Pathophysiology of hyperuricemia and its clinical significance - a narrative review.

Hyperuricemia, i.e. increased serum uric acid (UA) concentration, is a common problem in clinical practice. While there are clear guidelines concerning management of symptomatic hyperuricemia in acute conditions such as gout, urolithiasis or acute urate nephropathy, less is known about their secondary prevention. Moreover, despite the ongoing debate on the role of UA in the pathogenesis of chronic kidney disease, hypertension, cardiovascular disease and heart failure, the management of asymptomatic hyperuricemia in patients with these chronic conditions is still mainly up to physicians' judgement. Individual considerations should always be taken into account when prescribing urate-lowering therapy. In this narrative review study, we attempt to present current trends concerning treatment of patients with either symptomatic or asymptomatic hyperuricemia in the light of the available knowledge on the role of hyperuricemia in the development of gout, renal, cardiovascular and other diseases.

Interstitial lung disease in systemic sclerosis: challenges in early diagnosis and management.

Interstitial lung disease (ILD) is a group of lung diseases characterized by thickening of the interstitium surrounding pulmonary alveolar walls. It is related to specific radiographic features in lung imaging and/or the presence of restrictive disorders in pulmonary function tests (PFTs). ILD is one of the leading causes of death in systemic sclerosis patients. Major risk factors of ILD associated with SSc (SSc-ILD) include male sex, diffuse type of cutaneous SSc and presence of anti-Scl-70 antibodies. SSc-ILD is challenging to diagnose at an early stage as the symptoms are non-specific. The greatest risk of its development is during the 4-5 years after the initial diagnosis of systemic sclerosis. Clinical vigilance at the time, including regular pulmonary function tests and/or high-resolution com-puted tomography (HRCT), is needed. The aim of this paper is to summarize the current knowledge on early diagnostic methods and progression risk factors for SSc-ILD.

[Giving medico-legal opinions in cases with suspicion of medical mistake.part 1. between medicine and justice.]

Creating medico-legal opinion is a sophisticated investigative, analytical, decision-making and creative process. Forensic medicine specialist in cooperation with clinical medicine consultants, on the basis of evidence analysis, which was gathered during procedures and contained in the acts has to create an objective and essential opinion. This opinion is a vital, very important and irreplaceable proof in every case. Judicial body consults with forensic medicine specialist or specialists if there are circumstances for settlement of which there is a need of classified informations - art. 193 of Penalty Code. Forensic medicine specialists face many difficulties which may have effect on quality, positiveness of opinion, compliance with the deadline, increasing expectancy of judicial body or sides. It is very difficult to find clinical specialists which except their clinical knowledge have basic knowledge about law, the role and duties of an court expert. In this article we discuss creating-opinion problems, role and position of court expert in confrontation with expectations of judicial body and the Justice with particular emphasis on medical mistakes and assessment of medical proceedings. We show the complexity of creating of medical opinions, especially these institutional.

[Giving medico-legal opinions in cases with suspicion of medical mistake. part 2. Expert evidence in cases with suspicion of medical mistake - expectations, possibilities, threats ].

Problems of medical mistake and therapeutic failure are inextricably linked with realization of medical services. In recent years, mostly by the media and increasing demanding attitude, a rapid increase of initiated cases opened by judicial body in conjunction with medical mistake made by medical staff is observed. Making medico-legal opinions is not easy task and often face many difficulties. These consist of lacks in medical documentation, time rigor, formal tightening and need to create team that consist of both forensic medicine specialist and clinicians, who together shall write complex medico-legal opinion. This article touches the essence of the opinion-making problem in the aspect of medical mistake. It shows specifics of the role of forensic medicine specialist, his challenges and difficulties in creating opinions. The article confronts real possibilities of court experts with expectations of judicial body, outlining new challenges and dangers which court experts have to face.

[The teaching of medical ethics in medical school].

Medical ethics constitutes some kind of core, which enables the physicians to decide in complicated clinical situations. This subject is taught during medical studies through only one semester. Number of teaching hours designed for this crucial in later physician's practice subject is insufficient. Additional problem in teaching process is inconsistence between the Law and the Code of Medical Ethics. As a result it causes alarmingly weak preparation of students to take practical decisions according to ethical and moral values of the Code of Medical Ethics. What is also important, in 2012 a medical studies schedule was changed, which in author's opinion had very negative effect on medical ethics teaching. In our opinion it is vital to increase number of teaching hours spent on medical ethics, create a model of gradual ethical knowledge transfer to students on every year of studies, which should be based on clinical subjects in master-student relations. Authors of this article discuss in a complex way problems of medical ethics teaching at medical studies supporting their thesis with author's survey carried out on large group of students of Medical University of Silesia in Katowice.

