In the prevention of dementia, the focus should be on early and consistent treatment of hypertension

The brain is among the target organs of hypertension. Patients with hypertension have a higher risk of developing stroke as well as experiencing a decline in cognitive functions and dementia. Changes in the white matter and atrophy of the grey matter of the brain induced by high blood pressure develop insidiously since the onset of hypertension, even in young individuals. The effect of high blood pressure on the vessel wall cumulates in time; therefore, hypertension in younger people implies an increased risk of dementia in older age. Hypertension in young age cannot be considered a benign condition. Hypertension in middle age increases the risk of dementia by 61 %. Consistent and early hypertension control can reverse the adverse development towards dementia and lack of self-sufficiency in the patient. Data comparing individual antihypertensive drugs in terms of preventing dementia are scarce. However, renin angiotensin system blockers have been found to protect against Alzheimer's disease more than other classes of antihypertensive drugs. To achieve rapid and effective hypertension control, a combination of antihypertensive drugs is usually required. Using a fixed-dose triple combination of perindopril, indapamide, and amlodipine, blood pressure targets of < 130/80 mm Hg can be achieved within three months in 93 % of patients.

Polymorphism rs7079 in miR-31/-584 Binding Site in Angiotensinogen Gene Associates with Earlier Onset of Coronary Artery Disease in Central European Population

Angiotensinogen (AGT) represents a key component of the renin-angiotensin-aldosterone system (RAAS). Polymorphisms in the 3' untranslated region (3'UTR) of the AGT gene may alter miRNA binding and cause disbalance in the RAAS. Within this study, we evaluated the possible association of AGT +11525C/A (rs7079) with the clinical characteristics of patients with coronary artery diseases (CAD). Selective coronarography was performed in 652 consecutive CAD patients. Clinical characteristics of the patients, together with peripheral blood samples for DNA isolation, were collected. The genotyping of rs7079 polymorphism was performed with TaqMan^® SNP Genotyping Assays. We observed that patients with the CC genotype were referred for coronarography at a younger age compared to those with the AA+CA genotypes (CC vs. AA+CA: 59.1 ± 9.64 vs. 60.91 ± 9.5 (years), p = 0.045). Moreover, according to the logistic regression model, patients with the CC genotype presented more often with restenosis than those with the CA genotype (p = 0.0081). In conclusion, CC homozygotes for rs7079 present with CAD symptoms at a younger age compared with those with the AA+CA genotype, and they are more prone to present with restenosis compared with heterozygotes.

Longitudinal Monitoring of Hair Cortisol Using Liquid Chromatography-Mass Spectrometry to Prevent Hypercortisolism in Patients Undergoing Glucocorticoid Replacement Therapy

OBJECTIVE

Currently available methods for endogenous cortisol monitoring in patients with hormonal insufficiency rely on measurements of plasma levels only at a single time point; thus, any kind of chronic exposure to cortisol is challenging to evaluate because it requires collecting samples at different time points. Hair cortisol levels acquired longitudinally better reflected chronic exposure (both cortisol synthesis and deposition) and may significantly contribute to better outcomes in glucocorticoid replacement therapies.

DESIGN

Twenty-two patients on cortisol substitution therapy were monitored for plasma, urinary, and hair cortisol levels for 18 months to determine whether hair cortisol may serve as a monitoring option for therapy setting and adjustment.

METHODS

Plasma and urinary cortisol levels were measured using standardized immunoassay methods, and segmented (∼1 cm) hair cortisol levels were monitored by liquid chromatography coupled to mass spectrometry. A log-normal model of the changes over time was proposed, and Bayesian statistics were used to compare plasma, urinary, and hair cortisol levels over 18 months.

RESULTS AND CONCLUSIONS

Hair cortisol levels decreased over time in patients undergoing substitutional therapy. The residual variance of hair cortisol in comparison to plasma or urinary cortisol levels was much lower. Thus, longitudinal monitoring of hair cortisol levels could prove beneficial as a noninvasive tool to reduce the risk of overdosing and improve the overall patient health.

New onset of diabetes mellitus and weight loss as a manifestation of pancreatic cancer

The case report is about a 68-years-old man who developed a weight loss and diabetes mellitus as early symptoms of pancreatic cancer several months before the diagnosis. Unfortunately, the diagnosis was made too late, at the stage of generalized disease, when symptomatic treatment was the only possible way. The aim of the article is to warn about this possible way of pancreatic cancer manifestation, because only the diagnosis determined in time, when the tumor is localized, allows its resection - the only curative treatment method. For this reason, it is necessary to consider the presence of pancreatic cancer in the case of an atypical manifestation of diabetes.

Rivaroxaban for the treatment and prevention of reccurence of venous thromboembolism in children

Venous thromboembolism in children is rare, but the incidence has increased sharply during the last years. The standard of care for treating this disease consists of warfarin, unfractionated heparin, low-molecular-weight heparins and fondaparinux. Lately, the usage of rivaroxaban (direct oral anticoagulant) was officially approved. According to a recent study, treatment with rivaroxaban resulted in a similarly low recurrence risk and reduced thrombotic burden without increased risk of bleeding. The usage of direct oral anticoagulants could overcome the limitation of currently used care (mainly the necessity of regular laboratory monitoring and parenteral application) while providing similar efficacy and safety to treat venous thromboembolism in children.

Perindopril: a long-term certainty in treating hypertension

Blockade of the renin angiotensin aldosterone system (RAAS) is currently considered to be the gold standard of antihypertensive therapy. ACE inhibitors and AT1-blockers are clinically the most relevant groups of RAAS blockers. Even though both drug groups block angiotensin II, ACE inhibitors typically reduce the degradation of bradykinin, which leads to the release of nitric oxide and prostaglandins with subsequent vasodilation. These differences in the mechanism of action can be of clinical relevance for hypertensive patients. Morbidity mortality studies of RAAS blockers have been reported in which ACE inhibitors, particularly perindopril, improved the overall survival in hypertensive patients. In the ONTARGET trial, a direct comparison of both drug groups yielded comparable results. Perindopril, which has been used in the clinical practice for more than 25 years, is a long-acting lipophilic angiotensin-converting enzyme inhibitor with a once-daily dosage schedule and a high affinity to tissue-converting enzyme. Its safety, efficacy, and very good tolerance have been shown in a number of studies. It is part of many fixed combinations which improve patient compliance and increase the effect of treatment of cardiovascular diseases.

