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ABSTRACT: The exponential growth in medical knowledge is closely followed by expanding range of therapeutic options as well as increasing expenses associated with the use of new diagnostic techniques and treatments. This development requires organizational steps that would ensure that the expenditure is associated with the maximum benefit. The following text discusses foundation and development of a network of cancer care centres in the Czech Republic.
Vnitr̆ní lékar̆ství 03/2011; 57(3):317-9.
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Z Adam,
S Stepánková,
A Sirotková,
Z Cermáková,
L Pour,
M Krejcí,
L Zahradová,
Z Korístek,
J Lenz,
R Hájek, J Vorlícek,
J Mayer
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ABSTRACT: We describe a case of an untreated female patient monitored over 8 years for chronic B-lymphocytic leukaemia (B-CLL). Over the 8 years, the patient has gradually developed severe kidney failure, even though the criteria for B-CLL treatment had not been fulfilled. Kidney biopsy revealed renal damage due to lamda free light chains cast nephropathy as well as an infiltration of renal parenchyma with B-CLL cells. It was not before this biopsy that the presence of monoclonal immunoglobulins has been investigated. Immunofixation identified free monoclonal lamda light chains in the serum and urine. Their serum concentration, quantified by densitometry, was 2.6 g/l and urine concentration was 0.5 g/l. A specific evaluation of free light chains in the serum revealed an extremely high concentration of free X light chains, over 4500 mg/l, and normal concentration of K free light chains, 10 mg/l. The aim of this report is to emphasise that monoclonal immunoglobulin may be present in B-CLL as well as other lymphoprolipherative diseases and that it may cause damage to organs, similar to multiple myeloma or monoclonal gammopathy of undetermined significance. The described case confirms poor prognostic value of monoclonal immunoglobulin free light chains in patients with B-CLL and usefulness of an evaluation of their presence in patients with B-CLL, particularly if the patients have increased creatinine level. The described case also highlights the need for evaluation of the presence of free light chains in the serum of all patients with unclear cause of renal failure.
Vnitr̆ní lékar̆ství 02/2011; 57(2):214-21.
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ABSTRACT: Survey of the history and study of the psychical expressions of the oncology patients, the rules of communication ofoncologist and his patient. Personality of oncology patient and a Model of Kübler-Ross, then a decalogue of speaking about the oncology diagnosis. Clinical psychologict as an integral part of the medical team, which brings a supportive care for the oncology patients, then the psychopatological behaviour appears iside a medical team. In the end there are the authentic patients stories with the psychologist commentary.
Vnitr̆ní lékar̆ství 06/2010; 56(6):570-81.
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ABSTRACT: Since its establishment in 1990, a total of 22 patients with confirmed Langerhans cell histiocytosis (LCH) have been monitored and treated at the Clinic of Internal Medicine Haemato-Oncology in Brno. In 5 patients, the disease was diagnosed in childhood and 2 of these 5 patients had late neurodegenerative changes in the CNS with a typical picture on MR and a typical PET-CT imaging fluorodeoxyglucose hypometabolism in the cerebellar area. In 5 patients from the cohort of 22, the disease had unifocal form, dominant in the area of skeleton with no recurrence after the treatment. However, in 12 patients, the disease affected a number of organs simultaneously (multifocal form of LCH). The aim of the description below is to characterise the monitored cohort of 22 patients and describe the very different courses of multifocal forms of LCH in 12 patients.
Vnitr̆ní lékar̆ství 06/2010; 56(6):542-56.
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ABSTRACT: Sepsis and the septic shock and the up to date knowledge about them represent a marked drifting for diagnostics and the treatment of this complications. Their application in patients with the oncological disease or the other immunocompromised patients represents further extension in the specific group of patients with several unique properties. In despite of the improving results in the oncological treatment there are only few reports in literature about this group of patients and this one is steadily growing due to the progressive improving of the supportive care in oncology. This group of patients with the febrile neutropenia and the sepsis (the most frequent complication) request the special focus of general practitioners and the internists because these ones are with these patients in contact as a first. They have to master the basal image about the specialties of this patient group. In our article we analyze this group of patients with focus on antibiotics in febrilie neutropenia and sepsis and on the other supportive care in the immunocopromised patients.
