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-β1 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-β1 (TGF-β1) serum levels can be used as PH markers and reflect its severity.

MATERIAL AND METHODS

IL-18 and TGF-β1 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-β1 concentration was lower than in controls. MELD score correlated positively with IL-18 levels and negatively with TGF-β1 levels. IL-18 levels correlated positively with bilirubin, INR, ALT and AST levels, and negatively with albumin levels and erythrocyte count. TGF-β1 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-β1 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-β1 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.

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.

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.

Endothelin 1 and transforming growth factor-β1 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-β1/2 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-β1 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-β2 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-β1/2 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-β1 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.

The imbalance between matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 in acute pancreatitis

BACKGROUND

The balanced activity of matrix metalloproteinases and their tissue inhibitors is an important, albeit still not completely understood, determinant of extracellular matrix homeostasis, a factor involved in the pathogenesis of acute pancreatitis (AP).

AIMS

The aim of this study was to compare serum concentrations of matrix metalloproteinase 9 (MMP-9) and its tissue inhibitor (TIMP-1) in patients with AP of various severity and to investigate their relationship with prognostic indicators of AP severity, e.g., polymorphonuclear leukocyte elastase (PMN-E).

PATIENTS AND METHODS

The study included 37 patients with mild (n = 18) or severe AP (n = 19) and 15 healthy controls. Serum concentrations of MMP-9 and TIMP-1 were determined on admission (day 1) and on days 2, 3, 5 and 10.

RESULTS

Throughout the study period, the serum MMP-9 concentration in patients with severe AP was significantly higher than those in individuals with mild AP and in healthy controls. In turn, the serum MMP-9 concentrations in persons with mild AP did not differ significantly from those of the controls. The serum TIMP-1 concentrations in both groups were significantly higher than in the controls. Beginning from the 2(nd) day of hospital stay, the serum TIMP-1 concentration in patients with severe AP was significantly higher than in individuals with mild AP. There were significant correlations between: MMP-9 and PMN-E, TIMP-1 and PMN-E, and MMP-9 and TIMP-1.

CONCLUSION

A disturbed balance between MMP-9 and TIMP-1 observed during the early stages of severe AP suggests that endogenous TIMP-1 is unable to prevent excessive activation and release of MMP-9. MMP-9 may represent a new marker of AP severity.

[Reduction of intraoperative bleeding during functional endoscopic sinus surgery]

Functional endoscopic sinus surgery (FESS) is a surgical procedure, during which all necessary manipulations are performed while using a fibreoptic camera. The endoscope is inserted together with the surgical instruments, through the nasal cavity. During the surgery, bleeding has to be minimized, since even a small amount of blood may completely obstruct vision via the endoscope. Various approaches have been used to secure a dry operating field; among them are: topical vasoconstrictors, Fowler's position, alpha-and beta-adrenergic blockade, and preoperative steroids. All these methods are far from being effective and are associated with significant side effects. The recently approved approach to this problem is to combine total intravenous anaesthesia using propofol and remifentanil, together with esmolol. With the heart rate reduced to 60 bpm, excellent operative conditions can be achieved with moderate hypotension (MAP 65 mm Hg-8.7 kPa). Altered microcirculation and a low cardiac output are the principal underlying mechanisms in these cases.

[The role of tryptase assay in recognition of anaphylactic reaction to muscle relaxants]

The incidence of allergic reactions during anaesthesia has been estimated to be from 1:3500 to 1:20000, with muscle relaxants being the most common allergens. Symptoms may involve all organs and systems with various intensities--from mild skin reactions to bronchospasm and cardiovascular collapse in the most severe cases. In a case of suspected perioperative allergic reaction, the management should not be limited to resuscitation and restoration of basic life functions, but must include careful investigation of potential allergens. An appropriate diagnostic strategy is essential for confirmation of an allergic reaction, identification of the allergen, and recommendations for future prevention. In this review, the various aspects of anaphylaxis and anaphylactoid reactions to muscle relaxants are discussed, including the role of tryptase and its assay in the diagnostic regimen.

Serum chemokine growth-related oncogene alpha profile during abdominal aortic aneurysm repair: preliminary report

INTRODUCTION

High postoperative mortality in patients undergoing aortic abdominal aneurysm (AAA) repair is predominantly associated with ischemia and reperfusion organ injury followed by multiple organ dysfunction syndrome (MODS). Experimental studies have shown a role of growth-related oncogene a (GROa) chemokine in mediating organ damage during ischemia-reperfusion injury.

