[The treatment of hyperglycaemia in critically ill patients: comparison of standard protocol and computer algorithm]

INTRODUCTION

Hyperglycemia is commonly observed in patients hospitalized on intensive care units. It is has been demonstrated that normalization of blood glucose level using intensive insulin therapy significantly improves prognosis of these patients. The aim of our study was comparison of standard protocol of intensive insulin therapy used on cardiac surgery ICU in General University Hospital in Prague and computer algorithm MPC (Model Predictive Control).

PATIENTS AND METHODS

20 patients with glycaemia higher than 6.7 mmol/l at the time of admission to ICU were included into the study, 10 subjects were randomized for standard treatment, 10 for treatment with MPC algorithm. Glycaemia was measured hourly during 48 hours, insulin infusion was rate was adjusted hourly in MPC algorithm or in 1-2 hours in standard protocol group.

RESULTS

Blood glucose levels were in the target range significantly longer in MPC relative to standard protocol group (26.3 +/- 2.1 hrs vs 20.3 +/- 2.5 hrs). Mean blood glucose was also lower using MPC algorithm (6.47 +/- 0.11 vs 6.72 +/- 0.23 mmol/l). On the contrary the target range was established faster using standard protocol (8.9 +/- 1.2 vs 10.3 +/- 0.9 hrs), duration of hyperglycaemia was the same in both groups (7.3 +/- 1.9 in standard protocol vs 7.3 +/- 1.3 hrs in MPC algorithm). Average 48-hours insulin dose was higher in MPC than standard protocol group (230.2 +/- 38.8 vs 199.1 +/- 27.8 IU/48 hrs). 2 hypoglycaemic episodes occured in 2 patients in standard protocol group.

CONCLUSIONS

Our results show that the use of MPC algorithm result in more effective blood glucose control in critically ill patients than standard protocol.

[Intestinal ischaemia--consequence of intestinal malrotation]

The subsets of acute intestinal ischaemia include mesenterica arterial occlusion, venous thrombosis and non-occlusive mesenteric ischaemia. Advances in pathophysiology, diagnosis and treatment, prognostic problems are associated still in mortality rates of more than 60%. Early diagnosis is the first in possibility for better prognosis. In our article is case one young man with acute non-occlusive intestinal ischaemia described, diagnosis and treatment. Mucosal surface necrosis and hemorrhage was supposed, sepsis was expected, mucosal regeneration after ten days surprising. While changes on the bowel were hard to decide to resection, there are bioptic picture of mucosal layer in the time described (Fig. 5-9). We have written about similar case of young man with Waldayer hernia in 1999.

Short-term very low calory diet reduces oxidative stress in obese type 2 diabetic patients

Oxidative stress is higher in obese diabetic than in non-diabetic subjects. This pilot study evaluates oxidative stress during short-term administration of a very low calorie diet in obese persons. Nine obese Type 2 diabetic patients (age 55+/-5 years, BMI 35.9+/-1.9 kg/m2) and nine obese non-diabetic control subjects (age 52+/-6 years, BMI 37.3+/-2.1 kg/m2) were treated by a very low calorie diet (600 kcal daily) during 8 days stay in the hospital. Serum cholesterol, triglycerides, non-esterified fatty acids (NEFA), beta-hydroxybutyrate (B-HB), ascorbic acid (AA), alpha-tocopherol (AT), plasma malondialdehyde (MDA) and superoxide dismutase (SOD) activity in erythrocytes were measured before and on day 3 and 8 of very low calorie diet administration. A decrease of serum cholesterol and triglyceride concentrations on day 8 was associated with a significant increase of NEFA (0.30+/-0.13 vs. 0.47+/-0.11 micromol/l, p<0.001) and B-HB (0.36+/-.13 vs. 2.23+/-1.00 mmol/l, p<0.001) in controls but only of B-HB (1.11+/-0.72 vs. 3.02+/-1.95 mmol/l, p<0.001) in diabetic patients. A significant decrease of plasma MDA and serum AT together with an increase of SOD activity and AA concentration (p<0.01) was observed in control persons, whereas an increase of SOD activity (p<0.01) was only found in diabetic patients after one week of the very low calorie diet. There was a significant correlation between NEFA or B-HB and SOD activity (p<0.01). We conclude that one week of a very low calorie diet administration decreases oxidative stress in obese non-diabetic but only partly in diabetic persons. Diabetes mellitus causes a greater resistance to the effects of a low calorie diet on oxidative stress.

