Jan Skóra

Serum and urine metabolomic fingerprinting in diagnostics of inflammatory bowel diseases.

AIM To evaluate the utility of serum and urine metabolomic analysis in diagnosing and monitoring of inflammatory bowel diseases (IBD). METHODS Serum and urine samples were collected from 24 patients with ulcerative colitis (UC), 19 patients with the Crohns disease (CD) and 17 healthy controls. The activity of UC was assessed with the Simple Clinical Colitis Activity Index, while the activity of CD was determined using the Harvey-Bradshaw Index. The analysis of serum and urine samples was performed using proton nuclear magnetic resonance (NMR) spectroscopy. All spectra were exported to Matlab for preprocessing which resulted in two data matrixes for serum and urine. Prior to the chemometric analysis, both data sets were unit variance scaled. The differences in metabolite fingerprints were assessed using partial least-squares-discriminant analysis (PLS-DA). Receiver operating characteristic curves and area under curves were used to evaluate the quality and prediction performance of the obtained PLS-DA models. Metabolites responsible for separation in models were tested using STATISTICA 10 with the Mann-Whitney-Wilcoxon test and the Students t test (α = 0.05). RESULTS The comparison between the group of patients with active IBD and the group with IBD in remission provided good PLS-DA models (P value 0.002 for serum and 0.003 for urine). The metabolites that allowed to distinguish these groups were: N-acetylated compounds and phenylalanine (up-regulated in serum), low-density lipoproteins and very low-density lipoproteins (decreased in serum) as well as glycine (increased in urine) and acetoacetate (decreased in urine). The significant differences in metabolomic profiles were also found between the group of patients with active IBD and healthy control subjects providing the PLS-DA models with a very good separation (P value < 0.001 for serum and 0.003 for urine). The metabolites that were found to be the strongest biomarkers included in this case: leucine, isoleucine, 3-hydroxybutyric acid, N-acetylated compounds, acetoacetate, glycine, phenylalanine and lactate (increased in serum), creatine, dimethyl sulfone, histidine, choline and its derivatives (decreased in serum), as well as citrate, hippurate, trigonelline, taurine, succinate and 2-hydroxyisobutyrate (decreased in urine). No clear separation in PLS-DA models was found between CD and UC patients based on the analysis of serum and urine samples, although one metabolite (formate) in univariate statistical analysis was significantly lower in serum of patients with active CD, and two metabolites (alanine and N-acetylated compounds) were significantly higher in serum of patients with CD when comparing jointly patients in the remission and active phase of the diseases. Contrary to the results obtained from the serum samples, the analysis of urine samples allowed to distinguish patients with IBD in remission from healthy control subjects. The metabolites of importance included in this case up-regulated acetoacetate and down-regulated citrate, hippurate, taurine, succinate, glycine, alanine and formate. CONCLUSION NMR-based metabolomic fingerprinting of serum and urine has the potential to be a useful tool in distinguishing patients with active IBD from those in remission.

Vascular complications after the treatment with Ilizarov external fixators.

Iatrogenic vascular injuries from external fixation in orthopaedics and traumatology are frequent. Three cases of vascular injuries after the treatment with Ilizarov external fixators were treated at our institution. These include two cases of pseudoaneurysms and one case of acute ischaemia of the lower limb. Two patients became symptomatic only after removal of the fixator. In all cases, the diagnosis was made by color flow duplex sonography. All vascular injuries needed surgical repair.Iatrogenic vascular injuries from external fixation in orthopaedics and traumatology are frequent. Three cases of vascular injuries after the treatment with Ilizarov external fixators were treated at our institution. These include two cases of pseudoaneurysms and one case of acute ischaemia of the lower limb. Two patients became symptomatic only after removal of the fixator. In all cases, the diagnosis was made by color flow duplex sonography. All vascular injuries needed surgical repair.

Combined autologous bone marrow mononuclear cell and gene therapy as the last resort for patients with critical limb ischemia.

Introduction Our study was designed to investigate the safety and efficacy of combined autologous bone marrow mononuclear cell (MNC) and gene therapy in comparison to conventional drug therapy in patients with critical limb ischemia (CLI). Material and methods Thirty-two patients with CLI persisting for 12–48 months (average time 27.5 months) were randomized into 2 groups, each group consisting of 16 patients. In the first group, administration of autologous bone marrow MNC and vascular endothelial growth factor (VEGF) plasmid was performed. The patients from the second group were treated pharmacologically with pentoxifylline. Ankle-brachial index (ABI) was measured and angiography was performed before and finally 3 months after treatment. The pain was evaluated using the Visual Analog Scale (VAS) before and after 3 months. Results Ankle-brachial index improved significantly from 0.29 ±0.21 to 0.52 ±0.23 (p < 0.001) in 12 patients (75.0%) 3 months after the experimental therapy in group 1. In this group angiography showed the development of collateral vessels. Ischemic ulcers healed completely in 11 patients (68.75%). In group 2 the ABI did not improve in any patient; moreover the complete healing of skin ulcers was not found in any of the patients of this group. Amputation was performed in 4 (25.0%) patients in group 1, and in 8 patients (50%) from group 2. Conclusions These data after 3-month follow-up indicate that intramuscular injection of MNC combined with gene therapy in patients with chronic CLI is safe, and a more feasible and effective method of treatment than the conventional therapy. However, both therapies are limited by the degree of microcirculation damage.

