How much of the predisposition to Hashimoto's thyroiditis can be explained based on previously reported associations?

PURPOSE

Our insight in the genetics of Hashimoto's thyroiditis (HT) has become clearer through information provided by genome-wide association studies and candidate gene studies, but remains still not fully understood. Our aim was to assess how many different genetic risk variants contribute to the development of HT.

METHODS

147 HT cases (10.2% men) and 147 controls (13.6% men) were qualified for the analysis. Intrinsic and environmental factors were controlled for. Polymorphisms (SNP) were chosen based on the literature and included markers of the genes PTPN22, CTLA4, TG, TPO among others, and of genomic regions pointed by GWAS studies. SNP were typed on a microarray. Variants in the HLA-DRB1 gene were identified by Sanger sequencing.

RESULTS

Multivariate predisposition to HT was modeled. Based on the investigated group, a model of seven variables was obtained. The variability explained by this model was assessed at only 5.4821% (p = 2 × 10^-6), which indicates that many dozens of factors are required simultaneously to explain HT predisposition.

CONCLUSIONS

We analyzed genetic regions commonly and most significantly associated with autoimmune thyroid disorders in the literature, on a carefully selected cohort. Our results indicated a lack of possibility to predict the risk of HT development, even with a multivariate model. We therefore conclude that strong associations of single genetic regions with HT should be interpreted with great caution. We believe that a change in the attitude towards genetic association analyses of HT predisposition is necessary. Studies including multiple factors simultaneously are needed to unravel the intricacies of genetic associations with HT.

Assessment of incretins in oral glucose and lipid tolerance tests may be indicative in the diagnosis of metabolic syndrome aggravation

Incretins stimulated by oral meals are claimed to be protective for the pancreatic beta cells, to increase insulin secretion, to inhibit glucagon release, slow gastric emptying (glucagon-like peptide-1) and suppress appetite. Recently it has however been suggested that glucagon-like peptide-1 (GLP-1) is putative early biomarker of metabolic consequences of the obesity associated proinflammatory state. The study was aimed to compare the release of incretins and some of early markers of inflammation at the fasting and postprandial period induced by functional oral glucose as well as lipid load in healthy controls and patients with metabolic syndrome (MS) to see if functional tests may be helpful in searching for the inflammatory status of patients. Fifty patients with MS and 20 healthy volunteers (C) participated in this study. The 3-hour oral glucose (OGTT) and the 8-hour oral lipid (OLTT) tolerance tests were performed. At fasting leptin and adiponectin, as well as every 30 minutes of OGTT and every 2 hours of OLTT blood concentration of GLP-1, glucose-dependent insulinotropic polypeptide (GIP), glucose, insulin, triglycerides, free fatty acids, glutathione peroxidase, interleukin-6, sE-selectin, monocyte chemoattractant protein-1 (MCP1) and visfatin were measured. At fasting and during both OGTT and OLTT the level of incretins did not differ between the MS and the C group. Both glucose and lipids reach food activated incretins secretion. Glucose was the main GLP-1 release activator, while the lipid load activated evidently GIP secretion. A significantly larger AUC-GIP after the lipid-rich meal over the carbohydrate meal was observed, while statistically bigger value of AUC-GLP-1 was noticed in OGTT than in OLTT (P < 0.001) within each of the investigated groups. In patients with the highest fasting plasma GIP concentration (3(rd) tertile), IL-6, MCP-1, sE-selectin and visfatin blood levels were increased and correlated with glutathione peroxydase, leptin/adiponectin ratio, higher visfatin and interleukin-6 levels. The fat containing meals stimulate the long-lasting release of incretins, mainly GIP, parallel to the increase of the markers of low grade inflammation associating obesity in metabolic syndrome. The possibility of use of the postprandial (OLTT) GIP release measurement for the low grade inflammation progress in MS patients is suggested.

Glucagon-Like Peptide-1 Receptor Imaging with [Lys (40) (Ahx-HYNIC- (99 m) Tc/EDDA)NH 2 ]-Exendin-4 for the Diagnosis of Recurrence or Dissemination of Medullary Thyroid Cancer: A Preliminary Report

Introduction. Epidemiological studies on medullary thyroid cancer (MTC) have shown that neither a change in stage at diagnosis nor improvement in survival has occurred during the past 30 years. In patients with detectable serum calcitonin and no clinically apparent disease, a careful search for local recurrence, and nodal or distant metastases, should be performed. Conventional imaging modalities will not show any disease until basal serum calcitonin is at least 150 pg/mL. The objective of the study was to present the first experience with labelled glucagon-like peptide-1 (GLP-1) analogue [Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4 in the visualisation of MTC in humans. Material and Method. Four patients aged 22-74 years (two with sporadic and two with MEN2 syndrome-related disseminated MTC) were enrolled in the study. In all patients, GLP-1 receptor imaging was performed. Results. High-quality images were obtained in all patients. All previously known MTC lesions have been confirmed in GLP-1 scintigraphy. Moreover, one additional liver lesion was detected in sporadic MTC male patient. Conclusions. GLP-1 receptor imaging with [Lys(40)(Ahx-HYNIC-(99m)Tc/EDDA)NH2]-exendin-4 is able to detect MTC lesions. GLP-1 scintigraphy can serve as a confirmatory test in MTC patients, in whom other imaging procedures are inconsistent.

Stimulation of gastric slow waves with manual acupuncture at acupuncture points ST36 and PC6--a randomized single blind controlled trial

BACKGROUND

To investigate the effects of stimulated and non-stimulated manual acupuncture at ST36 and PC6 on gastric myoelectrical activity and autonomic function.