OBJECTIVES

The study evaluated serum GROalpha levels during elective AAA repair in humans and the relationship between their changes and ischemia-reperfusion and the postoperative course.

PATIENTS AND METHODS

Peripheral blood samples were taken from 17 patients before surgery (Preop), before aorta unclamping, 90 minutes after unclamping (90 min-Xoff) and 24 hours after surgery, and from 11 controls. The GROalpha was measured with an enzyme-linked immunosorbent assay.

RESULTS

During AAA repair the GROalpha level showed an insignificant decrease from 79 pg/ml at Preop to 61 pg/ml at 90 min-Xoff followed by an increase to 100 pg/ml 24 hours after surgery. In complicated cases the GROalpha level showed a tendency to intraoperative higher values and increased to 133 pg/ml 24 h after surgery. Significant positive correlations were found between GROalpha and duration of surgery (r = 0.317), duration of aorta clamping (r = 0.322) and MOD score (r = 0.417).

CONCLUSION

AAA repair is associated with insignificant alterations in the serum GROalpha level. A decrease in chemokine levels after ischemia and reperfusion may suggest uncomplicated postoperative courses. The tendency to high chemokine levels may be associated with high risk of postoperative organ dysfunction in patients undergoing AAA repair.

[Intraoperative identification of the recurrent laryngeal nerves in thyroid surgery]

Accidental injury to the recurrent laryngeal nerve is a common complication of thyroid surgery. Different mechanisms of injury have been described, such as mechanical, electrical, or thermal. Retrosternal operations, secondary bleeding requiring wound revision, or neoplastic tumors are also frequent causes of this complication. Intraoperative direct stimulation of suspected nerve structures as well as vagal nerve stimulation have been proposed to avoid the injury. The effect of stimulation can be assessed by direct observation of the vocal cords (direct laryngoscopy or fiberoscopy via a laryngeal mask airway), or electromyography of the posterior cricoarytenoid muscle. All of these methods limit the use of muscle relaxants during anaesthesia. Details of anaesthetic management are presented.

[Natriuretic peptides--relevance in intensive care]

The family of natriuretic peptides consists of the atria natriuretic peptide (ANP), the cerebral natriuretic peptide (BNP), the type C natriuretic peptide (CNP) and the peptide isolated from the dendroaspis snakes' poison (DNP), whose presence in humans has not been confirmed. The physiological function of ANP is in the control of arterial blood pressure by regulation of systemic vascular resistance of blood vessels. BNP is produced as one of the factors in the acute response to inflammatory tissue damage, mainly in coronary vessels. Increased serum concentrations of natriuretic peptides have been found in stress situations, such as trauma or major surgery, systemic hypotension, and in intrinsic myocardial dysfunction. High concentrations of natriuretic peptides were observed in severe sepsis, septic shock and in multiple organ failure, probably due to increased secretion by mediators of the inflammatory process.The highest concentrations of ANP and BNP were found in lethal conditions. On admission to ICU, the measurement of natriuretic peptide concentrations could be very helpful in differentiating the etiology of respiratory failure, and for assessment of the severity of ARDS. Quick tests for measurement of natriuretic peptides, so-called the "point of care testing (POCT)" are fast, easy to perform and, not requiring expensive equipment, are relatively cheap. Therefore, the assessment of natriuretic peptide may be used in scoring a patient's clinical status, for precise diagnosis in doubtful situations, and for determining appropriate treatment.

[Stress related mucosal disease prophylaxis in intensive care unit patients]

Among the patients admitted to the Intensive Care Unit there frequently occur disturbances of the upper gastrointestinal tract. They can be found as stress ulcerations which in turn may lead to bleeding. The high incidence of stress ulcers and bleedings from the upper gastrointestinal tract is associated with disturbances of gastric acid secretion, an interrupted integrity of gastric mucosa and abnormal motor activity of gastrointestinal tract. The presence of clinically important bleeding results in prolonged hospitalization and increased mortality. The aim of this study is twofold; first, the pathogenesis and the consequences of stress-related mucosal disease are elucidated. Afterwards, the prophylaxis modalities are presented on the basis of the latest medical literature.