Erythema nodosum - review of the literature.

Erythema nodosum is the most common form of panniculitis. It may have many aetiological factors. Erythema nodosum occurs three to five times more often in female patients. It appears as erythematous painful rounded nodules, located most often on the anterior surface of the lower extremities, and may be accompanied by systemic symptoms such as fever, malaise and arthralgia. During diagnosis, oncological vigilance should be maintained, because erythema nodosum may be a paraneoplastic symptom. It requires an interdisciplinary approach and exclusion of many underlying causes.

Erythema nodosum - presentation of three cases.

Erythema nodosum (EN) is a well-known form of panniculitis. It may occur as an idiopathic form and also can be induced by certain clinical conditions such as infections and granulomatous diseases such as sarcoidosis. Erythema nodosum may be accompanied by general symptoms such as fever, weakness, and severe pain, but skin lesions resolve without skin damage. Erythema nodosum occurrence is for the clinician a signal for a wider diagnosis and determination of the cause of occurrence of symptoms. The article presents three cases of EN with different causes and treatment.

Cadmium Body Burden and Inflammatory Arthritis: A Pilot Study in Patients from Lower Silesia, Poland.

The purpose of this study was to determine the relationship between cadmium exposure and the likelihood of developing or exacerbating symptoms of inflammatory arthritis (IA). The study included 51 IA patients and 46 control subjects. Demographic and lifestyle data were collected. Haematological and biochemical parameters and blood cadmium levels (Cd-B) were determined. Cd-B correlated positively with age, smoking, living in a high-traffic area, and serum levels of inflammatory markers and negatively with mean corpuscular haemoglobin concentration (MCHC). The binary logistic regression model implied that high Cd-B (≥0.65 µg/L) is linked with an increased risk of IA in the studied population (odds ratio: 4.4). High levels of DNA oxidative damage marker (8-hydroxy-2'-deoxyguanosine) (≥7.66 ng/mL) and cyclooxygenase-2 (≥22.9 ng/mL) and frequent consumption of offal was also associated with increased risk of IA. High Cd-B was related to increased risk of disease symptoms onset in the group of IA patients, decreased the level of interleukin 10, and positively correlated with the disease activity. Increased Cd-B is associated with intensified inflammatory processes and decreased haemoglobin levels; in IA patients with decreased anti-inflammatory interleukin 10. These changes partly explain why cadmium exposure and a high cadmium body burden may raise the risk of IA and of disease symptoms exacerbation.

[The evaluation of the mechanism and cause of death of mine rescuers during the group accident in the Niwka-Modrzejów Coal Mine in Sosnowiec in 1998]. / Ocena mechanizmu i przyczyny smierci ratowników górniczych podczas wypadku zbiorowego w Kopalni Wegla Kamiennego "Niwka-Modrzejów" w Sosnowcu w 1998 roku.

On February 24, 1998, in the Niwka-Modrzej6w Coal Mine in Sosnowiec, a group accident occurred and, as a result, six miners died and four others were injured. Mine rescuers, proceeding to work in out of action mining excavation, separated by an isolative dam, were using oxygen escape breathing apparatuses AU-9 type and oxygen breathing apparatuses for work WU-70 type. A comprehensive evaluation of the accident circumstances, medical papers, autopsy, histopatological and chemico-toxicological reports, technical surveys of the Central Station of Mine Rescue and the Military Institution of Chemistry and Radiometry (WIChiR), taking into consideration the microclimatic conditions in the sidewalk and testimonies of the survivors allowed for determining the cause of death in the victims. The authors emphasized special difficulties in compiling the comprehensive opinion in the reviewed case and the significant evidential value of the technical survey prepared by WIChiR that showed numerous and serious abnormalities in the performance of oxygen breathing apparatuses, which in a short time led in their users to acute respiratory insufficiency due to anoxia with its further consequences.

[Medico-legal assessment of the injuries of fatal victims of building collapse at Katowice International Fair in Katowice/Chorzów on January 28, 2006]. / Sadowo-lekarska ocena obrazen u smiertelnych ofiar katastrofy budowlanej na terenie Miedzynarodowych Targów Katowickich w Katowicach/Chorzowie w dniu 28.01.2006 roku.

