Poslijeoperacijsko liječenje boli nakon kirurškog liječenja sindroma karpalnog tunela: usporedba prakse sa smjernicama

Th e management of postoperative pain after carpal tunnel syndrome surgical treatment at a tertiary hospital was analyzed and compared with the guidelines for perioperative pain management. This retrospective study included 579 patients operated on for carpal tunnel syndrome at the Split University Hospital Center in Split, Croatia. Th e following key data were collected from patient medical records: age, gender, type and dosage of premedication, type and dosage of anesthesia, type and dosage of postoperative analgesia per each postoperative day. Th e procedures related to perioperative pain were analyzed and compared with the current guidelines for perioperative acute pain management. Study results showed that 99.6% of patients with carpal tunnel syndrome were operated under local anesthesia, of which 2.9% also received sedation. Analgesics were prescribed to 45% of patients after surgery, and according to patient charts, 39% of patients actually received postoperative analgesic(s). Generally, postoperative pain was treated on the fi rst postoperative day, mostly with nonsteroidal anti-infl ammatory drugs. Only two patients received weak opioids for postoperative pain. Many recommendations from the guidelines for perioperative acute pain management were not followed. In conclusion, the guidelines should be followed and appropriate interventions used to improve postoperative pain management.Analizirali smo liječenje poslijeoperacijske boli nakon kirurškog liječenja sindroma karpalnog tunela u tercijarnoj bolnici i usporedili ga sa smjernicama za liječenje perioperacijske boli. Proveli smo retrospektivnu studiju u koju je bilo uključeno 579 bolesnika koji su operirani zbog sindroma karpalnog tunela u Kliničkom bolničkom centru Split, Hrvatska. Prikupljeni su sljedeći podatci iz povijesti bolesti: dob, spol, vrsta i doza premedikacije, vrsta i doza anestezije, vrsta i doza poslijeoperacijske analgezije za svaki poslijeoperacijski dan. Analizirani su postupci vezani za perioperacijsku bol i uspoređeni s važećim smjernicama. Rezultati su pokazali da je 99,6% bolesnika operirano u lokalnoj anesteziji, a 2,9% ih je uz to primilo sedaciju. Analgetici su propisani u 45% bolesnika nakon zahvata, a prema povijestima bolesti 39% bolesnika je analgetik zaista i dobilo. Poslijeoperacijska bol je liječena uglavnom samo prvog poslijeoperacijskog dana, većinom pomoću nesteroidnih protuupalnih lijekova. Samo je dvoje bolesnika dobilo slabi opioid za ublažavanje poslijeoperacijske boli. Brojne preporuke iz smjernica za perioperacijsko liječenje boli nisu se slijedile. Zaključno, nužno je slijediti smjernice i provesti prikladne intervencije kako bi se poboljšalo perioperacijsko liječenje boli

Emotional and behavioral outcomes and quality of life in school-age children born as late preterm: retrospective cohort study

Aim To determine the effect of late preterm birth and treatment at the intensive care unit (ICU) on school-age children’s emotional and behavioral problems and quality of life (QoL). Methods Emotional and behavioral problems and QoL were investigated in 6-12-year-olds who were born late preterm at the University Hospital Center Split in the period from January 2002 to March 2008. The study included 126 late preterm children treated in ICU (LP-ICU group), 127 late preterm children not treated in ICU (LP-non-ICU group), and 131 full-term children treated in ICU (FT-ICU group). Emotional and behavioral difficulties were assessed using the Child Behavior Checklist. QoL was evaluated with the Royal Alexandra Hospital for Children Measure of Function questionnaire. The data was collected via telephone interview with mothers during 2014. Results Late preterm children had a nearly 5-fold risk for internalizing problems in comparison with FT-ICU children (OR 4.76, 95% confidence interval [CI] 2.37-9.56 and OR 4.82, 95% CI 2.25-10.37 in LP-ICU and LP-non-ICU children, respectively). They also had a greater risk for externalizing problems (OR 3.08, 95% CI 1.44-6.61 and OR 2.68, 95% CI 1.14-6.28, respectively) and total problems (OR 6.29, 95% CI 2.86-13.83 and OR 7.38, 95% CI 3.08-17.69, respectively) and a considerably increased risk for lower QoL (OR 12.79, 95% CI 5.56-29.41 and OR 5.05, 95% CI 2.04-12.48, respectively). Conclusion Children born late preterm had a greater risk for emotional and behavioral problems and lower QoL during childhood than their full-term born peers and they experienced serious health problems upon birth