[Thrombolysis during cardiopulmonary resuscitation--own clinical observations--case report]

Thrombolytic therapy is contraindicated in the course of cardiopulmonary resuscitation (CPR). If the primary cause of cardiac arrest is myocardial infarction or massive pulmonary embolism, fibrynolysis may be life-saving. We present a case report of a woman admitted to the Intensive Care Unit with cardiac arrest with symptoms suggesting myocardial infarction or pulmonary embolism. After unsuccessful conservative CPR a single dose of 500000 IU streptase was administered. Heart action returned 10 minutes later, nevertheless the patient needed mechanical ventilation and circulatory system stabilization therapy (catecholamines) in doses dependent on haemodynamic parameters. During hospitalization she regained consciousness. She presented no neurological defects and after 5 days was discharged to the Cardiology Department. Electrocardiography and echocardiography done after successful resuscitation was specific to infero-lateral myocardial infarction. Although safety and efficacy of thrombolytic therapy at resuscitation was extensively studied, this procedure is still controversial. Till now, there is no data concerning thrombolytic treatment in such clinical situations, which are based on clinical trials, and such treatment is introduced in dramatic situations, as a last, lifesaving option.

[Staphylococcal infections as an important problem in intensive therapy--own clinical observations]

The microbiological monitoring in the Intensive Care Units, in the last few years, revealed a significant increase of infections caused by Gram+ bacteria. Authors of multi-center studies focus upon the problems related to the treatment of the infections caused by the methicilline-resistant staphylococci (MRS) as well as to its spreading. The Staphylococcal infections were 26.6 % of all bacterial infections in the Intensive Care Unit of the Department of Anesthesiology and Intensive Care of the Medical Academy in Białystok, during one year observation. MRS rods counted 21.4% among all pathogens isolated from the specimens collected from the patients, undergoing the treatment in the ICU, and were responsible for 83.6% of all Staphylococcal infections. The analysis revealed the significant percentage MRS rods resistant to commonly used empirical antibiotic therapy. Our experience shows that vancomycin or linezolid should be used, as an empirical antibiotic therapy, in suspected MRS-caused severe infections along with the simultaneous monitoring of changes in G+ bacteria drug resistance and strict infection-control regime.

[Assessment of the release of thyroid hormones in septic shock--prognostic significance]

Septic shock is the reason of human body organs dysfunctions including the hormonal system. There are abnormal thyroid hormones releasing as well. It is also noticed that sepsis caused serious disturbances in pituitary-thyroid axis functions. This is called euthyroid sick syndrom - (ESS).

THE AIM

To qualify the prognostic value of thyroid hormones serum levels changes in patients with septic shock.

MATERIAL AND METHODS

20 patients with septic shock were included into study. Septic shock was diagnosed according to AACP/SCCM criteria. The study group was divided into two subgroups: survivors (n = 10) and nonsurvivors (n = 10). 20 healthy volunteers were the control group. Blood for analysis was taken at the moment of septic shock recognition and on the 1st, 2nd, 5th and 10th day of the observation between 8 a.m. and 9 a.m. We studied thyrotropin (TSH), free triiodothyronine fraction (fT3) and free thyroxin fraction (fT4) serum levels, APACHE II and APACHE III score, acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).

RESULTS

During our study we noticed significant decrease of fT3 and TSH serum levels (respectively 2.36 +/- 0.79 pg/ml and 0.76 +/- 1.12mU/I) according to the control group (respectively 3.28 +/- 0.61 pg/ml and 0.95 +/- 0.46mU/l). Nonsurvivors had significantly lower TSH serum level (0.37 +/- 0.62 mU/I) in comparison to survivors (1.27 +/- 1.45 mU/I) in spite of very similar fT3 serum level (respectively 2.45 +/- 0.87 pg/ml and 2.22 +/- 0.66 pg/ml). It could mean that there were disturbances in the pituitary-thyroid axis function in patients who did not survive. Our study did not show any correlations between thyroid hormones serum levels and APACHE II score, APACHE III score, ALI or ARDS.

CONCLUSIONS

This study show that low TSH serum level could be a significant prognostic factor of death in patient with septic shock especially with low fT3 serum level. The results also suggest that ESS could be a consequence of pituitary TSH releasing disturbances.

