[Q fever - an occupational disease leading to disability - case report]. / Q-horecka jako profesionální onemocnení vedoucí k invalidite - kazuistika.

Q fever is a zoonosis caused by the bacterium Coxiella burnetii. The infection results from inhalation of infected droplets or aerosols. The most frequent sources in the Czech Republic are sheep, horses, cattles, goats, and pigs. Frequently, the disease is deemed occupational, with male sex being a risk factor for its symptomatic form. Presented is a case of a 27-year-old male diagnosed with a chronic form of Q fever after six months of worsening symptoms. Even years later, his condition is manifested as osteoarthritis, granulomatous hepatitis, and microcytic hypochromic anemia. The source of infection was probably animal food stored in a facility where the patient was employed. He was recognized as having an occupational disease and being disabled, especially due to his severely impaired mobility.

Osteoprotegerin, RANK, RANKL.

Osteoprotegerin, RANK (Receptor Activator of Nuclear factor kappa B) and RANKL (Receptor Activator of Nuclear faktor kappa B ligand) became the aim of intensive research. RANK is considered as a hematopoietic surface receptor controlling osteoclastogenesis and calcium metabolism. RANKL may promote osteoresorption by induction of cathepsin K gene expression. The present paper summarizes the most significant data in osteoprotegerin, RANK and RANKL problems obtained.

[Assessment of risk for the development of manifest atherosclerosis and indications for hypolipidemic therapy (global risk assessment)]. / Odhad rizika vzniku manifestní aterosklerózy pri indikaci hypolipidemické lécby (Global Risk Assessment).

The estimated risk of development of complications of atherosclerosis (coronary or cerebral ischaemia) is one of the activities every physician should include in the diagnostic and therapeutic algorithm. Treatment with hypolipidaemic agents is indicated according to the European consensus if the danger of a coronary or cerebral event is 20%/10 years. The objective of preventive provisions should be reduction of this risk to < 5%/10 years in younger subjects (< 45 years in men and < 50 years in women) and < 10%/10 years in elderly subjects. These recommendations obviously do not apply to secondary prevention (in case of complications of atherosclerosis) where treatment with hypolipidaemic agents is indicated already when the LDL-cholesterol level is 2.3 mmol/l or when triacylglycerols are 2.3 mmol/l, combined with a drop of HDL-cholesterol to < 0.9 mmol/l.

[Personal experience with determination of carbohydrate-deficient transferrin]. / Vlastní zkusenosti s vysetrením karbohydrát-deficitního transferinu.

Assessment of carbohydrate-deficient serum transferrin CDT) is considered a very useful indicator of alcohol abuse. There is a number of methods for assessment of CDT. In clinical practice most frequently assessment of the percentage ratio of CDT in transferrin is used. In our hospital we assessed CDT by the method of homogeneous immunoanalysis (Boehringer Mannheim (CDT-BM). Because we obtained a relatively high percentage of false results and because we found in the literature reference to a new method of homogeneous immunoanalysis (The Sanqui BioTech-CD-SB) with a different cut-off, we decided to compare the results of the estimations by the two methods and assess the percentage of false results. We examined a group of 49 patients incl. 16 who admitted alcohol abuse (> 60 g alcohol more than four times per week). As anticipated, we found that the %CDT assessed by the CDT-BM method was significantly higher than the percentage CDT-SB. After classification of the group into sub-groups with regard to alcohol intake the two sub-groups differed significantly only in values of CDT-SB and CDT-BM. In the group of patients with alcohol abuse we found relations between CDT-MB and indicators of hepatic lesions. In CDT-SB we found only an association with AST. This finding could suggest a greater specificity of CDT-SB. We confirmed data in the literature that GMT is independent on CDT and the mean corpuscular volume is independent on CDT in subjects with alcohol abuse. In abstainers who negated alcohol intake we found also when assessing CDT-SB a significant gender differentiation which is described in the literature (the reason is probably the fact that the CDT-SB method analyzes, contrary to CDT-BM, only asialo,-monosialo and disialylic isoforms of transferrin and women have higher levels of monosialylic forms). In our group the examination of %CDT by the new method, the Sanqui Biotech for alcohol abuse, had an almost absolute specificity and sensitivity. Contrary to the older Boehringer-Mannheim method we did not record any false increase in any patient with signs of hepatopathy nor any false negative results). We assume that the described methodical innovation of the analysis could facilitate the differential diagnosis of various diseases in different medical disciplines (internal medicine, neurology, psychiatry, assessment of work capacity).

[Use of proinsulin analysis for estimates of insulin resistance]. / Vyuzití analýzy proinzulinu v odhadu inzulinové rezistence.

