Metal hypersensitivity in hip, knee and spine surgery

The number of implanted joint prostheses and damaged spinal components is steadily increasing. At the same time, rejection of the implanted material is observed in operated patients, which manifests itself in both skin and general reactions, as well as loosening and earlier wear of implanted prostheses, which was previously referred to as aseptic reactions. However, it has been shown that in a significant proportion of patients, rejection of implanted material may be caused by hypersensitivity to a specific metal. For this reason, patients qualified for implantation of foreign material, mainly nickel, titanium, chromium, molybdenum, and other alloys, should be subjected to allergy tests to detect possible risks in the form of metal sensitivity reactions.

[Is aseptic loosening of joint prostheses aseptic?]

The observed changes in the periarticular space may be caused by both mechanical action and biological reactions. Periprosthetic infections are the most common cause of loosening and destructive changes in the joints, however, the diagnosis of an aseptic reaction is not always fully obvious. Micromovements between the implant and the surrounding bone can cause remodeling of the bone trabeculae and migration of fibroblasts into the voids between the implant surface and the bone. In addition, repetitive stresses can induce fibroblast proliferation. On the other hand, the residues arising from the wear of implanted materials in the joints may play an important role in the process of loosening of prostheses - both aseptic and septic. Direct interactions between the released molecule and the macrophage surface are sufficient to activate osteoclastogenic signaling pathways. You cannot ignore allergic reactions to metals used in prostheses in patients undergoing arthroplasty. Demonstration of hypersensitivity to the components of dentures in some cases requires the use of appropriate material in order not to cause an inflammatory allergic reaction. Emerging treatment strategies using mesenchymal stem cells (MSCs) are aimed at improving the initial implant integration and preventing periprosthetic osteolysis. It should be emphasized, however, that the diagnosis of aseptic loosening in many clinical situations raises doubts, because it is at the root of everyone.

Analysis of mortality between 2019-2020 at the Neuroorthopedic and Traumatic Orthopedic Departments

The number of deaths from skeletal injuries is still significant, but is declining with advances in emergency medicine. The adopted principles of emergency procedures and the availability of specialist centres enable the treatment to be effective.

AIM

The aim of the study was to analyse the deaths of patients with spine and limb injuries who required surgery.

MATERIALS AND METHODS

The analysis covered 22 deaths in the years 2019-2020. The assessment took into account: the cause of admission, the condition of the patient and comorbidities, the medical scales which were used to assess the possible risk of complications, the diagnostic correctness and qualification for surgical treatment, the waiting time for surgery and the cause of death and prior course of action.

RESULTS

It can be stated that in 2019, the mortality rate was 0.21 (10 deaths out of 4658 hospitalized), in 2020, the mortality rate was 0.31 (12 deaths out of 3852 hospitalized). The mortality rate in the Department of Traumatic Orthopedics was: 0.30 in 2019 (8 deaths out of 2625 hospitalized) and 0.39 in 2020 (8 deaths in 2020 hospitalized). 10 patients with hip fractures (trochanteric and femoral neck) underwent surgery within 2.7 days (from 1 to 4 days). The causes of death within 1-9 days (average 4.86 days) from admission in this group were complex, and associated with the presence of chronic diseases, including: circulatory failure (9), septic shock (1), heart rhythm disturbances (7), renal failure (6), pulmonary congestion (4), hyperkalemia (1), coagulation disorders (1). In patients after spinal injury with quadriplegia, decompression (1), stabilization (1) and disc removal (1) were performed on the day of admission to the hospital. The patients were hospitalized in the ICU, and deaths occurred on days 9, 15 and 187 from admission due to respiratory and circulatory failure and sudden cardiac arrest. Patients after arthroplasty of the knee (1) and hip (2) were operated on day 2 from admission, and deaths occurred on day 4, 22 and 53 due to: sepsis (1), pulmonary embolism (1), respiratory failure in the course of pneumonia (1).

CONCLUSIONS

The deceased were admitted in a serious general condition, burdened with numerous concomitant chronic diseases and their age ranged from 66 to 97 years. The surgical treatment was undertaken for life saving reasons but 5 of the deceased did not undergo surgery due to the extreme general condition leading to respiratory and circulatory failure.

[Recognizing Alzheimer's disease in daily practice]

Early diagnosis of Alzheimer's disease (AD) is of great practical importance. The process of differentiating a disease with symptoms of dementia caused by another pathology of the nervous system is based on a subjective assessment. The pathogenesis of AD emphasizes the importance of neuropil beta-amyloid deposition in the brain and the tau protein inside neurons, which is found 20 years before the onset of clinical symptoms of the disease. The number of people suffering from AD doubles every 20 years and in 2050 there will be 115.4 million of them worldwide. The level of education and constant intellectual activity may be a factor protecting against the occurrence of AD. The diagnosis of AD takes into account information obtained from interviews as well as from additional imaging and laboratory tests. The available criteria for AD diagnosis are constantly modified and changed, which makes their application in everyday practice difficult.

Management of patients with chronic obstructive pulmonary disease (COPD) during COVID-19

COPD is one of the risk factors for contracting COVID-19. Good management of patients, appropriate treatment with inhaled preparations, including inhaled glucocorticosteroids, with simultaneous monitoring concomitant infections, and the use of vaccinations allow to reduce the risk of developing COVID-19. At the same time, it is necessary to limit the performance of spirometric tests to reduce the probability of SARS-CoV-2 infection. In the case of a confirmed infection, it is necessary to continue basic treatment, with strict adherence to the recommended dosage of drugs, which may significantly protect the patient against post-inflammatory fibrosis in the pulmonary parenchyma.

[Pro-health cycle lane versus environmental pollution and trauma]

A bicycle as a mean of transport and recreation, but is it a healthy lifestyle? The construction of numerous cycle lanes in cities and promotion of physical activity aims to encourage the public to move around by bicycle. The aim of mass cycling is to reduce car exhaust emissions and, on the other hand, to improve public health. The paper presents the potential benefits of cycling, but also its negative effects on the human body. Minimizing the danger of using a bicycle lies not only with cyclists, but also with people who are planning to build cycle lane.

Treatment of patients with asthma during COVID-19

Good management of patients with bronchial asthma protects against SARS-CoV-2 infection, which is associated with the activity limiting the virus penetration into the respiratory epithelial cells. A relationship between asthma exacerbation and SARS-CoV-2 infection has not yet been demonstrated. The available recommendations state that patients with asthma should use inhaled glucocorticosteroids (GCS) on a regular basis. In the case of exacerbation of asthma symptoms, it is necessary to administer higher doses of inhaled GCSs and to quickly add systemic GCSs, mainly methylprednisolone. Treatment with biological preparations does not increase the risk of SARS-CoV-2 infection, and is effective in reducing the number of asthma exacerbations.

[Pathogenesis and the contemporary picture of polyneuropathy]

Demyelinating changes in peripheral nerves are responsible for the neurological symptoms found. Diabetes mellitus is one of the most common causes of polyneuropathy and is found in 8-54% of patients with type I diabetes, 13-46% of patients with type II and 22-66% of alcohol abusers. In turn, chemotherapy, depending on the therapeutic regimens used, is responsible for the symptoms of polyneuropathy in 10-90% of patients. Separate disease syndromes create immunologically determined polyneuropathies. Chronic compression or irritation of the spinal nerves or their roots in diseases of the spine leads to ischemia and neuropathy. The spinal nerve is most often pinched and then there are mixed motor-sensory symptoms. In order to prevent the onset of polyneuropathy, it is necessary to release the nerves from pressure and ischemia as quickly as possible.

