Competences of internal medicine specialists for the management of patients with multimorbidity. EFIM multimorbidity working group position paper.

Patients with multimorbidity increasingly impact healthcare systems, both in primary care and in hospitals. This is particularly true in Internal Medicine. This population associates with higher mortality rates, polypharmacy, hospital readmissions, post-discharge syndrome, anxiety, depression, accelerated age-related functional decline, and development of geriatric syndromes, amongst others. Internists and Hospitalists, in one of their roles as Generalists, are increasingly asked to attend to these patients, both in their own Departments as well as in surgical areas. The management of polypathology and multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience. In addition, patients' needs, health-care environment, and routines have changed, so emerging and re-emerging specific competences and approaches are required to offer the best coordinated, continuous, and comprehensive integrated care to these populations, to achieve optimal health outcomes and satisfaction of patients, their relatives, and staff. This position paper proposes a set of emerging and re-emerging competences for internal medicine specialists, which are needed to optimally address multimorbidity now and in the future.

Differential coded aperture single-snapshot spectral imaging.

We propose a novel, to the best of our knowledge, concept of the differential coded aperture snapshot spectral imaging (D-CASSI) technique exploiting the benefits of using a {-1,+1} random mask, which is demonstrated by a broadband single-snapshot hyperspectral camera using compressed sensing. To double the information, we encode the image with two complementary random masks, which proved to be superior to two independent patterns. We utilize dispersed and non-dispersed encoded images captured in parallel on a single detector. We explored several different approaches to processing the measured data, which demonstrates significant improvement in retrieving complex hyperspectral scenes. The experiments were completed by simulations in order to quantify the reconstruction fidelity. The concept of differential CASSI could be easily implemented also by multi-snapshot CASSI without any need for optical system modification.

Development of an ultraprecision metal mirror on additively manufactured Ti-6Al-4V.

Metal mirrors for precise optical applications are commonly fabricated by coating of a metal base substrate with a nickel-phosphorus alloy (NiP). The NiP layer is then processed by precision diamond turning and polishing to obtain a high-quality mirror surface. In this work, Ti-6Al-4V samples that were made by additive manufacturing, also called 3D printing, were used as a base for the development of metal mirrors. The additively manufactured samples were electroplated with a NiP coating and machined using single-point diamond turning (SPDT) to obtain a flat mirror with optical quality and low form error surface. The periodic structure of the SPDT toolmark was then removed by polishing postprocessing. Polishing optimization was first performed on NiP-coated aluminum test samples to find an optimal polishing setup. Based on this optimization, postprocessing of titanium samples was carried out by pitch polishing in combination with 1, 0.25, and 0.1µm diamond slurries. Using this polishing processing, a scratch-free surface was attained with surface microroughness below 0.5 nm.

Enhancement of CASSI by a zero-order image employing a single detector.

Coded aperture snapshot spectral imaging (CASSI) makes it possible to recover 3D hyperspectral data from a single 2D image. However, the reconstruction problem is severely underdetermined, and efforts to improve the compression ratio typically make the imaging system more complex and cause a significant loss of incoming light intensity. In this paper, we propose a novel approach to CASSI that enables capturing both a spectrally sheared and an integrated image of a scene with a single camera. We performed hyperspectral imaging of three different testing scenes in the spectral range of 500-900 nm. We demonstrate the prominent effect of using the nondiffracted image on the reconstruction of data from our camera. The use of the spectrally integrated image improves the reconstruction quality, and we observed an approximately fivefold reduction in reconstruction time.

High resolution mass spectrometry analysis of the sertraline residues contained in the tissues of rainbow trout reared in model experimental conditions.

The growing consumption of pharmaceuticals in the human population and the insufficient efficiency of their elimination in waste water has a long-term negative impact on the environment of aquatic ecosystems, including the organisms that inhabit them. A significant contributor is the consumption of anti-depressants from the SSRI group, which corresponds to their increasing concentration in the environment. The aim of this work was to determine if antidepressant sertraline is able to be stored in fish organisms and to evaluate the content of residues in various body tissues. Rainbow trout (Oncorhynchuss mykkis) was selected as the test organism and was artificially exposed to the antidepressant for 1 month (concentrations 0; 4.2; 44 and 400 ng.g-1 sertraline in the feed). Liver, kidney, brain and muscle tissue biopsies samples were taken for analysis. Detection was performed using an Accela 1250 LC pump and an Accela autosampler coupled with a high-performance mass analyzer with a heated electrospray ionization source Q-Exactive Orbitrap, operating in positive ionization mode and in PRM mode (m/z 306.08108->275.03888 and 309.009991->275.03888 for sertraline and internal standard, respectively). The limit of quantification of the method was 0.1 ng.g-1 of sertraline and the calibration curve showed a good linearity up to 20 ng.g-1. From the collected data, amount of residues was found in the liver, kidney and brain. In contrast, the incidence of residues in muscle tissue was not detected in all groups, which is favorable from the point of view of fish meat consumption, by humans.

Sleep apnoea in patients with nocturnal hypertension - a multicenter study in the Czech Republic.

