Adam Hermanowicz

Home enteral nutrition reduces complications, length of stay, and health care costs: results from a multicenter study

BACKGROUND Home enteral nutrition (HEN) has always been recognized as a life-saving procedure, but with the ongoing economic crisis influencing health care, its cost-effectiveness has been questioned recently. OBJECTIVE The unique reimbursement situation in Poland enabled the otherwise ethically unacceptable, hence unavailable, comparison of the period of no-feeding and long-term feeding and the subsequent analyses of the clinical value of the latter and its cost-effectiveness. DESIGN The observational multicenter study in the group of 456 HEN patients [142 children: 55 girls and 87 boys, mean (±SD) age 8.7 ± 5.9 y; 314 adults: 151 women and 163 men, mean age 59.3 ± 19.8 y] was performed between January 2007 and July 2013. Two 12-mo periods were compared. During the first period, patients were tube fed a homemade diet and were not monitored; during the other period, patients received HEN. HEN included tube feeding and complex monitoring by a nutrition support team. The number of complications, hospital admissions, length of hospital stay, biochemical and anthropometric variables, and costs of hospitalization were compared. RESULTS Implementation of HEN enabled weight gain and stabilized liver function in both age groups, but it hardly influenced the other tests. HEN implementation reduced the incidence of infectious complications (37.4% compared with 14.9%; P < 0.001, McNemar test), the number of hospital admissions [1.98 ± 2.42 (mean ± SD) before and 1.26 ± 2.18 after EN; P < 0.001, Wilcoxons signed-rank test], and length of hospital stay (39.7 ± 71.9 compared with 11.9 ± 28.5 d; P < 0.001, Wilcoxons signed-rank test). The mean annual costs (

Serum AMH in Physiology and Pathology of Male Gonads

) of hospitalization were reduced from 6500.20 ± 10,402.69 to 2072.58 ± 5497.00. CONCLUSIONS The study showed that HEN improves clinical outcomes and decreases health care costs. It was impossible, however, to determine precisely which factor mattered more: the artificial diet itself or the introduction of complex care.

Development of surface plasmon resonance imaging biosensors for detection of ubiquitin carboxyl-terminal hydrolase L1.

AMH is secreted by immature Sertoli cells (SC) and is responsible for the regression of Müllerian ducts in the male fetus as part of the sexual differentiation process. AMH is also involved in testicular development and function. AMHs are at their lowest levels in the first days after birth but increase after the first week, likely reflecting active SC proliferation. AMH rises rapidly in concentration in boys during the first month, reaching a peak level at about 6 months of age, and then slowly declines during childhood, falling to low levels in puberty. Basal and FSH-stimulated levels of AMH, might become a useful predictive marker of the spermatogenic response to gonadotropic treatment in young patients with hypogonadotropic hypogonadism. After puberty, AMH is released preferentially by the apical pole of the SC towards the lumen of the seminiferous tubules, resulting in higher concentrations in the seminal plasma than in the serum. Defects in AMH production and insensitivity to AMH due to receptor defects result in the persistent Müllerian duct syndrome. A measurable value of AMH in a boy with bilateral cryptorchidism is predictive of undescended testes, while an undetectable value is highly suggestive of anorchia or ovaries, as would be the case in girls with female pseudohermaphroditism and pure gonadal dysgenesis. Lower serum AMH concentrations in otherwise healthy boys with cryptorchidism, who were compared with their age-matched counterparts with palpable testes, have been reported previously. AMH levels are higher in prepubertal patients with varicocele than in controls. This altered serum profile of AMH in boys with varicoceles may indicate an early abnormality in the regulation of the seminiferous epithelial function. Serum AMH is known to be valuable in assessing gonadal function. As compared to testing involving the administration of human chorionic gonadotropin, the measurement of AMH is more sensitive and equally specific. Measurement of AMH is very useful in young children, because serum gonadotropin concentrations in those who are agonadal are nondiagnostic in midchildhood and serum testosterone concentrations may fail to increase with provocative testing in children with abdominal testes.