METHODS

A total of 65 healthy volunteers were randomly assigned to a 1: 1: 2 ratio to receive either 15 min of verum acupuncture (VA) with stimulation followed by 15 min of VA without stimulation (nsVA), or 15 min of nsVA followed by 15 min of VA with stimulation (sVA), or 30 min of sham acupuncture (SA). Measures of autonomic function included electrogastrogram, electrocardiogram, impedance cardiography and assessment of blood pressure, breathing frequency, and electrodermal activity. Outcome parameters were compared between VA and SA, and between sVA and nsVA. The percentage of regular gastric slow waves (normogastria) was defined as the primary outcome.

KEY RESULTS

The percentage of normogastria was not significantly different between VA and SA. Differences in secondary outcomes such as power spectrum of gastric slow waves and heart rate variability parameters were pronounced in the comparison of sVA and nsVA. During sVA, the percentage of normogastria was lower (P = 0.005), the percentage of bradygastria was higher (P = 0.003) and power ratio was higher (P < 0.001), systolic blood pressure was lower (P = 0.039) and RMSSD was higher (P < 0.001) as compared with nsVA.

CONCLUSIONS & INFERENCES

Our study suggests that manual stimulation of acupuncture needles at ST36 and PC6 affects gastric myoelectrical as well as cardiac activities in healthy volunteers. The effect of stimulation in acupuncture deserves further investigation.

Moxa sticks: thermal properties and possible implications for clinical trials

OBJECTIVES

The aim of the study was to examine the infrared spectrum and the irradiance of different types of moxa sticks to develop a basis for a moxa stick control therapy.

DESIGN

An IR radiometer was used to measure the spectral infrared irradiance of seven glowing moxa sticks of different types in dependence of distance to the heat.

RESULTS

All sticks investigated showed a similar spectral distribution of the emitted IR radiation with maxima of about 83.5-87.5% in the range long-wavelength IR radiation (IR-C) and with small contributions of both short wavelength IR radiation (IR-A) between 2.2% and 5.5% and of middle wavelength IR radiation (IR-B) between 9.0% and 12.1% of the total IR emission.

CONCLUSIONS

Study results showed that only a small proportion of the IR radiation emitted by moxa sticks is capable of affecting subepidermal tissue. This finding indicates that thermal effects of moxa sticks are caused primarily by superficial effects on the skin. Because most heat receptors are located in the superficial skin, it thus appears impossible to separate the effects of moxa sticks from the sensation of heat. These results should be taken into account while developing placebo or sham moxibustion devices.

Radio-guided surgery with the use of [99mTc-EDDA/HYNIC]octreotate in intra-operative detection of neuroendocrine tumours of the gastrointestinal tract

PURPOSE

Radio-guided surgery (RGS) is an intra-operative localising technique which enables identification of tissue "marked" by a specific radiotracer injected before surgery. It is mainly used for sentinel node mapping and for detection of parathyroid adenomas and other tumours, including neuroendocrine tumours of the gastrointestinal tract (GEP-NET). The aim of this study was to determine whether intra-operative radio-detection with the use of [(99m)Tc-EDDA/HYNIC]octreotate, a new somatostatin analogue, is able to reveal an unknown primary and secondary sites, thereby improving surgical treatment and the final outcome of GEP-NET.

METHODS

The study group included nine patients with suspected GEP-NET (four carcinoids, five pancreatic NET) localised with somatostatin receptor scintigraphy (with [(99m)Tc-EDDA/HYNIC]octreotate), who had negative results on other pre-operative imaging tests. At surgery, suspected tumours were measured in situ and ex vivo and precise exploration of the abdominal cavity was performed with the intra-operative scintillation detector (Navigator).

RESULTS

Intra-operative gamma counting localised three carcinoids. In one patient SRS was false positive (owing to inflammatory infiltration). Compared with SRS, RGS revealed additional lymph node metastases in one case. RGS resulted in successful localisation of all pancreatic NET (the smallest lesion was 8 mm in diameter).

CONCLUSION

[(99m)Tc-EDDA/HYNIC]octreotate SRS followed by RGS is a promising technique to improve the rate of detection and efficacy of treatment of GEP-NET, especially in the presence of occult endocrine tumours. The imaging properties of [(99m)Tc-EDDA/HYNIC]octreotate and the 1-day imaging protocol offer opportunities for more widespread application of this tracer followed by RGS in oncology.

Physician and treatment characteristics in a randomised multicentre trial of acupuncture in patients with osteoarthritis of the knee

OBJECTIVE

The aim of this paper is to describe the treatment and physician characteristics in a randomised trial of acupuncture for osteoarthritis of the knee.

DESIGN

Three-armed, randomised, controlled multicentre trial with 1-year follow-up.

SETTING

Twenty-eight outpatient centres in Germany.

INTERVENTIONS

A total of 294 patients with osteoarthritis of the knee were randomised to 12 sessions of semi-standardised acupuncture (at least 6 local and 2 distant points needled per affected knee from a selection of predefined points, but individual choice of additional body or ear acupuncture points possible), 12 sessions of minimal acupuncture (superficial needling of at least 8 of 10 predefined, bilateral, distant non-acupuncture points) or a waiting list control (2 months no acupuncture).

OUTCOME

Participating trial physicians and interventions.

