Chronic lymphocytic leukemia (CLL) is characterized by extraordinary heterogeneity in terms of clinical course with overall survival ranging from several months to dozens of years. It is currently not possible to accurately predict the future clinical course in an individual patient. Angiogenesis has been recently reported as a potential prognostic factor in various hematological malignancies including CLL. The objective of the present study was to quantify plasma levels of key angiogenic activators vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in patients with CLL and determine their potential change after intensive fludarabine-based treatment. Peripheral blood EDTA plasma concentrations of bFGF and VEGF were measured using comercially available enzyme-linked immunosorbent assay in 73 patients with untreated CLL (43 males, 30 females, median age, 65 years, range 31-88) and 80 healthy donors serving as control group. We found statistically significant increase in concentrations in patients with chronic lymphocytic leukemia compared to the control group (p < 0.0001 for both cytokines). No differences in angiogenic factors were noted between subgroups with low vs. intermediate vs. high-risk stage according to modified Rai staging or males vs. females. In twelve patients who achieved at least partial response after intensive fludarabine-based treatment, levels of bFGF as well as VEGF decreased significantly (bFGF, p = 0.0005; VEGF, p = 0.0068); in addition, they were no more significantly different from controls (bFGF, p = 0.524; VEGF, p = 0.728). Our data showed that key angiogenic activators bFGF and VEGF were elevated in plasma of CLL patients. Furthemore, treatment with intensive fludarabine-containing regimens resulted in significant decrease of both cytokines. These data suggest that angiogenic cytokines may indeed play a significant role in CLL biology and that treatment with combination of fludarabine, cyclophosphamide ± rituximab may exhibit antiangiogenic properties. Further studies with longer follow-up are necessary for evaluation of a possible association between angiogenic markers and progression-free survival or overall survival.

Bcl-2/IgH rearrangement is a characteristic molecular rearrangement in patients with follicular lymphoma (FL), yet its prognostic significance is still unclear.
Objective:
Evaluation of the implications of achieving Bcl-2/IgH negativity for the prognosis of FL patients. Twenty seven patients (54 %) were receiving only chemotherapy (CHT), 23 patients (46 %) were receiving chemotherapy combined with monoclonal antibody anti/CD20, rituximab (R-CHT).
Results:
Molecular genetic remission was achieved in 7 out of 11 patients (64 %) after R-CHT, and only in 2 out of 14 patients (14 %) after CHT - this difference was statistically significant (p = 0.037). 4 weekly doses of rituximab were administered in a sequence to 17 out of 27 patients who had received only chemotherapy and failed to achieve complete remission. 12 out of 17 patients (71 %) on this therapy were Bcl-2/IgH positive prior to treatment. 7 out of 12 (58 %) patients were no longer Bcl-2/IgH positive in a check performed after one month; the remaining 2 out of 5 patients had a negative Bcl-2/IgH record for the interval of 3 months (1 patient) or 6 (1 patient) months, respectively. The following factors were associated with the achievement of Bcl-2/IgH negativity at any point during the treatment: age < 65 years (p = 0.02) and performance status 0 + 1 according to WHO at baseline (p = 0.02). Patients who were Bcl-2/IgH negative after treatment had a lower recurrence/progression risk rate than the Bcl-2/IgH positive group of patients, i.e. 27 % vs. 75 % (p = 0.03), and a higher chance for progression-free survival, i.e. 81 % vs. 38 % (p = 0.004), event-free survival, i.e. 74 % vs. 38 % (p = 0.01), and overall survival, i.e. 87 % vs. 74 % (p = 0.05) at 2 years.
Conclusion:
In our experience, achieving Bcl-2/IgH negativity after follicular lymphoma therapy implies a better prognosis.

Pheochromacytoma is a relatively rare cause of arterial hypertension. Untreated pheochromacytoma may however lead to a fatal hypertensive crisis during anaesthesia or another form of stress. It is therefore important to correctly diagnose this disease. 24-hour monitoring of blood pressure (BP) can already contribute to the diagnosis of pheochromacytoma based on the frequent occurrence of BP variability and the absence of a night-time fall in BP. 5 gene mutations have so far been identified that may be responsible for the familial form of pheochromacytoma: mutation of the von Hippel-Lindau (VHL) gene, leading to the onset of VHL syndrome, mutation of the RET-proto-oncogene in multiple endocrine adenomatosis type 2, mutation of the type 1 gene for neurofibromatosis, which is associated with von Recklinghausen's disease and finally mutation of the genes encoding the B and D subunits of succinate dhydrogenase (SDHB, SDHD), which are associated with familial paragangliomas and pheochromacytoma. Genetic analysis should therefore be carried out for all confirmed cases of pheochromacytoma, especially for young people under 50 years of age. Biochemical diagnostics relies mainly on measurements of free metanephrines in plasma or urine, which usually has greater diagnostic weight than plasma, or catecholamines in urine. The diagnosis of extraadrenal or multiple forms can use not only CT/MR but also imaging using the radiopharmaceutical 123I-Metaiodobenzylguanidine (MIBG) or 18F-fluorodopamine PET (only available in the USA). Pharmacological treatment using alpha or beta receptor blockers with subsequent laparoscopic excision of the tumor is usually successful in benign forms of pheochromocytoma. Unfortunately, there are still no convincingly effective therapeutic procedures available for malign forms.

