Emergency medical service in Poland--current state and a need of reform.

The article focuses on the question of reorganisation of Emergency Medical Service in Poland. First part of the paper contains a short description of a project of the Integrated Rescue System, which have been included in the National Emergency Medical Service Act enacted by Parliament in 2001. Considering to the fact, that implementation of this reform has been stopped after general elections in autumn 2001, in the second part of the paper some arguments supporting the postulate of urgent realisation of this project are discussed. The arguments refer to five spheres: epidemiological, social, political, legal and economical. The conclusions of the discussion are, that in every of those spheres negative consequences of blocking the reform may be observed. The final conclusion is, that reorganisation of ineffective Emergency Medical Service in Poland is still a challenge, which public authorities have to manage.

Contribution of individual amino acids to the nucleic acid binding activities of the Xenopus zinc finger proteins TFIIIIA and p43.

Xenopus transcription factor IIIIA (TFIIIA) binds to both 5S RNA and the 5S RNA gene in immature oocytes, an interaction mediated by nine zinc fingers. To determine the role of the central zinc fingers of the protein in these nucleic acid binding activities, a series of substitution mutants of TFIIIA were constructed and expressed as recombinant proteins in Escherichia coli. The mutant proteins were purified to homogeneity and analyzed for DNA and RNA binding activities using a nitrocellulose filter binding assay. Finger 5, but not finger 4, 6, or 7, is involved in sequence-specific binding to the 5S RNA gene. A TWT amino acid motif in finger 6 makes a significant contribution to the binding of TFIIIA to 5S RNA, while mutations in fingers 4, 5, and 7 have little or no effect on RNA binding by TFIIIA. In striking contrast, a TWT motif in finger 6 of p43, another Xenopus zinc finger protein that binds to 5S RNA, is not necessary for 5S RNA binding by this protein. Evidence for the presence of inhibitory finger-finger interactions that limit the nucleic acid binding properties of individual zinc fingers within TFIIIA and p43 is discussed.

Characterization of RNA aptamer binding by the Wilms' tumor suppressor protein WT1.

The interaction of the zinc finger protein WT1 with RNA aptamers has been investigated using a quantitative binding assay, and the results have been compared to those from a previous study of the DNA binding properties of this protein. A recombinant peptide containing the four zinc fingers of WT1 (WT1-ZFP) binds to representatives of three specific families of RNA aptamers with apparent dissociation constants ranging from 13.8 +/- 1.1 to 87.4 +/- 10.4 nM, somewhat higher than the dissociation constant of 4.12 +/- 0.4 nM for binding to DNA. An isoform that contains an insertion of three amino acids between the third and fourth zinc fingers (WT1[+KTS]-ZFP) also binds to these RNAs with slightly reduced affinity (the apparent dissociation constants ranging from 22.8 to 69.8 nM) but does not bind to DNA. The equilibrium binding of WT1-ZFP to the highest-affinity RNA molecule was compared to the equilibrium binding to a consensus DNA molecule as a function of temperature, pH, monovalent salt concentration, and divalent salt concentration. The interaction of WT1-ZFP with both nucleic acids is an entropy-driven process. Binding of WT1-ZFP to RNA has a pH optimum that is narrower than that observed for binding to DNA. Binding of WT1-ZFP to DNA is optimal at 5 mM MgCl(2), while the highest affinity for RNA was observed in the absence of MgCl(2). Binding of WT1 to both nucleic acid ligands is sensitive to increasing monovalent salt concentration, with a greater effect observed for DNA than for RNA. Point mutations in the zinc fingers associated with Denys-Drash syndrome have dramatically different effects on the interaction of WT1-ZFP with DNA, but a consistent and modest effect on the interaction with RNA. The role of RNA sequence and secondary structure in the binding of WT1-ZFP was probed by site-directed mutagenesis. Results indicate that a hairpin loop is a critical structural feature required for protein binding, and that some consensus nucleotides can be substituted provided proper base pairing of the stem of the hairpin loop is maintained.

Patent ductus venosus: diagnosis by MR angiography.

