Prognostic value of midregional proadrenomedullin in critically ill patients.

INTRODUCTION: Scoring systems can be used to predict the risk of mortality and outcomes in critically ill patients. Acute kidney injury (AKI) is one of the strongest factors negatively influencing patient outcomes. Midregional proadrenomedullin (MR­proADM) shows promising results as an outcome predictor in patients with sepsis. OBJECTIVES: We aimed to evaluate the value of MR­proADM in incident AKI and mortality prognostication among patients admitted to the intensive care unit (ICU) in comparison with commonly used scoring systems. PATIENTS AND METHODS: Our study included a single­center cohort of 77 patients admitted to the ICU. Plasma MR­proADM levels were measured within 24 h of admission. The Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) scores were used as a reference. The primary endpoints were incident AKI and in­hospital mortality. RESULTS: Patients who died during hospitalization period had a higher MR­proADM concentrations as compared with patients who survived (2592.5 pg/ml vs 995.3 pg/ml; P <0.001). The levels of MR­proADM correlated positively with the APACHE II or SOFA score (r = 0.3; P = 0.004 and r = 0.3; P = 0.008, respectively). In the receiver operating characteristics analysis, MR­proADM concentration was superior to both scoring systems (P = 0.002 and P = 0.001, respectively). In univariate logistic regression, MR­proADM was associated with in­hospital mortality (odds ratio [OR], 1.22; 95% CI, 1.11-1.35 per 100 pg/ml increase of MR­proADM) and after adjusting for multiple variables remained an independent predictor of death (OR, 1.35; 95% CI, 1.22-1.49 per 100 pg/ml increase of MR­proADM). MR­proADM was not useful in predicting incident AKI. CONCLUSIONS: MR­proADM can be applied in clinical practice as a prognostic tool for mortality but not incident AKI in the general ICU population with at least similar accuracy as APACHE II and SOFA scores.

Diagnostic effectiveness of soluble triggering receptor expressed on myeloid cells-1 in sepsis, severe sepsis and septic shock.

INTRODUCTION: Sensitivities and specificities of clinical signs and biochemical tests in sepsis diagnosis are not satisfactory. The aim of the study was to assess the diagnostic usefulness of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in sepsis, severe sepsis and septic shock against interleukin-6 (IL-6), C-reactive protein (CRP) and procalcitonin (PCT). MATERIAL AND METHODS: A prospective, observational study was conducted in 85 adults with sepsis, severe sepsis or septic shock and 22 with non-infective systemic inflammatory response syndrome (NI-SIRS). Serum levels of sTREM-1, CRP, PCT and IL-6 were measured on admission. RESULTS: Median serum sTREM-1 concentrations were higher in severe sepsis (540 pg/ml) and septic shock (536 pg/ml) in comparison with NI-SIRS patients (p < 0.05). There were no differences in sTREM-1 levels between NI-SIRS and sepsis. Similarly, CRP, PCT and IL-6 were significantly elevated in patients with severe sepsis and septic shock in comparison with NI-SIRS. The receiver operating characteristic curve analysis for diagnosis of severe sepsis showed higher discriminative value for CRP and IL-6 (AUC = 0.909, 95% CI: 0.829-0.99 and AUC = 0.854, 95% CI: 0.728-0.980, respectively) than sTREM-1 (AUC = 0.733, 95% CI: 0.596-0.870). In septic shock the highest AUC was found for CRP (AUC = 0.938, 95% CI: 0.872-1.0), lower for IL-6 (AUC = 0.869, 95% CI: 0.751-0.987), PCT (AUC = 0.828, 95% CI: 0.71-0.945) and sTREM-1 (AUC = 0.705, 95% CI: 0.553-0.856). CONCLUSIONS: Serum level of sTREM-1 has lower effectiveness as a diagnostic biomarker in severe sepsis and septic shock, in comparison with CRP and IL-6.

