Quantitative detection of melanoma-associated antigens by multimarker real-time RT-PCR for molecular staging: results of a 5 years study.

INTRODUCTION: Monitoring of circulating melanoma cells in the peripheral blood is a promising method for identifying a subgroup of patients with minimal residual disease. OBJECTIVES: To evaluate the prognostic impact of melanoma-associated antigens by multimarker real-time RT-PCR for disease-specific survival time. METHODS: Five melanoma markers: Melan-A, gp 100, MAGE-3, MIA and tyrosinase were detected by a quantitative multimarker real-time reverse transcription-PCR (RT-PCR). We included 65 patients with resected melanoma in stage II-III. Peripheral blood samples were examined every 3 months for 2 years. The expression of melanoma markers in 2925 RT-PCR assays was correlated with clinical staging results in total of 5 years. RESULTS: Twenty-seven patients relapsed during the study period and 26 of them revealed positive markers. MAGE-3 was the most sensitive progression marker in single occurrence or in combination with MIA and gp 100. The time distribution of metastases during the screened period was as follows: progression in the first year was observed in 40.7% patients, second year in 25.9%, third year in 18.6%, fourth and fifth year in 7.4% equally. CONCLUSIONS: Statistically significant tumor marker elevation during the first 2 years after the surgical treatment correlates with a worse prognosis of patients. In contrast, the group showing negative real-time RT-PCR results in 24 months serial blood testing was associated with prolonged 5-year disease-specific survival. Therefore, quantitative detection of melanoma-specific molecular markers in the presented setting represents a useful tool for selecting patients in a higher risk of disease recurrence.

Early detection of melanoma progression by quantitative real-time RT-PCR analysis for multiple melanoma markers.

Standard screening of melanoma patients is a useful tool for predicting outcome of patients, however, an instant methodology for exact detection of subclinical disease or monitoring treatment response is under investigation. Detection of circulating melanoma cells is, therefore, a possible novel promising staging method. However, inconsistent data on method sensitivity and on the predicted patient outcome has been shown repeatedly. Recently, a multimarker real-time RT-PCR methodology for quantification of five melanoma markers Melan-A, gp 100, MAGE-3, MIA and tyrosinase was described by our group. In the current prospective trial, blood specimens of 65 patients with AJCC stage IIB-III cutaneous melanoma after surgery were periodically examined. In the above group, 27 % of subjects relapsed during the study. Prior to the disease progression we could observe a statistically significant tumor marker elevation in previous 0 to 9 months in all patients with clinical relapse. MAGE-3 became the most sensitive progression marker. During progression, three concordant positive markers were seen in 39 % of patients, followed by two concordant positive markers in 28 % and 1 marker in 33 %. This study supports the use of a multimarker real-time RT-PCR as a disease progression predictor. The dynamic assessment of serially obtained blood specimens represents a useful method for early metastasis detection and treatment response of melanoma patients.

Blood glucose control by a model predictive control algorithm with variable sampling rate versus a routine glucose management protocol in cardiac surgery patients: a randomized controlled trial.

CONTEXT: Elevated blood glucose levels occur frequently in the critically ill. Tight glucose control by intensive insulin treatment markedly improves clinical outcome. OBJECTIVE AND DESIGN: This is a randomized controlled trial comparing blood glucose control by a laptop-based model predictive control algorithm with a variable sampling rate [enhanced model predictive control (eMPC); version 1.04.03] against a routine glucose management protocol (RMP) during the peri- and postoperative periods. SETTING: The study was performed at the Department of Cardiac Surgery, University Hospital. PATIENTS: A total of 60 elective cardiac surgery patients were included in the study. INTERVENTIONS: Elective cardiac surgery and treatment with continuous insulin infusion (eMPC) or continuous insulin infusion combined with iv insulin boluses (RMP) to maintain euglycemia (target range 4.4-6.1 mmol/liter) were performed. There were 30 patients randomized for eMPC and 30 for RMP treatment. Blood glucose was measured in 1- to 4-h intervals as requested by each algorithm during surgery and postoperatively over 24 h. MAIN OUTCOME MEASURES: Mean blood glucose, percentage of time in target range, and hypoglycemia events were used. RESULTS: Mean blood glucose was 6.2 +/- 1.1 mmol/liter in the eMPC vs. 7.2 +/- 1.1 mmol/liter in the RMP group (P < 0.05); percentage of time in the target range was 60.4 +/- 22.8% for the eMPC vs. 27.5 +/- 16.2% for the RMP group (P < 0.05). No severe hypoglycemia (blood glucose < 2.9 mmol/liter) occurred during the study. Mean insulin infusion rate was 4.7 +/- 3.3 IU/h in the eMPC vs. 2.6 +/- 1.7 IU/h in the RMP group (P < 0.05). Mean sampling interval was 1.5 +/- 0.3 h in the eMPC vs. 2.1 +/- 0.2 h in the RMP group (P < 0.05). CONCLUSIONS: Compared with RMP, the eMPC algorithm was more effective and comparably safe in maintaining euglycemia in cardiac surgery patients.