We report a 15-year-old boy with patent ductus venosus in whom the diagnosis was made by MR angiography. A patent ductus venosus Arantii is a rare form of portosystemic shunt. Only a few cases have been reported in adults and children. The diagnosis is usually made by US and digital subtraction angiography. In our patient, the diagnosis was first made by MR angiography. This demonstrates the excellent diagnostic potential of the method in paediatric patients.

[Results and complications of endovascular therapy of aortic aneurysms]. / Ergebnisse und Komplikationen nach endovaskulärer Therapie des Aortenaneurysmas.

INTRODUCTION: Endovascular repair (ER) has been established as an alternative treatment option for aortic aneurysm (AA) in case of a suitable morphology. However, there are specific problems related to diagnostic and therapeutic management including potential complications of the new procedure. PATIENTS AND METHODS: Between 8/1996 and 11/1999, 41 patients (6 female, mean age 67.9 (range 55-84) years) underwent an operation with the intention of ER. Modular, self-expanding stent-grafts were used for aorto-biiliacal (36), aorto-monoiliacal (1), and aorto-aortal (infrarenal-1, thoracic-1) aortic aneurysm (AA) exclusion. Postoperatively and during the follow-up period, diagnostic measures included clinical investigation, native X-ray, and color-coded Doppler sonography, and spiral computed tomography, and digital subtraction angiography. Results were analysed with special reference to complications and resulting therapeutic consequences. RESULTS: Technical success was achieved in 36/41 patients (87.8%). There were 2 primary distal endoleaks and 3 conversions because of lacking vascular access. Of 4 primary endoleaks, a proximal one was treated successfully by overstenting, a distal one was sealed off by iliac extension, and 2 distal ones were treated conservatively. Three secondary endoleaks, a proximal and 2 distal ones, required conversion each by retro- and transperitoneal approach. Presently, there are 4 endoleaks, with the maximal aortic diameter remaining constant except one case. Five secondary occlusions of an iliac limb (4) or artery (1) were treated by thrombectomy (1), PTA (1), PTA with overstenting (1), and cross-over (1) or ilicofemoral bypass (1). Three patients died of unrelated disease during the follow-up period. DISCUSSION: On condition of a critical indication, improved diagnostic management and further refinement of stent-graft systems ER constitutes an alternative, minimally invasive treatment option for AA. Long-term results must be obtained by means of continued prospective and comparative studies to definitely evaluate ER.

Vascular complications in acute pancreatitis assessed by color duplex ultrasonography.

We determined the sensitivity of computed tomography and color duplex ultrasonography in the detection and characterization of vascular complications in acute pancreatitis. The relationship of these complications with the etiology and activity of the disease was assessed. In a prospective study, 189 patients with acute pancreatitis seen in the Department of Gastroenterology. Charité Hospital in Berlin over a period of 38 months underwent color duplex ultrasonography every second day for 3 weeks and thereafter at least once a week for 2 months. Dynamic computed tomography was performed within 72 hours after admission, and follow-up computed tomography scans were obtained. In 45 patients (23%), at least temporary thromboses of portal venous vessels were demonstrated by color duplex ultrasonography. The incidence of venous thromboses was 30% in severe acute pancreatitis with fluid collections without necroses and 57% in necrotizing pancreatitis. In 27 of those 45 patients, a formation of collaterals was documented. In 13 patients, arterial pseudoaneurysms were demonstrated. Vascular complications were significantly more frequent in alcohol-induced than in gallstone-induced pancreatitis. Only 62% of all sonographically diagnosed thromboses and only 32% of all collaterals were demonstrated by computed tomography. The prevalence of vascular complications in acute pancreatitis was much higher as suspected. The risk of gastrointestinal bleeding was lower than previously reported. Color duplex sonography is the method of choice for the detection of vascular complications in acute pancreatitis.

Value of bronchial artery embolisation with platinum coils in tumorous pulmonary bleeding.