[Sotrovimab in controlling SARS-CoV-2 infection]

The new monoclonal antibodies - VIR -7831 (sotrovimab) and VIR- 7832 - show an action directly targeting the SARS-CoV-2 spike glycoprotein. Moreover, they strongly neutralize in vitro the wild-type Corona virus variants and the omicron variant. Sotrovimab is a monoclonal antibody capable of neutralizing SARS-CoV-2 as well as other sarbecoviruses (SARS-CoV-1 and SARS-CoV). The administration of 500 mg sotrovimab as a 1-hour intravenous infusion in 291 patients with COVID-19 with mild to moderate severity of symptoms prevented disease progression and the need for hospitalization.

[Assessment of the effectiveness of early treatment in SARS-CoV-2 infection]

Treatment of SARS-CoV-2 infection has been undertaken in all medical centers in the world. Based on the experience gained, in some of them it was possible to effectively control the course of the Corona virus infection depending on the stage of infection.

AIM

The aim of the study was to assess the effectiveness of early treatment depending on the stage of SARS-CoV-2 infection and the severity of symptoms, mainly in the respiratory system.

MATERIALS AND METHODS

Outpatient treatment included 104 patients infected with SARS-CoV-2, in whom infection was confirmed according to the adopted criteria. The first group of patients were infected with SARS-CoV-2 with mild symptoms, the time of probable infection was 3- 5 days ago. They were given arechin (Arechin, Adamed) 2 times 1 tablet (250 mg) for 6 days, azithromycin (Sumamed, Teva) 1 time a day 1 tablet (500 mg) for 6 days. After confirmation of persistence of cracks at the base of the lungs, treatment was continued by administering methylprednisolone (Metypred, Orion) orally at a dose of 0.2 mg/kg in reducing doses every 5 days and ciclesonide (Alvesco, Takeda Pharma) by inhalation 2 x 160 μg each. The second group consisted of people infected with SARS-CoV-2, who had not been treated, but were taking only antipyretic drugs and reported 7-10 days after the onset of infection. After revealing "ground-glass opacity" changes in chest CT, it was recommended to take levofloxacin (Levoxa, Actavis Polska) twice a day, 1 tablet (500 mg) for 3 days, and then once a day for the next 5-7 days, of methylprednisolone orally in a dose of 0.3 mg/kg in weight in decreasing doses every 5 days, according to changes found in imaging tests, and inhalation of ciclesonide 2 x 160 μg. Patients after COVID-19, hospitalized with respiratory disorders and changes in imaging tests, were the third group. They were treated according to the extent of the changes in chest CT and comorbidities, using methylprednisolone orally at a dose of 0.5 mg/kg in doses reducing every 5-10 days, depending on the rate of symptom relief and regression of changes in the tests. imaging and inhaled ciclesonide 2 x 320 μg. In each case, the treatment was individually selected according to the severity of the course of the disease.

RESULTS

In all patients, a significant improvement in general condition was achieved in the form of relief of dyspnea, cough and weakness, which correlated with a significant remission of the initial changes in the pulmonary parenchyma in the form of a "ground-glass opacity". In the first group, after the treatment (from 3-5 days after infection), only 17.6% of patients in the CT examination of the chest showed the presence of peripheral lesions of the "ground-glass opacity" type with an extent of 1-25%, and in 35.3% of patients "cotton foci". In the second group (treated from 7-10 days after infection), 18.7% of patients revealed the presence of "ground-glass opacity" lesions, which occupy more than 50% of the pulmonary parenchyma, and in 31.2% more than 25% of patients. After treatment, COVID-19 symptoms resolved, and chest CT showed a significant reduction in lesions - in 21.8% of patients <25% and in 25% of patients <10%. In the third group of COVID-19 patients after hospitalization, symptoms of the "groundglass opacity" type dominated, including in as many as 37.5% they affected more than 50% of the pulmonary parenchyma, and over 25% in 42.8% of the treated. After treatment, a significant reduction in the symptoms of the disease and an improvement in the CT image of the chest were achieved - in 50% of patients lung involvement <5% and in 28.6% with lesions <10%.

CONCLUSIONS

The effectiveness of azithromycin, arechin, methylprednisolone and ciclesonide in controlling inflammation caused by SARSCoV- 2 infection has been confirmed in treated patients with symptoms of COVID-19 on an outpatient basis. The use of the assessed drugs should take into account the time of onset of SARS-CoV-2 infection and the severity of the disease course, including comorbidities. The presented analysis of the effectiveness of early treatment in patients infected with SARS-CoV-2 requires further clinical trials.

Can we minimize carbon footprint by using "greener" inhalers and improve clinical outcome at the same time in asthma therapy?

The treatment of patients with obstructive airway diseases is based on the use of inhalation preparations. Some of them, mainly including pressurized metered dose inhalers (pMDIs), contain compressed gases - hydrofluoroalkanes, which generate carbon dioxide emissions, creating the so-called carbon footprint.

AIM

The aim of the study was to evaluate the consumption of individual active substances, the types of inhalers used and calculation of the carbon footprint of therapies in patients with asthma in 2018 and 2019 in Poland.

MATERIALS AND METHODS

The ratio of pMDI vs DPI (dry powder inhaler) data and the data on using in patients with asthma long-acting β2-agonists (LABAs), short-acting β2-agonists antagonists (SABAs), long-acting muscarinic antagonists (LAMAs), LAMA+LABAs, LAMA+LABA+ICSs (inhaled corticosteroids) on Polish market during 2018 and 2019 were analyzed. The carbon footprint of such therapies was counted. Then, we studied the reduction of the carbon footprint for scenario A (reducing pMDI by 50%) and scenario B (reducing pMDI by 80%) in the following steps of analysis.

RESULTS

The general structure of pMDI/DPI in Poland in asthma patients was not changed in 2019 vs 2018. The carbon footprint is primarily created by pMDI SABAs. In 2019 in Poland pMDI SABAs were 1.9 mio units (the same as in 2018), which generated 36.8 kt CO2e annually. Scenario A gives us a benefit of 17.4 kt CO2e reduction and scenario B brings us a benefit of 28.0 kt CO2e reduction of emissions.

CONCLUSIONS

Despite Poland's ratification the Kigali amendment did not affect pMDI consumption by asthma patients and did not reduce the carbon footprint. The lower carbon footprint of DPIs should be considered alongside other factors when choosing inhalation devices.

Hip arthoplasty in a forester after numerous tick bites

Arthritis is one of the most important symptoms of late-stage borreliosis, observed in approximately 60% of untreated patients with Lyme disease. In several percent of them, this manifestation is of interest to orthopedic surgeons. The authors present a case of a patient, working as a forester, who underwent left hip replacement arthroplasty having contracted a Borrelia burgdorferi infection in the past, and who was hospitalized 12 years before in the infectious ward due to suspected neuroborreliosis for which he was treated with Ceftriaxone 2 × 2.0 g intravenously for 4 weeks. At that time, a tomographic examination of the spinal cord revealed herniated nuclei at levels L4/L5 and L5/S1, which filled the left lateral recess, narrowing the intervertebral holes and compressing the nerve roots on the left side of L4 and L5. In September 2019, total hip replacement in the patient's left hip joint was performed. It is concluded that an active role of neuroborreliosis in this process of hip joint destruction may be suggested. Int J Occup Med Environ Health. 2021;34(5):693-9.

