Flow-mediated vasodilatation in the patients with anorexia nervosa.

OBJECTIVE: To compare flow-mediated vasodilatation in patients with anorexia nervosa and healthy subjects. BACKGROUND: Endothelial dysfunction is present in the patients with anorexia nervosa. However, flow-mediated vasodilatation in the patients with anorexia nervosa in comparison with control subjects has not been yet evaluated. METHODS: Flow-mediated vasodilatation in the brachial artery was examined in 30 patients with anorexia nervosa admitted to metabolic care unit for realimentation and compared to 30 control subjects. RESULTS: The average age of the patients with mental anorexia was 25.0±5.2 compared to 25.5±4.5 years of the healthy control subjects (NS). BMI was in 14.0±1.7 kg/m2 in patients with anorexia nervosa comparing to 20.4±1.0 kg/m2 in the healthy control subjects (p<0.001). The baseline mean diameter of the right brachial artery was 0.33±0.06 cm in the anorexia nervosa patients and 0.35±0.05 cm in the control subjects (NS). The absolute increase of brachial artery size after reactive hyperemia was 0.029±0.006 cm (9%) in the anorexia nervosa patients and 0.039±0.006 cm (11 %) in the control subjects (p=0.002). After realimentation, the baseline mean diameter of the right brachial artery was comparable to the result before nutrition intervention - 0.34±0.05 cm but brachial artery increase due to reactive hyperemia was 0.036±0.05 cm (10.5 %). It was for 19 % higher compared to the first examination (p<0.001). CONCLUSION: Flow-mediated vasodilatation is decreased in the patients with anorexia nervosa in comparison with the healthy control subjects and improves after realimentation (Tab. 1, Ref. 20).

[Chronic obstructive pulmonary disease in the light of new guidelines -  brief summary of phenotypically oriented guidelines for nonpulmonary physicians]. / Chronická obstrukcní plicní nemoc pohledem nových doporucení -  souhrn aktuálního fenotypove zamereného standardu Ceské pneumologické a ftizeologické spolecnosti pro internisty.

INTRODUCTION: COPD is a global health and social problem. Morbidity and mortality increases in the Czech Republic. There are currently several global statements and strategies. METHODS: The Czech Pneumological and Phthisiological Society (CPFS) at the end of 2011 mandated the Section of bronchial obstruction in drafting national guidelines concerning the stable COPD. Subsequently, this document was discussed during the National Consensus Conference (COPD forum) in November 2012 and presented at series of local workshops and national conferences. National guidelines has been subject to a review and eventually posted on the website for another round of comments. DIAGNOSIS: A modern approach to COPD is a view of the patient through the pulmonary function, symptoms, exacerbation rates and the presence of specific phenotypes. CPFS identified six clinically relevant phenotypes: frequent exacerbators, COPD and asthma overlap, COPD and bronchiectasis overlap, emphysematic phenotype, bronchitic phenotype and phenotype of pulmonary cachexia. TREATMENT: TREATMENT recommendations can be divided into four elementary steps: the first step is the Elimination of all risks factors. The second one is the Standard therapy including in particular inhaled bronchodilators, pulmonary rehabilitation, and treatment of severe comorbidities. The third step is the Targeted therapy centered on clinical phenotypes of COPD. The final fourth step is the treatment of respiratory insufficiency and palliative care of the terminal COPD. CONCLUSION: The optimal treatment of COPD requires a personalized approach to the patient.

Exercise Tolerance in Patients With Idiopathic Pulmonary Fibrosis, Effect of Supplemental Oxy-Gen.

Exercise tolerance in patients with idiopathic pulmonary fibrosis IPF is mainly limited by mechanical constrain of ventilation and high physiologic dead space. Oxygen enriched gas inhalation seems to increase ventilatory efficiency by reduction of dead space to tidal volume ratio (VD/VT) which probably mirrors improved pulmonary capillary flow and leads to longer physical tolerance at lower level of minute ventilation. The effect is noticeable at FIO2 that can be delivered in rehabilitation purposes or daily living activities.

The impact of early diastolic myocardial relaxation on the other parameters of diastolic function and association of tissue Doppler parameters of diastolic function with diabetes compensation and duration in type 2 diabetic patients.

