Damian Ziaja

Compliance with compression stockings in patients with chronic venous disorders.

Objective The aim of this large survey was to evaluate non-compliance with compression stockings in chronic venous disorder (CVD) patients. Method A total of 16,770 CVD patients participated in this study. Results Compression stockings were used by 25.6% of CVD patients and 46.6% of the patients were never prescribed compression therapy. Compression stocking use was found to increase with the clinical stage of CVD. The percentage of patients using compression stockings during control visits increased to 37.4%. Furthermore, 5.3% of the patients coming to control visits discontinued the use of compression stockings owing to high cost, sweating, itching, cosmetic reason, oedema exacerbation, exudation lesions of lower legs and application difficulty. Past episodes of vein thrombosis (OR = 0.80), of stroke (OR = 0.28) and of varicose veins surgery (OR = 0.28) were decreasing, while the management by a general practitioner was increasing the risk (OR = 1.36) of compression therapy cessation. Conclusion (1) Compression stockings are too rarely prescribed and often unaccepted at early stages of CVD; (2) The common reason for discontinuation of compression therapy is its high cost.

Neck duplex Doppler ultrasound evaluation for assessing chronic cerebrospinal venous insufficiency in multiple sclerosis patients

Introduction: Recent clinical studies have suggested a relationship between multiple sclerosis (MS) and the occurrence of pathological changes in the jugular, vertebral and azygous veins that result in abnormal blood outflow from the brain and the spinal cord. Together, these pathological changes have been designated chronic cerebrospinal venous insufficiency (CCSVI). The aim of the present study was to evaluate the usefulness of duplex Doppler ultrasound in the evaluation of central nervous system venous outflow disturbances in patients suffering from MS. Methods: We examined 181 patients with MS, diagnosed on the basis of the McDonald criteria, and 50 healthy volunteer controls. All patients underwent Doppler ultrasound examination of the internal jugular veins (IJV) and vertebral veins (VVs). The presence of outflow disturbances and morphological abnormalities were evaluated. Results: Pathological changes in the extracranial jugular veins were diagnosed in 148/181 MS patients (82%) and 7/50 control group volunteers (14%). The following abnormalities in the MS group were revealed: the presence of a reflux in the IJVs and/or VVs (54%), narrowing (54%), a complete block in the flow through the IJV (10%) and an abnormal postural control of the cerebral outflow route (25%). These particular pathologies were of statistical significance in the MS group compared with the control group. This study also revealed a correlation between the occurrence of inverted flow in patients in a sitting position and chronic progressive MS (P = 0.0033). Conclusions: The examinations undertaken indicate a possible connection between MS and CCSVI. The widely accessible and highly sensitive and specific Doppler ultrasound test may be useful for revealing, and preliminary analysis of, CCSVI pathologies.

Inflammatory markers in patients with internal carotid artery stenosis.

Introduction Available reports underline the significance of the inflammatory process in the development, progression and destabilisation of atherosclerotic plaques in the internal carotid artery (ICA). The aim of this study was to evaluate the relationship between the degree of ICA stenosis, ultrasound plaque morphology and serum concentration of selected inflammatory markers. Material and methods Sixty-five patients with ICA stenosis > 50% (39 symptomatic) and 30 healthy volunteers were enrolled in the study. Clinical, neurological examination and laboratory evaluation (leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, tumour necrosis factor-α (TNF-α), interleukins (1β, 6 and 10), anti-cytomegalovirus IgG antibody titre) were performed. Stenosis grade ≥ 70%, ulcerations on the plaque surface and a hypoechoic (or predominantly hypoechoic) structure of the plaque, obtained by colour-coded duplex examination, were accepted as the characteristics of unstable stenoses. Results Unstable ultrasound features of ICA stenosis were found significantly more often in symptomatic than in asymptomatic patients (71.79% vs. 30.71% for stenosis degree ≥ 70%, p = 0.001 and 61.23% vs. 38.46% for unstable plaque morphology, p = 0.01). Patients with ICA stenosis had significantly higher serum concentrations of interleukin-6, fibrinogen, ESR and higher CRP values than the individuals from the control group (p = 0.001, p = 0.009, p = 0.036, p = 0.009 respectively). Patients with unstable plaques structure had significantly higher concentrations of TNF-α, interleukin-6, fibrinogen, higher number of leukocytes, monocytes and higher CRP values than patients with stable plaques (p = 0.008, p = 0.049, p = 0.012, p = 0.0002, p = 0.006, p = 0.0003 respectively). No significant differences in above-mentioned parameters between the groups with stenosis < 70% and ≥ 70% were found. Conclusions There is a relationship between the activity of the selected inflammatory markers in serum and atherosclerotic unstable internal carotid artery stenosis. There is no relationship between serum concentration of inflammatory markers and degree of carotid artery stenosis.

Self-expandable metallic stents in the treatment of post-esophagogastrostomy/post-esophagoenterostomy fistula

SUMMARY.  Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4–27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5–8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed – covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators.

