A case of ANCA-associated vasculitis presenting de novo in pregnancy, successfully treated with rituximab.

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitides are rare small vessel vasculitides of unknown cause. The pathogenic role of MPO-ANCA in the vasculitides has been supported using various animal models, with B-cells playing a role in the disease pathogenesis. Pregnancy in the presence of an autoimmune disease such as vasculitis is often associated with significant morbidity. Little is known about the outcomes when women present with de novo vasculitis during pregnancy, and the appropriate management of such presentations is unclear. We describe a case of a 33-year-old female presenting in her second pregnancy with new onset ANCA vasculitis at 12 weeks' gestation. She was successfully treated with prednisolone and rituximab, and delivered a healthy 2.8 kg boy at 36 weeks' gestation with no clinical manifestations of vasculitis or neutropenia in the neonate.

Mechanisms involved in the development of the small intestine mucosal layer in postnatal piglets.

The use of complementary visualization and measurement techniques allowed accurate description and quantification of changes in the intestinal mucosal architecture and provided a comprehensive outlook on the dynamics of remodelling and maturation processes of the mucosal layer taking place in the small intestine of piglets from birth to weaning. The aim of the study was to examine the early postnatal development of the small intestine in pigs. Three techniques were used: scanning electron microscopy (measurements of villus density and shape, height of enterocytes and microvilli, cell exfoliation, and location of extrusion zones), optical microscopy (cross section, measurement of structures: villus length and width; crypt depth; mucosal thickness), and confocal microscopy (cell localization, apoptosis, exfoliation and migration). The postnatal development of the mucosal layer of the small intestine was reflected in changes in the density, length, width, and shape of villi, crypt depth, replacement of enterocyte population, and arrangement. The presence of deep transverse furrows on villus corpus and vacuolated fetal-type enterocytes in the mucosal layer of the small intestine, which are able to engulf large amounts of colostrum shortly after birth, appears to play an important role in the observed phenomenon of straightening of the villus height and increasing of the villus diameter shortly after birth. We hypothesized that the intestinal mucosal layer is compressed before birth and ready to unfold within a short time after birth.

Intestinal MMC-related electric fields and pancreatic juice control the adhesion of Gram-positive and Gram-negative bacteria to the gut epithelium--in vitro study.

The adhesion of six different Lactobacillus and Lactococcus and three pathogenic Escherichia and Salmonella strains was studied using Caco-2 cell line. In this in vitro model system the influence of weak electric field (EF) on bacterial adhesion was tested. The EF source was the in vitro reconstruction of spiking potentials recorded in the duodenum of a healthy calf during one myoelectrical migration complex (MMC) cycle. The ability to adhere to Caco-2 cells of bacteria belonging to two groups, Gram-positive lactobacilli and lactococci, and Gram-negative Escherichia and Salmonella differed considerably. The pathogenic bacteria adhered better to well-differentiated Caco-2 cells whereas lactobacilli and lactococci displayed better adhesion to non-differentiated Caco-2 cells. In the presence of MMC-related EF an increased adhesion of Lactobacillus and Lactococcus but not of Salmonella enterica s. Enteritidis and E. coli 269 to Caco-2 cells was observed. Two later strains adhered even less in the presence of EF. The same tendency was found in the presence of pancreatic juice in a cell medium. In conclusion, the myoelectric component of the small intestinal motility, the MMC-related EF, and pancreatic juice may increase the ability of lactic acid bacteria to adhere to GI epithelial cells, creating better environmental conditions for colonization of the intestine and competition with Gram-negative pathogens.

Gradual disappearance of vacuolated enterocytes in the small intestine of neonatal piglets.