This study assessed the impact of tissue Doppler derived myocardial early diastolic relaxation velocity (E(m)) on the other parameters of diastolic function (preload dependent transmitral early diastolic velocity [E], tissue Doppler derived myocardial late diastolic velocity [A(m)], preload dependent transmitral late diastolic velocity [A]) and evaluated the correlation of these parameters with selected clinical variables in type 2 diabetic patients. Using tissue Doppler echocardiography, 82 type 2 diabetic patients were evaluated, divided into two equal groups of E(m) < 7.5 cm/s or > or = 7.5 cm/s. Patients with E(m) < 7.5 cm/s had significantly lower E/A and E(m)/A(m), and higher E/E(m) values. Multilinear regression showed a negative correlation between E(m) and glycated haemoglobin (Hb(A1c)) and duration of diabetes, a negative correlation of E(m)/A(m) with age, duration of diabetes and Hb(A1c), and a positive correlation of E/E(m) with age, duration of diabetes and use of diuretics. The E/A ratio only correlated negatively with age. It is concluded that E(m) is a reliable parameter of diastolic function, and that the tissue Doppler parameters of diastolic function are associated with diabetes compensation and diabetes duration.

Common carotid artery intima-media thickness is not increased but distensibility is reduced in normotensive patients with type 2 diabetes compared with control subjects.

This study evaluated carotid artery parameters in normotensive patients with type 2 diabetes compared with non-diabetic control subjects. Using a high-resolution B-mode ultrasound scanner, common carotid artery intima-media thickness (IMT) and carotid tree atheroma thickness were measured in 82 patients with type 2 diabetes and 41 controls. The distensibility of the common carotid artery was calculated using the Reneman equation. Distensibility was significantly decreased and atheroma thickness was significantly increased in the diabetes group. There was no significant difference in IMT between the two groups. Stepwise linear regression analysis revealed an association between common carotid artery distensibility and post-ischaemic dilatation of the brachial artery (a measure of endothelial function), body mass index and diabetes duration in patients with type 2 diabetes. In conclusion, common carotid artery IMT in normotensive patients with type 2 diabetes is comparable to that of control subjects, whereas atheroma thickness is higher and arterial stiffness more pronounced in those with type 2 diabetes, indicating the existence of atherosclerotic changes in normotensive type 2 diabetes patients.

Echocardiography and carotid sonography in diabetic patients after cerebrovascular attacks.

This study evaluated the aetiological factors for cerebrovascular attack (CVA) using echocardiography and sonography of the carotid arteries. Results from 253 patients with CVA were evaluated retrospectively and analysed according to the presence or absence of diabetes and atrial fibrillation. In patients with sinus rhythm (n = 182), the presence of diabetes was associated with an increased incidence of atherosclerotic changes and significant stenosis of the carotid artery as well as greater intima-media thickness. In contrast, when evaluating signs of thromboembolic risk, there were no statistically significant differences in left atrial diameter or left ventricular ejection fraction between the two groups. In patients with atrial fibrillation (n = 71), no significant differences were observed between diabetic and non-diabetic patients in any of the parameters measured. These findings suggest that the increased risk of ischaemic CVA in diabetic patients is due to atherosclerosis in the carotid vessels rather than embolism of cardiac origin.

Non-invasive assessment of respiratory muscle function and its relationship to exercise tolerance in patients with chronic obstructive pulmonary disease.

Most patients with chronic obstructive pulmonary disease (COPD) have impaired respiratory muscle function. Maximal oesophageal pressure correlates closely with exercise tolerance and seems to predict the distance walked during the 6-min walk test. This study assessed the non-invasive parameters of respiratory muscle function in 41 patients with COPD to investigate their relationship to pulmonary function tests and exercise tolerance. The COPD patients, who demonstrated the full range of airway obstruction severity, had a mean forced expiratory volume in 1 s of 42.5% predicted (range, 20 - 79% predicted). Both the maximal inspiratory muscle strength and non-invasive tension-time index were significantly correlated with the degree of lung hyperinflation, as expressed by the ratio of residual volume to total lung capacity, and the distance walked in 6 min. We conclude that respiratory muscle function was influenced mainly by lung hyperinflation and that it had an important effect on exercise tolerance in COPD patients.