Soluble leptin receptor levels in patients with chronic renal failure

Soluble leptin receptor (SLR) is the extracellular part of the leptin receptor. This protein is released into circulation and constitutes the main circulating leptin-binding protein. The aim of our study was to measure SLR concentrations in patients with chronic renal failure (CRF) and healthy subjects and to explore the relationship of SLR to other hormones and cytokines. The patients with CRF had significantly higher serum leptin, TNF-alpha and insulin levels than healthy subjects (25.1+/-23.5 vs. 9.4+/-7.6 ng.ml(-1) (S.D.); 14.2+/-4.2 vs. 4.55+/-2.5 ng.ml(-1); 39.8+/-36.1 vs. 20.3+/-11.1 mU.l(-1)). Serum soluble leptin receptor levels did not differ between these groups (19.1+/-11.3 vs. 19.6+/-6.1 U.ml(-1)). An inverse relationship between serum SLR and leptin levels was found in both groups. In patients with CRF the inverse relationship between SLR and insulin, body fat content and total protein levels were also found, while in healthy subjects only inverse relationship of SLR with insulin and albumin concentrations were detected. We conclude that soluble leptin receptor levels in patients with chronic renal failure do not differ from those of healthy subjects despite higher serum leptin levels in CRF patients. The physiological consequences of this finding require further investigation.

Plasma ghrelin levels and malnutrition: a comparison of two etiologies

Ghrelin is a peptide hormone that is involved in regulating growth hormone secretion as well as food intake and energy homeostasis. The aim of this study was to compare changes in plasma ghrelin levels in patients with malnutrition due to anorexia nervosa (AN) or short bowel syndrome (SBS). Blood samples for laboratory analyses were taken from 16 AN patients (plus 13 comparable healthy controls) and 27 SBS patients (plus 13 comparable healthy controls) after an overnight fast. In comparison with their respective control groups, plasma ghrelin levels were increased in the AN patients (p < 0.05) and significantly decreased in the patients with SBS (p < 0.01). These results suggest that quantitative ghrelin secretion in the gut wall is important in determining ghrelin concentrations in the systemic circulation.

[Relation between serum leptin levels and selected nutritional parameters in hemodialyzed patients]

Leptin is a protein hormone produced predominantly by adipocytes. Its serum concentrations positively correlate with body fat content and body mass index (BMI) i.e. they are lower in lean than obese subjects. The aim of our study was to compare serum levels of leptin, selected nutritional parameters and serum lipids in hemodialysed patients (n = 46) and healthy subjects (n = 24) and to explore the relationship between serum leptin levels and the rest of nutritional parameters in both groups. The tendency towards higher serum leptin levels in hemodialysed patients compared to control group was found, but the difference did not reach the statistical significance (24.31 +/- 24.06 ng/ml vs. 7.97 +/- 4.4 ng/ml). The leptin/body fat content ratio was significantly higher in hemodialysed patients compared to control subjects (0.85 +/- 0.74 vs. 0.27 +/- 0.11, p plain 0.01). The serum total protein, transpherine, albumin and cholesterol levels were significantly lower in hemodialysed patients compared to control group (68.14 +/- 5.56 g/l vs. 75.53 +/- 3.43 g/l; 2.04 +/- 0.49 g/l vs. 2.5 +/- 0.23 g/l; 33.65 +/- 2.86 g/l vs. 48.38 +/- 3.5 g/l; 4.56 +/- 1.19 mmol/l vs. 5.82 +/- 0.98 mmol/l; p = 0.001). Serum triglyceride levels were significantly lower in hemodialysed patients compared to controls (1.29 +/- 0.5 mmol/l vs. 2.31 +/- 1.23 mmol/l, p < 0.0001). Serum leptin levels in hemodialysed patients correlated positively with body fat content, serum cholesterol and triglyceride levels. In the control group only the significant positive correlation with body fat content was found. In conclusion, this study demonstrated relatively higher serum leptin levels in hemodialysed patients compared to healthy subjects, although their nutritional status expressed by serum protein nutritional parameters and body fat content is significantly impaired. Except of the positive correlation with serum lipids levels no statistically significant relationships between serum leptin levels and biochemical nutritional parameters were found in our study.