Autofluorescence endoscopy with “real-time” digital image processing in differential diagnostics of selected benign and malignant lesions in the oesophagus

BACKGROUND Oesophageal papilloma and Barretts oesophagus are benign lesions known as risk factors of carcinoma in the oesophagus. Therefore, it is important to diagnose these early changes before neoplastic transformation. METHOD Autofluorescence endoscopy is a fast and non-invasive method of imaging of tissues based on the natural fluorescence of endogenous fluorophores. The aim of this study was to prove the diagnostic utility of autofluorescence endoscopy with digital image processing in histological diagnosis of endoscopic findings in the upper digestive tract, primarily in the imaging of oesophageal papilloma. RESULTS During the retrospective analysis of about 200 endoscopic procedures in the upper digestive tract, 67 cases of benign, precancerous or cancerous changes were found. White light endoscopy (WLE) image, single-channel (red or green) autofluorescence images, as well as green and red fluorescence intensities in two modal fluorescence image and red-to-green (R/G) ratio (Numerical Colour Value, NCV) were correlated with histopathologic results. The NCV analysis in autofluorescence imaging (AFI) showed increased R/G ratio in cancerous changes in 96% vs. 85% in WLE. Simultaneous analysis with digital image processing allowed us to diagnose suspicious tissue as cancerous in all of cases. Barretts metaplasia was confirmed in 90% vs. 79% (AFI vs. WLE), and 98% in imaging with digital image processing. In benign lesions, WLE allowed us to exclude tissue as malignant in 85%. Using autofluorescence endoscopy R/G ratio was increased in only 10% of benign changes causing the picture to be interpreted as suspicious, but when both methods were used together, 97.5% were cases excluded as malignancies. Mean R/G ratios were estimated to be 2.5 in cancers, 1.25 in Barretts metaplasia and 0.75 in benign changes and were statistically significant (p=0.04). CONCLUSION Autofluorescence imaging is a sensitive method to diagnose precancerous and cancerous early stages of the diseases located in oesophagus. Especially in two-modal imaging including white light endoscopy, autofluorescence imaging with digital image processing seems to be a useful modality of early diagnostics. Also in observation of papilloma changes, it facilitates differentiation between neoplastic and benign lesions and more accurate estimation of the risk of potential malignancy.

Endothelium injury and inflammatory state during abdominal aortic aneurysm surgery: scrutinizing the very early and minute injurious effects using endothelial markers – a pilot study

Introduction One of the most severe complications of repair surgery for abdominal aortic aneurysms (AAA) is acute kidney injury (AKI). Acute kidney injury is an inflammatory process whose pathogenesis involves endothelial cells (EC). The aim of this study was to assess the dynamics of endothelium injury markers measured during elective AAA surgery which might confirm the inflammatory character of AKI. Material and methods The study group consisted of 14 patients with AAA. We measured plasma soluble forms of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin, P-selectin as well as the levels of von Willebrand factor (vWF) before, during (including intra-abdominal vein levels before and after aortic clamp removal) and within 2 days after surgery. Results We have found a biphasic response of ICAM-1, VCAM-1 and P-selectin with an initial fall and subsequent rise. However, only VCAM-1 changes were significant compared to its baseline value. The maximum decrease of VCAM-1 was observed in the renal vein 5 min after aortic clamp removal (335.42 ±129.63 ng/ml vs. 488.90 ±169.80 ng/ml baseline value, p < 0.05), and the highest rise 48 h after aortic clamp removal (721.46 ±333.99 vs. baseline, p < 0.05). Conclusions Vascular cell adhesion molecule-1 turned out to be the most sensitive indicator of EC injury and inflammatory status after AAA surgery. During AAA surgery, soluble forms of P-selectin, ICAM-1 and VCAM-1 demonstrate a biphasic response with an initial fall and subsequent rise. These soluble forms could have a modulatory effect on the development of inflammation.

Assessment of subclinical acute kidney injury after abdominal aortic aneurysm surgery using novel markers: L-FABP and H-FABP

BACKGROUND One of the most severe complications of repair surgery for abdominal aortic aneurysms (AAA) is acute kidney injury (AKI). Even small rises in serum creatinine are associated with increased mortality. The aim of this study was to assess the dynamics of AKI after elective AAA surgery using novel markers. METHODS The study group consisted of 22 patients with AAA. We measured urinary liver- (u-L-FABP) and heart-type fatty acid-binding proteins (u-H-FABP) before, during and within 3 days after surgery. RESULTS We found an abrupt and significant elevation of both urine FABPs normalized to urinary creatinine; u-L-FABP reached its peak value 2 hours after aortic clamp release {137.79 (38.57-451.79) vs. 9.94 (6.82-12.42) ng/mg baseline value, p<0.05; values are medians (lower-upper quartile)}. The peak value of u-H-FABP was reported 72 hours after aortic clamp release {16.462 (4.182-37.595) vs. 0.141 (0.014-0.927) ng/mg baseline value, p<0.05}. The serum creatinine level did not changed significantly during the investigation period. CONCLUSIONS The significant rise of both u-L-FABP and u-H-FABP after AAA surgery indicates renal proximal and distal tubule injury in this population. Our results suggest that, after AAA surgery, the distal tubules could be more affected than the proximal ones. u-FABPs could serve as sensitive biomarkers of kidney tubular injury and may allow to detect the very early phases of AKI.