Design:
Chemotherapy of BOVAPEC is the modification of temporary intensified Stanford V protocol, an effective primary treatment of advanced Hodgkin's lymphoma (HL) in spite of limited toxicity. Nitrogen mustard was substituted by less myelotoxic cyclophosphamide and the protocol has been used in the treatment of patients with an intermediate stage of HL.
Methods:
The primary treatment with BOVAPEC was started in 62 patients. Complete chemotherapy schedule was administered to 60 patients (97 %) and the median of its overall duration was 13 (12-18) weeks. 31 patients (50 %) underwent adjuvant "involved field" radiotherapy (RT). The median of posttherapeutic follow-up was 37 (range 8-85) months.
Results:
During the treatment, a neutropenia of grade 3 and 4 was observed in 14 patients (23 %) but without the development of any serious infectious complications. The manifestation of early non-hematological toxicity did not overcome grade 2. 58 patients (94 %) achieved the complete remission of HL. A relapse was observed in 11 cases (19 %) and estimated five years disease-free survival (DFS) is 72 %. The combination of BOVAPEC and RT in primary treatment was associated with higher probability of five years DFS but actually without statistical significance (88 % vs 58 %; p = 0.08).
Conclusion:
The BOVAPEC regimen with its acceptable toxicity may represent effective primary therapeutic approach to the patients with the intermediate stage of HL. Adjuvant RT is essential in all patients diagnosed with nodal bulk and/or residual lymphadenomegaly.

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of osteoporosis because of their age, limited physical activity, low body mass index, smoking, hypogonadism, malnutrition, and use of corticosteroids. Systemic inflammation represents an additional pathomechanism contributing to the development of osteoporosis in COPD patients. Males in their mid to late 60s with a smoking history of greater than 60 pack-years have a prevalence rate of vertebral fractures similar to, and possibly greater than, postmenopausal women greater than or equal to 65 years old: in patients with severe COPD, up to 50-70% have osteoporosis or osteopenia, and up to 24-30% have compression vertebral fractures. Correlates of osteoporosis in COPD are mainly measures of body composition, disease severity and the use of corticosteroids, although causality has not been proven. Systemic corticosteroids remain the most common cause of drug-related osteoporosis, and a meta-analysis concluded that the use of more than 6.25 mg prednisone daily led to decreased bone mineral density (BMD) and increased fracture risk. In contrast, the effects of the long-term use of inhaled corticosteroids on BMD remain debatable. Effects of treatment of osteoporosis have not been investigated in samples consisting of COPD patients only but the recommendations follow the general recommendations for the diagnosis and treatment of osteoporosis. Early recognition of BMD loss is essential, and assumes close interdisciplinary cooperation between respirologists and reumatologists. Longitudinal follow-up to assess determinants of osteoporosis in COPD and randomised placebo-controlled trials on the effects of treatment of osteoporosis in patients with COPD only are warranted. In the future, novel therapeutical strategies such as monoclonal antibodies against osteoclasts activators may prove their benefitial effects in the treatment of COPD-related osteoporosis.

Monoclonal gammopathy may manifest itself through a range of skin disorders, including plane normolipemic xanthoma and necrobiotic xanthogranuloma. The present paper describes two patients with these cutaneous symptoms. The first has extensive areas of skin affected by flat xanthomas, monoclonal gammopathy with > 10% infiltration of bone marrow with clonal plasmocytes and, according to PET-CT, unclear lymphadenopathy in the retroperitoneal area. The size of this lymphadenopathy (histologically no malignant infiltration and no confirmed infectious aetiology) has not changed significantly over a 4-year follow-up. Repeated PET-CT scans showed decrease in SUV value in this infiltration from 7.5 to 3.8. Four cycles of treatment with a combination of bortezomib, cyclophosphamide and dexamethasone brought neither reduction in monoclonal immunoglobulin nor change to skin morphology. We believe that the abdominal lymphadenopathy is associated with xanthomatosis but have been unable to confirm this unequivocally. The second patient is being followed up for more than 10 years, originally for MGUS, later for asymptomatic multiple myeloma. Last year, painful subcutaneous and cutaneous infiltrates, isolated on an upper limb and more frequent on lower limb, started to occur. These infiltrates are palpable. PET-CT imaging provided an excellent depiction of these infiltrates, showing no pathology on the head, chest and abdomen and no osteolytic foci on the skeleton. CT imaging showed clearly numerous infiltrates in the skin and subcutaneous tissue of lower limbs, particularly both shanks, reaching up to 2 cm in depth. The largest infiltrate, measuring 3.5 by 2 by 10 cm, was identified in the distal dorsal part of the right shank. PET imaging of lower limbs showed distinctly pathological accumulation in all infiltrates described above; the accumulation of glucose in the lower part of the right shank reached 10.0 SUV. CT images of lower limbs showed increased density saturated hypodermis even in the areas where there is no increased accumulation of ¹⁸fluoroglucose. Following 40 Gy irradiation, the size of infiltrate in the radiated area decreased and their soreness ceased. Conclusion: PET-CT imaging offered information on extra-cutaneous signs of plane normolipemic xanthomas and provided excellent depiction of the areas of the skin and hypodermis affected by necrobiotic xanthogranuloma. Chemotherapy with cyclophosphamide, bortezomib and dexamethasone brought no reduction in monoclonal immunoglobulin concentration, and no reduction in plane normolipemic xanthomas. Radiotherapy targeted at large foci of xanthogranulomas led to partial regression and ceased infiltrate soreness.