The imbalance of peripheral interleukin-18 and transforming growth factor-ß1 levels in patients with cirrhosis and esophageal varices.

INTRODUCTION: The presence of esophageal varices in liver cirrhosis indicates clinically significant portal hypertension (PH), that results from structural and dynamic changes in the liver and systemic circulation including the activation of several fibrotic and inflammatory pathways. We assessed if interleukin-18 (IL-18) and transforming growth factor-ß1 (TGF-ß1) serum levels can be used as PH markers and reflect its severity. MATERIAL AND METHODS: IL-18 and TGF-ß1 peripheral blood levels were analyzed in 83 cirrhotic patients with esophageal varices compared to healthy individuals, in relation to MELD and Child-Pugh scores, laboratory and Doppler ultrasound parameters, and non-selective beta-blocker therapy (NSBB). RESULTS: IL-18 concentration was significantly higher in cirrhotic patients, while TGF-ß1 concentration was lower than in controls. MELD score correlated positively with IL-18 levels and negatively with TGF-ß1 levels. IL-18 levels correlated positively with bilirubin, INR, ALT and AST levels, and negatively with albumin levels and erythrocyte count. TGF-ß1 levels correlated positively with platelet count, leukocyte, and erythrocyte count, and negatively with bilirubin levels and prothrombin time. Moreover, significant correlations were found: between IL and 18 levels and portal, mesenteric superior, and splenic vein velocity, and between TGF-ß1 levels and splenic vein diameter and spleen size. In a subgroup of patients, IL-18 levels significantly decreased after NSBB. CONCLUSION: The observed imbalance of peripheral IL-18 and TGF-ß1 levels indicates clinically significant PH associated with the presence of esophageal varices in cirrhosis. The correlation of IL-18 levels with liver failure indicators and decrease with NSBB suggest an important role of IL-18 in disease progression and its potential use as noninvasive test for PH assessment.

Soluble TREM-1 Serum Level can Early Predict Mortality of Patients with Sepsis, Severe Sepsis and Septic Shock.

Early prognostic prediction of sepsis is essential in adjusting therapeutic protocols to prevent deterioration and reduce mortality. We compared the predictive value of the serum concentration of the soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) for 28-day mortality and for the development of severe sepsis or septic shock on the third day with the levels of interleukin (IL)-6, C-reactive protein (CRP) and procalcitonin (PCT). The study was conducted on 85 patients with sepsis. sTREM-1, CRP, PCT and IL-6 concentrations were measured upon study inclusion (day 0) and on days 1, 2, 3 and 5. APACHE II, SAPS II and SOFA scores were analyzed. The sTREM-1 levels (pg/ml) were higher in non-survivors than in survivors at admission (773 vs. 391, p < 0.001) and on days 1, 2, 3 and 5. In predicting the development of severe sepsis, the highest AUCs were found for PCT (0.744, 95% CI 0.638-0.85) and sTREM-1 (0.664, 95% CI 0.55-0.778); and in septic shock prediction, for PCT (0.766, 95% CI 0.665-0.867) and IL-6 (0.707, 95% CI 0.595-0.819). sTREM-1 positively correlated with APACHE II, SAPS II and SOFA scores. At inclusion, significant AUC for predicting 28-day mortality was 0.772 for the sTREM-1 (95% CI 0.672-0.871), 0.858 for APACHE II (95% CI 0.768-0.948), 0.847 for SAPS II (95% CI 0.733-0.96), 0.806 for SOFA score (95% CI 0.698-0.915). sTREM-1 can early predict the 28-day sepsis mortality, although its effectiveness is lower in comparison with clinical severity scores.

C-terminal and intact FGF23 in critical illness and their associations with acute kidney injury and in-hospital mortality.

