Band 7, Heft 5

Background: Diverticular disease of the colon is common in the Western world. With the first episode of diverticulitis, most patients will benefit from medical therapy, but in 10% to 20% of cases some complications will develop, such as intra-abdominal abscesses, obstructions, fistulas. In these conditions it is important to define the most appropriate surgical approach. Discussion: The management of diverticular disease has been successful owing to the advances in diagnostic methods, intensive care and surgical experience, but there is debate about the best treatment for some conditions. Fistulas complicating diverticulitis are the result of a localized perforation into adjacent viscera. In particular, the connection between the colon and the urinary tract is a serious anatomical abnormality that must be urgently corrected before a serious urinary infection results. Indications, timing and surgical procedures are determined by the severity of the disease and the patient’s general condition. Summary: Diverticular disease can lead to many complications. One of the most difficult to correct is an internal fistula, such as a colo-vesical fistula. The correct approach in cases where the disorder is clinically suspected has always been controversial, and the guidelines for sigmoid diverticulitis have not established the most appropriate method for diagnosis and treatment. At present, the surgical strategy for these cases requires interruption of the fistula and resection to remove the inflamed colonic segment, with or without primary anastomosis, focusing attention on the construction of the anastomosis to well vascularized and anatomically healthy tissues. It is clear, therefore, that establishing guidelines is difficult, because many pathological situations may be related to diverticulitis, and so, as our experience shows, the surgical approach has to be tailored to the patient’s general and local condition.

Authors present a rare case of isolated hyoid bone fractures as a result of a traffic accident. Ten hours before the exam, the patient injured his neck by hitting it against a metal pole which he did not notice while riding a bicycle. Immediately afterwards he felt the pain, and came for an examination due to pain with swallowing. ENT examination discovered no signs of trauma in the oral cavity, oropharynx, hypopharynx, larynx and visible part of trachea. Computed tomography discovered an isolated fracture of hyoid bone. After 24 hour observation, patient was discharged for home care, and was shown a swallowing technique which significantly reduces swallowing pain. At control ENT examination 10 days later patient had no complaints. Control CT examination was not performed, as patient refused it.

We present a case which reports the occurrence of a potential elevation of Tacrolimus (Tac) plasma levels to toxic values in a renal transplant recipient after adding Metronidazole (Met) to the medication regimen. A 30-year old female, status post living-related renal transplant, who was stabilized on Tac 4.5 mg, twice daily, for 4 months, presented to the clinic with diarrhea. We used Microparticle Enzyme Immunoassay (MEIA) to determine Tac trough concentration (trough concentrations 5–10 ng/ml). After 6 days of Met therapy on 1.5 g/d, Tac trough concentration and serum creatinine (sCr) increased to 20.2 ng/ml and 7.8 mg/dl respectively. Met therapy was discontinued, also one dose of Tac was withheld, while daily dose was decreased to 2 mg/d. Four days after Met discontinuation, Tac concentration dropped to 8.7 ng/ml, sCr to 2.1 mg/dl, warranting Tac dose increase to 3 mg/d. Co-administration of Tac with Met may result in elevated Tac concentrations, possibly leading to tacrolimus nephrotoxicity. Clinicians should be aware of this potential interaction and closely monitor Tac concentration and renal function.

Neurotransmitters might participate in the development of diverticular disease. We measured fasting and postprandial serotonin levels in colonic diverticulosis patients and healthy volunteers. We demonstrated significantly lower maximal concentrations of serotonin in patients than the controls (respectively 109.8±61.4 and 251.3±44.1 ng/ml, p<0.001) as well as lower serotonin minimal values (respectively 38.4±21.8 and 124.6±41.4 ng/ml, p<0.001) and areas under time-course curves (respectively 288.8±139.8 and 739±167.4 ng/ml, p<0.001); significant difference between alternating pattern and normal bowel habit concerning fasting serotonin level, the hormone response to test meal (p=0.041) as well as minimal serotonin level (p=0.044). Bowel habit was also related to peak serotonin values following a test meal with 38.5 ng/ml in constipation, 139.5 ng/ml in diarrhea, 122.4 ng/ml in alternating pattern and 249 ng/ml in subjects with normal bowel habit (p=0.040) as well as AUC with 120.8 ng/ml in constipation, 416 ng/ml in diarrhea, 298 ng/ml in alternating pattern and 684 ng/ml in subjects with normal bowel habit (p=0.043). We demonstrated substantial differences in fasting serum serotonin levels as well as the hormone response to a test meal between colonic diverticulosis patients and healthy individuals, which seemed to be associated with abnormal bowel habits rather than presence of diverticula.

