The value of PLA2R antigen and IgG subclass staining relative to anti-PLA2R seropositivity in the differential diagnosis of membranous nephropathy.

BACKGROUND: The diagnostic performance of PLA2R and IgG subclass staining of kidney biopsies relative to anti-PLA2R seropositivity in the differentiation of primary and secondary membranous nephropathy (pMN, sMN) was examined. Besides PLA2R staining - which has a lower specificity than anti-PLA2R antibody serology - there is insufficient knowledge to decide which IgG1-4 subtype immunohistological patterns (IgG4-dominance, IgG4-dominance/IgG1-IgG4-codominance or IgG4-dominance/IgG4-codominance with any IgG subtype) could be used to distinguish between pMN and sMN. METHODS: 87 consecutive Hungarian patients (84 Caucasians, 3 Romas) with the biopsy diagnosis of MN were classified clinically as pMN (n = 63) or sMN (n = 24). The PLA2R and IgG subclass staining was part of the diagnostic protocol. Anti-PLA2R antibodies were determined by an indirect immunofluorescence test in 74 patients with disease activity. RESULTS: For pMN, the sensitivity of anti-PLA2R seropositivity was 61.1%, and the specificity was 90.0%; and similar values for PLA2R staining were 81.0%, and 66.7%, respectively. In all stages of pMN, IgG4-dominance was the dominant subclass pattern, while the second most frequent was IgG3/IgG4-codominance. The sensitivity and specificity scores were: IgG4-dominance 52.2% and 91.7%, IgG4-dominance/IgG3-IgG4-codominance 76.2% and 87.5%, IgG4-dominance/IgG1-IgG4-codominance 64.2% and 75%, and IgG4-dominance/codominance with any IgG subclass 92.1% and 70.8%, respectively. Anti-PLA2R seropositivity, glomerular PLA2R, and IgG4-dominance/codominance significantly correlated with each other. The IgG4 subclass was rarely encountered in sMN. CONCLUSION: In our series, IgG4-dominance had the highest specificity in the differentiation of MN, just as high as that for anti-PLA2R seropositivity. The specificity values of PLA2R staining and IgG4-dominance/codominance with any IgG subclass or IgG4-dominance/IgG1-IgG4 codominance were ≤ 75%. Apart from IgG4 dominance, IgG4-dominance/IgG3-IgG4-codominance also had good statistical value in differentiating pMN from sMN. As IgG subclass switching during the progression of pMN was not the feature of our cohort, pMN in Hungarian patients is presumed to be an IgG4-related disorder right from the start. Although anti-PLA2R seropositivity has become the cornerstone for diagnosing pMN, if a kidney biopsy evaluation is conducted, besides the staining of PLA2R antigen, the evaluation of IgG subclasses provides relevant information for a differential diagnosis. Even in cases with IgG4-dominance, however, malignancy should be thoroughly checked.

May Measurement Month 2019: an analysis of blood pressure screening results from Hungary.

Cardiovascular diseases are not only the leading causes of mortality in Hungary but also the mortality rate is twice as high as the European Union average, so screening programmes identifying subjects with elevated blood pressure (BP) are of utmost importance. May Measurement Month (MMM) is an annual global initiative that began in 2017 aimed at raising awareness of high BP. Hungary joined the 3rd campaign of MMM in 2019 and an overview of the results are presented in this paper. An opportunistic cross-sectional survey of participants aged ≥18 years was carried out in May 2019. Hypertension was defined as systolic BP ≥140 mmHg and diastolic BP ≥90 mmHg or treatment for hypertension, statistical analysis followed the standard MMM protocol. In Hungary, 55 sites were set up in primary and secondary care facilities, in pharmacies, and in malls across all regions, in both cities and villages. Out of 2766 individuals screened, 1286 participants (46.5%) had hypertension. Out of 1869 participants not on antihypertensive medication, 389 (20.8%) had elevated BP. In the case of treated individuals (n = 897), 420 (46.8%) had uncontrolled hypertension. Almost every 2nd subject of the screened cohort had hypertension (treated and controlled, treated and uncontrolled, or untreated). In the untreated cohort, every 5th subject had elevated BP, whilst among patients on antihypertensive medication, every second had uncontrolled BP. By identifying almost one-third of the whole screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, our results confirm the importance of BP screening campaigns.

