Diagnosis and treatment of thyroid disorders in obese patients — what do we know?

Obesity-related changes in the composition of the body interfere with the proper functioning of the thyrotropic axis, leading to its disturbances and changes in the structure of the thyroid gland. Distinguishing what is related to obesity and what constitutes pathological changes is crucial for the proper treatment of patients. In this paper authors present a case of a patient with a diet-induced obesity, whose only abnormalities in thyroid assessment included an elevated level of thyroid stimulating hormone (TSH) and hypoechoic thyroid gland on ultrasound. Based on this clinical situation, we reviewed literature in order to establish rules regarding management of thyroid disorders in obese individuals. The most common obesity-related thyroid abnormality is an isolated increase of TSH, without clinical symptoms of hypothyroidism, defined as hyperthyrotropinaemia. In obese adults, autoimmune thyroid disease is found equally often as in the normal-weight population. Thyroid enlargement, increased risk of nodules, and decreased echogenicity, not related to autoimmunity, is frequent among obese individuals. Weight loss leads to the normalisation of TSH levels and thyroid echogenicity. Excessive weight can influence both the TSH level and ultrasound image of the thyroid gland; however, these findings can be reversed by weight reduction. Therefore, in asymptomatic obese patients elevated TSH should not be treated with thyroid hormone replacement

Sprint Fidelis implantable cardioverter-defibrillators lead patient management and survival: Single center study

Background: Over the last several years significant rises in the use of implanted cardioverter-defibrillators (ICD) have also resulted in a number of associated complications. This number includes lead failure. Sprint Fidelis (SF) ICD lead is regarded as a lead with elevated failure risk. Every center acting in accordance with the guidelines should observe patients more thoroughly especially with recalled leads and run a registry of their follow-up. The aim of this research was to present follow-up of the patients with SF leads (types 6948, 6949) from a single implantation center. Methods: There were 36 SF leads implanted in 36 patients. Mean follow-up period was 76 months (IQR 40.3–86.8). Patients were subjected to regular check-ups in 3 to 6 month intervals. Results: Patients were implanted at a median age of 66.5 years and majority of them had ischemic cardiomyopathy (72%). A majority of the studied population were men (72.2%). Predominantly dual-chamber ICD (ICD-DR) were implanted (50% ICD-DR vs. 47.2% ICD-VR). The guidelines for management of patients implanted with SF were fully implemented. During the follow-up 14 (38.9%) patients died. No deaths were noted that could be attributed to lead failure. In 5 cases lead failure was identified and of these 4 leads were replaced. Median time from implantation to the detection of lead dysfunction was 52 months (IQR 49; 83). The symptoms of failure consisted of: inappropriate shocks, alternating ventricular lead signal, or loss of ventricular stimulation. Conclusions: The follow-up of patients with recalled SF leads in a single center supports that implementation SF management guidelines could be effective in clinical practice

Optimal aNtiplatelet pharmacotherapy guided by bedSIDE genetic or functional TESTing in elective PCI patients: A pilot study: ONSIDE TEST pilot

Background: Dual antiplatelet therapy (DAPT) is recommended after elective percutaneous coronary intervention (PCI) in stable coronary artery disease (SCAD) patients; however, still one-third of patients do not obtain adequate platelet inhibition that may result in increased cardiovascular risk. The aim of the ONSIDE TEST study is to evaluate the clinical impact of point-of-care genotyping- and platelet function-based personalized dual antiplatelet strategies in SCAD individuals undergoing PCI. Methods: Fifty patients were randomized to one of the three study arms: 1) genotyping, 2) platelet function testing (PFT) and 3) control. Patients were tested with point-of-care Spartan RX CYP2C19 System (group 1) and VerifyNow P2Y12 assay (group 2). In cases of inadequate response to clopidogrel, a loading dose of prasugrel was administered before PCI. The main clinical endpoint is the incidence of periprocedural myocardial injury (PMI). Results: Five (32%) patients in the genotyping arm and two (13%) in the in the PFT arm were identi-fied as poor clopidogrel metabolizers. The periprocedural platelet reactivity was significantly lower in the genotyping (80 ± 49.0 PRU) and PFT (36.5 ± 47 PRU) arms as compared to the control arm (176 ± 67.8 PRU), p = 0.01 and p = 0.03, respectively. PMI appeared in 17 (37%) patients of the entire study population. Conclusions: Personalized DAPT results in an improved platelet inhibition. Apart from genotyping and aggregometry, it is feasible to integrate into everyday clinical practice PMI rates which are relevant when comparing different strategie