BACKGROUND: FGF23 proved its value in prognostication of cardiovascular events and mortality among renal patients and general population. Limited data exist whether FGF23 may have any use in prediction of negative outcomes among critically ill patients admitted to intensive care unit (ICU). METHODS: Single center cohort study performed among patients admitted to ICU. The primary exposure was FGF23 plasma concentration measured within 24 h of ICU admission. The primary outcome was incident Acute Kidney Injury (AKI) and in-hospital mortality during the ICU stay. RESULTS: The study enrolled 79 patients admitted to ICU. C-terminal FGF23 (cFGF23) but not intact FGF23 (iFGF23) concentration was significantly elevated in patients, who acquired AKI and non-survivors (p < .001). ROC analysis of cFGF23 yielded an AUC of 0.81 and 0.85 for prediction of incident AKI and death during ICU stay, respectively. Multivariate analysis showed higher odds for AKI (OR 1.80; 95% CI 1.10-2.96) and in-hospital mortality (OR 2.85; 95% CI 1.60-5.06) for one unit increase of log transformed cFGF23. CONCLUSIONS: cFGF23 measurement may serve as a novel biomarker for incident AKI and death among critically ill patients.

Estimation of V-POSSUM and E-PASS Scores in Prediction of Acute Kidney Injury in Patients after Elective Open Abdominal Aortic Aneurysm Surgery.

BACKGROUND: V-POSSUM and E-PASS scoring systems are usually used to predict morbidity and early mortality in surgical patients. We conducted this study to assess the validity of the V-POSSUM and E-PASS scores in predicting risk of acute kidney injury (AKI) development in patients undergoing elective open abdominal aortic aneurysm (AAA) repair. METHODS: We studied a consecutive series of 171 patients with AAA, qualified for elective open infrarenal repair. Patients underwent a thorough examination, and the physiological and surgical stress components of the V-POSSUM and E-PASS scores were calculated. The classification of patients in terms of postoperative AKI was performed in accordance with KDIGO criteria. RESULTS: AKI was recognized in 62 patients. In these patients, we found significantly higher physiological and surgical stress components of V-POSSUM and E-PASS scores in relation to patients without AKI. ROC analysis showed that the E-PASS score with a cutoff point ≥0.796 and the V-POSSUM score (morbidity) with a cutoff point ≥77.2% with sensitivity of 75.8% and 74.2%, respectively, and with specificity of 83.5% for both, identified patients with postoperative AKI. CONCLUSIONS: V-POSSUM and E-PASS scores have similar good properties in predicting postoperative AKI in patients undergoing elective open AAA repair.

Total knee replacement induces peripheral blood lymphocytes apoptosis and it is not prevented by regional anesthesia - a randomized study / Artroplastia total do joelho induz apoptose em linfócitos de sangue periférico e não é evitada por anestesia regional - Estudo randomizado

ABSTRACT BACKGROUND: Among the many changes caused by a surgical insult one of the least studied is postoperative immunosuppression. This phenomenon is an important cause of infectious complications of surgery such as surgical site infection or hospital acquired pneumonia. One of the mechanisms leading to postoperative immunosuppression is the apoptosis of immunological cells. Anesthesia during surgery is intended to minimize harmful changes and maintain perioperative homeostasis. The aim of the study was evaluation of the effect of the anesthetic technique used for total knee replacement on postoperative peripheral blood lymphocyte apoptosis. METHODS: 34 patients undergoing primary total knee replacement were randomly assigned to two regional anesthetic protocols: spinal anesthesia and combined spinal-epidural anesthesia. 11 patients undergoing total knee replacement under general anesthesia served as control group. Before surgery, immediately after surgery, during first postoperative day and seven days after the surgery venous blood samples were taken and the immunological status of the patient was assessed with the use of flow cytometry, along with lymphocyte apoptosis using fluorescent microscopy. RESULTS: Peripheral blood lymphocyte apoptosis was seen immediately in the postoperative period and was accompanied by a decrease of the number of T cells and B cells. There were no significant differences in the number of apoptotic lymphocytes according to the anesthetic protocol. Changes in the number of T CD3/8 cells and the number of apoptotic lymphocytes were seen on the seventh day after surgery. CONCLUSION: Peripheral blood lymphocyte apoptosis is an early event in the postoperative period that lasts up to seven days and is not affected by the choice of the anesthetic technique.

