The role of urinary aldosterone for the diagnosis of primary aldosteronism.

When diagnosing primary aldosteronism, the measurement of urinary aldosterone after oral sodium loading is one of the currently recommended confirmatory tests. The aim of the study was to assess the repeatability and interpretation of urinary aldosterone in patients examined for suspected primary aldosteronism. Sixty-four hypertensive patients with suspected primary aldosteronism were prospectively enrolled and examined according to the study protocol. After antihypertensive medications interfering with renin-angiotensin-aldosterone system were withdrawn for at least 2 weeks, the confirmatory testing was performed: oral sodium loading preceded the collection of 24-h urine sample and subsequent saline infusion test. The identical procedures were repeated after 2 weeks. The concordant results of both saline infusion tests served for confirmation/exclusion of primary aldosteronism. Forty-nine patients were included in data analysis. Primary aldosteronism was excluded in 16, and confirmed in 33 individuals. The repeatability of urinary aldosterone was evaluated in 44 patients: the difference of urinary aldosterone levels ranged between 1 and 88% (median 31%). Ninety-three urine samples from 49 patients were used to validate the interpretation of urinary aldosterone in respect to the diagnosis of primary aldosteronism made by saline infusion testing; 96% sensitivity was characterized by urinary aldosterone ≥19 nmol/day, and 96% specificity was associated with urinary aldosterone ≥92 nmol/day. In 22 (45%) patients, urinary aldosterone remained in the "gray" zone between 19 and 92 nmol/day in all provided samples. The estimation of urinary aldosterone excretion after oral sodium loading is associated with marked intraindividual variability, and significant number of inconclusive results.

Impairment of nasal mucociliary clearance in former smokers with stable chronic obstructive pulmonary disease relates to the presence of a chronic bronchitis phenotype.

BACKGROUND: Associations between nasal and bronchial impairment have been repeatedly described in chronic obstructive pulmonary disease (COPD), whereas nasal mucociliary clearance (MCC) in COPD patients is not yet fully understood. We studied nasal MCC parameters in COPD patients and compared them with healthy adults (HA) and with cystic fibrosis (CF) patients with compromised MCC. METHODOLOGY: An observational study of 98 COPD ex-smokers and subjects from control groups evaluated for nasal MCC time (NMCCt) and by digital video microscopy of nasal mucosa recording ciliary beat frequency (CBF) and ciliary beat pattern. RESULTS: The NMCCt was decreased in HA compared to those with COPD and decreased in those with COPD compared to those with CF. CBF in COPD was lower compared to HA. The index of ciliary dyskinesia in COPD patients differed from HA. We detected higher NMCCt and lower nasal CBF in patients with chronic bronchitis phenotype (CB) compared to non-CB patients. CONCLUSIONS: We confirmed the presence of impaired nasal MCC in COPD ex-smokers. These impairments were apparent predominantly in the CB phenotype.

[Is confirmation of an adrenal adenoma in patients with primary aldosteronism sufficient for indication of adrenalectomy?]. / Je prukaz adenomu nadledviny u pacientu s primárním hyperaldosteronizmem dostatecný pro indikati adrenalektomie?

BACKGROUND: Primary aldosteronism is one of the most common forms of secondary arterial hypertension. Adrenalectomy is effective in patients with proven unilateral hypersecretion of aldosterone whereas pharmacotherapy is indicated in bilateral forms of the disease. We can meet the opinion that in patients with confirmed primary aldosteronism and finding ofsuprarenal adenoma > or = 1 cm on computed tomography (CT) scanning, adrenalectomy can be recommended without further investigation. On the other hand we can perform adrenal venous sampling (AVS) to prove unilateral overproduction of aldosterone. OBJECTIVES: To evaluate whether AVS is necessary in all patients with unilateral adenoma > or = 1 cm. METHODS: We analyzed data from patients with proven primary aldosteronism, CT finding of adenoma > or = 1 cm along with normal morphology of contralateral adrenal gland, and successfully performed AVS. RESULTS: Out of 107 patients with proven primary aldosteronism, indicated for AVS, we included 30 patients with CT finding of suprarenal adenoma > or = 1 cm along with normal morphology of contralateral adrenal gland and successful AVS. Unilateral overproduction of aldosterone was found only in 17 cases (56.7%), the results in remaining 13 patients (43.3%) did not confirm activity of adenoma. CONCLUSION: Our results support necessity of performing AVS in all patients with primary aldosteronism in whom surgical treatment is considered, CT confirmation ofan adenoma is insufficient in this indication.

Neurovascular compression: sympathetic activity in severe arterial hypertension.

Compression of the rostral ventrolateral medulla oblongata (RVLM) by an abnormally located artery is regarded as one possible cause of arterial hypertension. There exists a limited set of data suggesting that increased sympathetic activity in patients with RVLM compression may lead to arterial hypertension. Accordingly, we decided to assess the sympathetic activity in patients with severe arterial hypertension and to investigate any correlation with the presence of RVLM compression. Sixty-four patients with severe arterial hypertension were enrolled in our study. Sympathetic activity was evaluated using 24-hour urinary norepinephrine as measured by high-pressure liquid chromatography with electrochemical detection. The presence of RVLM compression was assessed with magnetic resonance imaging. Neurovascular compression of the RVLM was identified in 40 patients, 27 of whom presented left-sided compression. Twenty-four hour urinary norepinephrine averaged 263.6+/-135.9 nmol in patients with neurovascular compression - 255.6+/-137.3 nmol in those with left-sided compression and 251.6+/-138.5 nmol in patients without RVLM compression. We did not identify any increase in urinary norepinephrine in patients with severe arterial hypertension and neurovascular compression of the RVLM. Our results do not support the hypothesis that neurovascular compression of RVLM may exhibit a sympathetically mediated increase in blood pressure.