Hyperglycemia and insulin resistance develop in the majority of severe acute illness and/or injury. One of the main causes of hyperglycemia in critically ill patients is the release of counterregulatory stress hormones and proinflammatory cytokines, in addition to increased production of glucose along with its decreased utilization. Hyperglycemia plays an important role not only in influencing the cascade of inflammatory cytokines, but it also increases oxidative stress. In the past, stress hyperglycemia was thought to be an evolutionary protective, natural adaptive response of the body to current threat, which allows increased entry of glucose into the cells of non-insulin-tissues, thus improving chances for survival. At present, however, this state of insulin resistance, glucose intolerance and hyperglycemia is called "stress diabetes" or "diabetes of injury". Ever since the time of the breakthrough "Leuven" study, which brought significant reduction in morbidity and mortality in surgical critically ill patients with tight glycemic control, hospitals, particularly their intensive care units, have focused on the treatment of hyperglycemia. Although extensive observational data have shown a consistent, almost linear relationship between blood glucose concentrations seen in hospitalized patients and the incidence of adverse clinical results, there have been particular doubts concerning the universality of control, its safety, and pitfalls resulting from hypoglycemia. This controversial debate is currently enriched by the recent international trial - the NICE-SUGAR, whose post-hoc analyses are currently underway. Despite the controversy there is no doubt that the deliberate control of blood glucose control in critically ill patients is justified. It is the insulin application regimen - the insulin protocol per se - that remains the biggest problem in the implementation of glycemic control. Regarding targets, it is necessary to take into account that the best positive effects on outcomes can be anticipated in certain subgroups of critically ill patients, which is currently the subject of further study. Continued streamlining, achieving optimal blood glucose ranges in critically ill patients will allow us to develop and apply computer algorithms that greatly simplify and improve continuous monitoring of blood glucose. Procedures seeking optimal intensive control in critically ill patients are accepted in intensive care units. However, it is undoubtedly necessary to improve monitoring techniques and the quality of biosensors in order to ensure the safety and effectiveness of interventions aimed at reducing blood glucose levels while using advanced protocols. Automatic closed systems are a promise for the future.

The patients without ventricular arrhythmias with markers of high risk of sudden cardiac death are indicated for ICD implantation today. Last generation of ICD systems are equipped with high capacity batteries, with many automatic functions, capabilities of data sending and possibilities of prediction of worsening of heart failure. Nowadays ICD systems offers not only elimination of the risk of sudden cardiac death but reduction of symptoms of chronic heart failure through the resynchronization therapy, too.

Introduction:
The aim of this research was to, in patients with severe (tight) aortic stenosis (AoS), evaluate a) an association between clinical and some haemodynamic characteristics and natriuretic peptides (ANP, BNP) concentrations and b) usefulness of these hormones in the decision making on the next therapeutic steps.
Methods:
Echocardiography and 6-minut exertion walking test were performed in 23 consecutive patients (12 men, 11 women; age 67 ± 7 years) and 20 controls together with ANP and BNP measurements from three plasma samples before, immediately after and 20 minutes after the exertion test.
Results:
There was high inter-individual variability in the ANP and BNP concentrations in patients with AoS. All ANP and BNP were significantly higher than in the controls (ANP 1, 2, 3, p < 0.001; BNP 1, 2, 3, p < 0.001). Only the ANP levels increased significantly after the exercise (ANP 1 vs. ANP 2 = 0.011; ANP 2 vs. ANP 3 p = 0.037). We identified significant correlations between aortic peak gradient and BNP 1, 2 (r = 0.821, p < 0.001) and ANP 1, with BNP correlations being stronger. We did not find any correlations with aortic valve area and the left ventricle mass. The hormone levels were non-significantly increased depending on NYHA classification. Exercise did not improve validity of ANP and BNP measurement. Their values had high sensitivity but low specificity in detecting critical AoS.
Conclusion:
ANP and mainly BNP helped to exclude severe AoS but they were not useful in detecting lower, borderline gradients. We did not prove ANP and BNP to be significant factors in decision making about the timing of AoS surgery.

