Intense remodeling of extracellular matrix within the varicose vein: the role of gelatinases and vascular endothelial growth factor.

BACKGROUND: Increased blood pressure in the varicose veins (VV) can contribute to the overexpression of matrix metalloproteinases (MMPs), affecting the endothelium, smooth muscle, and extracellular matrix of the vein wall. Gelatinases (MMP-2 and MMP-9), hypoxia, and inflammation occurring in the VV wall contribute to the increased expression of vascular endothelial growth factor (VEGF). AIMS: Our objective was to analyze the concentration of gelatinases and VEGF in the great saphenous VV wall and plasma of patients. METHODS: In total, 65 patients (2nd degree according to clinical state classification, etiology, anatomy, and pathophysiology-CEAP classification) aged 22 to 70 were enrolled. Control veins (n = 10) were collected from the patients who underwent coronary artery bypass graft surgery. Control plasma (n = 20) was obtained from healthy individuals. Gelatinases and VEGF levels were measured with the usage of ELISA method. RESULTS: A significant increase in MMP-9 (11.2 vs. 9.98 ng/mg of protein) and VEGF (41.06 vs. 26 ng/g of protein) concentration in VV wall compared with control veins was observed. A positive correlation between VEGF versus MMP-2 (p = 0.03, r = 0.27) was found in the VV wall. However, no correlation was found between the concentration of VEGF and MMP-9 (p = 0.4, r = 0.11) in the VV wall. In addition, no statistical differences between MMP-9, MMP-2, and VEGF levels in plasma of VV patients compared with controls were noticed. CONCLUSIONS: The results of the present study confirm that VV's patients have altered expression of MMPs and VEGF. Overexpression of MMP-9 and VEGF in the VV wall may contribute to the spreading of inflammatory process and suggests the intense remodeling of extracellular tissue within the VV wall.

Antioxidative mechanism in the course of varicose veins.

Objective Our objective was to evaluate the state of oxidative stress in the great saphenous varicose vein wall and blood of varicose vein patients taken from the antecubital vein. Methods The superoxide dismutase, reduced glutathione (GSH) and total antioxidant status were measured with commercially available colorimetric kits in erythrocytes, plasma and varicose vein wall of 65 patients (second degree of clinical state classification, etiology, anatomy and pathophysiology) aged 22-70 (49 women, 16 men) in comparison to normal great saphenous vein walls collected from 10 patients who underwent coronary artery bypass graft and blood collected from 20 healthy individuals. Results A statistically significant decrease (p < 0.001) in superoxide dismutase activity in erythrocytes and the increase (p < 0.05) in superoxide dismutase activity in varicose vein has been observed. There have been no significant changes in the concentration of GSH in plasma and in varicose vein. The decreased concentration of total antioxidant status in plasma (p < 0.001) and in varicose vein wall (p < 0.05) in comparison to the control has been noticed. Conclusion The varicose vein patients are affected by oxidative stress. Our results indicate impaired antioxidant defense mechanism in the blood of varicose vein patients. In contrast to the blood, an increased process of antioxidant defense in the varicose vein wall was noticed.

[Review of the effectiveness of an empirical antibiotic therapy in suspected ventilator-associated pneumonia]. / Ocena skutecznosci rekomendowanych scheatów antybiotykoterapii emprirycznej VAP w oparciu o analize in vitro lekowraziliwosci glównych patogenów.

