Chemerin, vaspin and insulin resistance in chronic hepatitis C.

Adipocytokine profile seems to play a distinct role in the pathogenesis of chronic hepatitis C (CHC). Chemerin and vaspin are recently described adipocytokines with various suggested functions and potential to modulate inflammatory response and insulin resistance (IR). We assessed chemerin, vaspin and leptin serum concentration and studied their association with IR laboratory and morphological features in patients with hepatitis C. The study included 40 patients with hepatitis C and 20 healthy volunteers, similar in age and body mass index (43.6 +/- 11.6 vs 40.9 +/- 11.8 years and 25.0 +/- 4.1 vs 23.9 +/- 3.3 kg/m(2), respectively). Patients had to have a normal lipid profile, and diabetes was an exclusion criteria. Serum chemerin and leptin levels and IR were significantly higher in patients with hepatitis C when compared to the controls (P = 0.02, P = 0.02 and P = 0.02, respectively), whereas vaspin level was significantly decreased (P = 0.01). Serum chemerin was negatively associated with necro-inflammatory grade (r = (-0.49), P = 0.01). The lowest levels of serum chemerin were found in patients with moderate/severe inflammation (P = 0.03). Serum leptin tended to be up-regulated in patients with minimal inflammatory activity. Serum vaspin was higher, although not significantly, when fibrosis was more advanced. IR was positively associated with fibrosis stage (r = 0.33, P = 0.03). Serum chemerin and leptin were related to each other (r = 0.45, P = 0.02).Our findings support a complex interaction between the analysed adipokines and pathogenesis of inflammatory process in CHC. The role of chemerin and vaspin in pathogenesis of inflammatory response should be further investigated.

Drug-induced aseptic meningitis in suspected central nervous system infections.

This study presents eight patients with drug-induced aseptic meningitis (DIAM) admitted to our centre with an initial suspicion of central nervous system (CNS) infection. In all patients clinical findings, cerebrospinal fluid (CSF) examination, a cause-effect relationship according to the Naranjo adverse drug reactions probability scale and other diagnostic criteria required for DIAM recognition, were fulfilled. Nonsteroidal anti-inflammatory drugs were the most frequent cause of DIAM. In two cases, there was previous antimicrobial use. The time between use of the causative drug and onset of the symptoms ranged from 2 to 7 days. Clinical symptoms and CSF findings in patients with DIAM are indistinguishable from the early stage of infections of the CNS. Detailed anamnesis is essential, particularly related to medication use immediately prior to the appearance of symptoms of CNS impairment. In conclusion, the differential diagnosis of CNS infections should include DIAM.

Nutritional status of patients hospitalised in Poland.

AIM: Screening and extended assessment of the nutritional status of patients on admission and on discharge from hospital were carried out. DESCRIPTION: The studies were carried out in four teaching hospitals, four provincial hospitals and four county hospitals in Poland. SUBJECTS: Screening examinations were carried out for 3310 randomly selected patients (every 10th patient admitted to hospital, including 1916 female cases aged from 16 to 92 y and 1394 male patients aged from 16 to 100 y). Extended examinations were carried out on 210 patients aged from 16 to 87 y (including 122 female and 88 male). MAIN ASSESSMENT PARAMETERS: Anthropometric (height, weight, body mass index (BMI), waist-to-hip ratio (WHR), arm circumference) and biochemical indices (erythrocyte count, haemoglobin concentration, white blood cell count, blood lymphocyte count and serum albumin serum concentration). The extended examinations included determination of antioxidant vitamins (A, C, E), vitamin B(12) and folic acid. RESULTS: On admission to hospital, 10.43% of the patients surveyed had a BMI below 20 kg/m(2), in 20.74% of patients serum albumin concentration was below 3.5 g/dl, indicating possible protein energy malnutrition. In addition, 21.02% had lymphocyte count below 1.5 x 10(3)/mm(3). During hospitalisation, deterioration in the nutritional status of the patient population occurred. On discharge from hospital, the percentage of patients with BMI < 20 kg/m(2) increased to 11.21% and the percentage with low blood albumin (<3.5 g/dl) increased to 28.57%. On admission, vitamin C deficiency was present in 51.8% of patients, folic acid deficiency in 32%, vitamin E deficiency in 10%, vitamin B(12) deficiency in 6.8% and vitamin A deficiency in 1.4%. Vitamin deficiencies were present equally in malnourished, overweight and obese patients. CONCLUSIONS: In patients admitted to hospitals in Poland, malnutrition risk demonstrated by BMI was observed in 10.43% of patients. On the basis of biochemical indices, increased nutritional risk was demonstrated in 21% of patients. Vitamin malnutrition was seen in the majority of patients. A significant correlation between weight, BMI, arm circumference, blood lymphocyte count and the number of days spent in hospital was observed. SPONSORSHIP: The Committee of Scientific Research and the Ministry of Health-PBZ 012-14.

