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ACTA<br />

MEDICA<br />

MARTINIANA<br />

JESSENII FACULTAS MEDICA MARTINENSIS<br />

Universitatis Comenianae<br />

ISSN 1335 - 8421<br />

Journal for Biomedical Sciences,<br />

Clinical Medicine and Nursing<br />

2011<br />

11/1<br />

ISSN 1339 - 4139 (online)


Moderné vzdelávanie pre vedomostnú spoločnosť/Projekt je spolufinancovaný zo zdrojov EÚ<br />

Modern education for modern society/Project is co-financed from EU sources<br />

Vydanie ACTA MEDICA MARTINIANA 11/01<br />

bolo podporené projektom<br />

Podpora rozvoja ľudských zdrojov<br />

s využitím najmodernejších postupov<br />

a foriem vzdelávania na JLF UK v Martine<br />

spolufinancovaným zo zdrojov EÚ<br />

a Európskeho sociálneho fondu.<br />

Publishing of <strong>Acta</strong> <strong>Medica</strong> <strong>Martiniana</strong> 11/01<br />

was supported by project<br />

„Support of human resources development<br />

using the most modern methods<br />

and forms of education at JLF UK in Martin“<br />

co-financed from EU sources and European Social Fund.


ISSN 1335-8421, ISSN 1338-4139 (online) <strong>Acta</strong> Med Mart 2011, 11(1)<br />

ACTA MEDICA<br />

MARTINIANA<br />

Journal for Biomedical Sciences,<br />

Clinical Medicine and Nursing<br />

Contents<br />

5<br />

Genetics of psoriasis – short resume<br />

Valentova V., Galajda P., Pec M., Mokan M., Pec J.<br />

14<br />

Activity of monoamine oxidases in rat female genital organs during<br />

preimplantation period of pregnancy<br />

Mihalik J., Kravcukova P., Hodorova I., Vecanova J., Rybarova S.<br />

21<br />

Renal ontogeny of P-glycoprotein/MDR1 in rat<br />

Hodorova I., Mihalik J., Vecanova J., Dankova M., Rybarova S.<br />

27<br />

Investigating dyspepsia in clinical practice – a trap for Giardia.<br />

Banovcin P. Jr., Demeter M., Bozikova J., Hyrdel R.<br />

35<br />

Point prevalence survey of nosocomial infections in University Hospital in Martin<br />

Zabkova E., Murajda L., Hudeckova H.<br />

Published by the Jessenius Faculty of Medicine in Martin,<br />

Comenius University in Bratislava, Slovakia


4<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

Editor – in – Chief:<br />

Javorka Kamil, Martin, Slovakia<br />

International Editorial Board:<br />

Belej Kamil, Martin, Slovakia<br />

Belova Nina, Sofia, Bulgaria<br />

Bohlin Kajsa, Stockholm, Sweden<br />

Danko Jan, Martin, Slovakia<br />

Honzikova Natasa, Brno, Czech Republic<br />

Jakus Jan, Martin, Slovakia<br />

Javorka Kamil, Martin, Slovakia<br />

Kliment Jan, Martin, Slovakia<br />

Lehotsky Jan, Martin, Slovakia<br />

Mares Jan, Praha, Czech Republic<br />

Mechirova Eva, Kosice, Slovakia<br />

Mistuna Dusan, Martin, Slovakia<br />

Mokan Marian, Martin, Slovakia<br />

Mokry Juraj, Slovakia<br />

Musial Jacek, Krakow, Poland<br />

Plank Lukas, Martin, Slovakia<br />

Stasko Jan, Martin, Slovakia<br />

Stransky Albert, Martin, Slovakia<br />

Tatar Milos, Martin, Slovakia<br />

Zibolen Mirko, Martin, Slovakia<br />

Zubor Pavol, Martin, Slovakia<br />

Editorial Office:<br />

<strong>Acta</strong> <strong>Medica</strong> <strong>Martiniana</strong><br />

Jessenius faculty of Medicine, Comenius University<br />

(Dept. of Physiology)<br />

Mala Hora 4<br />

036 01 Martin<br />

Slovakia<br />

Instructions for authors: http://www.jfmed.uniba.sk (<strong>Acta</strong> <strong>Medica</strong> <strong>Martiniana</strong>)<br />

© Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia, 2011


ACTA MEDICA MARTINIANA 2011 11/1<br />

DOI: 10.2478/v10201-011-0001-0<br />

5<br />

GEnEtICS OF PSORIASIS – SHORt RESUME<br />

Valentova V. 1 , Galajda P. 2 , Pec M. 1 , Mokan M. 2 , Pec J. 3<br />

1<br />

Department of <strong>Medica</strong>l Biology, Jessenius Faculty of Medicine, Comenius University, Martin, 2 Clinic<br />

of Internal Medicine I., Jessenius Faculty of Medicine, Comenius University, Martin, 3 Clinic of<br />

Dermatovenerology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovak Republic<br />

ABStRACt<br />

Psoriasis is a disease with a genetic background (4). Several psoriasis susceptibility loci (PSORS) have been<br />

found on various chromosomes: PSORS1 on 6p21.3, PSORS2 on 17q, PSORS3 on 4q, PSORS4 on 1q21,<br />

PSORS5 on 3q21, PSORS6 on 19p, PSORS7 on 1p, PSORS8 on 16q, PSORS9 on 4q31, PSORS10 on 18p11,<br />

PSORS11 on 5q31-q33 and PSORS12 on 20q13. (27). However, the exact genes and their functions, or their<br />

respective malfunctions, in psoriasis and arthritis have not been unambiguously identified. Recently, it has<br />

been argued that PSORS1 may indeed be the HLA-Cw*06 allele encoding the HLA-Cw6 molecule (35).<br />

Psoriasis is a chronic inflammatory disease of skin that also often affects joints and nails. This disorder is<br />

characterized by hyperproliferation of keratinocytes, activation of angiogenesis, vasodilatation and mainly by<br />

lymphocyte infiltration of dermis and epidermis (45). The process of maturation of keratinocytes is accelerated<br />

and thus not quite terminated. Psoriatic lesion appears on skin.<br />

Skin manifestations are typically red bounded areas of different size and shape with characteristic silvery<br />

scales (9). Lesions appear mostly on the skin of elbows and knees, scalp including genitals. Individual<br />

manifestations differ in size and severity from localized lesions to whole body involvement. Very often psoriasis<br />

affects nails of hands and feet. It can also cause inflammatory changes on joints, named as psoriatic arthritis.<br />

Similarly to rheumatoid arthritis and sclerosis multiplex, psoriasis is classified as an immune mediated<br />

inflammatory disorder. Those disorders are characterized by chronic progression of an inflammatory process<br />

and important role of TNF alpha. Because of the role of TNF alpha in pathogenesis, we can use its inhibitors<br />

in therapy. It also affects progress of different comorbidities such as diabetes mellitus 2 and cardiovascular<br />

problems (21). Patients with psoriasis have often other risk factors for atherosclerosis such as lipid metabolism<br />

disorders and overweight (37).<br />

Key words: psoriasis, PSORS, HLA-Cw6<br />

IntRODUCtIOn<br />

Psoriasis is characterized by hyperproliferation and abnormal differentiation of epidermal<br />

keratinocytes, by lymphocytary infiltrate composed mainly of T-cells. Other features<br />

are change of endothelium, angiogenesis, dilatation and formation of high endothelial<br />

venules (HEV) (29).<br />

Exact pathogenesis of this disorder is unknown, but it is supposed that main role<br />

plays an immune system (42, 45).<br />

Theory that psoriasis is primarily keratinocyte proliferation disorder is based on abnormally<br />

fast mitotic activity of keratinocytes. T-cell hypothesis imply an abnormal activation<br />

of an acquired immunity. Knowing that TNF alpha therapies are very effective,<br />

suggests an important role of innate immunity in pathogenesis (5).<br />

Address for correspondence:<br />

Mgr. Vanda Valentova, Department of <strong>Medica</strong>l Biology, Jessenius Faculty of Medicine, Comenius University<br />

Mala Hora Str. 4, 036 01 Martin, Slovak Republic, Phone: +4210434131425, E-mail: valentova@jfmed.uniba.sk


6<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

SHORt REVIEw OF LOCI AnD CAnDIDAtE GEnES<br />

In the early 1970s psoriasis was placed into associations with the HLA complex on<br />

chromosome 6p. Russell et al. in 1972 first reported association with allele HLA-B13.<br />

After that, were identified strong associations with other two alleles, Cw6 and DR7 (22,<br />

49). These two alleles were estimated to be relative risk factors for the disease.<br />

There are two types of psoriasis (23):<br />

• a familial, early age of onset form (


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 7<br />

It is possible that malfunction of CD4+CD25+ regulatory lymphocytes can be partially<br />

based on abnormal hematopoietic cells and with genetic background (55).<br />

table 1: PSORS loci (10)<br />

Locus name Chromosomal location Reference<br />

PSORS 1 6p21.3 Zhang et al., 2002<br />

PSORS 2 17q24-25 Samuelsson et al., 1999<br />

PSORS 3 4q34 Samuelsson et al., 1999<br />

PSORS 4 1q21 Capon et al., 1999<br />

PSORS 5 3q21 Enlund et al., 1999<br />

PSORS 6 19p13-q13 Lee et al., 2000<br />

PSORS 7 1p35-p34 Veal et al., 2001<br />

PSORS 8 16q Karason et al., 2003<br />

PSORS 9 4q31 Zhang et al., 2002<br />

PSORS 10 18p11.23 Asumalahlati et al., 2002<br />

PSORS 11 5q31-q33 www.ncbi.nlm.nih.gov/omim<br />

PSORS 12 20q13 www.ncbi.nlm.nih.gov/omim<br />

PSORS1<br />

The most studied locus is PSORS1 mapped to MHC complex on chromosome 6. This<br />

region contains genes coding proteins of immunological pathways and is strongly associated<br />

with genes of lymphocyte antigens also situated in this area (1, 11). Main marker<br />

of this area is HLA-Cw6 (48). This allele is most frequently mapped in population with<br />

early onset psoriasis (36).<br />

Human leukocyte antigen<br />

Psoriasis has signs of an autoimmune disease and there is no surprise that there was<br />

found association with certain HLA alleles. Also a role for CD8+ cells is favoured by the<br />

observed linkage of psoriasis to certain MHC I alleles, especially HLA Cw6 (20).<br />

Only about 10 % of HLA-Cw6-positive individuals develop psoriasis, suggesting a major<br />

role for additional genes and/or environmental triggers (30).<br />

The observation that a large, multiply affected family demonstrated linkage of psoriasis<br />

susceptibility to 17q25 (50) and not to HLA suggests that other genes can confer<br />

susceptibility. In a study of 23 multiply affected families was observed that 25 % are<br />

HLA-Cw6 positive. In one family, all three affected members are HLA-B27 (4, 33, 35).<br />

PSORS2<br />

Locus is situated near telomeres of chromosome 17q (50). Exact localization of risk allele<br />

is not known. In this area at least two candidate genes are expected, but last large<br />

study eliminated them both (47).


8<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

PSO0RS3<br />

Localized is on chromosome 4, in position 4q34. A relation with early onset psoriasis<br />

was found in this area (17). Responsible gene is mapped about 50kb from former marker<br />

of PSORS3 locus. The newest localization is for PSORS9 locus, mapped closer to centromere<br />

(4q31) in PSORS3 area (25, 56). In this region are situated different genes coding<br />

immunologically important proteins, including IL-15 gene (53).<br />

PSORS4<br />

Locus PSORS4 mapped to 1q21 of chromosome 4, in area of Epidermal differentiation<br />

complex. This region involves 13 genes coding S100 calcium binding proteins. Some of<br />

them, S100A7, S100A8 a S100A9 are known to be increased in keratinocytes of psoriatic<br />

patients (44). S100 proteins are responsible for chemotaxis of leukocytes.<br />

PSORS5<br />

Localized to 3q21 but his exact position is need to be confirmed by more studies (43).<br />

PSORS6<br />

Mapped to 19p13 and his position is also not exact. In this area is mapped also gene<br />

JUNB, which product is member of AP-1 family of transcriptional factors, that control<br />

differentiation of keratinocytes (54).<br />

PSORS7<br />

Locus is situated in position 1p. Veal et al. (52) referred to fact that gene EPS15<br />

coding intracellular substrate for EGF receptors, highly expressed in psoriatic skin,<br />

and is mapped to critical region in position of 1p.<br />

PSORS8<br />

This locus is mapped to 16q. Nair et al. (35) referred that PSORS8 area is overlapping<br />

with susceptibility locus for Crohn disease. They found that this locus contains NOD2/<br />

CARD15 gene. They also found that psoriasis is more often in patients with Crohn disease,<br />

in comparison to control group. It shows a possibility that in this region is localized<br />

an immunomodulatory locus able to affect both diseases.<br />

PSORS9<br />

Locus is mapped to 4q position.<br />

IL-10<br />

IL-10 plays an important role in the pathophysiology of psoriasis. This disease is characterized<br />

by a relative IL-10 deficiency that can in part explain the predominance of a<br />

Th1 response. The IL-10 promoter region is very polymorphic and controls transcription<br />

of the IL-10 gene (3, 24).<br />

While the concept of an allele that makes an individual susceptible to a disease is easily<br />

understood, the concept of a protective allele of a predisposing gene is rather new in<br />

the genetics of psoriasis.


