„Zakażenia szpitalne w onkologii”

Recenzja pierwszego wydania książki pt. „Zakażenia szpitalne w onkologii” (Warszawa: PZWL, 2018), dzieła zbiorowego 18 autorów, którego redaktorem naukowym jest prof. dr hab. n. med. Andrzej W. Szawłowski

Ocena wyników leczenia wypadania narządów dna miednicy metodą zmodyfikowanej perineokolporektopeksji. Doświadczenia własne

Objectives: Anatomical and functional results of a modified sacral perineocolporectopexy for extreme forms of complex pelvic organs prolapse. Material and methods: Between 2005 and 2010, 10 women aged 47-75 years were treated by abdomino-perineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed-up. They were suffering from enterocele (9 pts), genital prolapse (8 pts), descending perineum (5 pts), rectal prolapse (4 pts), rectocele (3 pts). Five women were incontinent (mean Wexner: 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III°(5 pts) and II°(4 pts). MR designed descending perineum in 5 pts (mean: 3,8cm). Results: Permanent reconstruction of the pelvic floor and remission of organs prolapse was achieved at 12-months follow-up in all except 1 patient. There were 2 small vaginal erosions of the mesh and 1 haematoma within the pelvic floor. Improvement at rectal emptying was found in 4 patients, feeling of pelvic heaviness in 6 patients, dyspareunia in 3 patients. Mean incontinence score decreased from 9 to 4. Conclusions: 1. Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. 2. Improvements in rectal emptying, pelvic feeling of heaviness and dyspareunia have been achieved. 3. The implant tolerance was good and the complications rate was law.Cel pracy: Ocena wyników leczenia wypadania narządów dna miednicy metodą zmodyfikowanej perineokolporektopeksji. Materiał i metody: W latach 2005–2010, 10 pacjentek w wieku od 45 do 75 lat zostało poddanych zabiegowi perineokolporektopeksji z implantacją siatki polipropylenowej z dostępu brzuszno-kroczowego. U 9 pacjentek występowało enterocele, u 8 wypadanie narządów rodnych, w 5 przypadkach obniżenie dna miednicy, w 4 przypadkach wypadanie odbytnicy, a w 3 rektocele. Pięć kobiet skarżyło się na nietrzymanie stolca (śr Wexner: 9) a 6 na brak pełnego opróżnienia odbytnicy. Defekografia wykazała obecność enterocele III° u 5 pacjentek i II° u kolejnych 4 rezonans magnetyczny uwidocznił obniżenie dna miednicy w 5 przypadkach (śr o 3,8cm). Wyniki: U 9 pacjentek w 12-mięsięcznej obserwacji osiągnięto trwałą rekonstrukcję dna miednicy i ustąpienie wypadania narządów. Odnotowano dwa przypadki erozji siatki przez pochwę oraz jeden krwiak w miednicy mniejszej. Poprawę opróżniania odbytnicy stwierdzono u 4 pacjentek, uczucia ciężkości w miednicy u 6, a dyspareunii u 3 kobiet. Średni współczynnik nietrzymania stolca obniżył się z 9 do 4. Wnioski: 1. Zmodyfikowana krzyżowa perineokolporektopeksja jest skutecznym leczeniem złożonych anatomicznie defektów dna miednicy oraz wypadania narządów. 2. Osiągnięto poprawę w zakresie opróżniania odbytnicy, uczucia ciężkości w miednicy i dyspareunii. 3. Zabieg cechował się dobrą tolerancją materiału protetycznego i niskim odsetkiem powikłań

Practical approach to constipation in adults

The authors present epidemiology, etiology, pathophysiology, management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common – primary and less frequent – secondary. The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or, twice as likely, pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry. Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery. Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum

Natural Killer Cell Cytotoxicity and Immunosuppressive Cytokines (IL-10, TGF-β1) in Patients with Gastric Cancer