Endoscopic diagnostics and therapy of pancreatobiliary diseases in persons after gastric resection according to Billroth I

The stomach resection according to Billroth I (B I) is very rarely done. The aim of this retrospective study is to evaluate our experience with diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients after stomach resection according to Billroth I. In patients with a condition after stomach resection according to B I, a study of the group of 20 years (November 1994 - December 2014) took place. Three patients were evaluated retrospectively after B I stomach resection with biliary obstruction. For the ERCP was used the Olympus therapeutic videotheroscop in all cases with the standard (as in normal anatomical situation). Cannulation success in diagnostic ERCP was achieved in 3 out of 3 patients - 100% success rate of ERC diagnosis. For all these 3 patients CDL was found in the ERCP. In addition, endoscopic treatment was performed immediately after ERCP diagnosis in all 3 patients with a CDL pathologic ERCP diagnosis, the initial endoscopic papillotomy (EPT) performed in the standard procedure (as in normal anatomy). Subsequently, endoscopic extraction of all CDL from hepatocholedocus to duodenum was performed. Overall the ERCP was completely successful in all 3 of the 3 (100% of 3) patients who initially started endoscopic therapy. There were no complications in our group of 3 patients. For ERCP in patients with BI stomach resection, we had 100% success rate of diagnostic and therapeutic ERCP in all of these patients (3 CDL patients).

Non-coding RNAs and Cardiac Arrhythmias

Cardiac arrhythmias represent wide and heterogenic group of disturbances in the cardiac rhythm. Pathophysiology of individual arrhythmias is highly complex and dysfunction in ion channels/currents involved in generation or spreading of action potential is usually documented. Non-coding RNAs (ncRNAs) represent highly variable group of molecules regulating the heart expression program, including regulation of the expression of individual ion channels and intercellular connection proteins, e.g. connexins.Within this chapter, we will describe basic electrophysiological properties of the myocardium. We will focus on action potential generation and spreading in pacemaker and non-pacemaker cells, including description of individual ion channels (natrium, potassium and calcium) and their ncRNA-mediated regulation. Most of the studies have so far focused on microRNAs, thus, their regulatory function will be described into greater detail. Clinical consequences of altered ncRNA regulatory function will also be described together with potential future directions of the research in the field.

Rivaroxaban in COMPASS trial

Cardiovascular diseases (CVD) are still at the first place in the case of mortality in European countries. Consistent secondary prevention for CVD is very important aspect in the fight with this negative statistics. We consider antithrombotic treatment as a gold standard in secondary prevention for CVD . There are a lot of latest trials about this problematics. COMPASS trial targets the effectiveness of rivaroxaban in patients with CVD as a secondary prevention. The results of this trial are very positive about using rivaroxaban and acetylsalicylic acid together in effort to avoid progression or relapse of CVD.

ERCP in patients after choledochodenoanastomosis

The aim of this retrospective study is to evaluate our experience with diagnostic and therapeutic endoscopic retrograde cholangiopancreaticography (ERCP) in patients after choledochoduodenoanastomosis.

METHODS

The study took 20 years (November 1994 - December 2014). Three patients after choledochoduodenoanastomosis who had symptoms of biliary obstruction were retrospectively evaluated. In all cases, a standard therapeutic videolateroscope was used to perform ERCP.

PATIENTS AND RESULTS

We achieved ERCP in these 3 patients with choledochoduodenoanastomosis 100% cannulation success rate - 3 out of 3 patients. This was 100% success rate of diagnostic ERCP. In all of these patients, ERCP was found - both stenosis of the natural mouth of the Vater papilla, stenosis of choledochoduodenoanastomosis, and suprastenotic distal choledocholithiasis. In all patients with the above-described ERCP pathology, endoscopic treatment was initiated immediately after diagnostic ERCP, consisting of standard endoscopic papillotomy of the stenotic Vater papilla, balloon dilatation of choledochoduodenoanastomosis stenosis, and endoscopic extraction of suprastenotic distal choledocholithiasis. In total, therapeutic ERCP was completely successful in all 3 patients out of 3 (100%) who had initially started endoscopic treatment. There were no complications in our group of 3 patients.

CONCLUSION

In ERCP in patients after choledochoduodenoanastomosis, we achieved 100% success of both diagnostic and therapeutic ERCP in all of our 3 patients.

Correlation of tumor necrosis factor alpha, interleukin 6 and interleukin 10 with blood pressure, risk of preeclampsia and low birth weight in gestational diabetes

Several pathophysiological mechanisms have been proposed in the development of pregnancy complications, including endothelial dysfunction, an inflammatory pathway and oxidative stress. The aim of the present study was to evaluate the correlation between proinflammatory cytokines TNF-alpha, IL-6 and dual cytokine IL-10 in the mother's peripheral blood and systolic blood pressure, risk of preeclampsia and low birth weight in gestational diabetes (GDM). We observed 40 women with GDM divided into a gestational hypertension group (n=20) and comparison group (n=20) with normal blood pressure. We found a significant positive correlation between TNF-alpha; IL-6; IL-10 levels and systolic blood pressure (SBP) in the second trimester (p<0.001; p<0.001; p<0.001); the third trimester (p<0.001; p<0.001; p<0.05). We also proved correlations for diastolic blood pressure (DBP) during the second; third trimester (p<0.001; p<0.001; p<0.001); (p<0.001; p<0.001; p<0.0015). We demonstrated a statistically significant positive association between high TNF-alpha group and preeclampsia risk in the third trimester (p=0.04). We also determined the negative correlation in the second trimester between birth weight and TNF-alpha; IL-6, IL-10 levels (p<0.05; p<0.001; p<0.001). To conclude, our data highlight the importance of cytokines TNF-alpha, IL-6 and IL-10 in blood pressure regulation. In addition, high levels of TNF-alpha have been associated with increased risk of preeclampsia. We found a significant negative correlation between levels of TNF-alpha, IL-6, IL-10 and birth weight.