[Anti-inflammatory effects of amantadine and memantine in SARS-CoV-2 infection]

Amantadine and memantine, apart from their action on cholinergic receptors and dopamine secretion, have a significant influence on the inflammatory process, including the so-called "cytokine storm" and reduction of apoptosis and oxidative stress. Amantadine also inhibits the induction of inflammatory factors such as RANTES, activates kinase p38 of mitogen-activated protein (MAP) and c-Jun-NH2-terminal kinases (JNK), which inhibit viral replication. It also significantly inhibits the entry of SARS-CoV-2 into the bronchial epithelial cell and blocks the viroporin proton channel of the virus. In addition, it has the ability to pass through the membrane of lysosomes into their interior and act as an alkalizing agent, which prevents the release of viral RNA into the cell, which may be a key element in therapeutic management. Memantine also reduces inflammation, mainly in the nervous system, but also acts as a lysosomotropic factor, inhibiting viral replication. However, it is important to bear in mind when undertaking amantadine or memantine therapy with side effects that may overlap with COVID- 19 symptoms, worsening the condition of patients. Currently, the effectiveness of amantadine and memantine in the treatment of patients with COVID-19 symptoms has been demonstrated in a few clinical trials, mainly in patients treated for neurodegenerative diseases. The obtained results are of considerable value, but require confirmation in further studies.

Carbon footprint of inhalers in COPD therapy in 2018 and 2019 in Poland in response to the Kigali amendment

The treatment of patients with obstructive airway diseases is based on the use of inhalation preparations. Some of them, mainly including pressurized metered dose inhalers (pMDIs), contain compressed gases - hydrofluoroalkanes, which generate carbon dioxide emissions, creating the so-called carbon footprint.

AIM

The aim of the study was to evaluate the consumption of individual active substances, the types of inhalers used and calculation of the carbon footprint of popular therapies in 2018 and 2019 in Poland.

MATERIALS AND METHODS

The ratio of pMDI vs DPI (dry powder inhaler) data and the data on using long-acting β2-agonists (LABAs), shortacting muscarinic antagonists (SAMAs), long-acting muscarinic antagonists (LAMAs), LAMA+LABAs, LAMA+LABA+ICSs (inhaled corticosteroids) on Polish market during 2018 and 2019 were analyzed. The carbon footprint of such therapies was counted. Then, we studied the reduction of the carbon footprint for scenario A (reducing pMDI by 50%) and scenario B (reducing pMDI by 80%) in the following steps of analysis.

RESULTS

The general structure of pMDI/DPI in Poland in COPD area was not changed in 2019 vs 2018. The carbon footprint is primarily created by pMDI SAMAs. In 2019 in Poland pMDI SAMAs were 1.6 mio units (the same as in 2018), which generated 33.5 kt CO2e annually, but the whole category generates 40.8 kt CO2e. Scenario A gives us a benefit of 18.8 kt CO2e reduction and scenario B brings us a benefit of 29.9 kt CO2e reduction of emissions.

CONCLUSIONS

Despite Poland's ratification the Kigali amendment did not affect pMDI consumption and did not reduce the carbon footprint. The lower carbon footprint of DPIs should be considered alongside other factors when choosing inhalation devices.

The actual threat of COVID-19

A pandemic (in Greek, pan "all", demos "people") is a term used to describe an epidemic of an infectious disease that causes significant mortality over a large area, including countries and continents. Could a virus currently spreading around the world that causes pseudoinfluenza symptoms be the basis for changing the criterion for determining a pandemic? According to WHO data from May 15, 2020, out of 153,517 confirmed COVID-19 cases, 5,735 deaths were recorded, allowing to determine the mortality rate at about 3.7%, which decreased significantly in the following months. The presented analysis from USA indicated that the elderly and those burdened with comorbidities are the most at risk groups, among them mainly those with cardiovascular diseases, diabetes, and chronic obstructive pulmonary disease. Similar data were obtained in Sweden, a country where no strict sanitary regimen was introduced, adopting the principle of creating herd immunity. On the other hand, Polish information is not corroborated by reliable studies, both in terms of the number and quality of diagnostic tests performed and the treatment used in individual groups infected with SARS-CoV-2 and patients. This leads to questioning the legitimacy of the introduced epidemiological restrictions. Wellknown mechanisms of SARS-CoV-2 infection and actions of basic drugs indicate the possibility of controlling the potential infection of the whole society.

Chloroquine in controlling biological infections

From the middle of the 17th century, Cinchona tree's bark, which contains quinine, was used as an anti-malarial agent. It wasn't until the midtwentieth century that chloroquine was synthesized, followed by its further derivatives. Chloroquine inhibits protozoan polymerase activity, leading to an increase in heme, which is toxic to Plasmodium. The sensitivity of the protozoan to chloroquine depends on its ability to accumulate the drug in aquatic vacuolas. The medicine is also directly toxic to protozoa of the genus Entamoeba histolytica. The immunomodulatory properties of chloroquine have led to its use in collagen diseases, rheumatic disease, chronic rheumatoid and ankylosing arthritis and autoimmune skin disease. Chloroquine has recently been shown to be effective in controlling infection caused by the new Corona virus 2019- nCov (SARS-CoV-2). The drug inhibits viral infectivity by increasing endosomal pH in cells and blocking virus-cell interference by glycosylating SARS-CoV-2 cell receptors. Chloroquine has been shown to be able to bind sialic acid and gangliosides effectively by blocking the combination of virus S protein with gangliosides, which prevents the infection from starting. The effectiveness of the drug in the first stage of infection by SARS-CoV-2 was confirmed in clinical observations and the drug was included in the developed therapeutic recommendations.

[Options for controlling new Corona virus infection - 2019-nCoV]

According to the Situation Report 65 of the World Health Organization of March 25, 2020, the COVID-19 incidence rate indicates 413 467 confirmed cases and 18 433 deaths. Genetic diversification of the Corona virus has resulted in strains that cause severe respiratory tract infections in humans via drip and animal mediation. S-proteins covering its surface, which bind to the cell receptor - angiotensin converting enzyme 2 (ACE-2) and transmembrane serine protease (TMPRSS2) are important in shaping virus activity. The course of infection varies from mild to severe. The ability to control infection is limited because there are no drugs that fully inhibit 2019-nCoV. Interferon-alpha (5 million U twice daily by inhalation), lopinavir/ritonavir (400/100 mg twice daily orally), as well as chloroquine (500 mg twice daily orally for 10 days) and azithromycin (500 mg twice per day) cause a milder course of the disease and reduce the duration of treatment. The administration of glucocorticosteroids and research drugs (tocilizumab) is acceptable for massive infiltrative lesions in the pulmonary parenchyma causing severe lung injury (ALI) and acute respiratory distress syndrome (ARDS). In the system operation it is necessary to create the socalled a safety matrix that would take into account the existing threat on the one hand and all available services and resources on the other. Precise analysis and separation of individual tasks can enable the creation of a real crisis management plan.