Cytotoxic activity of NK cells was estimated as related to IL-10 and TGF-β1 serum levels and Helicobacter pylori infection in gastric cancer patients. Moreover, we sought to determine whether human gastric adenocarcinoma cells in vitro release IL-10, TGF-β1 or factor(s) affecting NK cytotoxicity. The studies were conducted on 42 patients with gastric cancer (14 with I-II stage—group 1; 28 with III-IV stage—group 2) and on 20 healthy volunteers. The cytotoxicity was tested on NK cells isolated from peripheral blood. IL-10 and TGF-β1 levels were determined by ELISA. H. pylori was detected in cultures of gastric mucosa biopsies and in direct preparations. In 71.4% patients of group 1 NK cytotoxicity and IL-10 serum levels remained within a normal range while in 68% patients of group 2 a marked decrease was noted in cytotoxic function of NK cells, accompanied by increased levels of IL-10 in serum. In turn, in most patients of either group, independently of NK cytotoxicity and stage grouping in the patients, elevated serum levels of TGF-β1 were detected. Presence of H. pylori infection manifested no relationship with NK cytotoxicity, IL-10, or the TGF-β1 serum levels. In cultures of tumour cells presence of IL-10 and TGF-β1 was demonstrated. Nevertheless, supernatants of the cultures did not change cytotoxic activity of NK cells. Development of gastric carcinoma is accompanied by markedly decreased cytotoxic function of NK cells and by elevated IL-10 and TGF-β1 serum levels. Gastric carcinoma cells may release IL-10, the suppressive activity of which may in a secondary manner decrease NK cytotoxicity

Negative pressure wound therapy with instillation (NPWTi): Current status, recommendations and perspectives in the context of modern wound therapy.

Introduction of negative pressure wound therapy (NPWT) revolutionized the conception of wound healing. Currently, there are an increased number of studies confirmed the high efficiency of this therapy in many clinical scenarios. Moreover, some innovations have been introduced in recent years to improve the management of complex and chronic wound. NPWT with instillation (NPWTi) combines traditional NPWT with application of topical irrigation solutions within bed of the wound. Bioburden reduction, decrease time to wound closure, promotion in granulation tissue formation, fewer operative visits have been revealed using NPWTi compared to standard NPWT. However, there are still some questioned aspect of the NPWTi and thus its superiority over standard NPWT has not been fully indicated. Moreover, based on current studies no firm conclusions have been taken concerning the type of instilled solution preferably used, range of dwell- time phase, range of negative pressure and others. The main goal of the publication is to overview and summarize the current state of art concerning NPWTi. Moreover, mechanisms of action, review of the most common used instilled solution are discussed and clinical evidence of NPWTi are described

Discrepancy between clinical and histological effects of DHA supplementation in a rat model of pouchitis

Docosahexaenoic acid (DHA) potentially modulates inflammatory processes. Therefore, the aim of this study was to determine the influence of DHA supplementation on the expression of intestinal inflammation and nutritional status in rats which have undergone restorative proctocolectomy. Twenty-four Wistar rats were operated. After the induction of pouchitis, animals were randomly divided into a control group (CG) and supplementation groups receiving respectively a semi-synthetic diet without or with DHA (in a lower or higher dose, respectively known as the lower dose, LD, and higher dose, HD, groups) for six weeks. Selected nutritional parameters were assessed. Histopathological and immunohistochemical analysis of pouch mucosa specimens was also performed. The effectiveness of feeding and quality of stools were significantly better in the HD group than in the CG. The intensity of inflammation (Moskovitz scale) was higher in HD and LD than in CG (p = 0.03 and p = 0.0006, respectively). Nevertheless, pouch adaptation (Laumonier scale) was more significant in LD than in CG (p = 0.007). On the other hand, tissue expression of IL-1α and IL-10 was higher in HD and LD than in CG (IL-1α, p = 0.009 and p = 0.05, respectively; IL-10, p = 0.04 for both). DHA supplementation has no impact on body weight gain. Yet it seems that it may improve the effectiveness of nutrition and stool quality in rats which have undergone restorative proctocolectomy. Simultaneously, it increases the intensity of pouch adaptation and inflammation. The specificity of observed changes is not clear. However, it may imply potential modulation of inflammatory processes of pouch mucosa

Trace elements and rat pouchitis

The procedure of restorative proctocolectomy is associated with a complete removal of the colon and slight reduction of ileum length, which together can lead to systemic shortages of trace elements. Inflammatory changes in the pouch mucosa may also have some impact. However, there is no data on trace elements in pouchitis. Therefore, in the present study we aimed to assess the effect of acute pouchitis on the status of selected trace elements in rats. Restorative proctocolectomy with the construction of intestinal J-pouch was performed in twenty-four Wistar rats. Three weeks after the surgery, pouchitis was induced. Eight untreated rats created the control group. Liver concentrations of selected micronutrients (Zn, Cu, Co, Mn, Se) were measured in both groups six weeks later, using inductively coupled plasma mass spectrometry. Liver concentrations of trace elements did not differ between the study and the control groups. However, copper, cobalt and selenium concentrations [μg/g] were statistically lower (p<0.02, p<0.05 and p<0.04, respectively) in rats with severe pouchitis (n=9) as compared with rats with mild pouchitis (n=7) [median (range): Cu - 7.05 (3.02-14.57) vs 10.47 (5.16-14.97); Co - 0.55 (0.37-0.96) vs 0.61 (0.52-0.86); Se - 1.17 (0.69-1.54) vs 1.18 (0.29-1.91)]. In conclusion, it seems that acute pouchitis can lead to a significant deficiency of trace elements