Despite many decades of laboratory and clinical research of pathogenesis bleeding and thrombosis and the search for the identification of the risk factors, the accomplished results are unsatisfactory in clinical praxis. In our article, we discuss incidence, pathogenesis, clinical manifestation and the risk factors for coagulopathy in patients with myeloproliferative disease. The surgical procedures are associated with higher risk of morbidity and mortality. The aim of the article is the formulation of the recommendations concerning management of surgical interventions with the goal to reduce the risk of bleeding and thrombotic diathesis.

Hypopituitarism is a condition linked with insufficient function of the adenohypophyse and occurs in the case of destruction of its greater part. It may take the form of an isolated deficit or a combined disorder - panhypopituitarism. The most common cause is an expansion in the region of sella turcica, irradiation, traumas, inflammations, bleeding, puerperal ischemic necrosis (Sheehan syndrome) or an affection of the hypothalamus. The cause remains unclear in the case of idiopathic hypopituitarism. Clinical picture: the most common case in children is the deficit of the growth hormone, manifested by retarded growth. Sometimes it is combined with the deficit of gonadotropins which causes pubertas tarda. The clinical picture in adult patients is proportionate to the degree and type of disorder of the different hypophysial functions. Diagnosing of the disease is based on the clinical picture and laboratory examination of hypophysial hormones together with the respective peripheral gland hormones. Dynamic stimulation tests need to be used for more precise diagnosis in the case of threshold results. Therapy: expansive processes in the region of the hypophysis are treated by surgery or irradiation, mostly using the gamma knife. Substitution by peripheral gland hormones is used in persistent hormonal deficits. Hypocorticism is treated by hydrocortizone at a dose of 10-30 mg per day administered per os, respecting the diurnal rhythm. The dose should be adjusted in case of strain, and parenterally administered hydrocortizone is necessary in the case of decompensation, pituitary crisis or surgery. Hypothyreosis is treated by thyroxin, the usual substitution dose ranging between 50 and 150 μg per day. The dose is titrated according to the clinical condition and free thyroxin level. Testosterone substitution therapy is used to treat male hypogonadism. In women, a combination of estrogens and gestagens is used on a cyclic or a continuous basis. If fertility is the therapeutic objective, temporary administration of injection gonadotropins or gonadoliberin is necessary in both the sexes. Therapy with growth hormone is indicated in children and in adults with sever, clinically manifested deficit of GH where its administration clearly improves the quality of life, promotes the growth of lean body mass, an increase in bone density and the improvement of metabolic parametres.

Hashimoto's encephalopathy (HE) is a brain disease associated with autoimmune thyroid disease. Over 100 articles have been published on the topic, especially in connection with hypothyroidism. In addition to an overview of the relevant literature, we also report a case of a female patient with a rare association of HE with thyreotoxicosis. The patient presented with varied clinical-neurological symptoms: she had convulsions, psychotic symptoms, altered consciousness Examinations (laboratory tests, CT, MRI, EEG, CSL exams) detected increased level of proteins in the liquor, episodes of rhythmic δ activity on EEG, increased antithyreoidal antibody titre (TOOab, TGAb, TRAb) in serum. After initial treatment with carbimazole and hydrocortizone, the patient's condition dramatically improved and she was disconnected from artificial lung ventilation, conscious and convulsion-free. During the following 30 days, the patient would get worse after attempts to withdraw glucocorticoids. In spite of thyreotoxicosis, we classified the condition as HE and the patient was fully stabilised after pulse treatment with methylprednisolone. Clinically, the patient was subject to further outpatient follow up, without symptoms of encephalopathy; glucocorticoids were gradually withdrawn and were discontinued completely after another four months. The authors conclude that HE, even though rare, may pass unnoticed due to its symptoms which are similar to many other and more frequent diseases. HE should be considered in patients with potential or known autoimmune thyroidism and atypical neuropsychiatric manifestation responding to corticoid treatment.