Parkland formula role in treatment of severe burn – Case report

Cilj je ovog rada prikaz bolesnika s iznimno opsežnim opeklinama svih dijelova tijela. Muškarac srednjih godina 12-ak sati prije početka bolničkog liječenja u KBC-u Split pokušao je suicid paljenjem plinske boce u zatvorenom prostoru, oko 150 kilometara od ustanove gdje je započeto liječenje. Eksplozija i požar kojima je pacijent bio izložen uzrokovali su opekline visokog stupnja na velikoj tjelesnoj površini. U trenutku prijma na bolničko liječenje pacijent je bio ekstremno agresivan i nesuradljiv. Važno je naglasiti da pacijent u trenutku prijma na bolničko liječenje nije imao uspostavljen venski put. U bolnicu je primljen sa znatnom odgodom (12 sati +/- 1 sat), koja je produbila dehidraciju i pogoršala njegovo, već ionako životno ugroženo stanje. Dubina opeklina procijenjena je na stupnjeve II. b i III., a zahvaćale su 70% ukupne površine tijela (engl. Body surface area – BSA). Prvi cilj prije volumne nadoknade bila je uspostava odgovarajućega venskog puta, koji pacijent u trenutku prijma u bolnicu nije imao. Zbog agitiranosti i agresivnosti intramuskularno se injicirala kombinacija midazolama, ketamina i atropina, a središnji venski pristup uspostavio se tek kad je pacijent bio anesteziran. Obilna nadoknada kristaloidima za vrijeme inicijalnoga trosatnog zbrinjavanja privremeno je stabilizirala bolesnika, a agresivna nadoknada kristaloidima i koloidima nastavljena je u jedinici intenzivnog liječenja. Potrebe za kristaloidima u prva 24 sata izračunane su s pomoću Parklandske formule i iznosile su 25.200 mL kristaloida. Tijekom liječenja pacijent je šest puta podvrgnut kirurškim zahvatima uz svakodnevna previjanja u općoj anesteziji. Boravak se zakomplicirao zbog infekcije multirezistentnim Acinetobacter baumannii. Zaključno, Parklandska formula ostaje okosnica volumne nadoknade pacijenata s opeklinama II. i III. stupnja. Odgoda liječenja, prisutna u ovom slučaju, rezultirala je enormnom dehidracijom i gubitkom intravaskularnog volumena sa svim patofiziološkim poremećajima pridruženima takvom stanju. Zbrinjavanje pacijenta bilo je dodatno otežano zbog njegove agresivnosti pri prijmu, nedostatka venskog puta i nemogućnosti započinjanja liječenja odmah ili vrlo brzo nakon nastalih opeklina.In this case report a rarely seen and a fairly demanding patient is presented. A middle-aged male with severe and extensive burns sustained after attempted suicide with ignited propane butane containing gas bottle was transported to the emergency department of University Hospital Centre Split after more than 12 hours since initial injury. Explosion and fire caused the second and third degree burns to the patient on a very large body surface area (70 percent). At the moment of admission, he was extremely aggressive, combative and uncooperative. Also, it is important to emphasize that the patient had no intravenous access. Due to the absence of intravenous access, and due to the patients’ condition, the author decided to apply midazolam, ketamine and atropine intramuscularly. After the patient was in general anaesthesia, central venous access was established via left subclavian vein, and immediate crystalloid infusion therapy was initiated. According Parkland formula, volume of crystalloid replacement should be 25200 mL during the first 24 hours. Since more than eight hours passed from the time of the injury, fluid deficit was theoretically more than 8400 mL. During the initial treatment and three hour surgery, the patient received 5500 mL of Plasma-Lyte solution. He was treated in the intensive care unit for a prolonged period of time, and complicated with multiresistant Acinetobacter baumannii infection. Finally, Parkland formula remains the basic tool in burn fluid resuscitation. Our intention was to present an interesting case of a middle-aged patient with extensive burns, whose care was complicated with aggression at admission, lack of intravenous access, and a prolonged period between the initial injury and the start of hospital treatment. These greatly complicate the treatment, patients’ recovery and overall morbidity and mortality

