Insulin resistance may accelerate typical changes in heart function among type 1 diabetes patients, particularly in overweight patients: a preliminary study.

Introduction: Type 1 diabetes (T1D) is a metabolic disease characterized by insulin deficiency and subsequent hyperglycemia. Cardiovascular diseases are the prime cause of mortality and morbidity among patients with T1D. Accumulating metabolic disturbances and accelerated cardiac fibrosis fuel the development of heart dysfunction. As insulin resistance (IR) is a risk factor for the development and worsened course of heart failure, this study aimed to assess its impact on heart function in patients with T1D. Methods: Adult participants were recruited prospectively. The inclusion criteria included a diagnosis of T1D. The exclusion criteria were other types of diabetes, symptoms/treatment of heart failure, AST and/or ALT exceeding the upper reference limit by ≥2x, hepatitis, alcoholism, metformin treatment, and pregnancy. The participants underwent a medical interview, physical examination, biochemical test, and echocardiography. Results: The mean age in the study group was 38 ± 9.6 years, and the mean diabetes duration was 21.8 ± 11.3 years. The median BMI in the study cohort was 23.39 kg/m2. Patients with IR had significantly lower mitral E/A ratio and left ventricular and left atrial volume ratio (LVLAVR), higher LV mass index, and presented with altered mitral annular velocities. Conclusions: IR seems to accelerate the pattern of typical changes in heart function among patients with T1D, especially in the overweight subgroup.

[Patient - doctor relationship from perspective of the Karpman drama triangle]. / Relacja pacjent ­ lekarz z perspektywy trójkata dramatycznego Karpmana.

Patients' confidence in doctors has been decreased for last years despite successes of Polish medicine. It seems to be related to particular conditions of patient - doctor relationship and patient's negative emotions may frequently burden it from the beginning. They may allow an interpersonal game, the Drama Triangle, to appear in the relationship. 3 persons are typically involved in the game: a victim, a persecutor and a rescuer. All of them neither feel guilty about the situation nor their activities are aimed at solving the crucial problem. It maintains continuation of the game. Both patient and doctor are capable to attend the game as any of the person mentioned above. Authors of the article think frameworks of organization of the health care system should permit doctors not only to tackle main disease but also to devote time individually tailored to patient's emotional problems.

[Interpersonal games as a method for doctors' occupational stress]. / Gry miedzyludzkie jako sposób na stres zawodowy lekarzy.

Doctors are frequently expose to stress during their occupational work. It is mainly the result of burdens caused by taking care of patients, dysfunctional arrangements of the health care system and difficult relationships in their workplace. Chronic stress brings negative emotions and they need to cope with them . Doctors, willing to achieve it, may initiate interpersonal games with the hidden motive of restoring their internal balance. Based on transactional analysis, the authors describe some of the games which may be found in doctors' environment: "How to get out of there", "Mine is better than yours", "Scapegoat", "Fault" and "double bind". The outcome of the games may be receiving a support, proving a benefit derived from stress, getting the feeling of being not guilty, justification, or releasing emotions in apparently unintended way. Interpersonal games may help stressed doctors to get rid of internal tension but at the same time they may be a source of stress for other participants in the games. The way to limit their destructive impact is to create such administrative and organizational solutions which allow to make working conditions more friendly.

[Professional burnout among family doctors and games in patient - doctor relationship]. / Wypalenie zawodowe lekarzy rodzinnych a gry w relacji pacjent - lekarz.

S Burnout syndrome reveals high prevalence among family doctor in many countries. Its universality in outpatient practice is influenced by numerous relationships with demanding patients. The authors of this work described chosen interpersonal games in patient - doctor relationships on the base of transactional analysis. These games, bearing significant emotional burden, predispose doctors to burnout. In the authors' opinion a diminishing of the prevalence of burnout syndrome in family doctors may be achieved with creating a friendly work environment for them and developing their skills in managing with difficult patient - doctor relationships.

Universality of physicians' burnout syndrome as a result of experiencing difficulty in relationship with patients.

The aim of our work is to present the universality of burnout syndrome among physicians worldwide and to demonstrate selected aspects of the relationship between patients and doctors as a common factor predisposing to burnout. We looked up 20 original pieces of research from the Medline database published in the last 10 years to determine the prevalence of burnout among doctors in different countries. In all quoted works a remarkable percentage of doctors of interventional and non-interventional specialties suffered burnout. Because it is the relationship with patients that constitutes a key denominator for their work, in the discussion we have exposed an important aspect of it, destructive patient games, described on the basis of transactional analysis. Since universal burnout causes a deterioration of doctors' service, for the optimal good of the patient to survive preservation of the doctor's well-being in the patient-doctor relationship is needed everywhere.

The role of the immuno-inflammatory response in patients after cardiac arrest.

