PATHOLOGICALLY-CONFIRMED ISOLATED HYPOTHALAMO-PITUITARY SARCOIDOSIS REFRACTORY TO PULSE-DOSE GLUCOCORTICOIDS AND SUCCESSFULLY TREATED WITH METHOTREXATE.

Isolated sarcoidosis of the hypothalamic-pituitary system is a very rare form of neurosarcoidosis. A high index of suspicion is required for diagnosis and the choice of therapy embodies another challenge due to lack of standardized protocols. Glucocorticoids are the mainstay of initial treatment, whereas the second and third-line therapy include immunomodulators and cytotoxic drugs, in addition to monoclonal antibodies. This report presents an unusual case of panhypopituitarism in a 32-year-old previously healthy male patient due to isolated hypothalamo-pituitary sarcoidosis confirmed histologically, refractory to pulse-dose glucocorticoids and then successfully treated by methotrexate. Based on our report, in patients requiring additional therapy usage of the methotrexate as the second line agent should be considered, however the time frame and the dosing schedule of methotrexate are still unknown and deserve further investigation.

RESPONSE OF THE CZECH RMN NETWORK TO THUNDERSTORM ACTIVITY.

Thunderstorm ground enhancement (TGE) is a phenomenon that enhances radiation background on the ground related to thunderstorm activity and charge structure of the thundercloud. On the other hand, the rise of gamma background is connected with precipitation by the washout of radon progeny from the atmosphere. In our analysis, we examined known enhancements of gamma background, previously attributed solely to radon progeny, using data from the Czech Radiation Monitoring Network (RMN) to investigate the enhancements with respect to thunderstorms and TGE phenomena. We also used radar precipitation data and data from the lightning location network to analyze their influences on the radiation background enhancement during three thunderstorm events that occurred in summer 2016 over the Czech Republic (Central Europe). We state that the RMN might have detected TGE over the Czech Republic.

A fast and simple approach for the estimation of a radiological source from localised measurements after the explosion of a radiological dispersal device.

After an explosion of a radiological dispersal device, decision-makers need to implement countermeasures as soon as possible to minimise the radiation-induced risks to the population. In this work, the authors present a tool, which can help providing information about the approximate size of source term and radioactive contamination based on a Gaussian Plume model with the use of available measurements for liquid or aerosolised radioactivity. For two-field tests, the source term and spatial distribution of deposited radioactivity are estimated. A sensitivity analysis of the dependence on deposition velocity is carried out. In case of weak winds, a diffusive process along the wind direction is retained in the model.

Field tests using radioactive matter 2.

Results of field tests with explosive dispersal of a radioactive substance (RaS) are presented. The paper deals with tests exploiting artificial obstacles as a continuation and expansion of the tests used in this study performed in free area described previously. The essential goal of the tests was to estimate the distribution of the released RaS in the case of intentional abuse of radioactive sources and to get a set of data applicable to testing physical or mathematical models of propagation. Effects of different geometrical and meteorological conditions on the distribution of dispersed RaS were studied via the assessment of dose rate, surface and volume activities, aerosol mass and activity aerodynamic diameters. The principal results can be summarised as follows: the prevalent proportion of the activity of the radionuclide dispersed by an explosion (born by the blast wave and by air convection) is transferred to the detection system/collecting pads essentially within the first minute. Enhanced aerosol mass concentrations were also detected within the same period. The RaS carried by the blast wave passed through the polygon (50 m) within <1 s. An expected crucial impact of meteorological conditions at the moment of the explosion and shortly after was proved by the tests.

Effect of a public awareness campaign on the incidence of symptomatic objectively confirmed deep vein thrombosis: a controlled study.

BACKGROUND: Although there have been attempts to raise public awareness about deep vein thrombosis (DVT), their influence on identifying confirmed cases is unknown. OBJECTIVE: To determine the effect and its duration of a public awareness campaign about venous thromboembolism. PATIENTS/METHODS: A campaign to raise public awareness of DVT was conducted during one year in an urban population of approximately 100,000 (pop A). A comparison urban population of approximately 1,574,000 (pop B) was not exposed to this campaign. Patients symptomatic for DVT in both populations were referred by general practitioners for a standardized compression ultrasound (CUS) of the whole leg at no charge. Positive CUS examinations documented by photographs were analyzed by an independent adjudication committee blinded to the population. Pop A was followed for 8 months after the information campaign ended. RESULTS AND CONCLUSIONS: Symptomatic objectively confirmed DVT was found in 48 of 800 subjects tested in pop A and 226 of 2384 tested in pop B. The 1-year incidence of confirmed DVT (proximal and distal) was 46/100,000 (95% CI, 33-59) in A and 14/100,000 (95% CI, 12-16) in B (P < 0.001). The increase in pop A was due to distal DVT (36/100,000 vs. 5/100,000 in pop B, P < 0.001). The DVT rate for pop A in an 8-month follow-up period was 12/100,000, significantly lower than in the first 8 months of the study period (34/100,000/8 months) (P = 0.001). The public awareness campaign significantly increased the diagnosis of distal DVT. When the campaign ended, DVT rates returned to community baseline.