Long-term relationship between unattended automated blood pressure and auscultatory BP measurements in hypertensive patients

AIMS

Unattended automated office blood pressure (uAutoOBP) has attracted more attention since SPRINT trial had been published. However, its long-term relationship to attended office blood pressure (AuscOBP) is not known.

MATERIAL AND METHODS

Stable treated hypertensive subjects were examined in four Czech academic hypertension centers. All subjects attended four clinical visits three months apart. uAutoOBP was measured with the BP Tru device; AuscOBP was measured three times with auscultatory method by the physician. 24-hour ambulatory blood pressure monitoring (ABPM) was performed within one week from the second clinical visit.

RESULTS

Data on 112 subjects aged 65.6 ± 10.8 years with mean AuscOBP 128.2 ± 12.2/78.5 ± 10.3 mm Hg are reported. Across the four clinical visits, the uAutoOBP was by 10.1/3.7 mm Hg lower than AuscOBP and the mean difference was similar during all four visits (P≥.061). Both uAutoOBP and AuscOBP had similar intra-individual variability during study follow-up as demonstrated by similar intraclass correlation coefficients (ICC, for systolic ICC = 0.50, for diastolic ICC = 0.72). However, the intra-individual variability of the systolic AuscOBP and uAutoOBP difference was high as demonstrated by low ICCs for absolute (ICC = 0.17 [95%CI, 0.09 - 0.25]) and low κ coefficients for categorized differences (κ ≤ 0.16). The main determinant of AuscOBP-uAutoOBP difference was AuscOBP level. The AuscOBP-uAutoOBP difference was poor tool to identify hypertension control categories defined on the basis of AuscOBP and ABPM.

CONCLUSIONS

Although mean AuscOBP-uAutoOBP differences were relatively similar across the four clinical visits, intra-individual variability of this difference was high. The AuscOBP-uAutoOBP difference was poor tool to identify hypertension control categories defined on the basis of AuscOBP and ABPM. Therefore, uAutoOBP cannot be used as a replacement for ABPM.

A multicentre study on unattended automated office blood pressure measurement in treated hypertensive patients

AIMS

Unattended automated office blood pressure (uAutoOBP) may eliminate white-coat effect. In the present study, we studied its relationships to attended office blood pressure (BP) and ambulatory BP monitoring (ABPM).

MATERIAL AND METHODS

Stable treated hypertensive subjects were examined in four Czech academic hypertension centres. uAutoOBP was measured with the BP Tru device; attended BP was measured six times: three times with auscultatory method (AuscOBP) by the physician followed optionally by three oscillometric measurements (OscOBP). ABPM was performed within one week from the clinical visit.

RESULTS

Data on 172 subjects aged 63.7 ± 12.4 years with AuscOBP 127.6 ± 12.1/77.6 ± 10.0 mm Hg are reported. uAutoOBP was by 8.5 ± 9.0/3.0 ± 6.1 mm Hg lower than AuscOBP. The AuscOBP-uAutoOBP difference increased with the AuscOBP level and it did not depend on any other factor. OscOBP differed by 8.6 ± 8.6/1.9 ± 5.7 mm Hg from uAutoOBP. 24-hour mean BP was by 4.2 ± 12.1/3.5 ± 7.8 mm Hg lower than AuscOBP and by 4.3 ± 11.0/0.5 ± 6.9 mm Hg higher than uAutoOBP; the correlation coefficients of 24-hour mean BP with AuscOBP and with uAutoOBP did not differ (p for difference ≥.13). In the lowest BP group (systolic AuscOBP <120 mm Hg or diastolic AuscOBP <70 mm Hg), both AuscOBP and uAutoOBP were lower than 24-hour mean BP, while in the highest BP group (systolic AuscOBP ≥140 mm Hg or diastolic AuscOBP ≥90 mm Hg), they were higher.

CONCLUSIONS

Compared to uAutoOBP, attended BP measurement gives higher values, both when measured with auscultatory or oscillometric method. Inter-individual variability of AutoOBP - uAuscOBP difference, as well of uAutoOBP - ABPM difference, is large. We did not prove that uAutoOBP would be associated to 24-hour ambulatory BP more closely than attended BP.

[Long non-coding RNAs in the pathophysiology of atherosclerosis]

The human genome contains about 22 000 protein-coding genes that are transcribed to an even larger amount of messenger RNAs (mRNA). Interestingly, the results of the project ENCODE from 2012 show, that despite up to 90 % of our genome being actively transcribed, protein-coding mRNAs make up only 2-3 % of the total amount of the transcribed RNA. The rest of RNA transcripts is not translated to proteins and that is why they are referred to as "non-coding RNAs". Earlier the non-coding RNA was considered "the dark matter of genome", or "the junk", whose genes has accumulated in our DNA during the course of evolution. Today we already know that non-coding RNAs fulfil a variety of regulatory functions in our body - they intervene into epigenetic processes from chromatin remodelling to histone methylation, or into the transcription process itself, or even post-transcription processes. Long non-coding RNAs (lncRNA) are one of the classes of non-coding RNAs that have more than 200 nucleotides in length (non-coding RNAs with less than 200 nucleotides in length are called small non-coding RNAs). lncRNAs represent a widely varied and large group of molecules with diverse regulatory functions. We can identify them in all thinkable cell types or tissues, or even in an extracellular space, which includes blood, specifically plasma. Their levels change during the course of organogenesis, they are specific to different tissues and their changes also occur along with the development of different illnesses, including atherosclerosis. This review article aims to present lncRNAs problematics in general and then focuses on some of their specific representatives in relation to the process of atherosclerosis (i.e. we describe lncRNA involvement in the biology of endothelial cells, vascular smooth muscle cells or immune cells), and we further describe possible clinical potential of lncRNA, whether in diagnostics or therapy of atherosclerosis and its clinical manifestations.Key words: atherosclerosis - lincRNA - lncRNA - MALAT - MIAT.