[Serum concentration of interleukin-12 (IL-12) in patients undergoing abdominal aortic aneurysm repair--preliminary report]

Abdominal aortic aneurysm surgery (AAA) is associated with perturbations of immune response and decreased immunity to infection, followed by high risk of organ and systemic complications development, including sepsis. The postoperative mortality in patients with AAA comes up to 10-12% and determines us to look for factors that may influence the immune response and are important for uneventful postoperative course. IL-12 is a potent immunoregulatory cytokine, that regulates cellular and humoral immunity. The aim of this study was to determine the IL-12 serum level in patients with AAA and its relation to ischaemia and reperfusion during aortic surgery. The study comprised 17 patients undergoing AAA repair and 10 patients of control group. Peripheral blood samples were taken before surgery (T0), before unclamping of aorta (T1), 90 minutes after unclamping (T2) and 24 h after surgery (T3). The IL-12 serum concentrations were measured with high sensitivity ELISA technique. IL-12 serum concentration was significantly higher in patients with AAA than in control group. During surgery a slight elevation after ischaemia (T1) and great depletion after reperfusion (T2) were observed. We found a significant correlation between IL-12 level at T2 and the length of surgery. The serum level of IL-12 is higher in AAA patients than in healthy men. Ischaemia and reperfusion during AAA repair results in an increase followed by decrease of cytokine serum level. There was not relationship between IL-12 level and its changes and postoperative course of AAA patients.

Serum concentrations of MCP-1 and RANTES in patients during aortic surgery: the relationship with ischemia-reperfusion

INTRODUCTION

Surgical trauma is associated with depression of the immune system, which results in a high complication rate following abdominal aortic aneurysm (AAA) repair. Monocyte chemotactic protein-1 (MCP-1) and regulated-on-activation normal T cell expressed and secreted (RANTES) protein are important mediators of the immune and inflammatory response. The aim of this study was to determine whether there is any relationship between MCP-1 or RANTES and operative injury and ischemia-reperfusion during AAA surgery in human.

MATERIAL AND METHODS

Peripheral blood samples were taken from 12 patients before surgery, after anesthesia induction, before unclamping of aorta (PreXoff), 90 min after unclamping (90 minXoff), and at 24 and 48 h after surgery.

RESULTS

The MCP-1 and RANTES serum concentrations were measured with the ELISA technique. MCP-1 concentration significantly increased after reperfusion (90 minXoff) in comparison with the PreXoff level (p=0.001). Twenty-four hours after AAA repair, MCP-1 significantly decreased 269-225 pg/ml (p=0.005) and reached preoperative value. RANTES level was higher in AAA patients before surgery than in controls (p=0.025) and decreased significantly after ischemia-reperfusion to 13 ng/ml (p< 0.001) at 90 minXoff. We showed increases in RANTES concentration to 26 ng/ml on the 1st and to 31 ng/ml on the 2nd day after surgery (p=0.020, p=0.012, respectively) compared with the 90 min Xoff level.

CONCLUSIONS

Ischemia-reperfusion during AAA repair results in an increase in MCP-1 and decrease in RANTES concentrations in serum. The changes in chemokine concentrations may influence the development of immunosuppression after AAA repair, contributing to the postoperative course.

The importance of interleukin 18, glutathione peroxidase, and selenium concentration changes in acute pancreatitis

Cytokinemia and oxidative stress are important factors responsible for an inadequate immune response in the early course of acute pancreatitis (AP). The aim of the study was to evaluate the profiles of interleukin 18 (IL-18), glutathione peroxidase (GPx), and selenium concentrations in serum with respect to AP severity and to study the relationships between these parameters and recognized prognostic indicators of AP severity. Prospective clinical analyses were performed on 61 patients with mild and severe forms of AP and for 15 healthy volunteers. In both forms of AP severity, the IL-18 concentration in the serum was significantly higher than in healthy controls. In the severe form of AP, the IL-18 concentration was the highest and exceeded significantly the values recorded on the 1st, 2nd, 3rd, 5th, and 10th days of mild AP. A significantly lower GPx concentration in the serum was recorded in severe AP compared to the mild form and in the control group. There was a significantly lower selenium concentration in the severe form of AP. Significant correlations between GPx and selenium, between IL-18 and GPx, and between IL-18 and selenium were recorded. The ROC analysis shows a high prognostic accuracy of IL-18 and GPx concentrations in the determination of AP severity. IL-18 is released early in the course of AP and may be a key immunomodulator of the inflammatory response in the severe form of this disease. Low GPx and selenium concentrations in severe AP reflect the lower antioxidative ability in this form of AP. IL-18 and GPx may represent new indicators of AP severity.

