Vnitrni lekarstvi最新文献

Dyslipidemia (DLP) is the most important risk factor for atherosclerotic cardiovascular disease (ASCVD) and, in the context of severe hypertriglyceridemia (TG > 10 mmol/l), a risk factor for the development of acute pancreatitis. The prevalence of DLP is very high, but their control, especially among the patients at highest risk, is often inadequate. When diagnosing DLP, we should always exclude its possible secondary aetiology (e.g. DLP in the context of hypothyroidism, diabetes, ...). Based on the assessment of the overall CV risk (according to SCORE2/SCORE2-OP or according to the comorbidities of the individual), target values for blood lipids, especially LDL-cholesterol, are determined according to the risk category. The basis of the management of DLP in the prevention of ASCVD is dietary and regimen measures, followed by adequate lipid-lowering therapy in indicated cases. As of April 2023, the portfolio of lipid-lowering medication has been expanded to include inclisiran (small interfering RNA against proprotein convertase subtilisin/kexin type 9 (PCSK9)), which is administered directly in cardiologists' and internists' outpatient clinics, ensuring 100% adherence. In severe hypertriglyceridaemia, fibrate monotherapy may be indicated in addition to dietary and regimen measures; if this treatment fails, some patients may be offered lomitapide, volanesorsen or evinacumab as part of clinical trials or specific treatment programmes if very strict indication criteria are met.

Orthostatic intolerance (OI) is defined as a group of diseases which symptoms are typically manifested in a standing position. These symptoms result from cerebral hypoperfusion and disappear in the supine position. We include postural orthostatic intolerance syndrome (POTS), orthostatic hypotension (OH) and vasovagal orthostatic syncope in this group of diseases. Each of them have similar clinical presentation (blurred vision, weakness, dizziness, nausea, headaches, fatigue). However, they vary from each other in biochemical, autonomic and hemodynamic characteristics. The aim of the work is to provide an overview of humoral and non-human markers that are involved in the etiopathogenesis of orthostatic intolerance.

Variceal bleeding belongs to the one of the complications of portal hypertension and is a life-threatening condition. A transjugular intrahepatic portosystemic shunt (TIPS) is indicated in case of failure of the pharmacological and endoscopic therapy, even if it is associated with complications. Stent migration to the heart, is a rare event which may cause perforation of the right cardiac chambers or damage to the tricuspid valve. However, it may not be a problem in some cases. There are two approaches to extraction - percutaneous or surgical. Leaving the stent in situ is possible, especially in polymorbid patients. Choosing an optimal approach often requires interdisciplinary cooperation.

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition characterized by the development of a peri-aortic and peri-iliac tissue showing chronic inflammatory infiltrates and pronounced fibrosis. Ureteral entrapment with consequent obstructive uropathy is one of the most common complications, which can lead to acute renal failure and, in the long term, to varying degrees of chronic kidney disease. Common symptoms at onset include lower back, abdominal or flank pain, and constitutional symptoms such as malaise, fever, and anorexia and weight loss. Pain is frequently referred to the hip, to the groin and to the lateral regions of the leg, with nocturnal exacerbations, and typically does not modify with position. We report a case of 56 year-old male with recurrent lower back pain and lower abdominal pain. Contrast-enhanced computed tomography and was suggestive of retroperitoneal fibrosis and unilateral ureteral occlusion. Histologic examination with immunohistochemical staining for IgG4 demonstrate IgG4-related retroperitoneal fibrosis. Therapy was started with prednison 1 mg/kg, but the tolerance of this dose was poor. Therefore the therapy was switched to combination of rituximab 375 mg/ m2 on day 1, cyclophosphamide 300 mg/m2 mg infusion and dexamethasone 20 mg total dose infusion on day 1 and 15 in 28 days cycle. FDG-PET/CT control in fourth month showed residual accumulation of FDG in retroperitoneal fibrotic mass, and therefore the therapy was prolonged to 8 month. The subjective symptoms of this diseases disappeared in the 8th month. Then the maintenance therapy, administration of rituximab in 6 month interval, was started. The activity of this disease be further evaluated by FDG-PET/CT imagination. Glucocorticoids are considered the cornerstone of therapy. The use of other immunosuppressive agents, including cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil and biological agents such as rituximab, tocilizumab and infliximab and sirolimus have been reported as a valuable option mostly in case reports, cases series and small studies. This agents allowed to reduce cumulative dose of glucocorticoids and its adverse effects. Therefore in our patients we preferred combination of rituximab cyclophosphamide s dexamethasone with lover dose of prednisonem. This combination is preferable for patients who cannot tolerate glucocorticoids or who are likely to suffer from significant glucocorticoids -related toxicity.