The objective of this report is to propose a classification of endoscopic changes for chagasic megaesophagus based on macroscopic findings. Thirty patients with advanced megaesophagus surgically treated using the Doria Serra technique (1968)3 were enrolled in this quasi-randomized study. All participants were treated in the Surgical Department of Hospital de Base of the Medicine School in São José do Rio Preto (FAMERP), Brazil from January 1995 to December 1999. The ages of the 17 male (56.6%) and 13 female (43.3%) patients ranged from 38 to 71 years. All participants were submitted to esophagogastroduodenal endoscopy with the following classification being proposed: mild, moderate and severe esophagitis. The current study demonstrates a correlation between the classifications of endoscopic changes and the degree of histological alterations of the esophageal mucosa in chagasic megaesophagus. Thus, this is a novel option for endoscopic evaluation of patients with this disease.

A wide range of molecular markers and different types of cells in liver are possible factors for progression of non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH) development of liver fibrosis. We investigated biopsies from 57 patients with NASH. The material was obtained from livers and was proceed immunohistochemistry antibodies against CD68 and TGF-beta 1. In addition, biopsies were evaluated for iron content. Macrophages/-positive/could be found in all 57 cases. The number of macrophages in the sinusoids correlated with the degree of portal fibrosis:64.% of the patients with mild or intensive fibrosis had high infiltration with CD68-positive cells, while 100% of the patients without fibrosis hadlow infiltration (χ2=8.56; p=0.003). In specimens we, 69.% of patients with different degree of fibrosis expressed TGF-β1 in their portal tracts, and 100% of patients without fibrosis did demonstrate expression of the protein (χ2=23.7; p<0.001). Hepatic iron was found in 100% (9) of patients with intensive fibrosis vs. 10.3% of the patients mild fibrosis (χ2=23.4; p<0.001). Our results suggest that the macrophages and macrophage-derived TGF-beta1 are the major factors responsible for development of fibrosis and progression of chronic liver disease.

The proteins of the fibrinolytic system — urokinase plasminogen activator(uPA), tissue plasminogen activator (tPA)and plasminogen activator inhibitor type IPAI-I) — play important roles in fibrotization in various organs and including peritoneum. To study the cellular localization of PAI-1, tPA and uPA within the adipose tissue of the peritoneal membrane in patients at the onset of peritoneal dialysis(PD) we determined the initial expression of these proteins in relationship to multiple clinical variables. Methods: routinely performed parietal peritoneal biopsies in 12 patients undergoing peritoneal catheter implantation were examined. We used formalinfixed, paraffin-embedded specimens for immunohistochemical localization of these proteins along with the stereological pointcounting method for quantification of their expression within the peritoneal adipose tissue. Results: strong positive mutual correlation between the expression of PAI-1 and both uPA (SpearmanR=0.66) and tPA (R=0.59) as well as between the expression of uPA and tPA (R=0.77) was found without any relatioship to BMI, age, peritoneal transport characteristic or diabetes status. Conclusion: Adipose tissue within the peritoneum is capable of producing fibrinolysis regulators (independently on clinical parameters) thus possibly affecting the fibrotization and function of peritoneum as dialysis membrane. The effect of dialysis solution dosing, composition and other dialysis related factors should be clarified in future studies.

Hemorrhagic fever with renal syndrome (HFRS) is an acute infective multisystemic disease that commonly presents with fever, hemorrhage and acute renal failure. A 17-year-old boy presented with thrombocytopenia, profuse subconjunctival hemorrhage and anuric renal failure with fluid overload. The patient required continuous ambulatory peritoneal dialysis. He developed diuresis but did not recover renal function during reconvalescent period. Hantaan, Puumala, Seoul, Belgrade virus infection with haemorrhagic fever with renal syndrome was confirmed by serologic test.