The effect of an exam period as a stress situation on baroreflex sensitivity among healthy university students.

Purpose: Authors investigated the effect of a university exam period on blood pressure (BP) and baroreflex-sensitivity (BRS) among healthy students.Materials and methods: Fifty-three healthy normotensive university students participated in the test. BP values and BRS were recorded once during a 14-week long semester and once during a 6-week long exam period with a Finometer device. The time-domain spontaneous BRS in lying position and after standing up was calculated with Nevrokard software. Students were divided into optimal, normal, high-normal and hypertension (HT) groups by BP values.Results: All the BRS values calculated in the exam period were significantly lower compared to the semester period in the same positions. In supine position: (semester vs. exam) up-BRS was 21.9 ± 13.2 ms/mmHg vs. 18.5 ± 11.9 ms/mmHg (p = .013), down-BRS was 22.3 ± 9.3 ms/mmHg vs. 18.4 ± 8.2 ms/mmHg (p = .019). After standing up: (semester vs. exam) up-BRS was 9.3 ± 3.3 ms/mmHg vs. 7.6 ± 3.1 ms/mmHg (p = .02), down-BRS was 9.5 ± 3.6 ms/mmHg vs. 7.0 ± 2.8 ms/mmHg (p < .0001). The number of students decreased in optimal BP group and increased in normal and HT groups in the exam period.Conclusions: A 6-week long exam period had enough stress effect to change cardiovascular parameters towards a higher risk even in healthy young people.

May Measurement Month 2017: an analysis of blood pressure screening in Hungary-Europe.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. The cardiovascular mortality rate in Hungary is twice as high as the European Union average. In a recent Hungarian screening programme, among those volunteers who claimed to be healthy, BP was above 140/90 mmHg in 24% and 39% in women and men, while the control rate was 45% and 36% in women and men, respectively. May Measurement Month (MMM) is a global initiative by the International Society of Hypertension aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. BP measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. In Hungary, 97 sites were set-up in primary and secondary care facilities, in pharmacies and in malls. All regions, both cities and villages were involved. A total of 3967 individuals were screened. After multiple imputation, 2052 subjects (51.8%) had hypertension. 553 (22.4%) of untreated individuals had hypertension, and 666 (44.5%) of treated individuals had uncontrolled BP. More than 50% of the screened cohort had hypertension (treated and controlled, treated and uncontrolled or untreated). By identifying almost one-third of the screened cohort with the possibility of newly diagnosed or uncontrolled hypertension, the Hungarian part of MMM17 suggest that opportunistic screening can identify significant numbers with raised BP.

[Rapidly progressive proliferative glomerulonephritis with monoclonal immunoglobulin G deposits despite the mild histological changes. Case report]. / Enyhe szövettani eltérések ellenére gyors progressziójú proliferativ glomerulonephritis monoklonális immunglobulin-G-depozitumokkal.

Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits is characterized by granular deposits of monoclonal IgG; histologically it has typically a membranoproliferative or endocapillary pattern, and seen electronmicroscopically there are dense deposits without substructure. Here, we present the case of a 62-year-old Caucasian woman who was admitted with rapidly progressive kidney failure. The patient's status, the laboratory and imaging examinations did not support prerenal, postrenal and - among the intrinsic causes - vascular and tubulointerstitial origin. The proteinuria and dysmorphic microhematuria suggested rapidly progressive glomerulonephritis. Tests for anti-neutrophil cytoplasmic antibodies, anti-glomerular basement membrane, antinuclear antibodies and cryoglobulins were negative, the C3 and C4 levels were normal. The biopsy evaluation diagnosed proliferative glomerulonephritis with monoclonal IgG deposits because of mesangial granular deposits of IgG3-kappa, C3, and C1q, and ultrastructurally electron-dense deposits (incidence in our adult native kidney biopsy series: 0.18%). 31 glomeruli were assessed histologically. 29 glomeruli displayed mild mesangial hypercellularity, 2 glomeruli were globally sclerotic. Crescents were not observed. Mild arteriolar hyalinosis, interstitial fibrosis and tubular atrophy accompanied the glomerular alterations. In the postbiopsy evaluation, paraprotein or multiple myeloma was not detected. Despite the mild histological findings, the kidney failure progressed, and hemodialysis had to be started two weeks after the biopsy. Steroids, cyclophosphamide and rituximab did not affect her kidney function, and she remained on hemodialysis during the follow-up of 39 months. This report presents for the first time proliferative glomerulonephritis with monoclonal IgG deposits as the possible cause of rapidly progressive nephritic syndrome in the absence of pronounced glomerular proliferative, sclerotic or tubulointerstitial lesions. Orv Hetil. 2018; 159(38): 1567-1572.

