external sound(s). Tinnitus can be perceived in one or both ears or in the head. It is usually described as an unpleasant noise, but in some patients it takes the form of a ringing, buzzing, hissing, humming, or whistling sound, or as ticking, clicking, roaring, tunes, songs, or beeping. It is estimated that 1 out of every 5 people experience some degree of tinnitus. Tinnitus is not itself a disease but an unwelcome symptom. It can be accompanied by audiometric evidence of deafness which occurs in association with both conductive and sensorineural hearing loss resulting from a range of underlying causes, including ear infections, foreign objects orwax in the ear, and injury from loud noises. Tinnitus is also a side-effect of some metabolic disorders, medications, and may also result from an abnormally low level of serotonin or high level of insulin. As mentioned above, some foods are found by some people to make their tinnitus worse. The inner ear, like the brain, is totally lacking in energy reserves. Its metabolism depends directly on the supply of oxygen and glucose from the blood supply. Alterations in glucose metabolism therefore have great potential for disturbing the workings of the inner ear. Because tinnitus is often defined as a subjective phenomenon, it is difficult to measure using objective tests. Although there is no specific cure for tinnitus, those affected can learn techniques to successfully manage their tinnitus to the point where it is no longer a problem for them.

[The position of neoadjuvant chemotherapy in the treatment of non-small-cell lung carcinoma].

Abstract: Surgical treatment of patients with non-small-cell lung carcinoma (NSCLC) offers greatest chances for long-term survival. However, the treatment is applicable only to patients diagnosed at an early stage of the disease, i.e. at stage I or II. The five year survival rate of patients operated at stage IIIA is as low as 23%. Hence there is a great need for improving survival results, especially in the sphere of systemic chemotherapy, as most tumour relapses involve the formation of metastases. Even though neoadjuvant chemotherapy in the operable stages of NSCLC still appeared very promising as a method of treatment a couple of years ago, recently published results have shown that its role has not yet been fully clarified and is still a subject of research. Additional results from randomised studies are necessary before neoadjuvant therapy may become a treatment standard. The dilemma as to whether or not to apply adjuvant, neoadjuvant or both types of chemotherapy in patients operated on for NSCLC therefore remains unsolved. On the whole, the positive role of neoadjuvant chemotherapy does not appear to be proven in the treatment of operable stage I and II NSCLS. In contrast, results of randomised studies first published in 2004 were in favour of post-surgical adjuvant chemotherapy as opposed to surgical treatment alone in NSCLC stage IB, II and IIIA. The question of whether it is better to apply chemotherapy prior to or after surgery can only be answered by the extensive randomised studies underway. The role of neoadjuvant chemotherapy in patients with NSCLC at clinical stage IIIA remains uncertain. The most rational approach to such patients appears to be neoadjuvant chemotherapy or chemotherapy with subsequent surgery.

The etiology of upper gastrointestinal bleeding in patients with liver cirrhosis

Abstract: 108 patients suffering from the cirrhosis of the liver and acute bleeding into the upper digestive tract underwent a prospective endoscopic examination with diagnostic and therapeutic objectives. The most frequent causes of acute bleeding included oesophagus varices (57.4%) followed by peptic gastric ulcer (13.9%) and peptic ulcer of duodenum (11.1%), then portal hypertension gastropathy (5.6%), gastric varices (4.6%), reflux oesophagitis (2.8%), Mallory-Weiss syndrom (2.8%) and erosive gastropathy (0.9%). The endoscopy of the upper digestive tract in one patient resulted in negative diagnosis. 69% of examinations showed multiple findings in the upper digestive tract, each of which could have been a potential cause of bleeding. To determine the source of bleeding the specialist's attitude presented at the end of the endoscopic examination was taken into consideration. In 67.6% of patients the bleeding was a direct consequence of portal hypertension, in 62% it was caused by varices. The emphasis is put on early and thorough endoscopic examinations aimed at proper diagnosis and therapy.

[The treatment of hyperglycaemia in critically ill patients: comparison of standard protocol and computer algorithm].

