Body mass index of girls in health influences menarche and skeletal maturation: a leptin-sympathetic nervous system focus on the trunk with hypothalamic asymmetric dysfunction in the pathogenesis of adolescent idiopathic scoliosis?

Lower body mass index (BMI) and lower circulating leptin levels have been reported in girls with AIS. In this paper we evaluate skeletal sizes and asymmetries by higher and lower BMI subsets about the means for each of three groups of girls age 11-18 years: 1) normals, 2) school screening referrals, and 3) preoperative girls. Higher and lower BMI subsets, likely to have separated subjects with higher from those with lower circulating leptin levels, identify: 1) girls with relatively earlier and later menarche; 2) trunk width size greater in the higher than in the lower BMI subset, of all three groups; 3) abnormal upper arm length (UAL) asymmetries (right minus left) in the lower BMI subset of the preoperative girls; and 4) in thoracic AIS of screened and preoperative girls, Cobb angle and apical vertebral rotation each significantly and positively correlate with UAL asymmetry in the lower BMI subset but not in the higher BMI subset. In preoperative girls, the lower BMI subset shows the combination of relatively reduced pelvic width and abnormal UAL asymmetry, suggesting that both are linked to lower circulating leptin levels. An earlier puberty with hormonal changes provides a plausible explanation for the larger trunk width at the shoulders and pelvis especially at the younger ages in the higher BMI subsets. At the shoulders, this widening is driven by the ribcage which, in human evolution was acquired with decoupling of head and trunk movements required for efficient bipedal gait. The UAL asymmetry patterns within the groups and BMI subsets are not explained by hormonal mechanisms. It is hypothesized that 1) normal trunk widening of the thoracic cage by hormones in human adolescence is supplemented via the sympathetic nervous system under leptin-hypothalamic control influenced by energy stores (metabolic fuel); and 2) hypothalamic dysfunction with altered hypothalamic sensitivity to leptin through a SNS-driven asymmetric effect may create skeletal length asymmetries in upper arms, ribs, ilia and vertebrae, and initiate AIS. Additional mechanisms acting in the spine and trunk may be required for AIS to progress including 1) somatic nervous system dysfunction, 2) biomechanical spinal growth modulation, and 3) osteopenia.

Ultrasound femoral anteversion (FAV) relative to tibial torsion (TT) is abnormal after school screening for adolescent idiopathic scoliosis (AIS): evaluation by two methods.

In the scoliotic spine, torsion is generally evaluated in relation to axial rotation of the apical vertebra. In the lower limbs, the changes in torsion by age of femoral anteversion (FAV) relative to tibial torsion (TT) have been studied in dried bones, normal growing subjects and adults and subjects with osteoarthritis of the hip or the knee. This paper reports the application of real-time ultrasound to FAV and TT in normal children age 11-18 years and in scoliosis screening referrals with particular reference to how FAV relates to TT as 1) ratios, and 2) tibio-femoral index (TFI) of torsion, calculated as TT minus femoral FAV. The FAV/TT ratio findings show an abnormal normal relationship of FAV to TT both proximo-distally and in left-right asymmetry. These may express torsional abnormalities in femoral and/or tibial growth plates with left-right asynchrony suggesting the possibility of similar torsional abnormalities in vertebral end-plates and/or rib growth plates initiating the deformity of AIS. TFI of the right limb in the scoliosis girls is greater than in the normals that is interpreted as resulting from earlier skeletal maturation of FAV. FAV/TT ratios and TFI are unrelated to the spinal deformity (Cobb angle and apical vertebral rotation) except for boys where TFI is associated with apical vertebral rotation. FAV/TT ratios may be a more accurate method estimating the relationship of FAV to TT. than TFIs.

Leg-arm length ratios correlate with severity of apical vertebral rotation in girls after school screening for adolescent idiopathic scoliosis (AIS): a dynamic pathomechanism in the initiation of the deformity?