INTRODUCTION: The aim of the research was to assess whether concentrations of inflammatory markers in blood of patients after cardiac arrest (CA) are related to their clinical state and survival. MATERIAL AND METHODS: Forty-six patients, aged 63 ±12 years, 21 of them after out-of-hospital CA and 25 after in-hospital CA, were enrolled in the study. Twenty-five patients survived and were discharged from hospital (CA-S); 21 died during hospitalization (CA-D). The clinical state of the patients was evaluated by the Glasgow Coma Scale (GCS) and the Acute Physiology and Chronic Health Evaluation II (APACHE II). On the day immediately after CA (day 1) and on the following day (day 2) the plasma concentration of high specific C-reactive protein (hs-CRP), tumour necrosis factor (TNF)-α, interleukin-10 and interleukin-6 (Ile-6) were measured. RESULTS: In CA-D patients, compared with CA-S, a significantly higher concentration of hs-CRP (on day 1, 19 ±5 vs. 15 ±4; on day 2, 21 ±3 vs. 16 ±5 mg/l, p < 0.001) and Ile-6 (on day 1, 24.9 ±19.8 vs. 9.2 ±11.3; on day 2, 24.2 ±19.7 vs. 6.9 ±6.8 IU/ml, p < 0.001) was found. The level of TNF-α was greater in CA-D on day 1 (0.42 ±0.75 vs. 0.18 ±0.21 IU/ml, p < 0.04). Concentrations of hs-CRP and Ile-6 were correlated with the scores of GCS and APACHE II. Using logistic regression analysis and ROC curves the prognostic value of hs-CRP and Ile-6 for survival was proven. CONCLUSIONS: Post-cardiac arrest immuno-inflammatory response, reflected mainly in elevated plasma concentration of hs-CRP and Ile-6, is not only correlated with patients' clinical state but also with prediction of survival.

[Inflammatory cytokines and long-term prognosis after cardiac arrest]. / Rokownicza wartosc stezenia cytokin u chorych po naglym zatrzymaniu krazenia.

BACKGROUND: The long-term survival rate after sudden cardiac arrest remains low despite progress in resuscitation, possibly due to acute ischemia of vital organs and subsequent general inflammatory reaction. We investigated a possible relationship between inflammatory cytokine concentrations and cardiac arrest (CA) survival. METHODS: Fifty one adult acute coronary syndrome patients, 35 males and 16 females, aged 62 +/- 12 years, who survived out-of-hospital CA (45%) and in-hospital CA (55%) were enrolled in the study. Twenty four of the patients died (D-CA); the other 27 survived and were discharged from the hospital (S-CA). Clinical conditions were rated by the Simplified Acute Physiology Score II (SAPS II) and Multiple Organ Dysfunction Score (MODS). Blood samples were obtained immediately after cardiac arrest. Serum concentrations of IL-6, IL-10 and TNF-alpha were analysed and rated against survival rates. RESULTS: Higher mean concentrations of all cytokines were found in the D-CA group, when compared to the S-CA group. The mean concentration of IL-6 was 225 +/- 178 IU mL(-1) in the D-CA patients and 88 +/- 120 IU mL(-1) in the S-CA group (p = 0.006), and correlated inversely with survival (p = 0.018). The higher concentrations of IL-10 and TNF-alpha in non-survivors were not significant and bore no relation to survival rates. We also found significantly higher SAPS II and MODS scores, which correlated with both IL-6 levels and survival rates. CONCLUSIONS: The relationship between the concentration of inflammatory cytokines and survival has been reported by others and should be regarded as a marker of generalized inflammatory response. A concentration of IL-6 is of high prognostic value.

[Concentrations of adrenal steroids and sex hormones in postmenopausal women suffering from coronary artery disease]. / Stezenia steroidów nadnerczowych i hormonów plciowych u kobiet po menopauzie z rozpoznana choroba wiencowa.

UNLABELLED: The lack of the benefits in the prevention of coronary artery disease (CAD) from the hormonal substitution with preparations of estradiol (E2) suggests that higher frequency of CAD in postmenopausal women (PMW) may be influenced by a hormonal mechanism different from the postmenopausal hypoestrogenism. AIM OF THE STUDY: Due to the fact adrenal glands are the important source of steroids in PMW the aim of our research was the assessment of the concentrations of the adrenal hormones and their possible relations with CAD. MATERIAL AND METHODS: W-CAD group--31 PMW at the age of 66 +/- 9 years with angiographically proven CAD; 3/4 of them suffered from myocardial infarction. W-H group--17 healthy women at the age of 59 +/- 7 years. Common clinical and biochemical risk factors were searched for in each and every of the PMW. In the venous blood samples taken from them by means of immunological methods the concentrations of the hormones were assessed: starving insulin, adrenocorticotropic hormone (ACTH), E2, progesterone, testosterone, dehydroepiandrosterone sulfate (DHEAS), cortisol, aldosterone, androstenedione, folliculotropic hormone and luteinising hormone. The levels of the hormones were compared between the groups. Logistic regression analysis was used to discover possible relations among the clinical and hormonal parameters and CAD. RESULTS: In W-CAD mean concentration of DHEAS was lower than in W-H, close to the significant value (75 +/- 76 vs 102 +/- 79 microg/dl, p<0,08). In PMW with CAD mean concentration of cortisol (18 +/- 5 vs 15 +/- 6 microg/dl, p<0,07) and ACTH was higher, but mean concentration of aldosterone was more than twice as small as in the healthy ones. The levels of the rest aforementioned hormones were similar in the groups. In the univariate model created by logistic regression analysis DHEAS was the only hormone that revealed the significant relation between its level and the occurrence of CAD. CONCLUSION: In PMW diminished concentration of DHEAS is correlated with occurrence of CAD. The differences of the concentrations of the other hormones between PMW with and without CAD need further observation.