[Axial spondyloarthritis]

Axial spondyloarthritis (axSpA) is a common name for the non-radiographic form of the disease and radiographic axial spondyloarthritis, known as ankylosing spondylitis (AS). The disease is typically manifested at a young age, characterized by affection of axial skeleton, and in the most severe form can lead to complete ankylosis of the spine. Etiology of diseases have not yet been clarified, however, the genetic background, especially the binding to HLA-B27 antigen, is obvious. Clinical manifestations are dominated by chronic pain in the lower pain or buttocks that occurred in young age, in a large proportion of patients having the character of so-called inflammatory pain. In addition to the axial skeleton, axSpA there is also common affection of peripheral skeleton in the form of enthesitis, arthritis, and less often dactylitis. At present, enthesitis is considered as a hallmark of the entire spondyloarthritis group. Typical for axSpA is the frequent presence of extraskeletal manifestations in the form of uveitis, idiopathic intestinal inflammation and psoriasis. In the axSpA diagnosis, significant advances have been made in recent years in the field of imaging techniques. Magnetic resonance imaging can also identify the early stage of the disease before the development of structural lesions. Also, the newer concepts of the entire spondyloarthritis group, based on the 2009 ASAS (Assessment of SpondyloArthritis international Society) classification criteria, contributed to early diagnosis of the disease, and in particular to the underlying importance of association with HLA-B27 antigen and the presence of peripheral and non-articular manifestations. Non-steroidal anti-rheumatic drugs (NSAIDs) and TNFα blockers are effective axSpA therapy, which has been recently enhanced by interleukin 17 blockade (IL17).Key words: axial spondyloarthritis - biological treatment - enthesitis - extraarticular manifestations - magnetic resonance imaging - non-radiographic axial spondyloarthritis - sacroiliitis.

[Relapsing autoimmune pancreatitis type 1: case report]

Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis, classified into 2 subtypes - AIP type 1 and AIP type 2. We present a case of a 31-years-old female admitted to our institution with upper abdominal pain and obstructive jaundice. Endoscopic retrograde cholangiopancreatoscopy (ERCP) revealed stenosis of intrapancreatic distal bile duct. Diffuse parenchymal enlargement and typical features of AIP were shown by computed tomography (CT) and endoscopic ultrasonography (EUS). The patient´s serum IgG4 was elevated at 3.8 g/l (range 0.08-1.4 g/l). She was diagnosed with AIP type 1 and treated with prednisone (initial dose of 30 mg per day, then tapered by 5 mg/day every week). The maintenance dose of 5 mg per day was continued for 6 months. Despite clinical and radiological remission, serum levels of IgG4 remained elevated. The patient experienced disease relapse 25 months after first attack. Moreover, new finding of calcifications occured in pancreas. The relapse was managed with corticosteroids and maintenance immunosupression with azathioprin was started. Literature review on risk factor of relapse, long-term immunosupressive therapy indication and optimal follow-up of AIP type 1 patients are discussed.Key words: autoimmune pancreatitis type 1 - long-term follow-up - relapse - therapy.

[Arterin - a nutritional supplement in the treatment of dyslipidemia: results of a short-term clinical follow-up study]

Elevated LDL-cholesterol levels are among the main risk factors for ischemic heart disease. It can be influenced by pharmacotherapy, but also by changes in eating and life habits. The most recent recommendations on the treatment of dyslipidemia devote special attention to nutritional supplements and functional foods.Key words: arterin (monacolin K) - dyslipidemia - cardiovascular complications - lipid spectrum.

[SPRINT study: far lower systolic blood pressure]

There is still no consensus, which blood pressure value is the most profitable for the patients when treating the systolic hypertension in the context of reduction of cardiovascular events and cardiovascular and overall mortality.Researchers of the ACCORD study were comparing intensive treatment of systolic blood pressure bellow 120 mmHg and standard treatment reaching bellow 140 mmHg and showed no influence of intensive treatment on the primary goal in individuals with diabetes mellitus.Last autumn, SPRINT study was presented and published showing the favourable effect of intensive (i. e. bellow 120 mmHg) blood pressure lowering on combined primary goal which was myocardial infarction, other acute coronary syndromes, ischemic stroke, heart failure or death from cardiovascular reasons. On the other hand, intensive treatment also resulted in statistically significant occurrence of adverse events (hypotension, syncope, renal injury of failure).

[microRNA and internal medicine: from pathophysiology to the new diagnostic and therapeutic procedures]

microRNAs (abbreviated miRNAs or miRs) represents one of the group of so called small non-coding RNAs which participate in the negative post-transcriptional regulation of gene expression. According to the base complementarity they target molecules of messenger RNAs (mRNAs) which results either in translational blockade or in degradation of target mRNA. One miRNA usually targets more mRNA and one mRNA is usually targeted by more than one miRNA - complicated and interconnected regulatory networks are thus created and their disruption leads to the abnormalities in development or results in the development of diseases. Within the past two decades, novel mechanisms were described that enable us to modulate miRNA levels (either causing upregulation or downregulation) - miRNAs can thus be considered as a novel potential group of therapeutic targets. First clinical trials using the blockade of liver specific miR-122 showed very promising results in the treatment of chronic hepatitis C virus infection. Results of preclinical and animal studies are also promising providing future rationale for the development of new therapeutics for various internal diseases including heart failure, bronchial asthma or inflammatory bowel diseases. Moreover, miRNAs are not only affecting the pathophysiology of internal diseases, but they can also reflect their presence - there is a group of miRNAs called extracellular, or circulating miRNAs, i.e. miRNAs that are present in extracellular space including all known body fluids such as plasma, serum, urine, saliva or sweat. Circulating miRNAs are stable; their levels are constant among the individuals of one species, methods determining their levels are reproducible and last but not least - levels of extracellular miRNAs differ between healthy and diseased individuals. They are released into the circulation either after the cell necrosis or by active transport. Except of being potential novel biomarkers, these miRNAs represent a novel mean of intercellular communication. Their levels thus reflect not only the organ damage but also the changes of the homeostasis during various illnesses. The aim of the current study is to provide the first insight into the miRNA world to clinicians, especially to internal medicine specialists. Using simple examples from clinical praxis or clinical pathophysiology, we are trying to present diagnostic and therapeutic potential that is hidden within these tiny interesting molecules.

KEY WORDS

circulating microRNA - diagnostics - internal diseases - microRNA - therapy.