Strategy aimed at reduction of sputum eosinophils decreases exacerbation rate in patients with asthma.

Under Global Initiative for Asthma guidelines, the clinical control of disease activity and the adjustment of treatment in patients with asthma are based on symptoms, use of rescue medication, lung function and peak expiratory flow measurement (standard strategy). We investigated whether a strategy to reduce the number of sputum eosinophils (EOS strategy) gives better clinical control and a lower exacerbation rate compared with the standard strategy. Fifty-five patients with moderate to severe asthma entered this open, randomized, parallel-group study and visited the out-patient department every 3 months for 18 months. The dose of corticosteroids was adjusted according to the standard strategy or the percentage of sputum eosinophils (EOS strategy). During the study period, the EOS strategy led to a significantly lower incidence of asthma exacerbations compared with the standard strategy group (0.22 and 0.78 exacerbations per year per patient, respectively). There were significant differences between the strategies in time to first exacerbation.

The significance of carotid artery plaques in the detection of coronary artery disease in asymptomatic type 2 diabetic patients.

This study aimed to evaluate whether there was any association between carotid artery ultrasound parameters and the results of stress myocardial single photon emission computed tomography (SPECT) and coronarography in 126 asymptomatic type 2 diabetic patients. Thirty-three (26%) patients had an abnormal SPECT result, 33 (26%) had an intermediate result and 60 (48%) had a normal result. Carotid ultrasound demonstrated a significant association between an abnormal SPECT result and the presence of atheroma plaques and reduced distensibility of the common carotid artery, but there was no association with intima-media thickness (IMT). In 38 diabetic patients who agreed to be examined with selective coronarography, significant coronary stenosis (at least one stenosis > or = 70%) was diagnosed in 22 (58%) patients. A significant association was demonstrated between significant coronary stenosis and the presence of atheroma plaques; however, there was no association between stenosis and reduced distensibility of the common carotid artery or IMT.

[The role of bronchial artery embolization in the treatment of hemoptysis]. / Postavení embolizace bronchiální tepny v terapii klinicky významné hemoptýzy.

BACKGROUND: Moderate and severe hemoptysis is a potential life-threatening condition which requires immediate medical examination and intervention. AIM: Retrospective evaluation of the effectiveness of bronchial artery embolization in the management of hemoptysis (over 50 ml per 24 hours) in the university hospital (from 1998 to 2005). METHODS: A retrospective case study. Forty seven consecutive patients with hemoptysis over 50 ml per 24 hours were reviewed and data collected from medical documentation (medical history, chest X-ray, bronchoscopy, thorax spiral CT, pulmonary and bronchial angiography). RESULTS: Forty seven patients, 34 men and 13 women aged between 19-87 years, mean age of 57.1 years, were included in this study. All patients had clinically important hemoptysis (more than 50 ml blood in 24 hours), 23 patients 50-200 ml, 14 patients 200-500 ml, 10 patients over 500 ml. Twenty eight patients had reccurent hemoptysis and nineteen patients had the first stage of hemoptysis. Within the study group we recorded the following clinical causes of hemoptysis: 12 COPD with bronchiectasis, 11 pulmonary malignancy, 11 idiopatic hemoptysis, 5 arterioarterial shunts, 3 pneumonia, 2 aspergillomas, 1 posttuberculous scars, 1 pulmonary trauma, 1 pulmonary arteriovenous malformation. All 47 patients underwent angiography. Thirty seven bronchial artery embolizations (BAE) were performed on the side with greater bronchoscopy and CT abnormality. Polyvinyl-alcohol (sponge particles 45-350 pm) or acrylate glue were used as embolizing agents. We did not observe any complication during this procedures (BAE). Immediate success i.e. cessation of hemoptysis was achieved in 36 patients (97%). Follow-up lasted 4-63 months (33 patients). BAE resulted in long-term success i.e. no recurrent hemoptysis for 28 patients (85%). CONCLUSION: Transcatheter bronchial artery embolization is an effective and safe procedure for patients suffering from clinically important hemoptysis. Short-term control of hemoptysis can be achieved in 97% and long-term control in 85% of cases. Bronchial artery embolization is a treatment which can reduce the need for acute thoracic surgery.