The unique feature of enterocytes in newborn mammals is the presence of an apical canalicular system (ACS) leading to production of large vacuoles, important for colostral macromolecule uptake. The vacuolated fetal-type enterocytes (VFE) enable transfer of colostral and milk proteins from the intestinal lumen across the epithelium without loosing their biological activity. First VFE are observed in the pig and lamb fetuses in the second trimester of pregnancy, located at the upper part of villi in the proximal region of the fetal small intestine and subsequently in the middle and distal regions. After birth the VFE are replaced with enterocytes lacking ACS. The present study aimed to investigate the depletion of VFE in the small intestine in the sow reared pig neonates during the first postnatal weeks using scanning electron microscopy (SEM). The SEM analysis demonstrated the gradual disappearance of vacuolated enterocytes in time. VFE remained in the jejunum for a few days after birth, whereas in the duodenum single VFE were present only at birth. In the proximal jejunum, the VFE were localized in the upper part of the villi, and disappeared until the day 3 of life. VFE were present in the mid and distal jejunum, and diminished gradually until day 14 of life. By the day 21 of life, the vacuolated cells were not observed neither in the jejunum nor ileum. In conclusion, morphology analysis of pig small intestinal mucosa suggests that replacement of fetal type vacuolated enterocytes is resumed within 21 days after birth.

Into the unknown--the death pathways in the neonatal gut epithelium.

Apoptosis is a fundamental process in the development of the fast growing intestinal mucosa. Apoptotic cells are present along the whole length of the villi and in the crypts. The mechanisms involved in the induction of apoptosis in the gut mucosa are still unknown. Cytokines are believed to play a role in auto- and paracrine models because the cells are dying in so-called "packets" containing neighboring cells. In the rapidly developing gut of neonates, the apoptosis rate is transiently reduced in the first days of life, enhancing the growth of mucosa. Afterwards, apoptosis plays a role in the exchange of the enterocyte population, facilitating maturation of the mucosa. The presence of autophagic cells has been confirmed for the first time in the developing gut. Deprivation of growth factors during feeding artificial milk formula led to an increased apoptosis rate. Supplementation with leptin reduced cell apoptosis and increased the mitosis-to-apoptosis ratio. Autophagy was also diminished. The key to healthy gut mucosa growth in early life, especially in fast-growing animals, is colostrum, which supplies nutritional and defensive components together with supplementary growth factors, cytokines and hormones essential for growth and maturation of gut mucosa.

Light and scanning electron microscopy evaluation of the postnatal small intestinal mucosa development in pigs.

Modifications in the structure of gastrointestinal mucosa is often used to evaluate gut function for instance during the development or in response to particular food components. Scanning electron microscopy (SEM) gives a chance to observe the surface of the gut epithelium in three dimensions. However, this technique is seldom used due to technical difficulties. The present study attempted to investigate the intestinal mucosa structure changes in the postnatal pig using light and scanning electron microscopy technique. Experiments were carried out on sow reared piglets from birth until 38 days of age. Piglets were sacrificed at birth and at the 3(rd), 7(th), 21(st) and 38(th) day of life. The entire gastrointestinal tract was immediately harvested and the whole thickness tissue samples were taken from the duodenum, jejunum and ileum for optical and scanning electron microscopy. SEM analyses corroborated with histometry made by optical microscopy. Moreover, a number of shape modifications of the villi and its surface have been observed. The development changes in small intestine mucosa during the first 3 weeks were manifested in shape, size and density of villi. In conclusion, the structure of small intestinal mucosa undergoes profound structural changes. SEM gives a new dimension in the investigation of gut mucosa.

[Classification of the adolescent idiopathic scoliosis and preoperative strategy]. / Klasyfikacja mlodzienczych skolioz idiopatycznych i jej przydatnosc w planowaniu leczenia operacyjnego.