INTRODUCTION: According to contemporary estimates diabetes is present in 120 million subjects. This disease is associated with the incidence of a number of very serious organ complications and very frequently is diagnosed late (several years after its development). Because despite increased diagnostic and therapeutic efforts the number of diabetic patients is increasing, new diagnostic and therapeutic means are sought. Evidence was provided that some complications of diabetes develop not only in case of poor compensation but also in hyperinsulinaemia (hypertension, ischaemic heart and coronary artery disease etc.). In clinical practice it is however possible to assess hyperinsulinaemia or incipient insulin resistance only with difficulty because classical examinations (insulin and C-peptide on fasting) have a very low specificity and sensitivity. Therefore for estimation of insulin resistance loading tests are used (e.g. examination of insulin after stimulation with glucose, or C-peptide after stimulation with glucagon, insulin tolerance and suppression tests, or in research projects so-called minimal models or clamp techniques). Any loading test is however demanding from the aspect of time, money, technical aspects and staff and therefore possibilities are sought how to estimate the degree of insulin resistance and sensitivity in a specimen of biological material under basal conditions. OBJECTIVE OF INVESTIGATION: Because in the literature only sporadically assessment of intact proinsulin is mentioned as the ideal marker of insulin resistance under basal conditions, the authors decided to assess the relations between intact proinsulin (PI) and other biochemical parameters in patients with type 2 diabetes and dyslipidaemia (200 probands) and to assess whether PI correlates with the results of loading tests (modified oGTT with calculation of the sum and delta-insulin--120 probands). RESULTS: It was revealed that PI (contrary to insulin, C-peptide and total proinsulin) correlates with the results of the loading test characterizing insulin resistance (sum and delta insulin, correlation coefficient 0.84) (n=120 subjects). It was furthermore found that probands (n=200 subjects) who are followed up on account of type 2 diabetes or dyslipidaemia (or both) differ from the control group (n=20 subjects) as regards biochemical parameters only in the PI concentration (dispensarized patients have higher levels, p>0.99), whereby in other standard basal characteristics of insulin secretion and resistance the groups did not differ. The differences were correlated with HOMA models of insulin secretion and resistance and no correlations were found. The PI concentration in this group correlated significantly with the cholesterol, fibrinogen and triacylglycerol concentration. No relations were found between the values of intact proinsulin with C-peptide and insulin. CONCLUSION: Based on the results of their study the authors assume that examination of intact proinsulin is a valid "basal" indicator of insulin resistance. From the results ensues also that intact proinsulin is probably a very good predictor as regards the risk of development of cardiovascular disease.

[Benefit of direct determination of LDL-cholesterol (comparison with LDL measurement using calculated estimates]. / Benefit prímého stanovení LDL-cholesterolu (srovnání merení LDL s jeho odhadem pomocí výpoctu).

Treatment of dyslipidemia and its frequently associated complications (manifest atherosclerosis) is very pretentious from the economic aspect. Diagnostic and therapeutic criteria are based mainly on biochemical analyses. Although demands on laboratories are relatively strict (respecting defined laboratory errors, analytical and preanalytical conditions), when defined diagnostic criteria are used, the results of biochemical analyses are not yet satisfactory. A typical example is the stratification of risk patients according to the LDL concentration which in our country is very often preferred, although the LDL concentration is based only on calculation (contrary to investigations from which the majority of recommendations was derived where the LDL concentration was assessed directly). We know from our own experience that a large percentage of results of estimated and assessed LDL differs significantly. Therefore we wanted to know whether the assessed LDL concentration correlates with its estimate according to Friedewald s formula and which analytes have the greatest impact on the LDL concentration. Our objective was also to assess th percentage of incorrectly listed patients (according to the LDL stratification scale). In 1997-1998 we examined a group of 4578 probands, patients of the consultant out-patient departments of the Sternberk hospital. Their mean age was 56 years. On average subjects with as slightly atherogenic phenotype were involved (classification A according to EAS). The values of lipid parameters did not differ significantly in the two sexes. The cholesterol, LDL and triacylglycerol concentrations increased with advancing age. The LDL values obtained by assessment and calculation correlated closely. The LDL value was influenced most by ApoB and total cholesterol. Triacylglycerols correlated with LDL assessment only up to a concentration of .3 mmol/l. HDL, ApoA-1 and higher triacylglycerol concentrations (1.3 mmol/l) did not correlate with the LDL value. The authors provided evidence that in subjects where it was possible to calculate LDL lege artis (2458 probands) were listed according to LDL calculation into a wrong group (stratification according to NCEP) whereby up to an LDL concentration .11 mmol/l this parameter cannot be predicted at all by calculation (error up to 85%). A satisfactory estimate is assumed only at LDL concentrations 5.2 mmol/l. Because the estimated LDL values are in the majority of patients lower than the calculated values, it may be assumed that during stratification of LDL obtained by calculation the patients are treated too aggressively. Assuming pharmacological treatment of all mentioned patients, it may be estimated that by using analyses of direct LDL for stratification of probands the costs of hypolipidaemic treatment will by reduced by about 1/4-1/3 (in the catchment area of the Sternberk hospital this would save more than 10 million crowns). The costs of LDL analyses per year are about 180,000 crowns (in the Sternberk hospital--which amounts to cca 1.5% of the money saved on pharmacotherapy).