[Serum leptin levels and soluble leptin receptors in female patients with anorexia nervosa]

BACKGROUND

Leptin action in peripheral tissues is enabled by an interaction with specific transmembrane receptors. Several of leptin receptor isoforms were identified, including soluble leptin receptor isoform structurally identical to extracellular domain of the the long leptin receptor isoform. The soluble receptor isoform is released to the circulation and acts probably as leptin-binding factor. The aim of our study was to measure serum concentrations of the soluble leptin receptor in patients with anorexia nervosa and in the control group of healthy women. Relationships of soluble leptin receptor levels to body mass index (BMI), body fat content, serum leptin, TNF-alpha and insulin levels were also studied.

METHOD AND RESULTS

16 patients with anorexia nervosa and 16 age-matched lean healthy women were included into the study. All of the subjects were measured and weighed, the body fat content was estimated from the skinfold thickness measurement. The blood for the determination of leptin, soluble leptin receptor and other hormonal parameters was obtained from all subjects after the overnight fasting. BMI, body fat content, serum leptin and insulin levels in patients with anorexia nervosa were significantly lower than in the control group (BMI: 14.98 +/- 2.32 vs. 22.21 +/- 2.48, p < 0.01, % fat content: 16.43 +/- 4.56 vs. 27.19 +/- 4.59, p < 0.01, leptin: 1.37 +/- 1.85 ng.ml-1 vs. 7.19 +/- 3.49 ng.ml-1, p < 0.01, insulin: 12.97 +/- 2.89 mU.l-1 vs. 17.09 +/- 5.57 mU.l-1, p < 0.05). Serum soluble leptin receptor levels in patients with anorexia nervosa were significantly higher compared the to control group (24.67 +/- 8.3 U.ml-1 vs. 15.71 +/- 2.79 U.ml-1, p < 0.01). No significant differences in serum TNF-alpha levels between the groups studied were found. Serum leptin levels in both groups correlated positively with BMI and body fat content. Serum soluble leptin receptor levels in both groups correlated negatively with BMI only. No statistically significant relationships between serum soluble leptin receptor levels and the rest of parameters studied were found in any of the groups studied.

CONCLUSIONS

Serum soluble leptin receptors levels in patients with anorexia nervosa were significantly higher in comparison with the healthy subjects. Except of the negative correlation between serum soluble leptin receptor levels and BMI no statistically significant relationships between serum soluble leptin receptor and the rest of parameters studied were found.

[The effect of partial refeeding on serum levels of leptin and resting energy expenditure in female patients with anorexia nervosa]

BACKGROUND

Serum leptin levels and resting energy expenditure are significantly decreased in patients with anorexia nervosa compared to healthy subjects. Partial realimentation of patients with anorexia nervosa increases both these parameters. However, there so far are no data concerning the relationship of serum leptin levels and resting energy expenditure in patients with anorexia nervosa. The aim of our study was to follow the relationship of serum leptin levels and resting energy expenditure in patients with anorexia nervosa before and after refeeding.

METHODS AND RESULTS

It was found that serum leptin levels in patients with anorexia nervosa both before and after partial realimentation were significantly lower compared to healthy subjects (0.86 +/- 0.9 ng.ml-1 and 1.77 +/- 1.9 ng.ml-1 vs 6.85 +/- 3.0 ng.ml-1, p < 0.05). The total resting energy expenditure in patients with anorexia nervosa both before and after realimentation were significantly lower than in the control group (4973 +/- 979 and 5263 +/- 899 vs 6401 +/- 827 kJ/day, p < 0.05). When expressed per body weight the resting energy expenditure in patients with anorexia nervosa was significantly higher in comparison with the control group (122.3 +/- 20.6 and 121.5 +/- 14.2 vs 104.2 +/- 14.6 kJ/day, p < 0.05). The differences in resting energy expenditure in patients with anorexia nervosa before and after refeeding did not reach statistical significance. The body mass and the body fat content increased significantly after realimentation index (14.5 +/- 1.4 vs 15.6 +/- 1.5 kg.(m2)-1 and 14.9 +/- 3.4 vs 16.6 +/- 3.7, p < 0.05) but remained still below of those of control group (BMI 22.3 +/- 2.7, body fat content 26.9 +/- 4.2).

CONCLUSIONS

Our study confirmed the reduced serum leptin levels and the total resting energy expenditure in patients with anorexia nervosa compared to healthy age-matched subjects. No statistically significant relationships were found between serum leptin levels and resting energy expenditure either in healthy subjects or in patients with anorexia nervosa before or after partial realimentation respectively.

