Band 8, Heft 5 - Full Title of topical issue: Advances in Internal Medicine

Obesity, particularly abdominal obesity, is associated with increased risks of arterial hypertension, diabetes mellitus, hyperlipidemia, sleep apnea, coronary artery disease, stroke and mortality. Weight loss surgery is the most effective treatment for morbid obesity, mainly because medical and dietary treatments have been proven insufficient in the long run. Our primary end point was to study the gender effect on vascular responsiveness (endothelial function and the ankle brachial index [ABI]) 3 months post bariatric surgery. Our secondary end points were to study the effect of gender on antropometric parameters (BMI, waist circumference) and chronic diseases (diabetes mellitus type II, arterial hypertension) 3 months following bariatric surgery, and to find independent variables that may affect and predict the post-operative clinical outcome. Methods: In this prospective study, patients were evaluated one day before surgery and 3 months afterwards. Ankle brachial index was measured while the patient was supine after 15 minutes rest and measurement of the systolic blood pressure in all four extremities was done. The brachial artery method was used to measure endothelial function expressed as flow mediated diameter percent change (FMD %). FMD% more than 10% is considered a normal response. Results: Compared with diabetic females, diabetic males had a higher postoperative BMI (men with diabetes mellitus did not lose weight as much as diabetic women) (β=-0.299; P=0.04), while women with diabetes mellitus had a more significant reduction in BMI postoperatively (β=+0.287; P=0.04). Following bariatric surgery, 12 of the 21 patients with diabetes mellitus type II did not need any medications for diabetes (kept HbA1c% less than 6.5%). All other diabetic patients improved their diabetes mellitus status. Women significantly improved their ABI (average increase of 0.07, p=0.04) and their endothelial function (FMD% change was improved from -3.5±9.0% to 14.8±8.1%, an improvement of 18.3%, p<0.001). Systolic blood pressure was decreased significantly (by 6.6 mmHg, p=0.04). Men improved their endothelial function (FMD% change was improved from -1.3±10.1% to 11.7±6.2%, p<0.001), but no significant change was observed in systolic blood pressure (p=0.29) nor in ABI (P=0.8). A linear regression analysis found that a higher baseline FMD% significantly predicted a higher postoperative FMD% (β=0.294, P=0.03). In obese males, the higher the baseline BMI the worse the post operative endothelial function (β=-0.921, Pd<0.001) and the same adverse effect was documented for hypertensive men (β=-0.380, P=0.05). For females, the higher the baseline FMD% the higher the postoperative FMD% (β=+0.397; P=0.01) [a favorable outcome]. Discussion: Our study has demonstrated a possible mechanistic insight into gender effects observed in epidemiological studies through improvement in vascular response in females undergoing this operation including a better reduction in systolic blood pressure and a better weight reduction in diabetic women with improvement in ABI; unlike males, who did not improve their ABI and did not decrease systolic blood pressure, and the finding that obese diabetic males and obese hypertensive males did the worst.

Deep vein thrombosis and pulmonary embolism are two clinical entities of a single disease called venous thromboembolism. Venous thromboembolism is an important cause of maternal morbidity and mortality. Diagnosis and treatment of venous thromboembolism in pregnant women are much more difficult than in non-pregnant women. Pregnant patients were excluded from all major clinical trials investigating therapeutic combinations for acute thromboembolism. Although, for many years, the standard anticoagulant during pregnancy and postpartum was unfractionated heparin, current guidelines recommend low molecular weight heparin. The advantages of low molecular weight heparin are lower risk of bleeding, predictable pharmacokinetics, lower risk of fracture because of thrombocytopenia and heparin-induced osteoporosis.

The blue (or purple) toe syndrome describes the development of a blue or violaceous discoloration in one or more toes in the absence of obvious trauma, serious cold-induced injury or disorders producing generalized cyanosis. The presence of blue toe syndrome requires the clinician to search for primary systemic vasculitides, as well as for malignancy, underlying infection, thrombosis, cardiovascular pathology and other diseases. An accurate diagnosis is critical because many of the causes threaten life or limb, but the patient’s medical history, accompanying non-dermatologic findings on physical examination and the use of discriminatory laboratory tests are usually more important than the nature of the cutaneous abnormalities. We describe the case of a 53-year-old Caucasian male patient presenting with blue toe syndrome as the initial manifestation of ANCA-associated vasculitis.

In treatment of manic-depressive conditions long-term lithium therapy may be combined with an effective and relatively safe antidepressant venlafaxine. Combined overdose may increase the risk of early toxicity of both drugs and of delayed lithium intoxication, responding to symptomatic and renal replacement therapy. We present a patient with combined lithium and venlafaxine self-poisoning with nothing but delayed signs of lithium intoxication with the emphasis on early and late treatment. 41-year old woman attempted suicide by large amount of lithium and venlafaxine. On admission she was asymptomatic, but with increased serum lithium over 5mmol/L. After gastric lavage, active charcoal and laxative administration she was receiving IV fluids. After a delay of 63 hours she deteriorated acutely by disorientation, confusion, fasciculation and tremor and was readmitted to Intensive care unit. In spite serum lithium decreased to 2mmol/L clinical signs were attributed to delayed lithium intoxication. After symptomatic and renal replacement therapy the patient’s condition improved after few days. We conclude that decontamination procedures are effective in particular for venlafaxine poisoning. If increased serum lithium levels are noted renal replacement therapy may be started even in asymptomatic patients as delayed lithium intoxication is most likely after few days.