Abstract: INTRODUCTION Hyperglycemia is commonly observed in patients hospitalized on intensive care units. It is has been demonstrated that normalization of blood glucose level using intensive insulin therapy significantly improves prognosis of these patients. The aim of our study was comparison of standard protocol of intensive insulin therapy used on cardiac surgery ICU in General University Hospital in Prague and computer algorithm MPC (Model Predictive Control). PATIENTS AND METHODS 20 patients with glycaemia higher than 6.7 mmol/l at the time of admission to ICU were included into the study, 10 subjects were randomized for standard treatment, 10 for treatment with MPC algorithm. Glycaemia was measured hourly during 48 hours, insulin infusion was rate was adjusted hourly in MPC algorithm or in 1-2 hours in standard protocol group. RESULTS Blood glucose levels were in the target range significantly longer in MPC relative to standard protocol group (26.3 +/- 2.1 hrs vs 20.3 +/- 2.5 hrs). Mean blood glucose was also lower using MPC algorithm (6.47 +/- 0.11 vs 6.72 +/- 0.23 mmol/l). On the contrary the target range was established faster using standard protocol (8.9 +/- 1.2 vs 10.3 +/- 0.9 hrs), duration of hyperglycaemia was the same in both groups (7.3 +/- 1.9 in standard protocol vs 7.3 +/- 1.3 hrs in MPC algorithm). Average 48-hours insulin dose was higher in MPC than standard protocol group (230.2 +/- 38.8 vs 199.1 +/- 27.8 IU/48 hrs). 2 hypoglycaemic episodes occured in 2 patients in standard protocol group. CONCLUSIONS Our results show that the use of MPC algorithm result in more effective blood glucose control in critically ill patients than standard protocol.

[Diagnostic and therapeutic procedures in pheochromocytoma: current trends].

Abstract: Pheochromacytoma is a relatively rare cause of arterial hypertension. Untreated pheochromacytoma may however lead to a fatal hypertensive crisis during anaesthesia or another form of stress. It is therefore important to correctly diagnose this disease. 24-hour monitoring of blood pressure (BP) can already contribute to the diagnosis of pheochromacytoma based on the frequent occurrence of BP variability and the absence of a night-time fall in BP. 5 gene mutations have so far been identified that may be responsible for the familial form of pheochromacytoma: mutation of the von Hippel-Lindau (VHL) gene, leading to the onset of VHL syndrome, mutation of the RET-proto-oncogene in multiple endocrine adenomatosis type 2, mutation of the type 1 gene for neurofibromatosis, which is associated with von Recklinghausen's disease and finally mutation of the genes encoding the B and D subunits of succinated hydrogenase (SDHB, SDHD), which are associated with familial paragangliomas and pheochromacytoma. Genetic analysis should therefore be carried out for all confirmed cases of pheochromacytoma, especially for young people under 50 years of age. Biochemical diagnostics relies mainly on measurements of free metanephrines in plasma or urine, which usually has greater diagnostic weight than plasma, or catecholamines in urine. The diagnosis of extraadrenal or multiple forms can use not only CT/MR but also imaging using the radiopharmaceutical 123I-Metaiodobenzylguanidine (MIBG) or 18F-fluorodopamine PET (only available in the USA). Pharmacological treatment using alpha or beta receptor blockers with subsequent laparoscopic excision of the tumor is usually successful in benign forms of pheochromocytoma. Unfortunately, there are still no convincingly effective therapeutic procedures available for malign forms.

Epilepsy and disorders of reproduction

Abstract: Epilepsy in women is relatively often linked with reproductive disorders which include polycystic ovarian syndrome, hypothalamic amenorrhea and functional hyperprolactinaemia. These disorders have a significant share in a high incidence of infertility and premature menopause while the polycystic ovarian syndrome, also manifested by the metabolic syndrome, places the affected patients at risk of later consequences such as type 2 diabetes mellitus, cardiovascular diseases including arterial hypertension, gynaecological neoplasias (the breast and the endometrium), and in the case of pregnancy, a higher incidence of pregnancy induced hypertension. Apart from epilepsy as such, also antiepileptic treatment may have negative impact on the female's reproductive functions. In many cases, adverse effects of treatment complicate the patient's life more than the attacks alone. Medication induced weight gain might be responsible for different endocrine diseases (menstruation disorders, polycystic ovarian syndrome, hyperandrogenism). The article analyses the influence of side effects of the different antiepileptic drugs on the development of metabolic and endocrine anomalies. The role of antiepileptic drugs in the development of reproductive and endocrine disorders was first described by Isojarvim in 1993. A high incidence of polycystic ovarian syndrome and/or hyperandrogenism (43%) was observed in women taking valproat, which was clearly higher than in women taking other antiepileptics. Results reported in literature are rather controversial. The article gives an overview of current knowledge with respect to the influence of epilepsy and antiepileptics on the incidence ofpolycystic ovarian syndrome, which is considerably higher in women with epilepsy (10-25%) than in the unaffected population (4-7%), and of the related metabolic syndrome. The article concludes with recommendations for clinical practice in the treatment of epilepsy in women in reproductive age.