CLINICAL GUIDELINES FOR DIAGNOSIS, TREATMENT AND MONITORING OF PATIENTS WITH INVASIVE BREAST CANCER – CROATIAN ONCOLOGY SOCIETY

Rak dojke najčešći je zloćudni tumor u žena koji se može probirom, redovitim kontrolama i zdravstvenim odgojem otkriti u ranim stadijima bolesti i uspješno liječiti. Metode liječenja uključuju kirurgiju, kemoterapiju, radioterapiju, hormonsku terapiju i ciljanu biološku terapiju ovisno o stadiju bolesti, biološkim obilježjima tumora i općem stanju bolesnice. Odluku o liječenju donosi multidisciplinarni tim. S obzirom na važnost ove bolesti, potrebno je definirati i provoditi standardizirani pristup u dijagnostici, liječenju i praćenju ovih bolesnica. U tekstu koji slijedi iznesene su kliničke smjernice s ciljem implementacije standardiziranih postupaka u radu s bolesnicama s rakom dojke u Republici Hrvatskoj.Breast cancer is the most common cancer in women. It can be diagnosed in early stage through screening, early detection and educational programs, and when diagnosed early it can be efficiently treated. Treatment modalities include surgery, chemotherapy, radiotherapy, hormonal therapy and targeted biologic therapy, according to the stage of the disease and patient condition. Treatment decisions should be made after multidisciplinary team discussion. Due to the significance of this disease it is important to define and implement standardized approach for diagnostic, treatment and monitoring algorithm as well. The following text presents the clinical guidelines in order to standardize the procedures and criteria for diagnosis, management, treatment and monitoring of patients with breast cancer in the Republic of Croatia

The role of fibrinogen in idiopathic carpal tunnel syndrome

UVOD. Idiopatski sindrom karpalnog tunela (ICTS) je najučestalija kompresijska neuropatija koja češće zahvaća žene. Iako su neki slučajevi ICTS-a povezani s mutacijama u genu za transtiretin ili su udruženi sa sistemskom amiloidozom, glavnina slučajeva sindroma karpalnog tunela je nepoznate etiologije. METODE. U studiju je uključen 71 pacijent s ICTS-om i 68 kontrolnih ispitanika. Razina fibrinogena u plazmi mjerena je prije operacije, a depoziti fibrinogena u transverzalnom karpalnom ligamentu (TCL) su pronađeni imunohistokemijskom metodom, te potvrđeni western blot-om i masenom spektrometrijom. Interakcija fibrinogena s drugim proteinima je proučavana imunoprecipitacijskim esejom. REZULTATI: Pokazali smo da je povišena razina proupalnog i hemostatskog proteina fibrinogena u plazmi bolesnika s ICTS-om. Mjerenja drugih sistemskih upalnih biljega nisu pokazala odstupanja od normale, a lokalni upalni odgovor u TCL-u bio je odsutan. Bolesnici s ICTS-om imali su kraće vrijeme krvarenja, najvjerojatnije radi povećane razine fibrinogena u plazmi. Poznato je polimorfizam u promotorskoj regiji gena za fibrinogen B povezan s povišenom razinom fibrinogena u plazmi, ali takva povezanost nije primijećena kod bolesnika s ICTS-om. Iako smo ustanovili da je transkripcijska aktivnost gena za fibrinogen u TCL-u niska, otkrili smo depozite fibrinogena u TCL-u. Neki proteini koji se odlažu kod neurodegenerativnih bolesti, uključujući transtitetin i α-synuclein također su pronađeni u TCL-u te je njihova lokalna transkripcijska aktivnost visoka. Naposljetku, pokazali smo da je fibrinogen u interakciji s transtiretinom i α-synucleinom u lizatima tkiva TCL-a. ZAKLJUČAK: Podatci u ovoj studiji pokazuju da fibrinogen i drugi proteini skloni agregaciji imaju važnu ulogu u patogenezi ICTS-aOBJECTIVE. Idiopathic carpal tunnel syndrome (ICTS) is a common entrapment neuropathy that primarily affects women. Though some cases of ICTS are linked to mutations in the transthyretin gene or are associated with systemic amyloidosis, the majority of ICTS cases are of unknown etiology. METHODS. A total of 71 ICTS patients and 68 control individuals were included in the study. Fibrinogen levels were determined prior to surgery and fibrinogen deposition in transversal carpal ligament (TCL) was detected by immunohistochemistry, western blot and mass spectrometry. Fibrinogen interaction with other proteins was studied by immunoprecipitation assays. RESULTS. We report that plasma levels of the pro-inflammatory and haemostatic protein fibrinogen is elevated in ICTS patients. Other measured systemic inflammatory markers were not affected and local inflammatory responses in TCL were absent. ICTS patients have shorter bleeding times most probably due to elevated plasma levels of fibrinogen. Polymorphisms of the fibrinogen B promoter region were previously associated with elevated plasma fibrinogen but this association was not observed among patients with ICTS. Interestingly, we detected fibrinogen deposits in the TCL while transcriptional activity of the fibrinogen genes in TCL was low. Some amyloidogenic proteins, including transthyretin and -synuclein, were also found in the TCL while their local transcriptional activity was rather high. Finally, we demonstrated that fibrinogen interacts with transthyretin and -synuclein in TCL lysates. CONCLUSIONS. Our data indicate that fibrinogen and other aggregation-prone proteins potentially have an important role in the pathogenesis of ICTS

