#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Syndrom polycystických ovarií a metabolický syndrom


Syndrom polycystických ovarií a metabolický syndrom

Syndrom polycystických ovarií (PCOS) tvoří heterogenní skupinu onemocnění, jejímiž hlavními klinickými znaky jsou nepravidelnost menstruačního cyklu, snížená fertilita a hyperandrogenismus. Prevalence PCOS je závislá na etnické příslušnosti pacientky, na environmentálních a genetických faktorech a také na kritériích, která tento syndrom definují. Na druhé straně představuje metabolický syndrom soubor metabolických poruch zahrnujících hlavně abdominální obezitu, inzulinovou rezistenci, narušený metabolismus glukózy, hypertenzi a dyslipidémii. Tyto přidružené poruchy přímo úměrně zvyšují riziko vzniku diabetes mellitus typu 2 (DMT2), onemocnění koronárních tepen (CHD), onemocnění kardiovaskulárního aparátu (CVD) a karcinomu endometria. Mnoho pacientek s PCOS má znaky metabolického syndromu, jako je viscerální obezita, hyperinzulinémie a inzulinová rezistence. Pacientky s PCOS jsou ve vysokém riziku rozvoje kardiovaskulárních chorob (CVD), cukrovky typu 2 (DMT2) a gynekologických nádorů, hlavně karcinomu endometria. Výskyt metabolického syndromu je taktéž častější u neplodných žen s PCOS. Cílem tohoto přehledového článku je poskytnout jasné a nejnovější informace o PCOS a o jeho souvislostech s metabolickým syndromem a o možných interakcích mezi různými metabolickými poruchami.

klíčová slova:
syndrom polycystických ovarií, metabolický syndrom, inzulinová rezistence, hypertenze


Autoři: Aus Tariq Ali
Působiště autorů: Department of Chemical Pathology, Tygerberg Hospital and Stellenbosch Medical School, Cape Town, South Africa
Vyšlo v časopise: Ceska Gynekol 2015; 80(4): 279-289

Souhrn

Syndrom polycystických ovarií (PCOS) tvoří heterogenní skupinu onemocnění, jejímiž hlavními klinickými znaky jsou nepravidelnost menstruačního cyklu, snížená fertilita a hyperandrogenismus. Prevalence PCOS je závislá na etnické příslušnosti pacientky, na environmentálních a genetických faktorech a také na kritériích, která tento syndrom definují. Na druhé straně představuje metabolický syndrom soubor metabolických poruch zahrnujících hlavně abdominální obezitu, inzulinovou rezistenci, narušený metabolismus glukózy, hypertenzi a dyslipidémii. Tyto přidružené poruchy přímo úměrně zvyšují riziko vzniku diabetes mellitus typu 2 (DMT2), onemocnění koronárních tepen (CHD), onemocnění kardiovaskulárního aparátu (CVD) a karcinomu endometria. Mnoho pacientek s PCOS má znaky metabolického syndromu, jako je viscerální obezita, hyperinzulinémie a inzulinová rezistence. Pacientky s PCOS jsou ve vysokém riziku rozvoje kardiovaskulárních chorob (CVD), cukrovky typu 2 (DMT2) a gynekologických nádorů, hlavně karcinomu endometria. Výskyt metabolického syndromu je taktéž častější u neplodných žen s PCOS. Cílem tohoto přehledového článku je poskytnout jasné a nejnovější informace o PCOS a o jeho souvislostech s metabolickým syndromem a o možných interakcích mezi různými metabolickými poruchami.

klíčová slova:
syndrom polycystických ovarií, metabolický syndrom, inzulinová rezistence, hypertenze


Zdroje

1. Agnoli, C., Berrino, F., Abagnato, CA., et al. Metabolic syndrome and postmenopausal breast cancer in the ORDET cohort: a nested case-control study. Nutr Metab Cardiovasc Dis, 2010, 20, p. 41–48.

2. Aleman, BM., van den Belt-Dusebout, AW., Klokman, WJ., et al. Long-term causes pecific mortality of patients treated for Hodgkin’s disease. J Clin Oncol, 2003, 21, p. 3431–3439.

