Robert Gürlich

Increased proinflammatory cytokine production in adipose tissue of obese patients with chronic kidney disease

ZusammenfassungHINTERGRUND: Die Adipositas ist ein Hochrisikofaktor sowohl für die Entwicklung von Gefäßerkrankungen als auch für chronische Niereninsuffizienz (CKD). Ziel dieser Studie ist es, den Einfluss des Fettgewebes auf den Entzündungsstatus bei adipösen Patienten mit CDK zu erfassen. PATIENTEN UND METHODEN: In einer prospektiven Querschnitt-Studie analysierten wir 40 CDK (Stadium 3–4) Patienten mit milder Proteinurie (2,3–3,5 g/Tag): 20 Patienten mit Adipositas (Gruppe 1) und 20 normalgewichtigen Patienten (Gruppe 2) wurde während einer elektiven Abdominaloperation (laparoskopische Cholecystektomie) einmalig Blut abgenommen, sowie Proben des subkutanen und des viszeralen Fettgewebes entnommen. Die Serumkonzentrationen folgender Parameter wurden bestimmt: Asymmetrisches Dimethylarginin (ADMA), Adiponektin (ADPN), C-reaktives Protein (CRP), Interleukin-6-(IL-6), Tumor Nekrose Faktor-α (TNF-α), Pentosidin, Monocyte Chemoattractant Protein-1 (MCP-1). Mit Hilfe von Real-Time-PCR wurde die Expression der Messenger RNA (mRNA) von TNF-α, MCP-1 und der Adiponektin Rezeptoren 1 und 2 sowie des immunkompetenten Zellmarkers CD68 im subkutanen sowie im viszeralen Fettgewebe bestimmt. Das Fettgewebe wurde immunhistochemisch auf CD68 positive Zellen geprüft. Außerdem wurden in beiden Gruppen folgende weitere biochemische Parameter bestimmt: Insulin, HbA1c, Cholesterin, LDL-Cholesterin, und Triglyzeride. ERGEBNISSE: Die Serumkonzentrationen von ADMA, CRP, Pentosidin, Interleukin-6, TNF-α, and MCP-1 waren bei den adipösen CDK-Patienten signifikant höher. Das Adiponektin war signifikant im Vergleich zur Kontrollgruppe erniedrigt. Die subkutane und viszerale mRNA Expression von TNF-α, CD68, Adiponektin Rezeptor-1 and MCP-1 war bei den adipösen CDK Patienten signifikant erhöht. Die mRNA Expressionen waren im viszeralen Fettgewebe signifikant höher als im subkutanen Fettgewebe (p < 0,01 vs. p < 0,05). Die Expressionen der mRNA von Adiponektin, Interleukin-6, und des Adiponektin Rezeptors-2 beider Fettdepots waren nicht unterschiedlich in den beiden Gruppen. Bei den adipösen CDK-Patienten wurde im subkutanen und im viszeralen Fettgewebe eine erhöhte Infiltration mit CD68 positiven immunkompetenten Zellen gefunden. Die Fettstoffwechsel-Parameter waren in der Gruppe 1 gering, aber signifikant (p < 0,02) erhöht. Ausgeprägter waren die Veränderungen in den Triglyzeriden (p < 0,01). Ein ähnlicher Anstieg wurde bei den Insulin und HbA1c Werten der Gruppe 1 beobachtet (p < 0,02). SCHLUSSFOLGERUNGEN: Im Fettgewebe adipöser Patienten mit CKD im Stadium 3–4 wurde eine erhöhte Expression von proinflammatorischen Zytokinen und eine gesteigerte Infiltration mit immunkompetenten Zellen gefunden. Diese hinauf-regulierte Entzündung könnte zur Auslösung eines systemischen proinflammatorischen Zustands bei Patienten mit CDK beitragen und das Fortschreiten der Störung der Nierenfunktion beschleunigen.SummaryBACKGROUND: Obesity is a known high-risk factor for the development of vascular diseases and chronic kidney disease (CKD). In this study we aimed to elucidate the impact of adipose tissue on the inflammatory state in CDK patients with obesity. PATIENTS AND METHODS: A cohort of 40 patients with CKD (stages 3–4) with mild proteinuria (2.3–3.5 g/day) were analyzed in a prospective cross-sectional study: single blood samples and visceral and subcutaneous samples of adipose tissue were taken from 20 patients with obesity and 20 without obesity (control group) during elective abdominal surgery (laparoscopic cholecystectomy). Serum concentrations of asymmetric dimethylarginine (ADMA), adiponectin, C-reactive protein, interleukin-6, tumor necrosis factor-α, pentosidine and monocyte chemoattractant protein-1 were measured. Messenger RNA expression of tumor necrosis factor-α, monocyte chemoattractant protein-1, adiponectin receptors 1 and 2, and immunocompetent cell marker CD68 was measured in subcutaneous and visceral fat samples using real-time PCR. Adipose tissue was examined immunohistochemically for CD68-positive cells. Other biochemical parameters (insulin, glycated hemoglobin, cholesterol, LDL cholesterol, and triglycerides) were assessed in the two groups of patients at the same time. RESULTS: Serum concentrations of ADMA, C-reactive protein, pentosidine, interleukin-6, tumor necrosis factor-α and monocyte chemoattractant protein-1 were significantly higher in obese CKD patients than in the control group; adiponectin was lower in the obese group. Subcutaneous and visceral mRNA expressions of tumor necrosis factor-α, CD68, adiponectin receptor-1, and monocyte chemoattractant protein-1 were significantly increased in the obese patients, whereas expression of adiponectin, interleukin-6, and adiponectin receptor-2 did not significantly differ between the patient groups. In general, mRNA expressions were higher in visceral than in subcutaneous samples (P < 0.01 vs. P < 0.05). Increased infiltration of subcutaneous and visceral adipose tissue by CD68-positive immunocompetent cells was found in the obese CKD group. With respect to lipid metabolism parameters, a small but significant increase in levels was found in the obese patients (P < 0.02). Changes in triglycerides were more marked in this group (P < 0.01) and a similar increase was noted in insulin and HbA1c levels (P < 0.02). CONCLUSION: Increased expression of proinflammatory cytokines and increased infiltration by immunocompetent cells were found in adipose tissue of obese patients with CKD stages 3–4. This upregulated inflammation may contribute to the induction of a systemic proinflammatory state in patients with CKD and could accelerate the progression of renal dysfunction.