BACKGROUND: Ventilator-associated pneumonia (VAP) occurs in approximately 10-20% of mechanically ventilated patients, and is associated with an extremely high mortality rate (up to 70%). The purpose of the study was to determine the susceptibility spectrum of Klebsiella, Pseudomonas and Acinetobacter strains isolated from VAP patients. METHODS: We analysed 81 strains of microorganisms isolated from bronchoalveolar lavages (BAL) of VAP patients. The minimal inhibitory concentrations (MIC) of antibiotics recommended for empirical therapy were determined using an automated VITEK 2 system, and for the MIC of doripenem - the Etest assay. Results were analysed following the guidelines of the Clinical and Laboratory Standards Institute. RESULTS: For infections caused by the group of bacteria under investigation, the most successful regimen was monotherapy with carbapenems (doripenem, meropenem and imipenem). Cephalosporins (cefepim and ceftazidim) were less effective in vitro. The worst results were obtained with the combination of piperacillin/tazobactam with aminoglycosides (amikacin or gentamicin) or fluoroquinolones (ciprofloxacin). CONCLUSIONS: Antibiotic monotherapy proved to be more effective in VAP patients than combined therapy; the best results were achieved with carbapenems. Doripenem showed strong activity in vitro against P. aeruginosa and Klebsiella sp. and should be considered for empirical VAP therapy; however, carbapenems may be less effective against Acinetobacter baumannii. The wide range of bacteria, and their broad range of susceptibility to antibiotics, suggests the need for modification of current recommendations.

Plasma matrix metalloproteinase 9 correlates with disorders of brain magnesium homeostasis in patients undergoing coronary artery bypass surgery.

BACKGROUND: Changes in plasma matrix metalloproteinase 9 (MMP-9) concentrations and parallel changes in brain magnesium homeostasis have not been examined in cardiac surgery patients. The purpose of the present study was to analyse these relationships in patients undergoing coronary artery bypass surgery (CABG) with extracorporeal circulation (ECC). Additionally, the effect of volatile anaesthetics was considered. PATIENTS AND METHODS: Adult patients undergoing CABG with ECC under general anaesthesia were studied. Plasma MMP-9 and total (tMg) and ionized (iMg) magnesium concentrations were measured during surgery and during the early postoperative period. The plasma arteriovenous (a-v) tMg and iMg differences in the brain circulation were considered to be markers for brain magnesium homeostasis. The Mini-Mental State Examination test and computer tomography were used to diagnose postoperative neuropsychological disorders (PNPDs). RESULTS: In total, 92 patients were examined. PNPDs were noted in 17 cases. Cardiac surgery resulted in increased plasma levels of MMP-9. The highest MMP-9 concentrations were observed in patients with PNPDs. MMP-9 concentrations strongly correlated with a-v tMg and a-v iMg differences. Compared with arterial measurements, venous tMg and iMg concentrations were higher during and immediately after surgery and lower during the early postoperative period. The most severe differences in a-v tMg and iMg were noted in patients with PNPDs. CONCLUSION: 1. Cardiac surgery resulted in an increase in plasma MMP-9 concentrations. 2. This increase in MMP-9 was significantly greater in patients with PNPDs. 3. The plasma MMP-9 concentration was correlated with disorders of brain Mg homeostasis.

Changes in intra-abdominal, iliac venous and central venous pressures in patients undergoing abdominal surgery due to large tumors of the colon--a pilot study.

Changes in intra-abdominal pressure during bowel tumor surgery have not been documented. The purpose of the present study was to analyze changes in intra-abdominal pressure (IAP), central venous pressure (CVP) and iliac venous pressure (IVP) in patients undergoing laparotomy due to large tumor of the bowel. Twenty-one adult patients undergoing elective abdominal surgery were examined. Intra-abdominal pressure, CVP and IVP were measured during anesthesia, surgery and early postoperative period. The mean IAP before anesthesia was 12.76 +/- 1.09 mm Hg and mean bowel tumor volume 1550 +/- 227.48 mL. Anesthesia induction decreased IAP to 10.52 +/- 1.32 mm Hg and excision of intra-peritoneal tumors to 5.24 +/- 1.51 mm Hg (49.7%). Ten minutes after anesthesia, IAP increased to 7.47 +/- 1.2 mm Hg and one hour after surgery decreased to 6.19 +/- 1.43 mm Hg. There was a strong overall correlation between IAP and CVP (P = 0.0000; r = 0.7779), as well as between IAP and IVP (P = 0.0000; r = 0.8635). Moreover, IAP correlated with IVP immediately after anesthesia and one hour after anesthesia. In conclusion, induction of anesthesia decreased IAP; excision of large bowel tumors decreased IAP; and IAP strongly correlated with CVP and IVP.

[Isolated right ventricular myocardial infarction in cardiosurgery practice]. / Zawal prawej komory w praktyce kardiochirurgicznej.