Iatrogenic pseudoaneurysm of the popliteal artery following corrective tibial osteotomy.

Due to its anatomical location the popliteal artery is exposed to injury during surgical procedures in the region of the knee joint, in particular during high-level corrective osteotomies of the proximal tibial epiphysis. Nevertheless, posttraumatic (iatrogenic) pseudoaneurysm constitutes a very rare complication of the procedure. Only few reports of such complication have been published and they were usually connected with lateral tibial osteotomy - the accidents after medial osteotomy are seldom. The complication we report was observed in a 52-year-old female patient after corrective osteotomy of the medial portion of the proximal tibial epiphysis. The complication was diagnosed 7 days after surgery on US-examination and subsequently confirmed by emergently performed angio-CT. The patient was referred for urgent reconstructive surgery. No significant complications were observed, neither postoperatively nor during follow-up visits.

Evaluation of the humoral and cellular immune responses after implantation of a PTFE vascular prosthesis.

INTRODUCTION The experiment was designed in order to determine the immunological processes that occur during the healing in synthetic vascular grafts, especially to establish the differences in the location of the complement system proteins between the proximal and distal anastomosis and the differences in the arrangement of inflammatory cells in those anastomoses. The understanding of those processes will provide a true basis for determining risk factors for complications after arterial repair procedures. MATERIAL/METHODS The experiment was carried out on 16 dogs that underwent implantation of unilateral aorto-femoral bypass with expanded polytetrafluoroethylene (ePTFE). After 6 months all animals were euthanized to dissect the vascular grafts. Immunohistochemical assays and electron microscopic examinations were performed. RESULTS Immunohistochemical findings in the structure of neointima between anastomoses of vascular prostheses demonstrated significant differences between humoral and cellular responses. The area of proximal anastomosis revealed the presence of fibroblasts, but no macrophages were detected. The histological structure of the proximal anastomosis indicates that inflammatory processes were ended during the prosthesis healing. The immunological response obtained in the distal anastomosis corresponded to the chronic inflammatory reaction with the presence of macrophages, myofibroblasts and deposits of complement C3. DISCUSSION The identification of differences in the presence of macrophages and myofibroblasts and the presence of the C3 component between the anastomoses is the original achievement of the present study. In the available literature, no such significant differences have been shown so far in the humoral and cellular immune response caused by the presence of an artificial vessel in the arterial system.

Iatrogenic injuries of the carotid arteries

BACKGROUND Iatrogenic trauma of the carotid artery (CA) is a dangerous intraoperative complication, especially during oncological and endocrinological procedures. In these cases massive hemorrhage and severe neurological complications may occur. The outcome of reconstructive procedures is often fatal because of the long delay of surgery after the injuries occuring in non-vascular centers. PATIENTS AND METHODS In this paper 22 cases of iatrogenic CA trauma will be presented, operated in the period of 1980-2003. Different methods of operation were performed according to the extent of trauma and anatomical changes. RESULTS In spite of emergency help two patients died. In three cases cerebral stroke was observed. Additionally peripheral nervous damages were noted. CONCLUSIONS Iatrogenic CA trauma is one of the most dangerous vascular injuries, connected with hemorrhage and neurological complications. We recommend intravenous administration of 5000 units unfractionated Heparin, anatomical artery preparation, then shunt inserting. Autogenous material should be used if possible. For reconstruction of the initial part of internal carotid artery the transposition of the external carotid artery is useful.

Gefäßkomplikationen nach der Behandlung mit dem Ilizarov-Ringfixateur

Iatrogenic vascular injuries from external fixation in orthopaedics and traumatology are frequent. Three cases of vascular injuries after the treatment with Ilizarov external fixators were treated at our institution. These include two cases of pseudoaneurysms and one case of acute ischaemia of the lower limb. Two patients became symptomatic only after removal of the fixator. In all cases, the diagnosis was made by color flow duplex sonography. All vascular injuries needed surgical repair.Iatrogenic vascular injuries from external fixation in orthopaedics and traumatology are frequent. Three cases of vascular injuries after the treatment with Ilizarov external fixators were treated at our institution. These include two cases of pseudoaneurysms and one case of acute ischaemia of the lower limb. Two patients became symptomatic only after removal of the fixator. In all cases, the diagnosis was made by color flow duplex sonography. All vascular injuries needed surgical repair.

Prognostic value of tissue factor in patients with abdominal aortic and iliac arterial aneurysms - preliminary study.