[Systolic blood pressure targets]

When treating systolic hypertension we do not know the optimum blood pressure which leads to the reduction of cardiovascular events and cardiovascular and total mortality. The results of the ACCORD study, when comparing intensive treatment of systolic blood pressure (SBP) < 120 mm Hg and standard treatment < 140 mm Hg, did not lead to affecting the primary target for patients with diabetes mellitus. The SPRINT study (Systolic Blood Pressure Intervention Trial) has shown that more intensive treatment of hypertension (aimed at readings lower than the generally recommended target readings) significantly reduces incidence of cardiovascular diseases and lowers the risk of death. On the other hand, a statistically significant incidence of side effects (hypotension, syncope, renal impairment or failure) has been identified. The first results were presented at the American Heart Association Congress on 9 November 2015.

KEY WORDS

target values - hypotension - cardiovascular events - systolic blood pressure.

[Symptomatic and asymptomatic primary hyperparathyroidism in outpatient care - current issues]

OBJECTIVE

To assess the diagnostic and therapeutic options in the care of patients with primary hyperparathyreosis in outpatient practice.Cohort and methods: The study included all the patients with primary hyperparathyroidism treated at the 2nd Internal Medicine Department, Masaryk University and the University Hospital of St. Anne in Brno in the period from Jan 1, 2008 to Dec 31, 2013. The sample consisted of 218 patients, including 41 men and 177 women. Patients with secondary hyperparathyroidism, especially patients with underlying hypovitaminosis D, renal insufficiency and those taking medications with possible effects on parathyroid hormone levels, have not been included in the study. A special attention was paid to differences between the normocalcaemic and hypercalcaemic patients. Ultrasound scanning was performed in all patients, while scintigraphy was indicated in patients who are considered for possible surgical treatment.

RESULTS

In the group of 218 patients, serum calcium levels at the baseline were pathologically elevated in 31 patients (14 %) and normal in 187 patients (86 %). One fifth of patients with normocalcaemic primary hyperparathyroidism developed long-term hypercalcaemia - within two years in two thirds of the patients from the onset of the disease and sporadically also after more than four years of follow-up. Parathyroid adenoma was found and removed in 30 hypercalcemic patients (in 97 % of all 31 hypercalcemic patients operated on) and in 2 normocalcemic patients (40 % of all 5 the normocalcemic patients operated on). Pharmacological treatment was administered to 22 patients, of which 9 patients received long-term treatment and 13 patients received pharmacotherapy only during the preoperative preparation for patients with very high serum calcium levels.

CONCLUSION

The results support the opinion that primary hyperparathyroidism is a biphasic disease. The initial normocalcemic period is often asymptomatic or associated with symptoms of little importance. Severe complications, however, may already be present also in normocalcemic patients. The decision of when patients with normocalcemic primary hyperparathyroidism should be monitored and when initiation of treatment is needed should also require more detailed information.Key words: hypercalcaemia - hyperparathyroidism asymptomatic and primary - normocalcaemia - outpatient care - parathyroid hormone - surgery and pharmacotherapy.

[The SPRINT study - the outcomes of the most important study over the recent period focused on hypertension]

When treating systolic hypertension we do not know the optimum blood pressure which leads to the reduction of cardiovascular events and cardiovascular and total mortality. The results of the ACCORD study, when comparing intensive treatment of systolic blood pressure < 120 mm Hg and standard treatment < 140 mm Hg, did not lead to affecting the primary target for patients with diabetes mellitus. In the autumn last year the SPRINT study was presented and published, showing favourable impact on the combined primary target, which involved myocardial infarction, other acute coronary syndromes, stroke, heart failure or death from cardiovascular causes during intensive treatment of systolic blood pressure, i.e. < 120 mm Hg, but on the other hand with a statistically significant incidence of secondary effects (hypotension, syncope, renal impairment or failure).Key words: target values - hypotension - cardiovascular events - systolic blood pressure.

[The role of metabolic syndrome in gastroenterology]

GOAL

Metabolic syndrome and its components play an important part in the development of not only cardiovascular conditions, but also digestive and pancreaticobiliary system diseases. The aim of our study is to present a comprehensive overview of the diseases where metabolic syndrome is an inducing risk factor, or where it affects the course of the disease.

RESULTS

Metabolic syndrome is a significant risk factor of induction of gastroesophageal reflux and its complication, which is Barretts esophagus. Metabolic syndrome was described as the disease closely linked to idiopathic intestinal inflammations, diseases of the biliary tree and pancreas. Acute pancreatitis, both its development in obese individuals and the burden of its course, are in close correlation with metabolic syndrome, similarly as the course of chronic, mainly alcoholic pancreatitis. Study of non-alcoholic steatopancreatitis presents a challenge, most importantly with regard to the function of pancreatic B cells in obese individuals. Non-alcoholic hepatic steatosis and its forms may as much as lead to the stage of cirrhosis of the liver and they pose a risk of hepatocellular carcinoma. Metabolic syndrome was also described in a population study as a risk factor for carcinoma of the colon.

SUMMARY

Metabolic syndrome and its components present an important risk factor in relation to inducing some benign as well as malignant gastrointestinal and pancreaticobiliary diseases. A systemic approach to influencing the metabolic syndrome and its components is therefore one of the important approaches to influencing the development and course of not only cardiovascular conditions.

[Lowering of blood pressure - by treatment of other risk factors]

Reaching the target value of blood pressure is still a big problem. A mere 30 % of treated hypertensives reach blood pressure values < 140/90 mm Hg. Hypertensive patients often exhibit further risk factors - diabetes mellitus, dyslipoproteinemia, excess weight and obesity, all of which are included in the definition of metabolic syndrome. The cardiovascular risks associated with the individual risk factors are not summed, they are multiplied. Unfortunately, the individual risk factors have been treated separately until now. However, there is an effort aimed at treating individual risk factors in the way that may positively affect others. The study focuses on the treatment of type 2 diabetes mellitus, dyslipidemia, excess weight and obesity taking account of possible influencing of blood pressure values.