Diagnostic value of pancreatic elastase-1 in human acute pancreatitis

The diagnosis of acute pancreatitis (AP) is usually confirmed by a significant increase of the serum amylase and/or lipase level. However, serum pancreatic elastase-1 (pEla-1) was found to be a more sensitive diagnostic marker in AP, when assayed by the radioimmunoassay procedure. We analyzed the serum concentration of pEla-1, measured by the ELISA technique in 46 patients with AP and in a control group of 12 healthy volunteers. On admission (day 1) we found significantly higher pEla-1 levels in patients with AP than in the controls. During the following days, the concentration of pEla-1 rapidly decreased to nearly undetectable values on the 3rd day. There was no significant difference between patients with mild and severe AP nor those of different etiology. We suggest that pEla-1 has little diagnostic value and does not provide additional information to that of the less expensive and more widely available serum amylase and lipase.

[Interleukin 18 as a new immunomodulator of some digestive tract diseases]

Interleukin 18 has been known since 1989 and since its properties have been recognized, an interest in it is constantly growing. IL-18 induces synthesis and release of proinflammatory cytokines, chemokines and nitric oxide. Thus, it modulates the function of many immunocompetent cells: macrophages, monocytes, lymphocytes and granulocytes. In the paper, properties of IL-18 are reviewed and its implications for pathogenesis of some gastrointestinal diseases, particularly inflammatory bowel diseases, i.e. Crohn Disease and colitis ulcerosa, inflammatory liver diseases such as persistent active hepatitis and primary biliary cirrhosis and acute pancreatitis are discussed.

[Biological properties of interleukin 18]

IL-18 was first described in 1989 and since its properties have been recognized, an interest in it is constantly growing. IL-18 induces synthesis and release of interferon gamma (IFN-gamma), interleukins 8, 4 and 13, tumor necrosis factor alpha (TNF-alpha) and granulocyte/macrophage colony stimulating factor (GM-CSF). Thus, it modulates the function of many immunocompetent cells: macrophages, monocytes, lymphocytes and granulocytes. Another important feature of IL-18 is its ability to induce apoptosis of many cell types by inducing Fas ligand and Fas receptor, and granzymes. IL-18 seems to be particularly attractive as a highly specific marker of Th1-response and a potential element of complex antitumor therapy. In paper, the processes of synthesis, releasing and biological properties of IL-18 are reviewed, particularly in the aspects of immunomodulatory and antitumor activity.

[Risk assessment of patients and preparation for abdominal aortic aneurysm repair--the effect of collaboration among the internist, anaesthesiologist and surgeon]

Abdominal aortic aneurysm (AAA) is a common cardiovascular disease of increasing incidence. The complex clinical assessment with regard to indications for surgical treatment is necessary for each patient with AAA diagnosis. Taking into consideration the high postoperative complication risk and mortality rate among these patients, the general evaluation especially the function of cardiovascular system together with surgical and anaesthesiological management are required. Proper cooperation with specialists of internal medicine and often with cardiologist is essential for reduction of perioperative risk as a consequence of treatment, that improves the function of the most important organs, in the best possible manner. The engagement of specialists in internal medicine, anaesthesiology and surgery enables the patient to carry through the operation in safe conditions. We describe perioperative risk factors and basic principles of patient evaluation and preparation for AAA reconstructive surgery.

[Validation of organ failure scoring systems in objective illness characterization]

Multiple organ failure syndrome is the leading cause of death in intensive care units. Medical scales and scoring systems are used for objective characterization of patients, quantitation of illness severity, prognosis, identification of high-risk patients, determination of treatment effectiveness and final outcome. We reviewed some data about the most frequently used scoring systems describing organ failure. Multiple Organ Dysfunction score (MODs) grades increasing severity of dysfunction of vital significant organ systems and it reflects intensity of SIRS.APACHE II and APACHE III scoring systems and SOFA score are used widely in clinical practice.