RESUMO JUSTIFICATIVA E OBJETIVO: Dentre as muitas alterações causadas por uma ferida cirúrgica, uma das menos estudadas é a imunossupressão pós-operatória. Esse fenômeno é uma causa importante das complicações infecciosas relacionadas à cirurgia, como infecção do sítio cirúrgico ou pneumonia nosocomial. Um dos mecanismos que levam à imunossupressão pós-operatória é a apoptose de células imunológicas. Durante a cirurgia, a anestesia se destina a minimizar as alterações prejudiciais e manter a homeostase perioperatória. O objetivo deste estudo foi avaliar o efeito da técnica anestésica usada para artroplastia total de joelho sobre a apoptose em linfócitos de sangue periférico no pós-operatório. MÉTODOS: Trinta e quatro pacientes submetidos à artroplastia total primária de joelho foram randomicamente designados para dois protocolos de anestesia regional: raquianestesia e bloqueio combinado raqui-peridural. Onze pacientes submetidos à artroplastia total do joelho sob anestesia geral formaram o grupo controle. Antes da cirurgia, logo após a cirurgia, durante o primeiro dia de pós-operatório e sete dias após a cirurgia, amostras de sangue venoso foram colhidas e o estado imunológico do paciente foi avaliado com o uso deflow cysts 87 m, juntamente com apoptose de linfócitos com o uso de microscopia de fluorescência. RESULTADOS: Apoptose em linfócitos de sangue periférico foi observada imediatamente no pós-operatório e acompanhada por uma redução do número de células T e B. Não houve diferença significativa no número de linfócitos apoptóticos de acordo com o protocolo anestésico. Alterações no número de células T CD3/8 e no número de linfócitos apoptóticos foram observadas no sétimo dia após a cirurgia. CONCLUSÃO: Apoptose em linfócitos de sangue periférico é um evento precoce no período pós-operatório que dura até sete dias e não é afetado pela escolha da técnica anestésica.

Total knee replacement induces peripheral blood lymphocytes apoptosis and it is not prevented by regional anesthesia - a randomized study.

BACKGROUND: Among the many changes caused by a surgical insult one of the least studied is postoperative immunosuppression. This phenomenon is an important cause of infectious complications of surgery such as surgical site infection or hospital acquired pneumonia. One of the mechanisms leading to postoperative immunosuppression is the apoptosis of immunological cells. Anesthesia during surgery is intended to minimize harmful changes and maintain perioperative homeostasis. The aim of the study was evaluation of the effect of the anesthetic technique used for total knee replacement on postoperative peripheral blood lymphocyte apoptosis. METHODS: 34 patients undergoing primary total knee replacement were randomly assigned to two regional anesthetic protocols: spinal anesthesia and combined spinal-epidural anesthesia. 11 patients undergoing total knee replacement under general anesthesia served as control group. Before surgery, immediately after surgery, during first postoperative day and seven days after the surgery venous blood samples were taken and the immunological status of the patient was assessed with the use of flow cytometry, along with lymphocyte apoptosis using fluorescent microscopy. RESULTS: Peripheral blood lymphocyte apoptosis was seen immediately in the postoperative period and was accompanied by a decrease of the number of T cells and B cells. There were no significant differences in the number of apoptotic lymphocytes according to the anesthetic protocol. Changes in the number of T CD3/8 cells and the number of apoptotic lymphocytes were seen on the seventh day after surgery. CONCLUSION: Peripheral blood lymphocyte apoptosis is an early event in the postoperative period that lasts up to seven days and is not affected by the choice of the anesthetic technique.

[Total knee replacement induces peripheral blood lymphocytes apoptosis and it is not prevented by regional anesthesia - a randomized study]. / Artroplastia total do joelho induz apoptose em linfócitos de sangue periférico e não é evitada por anestesia regional - estudo randomizado.