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 9<br />

table 3: Frequencies and allele sizes of interleukin (IL)-10.G (a) - Allele nomenclature at the Genome Data<br />

Base (http://www.gdb.org) (24).<br />

Size (bp) Frequency GDB a<br />

132 0.022 Allele 12<br />

134 0.034 Allele 11<br />

136 0.399 Allele 10<br />

138 0.075 Allele 9<br />

140 0.079 Allele 8<br />

142 0.052 Allele 7<br />

144 0.240 Allele 6<br />

146 0.086 Allele 5<br />

148 0.011 Allele 4<br />

Other study analyzed the highly polymorphic IL10.G microsatellite to determine if IL-<br />

10 has a role in psoriasis susceptibility. Findings showed a possible role of IL-10 promoter<br />

polymorphism in disease susceptibility and the G13 allele at the IL10.G locus was<br />

found to be associated with psoriasis (3).<br />

Other allele, allele 3 (IL10.G9) apparently has a small protective effect and is the most<br />

frequent allele of this multiallelic polymorphism allele 3 (IL10.G9) was present in 80 %<br />

of the families (24).<br />

The effect of the IL10.G9 promoter polymorphism observed by Hensen et al. is small<br />

compared with the effect of the PSORS1 marker. They also observed a small effect for<br />

allele 8 (IL10.14). This allele was present in only 28 % of the families (24).<br />

SPP2 (Secreted phosphoprotein 2)<br />

Bandshift analysis showed that SPP2 is NF-κB dependent gene. High positive regulation<br />

of NF-κB dependent gene was detected in samples from affected skin of psoriatic<br />

patients (34). NF-κB induces expression of VCAM-1 trough homocysteine. Protein vCAM-<br />

1 enables adhesion of lymphocytes, monocytes, eosinophiles and basophiles to endothelium<br />

of blood vessels. It also has a function in signal transport between leukocytes and<br />

endothelial cell.<br />

VDR<br />

D vitamin receptor is one of the candidate genes in psoriasis. It has immunosuppressive<br />

effects and is involved in an antiproliferation and prodifferentiaton cascades in<br />

keratinocytes (18). Neutrophils are expressing VDR. Polymorphism in A allele, A-1012G,<br />

is linked to negative regulation of TH1 response trough Trans-acting T-cell-specific transcription<br />

factor GATA-3. Alleles F and T of Fok1 and Taq1 genes are involved in increased<br />

activity of VDR. A-1012G, Fok1 and Taq1 VDR gene polymorphism is linked to<br />

with answer to calcipotriol (synthetic vitamin D3). A-1012G and Fok1 have relationship<br />

with susceptibility to non-familial psoriasis (18).


10<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

ADAM33 and other genes<br />

Polymorphism in locus ADAM33, first gene identified in asthma, is in these days given<br />

to relation with psoriasis (46).<br />

Li et al. have tested 15 SNPs form 7 expected psoriatic risk genes: rs597980 in allele<br />

ADAM33, rs6908425 in CDKAL1 and rs3789604 in PtPn22. Results have shown as<br />

significant for the same alleles as in previous studies. This data show, that ADAM33,<br />

CDKAL1, and PTPN22 are risk genes for psoriasis (32).<br />

Study of Oudota et al. in year 2009, confirmed linkage of other six candidate genes<br />

to susceptibility to psoriasis: SCL12A8, belongs to group of free transposing genes;<br />

FLG and tGM5, involved in epidermal differentiation; CARD15 and CYLD, that modulate<br />

transcriptional factor NF-κB and IL1Rn, coding antagonist receptor of IL-1. It was<br />

proved that an association exists between main risk allele HLA-Cw6 and CARD15, CYLD<br />

and TMG5 alleles. Together these results show that etiology of psoriasis and other disorders<br />

is cooperation of different genetic factors (40).<br />

One region is within the MHC complex on 6p21.3 (51) and includes the non-HLA gene–<br />

encoding corneodesmosin (CD) — a protein with homology to keratin-10 (2). The other<br />

region includes a cluster of genes on chromosome 1q21 (19, 38). Potential candidate<br />

genes encode markers of epidermal differentiation such as corneodesmosin, psoriasin,<br />

and CD1d, to name a few (19).<br />

IL-20R<br />

Complex of IL-20 receptor is composed from two chains IL20RA and IL20RB. Its ligands<br />

are three members from IL-19 subfamily, IL-19, IL-20 and IL-24. These cytokines<br />

are important for manifestation of psoriatic lesions and recently was described also a<br />

relation between IL20 gene polymorphism and psoriasis. In last studies the hypothesis<br />

is tested, that genetic variants of IL-20-RI influence susceptibility to psoriasis. To these<br />

days there isn’t proved relationship between SNP in that gene and psoriasis. SNPs in<br />

two risk haplotypes influence two transcriptional factors leading to differentiation of<br />

immune cells. Other studies are necessary to confirm genetic association of IL-20-RA<br />

haplotypes with psoriasis (27).<br />

Conclusion<br />

In the last few years, molecular genetics analyses have permitted novel insights into<br />

psoriasis, a disease characterized by uncontrolled proliferation of keratinocytes and<br />

recruitment of T cells into the skin. HLA studies revealed an association with certain<br />

alleles, notably HLA-Cw6. Despite this HLA component, psoriasis in some families is<br />

inherited as an autosomal dominant trait with high penetrance.<br />

Significant progress has been made in the understanding of the genetic, immune and<br />

pathogenetic aspects of psoriasis.<br />

Understanding the genetics of psoriasis, and why some people are affected and others<br />

are not could lead to more effective treatments. They could work blocking the action of<br />

concrete genes, changing their behaviour or by replacing mutated genes with healthy<br />

ones via gene therapy.


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 11<br />

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locus on chromosome 19p13. Am J Hum Genet 2000; 67:1020-1024<br />

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arthritis and psoriasis. Semin Immunol 2009; 21:318-27<br />

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(PV): evidence for genetic heterogeneity. Hum Immunol 1997; 55:51<br />

34. Mechtcheriakova D, Wlachos A, Sobanov J, Kopp T, Reuschel R, Bornancin F, Cai R, Zemann B, Urtz N,<br />

Stingl G, Zlabinger G, WoisetschlĂger M, Baumruker T, Billich A. Sphingosine 1-phosphate phosphatase<br />

2 is induced during inflammatory responses. Cell Signal 2007; 19:748-60<br />

35. Nair RP, Henseler T, Jenisch S, Stuart P, Bichakjian CK, Lenk W, Westphal E, Guo SW, Christophers<br />

E, Voorhees JJ, Elder JT. Evidence for two psoriasis susceptibility loci (HLA and 17q) and two novel<br />

candidate regions (16q and 20p) by genome-wide scan. Hum Molec Genet 1997; 6:1349-56<br />

36. Nair RP, Stuart PE, Nistor I, Hiremagalore R, Chia NV, Jenisch S, Weichenthal M, Abecasis GR, Lim HW,<br />

Christophers E, Voorhees JJ, Elder JT. Sequence and haplotype analysis supports HLA-C as the psoriasis<br />

susceptibility 1 gene. Am J Hum Genet 2006; 78:827-51<br />

37. Naldi L, Chatenoud I, Linder D, Belloni FA, Peserico A, Virgili AR, Bruni PL, Ingordo V, Lo Scocco G,<br />

Solaroli C, Schena D, Barba A, Di Ladro A, Pezzarossa E, Arcangeli F,Gianni C, Betti R, Carli P, Farris A,<br />

Barbino GF, La Vecchia C. Cigarette smoking, body mass index, and stressful life events as risk factors for<br />

psoriasis: results from an Italian case control study. J Invest Dermatol 2005; 125:61–67<br />

38. Nickoloff BJ. The immunologic and genetic basis of psoriasis. Arch Dermatol 1999; 135:1104-10<br />

39. Nomura I, Goleva E, Howell MD, Hamid QA, Ong PY, Hall CF, Darst MA, Gao B, Boguniewicz M, Travers<br />

JB, Leung DY. Cytokine milieu of atopic dermatitis, as compared to psoriasis, skin prevents induction of<br />

innate immune response genes. J Immunol 2003; 171:3262-9<br />

40. Oudot T, Lesueur F, Guedj M, de Cid R, McGinn S, Heath S, Foglio M, Prum B, Lathrop M, Prud’homme<br />

JF, Fischer J. An Association Study of 22 Candidate Genes in Psoriasis Families Reveals Shared Genetic<br />

Factors with Other Autoimmune and Skin Disorders. J Invest Dermatol 2009; 129:2637-45<br />

41. Quekenborn-Trinquet V, Fogel P, Aldana-Jammayrac O, Ancian P, Demarchez M, Rossio P, Richards HL,<br />

Kirby B, Nguyen C, Voegel JJ, Griffiths CE. Gene expression profiles in psoriasis: analysis of impact of<br />

body site location and clinical severity. Br J Dermatol 2005; 152:489-504<br />

42. Sabat R, Philipp S, Höflich C, Kreutzer S, Wallace E, Asadullah K, Volk H-D,Sterry W, Wolk K.<br />

Immunopathogenesis of psoriasis. Exp Dermatol 2007; 16:779–798<br />

43. Samuelsson L, Enlund F, Torinsson A, Yhr M, Inerot A, Enerback C, Wahlstrom J, Swanbeck G,<br />

Martinsson T. A genome-wide search for genes predisposing to familial psoriasis by using a stratification<br />

approach. Hum Genet 1999; 105:523-529<br />

44. Semprini S, Capon F, Tacconelli A, Giardina E, Orecchia A, Mingarelli R, Gobello T, Zambruno G, Botta<br />

A, Fabrizi G, Novelli G. Evidence for differential S100 gene over-expression in psoriatic patients from<br />

genetically heterogeneous pedigrees. Hum Genet 2002; 111:310-3<br />

45. Schön MP, Boehncke WH. Psoriasis. N Engl J Med 2005; 352:1899-912<br />

46. Siroux V, Bouzigon E, Dizier MH, Pin I, Demenais F, Kauffmann F. Replication of association between<br />

ADAM33 polymorphisms and psoriasis. PLoS ONE 2008; 3:2448<br />

47. Stuart P, Nair RP, Abecasis GR, Nistor I, Hiremagalore R, Chia NV, Qin ZS, Thompson RA, Jenisch S,<br />

Weichenthal M, Janiga J, Lim HW, Christophers E, Voorhees JJ, Elder JT. Analysis of RUNX1 binding<br />

site and RAPTOR polymorphism in psoriasis: no evidence for association despite adequate power and<br />

evidence for linkage. J Med Genet 2006; 43:12-7


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48. Suomela S, Kainu K, Onkamo P, Tiala I, Himberg J, Koskinen L, Snellman E, Karvonen SL, Karvonen J, Uurasmaa<br />

T, Reunala T, Kivikäs K, Jansén CT, Holopainen P, Elomaa O, Kere J, Saarialho-Kere U. Clinical associations of<br />

the risk alleles of HLA- Cw6 and CCHCR1*WWCC in psoriasis. <strong>Acta</strong> Derm Venereol 2007; 87:127-34<br />

49. Tiilikainen A, Lassus A, Karvonen J, Vartiainen P, Julin M. Psoriasis and HLA-Cw6. Br J Dermatol. 1980;<br />

102:179-84<br />

50. Tomfohrde J, Silverman A, Barnes R, Fernandez-Vina MA, Young M, Lory D, Morris L, Wuepper KD,<br />

Stastny P, Menter A et al. Gene for familial psoriasis susceptibility mapped to the distal end of human<br />

chromosome 17q. Science 1994; 264:1141-5<br />

51. Trembath RC, Lee Clough R, Rosbotham JL, Jones AB, Camp RDR, Frodsham A, Browne J, Barber R,<br />

Terwilliger J, Lathrop GM, Barker JNWN. Identification of a major susceptibility locus on chromosome 6p<br />

and evidence for further disease loci revealed by a two stage genome-wide search in psoriasis. Hum Mol<br />

Genet 1997; 6:813-820<br />

52. Veal CD, Clough RL, Barber RC, Mason S, Tillman D, Ferry B, Jones AB, Ameen M, Balendran N, Powis<br />

SH, Burden AD, Barker JNWN, Trembath RC. Identification of a novel psoriasis susceptibility locus at 1p<br />

and evidence of epistasis between PSORS1 and candidate loci. J Med Genet 2001; 38:7-13<br />