Taurolidine Lock in Home Parenteral Nutrition in Adults Results From an Open-Label, Randomized, Controlled Clinical Trial

We have developed a new method for highly selective determination of the ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) concentration using a surface plasmon resonance imaging (SPRI) technique and two different biosensors. UCH-L1 was captured from a solution by immobilized specific rabbit monoclonal antibody or specific LDN-57444 inhibitor due to formation of receptor-UCH-L1 complex on the biosensor surface. The analytically useful dynamic response range of both biosensors is between 0.1 and 2.5ng/ml. The detection limit is 0.06ng/ml for the biosensor with antibody and 0.08ng/ml for the biosensor with inhibitor. Biosensors based on both antibody and inhibitor were found to be suitable for quantitative determination of the UCH-L1 and exhibit good tolerance to the potential interferents. Both biosensors gave comparable results in the range of 0 to 0.20ng/ml for plasma samples and 0.30 to 0.49ng/ml for cerebrospinal fluid samples. To validate the new methods, comparative determination of UCH-L1 by the commercial enzyme-linked immunosorbent assay (ELISA) kit was performed. In general, in terms of UCH-L1 concentration, a good correlation between SPRI and ELISA was found. The developed biosensors can be used successfully for the determination of UCH-L1 in body fluids.

Topography and morphometry of intestinal mast cells in children with Hirschsprung's disease.

BACKGROUND AND AIM Many techniques have been tested to reduce the incidence of catheter-relater bloodstream infections (CRBSIs) during home parenteral nutrition (HPN). One of these methods, taurolidine lock, has shown some potential in several studies, but it has been studied primarily in patients with a relatively high CRBSI rate. Therefore, the aim of this study was to analyze the clinical value of taurolidine in patients receiving HPN who have a low infection rate. METHODS The CRBSI ratio at the Skawina HPN center has remained at 0.3-0.4 episodes/patient/y for the past 7 years. In November 2012, 30 patients (17 men, 13 women, mean age 52.3 years) were randomized to 1 of 3 groups: 2% taurolidine lock (group A), 1.35% taurolidine + citrate lock (B), and control-saline flush (C). Patients were observed for 12 consecutive months for catheter-related complications. Blood cultures were collected in each case in which an infection was suspected. RESULTS The total number of catheter days reached 10,968, with the following number of days per group: group A, 3658; group B, 3650; and group C, 3660. No complications were observed in the control group, while patients in the study groups had 1 catheter infection (group A) and 1 occlusion (group B). The CRBSIs were treated successfully with antibiotics. The cost of treatment in groups A and B was significantly higher than that in group C (P < .05). CONCLUSION The study did not observe any additional clinical value of taurolidine in patients receiving HPN who have a low infection rate and found low cost-effectiveness. Taurolidine should most likely be used only in patients with a high CRBSI rate.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy.

Mast cells (MC) are source of many biological active compounds like cytokines, arachidonic acid derivates, proteoglicanes, prostaglandins, proteases, free oxygen radials, NGF, PAF and many more. The role of MC in pathogenesis of Hirschsprungs disease (HD) is not clear. Substances produced by MC may exert an important effect on embryology, growth, differentiation and regeneration of intestinal nervous system. Additionally, MC products modulate inflammation processes thus influencing on the clinical course of HD. Present study was established to evaluate the morphologic MC examination as a support of making diagnosis in HD. The MC topography and morphometry were evaluated in specimens collected from aganglionic colon of patients with diagnosed HD. The results were compared with corresponding data from normally innervated colon of patients suffering from constipation, and normal colon of children not presenting defecation problems. MC were visualized using indirect immunohistochemical method LSAB with mouse antibody against human tryptase. The MC visualized in submucosa and muscular layer in Hirschsprungs disease were significantly larger in comparison with control group (p<0.05). Also the number of MC/mm2 in mucosa and lamina propria in HD was significantly elevated (p<0.05). However, the MC density in submucosa was also higher but it was not high statistically significant. In muscular layer and in serosa density of MC/mm2 was not statistically significant. In the intestinal wall MC in aganglionic segment in Hirschsprungs disease are significantly activated comparing with normally innervated colon segments taken from the patients from other groups. This may confirm the role of MC both in pathogenesis of HD and in the reparation processes of bowel nervous system.

Expression of MMP-9 and VEGF in meningiomas and their correlation with peritumoral brain edema.