Instillation-TIME (iTIME) as a rationale amendment for TIME conception. Is there enough evidence for the efficiency of negative pressure wound therapy with instillation (iNPWT) to announce a breakthrough idea for wound treatment?

An increased number of patients developing difficult-to-heal wounds results in billions spending for chronic wound care management. Introduction of TIME conception has been a breakthrough idea for wound healing based on phase-adapted wound therapy that interacts and influence each other and included: T – tissue management, I - infection control, M - moisture balance, E - edge of the wound. Negative pressure wound therapy (NPWT) revolutionized the management of wound healing. Moreover, recently NPWT with instillation (iNPWT) has gained the popularity of optimizing wound healing. In the context of acceleration of wound healing, iNPWT meets the criteria of the TIME conception. All individual components of TIME strategy are found in iNPWT providing “all in one” conception. Such management is easy to apply, monitor and it is well- tolerated by patients. Based on the current studies, iNPWT is found to be an important alternative for other methods of wound healing. It is believed that iNPWT will evolve and gain popularity as an innovative treatment for TIME conception

Warianty genetyczne śródbłonkowej syntazy tlenku azotu (eNOS) w nadciśnieniu ciążowym i stanie przedrzucawkowym

Aim of the study: To evaluate the correlation of 894G>T (Glu298Asp) and -786T>C polymorphisms of NOS3 gene with the development of preeclampsia (PE) and gestational hypertension (GH). Material and methods: 110 hypertensive pregnant women (mean age 29.46±4.54 years, mean gestational age 36.88±3.50 gw., mean systolic blood pressure 167.82±16.87 mmHg, mean diastolic blood pressure 104.32±11.62 mmHg) were enrolled into the study group. The whole study group was further subdivided into two subgroups: women with gestational hypertension (GH, n=69) and with preeclampsia (PE, n=41). Gestational hypertension and preeclampsia were diagnosed according to the ACOG standards. All patients with multiple pregnancy, diabetes, vascular changes and thrombotic complications were excluded from the study. The control group consisted of 150 healthy pregnant women (mean age 28.29±4.40 years, mean gestational age 39.06±1.28 gw., mean systolic blood pressure112.07±10.75 mmHg, mean diastolic blood pressure 70.62±9.13 mm Hg). The frequency of investigated genotypes of NOS3 gene polymorphisms was examined by polymerase chain reaction and restriction fragment length polymorphism (PCR/RFLP) method. Results: As far as the 894G>T polymorphism was concerned, a higher frequency of 894TT genotype in the control group in comparison to the whole study group was observed (8.7 vs. 5.4%; WR=0.61, p=ns). A similar observation was made about the 894T allele (25.4 vs. 30.0%, WR=0.79, p=ns). The frequency of the 894T allele was also higher in controls in comparison to the PE group (30% vs. 26.8%, p=ns) and GH group (30% vs. 24.6%, p=ns). Analyzing the -786T>C polymorphism no statistically significant differences between the whole study and the control groups was found. The frequency of the mutated -786CC genotype was similar in the entire study group and controls (13.6 vs. 15.3%, p=ns). The frequency of the mutated -786C allele was also similar in both analyzed groups (37.3 vs. 38.0%, p=ns). A statistically significant difference in the frequency of coexistence of mutated homozygotic genotypes 894TT/-786CC between the investigated groups (0.9% in the whole study group vs. 6.7% in the control group, p=0.019) was observed. Coexistence of 894GT/-786TC genotypes was noted more frequently in the control group (19,1% in the whole study group vs. 24.7% in the control group, p=ns). The frequency of other combinations of investigated genotypes coexistence did not significantly differ between the control group, the entire study group, and the PE and GH groups. In the PE group, a higher systolic blood pressure was noted in patients with -786CC genotype (205.0±21.2 