[Keto acidosis and coma in 44-years old man with diabetes t1 in Internal Diseases Department in Dabrowa Tarnowska]. / Kwasica i spiaczka ketonowa u 44-letniego mezczyzny z cukrzyca t1 na Oddziale Wewnetrznym w Dabrowie Tarnowskiej.

Diabetic ketoacidosis (DKA) is an acute complication metabolic occur- ring in patients with diabetes type-1 and much less likely to type 2 diabetes. This article shows clinical manifesta- tion, biochemical criteria and algorithm for the immediate assessment and management of diabetic acidosis in a 44 years old men. This specification describes a rare case of keto acidosis and coma therapy and the challenges that these disorders carry.

Triple immunofluorescence labeling of atherosclerotic plaque components in apoE/LDLR -/- mice.

This paper presents a simple and reliable method of triple immunofluorescence staining that allows simultaneous detection of various cell types present in atherosclerotic plaque of apolipoprotein E and LDL receptor-double knockout (apoE/LDLR -/-) mice. We used combined direct and indirect procedures applying commercially available primary antibodies raised in different species to detect smooth muscle cells (Cy3-conjugated mouse anti-smooth muscle actin, SMA), macrophages (rat anti-CD68) and T lymphocytes (rabbit anti-CD3). Fixation of the material in acetone and modified incubation protocol employing nonfat dry milk in preincubation and incubation media significantly increased the intensity of labeling and effectively quenched the background. Our method offers an efficient way to detect qualitative as well as quantitative changes of macrophages, T lymphocytes and smooth muscle cells in atherosclerotic plaque of apoE/LDLR -/- mice during atherosclerosis development or in response to pharmacological treatment.

Hepatitis C virus infection in dialysis patients.

Hepatitis C virus (HCV) infection is a global health problem, common worldwide, leading to acute and chronic hepatitis and its consequences of hepatocirrhosis and hepatocellular carcinoma. Patients on hemodialysis belong to the high-risk group of HCV infection. The prevalence of HCV infection in dialysis patients ranges from 4% to more than 70% in some countries. The main reasons for such a high incidence of infections are a high prevalence of HCV infection in the general population, lack of standard infection precautions and effective vaccination, inadequate disinfection procedures of dialysis machines and other medical equipment, as well as spread of infection from patient to patient, especially in dialytic centers with a high percentage of infected patients. The diagnostic procedures useful in the evaluation of HCV infection are detection of anti-HCV antibodies, identification of HCV RNA, counts of virus copies, and identification of its genome. From the 6 major genotypes and multiple subtypes of the HCV, genotypes 1a and 1b are the most common in Europe and Japan, and 1b is responsible for more severe liver disease and aggressive course leading to liver fibrosis. Antiviral therapy of HCV+ dialysis patients with interferon-alpha (INF-alpha) gives slightly better results than in the general population, but is poorly tolerated and associated with side effects. Although ribavirin in not recommended for dialysis patients, the addition of small doses of this compound to pegylated INF is discussed, especially for patients in whom previous infection treatment failed.

The evaluation of the effectiveness of multiple dose intradermal hepatitis B re-vaccination in hemodialyzed patients not responding to standard method of immunization.

Hepatitis B is a serious epidemiological problem in uremic patients treated with renal replacement therapy. A high proportion of hemodialyzed patients do not respond to the standard method of intramuscular (i.m.) hepatitis B vaccination. Low-dose intradermal (i.d.) inoculations and supplementary i.m. injections have been reported to improve the responsiveness in formerly non responding uremic patients. We applied a inoculation schedule of 10 microg Engerix B i.d. in 49 pts and i.m. (control group) in 13 pts once a week during 12 consecutive weeks in order to compare the effectiveness of the various ways of immunization in maintenance dialyzed patients not responding to standard vaccination. Serum anti-HBs antibody level, as well as biochemical and immunological parameters were examined. Already one month after initiation of the cycle, 57.1% of patients in the i.d. group responded by achieving the minimum protective anti-HBs antibody level (>10 IU/I.); while 14.3% reached full adequate anti-HBs antibody level (>100 IU/I.). After the full therapy period, anti-HBs antibody level >100 IU/I. was achieved in 42.9% of the patients, while a total of 81.7% of patients reached the anti-HBs antibody level >10 IU/I. In 18.4% of patients no response was observed. Surprisingly similar results were achieved in the i.m. group. Twelve months after termination of the inoculation cycle we noted decrease of anti-HBs antibody level; the values >100 IU/ I. was observed only in 18.4% of the study group, while 87.8% reached a titre >10 IU/I. We found a relationship between the effectiveness of immunization and RBC count, total serum protein and albumin levels and GGTP activity. Mitogen stimulation indexes in both groups were 4-5 times lower in comparison to reference values in the general population. In the study group that did not respond to vaccination, mitogen stimulation indexes were 2 times lower as compared to the group characterized as having a good response. In conclusion, the route of injection seems to be less important than the frequency and number of doses of the vaccine. Anemia and malnutrition may be responsible for the worse response to vaccination against hepatitis B virus.

