[What has the largest study in the history of diabetology brought us?]. / Co nám prinesla nejvetsí studie v historii diabetologie?

UNLABELLED: The main objective of the ORIGIN study was an observation of the effects of treatment with insulin analogue, insulin glargine on cardiovascular complications in patients with severe atherosclerosis and early stages of well-compensated diabetes and prediabetes. The authors expected that a long-term reduction of glycaemia on an empty stomach will reduce the number of occurrences of cardiovascular complications. The study, which was conducted over a period of more than six years, showed neither a positive nor a negative effect of insulin treatment on cardiovascular complications. The second main objective of the study was the following: to compare the effect of the omega-3 fatty acid treatment versus placebo on the development of cardiovascular complications. However, no influence of n-3 fatty acids on the development of cardiovascular complications was found. The study investigated whether the insulin glargine treatment leads to an increased number of cancer occurrences. No correlation between cancer and the insulin glargine treatment was proven in this study. Long-term insulin treatment in the early stages of diabetes led to a minimal increase in weight through the course of six years (1.5 kg) and to three times more hypoglycaemia occurrences compared to placebo. However, the number of hypoglycaemia occurrences was very small. CONCLUSION: The study has confirmed the safety of the insulin glargine treatment combined with metformin in the early stages of diabetes, without an increased number of atherosclerosis or cancer occurrences, and with minimal weight gain.

Voiding difficulties after vaginal mesh cystocele repair: does the perivesical dissection matter?

INTRODUCTION AND HYPOTHESIS: Our purpose was to verify whether extensive dissection toward the sacrospinous ligament (SSL) needed for mesh fixation during anterior compartment repair increases the risk of postoperative voiding difficulties. METHODS: A total of 124 patients after anterior compartment mesh repair without simultaneous suburethral sling placement operated on in the period 2005-2012 were enrolled in this retrospective observational study. Patients with previous anti-incontinence surgery with normal urodynamics were not excluded; 30 patients with incomplete data, severe perioperative complications, and urinary retention before and after the surgery were excluded. Urinary retention was defined as post-void residual over 150 ml more than 48 h after permanent catheter removal. The rate of urinary retention after anterior compartment repair by mesh anchored to the SSL from an anterior approach (SSLS group) was compared to that following transobturator mesh repair often combined with SSL fixation from the posterior approach (TOT group). RESULTS: Of the 94 patients considered for statistical analysis, 62 were from the SLSS group and 32 from the TOT group. The groups were comparable in age (mean 65.5 vs 66.3), body mass index (24.8 vs 25.9), and parity (2.4 vs 2.9). Patients from the SSLS group had higher rates of prior vaginal reconstructive (27 vs 19 %) and anti-incontinence surgery (26 vs 19 %). Postoperative urinary retention was statistically significantly more frequent in the SSLS group compared to the TOT group [(17 (27 %) vs 2 (6.25 %), odds ratio 5.7, 95 % confidence interval 1.2-26.3, p = 0.027]. Hospital discharge with self-catheterization was statistically insignificantly more frequent in the SSLS group [8 % (5) vs 3 % (1)]. CONCLUSIONS: Extensive dissection needed for SSL suspension from an anterior approach may lead to more frequent postoperative voiding difficulties. This phenomenon could be explained by more considerable injury to pelvic splanchnic nerves during the dissection. A large prospective study is needed for validation of our results.

[Unusual cause of foot defect in patient with diabetes mellitus]. / Neobvyklá prícina defektu nohy u nemocného s diabetes mellitus.

Foot complications are one of the most serious and costly complications of diabetes mellitus. Amputation of a part of a lower extremity is usually preceded by a foot ulcer. There have been also other not so typical causes of foot defect. The paper describe a history of a male diabetic patient with an atypical course of the foot defect.

The relationship between glycemia, insulin and oxidative stress in hereditary hypertriglyceridemic rat.

The aim of this study was to determine the effects of insulin infusion on oxidative stress induced by acute changes in glycemia in non-stressed hereditary hypertriglyceridemic rats (hHTG) and Wistar (control) rats. Rats were treated with glucose and either insulin or normal saline infusion for 3 hours followed by 90 min of hyperglycemic (12 mmol/l) and 90 min of euglycemic (6 mmol/l) clamp. Levels of total glutathione (GSH), oxidized glutathione (GSSG) and total antioxidant capacity (AOC) were determined to assess oxidative stress. In steady states of each clamp, glucose infusion rate (GIR) was calculated for evaluation of insulin sensitivity. GIR (mg.kg(-1).min(-1)) was significantly lower in hHTG in comparison with Wistar rats; 25.46 (23.41 - 28.45) vs. 36.30 (27.49 - 50.42) on glycemia 6 mmol/l and 57.18 (50.78 - 60.63) vs. 68.00 (63.61 - 85.92) on glycemia 12 mmol/l. GSH/GSSG ratios were significantly higher in hHTG rats at basal conditions. Further results showed that, unlike in Wistar rats, insulin infusion significantly increases GSH/GSSG ratios in hHTG rats: 10.02 (9.90 - 11.42) vs. 6.01 (5.83 - 6.43) on glycemia 6 mmol/l and 7.42 (7.15 - 7.89) vs. 6.16 (5.74 - 7.05) on glycemia 12 mmol/l. Insulin infusion thus positively influences GSH/GSSG ratio and that way reduces intracellular oxidative stress in insulin-resistant animals.

