The advantages and limitations of impedance aggregometry in detection of heparin-induced thrombocytopenia.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) represents a serious complication of heparin treatment. IgG antibodies binding platelet factor 4 (PF4) and heparin trigger the clinical manifestations of HIT. However, only a portion of the antibodies have the ability to activate platelets, and these can be identified by a platelet aggregation test (functional testing). Current methods HIPA and SRA are time-consuming and difficult if HIT is clinically suspected; therefore, numerous new methods have recently been developed. METHODS: To determine HIT, impedance aggregometry using the Multiplate analyzer (MEA) as heparin-induced aggregation techniques and the Technozym HIT Ig ELISA test were used. The MEA method uses sensitization of donor platelets with patient plasma in the presence of heparin at a concentration of 0.5 IU/mL. The results were compared with the ELISA test. RESULTS: We examined 190 patients at clinically intermediate and higher risk of HIT according to the 4T score. All samples were examined by the ELISA test and MEA, with positive samples being further confirmed by high-concentration heparin. The methodology was modified with respect to the dilution for high positive samples and assessment has been extended to an index of inhibition. CONCLUSIONS: In the studied group, we demonstrated that MEA has sufficient sensitivity and higher specificity. In the group of patients, 10.0% showed positive results by MEA as compared with 7.3% determined by ELISA. Unlike the ELISA methods of the same quality, MEA is more suitable for detecting platelet-activating HIT antibodies in practice.

[Dabigatran etexilate in clinical practice for prevention of thromboembolic events in patients with atrial fibrillation]. / Dabigatran-etexilát v klinické praxi pro prevenci tromboembolických príhod u nemocných s fibrilací síní

Dabigatrane is the first new generation antiacoagulant that at a dose of 150 mg twice daily was, in the RE-LY study, more effective in cerebrovascular event and systemic embolisation prevention than well-controlled warfarin and had comparable or better safety profile than well-controlled warfarin. The 110 mg twice daily dose showed comparable efficacy and superior safety against warfarin. Crucial and unique among modern anticoagulants is its ability to significantly reduce ischemic as well as hemorrhagic CVEs at a dose of 150 mg twice daily. In addition, dabigatran significantly facilitates management of patients with atrial fibrillation as it does not require laboratory monitoring, has predictable pharmacokinetics, simple dosing regimen that does not require complicated dose adjustments, and does not interact with food. However, it is important to remember that it is an anticoagulant. Care should, therefore, be exercised when the treatment is indicated, renal function has to be known and it needs to be kept in mind that, as with any anticoagulant, the treatment may be associated with bleeding. However, when indication criteria are observed, the above listed advantages considered and careful patient monitoring put in place, the bleeding will be, compared to standard warfarin treatment, minimized. Key words: dabigatran - atrial fibrillation - tromboembolism.

[Basic anthropometric characteristics and their relationship with the metabolism of saccharides in women with PCOS]. / Vybrané antropometrické parametry a jejich vztah k metabolismu sacharidu u zen s PCOS.

AIM OF STUDY: To determine basic anthropometric characteristics and their relationship with the metabolism of saccharides in women with PCOS in the Olomouc region. TYPE OF STUDY: Retrospective study of the results of 72 women with PCOS examined in the endocrinology clinic. MATERIAL AND METHOD: The study entailed the processing of data gained on the basis of examination of women sent to endocrinology clinic for examination in the years 2008-2010, who corresponded to the diagnostic criteria for PCOS according to the Rotterdam consensus. The obtained results of anthropometric measurement and characteristic saccharide metabolism were compared with a group of healthy women. RESULTS: In groups of women of comparable age (PCOS average age 31.6, control group average age 31.4) the average BMI in women with PCOS was 26.76 kg m(-2), the average waist measurement was 84.43 cm, the waist/hips ratio was 0.79, in the control group the average BMI was 24.73 kg m(-2), the waist/hips ratio was 0.76, the differences between the two groups were not statistically significant. There was a statistically significant difference between women with PCOS and the healthy control group in C peptide values, even in comparable anthropometric parameters. Levels of fasting glycaemia and glycated haemoglobin were comparable. Waist measurement, as a parameter for evaluating the level of visceral accumulation of fat in women with PCOS, was related to all monitored characteristics of saccharide metabolism (statistically significant correlation with fasting glycaemia, glycated haemoglobin and C peptide). Unlike the waist measurement, the waist/hips ratio indicated a smaller percentage of women with abnormal obesity in both groups, in women with PCOS it correlated with fasting glycaemia and C peptide. CONCLUSION: On the basis of our results it can be stated that women with PCOS do not necessarily differ from the healthy control group in anthropometric parameters. However, with comparable age, BMI and level of visceral obesity, women with PCOS require a greater amount of insulin to maintain normoglycaemia than healthy women.

