Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications.

Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.

Collision Lesions: Genuine Collision (Conflict) or not?

By definition, the term "collision lesion" refers to two or more tumors coinciding in the same anatomic position or visceral organ. Collision lesions coexisting on the same skin location are defined as collision skin lesions (CSLs). Although this term implies a conflict between the tumors, this is not the case. CSLs appear to be rare, but still pose a significant diagnostic problem in everyday clinical practice and clinicians should be aware of their existence. The aim of this study was to elucidate the problem of CSLs in clinical practice, with an emphasis on classification of CSLs according to position dependence, tumor histogenesis, etiology, and possible lesion combinations in CSLs, as well as diagnostic possibilities. According to our results, accurate clinical diagnosis could be only rarely reached, requiring lesion excision and pathohistological confirmation of CSLs. Considering the fact that tumors in CSLs can be partially or completely overlying or can even be positioned one within the other, the existence of two or more tumors is extremely difficult to detect.

Hyperbaric oxygen treatment: A complementary treatment modality of Modic changes?

Modic changes (MCs) have attracted great interest in recent years. The complex process of MC development and progression seems to involve interplay between mechanical, infective, inflammatory, and degenerative processes that cannot be clearly differentiated. Based on signal intensity on T1- and T2-weighted MRI scans, MCs can be divided three types: Type 1, Type 2, and Type 3. Predominantly Type 1 MCs are commonly associated with chronic low back pain that is unresponsive to classic treatment options. Infection with low-virulent anaerobic microorganisms, most commonly Propionibacterium acnes, has been implicated in MC development following a disc herniation when a tear enables bacteria to enter the disc. Recent studies in patients with chronic low back pain following a lumbar disc herniation associated with Type 1 MCs have reported promising results following prolonged systemic antibiotic treatment with amoxicillin-clavulanate. Hyperbaric oxygen therapy, as primary or adjuvant treatment in association combination with systemic antibiotics or anti-inflammatory therapy, could offer important advantages in treating patients with suspected low-virulent disc infections due to anaerobic microorganisms associated with Type 1 MCs. We believe that hyperbaric oxygenation could contribute to faster resolution of Type 1 MCs and associated pain through multiple effects-including direct antimicrobial effects through formation of reactive oxygen species (ROS), altering the favorable low oxygen tension milieu such that it becomes unfavorable for bacterial growth and survival, and anti-biofilm effects. Additionally, hyperbaric oxygenation could contribute to faster pain resolution via direct and indirect anti-inflammatory effects. As an adjuvant treatment administered in combination with systemic antibiotics, HBOT could increase the sensitivity of Propionibacterium acnes to antimicrobial drugs under hyperoxic conditions, resulting in faster MC resolution. Overall, the faster infection resolution, diminished bacterial load, and anti-inflammatory effects due to reduced cytokine expression and levels of infectious by-products could lead to faster pain resolution following HBOT, and a significant improvement of quality of life in these patients.

Kaposi's sarcoma in an HIV-negative chronic lymphocytic leukemia patient without immunosuppressive therapy: A case report.

Kaposi's sarcoma is a neoplasm of endothelial cells. That vascular tumor is usually limited to the skin, but it may involve mucous membranes, visceral organs, and lymph nodes. Serological evidence has shown that human herpesvirus 8 infection is required for the development of Kaposi's sarcoma. Chronic lymphocytic leukemia is the most common leukemia all over the world. Increased skin cancer risk has been reported for patients with chronic lymphocytic leukemia. The relation between these two pathologies has not yet been clarified. We report a case of Kaposi's sarcoma along with chronic lymphocytic leukemia in a patient who did not receive therapy for chronic lymphocytic leukemia.

Endothelial dysfunction as assessed with magnetic resonance imaging - A major determinant in chronic heart failure.

