Different perforin expression in peripheral blood and prostate tissue in patients with benign prostatic hyperplasia and prostate cancer.

Perforin (P) is a prototypical cytotoxic molecule involved in cell-mediated immunity against various pathogens, alloantigens and particularly different tumours. The purpose of this study was to determine P expression in different lymphocyte subpopulations isolated from peripheral blood and prostate tissue of patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa) and compare it with the P expression found in the control group. Twenty subjects were recruited in each of the groups. Prostate mononuclear cells of the BPH and PCa tissues were isolated by enzymatic digestion and gradient density centrifugation, whereas peripheral blood mononuclear cells were isolated by gradient density centrifugation alone. Cells and tissue samples were labelled using monoclonal antibodies against P and different surface antigens (CD3, CD4, CD8 and CD56) and analysed by immunofluorescence and flow cytometry. Total P expression in peripheral blood lymphocytes did not differ significantly between BPH/PCa patients and control group, although the BPH and PCa tissue showed lower P expression level. A negative correlation between prostate-specific antigen levels and the overall percentage of P(+), CD3(+) CD56(-) P(+) , and CD3(-) CD56(+) P(+) cells in the prostate tissue was observed only in patients with PCa. Our findings indicate that the low frequency of P(+) lymphocytes, including T, NKT and NK cells, in the prostate tissue of patients with BPH and, particularly, PCa could be the consequence of local tissue microenvironment and one of the mechanisms involved in the pathogenesis of prostate hyperplasia following malignant alteration.

The proposed mechanism of action during different pain management techniques on expression of cytolytic molecule perforin in patients after colorectal cancer surgery.

The postoperative period is accompanied with neuroendocrine, metabolic and immune alteration which is caused by tissue damage, anesthesia, postoperative pain and psychological stress. Postoperative pain contributes to dysfunction of immune response as a result of interaction between central nervous and immune system. The postoperatively activated hypotalamo-pituitary-adrenocortical axis, sympathic and parasympathic nerve systems are important modulators of immune response. According to bidirectional communication of immune and nervous system, appropriate postoperative pain management could affect immune response in postoperative period. Although the postoperative suppression of immune response has been reported, a very little are known about the influences of different pain management techniques on cytotoxic function of immune cells in patients with colorectal cancer in early postoperative period. Perforin is a cytotoxic molecule expressed by activated lymphocytes which has a crucial role in elimination of tumor cells and virus-infected cells, mostly during the effector's phase of immune response. Immune compromise during the postoperative period could affect the healing processes, incidence of postoperative infections and rate and size of tumor metastases disseminated during operation. The pharmacological management of postoperative pain in patients with malignancies uses very different analgesic techniques whose possible influence on cytotoxic functions of immune cells are still understood poor. For decades the most common way of treating postoperative pain after colorectal cancer surgery was intravenous analgesia with opiods. In the last decade many investigations pointed out that opiods can also contribute to postoperative suppression of immune response. Epidural analgesia is a regional anesthesia technique that acts directly on the origin of pain impulses and pain relief can be achieved with small doses of opiods combined with local anesthetics. Local anesthetics potentate analgesic properties of opiods but per se are also acting as antiinflammatory drugs. Afferent neural blockade by epidural analgesia attenuates neuroendocrine stress response. We propose that epidural analgesia could be more convenient that intravenous analgesia in maintenance of immunological homeostasis that is altered by surgical stress, tumor growth and pain.

Early changes in frequency of peripheral blood lymphocyte subpopulations in severe traumatic brain-injured patients.