RESULTS

Forty-seven physicians specialised in acupuncture (mean age 43+/-8 years, 26 females) provided study interventions in 28 outpatient centres in Germany. The median duration of acupuncture training completed by participating physicians was 350 h (range 140-2508). The total number of needles used was 17.4+/-4.8 in the acupuncture group compared to 12.9+/-3.3 in the minimal acupuncture group. In total, 39 physicians (83%) stated that they would have treated patients in either a similar or in exactly the same way outside of the trial, whereas 7 (15%) stated that they would have treated patients differently (1 missing).

CONCLUSIONS

Our documentation of the trial interventions shows that semi-standardised acupuncture strategy represents an acceptable compromise for efficacy studies. However, a substantial minority of participating trial physicians stated that they would have treated patients differently outside of the trial.

99mTc-EDDA/HYNIC-octreotate scintigraphy, an efficient method for the detection and staging of carcinoid tumours: results of 3 years’ experience

PURPOSE

At all stages of the disease, serious difficulties are encountered in the imaging diagnosis of carcinoids. Somatostatin receptor scintigraphy (SRS) holds great promise for detecting primary tumours and metastases. 99mTc-EDDA/HYNIC-octreotate should significantly improve the diagnosis of carcinoids in comparison with 111In-Octreoscan owing to the better affinity for SSR2 and the higher count rate. The aim of this study was to assess the diagnostic efficiency of 99mTc-EDDA/HYNIC-octreotate scintigraphy in the detection and staging of carcinoid tumours.

METHODS

The study population comprised 75 patients (age 48.5+/-15.5 years): 46 with histological confirmation of carcinoid and 29 with suspected disease. 99mTc-EDDA/HYNIC-octreotate (740 MBq) SRS and CT were performed in all patients. Fifteen patients were examined with 111In-Octreoscan.

RESULTS

High-quality 99mTc-EDDA/HYNIC-octreotate images were obtained in all cases, with maximum tumour tracer accumulation 4 h p.i. The mean target/non-target ratios for whole body (WB) and SPECT scans were, respectively, as follows: primary lesions: 4.5 and 10.2; metastases: liver, 3.1 and 12.3; abdominal focal lesions, 2.7 and 5.8; lung, 2.7 and 8.3; mediastinum, 3.4 and 7.6; bones, 6.8 and 19.0. 99mTc-EDDA/HYNIC-octreotate WB scans revealed more metastases than 111In-Octreoscan, with better individual separation. 99mTc-EDDA/HYNIC-octreotate SRS revealed new metastatic lesions in seven patients with confirmed carcinoid, and in four with dissemination the primary focus was found. Five patients qualified for radioguided surgery and 11 were referred to 90Y-DOTA-TATE therapy. The sensitivity of SRS in comparison with CT was higher for primary lesions and liver and abdominal lymph node metastases. In the subgroup of patients with suspected neuroendocrine tumours, two duodenal carcinoids, one thymic carcinoid and one ileal carcinoid were found.

CONCLUSION

99mTc-EDDA/HYNIC-octreotate, with high imaging quality, is an excellent alternative to 111In-Octreoscan for staging of carcinoids, and it seems to be the method of choice for detection of the primary focus in patients with metastases from an unknown primary tumour.

Availability of research results on traditional chinese pharmacotherapy

INTRODUCTION

The use of Traditional Chinese Medicine (TCM) has been increasing in the Western world over the last few years. Although Traditional Chinese Pharmacotherapy (TCP) plays a central role in TCM treatment in China, acupuncture is a more common form of treatment in the Western world than TCP.

OBJECTIVE

The aim of our study was to evaluate the quantity and availability of clinical trials on TCP using Medline.

METHODS

Medline searches were performed in PubMed (1966-June 2001) using the MeSH (Medical Subjects Heading) term 'drugs, Chinese herbal.' In a second step we restricted the search to meta-analyses, reviews, randomized controlled trials and clinical trials. Additionally we used the PubMed-Research- Methodology-Filter. Abstracts and information concerning the publication type were used to assess the available information.

RESULTS

Using the MeSH term 'drugs, Chinese herbal', 6,504 publications (50% in Chinese) published in 662 journals were identified. The specific search using the PubMed-Research-Methodology-Filter adjusted to 'therapy' and 'specificity' identified 118 studies (11 reviews, 55 randomized controlled trials, 26 controlled trials, 7 longitudinal studies, 12 experiments, and 7 others), 65 of which were written in English. Most studies used western diagnoses for treatment. The most common investigated diagnosis was atopic dermatitis (7 trials) followed by angina pectoris (6 trials).

CONCLUSION

Only limited information about TCP research is accessible for physicians using PubMed. Moreover, half of the studies are published in Chinese. The PubMed-Research- Methodology-Filter proved to be an effective tool in restricting the search to relevant publications.

[Co-occurrence of diabetic gastropathy and cardiovascular vegetative neuropathy in patients with diabetes type 1. ]

The occurrence of autonomic neuropathy in patients with diabetes is associated with increased incidence of cardio-vascular events and increased mortality. The character of such process is not clear yet and the question if the damage to autonomic nerves equally involves particular organs and systems is open. The aim of the study was to assess the concordance of cardio-vascular neuropathy with diabetic gastropathy in type 1 diabetic patients. The study involved 42 subjects with type 1 diabetes mellitus (age 36.7 +/- 8.3 years; duration of the disease 14.8 +/- 33 years). Gastric emptying of solid food was assessed scintigraphically. T1/2 max and residual isotope activity (expressed as the percentage of initial value) at 45th minute of the study were estimated. Autonomic cardio-vascular neuropathy was assessed based on the Ewing battery tests results.