In the years 1995–2002, a survey was conducted involving 5 263 individuals (2 276 males, 2 987 females) between the ages of 6–98. They were selected randomly from the central registery in 7 counties in the Czech Republic. The level of urinary iodine in these individuals was established using the Sandell-Kolthoff rection which was preceded by the alkaline ashing of the samples as follows: (n = 5 263), thyroglobulin (TG, n = 3 902), thyrotropin(TSH, n = 5 162) freee thyroxin (fT₄, n = 5 160) and free triiodothyronine (fT₃, n = 4 931), where the thyroid hormones, TSH, and TG were determined in serum using immunoassays. The individuals were divided into groups according to their iodine deficiency, i.e. to the group with urinary iodine concentration < 50, 50–100, 100–200, and > 200 μg I/l of urine. In these groups the mean and median of TG, TSH, fT₄, and fT₃ were calculated. The means and medians of TG and fT₄ increased with the decrease of urinary iodine, and conversely TSH decreased with the decrease of urinary iodine. The values of fT₃ were relatively unaffected by the changes in the concentrations of urinary iodine. All the hormonal changes fell into the normal reference rang.. It is evident from our results that in cases iodine deficiency in the organism, there is a tendency to raise the sensitivity thyrocytes to TSH stimulation rather than a rise in the concentration of circulating TSH. Of all the hormones observed, thyroglobulin was the best indicator of iodine retention in the organism.

In clinical practice, we often observe conditions accompanied by secondary drop of binding proteins that bind, more or less specifically, thyroidal hormones. This is usually considered as normal situation that is often not properly interpreted from clinical point of view. In other words, we tolerate such conditions because we build on values of free hormones FT3 and FT4. However, it is very rare to observe significant decrease or even absence of thyroxin binding globulin (TBG) due to inborn error of metabolism. In such situations, the overall level of thyroidal hormones becomes a part of evaluated laboratory profile. Unusual laboratory constellation is in sharp contrast to the so-called "healthy patient". Due to increased migration of persons, we had an opportunity to take care of a patient of this kind.

Free oxygen radicals (FOR) are one of the factors which participate via lipoperoxides in the development of atherosclerosis. Atherosclerosis complications affect a large part of diabetic patients. The objective of the present work was to test whether in diabetic patients there is, as compared with healthy subjects, a difference in the FOR activity and in the lipoperoxide blood level. A total of 30 patients with insulin non-dependent diabetes and a control group of 31 healthy subjects were examined. The FOR formation in blood, the concentration of malondialdehyde (MDA) as a marker of lipid paroxidation and serum lipid concentrations were assessed. In patients with diabetes a statistically significant increase in the FOR formation in blood (p < 0.01) and an increased MDA serum concentration (p < 0.01) were found. The mean serum lipid concentrations in the two groups did not differ significantly. The results suggest a significant participation role of highly reactive oxygen species in the development of vascular atherosclerosis complications.

In the last 15 years enteral nutrition has been getting ahead of parenteral nutrition. Enteral nutrition allows natural supply of nutrients, stimulates immunity, reduces overgrowth of intestinal microflora, reduces intestinal permeability, and has a positive effect on intestinal peristalsis. Substrates of enteral nutrition are nutritionally defined, low osmolar, and usually residual-free, do not contain lactose and gluten. A number of substances is flavoured, allowing continual drinking of the nutrition throughout the whole day. This mode of nutrition is increasingly used and referred to as sipping or drink feeding. Enteral nutrition is also suitable for diabetics, however, it is necessary to calculate with the amount of glucose contained in the nutritional solution. A suitable treatment strategy needs to be established through frequent glyceamia monitoring and calculating of consumed sugars in food and in the enteral nutrition with preferential utilisation of insulin treatment for its anabolic effect.

Aims of the study:
The aim of this retrospective study was to analyse diagnostic and therapeutic success of endoscopic retrograde cholangiopancreatography (ERCP) in our sample of patients following Billroth II gastric resection, where, due to significantly modified anatomic ratios, this surgery represents a specific and often extremely difficult technical problem when performing ERCP. Materials and methodology: The sample was followed up for 13 years (November 1994 - December 2007). The data on 112 patients after Billroth II gastric resection were assessed retrospectively; indications for ERCP included cholestasis in 92 patients, acute biliary pancreatitis in 12 patients, acute cholangitis in 6 patients and suspected bile leak following laparoscopic cholecystectomy (LCE) in 2 patients. Results: Cannulation success during ERCP in the 112 patients following Billroth II gastric resection was 90.2% (i.e. 101 of the 112 patients). Normal ERCP finding was recorded in 4 patients. The remaining 97 patients had pathological results on ERCP (choledocholitiasis was found in 78 patients, malignant biliary stenosis in 14, benign biliary stenosis in 3 a bile leak following LCE in 2). Endoscopic treatment was initiated immediately after diagnostic ERCP in all these 97 patients, the initial step was in all cases endoscopic papillotomy using one of the special papillotomes (diathermy wire). Overall, therapeutic ERCP was completely successful in 83 of the 97 patients (85.6% of 97) in whom the originally endoscopic treatment had been initiated. Conclusions: ERCP following Billroth II gastric resection is, due to modified post-surgery anatomy, markedly more challenging then the conventional procedure. Availability of a variety of tools as well as, understandably, extensive experience and skill of an endoscopist are prerequisite to ERCP success in these patients. Correctly performed ERCP in patients following Billroth II gastric resection is a highly effective and safe method for diagnostics and, in particular, treatment of pancreatic-biliary diseases, in which similar success as under standard anatomic conditions can be achieved.