53. Villadsen LS, Schuurman J, Beurskens F, Dam TN, Dagnaes-Hansen F, Skov L, Rygaard J, Voorhorst-<br />

Ogink MM, Gerritsen AF, van Dijk MA, Parren PW, Baadsgaard O, van de Winkel JG. Resolution of psoriasis<br />

upon blockage of Il-15 biologic activity in a xenograft mouse model. J Clin Invest 2003; 112:1571-80<br />

54. Zenz R, Eferl R, Kenner L, Florin L, Hummerich L, Mehic D, Scheuch H, Angel P, Tschachler E, Wagner<br />

EF. Psoriasis-like skin disease and arthritis caused by inducible epidermal deletion of Jun proteins. Nat<br />

2005; 437:369-75<br />

55. Zhang K, Li X, Yin G, Liu Y, Niu X, Hou R. Functional characterization of CD4+CD25+ regulatory T cells<br />

differentiated in vitro from bone marrow-derived haematopoietic cells of psoriasis patients with a family<br />

history of the disorder. Br J Dermatol 2008; 158:298–305<br />

56. Zhang XJ, He PP, Wang ZX, Zhang J, Li YB, Wang HY, Wei SC, Chen SY, Xu SJ, Jin L, Yang S, Huang W.<br />

Evidence for a major psoriasis susceptibility locus at 6p21 (PSORS1) and a novel candidate region at 4q31<br />

by genome-wide scan in Chinese hans. J Invest Dermatol 2002; 119:1361-6<br />

57. Zhou X, Krueger JG, Kao MC, Lee E, Du F, Menter A, Wong WH, Bowcock AM; Novel mechanism of T-cell<br />

and dendritic cell activation revealed by profiling of psoriasis on the 63,100-element oligonucleotide array.<br />

Physiol Genomics 2003; 13:69-78<br />

Received: December,6,2010<br />

Accepted: January,7,2011


14<br />

ACTA MEDICA MARTINIANA 2011 11/1<br />

DOI: 10.2478/v10201-011-0002-z<br />

ACtIVItY OF MOnOAMInE OxIDASES In RAt FEMALE GEnItAL<br />

ORGAnS DURInG PREIMPLAntAtIOn PERIOD OF PREGnAnCY<br />

Mihalik J. 1 , Kravcukova P. 2 , Hodorova I. 1 , Vecanova J. 1 , Rybarova S. 1<br />

1<br />

Department of Anatomy, P.J.Safarik University, <strong>Medica</strong>l Faculty, Kosice, Slovak Republic<br />

2<br />

Neurobiological Institute, Slovak Academy of Sciences, Kosice, Slovak Republic<br />

ABStRACt<br />

Our objectives in the present study were to determine the activity of monoamine oxidases A and B (MAO AB)<br />

in rat ovary, oviduct and uterus during preimplantation period of pregnancy. It should help us to clarify and<br />

better understand possible involvement of both MAO enzymes in the reproductive process. Pregnant females<br />

were killed employing a lethal dose of thiopental on the first (D1), on the third (D3), and on the fifth (D5)<br />

days of pregnancy. Rats were perfused transcardially with the PBS to rinse out of the body as much blood as<br />

possible. Ovaries, oviducts and uteri were immediately removed and stored until the measurement was done.<br />

MAO activity was determined by fluorescent monoamine oxidase detection kit. In the ovaries we have found<br />

the highest MAO activity at D3, followed by D1, and the lowest levels were recorded at D5 of pregnancy. In<br />

the oviducts, the highest MAO activity was detected again at D3, followed by D5, and by D1 of pregnancy. But<br />

statistical analysis did not reveal any difference between individual days of pregnancy nor in the ovaries, neither<br />

in uterine tubes. Uteri were the only organs, in which statistically significant differences were detected (p


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 15<br />

numerous, but information about the quantification of MAO in female gonads during<br />

pregnancy is limited.<br />

Recently we have observed an antagonistic effect of chronic treatment with deprenyl,<br />

a potent MAO-B inhibitor, at the dose 0.25 mg/kg on embryo development in rats. Significantly<br />

less degenerated embryos were isolated from experimental females, but on the<br />

other hand, a decreased mean cell number in blastocysts was recorded [5]. Our objectives<br />

in the present study were to determine the activity of MAO in rat ovary, oviduct and uterus<br />

during preimplantation period of pregnancy, which should help us to clarify and better<br />

understand possible involvement of both MAO enzymes in the reproductive process.<br />

MAtERIAL AnD MEtHODS<br />

Animals<br />

All procedures performed with animals adhered to the permission granted by the Committee<br />

for Ethical Control of Animal Experiments at Safárik University and the permission<br />

of the State Veterinary and Food Administration of the Slovak Republic (permission<br />

No. 715/08-221b). All efforts were made to minimize both the number of animals and<br />

their suffering.<br />

Experiments were carried out on 15 young, virgin female Wistar rats (200-240 g, 85-90<br />

days old) obtained from the animal facility of the University. The animals were given free<br />

access to standard diet and water and were maintained in a 12 h light/12 h dark cycle. Females<br />

were mated for two hours from 07:00-09:00 a.m. with males of the same strain. The<br />

first day on which a vaginal plug was present was designated as day 1 of pregnancy. Pregnant<br />

rats were killed by a lethal dose of thiopental (40 mg/kg; ICN Czech Pharma, Prague,<br />

Czech Republic) on the first (D1), on the third (D3), and on the fifth (D5) day of pregnancy.<br />

After a lethal injection of thiopental rats were perfused transcardially with 100 ml of<br />

room-temperature PBS (ph 7.4) to rinse out as much blood as possible. Ovaries, oviducts,<br />

and uteri were immediately removed and stored in Eppendorf tubes at -80 °C<br />

until the measurement was done.<br />

MAO AB activity<br />

Activity of MAO was measured by fluorescent monoamine oxidase detection kit (Bachem;<br />

Cat. No. S-90092) based on detection of H2O2 released from the conversion of a<br />

substrate to its aldehyde via both forms MAO A and MAO B. H2O2 oxidizes the detection<br />

reagent in a 1:1 stoichiometry to produce the fluorescent product. A standard curve was<br />

prepared from resorufin to determine moles of product produced.<br />

Briefly, organs were homogenized in five volumes (w/v) of the 25mmol/l TRIS-HCL (pH<br />

7.4) mixed with 1mmol/l EDTA and subsequently were centrifuged at 10,000xg for 15<br />

min at 4 °C. To a black 96 well plate 100 ml of samples and 100 ml of reaction cocktail<br />

were added into individual wells to incubate at room temperature for 30-60 minutes.<br />

Reaction cocktail was prepared obeying the manufacturer’s instructions and consisted<br />

of the detection reagent, horse radish peroxidase and dimethyl sulfoxide (DMSO). Samples<br />

were read using excitation at 570 nm and fluorescence was measured at 590-600<br />

nm employing the fluorescence plate reader. Activity of MAO expressed as the µmol/l<br />

resorufin was normalized on the basis of total protein content (µmol/l of resorufin/<br />

mg of protein). Chemicals used for assessing of enzymes activity were purchased from<br />

Sigma-Aldrich (St. Louis, MO, USA).<br />

Statistical analysis<br />

Data are expressed as the mean ± SD. Differences in the MAO AB activity were analyzed by<br />

the Kruskal-Wallis test for multiple comparisons. P


16<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

RESULtS<br />

Fig. 1 Activity of MAO in the rat ovary on the first (D1), third (D3), and on the fifth (D5) day of pregnancy.<br />

Results are depicted as a µmol/l of resorufin/mg of proteins ± S. D. (p>0.05)<br />

Concerning ovary (Fig. 1), we have found the highest MAO AB activity at D3 (72.44 ±<br />

22.66), followed by D1 (67.10 ± 32.12) and the lowest activity was recorded at D5 (57.90<br />

± 17.60) of pregnancy. Kruskal-Wallis test did not reveal any significant difference compared<br />

individual days of pregnancy (p>0.05).<br />

Fig. 2 Activity of MAO in the rat oviduct on the first (D1), third (D3), and on the fifth (D5) day of pregnancy.<br />

Results are depicted as the µmol/l of resorufin/mg of proteins ± S. D. (p>0.05)<br />

In regard to oviduct (Fig. 2), the highest MAO AB activity was detected at D3 (45.44 ± 12.97),<br />

followed by D5 (42.09 ± 27.40) and D1 (36.49 ± 16.91) of pregnancy. Statistical analysis did<br />

not confirm any significant difference between individual days of pregnancy (p>0.05).


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 17<br />

Fig. 3 Activity of MAO in the rat uterus on the first (D1), third (D3), and on the fifth (D5) day of pregnancy.<br />

Results are depicted as the µmol/l of resorufin/mg of proteins ± S. D. (* it means p


18<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

in the CL of rat ovary employing enzymatic histochemical method [17]. In our work we<br />

found the highest MAO activity on the D3 of pregnancy, when corpora lutea are already<br />

formed. Similar results were recorded in women employing monoclonal antibodies. MAO-<br />

A was intensely expressed in CL of pregnancy, especially in large luteal cells [18]. MAO<br />

enzymes were also detected in the intersticial gland cells and in the blood vessels of rat<br />

ovary [17]. It has been recorded [19], that MAO activities in the vessels of ovarian pedicle<br />

of pigs were the highest on the 13-14 day of the estrous cycle. Authors suggest that high<br />

MAO activity in the vessels may be a significant factor in the regulation of the ovarian<br />

vasotone and might be responsible for increasing in the ovarian blood flow during the<br />

luteal phase of ovarian cycle. Interstitial glands are situated near to the blood vessels in<br />

the ovarian stroma, and arise from the follicles, which undergo atrophic process. Probably<br />

this is the reason why the further catecholamine accumulation is not needed and<br />

these substances are rather metabolized through MAO enzymes. Taken together, results<br />

suggest that MAO activity in the ovary might be involved in follicular development and<br />

progesterone metabolism.<br />

High concentrations of NA have been detected in the human and cow oviductal compartments<br />

[20, 21]. The highest concentrations were found in the isthmus, where the<br />

adrenergic nerves are primarily related to smooth muscles [20]. Recently we have found<br />

that high doses of deprenyl (2.5 mg/kg), a potent MAO-B inhibitor, significantly slow<br />

down the movement of rat embryos through the female reproductive tract [22]. These<br />

findings need another investigation, because MAO-B and MAO-A are responsible for the<br />

DA degradation and DA was also detected in the human [20] and cow [21] oviduct compartments.<br />

Moreover, the addition of DA into the incubation bath significantly reduced<br />

the strength and frequency of spontaneous rhythmic contractions of the rat uterus [23].<br />

NA was also identified in bovine oviductal fluid [24], and it could influence the oviduct<br />

epithelium via adrenergic receptors, which have been shown in the oviduct epithelian<br />

cells of several species [25, 26]. Recently, it was clearly demonstrated that mouse oocytes<br />

and embryos express α2C- and β2-adrenergic receptors, too [27]. As one could expect,<br />

MAO activity in the human oviduct has been detected on the same places, as their<br />

catecholamine substrates are located. It means in the epithelium and in the muscular<br />

layer [28]. Despite the fact that we have recorded the highest activity of monoamine oxidases<br />

on D3 and on D5, when embryo goes through the oviduct into the uterus, activity<br />

of MAO did not differ significantly compared the individual days of pregnancy. Probably,<br />

it could be the sign of similar metabolic MAO activity, as the oviduct almost permanently<br />

moves during the transport of spermatozoa in the time of fertilization and subsequently<br />

during the embryo passage down into the uterine cavity. Based on the works mentioned<br />

above, catecholamines play the pivotal role in this process.<br />

Uterus is the only one reproductive organ, in which significantly different MAO activity<br />

during preimplantation period of pregnancy was recorded. In the time, when the oocytes<br />

and subsequently embryos are located in the oviduct, extremely low MAO activity in rat<br />

uterus was detected. However, on the D5, when embryos are present in the uterine cavity<br />

and their implantation into the uterine wall occurs, MAO activity significantly increased<br />

several times. Successful implantation depends both on the quality of the embryo and on<br />

the endometrial receptivity. The later depends on the progesterone-induced changes in<br />

gene expression. One of the genes whose transcription appears to be enhanced during the<br />

receptive period is probably gene for MAO. Similar results were obtained in women [29].<br />

MAO-A transcript levels increased in human uterus between the pre-receptive and receptive<br />

phase with a median increase of 25-fold. Conversely, prior failure of embryo implantation<br />

was associated with a 29-fold decrease in MAO-A mRNA levels and a substantial<br />

reduction in MAO-A protein immunofluorescent label score. These results show a strong<br />

association between endometrial receptivity and MAO-A expression in the endometrial<br />

epithelium, suggesting an important role for this enzyme in normal implantation.