Serum profiles of E-selectin, interleukin-10, and interleukin-6 and oxidative stress parameters in patients with acute pancreatitis and nonpancreatic acute abdominal pain

INTRODUCTION

Excessive inflammatory response is one of the major causes of early mortality in acute pancreatitis (AP).

AIM

To evaluate the serum profiles of E-selectin, interleukin (IL)-6, and IL-10 along with their correlation to the markers of oxidative stress and neutrophil activation in patients with AP and patients with nonpancreatic acute abdominal pain (NPAAP).

METHODOLOGY

This prospective clinical study included 56 patients with AP (28 with mild AP and 28 with severe AP) as well as 15 patients with NPAAP.

RESULTS

Serum concentrations of E-selectin, IL-10, and IL-6 and plasma concentrations of polymorphonuclear leukocyte elastase (determined on days 1-3, 5, and 10 after admission) were the highest in severe AP during the first 3 days and then declined. At day 10, the E-selectin level in severe AP was still higher than that in mild AP, and the IL-10 concentration increased again. There was no elevation in the E-selectin concentration in NPAAP patients, and IL-10 levels remained unchanged in mild AP. Oxidative stress, measured by serum malondialdehyde and 4-hydroxyalkenals levels, was the most pronounced in severe AP.

CONCLUSIONS

The serum E-selectin concentration is markedly elevated in severe AP and is less in mild AP but not in NPAAP. It may result from stimulation with different inflammatory mediators or indicate vascular endothelium injury mediated by oxidative stress, especially in the severe form of AP.

[Serum levels of luteinizing hormone, testosterone and prolactin in patients with septic shock]

Many studies show important disturbances in hormonal balance in patients with severe sepsis. There are a lot of factors, which are involved in this process but the role of sex steroid hormones is unknown; especially, the role of testosterone, which is one of the anabolic hormones and a immune function modulator. We hope that sex steroid hormone mechanisms of action recognition in septic shock may help in treatment of such patients. The aim of this study was to evaluate changes in sex hormone concentrations in septic patients and their prognostic significance. We studied serum level of luteinizing hormone (LH), testosterone (T) and prolactin (PRL) in 20 patients with septic shock and in healthy male volunteers (n = 20). Septic patients were divided into two groups: survivors (group I, n = 10) and nonsurvivors (group II, n = 10). We noticed significant decrease of testosterone and LH serum levels in septic group vs the controls and correlation between T and LH serum levels and survival. Acute lung injury was associated with higher PRL serum level and was independent from the LH and T serum level. We also noticed incorrect pituitary down-regulation of testosterone secretion. Our study showed that sex steroid hormones can be good prognostic factors of survival and complications of septic shock.

Serum profiles of interleukin-18 in different severity forms of human acute pancreatitis

BACKGROUND

Interleukin 18 (IL-18) is a new mediator and modulator of the immune response; its role in acute pancreatitis (AP), however, has not yet been fully explained. The aim of our study was to evaluate the profile IL-18 serum concentrations in the course of acute pancreatitis.

METHODS

The prospective study involves 30 patients with AP (n = 15 with mild AP and n = 15 with severe AP) as well as 10 healthy subjects. AP severity was defined according to Ranson's and Balthazar's criteria, supplemented by serum CRP concentration measurements. In the course of hospitalization, 2 patients with severe AP died. Serum IL-18 and plasma polymorphonuclear leukocyte elastase (PMN-E) concentrations were measured at admission (day 1) and on days 2, 3, 5 and 10.

RESULTS

In both the mild and the severe forms of AP, serum IL-18 concentration was significantly higher than in the healthy controls. In severe AP, serum IL-18 reached the highest levels in all observed periods compared to that in patients with mild AP. Significant correlations, calculated for day 1, were found between serum IL-18 and plasma PMN-E (Rs = 0.514. P < 0.001) and between IL-18 and CRP (Rs = 0.463, P < 0.001) levels.

CONCLUSIONS

Serum profile IL-18 during AP indicates that this cytokine was released early after AP onset and may play the key role in inflammatory and immune response. Positive correlation between serum IL-18 and commonly known early prognostic markers of AP severity suggest that serum IL-18 concentrations may represent another early marker indicating severe course of AP.