Isolated right ventricular myocardial infarction (RVMI) is a very rare complication of ischemic heart disease. Generally it accompanies infero-posterior or antero-septal myocardial infarction cases. Right ventricular myocardial infarction is a strong predictor of acute right ventricular failure, bradyarrythmia, ischemic and mechanical complications and is frequently complicated by cardiogenic shock which often leads to death. Acute right ventricular ischemia (RVI) and RVMI are big problem particularly during and early post-operative cardiosurgery procedures. Atherosclerotic changes and heart blood flow disturbances predispose to RVI or RVMI that occur more often in cardiosurgical patients, especially in early postoperative period. On the other hand early intraoperative diagnosis and longer reperfusion period result in the correction of heart function and better prognosis.

[The accidental cannulation of subclavian artery in a patient undergoing CABG]. / Niezamierzona kaniulacja tetnicy podobojczykowej u pacjentki poddanej chirurgicznej rewaskularyzacji miesnia sercowego.

Obtaining central venous access is a standard procedure necessary for safe anesthesia in patients undergoing surgery with extracorporeal circulation. It is well known that jugular way is safer and causes less complication than subclavian. The authors present a case of accidental left subclavian artery cannulation during left internal jugular vein catheterisation. Due to the complex character of myocardial revascularization procedure with extracorporeal circulation and specific catheter localization surgical removal was necessary. This case underline well documented high risk of internal jugular vein cannulation even in operating room condition.

Use of drotrecorgin alfa--recombinant activated human protein C in treatment of septic shock in the course of therapy for nephrolithiasis.

BACKGROUND: Septic shock is the most dangerous complication of nephrolithiasis management utilizing percutaneous methods. CASE REPORT: The patient, D.M., aged 60 was subjected to scheduled percutaneous nephrolithotomy due to coral calculosis of the pyelocalyceal system. As pyuria was noted intraoperatively, nephrostomy was left after the procedure. Over ten hours after the surgery the patient developed the symptoms of severe septic shock with progressive respiratory distress, renal failure, intravascular coagulation syndrome and impaired consciousness. Nephrectomy was performed, antibiotic treatment and high doses of norepinephrine instituted. Hemodynamic stabilization was obtained, without, however, marked improvement of the patient's condition. Because of persistent coagulation disorders and multiorgan dysfunction, recombinant activated protein C preparation--drotrecorgin alfa (Xigris Eli Lilly) was added to the therapeutic regimen. From the second day of infusion, systematic improvement of the coagulation system parameters was observed, making it possible to reduce the doses of catecholamines, oxygen concentration in the gas mixture used for ventilation, as well as stabilization of the function of the preserved kidney. The patient was weaned off the respirator on the 8th day of treatment and on the 13th day referred to the Urology Department, from which she was soon discharged home. CONCLUSIONS: 1. Surgical resection of the infection source and cause of the septic shock is the prerequisite for successful pharmacological treatment. 2. Administration of rh-APC to a patient meeting the PROWESS criteria may be an effective and safe method of treatment in the complex management of septic shock.

Intravascular thrombosis as a result of central venous access.

Central venous access represents one of the most basic therapeutic procedures in modern medicine. Unfortunately, numerous advantages that result from maintaining a central venous line are accompanied by some complications among which the venous thrombosis is the most significant clinically. The study was designed to assess frequency and natural history of this complication in the setting at a multi profile clinical hospital. Central venous cannulation was performed by a fully qualified anaesthesiologist in every case. There were 887 cannulations and only 5 patients with clinically significant venous thrombosis. The analysis of the collected data allowed us to state that the frequency of intravascular thrombosis is low, but this complication is often associated with extensive impairment of patency of the central veins. Full recanalization is not always achieved regardless of the treatment applied. Pulmonary embolism in the course of central venous thrombosis was diagnosed in one patient only and appeared as a multiple and fine X-ray infiltrates. It seems that in the presence of permanent or even life threatening complications of central venous thrombosis their risk should be minimized by frequent examination of the cannulation site and early initiation of antithrombotic treatment.