BACKGROUND: Among the many changes caused by a surgical insult one of the least studied is postoperative immunosuppression. This phenomenon is an important cause of infectious complications of surgery such as surgical site infection or hospital acquired pneumonia. One of the mechanisms leading to postoperative immunosuppression is the apoptosis of immunological cells. Anesthesia during surgery is intended to minimize harmful changes and maintain perioperative homeostasis. The aim of the study was evaluation the effect of the anesthetic technique used for total knee replacement on postoperative peripheral blood lymphocyte apoptosis. METHODS: 34 patients undergoing primary total knee replacement were randomly assigned to two regional anesthetic protocols: spinal anesthesia and combined spinal-epidural anesthesia. 11 patients undergoing total knee replacement under general anesthesia served as control group. Before surgery, immediately after surgery, during first postoperative day and seven days after the surgery venous blood samples were taken and the immunological status of the patient was assessed with the use of flow cysts 87 m, along with lymphocyte apoptosis using fluorescent microscopy. RESULTS: Peripheral blood lymphocyte apoptosis was seen immediately in the postoperative period and was accompanied by a decrease of the number of T cells and B cells. There were no significant differences in the number of apoptotic lymphocytes according to the anesthetic protocol. Changes in the number of T CD3/8 cells and the number of apoptotic lymphocytes were seen on the seventh day after surgery. CONCLUSION: Peripheral blood lymphocyte apoptosis is an early event in the postoperative period lasts up to seven days and is not affected by the choice of the anesthetic technique.

Endothelin 1 and transforming growth factor-ß1 correlate with liver function and portal pressure in cirrhotic patients.

OBJECTIVE: The invasive measurement of hepatic venous pressure gradient is the recommended method for the assessment of portal hypertension. We assessed if the mediators that regulate portal hypertension may be used as noninvasive markers of portal hypertension and liver insufficiency. MATERIALS AND METHODS: We explored in prospective, observational study the concentration of endothelin-1, nitric oxide, and transforming growth factor-ß1/2 in peripheral and hepatic venous blood; their relationship with the values of portal hypertension and liver insufficiency; and their level changes 4-6 months after non-selective beta-blocker therapy in cirrhotic patients with non-bleeding esophageal varices. RESULTS: (1) Cirrhotics have significantly increased peripheral endothelin 1 and decreased transforming growth factor-ß1 levels; (2) peripheral levels of all factors correlated significantly with their hepatic levels; (3) after therapy, peripheral endothelin-1 levels significantly increased, but transforming growth factor-ß2 levels decreased and were lower in patients with pressure gradient value normalization; (4) before and after therapy, peripheral and hepatic endothelin-1, transforming growth factor-ß1/2 levels correlated significantly with liver failure indicators (laboratory parameters, Child-Pough and MELD scores) and pressure gradient values. CONCLUSIONS: Peripheral endothelin-1 and transforming growth factor-ß1 levels, which strongly correlate with their hepatic levels, reflect the stage of portal hypertension and liver insufficiency in cirrhosis.

Circulating endothelial mediators in human pancreatitis-associated lung injury.