[Dynamic of IL-6 and IL-8 concentrations in patients after surgery treated with total parenteral nutrition]. / Dynamika zmian stezenia interleukin 6 i 8 u chorych po zabiegach chirurgicznych leczonych calkowitym zywieniem pozajelitowym.

Exaggerated cytokines productions and development of systemic inflammatory response (SIRS) is the most common cause of postoperative complications and death after major abdominal surgery. The present study was conducted to investigate alterations in systemic production of interleukin-6 (IL-6) and interleukin-8 (IL-8) after total parenteral nutrition (TPN) in surgical patients. Plasma concentrations of IL-6 and IL-8 were measured in 22 patients (10 treated with TPN and 12 without TPN) before major surgery and on the days 1, 3, 7, 10 and 14-16 after, by ELISA test (indications for surgery: stomach, pancreatic and colon carcinoma, complications of IBD and acute pancreatitis). There were no differences between preoperative levels of IL-6 and IL-8 in the examined groups of patients. The highest (on the days 1, 3, 7, 10: 268.3 (p = 0.002), 41.9 (p = 0.03), 122.6 (p = 0.009), 29.3 (p = 0.03) pg/ml respectively) and longer lasting significantly elevated level of IL-6 was observed in the group of patients after major surgery without TPN. In the group of patients received TPN (with glutamine) there was a significantly increased but in comparison with group of patients without TPN, significantly lower level of IL-6 on days 1 and 7 (103.4 and 34.7 pg/ml respectively, p = 0.01). There was no significant change in postoperative concentration of IL-8 after major surgery in the group of patients treated with TPN. The level of IL-8 was significantly elevated (p = 0.01) in the group of patients without TPN on day 1 and 3 following surgery. The IL-8 level in the TPN group vs. group of patients without TPN was significantly lower on day 1 after surgery. After TPN concentration of cholesterol was significantly higher and CRP level significantly lower. We conclude that TPN improved immunological response to major surgical trauma by reduction of the inflammatory response.

[Cellular immunity changes after total parenteral nutrition enriched with glutamine in patients with sepsis and malnutrition]. / Wplyw zywienia pozajelitowego wzbogaconego glutamina na wybrane wskazniki odpornosci komórkowej u niedozywionych chorych chirurgicznych z masywnym zakazeniem.

The influence of glutamine on human immune system is multidirectional but the exact changes still remain unclear. In this study the effect of total parenteral nutrition (TPN) enriched with glutamine on some selected immunological and nutritional parameters was examined in twelve surgical patients with sepsis and malnutrition. The reason for glutamine supplementation was lack of clinical improvement after standard TPN. All patients received TPN enriched with glutamine for 10 days. Phenotypic analysis of peripheral blood mononuclear subsets (CD4, CD8, CD16, CD56, HLA-DR) were measured before, during (on days 2, 4, 6) glutamine administration and two days after (day 12) glutamine withdrawal. Simultaneously some nutritional parameters were assessed. The number and percentage of CD4, CD16, CD56 mononuclear subsets increased significantly on day 2 and stayed on the same level during observation (with exception in CD4 on day 6, 12 and CD56 on day 4). No significant differences in CD8 and HLA-DR number and percentages were observed after TPN enriched with glutamine. BIA examination revealed on days 2 and 12 significant decrease of total body water and significant increase of body cell mass, intracellular water on day 12. It was correlated with significant higher total lymphocytes count and significantly higher total protein, serum albumin, transferrin, cholesterol and CRP concentration. Results demonstrated that TPN supplemented with glutamine improved rapidly some immunological and nutritional parameters in surgical, malnutrition patients with sepsis.

[Value of chosen immunologic parameters in assessment of surgical trauma extent]. / Wartosc wybranych wskazników immunologicznych w ocenie wielkosci urazu operacyjnego.