Airflow limitation is accompanied by diaphragm dysfunction.

Chronic airflow limitation, caused by chronic obstructive pulmonary disease (COPD) or by asthma, is believed to change the shape and the position of the diaphragm due to an increase in lung volume. We have made a comparison of magnetic resonance imaging (MRI) of diaphragm in supine position with pulmonary functions, respiratory muscle function and exercise tolerance. We have studied the differences between patients with COPD, patients with asthma, and healthy subjects. Most interestingly we found the lung hyperinflation leads to the changes in diaphragmatic excursions during the breathing cycle, seen in the differences between the maximal expiratory diaphragm position (DPex) in patients with COPD and control group (p=0.0016). The magnitude of the diaphragmatic dysfunction was significantly related to the airflow limitation expressed by the ratio of forced expiratory volume in 1 s to slow vital capacity (FEV(1)/SVC), (%, p=0.0007); to the lung hyperinflation expressed as the ratio of the residual volume to total lung capacity (RV/TLC), (%, p=0.0018) and the extent of tidal volume constrain expressed as maximal tidal volume (V(Tmax)), ([l], p=0.0002); and the ratio of tidal volume to slow vital capacity (V(T)/SVC), (p=0.0038) during submaximal exercise. These results suggest that diaphragmatic movement fails to contribute sufficiently to the change in lung volume in emphysema. Tests of respiratory muscle function were related to the position of the diaphragm in deep expiration, e.g. neuromuscular coupling (P(0.1)/V(T)) (p=0.0232). The results have shown that the lung volumes determine the position of the diaphragm and function of the respiratory muscles. Chronic airflow limitation seems to change the position of the diaphragm, which thereafter influences inspiratory muscle function and exercise tolerance. There is an apparent relationship between the position of the diaphragm and the pulmonary functions and exercise tolerance.

The association between left ventricle diastolic dysfunction and endothelial dysfunction and the results of stress myocardial SPECT in asymptomatic patients with type 2 diabetes.

Diabetes mellitus is associated with a poor cardiovascular prognosis. Stress myocardial single-photon emission computed tomography (SPECT) reliably detects coronary ischaemia in asymptomatic patients. Our study aimed to evaluate the association between systolic and diastolic left ventricular function, left ventricular hypertrophy, endothelial function and the results of stress myocardial SPECT in 126 patients with type 2 diabetic patients with no cardiovascular symptoms. Thirty-three patients (26%) had abnormal SPECT results, 33 patients (26%) had intermediate (equivocal) results, and 60 patients (48%) had normal results. We found a significant association between an abnormal SPECT result, left ventricular diastolic dysfunction and impaired post-ischaemic dilatation of the brachial artery. No association was found between the SPECT result and systolic function and left ventricular hypertrophy, however. An abnormal SPECT result was significantly associated with left ventricular diastolic dysfunction and the deterioration of post-ischaemic dilatation of the brachial artery in asymptomatic patients with type 2 diabetes.

[Exercise tolerance in patients with chronic obstructive pulmonary disease]. / Tolerance fyzické záteze u pacientu s chronickou obstrukcní plicní nemocí.

Limitation of exercise tolerance, especially activities of daily living, is the most significant clinical experience, which greatly affects quality of life of patients with chronic obstructive pulmonary disease (COPD). Many advances in the understanding of the pathophysiological mechanisms of bronchial obstruction in patients with COPD and their meanings for diagnosis and monitoring of the disease have occurred during the last two decades. The author discusses the most significant factors, which influence tolerance of physical exercise in patients with more advanced forms of COPD, and brings the attention to a practical test of physical capacity.

Primary sclerosing cholangitis. Light and electron microscopy of hepatic tissue in two cases.