[Kinetic analysis in the evaluation of glucose tolerance disorders. Evaluation and use of a new method in the diagnosis of glucose tolerance in clinical practice]. / Kinetická analýza pri hodnocení poruch glukózové tolerance. Zhodnocení a vyuzití nové metody v diagnostice tolerance glukózy v klinické praxi.

A kinetic model of oGTT has been used. This model is characterized by 7 glycaemia collections (0, 30, 45, 60, 120, 180 min). In some cases this is supplemented by determination of C-peptide and insulin values (0, 60, 120 min). This method is very simple and highly useful in clinical practice because it gives information about physiological stimulation by enterohormones, the first glucose passage through liver and next glucose utilization. The first part of the study deals with random error of the kinetic model of oGTT found by repeated calculations (> 10,000 repeatings) of identical initial glycaemias in individual groups (DM, PGT, N). Random error of glucose clearance (the most suitable parameter) ranged within 0.2 -2.1% in individual deviations. Then the identical calculations were made but loaded with glycaemia and with certain error in individual collection intervals (glycaemia 0.1, 0.2, 0.5 mmol/l; collection with 30, 60, 300 s). Random error of the method increased significantly with dispersion variance of glycaemias (maximum 17% with glucose clearance at glycaemia dispersion variance of 0.5 mmol/l); changed time intervals less affected random error quantity. As acceptable and frequent deviation in practice was determined glycaemia dispersion variance of 0.2 mmol/l (corresponding to a total analytical error of glycaemia measurement) and dispersion variance of time intervals of 60 s. At these values, random error of the method increased maximally to 10.3%. Glucose has also a biological variability (not published yet for individual time intervals), the value of random error may be higher but will not achieve half of values of random error obtained at the classical oGTT. The second part of the study deals with comparison of both the tests (classical oGTT, kinetic curve of oGTT) in 126 probands examined at metabolic and diabetologic out-patient department of the Hospital in Sternberk. It can be concluded that using a classical oGTT, 60% of patients were classified into incorrect groups as defined by dynamic results obtained by analysis of the kinetic model. Interesting enough is the fact that almost half of persons who cannot be classified by the classical oGTT had impaired glucose tolerance. Out of them, 15.6% had diabetes mellitus; almost 20% of normal patients also had impaired glucose tolerance. Over 1/5 of persons with impaired tolerance for glucose according to the classical oGTT was found by the kinetic model to have diabetes mellitus. On the contrary, 1/10 of diabetic patients diagnosed by oGTT had normal glucose clearance, over 1/2 of patients had only impaired glucose tolerance. Then in 126 persons random error of the method was again calculated (> 2,000 repeated calculations for each proband) amounting 6.6%.

[Leptin in persons with simple obesity]. / Leptin u osob s prostou obezitou.

Obesity is a disease with distinct genetic determination and its phenotype is defined by the still unknown number of genes whose expression can be influenced by environmental factors. Several years ago, "obesity gene" was isolated in animals. This gene, coding protein which consists of 165 amino acids, is called leptin. Leptin is supposed to be a key substance controlling homeostasis of body weight and energy balance; it is produced by adipocytes and its value correlates highly significantly with anthropometric parameters that characterize physical constitution and amount of subcutaneous fatty tissue. The obese individuals often display hyperleptinemia which is frequently caused by a postreceptor disorder; sporadically, a different leptin structure or hypoleptinemia (caused by genetic anomaly) are reported. It is supposed that either absolute or relative leptin deficiency in obese persons are associated with causal obesity (e.g. appetite stimulation). Leptinemia values correlate with percentage of subcutaneous fatty tissue, insulinemia and sometimes with glycemia. In our study we examined 200 probands, patients of the Metabolic and Diabetologic Out-Patient Department, Hospital in Sternberk. A very close correlation between the amount of subcutaneous fatty tissue (measured by a caliper in 10 skinfolds) and the leptine serum concentration was found. The values of leptinemia in men of normal constitution ranged within 1-11 ng/ml, non-obese women had 3-4 times higher values. Leptinemia in some obese individuals reached up to 70 ng/ml. However, the currently calculated and reported parameters of physical constitution (BMI, WHR, Grant index) did not correlate significantly with leptinemia. Similarly, biochemical parameters considered as general markers of insulin resistance (often associated with obesity) did not correlate significantly with leptinemia. This finding indicates that some calculated parameters, quantifying and gualifying physical constitution, may be ambiguous and leptinemia was found to give more detailed information about the amount of subcutaneous fatty tissue than WHR or BMI. An accidental finding was an important positive correlation between myoglobin concentration and creatinemia. At monitoring the effect of hypolipidemic agents we use the myoglobin examination and therefore we consider this correlation to be very important and every physician performing this analysis should be informed about it. The present study thus confirmed that a more accurate quantification of subcutaneous fatty tissue is required. On the other hand, we believe that examination of leptinemia can contribute significantly to stratification of patients into risk groups (with respect to clinical, economic and time differentiation) and subsequently to the treatment of these patients. In future, criteria for quantification of leptinemia and leptine resistance should be defined precisely.