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 19<br />

In the present study, we determined activity of monoamine oxidases in rat ovary,<br />

oviduct and uterus on the first, on the third and on the fifth day of pregnancy. We can<br />

conclude that significant elevation of MAO activity was recorded in the rat uterus in the<br />

time of embryonic implantation. The data obtained extend our knowledge about MAO<br />

enzymes in rat reproductive organs during early period of embryo development. To our<br />

knowledge this is the first paper describing the MAO activity in female reproductive organs<br />

during the whole preimplanation period of pregnancy in mammals.<br />

Acknowledgement: This research work was supported by the VEGA Agency [grant 1/4227/07].<br />

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11. Itoh MT, Ishizuka B, Kuribayashi Y, Abe Y, Sumi Y. Noradrenaline concentrations in human preovulatory<br />

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12. Bodis J, Bognar Z, Hartmann G, Török A, Csaba IF. Measurement of noradrenaline, dopamine and<br />

serotonin contents in follicular fluid of human Graafian follicles after superovulation treatment. Gynecol<br />

Obstet Invest 1992; 33: 165-7.<br />

13. Mayerhofer A, Smith GD, Danilchik M, Levine JE, Wolf DP, Dissen GA, Ojeda SR. Oocytes are a source<br />

of catecholamines in the primate ovary: evidence for a cell-cell regulatory loop. Proc Natl Acad Sci USA<br />

1998; 95: 10990-5.<br />

14. Kotwica J, Bogacki M, Rekawiecki R. Neural regulation of the bovine corpus luteum. Domest Anim<br />

Endocrinol 2002; 23: 299-308.<br />

15. D’Albora H, Anesetti G, Lombide P, Dees WL, Ojeda SR. Intrinsic neurons in the mammalian ovary.<br />

Microsc Res Tech 2002; 59: 484-9.<br />

16. Rey-Ares V, Lazarov N, Berg D, Berg U, Kunz L, Mayerhofer A. Dopamine receptor repertoire of human<br />

granulose cells. Reprod Biol Endocrinol 2007; 5: 40.<br />

17. Yoshimoto Y, Sakumoto T, Arai R, Miyake A, Kimura H, Aono T, Tanizawa O, Maeda T. Monoamine oxidase<br />

in rat ovary during the estrous cycle. A histochemical study by a new coupled peroxidatic oxidation<br />

method. Endocrinology 1986; 119(4): 1800-4.<br />

18. Takao Y, Fujiwara H, Yoshioka S, Fujii S, Ueda M. Monoamine oxidase A is highly expressed by the<br />

human corpus luteum of pregnancy. Reproduction 2008; 136(3): 367-75.<br />

19. Dynarowicz I, Szurmiński M. Monoamine oxidase activity in the uterine and mesenteric arteries, vessels<br />

of ovarian pedicle and myometrium of pigs during the oestrous cycle. Arch Vet Pol 1995; 35(1-2): 45-52.<br />

20. Helm G, Owman CH, Rosengren E, Sjöberg NO. Regional and cyclic variations in catecholamine<br />

concentration of the human Fallopian tube. Biol Reprod 1982; 26: 553-8.<br />

21. Kotwica G, Kurowicka B, Franczak A, Grzegorzewski W, Wrobel M, Mlynarczuk J, Kotwica J. The<br />

concentrations of catecholamines and oxytocin receptors in the oviduct and its contractile activity in<br />

cows during the estrous cycle. Theriogenology 2003; 60: 953-64.


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22. Mihalik J, Kravčuková P, Špakovská T, Mareková M, Schmidtová K. Study of high deprenyl dose on the<br />

preimplantation embryo development and lymphocyte DNA in rat. Gen Physiol Biophys 2008; 27: 121-6.<br />

23. Czerski A, Zawadzki W, Zawadzki M, Czerska Z. Influence of dopamine on rat uterine motility in vitro.<br />

<strong>Acta</strong> Vet Brno 2005; 74: 9-15.<br />

24. Way AL, Barbato GF, Killian GJ. Identification of norepinephrine in bovine oviductal fluid by high<br />

performance liquid chromatography. Life Sciences 2001; 70: 567-76.<br />

25. Tolszczuk M, Pelletier G. Autoradiographic localization of beta-adrenergic receptors in rat oviduct. Mol<br />

Cell Endocrinol 1988; 60: 95-9.<br />

26. Einspanier R, Gabler C, Kettler A, Kloas W. Characterization and localization of B2-adrenergic receptors<br />

in the bovine oviduct: indication for progesterone-mediated expression. Endocrinology 1999; 140: 2679-<br />

84.<br />

27. Čikoš Š, Veselá J, Iľková G, Rehák P, Czikková S, Koppel J. Expression of beta adrenergic receptors in<br />

mouse oocytes and preimplantation embryos. Mol Reprod Dev 2005; 71: 145-53.<br />

28. Donnez J, Goenen E, Casanas-Roux F, Caprasse J, Ferin J, Thomas K. Monoamine oxidase reactivity in<br />

the human fallopian tube. Fertil Steril 1995; 43(3): 488-90.<br />

29. Henriquez S, Tapia A, Quezada M, Vargas M, Cardenas H, Rios M, Salvatierra AM,Croxatto H, Orihuela<br />

P, Zegers-Hochschild F, Munroe DJ, Velasquez L. Deficient expression of monoamine oxidase A in the<br />

endometrium is associated with implantation failure in women participating as recipients in oocyte<br />

donation. Mol Hum Reprod 2006; 12(12): 749-54.<br />

Received: December,14,2010<br />

Accepted: January,10,2011


ACTA MEDICA MARTINIANA 2011 11/1<br />

DOI: 10.2478/v10201-011-0003-y<br />

21<br />

REnAL OntOGEnY OF P-GLYCOPROtEIn/MDR1 In RAt<br />

Hodorova I. 1 , Mihalik J. 1 , Vecanova J. 1 , Dankova M. 2 , Rybarova S. 1<br />

1<br />

Department of Anatomy, P. J. Safarik University, Faculty of Medicine, Kosice, Slovak Republic; 2 Department<br />

of Histology and Embryology, P. J. Safarik University, Faculty of Medicine, Kosice, Slovak Republic<br />

ABStRACt<br />

BACKGROUND: P-glycoprotein (Pgp/MDR1) is an ATP-dependent, integral plasma-membrane efflux pump<br />

that is constitutively expressed on adult apical brush-border epithelium of renal proximal tubules. This Pgp/<br />

MDR1 tissue distribution and localization affects the absorption, distribution, metabolism, and excretion of<br />

Pgp/MDR1 substrates. The ontogeny of rat Pgp/MDR1 is still doubtful, and such knowledge may be helpful<br />

in understanding age-related pharmacokinetics. The purpose of this study was to determine, whether Pgp/<br />

MDR1 expression is altered during development.<br />

METHODS: Postnatal expression of Pgp was determined using immunohistochemical method. Tissue from<br />

Wistar rat were isolated on the 1st day (D1), 7th day (D7), 14th day (D14), 21st day of life (D21) and from adult<br />

animals (60 days old; Ad).<br />

RESULTS: Our ontogeny study illustrated that expression of Pgp was relatively constant from birth to adulthood.<br />

CONCLUSIONS: Knowledge of the ontogeny of transport proteins involved in distribution and elimination of<br />

drugs is important for adequate interpretation of the results of toxicity studies in juvenile animals.<br />

Key words: Pgp/MDR1, rat, immunohistochemistry<br />

IntRODUCtIOn<br />

ATP-binding cassette (ABC) superfamily now includes about 300 proteins, among the<br />

transporters of quite different compounds (1,2,3). Proteins of this family are present in<br />

all living organisms. About fifty ABC proteins have been found in man and approximately<br />

the same number in mouse (4). Since a great number of ABC proteins were discovered<br />

only recently, many of them are still poorly studied. Studies of ABC proteins are important<br />

both for medicine and biology because they concern problems of protection of all<br />

living cells. Human proteins of the ABC family are divided to seven subfamilies (class A<br />

to G) (4,5). The affiliation of each protein to a subfamily is determined by its domain organization,<br />

namely by the number and combination of transmembrane domains (TMDs)<br />

and ATP-binding domains (NBDs, nucleotide-binding domains) (6). In total, there are 49<br />

protein members in this family, but only three are well known for their multidrug resistance<br />

(7). There are P-glycoprotein (Pgp/MDR1, ABCB1), MDR-associated protein (MRP1,<br />

ABCC1) and breast cancer resistance protein (BCRP, ABCG2). Pgp, paradigm ABC drug<br />

efflux transporter, is the first detected and to date the best characterized of the family of<br />

ABC drug efflux transporters. It gained worldwide attention about three decades ago for<br />

its role in the phenomenon of multidrug resistance in tumor cells (8,9). Subsequently,<br />

constitutive expression of Pgp/MDR1 has been described in a variety of other tissues including<br />

liver, intestine, kidney, pancreas, adrenal, capillary endothelium of blood-brain<br />

and blood-testis barrier, choroid plexus, placental trophoblast and others (10). The polarized,<br />

apical membrane localization of Pgp/MDR1 causes that its substrates are prefeerentially<br />

translocated from basolateral to the apical side of the epithelium. Thus, Pgp/<br />

MDR1 limits the influx and facilitates the efflux of its substrates, eventually preventing<br />

their intracellular accumulation. Many in vitro and in vivo studies demonstrated high<br />

Address for correspondence:<br />

Hodorova Ingrid, MD, PhD, Department of Anatomy, P.J. Safarik University, <strong>Medica</strong>l Faculty<br />

Srobarova Str. N. 2, 040 01 Kosice, Slovak Republic, Phone: ++ 421 055 6228866; e-mail: ingrid.hodorova@upjs.sk


22<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

impact of Pgp/MDR1 on drug pharmacokinetics in these organs (10). It is likely that<br />

Pgp/MDR1 and other ABCs have evolved in these “normal” tissues to protect them from<br />

potentially damaging effect of toxic compounds.<br />

In the kidney, Pgp/MDR1 is expressed mainly at the apical (luminal) brush-border membrane<br />

of proximal tubular cells (11) and to lesser extent in the thick limb of Henle’s loop,<br />

collecting ducts, and glomerular mesangium. Many substances are actively transported by<br />

Pgp/MDR1, e.g. calcium channel blockers, immunosuppressants, cardioactive glycosides,<br />

antibiotics, antineoplastic and severel others peptides and steroids (12,13). Thus Pgp/MDR1<br />

functions as an efflux pump which represents a protective mechanism to exclude endogenous<br />

and exogenous toxins from normal cells and to ultimately excrete them into the bodily<br />

secretions. In humans, two genes (MDR1 and MDR2) encode this protein, whereas in rodents<br />

there are three homologs of this protein, mdr1 (mdr1b), mdr2, mdr3 (mdr1a) (14,15,16).<br />

The aim of the present study was to determine postnatal expression of Pgp/MDR1 in rat kidney<br />

by two widely used monoclonal antibodies for Pgp/MDR1: C219 and UIC2 .These antibodies<br />

are known to detect Pgp/MDR1 in paraffin-embedded histological tissue in many histopathological<br />

laboratories. The neonatal rat is a useful model for kidney developmental studies since<br />

rats are born with immature kidneys and there is considerable postnatal renal development.<br />

MAtERIAL AnD MEtHODS<br />

Animals<br />

All procedures performed with animals adhered to the permission of the Committee for<br />

Ethical Control of Animal Experiments at Safarik University and the permission of the<br />

State Veterinary and Food Administration of the Slovak Republic (permission No. 7881/04-<br />

220/3). All efforts were made to minimize both the number animals and their suffering.<br />

To acquire rat cubs, female Wistar rats were mated with males of the same strain overnight.<br />

Tissue from Wistar rat were isolated on the 1st day (D1), 7th day (D7), 14th day<br />

(D14), 21st day of life (D21) and from adult animals (60 days old; Ad) by ether anaesthesia.<br />

Three animals were killed on each day examined. The kidneys were obtained by medial<br />

laparotomy carried out in deeply anaesthetised animals. At the end of surgery rats were<br />

killed by overdose of ether. Rat kidneys were immersed in a neutral buffered formalin solution<br />

for 72 hours at room temperature. Tissue blocks were dehydrated in increasing alcohols<br />

and embedded in paraffin. Seven-micron-thick serial sections were cut and attached<br />

to the slide with alum gelatine. The slides were processed for immunohistochemistry.<br />

Antibodies:<br />

We have used the following primary monoclonal antibodies: mouse anti-MDR1, clone<br />

C219 (Signet Laboratories, Inc.) and mouse anti-MDR1, UIC2 – clone C494 (Santa Cruz<br />