AIM To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy (PEG) could be a valuable option for patients with complicated anatomy. METHODS A retrospective analysis of twelve patients (seven females, five males; six children, six young adults; mean age 19.2 years) with cerebral palsy, spastic quadriparesis, severe kyphoscoliosis and interposed organs and who required enteral nutrition (EN) due to starvation was performed. For all patients, standard PEG placement was impossible due to distorted anatomy. All the patients qualified for the laparoscopy-assisted PEG procedure. RESULTS In all twelve patients, the laparoscopy-assisted PEG was successful, and EN was introduced four to six hours after the PEG placement. There were no complications in the perioperative period, either technical or metabolic. All the patients were discharged from the hospital and were then effectively fed using bolus methods. CONCLUSION Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.

Correlation between circulating proteasome activity, total protein and c-reactive protein levels following burn in children

Meningiomas constitute up to 13% of all intracranial tumors. The predictive factors for meningioma have not been unambiguously defined; however some limited data suggest that the expression of matrix metalloproteinases (MMPs) and vascular endothelial growth factor (VEGF) may be associated with the presence of peritumoral brain edema (PTBE) and worse clinical outcome. The aim of this study was to analyze the expressions of MMP-9 and VEGF in a group of meningiomas of various grades and to study associations between these two markers and PTBE. The study included patients with supratentorial meningiomas. The patients were divided into low- (G1) and high-grade meningiomas (G2 and G3). PTBE was assessed on MRI. The expressions of VEGF and MMP-9 were determined immunohistochemically. The expression of MMP-9 was observed significantly more often in G3 meningiomas than in lower grade tumors. The presence of stage II or III PTBE was associated with a significant increase in MMP-9 expression. The expression of VEGF did not differ across the PTBE stages. Our findings point to a significant role of MMP-9 and VEGF in the pathogenesis of peritumoral brain edema in low- and high-grade meningiomas.

The comparison of C-proteasome activity in the plasma of children after burn injury, mild head injury and blunt abdominal trauma

AIM OF THE STUDY To characterize burn-induced changes following burn in children by analyzing circulating proteasome (c-proteasome) activity in the plasma in correlation with total protein and c-reactive protein levels in the plasma, and the severity of the burn. METHODS Fifty consecutive children scalded by hot water who were managed at the Department of Pediatric Surgery after primarily presenting with burns in 4-20% TBSA were included into the study. The children were aged 9 months up to 14 years (mean age 2.5±1 years). Patients were divided into groups according to the pediatric injury severity score used by American Burns Association. Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2-6 h, 12-16 h, 3 days, 5 days, and 7 days after injury. 20 healthy children consecutively admitted for planned inguinal hernia repair served as controls. RESULTS Statistically significant elevation of plasma c-proteasome activity was noted in all groups of burned children 12-16 h after the injury. We found a strong negative correlation of c-proteasome activity with total protein levels, and positive correlation with CRP levels 12-16 h after burn. We also found stronger correlation between c-proteasome activity and severity of burn, than CRP level and severity of burn 12-16 h, and 3 days after the burn. Correlations were statistically significant. CONCLUSIONS This study characterized circulating 20S proteasome activity levels after burn. C-proteasome activity elevate after burn and correlate negatively with plasma total protein level, thus plasma 20S proteasome activity could be additional biomarker of tissue damage in burn in pediatric population.

Treatment of rapidly proliferating haemangiomas in newborns with propranolol and review of the literature

PURPOSE We aimed to evaluate and compare the changes in circulating 20S proteasome activity in the plasma of children suffering from blunt abdominal trauma, thermal injury and mild head injury. PATIENTS AND METHODS The study population comprised 40 patients with burns, 35 children admitted due to mild head injury, and 30 children suffering from blunt abdominal trauma, who were admitted to Pediatric Surgery Department of Medical University of Bialystok Poland, between 2010 and 2014, and their parents gave informed consent, were included into the study. Patients were aged 9 months to 17 years (median=5.73±1.91y). The girls to boys ratio was nearly 1:2 (34 girls and 106 boys). Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2-6h, 12-16h, and 48h after the injury. 20 healthy children admitted for planned inguinal hernia repair served as controls. RESULTS In our series of patients, the C-proteasome activity was much higher 12-16h after burns, than after mild head injuries, or blunt abdominal injuries, and the difference was statistically significant (p<0.05). CONCLUSIONS Circulating 20S proteasome is probably released from damaged tissues in response to the injury and is a biomarker of tissue damage - more severe in the group of burnt patients in comparison to the patients with mild head injury and blunt abdominal trauma. Therefore detection of 20S proteasome may represent a novel marker of immunological activity and cellular degradation in trauma patients.