On January 28, 2006, during an exhibition of carrier pigeons, the roof of one of the buildings at Katowice International Fair collapsed. At the time of accident, there were 700 people in the building--65 died and 171 were injured. It was the biggest building disaster in the history of modern Poland. The aim of this study was to present the type (character) of the observed injuries, the cause of death of 48 fatal victims and the range of activities and medico-legal examinations performed in the Department of Forensic Medicine, Medical University of Silesia in Katowice. In the period of January 29-February 1, 2006, on February 14, 2006, and February 17, 2006, post-mortem examinations of the 48 deceased were carried out, and in some cases additional dissecting techniques were employed. During autopsies, numerous specimens for various additional examinations (histopathological, toxicological) were collected. For identification purposes, photographic material and specimens, necessary for genetic identification, were secured. Additionally, the bodies were identified by families. The post-mortem procedures eventually allowed for establishing the cause of death of all the victims. The authors emphasize the range of necessary medico-legal procedures and examinations that should be carried out in a Department of Forensic Medicine in case of a building collapse with a large number of fatalities in order to determine the type of injuries, cause and mechanism of death and to identify the deceased.

[Strangulation caused by a horse]. / Zadzierzgniecie z uzyciem konia zaprzegowego.

The report presents an unusual case of strangulation, where the loop on the neck was tightened by a runaway horse. The suspect states that during an argument with his father, he threw reins on his parent's neck. The horse got scared and ran away, dragging the victim along. During the investigation, many versions of this situation were considered: the horse running away as an accident, the horse being lashed to speed by the suspect and homicidal strangulation by the reins held in his hands.

[Medico-legal assessment of medical management in "chest pain" cases based on the review of cases analyzed in the Chair and Department of Forensic Medicine, Medical University of Silesia, Katowice, in the years 2000-2006]. / Sadowo-lekarska ocena postepowania lekarskiego w przypadkach ostrych dolegliwosci bólowych w klatce piersiowej na podstawie analizy materialu aktowego Katedry Medycyny Sadowej w Katowicach w latach 2000-2006.

Among all investigations aiming at assessing medical management carried out in our department between 2000 and 2006, the cases of "chest pain" constituted the largest percentage. In 70% of such cases, the employed medical procedures were found to be incorrect; what might be qualified as medical decisive errors, committed in rescue ambulances, outpatient clinics or in admission rooms. The authors present some examples of causes of such incorrect management strategies, such as neglecting proper and profound clinical examination (with medical history taking); lack or incomplete differential diagnosis; failure to observe appropriate critical attitude and prudence; focusing only on one, most common disease.

[Injuries of the vertebral column--differentiating between natural illnesses manifested at work and illnesses caused by work accidents. Opinionating problems in cases associated with recognizing an event as a work accident in the analysis of materials of the Chair and Department of Forensic Medicine, Medical University of Silesia]. / Uraz kregoslupa--zachorowanie w pracy, czy wypadek przy pracy. Problemy opiniodawcze w sprawach o uznanie zdarzenia za wypadek przy pracy na podstawie analizy materialu aktowego Katedry i Zakladu Medycyny Sadowej i Toksykologii Sadowo-Lekarskiej Slaskiego Uniwersytetu Medycznego.

In opinionating practice of the Department of Forensic Medicine, Medical University of Silesia, a substantial problem is posed by cases associated with qualifying an event as a work accident or a "natural" illness manifested at work, when the consequence is spinal injury, especially of the overwork (surcharge; overstrain) character. Between 1998-2007, among all 284 medicolegal opinions concerning work accidents and their consequences, 76 opinions (27%) referred to vertebral column injuries or radicular pain syndromes. This has prompted the authors to investigate the problems of spinal injuries analyzed in the context of recognizing an event as a work accident. The paper constitutes a preliminary report and material for more extensive deliberations, demonstrating problems faced by experts passing opinions in cases of this type. In addition, the authors present their observations addressing legal regulations in force and common opinionating practices.

[Thromboembolic complications in orthopedic surgery--medico-legal assessment in evaluation of correctness of medical treatment in selected cases]. / Powiklania zakrzepowo-zatorowe w ortopedii-sadowo-lekarska ocena prawidlowosci postepowania lekarskiego w wybranych przypadkach.

Thromboembolic events continue to account for a high percentage of complications after orthopedic surgery. Of significance in prevention of these diseases is appropriate pharmacotherapeutic prophylaxis, both pre and postoperative, as well as orthopedic and trauma surgeons being aware of the risk of such complications and of possibilities of avoiding or minimizing thromboembolic events. The authors present some cases that were certified in Chair of Forensic Medicine, Silesian Medical University in Katowice, in which thromboembolic complications did develop after conservative or surgical orthopedic treatment, emphasizing possible difficulties in unequivocal assessment of the cause-effect relationship between the employed treatment and the thromboembolic event in the aspect of medico-legal certification.

