Age dependent influence of external temperature on the pathogenesis of idiopathic lower extremity deep vein thrombosis

AIM

The aim of the present study was to investigate the relationship between the incidence of idiopathic lower extremity deep vein thrombosis (DVT), age, location of the thrombus, and changes of temperature.

MATERIAL AND METHOD

During the two year period between May 2009 and April 2011, inclusive, 124 consecutive patients were diagnosed as having idiopathic lower extremity DVT at the Vascular Surgery Clinic, Clinical Center of Nis, Serbia.

RESULTS

In patients younger than 45 years, the increase in average daily temperature with 1 degree C 7 days before the event took place was associated (p 0.05) with a decrease of the risk of occurrence of idiopathic DVT of the lower limbs of 3.6% (0.4 6.7%) as well as DVT above the knees (p 0.01) of 4.7 % (1.3 8.0%). In patients of the age of 45 years and over the age of 45 years the increase of average daily temperature with 1 degree C 7 days before the event took place was associated (p 0.01) with the increase of the risk of occurrence of DVT below the knees of 9.4% (3.3 15.9%).

CONCLUSION

According to the results of this study, one can conclude that the influence of external temperature change on DVT incidence and location is based on age.

Correlation between the climatic factors and the pathogenesis of deep vein thrombosis

There are numerous researches dealing with the correlation between the seasons and climatic factors and the pathogenesis of deep vein thrombosis (DVT). The presented researches show an undoubted correlation between the climatic factors and the pathogenesis of DVT. In the majority of researches, retrospection is noted as a disadvantage. Further prospective researches could aim on testing the correlation between both climatic and thrombotics factors and the pathogenesis of DVT. This may additionally clarify the pathophysiological mechanism of the DVT incidence and contribute to the prevention and treatment of risk groups of patients in certain periods of the year.

Role of plasma exchange in autoimmune hyperthyroidism complicated by severe tiamazol-induced cholestatic jaundice

Therapeutic plasma exchange (TPE) is an alternative treatment for hyperthyroidism, resulting in a rapid decline in plasma thyroid hormones and anti-thyroid antibodies. TPE has also been used both in primary liver disease and in drug-induced cholestasis. Data on thyrotoxic patients with severe hepatic complications are scarce. Cholestasis induced by imidazol-derived anti-thyroid drugs is extremely rare. The use of TPE for treating this complication was not previously reported. We report the experience of one such patient with a favorable response to TPE. A 45-year-old male patient with Graves' disease, presented with severe jaundice and extremely high serum bilirubin levels due to hepatotoxicity induced by tiamazol. Through extensive investigation primary liver disease, including viral, metabolic, neoplastic and autoimmune disease, as a cause of cholestasis were all ruled out. The patient underwent total of 6 TPEs which in combination with low dose of glucocorticoids and standard supportive measures, resulted in normalization of thyroid hormones and normal liver function tests. TPE provided a safe, rapid and effective treatment of severe drug-induced cholestasis and auto immune hyperthyroidism. From this case we conclude that TPE should be considered as a valuable alternative therapeutic option in thyrotoxic patients with severe complications. Guidelines and indication criteria for TPE treatment in patients with hyperthyroidism are still lacking.

Effects of alternate fasting or very low calorie diet and low calorie diet on metabolic syndrome in severely obese patients

BACKGROUND AND AIM

Weight loss improves the metabolic syndrome (MetS) features and related clinical abnormalities in obese subjects. The aim of this study was to assess the effects of a non-surgical therapeutic program on the MetS in severely obese patients.

PATIENTS AND METHODS

Sixty-four extremely obese patients were involved in the therapeutic program, which consisted of two alternating phases: the three-week therapeutic fasting or semi-fasting in hospital conditions and the low calorie diet with dosed physical activity in outpatient conditions. At the baseline we measured: anthropometric parameters, blood pressure and lipid profile. Subjects underwent an oral glucose tolerance test and insulin resistance/sensitivity was evaluated by the homeostasis model assessment and the oral glucose insulin sensitivity. After weight reduction by at least 10%, all mentioned assessments were repeated.