Chronic heart failure (CHF) is a clinical syndrome resulting from interaction of different structure and functional disturbances leading to decreased heart ability to ensure adequate supply of oxygenized blood to tissues and ensure adequate metabolic needs in the cases of normal or increased afterload. Endothelial dysfunction (ED) is a pathological condition characterized by general imbalance of all major endothelial mechanisms with key role in development and progression of atherosclerotic disease. ED has been associated with most cardiovascular risk factors. There is increasing interest in assessing endothelial function non-invasively, leading to development and evaluation of new diagnostic methods. We suggest that MRI is safe and reliable test that offers important advantages over ultrasound for the detection of ED and monitoring of the expected therapeutic effect. We believe that ED plays a pivotal role in chronic heart failure development and progression, regardless of its etiology, and that MRI should be introduced as a "gold standard" in diagnostic procedure and treatment.

Melanoma can control development of metastasis--Fact or myth?

The malignant melanoma spreading process cannot explain occurrence of metastases several years following local surgical therapy of primary malignancy. But, this complex process of delayed metastases is still challenging and not completely understood. We hypotheses that melanoma metastases occur early in disease, probably at the same time with the occurrence of the primary melanoma. We suggest that dissemination of metastatic "seed cells" occur at an early stage of the disease together with the development of primary melanoma and cannot be detected by standard diagnostic methods. These cells are masked between healthy cells and have the potential to proceed in true metastasis following the activation triggered by signal from primary tumor or other source. Other possibility includes the existence of two different genes, one responsible for development of primary melanoma, and the other with a roll in development of metastases. We believe that future investigation should be directed toward better understanding of mechanisms involved in metastases development keeping in mind that melanoma behavior is irrational and defies logical thinking.

Differences between keratoacanthoma and squamous cell carcinoma using TGF-alpha.

Squamous cell carcinoma (SCC) and keratoacanthoma (KA) are skin neoplasms of epithelial origin. In contrast to clearly malignant skin neoplasm SCC, KA is an unusual cutaneous neoplasm with a tendency to regression. The distinction between these two neoplasms, on histological grounds only, is still a challenge. In order to investigate further and to assess the possible differences in transforming growth factor-alpha (TGF-alpha) expression between SCC and KA, 40 of skin tumor specimens, 20 cases of each SCC and KA were analyzed immunohystochemicaly. We have found a significant difference in staining patterns between KA and SCC. In KAs we have detected TGF-alpha staining mainly diffusely (90% of cases) and without peripheral staining of cells in 1-2 layers (60% of cases). Contrary, there was a mostly patchy staining (55% of cases) with peripheral staining of cells in 1-2 layers (100% of cases) in SCCs. Generally, differentiation between KA and SCC can be based on clinical and histological ground, but the distinction between these two skin tumors could sometimes be difficult. We have shown that these skin neoplasms could be differentiated based on staining patterns of TGF-alpha expression, thus this method could aid in differentiation between these two closely related entities in clinical practice.

Adverse reactions and alleged allergy to local anesthetics: analysis of 331 patients.

The aim of this study was to determine the prevalence of true local anesthetic (LA) allergy among patients referred for suspected hypersensitivity and to describe the main characteristics of adverse drug reactions (ADR) induced by LA in our population. We retrospectively analyzed the medical files of patients referred to the Department of Dermatovenereology, University Hospital Center Rijeka, Rijeka, Croatia, for the investigation of LA hypersensitivity in the period between January 2000 and December 2012. A total of 331 patients underwent skin testing and, in cases of negative results, subcutaneous exposition to LA. In patients with suspected delayed reaction, patch test was performed. Altogether, 331 patients reported 419 independent ADR occurring during 346 procedures. Most commonly, patients reported having only one ADR, but 41 (12.4%) of them had two reactions, 14 (4.2%) had three, five (1.5%) had four and in one patient (0.3%) five ADR to LA were observed. The majority of reactions occurred during dental procedures when most commonly lidocaine and articaine were used. Local reactions were reported in 44 patients, whereas 490 general symptoms occurred during 375 independent ADR in 287 patients. The most common symptoms were cardiovascular system reactions in 89 patients (18.2%). Allergic reaction was detected in three patients (0.91%). One patient showed immediate-type reaction to bupivacaine and two patients had a delayed-type reaction to lidocaine. Adverse reactions to LA are common and are mostly due to their pharmacological properties and drug combinations or psychogenic origin. Allergic accidents to LA are rare.

