Modified algorithm in treatment of patients with chronic low back pain with neuroradiological diagnostic techniques]

The most difficult in proper qualification of the patient with chronic low back pain for an operative treatment is determination of the chance for satisfactory result. The diversity of the pain eliciting structure in the spine influence the decision. In the paper we have analyzed patient where the operative treatment was considered. In 149 patients divided in two groups the (not being previously operated on the spine--group 1 and after spine surgery--group 2) the neuroradiological procedures were performed (sacral epidural block, facet injections, root injections of the lumbar spine). As the result of this procedure in 108 patients (72%) surgical intervention at that time was abandoned. Conclusion. In our opinion the neuroradiological diagnostic procedures should be mandatory in back pain management of the patient were operative treatment is considered. We present the modified algorithm in diagnostic procedure preceding the operation.     

Avantage double mobility press--fit cup in total hip arthroplasty]

The Avantage double mobility press-fit cup was devised by Dr. Bousquet in the 70's to bring reasonable response to a problem of recurrent dislocation after total hip arthroplasty. The cup is attached to the femoral head by a bipolar polyethylene liner. The polyethylene liner moves freely inside a shiny--polished metal cup. The angular range of motion before impingement is increased by the mobility of the liner. The double connection (cup-liner, liner-head) reduces the stress on the metal cup and improve the stability of the prosthesis. The solution has proved to be efficient in reducing dislocation risk and maintains at the same time the appropriate range of motion. Between January 2004 and November 2005, 113 hip arthroplasties in 108 women with use of the double mobility cup were performed. The cemented version of the Avantage cup was inserted in 15 patients (mean age--76.9 years). Uncemented, HA coated implant was used in 98 patients (with mean age of 55 years). The mean follow-up was 20.4 months. No one patient was lost to follow-up. No postoperative dislocation was observed during follow-up. There was no unwanted leg lengthening greater than 1 cm. The Avantage cup may be indicated in any primary total hip arthroplasty especially in those with increased risk of postoperative dislocations. This cup enables a correct balance of the hip without a need of the unwanted lengthening of the leg.     

Assessment of fetal circulation in the late first trimester--preliminary study

OBJECTIVES: to confirm that fetal echocardiography is indeed possible in late first trimester and that it improves the standard of the so-called "genetic" ultrasound scan. MATERIAL AND METHODS: Early echocardiography was performed in 75 fetuses from high and low risk pregnancies. All fetuses underwent echocardiography examination in 18-22 weeks of gestation and established follow up. RESULTS: The most suitable method of visualization seems to be transabdominal examination, between 13.0-13.6 weeks of gestation, an transvaginal one, between 12.0-12.6 weeks of gestation, with 90% effectiveness. In researched group of 75 fetuses (with established follow up) there were four heart defects (5.3%). Three of them were diagnosed before 14th week of gestation. One case (tetralogy of Fallot) was overlooked. There were two false positive diagnosis verified at 20th week of gestation. CONCLUSIONS: Early echocardiography, especially between 12.0-13.6 weeks of gestation, is a possible and valuable method of diagnosis. Reference evaluation should be performed between 18 and 22 weeks of gestation. In cases with suspected anomalies karyotyping is recommended. Congenital heart disease diagnosed at late first trimester should be treated as the next potential marker of genetic disorder.     

Subacute stent thrombosis following coronary angioplasty: incidence and risk factors

BACKGROUND: Subacute stent thrombosis was a significant complication in the early years of coronary stenting, often leading to myocardial infarction, need for urgent surgery or even death. The introduction of intracoronary ultrasound enabled the identification and proper treatment of the main causes of stent thrombosis, reducing the rate of this complication to 1%. AIM: To identify risk factors of subacute stent thrombosis. METHODS: Data concerning 845 procedures with a single stent implantation in patients with stable or unstable angina, undergoing this procedure between 1998 and 2000, were analysed. RESULTS: Subacute stent thrombosis occurred in 13 (1.54%) patients. Risk factors for this complication included urgent procedures (so-called bailout stenting), improper pre-treatment with drugs ("ad hoc" procedures), dissection uncovered by stent, and poor final result of procedure (higher degree of residual stenosis). The majority of these patients developed myocardial infarction in spite of the fact that the patency of stented vessel was quickly achieved in all but one patient. CONCLUSIONS: Urgent stenting, improper drug pre-treatment and suboptimal result of the procedure are the risk factors of subacute stent thrombosis.     

Frailty in Heart Failure

Considering the increasing age of individuals affected with heart failure (HF), a specific approach to their treatment is required, with more attention paid to geriatric conditions such as poor mobility, multiple disabilities, and cognitive impairment. Frailty is a distinct biological syndrome reflecting decreased physiologic reserve and resistance to stressors. It was shown to occur frequently in patients with heart failure, with the prevalence ranging from 15 to 74 %, depending on the studied population and the method of assessment. We reviewed literature data on the influence of frailty, skeletal abnormalities, comorbidities and geriatric condition on diagnosis, treatment, and outcomes in elderly patients with HF. Identification of frailty in patients with HF is important from the clinical point of view, as this condition exerts unfavorable effects on the course of heart failure. Frailty contributes to a higher frequency of visits to emergency departments, hospitalizations, and mortality in patients with HF. Exercise may improve mobility, and nursing support can be implemented to help the patients adhere to medications. Therefore, frail patients should be diagnosed and treated according to available guidelines, and successfully educated about their condition.     