OBJECTIVES: To investigate the role of endothelial cell mediators, E-selectin (ES), intercellular adhesion molecule-1 (ICAM-1), tissue factor (TF), and von Willebrand factor (vWF), in the early phase of severe acute pancreatitis (SAP) complicated with respiratory failure [pancreatitis-associated lung injury (PALI)]. PATIENTS AND METHODS: This study included 30 patients with SAP and 39 patients with PALI. Blood samples were taken from SAP and PALI patients on presenting to the hospital (day 1), and days 2, 3, 5, and 10. The relationship between blood concentrations of the studied endothelial mediators and lung function tests was analyzed. RESULTS: PALI patients had significantly higher ES, ICAM-1, TF, and vWF blood levels than those with SAP as early as at admission and throughout the period studied. We found the highest concentration of ES on the second day, ICAM-1 and TF at admission, and vWF level on the fifth day. There were adverse correlations between ES, ICAM-1, TF, vWF concentrations, and the index of oxygenation--PaO2/FiO2 ratio (Rs=-0.385, Rs=-0.523, Rs=-0.505, Rs=-0.408, P<0.001, respectively). The most accurate prediction of PALI was provided by ICAM-1 and TF levels on the day of admission [areas under curve (AUCs): ES, 0.704; ICAM-1, 0.787; TF, 0.757; and vWF, 0.686]. CONCLUSION: Endothelium-related mediators ES, ICAM-1, TF, and vWF appear to participate in pancreatitis-associated lung injury. In SAP, the measurement of endothelial mediator levels (especially ICAM-1 and TF) may be used as an early prognostic indicator that would predict the development of respiratory failure and to monitor the severity of lung dysfunction.

Buprenorphine added to bupivacaine prolongs femoral nerve block duration and improves analgesia in patients undergoing primary total knee arthroplasty-a randomised prospective double-blind study.

The aim of the study was to determine whether the addition the long-acting opioid buprenorphine as an adjuvant to the local anaesthetic agent would improve quality and prolong duration of femoral nerve blockade in post-operative analgesia following primary total knee arthroplasty. The study involved 48 patients. The femoral nerve was anaesthetised with a 0.25% solution of bupivacaine with adrenaline or with the addition of 0.3mg of buprenorphine. The duration of the sensory block and analgesic effect was assessed according to NRS scale at 12, 24, 36, 48, 60 and 72 hours post-surgery. Patients who received buprenorphine as an adjuvant to the local anaesthetic had significantly longer sensory blockade and lower NRS-rated pain intensity with the difference reaching statistical significance at 12 hours post-surgery.

[Ventilator-associated pneumonia and other infections]. / Zapalenie pluc i inne infekcje zwiazane z wentylacja mechaniczna

One of the fundamental elements of therapy in patients hospitalised in the Intensive Care Unit (ICU) is mechanical ventilation (MV). MV enables sufficient gas exchange in patients with severe respiratory insufficiency, thus preserving the proper functioning of organs and systems. However, clinical and experimental studies show that mechanical ventilation may cause severe complications, e.g. lung injury (VALI, VILI), systemic inflammatory response syndrome (SIRS), and, on rare occasions, multiple organ failure (MOF). Mechanical ventilation and especially endotracheal intubation are associated also with higher risk of infectious complications of the respiratory system: ventilator-associated respiratory infection (VARI) and ventilator-associated pneumonia (VAP). The complications of the MV listed above have a significant influence on the length of treatment and also on the increase of the costs of therapy and mortality of patients who stay in an ICU. These negative effects of supported breathing are the reasons for intensive research to find new biological markers of inflammation and lung injury, more sensitive and specific diagnostic instruments, more effective methods of therapy, and programs of prevention. The purpose of this article is the presentation of current knowledge concerning VAP-related infections, to allow pulmonologists and general practitioners to become more familiar with the problem. Basic and the most important data concerning the definition, epidemiology, pathophysiology, microbiology, diagnostics, treatment, and prevention of VAP have been included. Additionally, ventilator-associated tracheobronchitis (VAT) was discussed.

[The role of selected cytokines and proteins analyzed in bronchoalveolar lavage fluid in lung injury]. / Rola wybranych cytokin i protein, badanych w popluczynach oskrzelowo-pecherzykowych, w uszkodzeniu pluc.