Clinical evaluation of alternative-site glucose measurements in patients after major cardiac surgery.

OBJECTIVE: Tight glycemic control improves outcome in critically ill patients but requires frequent glucose measurements. Subcutaneous adipose tissue (SAT) has been characterized as promising for glucose monitoring in diabetes, but it remains unknown whether it can also be used as an alternative site in critically ill patients. The present study was performed to clinically evaluate the relation of glucose in SAT compared with arterial blood in patients after major cardiac surgery. RESEARCH DESIGN AND METHODS: Forty critically ill patients were investigated at two clinical centers after major cardiac surgery. Arterial blood and SAT microdialysis samples were taken in hourly intervals for a period of up to 48 h. The glucose concentration in dialysate was calibrated using a two-step approach, first using the ionic reference technique to calculate the SAT glucose concentration (SATg) and second using a one-point calibration procedure to obtain a glucose profile comparable to SAT-derived blood glucose (BgSAT). Clinical validation of the data was performed by introducing data analysis based on an insulin titration algorithm. RESULTS: Correlation between dialysate glucose and blood glucose (median 0.80 [interquartile range 0.68-0.88]) was significantly improved using the ionic reference calibration technique (SATg vs.blood glucose 0.90 [0.83-0.94]; P < 0.001). Clinical evaluation of the data indicated that 96.1% of glucose readings from SAT would allow acceptable treatment according to a well-established insulin titration protocol. CONCLUSIONS: The results indicate good correlation between SATg and blood glucose in patients after major cardiac surgery. Clinical evaluation of the data suggests that with minor limitations, glucose from SAT can be used to establish tight glycemic control in this patient group.

Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients.

OBJECTIVE: To evaluate a fully automated algorithm for the establishment of tight glycemic control in critically ill patients and to compare the results with different routine glucose management protocols of three intensive care units (ICUs) across Europe (Graz, Prague, and London). RESEARCH DESIGN AND METHODS: Sixty patients undergoing cardiac surgery (age 67 +/- 9 years, BMI 27.7 +/- 4.9 kg/m2, 17 women) with postsurgery blood glucose levels >120 mg/dl (6.7 mmol/l) were investigated in three different ICUs (20 per center). Patients were randomized to either blood glucose management (target range 80-110 mg/dl [4.4-6.1 mmol/l]) by the fully automated model predictive control (MPC) algorithm (n = 30, 10 per center) or implemented routine glucose management protocols (n = 30, 10 per center). In all patients, arterial glucose was measured hourly to describe the glucose profile until the end of the ICU stay but for a maximum period of 48 h. RESULTS: Compared with routine protocols, MPC treatment resulted in a significantly higher percentage of time within the target glycemic range (% median [min-max]: 52 [17-92] vs. 19 [0-71]) over 0-24 h (P < 0.01). Improved glycemic control with MPC treatment was confirmed in patients remaining in the ICU for 48 h (0-24 h: 50 [17-71] vs. 21 [4-67], P < 0.05, and 24-48 h: 65 [38-96] vs. 25 [8-79], P < 0.05, for MPC [n = 16] vs. routine protocol [n = 13], respectively). Two hypoglycemic events (<54 mg/dl [3.0 mmol/l]) were observed with routine protocol treatment. No hypoglycemic event occurred with MPC. CONCLUSIONS: The data suggest that the MPC algorithm is safe and effective in controlling glycemia in critically ill postsurgery patients.

Increased subcutaneous and epicardial adipose tissue production of proinflammatory cytokines in cardiac surgery patients: possible role in postoperative insulin resistance.

CONTEXT: Hyperglycemia and insulin resistance frequently occur in critically ill patients even without a history of diabetes. OBJECTIVE: Our objective was to study the role of adipose tissue hormonal production in the development of insulin resistance in cardiac surgery patients. PARTICIPANTS, INTERVENTIONS, AND SETTINGS: Fifteen patients with elective cardiac surgery underwent blood sampling before, at the end, and 6, 12, 24, 48, and 120 h after the end of their operation. Epicardial and sc adipose tissue sampling was done at the beginning and at the end of surgery in the Department of Cardiac Surgery. MAIN OUTCOME MEASURES: We measured serum concentrations and sc and epicardial adipose tissue mRNA expression of IL-6, monocyte chemoattractant protein-1 (MCP-1), TNF-alpha, leptin, resistin, and adiponectin and sc and epicardial adipose tissue mRNA expression of CD14, CD45, and CD68. RESULTS: The rate of insulin infusion required to maintain euglycemia increased up to 7-fold 12 h after the operation, suggesting the development of insulin resistance. Serum IL-6 levels increased 43-fold 12 h after surgery. MCP-1 peaked 6-fold at the end of surgery. Smaller peaks of TNF-alpha and leptin appeared 6 and 12 h after surgery, respectively. Resistin levels peaked 4-fold 24 h after surgery, but adiponectin levels were not significantly affected. TNF-alpha and CD45 mRNA expression increased markedly during the operation in sc adipose tissue. IL-6, resistin, and MCP-1 mRNA expression increased in both sc and epicardial adipose tissue. Leptin, adiponectin, CD14, and CD68 mRNA expression did not change significantly. CONCLUSIONS: Both sc and epicardial adipose tissue is a source of proinflammatory cytokines in cardiac surgery patients and may contribute to the development of postoperative insulin resistance.