We performed bronchial artery embolizations (BAE) using platinum coils with Dacron fibres in 30 consecutive patients with haemoptysis due to bronchial carcinoma. The aim of the study was to compare immediate results of bleeding cessation, recurrence and survival rates with a historical control group of 15 patients with tumorous pulmonary bleeding who were treated conservatively (non-BAE-group). Bronchial artery embolisation with platinum coils stopped active bleeding in all patients immediately. Comparing the BAE group and controls the cessation of first time haemoptysis (BAE 100% versus non-BAE 93%) and the rates of bleeding recurrence (BAE 50% versus non-BAE 47%) were similar in either group. In case of recurrent bleeding, repeated BAE led to a definite cessation of pulmonary haemorrhage in every case. In contrast, all patients with recurrent haemoptysis without a repeated BAE (8 patients, 27%) and all patients with bleeding recurrence in the non-BAE group died from pulmonary haemorrhage (8 patients, 53%). The mean survival time of the BAE group was significantly longer compared with the non-BAE group, 139 (range: 1-818) days versus 62 (range: 1-186) days (P<0.05). We conclude that consistent BAE proved beneficial in tumorous pulmonary bleeding, particularly with regard to the permanent arrest of haemorrhage in case of recurrence.

Post-feeding hyperammonaemia in patients with transjugular intrahepatic portosystemic shunt and liver cirrhosis: role of small intestinal ammonia release and route of nutrient administration.

BACKGROUND: Hyperammonaemia is a pathogenetic factor for hepatic encephalopathy that may be augmented after a transjugular intrahepatic portosystemic shunt (TIPS). Experimental data suggest that hyperammonaemia may be caused to a large extent by metabolism of small intestinal enterocytes rather than colonic bacteria. AIMS: To evaluate if ammonia release and glutamine metabolism by small intestinal mucosa contribute to hyperammonaemia in vivo in patients with liver cirrhosis. METHODS: Using TIPS to examine mesenteric venous blood, we measured mesenteric venous-arterial concentration differences in ammonia and glutamine in patients with liver cirrhosis before, during, and after enteral (n = 8) or parenteral (n = 8) isonitrogenous infusion of a glutamine containing amino acid solution. RESULTS: During enteral nutrient infusion, ammonia release increased rapidly compared with the post-absorptive state (65 (58-73) v. 107 (95-119) micromol/l after 15 min; mean (95% confidence interval)) in contrast with parenteral infusion (50 (41-59) v. 62 (47-77) micromol/l). This resulted in a higher portal ammonia load (29 (21-36) v. 14 (8-21) mmol/l/240 minutes) and a higher degree of systemic hyperammonaemia (14 (11-17) v. 9 (6-12) mmol/l/240 minutes) during enteral than parenteral infusion. The mesenteric venous-arterial concentration difference in glutamine changed from net uptake to release at the end of the enteral infusion period (-100 (-58 to -141) v. 31 (-47-110) micromol/l) with no change during parenteral nutrition. CONCLUSIONS: These data suggest that small intestinal metabolism contributes to post-feeding hyperammonaemia in patients with cirrhosis. When artificial nutrition is required, parenteral nutrition may be superior to enteral nutrition in patients with portosystemic shunting because of the lower degree of systemic hyperammonaemia.

Dissecting aneurysm of the infrarenal abdominal aorta.

The aim of this study was to report the case of a patient with chronic dissecting infrarenal abdominal aortic aneurysm (AAA) and to review the literature for this rare vascular disorder. The preoperative assessment, surgical treatment, and postoperative course of a patient with a dissecting AAA and associated left iliac artery dissection were analyzed. The literature is reviewed with respect to etiology and pathogenesis as well as diagnostic and therapeutic management of infrarenal dissecting AAA. The preoperative diagnosis of dissecting infrarenal AAA was made by computed tomography and aortography and confirmed during surgery. Successful repair was accomplished by use of a bifurcated aortobiiliacal Dacron graft. A review of the literature demonstrates the rarity of dissecting aneurysm exclusively involving the infrarenal aortic segment. Primary dissecting aneurysm of the infrarenal abdominal aorta is a rare morphologic finding. Principles of diagnostic and therapeutic management of common atherosclerotic AAA also apply to dissecting AAA.

Ornithine decarboxylase is a transcriptional target of tumor suppressor WT1.