Azithromycin in the treatment of patients with exacerbation of chronic obstructive pulmonary disease

The beneficial effects of low dose azithromycin on reducing the number of exacerbations in patients with chronic obstructive pulmonary disease (COPD) have been the subject of many clinical studies. Long-term administration of low dose azithromycin is known to suppress proinflammatory cytokine production, potentiate macrophage phagocytosis and anti-inflammatory cytokine expression. The effect of azithromycin is also associated with a decrease in the expression of human HLA (human leukocyte antigen) complex molecules in the respiratory tract, including HLA-A, HLA-B, HLA-DPA1, HLA-DRA, HLA-DRB4. In contrast, inhibition of viral infections by azithromycin is caused by a suppressive effect on the production of viral interferon. In the COLUMBUS study conducted in 92 COPD patients with frequent exacerbations who were given azithromycin for a year, inflammatory markers, eosinophilia, and GOLD severity were analyzed. It was found that the antibiotic therapy was most effective in patients with COPD with frequent exacerbations in GOLD 1 and 2 and GOLD C, as well as in patients with blood eosinophilia over 2%. An analysis of the costs of prophylactic administration of chronic azithromycin in patients with COPD in Belgium showed that the cost would be EUR 595 million, saving EUR 950 million for the treatment of COPD exacerbations. According to the recommendations in GOLD2020, azithromycin (250 mg or 500 mg daily three times a week) for 1 year in COPD patients significantly reduces the number of exacerbations.

Post-traumatic bilateral scapular and thoracic vertebral body fractures - a case report

The simultaneous fracture of both scapulae with coexisting fracture of the thoracic vertebral body is observed extremely rarely and is fully dependent on the mechanism that caused them.

A CASE REPORT

The 59-year-old patient was admitted to the trauma and orthopedic department because of back pain and the inability to move independently. A few hours earlier he suffered bludgeoning trauma from a thick branch falling from a tree. During the physical examination significant limitation the range of motion in shoulder joints with was found. <15 ° flexion and <30 ° abduction, with limited external rotation in the right shoulder joint, and <15 ° flexion and <15 ° abduction, with significant external rotation deficiency. Normal range of motion in both hands was preserved. No sensory deficits or paresis were observed. Radiographic examination revealed the presence of a multifragmentary fracture of both scapulae and a fracture of the Th9 vertebral body, which was confirmed by computed tomography of the chest. The patient was qualified for conservative treatment of scapular fractures and was fitted with an abduction splint for the left shoulder. The Th9 vertebral body required surgical approach. The patient underwent transpedicular stabilization of the Th7,8,9,10 vertebrae with precontoured rods for the kyphotic deformation of the spine. After the procedure, the patient was provided with Javette's brace strengthening the spine correction and discharged for further outpatient observation.

CONCLUSIONS

Fracture of the scapula is one of the most demanding fractures to diagnose in the classic radiological examination. CT scans with 3D reconstruction can be considered to be the "gold standard". Surgical procedures is indicated for patients with severe comminution of fracture fragments and neurological symptoms. Minor fracture displacements can be conservatively treated. Coexisting Th9 vertebra fracture in this case required surgery by posterior transpedicular stabilization.

[The importance of biofilm in the context of increasing bacterial resistance to antibiotics]

Biofilm is a form of bacterial life in extreme environmental conditions. The known structure and functions of biofilm indicate that it is one of the most widespread and most successful life forms on earth. The quorum sensing (QS) system plays a key role in biofilm because it is a mechanism by which bacteria regulate the gene expression profile according to the size of the microbial population, causing the formation of different forms of biofilm. The QS includes the auto-inducer-1 (AI- 1) system, which uses N-acyl-homoserine lactones as a signaling factor in the formation of biofilm by Acinetobacter baumannii and Pseudomonas aeruginosa, and the auto-inducer-2 (AI-2) system identified as furanosyl borate diester present in Gram-positive and Gram-negative bacteria. Antimicrobial proteins (AMPs) have a natural antibacterial effect, which are produced by eukaryocytes and prokaryocytes, and have the ability to form pores in the bacterial cell membrane or interfere with its function. On the other hand, biofilm degrading enzymes - DNase I, alpha-amylase and dispersin B - reduce the weight of exopolysaccharides (EPS) and the number of cells in the biofilm. Natural compounds that inhibit the formation of bacterial biofilm have been distinguished, so-called QS inhibitors (QSI) and which "quench" active process (QSQ). In turn, genetic diversification of microorganisms in biofilm is largely responsible for shaping antibiotic resistance. The combined use of antibiotics with nanoparticles seems to be the most promising therapeutic option for bacterial biofilm. Silver nanoparticles with citrate in combination with aztreonam have been shown to have significant biofilm-destroying efficacy for Pseudomonas aeruginosa, and selenium nanoparticles used together with ampicillin, oxacillin and penicillin in 94% inhibited and interrupted the MRSA (methicillin-resistent) biofilm. Research on biofilm control is very advanced and will soon be subject to clinical evaluation.

Finegoldia magna the cause of hip revision surgery - a two case report

The cause of septic arthritis in 20% of cases is anaerobic bacteria, including infections caused by Finegoldia magna. The occurrence of this pathogen in the etiology of postoperative post-implantive septic joint inflammations is estimated at 5-12% of all anaerobic infections, and 20-40% of all gram-positive anaerobic coccus (GPAC).

CASE REPORTS

The 65-year-old male patient was admitted due to symptoms of pain in the left hip after having undergone arthroplasty three years prior. It was found that the relative length of the left lower limb was shortened by 1.5 cm and there was limited mobility of the left hip joint. The radiological image of the left hip indicated the loosening of the endoprosthesis, which qualified for a revision surgery. During hip revision surgery, the material was collected from the site, for microbiological examination, in which Finegoldia magna was detected, sensitive to Amoxicillin with Clavulanic acid, Clindamycin, Chloramphenicol, Imipenem, Metronidazole and Piperacillin with Tazobactam. Based upon the antibiogram, the patient was given piperacillin with tazobactam (Tazocin, Pfizer) 4 times a day 4.5 g intravenously over 7 days, resulting in a clinical improvement. The 55-year-old female patient was admitted due to recurrent exudates in left trochlear bursa which arose 5 years after left hip arthroplasty. The patient had limited movements in the left hip. Ulrasound diagnostics showed a presence of a thick fluid reservoir located under the fascia in the lateral side of the left thigh measuring 160 x 42 x 25 mm, which had contact with the hip joint. In the radiographic image of the joint, a cyst around the bottom of the implanted acetabular component was revealed. The patient underwent hip revision surgery, and an anaerobic bacterium Finegoldia magna was isolated from a swab taken from the acetabulum. The patient was given piperacillin with tazobactam (Tazocin, Pfizer) 4 times a day 4.5 g intravenously over 7 days, with good clinical effect.

CONCLUSIONS

In both cases, the post-implantation septic infection was triggered by Finegoldia magna. Arthroplasty with subsequent antibiotic therapy resulted in an improvement of the patients' condition and joint reconstruction. In orthopedic practice it should be noted that infections due to the anaerobic bacteria Finegoldia magna may be the cause of complications after the arthroplasty of the joints.

[The growing resistance of bacterial strains to antibiotics]

Understanding the mechanisms of bacterial resistance to antibiotics made it possible to divide this phenomenon into natural and acquired resistance. The natural resistance of the bacteria is related to the lack of antibiotic ability to penetrate into the interior of the bacteria and limit the ability of penetration through the cell wall, as well as the poor affinity of the drug for the receptor or the lack of such a receptor. The acquired bacterial resistance is related to the changes occurring within the resistance genes and their rapid transfer, in which plasmids participate. The single- and multistage mutations of TEM (temoneira), SHV (sulfhydryl variable) and CTX-M (cefotaximase) lead to ESBL (extended-spectrum beta-lactamase) resistance. The main mechanisms responsible for shaping bacterial resistance to antibiotics are intracellular transformations determining internal resistance, acquisition of resistance in the process of mutation or transfer of horizontal resistance genes, and adaptive resistance, which is defined as a transient increase in resistance due to gene induction by the antibiotic itself, e.g. as a result of interaction with an antibiotic. Observed increasing resistance of bacteria to antibiotics is associated with their abuse without reasonable indications and with extensive use in veterinary and food industry. In Europe, about 25,000 people die every year due to antibiotic-resistant infections, which involves costs - about 1.5 billion euros a year.