Leptin as an Acute Phase Reactant after Non-Adjustable Laparoscopic Gastric Banding

Background: Leptin is a hormone that regulates food intake; its concentrations are elevated in the majority of obese individuals. During inflammation, plasma leptin is usually increased and may contribute to the anorexia and cachexia of infection.The purpose of this study was to characterize the dynamics of circulating leptin in the early postoperative period in relation to the acute phase response in extremely obese patients undergoing laparoscopic non-adjustable gastric banding (LNAGB). We compared plasma leptin changes with 4 proinflammatory cytokines and BMI. Methods:The prospective study was performed on 18 patients with 3rd degree obesity. Plasma concentration of leptin, tumor necrosis factor-α (TNF-α), interleukin (IL)-1, soluble IL-2 receptor (sIL-2R), and IL-6 were estimated before operation and 24, 48, and 72 h after NALGB. Results: We demonstrate statistically significant elevation of plasma leptin concentration (32.2±10.2 µg/l) 24 h after operation compared with preoperative status (18.4±5.2 µg/l, p<0.05). There was diminished correlation of plasma leptin and BMI in this period. Leptin levels +48 and +72 h after banding quickly returned to preoperative levels. The regression coefficient was the highest for leptin and TNFalpha 24 h after surgery (r = 0.40, p < 0.05), and for leptin and IL-6 24 h after surgery (r = 0.29, p < 0.05). There was no significant correlation between leptin and IL-1 and between leptin and sIL-2R respectively. Conclusions: During the non-infectious stress response (as with abdominal surgery), leptin shows itself as an acute phase reactant. Proinflammatory cytokines can be the main regulatory factors of leptin in this period.Significant correlation between leptin and TNF-alpha (similarly demonstrated by other authors in models of bacterial inflammation) indicates that TNF-alpha can be a crucial regulator of leptin generation in the early postoperative period.