In an 18 year-old woman presenting with an intra- and extrahepatic form of sclerosing cholangitis needle biopsy of the liver revealed, in addition to a conspicuous proliferation of biliary ductules and mild inflammatory infiltrations of the portal tract, piece-meal necroses and focal intralobular inflammatory changes. In the second case - a 49-year-old man - presenting with an extrahepatic location of stenoses there were infrequent proliferating biliary ductules in the enlarged fibrotic portal tracts. Ultrastructural investigations revealed in both patients adverse regressive changes in the epithelium of proliferating biliary ductules, seen as microvillous damage on the luminal surface, dilation of the endoplasmic reticulum and mitochondrial swelling; in the second patient there was, moreover, electrondense material in epithelial cytoplasm, probably corresponding to bile components. In the first patient predominated among ultrastructural changes increase of cytoskeletal filaments in some epithelia and pronounced reduplication of the basement membranes of small biliary ducts. These "cholestatic" modifications, expressed in different form in the two patients, were accompanied by dilatation and damage, sometimes total disappearance of microvilli of biliary canaliculi.

Sarcoidosis of the stomach. Endoscopic diagnosis and possibilities of conservative treatment.

Previously, the diagnosis of gastric sarcoidosis was only possible in retrospect - on the basis of the histology of the excised part of the stomach, since most patients with a suspected malignancy of the stomach or ulcerative haemorrhages underwent surgery. The diagnosis was verified by a positive Kveim test. Contemporary possibilities of endoscopic diagnosis, together with bioptic verification, permit conservative treatment as an alternative that spares the patient a resection of the stomach. Experience with such a conservative approach is, however, as yet somewhat scanty. The authors submit the case of a 31-year-old patient, in whom sarcoidosis of the stomach - initially identified at our department during 5000 routine fibroendoscopies of the upper digestive tract - was diagnosed endoscopically and bioptically and confirmed by the Kveim test. Prednisone (30 mg a day) was administered in decreasing doses - at present, the patient is on a maintenance dose of 5 mg a day. His digestive complaints quickly disappeared, he gained weight and returned to his job. Objectively, too, the macroscopic changes in the gastric mucosa regressed, although granulomas persist to a lesser extent in biopsy findings. With conservative treatment regular endoscopic and biopsy checkups are essential.

Comparison of the exercise ECG and stress myocardial SPECT in detection of the significant coronary artery disease in the asymptomatic patients with diabetes mellitus type 2.

BACKGROUND: Diabetes mellitus is known to be a risk factor of the coronary heart disease even in the asymptomatic patients. Only a limited number of reports comparing the significance of different noninvasive stress tests in establishing the diagnosis of the advanced coronary lesions exists. OBJECTIVES: The aim of the study was to compare the significance of 12-lead exercise ECG and the myocardial SPECT in order to detect the significant coronary heart disease in asymptomatic type 2 diabetics. METHODS: 126 type 2 diabetic patients with negative history and no clinical or electrocardiographic signs of coronary heart disease were examined with the exercise ECG and the stress myocardial SPECT. The selective coronary angiography (SCG) was recommended to all patients with an abnormal SPECT or (and) a positive exercise ECG. The SCG was recommended to patients with equivocal results of the stress myocardial SPECT as well. RESULTS: 33 out of 126 examined patients (26.2%) had an abnormal, 33 equivocal and 60 normal stress myocardial SPECT. The exercise test could be evaluated in 99 examined patients (78%). 25 diabetics had positive test (19.8%). The correlation between the results of 2 tests was very good (p=0.0001). 38 patients had SCG, 24 with the abnormal SPECT, 13 with equivocal and 1 with normal SPECT. Out of these 20 patients had positive, 10 negative and 8 non-assessable exercise ECG. The relation between the presence of significant coronary stenosis (stenosis >70%) and the presence of abnormal stress myocardial SPECT was stronger (p=0.006) when compared with the positive exercise test (p=0.037). For the significant coronary stenosis the positive predictive value was 90% with the stress myocardial SPECT and 68% with the exercise ECG. CONCLUSION: The significance of the exercise ECG is lower predominantly due to high proportion of patients with non-assessable results. For the presence of significant coronary stenosis the positive predictive value of the stress myocardial SPECT is better than that of the exercise ECG. (Tab. 2, Ref: 25.)

[A modern approach to the treatment of bronchial asthma]. / Moderní prístup k lécbe asthma bronchiale.