3. Ali, AT., Ferris, WF., Naran, NH., Crowther, NJ. Insulin resistance in the control of body fat distribution: a new hypothesis. Horm Metab Res, 2011, 43(2), p. 77–80.

4. Alvarez Cosmea, A., Lopez Hernandez, V., Suarez Garcia, S., et al. Differences in the prevalence of metabolic syndrome according to the ATP-III and WHO definitions. Medical Clinics, 2005, 124, p. 368–370.

5. Asuncion, M., Calvo, RM., San Millan, JL., et al. A prospective study of the prevalence of the polycystic ovary syndrome in unselected Caucasian women from Spain. J Clin Endocrinol Metab, 2000, 85, p. 2434–2438.

6. Azevedo, MF., Costa, EC., Oliveira, AI., et al. Elevated blood pressure in women with polycystic ovary syndrome: prevalence and associated risk factors. Rev Bras Ginecol Obstet, 2011, 33(1), p. 31–36.

7. Azziz, R., Carmina, E., Dewailly, D., et al. Positions statement; criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metabol, 2006, 91(11), p. 4237–4245.

8. Azziz, R., Woods, KS., Reyna, R., et al. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab, 2004, 89, p. 2745–2749.

9. Barber, TM., McCarthy, MI., Wass, JA., Franks, S. Obesity and polycystic ovary syndrome. Clin Endocrinol (Oxf), 2006, 65, p. 137–145.

10. Bjørge, T., Lukanova, A., Jonsson, H., et al. Metabolic syndrome and breast cancer in the Me-Can (Metabolic Syndrome and Cancer) project. Cancer Epidemiol Biomarkers Prev 2010, 19, p. 1737–1745.

11. Bjørge, T., Lukanova, A., Tretli, S., et al. Metabolic risk factors and ovarian cancer in the Metabolic Syndrome and Cancer project. Int J Epidemiol, 2011, 40(6), p. 1667–1677.

12. Bjørge, T., Stocks, T., Lukanova, A., et al. Metabolic syndrome and endometrial carcinoma. Am J Epidemiol, 2010, 171, p. 892–902.

13. Boyle, P., Boniol, M., Koechlin, A., et al. Diabetes and breast cancer risk: a meta-analysis Brit J Cancer, 2012, 107, p. 1608–1617.

14. Calle, EE., Kaaks, R. Overweight, obesity and cancer: epidemiological evidence and proposed mechanisms. Nat Rev Cancer, 2004, 4(8), p. 579–591.

15. Carmina, E., Napoli, N., Longo, RA., et al. Metabolic syndrome in polycystic ovary syndrome (PCOS): lower prevalence in southern Italy than in the USA and the influence of criteria for the diagnosis of PCOS. Eur J of Endocrinol, 2006, 154, p. 141–145.

16. Chen, HF., Chang, YH., Ko, MC., Li, CY. A large scale population-based cohort study on the risk of ovarian neoplasm in patients with type 2 diabetes mellitus. Gynecol Oncol, 2014, 134(3), p. 576–580.

17. Chen, HF., Liu, MD., Chen, P., et al. Risks of Breast and Endometrial Cancer in Women with Diabetes: A Population-Based Cohort Study. PLoS One, 2013, 8(6), e67420.

18. Chen, X., Yang, D., Li, L., et al. Abnormal glucose tolerance in Chinese women with polycystic ovary syndrome. Hum Reprod, 2006, 21, p. 2027–2032.

19. Chen, X., Yang, D., Mo, Y., et al. Prevalence of polycystic ovary syndrome in unselected women from southern China. Eur J Obstet Gynecol Reprod Biol, 2008, 139(1), p. 59–64.

20. Clayton, RN., Ogden, V., Hodgkinson, J., et al. How common are polycystic ovaries in normal women and what is their significance for the fertility of the population. Clin Endocrinol (Oxf), 1992, 37, p. 127–134.

21. Clayton, RN., Ogden, V., Hodgkinsonc, J. How common are polycystic ovaries in normal women and what is their significance for the fertility of populations. Clin Endocrinol, 1992, 39, p. 623–632.