Biotechnology, Inc.).<br />

Immunohistochemical detection of Pgp:<br />

For immunohistochemistry, paraffin embedded sections of the rat kidney were deparaffinized<br />

with xylene and rehydrated in decreasing ethanols to water. The slides were finally washed in<br />

phosphate-buffered saline containing 0.05 % Tween-20 (PBS-Tw), pH 7.6. Endogenous peroxidase<br />

activity was blocked by 0.3 % H202 in methanol for 30 minutes at room temperature. To<br />

re-establish an original conformation of epitopes modified after fixation, we performed antigen<br />

retrieval using a microwave (in sodium citrate solution for 2x5 minutes at 500 watts). Pgp/<br />

MDR1 staining procedure continued by blocking nonspecific staining with milk buffer (5 %<br />

dry milk in TRIS buffer) for 30 minutes at room temperature. Primary antibodies were applied<br />

overnight in humidified chamber at 4˚C. After rinsing in PBS-Tw (3x5 minutes) the sections<br />

were subsequently incubated with the secondary antibody (30 minutes) and strepatavidin-


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 23<br />

biotin (30 minutes) (Universal detection kit LSAB+KIT/HRP, Dako). Next, the sections were<br />

visualized with DAB (3.3’- diaminobenzidine tetrahydrochloride) at a concentration of 0.5 mg/<br />

ml in Tris buffer, pH 7.6 and 0.015 % H2O2. Slides were stream-rinsed with tap water, counterstained<br />

with Mayer’s hematoxylin for 2 minutes, washed in tap water, dried, mounted and<br />

coverslipped. Sections processed with omission of primary antibody served as control.<br />

Semiquantitative evaluation<br />

Immunostaining was assessed by two independent observers blinded to animal<br />

characteristics.<br />

Expression of Pgp/MDR1 was evaluated separately using the following scale: 3+ =<br />

high level (91-100 % of positive cells), 2+ = medium level (11-90 % of positive cells), 1+ =<br />

low level (up to 10 % of positive cells), – = negative cells (0 % of positive cells). Samples<br />

with high [3+] and medium level [2+] of proteins expression were considered as positive.<br />

Samples scored as [1+] and [–] were considered as negative.<br />

RESULtS<br />

Kidney of rat cubs<br />

Using monoclonal antibody mouse anti-MDR1 clone C219 we have detected moderate<br />

immunopositivity for Pgp/MDR1 in all developmental stages (D1, D7, D14, D21). Employing<br />

semiquantitative evaluation of tissue samples we have found no differences in<br />

expression of Pgp/MDR1 in epithelial cells of proximal tubules. The remaining structures<br />

(epithelial cells of distal tubules, glomerulus and glomerular capsule) did not show any<br />

positivity for Pgp/MDR1.<br />

Using monoclonal antibody mouse anti-MDR1 UIC2 – clone C494 we have detected in all developmental<br />

stages the same spatial protein distribution but its signal was significantly weaker.<br />

Kidney of rat adults<br />

Using both monoclonal antibodies (mouse anti-MDR1:clone C219 and mouse anti-<br />

MDR1:UIC2 – clone C494) we have observed expression of Pgp/MDR1 in epithelial cells of<br />

proximal tubules in adult kidney, too. Employing semiquantitative evaluation we have found<br />

no differences in expression of Pgp/MDR1 in all tissue samples. The immunoreactivity for<br />

this protein was strongly restricted to the apical membrane and weakly to the cytoplasm of<br />

proximal tubular cells. No signal for this protein in the other cells of rat kidney was found.<br />

A<br />

B<br />

Fig. 1. 1-day old rat kidney – D1. Immunohistochemical detection of Pgp/MDR1 by monoclonal antibody:<br />

mouse anti-MDR1 - clone C219 (A), UIC2 – clone C494 (B). Positive expression of Pgp/MDR1 in proximal<br />

tubular epithelial cells of rat kidney – cytoplasmic staining (A, B).


24<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

A<br />

B<br />

Fig. 2. Pgp/MDR1 was expressed in epithelial cells of proximal tubules in 7-day old rat kidney - D7 (A) and adult<br />

kidney (B) by mononoclonal antibody: mouse anti-MDR1 – clone C219. The remaining structures (epithelial cells<br />

of distal tubules, glomerulus and glomerular capsule) did not show any positivity for Pgp/MDR1.<br />

DISCUSSIOn<br />

Knowledge of the ontogeny about transport proteins involved in distribution and elimination<br />

of drugs is important for adequate interpretation of the results of safety studies<br />

in juvenile animals. Since rat is one of the most frequently species used in non-clinical<br />

testing we used this species in our study on the age-dependent changes in Pgp/MDR1<br />

expression. We focused on the age shortly after birth until early adulthood of the animals<br />

(D1, D7, D14, D21, Ad). The transport proteins in the kidney are involved in the passage of<br />

compound through the tubular epithelial cells, prior to urinary excretion. Urinary excretion<br />

of drugs is a complex interplay of three mechanisms: glomerular filtration, tubular<br />

secretion, and tubular reabsorption. The basic prerequisite for excretion into urine is water<br />

solubility of drug and/or its metabolites as no transporting carrier is available in this body<br />

fluid. Accordingly, the primary mechanism for drug excretion is glomerular filtration, a<br />

passive process influenced by molecule size, concentration of unbound fraction of drug in<br />

plasma and renal blood perfusion. Tubular secretion and partly also reabsorption are active<br />

mechanisms requiring transporters. The function of renal proximal tubular epithelial<br />

cells is the most significant factor for active drug renal excretion (17).<br />

The large differences in ontogeny of the individual transport proteins were observed,<br />

with some transporters having the highest expression at birth (MRP1 and MRP3), and<br />

other having a more or less constant expression during development (MRP2 and BCRP)<br />

(18). It was reported that Pgp/MDR expression increased up to Day 26, with a subsequent<br />

decrease to adult levels at Day 42 (18). On the other hand, other authors found<br />

continuously increasing level of Pgp/MDR1 up to Day 60 (19). In our study we have<br />

found relatively constant levels of Pgp/MDR1 protein from the birth to the adulthood.<br />

It should be noted that all our data on transport protein is limited to actual functionality<br />

of Pgp/MDR1. The mRNA expression of this transporter was not studied such<br />

as in previous mentioned publications. The reason for the differences between the data<br />

obtained in our study and those already published, as well as the differences between<br />

individual publications, are most likely related to differences in methodology (sample<br />

preparation, differences in diet, etc.).<br />

Despite these differences, the results indicate that expression of majority of the transport<br />

proteins studied vary during development. Cellular and tissue distribution as well<br />

as elimination of transported substrates will therefore also change during development.<br />

Knowledge of these ontogenic differences in absorption, distribution, metabolism and<br />

excretion (ADME) processes of test compound in development may help to interpret differences<br />

in toxicity observed between adult, neonate and young animals.


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 25<br />

REFEREnCES<br />

1. Ambudkar SV, Dey S, Hrycyna CA, Ramachandra M, Pastan I, Gottesman MM. Biochemical, cellular, and<br />

pharmacological aspects of the multidrug transporter. Annu Rev Pharmacol Toxicol. 1999; 39:361-98.<br />

Review.<br />

2. Stavrovskaya AA. Cellular mechanisms of multidrug resistance of tumor cells. Biochemistry (Mosc).<br />

2000; 65(1):95-106. Review.<br />

3. Higgins C. F. Multiple molecular mechanisms for multidrug resistance transporters.<br />

4. Nature 2007; 446, 749-757.<br />

5. Dean M, Rzhetsky A, Allikmets R. The human ATP-binding cassette (ABC) transporter superfamily.<br />

Genome Res. 2001; 11(7):1156-66. Review.<br />

6. Neyfakh AA. Mystery of multidrug transporters: the answer can be simple. Mol Microbiol. 2002;<br />

44(5):1123-30. Review.<br />

7. Sarkadi B, Homolya L, Szakács G, Váradi A. Human multidrug resistance ABCB and ABCG transporters:<br />

participation in a chemoimmunity defense system. Physiol Rev. 2006; 86(4):1179-236. Review.<br />

8. Stavrovskaya AA, Stromskaya TP. Transport proteins of the ABC family and multidrug resistance of<br />

tumor cells. Biochemistry (Mosc). 2008; 73(5):592-604. Review.<br />

9. Bosch I, Croop J. P-glycoprotein multidrug resistance and cancer. Biochim Biophys <strong>Acta</strong>. 1996;<br />

1288(2):F37-54. Review.<br />

10. Goldstein LJ, Gottesman MM, Pastan I. Expression of the MDR1 gene in human cancers. Cancer Treat<br />

Res. 1991; 57:101-119. Review.<br />

11. Schinkel AH, Jonker JW. Mammalian drug efflux transporters of the ATP binding cassette (ABC) family:<br />

an overview. Adv Drug Deliv Rev. 2003; 55(1):3-29. Review.<br />

12. Thiebaut F, Tsuruo T, Hamada H, Gottesman MM, Pastan I, Willingham MC. Cellular localization of the<br />

multidrug-resistance gene product P-glycoprotein in normal human tissues. Proc Natl Acad Sci U S A.<br />

1987; 84(21):7735-7738.<br />

13. Ernest S, Bello-reuss E. P-glycoprotein functions and substrates: possible roles of MDR1 gene in the<br />

kidney. Kidney Int 1998; 65: S11-S17.<br />

14. Shinkel AH. The physiological function of drug-transporting P-glycoproteins. Semin Cancer Biol 1997;<br />

8:161-170.<br />

15. Eraly SA, Blantz RC, Bhatnagar V, Nigam SK. Novel SK. Novel aspects of renal organic anion and cation<br />

transporters. Curr Opin Nephrol Hypertens 2003; 12: 551-558.<br />

16. Gottesman MM and Pastan I. Biochemistry of multidrug resistance mediated by multidrug transporter.<br />

Annu Rev Biochem 1993; 62: 385-427.<br />

17. Inui KI, Masuda S, Saito H. Cellular and molecular aspects of drug transport in the kidney. Kidney Int<br />

2000; 58: 944-958.<br />

18. Lash LH, Putt DA, Cai H. Drug metabolism enzyme expression and activity in primary cultures of human<br />

proximal tubular cells. Toxicology 2008, 244:56-65.<br />

19. de Zwart L, Scholten M, Monbaliu JG, Annaert PP, Van Houdt JM, Van den Wyngaert I, De Schaepdrijver<br />

LM, Bailey GP, Coogan TP, Coussement WC, Mannens GS. .The ontogeny of drug metabolizing enzymes<br />

and transporters in the rat. Reprod Toxicol. 2008, 26(3-4):220-230.<br />

20. Rosati A, Maniori S, Decorti G, Candussio L, Giraldi T, Bartoli F. Physiological regulation of P-glycoprotein,<br />

MRP1, MRP2 and cytochrome P450 3A2 during rat ontogeny. Dev Growth Differ. 2003 Aug;45(4):377-387.<br />

Acknowledgement: This work was supported partly by grant VEGA 1/0388/08 and partly by grant VVGS<br />

25/10-11.<br />

Received: November,12,2010<br />

Accepted: December,16,2010


26<br />

ACTA MEDICA MARTINIANA 2011 11/1<br />

DOI: 10.2478/v10201-011-0004-x<br />

InVEStIGAtInG DYSPEPSIA In CLInICAL PRACtICE – A tRAP<br />

FOR GIARDIA<br />

Banovcin P. Jr., Demeter M., Bozikova J., Hyrdel R.<br />

Department of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine, Commenius University<br />

and University Hospital Martin, Slovak Republic<br />

ABStRACt<br />

Introduction: Dyspepsia is a very common condition with significant morbidity and economic implications.<br />

Dyspeptic symptoms have heterogeneous pathogenic mechanisms, including several organic, systemic or<br />

extragastrointestinal causes, however, origin of the most cases of dyspepsia remains unclear. This study aimed<br />

to focus on potential causes in patients with nonspecific dyspeptic symptoms in absence of organic, systemic<br />

or biochemical and hematological findings that readily explain their symptoms.<br />

Methods: We studied presence of persistent abdominal symptoms (heartburn, dull epigastric pain, epigastric<br />

cramps, epigastric fullness, flatulence, diarrhoea), weight loss. All patients (116 patients, 29 males/87 females)<br />

had normal laboratory tests, negative abdominal ultrasound evaluation and upper endoscopy findings.<br />

Presence of Giardia intestinalis (GI), Helicobacter pylori (HP) infection and coeliac disease (CD) was evaluated<br />

by obtaining biopsy samples and duodenal fluid aspiration during upper endoscopy. We determined the effect<br />

of eradication treatment on dyspepsia symptoms 2 months after therapy.<br />

Results: HP infection was present in 28 %, coeliac disease in 6 %, GI infection was diagnosed in 27 % patients<br />

GI and HP in 12 %, CD and HP in 1 %, GI and CD in 2 %. None of these causes were presented in 39 %. Most<br />

frequent symptoms were epigastric fullness (69 %), dull epigastric pain (38 %), heartburn (35 %), flatulence<br />