The subject of study was to assess the sensitivity of chosen immunological parameters in the extension of the post operative trauma. Two groups of patients were studied: group I--12 patients underwent laparoscopic cholecystectomy (ChL), group II--18 patients underwent conventional cholecystectomy (ChK). We compared changes in the concentration of interleukin 1 receptor antagonist (IL-1ra) and interleukin 6 (IL-6) in blood. Blood tests were taken before operation and 1, 3, 7, 10 days after operation. Levels of IL-1ra and IL-6 were determined by ELISA. It was stated that cholecystectomy (ChK, ChL) evoked statistically significant changes in the value of chosen immunological parameters. In comparison with ChK the ChL evokes significant but smaller and shorter lasting changes in tested parameters of the immunological response that indicates that ChL is less invasive surgical procedure. The IL-1ra and IL-6 concentration changes constitute a very sensitive markers of immunological response to surgical trauma. The value of IL-1ra and IL-6 changes in immunological response monitoring, especially in the patients with postoperative complications requires further investigations.

[Clinical evaluation of amino acid solution]. / Ocena kliniczna roztworu aminokwasów.

Glutamine, a conditionally essential amino acid, is important for immune function. It is now being formulated for incorporation in to total parenteral nutrition (TPN). The aims of this study were to examine the effect of glutamine administration on clinical status, body composition, protein synthesis and immune function in critically ill patients with sepsis. Eleven patients were included into the study. Seven of them have been on conventional TPN for 8-63 days without significant clinical and nutritional improvement. Glutamine supplemented TPN was implemented for 10 subsequent days. Before, during and after the study venous blood samples were taken for the cellular immunity examination, and for the measurement of plasma albumin, transferrin and triglycerides levels. Nitrogen balance was calculated every day during the study. No side effects were noted. Patients receiving amino acid solution revealed improved nitrogen balance, body composition and body water distribution. Plasma proteins concentrations and immunological indices significantly increased during ten days TPN with Glamin. We confirm the beneficial effects of amino acid solution-supplemented TPN on nitrogen balance, plasma proteins, and immune status of critically ill patients.

[Total parenteral nutrition. History. Present time. Future]. / Calkowite zywienie pozajelitowe. Historia. Terazniejszosc. Przyszlosc.

Total parenteral nutrition (TPN) has been available for only 30 years. However, history in this field goes back more than 350 years with the first landmark being the description of general blood circulation by William Harvey in 1628. His discovery is the anatomical basis for intravenous infusions. Many investigations were performed during the following centuries showing that solutions containing electrolytes and glucose could be given intravenously in man. The accumulated knowledge of protein metabolism formed the basis for studies on intravenous nutrition with protein hydrolysates, peptides and amino acids. The observation in the late 30-s by Robert Elman that amino acids in the form of protein hydrolysate could be safely administered intravenously in man was the first major step toward TPN. During the following years, major efforts were made to find methods to prepare infusion solutions with a high energy content and low osmotic pressure. The most realistic alternative seemed to be fat in the form of an emulsion. Many studies of a large number of various fat emulsions were made however, all of these emulsions caused severe adverse reactions in man. The first safe fat emulsion, intralipid, was made available in the early 60s. This was the second major step toward TPN. It was then no problem to include vitamins, electrolytes and trace elements in the fat emulsions and the solutions of amino acids and glucose. A few years later it was shown that a central venous catheter could be used to administer the infusion fluid intravenously. Many clinical investigations and reports have shown that the newly developed intravenous nutritional regimens are adequate alternatives to the ordinary diet. In this way it has been possible to maintain or obtain a good nutritional condition in most situations when oral or tube feeding can not be used. TPN has been shown to be of very great clinical importance to prevent and treat starvation often related to high morbidity and mortality.

[Parenteral nutrition in postoperative period]. / Zywienie dojelitowe w okresie okolooperacyjnym.

Results of surgical procedures in malnutrished patients are worse than in well-nutrished patients. Perioperative nutritional treatment lead to diminished percentage of postoperative complications and mortality. Authors presents the influence of early postoperative enteral nutrition in 35 malnutrished patients on body composition and anthropometrical and biochemical parameters of their nutritional status. Results shows that enteral nutrition in postoperative phase can decrease catabolic effect of surgical treatment.

[Computer program "PANCREAS"]. / Program komputerowy "PANCREAS".

Contemporary computer technology allows precise and fast large database analysis. Widespread and common use depends on appropriate, user friendly software, usually lacking in special medical applications. The aim of this work was to develop an integrated system designed to store, explore and analyze data of patients treated for pancreatic cancer. For that purpose the database administration system MS Visual Fox Pro 3.0 was used and special application, according to ISO 9000 series has been developed. The system works under MS Windows 95 with possibility of easy adaptation to MS Windows 3.11 or MS Windows NT by graphic user's interface. The system stores personal data, laboratory results, visual and histological analyses and information on treatment course and complications. However the system archives them and enables the preparation reports of according to individual and statistical needs. Help and security settings allow to work also for one not familiar with computer science.