Cultivation of circulating tumor cells in esophageal cancer

The presence of circulating tumor cells (CTCs) in patients with metastatic carcinoma is generally associated with poor clinical outcome. There have been many investigations showing a possible use of CTCs as minimally invasive predictive and prognostic biomarker in cancer medicine. In this report a size-based method (MetaCell®) for quick and easy enrichment and cultivation of CTCs is presented to enable possible CTCs use in esophageal cancer (EC) management. In total, 43 patients with diagnosed EC, 20 with adenocarcinoma (AdenoCa) and 23 with squamous cell carcinoma (SCC), were enrolled into the adaptive prospective-like study .All the patients were candidates for surgery. The CTCs were detected in 27 patients (62.8%), with a higher rate in adenocarcinoma (75%) than SCC (52%). Finally, there were 26 patients with resectable tumors exhibiting CTCs-positivity in 69.2% and 17 patients with non-resectable tumors with 41.7% CTCs-positivity. Interestingly, in the patients undergoing neoadjuvant therapy, the CTCs were detected at time of surgery in 55.5% (10/18). The overall size-based filtration approach enabled to isolate viable CTCs and evaluate to their cytomorphological features by means of vital fluorescent staining. The CTCs were cultured in vitro for further downstream applications including immunohistochemical analysis. This is the first report of the successful culturing of esophageal cancer CTCs. The detection of CTCs presence could help in the future to guide timing of surgical treatment in EC patients.

Transcutaneous Electrogastrography in Patients with Ileus

Background: The aim of the prospective study was to characterize the disturbance of gastric electrical control activity in different types of ileus and to correlate surface electrogastrography (EGG) findings with a set of inflammatory markers. Patients and Methods: Fifty-four adult patients with mechanic, vascular and paralytic ileus proven on clinical and radiological exams and 14 age- and sex-matched controls were examined. Gastric myoelectrical activity was recorded using 3 Ag-AgCl disposable skin electrodes connected in pseudo-unipolar mode by Microdigitrapper device. The captured signal was amplified and digitalized. The dominant frequency was calculated using computerized algorithms (Fast Fourier transform and running spectrum analysis). The results were correlated with the known pathological diagnoses and 4 inflammatory parameters – interleukin (IL)-1β, IL-6, procalcitonin (PCT) and C-reactive protein. Results: Irregular EGG activity without a dominant frequency or bradygastria (electrical control activity frequency <2.4 cycles/min) was seen in all patients with both vascular and parayltic ileus and in 67.86% of the patients with obstructive ileus. Normogastria (2.4–3.7 cycles/min) was found in 32.14% of the patients with obstructive ileus. Among the patients with obstructive ileus and bradygastria, higher concentrations of IL-6 (642.0 ± 214.7 ng/l) and PCT (0.93 ± 0.22 µg/l) were observed compared with the patients with normogastria – IL-6 (354.5 ± 109.2 ng/l), PCT (0.69 ± 0.11 µg/l); p < 0.05 for both. The C-reactive protein concentration did not differ in both subgroups on p < 0.05. Conclusions: EGG examination confirmed a high sensitivity in the evaluation of gastric electrical control activity in both vascular and paralytic ileus. Significant correlation of EGG findings and both IL-6 and PCT plasma levels supports a role of the inflammatory milieu in the pathogenesis of impaired gastric electrical activity in patients with ileus.

Muscle and fat metabolism in obesity after kidney transplantation: no effect of peritoneal dialysis or hemodialysis.