[Pathogenetic conditions of treatment of infections caused by antibiotic-resistant strains Klebsiella pneumoniae]

Klebsiella pneumoniae belongs to the Enterobacteriaceae family and is responsible for 70% of human infections. From 20 to 80% strains of Klebsiella pneumoniae reveal resistance to first line antibiotics, including cephalosporins, fluoroquinolones and aminoglycosides, as well as carbapenems. Due to the resistance found in MDR (multidrug resistant) Klebsiella pneumoniae is classified according to the sequence types (ST), which are defined on the basis of the nucleotide sequence in the 7 loci (mdh, infB, tonB, gapA, phoE, pgi, and rpoB). Klebsiella pneumoniae uses several methods to protect against the effects of the human immune system. It affects receptors that recognize patterns expressed on epithelial cells and the immune system that are responsible for initiating signal cascades and phagocytic influences, including Toll-like receptors (TLRs) 2 and 4. Activates interleukins (IL) 12 (IL-12) and IL-23p40 by natural stimulation and leads to a decrease in the level of activation of interferon gamma (IFN-γ), IL-17, tumor necrosis factor (TNF-α) and IL-1β, resulting in neutrophil and macrophage inflow and induction of humoral and cellular responses. Capsular polysaccharides and other components of the bacterial cell membrane protect it from the natural mechanisms of resistance, making it resistant to beta-defensins against bacteria. Increased virulence of Klebsiella pneumoniae is related to the protein structure associated with the capsule, especially in strains with increased virulence (HV - hypervirulent), lipopolysaccharides (LPS), siderophores and cilia (fimbriae). Today, two main types of Klebsiella pneumoniae strains are distinguished depending on the mechanism of resistance to antibiotics: strains that express beta-lactamases with extended spectrum (ESBL - extended spectrum beta-lactamases) that are resistant to cephalosporins and monobactams and strains that reveal the expression of carbapenemases, which they show resistance to available beta-lactams, including carbapenes. Polymyxins are useful in the treatment of patients infected with Klebsiella pneumoniae NDM (New Delhi metallo-beta-lactamase), where the effectiveness of therapy is greater when colistin is used together with carbapenem or rifampicin or tigecycline. The introduced abivactam in combination with ceftazidime is a promising therapeutic combination in severe infections. Similar clinical assessments were obtained with sulbactam, especially in combination with meropenem and colistin.

[A "new" look at "old" borreliosis]

The threat of borreliosis is a growing medical problem. The number of cases is constantly increasing, and the diagnostic methods and recommended treatment methods do not bring new values in comparison to the findings from over 30 years ago. Among the pathogens transmitted by ticks, apart from Borrelia burgdorferi, Anaplasma phagocytophilum, Babesia species, Neoehrlichia mikurensis, as well as fever caused by rickettsiae and others, are referred to as "emerging" or "rediscovered". Recently published new recommendations for the diagnosis and treatment of Lyme disease developed by specialists from the National Institute for Health and Care Excellence (NICE) in the United Kingdom did not bring significant changes to the existing recommendations for the diagnosis and treatment of patients with borreliosis. This study does not provide information about vaccine research, which, it turned out, was introduced in the 1990s and withdrawn from the market. Research is currently under wal into an anti-tick "vaccine" undertaken by the team under the EU project "ANTIDOTE" (Anti-tick Vaccines to Prevent Tick-borne Diseases in Europe). The first effects of the research are already presented, but we still have to wait for the final product.

[Stem cells in contemporary medicine]

Stem cells are characterized by remarkable plasticity and the ability to differentiate into other types of cells. They are obtained from bone marrow (BMSCs - bone marrow-derived stem cells), from adipose tissue (ADSCs), from joint tissue (SMSCs - synovium-derived stem cells), umbilical cord blood (UCMSCs - umbilical cord stem cells) MSCs), as well as other tissues and organs. Stem cells secrete biologically active factors with immunomodulatory and angiogenic properties, and also suppress leukocyte activity, which actively participate in the atherosclerotic process. This justifies their use in the repair treatment of damaged myocardium. The effectiveness of stem cell administration was also demonstrated in the first stage of septic shock and in patients with ARDS. The treatment of stem cell transplantation to the nucleus pulposus of the intervertebral disc, knee and hip joint in progressive inflammatory lesions, creates new opportunities for patients who are permanently disabled.

[New antibiotics in infection treatment]

The introduction of new molecules with antimicrobial activity is an opportunity for modern antibiotic therapy in the era of rapidly growing resistance to antibiotics. Beta-lactamase-inhibiting antibiotics, cephalosporinases and carbapenemases represent a breakthrough in previous treatments for infections caused by resistant pathogens. Ceftazidime with avibactam and ceftolozane with tazobactam show exceptional efficacy in severe infections. Karbavans is a combination of meropenem and a new boron beta-lactamase inhibitor, as well as the combination of avibactam and aztreonam, are a hope for the treatment of infections caused by Klebsiella pneumoniae resistant to the majority of available antibiotics. S649266 is itself an inhibitor of beta-lactamases. Plazomycin, in turn, is a new aminoglycoside that allows the control of severe bacterial infections caused by multiresistant Enterobacteriaceae, including those resistant to carbapenems. In contrast, omadacyclin, a semi-synthetic derivative of tetracycline, has activity against Gram-positive, Gram-negative, aerobic and anaerobic as well as atypical bacteria. Solithromycin, a new ketolide, has immunomodulatory effects and a broad antiinflammatory spectrum, with no side effects caused by older generations of macrolides. New fluoroquinolones (delafloxacin, zabofloxacin, finefloxacin, nemonoxacin, zoliflodacin) show a wide spectrum of action with less and less side effects. The new MRX-1 preapplate, alongside tedizolid and cadazolid, are further oxazolidinones that show significant activity against multi-resistant Gram-positive pathogens. The presented palette of new molecules with antimicrobial activity will certainly significantly improve the effectiveness of antibiotic therapy.

[Safety of e-cigarettes]

Electronic cigarettes (vaping) make a booming career around the world. They were introduced as an alternative to tobacco cigarettes, the harmfulness of which has been repeatedly documented. After a dozen or so years of their application, however, there are doubts about their full safety. In conducted studies, it has been shown that e-cigarettes contain a number of toxic compounds, the action of which on the human body is harmful. In vitro studies have demonstrated direct cytotoxic effects of e-cigarettes on human and mouse stem cells. The observed changes in the value of spirometric parameters during the using e-cigarettes also require verification of current views in this respect. The WHO report on "vaping" recommends considering a ban on the legal use of e-cigarettes in public closed places, and the International Agency for Research on Cancer indicates carcinogenic harmfulness of "vaping".

[Differentiation of dyspnea in patients with asthma and lung sarcoidosis]

Dyspnea as a subjective feeling of lack of air is the patients with the pathology of the respiratory system. Objectivization of this phenomenon is difficult, despite the introduction of questionnaires about the degree of dyspnoea. The results of these assessments do not always correlate with the results of spirometric tests. In patients with asthma, dyspnoea is caused by airway obstruction. In the case of patients with lung sarcoidosis, the complexity of the phenomenon causes that many mechanisms and factors are responsible for the dyspnea symptoms in these patients. Dyspnea in patients with sarcoidosis is progressive and is closely related to the extent of interstitial exchanges. The diffusion capacity for carbon monoxide (DLco) determined in these patients reflects the degree of respiratory distress. Therapeutic procedures are also dependent on this parameter.