mmHg) in comparison to patients with -786TT (177.0±17.8 mmHg) or -786TC (173.4±13.5 mmHg) genotypes (p=ns). Conclusions: The presence of the 894TT genotype of the 894G>T (Glu298Asp) polymorphism may play a protective role in the development of preeclampsia. The presence of the -786CC genotype of the -786T>C polymorphism may correlate with the increase of the systolic blood pressure in pregnant women with preeclampsia.Wstęp: W patogenezie stanu przedrzucawkowego ważną rolę pełni obniżony poziom tlenku azotu (NO – nitric oxide). Zmniejszenie stężenia NO może być spowodowane genetycznie uwarunkowanymi zaburzeniami aktywności śródbłonkowej syntazy NO (eNOS – endothelial nitric synthase). Cel pracy: Ocena częstości występowania polimorfizmów 894G>T (Glu298Asp) oraz -786T>C genu NOS3 i ich znaczenia w rozwoju stanu przedrzucawkowego oraz nadciśnienia ciążowego. Materiał i metody: W grupie badanej analizowano 110 kobiet z nadciśnieniem w ciąży (69 z nadciśnieniem ciążowym - GH oraz 41 ze stanem przedrzucawkowym - PE). Grupę kontrolną stanowiło 150 zdrowych ciężarnych. Częstość występowania badanych polimorfizmów oznaczano metodą reakcji łańcuchowej polimerazy oraz metody polimorfizmu długości fragmentów restrykcyjnych (PCR/RFLP). Wyniki: W zakresie polimorfizmu 894G>T (Glu298Asp) zaobserwowano wyższą frekwencję genotypu 894TT w grupie kontrolnej w porównaniu do całej grupy z nadciśnieniem (5,4 vs. 8,7% w grupie kontrolnej, WR=0,61, p=ns). Podobne obserwacje dotyczyły zmutowanego allela 894T (25,4 vs. 30,0% w grupie kontrolnej, WR=0,79, p=ns). Analiza polimorfizmu -786T>C genu NOS3 nie wykazała różnic statystycznie istotnych pomiędzy całą grupą z nadciśnieniem w ciąży oraz grupą kontrolną zdrowych ciężarnych. Natomiast w grupie PE odnotowano tendencję do zdecydowanie wyższego ciśnienia skurczowego u nosicielek zmutowanego genotypu -786CC (205,0±21,2 mmHg) w porównaniu do kobiet nosicielek genotypu -786TT (177,0±17,8 mmHg) oraz -786TC (173,4±13,5 mmHg) (p=ns). Wnioski: W przypadku polimorfizmu 894G>T (Glu298Asp) genu NOS3 obecność zmutowanego genotypu 894TT może mieć wartość ochronną w stosunku do wystąpienia stanu przedrzucawkowego. Obecność zmutowanego genotypu -786CC polimorfizmu -786T>C genu NOS3 może korelować ze wzrostem ciśnienia skurczowego w przebiegu stanu przedrzucawkowego

Perinatal outcome according to chorionicity in twins — a Polish multicenter study

Objectives: The aim of the study was to analyze the perinatal outcome of twin gestations and estimate the influence of chorionicity on the outcome in a large cohort of twin pregnancies in Poland. Material and methods: A retrospective analysis of 465 twin deliveries in 6 Polish centers in 2012 was conducted. Baseline characteristics, the course of pregnancy and labor, as well as the neonatal outcome were analyzed in the study group and according to chorionicity. Results: A total of 356 twin pregnancies were dichorionic (DC group) (76.6%), and 109 were monochorionic (MC group) (23.4%). There were no differences in the occurrence of pregnancy complications according to chorionicity, except for IUGR of at least one fetus (MC 43.1% vs. DC 34.6%; p = 0.003). 66.5% of the women delivered preterm, significantly more in the MC group (78% vs. 62.9%; p = 0.004). Cesarean delivery was performed in 432 patients (92.9%). Mean neonatal birthweight was statistically lower in the MC group (2074 g vs. 2370 g; p &lt; 0.001). Perinatal mortality of at least one twin was 4.3% (2.8% in the DC group vs. 9.2% in the MC group; p = 0.004). Neonatal complications, including NICU admission, respiratory disorders, and infections requiring antibiotic therapy, were significantly more often observed among the MC twins. Conclusions: The overall perinatal outcome in the presented subpopulation of Polish twins and its dependence on cho­rionicity is similar to the reports in the literature. Nevertheless, the rates of preterm and cesarean deliveries remain higher. It seems that proper counselling of pregnant women and education of obstetricians may result in reduction of these rates