New-onset type 2 diabetes mellitus--A high-risk group suitable for the screening of pancreatic cancer?

BACKGROUND: Type 2 diabetes mellitus is widely considered to be associated with pancreatic cancer. OBJECTIVE: To determine the incidence of pancreatic cancer in new-onset type 2 diabetic patients by measuring the serum level of CA 19-9 and performing abdominal ultrasonography (US). PATIENTS AND METHODS: Consecutive type 2 diabetic patients in whom diabetes was diagnosed within 36 months were included in this prospective study. Serum CA 19-9 measurement and US were performed in all patients. If any of two was positive, abdominal computer tomography (CT) was carried out. Endoscopic ultrasound-guided fine needle aspiration or direct surgical referral was performed on patients with CT-identified lesions. RESULTS: A total of 115 patients were enrolled. CA 19-9 was elevated in 10 patients but pancreatic cancer diagnosed in neither of them. Pancreatic cancer was revealed by morphological means in three patients without elevated CA 19-9 level. The sensitivity, specificity, positive-, negative predictive values and validity were 0%, 90.4%, 0%, 97.9% and 87.9% for CA 19-9, 66.7%, 100%, 100%, 99% and 99% for US, respectively. The value of the Standardized Incidence Ratio for pancreatic cancer in new-onset type-2 diabetic patients was 198.6 (95% CI = 6.25-46.9). CONCLUSIONS: The prevalence of pancreatic cancer in patients with new-onset type-2 diabetes is significantly higher than that in the general population and screening is beneficial for detecting PaC in this patient population. CA 19-9 and US is not reliable screening modality for pancreatic cancer screening in this population.

Observations of changes of blood pressure before and after neurosurgical decompression in hypertensive patients with different types of neurovascular compression of brain stem.

AIMS: The neurovascular pulsatile compression of the rostral ventrolateral medulla can be divided into different subtypes. The posterior inferior cerebellar artery and/or vertebral artery can compress either the rostral ventrolateral medulla or the cranial nerves IX and X or both and on left, right or both sides. METHODS: It was retrospectively investigated whether the types of neurovascular compression can influence blood pressure values. Data from 13 resistant hypertensive patients after decompression were investigated. RESULTS: Six patients had 2 compressions, two had only medulla compression, four had only nerve compression on the left side and one had 2 compressions on both sides. There was no correlation between the types of compression and the levels of blood pressure, either before or after the decompression. Both, systolic and diastolic blood pressures and pulse pressure also decreased in all cases after the decompression but the change was significant only in the group with 2 compressions on the left side. CONCLUSION: According to our data, in a severe hypertension not responding to conventional antihypertensive therapy, the surgical decompression of the brain stem independently of the types of neurovascular compression could guarantee a decrease of blood pressure and improved sensitivity to antihypertensive medication.

Investigation of cardiac autonomic and peripheral sensory neuropathy in diabetic and nondiabetic patients with hypertension.

Peripheral sensory function and cardiac autonomic neuropathy were studied in 18 nondiabetic and 10 type-2 diabetic hypertensives compared with 11 healthy controls. All the patients were treated with antihypertensive drugs. Cardiac autonomic neuropathy using Ewing method was detected in all patient groups. The current perception threshold values on peroneal nerve at 250 Hz in nondiabetic group and at 250 Hz and at 5 Hz in diabetic group were found increased compared with the controls. In conclusion, so-called typical complications of diabetes can be observed in nondiabetic hypertensives also. Our data might support the essential role of vascular factors in the development of neuropathy.

Comparison of pattern VEP results acquired using CRT and TFT stimulators in the clinical practice.