Vnitr̆ní lékar̆ství 06/2010; 56(6):557-69.
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ABSTRACT: In order for the schools of medicine to produce high quality physicians, they have to provide high quality education as well as they must ensure that knowledge building is taking place in the course of the programme and that the students whose efforts and/or abilities do not allow achievement of the required criteria are eliminated. Exams used to be the standard quality control tool. However, current information technologies allow doubling-up of this control; retaining the traditional examinations but preceding them with the requirement to complete multiple-choice tests. The text summarizes our experience with examining the students' mental presence during teaching with tests and our plans for the combined form of exit control using tests, completion of which will be prerequisite to admission to the exam itself. We do not believe that tests should completely replace exams but we do believe that the requirement to pass the exam should only take place following previous successful completion ofa test. This is achievable ifwe manage to establish a computer teaching room, i.e. examination room, and transform a vast number of questions into high quality multiple choice tests.
Vnitr̆ní lékar̆ství 06/2010; 56(6):624-8.
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ABSTRACT: 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.
Vnitr̆ní lékar̆ství 09/2009; 55(9):746-65.
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ABSTRACT: 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.
Vnitr̆ní lékar̆ství 09/2009; 55(9):767-72.
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ABSTRACT: Autologous and allogeneic transplantations of haematopoietic cells form an important part of treatment of, particularly haematological, malignancies but have their place in the treatment of other diseases as well. Transplantation brings permanent remission in a number of patients. However, transplantation, and the allogeneic one in particular, is associated with a range of complications. The following review paper provides information on the types of transplants, their collection and processing, on the options for and ways to seek suitable donors of haematopoietic cells. Other sections of the paper focus on preparatory pre-transplantation regimens and complications that might occur after the transplantation. Finally, the paper reviews clinical uses of haematopoietic cell transplantations and provides a summary of diagnoses in which this treatment method can be applied.
Vnitr̆ní lékar̆ství 09/2009; 55(9):738-45.
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Z Adam,
L Krikavová,
M Krejcí,
M Mechl,
L Pour,
M Moulis,
J Vanícek,
C Neumann,
M Navrátil,
K Veselý, J Vorlícek
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ABSTRACT: Multiple angiomatosis is a very rare disease formed by histologically benign angiomas spreading beyond single organ or tissue. In the case reported herein, hemangiomas affected several vertebrae of a young man and spread through his peritoneal cavity projecting to his stomach and causing recurrent hematemesis. Also affected was the mediastinum. The patient suffered from bone pain and digestive problems. Initial treatment involved 2 drugs with antiangiogenic effect: interferon alpha (initial dose of6 million units 3 times a week, later reduced to 3 million units 3 times a week due to adverse effects) and zoledronate (4 mg i.v. every 28 days). Even though the therapy eliminated bone pain after 2 months, CT check at a later stage showed but little regression of the mass of the angiomas in the abdominal cavity and the mediastinum. Substantial reduction in the mass of the angiomas to merely residual quantity, i.e. partial remission of the disease, was achieved only after the addition of 100 mg/day thalidomide (Myrin) to the above mentioned doses of interferon and zoledronate administered on a regular basis. However, the disease recurred after the therapy was interrupted, and the above triple combination therapy has had to be restored. Maintenance therapy will succeed to repeated achievement of remission of angiomas. A very good therapeutic effect was recorded for combined interferon alpha, thalidomide and zoledronate in this specific case of multiple angiomatosis.
Vnitr̆ní lékar̆ství 07/2008; 54(6):653-64.
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ABSTRACT: CD4+56+ hematodermic neoplasm or leukemia from early plasmocytoid dendritic cells type DC2 was recognized by WHO-EORTC classification of cutaneous lymphomas as a separate entity related to the plasmacytoid precursor dendritic cell (pDC). This diagnosis is based on expression of CD4 and CD56 antigens and absence of B, T or myeloid lineage markers. Immunohistochemistry and flow cytometry are the only methods, which allow identification of this disease, either in isolated skin lesions or in a leukemic form. Although the co-expression of CD4 and CD56 is rare and the number of described cases is low, this group bears similar characteristics in a clinical course of disease. It is a very aggressive leukemia/lymphoma, usually with primary skin involvement, in half of the cases infiltrating bone marrow or lymph nodes. Despite high rate of initial response to treatment, early and widespread relapses occur and patients die of disease progression. Although the physiological counterpart of tumour cells was identified, the origin of the disease is still discussed because of aberrant expression of cell markers. Optimal treatment is not known. However, this aggressive disease requires radical approach with intensive chemotherapy regimens, prophylaxis of CNS involvement and early indication of allogeneic bone marrow transplantation. Two case reports are described.