Hyperthyroidism secondary to a hydatidiform mole

The case presented in the article is that of a 47-year-old female patient with hyperthyroidism induced by a hydatidiform mole. Attention was drawn to the necessity of preparing the patient for a procedure with drugs that stabilize the hormonal activity of the thyroid. The removal of the hydatidiform mole resulted in gradual normalization of thyroid hormone levels. The trophoblast has a hormonal activity, secrete hCG (human chorionic gonadotropin).The  hCG partial structural homology causes affinity to the TSH (thyroid stimulating hormone) receptor. The higher the weight of the trophoblast, the higher the production and concentration of hCG in the blood. Therefore, gestational trophoblastic disease may be accompanied by hyperthyroidism. The problem is frequently described, however, due to the risk of developing thyroid storm, it cannot be overlooked [1].

Analiza proliferacji i apoptozy komórek po promieniowaniu UV

Większość żywych organizmów jest narażona na działanie promieniowania UV, czynnik toksyczny i genotoksyczny powodujący śmierć komórki i zahamowanie proliferacji. Celem pracy było sprawdzenie odpowiedzi komórkowej na promieniowanie UV w trzech liniach komórkowych Me45, NHDF oraz HCT116, z których dwie są wyprowadzone z komórek występujących w skórze, takich, które mogą być bezpośrednio narażone na to promieniowanie. Badano podziały komórkowe i oceniano stopień indukcji apoptozy z użyciem zmodyfikowanego testu mikrojądrowego z blokadą cytokinezy przez cytochalazynę B. Stopień indukcji apoptozy oraz liczba podziałów różniły się w zależności od dawki, typu promieniowania (UVA, UVB, UVC) oraz linii komórkowej, a otrzymane wyniki sugerują, że promieniowanie UV może zarówno stymulować, jak i hamować proliferację oraz zwiększać apoptozę w zależności od typu komórek, wskazując na ich zróżnicowaną wrażliwość na dane czynniki

Implantacja stentów w poszerzaniu pooperacyjnej rekoarktacji aorty u osób dorosłych i nastolatków

Background: Results of stent implantation (SI) of postsurgical recoarctation of the aorta (ReCoA) are not frequently published. Aim: This study sought to retrospectively evaluate results of SI in ReCoA in older children and adults. Methods: Twenty-eight SIs were performed on 26 ReCoA patients with a median age of 23 (10–65) years. Dependent upon availability, the following stents were applied: Palmaz, Cheatham Platinum (CP), Andrastents XL/XXL (AS), Covered CP (CVCP) stents, and self-expanding stents (Smart). Generally, high-pressure balloons were applied to dilate stents. Results: The procedure was effective in 20/26 patients (77.7%). The mean peak systolic gradient reduced from 40.5 ± 18.7 mm Hg to 13.1 ± 12.1 mm Hg (p < 0.05), and the diameter of the stenosed segment increased from 7.5 ± 3.02 mm to 13.1 ± 3.32 mm (p < 0.05). In six cases (including a patient treated with a Smart stent) transaortic pressure gradient after SI remained > 20 mm Hg (stiff postsurgical lesion). For one patient (40-year-old male), an acute dissection of the aorta occurred during balloon predilatation. Immediate CVCP implantation resolved this problem. Two more CVCPs were used — one to close a small aortic aneurysm that appeared five years after a Palmaz SI and another to stabilise a broken CP bare metal stent. There were no deaths or aortic dissections during follow-up, and most patients were able to reduce or suspend their medication for systemic hypertension. Conclusions: Endovascular stenting of ReCoA in adults and adolescents appears to be an acceptable method of treatment in experienced hands. However, for some patients the presence of a stiff lesion can provoke suboptimal results. Considering the serious complications that can occur after SI, all patients should have regular follow-up (including an imaging study). Covered stents should always be available in the cathlab as a rescue device when implanting stents in coarctation of the aorta patients.Wstęp: Wyniki implantacji stentów w pooperacyjnej rekoarktacji aorty są rzadko publikowane. Cel: Celem niniejszej pracy była retrospektywna ocena wyników implantacji stentów w pooperacyjnej rekoarktacji aorty u starszych dzieci oraz u osób dorosłych, Metody: Dwadzieścia osiem implantacji stentów zostało przeprowadzonych u 26 pacjentów z rekoarktacją aorty, których średni wiek wynosił 23 (10–65) lata. Zależnie od dostępności stosowano następujące stenty: Palmaz, Cheatham Platinum (CP), Andrastenty XL/XXL (AS), Covered CP (CVCP) oraz u jednego dziecka stent samorozprężalny (Smart). U większości stenty były rozprężane przy użyciu balonów wysokociśnieniowych. Wyniki: Zabieg był skuteczny u 20/26 pacjentów (77,7%). Średni gradient obniżył się z 40,5 ± 18,7 mm Hg do 13,1 ± ± 12,1 mm Hg (p < 0,05), a średnica aorty na poziomie zwężenia zwiększyła się z 7,5 ± 3,02 mm do 13,1 ± 3,32 mm (p < 0,05). U 6 osób (w tym u 1 pacjenta, u którego zastosowano stent Smart) gradient w pomiarze bezpośrednim po implan­tacji stentu utrzymywał się > 20 mm Hg (niepodatne zwężenie pooperacyjne). U 1 chorego (40-letni mężczyzna) wystąpiło ostre rozwarstwienie aorty w trakcie balonowej predylatacji. Natychmiastowa implantacja stentu CVCP rozwiązała problem. Ponadto zastosowano 2 stenty CVCP — jeden do zamknięcia małego tętniaka aorty, który pojawił się 5 lat po implantacji stentu Palmaz, oraz jeden do stabilizacji złamanego metalowego stentu CP. W okresie obserwacji nie odnotowano żadnego zgonu czy rozwarstwienia aorty, a u większości pacjentów możliwa była redukcja dawek lub całkowite zaprzestanie stosowania leków hipotensyjnych. Wnioski: Wewnątrznaczyniowa implantacja stentu w rekoarktacji aorty u osób dorosłych oraz nastolatków wydaje się dobrą metodą terapii stosowaną przez doświadczonych lekarzy. Jednak u pacjentów, u których występuje niepodatne zwężenie, wyniki mogą być tylko częściowo zadowalające. Stenty pokryte powinny być zawsze dostępne w pracowniach hemodynamiki, w których poszerzana jest koarktacja aorty, jako urządzenie mogące zabezpieczyć potencjalne komplikacje, a nawet uratować życie pacjenta. Uwzględniając poważne powikłania, które mogą wystąpić po implantacji stentu w okresie pozabiegowym, wszyscy chorzy powinni zostać objęci obserwacją (uwzględniając kontrolne badania obrazowe)