[The role of monocytes/macrophages and their cytokines in the development of immunosuppression after severe injury]

Despite new generations of antibiotics and great improvement in the fields of rescue and modern intensive care medicine, sepsis remains one of the most frequent causes of complications and death in severely injured patients. Shock, bacterial colonization, invasive methods of treatment and immune mechanisms are reported to be responsible for the increased susceptibility of patients to sepsis after trauma. Posttraumatic immune abnormalities consist of two mechanistic entities: inappropriately hyperactive inflammatory processes and profound depression of cell-mediated immune function. Monocytes/macrophages carry out the fundamental protective functions of ingesting and killing invading microorganisms. Macrophages play a central role in the immune response by presenting antigens to lymphocytes, modulating T cell functions and by secreting a large number of inflammatory mediators. Macrophage-derived cytokines play key roles in the amplification of both humoral and cell-mediated immune responses. Depression of macrophage function appears to have serious deleterious effects in critically injured patients and has been associated with increased mortality. Phagocytosis, oxidative burst activity and cytokine secretion are impaired in macrophages early after traumatic injury. However, a widely accepted clinical treatment for post-injury immunosuppression does not currently exist. As our understanding of the pathogenesis of injury-induced immunosuppression progresses, our treatment approaches will likely improve.

Soluble selectin profiles associated with severe trauma

Severe trauma acts as a trigger for the complex cascade of postinjury events leading to the release of different mediators and the development of generalized inflammation. Selectins are a family of adhesion proteins that are responsible for the adherence of polymorphonuclear neutrophils to the endothelium. This interaction plays an important role in the development of severe complications after multiple trauma. The aim of the present study is to follow the sequential alterations in circulating selectin levels after severe injury and to evaluate the clinical significance of these mediators in monitoring prognosis and outcome. Thirty four severely traumatized patients were entered into the study. Serum sE-selectin, plasma sP-selectin and sL-selectin concentrations were measured and an APACHE II score was calculated on admission to the intensive care unit and during the subsequent 5 days. The patients were divided into survivors and nonsurvivors. Initial soluble P- and E-selectin concentrations were significantly elevated in all trauma patients. The highest values of these adhesion molecules were measured in all the observed days in patients with poor prognosis and outcome. In survivors we found a systematic decrease in the sP-selectin concentrations. On admission, the sL-selectin concentrations in all trauma patients were decreased. There were stable, very low values in nonsurvivors and a slow increase in circulating L-selectin in patients who survived. The pattern of soluble selectins in patients with severe trauma is characterized by increased levels of P- and E-selectin and a decreased concentration of L-selectin. These findings suggest a widespread microvascular endothelial activation on injury in the early posttraumatic period, which may be associated with increased neutrophil-endothelial adhesion, neutrophil extravasation and migration. We suppose that these parameters of endothelial cell activation/injury may be useful as another early prognostic factor in severe trauma.

[Effect of severe multiple trauma complicated by acute lung injury on endothelial cell activity]

The pulmonary endothelium synthesizes many bioactive compounds and their activation or injury may cause release these substances into the blood. We determined the influence of trauma severity for endothelium activation/injury by measurement of specific endothelial cell markers--soluble E-selectin (sES) and von Willebrand factor antigen (vWF:Ag). Thirty six severely traumatized patients were stratified according to an Injury Severity Score (ISS). Group I--patients with ISS > or = 35, Group II--patients with ISS < 35. Eleven healthy volunteers served as controls. Serum sES and plasma vWF:Ag concentrations were measured and PaO2/FiO2 ratio, Lung Injury Score (LIS) and APACHE II ratio were calculated at the admission to IC, after 24 h and on 2, 3, 5, 7, 10th day. In all investigated time periods, we observed significant increase in serum sES concentration among patients from group I, in comparison to initial value and control. On day 3, serum sES concentration was significantly increased in group I, in comparison to group II. In the first seven days, plasma vWF:Ag concentration in patients with severe multiple trauma (ISS > or = 35) was significantly elevated, in comparison to group II and control. At the admission, significant correlation between plasma vWF:Ag and ISS was found (Rs = 0.568, p < 0.001). Significant correlation between plasma vWF:Ag and serum sES concentration was also observed (Rs = 0.501, p < 0.001). In conclusion, severe trauma patients manifest endothelial cell activation/injury. Plasma vWF:Ag concentration seems to be an important, early marker of trauma severity, while serum sE-selectin level may serve as prognostic factor in immediate postinjury period course.