Casopís lékar̆ů c̆eských 02/2008; 147(10):511-5.
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ABSTRACT: Fatigue is the most frequent symptom accompanying a cancer disease and its treatment according to the visual analogue scale. Fatigue is reported by as many as 100% of patients in the course of cancer treatment and still by 40 to 70% of patients one year after the treatment has finished. This symptom has become known under the designation of "cancer-related fatigue" in the English language literature on the subject. The knowledge of the causes and mechanisms of fatigue is relatively limited. Based on practical guidelines, an algorithm has been used to detect, evaluate and influence by treatment the syndrome of fatigue caused by a cancer disease. Research in the field has been focused on both pharmacological and non-pharmacological approach. The highest efficiency in the treatment of fatigue syndrome has been recorded for the treatment of anaemia with erythropoietin, while aerobic exercise programmes have proven to be most efficient among the behavioural measures. In spite of a dramatically growing interest in the above problem in the past decade, a number of issues continue unresolved with respect to chronic fatigue syndrome related to a cancer disease or to its treatment. Based on their own experience and on the relevant literature, the authors deal with issues of chronic fatigue syndrome and the options for its diagnosing and treatment in patients undergoing cancer treatment.
Vnitr̆ní lékar̆ství 10/2007; 53(9):979-85.
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ABSTRACT: The text maps the changes in treatment results and costs for three haematological diseases; multiple myeloma; diffuse large B-cell lymphoma and chronic myeloid leukaemia. At the beginning of the 1990's, the alkeran-prednisone combination was the golden standard in the treatment of myeloma. In the mid 1990's, the treatment results in younger patients were dramatically improved by high-dose chemotherapy with autologous transplantation. The first decade of the new millennium has brought about even better results after the introduction of thalidomide in the initial treatment in patients not indicated for transplantation. Improvement is also expected in patients of a younger age group thanks to the combination of new drugs with autologous transplantation. A breakthrough in the treatment of patients with diffuse large cell lymphoma was the introduction in the treatment regimen of high-dose chemotherapy with autologous transplantation, and primarily the introduction of a new drug--a monoclonal antibody antiCD20, rituximab, in initial treatment. The golden standard for patients with chronic leukaemia in the early 1990's was hydroxyurea treatment. This was replaced by a new golden standard--interferon alpha, which was, in turn, replaced by the specific blocker of bcr-abl thyrosine kinase-imatinib. The text contains tables and charts showing the therapeutic benefit of the options mentioned above and the related costs.
Vnitr̆ní lékar̆ství 07/2007; 53(6):735-49.
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ABSTRACT: The determination of concentration of CD34+ cells is the standard method for evaluation of the quality of a bone marrow graft and of peripheral stem cells. Although the relationship between the dose of CD34+ cells and the speed of graft healing in autologous transplants is a proven fact, it may not always be the case in allogenic transplants.
The correlation between the dose of CD34+ cell subpopulations and the speed of healing was monitored in patients indicated for allogenic transplantation of haematopoietic stem cells. The patients were divided according to the type of preparatory regimen they underwent for the purpose of analysis; one group contained those under a myeloablative regimen; a second group contained those under a non-myeloablative regimen. The data was subject to analysis of variance in regression models and non-parametric tests.
From among the monitored subpopulations, CD34+36+ cells had the greatest effect on the healing process and were the most significant predictor of the speed of healing in patients under a myeloablative regimen. Nevertheless, a dose ofCD34+ cells continued to be the best healing predictor in patients under a non-myeloablative regimen. Also subpopulations of CD34+38+ and CD34+61+ cells had a significant effect on the speed of healing in both groups.