22. Cussons, AJ., Watts, GF., Burke, V., et al. Cardiometabolic risk in polycystic ovary syndrome: a comparison of different approaches to defining the metabolic syndrome. Human Reprod, 2008, 23, p. 2352–2358.

23. Darby, SC., Ewertz, M., Hall, P. Ischemic heart disease after breast cancer radiotherapy. N Engl J Med, 2013, 368(26), p. 2527.

24. Darby, SC., Ewertz, M., McGale, P., et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med, 2013, 368(11), p. 987–998.

25. DeFronzo, RA. Pathogenesis of type 2 diabetes mellitus. Med Clin North Am, 2004, 88(4), p. 787–835.

26. DeFronzo, RA., Tripathy, D. Skeletal muscle insulin resistance is the primary defect in type 2 diabetes. Diabetes Care, 2009, 32, Suppl. 2, p. S157–163.

27. Diamanti-Kandarakis, E., Kouli, CR., Bergiele, AT., et al. A survey of the polycystic ovary syndrome in the Greek island of Lesbos: hormonal and metabolic profile. J Clin Endocrinol Metab, 1999, 84(11), p. 4006–4011.

28. Dokras, A., Bochner, M., Hollinrake, E., et al. Screening women with polycystic ovary syndrome for metabolic syndrome. Obstet Gynecol, 2005, 106, p. 131–137.

29. Dunaif, A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev, 1997, 18(6), p. 774–800.

30. Ehrmann, DA., Barnes, RB., Rosenfield, RL., et al. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care, 1999, 22, p. 141–146.

31. Eeg-Olofsson, K., Gudbjörnsdottir, S., Eliasson, B., et al., on behalf of the NDR. The triglycerides-to-HDL-cholesterol ratio and cardiovascular disease risk in obese patients with type 2 diabetes: An observational study from the Swedish National Diabetes Register (NDR). Diabetes Res Clin Pract, 2014.

32. elTabbakh, GH., Lotfy, I., Azab, I., et al. Correlation of the ultrasonic appearance of the ovaries in polycystic ovarian disease and the clinical, hormonal, and laparoscopic findings. Am J Obstet Gynecol, 1986 ,154, p. 892–895.

33. Escobar-Morreale, HF., San Millan, JL. Abdominal adiposity and the polycystic ovary syndrome. Trends Endocrinol Metab, 2007, 18(7), p. 266–272.

34. Esposito, K., Chiodini, P., Colao, A., et al. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care, 2012, 35(11), p. 2402–2411.

35. Farquhar, C. Introduction and history of polycystic ovary syndrome. In: Kovacs. G., Norman. R., editors. Polycystic Ovary Syndrome. 2nd ed. Cambridge, UK: Cambridge University Press, 2007, p. 4–24.

36. Farquhar, CM., Birdsall, M., Manning, P., et al. The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women. Aust NZ Obstet Gynaecol, 1994, 34, p. 67–72.

37. Ford, ES., Giles, WH., Dietz, WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. J Amer Med Assoc, 2002, 287, p. 356–359.

38. Friberg, E., Mantzoros, CS., Wolk, A. Diabetes and risk of endometrial cancer: a population-based prospective cohort study. Cancer Epidemiol Biomarkers Prev, 2007, 16, p. 276–280.

39. Giovannucci, E., Harlan, DM., Archer, MC., et al. Diabetes and cancer: a consensus report. Diabetes Care, 2010, 33(7), p. 1674–1685.

40. Goodarzi, MO., Quinones, MJ., Azziz, R.,et al. Polycystic ovary syndrome in Mexican-Americans: prevalence and association with the severity of insulin resistance. Fertil Steril, 2005, 84(3), p. 766–769.

41. Group PCW: Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril, 2004, 81(1), p. 19–25.

42. Haffner, SM., Stern, MP., Hazuda, HP., et al. Cardiovascular risk factors in confirmed prediabetic individuals. JAMA, 1990, 263, p. 2893–2898.