Sleep apnoea (SA) is common in patients with hypertension. Nowadays, limited data on the prevalence of SA in nocturnal hypertension (NH) exist. Therefore, we studied the occurrence of SA in Czech patients and its association with 24-h ambulatory blood pressure monitoring (ABPM), breathing disturbances in sleep, anthropometric data, Mallampati score and Epworth sleepiness scale (ESS) using the Apnea Link device. Undiagnosed SA was found in 72.9 % patients (29.3 % mild, 26.6 % moderate, 17.0 % severe) of 188 patients with NH measured by ABPM. The median of the apnoea-hypopnoea index (AHI) was 12.0 (25th-75th percentile 5.0-23.8). Moderate/severe SA (AHI>/=15) was associated with BMI, waist circumference, mean night saturation (SpO(2)), t90, oxygen desaturation index (ODI), ESS (daytime BP only) (p0.09). A likelihood of moderate/severe SA was enhanced by ODI>14.5 events/h (odds ratio=57.49, 95 % CI=22.79-145.01), t90>6.5 % (8.07, 4.09-15.92), mean night SpO(2)<93.5 % (3.55, 1.92-6.59), BMI>29.05 kg/m(2) (6.22, 3.10-12.49), circum waist>105.5 cm (3.73, 1.57-8.83), but not by any ABPM parameter. In conclusion, a high incidence of SA (72.9 %) was observed in Czech patients with NH. SA severity was associated with body characteristics and oxygenation parameters, but not with ABMP parameters and Mallampati score.

Digital synthetic impedance for application in vibration damping.

In this work we present construction details of a precision, standalone, and compact digital synthetic impedance for application in the field of vibration damping. The presented device is based on an embedded ARM microcontroller with external AD and DA converters and a special analog front-end. The performance of the device is tested by comparing the actually synthesized impedance with several prescribed impedances and shows very good match. Fine-tuning ability of the device, which is crucial for the considered application, is also demonstrated and reaches as small step as 0.1% for the most complicated impedance structure and drops below the level of direct measurability with less complex structures. The real application in vibration damping is demonstrated on a simple and well understood case of a one-dimensional vibrating spring-mass system with piezoelectric actuator embedded as the interface between source of vibrations and vibrating mass.

Synthesis of quaternary α-perfluoroalkyl lactams via electrophilic perfluoroalkylation.

Efficient protocols enabling the rapid installation of trifluoromethyl, as well as further functionalized fluoroalkyl groups by an electrophilic perfluoroalkylation of lactam-derived ketene silyl amides (KSAs) using hypervalent iodine reagents 1 and 2 have been developed.

Enantioselective hydrogenation of cyclic imines catalysed by Noyori-Ikariya half-sandwich complexes and their analogues.

A method for enantioselective hydrogenation of cyclic imines with gaseous hydrogen has been developed. Easily accessible Noyori-Ikariya Ru(II) and Rh(III) complexes can be used directly without an inert atmosphere. Substrate activation has been achieved by trifluoroacetic acid. A new hydroxyl-functionalized complex is reported, showing high activity in transfer hydrogenation.

[Perindopril in the treatment of hypertension and cardiovascular diseases: evolution continues with the orodispersible dosage form]. / Perindopril v lécbe hypertenze a kardiovaskulárních chorob: evoluce pokracuje orodisperzní formou.

Perindopril is a long acting ACE inhibitor with a 24- hour lasting effect. Its positive effect on a reduction in cardiovascular events has been confirmed in a range of large randomized clinical trials and in a wide spectrum of patients: hypertonic patients, diabetics, patients with stable ischaemic heart disease, elderly patients, or patients who have undergone a cerebrovascular accident. The extending range of various fixed combinations as well as new pharmaceutical dosage forms, including the newly introduced orodispersible tablets of perindopril, enables optimization of treatment for every patient, an increase in the patients treatment adherence, and also improvement in longterm blood pressure control with a consequent effect on reduction of morbidity and mortality.

[Diagnostic algorithm of syncope: integrative approach]. / Diagnostický algoritmus synkop: integrativní prístup.

Syncope is a symptom, defined as transient loss of consciousness and postural tone with spontaneous and mostly prompt recovery. At first it is necessary to differentiate other non-syncopal transient loss of consciousness and simple falls, where thorough history taking is pivotal. EGSYS and OESIL risk scores seem to be contributional in initial risk stratification, however they are neither widely accepted nor a part of national guidelines. They are part of the European society of cardiology guidelines, though. Next it is essential expert ECG evaluation, thorough physical status examination, supine and standing blood pressure measurement and carotid sinus massage, if not contraindicated. Successively one has to decide if hospitalization or outpatient management is more suitable. Recently it has been shown, that so-called syncope management units (aimed for short-term hospitalization or fast outpatient examination, including vital function monitoring, echocardiography and facile cathlab access) are effective in fast syncope evaluation. Echocardiography, ECG monitoring and head-up tilt test should be a part of complex diagnostic evaluation. If syncope is not clarified by upon stated methods moreover syncope is recurrent, electrophysiological study, ILR implantation or both are justified. Despite of entire health practitioner's effort, more than 1/3 of syncopes remain unexplained.