Platelet reactivity in thromboelastometry. Revision of the FIBTEM test: a basic study

Abstract This study aimed to investigate modifications to the FIBTEM test to better assess fibrinogen levels and the quality of fibrin polymerization in citrated blood using Multiplate impedance aggregometry to verify platelet inhibition. Blood samples from 26 healthy volunteers were subjected to thromboelastometry studies (EXTEM/FIBTEM tests) in accordance with the standard study protocol (cytochalasin D) and according to a modified protocol (synthetic IIbIIIa receptor antagonist vs. acetylsalicylic acid [ASA] + synthetic IIbIIIa receptor antagonist instead of cytochalasin D). Independent of thromboelastometry, Multiplate impedance aggregometry was used to assess the degree of restriction by the platelet blocked with the following treatments: (1) cytochalasin D, (2) synthetic IIbIIIa antagonist or (3) ASA + synthetic IIbIIIa antagonist to assess the aggregation response to activation with an agonist (ADP, collagen, thrombin receptor activating peptide-6 [TRAP-6], and arachidonic acid). Via aggregometry, cytochalasin D more weakly inhibited platelet aggregation than simultaneous administration of the -IIbIIIa receptor antagonist with ASA. However, total platelet aggregation inhibition was observed after simultaneous administration of cytochalasin D combined with a synthetic IIbIIIa receptor antagonist. In the thromboelastometry, a significant decrease of the A10, A20 and MCF parameters were observed in the EXTEM/FIBTEM tests after they were modified by the addition of a synthetic IIbIIIa receptor antagonist alone or in combination with ASA. In conclusion, in this Multiplate- and ROTEM-based laboratory approach, a two-way blockade (IIbIIIa-antagonist + cytochalasine D) was sufficient to completely inhibit procoagulant platelet function as observed by aggregometry and thromboelastometry.

The Hemodynamics of Blood Flow through the Internal Jugular Veinsafter CCSVI Endovascular Treatment and its Impact on the Quality of Lifein Patients with Chronic Cerebrospinal Venous Insufficiency

Objectives: The aim of the study was to compare pre- and post-operative blood flow through the internal jugular veins (IJVs) in patients with multiple sclerosis and chronic cerebrospinal venous insufficiency, who were subjected to endovascular treatment. The results were correlated with respect to changes in the quality of life. Methods: 144 MS patients underwent endovascular treatment of the IJVs. The blood flow through the IJVs was assessed by the means of the Doppler ultrasonography. The clinical neurological evaluation was based on the various diagnostic tools (scales). The assessment of the blood flow through the IJVs and an evaluation of the quality of life changes were performed before surgery, and at 1, 3 and 6 months after surgery. Results: A statistically significant increase in the blood flow through the IJVs was identified on both sides during all three postoperative controls. The relationship between the IJV flow changes and the parameters related to the quality of life assessment, a statistically significant positive correlation between the flow improvement in the right IJV and Multiple Sclerosis Impact Scale, as well as Fatigue Severity Scale scores, were found. For the remaining evaluated scales (Expanded Disability Status Scale, Heat Intolerance Scale and Epworth Sleepiness Scale), as well for the flow in the left IJV, there were no statistically significant correlations confirmed. Conclusion: Despite a significant improvement in the blood flow through the IJVs after endovascular interventions on the IJVs in CCSVI patients, it has not demonstrated that hemodynamic changes improve the quality of life in MS patients.

The influence of atmospheric pressure on aortic aneurysm rupture — is the diameter of the aneurysm important?

BACKGROUND The rate of aortic aneurysm rupture correlates with the aneurysms diameter, and a higher rate of rupture is observed in patients with larger aneurysms. According to the literature, contradictory results concerning the relationship between atmospheric pressure and aneurysm size have been reported. AIM In this paper, we assessed the influence of changes in atmospheric pressure on abdominal aneurysm ruptures in relationship to the aneurysms size. METHODS The records of 223 patients with ruptured abdominal aneurysms were evaluated. All of the patients had been admitted to the department in the period 1997-2007 from the Silesia region. The atmospheric pressures on the day of the rupture and on the days both before the rupture and between the rupture events were compared. The size of the aneurysm was also considered in the analysis. RESULTS There were no statistically significant differences in pressure between the days of rupture and the remainder of the days within an analysed period. The highest frequency of the admission of patients with a ruptured aortic aneurysm was observed during periods of winter and spring, when the highest mean values of atmospheric pressure were observed; however, this observation was not statistically confirmed. A statistically non-significant trend towards the higher rupture of large aneurysms (> 7 cm) was observed in the cases where the pressure increased between the day before the rupture and the day of the rupture. This trend was particularly pronounced in patients suffering from hypertension (p = 0.1). CONCLUSIONS The results of this study do not support the hypothesis that there is a direct link between atmospheric pressure values and abdominal aortic aneurysm ruptures.