There is increasing support for the view that the unique human bipedalism and the erect posture are prerequisites for the pathogenesis of adolescent idiopathic scoliosis (AIS). How human bipedalism may contribute to the pathogenesis of AIS is not clear. In normal humans, axial rotations and counter-rotations of the trunk are carried out frequently and forcibly in activities that are not performed by quadrupeds. Some workers have analysed gait in AIS subjects, others have studied torsions in lower limb bones, but there are only two reports on leg-arm ratios in relation to AIS. In this paper, leg-arm ratios studied in relation to the spinal deformity in scoliosis screening referrals, reveal a highly significant correlation with the apical vertebral rotation but not the Cobb angle of the scoliosis curves. We suggest that leg-arm proportions and movements during gait involving pelvi-spinal axial rotations and thoracic counter-rotations contribute a dynamic pathomechanism to early AIS from whatever cause and involving the thoracic cage. Curve progression needs other mechanisms that may include a central nervous system failure to control structural asymmetry of vertebral axial rotation, and biomechanical spinal growth modulation.

Ultrasound femoral anteversion (FAV) and tibial torsion (TT) after school screening for adolescent idiopathic scoliosis (AIS).

Torsion and counter-torsion in the spine are features of the three-dimensional deformity of adolescent idiopathic scoliosis, Vertebral axial rotation has recently been found in the normal adult thoracic spine. Torsion in the lower limbs, femora and tibiae is a feature of normal human skeletal postnatal development. In recent years, femoral anteversion (FAV) and tibial torsion (TT) have been studied in normal children by imaging techniques, especially ultrasound. This paper reports summaries of the application of real-time ultrasound to FAV and TT of normal children and scoliosis school screening referrals. In the scoliosis girls and boys, the FAV decrease and FAV asymmetry compared with normals may result from abnormally increased femoral detorsion maturationally earlier with left-right asynchrony which, if repeated as a growth plate anomaly in the trunk (spine and/or periapical ribs), might initiate the AIS deformity, given other requirements. In scoliosis boys relative to girls, the TT decrease without asymmetry may result from sexually dimorphic maturation at knee tibial growth plates ? maturationally delayed TT with left-right synchrony.

The posterior skeletal thorax: rib-vertebral angle and axial vertebral rotation asymmetries in adolescent idiopathic scoliosis.

The deformity of the ribcage in thoracic adolescent idiopathic scoliosis (AIS) is viewed by most as being secondary to the spinal deformity, though a few consider it primary or involved in curve aggravation. Those who consider it primary ascribe pathogenetic significance to rib-vertebra angle asymmetry. In thoracic AIS, supra-apical rib-vertebra angle differences (RVADs) are reported to be associated with the severity of the Cobb angle. In this paper we attempt to evaluate rib and spinal pathomechanisms in thoracic and thnoracolumbar AIS using spinal radiographs and real-time ultrasound. On the radiographs by costo-vertebral angle asymmetries (rib-vertebral angle differences RVADs, and rib-spinal angle differences RSADs), apical vertebral rotation (AV) and apical vertebral translation (AVT) were measured; and by ultrasound, spine-rib rotation differences (SRRDs) were estimated. RVADs are largest at two and three vertebral levels above the apex where they correlate significantly and positively with Cobb angle and AVT but not AVR. In right thoracic AIS, the cause(s) of the RVA asymmetries is unknown: it may result from trunk muscle imbalance, or from ribs adjusting passively within the constraint of the fourth column of the spine to increasing spinal curvature from whatever cause. Several possible mechanisms may drive axial vertebral rotation including, biplanar spinal asymmetry, relative anterior spinal overgrowth, dorsal shear forces in the presence of normal vertebral axial rotation, asymmetry of rib linear growth, trunk muscle imbalance causing rib-vertebra angle asymmetry weakening the spinal rotation-defending system of bipedal gait, and CNS mechanisms.

[The use of thrombelastography in evaluation of coagulation in females with physiological or pathological gravidity]. / Uzití trombelastografie pri hodnocení koagulace u zen s fyziologicky a patologicky probíhajícím tehotenstvím.