Concurrent basal cell and squamous cell carcinomas associated with hydroxyurea therapy.

We report a case of a 76-year-old woman with concurrent onset of two primary cutaneous malignancies, one at the fourth finger and another at the dorsum of the same hand. The patient was on long-term therapy with hydroxyurea (HU) for polycythemia vera. Histopathologic and immunohistochemical studies revealed two different malignant cutaneous lesions, i.e. basal cell carcinoma (positive for bcl-2 and negative for vimentin, EMA and CK5/6) and poorly differentiated sarcomatoid squamous cell carcinoma (positive for vimentin, EMA and cytokeratins CK5/6, and negative for bcl-2). In addition, p53 was positive in approximately 50% of squamous cell carcinoma cells and in almost all basal cell carcinoma cells. The presence of low-risk human papillomavirus (HPV, types 6, 11) was verified by polymerase chain reaction, but only in the surrounding normal skin tissue, whereas HPV infection could not be detected in either carcinoma. In this patient, concurrence of two different skin carcinomas on sun-exposed skin, in the absence of HPV, suggest direct involvement of potentially mutagenic HU therapy, through influence on DNA synthesis and repair mechanisms, in conjunction with ultraviolet exposure. Therefore, we suggest that in patients on HU therapy with cutaneous side effects, referral to a dermatologist should be obligatory.

Psoriasis vulgaris - an inflammatory skin disease and/or benign epidermal hyperplasia.

Psoriasis vulgaris (PV) is a systemic inflammatory disease in which immune and genetic factors are involved in the pathogenesis. Some treatment approaches in PV patients have been similar to therapy of some tumors. This fact has led to a new scientific approach to PV not only as an inflammatory disease, but also as a benign epidermal hyperplasia or a benign tumor. In this article, we hypothesize that there has been a parallel between some benign tumors and neoplasms and PV. The aim of this article is to present the approach to PV as an inflammatory disease as well as benign epidermal hyperplasia or tumor, and to introduce a new meaning.

Gorski Kotar--an endemic region for primary gastric non-hodgkin lymphoma?

Primary gastric non Hodgkin lymphoma (PGNHL) is a distinct group of extranodal lymphomas with interesting geographical distribution and variable prevalence in different countries. We analysed epidemiological data of our patients with PGNHL in Primorsko-goranska County. Clinical data of 30 patients with PGNHL diagnosed and treated in Clinical Hospital Center of Rijeka, Croatia between January 1995 and December 2005 were prospectively analyzed. We used statistical analysis (t-test, chi2-test) for small groups. Out of 30 pts with PGNHL, 19 were born in Primorsko-goranska County, part of Croatia situated by the Adriatic sea which consists of three regions: City of Rijeka, Islands and Gorski Kotar. 6 of 19 patients (31.6%) were originally from Gorski Kotar which made incidence rate of PGNHL in Gorski Kotar 7 times higher than in other two regions. Many authors emphasized that relative frequency of PGNHL is very variable in various countries and regions. Geographical distribution of our patients was very surprising because Gorski Kotar is the region with lowest number of citizens, rural area without any known pollutants, and ecologically one of the most preserved microsystem in this part of Croatia. Gorski Kotar is known to be an endemic region for multiple sclerosis and lyme borreliosis. Is it for PGNHL too?

Effect of progesterone and pregnancy on the development of varicose veins.

The aim of this study was to investigate the contribution of progesterone in the development of primary varicose veins on lower limbs during pregnancy. In 50 primiparae with varicose veins, serum progesterone level was quantitatively determined in the 14th week of pregnancy and results were compared with those obtained in a control group of 25 primiparae without visible varicose veins. The mean serum progesterone concentration recorded in pregnant women with dilated veins (159.9+/-15.8 nmol/L) was significantly higher as compared with the control group (159.9+/-15.8 nmol/L vs. 40.4+/-1.6 nmol/L; P<0.0001). These findings supported the role of hormonal factor in the development of varicose veins in women.

The role of CD4 and CD8 lymphocytes and macrophages in psoriasis vulgaris.