The influence of sodium profiling on blood volume and intradialytic hypotension in patients on maintenance hemodialysis.

An accurate evaluation of water content in the body of hemodialyzed patients seems to be an important problem in chronic dialysotherapy. Acute intradialytic hypotension observed in 20-33% of hemodialysis patients is a very common complication of this kind of renal replacement therapy. The study was performed in 40 uremic patients, treated with hemodialysis at the Nephrology Clinic of the University Hospital in Cracow. In every patient, 3 model dialysis sessions were carried out. Total fluid removal was the same during every hemodialysis. The first model hemodialysis (HD1) was performed with constant dialysate sodium concentration (140 mmol/L), the second (HD2) with linear and the third (HD3) with expotential decrease of dialysate sodium concentration (from 144 to 136 mmol/L). Every hemodialysis was also monitored continuously with Crit-Line 2 R system (In-Line Diagnostics, Riverdale, UT). Before and after the first model hemodialysis (HD1), ultrasound examination of abdominal cavity was performed. The measurement of inferior vena cava diameter (mm), circumference (mm), area (mm2), at hepatic veins orifice-level, on expiration was performed. The fluid removal during the first model hemodialysis resulted in significant reduction of the vena cava inferior diameter, circumference and area, measured with ultrasound on expiration. The statistically significant lower fall of blood volume after the first and second hour of the second model hemodialysis session (HD2) was observed when compared to the first hemodialysis (HD1) - p<0.05 was observed. The statistically significant lower frequency of hypotension during the second hemo-dialysis session (HD2) as compared to HD1 (chi2=5.25 p<0.05). Differences among HD1 and HD3 and HD2 and HD3 did not reach statistical significance. The monitoring of hemodialysis with the Crit-Line instrument permits for optimalization of dry weight of dialyzed patients and allows reaching higher ultrafiltration rates during dialysis without hypotensive episodes. The changes in the blood volume, approximately 5% per one hour of dialysis session are an optimal value for these patients.

Dialysis induced hypotension--a serious clinical problem in renal replacement therapy.

The occurrence of DIH is 15-30 or even 50% of dialysis sessions. There are three clinical patterns of DIH: acute, recurrent and chronic. Intradialytic hypotension essentially augments mortality due to hypoperfusion and concomitant damage of many vital organs, as well as due to chronic overhydration and inability to reach proper dry weight. The main causes of dialysis induced hypotension are age hypovolemia (rapid ultrafiltration), and coexisting decreases: autonomic neuropathy, cardiovascular diseases, diabetes. Therapeutic strategies include: patient education and perfect supervision by dialysis staff dialysis procedure-related methods (extension of dialysis duration, low dialysate temperature, sodium and ultrafiltration profiling and usage of biofeedback technique) and pharmacological treatment (e.g. midodrine, caffeine, vasopressin analogues). Proper treatment includes usage of invasive or cardiosurgical methods of heart failure which is a common reason of hypotension in the dialyzed population. Dialysis-induced hypotension is a very important, multifactorial clinical problem in dialysotherapy. Its incidence increases because of the growing number of elderly and diabetic patients in the dialyzed population.

[Atherosclerosis risk factors among patients with diabetes mellitus type 2 diagnosed during hospitalisation due to other diseases in the year 2004]. / Czynniki ryzyka miazdzycy u chorych z cukrzyca typu 2 rozpoznana w trakcie hospitalizacji z powodu innych chorób w 2004 roku.

In the year 2004 there were 2515 patients hospitalysed in the Internal Diseases Department in Dabrowa Tarnowska. In this group 670 of persons suffered from diabetes mellitus t 2. In more than 62 patients the diabetes was detected coincidentally during hospitalization on account of other diseases. Analysed was the occurrence of other risk factors of artherosclerosis in this group, such as: age, sex, hypertension (mild in 17.7%, moderate in 29.1% and severe in 33.9% of patients), obesity (45%), high serum level of cholesterol (200-250 mg% in 45 % and >250 mg% in 24% of patients), BMI indicator (>30 in 40% of subjects), serum level of creatinine (>1.2 mg% in 35.5%), presence of microalbuminuria (30-300 mg/24h in 29%) and proteinuria (17.7%).

[Organ complications in patients with diabetes mellitus type 2 diagnosed during hospitalization due to other diseases in the year 2004]. / Powiklania narzadowe u chorych z cukrzyca typu 2 rozpoznana w trakcie hospitalizacji z powodu innych schorzen w 2004 roku.