[Issues of congenital syphilis in the past twenty years. I. Etiology, epidemiology and diagnosis]. / Problematikka vrozené syfilis v posledních dvacet letech. I. Etiologie, epidemiologie a diagnostika.

Since 1990 there is an upward trend in the incidence of both acquired and congenital syphilis in the Czech Republic. A similar situation exists in other European countries as well. Higher incidence of syphilis is clearly associated with urban agglomerates and sexual tourism destinations. The only way to reduce the number of cases is a consistent application of mandatory preventive and diagnostic measures. These important measures against the spreading of the infection include mandatory serological testing of pregnant women and newborns (from umbilical blood), antibiotic treatment and systematic follow-up of HIV-positive mothers and children. This paper describes the current epidemiological situation of syphilis in the Czech Republic and presents a review of available diagnostic tests and their significance for diagnosis.

[Issues of congenital syphilis in the past twenty years. II. Clinical picture]. / Problematikka vrozené syfilis v posledních dvacet letech. II. Klinický obraz.

The paper describes the clinical picture and management of congenital syphilis. In the introduction the origin of syphilis is mentioned. The etiologic agent -- Treponema pallidum subsp. pallidum (Tp) -- is transmitted to fetus almost exclusively via placenta. Perinatal infections are less frequent, and postnatal infections are only exceptionally. The symptoms of congenital syphilis may be divided into prenatal (syphilis materno-fetalis), neonatal, and rarely seen postnatal. Prenatal symptoms causing the immaturity of fetus are recognizable from the 7th month of pregnancy and associated with miscarriages, premature deliveries of still-born babies or live neonates with congenital syphilis. Neonatal and postnatal symptoms are manifested only after birth. They may present immediately at birth, develop within first two years of life as early congenital syphilis, or (similarly to acquired syphilis) later in life as a late localized form, often seen many years after birth, even at puberty -- late congenital syphilis. The clinical picture depends on many factors -- primarily on the duration of the infection in mother and the stage of pregnancy.

Serum adiponectin and resistin concentrations in patients with restrictive and binge/purge form of anorexia nervosa and bulimia nervosa.

To study the role of adipose tissue-derived hormones in the pathophysiology of eating disorders, circulating levels of adiponectin, resistin, and other hormonal and metabolic parameters were measured in 16 females with the restrictive subtype of anorexia nervosa (R-AN), 10 females with the binge/purge subtype of anorexia nervosa (P-AN), 15 females with bulimia nervosa (BN), and 12 age-matched healthy females (C). Body mass index (BMI), body fat content, and serum leptin levels were severely decreased in R-AN and moderately decreased in P-AN patients, whereas the BN group did not differ from C in these parameters. Serum soluble leptin receptor levels were increased in R-AN and P-AN and unchanged in BN patients. Circulating adiponectin levels were inversely related to BMI and were unchanged in BN patients and increased by 53% in P-AN and by 96% in R-AN relative to C group, respectively. In contrast, resistin levels in malnourished R-AN and P-AN were not different from either C or BN groups and showed no significant relationship to BMI or body fat content. We suggest that increased adiponectin levels reflect decreased body fat content in AN patients. In contrast, circulating resistin levels do not appear to be closely related to the nutritional status.

Clinical evaluation of subcutaneous lactate measurement in patients after major cardiac surgery.

Minimally invasive techniques to access subcutaneous adipose tissue for glucose monitoring are successfully applied in type1 diabetic and critically ill patients. During critical illness, the addition of a lactate sensor might enhance prognosis and early intervention. Our objective was to evaluate SAT as a site for lactate measurement in critically ill patients. In 40 patients after major cardiac surgery, arterial blood and SAT microdialysis samples were taken in hourly intervals. Lactate concentrations from SAT were prospectively calibrated to arterial blood. Analysis was based on comparison of absolute lactate concentrations (arterial blood vs. SAT) and on a 6-hour lactate trend analysis, to test whether changes of arterial lactate can be described by SAT lactate. Correlation between lactate readings from arterial blood vs. SAT was highly significant (r2 = 0.71, P < .001). Nevertheless, 42% of SAT lactate readings and 35% of the SAT lactate trends were not comparable to arterial blood. When a 6-hour stabilization period after catheter insertion was introduced, 5.5% of SAT readings and 41.6% of the SAT lactate trends remained incomparable to arterial blood. In conclusion, replacement of arterial blood lactate measurements by readings from SAT is associated with a substantial shortcoming in clinical predictability in patients after major cardiac surgery.