The role of fibrinogen in idiopathic carpal tunnel syndrome

UVOD. Idiopatski sindrom karpalnog tunela (ICTS) je najučestalija kompresijska neuropatija koja češće zahvaća žene. Iako su neki slučajevi ICTS-a povezani s mutacijama u genu za transtiretin ili su udruženi sa sistemskom amiloidozom, glavnina slučajeva sindroma karpalnog tunela je nepoznate etiologije. METODE. U studiju je uključen 71 pacijent s ICTS-om i 68 kontrolnih ispitanika. Razina fibrinogena u plazmi mjerena je prije operacije, a depoziti fibrinogena u transverzalnom karpalnom ligamentu (TCL) su pronađeni imunohistokemijskom metodom, te potvrđeni western blot-om i masenom spektrometrijom. Interakcija fibrinogena s drugim proteinima je proučavana imunoprecipitacijskim esejom. REZULTATI: Pokazali smo da je povišena razina proupalnog i hemostatskog proteina fibrinogena u plazmi bolesnika s ICTS-om. Mjerenja drugih sistemskih upalnih biljega nisu pokazala odstupanja od normale, a lokalni upalni odgovor u TCL-u bio je odsutan. Bolesnici s ICTS-om imali su kraće vrijeme krvarenja, najvjerojatnije radi povećane razine fibrinogena u plazmi. Poznato je polimorfizam u promotorskoj regiji gena za fibrinogen B povezan s povišenom razinom fibrinogena u plazmi, ali takva povezanost nije primijećena kod bolesnika s ICTS-om. Iako smo ustanovili da je transkripcijska aktivnost gena za fibrinogen u TCL-u niska, otkrili smo depozite fibrinogena u TCL-u. Neki proteini koji se odlažu kod neurodegenerativnih bolesti, uključujući transtitetin i α-synuclein također su pronađeni u TCL-u te je njihova lokalna transkripcijska aktivnost visoka. Naposljetku, pokazali smo da je fibrinogen u interakciji s transtiretinom i α-synucleinom u lizatima tkiva TCL-a. ZAKLJUČAK: Podatci u ovoj studiji pokazuju da fibrinogen i drugi proteini skloni agregaciji imaju važnu ulogu u patogenezi ICTS-aOBJECTIVE. Idiopathic carpal tunnel syndrome (ICTS) is a common entrapment neuropathy that primarily affects women. Though some cases of ICTS are linked to mutations in the transthyretin gene or are associated with systemic amyloidosis, the majority of ICTS cases are of unknown etiology. METHODS. A total of 71 ICTS patients and 68 control individuals were included in the study. Fibrinogen levels were determined prior to surgery and fibrinogen deposition in transversal carpal ligament (TCL) was detected by immunohistochemistry, western blot and mass spectrometry. Fibrinogen interaction with other proteins was studied by immunoprecipitation assays. RESULTS. We report that plasma levels of the pro-inflammatory and haemostatic protein fibrinogen is elevated in ICTS patients. Other measured systemic inflammatory markers were not affected and local inflammatory responses in TCL were absent. ICTS patients have shorter bleeding times most probably due to elevated plasma levels of fibrinogen. Polymorphisms of the fibrinogen B promoter region were previously associated with elevated plasma fibrinogen but this association was not observed among patients with ICTS. Interestingly, we detected fibrinogen deposits in the TCL while transcriptional activity of the fibrinogen genes in TCL was low. Some amyloidogenic proteins, including transthyretin and -synuclein, were also found in the TCL while their local transcriptional activity was rather high. Finally, we demonstrated that fibrinogen interacts with transthyretin and -synuclein in TCL lysates. CONCLUSIONS. Our data indicate that fibrinogen and other aggregation-prone proteins potentially have an important role in the pathogenesis of ICTS