Application of biochemical markers CA 19-9, CEA and C-reactive protein in diagnosis of malicious and benign pancreatic tumors

Introduction

We would save many lives and spare a lot of suffering if we could only detect and accurately determine the character and TMN staging of pancreatic tumors (PTs). With improved diagnosis, we could offer specific treatment that would result in better treatment outcome. The aim of study was to determine the significance of neoplastic markers CA 19-9 and CEA for prognosis in inflammatory and carcinomatous PTs.

Material and methods

We based our research upon a group of 170 patients. The patients were treated in our Oncologic Surgery Department from January 2007 to December 2010 for PTs. The patients were divided into four groups depending on the character of the tumor and underwent the following treatments: group 1 – 34 patients with carcinoma of the ampulla of Vater, group 2 – 64 patients with PTs at different stages (1, 2, 3) according to TMN classification, group 3 – 62 patients with PTs at stage 4 on the TMN scale (unresectable tumors), group 4 – 28 patients with inflammatory PTs.

Results

The results of Ca 19-9 in group 2 were 736.00 (25–75% 220.40–4285.00) ng/ml before surgery, 53.00 (25–75% 12.60–84.00) ng/ml in the 7 days after surgery, 29.4 (25–75% 7.90–113.00) ng/ml at day 30, and 119.00 (25–75% 96.30–621.00) ng/ml 3 months after the operation. These results were significantly higher than the control group but were significantly lower than the results for group 3 (unresectable tumors). The highest average concentration and median for CA 19-9 and CEA were noted in patients with unresectable PTs (the 3^rd group). The average concentration for CEA was lowest in group 4, but much higher than the lab limits.

Conclusions

The sensitivity of the CA 19-9 marker may be as high as 88%. Values of CA 19-9 above 852 U/ml may indicate TNM stage 4, consistent with an unresectable PT. In the cases where CA 19-9 is within normal limits but C-reactive protein is above normal limits (often thirty times the upper limit), in comparison to the control group and to patients with pancreatic neoplasms, strong consideration should be given towards the inflammatory characteristics of the pancreatic changes and conservative treatment should be applied.     

Treatment of undifferentiated embryonal sarcoma of the liver in children—single center experience

Background

Undifferentiated embryonal sarcoma of the liver (UESL) represents less than 5% of all malignant hepatic tumors in childhood. It is considered an aggressive neoplasm with an unfavorable prognosis. The aim of this paper is to present a single center experience in the treatment of children with UESL.

Materials and methods

Ten children with UESL were treated between 1981 and 2012. Age at diagnosis ranged from 4 months to 17 years (median age, 6 years and 9 months). Surgery after neoadjuvant chemotherapy (CHT) was performed in 7 patients, and in 3 patients primary surgery was done. Adjuvant chemotherapy was administered in all 10 patients (CYVADIC, CAV, CAV/ETIF/IF + ADM, CDDP/PLADO). Right hemihepatectomy was performed in 1 patient, extended right hemihepatectomy in 6, and partial resection of the right lobe (segments V-VI, segment V) in 2 patients. One patient with unresectable tumor affecting both lobes was listed for liver transplantation (LTx).

Results

Follow-up from diagnosis ranged from 50 to 222 months (mean 138 months). Among 9 patients treated with partial liver resection, distant metastases/local recurrence was not observed in any, and disease-free survival in this group is 100% (9 patients alive). The patient that underwent liver transplantation died of multiorgan failure 4 months postoperatively.However, this patient was misdiagnosed as having hepatoblastoma (HBL) and received PLADO chemotherapy. The overall survival rate is 90%.

Conclusion

Excellent results with long-term survival can be achieved in children with UESL with conventional therapy, including a combination of neoadjuvant and adjuvant chemotherapy and surgery, even in large extensively growing tumors.     

Efficacy of concomitant and adjuvant temozolomide in glioblastoma treatment. A multicentre randomized study

Background and purposeThe common treatment in patients with newly diagnosed glioblastoma multiforme is the ultimately radical surgical removal of the tumour combined with radiotherapy. This study compared safety and efficacy of radiotherapy alone with radiotherapy combined with temozolomide (TMZ) given before, during, and after radiotherapy.Material and methodsThe patients operated on for glioblastoma multiforme during the first 21 postoperative days were randomly assigned to the group treated with radiotherapy alone (involved-field radiotherapy in 2 Gy fractions daily five times a week up to the total of 60 Gy over 6 weeks of treatment) or to the group treated with radiotherapy and TMZ, initially in the dose of 200 mg/m² during 5 postoperative days and after 23 days followed by 75 mg/m² of body surface area daily, 7 days a week (from the first to the last day of radiotherapy). On completion of radiotherapy, five complementary courses of TMZ were introduced (150–200 mg/m² for 5 days, repeated every 28 days). The primary outcome measure was overall survival.ResultsFifty-eight patients from 3 centres were included in the study. The mean age of patients was 55 years and all the patients underwent a surgical procedure of glioblastoma removal. The mean overall survival in the group treated with TMZ was 16.0 months, whereas in the group with radiotherapy alone the overall survival reached 12.5 months. 24-month survival reached 23% in patients treated with TMZ and 6.7% in those who received radiotherapy only. Haematological complications of third or fourth degree were present in 10% of patients treated with radiotherapy and TMZ.ConclusionsThe introduction of TMZ before, during and after radiotherapy for newly diagnosed glioblastoma multiforme gives clinically and statistically significant improvement of survival with unremarkably increased toxicity of the treatment.