[Total permanent or major permanent inability to work in profession. Remarks about the possibility of criteria verification in medico-legal opinionating in criminal cases]. / "Calkowita lub znaczna trwala niezdolnosc do pracy w zawo- dzie". Uwagi o mozliwosci weryfikacji kryteriów w opiniowaniu sadowo-lekarskim w sprawach karnych.

Despite the fact that some criteria of medico-legal certification in criminal proceedings have been established, there are still some areas that--parallel to changes occurring in contemporary society--have started to be controversial. This phenomenon has prompted the authors to attempt establishing new criteria for certification in total/major permanent inability to work in profession. This work is a continuation of a cycle devoted to interpretation of article 156 of the Penal Code to meet the needs of medico-legal opinionating.

[A serious group accident in Zabrze-Bielszowice Coal Mine--medico-legal evaluation of health consequences for the purpose of criminal proceedings]. / Ciezki wypadek zbiorowy w KWK Zabrze-Bielszowice--sadowo-lekarska ocena nastepstw zdrowotnych dla potrzeb postepowania karnego.

On February 23/24, 2003, in Zabrze-Bielszowice coal mine, 840 m below the surface, a methane blast occurred twice. In group accidents, a total number of 35 miners were injured; the majority of them experienced extensive thermal injuries. The authors compiled a list of body injuries, including their character, severity, initial clinical assessment and types of employed medical procedures, taking into consideration also medical certification of the Social Insurance and results of medico-legal examinations of the miners. Department of Forensic Medicine in Katowice prepared comprehensive medico-legal opinions during preparatory prosecuting proceedings followed by precise, individualized opinions for the court, concerning legal qualification of the injuries, their underlying mechanisms, but also mental and physical suffering, treatment-associated hardships and prognosis for the future.

A two fatal cases of poisoning involving new cathinone derivative PV8.

α-Pyrrolidinoheptiophenone (PV8) is a representative of α-pyrrolidinophenone derivatives, a new group of synthetic cathinones. PV8 was first detected in illegal products in Japan in 2013. It is closely related to α-pyrrolidinovalerophenone (α-PVP), which was one of the most popular novel psychoactive substance (NPS) in Poland in years 2013-2015. The article presents two cases of fatal poisonings of 36-year-old man and 37-year-old woman, where a new cathinone derivative - PV8 was detected in biological material collected during medicolegal autopsies. The concentration of PV8, measured with LC-MS method, was in the first case - 0.26 µg/mL in blood and 0.11 µg/mL in urine and in the second - 0.07 µg/mL and 0.13 µg/mL, respectively. In both cases medicolegal experts finally have determined that the cause of death was fatal intoxication with the main role of PV8. This substance is another synthetic cathinone which is dangerous for live of the users and requires constant monitoring and further research.

[Estimation of percentage of detriment to health in cases of chronic virus hepatitis B and C with extrahepatic lesions involving other organs]. / Mozliwosc oceny wysokosci uszczerbku na zdrowiu w przypadkach przewleklych wirusowych zapalen watroby typu "b" i "c" ze zmianami narzadowymi pozawatrobowymi.

Among problems that are faced by the expert while passing opinions in civil cases regarding claims for compensation in infections by HBV and HCV, one of the most important issues is the estimation of the percentage of detriment to health. The analysis of records of proceedings in these cases shows considerable latitude on the part of experts and a high divergence of expert opinions. In their practice, the authors have encountered 12 documented and clinically confirmed cases of chronic virus hepatitis B and C associated with extrahepatic conditions that were causatively associated with chronic infections. Such extrahepatic manifestations included thyroid dysfunctions, renal failure due to glomerulonephritis, dermatoses, hematological conditions or periarteritis nodosa. The authors point out that in spite of a high risk of the development of extrahepatic complications in HBV/HCV patients, or even in view of an existing justified suspicion of the patient suffering from such complications, as a rule no detailed diagnostic management is carried out aiming at detection of possible late health-associated effects resulting from a chronic HBV and HCV infection. As a rule, such complications are diagnosed very late in the-course of the underlying disease and in the majority of cases are regarded as independent of hepatitis. Extrahepatic lesions undoubtedly significantly increase the percentage of detriment to health. In the investigated cases, the percentage of detriment to health was assessed as ranging between 40 to 100%.