The product of the Wilm's tumor suppressor gene, WT1, is a zinc-finger DNA-binding protein, which is thought to be a transcription factor. Two genes, those encoding epidermal growth factor receptor and syndecan-1, are known to be endogenous targets of WT1. Previous studies had identified binding sites for WT1 in the promoter of the ornithine decarboxylase (ODC) gene. In this paper, we tested whether the endogenous ODC gene might be a target of WT1 by establishing lines of baby hamster kidney (BHK) cells that expressed WT1 isoform A under control of a tetracycline-regulated expression system. When expression of WT1 was activated in BHK cells, the cellular level of ODC mRNA declined, with kinetics that correlated with the increase in WT1 level, demonstrating that the endogenous ODC gene was indeed responsive to cellular level of WT1. WT1 isoforms A and B inhibited the activity of the ODC promoter by approximately fivefold in transiently transfected BHK cells, while isoforms C and D, which have altered DNA binding domains, had no significant effect. The sequence CTCCCCCGC, located at nucleotides -106 to -98 relative to the site of transcriptional initiation in the ODC gene, interacted with the zinc-finger domain of isoforms A and B of WT1 with high affinity and specificity. A mutation in the binding site that disrupted this interaction partially removed the inhibition of ODC promoter activity by WT1, as did mutation of the two E-box sequences in intron I of the ODC gene. Simultaneous mutation of the WT1-binding motif and the two E-boxes completely abolished inhibition by WT1 of ODC promoter activity. These results, taken together, implicate the ODC gene as a downstream target of the tumor suppressor WT1.

Combined surgical and endovascular removal of thrombus entirely occluding a bifurcated aortic stent-graft.

PURPOSE: To explore a method combining interventional, endovascular, and conventional surgical techniques for treating a completely occluded bifurcated stent-graft after endovascular aortic aneurysm repair. METHODS AND RESULTS: A 60-year-old patient underwent endovascular repair of an abdominal aortic aneurysm (AAA) with a Talent bifurcated stent-graft. Five months later, after chronic thrombotic occlusion of the right iliac limb, he presented with acute occlusion of the entire stent-graft. Local intra-arterial infiltration thrombolysis successfully reconstituted flow through the main aortic segment and left iliac limb. With a combination of conventional surgical and intraoperative endovascular procedures, thrombectomy and recanalization of the right iliac limb was completed by stenting a severe stenosis of the proximal iliac limb. CONCLUSIONS: A combination of techniques may be essential for successful management of thrombotic complications after endovascular AAA repair.

A method for adjusting a malpositioned bifurcated aortic endograft.

PURPOSE: To report the successful application of a method to adjust a malpositioned bifurcated stent-graft after endovascular aortic aneurysm repair. METHOD AND RESULTS: A 62-year-old male patient underwent endovascular repair of a 5.1-cm abdominal aortic aneurysm (AAA) with a Vanguard bifurcated stent-graft. After complete deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected occlusion of the left renal artery. Intra-aortic adjustment of the bifurcated graft was possible with a crossover guidewire, which was pulled caudally. The method worked perfectly to restore blood flow to the left renal artery. The patient is well 16 months postoperatively without any evidence of endoleak or graft migration; the left renal artery remains open. CONCLUSIONS: A technique is demonstrated for intra-aortic repositioning of a bifurcated stentgraft to correct insufficient deployment. If required, this technique should be attempted before conversion to an open procedure.

Comparison of the DNA binding characteristics of the related zinc finger proteins WT1 and EGR1.

The interactions of the related zinc finger proteins WT1 and EGR1 with DNA have been investigated using a quantitative binding assay. A recombinant peptide containing the four zinc fingers of WT1 binds to the dodecamer DNA sequence GCG-TGG-GCG-TGT with an apparent dissociation constant (Kd) of (1.14 +/- 0.09) x 10(-9) M under conditions of 0.1 M KCl, pH 7.5, at 22 degrees C. Under the same conditions, a recombinant peptide containing the three zinc fingers of EGR1 binds to the dodecamer sequence, the first nine bases comprising the EGR consensus binding site, with an apparent Kd of (3.55 +/- 0.24) x 10(-9) M. The nature of the equilibrium binding of each peptide to DNA was investigated as a function of temperature, pH, monovalent salt concentration, and divalent salt concentration. The interaction of WT1 with DNA is an entropy-driven process, while the formation of the EGR1-DNA complex is favored by enthalpy and entropy. The DNA binding activities of both proteins have broad pH optima centered at pH 8.0. The binding of both proteins to DNA shows similar sensitivity to ionic strength, with approximately 7.7 +/- 0.8 ion pairs formed in the EGR1-DNA complex and 9.2 +/- 1.8 ion pairs formed in the WT1-DNA complex. Results of measuring the effects of point mutations in the DNA binding site on the affinity of WT1 and EGR1 indicates a significant difference in the optimal binding sites: for EGR1, the highest affinity binding site has the sequence GNG-(T/G)GG-G(T/C)G, while for WT1 the highest affinity binding site has the sequence G(T/C)G-(T/G)GG-GAG-(T/C)G(T/C).