[Advances in differential diagnosis and treatment of patients with sarcoidosis]

The implementation of treatment in patients with sarcoidosis (SA) must be associated with the certainty of diagnosis, which is difficult due to the lack of unambiguous criteria. Finding the presence of noncaseating granulomas in bioptic material is not always indicative of SA. The main point of SA's diagnosis is the level of its activity, because only patients in the active stage should be qualified for treatment. In therapy, glucocorticosteroids or second-line drugs - methotrexate or azathioprine are still recommended. Introduced monoclonal antibodies (infliximab, etanercept, adaluimumab, golimumab, rituximab), tested for efficacy in other pathologies associated with the formation of granulomas, have a limited application in patients with SA. In contrast, anti-fibrotics (pirfenidone and nintedanib) are in clinical trials. The latest method of controlling the fibrosis of the parenchyma in the course of SA is the use of mesenchymal cells obtained from umbilical cord blood. Preliminary results indicate a real possibility of using this therapy in patients with SA.

[The risk of perioperative infections after orthopedic surgery]

Perioperative infections after orthopedic surgery are complications that extend the process of treatment and rehabilitation of patients. The multifactor mechanism of their formation has already been defined, which allows effective control of the threat. In addition to the introduction of ever safer surgical techniques, strict epidemic surveillance and acceptable by the body implanted materials, widely prophylactic perioperative antibiotic therapy is applied. The effects of this action are demonstrated in available clinical analyzes, which indicate a reduction in the scale of the threat. When using antibiotics, pay attention to their spectrum of activity and penetrations to the place of the ongoing inflammatory process. On the basis of these parameters, the dose, time and route of administration should be set so that the prophylaxis is fully effective.

[Abscesses in the lumbo-sacral spine area - a case report]

Infection of the surgical operation site is found in approximately 3% of patients and 20% of patients undergoing urgent surgery. The occurrence of this type of complications is affected both by coexisting diseases and the presence of infection in the environment in which the patient is staying. It should also be taken into account that the bacteria found in the implanted material and surrounding tissues have the ability to adhere to the implant, creating a biofilm structure there. The presented patient is an illustration of such a problem, because after L5 laminectomy and extensive L2-L3 and L3-L4 one-sided fenestration and L2-L3-L4-L5 facetectomy, interbody bone arthrodesis and transpedicular stabilization, he reported for fever and pain in right lumbar area. In the patient, the presence of inflammatory infiltrate in the lumbar region of the lumbar tissues was found in imaging studies, with fluid reservoirs that surrounded pedicle screws and spinous processes, as well as abscesses and inflammatory changes in the spinal canal at the L4-L5 level. Empirical antibiotic therapy was ordered and decision about surgical treatment was made. A large amount of purulent and odorous secretion was evacuated at the site of previously performed laminectomy. In the postoperative period, targeted antibiotic therapy was applied based on the culture result obtained from the surgical site. The culture showed Staphylococcus aureus MSSA (methicillin-susceptible S. aureus) which was sensitive to the majority of antibiotics tested. The low effectiveness of this treatment caused the necessity to broaden the research, blood culture revealed Turicella otitidis, which was sensitive to gentamycin, vancomycin, linezolid and rifampicin. The applied rifampicin caused improvement of the patient's condition and the possibility of starting motor rehabilitation. The described case indicates real difficulties in the treatment of post-operative infections, despite invasive procedures and antibiotic therapy.

[Bronchipret TE® in therapy of acute infections of the respiratory tract]

Bronchipret TE® exhibits multidirectional anti-inflammatory effects as demonstrated in vitro and in vivo studies. It has been disclosed that the drug has the ability to activate the bronchial cleaning mechanism, inhibit the respiratory tract remodeling process by reducing the number of goblet cells, inhibiting enzyme activity and proinflammatory mediators. These mechanisms cause the administration of medication to cause acute bronchitis patients to shorten and alleviate the course of the disease with rapid cough elimination. Use of Bronchipret TE® is in accordance with the recommendations of the European Guideline Committee's and the German Respiratory Society.

[Actual guidelines of borreliosis treatment]

The treatment of patients infected with Borrelia burgdorferi was the subject of studies by numerous experts. The discrepancy of the recommendations is quite significant, especially in the choice of antibiotic, which is most important in the first stage of infection. The recommended doxycycline is in all recommendations although its MIC90 is 2.0 mg/L. Other antibiotics have better parameters, especially azithromycin topically administered in the first stage of infection, can be fully effective. In addition to the morphological and immunological variability of Borrelia burgdorferi, antibiotics that have an ability to enter the cell, such as azithromycin, should be noted. The combination of antibiotic treatment with inflammatory control in neuroboreal disorders seems reasonable. New therapies for Lyme disease provide a real chance of controlling infection.

[Clinical pictures of borreliosis]

Lyme disease occurs in a variety of clinical manifestations, ranging from skin lesions, through musculoskeletal, neurological, and cardiac syndrome, to severe irreversible lesions. Borrelia burgdorferi's organotropy has an impact on the development of the disease. In initial management, it is important to implement effective treatment to prevent further progression of infection. Dominant skin lesions should be differentiated in detail. In the form of disseminated disease complex of clinical syndromes is observed but it requires of confirmation in immunoassays. A particular difficulty in the management of the posttreatment Lyme borreliosis syndrome is when a severe disease of the organ is present. Symptoms appear after months or years after antibiotic therapy in 10-20% of patients. In patients with a syndrome, a clinical picture may develop as an autoimmune response that has developed after active infection and effective treatment that could have eradicated the causative agent. It has also been shown that the presence of persistent inactive microorganisms after antibiotic treatment can trigger local symptoms. The complexity of the clinical picture of Lyme disease requires a reliable diagnosis and a wide variety of pathologies.

[Morphological and immunological variation of Borrelia burgdorferi and diagnostic methods]

Diagnostic problems observed in patients infected with Borrelia burgdorferi are a significant impediment to therapeutic decision making. It appears that the pathogen is characterized by morphological and immunological variation in particular stages of development. The bacterium has the ability to morphologically transform into a cell wall deficient form of spheroplast, L-form, bleb-like spirochetes and round body/form cysts. It also has the ability to create biofilm, which is a major barrier to antibiotics. Bacteria are characterized by significant heterogeneity and antigen polymorphism, which greatly hampers the detailed definition of the pathogen, since the antibodies produced may differ significantly from the accepted patterns and also lead to cross reactions. The above conditions affect the reliability of diagnostic tests, especially screening, which may lead to wrong therapeutic decisions.

[Evaluation of effect of indacaterol (Onbrez) and/or glycopyrronium (Seebri) treatment on Quality of Life of COPD patients in medical practice in Poland - observational study (OSQO)]

Indacaterol, as well glycopyronium has been reimbursed lately in Poland, so patients have a greater access to this treatment in medical practice. Physicians do not realize the potential benefit of once daily ultra-LABA indacaterol and/or modern LAMA with fast-acting glycopyrronium on treatment results.

AIM

The aim of the study was to evaluate the impact of routinely administered treatment with either indacaterol (Onbrez) or glycopyrronium (Seebri) or both on patient reported outcomes in form of the health status (CCQ score - clinical COPD questionnaire) and level of dyspnoea (mMRC - modified Medical Research Council) in treatment naive COPD patients after the change of treatment as addon from any other COPD treatment in "real life" settings.