Introduction The decision on the time and choice of strategy of treatment of abdominal aortic aneurysm must be especially carefully balanced. The aim of the study was to evaluate the tissue factor (TF) plasma level as a potential factor useful in anticipation of abdominal aortic aneurysm and/or iliac arterial aneurysm via comparison of plasma TF level in patients with ruptured and non-ruptured aneurysms. Material and methods The study included 33 patients with aneurysm (17 operated on electively because of non-ruptured aneurysm and 16 operated on emergently due to ruptured aneurysm), 33 claudicant patients with atherosclerosis of the abdominal aorta and iliac arteries with normal diameter of arteries, and 30 healthy controls. Plasma TF level was assessed by ELISA method using the IMUBIND Tissue Factor ELISA Kit (American Diagnostica Inc.). Results The study showed an increased TF level in patients with aneurysm (134 ±54 pg/ml) and in patients with atherosclerosis without concomitant aneurysm (91 ±30 pg/ml) in comparison with the control group (62 ±20 pg/ml), respectively p < 0.001 and p = 0.008. A significantly higher TF plasma level was observed in patients with ruptured abdominal aortic aneurysms (160 ±57 pg/ml) as compared to patients with non-ruptured aortic aneurysms (109 ±39 pg/ml) or peripheral arterial occlusive disease (91 ±30 pg/ml), respectively p < 0.001 and p < 0.001. The difference in TF level between the group with non-ruptured aortic aneurysms (109 ±39 pg/ml) and the patients with atherosclerosis without aneurysm (91 ±30 pg/ml) was not statistically significant. Conclusions No difference in TF level between patients with non-ruptured AAA/IAA and patients with aortic and iliac atherosclerosis without aneurysm indicates that an increased TF plasma level is not specific for any of the above-mentioned vascular pathologies.

Surgical management of extracranial carotid artery aneurysms

BACKGROUND We present the methods and results of the surgical management of extracranial carotid artery aneurysms (ECCA). Postoperative complications including early and late neurological events were analysed. Correlation between reconstruction techniques and morphology of ECCA was assessed in this retrospective study. PATIENTS AND METHODS In total, 32 reconstructions of ECCA were performed in 31 symptomatic patients with a mean age of 59.2 (range 33-84) years. The causes of ECCA were divided among atherosclerosis (n = 25; 78.1%), previous carotid endarterectomy with Dacron patch (n = 4; 12.5%), iatrogenic injury (n = 2; 6.3%) and infection (n = 1; 3.1%). In 23 cases, intervention consisted of carotid bypass. Aneurysmectomy with end-to-end suture was performed in 4 cases. Aneurysmal resection with patching was done in 2 cases and aneurysmorrhaphy without patching in another 2 cases. In 1 case, ligature of the internal carotid artery (ICA) was required. RESULTS Technical success defined as the preservation of ICA patency was achieved in 31 cases (96.9%). There was one perioperative death due to major stroke (3.1%). Two cases of minor stroke occurred in the 30-day observation period (6.3%). Three patients had a transient hypoglossal nerve palsy that subsided spontaneously (9.4%). At a mean long-term follow-up of 68 months, there were no major or minor ipsilateral strokes or surgery-related deaths reported. In all 30 surviving patients (96.9%), long-term clinical outcomes were free from ipsilateral neurological symptoms. CONCLUSIONS Open surgery is a relatively safe method in the therapy of ECCA. Surgical repair of ECCAs can be associated with an acceptable major stroke rate and moderate minor stroke rate. Complication-free long-term outcomes can be achieved in as many as 96.9 % of patients. Aneurysmectomy with end-to-end anastomosis or bypass surgery can be implemented during open repair of ECCA.

OwN CLINICAL ObSERvAtIONS Of tREAtmENt OutCOmE IN ACutE tyPE b AORtIC dISSECtION

UNLABELLED The aim of the study was to analyse early results of treatment of acute type B aortic dissection. MATERIAL AND METHODS 59 patients, treated between 1998 and 2011, were divided into four groups. Group I comprised ten patients in whom hybrid procedures were performed: extra-anatomical by-pass graft from the brachio-cephalic trunk to the left carotid artery in six patients, transposition of the left carotid artery to the right one in two patients, and reversed Y prosthesis from the brachio-cephalic trunk to both carotids in the remaining 2 patients, to facilitate stent-grafting. Group II comprised 13 patients in whom endovascular procedures were performed (stent-grafting). Group III comprised 21 patients in whom conventional surgery was done. Group IV comprised 15 patients who were treated conservatively. RESULTS In group I, a very good clinical outcome, without complications, was achieved in six patients (60% of cases). The total mortality rate was 40%. One patient died on the operation table, following stent-grafting, due to the rupture of the aortic arch. Two patients died as a result of brain damage (cerebral aneurysm rupture in one, and ischemic stroke in the other). In one patient, an aorto-oesophageal fistula developed. In group II, one patient died during endovascular procedure. Another patient suffered from type 1 endoleak, requiring repeated endovascular surgery. In group III, 15 patients (72%) died. Moreover, four patients required acorrective cardiac surgery (Bentall procedure)which in three patients resulted in death. Thus, the total mortality rate in this group was as high as 85%. In group IV, the mortality rate was 13%. CONCLUSIONS We noticed a clear superiority of endovascular procedures over conventional surgeries-for acute type B aortic dissection. Hybrid procedures for acute, complicated type B aortic dissection evidently reduce mortality and postoperative morbidity. Uncomplicated acute type B aortic dissections should be treated conservatively at intensivecare units.