Infection and atherosclerosis

Abstract: Atherosclerosis is a chronic inflammation and the cause of most cardiovascular diseases. It is the main cause of death in the Western world today, even though growing incidence of atherosclerosis-related diseases has been recently observed in developing countries, too. In many patients with atherosclerosis, however, traditional risk factors for atherosclerosis are not identifiable. This has renewed the interest, in recent years, in the links between atherosclerosis and environmental exposures, including infectious agents. Infection was identified as as risk factor for atherosclerosis in the first half of the 20th century. Experimental and clinical studies have shown that infection can stimulate atherogenic processes and that there are significant interactions between infection and traditional risk factors. Yet there are questions concerning etiology, pathogenesis and appropriate interventions which remain unanswered. The following article provides an overview of the role of the infectious agents in atherosclerosis and discusses possible intervention strategies.

[The influence of long-term therapy with the insulin pump (CSII) in patients with type 1 diabetes mellitus on metabolic compensation and on the incidence of hypoglycaemia. Comparison with intensified conventional insulin therapy (MDI)].

Abstract: UNLABELLED The principal objective of this paper is to verify, in clinical practice, the long-term affect (7 to 8 year follow up) and safety of insulin pump treatment in type 1 diabetes mellitus patients and to compare the results for diabetes compensation in patients treated with the insulin pump with a control group of patients treated with intensified insulin therapy using the MDI (multiple daily injection) method. PATIENT SAMPLE AND METHOD We followed up 35 patients treated with the insulin pump and 35 patients in the control group. We evaluated the monitored parameters for both patient groups at the beginning and at the end of the follow up period. With respect to glycated haemoglobin, we evaluated the results on a yearly basis, and also on year by year changes. We assessed the incidence of hypoglycaemia in both groups on a yearly basis. The following aspects were considered in order to determine the level of statistical significance of the different parameters: (1) we compared the initial state with that seen at the end of the follow up, (2) we analysed the year by year changes in glycated haemoglobin, (3) we compared the patients treated with the insulin pump with those in the control group. Diabetes compensation was evaluated on the basis of measurement of glycated haemoglobin and calculation of glycaemia. Comparison of the incidence of hypoglycaemia was done for all hypoglycemic events and then separately for severe hypoglycaemia. Also evaluated were changes in weight and in insulin dose in 24 hours. RESULTS The group of patients treated with the insulin pump recorded a dramatic decrease in glycated haemoglobin in the course of the follow up, p 0.05, as compared with the initial state. In this group of patients, no significant improvement in average glycaemia, p > 0.05, was recorded when compared with the initial state. Comparison ofthe two groups of patients showed that HbA(1c), p 0.05, but a statistically significant difference was recorded in average glycaemia, p 0.05. No statistically significant difference between the two groups was recorded in the incidence of all hypoglycaemic episodes from the beginning of the follow up to its end, p > 0.05. In both groups of patients, a statistically significant gain in weight was seen from the beginning of the study to the end of the follow up period, however, its statistical significance was lower (p 0.05). CONCLUSION In the course of the follow up, we proved that treatment with the insulin pump in type 1 diabetes is more beneficial to patients than MDI treatment. This was reflected by both better compensation of diabetes and a lower incidence of severe hypoglycaemic episodes.

Endoscopic findings in upper gastrointestinal tract in patients with liver cirrhosis

Abstract: 151 patients suffering from the cirrhosis of the liver underwent a prospective endoscopic examination of the upper digestive tract. The most frequent diagnoses in the group with the cirrhosis of the liver included oesophagus varices (64.9%), portal hypertension gastropathy (45.7%) and the peptic ulcer of the gastroduodenum (25.8%). A normal diagnosis in the endoscopy of the upper digestive tract was found only in 8.6%. Other diagnoses comprised reflux oesophagitis (13.2%), diaphragm hiatus hernia (12.6 %), duodenogastric reflux (8.6 %), gastric antrum erosion (4.6 %), aphthic gastropathy (3.3 %), rhagades of the cardium (2%), gastric polyp (1.3%), mycotic oesophagitis, gastric carcinoma, oesophagus carcinoma and oesophagus achalasy (0.7% each). Further on the study discusses possible causes of the high incidence of peptic ulcers in the patients with the cirrhosis of the liver. All findings are correlated with literary data.