RESULTS

None of the patients had significant adverse effects. Forty-one patients aged 43.0±11.5 years completed the study. The mean weight loss was 27 kg or 18% of the initial weight (p<0.01), which was followed by a significant decrease of the insulin resistance, the overall prevalence of MetS (32%) and all MetS parameters, without the significant change in high-density lipoprotein. This weight loss pogram substantially improves the MetS in extremely obese patients.

CONCLUSION

The tailored alternating either fasting or semi- fasting should be considered as an optional approach to manage extreme obesity and related metabolic abnormality.

Vaccine model of antiphospholipid syndrome induced by tetanus vaccine

Successful induction of antiphospholipid syndrome (APS) in two different non-autoimmune prone mouse strains, BALB/c and C57BL/6, was achieved by tetanus toxoid (TTd) hyperimmunization using different adjuvants (glycerol or aluminium hydroxide), and different adjuvant pretreatments (glycerol or Complete Freund’s Adjuvant (CFA)). APS had different manifestations of reproductive pathology in BALB/c and C57BL/6 mice: fetal resorption (as a consequence of extreme T-cell activation obtained in the course of pretreatment), and lowering of fecundity (as a consequence of polyclonal B-cell stimulation), respectively. In BALB/c mice fetal resorption coincided with glycerol and CFA pretreatments, while in C57BL/6 mice lowering of fecundity was most obvious in CFA-pretreated mice immunized with TTd in aluminium hydroxide. Both molecular mimicry and polyclonal B-cell activation occur in APS induction, with molecular mimicry effects being dominant in BALB/c mice, and polyclonal cell activation being dominant in C57BL/6 mice. Confirmation of molecular mimicry effects, which in the condition of T-cell stimulation generated fetal resorptions in the BALB/c strain, was achieved by passive infusion of monoclonal antibody (MoAb) T-26 specific for TTd and anti-β2-glycoprotein I obtained after TTd hyperimunization. High polyclonal B-cell activation in C57BL/6 mice prevented fetal resorption but induced fecundity lowering, as was the case in passive administration of MoAb T-26 in this mouse strain. Passive infusion of anti-idiotypic MoAb Y7 into C57BL/6 mice induced fetal resorptions and confirmed the above suggestion on the protective role of polyclonal B-cell stimulation in fetal resorptions.

First generation antipsychotics switch with Risperidone in the treatment of chronic schizophrenic patients

BACKGROUND

Schizophrenia is a severe chronic psychiatric disorder for which treatment compliance is important in the prevention of relapse. Second generation antipsychotics (SGA), such as Risperidone, have been found to be more effective in the treatment of such patients than the high potency first generation antipsychotics (FGA). This is an open study where the same group of patients was first treated with FGA and then were switched to Risperidone, in controlled hospital conditions, after a wash- out period. The aim of the study was to examine whether patients with schizophrenia who were judged to be stable on long-term treatment with FGA would further benefit from a switch to an atypical antipsychotic drug.

SUBJECTS AND METHODS

Eighty hospitalized patients suffering from Schizophrenia or Schizoaffective disorder (male 54, female 26) were first treated with Haloperidol (N=60) or Fluphenazine (N=20), and then were switched to Risperidone. Their clinical state was monitored using the PANSS scale for Schizophrenia, measuring the Total PANSS score. The KLAWANS scale for assessment of extrapyramidal syndrome (EPS) was also used. Administration and dosage of Trihexiphenidil (THF) was recorded. The study lasted for 8 weeks, with 4 screenings (Visit 0-baseline- FGA, Visits 1-3 Risperidone on Day 14, 28 and 56, respectively).