The use of new antidiabetic drugs in clinical practice in the last two decades has completely changed the Type 2 diabetes management. Following the results of new clinical trials, international recommendations for the treatment of diabetes were regularly modified. In the field of Type 1 diabetes, new technologies have appeared, such as smart insulin pens. We can await once weekly insulins and dual GLP-1 and GIP analogues in the near future.

The introduction of point-of-care ultrasonography into practice in internal medicine and subsequently into the educational program for our specialty brought the need to define a curriculum for training in this method. We solve the question of "what to teach" - i.e. what core ultrasound competencies internists should learn for their practice. It is also necessary to define the procedure "how to teach" - the form and content of the education program, what the basic course should contain, and above all how the subsequent training should take place in practice. The third major problem to be solved is "who should teach", i.e. the definition of the requirements for trainers who will lead the training.

In developed countries, diabetes mellitus (DM) is one of the main causes of end stage renal disease (ESRD). In addition, the development of chronic kidney disease (CKD) further increases the already significantly increased cardiovascular (CV) risk in patients with diabetes. Both albuminuria and impaired renal function predict CV disease-related morbidity. The multifactorial pathogenesis of DM-related CKD involves structural, physiological, hemodynamic, and inflammatory processes. Instead of a so-called glucocentric approach, current evidence suggests that a multimodal, interdisciplinary treatment approach is needed to also prevent further progression of CKD and reduce the risk of cardiovascular events. Combined antihypertensive, antihyperglycemic and hypolipidemic therapy is the basis of a comprehensive approach to prevent the progression of diabetic kidney disease. According to recent evidence, adjunctive therapy with the non-steroidal mineralocorticoid receptor antagonist (MRA) finerenone - in addition to the use of an ACE (angiotensin converting enzyme) or AT1 (angiotensin II receptor subtype 1) blocker and an SGLT2 (sodium-glucose cotransporter-2) inhibitor - represents an effective therapeutic tool to improve nephroprotection in CKD. The aim of this review is to provide brief information on this promising pharmacotherapeutic approach to the treatment of diabetic kidney disease.

Pulmonary embolism in classical meaning is a complication of deep vein thrombosis (usually in the leg veins), developing after a part of the thrombus dislodged and got wedged in pulmonary arteries. However, in half of the patients with pulmonary embolism, deep vein thrombosis is not found. One potential explanation is a different, less common location of the thrombus or previous complete embolization of the whole thrombotic mass. Another possibility is pulmonary artery thrombosis in situ, which is a specific clinical entity associated with some typical risk factors. It develops in the place of vascular injury, as a consequence of hypoxia, inflammatory changes, endothelial dysfunction and injury. Pulmonary artery thrombosis in situ can be a complication after lung resection, radiation therapy, chest trauma, in the patients with Behçet´s disease, sickle cell anemia, chronic obstructive pulmonary disease, tuberculosis or covid pneumonia. Pulmonary artery thrombosis in situ may differ from classical pulmonary embolism in prognosis as well as in therapeutic approach.

The pandemic of the disease COVID-19 (COronaVIrus Disease 2019) caused by the SARS-CoV-2 coronavirus (severe acute respiratory syndrome coronavirus 2) resulted in millions of deaths and many patients have chronic consequences after overcoming the acute condition. Several vaccines have been developed in an effort to stop the spread of the virus, but they have potentially serious adverse effects. We present a case report of a patient with acute (myocarditis, exacerbation of bronchial asthma) and long-term (postural orthostatic tachycardia syndrome - POTS) complications after vaccination with the second dose of mRNA vaccine BNT162b2 (Comirnaty®). Treatment consists of regimen measures, numerous pharmacotherapy (metoprolol, ivabradine, corticosteroids, antihistamines, antiphlogistics, bronchodilators) and several nutraceuticals (maritime pine bark extract, quercetin, vitamins, magnesium, phosphatidylcholine). In the discussion, we analyze post-vaccination injury and present a short review of the current literature.

Nephrotic syndrome (NS) is characterized by high proteinuria (over 3,5g/24 hrs), hypalbuminaemia, general edemas and hypercoagulation. Beside of primary glomerulonephritides this is found in secundary glomerulopaties eg. diabetes, systemic inflammatory diseases, oncology, damage by drugs and poisoning, by alergy, serious infections and in children from hereditary reasons. The most frequent reason for NS in adults patiens is diabetes and diabetes with nephropathy represents almost 40% of dialysed patiens. From this point of view, there is great interest focusing on gliflozins (SGLT2 inhibitors) with positive nephroprotecive effect. It leads do increasing of glycosuria with concomitant natriuresis and osmotic diuresis. The effect is proportional to glomerulal filtration, but the effect on natriuresis stay in all stages of renal insufficiency.