There are several electrophysiological systems available commercially. Usually, control groups are required to compare their results, due to the differences between display types. Our aim was to examine the differences between CRT and LCD/TFT stimulators used in pattern VEP responses performed according to the ISCEV standards. We also aimed to check different contrast values toward thresholds. In order to obtain more precise results, we intended to measure the intensity and temporal response characteristics of the monitors with photometric methods. To record VEP signals, a Roland RetiPort electrophysiological system was used. The pattern VEP tests were carried out according to ISCEV protocols on a CRT and a TFT monitor consecutively. Achromatic checkerboard pattern was used at three different contrast levels (maximal, 75, 25%) using 1° and 15' check sizes. Both CRT and TFT displays were luminance and contrast matched, according to the gamma functions based on measurements at several DAC values. Monitor-specific luminance parameters were measured by means of spectroradiometric instruments. Temporal differences between the displays' electronic and radiometric signals were measured with a device specifically built for the purpose. We tested six healthy control subjects with visual acuity of at least 20/20. The tests were performed on each subject three times on different days. We found significant temporal differences between the CRT and the LCD monitors at all contrast levels and spatial frequencies. In average, the latency times were 9.0 ms (±3.3 ms) longer with the TFT stimulator. This value is in accordance with the average of the measured TFT input-output temporal difference values (10.1 ± 2.2 ms). According to our findings, measuring the temporal parameters of the TFT monitor with an adequately calibrated measurement setup and correcting the VEP data with the resulting values, the VEP signals obtained with different display types can be transformed to be comparable.

Peripheral sensory nerve hyperaesthesia in women with polycystic ovary syndrome.

Dysfunction of the nervous system is well-known in diabetes and also among patients with prediabetes, obesity and hypertension. However, there is only a limited amount of data available on the changes in neuronal function in polycystic ovary syndrome (PCOs), despite the fact that this condition is also accompanied by metabolic and vascular abnormalities. The aim of our study was to assess the cardiovascular autonomic and peripheral sensory function in patients with PCOs. The study involved 27 women with PCOs, and 24 healthy women as control subjects. Autonomic neuropathy (AN) was assessed using the four standard cardiovascular reflex tests. Peripheral sensory function was determined using the Neurometer. Electric stimulation was applied transcutaneously and the current perception threshold (CPT) values were determined on the median and peroneal nerves. No significant differences were found between the PCOs patients and the control group regarding the cardiovascular autonomic reflex tests and the AN scores. The CPT values of PCOs patients in the median and peroneal nerves were lower at all frequencies in comparison to controls. Conclusions: The cardiovascular autonomic nerve function was normal in the patients with PCOs. The current perception thresholds were consequently lower in the PCOs patients both in the upper and lower extremities at all frequencies, which serves as an early sign of neuropathy. As a novel observation, our results suggest that early neuronal damage manifests in the form of sensory hyperaesthesia in patients with PCOs.

[The clinical importance of hyponatremia]. / A hyponatraemia klinikai jelentosége.

Hyponatremia is a most common disorder of electrolytes encountered in everyday clinical practice. Although many cases are mild and relatively asymptomatic, hyponatremia is nonetheless important clinically because of the potential for substantial morbidity and mortality. Despite the knowledge of hyponatremia since the mid-20th century, this common disorder remains incompletely understood in many basic areas because of its causation by multiple etiologies with differing pathophysiological mechanisms. Up to this time, the optimal treatment strategies have not been well defined. The authors present 3 typical hypotonic hyponatremic patients for colleages in clinical practice for studying, for establishing a common conception for the managing of hyponatremia. Orv Hetil. 2019; 160(8): 314-319.

Neurovascular pulsatile compression and neurosurgical decompression of the rostral ventrolateral medulla in medically resistant hypertensive patients.

BACKGROUND/AIMS: In cases of severe primary hypertension not responding to conventional medical therapy, neurovascular pulsatile compression of the rostral ventrolateral medulla on the left side may be considered as an etiological factor in the hypertension. Through neurosurgical decompression, the blood pressure can be reduced in these cases, and the conventional medication can also become more effective. METHODS: The authors retrospectively analysed the changes in the blood pressure and therapy of patients with or without neurosurgical decompression over a 2-year period. The 2-year data were available for 9 operated and 7 non-operated patients with neurovascular compression. The data of control examinations performed 1, 3, 6, 12 and 24 months after the intervention (or after MR-angiography in the non-operated cases) were analysed. RESULTS: After the decompression, both the systolic and diastolic blood pressure decreased significantly and permanently in all cases, and there was an improved response to the medication. In the non-operated group, the blood pressure did not change significantly during the 2 years. CONCLUSION: In severe hypertension that does not respond to conventional therapy, neurosurgical decompression of the brain stem on the left side can guarantee a long-lasting blood pressure reduction and a better response to antihypertensive medication.