[Current use of magnetic resonance imaging in cardiology]. / Soucasné moznosti zobrazení magnetickou rezonancí v kardiologii.

Magnetic resonance imaging is a modern imaging technique that is characterized by high resolution and variable tomographic slices. The development of magnetic resonance technology in last decade led to the expansion of this method in many fields of medicine. In cardiology, the imaging is focused on the heart, aorta, pulmonary, coronary and renal arteries. Dynamic imaging is used for the evaluation of the kinetics and the function of the ventricles. Static imaging serves for the assessment of the myocardial wall in patients with cardiomyopathies and coronary artery disease. The quality of static imaging can improve paramagnetic contrast agent that increasingly accumulates in areas of acute necrosis, fibrosis or infiltration of the myocardium. Magnetic resonance imaging can also diagnose intracardiac tumors and thrombi, valvular heart disease and pericardial disorders. Despite of wide spectrum of diagnostic applications, the clinical use of magnetic resonance imaging is reduced by limited availability and high cost of the examination.

Clinical results of intensity-modulated radiation therapy (IMRT) for tumors of the head and neck region.

Intensity-modulated radiation therapy (IMRT) is an advanced form of the three-dimensional conformal radiation therapy (3D-CRT). Highly conformal dose distribution is the basic feature of IMRT. The head and neck region is suitable for this new technology since the primary tumor is often surrounded by several critical structures. IMRT offers the ability of dose escalation due to steep dose gradient towards healthy tissues. In this review, clinical results of IMRT in several head and neck sites are presented, including intracranial tumors. Parotid-sparing strategies and patterns of local-regional failures are analyzed. The possibilities of irradiation of recurrent malignancies are mentioned. In perspective, the potential of IMRT should be explored in conjunction with altered fractionation regimens, including simultaneous integrated boost (SIB). Particularly, studies with dose escalation are desirable.

[Dysfunction of a valve prosthesis]. / Dysfunkce umelé chlopne.

The authors describe the case of a haemodynamically unstable patient with dysfunction of a valvular prosthesis which was resolved by emergency surgery. In the discussion they deal with two basic causes of these dysfunctions and their possible solutions.

[The signal-averaged ECG in long-term monitoring of patients with fulminant myocarditis]. / Prumerované EKG v dlouhodobém sledování nemocného s fulminantní myokarditidou.

A case of a 24 year-old patient with fulminant myocarditis is described. The lymphocytic myocarditis was proved by endocardial biopsy. The patient had been followed for 15 months clinically, by transthoracic ultrasound and by the signal averaged ECG. The clinical and ultrasound parameters of the left ventricular systolic dysfunction subsided within 6 months, STT changes on the routine 12-lead ECG within 2 months. On the signal-averaged ECG, changes were observed in both the time and in the frequency domain. When the results of the initial examination (6 weeks after the beginning of the disease) were compared with the examination at the 7th month of the disease there was a prolongation of the QRS duration (from 95 ms to 104 ms), prolongation of the duration of the filtered ECG below 40 microV (from 21.5 to 36.2 microV) and the decrease of the total sum of the potential in the terminal part of the QRS. Most apparent was the decrease in the total sum of the high-frequency components (filter 70-250 Hz) of the QRS (RMSt: from 53.3 microV to 37.9 microV at the same noise level). In contrast to the changes in the time domain parameters there was no tendency in improvement of the RMSt. In patients with myocarditis the signal averaged ECG may prove to be a suitable tool for the long-term follow-up of the subclinical structural abnormalities of the left ventricular wall.

[Atheromatous (cholesterol) embolization]. / Klinicko-patologická konference. Ateromová (cholesterolová) embolizace.

A case is presented of an 89-year-old woman who died following an operation for arterial embolism of the lower limb. The autopsy histology showed acute occlusion of a stenosed sclerotic femoral artery by thrombotic and atheromatous emboli. In addition, it showed chronic cholesterol crystal embolism in multiple small arteries of abdominal organs, particularly of the kidneys. Abdominal aorta with severe ulcerated atherosclerosis appeared as the source of embolism.

Changes of signal-averaged ECG in normal subjects after one year.

Repeated signal-averaged electrocardiograms (SA ECG) were recorded twice with a mean interval of 13 months in 11 healthy volunteers in order to acquire basic information on long-term changes of SA ECG. After one year the duration of filtered QRS remains the most stable parameter of SA ECG on the contrary to parameters describing end of fQRS--i.e. both HFLA and RMS. Moreover fQRS seems to have better specificity in comparison to HFLA and RMS. An estimation of significant long-term changes in individual parameters of SA ECG was obtained. According to our results, only changes in QRS +/- 13 ms, fQRS +/- 8 ms, HFLA +/- 22 ms and RMS +/- 17 microV should be considered significant when found in a long-term follow-up of patients with a heart disease.

[Changes in late potentials in the time period after myocardial infarct]. / Zmeny pozdních potenciálu v case u pacientu po infarktu myokardu.

Late potentials are thought to be a non-invasive marker of discrete morphologic and electrophysiologic changes of the ventricular myocardium caused by fibrosis due to myocardial infarction. To find out whether there are significant changes in the signal-averaged ECG (SA ECG) over one year we examined 30 patients following myocardial infarction. When compared to the initial findings, significantly decreased incidence of late potentials was found after one year. Most of the changes in the filtered QRS were located in the terminal portion of the fQRS--in the area of low amplitude signals. Significant differences were noted in the changes found in patients with anterior myocardial infarction (MI) compared with the changes found in patients with posterior MI.