A 93-year-old woman with neurogenic bladder was admitted to our hospital because of impaired consciousness. Her urine culture revealed urease-test-positive Corynebacterium urealyticum. She was diagnosed with hyperammonemia due to an obstructive urinary tract infection that was caused by urease-producing bacteria. The patient showed rapid improvement of impaired consciousness and hyperammonemia after urine analysis. It is necessary to consider obstructive urinary tract infection as a differential diagnosis of hyperammonemia, which commonly occurs in urinary tract infections owing to the presence of urease-producing bacteria. Relief from obstruction is the most important treatment for hyperammonemia caused by this mechanism.

Introduction. StudHeart research was performed to evaluate the risk of diabetes mellitus type 2 (T2DM) amongst the senior medical students. Material and methods. The research involved 506 students aged 22–27 (mean age 23.96±1.52 yrs) in their 5th and 6th year of the medical faculties at the Medical University of Lodz. Each of the examined students has filled out an anonymous survey comprising 12 questions, which enabled us to use the FINDRISC scale in estimation of the risk for T2DM. Analysis was performed in relation to gender. Results. Overall in 16.80% of respondents the body mass index (BMI) was >25 kg/m2. Almost all students (93.48%) admitted to drinking alcohol and 9.68% smoked cigarettes. Only 13.64% of participants exercised daily (women 8.16% vs. men 21.30%; P=0.000). Everyday consumption of fruit and vegetables was reported by 55.34% of the respondents whereas 6.92% of them (women 4.42% vs. men 10.40%; P=0.026) ate fast-food 2–3 times a week. The overall risk for T2DM was elevated in 17.2% of examined students. It is predicted that by the time participants will reach age of 45, 40.52% of them (mostly men) will have their risk of T2DM elevated. Conclusion. Despite the awareness of risk factors for T2DM among senior medical students, their lifestyle remains unchanged. In the given population it is predicted that the risk of T2DM will enhance about 2.5-fold in the next 20 years.

The aim of this study was to investigate the quality of life (HRQoL) in coronary artery disease(CAD) patients, admitted for rehabilitation within 3 months after an acute coronary event, in relation to treatment strategy [conservative treatment without revascularization (WR), percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG)]. Methods: Overall 719 consecutive CAD patients were involved in the study: WR (n=170), PTCA (n=226), CABG (n=323). HRQoL was estimated using the SF-36 questionnaire for total QoL and its two dimensions for physical and mental health [physical and mental component scores (PCS, MCS)]. Sexual dysfunction was assessed using the ASEX scale. Results: Significantly higher PCS, MCS and total SF-36, but lower ASEX score, were found in men compared with women. The ASEX score was significantly affected by age. Significantly higher PCS was found in PTCA group compared with that of CABG group. In multivariate analysis a significant positive association was obtained between PCS/MCS and male sex, between regular exercise, hyperlipoproteinemia, and permanent stress. ASEX was significantly positively associated with the age, CHF and non smoking. Conclusion: The results of this study have demonstrated significantly better HRQoL in men, younger CAD patients, patients who underwent PTCA and in patients without self-reported exposition to stress.

This is a multicenter cross-sectional survey of 2,500 Bulgarian adult patients taking lipid-lowering drugs (LLDs) for at least 3 months with no dose change for a minimum of 6 weeks. The primary objective was to establish the proportion of patients who are on LDL-C target, according to the Fourth Joint European Task Force (FJETF) guidelines. The secondary objectives were to define the proportion of patients at target: according to the 2001 National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III and the 2004 NCEP ATP III guidelines. The patients’ demographics, current LLD treatment, cardiovascular medical history were recorded. Next the lipid profile, glucose level and HbA1c were obtained from these patients. The investigators and patients completed questionnaires related to the LLD therapy. Gender, BMI, history of CHD, therapy compliance, risk category, lack of patient’s awareness of LDL-C targets were all studied as determinants of the undertreatment. Despite the satisfactory awareness of guidelines for management of hypercholesterolaemia, their implementation in clinical practice is still poor. Only 43.10% of patients reached the FJETF-recommended LDL-C goal, 45.24% achieved the 2001 NCEP ATP III recommended LDL-C goal, and only 21.51% — reached the 2004 NCEP ATP III recommended target. Males, CHD patients and those who were aware of LDL-C targets had more chance of reaching their desired LDL-C target.