Cardiovascular Autonomic Neuropathy and Glucose Variability in Patients With Type 1 Diabetes: Is There an Association?

INTRODUCTION: The oxidative stress associated with glucose variability might be responsible for neuronal damage while autonomic neuropathy (AN) has a detrimental effect on metabolism. The aim of the study was to find relationship between AN and GV in type 1 diabetic patients and to identify further factors that affect GV. PATIENTS AND METHODS: Twenty type 1 diabetic patients were involved (age: 39.5 ± 3.4 years, duration of diabetes: 17.5 ± 2.5 years; HbA1c: 8.1 ± 0.2%, mean ± SE). AN was assessed by the cardiovascular reflex tests. The interstitial glucose levels were determined following insertion of a subcutaneous electrode during the continuous glucose monitoring (CGM) method on six consecutive days. GV was characterized by calculation of four parameters. RESULTS: SD of interstitial glucose values correlated positively with the overall AN score and the degree of the orthostatic reduction of systolic blood pressure (AN-score-SD ρ = 0.47, p < 0.05; orthostasis-SD: ρ = 0.51, p < 0.05). Mean absolute glucose (MAG) correlated with three parameters of AN (AN-score-MAG: ρ = 0.62, p < 0.01; 30/15 ratio-MAG: ρ = -0.50, p < 0.05; orthostasis-MAG: ρ = 0.59, p < 0.01). The HbA1c also correlated with two parameters of GV (HbA1c-continuous overlapping net glycemic action: ρ = 0.56, p < 0.05; HbA1c-MAG: ρ = 0.45, p < 0.05). The frequency of hypoglycemia did not exhibit any correlation with measures of GV. CONCLUSION: Severity of glucose variability but not overall glucose load correlates with both parasympathetic and sympathetic dysfunctions in type 1 diabetes. Higher HbA1c is associated with more severe glucose variability. The observed correlation between increased glucose variability and the severity of AN necessitates the further exploration of this relationship.

[Pseudosyncope and pseudoseizure]. / Alsyncope és álgörcsroham.

Syncope is a frequent complaint which imposes a considerable burden on the health care systems. Although our diagnostic tools have improved during the last decades, the exact cause of syncope still remains unknown in a small fraction of cases. In the heterogenous group of "syncope with unknown origin" there are a few cases of pseudosyncope. Unlike the true episodes of syncope, the episodes of pseudosyncope are not associated with compromised cerebral circulation. The pseudosyncope in reality is a manifestation of conversion disorder, and as such shares many features with pseudoseizure. The latter is also characterized by the lack of typical neurological and EEG manifestations at the time of attacks. We present a case of a 57-year-old female with a 30 year history of attacks corresponding either to pseudosyncope or pseudoseizure. A brief overview of literature of pseudosyncope is also given, and the importance of an interdisciplinary diagnostic approach is emphasized.

The Antihypertensive Efficacy of the Triple Fixed Combination of Perindopril, Indapamide, and Amlodipine: The Results of the PETRA Study.