The authors analysed 841 patients (83% girls and 17% boys) with adolescent idiopathic scoliosis. 678 patients (group I) were treated with the Harrington technique and 163 patients (group II) were treated using multisegmental instrumentation. Follow-up time in group I was on average 14.2 years, and 28 months in group II. Preoperative assessment of patients in group was based on clinical and radiological examination. Assessment of the spine was mainly based on coronal radiogram done in an upright position and lateral side-bending radiograms in a supine position. Traction and lateral X rays were rarely taken into account in this study. The fusion area was decided according to the end vertebrae of the structural curves. The caudal end of the fusion area was identified using Harrington's stable zone. The curves were classified in accordance with the SRS suggestions. Taking into account the apex of the curve, the deformations were classified into: cervico-thoracic, thoracic, thoraco-lumbar, lumbar and lumbo-sacral curves. In group II the triplanar (3D) character of the deformity was taken into account. In the coronal plane the upper and lower stable vertebra of the major structural curves were identified using the CSVL (Central Sacral Vertical Line) based on long films (70 cm x 110 cm) with and without traction. Lumbar curve was classified as mild, moderate, severe according to CSVL. In the axial plane vertebral rotation was assessed according to Nash and Moe method. A careful analysis of lateral radiograms in the upright standing position was performed. Lateral radiograms were performed also in maximal flexion and hyperextension of the spine to obtain a dynamic evaluation of the sagittal plane. Conoral radiograms with maximal rotation of the trunk to assess mobility of the caudad segments of the deformity. Classification of the scoliotic deformity based on its triplanar character included: thoracic curves (King III, IV, V types), double major (thoracic and lumbar), "false" double major curve (thoracic and lumbar) King type II, thoracolumbar/lumbar curves--the main curve is thoracolumbar lumbar/thoracolumbar curves--the main curve is lumbar--10 degrees the thoracolumbar component--King type I triple major curve--all curves have similar structural changes. Correct identification of the type of scoliosis, assessment of structural changes in the frontal, sagittal and axial plane (three dimensional 3D) and analysis of the size and correctiveness of the lumbar curve and all parameters which play a key role in rational preoperative planning. Redefining or at least maintaining lumbar lordosis is far more important than correction of thoracic kyphosis.

[Musculo-skeletal mechanisms of low back pain]. / Miesniowo-szkieletowy mechanizm bólu krzyza.

Authors presented in comprehensive form updated knowledge concerning reasons and mechanisms of musculoskeletal back pain nonspecific symptom which in majority of cases, provides only little inside into the nature of the underlying problem. The physician must however find sufficient time to educate the patient as to the nature of this disorder and likely course during treatment. Understanding the source and mechanisms of the patients pain allows the physician and patient to approach the problem rationally with mutual confidence. The basic aim of the physician is exact identification of the anatomic source of pain and exclude the possibility of underlying systemic or malignant process that might threaten the patient's life. The musculoskeletal system consists of the bones and articulations, ligaments, muscles and tendons, that connect and manipulate them within spinal column. All of these tissues are richly innervated and specific biomechanical conditions cause, that lumbar part of the spine and lumbosacral junction are extremely susceptible to direct and indirect affected by a spectrum of reasons causing pain. The pathomechanism of the pain originating within the facet joints, bone and periosteum, paraspinous muscles and tendons, intervertebral disks, posterior longitudinal ligament and dorsal root ganglion was discussed. Although in majority of causes it possible to control localized pain by means of conservative treatment, however in some patients (0.5%-1%) surgery is needed to decompress neurologic structures, restore stability, and eliminate pain.

[Idiopathic scoliosis: epidemiology and etiology]. / Skolioza idiopatyczna--epidemiologia i etiologia.

Authors present current knowledge about incidence and etiologic factors in idiopathic scoliosis (IS). Most data about incidence are based on screening examination in school children. Amount of patient with IS is related to the method of evaluation and experience of examiner. There is 1.9% to 3% cases in whole population if scoliosis is assumed as much as 10 degrees of Cobb angle (SRS). Etiology of IS is still in doubt despite of many investigations. There are many abnormalities in tissues but most of them probably secondary to this process. Etiology is multifactorial with dominance of inheritance. There are many genes responsible for occurrence of IS but genetic trait is still unknown.