[Adhesion molecules and their role in organ response after trauma]

In this paper, we presented general characterization of adhesion molecules and their role in organ response after injury. Severe trauma is frequently complicated by multiple organ dysfunction (MODS) or failure (MOF). The pathogenesis of these syndromes involves a complex interaction of humoral and cellular events. The recruitment of circulatory leukocytes into tissues is regulated in part by specific leukocyte-endothelial cell interactions with several families of cell adhesion molecules. In the adhesion cascade, the initial phase of inflammation, a transient slowing of neutrophils in postcapillary venules is mediated by selectins. Firm adhesion of neutrophils to the endothelium occurs by interaction of beta 2 integrins to ICAM-1. Diapedesis between endothelial cells requires the engagement of PECAM-1. Significance of the adhesion molecule in organ response after severe trauma permitted their diagnostic and prognostic use as well as new methods of treatment.

The diagnosis and surgical management of diseases of the adrenal glands

The authors present their own experience in the diagnosis and management of adrenal tumours and cysts. During the years 1980-2000, 74 patients were underwent surgical treatment. Of this group, 23 had Cushing's syndrome, 19 phaeochromocytomas, 4 Conn's syndrome, 2 virilising tumours, 2 adenocarcinomas, 2 ganglioneuromas, 7 adrenal cysts, 8 adenomas, 3 adenocortical carcinomas, 2 nodular hypertrophies, 1 myelolipoma and 1 liposarcoma. Treatment was effective in 73 (98.6%) of patients. We recommend the transperitoneal approach which allows the visual evaluation of both adrenals and extra adrenal tissue. We regard surgical intervention as being the only effective method of treating adrenal tumours.

von Willebrand factor antigen as a prognostic marker in posttraumatic acute lung injury

The specific endothelial cell product von Willebrand factor antigen (vWf:Ag) was measured in plasma and lung function tests were carried out and the following lung injury parameters measured: P(a)O2/F(i)O2 ratio, static respiratory compliance and Murray's lung injury score (LIS) in a follow-up study of 36 severely traumatized patients. Injury severity score (ISS) and APACHE II scores were calculated. Patients were classified according to the presence or absence of acute respiratory distress syndrome (ARDS) complications and survival versus death. Data collection was performed on admission to hospital and after 1-3, 5, 7, 10 days of ICU stay. On all of the occasions investigated, plasma vWf:Ag levels in ARDS patients and nonsurvivors were significantly greater than those in patients without ARDS and survivors, respectively. Significant correlations were observed between initial vWf:Ag concentration and ISS, APACHE II, LIS. Our study suggests that increased concentrations of vWf:Ag in plasma are predictive of the development of ARDS and signal poor prognosis in patients following severe trauma.

Lysosomal activity of pulmonary alveolar macrophages in acute experimental pancreatitis in rats with reference to positive PAF-antagonist (BN 52021) effect

The activation of pulmonary alveolar macrophages (PAM's), might play an important role in severe complications of acute pancreatitis. The aim of our study was to assess the labilization of macrophage lysosomal membranes and release of lysosomal cathepsin B (CB) and N-acetyl-beta-D-hexosaminidase (NAH) into bronchoalveolar lavage fluid (BALF) during taurocholate acute pancreatitis (AP) in rats treated with PAF-antagonist--BN 52021. Total activity of CB increased by 374% after 6 h and by 237% after 12 h of AP in lysosomal enriched fraction of PAM's. Fractional free activity of CB increased to 40% after 6 h and to 38% after 12 h of AP. Free activity of CB was increased 5 fold in the supernatant of macrophage homogenate, and 10 fold in the supernatant of BALF after 6 h of AP. The values of NAH activity roughly paralleled that of CB. Treatment with BN 52021 (5 mg x kg(-1) every 6 h i.v.) partially normalized the measured parameters. Our results indicate that the PAF-antagonist BN 52021 reduced the increase of total and free activity of lysosomal hydrolases of PAM's and partly prevented the labilization of their lysosomal membranes. Therefore, an important mechanism of BN 52021 beneficial effect in pulmonary complications of acute pancreatitis could be dependent on the stabilization of PAM's lysosomes.