[Akromegaly and pharmacotherapy]

Acromegaly is a rare and serious disease. A successful and rational therapy of acromegaly ought to combine surgery, radiotherapy and pharmacotherapy. The submitted article presents a case of acromegaly that was only diagnosed at the stage when total pituitary adenoma removal was impossible. Even so, the long-term stabilisation of the disease was reached by way of repeated surgery through transfenoidal and transcranial approach, by linear accelerator radiation therapy and Leksell Gamma Knife radiotherapy and by pharmacotherapy with somatostatin analogon octreotide and growth hormone receptor antagonist pegvisomant. The octreotide and pegvisomant dosage has been repeatedly changed according to IGF1 levels. The contemporary somatostatin analogon Sandostatin LAR 30 mg is given once every 3 weeks and the growth hormone receptor antagonist Somavert 20 mg is applied daily. Despite this serious disease, the patient has already been living contentedly for 10 years. From the ethical point of view, the financials costingness of the therapy should be considered as reasonable.

[Calcific uremic arteriolopathy - treatment with sodium thiosulfate]

Calcific uremic arteriolopathy or calciphylaxis is a rare disorder characterized by systemic medial calcification of arterioles that leads to ischemia and subcutaneous necrosis. It most commonly occurs in patients with end-stage renal disease who are on haemodialysis or who have received a renal transplant. Calciphylaxis is dangerous by its fast progression into tissue necrosis, difficult healing process and a great risk of secondary infection which is the most common cause of death in this condition. The reported mortality rates are as high as 60-80 % in a couple of months once it is diagnosed. The key to successful treatment of calciphylaxis is fast diagnosing of the disease and appropriate treatment management. On the examples of three patients from our haemodialysis centre we demonstrate typical clinical manifestation of calciphylaxis and its treatment, which requires close patient-medical staff cooperation. The basic principle of treatment of all our patients was normalization of calcium-phosphate metabolism and secondary hyperparathyroidism. Sodium thiosulfate had been administered to all patients at the end of haemodialysis session. The wound care played another major role with gentle debridement and intensive local care. After five to six months the skin defects resolved in the first patient, partially resolved in the second patient and deteriorated in the third patient. We have observed no side effects of sodium thiosulfate application.

[Treatment of hypertension may affect the incidence of dementia?]

High blood pressure is one of the main risk factor for developing dementia in high age. The connection between treatment of hypertension and reduced risk of cognitive impairment has been studied. Clinical trials have shown reduced risk of dementia after hypertension treatment. Efficacy of antihypertensive drugs varies in their impact on the incidence of dementia. Dementia together with higher life expectancy and prevalence of systolic hypertension will be real issue not only for health care in the near future. Primary and secondary prevention of dementia might be affected by hypertension treatment. Recently, it has been studied possible influence of subclinical damage by hypertension.

Systemic AL amyloidosis with unusual cutaneous presentation unmasked by carotenoderma

We present a case study of an elderly woman with systemic lambda-type AL amyloidosis that featured unusually extensive cutaneous involvement. The case initially presented with a sudden hyper β-carotenemia with carotenoderma that instigated the clinical examination including skin biopsy. A diagnosis of systemic amyloidosis was made. Immunohistochemistry and Western-blot analysis indicated the presence of lambda light chain proteins in skin amyloid deposits. However, notable co-deposition of wild-type apoA-I and transthyretin was observed which caused initial diagnostic confusion. Proteomic analysis of microdissected skin amyloid deposits by mass spectrometry confirmed lambda light chain proteins in amyloid deposits and co-deposition of apolipoprotein A-IV and serum amyloid P-component. The patient died from renal failure caused by amyloid nephropathy combined with analgesic nephropathy. The autopsy disclosed vascular, cardiac, renal and pulmonary amyloid deposition. While all amyloid deposits were positive for lambda light chain proteins, the immunodetection of apoA-I and transthyretin varied significantly among the visceral amyloid deposits. Although the patient exhibited a 1000-fold increase in serum β-carotene levels, only a mild increase in retinol and lutein concentrations was observed. Increased β-carotene values were also found in the liver and the skin. The mechanisms underlying this hyper β-carotenemia remain undetermined.

[Metabolic syndrome after kidney transplantation]

INTRODUCTION

Metabolic syndrome is a risk factor for cardiovascular diseases. Higher risk of the metabolic syndrome and its components in patients after kidney transplantation is caused by immunosuppressive therapy. THE AIM OF OUR STUDY was to evaluate the prevalence of the metabolic syndrome and its components in kidney transplant recipients and to analyse their influence on allograft function and albuminuria.

PATIENTS, METHOD AND RESULTS

In the study we monitored 69 patients after cadaveric kidney transplantation. The prevalence of the meta-bolic syndrome was 61.3 % 3 years after kidney transplantation. The prevalence of new onset diabetes mellitus after transplantation was 27 % and that of abdominal obesity 59.7 % of patients. The age of kidney transplant recipients with the metabolic syndrome was higher than of these without it, but not statistically significant. The age of kidney transplant recipients with new onset diabetes mellitus after transplantation was significantly higher, 54.0 (35.0; 69.0) years, than in patients without it, 45.5 (27.0; 60.0) years, OR (95% IS) 1.116 (1.031; 1.207), p = 0.006.The number of components of the metabolic syndrome was negatively correlated with the graft function (rs -0,275, p = 0,031). In patients with impaired renal function with estimated glomerular filtration (using MDRD equation) < 1 ml/s 3 years after kidney transplantation the prevalence of the metabolic syndrome and hypertriglyceridaemia was significantly higher. Chronic allograft dysfunction was predicted by donor age, delayed allograft function, rejection, low level of HDL-cholesterol, hypertriglyceridaemia and hyperuricaemia. Hyperuricaemia was the only significant predictor of allograft dysfunction independently of the presence of delayed allograft function, rejection episodes and donor age. The metabolic syndrome, elevation of apolipoprotein B and nonHDL-cholesterol and increased systolic blood pressure were associated with albuminuria. Higher levels of apolipoprotein B and total cholesterol were independent predictors of increased albumin-creatinine ratio. Obesity had no impact on graft function nor on albuminuria, the influence of the new onset diabetes mellitus after transplantation was not significant independently on other factors. We confirmed the correlation of the presence of the metabolic syndrome with increased levels of AFABP (adipocyte fatty acid-binding protein) and leptin. Increased level of AFABP predicted allograft dysfunction 3 years after kidney transplantation.