Current knowledge of the immunopathogenesis of psoriasis vulgaris is based on the crucial role of CD4 and CD8 lymphocytes. Also, the connection of activated lymphocytes with macrophages, especially dendritic cells and plasmacytoid dendritic cells, is considered to be significant. In the present study, the expression of CD4+ lymphocytes as well as CD8+ lymphocytes (P < 0.001) and macrophages (P < 0.001) was found to be significantly increased in lesional skin epidermis and dermis in psoriasis vulgaris patients as compared with healthy skin. These findings suggested a cascade or chain reaction with cells and cytokines playing an important role to be involved in the immunopathogenesis of psoriasis vulgaris.

Acute phase proteins in psoriasis.

Psoriasis is a chronic, relapsing, inflammatory and hyperproliferative skin disorder. The levels of acute phase proteins are suggested to be elevated in those patients with acute disease. The expression of selected acute phase proteins as the parameters of humoral immunity has been analyzed in 70 patients with acute psoriasis and 40 healthy controls. The aim was to evaluate the inflammatory response in the exacerbation of psoriasis and to determine the correlation of these objective inflammatory parameters with clinical features of disease activity. Main demographic and epidemiologic features were, as well, analysed. The plasma levels of C-reactive protein (CRP) (chi2 = 23.61; p < 0.005), and alpha1-acid glycoprotein (alpha1-AGP) (chi2 = 7.42; p < 0.01) were significantly increased in those patients with acute phase of the disease compared to healthy controls. Our results suggest that psoriasis is an inflammatory disease and therefore its worsening seemed to be linked to the increase in the inflammatory response. It seems that CRP and al-AGP levels could serve as important prognostic factors for the worsening of psoriasis.

The distinction between lesional and non-lesional skin in psoriasis vulgaris through expression of adhesion molecules ICAM-1 and VCAM-1.

Psoriasis vulgaris [pv] is a systemic inflammatory skin disease affecting 2-4% population. It is well known that pv affects some parts of the skin and also whole skin as in erythrodermic form. We still do not know why in pv some parts of the skin are affected and others are not. In our hypothesis we assumed that the whole skin is in <> position and non-lesional skin could become in every moment lesional. According to our hypothesis and also other author's research, high expression of adhesion molecules ICAM-1 and VCAM-1 in lesional as well as non-lesional skin in pv, supports this hypothesis, suggesting a significance of these molecules in pathogenesis of pv. Our hypothesis could be proved by immunohistochemical stain of ICAM-1 and VCAM-1 in lesional and non-lesional skin of pv patient in comparison with healthy skin.

Significance of continuous medical education of general practitioners about common diseases--iron deficiency anemia.

Three years long, prospective study was performed in order to evaluate a possible influence of continuing medical education of general practitioners on managing the patients with common diseases such as iron deficiency anemia (IDA). Altogether 1586 patients that were referred to Hematology Outpatient Clinic, University Hospital Center Rtjeka, Croatia due to diagnosis of IDA were examined by clinical hematologist during the first visit and follow up period, were questioned by the means of questionnaire and complete laboratory analyzes were performed in order to: evaluate physical condition and laboratory findings, to assess duration of anemia, possible other specialists' consultation, iron supplementation therapy, and finally, determine the type of anemia present. Initial group of 983 patients was examined during one year period. Following the education campaign the same parameters were analyzed in comparable (final) group of 603 patients during next one year period. Following the education, the number of patients referred to Outpatient Clinic due to diagnosis of IDA was significantly decreased from 983 (61.97%) to 603 (38.02%) (p < 0.05) as was the number of patients referred as having IDA but finally established to have a different type of anemia, from 661 (97.24%) to 149 (24.71%) (p < 0.001). The number of patients started on iron supplementation therapy before establishing the type of anemia was significantly decreased from 543 (55.24%) to 76 (12.60%) (p < 0.001) as well as duration of iron supplementation therapy administered in these cases (21 +/- 9.8 vs. 6 +/- 8.7 weeks) (p < 0.001). We have detected a significant decrease in: time necessary for definitive diagnosis (49 +/- 19.2 vs. 28 +/- 9.1 weeks) (p < 0.001), number of visits to other specialists (2.9 +/- 1.35 vs. 1.1 +/- 0.94) (p < 0.05), duration of anemia before treatment initialization (41 +/- 29.8 vs. 26 +/- 18.7 weeks) (p < 0.001). Average hemoglobin (Hg) level in patients referred to hematologist was significantly lower following education (98.9 +/- 15.5 vs. 82.6 +/- 14.2) (p < 0.05). Continuing medical education of primary care physicians has significant role in diagnosis and treatment of patients with IDA. Education programs result in benefits for the patients and physicians.