[Newly diagnosed Churga-Strauss syndrome in a female patient with suspect acute coronary syndrome]. / Nove diagnostikovaný syndrom Churga-Straussové u pacientky s podezrením na akutní koronární syndrom.

We present a case of 60 years old patient with the history of repeated sinusitis and bronchial asthma, who developed Churg-Strauss syndrome (CSS) with mono-neuritis multiplex, skin laesions on the head and acute perimyocarditis, which led to suspicion on myocardial infarction. Diagnosis of CSS was based on clinical manifestations, blood hypereosinophilia and histological examination of nasal mucous membrane biopsy. Subsequent immunosuppressive therapy led to regression of symptoms and improvement of temporarily decreased left ventricular function.

Proguanylin: development, analytical characterization, and clinical testing of a new ELISA.

The aim of our work was to develop an assay for the determination of proguanylin in human blood, and investigate its levels in healthy volunteers and donors suffer from hypertension often accompanied by body sodium accumulation and plasma volume expansion. We developed and evaluated the sandwich ELISA method for the quantitative determination of human proguanylin in serum samples. We conducted also the pilot study on individuals with hypertension and oh healthy probands and measured proguanylin serum levels, serum and urine sodium and creatinine levels. In the study on 256 healthy volunteers we demonstrated that women have significantly higher values of proguanylin than men (medians 12.7 vs. 9.6 ng/ml, p < 0.01) and proguanylin values increased with age of individuals (p < 0.01). Futhermore, we tested 17 individuals with hypertension and found that probands with anamnesi of hypertension had higher proguanylin values than healthy individuals from the first study (medians 16.2 vs. 11.3 ng/ml, p < 0.01). Both of groups did not differ in sex or age. Proguanylin values correlated with the systolic blood pressure (r = 0.41, p < 0.01), sodium fraction excretion (r = 0.72, p < 0.01) and serum sodium (r = -0.39, p < 0.01). No significant correlation we found with serum proguanylin and creatinine. In the group of 9 healthy probands we demonstrated the existence of a diurnal rhythm of proguanylin with its maximum in the evening hours (between 6-10 p.m.). The pilot study supports the hypothesis about the role of proguanylin in sodium metabolism and its possible importance for hypertension disorder. Further research is necessary to confirm our findings in individuals with hypertension with different medication in order to assess proguanylin value as a risk predictor of accelerated hypertension, and to classify individuals with hypertension for variuos types of diuretic therapy.

Aspirin resistance measured by cationic propyl gallate platelet aggregometry and recurrent cardiovascular events during 4 years of follow-up.

BACKGROUND: Aspirin resistance appears to be an important prognostic factor in patients with coronary artery disease, yet there is no standardized method to measure it and limited data on its correlation to clinical outcomes. METHODS: In a prospective study we followed 103 patients (mean age 64 years) with acute coronary syndrome (ACS) without ST segment elevation who were treated with 100 mg of aspirin (ASA) daily. Optical platelet aggregometry using cationic propyl gallate (CPG) as an inductor was measured at ACS onset and after 3, 12, 24, 36, and 48 months. ASA responsiveness was defined both by the slope of the aggregation curve (<53%/min) and by spontaneous aggregation (<5%). The primary outcomes were the recurrence of ACS or stroke. RESULTS: Patients with ACS exhibited a greater prevalence of ASA resistance (55%) than healthy volunteers (4%; p<0.01). ASA resistance occurred more often in patients with type 2 diabetes, hypertriacylglycerolemia, and decreased HDL levels, and in smokers (p<0.05). A single assessment of platelet aggregometry was sufficient to identify ASA-resistant patients. During the 4-year follow-up, the patients with ASA resistance had an 88% incidence of recurrent cardiovascular events versus 46% for the patients without ASA resistance (p<0.01). In the subgroup with recurrent cardiovascular (CV) events, significantly more patients were ASA-resistant than in the subgroup without recurrent CV events (72% vs. 8%, p<0.01). CONCLUSION: ASA resistance measured by CPG-induced platelet aggregometry is more common among patients with ACS and some metabolic risk factors, and ASA-resistant patients have a significantly higher recurrence of cardiovascular events.

Global gyrokinetic stability of pressure-gradient-driven electromagnetic modes in tokamaks with regions of low shear.

Tokamaks with large pressure gradients (alpha(max)) formed in regions of weak magnetic shear are shown to be susceptible to novel, low-n, global, kinetic, electromagnetic modes with a toroidal mode number n in the range 21 on the magnetic axis and alpha(max) near q(min), new, global kinetic infernal modes with a strong mode rotation omega(r) and a finite growth rate gamma<|omega(r)| are found. For equilibria with reverse shear where q(min) is off axis and alpha(max) near q(min), the existence of an unstable low-n global branch of Alfve n ion temperature gradient modes is revealed with an oscillatory gamma as a function of n. The addition of trapped electron dynamics is shown to be further destabilizing.