Digestive tract duplications are uncommon congenital anomalies, encountered mostly in the first 3 months of life. Overall the rectum is the least common site of alimentary duplications. We represent a case of large cystic non-communicating duplication that manifested with constipation and profuse rectal bleeding. When diagnosis was established, surgery was planned and the cyst was enucleated completely. Histopathology examination confirmed the diagnosis.

Major salivary gland tumors are very rare in the developmental period. Confirming tumor changes of the salivary gland requires precise diagnostic imaging involving an ultrasonography scan, computed tomography and magnetic resonance. A needle aspiration biopsy (NAB) of a tumor is of high importance. Excision of the tumor is the main treatment method in the case of parotid gland tumors. Statistical data concerning tumors suggest choosing less invasive methods, which seems very logical in children. The operational methods used in the tumor treatment are: extracapsular excision of a tumor, partial parotidectomy, total parotidectomy, sometimes proceeded with lymphatic nodes operations. Extracapsular excision of a tumor is a noninvasive method chosen because of simplicity and lesser risk of serious complications. This method is reserved only for the cases of benign tumors of the gland. Most authors, however, consider a partial parotidectomy as a method of choice in benign tumor cases and a total parotidectomy in cases of carcinomas of the parotid gland. Submandibular gland tumors need total gland excision. The clinical cases presented in this paper show the difficulties in diagnosis and treatment choices in cases of major salivary gland tumors in children.

The important risk factors of early initiation of smoking and alcohol drinking are: prosmoking family and peers, conduct disorders and delinquency, poor academic performance. The data obtained by physicians, teachers and children were collected at the age of 11 years. Children were divided into group A (without symptoms), Group B (with one or more symptoms). For statistic analysis, the programme EPI INFO was used.During the period between 7 and 11 years, new children with problematic behaviour (178=3.9%) were diagnosed in Group A, while substantial decreasing of children previously included in Group B was seen (by 59.1%). Together 7.05% of 11 years old children visited specialists (psychologists) due to their conduct disorders: 6.8% from Group A and 12.3% from Group B. Children more often than their teachers reported the frequent occurrence of conduct disorder. About 20% of children smoked, and more than 40% had tasted alcohol. However, the differences between Groups A and B were not significant. Our prospective study has demonstrated the possibility of misinterpretation of behavioural outputs. Children with previous behavioural problems had not a higher risk for early smoking and alcohol use.

Bone fractures may depend on Vitamin D Receptor Gene (VDR), bone mineral density, bone turnover markers. Patients and methods. 161 patients were recruited and underwent: skeletal densitometry (DXA) method and bone turnover studies (Osteocalcin and Ntx).The study group was evaluated using restriction enzyme digestion at BsmI (rs1544410), FokI (rs2228570), ApaI (rs7975232) and TaqI (rs731236), polymorphic sites of the VDR gene. Multivariate logistic regression was used to assess factor significance. The model included variables with sex- and age-standardized parameters, VDR genotypes, and bone metabolism marker levels. Results. Factors associated with fractures were: osteocalcin concentration and Z-score BMDt. Odds Ratio (OR) values equaled: 1.01 (95%Confidence Interval (95%CI) 1.00–1.02) for osteocalcin (p=0.006), and 0.66 (95%CI 0.42-1.03; p=0.07) for Z-score BMDt. In patients with reduced bone mass, factors related to fractures were: osteocalcin (0.04) and carriage of BsmI b (0.07) or ApaI a alleles (0.08). ORs were 1.01 (95%CI 1.00–1.02) for OC, 0.29 (95%CI 0.07–1.14) for BsmI, and 2.13 (95%CI 0.91–4.99) for ApaI polymorphic allele carriage. Conclusions. Carriage of BsmI b allele reduces, while carriage of ApaI a allele and heightened osteoclacin level increase the risk of fractures in study children with reduced bone mass. VDR polymorphism, bone mineral density and bone formation’s marker — osteocalcin maybe considered as risk factor for fracure in children from Lodz region.