Haematopoietic stem cells and progenitor cells defined by co-expression of specific antigens are likely to play a role, through different mechanisms of action, in the process of healing in patients in different pre-transplant regimens. While the dose of CD34+ cells is still the one which correlates best with the speed of healing in patients who underwent transplantation after non-myeloablative regimen, the dose of CD34+36+ cells appears to be a better predictor for the speed of healing after myeloablative regimens.
Vnitr̆ní lékar̆ství 07/2007; 53(6):646-51.
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Z Adam,
G Chlupová,
J Tomásek,
Z Fojtík,
M Navrátil,
P Stourac,
V Vasků,
S Skorskovská,
J Halámková,
J Stanícek,
K Bolcák,
T Nebeský,
B Prokes,
J Neubauer,
J Simonides,
Z Rehák,
J Vanícek,
Z Adamová, J Vorlícek
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ABSTRACT: Timely diagnosis of malignant diseases largely depends on attention being given to early symptoms and on timely start of an extensive diagnostic process. Only this way can a tumour be diagnosed in its initial stage, and better effect of therapy can be achieved. The following overview provides a list of systemic (paraneoplastic - distant) manifestations of a tumour, and of symptoms related to local tumour expansion. The objective of the overview is to draw attention to all early symptoms of malignant diseases in patients, and to contribute to timely diagnosis and treatment.
Vnitr̆ní lékar̆ství 04/2007; 53(3):253-85.
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ABSTRACT: Fever of unknown origin is a frequent and significant diagnostic problem often faced by physicians. The first part of the text is dedicated to its definition and wide-ranging aetiology. On the one hand, fever may be a banal and benign condition, on the other, it can be the symptom of a life threatening disease. The second part presents our suggestions for diagnostic approach to fever of unknown origin. We believe this text may become a useful tool for this extremely complex and interesting differential diagnostic. In view of extension and complexity of the topic, the text of this part is presented in full.
Vnitr̆ní lékar̆ství 03/2007; 53(2):169-78.
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Vnitr̆ní lékar̆ství 02/2007; 53(1):79-90.
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Vnitr̆ní lékar̆ství 02/2007; 53(1):91-6.
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Z Adam,
J Bednarík,
J Neubauer,
R Chaloupka,
Z Fojtík,
J Vanícek,
L Pour,
Z Cermákova,
V Scudla,
V Maisnar,
J Straub,
M Schützová,
E Gregora,
M Weinreb,
K Stuchlíková,
J Stanícek,
R Hájek,
M Krejcí, J Vorlícek
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ABSTRACT: The number of newly diagnosed cases of multiple myeloma in the Czech Republic is about 3-4 per 100 000 persons per year. In the higher age groups, the incidence increases. Multiple myeloma is an illness that reacts well to treatment which can result in periods of remission lasting for years. Some of the patients are even able to return to work. A pre-requisite for successful treatment is early diagnosis and this is usually in the hands of first line physicians. This is the reason why the Czech Myeloma Group, in conjunction with neurologists, orthopedicians and radio diagnosticians has issued the following recommendations for first line physicians containing a more detailed description of the symptoms and the diagnostic pitfalls of the disease. This disease reminds a chameleon for the variety of its symptoms. For the sake of clarification, we shall divide multiple myeloma symptoms into five points, each of which is reason enough to warrant an examination to confirm or rule out a malignant cause of health problems (a negative result does not automatically mean exclusion). If any of the recommended examinations results positive, the diagnostic process must be continued, in which case a general practitioner refers the patient to a specialist health centre. Observing these recommendations should minimize the number of cases of late diagnosis. 1. Bone destruction symptoms. - Unexplained backache for more than one month in any part of spine even without nerve root irritability or without pain in other part of skeleton (ribs, hips, or long bones). - Pain at the beginning of myeloma disease is very similar to benigne common discopathy, however the intensity of backache is decreasing within one months in benigne disease. In the case of malignant process the intensity of bone pain is steadily increasing. - Immediate imaging and laboratory investigation are indicated by resting and night pain in spinal column or in any part of skeleton. - Backache with the sign of spinal cord or nerve compression should be sent for immediate X Ray, and focussed CT/MRI followed by acute surgery if needed. - Osteoporosis especially in men and premenopausal women. 