RESULTS

11 of all subjects (group A) showed normal or increased gastric emptying of solid foods (T1/2 max 36.6 +/- 9.3 min, residual activity 39.6 +/- 12.1%) and 31 remaining subjects (group B) demonstrated delayed gastric emptying (T1/2 max 89.2 +/- 11.4 min, residual activity 74.6 +/- 5.2%), which was regarded as diabetic gastropathy symptom. 31 (74%) of all subjects were diagnosed with cardio-vascular neuropathy, 18 of them (43%) showed early autonomic neuropathy and remaining 13 (31%) presented decided cardio-vascular neuropathy. In group A2 (18%) subjects were diagnosed with early and 5 subjects (45%) with decided neuropathy. In group B early and decided autonomic neuropathy was present in 16 (51%) and 8 (26%) subjects. No statistically important difference between both groups was found.

CONCLUSIONS

The results of the study support the thesis of a disseminated nature of the diabetic autonomic neuropathy and of not concomitant involvement of autonomic nervous system in particular organs and systems of the human body.

[Evaluation of the burden of diabetes in Poland]

Burden of diabetes in terms of economic costs and life years lost due to premature deaths and disability in Poland is analyzed. This study calculates direct costs of type 1 and type 2 diabetes in Poland in 1998 and burden of diabetes in terms of years of life lost using Disability Adjusted Life Years (DALYs) measure within the Polish Multicenter Study of Diabetes Epidemiology (1998-1999). There is a consequent need to evaluate the burden of diabetes for the society and to develop affordable and cost-effective preventing strategies. The burden of diabetes is examined in terms of resources used by diabetic patients and time lost due to premature deaths and disability caused by diabetes. The profile of "a standard patient" (type 1 and type 2 diabetes) resource utilization is created using patient survey in Krakow. This includes main elements of cost associated with prevention, diagnosis and treatment: ambulatory care (visits); hospital care (bed/days and dialysis sessions); pharmaceuticals (goods consumed) and diagnosis (tests). This study calculates direct costs to the health sector of type 1 and type 2 diabetes in Poland 1998. Burden of diabetes in Poland in terms of time lost in 1998 is expressed in Disability Adjusted Life Years (DALYs) unit of measurement. DALY is a combination of two dimensions: YLL--number of years lost due to premature mortality; YLD--loss of healthy years due to disability caused by diabetes (with and without complications). The incidence approach is applied for the YLD caused by diabetes type 1 calculations by gender and age groups (0-29 years). Incidence rates are obtained from the prospective data collection [1, 2]. Other data as average age of onset, average duration of the disease (with or without complications), severity (age specific disability weight for treated or untreated forms of diabetes--with or without complications) are obtained from the GBD study for the Formerly Socialist Economies of Europe [9]. Discounting and age weighting procedure is applied. The prevalence approach is applied for YLD caused by diabetes type 2 calculations for treated and untreated forms of diabetes (with and without complications) by gender and age groups (35 years and more). Prevalence data are obtained from the Polish Multicenter Study on Diabetes Epidemiology. Age specific disability weights for treated or untreated forms of diabetes (with or without complication) are obtained from the GBD study for the Formerly Socialist Economies. Discounting procedure is not applied (duration of the disease is assumed 1 year). Years of Life Lost are calculated using Polish mortality data and life expectancy at the time of death in 1998. Cost of diabetes study is particularly useful in indicating the magnitude of the costs involved, which tend to be much higher than perceived by the general public. In 1998 the average diabetes type 1 patient's costs were 6.4 times and diabetes type 2 patient's costs 3 times higher than average public direct health care costs. The total costs of diabetes in Poland 1998 accounted for 9.3% of total public health care expenditures. The cost of diabetic patient's estimation indicates the potential benefits of effective medical interventions. Not only mortality rates should be taken into consideration in the creation of health policy and financial planning. Disability of the population is also an important factor, particularly in diseases which do not lead to fatalities. In 1998 112,584 DALYs (46% for males and 54% for females) were lost in Poland due to premature deaths and disability caused by diabetes. 72% of the total was due to disability. Secondary prevention is very important especially for diabetes type 2 patients. 95% of total time lost due to disability is caused by diabetes type 2. National burden of disease evaluation is helpful to develop a justifiable basis for setting priorities in purchasing and investing at central and local levels especially in prevention.

[Polish multicenter study on diabetes type I incidence in he age group 0-14 between 1998 and 1999]

The increase in diabetes type 1 incidence observed in various centers in Poland and the need for a centralized study covering large population have resulted in the construction of a standardized registry of type 1 diabetes in 1998 within the Polish Multicenter Study in Diabetes Epidemiology. The aim of the study was to present the incidence rates of type 1 diabetes in the age group 0-14 in 7 distinct regions of Poland (Krakow, Wroclaw, Warsaw, Bialystok, Poznan, Rzeszow and Olsztyn centers) with over 30% of the Polish population at risk in 1998 and 1999. The data for the standardized registry were obtained prospectively from paediatric hospital wards and diabetes outpatient units. The incidence rates calculated in 1998 showed the highest value of 14.6 and 14.5/100,000 for Olsztyn and Warsaw, and the lowest (8.4/100,000) for Poznan center. In 1999 the highest value of 14.7/100,000 was noted in Krakow and the lowest (9.3/100,000) in Poznan center. The differences in diabetes type 1 incidence rates between age groups 0-4, 5-9 and 10-14 were found to be significant (p < 0.0005) and were also significant when incidence rates were compared between males and females in these age groups in the whole study area in 1998-1999 (p = 0.002 and p = 0.015 respectively).