(34 %), abdominal cramps (31 %) and diarrhoea (16 %). We documented the remission of symptoms in 79 %<br />

examined patients 2 month after eradication therapy.<br />

Conclusion: The most common cause of dyspepsia was Helicobacter pylori infection and chronic giardiasis.<br />

Although H. pylori and coeliac disease are widely well known, we pointed out Giardia intestinalis as another<br />

possible cause of dyspepsia. Chronic giardiasis leads in selected individuals to dyspeptic symptomatology that<br />

mimics functional dyspepsia and irritable bowel syndrome. We recommend test for G. intestinalis infection in<br />

all patients with chronic dyspeptic complaints of unknown origin.<br />

Key words: Dyspepsia, functional dyspepsia, Giardia intestinalis, Helicobacter pylori, coeliac disease<br />

IntRODUCtIOn<br />

Dyspepsia is a very common condition with significant morbidity and economic implications.<br />

Around 25-40 % of adults in the general population have dyspepsia, but the prevalence<br />

and incidence depend on population study design, observation period, and definition<br />

of dyspepsia, itself (1,2). According to the Czech study, the prevalence of long-lasting<br />

dyspeptic symptoms in uninvestigated dyspepsia was 17 % (3). Dyspepsia accounts for<br />

2-5 % of primary care consultations, but patients that are most affected often do not seek<br />

medical care (4). A large number of patients in clinical practice present symptoms such<br />

as epigastric pain, abdominal cramps, excessive belching, early satiation, postprandial<br />

fullness or nausea. The dyspeptic symptoms can have several organic, systemic or extragastrointestinal<br />

causes. However, the origin of most of the cases of dyspepsia remains<br />

unclear. When these symptoms are chronic and occur in the absence of organic disease<br />

that readily explains them, patients are considered to have a functional gastroduodenal<br />

disorder (5). Functional dyspepsia remains a diagnosis of exclusion. The therapeutical<br />

Address for correspondence:<br />

Banovcin P.Jr. MD, Clinic of Internal Medicine, Gastroenterology Dept., Jessenius Faculty of Medicine<br />

CU and University Hospital in Martin, Kollarova Str. N. 2, 03601 Martin, Slovak Republic<br />

email: pbanovcin@gmail.com


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 27<br />

and diagnostical processes are often not optimal and still controversial. Due to these<br />

facts we focused on potential causes of non-specific dyspeptic symptomatology.<br />

Giardia intestinalis (also known as Giardia lamblia and Giardia duodenalis) is an<br />

enteric protozoan pathogen found in a variety of mammalian hosts, including humans,<br />

and causes one of the most common parasitic infections worldwide. It contributes to<br />

estimate of 280 million symptomatic human infections per year (6). One of the major<br />

sources of infection in humans is contaminated water; however, there is evidence that<br />

the parasite is transmitted by human-to-human contact or by the contact with the<br />

domestic or wild animals (7). The symptoms of human giardiasis are highly variable.<br />

They vary from asymptomatic to severe form with diarrhoea, fever, weight loss and malabsorbtion.<br />

Most prominent clinical symptoms are abdominal pain, vague abdominal<br />

discomfort, bloating, flatulence and diarrhoea. Various extra-intestinal manifestations<br />

have been reported such as maculopapular rush, pulmonary infiltrates, polyarthritis<br />

and urticaria (8, 9). Chronic courses are common, but are mostly asymptomatic or presented<br />

by non-specific mild symptoms that may result in a low clinical index of suspicion<br />

for the diagnosis. Chronic infection may be linked to the phenomenon of antigenic<br />

variation and individual response of the host. Recent data show that Giardia intestinalis<br />

infection has been found to trigger abdominal symptoms of functional gastrointestinal<br />

disorder such as irritable bowel syndrome or functional dyspepsia. (10,11,12)<br />

MAtERIAL AnD MEtHODS<br />

We enrolled to our study 116 patients (29 males/87 females) aged 18 years and over attending<br />

Gastroenterology Outpatient Unit due to chronic dyspeptic symptoms. Patients<br />

with persistent abdominal dyspeptic symptoms in duration at least 3 months were considered<br />

for the study. Patient with the alarm features (such as dysphagia, odynophagia,<br />

vomiting, bleeding or rapid weight loss) as well pregnant women and patients familiarly<br />

for malignant disease were excluded. All patients underwent complex physical examination,<br />

routine biochemical and hematological blood laboratory tests.<br />

Furthermore, ultrasound evaluation including hepatobiliary tract, pancreas, kidneys and<br />

upper endoscopy were performed. All examination had not produced relevant explanation<br />

for dyspepsia. Upper gastrointestinal endoscopy was accompanied by obtaining of<br />

multiplied biopsy samples from gastric antrum to investigate presence of Helicobacter<br />

pylori (H. pylori) infection. Duodenal biopsy samples (D2-D3) and serum anti-gliadin,<br />

anti-endomysial and anti-transglutaminase antibodies estimation was used to evaluate<br />

coeliac disease. Presence of Giardia intestinalis infection was performed by direct<br />

examination of duodenal juice aspirate. Aspiration of duodenal fluid was performed on<br />

the fasting patient, during the endoscopy so the position of the aspiration tube was correctly<br />

placed in the distal duodenum or proximal jejunum. Aspirates were immediately<br />

transported in sterile containers in a tempered medium to microbiology laboratory. The<br />

samples were processed within 2 hours for microscopic examination.<br />

We studied presence of H. pylori infection, G. intestinalis and coeliac disease and its<br />

relative contribution to overall dyspeptic symptoms (heartburn, dull epigastric pain, epigastric<br />

cramps, epigastric fullness, flatulence, diarrhoea). After identification of possible<br />

cause, appropriate treatment was initiated (eradication of H. pylori, gluten-free diet in coeliac<br />

disease and therapy with metronidazole 250 mg tid. In the case of giadriasis, we determined<br />

the effect of eradication treatment on functional dyspepsia symptoms 2 months<br />

after therapy. Statistical analysis was performed using the program PAST version 1.80.


28<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

RESULtS<br />

One hundred and sixteen patients (87F, 29M) fulfilled the inclusion criteria. The mean<br />

age of patients was 37.3 (18-67years). Giardia intestinalis infection was diagnosed in 27<br />

% of the patients. H. pylori infection was found in 28 %, coeliac disease in 6 %. Both<br />

G. intestinalis and H. pylori were present in 12 %, coeliac disease and H. pylori in 1 %,<br />

giardiasis and coeliac disease in 2 %. There were 39 % of the patients that did not exemplify<br />

any of the causes mentioned. Figure1. Most frequent symptoms were epigastric fullness<br />

(69 %), dull epigastric pain (38 %), heartburn (35 %), flatulence (34 %), abdominal<br />

cramps (31 %), and diarrhoea (16 %) Figure 2. Comparing frequency of symptoms, we<br />

didn’t confirmed statistically significant differences among investigated groups. Average<br />

lenght of dyspeptic syndrome history was 18.5 months and average weight loss was 2 kg.<br />

45%<br />

40%<br />

39%<br />

35%<br />

30%<br />

25%<br />

27%<br />

28%<br />

20%<br />

15%<br />

12%<br />

10%<br />

5%<br />

0%<br />

6%<br />

2%<br />

1%<br />

GI -total HP - total CD - total HP + GI HP + CD GI + CD Unkonwn<br />

Fig. 1. Summary of potential dyspepsia causes in study patients (totally). Giardia intestinalis (GI), Helicobacter<br />

pylori (HP) and coeliac disease (CD).<br />

80%<br />

70%<br />

60%<br />

50%<br />

40%<br />

30%<br />

Total=116<br />

Females n=87<br />

Males n=29<br />

20%<br />

10%<br />

0%<br />

Dull pain Cramps Heartburn Epigastric<br />

fullness<br />

Flatulence<br />

Diarrhoea<br />

Fig. 2. Prevalence of selected dyspepsia symptoms in study patients (totally)


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 29<br />

In the Giardia positive group was the most frequent symptom was epigastric fullness<br />

(86 %), dull epigastric pain (50 %). Frequencies of other symptoms are shown in Figure<br />

3. Average length of dyspeptic syndrome was 23.3 months in total G. intestinalis<br />

infection (32 months in isolated infection) with weight loss of 2.8kg (3.5 giardia isolated).<br />

Fourteen patients with giardiasis (43 %) had simultaneous H. pylori infection. We<br />

documented the remission or significant improvement of symptoms in 79 % of Giardia<br />

positive patients 2 month after therapy (treatment with metronidazole). Approx. 7 % of<br />

patients did not response to therapy, and 14 % of the patients cancelled their follow up,<br />

thus we do not have any response for that group. Figure 4.<br />

100%<br />

90%<br />

80%<br />

70%<br />

60%<br />

50%<br />

40%<br />

30%<br />

20%<br />

10%<br />

0%<br />

38%<br />

50%<br />

Dull<br />

epigastric<br />

pain<br />

22%<br />

29%<br />

Abdominal<br />

cramps<br />

35%<br />

43%<br />

Heartburn<br />

80%<br />

86%<br />

Epigastric<br />

fullness<br />

35%<br />

36%<br />

Flatulence<br />

19%<br />

29%<br />

Diarrhoea<br />

GI total /n=31/<br />

GI isolated /n=14/<br />

Fig. 3. Prevalence of symptoms in Giardia intestinalis positive patients.<br />

Fig. 4 Effect of 14 days metronidasole 250mg tid. treatment on dyspepsia symptoms. Evaluated 2 months<br />

after treatment.<br />

Persistence of symptoms after therapy in patienst with GI<br />

7%<br />

14%<br />

remission<br />

persist<br />

not known<br />

79%


30<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

DISCUSSIOn<br />

Dyspepsia is common and global problem with board differential. This study aimed<br />

to focus on patients with nonspecific dyspeptic symptoms in absence of organic, systemic<br />

or biochemical and hematological findings that explain their symptoms. In order<br />

to prevent serious illness, patient complaining of alarm symptoms were excluded. The<br />

negative aspect of this study was our failure to fulfill the diagnosis of functional gastrointestinal<br />

disorders according to ROME III criteria. However, the aim of the study was<br />

to identify other possible agents that may contribute to development of gastrointestinal<br />

symptoms. The role of H. pylori in functional disease has been controversial. Recent<br />

meta-analyses suggest some benefit from H. pylori eradication (13). In our findings was<br />

the H. pylori infection most common agent. After eradication therapy, 72 % of patients<br />

reported benefits from this therapy.<br />

Coeliac disease was diagnosed in 6 %. As expected, flatulence fullness and diarrhoea<br />

were the dominant symptoms, but not significantly different from other groups. On the<br />

other hand, in our study were not sufficiently many patients with coeliac disease to<br />

conclude any decision.<br />

Incidence of giardiasis varies from 20 % to 60 % in endemic areas and 2-7 % in industrialized<br />

countries depending on region and age (6). We found out that 27 % of studied<br />

patients had giardia infection. The rate is higher compared to general population in<br />

western countries mostly due to selection of symptomatic patients.<br />

Traditional diagnosis of giardiasis is set by the direct detection of trophozoites or cysts<br />

in a stool sample; however, repeated stool examinations are needed to avoid false-negative<br />

results, because cyst excretion may be intermittent. This may be difficult sometime<br />

in outpatient units because of patient compliance. The data show that histological examination<br />

of duodenal biopsies is unsuitable (15,16,17). In recent years, rapid diagnostic<br />

tests that use antigen detection methods or PCR have been employed. These tests are<br />

both highly specific and sensitive, but still expensive (14). The specificity and sensitivity<br />

is also questionable in case of chronic giardiasis. Diagnosis of Giardia intestinalis in our<br />

study was performed by microscopic evaluation of duodenal juice aspirate. There are<br />

studies that show yields of microscopic examination of duodenal aspirate that vary from<br />

0.7 % to 47.6 % (15,16). There is disadvantage to duodenal fluid aspiration in that it is<br />

performed during endoscopy therefore it is not suitable for routine screening. Another<br />

disadvantage of this evaluation is that aspirate should be preceded within 2 hours of<br />

aspiration and transported in temperate medium.<br />

Giardia intestinalis infection in humans has a wide spectrum of clinical manifestation<br />

ranging from asymptomatic to serious diarrhoea. In our study the most frequent symptom<br />

was abdominal fullness and diarrhoea followed by heartburn, dull epigastric pain<br />

abdominal cramps, and flatulency. There were no symptoms or symptom-complex that<br />

reliably allowed the recognition of giardiasis. Again our results were similar to previously<br />

published studies. (17,18)<br />

The pathophysiology of these symptoms in giardia infection has not been well understood.<br />

The possible mechanisms include direct damage to the intestinal brush and<br />

mucosa resulting in secondary lactose intolerance, reduced intestinal absorption and<br />

deconjugation of bile salts. Recent hypothesis also suggests induction of apoptosis in<br />

intestinal epithelial cells and disruption of tight junctional zona-occludens followed by<br />

increased epithelial permeability across epithelial monolayers. (19,20, 23) Compared to<br />

other studies, diarrhoea was not so common feature in our study. as reported from in<br />

endemic areas. This difference might be caused by low initial dose of giardia cysts, in<br />

non-endemic area therefore the host is able to maintain parasite count at very low level,<br />

or it may be due to the distribution of different pathogenic strains. But this assumption<br />

is highly speculative. The association with clinical manifestation and parasite genotype<br />

is not definitive to date (18,21,22).