MATERIALS AND METHODS

This study was designed as an observational, non-interventional and multicenter project in COPD patients being treated with Onbrez and/or Seebri in 32 medical centers in Poland. The observation period covered 6 months from the first taking of Onbrez and/or Seebri. No diagnostic or monitoring or treatment procedures have been applied to the patients, other than those which are applied in the course of standard, current practice. The total number of enrolled patients was 633. Because of inability of verification the medical records or failure to meet data collection requirements 587 patients enrolled to the registry has been evaluated. Within this number of patients 171 had delayed the time of visits or they had not second visit. Due to therapy change additional 20 patients has been withdrawn. 396 patients were taken for the final analysis.

RESULTS

Improvement of mMRC and CCQ scores was observed in all treatment groups e.g. indacaterol solely, glycopyrronium solely and combination therapy of indacaterol and glypyrronium.

CONCLUSIONS

The study revealed that the best results can be achieved with combination therapy accordingly with clinical recommendation for COPD treatment (GOLD). The results have been achieved in the real world settings, showing that this treatment may be used in daily routine practice by general practitioners.

[History of the study, epidemiology of the disease and characterization of Borrelia burgdorferi infection]

From the beginning of the twentieth century interest in tick-borne borreliosis continues to be an important diagnostic and therapeutic problem. In 1977, in Lyme and Old Lyme, Cunnecticut, in the United States, arthritis and skin lesions were described in 12 children, which were associated with tick bites. The name of the place was called a syndrome of Lyme disease. Dr Willy Burgdorfer observed microaerophilic Gram-negative bacteria (Spirochetes) with a diameter of 0.3-0.5 µm and a length of about 20-30 µm, which were isolated from the tick colon. Lyme disease (borreliosis) is the most common tick-borne disease in the world. In Poland, most cases of Lyme disease occur between May and November, and more than 80% of cases are found in June and July during the nymph ticks feeding. The northern part of the country is considered endemic. The reservoir of bacteria is about 300 different species of mammals. These are mainly rodents of the norovirus and mouse family, and live deer, deer and wolves, as well as some species of birds. Ticks are infected with Borelia burgdorferi through the blood of infected animals. However, adult ticks are infested with Lyme spirochetes, depending on the region of the country. It infects 5-20% nymph and 15-40% adult individuals. The sequence of the Lyme disease spirochetes reveals a number of interesting traits. Classical virulence factors have not been isolated and therefore it is suspected that the vertebrate does not contain it in relation to mammals. However, a number of lipoproteins have been defined and some of them may be factors contributing to the innate immune system.

[Butamirate citrate in control of cough in respiratory tract inflammation]

Cough is the reflex defense response of the respiratory tract to the present secretions in the throat, trachea and bronchi, and ongoing inflammation in the mucous membranes of the upper and lower respiratory tract. From a practical point of view, cough is dry (unproductive) and productive cough with expulsion of significant amounts of secretion. Drugs used to treat cough differ in both mechanism of action and pharmacokinetic activity. Butamirate citrate belongs to a new class of cough suppressants acting centrally through the receptors in the brainstem. In addition, it has a very beneficial effect, because it reduces the resistance in the airways by inhibiting bronchospasm and anti-inflammatory effect. It is rapidly absorbed after oral administration and its therapeutic plasma concentration is determined after 5-10 minutes of administration, irrespective of the dose. Possible side effects are rarely seen in 0.5-1% of patients, mainly in the form of skin rash, nausea, diarrhea, dizziness, which usually resolves during treatment. The cough effect of most cough suppressants is good, but their mechanisms are different and for that reason they should be individually selected. An important asset of this group of drugs is peripheral activity and effects on bronchodilator muscles, such as in the case of butamirate. Inclusion of this feature is particularly beneficial in chronic inflammatory bronchial diseases.

[Stem/progenitor cells in diseases of the respiratory tract]

Stem cells (SCs - stem cells) are characterized by plasticity and the ability to differentiate into other cell types. They are obtained from bone marrow, peripheral blood and cord blood. Mesenchymal stem cells (MSCs) shows a broad immunomodulating, increases the number of regulatory T cells (Treg), modifies the activity of T cells, dendritic cells and NK (natural killer). Direct impact on reducing the release of proinflammatory cytokines and increased release of proinflammatory cytokines. Within the respiratory tract has a number of resident stem and progenitor cells referred to as L-MSCs (lung mesenchymal stem cells) whose presence was confirmed by markers as defined in the trachea, epithelial cells and alveolar. Demonstrated the efficacy of MSCs administration in the first stage of septic shock and acute respiratory distress syndrome (ARDS - acute respiratory distress syndrome). There was a significant stimulation of repair processes, along with an improvement in lung function. Embryonic stem cells (ESCs - embryonic stem cells) are the latest addition in the treatment of congenital and acquired diseases of the airways and lung parenchyma. In patients with sarcoidosis MSCs are obtained from umbilical cord blood (PDA - placenta-derived mesenchymal-like cells) with phenotype CD34 +, CD10 +, CD105 + and CD200 +. The results of this therapy are very encouraging, and for this reason it is taken in subsequent research centers.

[New bronchodilation treatment options for patients with COPD]

The main aim of treatment of patients with symptoms of airway obstruction is to improve their quality of life by reducing or removing the main symptoms. To get this effect, you must be able to control the bronchial smooth muscle. This is becoming more possible by the introduction of new inhaled particles, which acting Β2-adrenergic receptors or muscarinic receptors dilate bronchial lumen. New drugs to control Β2-adrenergic receptors exhibit a long duration of action - LABA (long-acting beta-agonist), for example indacaterol, vilanterol or olodaterol can be used once a day, because their action exceeds 24 hours. Similarly, new anticholinergic particles - LAMA (long-acting muscarinic antagonist), for example. tiotropium, glycopyrronium, aclidinium, umeclidinium - also exert their activity by 12-24 hours. Combined preparates LAMA-LABA represent a further significant advance in the treatment, as provided in this form tend to perform better than used alone. In turn, the new bi-functional molecule (dual pharmacophore), which discloses a dual effect by bronchodilating effects by antagonists at muscarinic receptors and agonists at Β2- adrenergic receptors, was described as MABA (muscarinic antagonist and Β2 agonist). The complementary nature of the two receptors was used in construction of this particle. It is expected that the introduction of this new therapy will allow more effective control of airflow obstruction in patients with COPD.

[Pathogenesis, diagnosis and treatment of chronic obstructive pulmonary disease in the light of new research]

Accurate number of patients with chronic obtructive pulmonary disease (COPD) is difficult to determine, both in Poland and in the world. Quoted estimates and fragmented with the research indicate that approx. 10% of the world's population may be burdened by this disease. As it turns out, COPD is recognized in 25-45% in non-smokers, suggesting a genetic link. This is confirmed by new data that indicates that further embodiments having genetic polymorphisms associated with the occurrence of the disease. It was further found that the allele GC-1F vitamin D were risk factor for development of COPD. It is emphasized that respiratory epithelial cells directly responsible for the response to inhaled agents. Attention was also drawn to the role of eosinophiles. It has been shown that in patients with COPD with the dominant of eosinophilic faction glucocorticoids work very efficiently, indicating the validity of the division to "responders" and "non-responders" for treatment. As a new biomarker for COPD is proposed irisin, released from skeletal myocytes, which is beneficial to exercise tolerance in patients with COPD.