2. Features of changed immunity or bone marrow function. Persistent and recurrent infection, typical is normochromic anaemia, with leucopenia and trombocytopenia. 3. Raised erythrocyte sedimentation rate even increase concentration of total plasma protein. 4. Impaired renal function. Increased level of creatinin or proteinuria, nephrotic syndrome with bilateral legs oedema. 5. Hypercalcemia with typical clinical symptoms (polyuria with dehydratation, constipation, nausea, low level conscience, coma). Every one from these points has to be reason for general medical doctor to start battery of tests: -X-ray of bones focused to painful area (mandatory before physiotherapy, local anaesthesia or other empiric therapy). If plain X-ray does not elucidate pain and symptoms are lasting more than one month, please consider all circumstances and results from laboratory investigation. This patient needs referral to the centre with MRI/CT facilities (CT or MRI is necessary investigation in case of nerve root or spine compression). -Investigation of erythrocyte sedimantion rate (high level of sedimentation of erythrocyte can indicate multiple myeloma). -Full blood count. -Basic biochemical investigation serum and urine: serum urea, creatinin, ionts including calcium, total protein, and albumin CRP (high concentration of total protein indicates myeloma, low level of albumin indicates general pathological process, similary increased concentration of fibrinogen, impaired renal function indicates myeloma kidney, however hypercalcemia is typical for highly aggressive myeloma). -Quantitative screening for IgG, IgM and IgA in serum (isolated raised level one of immunoglobulin with decreased level of the others indicates myeloma). -Common electrophoresis of serum is able to detect monoclonal immunoglobulin level at few gramm concentration. If all the laboratory investigation are in normal level the possibility that the current problems are multiple myeloma origine is smaller, but it does not exclude one of rare variant--non secretory myeloma (undifferentiated plasmocyt lost characteristic feature to produce monoclonal immunoglobulin). If any of tests indicate the possibility of myeloma, patient require urgent specialist referral to department with possibility to make diagnosis of malignant myeloma.
Vnitr̆ní lékar̆ství 12/2006; 52 Suppl 2:9, 11-31.
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ABSTRACT: The aim of the study was to find out the relationship between plasmatic levels of brain natriuretic peptide (BNP) and echocardiographic indicators of left ventricle (LV) function in patients who were in a long-term remission after the therapy of hematological malignity and examined in order to diagnose the late cardiotoxicity of doxorubicin. METHODS AND PATIENT SAMPLE: We enrolled 55 patients (31 men/24 women) aged 43 +/- 16 (median 41; 21-79) who were treated for historically diagnosed malignant lymphoma. At the time of examination, all patients were in a long-term remission and, at the same time, they completed their initial therapy 6.2 +/- 1.5 (median 5; 5-10) years ago. Patients were examined via resting echocardiography before and after the therapy and during the follow-up examination. We determined the left ventricle ejection fraction (LV EF), parameters of diastolic function and the Doppler parameters of systolic and diastolic function (MPI-Tei index). During the follow-up examination, we measured plasmatic levels of BNP (standard levels were between 0 and 29 pmol/1).
Follow-up examination showed that EF of five patients (9 %) decreased below 50% and three patients had symptoms of heart failure. Although EF of another eleven patients (20%) was in the physiological range, it decreased by more than 10% as compared with their pre-treatment EF values. Seventeen patients (30 %) showed higher MPI > 0.55 and twenty patients (36%) demonstrated diastolic dysfunction (impaired relaxation). BNP > 29 pmol/l was observed only in patients with EF < 50% and heart failure symptoms. BNP values significantly correlated only with endsystolic (r = 0.82; p < 0.0001) and enddiastolic (r = 0.72; p < 0.0001) volume of LV. On the other hand, BNP of 11.4 pmol/l showed negative predictive value for the following parameters: 80% for decrease of EF by more than 10%; 72% for detection of MPI > 0.55; and 70% for detection of relaxation disorder, i.e. the diagnostics of subclinical cardiotoxicity.
The present study highlights the practical importance of measuring BNP levels when diagnosing the late changes of LV functions after doxorubicin chemotherapy. Standard cut-off BNP (29 pmol/1) used in diagnostics of heart failures identifies patients with pathological EF and heart failure symptoms. Cut-off BNP of 11.4 pmol/l has sufficient negative predictive value to exclude subclinical damage to the myocardium.
Vnitr̆ní lékar̆ství 06/2006; 52(6):563-70.