B-cell chronic lymphocytic leukaemia and the similar diseases are seen predominantly in patients above the age 50 years, i.e. at the age when the patients also have other co-morbidities. The knowledge of these diseases on molecular level has improved significantly over the last decade. Molecular and biological prognostic factors are available in routine everyday practice. Assessment of these factors enables prediction of prognosis and, in some cases, also the response to therapy. The aim of the present review is to provide the medical community with the main information on this disease as patients with B-cell chronic lymphocytic leukaemia and similar disease states are of older age and very often suffer from a range of co-morbidities. Consequently, care for these patients involves physicians from various specialities. The aim of the following text is to present a clear overview of the basic information about this group of diseases that might be useful to all physicians who provide care to patients with B-cell chronic lymphocytic leukaemia and similar conditions. Since monoclonal immunoglobulin is sometimes identified in patients with these diseases, it is important to consider these conditions in the differential diagnosis of the states with the presence of monoclonal immunoglobulin.

Several randomized clinical trials in multiple myeloma (MM) completed in the last two decades have clearly shown that high-dose chemotherapy with hematopoietic stem cell support significantly increases the number of complete remissions and median overall survival in comparison to conventional chemotherapy. The median survival of MM patients treated with conventional chemotherapy is approximately 4 years in contrast to 5 to 6 years with autologous transplantation. Although high-dose chemotherapy with autologous transplantation is not curative and most patients will eventually relapse, more than 20% of patients treated using this strategy experience survival longer than 10 years. Thus, autologous transplantation is the preferred treatment option for all eligible patients with MM.

Background:
Surgical embolectomy is established method of treatment of pulmonary embolism. The aim of the study is to evaluate the experience with this procedure.
Patients and methods:
Twenty two patients, aged 22-77 years, were operated on in Centre of cardiovascular surgery and transplantation in Brno from 1999 to 2009. Nine patients suffered from massive pulmonary embolism with hemodynamic instability, 13 were stable. All the operations were performed in cardiopulmonary bypass with cross clampimg time 50.4 minutes on average. In six patients the retrograde perfusion via pulmonary veins were used. Emboli in the main trunk and/or in both pulmonary branches were found in 16 patients (72.7%). No macroscopic emboli were found in three patients, but they were flushed from the pulmonary vessels during the retrograde perfusion in two of them. Emboli or thrombi in cardiac atria or ventricles were detected in 8 patients simultaneously.
Results:
Five patients died early after operation (mortality 22.7%). The mortality was different in the group of patients with massive pulmonary embolism and cardiogenic shock (44.4%) and with submassive embolism and hemodynamic stability (7.7%).
Conclusion:
Developments in surgical technique with retrograde perfusion offer removing of emboli not only from the pulmonary trunk and main branches, but also from the peripheral branches. It improves results and facilitates extension of indications for surgical treatment.

Many of medical patients are significant risk of venous thromboembolism (VTE). VTE is the most common cause of preventable death in hospitalized patients. Prophylaxis is highly effective in reducing the risk of deep vein thrombosis and pulmonary embolism and should be used in most hospitalized patients. Various strategies improve adherence to evidence-based guidelines on the use of prophylaxis, including audit and feedback, and automatic reminders. The important clinical risk factors for PE (or venous thromboembolism VTE) include advanced age, general anaesthesia, prolonged immobility or paralysis, previous VTE, cancer, duration of surgery, orthopaedic surgery of lower limb leg, hip or pelvic fracture, major trauma, stroke, obesity, varicose veins, postoperative infection and heart failure. Medical patients ad bed rest or who are sick are in moderate risk of VTE and evidence based guidelines recommended thromboprophylaxis with low molecular weight heparin, or low dose of unfractionated heparin or Fondaparinux. For all situations both guidelines recommended against the use of aspirin for VTE prevention.

Incidence of thrombosis is age dependent with the lowest risk in the childhood. Children mostly suffer from vein thrombosis. Incidence of thrombosis in children is only 0.07/10 000, but it increases among hospitalized children (3.5/10 000). Subcutaneous administration of low molecular weight heparin (LMWH) is preferred treatment of deep vein thrombosis in children. In this study we present group of 33 children with deep vein thrombosis, who were treated with LMWH for their first thrombosis from 2003 till 2006. Twenty-one (63.6%) patients were treated with LMWH by continuous infusion and 12 (36.3%) patients by subcutaneous injection. Duration of the treatment with LMWH was modified in accordance with the course of thrombosis (monitored by Doppler ultrasound with compression) with median of 15 days in patients treated by continuous infusion and 18.5 days when treated subcutaneously. Median dose of LMWH for intravenous and subcutaneous application was 240 IU/kg/24 h and 215 IU/kg/24 h respectively. The administered dose of LMWH was modified to achieve and maintain required therapeutic antiXa level within the range of 0.5-1 IU/ml. The treatment with continuous infusion led to total recanalisation of the occluded vein in 3 cases (14.3%), partial recanalisation was achieved in 15 (71.4%) patients. Three (14.3%) patients were without any recanalisation. The treatment by subcutaneous injection led to total recanalisation of the vein in 4 cases (33.3%), partial recanalisation was seen in 4 (33.3%) patients. Four (33.3%) patients were without any recanalisation. The difference in the outcomes of the therapy between both groups appears to be statistically significant (p = 0.041, nonparametric Mann-Whitney test). We have not noticed any severe adverse event of the treatment in any of our patients. Our results support the hypothesis that the treatment of DVT with continuous infusion of LMWH might be efficient and safe alternative to subcutaneous application in those children in whom we want to avoid subcutaneous administration from certain reasons.