[Infective endocarditis--crucial early diagnosis]. / Infekcní endokarditida--klícová vcasná diagnóza.

A 64-year old female patient with polymorbidity, including diabetes, was admitted to our clinic with a suspicion of silent myocardial infarction. However, no acute coronary lesion was subsequently confirmed. Transthoracal echocardiography performed just after the admission suggested infective endocarditis. The diagnosis was difficult due to a lack of collaboration by the patient who was disoriented and confused. Because of the suspicion ofendocarditis, a therapy with antibiotics was started immediately and the diagnosis was confirmed by oesophageal echocardiography and heart MR performed after the patient was stabilized. An early diagnosis and an intensive antibiotic treatment are crucial for the management of the frequently fatal infective endocarditis.

[The hepatic form of Wilson's disease in young patients]. / Jaterní forma Wilsonovy nemoci u mladých pacientu.

UNLABELLED: Wilson's disease (WD) is a hereditary disorder of the copper metabolism with very varied clinical and biochemical symptoms. Hepatic and neurological forms are the most frequent manifestations of this rare disease. In schoolchildren and adolescents symptoms of liver damage predominate. In a retrospective study 19 patients were evaluated with biochemical signs of hepatopathy manifested before the age of 18 years. The diagnosis of WD was established at the age of 7 to 27 years. One female patient was admitted with fulminant hepatic failure which was treated by acute transplantation of the liver in the Institute of Clinical and Experimental Medicine in Prague. Only 9 of 18 patients with chronic hepatic affection at the time of diagnosis met the Sternlieb diagnostic criteria. These patients had reduced ceruloplasmin levels (0.08-0.18 g/l) and a high copper content in the hepatic dry matter (783 ug/g +/- 323 [SD]). In the remaining 9 patients the ceruloplasmin level was normal, however, in 8 a high copper content of the hepatic dry matter was found (696 ug/g (+)- 352[SD]. The last patient from this group had Kayser-Fleischer's (K-F) ring. It was possible to confirm the high copper content in the hepatic dry matter only after one year's penicillinamine treatment because at the time of the diagnosis poor coagulation did not permit to perform a liver biopsy. There was a statistically significant difference in the copper content of the hepatic dry matter in patients meeting and not meeting Sternlieb's criteria. Statistically significant differences between both groups were found in the plasma copper levels and in the 24-hour urinary copper excretion. Histological examination of the liver under a light microscope revealed findings from minimal changes associated with the presence of glycogen nuclei in hepatocytes to the picture of active chronic hepatitis. In all 19 patients the gene mutation H1069Q was examined and the results were positive in 39.8%. In 3 asymptomatic patients it was present in the homozygous form. CONCLUSION: Early detection of the atypical form of WD remains very difficult. The gold standard is still in all cases assessment of copper in the dry liver tissue. In the near future an important place will be held also by direct DNA analysis although its use is limited not only by the large number of known mutations but also by the financial costs of the method.

[Idiopathic hypoparathyroidism with celiac disease--diagnostic and therapeutic problem]. / Idiopatická hypoparatyreóza s celiakií--diagnostické a lécebné problémy.