[Economic aspects of the diabetic foot syndrome]. / Ekonomický pohled na syndrom diabetické nohy.

UNLABELLED: The diabetic foot is one of the most expensive complications of diabetes mellitus. AIMS: To determine the direct costs of both inpatient and outpatient care of diabetic foot provided in Diabetic Centre University Hospital in Plzen. METHODS: 42 patients with diabetic ulcers (45% neuropathic, 26% ischaemic and 29% mixed) who have attended the podiatric surgery from January to June 2000 were randomly selected. SUBJECT CHARACTERISTICS: 4 patients with type 1 diabetes, 38 patients with type 2 diabetes, mean of age 63 years (37-81), mean of duration of diabetes 17 years (1-31), mean of duration of diabetic ulcers 37 months (1-168) ulcers. Patients visited Diabetic Centre 9 times (5-13). 23 hospitalizations occurred in 17 patients (40%) with mean of 14 days duration (3-42). The AP-DRG (all patients diagnosis related groups) model was used to determine the hospital direct costs. The ambulatory costs included the reimbursed care, drugs (local treatment, antibiotics and antiagregans), bandages, patient transport and home care. Antidiabetic drugs and insulin or antihypertensive drugs were not included. RESULTS: Total direct costs of diabetic foot care 42 patients were 1,440.600.-CK, 34.500.-CK (6.300.-CK-190.200.-CK)/patient in Diabetic Centre Plzen during 6 months. 37% of total costs (533.000.-CK), resp. 12.500.-CK (5.900.-CK -45.700.-CK)/patient represented ambulatory and 63% of total cost (907 600.-CK), resp. 53.700.-CK (18.000.CK-180.600.-CK)/patient hospital care.

[Treatment of diabetic neuropathic defect at the surgery department and at the center for diabetic foot care]. / Lécba diabetického defektu neuropatické etiologie na chirurgické klinice a v centru diabetické nohy.

UNLABELLED: The aim of the study was to evaluate the treatment of neuropathic diabetic ulcer at the surgery department and the treatment at the diabetic foot centre at dismissal time and 3 months after the dismissal. METHODS: For assessment of treatment success parameters of glucose control were used (average of daily blood glucose values, glycosylated haemoglobin--HbA1C and glycosylated protein), healing of ulcers (Wagner classification), hospitalisation time and number of amputations. 22 diabetic patients at the centre and 17 patients at the surgical department were observed in this investigation. There was no difference between the groups as for the age, glucose control (HbA1C), and severity of diabetic ulcers (Wagner 3-4). Local and antibiotic therapies were the same ones. Results as median and difference 75th and 25th percentile were evaluated by Wilcoxon test for paired data within the groups and by Man-Whitney test between both of the groups. RESULTS: In the both group the diabetic control and ulcer healing were significantly improved during hospitalisation period, 3 months after discharge deteriorate diabetic control and ulcer healing stagnated, however, only in the group treated at the surgical department. The hospitalisation time was significantly longer in the surgical group in comparison with the centre group [median 52 days (35)] vs. [median 31 days (38)], p < 0.01. Amount of transmetatarsal and higher amputations was lower at the foot centre in comparison with the surgical group (1 vs. 7). Statistical evaluation was not used for low amount of amputations. CONCLUSION: Team approach at the centre of diabetic foot is effective in the treatment of diabetic foot ulcers, significantly shortened the hospital stay, probably decrease amount of amputations. Three months after discharge the diabetic control and ulcer healing were significantly better in patients treated at the diabetic foot centre.

[Effect of composition of enteral nutrition on energy expenditure and CO2 production during periods of average and excessive energy intake]. / Vliv slození enterální výzivy na energetický výdej a produkci CO2 v období primereného a nadmerného prívodu energie.