CONCLUSION

The influence of imunosuppressive treatment on new onset diabetes mellitus after transplantation is well documented. However, we conclude that age is an important additional risk factor for the development of diabetes mellitus in kidney transplant recipients group and it is recommended to follow mainly older patients. Early detection of metabolic abnormalities and dietary and therapeutic intervention in kidney transplant recipients may help to prevent chronic allograft dysfunction.

[Oral infection and rheumatic diseases]

Periodontitis (PD) is one of the most common infectious diseases of dental attachment. From epidemiological studies there is known association of periodontitis with chronic diseases as for example diabetes mellitus, cardiovacular diseases, atherosclerosis or Crohn disease. In last decade there is an increasing evidence for association of rheumatoid arthritis (RA) and periodontitis also. RA and PD have some common genetic, environmental and immunopathological characters. Important aspect of reciprocal relationship is also ability to citrullination, which is innate to one of most important oral patogen - Porphyromonas gingivalis. Citrullination and production of autoantibodies against this modified proteins is one the important pathophysiological actions in course of RA. Recently, there has been published papers drawing attention to potential influence of periodontitis therapy to course and activity of RA. Furthermore there appear some information pointing to possible association between PD and other rheumatic diseases as for exam-ple spondyloarthritis. Interrelationship between PD and rheumatic diseases thus stay important and still open question in research of pathophysiology, course and therapeutic possibilities of rheumatic diseases.

[Use of natriuretic peptides in diagnosis of left ventricular hypertrophy in obese hypertensive patients with metabolic syndrome]

INTRODUCTION

Presence of left ventricular (LV) hypertrophy significantly increases cardiovascular risk in patients suffering from hypertension. Diagnostics of LV hypertrophy in hypertensive patients is not easy and there is still no method of enabling a simple and sufficiently sensitive dia-gnosis across a large patient population. The golden standard in LV hypertrophy diagnostics is echocardiography, and there are adverse opinions regarding the use of natriuretic peptides BNP and NT proBNP (NP) to diagnose LV hypertrophy.

PATIENTS AND METHODS

We examined through echocardiography 173 hypertensive patients with signs of metabolic syndrome and a moderate increase in blood pressure (130- 159/ 85- 99 mm Hg) with an average age of 54.8 ± 13.54 years, i.e. 119 men and 54 women, who were divided into 2 groups; 1 with BMI > 30 (group A with a severe obesity) and the other without obesity, BMI < 30 (group B). Both groups were examined for BNP and NT proBNP levels.

RESULTS

We found a positive correlation between NP and LVMi, both for BNP (r = 0.169; p = 0.033) and for NT proBNP (r = 0.240; p = 0.002). NT proBNP statistically significantly predicts the given LV hypertrophy LK in people with BMI < 30 but not in obese people (BMI > 30).

CONCLUSION

Obese patients suffer from a higher occurrence of left ventricular hypertrophy and paradoxically a lower NP value than patients with a metabolic syndrome (MS) who are not obese. Natriuretic peptides have a limited diagnostic value when assessing left ventricular hypertrophy. They are only of value in patients who are not obese and whose kidney function and systolic myocardial function have not been impaired.

[Where is the treatment of hypertension heading?]

High normal blood pressure is defined as pressure of 130- 138/ 85- 89 mm Hg. The term prehypertension is used for systolic blood pressure of 120- 139 mm Hg and diastolic pressure of 80- 89 mm Hg. The question is whether blood pressure at those levels should be treated and if so, in which patients. Another question is, whether the therapy can affect the incidence of hypertension and cardiovascular complications.

[Adherence and persistence with a focus on the treatment of hypertensive patients]

Insufficient adherence of patients to treatment is a serious problem and it is monitored most frequently in hypertensive patients. The possibilities of increasing adherence to longterm treatment include mainly the motivation and education of patients, simple dosage regimes, telephone consultations and involving the patient in the treatment process (self monitoring), but it also means providing information about the consequences of failure to adhere to the treatment process. Other possibilities can include new dosage forms which increase the biological availability of medicines, reduce the variability of absorption, and thus allow for achieving their more stable levels. It is possible to take advantage of fixed combinations which can improve adherence. Some new dosage forms simplify the therapy for patients and make it more pleasant. One of the latest innovations is for example, orodispersible dosage forms, which have been recently introduced in the therapy of arterial hypertension. In order to improve the adherence of patients to hypertension treatment it is necessary to use all means available adjusted to the individual needs of patients.

[Spondyloarthritides: current perspective on diagnosis and classification]

Spondyloarthritides (SpA) are a heterogeneous group of chronic inflammatory diseases with common clinical features and genetic basis. They primarily affect the axial skeleton, especially the sacroiliac joint, other localizations of the affection being peripheral joints and entheses -  typical of the group of spondyloarthritides. On the basis of the predominant affection of the axial or peripheral skeleton, they can be divided, according to the current classification criteria, into axial SpA and peripheral SpA. Apart from axial and peripheral articular manifestations, many patients also display extra articular manifestations, which can thus become an important diagnostic clue and also the first symptom of the disease. The most frequent of them are anterior uveitis, inflammatory bowel diseases, and psoriasis. Also the strong binding of spondyloarthritides to the positivity of HLA B27 antigen or a family history of the disease is important information which helps in the diagnosis. Comorbidities, the most common and important of which are cardiovascular diseases or osteoporosis and its consequences in the form of fractures, are an integral part of the issue of spondyloarthritides.

[Comparison of MRCP a ERCP in diagnosis of choledocholithiasis]

INTRODUCTION

Choledocholithiasis is the most common cause of biliary obstruction. Each of the testing methods used in its diagnosis has its advantages and disadvantages.

OBJECTIVE OF THE STUDY

The objective of this prospective study is to compare endoscopic retrograde cholangiopancreatography with magnetic resonance cholangiopancreatography in the diagnosis of choledocholithiasis on the basis of own experience and literature data. Set of patients and methodology: The set was studied from the beginning of 2007 to the end of 2012 (i.e. six years). The study assessed prospectively 45 patients (age range 28- 72 years) with symptoms of biliary obstruction, who first underwent magnetic resonance cholangiopancreatography and subsequently endoscopic retrograde cholangiopancreatography.

RESULTS

The sensitivity, specificity and diagnostic accuracy of magnetic resonance cholangiopancreatography was lower, both in our set of patients and according to the literature data, compared to the endoscopic retrograde cholangiopancreatography (92%, 91% or 93 %).