Infections are leading causes of increased morbidity and mortality of severe traumatic brain-injured (STBI) patients. The mechanism underlying the susceptibility to the infections is still unexplained. The purpose of the study was to investigate changes in frequency of leucocytes subpopulations in peripheral blood of patients with STBI during the course of intensive care treatment. Twenty patients with STBI were included in the study. Healthy age- and sex- volunteers served as control. Peripheral blood samples were taken from these patients at day 1, 4 and 7, and peripheral blood mononuclear cells (PBMC) were isolated. The percentage of T, B lymphocyte, NK and NKT cells as well as monocytes was analysed by simultaneous detection of surface antigens using fluorochrome-conjugated monoclonal antibodies. The two major subsets of T lymphocytes (CD3(+)CD56(-)CD4(+) and CD3(+)CD56(-)CD8(+)) and NK cells (CD3(-)CD56(+dim) and CD3(-)CD56(+bright)) were also analysed by flow cytometry. Extracranial infections were presented in 55% patients with STBI. At day 4, the percentage of T lymphocytes with cytotoxic phenotype significantly diminished and their numbers restored at day 7. The frequency of NKT cells showed the identical time-dependent pattern, whereas the percentage of NK cells diminished on day 4 but did not restore after 7 days. The frequency of B lymphocytes did not change significantly during the time investigated, whereas the percentage of monocytes increased immediately after the injury and gradually diminished. The decrease in cells with cytotoxic phenotype might explain high incidence of susceptibility to infection of patients with STBI.

War head injury score: an outcome prediction model in War casualties with acute penetrating head injury.

OBJECTIVE: To evaluate in war casualties with acute penetrating head injury whether the summed War Head Injury Score (WHIS) is a better predictor of mortality than either the Glasgow Coma Scale (GCS) score or the Injury Severity Score (ISS) alone and to establish its specific applicability. METHODS: Sensitivity, specificity, correct outcome prediction, and discrimination were assessed in 43 patients in the war group (ballistic injuries) and 41 patients in the civil group (nonballistic injuries) during the period 1991 to 1995. The new model was generated using the sum of GCS scores and ISS, to which a coded value was applied for summation. RESULTS: In the war group, the mortality rate was 23%; the sensitivity and specificity of WHIS were 100% and 79%, the sensitivity and specificity of GCS score were 90% and 85%, and the sensitivity and specificity of ISS were 100% and 49%, respectively. In the civil group, the mortality rate was 39%; the sensitivity and specificity of WHIS were 87% and 76%, the sensitivity and specificity of GCS score were 63% and 90%, and the sensitivity and specificity of ISS were 100% and 56%, respectively. CONCLUSION: With regard to civilians, war casualties with acute penetrating head injury more often have multiple injuries. WHIS represents a new scoring system that incorporates both GCS score and ISS.

Ultrasound-guided percutaneous dilatational tracheostomy: a safe method to avoid cranial misplacement of the tracheostomy tube.

The aim of this investigation was to evaluate the role of ultrasonography in avoiding cranial misplacement of the tracheostomy tube and tracheal ring fractures during percutaneous dilatational tracheostomy (PDT). The tracheas of 26 consecutive ICU patients who had undergone PDT but who later died were removed en bloc at autopsy. The tracheas were opened along the membranous portion and the condition of tracheal rings and the site of tracheostomy macroscopically evaluated. The patients were divided in two groups: group A with 15 patients who underwent "blind" PDT and group B with 11 patients who underwent ultrasound-guided PDT. In five (33%) patients from group A, autopsy revealed that the tracheostomy tube was placed between the cricoid cartilage and the first tracheal ring (cranial misplacement) and in six (43%) patients a fracture of one tracheal ring was found. Cranial misplacement of the tracheostomy tube in patients from group B was not found (P < 0.05) and four (36%) patients had a broken tracheal ring (P = NS). The authors maintain that by using ultrasound-guided PDT cranial misplacement of the tracheostomy tube may be entirely avoided.

Influence on gallbladder volume of early postoperative gastric supply of nutrients.