RESULTS

The average age was 38. Patients usually suffered the paranoid form of Schizophrenia (55%). The duration of illness was more than 5 years (38.8%). During the eight- week trial on Risperidone, using the PANSS total scores, we observed clinical improvement where the therapy switch had caused an initial worsening (p<0.05). Also, the compared baseline (FGA) and last visit showed a low, but statistically significant benefit in favor of Risperidone (t=5.45, df=79, p<0.005). Intensity of EPS measured by KLAWANS scores significantly decreased during time (F=4.115; p=0.016; Partial Eta Square=0.058). Average Trihexiphenidil doses followed Risperidone in a dose dependent manner (r=0.748, r=0.661, respectively, p<0.01) with the consequent decrease of patients needing THF corrective therapy (68.8% at the baseline toward 22.5% on last visit).

CONCLUSION

Switch to Risperidone medication provided significant additional improvement in symptom severity, extrapyramidal side effects and need for anticholinergic medication. This suggests that one might expect better compliance in future treatment in this population of chronic schizophrenic patients.

The identification of a low molecular mass bacteriocin, rhamnosin A, produced by Lactobacillus rhamnosus strain 68

AIMS

This study focuses on the isolation and characterization of a peptide with bacteriocin-like properties isolated from Lactobacillus rhamnosus strain 68, previously identified by 16S rRNA gene sequencing and originating from human gastrointestinal flora.

METHODS AND RESULTS

The peptide was isolated from a supernatant of bacteria maintained under restrictive conditions by a combination of ethanol precipitation and reversed-phase chromatography. The molecular mass of the peptide as assessed by mass spectrometry was 6433.8 Da. An isoelectric point of 9.8 was determined by 2D-PAGE. The peptide designated rhamnosin A inhibited Micrococcus lysodeikticus ATCC 4698 but did not inhibit Lactobacillus plantarum 8014 or Lact. plantarum 39268. Inhibitory activity against M. lysodeikticus at concentrations used in this study was shown to be bacteriostatic rather than bacteriolytic or bactericidal. Rhamnosin A retained biological activity after heat treatment (95 degrees C, 30 min) but was sensitive to proteolytic activity of pepsin and trypsin.

CONCLUSIONS

The N-terminal sequence of rhamnosin A, as determined by Edman degradation and in more detail by blast analysis, did not show identity with any currently available Lact. rhamnosus HN001-translated protein sequences, nor any significant similarity with other sequences in the nonredundant protein sequence database. Being a small, heat-stable, nonlanthionine-containing peptide, rhamnosin A should be categorized as a class II bacteriocin.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study describes a partial bacteriocin sequence isolated from Lact. rhamnosus 68 and broadens our understanding of bacteriocins.

TSH receptor antibodies for confirming the diagnosis and prediction of remission duration, in newly diagnosed Graves' disease patients

Antibodies to TSH receptors (TRAb) have great pathogenetic importance in the development and maintenance of hyperthyroidism in Graves' disease (GD). Measurement of their serum level could be of diagnostic and prognostic importance in autoimmune hyperthyroidism and in monitoring the efficiency of thyrosuppressive drug (TSD) treatment in GD. The aim of our study was to assess the sensitivity (SN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) of the TRAb assay in confirming the diagnosis and to define its prognostic value for remission duration in GD patients at the end of TSD treatment with thionamide derivatives, propylthiouracil or methimazole. We studied 99 patients, 65 female, 34 male, 18-76 years old; 52 GD patients and 47 as control group. We have studied frequency of relapses and remission duration in GD patients by a 2nd generation serum TRAb commercial kit. Our results showed that, the SN, SP, PPV and NPV of the TRAb test were 100%, 97%, 98% and 100%, respectively. Remission duration after TSD treatment was longer and relapses were fewer in GD patients with lower levels of TRAb before (P<0.01) and at the end of TSD treatment (P<0.05). In conclusion, our results suggest that serum TRAb is very sensitive and specific for confirming the diagnosis of GD. TRAb levels at the beginning of TSD treatment, above 5 IU/L gives 18% greater chance, and above 15 IU/L, 36% greater chance for remission, shorter than 6 months.