[Polish multicenter study on type I diabetes incidence in the age group 15-29 between 1998 and 1999]

The increase in diabetes type 1 incidence observed in various centers in Poland and the need for a centralized study covering a large population have resulted in the construction of a standardized registry of type 1 diabetes in 1998 within the Polish Multicenter Study in Diabetes Epidemiology. The aim of the study was to evaluate the incidence of type 1 diabetes in the age group 15-29 in 5 distinct regions of Poland (Krakow, Warsaw, Bialystok, Rzeszow and Olsztyn centers) with over 15% of the Polish population at risk in 1998 and 1999. The data for the standardized registry were obtained prospectively from hospital departments and diabetes outpatient units. The incidence rates calculated in 1998 showed the highest value of 11.2/100,000 for Krakow and its region, and the lowest (4.4/100,000) for Bialystok and its region. In 1999 the highest value of 12.3/100,000 was noted in Olsztyn and its region and the lowest (3.4/100,000) in Warsaw. There were significant differences in the incidence rates between the study centers were found. Incidence rates in the whole study area were significantly higher among males as compared with females in 1998 and 1999 (8.9/100,000 vs. 4.9/100,000; p = 0.0001), marked in the age groups 15-19 and 20-24 (p = 0.001 and p = 0.002 respectively). A significant increase in diabetes type 1 incidence (from 4.6/100,000 to 6.9/100,000) was found as compared with results of the "Three Cities Study" (1986-1988).

The changes in spirometric measurements during 6 months' methadone maintenance treatment in opiate dependent patients

The aim of the study was to evaluate the respiratory system response to individually specified doses of methadone in opiate dependent patients during 6 months' methadone maintenance treatment at the Department of Clinical Toxicology CM UJ. There were 34 persons (14 women aged from 21 to 33 years and 20 men aged 21-46 years) under examination. Examinations were performed three times: I--initial examination--before administration of methadone maintenance treatment; II--control examination after 3 months--methadone maintenance treatment; III--control examination after 6 months--methadone maintenance treatment. Ventilation efficiency was assessed on the basis of the results from a "flow-volume" loop, spirometry and the measurements of the respiratory tract resistance (Rrs) in a computerised system. Rrs was determined by means of the flow-interruption method. The parameters obtained from a "flow-volume" loop and spirometry were stabile within opiate substitution with methadone, whilst the values of respiratory resistance were significantly different. Significant increase in respiratory resistance values between initial and control examination (after 3 months) was noted. The normalisation of respiratory resistance was proved after 6 months treatment. It can indicate the impact of nervous component on spastic reaction of central bronchi.

Usefulness of rest and forced perfusion scintigraphy (SPECT) to evaluate cardiotoxicity in acute carbon monoxide poisoning

The aim of the study was to evaluate myocardial perfusion in acute carbon monoxide poisoned patients using rest and stress Tc 99m-MIBI SPECT scintigraphy. There were 29 study patients (15 men and 14 women) aged from 14 to 46 years poisoned acutely with CO at home. Measurement of COHb, blood lactate level, duration of exposure and ECG examination were performed on admission to the Clinic. The enzymes activity (ALT, AST, CBK) were evaluated after 24 hours. The first rest Tc99m-MIBI SPECT was performed in all patients two to five days after intoxication. Fifteen of the patients underwent the control examination: stress and rest scintigraphy six months after CO exposure. Moving track exercise according to the Bruce protocol was used in each the patients. The control rest scintigraphy was performed 48 hours after exercise. Abnormal, differently intensified scans were noted in all the subjects: 5 patients had a I degree of pathological changes, 7 patients had II degree, 16--III degree and 1 patient had a IV degree of pathological changes. In 14 of the patients with pathological scintigraphic scans the normal EKG curves were noted. The mean COHb level was 35.0 +/- 7.22%, the blood lactate concentration was 4.4 +/- 3.7 mmol/L. The average duration of exposure was 108.4 +/- 163.9 min. Effort related ischemia was not noted in 10 of the patients who underwent control examination. An improvement in rest scintigraphic scans was stated in 12, and no changes were observed in 3 of the controlled patients. Deterioration was not found in any patient. No correlation between ECG results and scintigraphic image of myocardium was found. Tc 99m-MIBI SPECT scintigraphy is a more sensitive method than electrocardiography and measurement of enzymes activity for the evaluation of CO cardiotoxicity in acute poisoning. The method enables evaluation of the localization and disease extent.

An evaluation of breathing nervous regulation of opiate dependent patients during in 6 months' methadone maintenance treatment programme

During the methadone maintenance treatment an individually specified doses of methadone should prevent a withdrawal syndrome and may stabilise the activity of respiratory centres of opiate dependent patients. The aim of the study was to evaluate the direction of changes in respiratory pattern parameters of 34 opiate dependent patients (14 women and 20 men) during 6 months' methadone maintenance treatment at the Kraków Department of Clinical Toxicology. Respiratory pattern parameters and occlusion pressure were measured by means of a computer spirometer using "on line" during unrestrained breathing with atmospheric air. Examination of respiratory pattern were performed three times: I--initial examination--before administration of methadone maintenance treatment; II--control examination after 3 months' methadone maintenance treatment; III--control examination after 6 months' methadone maintenance treatment. An increase in values of occlusion pressure and minute ventilation were observed. The times of expiration and total times of inspiration-expiration cycle were shorter in III examination than in the examination before methadone administration. The values for the breathing cycle neuromuscular drive (VT/Tin) were relatively stable, but they were higher than those obtained in the control group. It may be related to the anxiety states and mood alteration. The largest individual variation in consecutive examination were observed for Tin/Ttot index being the timing component of respiratory patterns characteristic for parasympathetic control of breathing.