Intravascular disruption of central venous ports.

Intravasal catheter disruption is a rare complication of central venous ports. Main causes are chronic trauma due to compression of the catheter between clavicle and first rib, or primary damage by sharp instruments during insertion. Utilizing the subclavian route, a more lateral insertion can minimize the risk of catheter compression. Regular postoperative X-ray controls can help to recognize progressive catheter compression. In the case of significant compression, early replacement is advisable to avoid disruption. Percutaneous transvenous snare technique is the therapy of choice to retrieve dislocated fragments.

Interventional pneumology in pulmonary bleeding; a review: from the bronchus to the vessel.

Interventional pneumology includes both bronchological and vascular methods of diagnosis and therapy, especially in emergency situations such as pulmonary hemorrhage. In massive pulmonary hemorrhage bronchological diagnosis is required to determine the site and extent of bleeding, as well as angiography of bronchial arteries, and of pulmonary arteries. Bronchus occlusion by aid of balloon catheter or double lumen tube are holding measures until definitive surgery or embolization of bronchial or pulmonary arteries can be performed. The paper suggests a close relationship between bronchoscopic and angiographic diagnosis and therapy in case of severe pulmonary bleeding.

Superior vena cava syndrome. From the bronchus to the vessel.

This paper addresses the diagnosis and management of superior vena cava syndrome (SVCS) due to malignant intrathoracic tumours. Diagnosis of SVCS is usually established by bedside examination. Chest X-ray and computed tomography may be helpful, but the cavography remains the "gold-standard". Other imaging techniques (MRI, nuclear flow studies) are more of scientific interest. Bronchoscopy helps to evaluate the risk of pulmonary complications and endoscopic procedures often lead to histological findings. In the treatment of malignant SVCS surgery, radiotherapy, and chemotherapy have been successfully used. The placement of a vascular stent might be an additional or alternative possibility. There are no conclusive indication criteria and no conclusive regimen concerning post-stenting anticoagulation. From all reported results and published papers we draw the conclusion that the immediate effects of stent implantation and the long-term results of tumour-specific therapy are complementary to one another. The stent dilates the local venous stenosis while tumour-specific therapy has a general effect on the vascular and respiratory situation in a multi-therapy concept.

Covalent immobilization of hirudin improves the haemocompatibility of polylactide-polyglycolide in vitro.

A biodegradable polymer, poly(D,L-lactide-co-glycolide) RESOMER RG756, was modified by surface immobilization of recombinant hirudin (r-Hir) with glutaraldehyde as coupling reagent to improve the blood contacting properties of the polymer. The activity of immobilized hirudin on the polymer was estimated by a chromogenic assay to about 2.5 ATU r-Hir cm-2. The improvement of the haemocompatibility of the modified RG756 was evaluated in terms of platelet adhesion/activation, whole blood clotting times and clot formation rate. Fluorescence microscopy revealed that surface modification with r-Hir resulted in decreased platelet adhesion and activation. An ELISA for P-selectin, a marker of platelet activation, was used to confirm this result. Clotting time experiments demonstrated significantly prolonged non-activated partial thromboplastin times, and a decreased clot formation rate of whole blood in contact with r-Hir modified RG756 compared with the plain polymer. Comparison of immobilized r-Hir with bound heparin yielded equivalent improvement of blood-contacting properties of the investigated polymers. These in vitro investigations indicate that the immobilization of r-Hir on RG756 is a useful method to improve the blood contacting properties of polylactides/polyglycolides and other polymers as well.

Effects of Denys-Drash syndrome point mutations on the DNA binding activity of the Wilms' tumor suppressor protein WT1.