[Cellular immunity in patients with non-specific inflammatory bowel disease for an extended period after surgery]. / Odpornosc komórkowa u chorych z nieswoistymi chorobami zapalnymi jelit w odleglym czasie po operacji.

The study was aimed at investigating the expression of HLA-DR, CD4, CD8, CD56 surface antigens on peripheral blood lymphocytes in patients with non-specific inflammatory bowel diseases in the period of 1-5 years after the surgical procedure. The percentage of rosette forming T-cells in the theophylline test and skin reaction to mycotic and bacterial antigens were assessed simultaneously. The experiment included group of 12 patients (aged 5-55), treated surgically because of Crohn's disease or ulcerative colitis. The lymphocytes' surface antigens were examined by means of monoclonal antibodies and the APAAP procedure. Significantly increased (p < 0.001) percentage of lymphocytes with HLA-DR surface antigens and significantly decreased (p < 0.002) percentage of lymphocytes with CD8 surface antigens were observed in patients with non-specific inflammatory bowel diseases. In 6 of 12 patients the skin test results were negative. The clinical symptoms, which may suggest the maintaining inflammation of the intestinal mucosa were found in 50% of patients examined after surgical procedure because of Crohn's disease. The results suggest there are significant disturbances of cellular immunoreactivity parameters in patients with non-specific inflammatory bowel diseases. It may be one of the causes, which maintain the chronic inflammation of the intestinal mucosa and favour disease recurrence. The cellular immunoreactivity disturbances demonstrated in this study may be the result of the still persisting intestinal mucosa. Inflammation, in spite of deficiency of synonymous clinical symptoms indicating the disease recurrence.

[Pancreatic fistulas]. / Przetoki trzustkowe.

The aim of our study was retrospective analysis of causes and treatment results of pancreatic fistula. In years 1989-1996, 40 patients aged 14-74 years were treated for pancreatic fistula in the Department of Gastroenterologic Surgery of Medical University in Warsaw. The majority of patients (36 adults) were treated conservatively, with the use of parenteral nutrition, drainage and somatostatin (in case of 4 patients). The healing of pancreatic fistula occurred in 27 medically treated patients after 26 days of therapy (mean value), the remaining patients were treated surgically. The applied treatment was effective in 38 out of 40 cases, 2 patients died (5.0%) due to the complications not connected with pancreatic fistula. In our opinion, in early stages of treatment of pancreatic fistula the conservative therapy with the use of parenteral nutrition is the treatment of choice and elective surgery should be used in patients, in whom conservative treatment fails.

[Selected aspects of nutritional support in patients after liver transplantation]. / Wybrane aspekty leczenia zywieniowego u chorych po przeszczepieniu watroby.

The majority of liver transplanted patients are severely malnourished that increases the incidence of postoperative morbidity and mortality. The authors analysed the effects of nutritional support-total parenteral nutrition-in 11 adult orthotopic liver allograft recipients (9 women, 2 men) transplanted for chronic or acute liver failure in 1994-1997. 4.3-9.75 g of N/24h, 1200-1700 kcal in 1750-2750 ml, from 2-5th postoperative day was administered via central vein in all-in-one system for 4-46 days. Neither metabolic nor septic complications related to the nutrition were observed. The function of the transplanted liver was not impaired by the nutrition. One patient died in course of hepatic coma, 10 patients are alive and in good general condition (1-29 months). In conclusion, the total parenteral nutrition is safe, beneficial and thus recommended routine therapy in the treatment of the liver transplanted malnourished patients.

[Selected cellular immunity parameters in patients with Lesniowski-Crohn disease]. / Wybrane parametry odpornosci komórkowej u chorych z choroba Lesniowskiego--Crohna.

The study was aimed at investigating the expression of HLA-DR, CD4, CD8, CD56 and CD16 surface antigens on peripheral blood lymphocytes in patients with Crohn's disease. The percentage of rosette-forming T-cells in theophylline test was assessed simultaneously. The experiment at group consisted of 18 patients (aged 16-66) of long standing Crohn's disease history, being in the remission period and not treated by steroid antiinflammatory drugs. The percentage of lymphocytes with HLA-DR, CD4, CD8, CD56 and CD16 surface antigens was examined by means of the monoclonal antibodies (DAKO), and the APAAP procedure. The immunological test included also an assessment of the number of T-cells forming active (ARFC) and total (TRFC) rosettes in the theophylline test. Significantly increased (p < 0.001) percentage of lymphocytes with HLA-DR surface antigens was observed in patients with Crohn's disease. The percentage of lymphocytes with CD4, CD8, CD56 and CD16 surface antigens did not differ significantly from the control group, although the tendency for increase in the percentage of lymphocytes with CD8 surface antigens was clearly marked. The ratio of lymphocytes with CD4 to CD8 surface antigens and the number of T-cells forming active and total rosettes were significantly lower (p < 0.05) in patients with Crohn's disease. In 10 of 18 patients the number of T-cells forming active and total rosettes was lower than 500 cells in 1 mm3 peripheral blood. In addition particular notice should be given to the fact that no T-cells reaction to theophylline was obtained in patients' group. The results suggest significant cellular immunoreactivity disturbances which may be the result of the persisting intestinal mucosa's inflammation in patients with Crohn's disease being in the remission period. The studies of peripheral blood lymphocytes with HLA-DR surface antigens may have significance in Crohn's disease's clinical monitoring.