Our prospective study analyzed selected adipocytokines: adiponectin (ADPN), leptin, visfatin, and asymmetric dimethylarginine (ADMA) in the plasma of renal transplant recipients previously treated by peritoneal dialysis and hemodialysis. A total of 70 patients were on follow-up for 12 months after transplantation. Of these, 30 patients (group I) developed obesity, and 40 patients were nonobese (group II). All were receiving standard immunosuppressive therapy (cyclosporine A or tacrolimus and mycophenolate mofetil, with prednisone added in the early posttransplant period) and did not differ statistically in HLA typing, age, sex, duration of previous dialysis, history of cardiovascular disease, and rate of rejection episodes. At the end of the study period, there were significant differences between groups I and II (t test, analysis of variance) in plasma: ADPN, 22.30 ± 10.2 versus 14.3 ± 7.2 μg/mL; visfatin, 1.7 ± 0.1 versus 1.2 ± 0.1 ng/mL; ADMA, 3.60 ± 0.47 versus 2.10 ± 0.36 μmol/L; P < .01; leptin, 55.6 ± 10.2 versus 25.6 ± 8.3 ng/L; P < .01 (P < .02). In conclusion, an increase of body fat after renal transplantation was associated with an increase of ADMA and leptin, TNF-α, MCP-1, and visfatin and decrease of adiponectin. Our study documented there was now long-term beneficial metabolic effect of peritoneal dialysis in developing posttransplant obesity.

Rectal injury following delivery as a possible consequence of endometriosis of the rectovaginal septum.

1.7% of women in group 1 and 2.8% of women in group 2 (P=0.340). Blood transfusion and additional surgical procedures were required for 1woman in group 1, and 2women in group 2 (P=0.563). Hysterectomy and ligation of vesselswere not performed. Therewas a significant reduction in hematocrit and hemoglobin levels after labor in both groups (P b 0.0001). Hematocrit levels in group 1 were significantly lower after labor than those in group 2 (P=0.035). There were no significant differences between the groups in hemoglobin level after labor. Table 1 Laboratory indices of hemoglobin and hematocrit, and total blood loss.

Anaplastic Large-Cell Lymphoma Associated with Breast Implants: A Case Report of a Transgender Female

AbstractBreast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare peripheral T cell lymphoma. BIA-ALCL is a disease of the fibrous capsule surrounding the implant and occurs in patients after both breast reconstruction and augmentation. More than 300 cases have been reported so far, including two in a transgender patient. Here we describe BIA-ALCL presented with a mass in a transgender patient and the first case of BIA-ALCL in the Czech Republic. In 2007, a 33-year-old transgender male to female underwent bilateral breast augmentation as a part of his transformation to female. In June 2014, the patient developed a 5-cm tumorous mass in her left breast. Magnetic resonance imaging of the chest revealed a ruptured implant and a tumorous mass penetrating into the capsule and infiltrating the pectoral muscle. An R0 surgery was indicated—the implant, silicone gel and capsule were removed, and the tumorous mass was resected together with a part of the pectoral muscle. Histology revealed anaplastic large-cell lymphoma. The patient underwent standard staging procedures for lymphoma including a bone marrow trephine biopsy, which confirmed stage IE. The patient was treated with the standard chemotherapy for systemic ALCL—6 cycles of CHOP-21. The patient was tumor-free at the 2-year follow-up. BIA-ALCL has been reported mostly in women who received implants for either reconstructive or aesthetic augmentation. This is the third report of BIA-ALCL in a transgender person, the first in the Czech Republic. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Circulating tumor cells in different stages of colorectal cancer