[Relation of serum leptin levels and regulation of resting energy expenditure]

Leptin is a protein hormone produced by adipocytes. Its serum concentrations in the most of cases positively correlate with total body fat content and body mass index (BMI). Leptin plays a role in the food intake regulation. It also increases resting energy expenditure in hypoleptinaemic ob/ob mice. Its relationship to resting energy expenditure in human is less clear. The aim of our study was to follow the serum leptin levels in healthy females (n = 12) and males (n = 14) and their relationship to resting energy expenditure, body fat content, other antropometric and nutritional biochemical parameters. It was found that serum leptin levels were significantly higher in females comparing to males (6.8 +/- 3 ng.ml-1 vs. 2.6 +/- 1 ng.ml-1, p < 0.05). The serum leptin levels correlated positively with body fat content and body mass index in both groups. In females the positive correlation between body weight and serum leptin levels was found. No statistically significant relationship between serum leptin levels and resting energy expenditure, serum total protein, albumin or prealbumin concentration was found in any of studied groups. The results of our study do not testify to direct relationship between serum leptin levels and resting energy expenditure in young healthy individuals.

[Nutritional status of drug addicts in a methadone program]

BACKGROUND

Substitution treatment of drug addicts with methadone has been used in many countries for more than 35 years. In our country it was started in 1997. The objective was above all to evaluate the nutritional status and some biochemical parameters before and after 18 months of methadone substitution.

METHODS AND RESULTS

A total of 14 patients were examined (9 men, 5 women), mean age 35 years, range 26-44 years, highly dependent on opiates: heroin, codeine and its derivatives). The examination was made before onset of treatment and after 18 months of treatment. The subjective feeling of all patients improved, they felt more active and efficient. The Kehlet score declined from 5.8 +/- 1.9 to 3.8 +/- 1.5. The body weight increased from 69.3 +/- 14.8 to 78.6 +/- 19.7 kg. BMI from 22.8 +/- 3.2 to 25.5 +/- 5.0 (kg/m2), the skinfold above the triceps muscle from 11.9 to 16.6 mm, prealbumin from 0.17 +/- 0.05 to 0.22 +/- 0.66 g/l). The handgrip strength did not increase, no significant changes were recorded in albumin and transferrin levels. The raised serum aminotransferase levels did not change (due to chronic hepatitis).

CONCLUSIONS

Substitution treatment of drug addicts with methadone leads not only to improvement of the subjective state but also to objective signs of a better nutritional status.

Relationship of serum leptin levels and selected nutritional parameters in patients with protein-caloric malnutrition

Leptin is a protein hormone produced by adipocytes that reflects the body fat content, i.e., its serum concentration in healthy individuals positively correlates with the body mass index and body fat content. Serum leptin levels are lower in both patients with anorexia nervosa and protein-caloric malnutrition caused by chronic non-malignant illnesses. The aim of the present study was to compare serum leptin levels and selected, routinely used nutritional parameters in women with anorexia nervosa (n = 17), severely malnourished patients with short bowel syndrome (n = 13), and control non-obese healthy women (n = 17) to clarify the relation between selected nutritional parameters and serum leptin levels. We found that serum leptin levels in the anorexia nervosa and short bowel syndrome groups were significantly lower than those in the control group (in ng/mL: 3.63 +/- 1.64 and 2.59 +/- 1.17 versus 12.06 +/- 7.59, respectively). Protein malnutrition expressed by decrease in serum concentrations of total protein, albumin, and prealbumin was more pronounced in the short bowel syndrome group. Triceps skin fold, arm muscle circumference, and body mass index were significantly lower in the patient group than in the control group and did not significantly differ between the short bowel syndrome and anorexia nervosa groups. No significant difference in serum leptin concentration between the short bowel syndrome and anorexia nervosa groups was found. Serum leptin levels correlated positively with body mass index and triceps skin fold in the control and anorexia nervosa groups but not in the short bowel syndrome group. We conclude that serum leptin levels in patients with anorexia nervosa and short bowel syndrome are significantly lower than in healthy individuals and have no statistically significant relation to serum total protein, abumin, and prealbumin.