[Excessive body weight and coexisting with it changes in levels of hormones of adrenal and gonadal origin are associated with coronary artery disease in men]. / Nadmierna waga ciala i wspólistniejace zmiany stezenia hormonów pochodzenia nadnerczowego i gonadalnego zwiazane z choroba wiencowa u mezczyzn.

UNLABELLED: The aim of study was to estimate relation between excessive body weight (EBW) and coronary artery disease (CAD) in men and to assess changes in concentrations of hormones due to EBW which may predispose to atherogenesis. MATERIAL AND METHODS: Study group (CADM) - 33 men in the age 52 +/- 6 years, with body mass index (BMI) above 25 kg/m2 and angiographically documented CAD. Comparative group (CM) - 13 men in the same age without CAD. Apart from evaluation of occurence of risk factors in men of both groups concentrations of hormones in blood were assessed: insulin, insulin-like growth factor I, estradiol (E2), testosterone (T), dehydroepiandrosterone sulfate (DHEAS), follicle-stimulating hormone, luteinizing hormone, progesterone (Prog), cortisol (Cort) and leptin (Lept). RESULTS: In CADM, comparing to CM, greater values of parameters related to EBW, BMI (30,0 +/- 2,6 vs. 26,8 +/- 2,6 kg/m2, p<0,0007) and waist-hip ratio (WHR 1,07 +/- 0,04 vs. 0,92 +/- 0,03, p<0,000001), higher concentrations of Prog (3,0 +/- 1,3 vs. 1,4 +/- 0,9 nmol/l, p<0,0003), Kort (350 +/- 108 vs. 246 +/- 97nmol/l, p<0,006) and Lept (18,2 +/- 10,5 vs. 8,0 +/- 3,6 lU/l, p<0,0003) and lower of T (9,9 +/- 4,0 vs. 12,3 +/- 3,2 nmol/l, p<0,046) were found. In regression analysis coexistence of EBW and eleveted level of Prog revealed the best fit with presence of CAD. Positive correlation between EBW and concentration of Lept and E2 and negative correlation between EBW and concentrations of T, Cort and DHEAS in CADM were found. CONCLUSIONS: EBW is a highly aggravating risk factor of CAD in men and is linked to proatherogenic changes in levels of steroid hormones of adrenal and gonadal origin.

[Hyperandrogenism as a risk factor of coronary artery disease in young women]. / Hiperandrogenizm jako czynnik ryzyka choroby wienicowej u mlodych kobiet.

The aim of the study was an attempt to assess the relative roles of common risk factors of coronary artery disease (CAD) and sex hormones in the pathogenesis of CAD in young menstruating women. 38 women in the age of 35-47 years with past myocardial infarction and angiographically proven critical changes in coronary arteries, with one-vessel disease in 22 women (58%) or multi-vessel disease in 16 (42%) were examined. A referee group consisted of 15 healthy women in the age of 35-45 years. In all women multiple risk factors were searched, including value of body mass index (BMI) and waist-hip ratio (WHR). In 4-7 day of sexual cycle at 8.00 a.m. blood from cubital vein was taken to measure concentrations of biochemical parameters and hormones: estradiol, testosterone (T), dehydroepiandrosterone sulphate, folliclestimulating hormone, luteinizing hormone, prolactin, thyreotropin, progesterone, cortisol and sex-hormone binding globulin. In women with CAD, comparing to healthy ones, a higher frequency of arterial hypertension (55% vs 7%), cigarete smoking (95% vs. 46%), hirsutism (84% vs. 30%) and dyslipidaemia was found. Concentration of T was significantly higher in women with CAD than in healthy women (3.5 +/- 1.5 nmol/l--vs. 2.4 +/- 1.0, p < 0.014). In regression analysis was revealed that in multiple parameters a cluster of 2 parameters, dyslipidaemia and hirsutism, was of the best goodness of fit with occurence of CAD. Significant relation with CAD was proven for visceral obesity, eleveted concentration of T and cigarette smoking, either. Conclusions. Apart from common known risk factors as visceral obesity, dyslipidaemia and cigarette smoking it is hiperandrogenism that may participate in pathogenesis of CAD in women in the reproductive age.

[Coma--the interdisciplinary problem]. / Problem interdyscyplinarny--spiaczka.

5% of all patients admitted to emergency units suffer from disturbances of state of consciousness. Early assessment/appreciation of degree of unconsciousness and identification of its etiology influences on and sometimes decides success of its therapy. In the article below epidemiology, diagnosis, prognosis and main principles of procedures employed in senseless patients are discussed.