[Rating criteria for selection of an inhaler and instructing its use in patients with asthma and COPD]

The clinical efficacy of inhaled therapy in patients with asthma and COPD is dependent on the choice of inhaler and proper use of it. The need to instruct patients in the use of the recommended inhaler seems obvious, but in clinical practice is not always followed.

AIM

The aim of the study was the comparative evaluation of the selection criteria and the method of instructing in operating the device in asthma and COPD patients.

MATERIALS AND METHODS

The study was conducted in 80 patients with asthma and COPD in 9 European countries: France, Germany, Italy, Spain, Great Britain, Holland, Belgium, Denmark, Sweden. Patients (asthma / COPD) - 10 from each country - aged 18-65 years were diagnosed by a physician for asthma (2/3 patients) and COPD (1/3 patients) at least one year ago. The study involved using Symbicort Turbuhaler (8 patients in each country) or Seretide Accuhaler (2 in each country, 3 patients in the Netherlands). Evaluated the criteria for selecting the inhaler and the time and place of transfer of information technology inhalation.

RESULTS

It has been shown that the main criterion for choosing an inhaler by a doctor was the construction of an inhaler and size of particles generated by it. More than 1/3 of the patients did not receive information about how to use the inhaler. In turn, granted briefing in most lasts less than 5 minutes.

CONCLUSIONS

In the selection of the inhaler taken into account in the construction and the ability to generate particles of the expected size. Informing patients about how to use the inhaler it is considered marginal in most of the resorts in Europe.

Progenitor cells in sarcoidosis

Sarcoidosis is a systemic disease of unknown initiating factor. In the pathogenesis of the disease it emphasizes the importance of genetic factors, specificity of inflammation and toll-like receptors. No less important cell in the development of lesions is fibrocyte, which creates the final image of the disease in the form of fibrosis of the lung parenchyma. Data from experimental and clinical studies indicate that the progenitor cell can turn into fibrocyte. This indicates the possibility of controlling the process, which is already implemented in practice in Lung Institute in Pittsburgh, USA. The results of these new therapies are encouraging and suggest a new way to treat patients with pulmonary pathology, including sarcoidosis.

[Zika virus as a new threat to the health and life]

The newly emerging pathogens are increasingly becoming a threat to health and life, as the cause of epidemic infections. In the last three years there were outbreaks caused by Zika virus, which was transmitted by mosquitoes mainly from the region of South America. However, reports WHO and CDC indicate that infection has now reached to most countries of the world, including European countries. The clinical picture of what is observed during the infection is not very distinctive, because apart from febrile states, and pain syndrome, including retrobulbar pain syndrome in the acute phase there are no other symptoms. The problem is especially severe neurological complications in the form of Guillain-Barre syndrome and other neurological disorders, as well as microcephaly had been found in newborns of mothers infected with the virus Zika. Treatment of infected patients boils down to symptomatic, because there is no vaccine or drugs to inhibit the replication of the virus. Underway while work on genetically modified mosquitoes to their offspring quickly wasting away. As part of the preventive measures recommended to bypass areas where the density of mosquitoes is particularly dangerous.

[Shiga toxin and tetanus toxin as a potential biologic weapon]

Toxins produced by the bacteria are of particular interest as potential cargo combat possible for use in a terrorist attack or war. Shiga toxin is usually produced by shiga toxigenic strains of Escherichia coli (STEC - shigatoxigenic Escherichia coli). To infection occurs mostly after eating contaminated beef. Clinical syndromes associated with Shiga toxin diarrhea, hemorrhagic colitis, hemolytic uremic syndrome (HUS - hemolytic uremic syndrome) or thrombotic thrombocytopenic purpura. Treatment is symptomatic. In HUS, in which mortality during an epidemic reaches 20%, extending the kidney injury dialysis may be necessary. Exposure to tetanus toxin produced by Clostridium tetani, resulting in the most generalized tetanus, characterized by increased muscle tension and painful contractions of individual muscle groups. In the treatment beyond symptomatic behavior (among others spasticity medications, anticonvulsants, muscle relaxants) is used tetanus antitoxin and antibiotics (metronidazole choice). A common complication is acute respiratory failure - then it is necessary to implement mechanical ventilation.

[Damage of the lungs after exposure to obscurant smoke - a case report]

Firing smoke candle, on reaction of pyrotechnic mixture of zinc oxide and hexachloroethane, releases of white smoke, which can damage the pulmonary parenchyma. Presented case illustrates the effects of such an inhalation injury that has led to acute respiratory distress syndrome (ARDS). The use of mechanical ventilation and administration of antibiotics and corticosteroids give the possibility to obtain clinical improvement. The resulting changes in the lung parenchyma shown on imaging studies resulted in significant impairment of breathing.

[The threat of snake and scorpion venoms]

Venoms of snakes and scorpions pose a significant threat to the health and life of humans. The speed and range of their actions causes damage of the organ responsible for the maintenance of vital signs. Venomous snake venoms cause blood clotting disorders, tissue necrosis and hemolysis, and the release of a number of proinflammatory cytokines and impair antibody synthesis. Availability of antitoxins is limited and in the most cases supportive treatment is recommended. In turn, the venom of scorpions beside intestinal symptoms cause significant impairment of neuromuscular conduction, causing severe respiratory disorders. Action venom poses a particular threat to sensitive patients. The degree of threat to life caused by the venom of snakes and scorpions authorizes the treatment of these substances as a potential biological weapon.

[Today's threat of use of organophosphorus compounds]

Organophosphates are stable cholinesterases inhibitors (AChE). Inhibition of AChE activity leads to the accumulation of large amounts of acetylcholine and hyperactivity of the cholinergic system by stimulating acetylcholine receptors - muscarinic and nicotinic. This group included tabun, sarin, soman and VX gases. Exposure to gaseous form causes symptoms within a few seconds of exposure. This depends on the gas concentration in the atmosphere. The most sensitive organ is the eyes and the respiratory system. Severe poisoning are characterized by the immediate loss of consciousness with convulsions. Therapeutic management of acute poisoning organophosphorus compounds boils down to treating symptomatic and supportive vital functions. Monitoring of cardiovascular, respiratory and renal failure in intensive care gives only guarantee the effective treatment of poisoning. Properties toxic organophosphorus compounds also are of interest to terrorist groups.

[Today's threat of ricin toxin]

Since the late 70s of the last century there were more than 700 incidents related to the use of the ricin toxin. For this reason, CDC (Center of Disease Control and Prevention) recognized toxin as a biological weapon category B. The lethal dose of ricin toxin after parenteral administration is 0.0001 mg/kg and after oral administration 0.2 mg. The first symptoms of poisoning occur within a few hours after application of toxin as a nausea, vomiting and abdominal pain. In the final stage there are observed: cardiac arrhythmia, collapse and symptoms suggestive of involvement of the central nervous system. Stage immediately preceding death is a state of coma. The ricin toxin is still the substance against which action has no optimal antidote. Developed a vaccine called RiVax is waiting for its registration. It should be pointed out that the availability of a ricin toxin makes it possible to use it for real bioterrorists.

[Toxins as a biological weapon]

The criteria for recognizing a chemical compound for the toxin are vague and gave it the possibility of inclusion in this group a number of biological agents. Toxins list is extensive, but the interest is focused on bacterial toxins, poisons derived from snake venoms, algae and plant proteins, and small molecules. Particular attention is focused on the so-called "sea" toxins, which include tetrodotoxin, brevetoxin and saxitoxin. This indicates the search for a new hitherto unknown potential bioterrorist threats.