Introduction:
Aortic allograft implantation into the aortic position in adults is standard procedure with some controversary. The most popular indication is bacterial endocarditis. We would like to present our midterm results.
Results:
We implanted 61 allografts in 60 patients (between 10/2002 and 04/2008). Men were 46 (76.8%) and average age was 57 ± 10.76 year. 30 days mortality was 9 people (15.0%, all with bacterial endocarditis). Late mortality 1 man (1.6%). Follow up 1-66 months, average 39.18 SD ± 14.3 months, median 42 months.
Conclusion:
Implantation of aortic allograft into the aortic position is standard procedure with good midterm results. Relative high early mortality is dependent on preoperative status in patiens with acute bacterial endocarditis - all early death people were people with acute bacterial endocarditis and minimally one vital organ severe dysfunction.

Background and aims:
Familial combined hyperlipidemia is the most frequent hereditary dyslipidemia, usually associated with insulin resistance. Recently, the diagnostic criteria of familial combined hyperlipidemia were redefined: There should be at least two 1st degree hyperlipidemic relatives with both triglycerides ≥ 1.5 mmol.L^-1 and apolipoprotein B ≥ 1.20 g L^-1. The aim of this study was to evaluate the relationship between this lipoprotein phenotype and the presence of insulin resistance and to assess the presence of metabolic syndrome.
Methods:
Lipid parameters and parameters associated with insulin resistance were determined in 90 subjects of families with familial combined hyperlipidemia and 38 controls. The members of affected families were further divided into the hyperlipidemic and normolipidemic group.
Results:
The hyperlipidemic group showed only significantly higher fasting proinsulin levels [HL 17,4 ± 1.5 vs NL 12.8 ± 1.4 (p = 0.030); and vs CO 11.1 ± 1.4 (p = 0.003)] in comparison with the normolipidemic and control groups. Differences in fasting insulin [HL 9.40 ± 0.78 vs NL 7.78 ± 0.71 (p = NS); and vs CO 7.30 ± 0.76 (p = NS)], C-peptide [HL 2.56 ± 0.19 vs NL 2.27 ± 0.17 (p = NS); and vs CO 2.07 ± 0.18 (p = NS)], and HOMA [HL 2.16 ± 0.21 vs NL 1.84 ± 0.20 (p = NS); and vs CO 1.69 ± 0.21 (p = NS)] did not reach statistical significance. On the contrary, the members of families with familial combined hyperlipidemia with the presence of metabolic syndrome (NCEP-ATP III) had significantly higher fasting insulin [FCH with MS 12.74 ± 1.42 vs HL without MS 9.21 ± 0.92 (p = 0.030); and vs NL without MS 6.75 ± 0.80 (p = 0.001)], and proinsulin levels [FCH with MS 25.28 vs HL without MS 15.69 ± 1.75 (p = 0.002); and vs NL without MS 11.20 ± 1.51 (p = 0.0001)], and HOMA index [FCH with MS 3.03 ± 0.39 vs HL without MS 2.13 ± 0.25 (p = 0.042); and vs. NL without MS 1.56 ± 0.22 (p = 0.003)] in comparison with their relatives without metabolic syndrome and controls.
Conclusion:
The presence of the metabolic syndrome could detect the most insulin resistant subjects in families with familial combined hyperlipidemia who are at increased risk of cardiovascular disease.

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.