Ultrasound measurements of the newborn hip. Comparison of two methods in 657 newborns.

We compared ultrasound measurements using the Graf and Terjesen methods in 657 newborns. The alpha angle and femoral head coverage (FHC) were analyzed. The rate of DDH was 3.9%, according to Graf and 2.9%, according to Terjesen. The spontaneous increases in alpha angle and FHC were 5 degrees and 7%, respectively, during the first 2 months. Good accordance between the two methods was shown. A few hips were normal, according to one method and were subluxated, according to the other one. The methods gave similar results, except the percentage of "immature hips" IIa (29%) and "possible dysplastic hips" (14%). This might be a sign of better specificity of the Terjesen method. Good interosberver agreement and simple classification favor use of the Terjesen method. The method of Graf is the most commonly used and gives adequate evaluation of the hip, if the method of examination and rather complicated classification are followed closely.

[Algorithm in low back pain management in adults]. / Algorytm postepowania w bólach krzyza u doroslych.

Currently recommended management for low back pain in adults is presented. The algorithm consists of two phases. In a patient presenting acute low back pain with no previous history thorough clinical evaluation (phase I) should aim at exclusion of cauda equina syndrome, fracture, neoplasm, infection, progressive neurological deficit, or chronic pain syndrome. If none of these condition is responsible for low back pain 4-6 weeks therapy depending on the severity of symptoms should be commenced. Then clinical reevaluation is indicated and if pain persists patient should be referred to a specialist (phase II). Previous diagnosis and treatment should be reviewed critically; if found appropriate the treatment might be repeated during phase II. Primary sources of low back pain as herniated nucleus pulposus, unremitting low back pain (segmental instability), spondylolysis, isthmic spondylolisthesis degenerative spondylolisthesis with spinal stenosis should be identified and appropriate treatment (surgical or conservative) undertaken. Patient education is an important component of phase II. In general, phase II of the algorithm aims at returning the patient to full psychophysical activity and at prevention of low back pain recurrence.

[Range of distal spondylodesis in surgical treatment of idiopathic scoliosis using multisegmental instrumentation]. / Rozleglosc spondylodezy tylnej w leczeniu operacyjnym skolioz idiopatycznych przy uzyciu instrumentarium wielosegmentowego.

This presentation aim was to provide correct answer in question of range of spondylodesis (both proximal and distal levels) in surgical treatment of idiopathic scoliosis with multisegmental instrumentation. The postoperative evaluation o 88 patients (77 girls and 11 boys) was done according to King and Moe classification. Average patients age was 13.8 years (11.4-17.1) with 18.2 months (12-29) follow-up. In 53 cases it was longer than 2 years. The identification of the curve pattern in both the coronal and sagittal planes will allow you to decide which curves to fuse. In the choice of upper fusion level one should keep attention to shoulder balance and presence of superior junctional kyphosis, extending than range of the fusion up to T2. In the lower level there is important to keep distal fusion mass in vertical alignment transsected by CSL (just like in the upper end in thoracic spine) to preserve spine compensation and remaining as many sa possible mobile spine segments below the fusion.

[The most frequent errors during use of the surgical techniques of Cotrela-Dubousset (C-D) and Texas Scottish Rite Hospital (TSRH) for surgical treatment of idiopathic scoliosis]. / Najczesciej popelniane bledy podczas zastosowania techniki operacyjnej Cotrela-Dubousseta (C-D) i Texas Scottish Rite Hospital (TSRH) w leczeniu operacyjnym skolioz idiopatycznych.

Results of operative treatment of idiopathic scoliosis in 88 patients (77 girls and 11 boys) with an average follow-up of 18 months have been presented. Basic principles of surgical procedure and most commonly made errors are demonstrated on the basis of authors' experience and data from the literature. The method of strategic vertebrae selection for hook implantation depending on scoliosis type are discussed. Differences in surgical technique in respect to idiopathic lordoscoliosis or kyphoscoliosis have been highlighted.