A 65-year-old patient with a systolic murmur that developed five days after acute anteroseptal myocardial infarction was referred to our Institution. He had previously been treated with fibrinolytic therapy. The patient was in a stable hemodynamic condition when admitted, with sustained diuresis. Blood gas analysis revealed normal parameters, whereas a chest X-ray showed signs of pulmonary congestion. Transthoracic echocardiography revealed a 1.5×1.2 cm post-infarction ventricular septum defect (VSD) in the apical part of the septum. Because the patient’s hemodynamic conditions were stable, we decided to postpone the operative treatment to allow scarring of the infarcted area to make VSD repair feasible, thereby increasing the chance for success. Operative treatment was performed three weeks after admission. We performed closure of the VSD with a bovine pericardial patch. The patient was discharged in good condition and remained well three months after the surgery.

Emphysema is a progressive and irreversible disease for which there is no cure to date. Endoscopic lung volume reduction with valve implantation or using lung sealant is a treatment option for patients with severe emphysema. A 60-year-old ex-smoker (80 pack years) referred to our center because of severe lung emphysema with progressive worsening of the obstructive ventilator pattern and clinical condition. By our patient we detected collateral channels by using the Chartis system®, which allow airflow into the target lobe and prevent atelectasis and significant lung volume reduction. Thus, we decided to treat the advanced emphysema of our patient with endoscopic volume reduction using lung sealant (AeriSeal®). The foam of lung sealant AeriSeal® is instilled into the peripheral airways and alveoli where it polymerizes and functions as tissue glue, forming a film of material on the lung surface that seals the target region to cause durable absorption atelectasis. Over a period of 16 weeks, the air within the sealed region was absorbed. The follow- up evaluation of this patient showed improved lung function (increased FEV 1, and a reduction of TLC and RV) with improved quality of life. Correlation between changes in primary and secondary outcome measures in the lung function parameters and 6- minute-walking test before and after the application of AeriSealant revealed significant reduction of hyperinflation and improvement both in the flow rates and physical capacity of our patient.

Pulmonary inflammatory myofibroblastic tumor encompasses a heterogeneous spectrum of reactive, infectious, and neoplastic entities. It is composed of spindle-shaped myofibroblastic cells in a background of inflammatory cells and collagen fibres. Actinomycosis is a bacterial infection. It infects the lower respiratory tracts by inhalation or aspiration of oropharyngeal or upper gastrointestinal materials. Only eight cases of pulmonary IMT associated with actinomycosis have been reported in the literature so far. This is the ninth case reported.

This report describes a 24-year-old patient with marked and continuous hypoxemia resulting from severe acute respiratory distress syndrome (ARDS) secondary to pneumonia, which in turn was refractory to mechanical ventilation and other conventional adjunctive therapies. Veno-venous extracorporeal membrane oxygenation (ECMO) was applied for 14 days and resulted in significant improvement in the hypoxemia. We conclude that ECMO presents a therapeutic option for ARDS patients who fail to respond to conventional mechanical ventilation.

Vertebroplasty is a new minimal-invasive procedure for the treatment of painful vertebral fractures. The risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. However, data about the incidence and treatment strategies of pulmonary cement embolisms (PCE) are limited. We report a case of a patient with symptomatic pulmonary cement embolism after the vertebroplasty. The diagnosis was confirmed by means of CT- scan. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up. In our case of symptomatic embolisms, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy.

A literature trawl reveals a substantial number of reports on true visceral aneurysms, including the hepatic artery, but only a handful of cases of visceral pseudoaneurysms. The ones in relation to the biliary tree are associated with previous gall bladder surgery and can result in significant gastrointestinal bleeding. There are more than 10 reported cases of cystic artery pseudoaneurysms but a thorough search revealed only two cases in English (1,2) and perhaps one in Japanese literature of right hepatic artery pseudoaneurysm secondary to cholecystitis presenting as massive upper gastrointestinal bleed. We present a probable fourth case in a 52 year old woman with classical clinical/biochemical picture, typical radiological appearance and who underwent successful interventional radiological treatment of this condition.

We report herein a case of diabetic ketoacidosis associated with invasive aspergillosis that was successfully treated with liposomal amphotericin-B (L-AMB). Early intervention after confirming the diagnosis of invasive pulmonary aspergillosis is very important, and initiating early treatment with L-AMB can lead to a full recovery.

The aim of this study was to evaluate psychometric properties of the perceived constraints on the physical exercise scale and to indicate the most important perceived constraints that restrict the elderly from exercise.160 persons (aged 60–89) living in Lithuania, Kaunas city were interviewed in 2011. Physical activity was assessed using a short version of International Physical Activity Questionnaire. Constraints on physical exercise were determined according to a structured list of statements consisting of five domains: poor health, fear and negative experiences, lack of knowledge, lack of time and interest, and unsuitable environment. Perceived constraints on the exercise scale demonstrated satisfactory internal consistency and good construct validity: Cronbach’s alpha coefficients of internal reliability were above the standard (≥0.7) with the exception of lack of knowledge domain. Exploratory factor analysis revealed a fivefactor solution that accounted for 67.4% of the variance. Fear and negative experience during exercise increased the odds of insufficient physical activity by 3.3 (1.16–9.59) times whereas lack of time and interest — by 7.2 (2.98–17.31) times. Perceived constraints on the exercise scale is a suitable measure for the elderly investigations. Perceived constraints that most restrict elderly people from exercise were lack of time, interest, fear of falling and injuries.