Cortisol levels are more closely associated with depressiveness and other psychopathologies than catecholamine levels

Abstract: OBJECTIVE Quantification of changes in the levels of the above hormones, ie cortisol, adrenalin, noradrenalin and dopamine depending on the presence of depressive symptoms and other psychopathological symptoms SAMPLE 259 randomly selected individuals from the population of the city of Pilsen METHOD Zung self-assessment scale and SCL-90 questionnaire were used to assess depressiveness and other psychopathologies Serum cortisol levels were measured, as well as the levels ofcortisol and catecholamine (adrenalin, noradrenalin and dopamine) in a 24-hour urine sample The studied sample was divided, by an arbitrarily defined limit, into a group with a higher and a group with a lower excretion of the monitored hormones RESULTS The group with cortisol excretion higher than 300 nmol/24 h had a significantly higher score in terms of the SCL-90 questionnaire interpersonal sensitiveness, depression, anxiety, phobia, paranoidism and psychoticism as compared with the group with cortisol excretion below 300 nmol/24 h (p or = 50) has shown that women with a record of depressive symptoms had a statistically significant higher of urinary cortisol excretion in 24 hours (average 21940 as compared with 19164 nmol/24 h, respectively, p = 002) The group of men with depressive symptoms according to the score obtained on Zung self-assessment scale only showed a trend towards higher urinary noradrenalin excretion in 24 hours (average of 6977 as compared with 6384 microg/24 h, p = 017) CONCLUSION As shown by the above results, there is a link between 24-hour urinary cortisol excretion levels and the monitored parameters of psychic condition

Defining the level of physical activity for a diabetic who is obese

Abstract: Physical activity plays an important role in the treatment of metabolic syndrome and/or type 2 diabetes or obesity. Less than 20% of the adult population does physical exercise at least twice a week. The effectiveness of physical exercise depends on paying attention to the following parameters: the frequency, the intensity and the duration. The most difficult parameter to set for patients with obesity or metabolic syndrome is the optimum intensity of exercise. The most common means of measuring the intensity of physical activity is heart rate or pulse rate. With patients who take medicines that affect their heart rate, the Borg scale is used to give a subjective rating of perceived exertion. To set optimal intensity it is necessary to use exertion tests with these patients. The most accurate setting is a suitable combination of spiroergometry and a CHR (clamped heart rate) test. In practice, though, it is usually enough to combine ergometry together with the Borg scale. Tracking exertion parameters during exercise improves patient compliance and also the results of exercise.

[The MIAC (malnutrition, inflammation, atherosclerosis, calcification) syndrome].

Abstract: The number of patients with chronic renal failure is on the rise; these patients have a 10 to 20 times higher risk of development and progression of cardiovascular diseases. Higher cardiovascular risk in such patients cannot be satisfactorily explained by traditional risk factors defined in the Framingham study. On the contrary, a concept of reverse epidemiology has been brought forward, designating a situation in which the incidence of obesity and hyperlipoproteinemia is associated with a higher survival rate of the patients concerned. Higher risk is today explained by the "MIAC (malnutrition, inflammation, atherosclerosis, calcification) syndrome", which is present in patients with chronic kidney disease. New evidence has been recently obtained of different circulating molecules associated with atherosclerosis, the plasmatic levels of which are decreased or increased in such patients and which are in a way linked with the MIAC syndrome and the progression of atherosclerosis. Clinical management of the syndrome could increase survival in the future, and reduce morbidity and the number of hospitalisations. Circulating molecules could serve as markers evidencing the presence of the syndrome and its severity, as well as the success of treatment.

[Celiac disease--a frequent cause of "idiopathic osteoporosis" in premenopausal and early postmenopausal women].