A number of point mutations in the zinc finger domain of the Wilms' tumor suppressor protein WT1 have been isolated from the DNA of patients with Denys-Drash syndrome, an association of Wilms' tumor, nephropathy, and genital anomalies. To date, five different mutations that alter amino acids predicted to interact specifically with nucleotides in the target DNA sequence have been described. Two of these mutations are located in zinc finger 2 (R366H, R366C), and three are located in finger 3 (R394W, D396G, D396N). These five Denys-Drash mutations were introduced into WT1-ZFP, a recombinant polypeptide containing the zinc finger domain of WT1, and the effects of these mutations on DNA sequence specificity were determined using a selection, amplification, and binding (SAAB) assay. The SAAB assay was carried out using two different DNA templates, one with a randomized finger 2 subsite (GCG TGG NNN TGT) and one with a randomized finger 3 subsite (GCG NNN GCG TGT). A comparison of the DNA sequences selected by WT1-ZFP and by Denys-Drash mutants suggests that the point mutations reduce the sequence selectivity of the zinc finger protein. With the exception of the R394W mutant, the other Denys-Drash mutations selected one alternative sequence in addition to the wild-type DNA subsite sequence. The binding affinities of these proteins for their selected sequences were determined using a quantitative nitrocellulose filter binding assay. These results revealed that the wild-type WT1 binds with slightly higher affinity to sequences with GAG in the finger 2 subsite than sequences with the EGR-1 consensus GCG finger 2 subsite. With the exception of R394W, which appears to lack specific DNA binding activity, the Denys-Drash mutants bound to selected DNAs with 1.4-14-fold lower affinities than the wild-type WT1-ZFP. These results suggest that the clinical phenotype of Denys-Drash syndrome can be associated with a modest reduction in the DNA binding affinity of WT1.

Retinoid X receptor alters the determination of DNA binding specificity by the P-box amino acids of the thyroid hormone receptor.

Nuclear hormone receptors bind to hormone response elements in DNA consisting of two half-sites of 6 base pairs. The P-box amino acids of each receptor determine the identities of the central nucleotides of the half-site. 57 P-box variants of the human thyroid hormone receptor (hT3Rbeta) were used to demonstrate the relationship between P-box sequence and DNA binding specificity by homodimers and heterodimers formed with the retinoid X receptor (RXR). In general, the formation of heterodimers relieved many of the constraints on the compatibility of hT3Rbeta P-box sequences with DNA binding. Effects were most dramatic for heterodimers bound to a direct repeat spaced by four base pairs. RXR also overrides the P-box-derived DNA binding specificity of hT3Rbeta when heterodimers are bound to inverted or everted repeat elements. These effects of RXR are most pronounced on AGGTCA half-sites but are squelched when the RXR partner of the heterodimer is bound to an AGGACA half-site. The influence of RXR on hT3Rbeta DNA binding specificity varies with the orientation of half-sites in the element, the identity of the fourth base pair of the half-site, and the spacing between the half-sites of direct repeats. These differences suggest that the DNA binding domains of RXR-hT3Rbeta heterodimers are not positioned equivalently on the various elements, affecting the manner in which the P-box amino acids of hT3Rbeta interact with base pairs within the half-site.

[Interventional pneumology: procedures for pulmonary hemorrhage and tumor-induced superior vena cava syndrome]. / Interventionelle Pneumologie: Massnahmen bei pulmonaler Blutung und tumorbedingtem Vena-cava-superior-Syndrom.

Interventional pneumology includes both bronchological and vascular methods of diagnostic and therapy, especially in case of pneumological emergency, such as pulmonary hemorrhage and superior vena cava syndrome. In massive pulmonary hemorrhage bronchological diagnosis is needed to determine the location and activity of the bleeding, as well as angiography of bronchial arteries, and of pulmonary arteries, respectively. Bronchus occlusion by aid of balloon catheter or double lumen tube are intermediate methods to bridge over till defenitive surgery or embolisation of bronchial or pulmonal arteries as complementary methods in patients with pulmonary hemorrhage. In patients suffering from superior vena cava syndrome caused by neoplasms venous angioplasty and Wallstent implantation provide immediate clinical improvement.