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 31<br />

In our study, the mean age of patients with giardiasis was slightly lower (not significantly)<br />

compared to patients with H. pylori infection and in the group without any findings.<br />

It is well know, that giardiasis is more common in children and adolescents (28).<br />

From this point of view, age may have some attribution in diagnostic process in uninvestigated<br />

dyspepsia and related symptoms.<br />

Duration of symptoms was longest in patients with giardiasis. Possible reason of delayed<br />

diagnosis is that the G.intestinalis is generally considered to be on low degree of<br />

suspicion in non-endemic countries in comparison with the well-known H. pylori.<br />

Importantly, we documented total remission of symptoms in 79 % examined patients<br />

with G. intestinalis infection after 14-days course treatment with metronidazole at<br />

250mg tid. There were no statistically significant differences in symptoms distribution<br />

or metronidazole therapy effect on them in all G. intestinalis positive patients.<br />

Another finding was that giardiasis was associated with H. pylori infection. H. pylori<br />

was found in 14 patients of the 31 patients with giardiasis. This possibly reflects the<br />

fact that both G. intestinalis and H. pylori share similar risk factors (24). There is existing<br />

literature and data supporting possible synergy effect of infections, however, in our<br />

study were no significant differences between the giardia groups in symptoms presentation<br />

or distribution. Some authors suggest possible synergistic participation leading to<br />

metronidasole resistance and gastrointestinal neoplasia (24,25,26,27).<br />

Causal treatment of dyspesia led to resolution of dyspeptic symptoms; however in<br />

almost 39 % patients we did not find the cause of dyspepsia. Such patients are hypothesized<br />

to have functional gastrointestinal disorder. Given that functional gastrointestinal<br />

disorders are the diagnosis per exlusionem, further examinations are needed to proof<br />

the diagnosis according to ROME III criteria.<br />

COnCLUSIOn<br />

Chronic dyspeptic syndrome is a frequent problem of patients visiting gastroenterology<br />

outpatient unit. In our study most common cause of dyspepsia were Helicobacter<br />

pylori infection, chronic giardiasis and coeliac disease. Although H. pylori and coeliac<br />

disease are widely well known, we pointed out another possible cause of dyspepsia. According<br />

to our data, we are suggesting that chronic Giardia intestinalis infection leads<br />

to nonspecific dyspeptic symptomatology in selected individuals that mimics functional<br />

dyspepsia and irritable bowel syndrome. We recommend test GI infection in all patients<br />

with chronic dyspeptic complaints of unknown origin,<br />

REFEREnCES<br />

1. Talley NY, Vakil NB, Moayyedi P. American Gastroenterological Association technical review on the<br />

evaluation of dyspepsia. Gastroenterology2005;129:1756-80.<br />

2. McQuaid KR. Dyspepsia. In: Feldman M, Friedmann LS, Brandt LJ, editors. Sleisenger & Fordtran’s<br />

gastrointestinal and liver disease. 8th ed. Philadelphia: Saunders Elsevier; pp. 2006;121–142.<br />

3. Rejchrt S, Koupil I, Kopacova M, Vorisek V, Seifert B, Pozler O, Zivny P, Douda T, Palicka V, Holcik J, Bures<br />

J, European society for Primary care Gastroenterology. Prevalence and sociodemografic determinants of<br />

uninvestigated dyspepsia in the Czech republic.; Eur J gastroenterol Hepatol. 2008;Sep;20(9):898-905<br />

4. Baron JH, Sonnenberg A. Hospital admissions and primary care attendances for non ulcer dyspepsia,<br />

reflux oesophagitis and peptic ulcer in Scotland 1981-2004. Eur J Gastroenterol Hepatol 2008;20:180-6.<br />

5. Tack J, Talley NJ, Camilleri M et al. Functional gastroduodenal disorders. Gastroenterology 2006;130:1466–<br />

1479.<br />

6. WHO Protozoan Parasites (Cryptosporidium, Giardia, Cyclospora). Microbiological Agents in Drinking<br />

Water, 2nd edition. Addendum; 2002.<br />

7. Hunter PR, Thompson RC. The zoonotic transmission of Giardia and Cryptosporidium.Int J Parasitol.<br />

2005; Oct;35(11-12):1181-90.


32<br />

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8. M. Letts, D. Davidson and F. Lalonde, Synovitis secondary to giardiasis in children, Am J Orthop 1998;27<br />

pp. 451–454<br />

9. Nenoff P, Domula E, Willing U, Herrmann J.Giardia lamblia-cause of urticaria and pruritus or accidental<br />

association? Hautarzt. 2006;Jun;57(6):518-20, 521-2.<br />

10. Hanevik K, Dizdar V, Langeland N, Hausken T. Development of functional gastrointestinal disorders after<br />

Giardia lamblia infection. BMC Gastroenterol.2009; 9: 27.<br />

11. D’Anchino M, Orlando D, De Feudis L. Giardia lamblia infections become clinically evident by eliciting<br />

symptoms of irritable bowel syndrome. J Infect 2002; 45:169-172.<br />

12. Grazioli B, Matera G, Laratta C, Schipani G, Guarnieri G, Spiniello E, et al. Giardia lamblia infection in<br />

patients with irritable bowel syndrome and dyspepsia: a prospective study. World J Gastro-enterol 2006;<br />

12:1941-1944.<br />

13. Moayyedi P, Soo S, Deeks J, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Roalfe A, Bennett C,<br />

Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia. Cochrane Database Syst Rev. 2006<br />

Apr 19;(2):CD002096.<br />

14. Garcia LS, Shimizu RY. Evaluation of nine immunoassay kits (enzyme immunoassay and direct<br />

fluorescence) for detection of Giardia lamblia and Cryptosporidium parvum in human fecal specimens. J<br />

Clin Microbiol 1997; 35:1526-1529<br />

15. Diagnostic yield of duodenal aspirate for G. lamblia and comparison to duodenal mucosal biopsies.Gupta<br />

SK, Croffie JM, Pfefferkorn MD, Fitzgerald JF. Dig Dis Sci. 2003 Mar;48(3):605-7.<br />

16. McHenry R, Bartlett MS, Lehman GA, O’Connor KW: The yield of routine duodenal aspiration for Giardia<br />

lamblia during esophagogastroduodenoscopy. Gastrointest Endosc 1987; 6:425–426.<br />

17. Yakoob J, Jafri W, Abid S, Jafri N, Hamid S, Shah HA, Rizvi L, Islam M, Shaikh H. Giardiasis in patients<br />

with dyspeptic symptoms. World J Gastroenterol. 2005;Nov 14;11(42):6667-70<br />

18. Read CM, Walters J, Robertson ID, Thompson RCA Correlation between genotype of Giardia duodenalis<br />

and diarrhoea. Int J Parasitol 2002; 32:229–231<br />

19. Chin AC, Teoh DA, Scott KG, et al. Strain-dependent induction of enterocyte apoptosis by Giardia lamblia<br />

disrupts epithelial barrier function in a caspase-3-dependent manner. Infect Immun 2002; 70:3673-3680<br />

20. Scott KG, Meddings JB, Kirk DR, et al. Intestinal infection with Giardia spp. reduces epithelial barrier<br />

function in a myosin light chain kinase-dependent fashion. Gastroenterology 2002; 123:1179-1190<br />

21. Homan WL, Mank TG. Human giardiasis. genotype linked differences in clinical symptomatology. Int J<br />

Parasitol 2001; 31:822-826<br />

22. Sahagun J, Clavel A, Goni P, Seral C, Llorente MT, Castillo FJ, Capilla S, Arias A, Gomez-Lus R. Correlation<br />

between the presence of symptoms and the Giardia duodenalis genotype. Eur J Clin Microbiol Infect Dis<br />

2008; 27(1):81-83<br />

23. Das S, Schteingart CD, Hofmann AF, Reiner DS, Aley SB, Gillin FD. Giardia lamblia: evidence for carriermediated<br />

uptake and release of conjugated bile acids..Exp Parasitol. 1997; Oct;87(2):133-41.<br />

24. Moreira ED Jr, Nassri VB, Santos RS, Matos JF, de Carvalho WA, Silvani CS, Santana CS. Association of<br />

Helicobacter pylori infection and giardiasis: results from a study of surrogate markers for fecal exposure<br />

among children. World J Gastroenterol 2005; 11: 2759-2763<br />

25. Abou Holw SA, Anwar MM, Heshmat MG, Enany AY, Rashad MM. Effect of concommitant Helicobacter<br />

pylori infection in patients with Giardia lamblia in Egypt. J Egypt Soc Parasitol. 2009; Aug;39(2):439-46.<br />

26. Land KM, Johnson PJ. Molecular basis of metronidazole resistance in pathogenic bacteria and protozoa.<br />

Drug Resist Update 1999; 2: 289-294<br />

27. Patterson MM, Schrenzel MD, Feng Y, Fox JG. Gastritis and intestinal metaplasia in Syrian hamsters<br />

infected with Helicobacter aurati and two other microaerobes. Vet Pathol 2000; 37: 589-596<br />

28. Farthing MJ. Giardiasis. Gastroenterol Clin North Am 1996; 25: 493–515<br />

Received: December,1,2010<br />

Accepted: January,6,2011


ACTA MEDICA MARTINIANA 2011 11/1<br />

DOI: 10.2478/v10201-011-0005-9<br />

33<br />

POInt PREVALEnCE SURVEY OF nOSOCOMIAL InFECtIOnS In<br />

UnIVERSItY HOSPItAL In MARtIn<br />

Zabkova E., Murajda L., Hudeckova H.<br />

Department of Public Health, Jessenius Faculty of Medicine, Comenius University, Slovak Republic<br />

Abstract<br />

Nosocomial infections (NI) are a serious problem not only in Slovakia but in all countries. The European<br />

Commission decided on their standardized surveillance in the whole European Union. According methodology<br />

elaborated by experts from the European Centre for Disease Control and Prevention (ECDC) in Stockholm we<br />

performed a point prevalence survey in the University Hospital Martin (UHM). In this article we present the<br />

results which show that the prevalence of NI in UHM (5.5 %) is comparable with the average in other European<br />

hospitals. In comparison with occurrence of NI (0.64 %) reported through the Epidemiological Information<br />

System of the Slovak Republic, our results are 8.5-times higher. The highest point prevalence of NI was found<br />

at the Clinic of Hematology and Transfusiology – 7 patients (out of 15 hospitalized) which is 46.7 %. The most<br />

common type of NI was sepsis (25.9 %) and urological infection (22.2 %). Based on the results obtained we<br />

recommend to continue in international projects of NI surveillance, so that it would be possible to acquire<br />

more accurate data on NI prevalence in UHM and do the benchmarking among hospitals in countries of the<br />

European Union.<br />

Key words: nosocomial infection, prevalence, University Hospital Martin<br />

IntRODUCtIOn<br />

A nosocomial infection (NI) is defined in Slovak legislation as an infection of internal<br />

or external origin, which occurred in direct relation with hospital stay or healthcare<br />

performance in a healthcare facility or social care facility (1).<br />

Centers for Disease Control and Prevention (CDC) in USA defines nosocomial infections<br />

as infections which occurred in a healthcare facility, were not present at admission<br />

and the patient was not in incubation period of the relevant infection at admission. If<br />

incubation period is unknown, an infection is considered nosocomial when occurred<br />

later than 48-72 hours after admission to hospital. Infection present at admission can<br />

be considered as nosocomial only if it is epidemiologically related to a precedent hospitalization.<br />

All other infections are considered as community acquired. The CDC has also<br />

specific diagnostic criteria for the infection types. Using these criteria and same methods<br />

of surveillance enables mutual comparability of the acquired data (2).<br />

The NI occurrence is watched in Slovakia through an obligatory reporting. Regulation<br />

of the Ministry of Health of Slovak Republic No. 553/2007 on requirements for healthcare<br />

facilities about health protection, sets for providers of healthcare and for healthcare<br />

workers a duty to avoid NI and to register NI in patient records and in a diary of NI, to<br />

perform an analysis of NI occurrence and of the reasons of their occurrence and to apply<br />

measures to decrease the occurrence, stop spread of NI and prevent them.<br />

The chief doctor of a ward has to inform the Regional Public Health Authority in 48<br />

hours by a written form. If there is an outbreak or clinically serious NI, death or suspicion<br />

of death for NI, reporting is performed immediately – personally, by telephone, fax<br />

or email. NI outbreak is an incidence of at least three cases of the same NI, which are in<br />

epidemiological relationship (3).<br />

Address for correspondence:<br />

Eva Zabková, Department of Public Health JFM CU<br />

Sklabinská Str. N. 26, 036 01 Martin, Slovak Republic, e-mail: evka.zabkova@gmail.com.