INTRODUCTION: The etiology of essential hypertension is multifactorial. Therefore, treatment with combinations of antihypertensive agents acting on multiple targets is necessary for successful therapy in the majority of patients. According to the experience and clinical data accumulated so far, combination therapy with three agents from different pharmacological classes is required in approx. 30% of patients in order to achieve long-term blood pressure control. The primary objective of the PETRA study was to evaluate the efficacy of blood pressure (BP) control with once daily administration of the different dosage strengths of the once-daily, triple fixed combination of perindopril, indapamide, and amlodipine. The evaluation was based on office BP readings and ambulatory blood pressure monitoring (ABPM) data gathered in routine clinical practice. METHODS: Data from 11,209 hypertensive patients (the proportion of female subjects was 47.6%) were processed and interpreted in a 3-month-long prospective, observational, non-interventional, open-label study conducted in 997 centers in Hungary. RESULTS: Mean baseline office BP was 156.58 ± 16.10/91.56 ± 9.33 mmHg (mean ± SD), whereas the mean duration of hypertension was 9.48 ± 7.19 years. Mean office BP decreased by 24.81 ± 15.47/11.41 ± 9.90 mmHg after switching to the triple fixed combination of perindopril, indapamide, and amlodipine (p < 0.0001). At the final visit 45.1% of patients took the 5/1.25/5 mg, 33.5% of them 10/2.5/5 mg, and 21.4% of them 10/2.5/10 mg strength of the perindopril/indapamide/amlodipine triple fixed combination. The 24-h blood pressure was obtained in 76 subjects. The mean 24-h BP decreased from 155.51 ± 17.43/85.28 ± 11.48 to 134.63 ± 12.51/77.83 ± 8.99 mmHg (p < 0.0001). Statistically significant (p < 0.0001) and clinically relevant improvement of a number of metabolic parameters-including total cholesterol (-8.6%), LDL-cholesterol (-11.4%), triglyceride (-12.1%), and fasting blood glucose (-6.6%) levels-was observed over the 3-month study period. CONCLUSIONS: During the 3 months of the PETRA study, the outstanding 24-h antihypertensive efficacy of the triple fixed combination of perindopril, indapamide, and amlodipine was confirmed both by office BP readings and by ABPM recordings. This combination may offer a new therapeutic option for hypertensive patients who have failed to achieve the desired BP target on their previous dual combination therapy. FUNDING: EGIS Pharmaceuticals PLC.

Increased Short-Term Beat-to-Beat QT Interval Variability in Patients with Impaired Glucose Tolerance.

Prediabetic states and diabetes are important risk factors for cardiovascular morbidity and mortality. Determination of short-term QT interval variability (STVQT) is a non-invasive method for assessment of proarrhythmic risk. The aim of the study was to evaluate the STVQT in patients with impaired glucose tolerance (IGT). 18 IGT patients [age: 63 ± 11 years, body mass index (BMI): 31 ± 6 kg/m2, fasting glucose: 6.0 ± 0.4 mmol/l, 120 min postload glucose: 9.0 ± 1.0 mmol/l, hemoglobin A1c (HbA1c): 5.9 ± 0.4%; mean ± SD] and 18 healthy controls (age: 56 ± 9 years, BMI: 27 ± 5 kg/m2, fasting glucose: 5.2 ± 0.4 mmol/l, 120 min postload glucose: 5.5 ± 1.3 mmol/l, HbA1c: 5.4 ± 0.3%) were enrolled into the study. ECGs were recorded, processed, and analyzed off-line. The RR and QT intervals were expressed as the average of 30 consecutive beats, the temporal instability of beat-to-beat repolarization was characterized by calculating STVQT as follows: STVQT = Σ|QTn + 1 - QTn| (30x√2)-1. Autonomic function was assessed by means of standard cardiovascular reflex tests. There were no differences between IGT and control groups in QT (411 ± 43 vs 402 ± 39 ms) and QTc (431 ± 25 vs 424 ± 19 ms) intervals or QT dispersion (44 ± 13 vs 42 ± 17 ms). However, STVQT was significantly higher in IGT patients (5.0 ± 0.7 vs 3.7 ± 0.7, P < 0.0001). The elevated temporal STVQT in patients with IGT may be an early indicator of increased instability of cardiac repolarization during prediabetic conditions.

Tolerability of beta-blockers in elderly patients with chronic heart failure: the COLA II study.

BACKGROUND: Beta-blockers are recommended therapy for patients with chronic heart failure (CHF). However, there remains concern regarding tolerability of these agents in the elderly, which has contributed to the limited uptake of these agents in clinical practice. AIMS: We conducted a multi-national, prospective evaluation of tolerability to carvedilol in 1030 CHF patients aged >70 years selected by their treating physician to receive this agent in everyday practice. METHODS AND RESULTS: NYHA Class II-IV CHF patients were assessed at baseline for key demographic parameters that may predict tolerability, then followed for 6 months after starting carvedilol. Tolerability was defined as being on >or=6.25 mg bd of carvedilol at 6 months having received a total of >or=3 months therapy. Tolerability overall was 80% with age 70-75 years 84.3%, 76-80 years 76.8% and >80 years 76.8%. Mean carvedilol dose achieved was 31.2 mg. In multivariate analysis, advanced age, low diastolic BP, LVEF, obstructive airways disease and presence of diabetes were predictors of tolerability. CONCLUSIONS: Carvedilol appears to be well tolerated in this elderly CHF patient cohort. Therefore, elderly CHF patients should not be denied treatment with carvedilol because of concerns regarding tolerability.