Field tests using radioactive matter.

During recent years, the assessment of possible radiological consequences of a terrorist attack associated with a release of radioactive substances (RaS) has been in the focus of interest of emergency preparedness and radiation protection specialists, as well as experts dealing with the dispersion of harmful substances in the atmosphere. Suitable tools for these analyses are applications of mathematical and physical models and simulation of this attack under 'realistic' conditions. The work presented here summarises the results of four tests, in which a RaS (a Tc-99 m solution) was dispersed over a free area with the use of an industrial explosive. Detection methods and techniques employed in these tests are described and values characterising the RaS dispersion--dose rates, surface activities in horizontal and vertical directions, volume activities, their space and time distributions and mass concentrations of aerosols produced after the explosion are presented and compared. These data will be applied to a comparison of outcomes of models used for the assessment of radiation accidents as well as in future field tests carried out under conditions of more complex geometry (indoor environment, terrain obstacles, etc.).

An evaluation of the response of a scintillation detector for estimating the radionuclide composition of a contaminated cloud.

We have made Monte Carlo calculations of the scintillation spectrometer response for the photon field from a cloud of contaminated air after selected scenarios of a nuclear power plant accident. Calculations (using MCNP5 code-X-5 Monte Carlo Team, 2005) were performed for 36 main energy lines of the expected radionuclides. The evaluated spectra enable us to simulate real composite spectra and their evolution in time, and to assess the applicability of a specific spectrometry system for a semi-qualitative and semi-quantitative analysis of the composition of the cloud.

Prevalence, severity and underdiagnosis of COPD in the primary care setting.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common disease with a steadily increasing prevalence and mortality. However, recent epidemiological estimates differ depending on the population studied and methods used. AIM: To investigate the prevalence, severity and burden of COPD in a primary care setting. METHODS: From 4730 patients registered in a single primary care practice, all 2250 patients aged 40 years or more were invited to participate. Participants completed a questionnaire on smoking, respiratory symptoms, education and social status. A physical examination was followed by pre- and post-bronchodilator (BD) spirometry. RESULTS: Of the eligible patients, 1960 (87%) participated. 92% of spirometric tests met the ATS criteria. Airflow limitation was demonstrated in 299 (15%) of the participants pre-BD and in 211 (11%) post-BD. COPD was diagnosed in 183 patients (9.3%). Of these patients, the degree of post-BD airflow limitation was mild in 30.6%, moderate in 51.4%, severe in 15.3% and very severe in 2.7%. Only 18.6% of these patients had previously been diagnosed with COPD; almost all of these had severe or very severe airflow limitation. As a result of the study, a diagnosis of asthma was made in 122 patients. CONCLUSIONS: The prevalence and underdiagnosis of COPD in adult patients in this primary care setting made case finding worthwhile. Large numbers of newly detected patients were symptomatic and needed treatment. Limiting investigations to smokers would have reduced the number of COPD diagnoses by 26%.

Management of purulent pericarditis.

A 50 year old man was admitted to ICU due to purulent pericarditis, purulent inflammation of the soft tissue of the neck, purulent mediastinitis and pneumonia. Subxyphoid periocardiotomy followed by the insertion of a drain into the pericardial space was performed. Four other drains were also inserted to drain purulent fluid from the neck (two drains) and mediastinum (two drains). During the surgical procedure, 700 ml of purulent pericardial fluid from the pericardial sac and 200 ml of purulent fluid from the mediastinum were drained. Antibiotic therapy was started upon admission to the hospital. Streptococcus species, Acinetobacter baumani and Enterococcus casseliflavus were cultured. Antibiotic therapy was adjusted to the results of the antibiogram. Despite revised antibiotic therapy, daily drainage from the pericardium--during several days after surgery--was around 200 ml. Due to the huge purulent pericardial drainage streptokinase, delivered directly into pericardial space, was given. The clinical effect of intrapericardial streptokinase administration was excellent. After 17 days drainage of purulent pericardial fluid was not observed. No clinical signs and symptoms of constrictive pericarditis developed. Repeated echocardiography examinations showed no signs of constrictive pericarditis and no pericardial fluid. The patient was discharged in good general condition.

[Usefulness of measuring levels of d-dimer for diagnosis of hospital venous thromboembolism]. / Przydatnosc oznaczania stezenia d-dimeru w diagnostyce szpitalnej zylnej choroby zakrzepowo-zatorowej (z.ch.z.z.).