43. Hahn, S., Tan, S., Sack, S., et al. Prevalence of the metabolic syndrome in German women with polycystic ovary syndrome. Exp Clin Endocrinol Diabetes, 2007, 115, p. 130–135.

44. Hardefeldt, PJ., Edirimanne, S., Eslick, GD. Diabetes increases the risk of breast cancer: a meta-analysis. Endocr Relat Cancer, 2012, 19, 19(6), p. 793–803.

45. Holte, J., Bergh, T., Berne, C., et al. Restored insulin sensitivity but persistently increased early insulin secretion after weight loss in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab, 1995, 80, p. 2586–2593.

46. Hopkinson, ZE., Sattar, N., Fleming, R., Greer, IA. Polycystic ovarian syndrome: the metabolic syndrome comes to gynaecology. BMJ, 1998, 317(7154), p. 329–332.

47. Ibanez, L., Dimartino-Nardi, J., Potau, N. Premature adrenarche – normal variant or forerunner of adult disease? Endocr Rev, 2000, 21, p. 671–696.

48. Indhavivadhana, S., Wongwananuruk, T., Rattana-chaiyanont, M., et al. Prevalence of metabolic syndrome in reproductive-aged polycystic ovary syndrome Thai women. J Med Assoc Thai, 2010, 93(6), p. 653–660.

49. Joham, AE., Teede, HJ., Ranasinha, S., et al. Prevalence of infertility and use of fertility treatment in women with polycystic ovary syndrome: data from a large community-based cohort study. J Womens Health (Larchmt), 2015, 24(4), p. 299–307.

50. Kabat, GC., Kim, M., Chlebowski, RT., et al. A longitudinal study of the metabolic syndrome and risk of postmenopausal breast cancer. Cancer Epidemiol Biomarkers Prev, 2009, 18, p. 2046–2053.

51. Kahsar-Miller, M., Nixon, C., Boots, LR., et al. Prevalence of the polycystic ovary syndrome (PCOS) among first degree relatives of patients with PCOS. Fertil Steril, 2001, 75, p. 53–58.

52. Katsoulis, M., Dimakopoulou, K., Pedeli, X., et al. Long-term exposure to traffic-related air pollution and cardiovascular health in a Greek cohort study. Sci Total Environ, 2014, 490, p. 934–940.

53. Kauffman, RP., Baker, VM., Dimarino, P., et al. Polycystic ovarian syndrome and insulin resistance in white and Mexican American women: a comparison of two distinct populations. Am J ObstetGynecol, 2002, 187(5), p. 1362–1369.

54. Kaur, JA. Comprehensive review on metabolic syndrome. Cardiol Res Pract, 2014, 2014, p. 943162.

55. Kirpichnikov, D., Sowers, J. Diabetes mellitus and diabetes-associated vascular disease. Trends Endocrinol Metab, 2001, 12, p. 225–229.

56. Knochenhauer, ES., Key, TJ., Kahsar-Miller, M., et al. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. J Clin Endocrinol Metab, 1998, 83(9), p. 3078–3082.

57. Kumarapeli, V., Seneviratne, de A., Wijeyaratne, CN., et al. A simple screening approach for assessing community prevalence and phenotype of polycystic ovary syndrome in a semi-urban population in Sri Lanka. Am J Epidemiol, 2008, 168(3), p. 321–328.

58. La Vecchia, C., Negri, E., Franceschi, S., et al. A case-control study of diabetes mellitus and cancer risk. Br J Cancer, 1994, 70, p. 950–953.

59. Liao, S., Li, J., Wei, W., et al. Association between diabetes mellitus and breast cancer risk: a meta-analysis of the literature. Asian Pac J Cancer Prev, 2011, 12, p. 1061–1065.

60. Lindholm, A., Andersson, L., Eliasson, M., et al. Prevalence of symptoms associated with polycystic ovary syndrome. Int J Gynaecol Obstet, 2008, 102(1), p. 39–43.

61. Mandrelle, K., Kamath, MS., Bondu, DJ., et al. Prevalence of metabolic syndrome in women with polycystic ovary syndrome attending an infertility clinic in a tertiary care hospital in south India. J Hum Reprod Sci, 2012, 5(1), p. 26–31.