New possibilities in scintigraphy detection of carbon monoxide cardiotoxicity

The blood clearance of Tc99m MIBI is rapid and biexponential, with an initial fast phase followed by a slow phase. The fundamental myocellular uptake mechanism involves passive distribution across plasma and mitochondrial membranes, and at equilibrium, sestamibi is sequestered within the mitochondria by the larger negative mitochondrial transmembrane potential. Reverse distribution into blood stream is stopped by the high membrane potential of the cardiac cells. Scintigraphic changes followed by the metabolic abnormalities in patients after acute carbon monoxide poisoning can be necrosis or only the transitory ischemia. It seems to detect accurately the extension of the early necrosis (unreversible) of the myocardium. Amiscan kit for the preparation of Tc99m-glucarate is being developed as a radiopharmaceutical diagnostic agent for the imaging of and diagnosis of acute myocardial necrosis. Cellular and subcellular uptake studies have shown that Tc99m-glucarate localizes in necrotic tissues binding primarily to the nucleoprotein sub-fractions and to a lesser extent to the DNA fractions. Glucarate is taken up rapidly by necrotic myocardium and cleared relatively rapidly from the circulation resulting in early, hight target-to-background ratios. In studies of Amiscan in patients with acute myocardial infarction, sensitivity was found to be 100% when Amiscan is administered within 9 hours of the onset of chest pain. In our preliminary study the scintigraphic scans using Tc99m-glucarate were performed in 10 patients after acute carbon monoxide poisoning. The study can confirm that some patients during acute CO poisoning have typical myocardial necrosis, but part of them have hibernating and/or stunned myocardium.

Nervous regulation of breathing in opiate dependent patient. Part II. Respiratory system efficiency and breathing regulation of persons classified to the methadone maintenance treatment

The measurements of respiratory pattern parameters, occlusion pressure and respiratory tract resistance had never been performed in opiate dependent persons administered by the methadone maintenance treatment. The aim of this study was assessment of ventilatory efficiency and nervous regulation of 35 depended on opiates before starting the treatment. The presently examined opiate addicts classified to the methadone programme had intensified changes in nervous breathing regulation compared to the group of opiate dependent patients treated at the Department of Clinical Toxicology CMUJ in the first stage of controlled abstinence and to the control group. They had the higher values of minute ventilation, occlusion pressure and higher value of tidal volume to the inspiratory flow (VT/TIN) index which is the driving component of the breathing cycle and reflects the activity of the respiratory centres in the spinal cord and pons. A monitoring of respiratory patterns parameters, occlusion pressure and respiratory resistance, which are not disturbed or biased by lack of patient's cooperation, will allow to determinate the direction of changes in ventilatory efficiency in the course of methadone maintenance treatment programme.

Nervous regulation of breathing in opiate dependent patient. Part I. Respiratory system efficiency and breathing regulation in the first stage of controlled abstinence

Neurotoxic properties of opioid drugs which are the central nervous system depressant may have also depressive action on the brain stem complex responsible for the breathing control. Disorders of breathing regulation are reflected in respiratory efficiency. The aim of this study was to evaluate the regulation of breathing by measuring of respiratory pattern parameters, occlusion pressure and also to estimate the respiratory efficiency in opiate abusers. There were 76 persons under examination: group I--36 opiates abusers (29 men and 7 women; mean age 22.6 years) treated in the Detoxification Unit of the Department of Clinical Toxicology; group II (control group)--40 healthy persons (25 men and 15 women; mean age 28 years) not dependent of opiates and never treated at the Department. During hospitalisation the functional state of respiratory system was monitored. Ventilation efficiency was determined on the basic of the results from a "flow-volume" curve, spirometry and the measurements of the respiratory tract resistance in a computerised system Lungtest-MES company (Poland). Respiratory regulation was evaluated by means of synchronic measurements of the respiratory pattern (according to the assumption of Milic-Emili) and occlusion pressure P 0.1 (according to Whitlaw assumptions). In the examination performed directly after admission to the Unit the normal respiratory efficiency was noted in 24 persons. 12 persons (33.3%) suffered from the bronchi obturation. In the examination performed after hospitalisation and 9 days of total abstinence the normal ventilatory efficiency was found in 23 persons. In 13 of the patients (38.5%) respiratory obturation was still observed. After treatment in group of opiate abusers compared to control group values of respiratory resistance, occlusion pressure, minute ventilation and VT/T(in) index describing the activity of the central breathing regulation were increased, while the time of expiration and time of total breathing cycle were shorter.

The comparison of respiratory resistance and occlusion pressure in alcohol dependent patients who complain or not of the respiratory system disorders

Alcohol abusers often complain of respiratory symptoms. The aim of the study was to analyse the respiratory pattern parameters and occlusion pressure in chronic alcoholics who complained of respiratory symptoms vs. those who did not suffer from any symptoms before the admission. Also dynamics in changes of spirometry parameters and respiratory pattern parameters during controlled, absolute abstinence while hospitalisation in the Detoxification Unit of the Department of Clinical Toxicology was evaluated. There were 124 study patients: 84 ethanol dependent patients and 40 healthy subject not dependent on ethanol (control group). Ethanol dependency was diagnosed using ICD-10 criteria. The questionnaire according to Fletcher was gathered for each of the subject. The positive results of Fletcher questionnaire (chronic cough + chronic expectoration) was obtained in 43 of the ethanol abusers-group I. The rest of abusers who did not complain of any respiratory symptoms was included to the group II. Respiratory tract resistance was significant the differential factor between the patients with positive results of Fletcher questionnaire and patients who did not suffer any symptoms before admission. Significant differences in occlusion pressure values, were noted between the group of abusers with and without the respiratory symptoms both in the first and control examination.