In the last years the occurrence of type 2 diabetes mellitus has rapidly increased. The presence of cardiovascular complications, retinopathy, nephropathy and neuropathy are the results of delayed diagnosis. In the year 2004, in the Internal Diseases Depertment in Dabrowa Tarnowska, type 2 diabetes mellitus was diagnosed for the first time in 62 patients. In this group the majority of patient suffered from I-III degree hypertension, 27% had ishaemic heart disease, and 11% were hospitalized because of heart infarction. Heart failure was present in 20% and paroxysmal atrial fibrillation in 21% of them. The other diabetic complications diagnosed in this group were: microalbuminuria (43%), proteinuria (27%), simple retinopathy (64%), proliferative retinopathy (21%), and peripheral neuropathy in 40 of patients.

[Chronic renal failure diagnosed among patients hospitalised in internal ward in 2004 yuear]. / Przewlekla niewydolnosc nerek rozpoznawana przypadkowo u pacjent6w hospitalizowanych na Oddziale Wewnetrznym w 2004 roku.

In 52 patients treated in Internal Diseases Depertment of the hospital in Dabrowa Tarnowska because of other diseases, the chronic renal failure was primary diagnosed. In 11 of patients diabetes t 2 was also for the first time detected. 80% of patients was over 70 years. Mild hypertension was present in 23% persons, moderate in 21%, and in 27% severe hypertension. In 48% of patient latent renal failure was ascertained, stable in 40.5%, and unstable renal failure was prevailing in 11.5% of patients. Ultrasonography displayed essential decrease of kidney's size in 19% of patients, fuzzily of cortical-medullar structure and thickness of cortical layer in 64%. Anaemia was present in 27% of patients.

[Central located lung tumor in patients hospitalized in years 2004 in Pulmonology Department of the Internal Ward in Dabrowa Tarnowska]. / Guz centralny pluca u pacjentów hospitalizowanych w 2004 roku w Pododdziale Pulmonologicznym Oddzialu Wewnetrznego Szpitala w Dabrowie Tarnowskiej.

In the year 2004 there were 699 patients hospitalized in the Pulmonology Department of the hospital in Dabrowa Tarnowska. In 189 of themm bronchoscopic examination was performed because of such indications: tumor- like lesions centrally localized, haemoptysis, persistent cough, unclear x-ray imaging. In every case of bronchoscopy, material for further histopatological examination was collected. Lung cancer was diagnosed in 19 patients.

[Hepatorenal syndrome]. / Zespól watrobowo-nerkowy.

Liver and kidney are essential organs for maintaining metabolic balance because of their detoxificational, excretory and regulatory functions. Liver insufficiency, especially alcohol-induced hepatocirrhosis with ascites may cause functional, potentially reversible kidney failure known as hepatorenal syndrome (HRS). Hepato-renal syndrome is the reason for 8-30% cases of acute kidney failure in cirrhotic patients. It is also an independent risk factor of mortality in this group of patients. There are two types of HRS with different dynamics of clinical course and different prognosis for long term survival of patients. The only efficient treatment for HRS is transplantation of liver or it's right lobe from a living donor. Transplantation removes unbeneficial effects of liver failure and also in most cases restores proper kidney function. The other methods of treatment concentrate to improve and retain kidney function as long as possible and simultaneously to reduce mortality in patients awaiting for liver transplantation. Some of them are: administration of intravenous albumin, diuretics and arterial vasoconstrictors or correction of portal hypertension with a trans-jugular intrahepatic portacaval shunt (TIPS). In patients qualified to liver transplantation renal replacement therapy should also be undertaken. The newest supporting extracorporeal technique for liver insufficiency with/or without HRS is albumin dialysis with MARS of Prometheus devices.

[Ethical and legal issues concerning renal replacement therapy withdrawal or withholding]. / Etyczne i prawne aspekty odstapienia od leczenia nerkozastepczego.

Rapid and dynamic increase of the number of patients that need different forms of renal replacement therapy can be noticed in the developed countries. This increase is associated with increased number of patients with 'diseases of modern civilization', such as diabetes and hypertension, which lead to kidney complications (e.g. diabetic and hypertensive nephropathy). Improved long-term care (especially diabetic and cardiologic) allows these patients to survive longer and to reach the stage of end-stage renal disease. This leads to increasing age and morbidity of patients treated with dialysis. In many cases, due to extremely advanced level of co-morbidity patients on dialysis are exposed to extreme level of suffering and unacceptably low quality of life. Persistent continuing of renal replacement therapy under such circumstances (with no hope for recovery or improvement) raises also some economical issues, especially in the context of permanent crisis and shortage of resources in health systems of most countries in the world. In this review the current practice concerning withdrawal or withholding of renal replacement therapy as well as some legal and ethical issues of this practice are discussed.

[Mesothelioma as delayed consequence of asbestos pollution]. / Miedzybloniaki oplucnej jako pózne nastepstwa zanieczyszczenia srodowiska azbestem.

Mesothelioma is a relatively rare cancer, who's course is dynamic and leads to cahexia and patient death. The relationship has been proven between its incidence and exposition to asbestos. We presented six cases of mesothelioma in patients without professional risk, which were hospitalized in the internal sections of Pulmonological wards. Unfortunately, administered treatment did not bring expected results.