[Serum leptin levels in female patients with protein-calorie malnutrition and its relation to biochemical indicators of nutritional status]

Leptin is a protein hormone produced by adipocytes. Its serum concentrations in the most of cases positively correlate with total body fat content. Serum leptin levels are increased in obese in comparison with lean subjects. Leptin levels in females are two or three times higher than in body mass index and age-matched males. The aim of our study was to investigate the serum leptin concentrations in females with protein-caloric malnutrition of various aetiology, the relationship between leptin levels and biochemical nutritional parameters and to compare the values with those of age-matched control group. Totally 12 patients with malnutrition of various aetiology and 14 control age-matched healthy subjects were included into the study. It was found that serum leptin levels were significantly decreased in malnutrition group in comparison with control group (3.09 +/- 1.33 ng.ml-1 vs 9.42 +/- 2.76 ng.,l-1, p < 0.05). A significant decrease in body mass index, serum total protein, albumin, prealbumin, cholesterol and triglycerides concentration was also found in malnutrition in comparison with control group. While a strong positive correlation between leptin concentrations and body mass index was found in control group (r = 0.72, p < 0.05), no statistically significant relation between leptin and body mass index was observed in malnutrition group. Furthermore, no significant relationship was found between serum leptin levels and serum total protein, albumin, prealbumin, cholesterol and triglycerides neither in control or in malnutrition group. We conclude that serum leptin levels in patients with malnutrition are significantly decreased in comparison with age-matched healthy control subjects. The loss of positive correlation between leptin and body mass index in malnutrition group is explainable by the changes of body composition in patient with malnutrition. The body mass index value in these patients reflects the total body fat content less precisely than in healthy controls.

[Use of collagen and gentamycin in the treatment of chronic soft tissue lesions]

The authors describe two case-histories where Garamycin-schwamm was used in the treatment of a chronic fistula and cavities in the subphrenium resulting from treatment of a subphrenic abscess, and in the pelvis minor as a result of a fistula which developed after establishment of an ileoanal intestinal pouch. They confirm the experience of authors abroad with the treatment of chronic cavities in soft tissues as a result of operations, which so far had to be treated by other methods.

[Transmission of the electrocardiogram via telephone. Analysis of 10 years' experience]

BACKGROUND

The problem of impaired cardiac rhythm is in recent years in the foreground of the interest of cardiologists. This was influenced not only by the conclusions of the CAST study which changed the therapeutic pattern used for some years but above all the diagnostic pitfalls of impaired rhythm as regards detection and identification. The objective of the present study was to provide evidence of the advantages and usefulness of the method of telephone transmission of the electrocardiogram within the complex of other diagnostic procedures.

METHODS AND RESULTS

The group was formed by 251 patients, incl. 186 men and 65 women, average age 51.7 years (range 19-85 years). The transmission of the ECG by phone was implemented by the system TESLAR (VUIS-CVUT) which comprises recording units and a terminal with a graphic outlet. A total of 3,727 electrocardiographic tracings were assembled. During their analysis the arithmetic mean was used as the characteristic of the position of the group or groups on the scale, the error of the mean expressing the ratio of the standard deviation to the number of cases. In nominal variables most frequently percentage expression was used, frequently with a confidence interval obtained from tables. Evidence of the usefulness of the method is the high rate of detected arrhythmias within emergency calls (88.5%), as compared with normal calls (10.6%) where the yield is close to that of Holter monitoring, however, with the advantage of time ad libitum and thus also a higher yield.

CONCLUSIONS

The presentation of long-term experience with electrocardiograms by telephone confirms unequivocally the assumption that the method extends existing diagnostic possibilities in short-term, symptomatic, but sporadic arrhythmias, that it makes possible dispensarization of risk patients as well as patients with permanent pacemakers and that it improves the tactics of antiarrhythmic treatment.

[Arrhythmia as a major manifestation of Lyme borreliosis]

The submitted case-history is focused on one of the leading manifestations of cardiac affection in Lyme borreliosis. The authors recapitulate and analyze the patient's complaints, her electrocardiographic and other findings and confront them with data from the literature on this "new" nosological unit.

[Initial experience with modification of dosage of anti-arrhythmic agents using telephone transmission of the electrocardiogram]

Despite the doubtless advances in the knowledge of cardiac electrophysiology, the mechanism of action of antiarrhythmia and the considerable clinical experience with these drugs, treatment of arrhythmia remains on a trial error basis. The authors tried to use the system serving the transmission of one lead electrocardiograms by telephone as a means of checking and correcting antiarrhythmia treatment. It is a method which despite its unpretentious character and reliability is used on a very limited scale. As compared with other contemporary means of the control of the effect of antiarrhythmia treatment, i.e. above all Holter's method or investigation of plasma levels of antiarrhythmia drugs, it is less time consuming and cheaper. The preliminary results of the authors, based on initial experience, are encouraging.