[Anal canal melanoma-- case report]

Anal canal melanoma is a rare disease comprising 1% of all colorectal ie. anal malignant tumours with very poor long term prognosis. Its significant biologic aggressivity is the consequence of the tendency towards lymphatic, local and hematogenous spread. At the moment of diagnosis even 30% of the patients have distant metastases. Surgical intervention represents the only possibility for cure. Modern approach to the anal canal melanoma treatment implies two types of intervention: wide local excision preserving the sphincter mechanism and abdominoperineal resection of the rectum. There are numerous dillemas about the choice of surgery in particular disease stages. The authors report on a 61 years old women in which anal canal melanoma with left inguinal lymphatic metastases was detected during the inspection of "haemorrhoids". After the diagnosis was established, abdominoperineal resection of the rectum was performed with dissection of both inguinal regions.

[An acute pancreatitis in a child caused by Na-valproate]

Na-valproat (Apilepsin, Eftil), is is a commonly prescribed medication approved for treatment of epilepsy, trigeminal neuralgy, migraine, and bipolar disorder. Although the common adverse effects associated with Na-valproat are usually benign, more serious and fatal complication like liver failure and acute pancreatitis (AP) can occur. Acute pancreatitis may take place in all ages, regardless of dose and serum levels of the medicine. An acute pancreatitis is relatively common after intravenous administration. The authors presented a case of acute opancreatitis in 13-years girl caused by Na-valproat.

[Reconstruction of large defects of the abdominal wall using dermal and synthetic grafts]

Large defects of abdominal wall (greater than 8 cm in diameter) related to different cause, are still difficult problem of modern surgery. The best results in order to obtain safe and permanent anatomical and functional abdominal wall integrity are reached by autogenous dermal and synthetic grafts. Controversies concerning quality of these procedures are still presents. Our work is based on two equal experimental groups of 20 Vister rats each, with large artificial abdominal wall defects: one treated with autogenous dermal graft, another with synthetic Mersilene mesh graft. The animals from both groups were sacrificed in previous planned time intervals (3rd, 7th, 14th and 48th days). Afterwards detailed microscopic and gross examination of abdominal wall reparation and quality of reconstructed abdominal wall defects had been performed. According to our results both methods are easy to be performed and safety surgical procedures. Overestimated usage of synthetic grafts should be diminished because of advantages of autologous dermal graft--availability, substitution of firmly fibrosis tissue and endurance against infection.

[Use of fibrin glue in the prevention of leakage in pancreatico-jejunal anastomoses]

The aim of this study was to test the protective effects of fibrin sealing on the pancreatico-jejunostomy (PJA), the high-risk anastomosis following pancreas head resection. Experimental study was performed on the mongrel dogs, divided in two groups (20 animals each): Experimental group-with end to end "dunking" PJA, protected by temporary occlusion of the pancreatic duct with fibrin sealant/Tissucol/Immuno Ag/, while control group was without any protective procedure. The animals were followed 5 months in order to study: protective effects of such procedure on the PJA quantified with the percent of anastomotic leakage, effects of the exocrine secretion and effects the endocrine function Results: PJA leakage occurred in 13.33% in control group. No leakage was registered in experimental group. Biochemical, histological and electron microscopic study showed slight transitory elevation of amylase levels. Fibrin glue plug was dissolved and pancreatic juice output was reestablished 12th days postoperatively. Long term follow-up showed no damages of the endocrine and exocrine pancreas. Pancreatic duct occlusion with fibrin glue appeared to be an useful method in the prevention of pancreatico-jejunostomy leakage, without negative effects on the exocrine and endocrine pancreas.