CONCLUSION

Considering the frequency of complications (in some cases serious ones) following endoscopic retrograde cholangiopancreatography, the magnetic resonance cholangiopancreatography is, in spite of its lower sensitivity, the method of choice in the diagnosis of choledocholithiasis by means of noninvasive methods, on the basis of which it is possible to refer the patients subsequently for therapeutic endoscopic retrograde cholangiopancreatography.

[Endoscopic retrograde cholangiography with a single-balloon enteroscope in patients with Roux-en-Y hepatico jejunal anastomosis]

AIMS OF THE STUDY

The aim of this retrospective study was to evaluate our experience with using a single-balloon enetroscope for diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepatico jejunal anastomosis (HJA). Due to the considerably changed anatomic circumstances after the surgery, ERC is, in comparison to the standard endoscopic retrograde cholangiopancraeaticography (ERCP), significantly more difficult to perform.

PATIENT SAMPLE AND METHODOLOGY

The sample was followed up from January 2009 to September 2011. The study retrospectively reviewed 14 patients with Roux-en-Y HJA with symptoms of biliary obstruction. A total of 21 ERCs were performed in these 14 Roux-en-Y HJA patients using the single-balloon videoenetroscope Olympus SIF Q 180.

RESULTS

Diagnostic ERC cannulation was successful in 11 of the 14 patients (79% success rate for the diagnostic ERC). One of the 11 patients had a normal finding on the ERC. The remaining 10 patients had a pathological finding on ERC that, in one patient (cystic dilatation of bile duct), was subsequently managed surgically. Endoscopic treatment was initiated in the remaining 9 patients (HJA stenosis in 4, choledocholithiasis in 2 and concurrent HJA stenosis and choledocholithiasis in 3) immediately after the diagnostic ERC; the surgery was successful in 8 of the 9 patients (89% success rate for the therapeutic ERC). The performed endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis 9 times (6 patients), choledocholithiasis extraction - 5 times (5 patients), biliary plastic stent placement - 5 times (3 patients), removal of biliary stents placed by us - 5 times (3 patients). We did not observe any complications in our sample of 14 patients.

CONCLUSIONS

ERC using a single-balloon enteroscope in patients with Roux-Y HJA is significantly more difficult than the standard ERCP due to different post-surgical anatomy. In our sample of patients, we achieved 79% success rate for the diagnostic ERC and 89% success rate for the therapeutic ERC. Additional time should be allowed for the individual procedures. Furthermore, the presence of an anaesthesiologist during these operations (deep analgosedation) is essential. This is a technically very demanding technique that, however, is effective and safe and importantly extends the options available for the management of biliary pathologies in these patients.

Main results of the ouabain and adducin for Specific Intervention on Sodium in Hypertension Trial (OASIS-HT): a randomized placebo-controlled phase-2 dose-finding study of rostafuroxin

BACKGROUND

The Ouabain and Adducin for Specific Intervention on Sodium in Hypertension (OASIS-HT) Trial was a phase-2 dose-finding study of rostafuroxin, a digitoxygenin derivative, which selectively antagonizes the effects of endogenous ouabain (EO) on Na+,K+-ATPase and mutated adducin. Rostafuroxin lowered blood pressure (BP) in some animal models and in humans.

METHODS

OASIS-HT consisted of 5 concurrently running double-blind cross-over studies. After 4 weeks without treatment, 435 patients with uncomplicated systolic hypertension (140-169 mm Hg) were randomized to rostafuroxin (0.05, 0.15, 0.5, 1.5 or 5.0 mg/d) or matching placebo, each treatment period lasting 5 weeks. The primary endpoint was the reduction in systolic office BP. Among the secondary endpoints were diastolic office BP, 24-h ambulatory BP, plasma EO concentration and renin activity, 24-h urinary sodium and aldosterone excretion, and safety. ANOVA considered treatment sequence (fixed effect), subjects nested within sequence (random), period (fixed), and treatment (fixed).

RESULTS

Among 410 analyzable patients (40.5% women; mean age, 48.4 years), the differences in the primary endpoint (rostafuroxin minus placebo) ranged from -0.18 mm Hg (P = 0.90) on 0.15 mg/d rostafuroxin to 2.72 mm Hg (P = 0.04) on 0.05 mg/d. In the 5 dosage arms combined, the treatment effects averaged 1.30 mm Hg (P = 0.03) for systolic office BP; 0.70 mm Hg (P = 0.08) for diastolic office BP; 0.36 mm Hg (P = 0.49) for 24-h systolic BP; and 0.05 mm Hg (P = 0.88) for 24-h diastolic BP. In the 2 treatment groups combined, systolic (-1.36 mm Hg) and diastolic (-0.97 mm Hg) office BPs decreased from week 5 to 10 (P for period effect ≤ 0.028), but carry-over effects were not significant (P ≥ 0.11). All other endpoints were not different on rostafuroxin and placebo. Minor side-effects occurred with similarly low frequency on rostafuroxin and placebo.

CONCLUSIONS

In 5 concurrently running double-blind cross-over studies rostafuroxin did not reduce BP at any dose.

TRIAL REGISTRATION

ClinicalTrials (NCT): NCT00415038.

CORD: COmparison of Recommended Doses of ace inhibitors and angiotensin II receptor blockers

The CORD trials tested ramipril and losartan in patients with hypertension. CORD A randomised 4016 patients with blood pressure (BP) <160/100 mm Hg, who had been treated with an ACEI for >3 months. The patients discontinued ACEI and switched to losartan. After 1 month the BP decreased to 7.7/4.7 mm Hg (p<0.001) and after 1 year to 13.8/8.7 mm Hg (p<0.001). CORD B compared ramipril and losartan in 3813 patients with hypertension who were not being treated with an ACEI or ARB. The patients were randomised to ramipril (n=1926) or losartan (n=1887). After 1 year the BP decreased in the ramipril group to 21.8/13.7 mm Hg (p<0.001) and in the losartan group to 22.0/13.3 mm Hg (p<0.001). No significant differences were found between the groups. No differences were in serious adverse events. Dry cough was more frequently after ramipril (33 vs 4, p<0.001).