Increased serum butyrylcholinesterase activity in type IIb hyperlipidaemic patients.

The inheritance of the apolipoprotein E4 (APOE4) allele has been shown to increase the plasma cholesterol level, but little information is as concerns the association of the APOE genotype and hyperlipidaemia and the activities of two serum enzymes, acetylcholinesterase (AChE) and butyrylcholinesterase (BChE). Blood samples from 55 type IIb hyperlipidaemic, non-demented patients and 55 age- and sex-matched controls were therefore examined in this pilot study. A significantly increased BChE activity was found in the serum of type IIb hyperlipidaemic patients, but the AChE activity did not differ significantly as compared with that in the control group. The APOE4 allele was significantly overrepresented among the hyperlipidaemic probands, but neither serum cholinesterase activity was affected by the dosage of the APOE4 gene. Our results point to a possible association between an abnormal lipid metabolism and the BChE activity and might have implications as regards the pathomechanism of both Alzheimer's and vascular dementias and the cholinesterase inhibitor therapy of dementing disorders.

[Therapeutic possibilities for the inhibition of the renin-angiotensin-aldosterone system]. / Terápiás lehetóségek a renin-angiotenzin rendszer aktivitásának gátlására.

The dysfunction of the renin-angiotensin-aldosterone system and its inhibition is a powerful therapeutic tool in the treatment of cardiovascular diseases. This system is a very ancient and sensitive mechanism, which reacts very much to the impacts from the environment. The system can be inhibited through four different ways; in the practice ACE inhibitors and ARBs are used mostly. Other--also beneficial--drugs might cause the over stimulation of the system. The inhibition of the RAAS system have significant impact on reduction in cardiovascular morbidity and mortality and have been shown convincingly additional benefits comparing to other treatments.

[The incidence of renal diseases as diagnosed by biopsy in Hungary]. / A biopsziával kórismézett vesebetegségek gyakorisága a Dél-Alföldön.

AIM AND METHODS: The authors analysed the incidence of renal diseases as diagnosed by biopsy in the population living on the southern Great Hungarian Plain. 798 biopsy specimens were examined between 1990 and 2002. RESULTS: The most common diseases in decreasing order of frequency were IgA nephropathy (15%), membranous nephropathy (12%), thin-basement-membrane nephropathy (8%), minimal change nephropathy (7%), lupus glomerulonephritis (7%), focal sclerosis (6%), hypertensive kidney disease and arteriolosclerosis (5%), diabetic nephropathy (5%), and crescentic glomerulonephritis (4%). The most frequent diseases in decreasing order of frequency in children were minimal change nephropathy, thin-basement-membrane nephropathy, Henoch-Schönlein nephropathy and IgA nephropathy; in adults were IgA nephropathy, membranous nephropathy, lupus glomerulonephritis and thin-basement-membrane nephropathy; and in the elderly were membranous nephropathy, amyloidosis, crescentic glomerulonephritis and diabetic nephropathy. The incidence of the diseases differed significantly between the genders in IgA nephropathy, thin-basement-membrane nephropathy, lupus glomerulonephritis, chronic sclerosing nephropathy and Alport nephropathy. At the time of the biopsy, 69 patients were suffering from diabetes mellitus. 37 patients were diagnosed as having diabetic nephropathy, and 32 as having non-diabetic nephropathy. In 6 cases, the diabetic nephropathy was accompanied by other glomerular disorders. In more than half of the diabetic patients with non-diabetic nephropathy, membranous nephropathy or focal sclerosis was diagnosed. Crescentic glomerulonephritis was diagnosed on 30 occasions, which was due to vasculitis in 20 cases, proliferative glomerulonephritis in 7 cases and anti-glomerular-basement-membrane nephritis in 3 cases. In the middle-aged and the elderly, the renal disease was relatively often a consequence of systemic disease. CONCLUSION: The incidence and the gender distribution of renal diseases diagnosed by biopsy were similar to those reported by other European kidney biopsy centres. IgA nephropathy was the most frequent disease in the biopsy registry of the authors. The high incidence of thin-basement-membrane nephropathy seems to be related to consequent biopsy examinations of glomerular haematuria. In diabetics and the elderly, the diagnosis of the renal disease may be challenging.