[Parenteral nutrition at home]. / Zywienie pozajelitowe w domu.

Development of home parenteral nutrition (HPN) allowed for long term survival for patients with chronic intestinal failure, followed mainly total or near total small bowel resection. Own 11 years long experience with 49 HPN patients treated for 98 patients years with a HPN model adapted to polish conditions is presented. Long term survival (4 patients over 10 years) and low complications rate, comparable to reported from West European countries and USA, shows HPN possible in Poland and developed HPN model is efficient and safe method of life-restoring therapy with long term survival of patients with severe disturbances of absorption otherwise leading to death by starvation.

[Evaluation of the effectiveness of cefazolin++ (Kefzol) in preventing infections in patients after abdominal surgery]. / Ocena skutecznosci cefazoliny (Kefzol) w zapobieganiu zakazeniom u chorych po operacjach brzusznych.

The purpose of the work as an assessment of the effectiveness of cefazolin (Kefzol) in preventing infections in patients after abdominal surgery. The prospective studies included 200 patients, out of whom in 100 patients in the studied group Kefzol was administered prior to and for 24 hours after operation, while in 100 patients in the control group no prevention was used. The percent of infections in the studied group was lower in comparison to the control group (9% vs 25%, p < 0.01). A statistically significant reduction was obtained of wound infection per cent from 19% in the control group to 7% in the studied group, including a reduction from 14.3% to 3.1% after operations on the gall bladder and bile ducts, and from 18.2% to 11.1% after gastroduodenal operations. The per cent of wound infections after appendectomy was 5.9% in the patients from the studied group receiving prophylactically Kefzol with metronidazole, and 20.6% in the patients from the control group. Bacteriological investigations, demonstrated that 87.5% bacterial strains were susceptible to cefazolin. In the authors' opinion cefazolin (Kefzol) is effective in the prevention of purulent complications, and the reduction of the per cent of infections causes lowering of treatment cost.

[Imipenem in the treatment of patients with severe surgical infection]. / Imipenem w leczeniu ciezkich zakazen u chorych chirurgicznych.

The clinical efficacy and safety of intravenously administered imipenem/cilastatin in the treatment of 45 patients with severe bacterial septicemia due to intra-abdominal abscesses, respiratory and urinary tract as well as skin, soft tissue and bone infections was studied in the prospective and open trial. The in vitro antimicrobial activity of imipenem has been assessed on the basis of 909 bacterial strains isolated from patients treated and non-treated with imipenem/cilastatin. Among them were 526 Gram-negative, 370 Gram-positive aerobic bacteria and 13 Gram-negative anaerobic bacteria (Bacteroides sp.). Pathogen susceptibility to imipenem was determined with a disc-diffusion technique using Merck, Sharp Dohme sensitive discs containing 10 mcg of imipenem. Highly sensitive to imipenem were 96.8% of Gram-negative 82.7% of Gram-positive aerobic bacteria and 100% of Bacteroides sp. All patients, in whom evident foci of infection e.g. intra-abdominal abscesses were discovered, were operated on. The dosage of imipenem/cilastatin ranged from 1.5 to 2.0 g/24 h. Clinical cure and bacteriological elimination was achieved in 39 (86.7%) of patients while 6 (13.3%) showed marked clinical improvement. Before and during therapy, aerobic and anaerobic cultures were taken from accessible sites. All specimens were worked up using conventional bacteriological techniques. Before during and after therapy, samples for hematology, biochemistry and urinanalysis were obtained. Adverse clinical effects were noted in 2 (4.4%) patients. One had nausea and vomiting which were probably related to rapid infusion and disappeared after increasing the administration time, and one had transient diarrhea. In conclusion, imipenem/cilastatin was a well tolerated and effective drug in the treatment of life-threatening surgical infections.