BACKGROUND & AIM: The gallbladder volume is a predictor of biliary stasis and the formation of biliary sludge. Biliary stasis and sludge have been recently recognized as the precursors of acute acalculous cholecystitis, as well as 'idiopathic' postoperative pancreatitis, rare but very serious complications after surgery. The aim of the study was to establish how early postoperative gastric supply of nutrients affects the gallbladder volume in patients after noncardiac and cardiac surgery. METHODS: In the two prospective, randomized studies 40 patients (study I-noncardiac surgery) treated at surgical ICU after major elective extrahepatobiliary and extragastrointestinal surgeries (7 thoracic, 19 vascular, 14 urological) and 40 patients (study II-cardiac surgery) treated at cardiosurgical ICU after CABG surgery were analyzed. In both studies the patients were divided into two groups: control group C (study I: 20 patients, age 45+/-18 yrs, male 65%; study II: 20 patients age 58+/-7 yrs, male 60%) and group E (group of early postoperative gastric supply of nutrients) (study I: 20 patients, age 52+/-17 yrs, male 50%; study II: 20 patients; age 59+/-8 yrs, male 65%). For the first 24 hours the patients in group C received only crystalloid solutions and the gallbladder volume was verified 24 hours after the surgery. In group E, postoperative gastric supply of nutrients began 18 hours after surgery (Osmolite, Ross; first 3 hours 30 ml/h and second 3 hours 50 ml/h; total 240 ml after 6 hours). In all patients sonographic measurement of gallbladder volume was performed immediately before surgery and 6 hours after the start of feeding (24 hours after surgery). The measurement was done with ultrasonographic scanner Hitachi 405 EUB (convex probe 3.5-5MHz) by the same specialist, and the volume was calculated using the ellipsoid method. RESULTS: The gallbladder volume measured by ultrasonography 24 hours after surgery in study I (noncardiac surgery) in group E amounted to 43+/-25 ml while in control group C it was significantly higher, i.e. 67+/-30 ml (P<0.05). In study II (cardiac surgery) in group E gallbladder volume amounted to 59+/-15 ml while in control group C it was also significantly higher, i.e. 71+/-11 ml (P<0.05). CONCLUSION: An early postoperative gastric supply of nutrients after both noncardiac and cardiac adult surgery diminishes the volume and probably stimulates the motility of the gallbladder, thus preventing biliary stasis and the formation of biliary sludge.

Ultrasonographically guided percutaneous dilatational tracheostomy after anterior cervical spine fixation.

Patients with anterior cervical spine fixation (ACSF) after acute spinal cord injury often require tracheostomy for prolonged ventilatory support and upper respiratory tract clearance. The authors report two patients with ACSF who underwent a successful ultrasonographically guided percutaneous tracheostomy with dilatation forceps technique. Possible advantages of the ultrasonographically guided method with dilatation forceps in patients with ACSF are discussed.

[Percutaneous tracheostomy]. / Perkutana traheostomija.

In the last few years numerous reports from intensive care units confirm that a nonsurgical percutaneous tracheostomy has successfully replaced elective conventional (surgical) tracheostomy. The majority of authors point out the advantages over surgical technique such as: the speed of procedure, the possibility of doing it at bedside thus excluding transport and the need for operating theatre, less infections around stoma, minor cosmetic defects and finally, more economical price. The article describes three, according to pertinent literature most often utilized techniques, i.e. percutaneous dilatation tracheostomy with dilators, percutaneous dilatation tracheostomy with forceps, and translaryngeal tracheostomy. Main differences, advantages and defects of each method are presented. Contraindications and eventual complications are discussed, as well as the utility of supporting methods for safer placement of tracheostomy tubes, such as endoscopy and ultrasonography.

Kidney length in postoperative acute renal failure.

PURPOSE: The aim of this study was to evaluate kidney length in patients with postoperative acute renal failure (PARF). METHODS: The effect of PARF on renal size was prospectively studied in 76 patients with PARF and 40 healthy volunteers. Sonographic measurements of kidney length and the level of serum creatinine were obtained each day patients stayed in our surgical intensive care unit. These measurements were done once in volunteers. All study subjects were divided into groups on the basis of age, those younger than 65 years and those 65 years or older. Statistical analyses on the relation of renal size, age, and degree of PARF used the kidney length:body height ratio (KBR) and the peak serum creatinine level. Follow-up kidney length and creatinine measurements were done in 24 patients 1-5 years after they recovered from PARF. RESULTS: Regardless of age, mean KBRs were significantly greater in patients than in healthy volunteers (< 65 years, p < 0.001; > or = 65 years, p = 0.008), with a negative correlation between KBR and patient age (r = -0.664; p < 0.001). A positive correlation was found between the KBR and the peak serum creatinine level in patients younger than 65 years (r = 0.543; p < 0.001); an insignificant negative correlation was found between these factors in patients 65 years or older (r = -0.264; p = 0.1). Follow-up on recovered patients showed that their KBRs were significantly lower than the values when patients had PARF (< 65 years, p < 0.001; > or = 65 years, p = 0.027). CONCLUSIONS: PARF produces a sonographically measurable increase in renal size.