The early organism response to injury or infection involves activation of the innate immune system, in which pattern recognition receptors (PRRs) participate. They recognize highly conservative structures that are called pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs). The interactions between PRRs and PAMPs or DAMPs lead to the activation of transcriptional factors which are responsible for gene expression of inflammatory mediators and synthesis and release of these factors, and result in the development of inflammation. RAGE (receptor for advanced glycation end products) and CD163 belonging to PRRs play a significant role in the early immune response in lungs. They are expressed on alveolar epithelial cells and alveolar macrophages, respectively. NK cells are also involved in lung response to injury, though their maturation and the ability to express PRRs depend on the presence of IL-15. Detailed knowledge about these factors enables us to understand the signal pathways that are activated in the course of infectious and noninfectious lung injury. The analysis of these proteins' concentrations in body fluids creates new possibilities in monitoring lung injury and predicting the results of treatment. In the future, the discussed mediators may become the targets for new forms of treatment in life-threatening respiratory diseases.

Increased expression of the intercellular adhesion molecule-1 (ICAM-1) on peripheral blood neutrophils in acute pancreatitis.

PURPOSE: Considering the important role of neutrophils' activation in the pathogenesis of acute pancreatitis (AP), the aim of our study was to evaluate the expression of leukocytes' adhesion molecules in patients with AP. PATIENTS/METHODS: Thirty-five patients (16 women and 19 men; age 32-77 years, median 56 years) with AP were prospectively included into our study. The absolute number of leukocytes was estimated by haematologic analyser. Surface neutrophils antigens (CD) were assayed by the direct fluorescence method for whole blood, using a flow cytometer. RESULTS: At the day 1, significant increase of ICAM-1 expression was found in patients with severe AP (S-AP) (7280 mm(-3) vs 2850 mm(-3) in healthy control; p<0.05). In the days 2, 3 and 5 it sharply decreased and peaked again to 4860 mm(-3) at the day 10. In patients with mild AP (M-AP), not significant elevation of ICAM-1 quickly returned to normal level. In both forms of AP, neutrophil CD62L (L-selectin) expression reached the highest level at the day 1 (8800 mm(-3) and 9020 mm(-3), respectively in M-AP and S-AP, in comparison to 3400 mm(-3) in control; p<0.05). Expression of CD69 (neutrophils' marker of early activation) significantly increased in both M-AP and S-AP. CONCLUSIONS: We have found an early and significant increase of peripheral blood neutrophil CD54/ICAM-1 expression, specific for S-AP but not for M-AP. It may provide a good marker predicting severe course of pancreatitis.

Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis.

OBJECTIVES: The exact time of initiation of total enteral nutrition (TEN) in severe acute pancreatitis (SAP) and its influence on the disease outcome are not well known. METHODS: An analysis of 197 cases with predicted SAP allocated to: group A (n = 97), early TEN (started within the first 48 hours after admission to hospital); and group B (n = 100), delayed TEN (started after 48 hours). RESULTS: Infection of necrosis/fluid collections occurred in 4 patients in group A and 18 patients in group B (P < 0.05). Respiratory failure and transfer to intensive care unit occurred more frequently in group B than in group A (15 vs 5 and 15 vs 3 patients; P < 0.05). Multiple-organ failure was observed in 9 patients in group A and 16 patients in group B (P > 0.05). Seven patients in group A and 11 patients in group B underwent surgery (P > 0.05). All 9 reported deaths occurred in group B (P < 0.05). The time to start TEN was a predictor of infected necrosis/fluid collection (odds ratio, 4.09; P = 0.028). CONCLUSIONS: Delayed compared to early TEN is associated with higher mortality, increased frequency of infected necrosis/fluid collections, respiratory failure, and a need for intensive care unit hospitalization. Enteral nutrition in SAP should be started within 48 hours after admission to hospital.

The use of regional anesthetic techniques in pain management in patients undergoing primary knee replacement.