62. March, WA., Moore, VM., Willson, KJ., et al. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod, 2010, 25(2), p. 544–551.

63. Marsh, KA., Steinbeck, KS., Atkinson, FS., et al. Effect of a low glycemic index compared with a conventional healthy diet on polycystic ovary syndrome. Am J Clin Nutr, 2010, 92, p. 83–92.

64. Mehrabian, F., Khani, B., Kelishadi, R., Ghanbari, E. The prevalence of polycystic ovary syndrome in Iranian women based on different diagnostic criteria. Endokrynol Pol, 2011, 62(3), p. 238–242.

65. Michelmore, KF., Balen, AH., Dunger, DB., Vessey, MP. Polycystic ovaries and associated clinical and biochemical features in young women. Clin Endocrinol (Oxf), 1999, 51, p. 779–786.

66. Mitchell, BD., Almasy, LA., Rainwater, DL.,et al. Diabetes and hypertension in Mexican American families: relation to cardiovascular risk. Am J Epidemiol, 1999, 149(11), p. 1047–1056.

67. Moran, LJ., Misso, ML., Wild, RA., Norman, RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome: a systematic review and meta-analysis. Hum Reprod Update, 2010, 16(4), p. 347–363.

68. Morrish, NJ., Wang, SL., Stevens, LK., et al. Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia, 2001, 44, Suppl 2, p. S14–21.

69. Nagel, G., Concin, H., Bjorge, T., et al. Metabolic syndrome and rare gynecological cancers in the metabolic syndrome and cancer project (Me-Can). Ann Oncol, 2011, 22(6), p. 1339–1345.

70. Orsini, LF., Venturoli, S., Lorusso, R., et al. Ultrasonic findings in polycystic ovarian disease. Fertil Steril, 1985, 43, p. 709–714.

71. Panidis, D., Macut, D., Tziomalos, K., et al. Prevalence of metabolic syndrome in women with polycystic ovary syndrome. Clin Endocrinol (Oxf), 2013, 78(4), p. 586–592.

72. Park, YW., Zhu, S., Palaniappan, L., et al. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the third National Health and Nutrition Examination Survey, 1988–1994. Arch Internal Med, 2003, 163, p. 427–436.

73. Patnaik, JL., Byers, T., DiGuiseppi, C., et al. Cardiovascular disease competes with breast cancer as the leading cause ofdeath for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res, 2011, 13(3), p. R64.

74. Pischon, T., Boeing, H., Hoffmann, K., et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med, 2008, 359(20), p. 2105–2120.

75. Polson, DW., Wadsworth, J., Adams, J., Franks, S. Polycystic ovaries – a common finding in normal women. Lancet, 1988, 1, p. 870–872.

76. Prasad, H., Ryan, DA., Celzo, MF., Stapleton, D. Metabolic syndrome: definition and therapeutic implications. Postgrad Med, 2012, 124(1), p. 21–30.

77. Rainwater, DL., Mitchell, BD., Comuzzie, AG., et al. Association among 5-year changes in weight, physical activity, and cardiovascular disease risk factors in Mexican Americans. Am J Epidemiol, 2000, 152, p. 974–982.

78. Rosato, V., Zucchetto, A., Bosetti, C., et al. Metabolic syndrome and endometrial cancer risk. Ann Oncol, 2011, 22 (4), p. 884–889.

79. Ross, R., Janssen, I., Dawson, J., et al. Exercise-induced reduction in obesity and insulin resistance in women: a randomized controlled trial. Obes Res, 2004, 12(5), p. 789–798.

80. Ruderman, N., Chisholm, D., Pi-Sunyer, X., Schneider, S. The metabolically obese, normal-weight individual revisited. Diabetes, 1998, 47(5), p. 699–713.

81. Russo, A., Autelitano, M., Bisanti, L. Metabolic syndrome and cancer risk. Eur J Cancer, 2008, 44, p. 293–297.

82. Santos, AC., Lopes, C., Barros, H. Prevalence of metabolic syndrome in the city of Porto. Revista Portuguesa de Cardiologia (Lisboa), 2004, 23, p. 45–52.