Postoperative Pain Management after Carpal Tunnel Syndrome Surgical Treatment: Comparing Practice with Guidelines

Th e management of postoperative pain after carpal tunnel syndrome surgical treatment at a tertiary hospital was analyzed and compared with the guidelines for perioperative pain management. This retrospective study included 579 patients operated on for carpal tunnel syndrome at the Split University Hospital Center in Split, Croatia. Th e following key data were collected from patient medical records: age, gender, type and dosage of premedication, type and dosage of anesthesia, type and dosage of postoperative analgesia per each postoperative day. Th e procedures related to perioperative pain were analyzed and compared with the current guidelines for perioperative acute pain management. Study results showed that 99.6% of patients with carpal tunnel syndrome were operated under local anesthesia, of which 2.9% also received sedation. Analgesics were prescribed to 45% of patients after surgery, and according to patient charts, 39% of patients actually received postoperative analgesic(s). Generally, postoperative pain was treated on the fi rst postoperative day, mostly with nonsteroidal anti-infl ammatory drugs. Only two patients received weak opioids for postoperative pain. Many recommendations from the guidelines for perioperative acute pain management were not followed. In conclusion, the guidelines should be followed and appropriate interventions used to improve postoperative pain management

Is the prolongation latency of visual evoked potentials a pathological sign in children with Down’s syndrome without ocular abnormalities? Case–control study of children with Down’s syndrome

Objective To evaluate retino-cortical function in children with Down’s syndrome (DS) and no evident ocular abnormalities beyond mild refractive error, by recording visual evoked potentials (VEP) in response to pattern-reversal stimuli and comparing to those of age-matched healthy controls.Methods and analysis All the children with DS registered at Split-Dalmatia County who met inclusion criteria of no ocular abnormalities and with refraction error between −0.5 and +2.0 D, and their age-matched healthy controls were included in the study (n=36 children, N=72 eyes, for both groups, respectively, with the same age of 9±2 years). Transient VEP was recorded and the waves with a positive peak as a response to a pattern-reversal stimulus, were analysed. The peak P100 latency, defined as the time from the stimulus onset to the main positive peak, and peak to peak amplitudes were measured.Results While P100 wave amplitudes were comparable between two groups (p=0.804), P100 latencies were from 4.3 to 28.5 ms longer in children with DS (p<0.001). Interocular latency difference between a VEP dominant and an inferior eye was pronounced in healthy (1.2 ms (0.2–4.0), but was almost diminished in children with DS (0.3 ms (0.1–0.5), p<0.001).Conclusion Our study has demonstrated that VEP response is divergent in children with DS compared with their age-matched healthy controls, indicating possible structural or functional abnormalities of the visual cortex. As VEP results are helpful in the diagnosis and treatment planning of vision-related disorders, we should reconsider the use of common VEP diagnostic criteria in subpopulation of children with DS