Assessment of nutritional state of alcohol abusers and drug poisoned patients

Beside the primary illness and environmental factors also alcohol addiction, similarly to another kind of dependency, is being considered as the causative factor of nutritional disorders. Alcohol and drug dependent people due to distorted eating behaviour are predisposed not only to eating disorders (anorexia, bulimia) but also to eating abuse (obesity, overweight, habitual eating). The aim of the study was to assess the nutritional state of alcohol abusers and drug poisoned patients. 113 patients treated at the Department of Clinical Toxicology in Kraków including 65 chronic alcoholics (85% men) and 48 drug poisoned patients (75% young women) were examined anthropometricaly. The measures were performed twice: on admission and on discharge from the Clinic. Nutritional state was unsatisfactory in 76.1% of examined patients and malnutrition or risk of malnutrition was more prevalent than overnutrition. Proportions of subjects qualified to specific groups of nutriture were different in alcohol abusers compared to drug poisoned patients. Also etiology of malnutrition was different. Irregular lifestyle and improper nutrition mode in the group of alcohol abusers (mainly men) and a phenomenon of "slimness terror" in the group of young woman with incidence of suicide attempt should be understood as significant factors of malnutrition. There was no detectable change in nutriture within the nine days long hospitalisation. Only slight, not significant, increase in values of anthropometric parameters was observed in the group of alcohol dependent patients.

[Evaluation of carbon monoxide cardiotoxicity in group poisonings]

The aim of the study was to estimate the usefulness of rest 99mTc-MIBI SPECT scintigraphy to evaluate carbon monoxide cardiotoxicity in acute group poisonings. There were 7 study patients (5 men and 2 women) aged from 14 to 35 years treated at the Department of Clinical Toxicology intoxicated with CO at three different sites: three persons were intoxicated at one, two persons at the second and the next two persons at another site of exposure. As derived from interview the circumstances, source and duration of exposure were similar within the separate group. This enables a comparison of clinical course of carbon monoxide poisoning, particularly the circulatory system of people who were simultaneously exposed to the same source of carbon monoxide. Measurement of COHb, blood lactate level, duration of exposure and ECG examination were performed on admission to the Clinic. The enzymes activity (ALT, AST, CPK) were evaluated after 24 hours. The rest 99mTc-MIBI SPECT scintigraphy was performed in all patients two to five days after intoxication. The changes in myocardial scans were graded according to the arbitrarily accepted point scale. Considering the results of ECG and enzymes activity only, no objective were found to diagnose the cardiac dysfunction. However the perfusion scintigraphy scans indicated regions of myocardium that have decreased blood flow in all the study patients.

The results of the brain computer tomography and clinical picture in acute cholinesterase inhibitors poisoning

The aim of this study was to evaluate a morphological and functional status of the CNS in acute cholinesterase inhibitors (ChI) poisonings using the brain computer tomography (CT) and complex psychiatric examination. Under examination there were 59 cholinesterase inhibitors orally poisoned patients, treated at the Department of Clinical Toxicology in years 1984-1997, aged from 14 to 68 (mean 34.7 +/- 12.8) years. The examined group comprised 9 women (15.3%) and 50 men (84.7%). Between the 3rd and 7th day of hospitalisation a complex psychiatric examination was performed. The CNS damage was diagnosed when the point score from complex psychiatric examination was minimum 5 points. CT was performed between the 3rd and 10th day after the intoxication. Incorrect CT scans were found in 78% of poisoned patients. The most common lesion was generalised cortex atrophy and subcortex atrophy of the brain (73.9%), followed by isolated cortex (17.4%) and subcortex atrophy with simultaneous areas of low density in the subcortical nuclei (8.7%). The frequency of incorrect CT scans was statistically higher (p < 0.01) in the group of organophosphorous compounds poisoned patients compared to those poisoned with carbamates. The complex psychiatric examination revealed in 24 patients (40.7%) the differently intensified alterations, but the point score was not higher than 4. Unquestionable damage of the CNS was recognised in 34 patients (57.6%) of the ChI poisoned patients. The frequency of CNS changes detected in complex psychiatric examination was statistically higher (p < 0.01) in the group of the severely poisoned patients. The significantly higher frequency of pathological changes revealed by the brain CT was found in the group of patients with higher than 5 point score obtained from the complex psychiatric evaluation compared to those with score lower than 5 (p < 0.001).