83. Sartor, BM., Dickey, RP. Polycystic ovarian syndrome and the metabolic syndrome. Am J Med Sci, 2005, 330, p. 336–342.

84. Sjöström, LV. Morbidity of severely obese subjects. Am J Clin Nutr, 1992, 55 (Suppl. 2), p. 508S–515S.

85. Sjöström, LV. Mortality of severely obese subjects. Am J Clin Nutr, 1992, 55 (Suppl. 2), p. 516S–523S.

86. Swanson, M., Sauerbrei, EE., Cooperberg, PL. Medical implications of ultrasonically detected polycystic ovaries. J Clin Ultrasound, 1981, 9, p. 219.

87. Swerdlow, AJ., Higgins, CD., Smith, P., et al. Myocardial infarction mortality risk after treatment for Hodgkin disease: a collaborative British cohort study. J Natl Cancer Inst, 2007, 99, p. 206–214.

88. The IDF consensus worldwide definition of the metabolic syndrome. Available at: http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf. (Last accessed on 2014 4thDec).

89. Turner, RC., Mann, J., Oakes, S., et al. United Kingdom Prospective Diabetes Study, a multicenter study. Hypertension, 1985, 7 (Suppl II), p. 8–13.

90. Vause, TD., Cheung, AP., Sierra, S., et al. Ovulation induction in polycystic ovary syndrome. J Obstet Gynaecol Can, 2010, 32(5), p. 495–502.

91. Vos, T., Flaxman, AD., Naghavi, M., et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012, 380 (9859), p. 2163–2196.

92. Weaver, KE., Foraker, RE., Alfano, CM., et al. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care?J Cancer Surviv, 2013, 7(2), p. 253–261.

93. Welt, CK., Adams, JM., Sluss, PM., Hall, JE. Inhibin A and inhibin B responses to gonadotropin withdrawal depends on stage of follicle development. J Clin Endocrinol Metab, 1999, 84, p. 2163–2169.

94. Yildiz, BO., Bozdag, G., Yapici, Z., et al. Prevalence, phenotype and cardiometabolic risk of polycystic ovary syndrome under different diagnostic criteria. Hum Reprod, 2012, 27(10), p. 3067–3073.

95. Zawadzki, JK., Dunaif, A. Diagnostic criteria for polycystic ovary syndrome: Towards a rational approach 1992. In Dunaif, A., Givens, JR., Haseltine, F., Merriam, GR., eds. Polycystic ovary syndrome. Boston: Blackwell, p. 377–384.

96. Zhang, PY. Cardiovascular disease in diabetes. Eur Rev Med Pharmacol Sci, 2014, 18(15), p. 2205–2214.

97. Zimmet, P., Alberti, KGMM., Shaw, J. Global and societal implications of the diabetes epidemic. Nature, 2001, 414, p. 782–787.

98. Zuliani, G., Morieri, ML., Volpato, S., et al. Insulin resistance and systemic inflammation, but not metabolic syndrome phenotype, predicts 9 years mortality in older adults. Atherosclerosis, 2014, 235(2), p. 538–545.

Štítky
Detská gynekológia Gynekológia a pôrodníctvo Reprodukčná medicína

Článok vyšiel v časopise

Česká gynekologie

Číslo 4

2015 Číslo 4
Najčítanejšie tento týždeň
Najčítanejšie v tomto čísle
Kurzy

Zvýšte si kvalifikáciu online z pohodlia domova

Aktuální možnosti diagnostiky a léčby litiáz
nový kurz
Autori: MUDr. Tomáš Ürge, PhD.

Všetky kurzy
Prihlásenie
Zabudnuté heslo

Zadajte e-mailovú adresu, s ktorou ste vytvárali účet. Budú Vám na ňu zasielané informácie k nastaveniu nového hesla.

Prihlásenie

Nemáte účet?  Registrujte sa

#ADS_BOTTOM_SCRIPTS#