Implantation of the Micra transcatheter pacing system: Single Polish center experience with the real costs of hospitalization analysis

Background: The Micra transcatheter pacing system (TPS) is a miniaturized, single-chamber pacemaker system. Study reported herein is an initial experience with implantation of the Micra TPS. Methods: The leadless pacemaker was implanted in 10 patients with standard indications for a permanent pacemaker implantation. All hospitalization costs were calculated for all patients. Results: The mean age of the patients was 75 ± 7.1 years, 6 were men and 4 were women. Four patients had permanent atrial fibrillation as the basal rhythm and 6 patients had sinus rhythm. All patients had at least one relative contraindication that precluded the use of a traditional pacing system. Mean intraoperative ventricular sensing amplitude was 10.6 ± 5.4 mV, impedance 843 ± 185 ohms, and pacing threshold at 0.24 ms was 0.56 ± 0.23 V. At discharge, those values were 13.9 ± 5.6 mV, 667 ± 119 ohms and 0.47 ± 0.17, respectively. The mean duration of implantation procedure was 82 min, while mean fluoroscopy time was 3.5 min. Two patients developed hematoma at the groin puncture site post-implantation. In 1 case there was a need for erythrocyte mass transfusion and surgical intervention. Mean total time of hospitalization was 26 days and time from procedure to discharge 12 days. Average cost of hospitalization per 1 patient was 11,260.15 EUR minimal cost was 9,052.68 EUR, while maximal cost was 16,533.18 EUR. Conclusions: Implantation of leadless pacemakers is feasible, safe and provides advantages over the conventional system. Hospitalization costs vary for individual patients in wide range

Cell type-specific differences in redox regulation and proliferation after low UVA doses.

Ultraviolet A (UVA) radiation is harmful for living organisms but in low doses may stimulate cell proliferation. Our aim was to examine the relationships between exposure to different low UVA doses, cellular proliferation, and changes in cellular reactive oxygen species levels. In human colon cancer (HCT116) and melanoma (Me45) cells exposed to UVA doses comparable to environmental, the highest doses (30-50 kJ/m2) reduced clonogenic potential but some lower doses (1 and 10 kJ/m2) induced proliferation. This effect was cell type and dose specific. In both cell lines the levels of reactive oxygen species and nitric oxide fluctuated with dynamics which were influenced differently by UVA; in Me45 cells decreased proliferation accompanied the changes in the dynamics of H2O2 while in HCT116 cells those of superoxide. Genes coding for proteins engaged in redox systems were expressed differently in each cell line; transcripts for thioredoxin, peroxiredoxin and glutathione peroxidase showed higher expression in HCT116 cells whereas those for glutathione transferases and copper chaperone were more abundant in Me45 cells. We conclude that these two cell types utilize different pathways for regulating their redox status. Many mechanisms engaged in maintaining cellular redox balance have been described. Here we show that the different cellular responses to a stimulus such as a specific dose of UVA may be consequences of the use of different redox control pathways. Assays of superoxide and hydrogen peroxide level changes after exposure to UVA may clarify mechanisms of cellular redox regulation and help in understanding responses to stressing factors