Breast infiltrating ductal carcinoma: analysis of hormone, HER-2 receptors and Ki-67 proliferation marker.

The aim of this study was to analyse breast carcinomas with discordant receptor status, probably hormonal dependent (estrogen receptor (ER) positive, progesterone receptor (PR) negative or ER-PR + subgroup profile) infiltrating ductal breast carcinomas not otherwise specified (IDC NOS). Specimens from 90 IDC NOS were grouped into three categories according to hormonal status: dependent (D) (ER +PR +), probably dependent (PD) (ER +PR- or ER-PR +) and non-dependent (ND) (ER-PR-); they were evaluated considering some established prognostic parameters in breast carcinomas. Statistically significant difference was found between tumor receptor status distribution and menopausal status (p = 0.0235), age of the patients (p = 0.000467), histological grade (p = 0.000003), vascular invasion (p = 0.006), HER-2 status (p = 0.0039) and Ki-67 proliferation rate (p = 0.000311). D tumors were found exclusively in post-menopausal patients (average age 68.9 years), most of which had intermediate (II) grade, without vascular invasion, with HER-2 status score predominantly 0 or 1 + and lower Ki-67 proliferation rate. PD tumors were found predominantly in younger post-menopausal patients (average age 57.5 years), with vascular invasion found in 23% of the cases. ND tumors mostly had higher histological grade, showed the highest percentage of the Ki-67 positive tumor cells and vascular invasion in 30% of the cases. We conclude that the patients with PD breast carcinomas were younger post-menopausal women with the tumors moderately differentiated, HER-2 score 0 or 1+ and with lower Ki-67 proliferation rate.

Cell apoptosis as assessed by M30 expression in keratoacanthoma and squamous cell carcinoma.

Involution displayed by keratoacanthoma (KA) represents an important difference between KA and squamous cell carcinoma (SCC). It has been suggested that apoptosis plays a part in process of involution of KA. Altogether 150 specimens were included in this study, 30 cases of each; normal skin (NS), proliferative (pKA) and regressing keratoacanthoma (rKA), well differentiated (wdSCC) and poorly differentiated (pdSCC) squamous cell carcinoma. All samples were examined immunohistochemically for expression of M30 protein. A significantly lower number of M30 positive cells has been detected in NS as compared to skin tumors examined (p<0.001), except for rKA (p=0.057). The highest percentage of M30 positive cells was detected in pdSCC (p<0.001) as compared with all other examined groups. Keratinocytes of normal and changed epidermis expressing higher levels of M30 protein were predominately found in sun-exposed areas (chi2=14.93; p=0.060). There was an increasing trend of M30 protein expression with increasing age of the patient in NS and skin tumors examined. Majority of skin tumors with higher percentage of M30 positive cells tended to display higher Ki-67 expression. M30 expression was highly correlated with bak (r=0.811; p=0.048) and granzyme B expression in rKA (r=0.733; p=0.015). Cell apoptosis as assessed by M30 expression is, generally, increased in examined skin tumors and related to cell proliferation. Cell apoptosis mediated by bak and granzyme B expression could contribute to KA regression.

Maculopapular eruption secondary to itraconazole.

Adverse cutaneous reactions to itraconazole are known to be quite rare. We report a case of maculopapular reaction caused by itraconazole. On the 7th day of itraconazole therapy for hand onychomycosis, in a 39-year-old woman pruritus occurred with a subsequent morbiliform, symmetric, maculopapular eruption on the upper torso, neck, trunk and pressure-bearing areas. Eruption progressed, becoming confluent and spreading to extremities. Due to increasing indications for the administration of itraconazole its increased usage as well as the possibility of allergic reactions should be expected even if these are a rare event.