Abstract: INTRODUCTION Celiac disease (CD) is an autoimmune disease with a wide variety of clinical symptoms. Osteopathy is its possible manifestation in adulthood. OBJECTIVE Verify the assumption, in view of contradictory literary data concerning serological screening for CD in osteoporosis, that the screened group could be women with idiopathic osteoporosis diagnosed in premenopause or within 5 years from its onset. PATIENT SAMPLE AND RESULTS: We examined 52 patients with idiopathic osteoporosis detected by a DXA test of LS or the femur in premenopause or within the maximum of 5 years after menopause for the presence of antibodies against gliadins IgA, IgG, endomyzium IgA and transglutaminase IgG. In the case of positive results for any of the antibodies, we also performed gastrofibroscopy and duodenal biopsy. The positivity of antibodies was detected in 21 patients (40.8%). In 15 (28.8%) patients, i.e. after the exclusion of Marsh I in 10 patients (19.8%), histopathology was positive for CD. Significantly higher levels of iPTH (p < 0.001) were detected in patients with CD. We did not find any statistically significant differences in other monitored parameters, i.e. in BMI, S-Ca, S-P, proteins, albumins, immunoglobins IgG, IgA, IgM, dUCa. The differences in the occurrence of prevalent fracture (33.4 or 19.8%), autoimmune thyreoiditis (20% or 5.4%), anemia (33% or 16.2%) and dyspepsia (40% or 24.3%) were not significant. CONCLUSION The above results confirm the need for serological screening for CD in premenopausal and early postmenopausal patients with "idiopathic osteoporosis".

[Hashimoto's encepahlopthy--a rare and unusual syndrome].

Abstract: Hashimoto's encephalopathy (HE) is a brain disease associated with autoimmune thyroid disease. Over 100 articles have been published on the topic, especially in connection with hypothyroidism. In addition to an overview of the relevant literature, we also report a case of a female patient with a rare association of HE with thyreotoxicosis. The patient presented with varied clinical-neurological symptoms: she had convulsions, psychotic symptoms, altered consciousness Examinations (laboratory tests, CT, MRI, EEG, CSL exams) detected increased level of proteins in the liquor, episodes of rhythmic delta activity on EEG, increased antithyreoidal antibody titre (TOOab, TGAb, TRAb) in serum. After initial treatment with carbimazole and hydrocortizone, the patient's condition dramatically improved and she was disconnected from artificial lung ventilation, conscious and convulsion-free. During the following 30 days, the patient would get worse after attempts to withdraw glucocorticoids. In spite of thyreotoxicosis, we classified the condition as HE and the patient was fully stabilised after pulse treatment with methylprednisolone. Clinically, the patient was subject to further outpatient follow up, without symptoms of encephalopathy; glucocorticoids were gradually withdrawn and were discontinued completely after another four months. The authors conclude that HE, even though rare, may pass unnoticed due to its symptoms which are similar to many other and more frequent diseases. HE should be considered in patients with potential or known autoimmune thyroidism and atypical neuropsychiatric manifestation responding to corticoid treatment.

Czech Atherosclerosis Society Guidelines for the diagnosis and treatment of dyslipidemias in adults

Abstract: The present guidelines are based on the recommendations published in 2005 entitled "Prevention of Cardiovascular Diseases in Adulthood" summarizing the conclusions of nine Czech medical societies and agree with them in the assessment of individual risks of mortality from cardiovascular disease (CVD) according to SCORE tables. They reflect new research data in pathophysiology of dyslipidemias (DLP) and particularly the results of recent clinical trials of lipid-lowering therapy and their meta-analyses. They establish priorities for the screening and management of DLP, present suitable diagnostic methods, additional investigations of potential use in risk assessment, including some emerging risk factors and detection of sub-clinical atherosclerosis in persons in a moderate-risk category. Major changes include a lower LDL-cholesterol treatment target (< 2.0 mmol/L for all CVD individuals) and a possible use of apolipoprotein B as a secondary target in selected persons (< 0.9 g/L in high risk without CVD, < 0.8 g/L for CVD patients) and nonHDL-cholesterol (< 3.3 mmol/L in high risk without CVD, < 2.8 mmol/L for CVD patients). Therapy of individual DLP phenotypes (monotherapy and combination therapy) as well as basic principles for control examination at lipid-lowering medication are described. Recommended therapeutic lifestyle changes are shown. Enclosed are five annexes: DLP diagnosis; causes of secondary DLP; additional investigations of potential use in risk stratification; familial hypercholesterolemia; list of recommended foods; two variants of SCORE tables for risk assessment for the Czech Republic; the scheme of recommended procedures and treatment algorithm in DLP asymptomatic individuals.