Diagnostic difficulties in establishing the cause of hemolytic uremic syndrome in children

Wstęp. Zespół hemolityczno-mocznicowy (ZHM) pod względem etiologii jest heterogennym zespołem objawów, stanowiącym najczęstszą przyczynę ostrego uszkodzenia nerek (OUszN) u dzieci poniżej 4 r.ż. Choć istnieją proste kryteria diagnostyczne, to w praktyce klinicznej napotyka się jednak trudności, zwykle związane z ustaleniem przyczyny ZHM. Materiał i metodyka. W pracy przedstawiono przebieg diagnostyki i leczenia trojga dzieci ze wstępnie ustalonym klinicznym rozpoznaniem ZHM. Pierwszy pacjent został przyjęty do szpitala w wieku 5 miesięcy, kiedy ujawnił „klasyczne” objawy ZHM poprzedzone epizodem ostrej biegunki. Po skutecznym leczeniu pierwszego epizodu ZHM u chłopca w ciągu kolejnych 30 miesięcy obserwowano 6 nawrotów „aktywnej” fazy choroby, łączących cechy ZHM i zespołu nerczycowego. Wprowadzenie profilaktycznych infuzji osocza utrzymuje aktualnie u chłopca stan remisji. Drugie dziecko zostało skierowane do szpitala w wieku 3 miesięcy z powodu triady objawów typowych dla ZHM, a ostatecznym wyjaśnieniem obserwowanych zaburzeń okazała się rozległa malformacja naczyniowa przestrzeni zaotrzewnowej z wtórną aktywacją wykrzepiania wewnątrznaczyniowego. Trzeci pacjent w wieku 2,5 roku zamanifestował objawy ZHM o łagodnym nasileniu. Wywiad rodzinny był obciążony zgonem brata z powodu ZHM o skrajnie ciężkim, uporczywie nawracającym przebiegu. Pełną remisję objawów uzyskano w wyniku terapii osoczem. Wnioski. W przypadku współistnienia niedokrwistości hemolitycznej, małopłytkowości i OUszN trzeba brać pod uwagę także przyczyny inne niż ZHM. Zróżnicowanie mechanizmów prowadzących do rozwoju ZHM przekłada się na szeroki zakres działań terapeutycznych w tej grupie pacjentów. Właściwie dobrane formy terapii dają szansę na szybkie i wolne od trwałych następstw uzyskanie remisji.Introduction. Hemolytic uremic syndrome (HUS) is a complex of symptoms with heterogeneous etiology, constituting the most common cause of acute kidney injury (AKI) in children below 4 years of age. Although there are simple diagnostic criteria, in clinical practice difficulties are observed, usually associated with the determination of HUS cause. Material and methods. The study presents the course of diagnosis and treatment of three children with pre-established clinical diagnosis of HUS. The first patient was admitted to hospital at the age of 5 months, when he presented the “classic” HUS symptoms preceded by an episode of acute diarrhea. After successful treatment of the first episode, in the next 30 months, 6 relapses of the “active” phase of HUS were observed, combining the features of HUS and nephrotic syndrome. The introduction of prophylactic plasma infusions currently enables maintaining the boy in the remission phase. The second child was sent to hospital at the age of 3 months because of a triad of symptoms typical of HUS. The ultimate explanation for the observed abnormalities proved extensive retroperitoneal vascular malformation with secondary activation of intravascular coagulation. The third patient was a 2.5-year-old boy, who manifested mild symptoms of HUS. Family history was remarkable (the death of his brother because of extremely severe HUS of persistent, relapsing course). A complete remission of the symptoms was obtained by repeated plasma infusions treatment. Conclusions. In the case of coexistence of hemolytic anemia, thrombocytopenia and AKI, it is necessary to take into account also the other causes than HUS. Differentiation of the mechanisms leading to the development of HUS translates into a wide range of treatment modalities in this group of patients. Properly selected therapies offer the opportunity for a quick remission free of severe complications