The influence of acute poisoning with an organophosphate compound on the regulation of breathing and the respiratory system efficiency

The female patient, aged 40, was admitted to the Department of Toxicology about fifteen hours after she had drunk 50 ml Basudin 25 EC (diazinon contents 25%) in a suicidal attempt. On admission the patients state was described as moderately severe (9 points). Starting with the first day after the poisoning, the functional state of the respiratory system was monitored. Ventilation efficiency was determined on the basis of the results from a flow-volume curve, spirometry and the measurements of the respiratory tract resistance (Rrs) in a computerised system Lungtest-MES company (Poland). Respiratory regulation was evaluated by means of synchronic measurements of the respiratory pattern and occlusion pressure. The results obtained from a respiratory pattern and P 0.1 were refereed to normal values. In the examination carried out directly after the poisoning slight obturation of the central bronchi and elevation in resistance of respiratory tract was noted. After a week, obturation was not noted and the resistance value was better. Also the respiratory pattern parameters and value of occlusion pressure were better. It seems that in this case the increase in resistance values in the respiratory tract should be related to the increased activity in the parasympathetic system. Basic, traditional spirometric even in the examination on the first day after the poisoning, were within normal limits, while the parameters of respiratory pattern, occlusion pressure and respiratory resistance were beyond the norm. The results obtained from the measurements of respiratory pattern parameters correlated well with the clinical condition of the patient and with the results of biochemical and enzymatic measurements.

Acute pesticides poisonings in pregnant women

44 pregnant women were treated at the Department of Clinical Toxicology in years 1986-1996 as a result of acute poisonings with different xenobiotics. Acute pesticide poisoning that involved 4 cases were always severe and had dramatic clinical course. Carbofuran intoxication stated in a 17-year-old woman (18 weeks of pregnancy) resulted in fetus death. Toxicological findings revealed that the level of the poison in the mothers blood was comparable to that in the fetus. Carbofuran evidently passed the placental barrier in concentration which was sufficient to cause the fetus death. In the second woman (20-year-old, 12 weeks pregnant) who was classified as severely poisoned on admission to the clinic a spontaneous abortion was stated on 27th day after poisoning. The highest level of carbofuran in the blood of the mother was 9.71 micrograms/g. A 30-year-old woman, 10 weeks pregnant took formothion (50 ml) per vaginam in order to provoke abortion. She was classified as moderately poisoned. Gynecological examination and ultrasonography confirmed the pregnancy. The fetus heart tones were audible. The patient was discharged from hospital after 3 days at her own request in a good general condition. The concentration of formothion in washings from vagina was similar to the levels observed in blood serum on the patient admission to the Clinic, and 24 hour later. A 21-year-old woman, 5 month pregnant ingested an unknown amount of endosulfan to provoke abortion. Gynecological examination and abdominal ultrasonography revealed longitudinal pelvic presentation of fetus. Neither fetal movement nor heart tones were audible as early as four hours after the clinical symptoms occurred. Such low concentration of endosulfan in the blood of the mother as 0.47 microgram/g of the poison caused relatively quick fetus death. The highest levels of endosulfan were found in the liver and in the fetus kidneys.

Multiorgan damage in acute oral carbamates poisonings

The aim of the study was to evaluate the frequency and the kind of multiorgan damage in acute oral carbamates poisonings. Under analysis there were 36 carbamates orally poisoned patients treated at the Department of Clinical Toxicology in the years 1987-1997. Patients with the liver or biliary tract diseases, chronic circulatory insufficiency symptoms, HBs antigen carriers, who suffered head traumas, CNS illness and heavy drinkers were excluded from the study. The organs damage was noted in 91.7% of the poisoned patients. The respiratory system followed by the CNS and the liver were mostly affected by carbamates toxicity. The frequency of pathological changes in the kidney and circulatory system was relatively lower. Only in a few persons peripheral nervous system injuries were noted. In 15% of the examined group the injuries of one organ only was stated. In 48.5% of the patients simultaneous injury of two and three organs or systems were noted. 36.3% of the patients suffered from multiorgan (four or more) damage. In all the severely poisoned patients (III degree) the organs damage was noted. In 53% of them the simultaneous damage of four or more organs/systems was noted. In the group of patients stated as moderately poisoned on admission to the clinic, the multiorgan damage (2-3 organs/systems) was found in 77% of the patients. The lowest number of organ damage was observed in the group of slightly poisoned patients.

The assessment of the condition of the liver in patients chronically exposed to mercury compounds in the place of settlement

Problems with the assessment of organ damage caused by toxic substances in places of residence have recently appeared with increasing frequency. In spite of this there have been so far no uniform, objective research methods which could allow their accurate evaluation. This is why the attempt has been made to assess morphological and functional condition of the liver in patients chronically exposed to mercury compounds in the place of settlement. The research group consisted of 62 patients exposed to metallic mercury at a yearly rate exceeding 24 kg for average duration of 16 years. Patients with the liver or biliary tract diseases, symptoms of chronic circulatory insufficiency, Australia (HBs+) antigen carriers and alcoholics were excluded from the research group. The control group consisted of 29 males. AST and ALT activity, prothrombin level, bilirubin and protein concentration in blood serum were measured and scintigraphic and USG examinations of the liver were performed. Mercury concentrations were also established. Scintigraphic examination yielded an abnormal image of the liver in 52% of the exposed patients. The differences in frequency and intensity of scintigraphic changes in comparison with the control group were of statistical significance. No pathological changes were found in USG examination. Significantly higher ALT activity and bilirubin concentration and significantly lower total protein concentration were found in the exposed group. The correlation between the intensity of scintigraphic changes and mercury concentration were noted. Liver scintigraphic examination combined with biochemical analysis allows an assessment of the liver condition in chronic exposure to mercury compounds in the place of settlement.

[Dynamics of the changes in insulin requirement during the treatment with biosynthetic human insulin]

In 20 patients treated previously with porcine insulin human recombined insulin Eli Lilly was tried. During one year of its use under strict therapeutic conditions a significant decrease of the requirement for insulin was achieved, especially in the first three months of the trial, especially in patients with shorter duration of diabetes. At the same time, carbohydrate metabolism improved significantly. No side effects of the new insulin were noted.