The aim of the paper was to examine the relation between bone density and certain parameters of lipid status in postmenopausal women. The research involved 300 women referred to densitometric examination as they belonged to the risk group of postmenopausal women. All the examinees had the following biochemical parameters determined: total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, glycemia, serum Ca and P. Univariate logistic regression analyses showed that each year of age, menopause duration, AH are significantly connected to risk increase for the appearance of osteopenia or osteoporosis. Increase in values of SBP, DBP, cholesterol, LDL and triglyceride are connected with significant risk increase for the appearance of osteopenia or osteoporosis. Patients with AH are connected to 11 times elevated risk for the appearance of osteopenia or osteoporosis, cigarette smoking increased the risk by seven times, physical inactivity even by 52 times, CVD in the family anamnesis by eight times, and osteoporosis in the family anamnesis is connected to the risk by four times. In our research, atherogenic lipoproteins negatively correlate with lumbar bone density. Disturbed lipide status is a risk factor for cardiovascular diseases, but also a risk factor for the appearance of osteoporosis.

A 73-year-old female, diagnosed with rheumatoid arthritis (RA), complicated with severe levels of joint destruction, started etanercept (ETN) because of high persistent RA disease activity. Although her articular symptoms dramatically improved, she developed marked pancytopenia after the introduction of ETN. Bone marrow aspirate specimen revealed hypocellular marrow in three hematopoietic series without atypical findings, which was compatible with aplastic anemia (AA). This is a rare case of severe pancytopenia due to AA presumably induced by ETN.

A malignant peripheral nerve sheath tumour (MPNST) is a rare variety of soft-tissue sarcoma of ectomesenchymal origin. The World Health Organisation created the term MPNST to replace previous terminology such as malignant schwannoma, malignant neurilemmoma, neurogenic sarcoma, and myxofibrosarcoma for tumours of neurogenic origin with similar biological behavior.[1–3] The vast majority of these tumours develop in extremities. They also tend to be located in unusual sites of the body, such as the pelvic retroperitoneum, infratemporal fossa, intrapericardium, and mediastinum.[1,3,4] This case study presents a patient with an extremely rare primary cardiac MPNST..

The aim of the present study was to investigate asymmetric (ADMA) and symmetric dimethylarginine (SDMA) production in patients presenting with one or more risk factor (RF) for coronary heart disease (CHD). Patients and methods: Overall, 113 participants were enrolled in the study, including 45 patients presenting with risk for CHD (27 male and 18 female; aged 55.9 ± 6.4 years), 30 sex and age-matched middle-aged healthy controls (16 male and 14 female; aged 56.3 ± 8.4 years), and 38 young healthy controls (38 male; aged 24.6 ± 3.9 years). Results: No significant differences for ADMA and SDMA were recorded between patients groups presenting with risk for CHD. However, ADMA and SDMA were significantly higher in all examined patient groups (≥3 and 1–2 RF, hypertensive and non-hypertensive, obese and non-obese, diabetics and non-diabetics) compared with both control groups (middle-aged and young controls) (p<0.001). ADMA significantly correlated with SDMA in ≥3 RF (p<0.05), hypertensive (p<0.05), non-obese (p<0.05), non-diabetics (p<0.01), as well in middle-aged (p<0.05) and young controls (p<0.001). Conclusion: Significantly higher ADMA and SDMA were found between patients presenting with risk for CHD (≥3 and 1–2 RF, hypertensive and nonhypertensive, obese and non-obese, diabetics and non-diabetics) and healthy, middle-aged and young controls. ADMA significantly correlated with SDMA in ≥3 RF, hypertensive, non-obese and non-diabetic patients, as well as in middle-aged and young controls.

Testicular cancer is rare but is the most common cancer in males between 15 and 34 years of age. Two principal types of testicular cancer are distinguished: seminomas and non-seminomas. If detected early, the overall cure rate for testicular cancer exceeds 90%. In this study, artificial neural network (ANN) analysis as a prognostic tool was demonstrated regard to five year recurrence after the non-seminoma treatment. Data from 202 patients treated for non-seminoma were available for evaluation and comparison. A total of 32 variables were analysed using the ANN. The ANN approach, as an advanced multivariate data processing method, was demon-strated to provide objective prognostic data. Some of these prognostic factors are consistent or even imperceptible with previously evaluated by other statistical methods.