Sonographic measurement of absolute and relative renal length in adults.

PURPOSE: The aim of this study was to evaluate sonographically measured absolute and relative lengths of normal kidneys according to subject height, sex, and age. METHODS: Real-time sonography was performed on 202 subjects. Measurements of longitudinal renal diameter represented absolute renal length. Relative renal length was calculated using the kidney length: body height ratio (KBR). RESULTS: Statistical analyses were done on findings in 175 subjects without renal impairment (104 men and 71 women) whose ages ranged from 17 to 85 years (mean +/- SD, 46.3 +/- 17.1). The mean heights of the subjects were 176 +/- 7 cm for men and 167 +/- 6 cm for women. The left kidney was absolutely (mean +/-SD, 112 +/- 9 mm) and relatively (mean KBR +/- SD, 0.655 +/- 0.042) longer than the right kidney (absolute length, 110 +/- 8 mm; KBR, 0.641 +/- 0.038), regardless of sex (p < 0.01). The absolute renal length was significantly greater in men than in women for both kidneys (p < 0.01), but there was no significant difference between KBRs (p > 0.05). Renal length decreased with age, and the rate of decrease seemed to accelerate at 60 years and older. When height and age were included in the multivariate regression analysis, sex was not a significant predictor of kidney length. CONCLUSIONS: Relative renal length better represents kidney size than absolute renal length because it eliminates sex and height differences.

Resistance and pulsatility indices in acute renal obstruction.

PURPOSE: The aim of this study was to evaluate the reliability of Doppler waveform alterations in diagnosing acute unilateral renal obstruction. METHODS: From December 1993 to January 1996, 54 patients with unilateral renal obstruction were prospectively examined by conventional and duplex Doppler sonography. Seventy-eight patients with nonrenal abdominal problems comprised the control group. Doppler signals were obtained from interlobar arteries and arcuate arteries at the corticomedullary junction. From the waveform analysis, we calculated resistance (RI) and pulsatility (PI) indices. We also used the differences in RI and PI between the 2 kidneys in the same examinee (delta RI and delta PI) for further statistical analysis. RESULTS: The mean RI and PI (+/- standard deviation) in the patients without renal impairment were 0.64 +/- 0.04 and 1.14 +/- 0.14, respectively. The mean delta RI and delta PI were 0.02 +/- 0.01 and 0.07 +/- 0.05, respectively. Both the RI and PI were significantly correlated with age (r = 0.74 and 0.69, respectively; p < 0.01). Acute renal obstruction significantly (p < 0.01) elevated the mean RI (0.72 +/- 0.04), delta RI (0.09 +/- 0.04), PI (1.42 +/- 0.17), and delta PI (0.33 +/- 0.18). Significant decreases in RI and delta RI were noted after relief of the obstruction. The best accuracy in diagnosing acute unilateral renal obstruction was achieved with the combination of delta RI > or = 0.06 and/or delta PI > or = 0.20, which had a sensitivity of 94% and specificity of 99%. CONCLUSIONS: Renal Doppler indices are reliable parameters in the sonographic diagnosis of acute unilateral obstructive uropathy.

Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy.

BACKGROUND: The effects of intraperitoneal administration of bupivacaine on pain after laparoscopic cholecystectomy were studied in a prospective, double-blind, randomised trial. METHODS: Eighty ASA 1 and 2 patients were randomly assigned to one of two groups. Immediately after pneumoperitoneum was obtained patients in group 1 were given 15 ml of 0.5% bupivacaine injected under direct vision into the hepato-diaphragmatic space, near and above the hepato-duodenal ligament and above the gallbladder. At the end of operation another 15 ml of bupivacaine was injected. Patients in group 2 were given 15 ml of 0.9% saline solution in a similar fashion. Postoperative pain was assessed using a visual analogue scale (VAS 100 mm) at 0.5, 4, 8, 12 and 24 h after surgery. Analgesic consumption was also recorded. RESULTS: Patients' data were similar in the two groups. Pain was more intense in the saline group at each time point. Significant differences between the groups were present for up to 8 h. Analgesic consumption was significantly lower in the bupivacaine group. No side-effects occurred. CONCLUSION: We conclude that reducing pain with intraperitoneal bupivacaine is effective, easy to administer, and without side-effects.