34<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

Analysis of occurrence of NI is annually published in the Annual report on activities<br />

of public health authorities in the Slovak Republic, published by the Public Health Authority<br />

of the Slovak Republic. Through the Regional Public Health Authority in Banská<br />

Bystrica the information on NI has been published since 2006 on web pages of the Epidemiological<br />

Information System (EPIS), too.<br />

MEtHODS<br />

We used a point prevalence survey to estimate prevalence of nosocomial infections in<br />

University Hospital Martin.<br />

The survey was realized from June 22nd till July 8th, 2010. Performing of the study<br />

was approved by the Ethical Committee of the Regional Public Health Authority in Martin.<br />

Collection of data at each ward had to be finished during the same day it started. The<br />

maximum lenght of survey for the whole hospital was set to three weeks. For privacy<br />

protection, every patient in the survey was given a code and his/her data were registered<br />

in database only under this code.<br />

We used the definitions of different types of NI from the Codebook by ECDC (4).<br />

There were two criteria for the study group. First, regarding the wards – only the acute<br />

care wards were included and the long-term care wards were excluded. The second was<br />

about patients – all patients admitted to the ward before 8.00 am and not discharged<br />

from the ward at the time of the survey were included.<br />

Our team consisted from researchers from the Department of Public Health of the Jessenius<br />

Faculty of Medicine, Comenius University, Regional Public Health Authority in Martin<br />

and the University Hospital Martin. These visited in three weeks according a set schedule all<br />

acute care wards of the hospital and in collaboration with appointed doctors at the wards<br />

they assessed data from patient records and registered active nosocomial infections according<br />

the definitions used in the survey. We processed and analyzed the results in Microsoft Excel.<br />

RESULtS<br />

There were 495 patients included in the survey, 268 men (54.1 %) and 227 women<br />

(45.9 %), with average age 51.5 years (min. 0, max. 89 years).Out of all patients included<br />

in the survey, there were 5.5 % patients found with an active NI. The average age of patients<br />

with NI was 50 years (min.0, max.85 years). We found NI in 44.4 % of women (12<br />

NI) and in 55.6 % of men (15 NI).<br />

22.2%<br />

18.6%<br />

11.1%<br />

22.2%<br />

PN<br />

UTI<br />

BSI<br />

EENT<br />

OTH<br />

25.9%<br />

Fig. 1. Prevalence of nosocomial infections at University Hospital Martin Legends for Fig.1 and Fig.5:<br />

PN – Pneumonia; UTI – Urinary tract infection; BSI – Bloodstream infection; EENT – Eye, Ear, Nose or Mouth<br />

infection; OTH – other; (according CDC definitions).


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 35<br />

The NI prevalence according age groups is on Figure 2.<br />

HI (abs.)<br />

7<br />

6<br />

5<br />

4<br />

3<br />

2<br />

1<br />

0<br />

0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85-<br />

age groups<br />

Fig. 2. Prevalence of nosocomial infections according age groups<br />

We present character distribution of NI found at the clinics visited on the following<br />

picture.<br />

PED<br />

25,93%<br />

14,81%<br />

14,81%<br />

11,11% 11,11%<br />

11,11%<br />

11,11%<br />

OR THO<br />

I.INT<br />

II. INT<br />

NE ON<br />

HAE M<br />

OTH<br />

Fig. 3. Proportion of nosocomial infections at clinics of University Hospital Martin<br />

Legends for Fig. 3, Fig. 4 and Fig. 5: PED – Paediatrics; ORTHO – Orthopaedics and<br />

Traumatology; I. INT – General Medicine; II. INT – Gastroenterology; NEON – Neonatology;<br />

HAEM – Haematology; NEUROL – Neurology; I.SUR - General Surgery; II.SUR –<br />

Transplant and Vascular Surgery; OTH – Other.<br />

On Figure 4 there is prevalence of NI at the clinics of UHM. At nine clinics the prevalence<br />

of NI was from 2.8 % to 46.7 %. At other clinics there was not found any NI during<br />

the survey.


36<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

HI%<br />

50<br />

46,7<br />

45<br />

40<br />

35<br />

30<br />

25<br />

20<br />

15 11,8<br />

10 10,3<br />

8,1<br />

8<br />

10<br />

5,9<br />

6<br />

5<br />

2,8<br />

0<br />

PED<br />

OR THO<br />

NE UR OL<br />

I. S UR<br />

II. SUR<br />

I.INT<br />

II. IN T<br />

NE ON<br />

Fig. 4. Prevalence of nosocomial infections at clinics of University Hospital Martin.<br />

HAE M<br />

On Figure 5 we present character of found NI according clinics of the hospital.<br />

100%<br />

90%<br />

80%<br />

70%<br />

60%<br />

50%<br />

40%<br />

30%<br />

20%<br />

10%<br />

0%<br />

PE D<br />

OTR HO<br />

I.INT<br />

II.INT<br />

NEON<br />

HAE M<br />

I. S UR<br />

II. S UR<br />

NEUROL<br />

PN<br />

UTI<br />

BSI<br />

EENT<br />

OTH<br />

Fig. 5. Character of nosocomial infections at clinics of University Hospital Martin.<br />

DISCUSSIOn<br />

The European Union put an effort on harmonisation of policies of surveillance of communicable<br />

diseases including nosocomial infections. In this context, the EU-funded<br />

HELICS project in 1993-2004 undertook a systematic overview of the national surveillance<br />

policies and organisation to identify similarities and discrepancies and to plan<br />

further progress to be made. Totally, around 2000 European hospitals participate in<br />

a surveillance network. The participation is voluntary and the estimated coverage is<br />

quite high: around 30 % (5).<br />

Based on the IPSE project (Improving Patient Safety in Europe) in hospitals in the<br />

European Union a need was defined for a surveillance of nosocomial infections on European<br />

level to estimate and watch the burden of nosocomial infections.<br />

Because a general continuous incidence surveillance is very expensive, the prevalence<br />

hospital surveys are considered efficient.


A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1 37<br />

In 2009 the experts from European Centre for Disease Control and Prevention (ECDC)<br />

and experts from member states of the European Union elaborated a protocol of the<br />

European point prevalence survey (6).<br />

Prevalence here means the number of all cases – new and also old but still present in population.<br />

Because this number is counted for a specific date, it is a point prevalence study (7).<br />

Currently, the average NI incidence among hospitalized patients in hospitals in developed<br />

countries is about 6-8 %. In less developed countries it is even more than 25 %.<br />

Infections, deaths and economic costs related to acquiring NI have been growing mainly<br />

in past thirty years. Although estimations of proportion of preventable NI differ, there is<br />

a general consent that it could be more than 20 % in developed countries and even more<br />

than 40 % from all NI in less developed countries (8).<br />

The biggest proportion of NI was the sepsis (25.9 %). In men it was 33.0 % from all<br />

found NI, in women 16.0 %. Then there were urological infections, which occurred in<br />

22.2 %. In men in 20.0 % and in women 25.0 % of all NI. Other infections were found in<br />

22.2 % of all NI. To this group we put the infections of gastrointestinal system, central<br />

nervous system, surgical site infections (SSI) and bone and joint infections.<br />

It results from the data from EPIS that in 2009 the most common reported NI were the<br />

SSI (22.96 %) and urological infections (20.41 %).<br />

We found most of the NI in the age group of 65-84 years, 12 cases (22.2 %). High number<br />

of NI occurred also in children under one year of age – 4 cases (14.8 %). In both these groups<br />

there was the highest number of hospitalized patients, too. We think that one of the most<br />

important causes underlying the high prevalence in these is the weak immune system.<br />

The highest proportion of NI found at the University Hospital Martin (UHM) was from<br />

the Clinic of Hematology and Transfusiology (25.9 %). There occurred all types of serious<br />

NI. This was probably due to characteristic weak immune system of the patients<br />

hospitalized at the clinic and to an aggressive chemotherapy.<br />

At the Clinic of Children and Adolescents there were 14.8 % of all NI in the hospital<br />

and equally 11.1 % at the Clinic of Orthopedics and Traumatology, Clinic of Internal<br />

Medicine I, Clinic of Internal Medicine-Gastroenterology and Clinic of Neonatology.<br />

Some clinics with lower NI prevalence (Clinic of Neurology, Clinic of Surgery, Clinic of<br />

Transplant and Vascular Surgery) represent 14.8 % from total number of found NI.<br />

There were no found NI at other clinics. When looking at data from EPIS, the highest<br />

number of NI in 2009 was reported from the Clinic of Surgery (25.51 %).<br />

The highest point prevalence - the proportion of NI from the total number of hospitalized<br />

patients at a clinic – was at the Clinic of Hematology and Transfusiology: 7 patients<br />

(46.7 %). In 2009 there was no NI reported to EPIS from this clinic. We assume that it was<br />

due to insufficient reporting. Similarly, in the Annual report on activities of public health<br />

authorities in the Slovak Republic in 2009 we may read that the low number of reported<br />

NI from all healthcare facilities in Slovakia is probably due to insufficient reporting, too.<br />

At the Clinic of Children and Adolescents we found 4 cases of NI (11.8 %), at Clinic of<br />

Neonatology we found 3 NI cases (10.3 %) and at Clinic of Internal Medicine-Gastroenterology<br />

3 NI cases (10.0 %). We found less than 10 % of NI cases among the patients<br />

at the Clinic of Orthopedics and Traumatology, Clinic of Neurology, Clinic of Surgery,<br />

Clinic of Transplant and Vascular Surgery and Clinic of Internal Medicine I.<br />

Summarizing, the prevalence of NI found in patients at the University Hospital Martin<br />

was higher (5.5 %) in comparison with the reported occurrence in the Epidemiological<br />

information system where NI represent 0.64 % (9). We are convinced that this is due to<br />

insufficient reporting of NI. There could be more reasons for that. Our main assumption<br />

is that there is a belief that a higher number of reported NI could lead to a negative assessment<br />

of quality of healthcare of the hospital.<br />

However, our results are in accord with data on reported NI in developed countries. Marcel<br />

et al. (10) state that the prevalence of NI in European hospitals is about 6-12 % (10).


38<br />

A C T A M E D I C A M A R T I N I A N A 2 0 1 1 1 1 / 1<br />

We suggest that the reporting of NI would be improved at the University Hospital<br />

Martin and that there would continue the participation in international projects of surveillance<br />

of NI and the infection control, so that it would enable benchmarking and<br />

consecutive improvement.<br />

REFEREnCES<br />

1. Act of the Parliament of the Slovak Republic No. 355/2007 on protection, promotion and development of<br />

public health. Code of laws, 2007 (154): 2402-75.<br />

2. Centers for Disease Control and Prevention: Definitions of Nosocomial Infections. [online ] [cit. 2009-03-<br />

10] Available on Internet: http://www.health2k.state.nv.us/sentinel/Forms/ UpdatedForms105/CDC_<br />

Defs_Nosocomial.pdf<br />

3. Regulation of Ministry of Health of the Slovak Republic No. 553/2007 on requirements for health<br />

protection in healthcare facilities.<br />

4. Point Prevalence Survey of Healthcare-Associated Infections and Antimicrobial Use in European Acute<br />

Care Hospitals, Pilot Protocol 3.3 - Codebook, ECDC, June 2010.<br />

5. IPSE, Improving Patient Safety in Europe, IPSE Annual Report 2005. Available on Internet: http://helics.<br />

univ-lyon1.fr/deliverables/IPSE_Annual_Report_2005_25oct06.pdf<br />

6. Point Prevalence Survey of Healthcare-Associated Infections and Antimicrobial Use in European Acute<br />

Care Hospitals, Pilot Protocol (final), Version 3.3, ECDC, June 2010.<br />

7. Bakoss, P. et al.: Epidemiológia. Bratislava, <strong>Univerzita</strong> <strong>Komenského</strong>, 2005. 488 p.<br />

8. Stefkovicova, M.: Prevencia nozokomiálnych nákaz je ako beh na dlhé trate. In: Nozokomiálne nákazy,<br />

2003 (2): 1-2.<br />

9. Annual Report on Activities of Regional Public Health Authorities in the Slovak Republic in 2009.<br />

Bratislava, Public Health Authority of the Slovak Republic, 2009. 776 p. Available on Internet: http://<br />

www.slovanet.sk/uvzsr/docs/vs/vyrocna_sprava_SR_09.pdf<br />

10. Marcel, J.P. et al.: Healthcare-associated infections: think globally, act locally. Clin Microbiol Infect.<br />

October 2008;14(10):895-907.<br />

Received: November,30,2010<br />

Accepted: February,14,2011

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