UNLABELLED: The objective of the presented work is to evaluate to what extent the CO2 production and O2 utilization and energy metabolism at rest (REE) are influenced by an excessive nutrient intake and to what extent by the composition of enteral nutrition. REE, CO2 production and O2 utilization were investigated in 9 patients on complete enteral nutrition by indirect calorimetry in four modifications: I--nutrition with 40% kJ fat in a ration 1.2x the energy output at rest at the onset of the trial; II--40% kJ and high energy intake (2.4x energy output at rest; III--60% kJ fat in ration of 1.2x energy output at rest; IV--60% kJ fat and energy intake 2.4x energy output at rest. At 40% (I) and 60% (III) fat content in a caloriocally adequate diet the energy output at rest, the CO2 production and O2 utilization did not differ (mean +/- SD: 1438 +/- 264.1 kcal/24 h, 179 +/- 31.6 nl/min, 209 +/- 38.1 ml/min vs. 1431 +/- 342.7, 190 +/- 54.2, 207 +/- 46.5). Comparison of modifications II and IV revealed a significant (p < 0.05) increase of CO2 production on a diet rich in carbohydrates (218 +/- 52.0 vs. 202 +/- 42.3). The energy output at rest (1674 +/- 389.6 vs. 1661 +/- 378.7), nor O2 production (240 +/- 54.5 vs. 242 +/- 55.4) changed. Overfeeding with 40% fat (II) as compared with (I) led to a rise of the energy output at rest (p < 0.05), O2 utilization (p < 0.05) and CO2 production (p < 0.01). Overfeeding with lipids (IV) led as compared with III to a rise of the energy output at rest and O2 utilization; CO2 production did not change. CONCLUSION: The composition of enteral nutrition according to the described modification does not influences the energy output at rest, O2 utilization and CO2 production under conditions of an adequate energy intake. In case of an excessive nutrient intake nutrition with 60% fat does not lead to an increase of CO2 production.

Hyperinsulinemia and oxidative stress.

The aim of the study was to compare the effect of short-term hyperglycemia and short-term hyperinsulinemia on parameters of oxidative stress in Wistar rats. Twenty male rats (aged 3 months, average weight 325 g) were tested by hyperinsulinemic clamp (100 IU/l) at two different glycemia levels (6 and 12 mmol/l). Further 20 rats were used as a control group infused with normal saline (instead of insulin) and 30 % glucose simultaneously. Measured parameters of oxidative stress were malondialdehyd (MDA), reduced glutathion (GSH) and total antioxidant capacity (AOC). AOC remained unchanged during hyperglycemia and hyperinsulinemia. Malondialdehyde (as a marker of lipid peroxidation) decreased significantly (p<0.05) during the euglycemic hyperinsulinemic clamp, and increased significantly during isolated hyperglycemia without hyperinsulinemia. Reduced glutathion decreased significantly (p<0.05) during hyperglycemia without hyperinsulinemia. These results suggest that the short-term exogenous hyperinsulinemia reduced the production of reactive oxygen species (ROS) during hyperglycemia in an animal model compared with the control group.

[Systemic amyloidosis with renal involvement]. / Povsechná amyloidóza s postizením ledvin.

Amyloidosis is a summary of a group of disorders of protein metabolism characterized by infiltration of amorphous substance into the tissues. The diagnosis can rarely be made during life. It is usually manifested by defects of the renale, cardiovascular or peripheral nervous system. Heterogenicity of clinical and histological classification of amyloidosis and clinical course in comparison with autopsy findings are presented by two cases of general amyloidosis--secondary amyloidosis of the kidneys and primary amyloidosis with a fatal prognosis.

[A vasoactive-intestinal-polypeptide producing tumor (VIPoma) as an uncommon cause of life-threatening hypokalemia]. / Nádor z bunek produkujících vazoaktivní intestinální polypeptid (VIPom) jako vzácná prícina zivot ohrozující hypokalémie.

The authors present a case of a 40-year-old female patient examined repeatedly in the course of 11 years and hospitalized on account of pain in the hypogastrium, subfebrile temperatures, watery diarrhoea, hypokaliaemic alkalosis, weakness, fatigue and loss of body weight. As to laboratory examinations hypokaliaemia, hyponatraemia, metabolic alkalosis, irregularly elevated CRP values and minor leucocytosis predominated. A weight loss of cca 8 kg along with a severe mineral deficiency and clinical symptomatology called for parenteral nutrition with a mean daily substitution of 240 mmol K and 200 mmol Na. Due to the clinical condition and non-specific results of graphic and histological examinations the possibility of a VIPoma was considered. This diagnosis was confirmed by laboratory examinations and clinically--after the onset of corticoid treatment marked improvement of the general condition occurred. Finally the authors discuss diagnostic and in particular therapeutic possibilities in this disease.