The currently used standard treatment for chronic hepatitis C using a dual combination of IFNα/RBV is only successful in 50 % cases. With the exception of some clinical and biochemical factors, degree of inflammation (grading) and degree of fibrosis (staging), there are no other known markers which may serve as valid predictors of response to therapy. Interference of hepatitis C virus (HCV) with signaling pathways modulated by JAK-STAT, ERK 1/2, NFκB and MAP proteins is one mechanism which may influence the interaction between HCV and IFNα. These proteins regulate different cell processes such as activation of cytokines, activation of apoptosis, regulation of cell proliferation etc. Therefore, it is possible that impaired signaling or inhibition/dysregulation of some of these proteins by HCV infection may cause resistance to IFNα treatment. This review is completed by results of preliminary study the aim of which was immunohistochemical assessment and analysis of expression of STAT 2, 3 proteins, their inhibitors SOCS 2, 3 and PIAS 3 and proteins JAK 1 and ERK 1/2 in liver biopsies of 26 patients with chronic hepatitis C treated by dual combination IFNα/RBV and subsequent correlation of the results of immunohistochemical analysis (histoscore) with histological picture and clinical response to treatment. The results shows increased expression of STAT 3, STAT 2 and ERK 1 proteins and decreased expression of SOCS 3 and SOCS 2 in hepatocytes of patients with more marked inflammation and fibrosis. In patients with sustained virological response there was increased expression of SOCS 3 and JAK 1 and decreased expression of SOCS 2. Relapse was associated with increased expression of SOCS 3 and PIAS 3. However, owing to the small sample size, the results only approximated statistical significance, but we suggest that proteins of STAT family and their inhibitors SOCS and PIAS probably play an important regulatory role during response to treatment for chronic hepatitis C.

One of the parameters of the electrical stability of the heart is also the QT interval (electrical systole) duration. It is dependent on the heart rate, during tachycardia is shortening, during bradycardia prolonging. However, its borders on the ECG are not very precisely defined, especially the end of T wave. For QT interval duration the ventricular cells of type M are mainly important and they have the very long action potentials. Since 1920, when the first regression equation of QT interval was published, there were plenty of equations linear or nonlinear (parabolic, cubic, hyperbolic, exponential, logarithmic) proposed, the most frequently used is the Bazett's one. QT duration and the mathematic formula of regression equation are dependent on several factors - gender, age, exercise, diseases, pharmacologic agents. QT duration in healthy women at the same heart rate is approximately by 10-20 ms longer than in healthy men, in older persons is longer than in younger ones. The slowed repolarization of ventricular cells in women is the cause of this difference. Many cardiovascular, cerebral, other diseases and some drugs are able to prolong QT interval. Change of the dependence of QT duration on the heart rate means a change of autonomic nervous system activity. QT interval is probably not a function of the heart rate or cardiac cycle duration. QT interval duration is influenced mainly by RR interval, therefore because of better comparison at various RR the so called corrected QT interval (QTc), deprived of heart rate or RR interval dependence, is used. Every regression QTc equation is valid under certain conditions and in certain range of heart rates only. Change of the mode of QT expressing or a used regression equation are able to alter the statistical significance of obtained differences. Relation between QT and RR intervals is highly individual and specific in every person, therefore to search some universally valid equation is probably not fruitful. Orientatively, a prolonged QT interval can be a value above 500 ms without correction for the heart rate.

Catheter ablation has been establishing as a routine curative method of atrial fibrillation. Immediate and long-term results of catheter ablation employing method of pulmonary vein isolation using conventional or electroanatomic mapping in patients with intermitent atrial firillation are presented. Patients and methods: Ablation was performed in 150 patients (26 females), aged 52.4 ± 10.7 years, in 173 procedures. Results: During the initial ablation procedure in the first 110 patients, full pulmonary vein isolation was achieved in 358 (96%) of 372 target pulmonary veins. In 286 (77%) out of these 372 pulmonary veins, investigated angiografically before and after the isolation, mean narrowing from 12.6 ± 2.7 to 12.1 ± 2.8 mm was measured. Asymptomatic ostial narrowing, ranging between 25 to 50%, occurred in 16 (5.6%) of pulmonary veins. In the subsequent 40 patients, full isolation was achieved in all 160 pulmonary veins, and in none of them ostial stenosis and turbulent flow were found one month after the ablation during transesophageal echocardiographic examination. Twenty-two patients (15%) underwent a second and one patient a third ablation. Complication (embolic stroke resulting in hemianopsia) occurred in one (0.06%) out of 173 procedures. The mean follow-up period was 15.9 ± 10.3 months. First 110 patients had the folow-up period of 9-40 months and the following 40 patients had follow-up period of 1-6 month after ablation. Among the first 110 patients, 77%, 82%, 83%, 83%, 86%, resp. 89% patients were free of atrial fibrillation at 3^rd, 6^th, 9^th, 12^th and 18^th month after ablation and the clinical benefit, ie. elimination of clinically significant atrial fibrillation was achieved in 85%, 89%, 91%, 93%, 92%, resp. 89% of the patients. In the last 40 patients, elimination of atrial fibrillation and clinical benefit at months 3 and 6 were achieved in 91% resp. 100% patients. Ablation was associated with a significant reduction of antiarhythmic and anticoagulation medication. Conclusion: Catheter ablation of intermitent atrial fibrillation in patients without major structural heart disease, based on full isolation of all pulmonary veins, is highly effective and relatively safe. Although technology and ablation strategies continuously evolve, ablation of atrial fibrillation can be currently considered a routine curative method.