A middle-aged woman developed gradually diseases where most probably the common denominator is an autoimmune process. The authors describe the clinical condition persisting for seven years, where hypoparathyroidism was associated with coeliac disease which did not respond to dietary measures. Malabsorption was manifested by a selective block for calcium absorption from the gut. The impaired conversion of vitamin D2 to D3 is of interest; it has obviously a multifactorial etiology. The main problem is the patient's tendency to respond by tachyphylaxis to oral vitamin D administration. The only effective therapeutic procedure apart from those listed is so far parenteral administration of vitamin D3, calcitrol.

[Fulminant liver failure as a sequelae of acute dystrophy of the right hepatic lobe]. / Fulminantní jaterní selhání jako následek akutní dystrofie pravého jaterního laloku.

A 38-year-old female patient developed signs of fulminant hepatic failure, caused by extensive, spontaneous, devastating ischaemia of the right liver lobe. The patient survived the acute attack. During the subsequent eight years hypertrophy of the intact left liver lobe occurred which eventually completely replaced the loss of the dominant right lobe.

[Sarcoidosis of the liver, a granulomatous process with an unclear prognosis]. / Sarkoidóza jater, granulomatózní proces s nejasnou prognózou.

The authors demonstrate on two patients the pitfalls of the diagnosis and prognostic uncertainty of systemic sarcoidosis. The typical pulmonary finding was in the background due to the very extensive and serious affection of the liver.

[Adrenal incidentalomas. Clinical experience]. / Incidentalomy nadledvin. Klinické zkusenosti.

In the course of two years the authors treated 27 patients with incidentally detected adrenal tumours. Detailed morphological and laboratory examination revealed four cases of non-classical late type adrenogenital syndrome (AGS) and two pheochromocytomas. From the submitted paper ensues that it is essential to provide interdisciplinary comprehensive treatment in departments which have sufficient experience with this problem.

[Colchicine in the treatment of liver cirrhosis. 12 years' experience]. / Soucasné postavení kolchicinu v lécbe jaterní cirhózy. 12leté zkusenosti.

The authors evaluate more than 12 years of their own experience with the administration of colchicine to patients with cirrhosis of the liver. Colchicine did not produce any apparent undesirable effects. The authors emphasize the absence of knowledge of prognostic parameters (except the stage of the disease and its activity) which would make it possible to evaluate in advance the effect of many years' treatment. They deal separately with a patient who entered their investigation in a very advanced stage of the disease and survived after he had recovered full compensation and did not depend on diuretic treatment.

Effect of physical load on the platelet function and ultrastructure in patients with ischemic heart disease.

The aggregability of the blood platelets and their ultrastructure were examined during the bicycle exercise test in 20 patients with ischemic heart disease and stable angina pectoris. In 8 patients with unequivocally positive exercise test a significant increment of stimulated aggregation from 58.2 (CV7%) to 71.2 (13.6%) resulted in comparison with a group of patients who did not fulfilled criteria of exercise testing. In this group the aggregability dropped from 56.0 (5%) to 38.7 (8.4%) eventually. No changes in a diameter and shape were observed during the exercise test was positive the amount of granules decreased. It is considered to be an indirect proof of the functional changes in thrombocytes during a certain rise in aggregability.

Malignant lymphoma involving the heart.

In a group of 116 patients with different types of malignant lymphoma, the frequency, type and clinical manifestations of heart involvement are evaluated. A case of primary cardiac lymphoma is demonstrated. Along with this, clinical and pathological findings in 15 further subjects with secondary lymphomatous infiltration of the heart are discussed; attention is being paid also to indirect factors causing cardiovascular damage, including radio- and chemotherapy.

Bleeding to the adrenal gland as a terminal manifestation of acute leukaemia.

The authors refer about an unusual localization of haemorrhage to the adrenal glands, observed in two patients with acute leukaemia similar to the picture of Waterhouse-Friderichsen's syndrome. This complication causing serious and dramatic effects should be taken into differential diagnostic consideration. Literature data and own results are given in order to review the general characteristics of bleeding in acute leukaemia.