BACKGROUND: During gravidity changes in coagulation develop, however different norms for pregnant women and prevailing population are rarely used. Pathological gravidity can be accompanied with more significant coagulopathies. Thrombelastography is more and more frequently used for evaluation of coagulation parameters of pregnant women. The aim of the study was to compare thrombelastographic coagulation parameters in females with physiological or pathological gravidity and with norms for prevailing population. METHODS AND RESULTS: 60 women in the 3rd trimester of physiological gravidity (group ZDRAVE) and 50 women with pathological gravidity (women with preeclampsia or with a dead fetus, group PATOL) were examined. Both groups were of the comparable age. Average values of studied parameters in the group ZDRAVE were found at the level of "procoagulation" limits for prevailing population. In the group PATOL, average values were even more "procoagulative", however, differences to the ZDRAVE group were nor significant: time r 4.7 (SD 1.7) vs. 4.4 (SD 2.0) p = 0.461 (norm for prevailing population 4-8 min), time to 1.5 (0.5) vs. 1.3 (0.4) p = 0.030 (norm 1-4 min), angle alpha 69.6 (5.5) vs. 71.0 (7.7) p = 0.324 (norm 47-74 degrees), maximal amplitude 71.3 (4.5) vs. 73.1 (4.7) p = 0.079 (norm 55-73 mm), coagulation index 2.7 (1.8) vs. 3.2 (1.8) p = 0.219 (norm (-3)-(+3)). In the group PATOL higher variability than in the group ZDRAVE was found. On the basis of the group ZDRAVE selection percentiles, new norms of thrombelastographic coagulation parameters for pregnant women were elaborated. CONCLUSIONS: Coagulation during pregnancy differs significantly from that of prevailing population. That is why the new thrombelastographic norms for pregnant women are submitted. Coagulation changes in pathological pregnancies are more difficult to anticipate than in healthy gestations.

Etiologic theories of idiopathic scoliosis: neurodevelopmental concept of maturational delay of the CNS body schema ("body-in-the-brain").

Several workers consider that the etiology of adolescent idiopathic scoliosis (AIS) involves undetected neuromuscular dysfunction. During normal development the central nervous system (CNS) has to adapt to the rapidly growing skeleton of adolescence, and in AIS to developing spinal asymmetry from whatever cause. Examination of evidence from (1) anomalous extra-spinal left-right skeletal length asymmetries, (2) growth velocity and curve progression, and (3) the CNS body schema, parietal lobe and temporoparietal junction, led us to propose a new etiologic concept namely of delay in maturation of the CNS body schema during adolescence. In particular, the development of an early AIS deformity at a time of rapid spinal growth the association of CNS maturational delay results in the CNS attempting to balance a lateral spinal deformity in a moving upright trunk that is larger than the information on personal space (self) already established in the brain by that time of development. It is postulated that the CNS maturational delay allows scoliosis curve progression to occur - unless the delay is temporary when curve progression would cease. The putative maturational delay in the CNS body schema may arise (1) from impaired sensory input: (2) primarily in the brain; and/or (3) from impaired motor output. Oxidative stress with lipid peroxidation in the nervous system may be involved in some patients. The concept brings together many findings relating AIS to the nervous and musculo-skeletal systems and suggests brain morphometric studies in subjects with progressive AIS.

[Nutritional support of patients treated with continuous hemofiltration methods in intensive care units]. / Výziva pacientu lécených kontinuálními hemoeliminacními metodami na pracovistích intenzivní péce.

The use of continuous renal replacement therapy (CRRT) can directly or indirectly influence patient's metabolism and nutritional status. The loss of nutrients into the filtrate is significant. It concerns aminoacids, glucose, water-soluble vitamins, some minerals and trace elements. The loss of aminoacids is about 1.2 to 7.0 g per day. The glucose balance during CRRT depends on the concentration of glucose in substitution solutions. When concentration between 80 to 180 mg/dl is used, the glucose balance in most of patients is kept. The loss of lipids and lipid-soluble vitamins is neglectable. From the micronutrients, significant becomes the loss of magnesium, calcium, phosphorus and that of water-soluble vitamins (mainly B1, B6, C and folic acid). Contrary to it, some components can cross from the substitution solution to the blood (e.g. lactate). Indirect effect of CRRT on the nutrition and metabolism represents the release of cytokins and inflammatory mediators resulting from the first contact of the blood with the filter membrane. The decrease of glutamine level in the beginning of therapy is probably a consequence of this inflammatory reaction. Nutritional plan of most of patients treated with CRRT is therefore necessary to adjust.

[Weaning from artificial pulmonary ventilation]. / Odvykání od umelé plicní ventilace.

Weaning from mechanical ventilation is not complicated in the majority of patients, in some, however, this process is very complicated and lengthy. These patients are described as difficult to wean. A suitable weaning strategy and properly timed extubation or decannulation is important not only from the aspect of the patient's health status but also with regard to costs of care. When selecting patients suitable for weaning it is useful to use prognostic indicators of success. The Tobin-Yang index and ratio Pa O2/FiO2 seem to be most useful. Based on available information it seems that the pressure support and weaning by means of T-piece is more effective than weaning using the SIMV regime. Promising seems the use of non-invasive ventilation but this was not proved unequivocally so far. The use of weaning protocols reduces the weaning period from mechanical ventilation. The authors summarize most recent findings on the weaning problem incl. the most frequently used ventilation regimes and prognostic indicators of successful weaning.