D-dimer measurement with highly sensitive tests seems useful to rule out pulmonary embolism (PE) and deep vein thrombosis (DVT). However, nonspecific increase in d-dimer is common among inpatients. The aim of our study was to check: 1) whether the frequency of normal DD level in inpatients justifies its assessment as a part of diagnostic strategy for VTE, 2) whether tests that we are using are sensitive enough to exclude PE and DVT. In 27 (47%) out of 58 hospitalised patients evaluated by ultrafast ELISA (VIDAS bioMerieux), but in none of 20/58 patients with confirmed VTE, DD-level was found normal. In 35 of those patients DD was measured also with microlatex tests--Tinaquant and BC d-dimer. In 14/35 patients imaging test confirmed VTE. Sensitivity, specificity and negative predictive value (NPV) respectively were following: VIDAS: 100%, 80%, 100%, Tinaquant: 100%, 48%, 100%, BC d-dimer: 29%, 90%, 70%. Our results suggest that: 1) the relatively high frequency of normal DD-level among inpatients justifies its use in diagnostic strategies involving hospitalised patients, 2) negative VIDAS test confirms its as reliability for excluding VTE while 3) high sensitivity found for Tinaquant test encourages further prospective studies, 4) sensitivity of BC d-dimer is too low to be useful for excluding VTE.

[Differences in hemodynamics of thromboembolic and primary pulmonary hypertension]. / Róznice w hemodynamice pierwotnego i zatorowego nadcisnienia plucnego.

It is not clear whether right ventricle to pulmonary artery coupling is modified by the site of vascular obstruction in patients with chronic severe pulmonary hypertension. We compared invasively (Swan Ganz) and non-invasively (echo/ /Doppler) assessed hemodynamics between two groups of patients with severe chronic thromboembolic pulmonary hypertension (CTEPH)--(n = 6; 52 +/- 24 yrs) and pulmonary arterial hypertension (PAH) (n = 5; 42 +/- 9 yrs) who had similar invasively measured right ventricular systolic pressure (CTEPH: 78 +/- 14 mm Hg; PAH: 83 +/- 17 mm Hg; p = NS), mean pulmonary arterial pressure (CTEPH: 51 +/- 10; PAH 56 +/- 11 mm Hg, p = NS) and pulmonary vascular resistance (CTEPH: 15.6 +/- 4.4 l/min; PAH: 19.2 +/- 6.1; p = ns). Patients with CTEPH have significantly shorter acceleration time corrected to ejection time (RVET): (AcT/RVET % = 24 +/- 5% vs 32 +/- 6% in PAH; p = 0.04) as well as AcT corrected by RR distance was highly significantly shorter (8 +/- 2% vs 12 +/- 2%; p = 0.006). AcT in the CTEPH group was shorter than in the PAH (60 +/- 5 vs 75 +/- 15; p = 0.047). The mid-systolic deceleration was significantly more frequent in the CTEPH group than in the PAH group (88% vs 30%; p = 0.005). If the mid-systolic deceleration was present in patients with PAH, the time to mid-systolic deceleration (t-N) had tendency to be longer in CTEPH group (118 +/- 22 ms vs 150 +/- 28 ms in PAH; p = 0.09). Significant differences appeared after correction t-N to RVET (t-N/RVET % = 46 +/- 9% vs 61 +/- 4%; p = 0.027) and to RR interval (t-N/RVET % = 16 +/- 2% vs 24 +/- 1%; p = 0.002). Doppler derived RV index proposed by Tei was slightly higher in CTEPH (0.81 +/- 0.18 vs 0.65 +/- 0.32 in PAH) but not significantly. Taken together our observations indicate that dynamical coupling between RV and pulmonary arteries is more disturbed in CTEPH than in PPH despite similar levels of chronically increased PAP.

[Thrombectomy in a patient with a mobile clot in the inferior vena cava--case report]. / Trombektomia u pacjenta z balotujaca skrzeplina w zyle glównej dolnej--opis przypadku.

Switching from heparin to acenocoumarol was complicated by severe retroperitoneal bleeding in a 50-years old patient with massive pulmonary embolism and deep venous thrombosis. The haematomas were evacuated by surgical procedure. Planned insertion of a vena cava filter was abandoned because of a mobile clot in inferior vena cava (IVC) reaching above renal veins as evidenced by spiral computed tomography (SCT). Patient was transferred to the Surgical Department of Medical Academy in Warsaw where thrombectomy was performed. In spite of mechanical and pharmacological methods of venous thrombosis prophylactic, thrombectomy was complicated by massive proximal deep venous thrombosis of right leg and distal part of IVC. Patient was successfully treated with UFH i.v. followed by low molecular weight heparins. No bleeding complications were observed. Screening for thrombophilia and cancer were negative. This case report is an example of difficulties in clinical management in a patient who has both life-threatening thromboembolic disease and bleeding.