INTRODUCTION Liquid biopsies are noninvasive tests using blood or body fluids to detect circulating tumor cells (CTCs) or the products of tumor cells, such as fragments of nucleic acids or proteins that are shed into biological fluids from primary tumor or its metastates. The analysis of published clinical studies provides coherent evidence that the presence of CTCs detected in peripheral blood is a strong prognostic factor in patients with colorectal carcinoma (CRC). The aim of the study was to implement size-based separation protocol of CTCs in CRC patients. MATERIAL AND METHODS Patients diagnosed with different stages of CRC (n = 98) were included in the study. All patients have been diagnosed for colorectal adenocarcinoma by pathology examination, 45 patients with colon carcinoma and 53 with rectosigmoid cancer. A size-based separation method (MetaCell®) for viable CTC enrichment from peripheral blood was used to assess the presence of CTCs by cytomorphological evaluation using vital fluorescence microscopy. RESULTS Cytomorphological analysis revealed that 81 (83%) tested samples were CTC-positive and 17 (17%) were CTC-negative. We report a successful isolation of CTCs with proliferation potential in patients with CRC. The CTCs were cultured in vitro for further downstream applications. Some of the isolated CTCs were able to grow in vitro for 6 months as a standard cell culture. CONCLUSIONS We established a reliable, inexpensive and relatively fast protocol for CTCs enrichment in CRC patients by means of vital fluorescence staining which enables their further analysis in vitro.

New therapy of pleural empyema by deoxyribonuclease

Empyema is a severe complication of different diseases and traumas. Management of this complication is difficult and should comprise general and local procedures. The general procedure is mainly based on administering wide-spectrum antibiotics. Local management depends on patient general condition, but in all cases the essential procedure is to insert a drain into the pleural cavity and to evacuate the pus. Sometimes pus is very thick and its evacuation and following re-expansion of the lung is rather impossible. In these patients surgical intervention is needed. The use of intrapleural enzymes to support the drainage was first described in 1949 by Tillett and Sherry using a mixture of streptokinase and streptococcal deoxyribonuclease. Nowadays, purified streptokinase has come into widespread use, but recent studies reported no streptokinase effect on pus viscosity. On the other side, deoxyribonuclease reduces pus viscosity and may be more useful in treatment. We report two cases of intrapleural administration of Pulmozyme (alfa dornase - deoxyribonuclease (HOFFMANN-LA ROCHE AG) in dosage 2×2.5mg with a significant improvement caused by changes in pus viscosity.

Transcutaneous electrogastrography in the perioperative period in patients undergoing laparoscopic cholecystectomy and laparoscopic non-adjustable gastric banding.

Background: Transcutaneous electrogastrography (EGG) is a non-invasive method of examination that allows monitoring of gastric myoelectric activity. The goal of this prospective study was to describe changes in gastric motility in the early postoperative period in extremely obese patients, who underwent planned surgery - Laparoscopic Non-Adjustable Gastric Banding (LNGB) and to establish the specificity of observed differences for this intervention. Patients and Methods: Myoelectric gastric activity was evaluated in the perioperative period in 20 extremely obese patients undergoing LNGB. The results of monitoring up to +24 h after the intervention were compared to a group of 15 healthy volunteers, and to a group of 20 patients undergoing laparoscopic cholecystectomy (LC). The recording was performed in both the patient and control groups 24 h before the operation and +5 h, +24 h and +48 h after the surgery, both in the fasting state and after stimulation with a liquid bolus. The data were recorded using the Microdigitrapper device and analyzed using the spectral analysis and Fourier transformation. Results: The finding characteristic in the early postoperative period was a decrease in frequency of both spontaneous and stimulated gastric contractions (bradygastria) at +5 h after the intervention, that was followed by rapid return to baseline activity. In patients after LNGB, the normalization of motility was seen within 24 h, and in patients after LC within 48 h after the intervention. Tachygastria was not found in any patient who did not have complications, but on the contrary it was found in both patients with significant dyspepsia after LC. Conclusions: In the early postoperative period after LNGB, significant changes in myoelectric gastric activity were seen and were characterized by transient bradygastria. Comparison with the reference group of patients after LC shows that the intensity and duration of basal and stimulated bradygastria has a non-specific relationship with the extent of tissue trauma caused by the intraabdominal surgery. It is not specific for the gastric banding itself. The method of measuring the basal stimulated EGG potentials can be used in routine surgical practice as an auxiliary method for evaluation of the functional status of the gastrointestinal tract after intraabdominal surgery.