[Acute necrotizing pancreatitis]. / Akutní nekrotizující pankreatitida.

Acute pancreatitis ranges from mild to severe necrotizing form complicated by multiorgan failure with high mortality rate. It has different causes, not entirely clear pathogenesis and unpredictable and variable course. Therapeutic measures are limited. The mainstay of therapy is supportive intensive care, prevention of sepsis and multiple organ failure and identification and treatment of infected pancreatic necrosis. Surgical approach is justified in verified infected necrosis. In case of sterile pancreatic necrosis complicated by organ failures is the role of surgical intervention debatable.

[Metabolic disorders in nonspecific inflammatory bowel diseases]. / Metabolický rozvrat u nespecifických strevních zánetu.

The primary function of the gastrointestinal system is to assist the intake and further processing of food and liquids. Besides that, it forms an anatomical barrier between the external environment and internal milieu. It is also highly important for its paracrine and endocrine function. Inflammatory bowel diseases, which frequently cause a gastrointestinal failure, form a specific group. Most frequently it is the ulcerative colitis and Crohn's disease. Impaired integrity of the gastrointestinal mucosa and failure of protective mechanisms lead to the increased permeability of the intestinal wall for antigens derived from food, saprophytic bacteria and pathogenic microorganisms. When the gastrointestinal failure is threatening, factors determining its residual function become more important. As decisive reveals the severity and location of the primary disease. Previous surgeries and adaptation of the residual part of the gastrointestinal system are important, as well as the possibility of peroral or enteral nutrient intake. Depending on the presence of risk factors and the degree of residual gut function, some complications can be expected: dehydration, mineral disorders, symptoms of protein and energy depletion, infection, and multiple organ dysfunction syndrome. It is highly important to decide whether the gastrointestinal system will be included into or excluded from the process of realimentation. Critically ill patients with inflammatory bowel diseases should be treated at an intensive care unit.

[Nonvariceal acute upper digestive tract hemorrhage--therapeutic approach]. / Nevarikózní akutní krvácení do horní cásti zazívacího traktu--terapeutický prístup.

Nonvariceal acute upper gastrointestinal hemorrhage continues to be a frequent cause for hospital admission, consumes considerable financial resources and belongs to diagnoses associated with significant morbidity and mortality. Despite the progress in endoscopic and intensive care therapies the mortality remained unchanged. It results from the increasing number of high risk patients, namely the older ones with significant comorbidity. The cornerstone of therapeutical success is considered to be the adequate hemodynamic and ventilatory stability, initiation of pharmacotherapy with proton pump inhibitors and eventually somatostatin, and in particular, the early endoscopy using modern methods of hemostasis. In case of two unsuccessful endoscopic sessions the surgical approach is justified.

Idiopathic myelofibrosis complicated by portal hypertension treated with a transjugular intrahepatic portosystemic shunt (TIPS).

Idiopathic myelofibrosis may be accompanied by portal hypertension. The authors report a 56-year-old man with idiopathic myelofibrosis and splenomegaly complicated by hepatopathy, severe portal hypertension and recurrent variceal bleeding. A transjugular intrahepatic porto-systemic shunt (TIPS) was inserted. Variceal bleeding never recurred. A short episode of encephalopathy, which is a known complication of porto-systemic shunting, ceased promptly after conservative treatment. The patient eventually died six months later due to metabolic deterioration and hepatic failure related to his underlying hematological disease. TIPS is a promising treatment modality for alleviating symptomatic portal hypertension in hematological disorders.

Thirty two years old patient with adult Still's disease.

Adult Still's disease is characterized by diverse clinical and laboratory findings, which may lead to errors in the differential diagnosis, and possible injury of the patient's health due to wrong therapeutic management. In the following case report, we describe a case of a 32-year old patient with fever of unknown etiology. The final diagnosis of Morbus Still adultorum was determined five months after his first check-up. The course of the disease was complicated by acute hepatitis caused by drug toxic damage. We have applied immunosuppressive therapy with very good clinical and laboratory responses. (Ref. 9.)

An evaluation of lycra garments in the lower limb using 3-D gait analysis and functional assessment (PEDI).