[Recombinant hirudine in suspected heparin induced thrombocytopenia--case report of pulmonary embolism]. / Rekombinowana hirudyna w podejrzeniu trombocytopenii zwiazanej z heparyna--opis przypadku zatorowosci plucnej.

A case of 68 years old women suffering from chronic anemia, myelodysplastic syndrome and treated with progestogen due to endometrial hypertrophy is presented. Initially she was admitted to a regional hospital because of progressive weakness and exertional dyspnea. Three months earlier she reported an episode of acute dyspnea and chest pain. On the basis of clinical symptoms and perfusion lung scintigraphy pulmonary embolism (PE) was diagnosed. Patient received i.v. heparin which was changed to s.c. nadroparine subcutaneously. Platelet count dropped to 55,000'/ml on fifth day of treatment from initial level of about 200,000'/ml. Heparin induced thrombocytopenia was diagnosed, heparin was stopped and ticlopidine was recommended. After 3 weeks symptoms suggesting recurrent PE were observed. The patient was transferred to National Tuberculosis and Lung Diseases Research Institute. Recombinant hirudine (Refludan) was administrated (bolus 0.4 mg/kg and initial dose of infusion 0.1 mg/kg/h) overlapping with acenocoumarol from second day. Dose of r-hirudine was adjusted to achieve APTT prolongation 1.5 to 2.5 times of mid-normal range. During treatment with r-hirudine no bleeding and new thromboembolic complications occurred. Platelets count remained within normal range. After 14 days clinical improvement was observed, though symptoms of right ventricular overload and hypoxemia were still present after 6 months of treatment with oral anticoagulants suggesting chronic thromboembolic pulmonary hypertension.

5-HT3 receptor antagonist, tropisetron, does not influence ethanol-induced conditioned taste aversion and conditioned place aversion.

Numerous works have demonstrated an interaction between 5-HT3 receptor antagonists and some of the effects of ethanol (EtOH) using biochemical, electrophysiological, and behavioral techniques. Thus 5-HT3 antagonists are capable of reducing EtOH-induced release of dopamine in the nucleus accumbens, EtOH-induced hyperlocomotion, and voluntary EtOH consumption in laboratory animals. In addition to its rewarding effect, EtOH possesses aversive properties as demonstrated in the conditioned taste aversion (CTA) and conditioned place aversion (CPA) paradigms. The role of 5-HT3 receptors in aversive effects of EtOH remains, however, unknown. We decided to study the effect of 5-HT3 antagonist, tropisetron, on aversive properties of EtOH (1.5 g/kg i.p.) in rats using the CTA and CPA models. In addition, effect of tropisetron on morphine (Mf)-induced CTA (10.0 mg/kg SC) was investigated. Tropisetron (0.001-0.5 mg/kg) did not influence CTA produced by EtOH and Mf. When given alone, it failed to produce any taste conditioning. Furthermore, tropisetron did not modify CPA induced by EtOH. Our results suggest that 5-HT3 receptors are not involved in aversive effects of acute doses of EtOH.

[Still's disease as an example of fever of unknown origin: diagnostic and therapeutic difficulties]. / Choroba Stilla przyczyna goraczki niejasnego pochodzenia: trudnosci diagnostyczno-róznicowe i lecznicze.

A case of systemic form of juvenile chronic arthritis (Still's disease) is presented. Difficulties in confirmation of diagnosis are described. After nonsteroidal-antiinflammatory drugs and cytostatics administration very good therapeutical effect was achieved.

Low dose of ethanol induces conditioned place preference in rats after repeated exposures to ethanol or saline injections.

Using the place conditioning paradigm (biased design), we have shown that five conditioning sessions with ethanol (0.5 or 1.0 g/kg i.p.) did not result in place conditioning response. In contrast, rats that received 20 injections of ethanol (0.5 g/kg) or saline, before the conditioning procedure, showed significant place preference to the compartment paired with 0.5 g/kg ethanol (but not 1.0 g/kg).

Conditioned place preference after prolonged pre-exposure to ethanol.

Conditioned place preference (CPP) paradigm has been used to test ethanol (EtOH) rewarding properties after repeated (20 days) injections of EtOH. Rats injected with 0.5 g/kg ip of EtOH during pre-exposure period and CPP procedure showed significant place preference to the compartment paired with the drug. Animals receiving higher dose of EtOH (1.0 g/kg) showed no CPP but rather relative aversion to the paired compartment (relatively to saline-treated group). Our result suggests a development of sensitization to EtOH rewarding effect after prolonged administration of low dose of EtOH.