The view on etiopathogenesis of bronchial asthma has changed considerably in recent years. Bronchial asthma is now understood as an inflammatory disease of the airways which show characteristic pathologic features: infiltration of the airways with inflammatory cells (especially eosinophils and T lymphocytes), epithelial shedding, airway smooth muscle thickening, subepithelial fibrosis, mucus gland and goblet cell hyperplasia with hypersecretion of mucus. Classification based on etiology unfortunately has not the immediate influence on the treatment of patients with asthma and therefore classification based on severity of disease was approved by several international consensus reports, which divide asthma into four groups: intermittent asthma, and mild, moderate and severe persistent asthma. From the second step (mild persistent asthma) antiinflammatory drugs are considered as the first line therapy, of which inhaled glucocorticosteroids are both in adults and children the most effective controllers. There is increasing evidence that early intervention with inhaled corticosteroids can prevent development of irreversible airway obstruction. Most patients with asthma can get their disease under optimal control and reach the goals of treatment by long-term management in the stepwise approach. Self-monitoring and regular follow-up with ongoing education is one of the most important part of long-term management program.

[Liver resection from the viewpoint of the internist]. / Resekce jater z pohledu internisty.

Resection of the liver as the most suitable mode of treatment of hepatocellular carcinoma is successful, if the principles of secondary prevention are enforced when following up known cirrhotic patients, and the hepatoma is detected in the initial stage with a defined focus of 2-4 cm in diameter. Alternative treatment can be direct under ultrasonographic control and administration of 96% alcohol, or a combination of the two procedures or the use of cytostatics. In benign focal hepatic processes such as hepatocellular adenoma, haemangioma, focal nodular hyperplasia, nowadays resection is usually not used if the benign character of the tumour is beyond doubt. An exception is hepatocellular adenoma, where the risk of haemorrhage is enhanced. Special attention should be paid to surgery of a single or few metastases in the liver found during surgery of colorectal carcinoma or during the follow-up of operated patients. Sometimes thus the quality of their lives is improved and prolonged.

[Non-alcoholic risks of alcoholic beverages]. / Nealkoholická rizika alkoholických nápoju.

Alcoholic beverages are a potential source of numerous health risks. The general risks are well known; first of all they result from the contents of the alcohol and their degree is directly proportional to the amount consumed. However, alcoholic beverages contain also a wide range of non-alcoholic components, which can be a source of health risks as well. Some of these substances work through allergic or pseudoallergic mechanisms and such undesired response can appear early after the consumption of a small amount of beverage. The article offers a basic survey of alcoholic beverages; it mentions important technological procedures of their production stating also the most significant resulting components of their individual types. A special attention is paid to the non-alcoholic components, which can be the cause of undesired effects on the human health.

[Doping in sports]. / Doping ve sportu.

The first organized doping controls were carried out in the 1970s. In 1993, the Czech Antidoping Charter was signed and the Antidoping Committee was established. The medical commission of International Olympic Committee decides, which substances and methods are prohibited. The current classification is as follows: I. prohibited classes of substances--stimulants, narcotics, anabolic agents, diuretics and some hormones. II. prohibited methods--blood doping and pharmaceutical, chemical or physical manipulation. III. classes of drugs subject to certain restrictions--alcohol, marijuana, local anesthetics, corticosteroids and beta blockers. All substances are characterized from the ergogenic viewpoint and health risks are particularly emphasized. In practice, doping control starts by drawing the athletes and ends by urine sample analysis in a special laboratory. In case of positive results, the sportsman is banned from sports activity for 3 months, 2 years or for the rest of his life. In 24 worldwide laboratories in 1995 93,938 urine samples were analyzed. 1516 (1.61%) proved to be positive, including 986 anabolic steroid use. In 1997, the Czech laboratory carried out 843 checks, of which 15 (1.7%) were positive. The largest positive doping group were body builders. Doping poses a major risk among junior sportsmen. Prevalence worldwide is estimated at 2-10% of the male population. In the future a severe antidoping attitude, as well as antidoping enlightenment, are certain to continue. By these standards the activity of the Czech Antidoping Committee is on a very high level.