Whole body lycra garments were assessed in eight children using gait analysis, the paediatric evaluation of disability index (PEDI), and a questionnaire of parental acceptance. Seven of the children had cerebral palsy and one Duchennes muscular dystrophy. After initial assessment and fitting of the garment, there was a 2-week introduction period followed by 6 weeks of wearing the garment for at least 6 h everyday, following which they were re-assessed. The root mean square error (RMSE) was used as a measure of variability over three separate passes through the gait laboratory and was a reference figure for gait stability. Proximal stability around the pelvis improved for five children and distal stability improved for three. Five children improved in at least one aspect of the PEDI scale. Although the parents and children detected these improvements, they did not outweigh the disadvantages of wearing the suit and as a consequence only one out of eight families considered continuing with the lycra garment.

[The effect of monotherapy with ciprofibrate and in combination with acetylsalicylic acid on the spectrum of lipids, thromboxane and fibrinogen in patients with atherosclerosis and hyperlipoproteinemia]. / Vplyv ciprofibrátu v monoterapii a v kombinácii s acetylosalicylovou kyselinou na spektrum lipidov, tromboxán a fibrinogén u pacientov s manifestnou aterosklerózou a hyperlipoproteinémiou.

Ciprofibrate is one of the basic drugs used to lower risk values of lipid parameters and fibrinogen in atherosclerosis patients. Since antiaggregation treatment with acetylsalicylic acid is a complex part of obligatory therapy of these patients, the authors studied the influence of ciprofibrate on chosen lipid parameters, fibrinogen and thromboxane in monotherapy, and also in combination with acetylsalicylic acid (ASA) in patients with advanced atherosclerosis and hyperlipoproteinemia. In the first group of patients (A-C, n = 12) after one month of low-lipid diet acetylsalicylic acid in a dose of 100 mg was administered daily during a period of 2 months followed by addition of 100 mg of ciprofabrate daily during the next 2 months. In the second group of patients (C-A, n = 11) after one month of low-lipid diet the same drugs were administered but in opposite order. Ciprofibrate was most effective in lowering the levels of triacylglycerids (-41%) and VLDL-cholesterol (-34%), but effectively lowered also the values of total cholesterol and LDL-cholesterol. In both studied groups it led to mild increase of HDL-cholesterol levels. Simultaneous administration of ASA did not significantly influence its hypolipemic activity. Ciprofibrate also significantly lowered the level of fibrinogen (-17%). Increase of the total number of platelets by about 10% was not accompanied by changes of the values and production of thromboxane. Simultaneous administration of ASA caused more than 90% inhibition of thromboxane production in monotherapy and in combination with ciprofibrate. Ciprofibrate is an effective hypolipidemic agent, also lowering the level of fibrinogen. Its combination with ASA is adequate, safe and without negative interaction influencing treatment. (Tab. 6, Fig. 1, Ref. 16.)

Segmental evaluation of the surface and radiological deformity after Cotrel-Dubousset (CD) instrumentation for King type II and III. adolescent idiopathic scoliosis (AIS): surgical and etiological implications.

In this paper we report the segmental effects of CD in each of the three planes of deformity (frontal, transverse and sagittal) in 35 children with AIS (King types II and III) treated by Cotrel-Dubousset instrumentation. Patients were examined preoperatively and in follow-up at 8 weeks and one year, and 15 patients were also examined at two years. Back shape was appraised segmentally as angle of trunk inclination (ATI) at each of ten levels by ISIS and the Scoliometer. The radiographs were measured nonsegmentally for Cobb angle, apical vertebral rotation and spinal balance, and segmentally for both vertebral rotation and tilt (frontal and sagittal plane), and in the rib cage for rib-vertebra angles (RVAs).

[An inverse reaction of the ST-T complex in the elctrocardiogram due to beta receptor inhibition]. / Uber eine durch beta-Rezeptorenhemmung bewirkte inverse Reaktion des ST-T-Komplexes im Elektrokardiogramm.

In this article shall be referred to a special form of reaction of the ST-T-complexes in the propranolol test. Instead of a normalisation of this section of the ECG an inverse reaction develops. It consists in the fact that after application of propranolol the negativities of the T-waves increase and the lowerings of the ST-distances deepen. They appear most frequently after an acute heart attack, such as after a spontaneous angina pectoris, and they can be reproduced only during some days. It is supposed that the cooperation of acute ischaemic myocardial processes with negative sequelae of the blockade of beta-receptors are responsible for this inverse reaction.