[Experimental and clinical possibilities of transplantation of the injured and totally devascularized spleen]

The most severe spleen lesions with conquasation and devascularisation of entire organ, when it is practically impossible to do any preservating surgical procedure, are the true indications for the transplantation of this extremely important immunological organ. We have performed the evaluation of the surgical procedure of heterotopic auto transplantation in the 30 dogs with severe spleen lesions. Simulation of totally devascularized spleen with the lesions of V degree was performed by disrupting all segmental blood vessels with deep and long longitudinal transhilar incision. During the 3 months follow-up period, animals were subjected to numerous explorations in order to macroscopically and histologically valuate the implant. In most cases (80-85%) implants had complete vitality with the preservation of normal tissue architecture, while 15-20% of implants had partial or total fibrosis. There were no mortality and no complications after this preservation procedure. The presence of fibrosis in some implants suggests that the implant preparation should be better performed and that transplantation of larger tissue volume is needed. Enriched with this experimental experience we have performed heterotopic auto transplantation in 2 patients with spleen lesion of V degree (car accident and injury at work) with very satisfactory results.

[Evaluation of the value of local protective methods using latex prosthesis and fibrin glue in colonic anastomoses]

In this experimental study on small animals (Wister rats) performed evaluation of local protective methods--latex prosthesis and fibrine adhesives--on colon anastomosis healing--prevention of dehiscency. Ninety experimental animals in whom segmental left colon resection was done, were divided into three groups of 30 animals. In the control group after segmental resection termino-terminal anastomosis with single-layer continuous suture was performed. In the second and third group with the same animals, anastomosis protection was performed with endoluminal latex prosthesis and extraluminal application of fibrine adhesives. In the postoperative course where the animals were monitored for 21 days in the control group, 3 (10%) died of acute diffuse peritonitis the cause of which was anastomosis dehiscency, in the latex prosthesis 2 animals (6.6%) died, while in the extraluminally applied fibrine glue group all animals survived. The results of this experiment demonstrate that local protective measures for colon anastomoses may produce better results, with fibrine adhesive administration as the best modality.

Epidemiology of end-stage renal disease and current status of hemodialysis in Yugoslavia

Maintenance hemodialysis (HD) in Yugoslavia started in the sixties and followed the dialysis trends in the Western Europe. However, in the last decade the development of renal replacement therapy (RRT) slowed down. In this report the epidemiology of ESRD from 1997-1999 and the survey of the status of HD treatment in Yugoslavia in 1999 are presented. Epidemiological data are obtained by the annual center questionnaires (response rate: 92.6 -94.2%). The survey of HD status is based on a specific questionnaire and covered 2108 patients (65%). At the end of 1999 there were 56 RRT centers in Yugoslavia treating 3939 patients: 3232 (82%) patients by HD, 248 (6.3%) by peritoneal dialysis, and 459 (11.7%) living with transplanted kidney. In a three year period, incidence of ESRD ranged from 108-128 pmp, point prevalence from 435-463 pmp and mortality rate from 20.7-17.9. Numerous refugee patients were treated over the last 10 years. Main causes of ESRD were glomerulonephritis (30%); Balkan nephropathy represented 11% and diabetic nephropathy 7% of all primary renal diseases. Cardiovascular and cerebrovascular diseases were the most common causes of death of RRT patients. Most centers are overcrowded and HD machines are worn out. Mean Kt/V was 1.19+/-0.08, mean URR% 58.8+/-7.4. The shortage of drugs prevented adequate management: 83% of HD patients had hemoglobin level less than 100 g/L but only 10.3 -17.8% were treated with rHuEpo; 64.5% of patients had phosphate levels higher than 1.7 mmol/L but only 33.5% used phosphate binders; 47% of patients had hypertension despite the antihypertensive therapy. The prevalence of hepatitis B remained unchanged (about 14%) in HD population during the last three years, but the prevalence of anti-HCV positive patients decreased (31-23%). In conclusion, there is a well developed dialysis service in Yugoslavia but insufficient conditions for adequate treatment.