During last 30 years orthopedic surgery dramatically improved. The most significant progress had place in joint surgery. Today in many orthopedic centers total hip and knee arthroplasties are made and may be counted in hundreds per year. Surgeons can choose among many different implant operation systems. Nevertheless this type of operations is connected with pain in immediate postoperative course. The aim of the paper was presentation of contemporary methods of pain management after big knee surgery, especially after total knee arthroplasty (TKA). Among presented methods of pain management the anesthetic techniques were discussed: epidural anesthesia (EA) and peripheral nerves blocks (PNB). They seem to be most interesting and evolutionary because of possibility of early ambulation and more effective postoperative rehabilitation. It directly corresponds to therapeutic effect of surgical procedure and patient's satisfaction. In the paper there are presented advantages and possible complications of regional techniques, particular block techniques and technical problems with possible modifications of pain management. This review is based on latest medical literature, especially on metaanalyses published during last few years comparing different modes of postoperative pain management.

Molecular basics of sepsis developement.

Bacterial infections and sepsis remain major causes of morbidity and mortality in intensive care units. The normal host response to infection is a complex process that serves to localise and control the invasion of microbes and to repair injured tissue. Local inflammatory processes are regulated through the production of cytokines by macrophages. In some cases, mediator release exceeds the boundaries of the local environment and results in the development of sepsis. It is well known that the innate immune system plays a crucial role in preventing microbial invasion. The human innate immune system consists of genetically programmed defence mechanisms that are directed against molecular components found only in microorganisms. Understanding the complexity of early response to infection with respect to innate immune response is required for the future development of drugs that will effectively control infectious diseases.

Stress hormone response to various anaesthetic techniques during thyroidectomy.

BACKGROUND: Thyroidectomy is among the most frequently performed procedures in endocrine surgery. The hormonal response to surgery and anaesthesia depends in part on the anaesthetic techniques used; therefore, we measured serum concentrations of TSH, fT4, and fT3 in patients scheduled for elective thyroidectomy under TIVA or VIMA. METHODS: Seventy-eight adult patients, of both sexes, with non-toxic or hyperthyroid nodular goitre, were divided into groups with regard to the goitre type and the technique of anaesthesia used during thyroid surgery. Serum concentrations of TSH, fT4, and fT3, were measured and the surgical stress was estimated using the E-PASS scale. RESULTS: In the groups examined, the mean serum concentrations of TSH remained unchanged during the period of observation. The initially high fT4 and fT3 concentrations gradually decreased, reaching their lowest level on the fourth day after surgery. CONCLUSIONS: [corrected] Both VIMA and TIVA can be regarded as safe techniques of anaesthesia for thyroidectomy.

Decreased serum level of IL-12 in the course of ischemia and reperfusion during abdominal aortic surgery.

Ischemic-reperfusion injury (IRI) is defined as tissue damage, organ dysfunction or failure developed in the course of inflammatory response following ischemia and reperfusion (IR). Abdominal aortic aneurysm (AAA) repair required IR of distal parts of the body carries a risk of organ injury and postoperative mortality of between 4% and 12%. The aim of this study was the evaluation of IL-12 serum level during AAA repair in relation to IR. Blood samples were taken before surgery (Preop), before aortic unclamping (Pre-X(off)), 90 min after unclamping (90 min-X(off)) and 24 h after surgery (Postop) from 37 AAA patients; and before surgery (Preop), at 90 min of surgery (90 min-surg), at 180 min of surgery (180 min-surg) and 24 h after operation (stop) from ten patients scheduled for elective surgery of lumbar discopathy (SC); and once from ten healthy controls. IL-12 was measured using the ELISA technique. Preoperative IL-12 was higher in AAA (0.21 pg/ml) and SC (0.31 pg/ml) patients than in controls (0.05 pg/ml). A significant decrease in IL-12 (0.09 pg/ml) was observed at 90 min-X(off) in comparison to the preoperative value in AAA but not in the SC group. 24 h after surgery, IL-12 levels were still low in the AAA group (0.13 pg/ml), and nonsignificantly surpassed the preoperative value in the SC group (0.36 pg/ml). We conclude that operative injury was associated with increased IL-12 levels, and IR with decreased IL-12 levels. Diminished IL-12 during AAA repair might be associated with a higher risk of postoperative complications, but this needs further evaluation.