A Comparison of the Interlaminar v. the Transforaminal Approach To Steroid Injections under Fluoroscopic Control in Treating Lumbar Radicular Pain

Background and Purpose: Lateral lumbar spinal compression is a common source of lower back and leg pain. Steroids injected around the dura-sac markedly decrease inflammation commonly associated with conditions such as, disc-herniation or s. This study’s goal was to prove how epidural injections of steroids, transforaminal or interlaminar, lead to improved pain reduction. Materials and Methods: 50 patients were included in the study by random choice. They were stratified with magnetic resonance imaging and mlectromyography, according to their confirmed diagnosis of lumbar lateral spinal compression. The selected patients were divided into two groups according to reception-path of epidural steroids. In both groups 25 patients were selected by random choice to receive interlaminar or transforaminal epidural steroid injections, in both cases under fluoroscopic guidance. The patients were monitored and their pain assessed by using the visual analogue scale (0–10) during each visit, and during the visits three and six months following the first injection (using VAS scores). Results and conclusions: After the first and second injection of steroids an efficient decrease of pain was evident, although a tendency towards further decrease was not continued after the third injection of steroids and local anaesthesia. The tendency towards decreasing and maintaining the level of pain was recorded as the same both with the interlaminar and the transforaminal approach to steroid injections. The difference in assessed pain between the group with the transforaminal approach and the group with the interlaminar approach did not appear significant in our study. The results of our research have demonstrated that there is no difference in the efficacy of the epidural steroid injection regarding its approach; that is the efficacy is at the same level both with the interlaminar approach as with the transforaminal approach

Respiratory infections in mechanically ventilated patients

Cilj istraživanja: Utvrditi učestalost respiratornih infekcija strojno ventiliranih bolesnika, rizične čimbenike odgovorne za nastanak tih infekcija, udio VAP-a i VAT-a u ukupnom broju infekcija te trajanje i ishod liječenja bolesnika. Ustroj studije: Retrospektivna studija. Ispitanici i metode: U istraživanje je uključeno 106 strojno ventiliranih bolesnika liječenih u JIL-u Klinike za anesteziologiju od 1. 1. 2014. do 31. 12. 2016. kod kojih se tijek liječenja komplicirao pojavom respiratorne infekcije. Podatci su prikupljeni iz medicinskih zapisa i statistički obrađeni pomoću programa MedCalc. Rezultati istraživanja: Učestalost respiratorne infekcije iznosi 8,5 na 1000 BD-a i 20,1 na 1000 respiratorskih dana. Većini bolesnika (50 %) indikacija za mehaničku ventilaciju bio je poremećaj središnjeg živčanog sustava (SŽS), 96% primalo je antimikrobnu terapiju prije nastanka respiratorne infekcije, a svi su bili na invazivnoj strojnoj potpori. Od ukupnog broja respiratornih infekcija, 74 % bolesnika imalo je VAT, a 26 % VAP. Uzročnik infekcija u 72 % slučajeva bio je Acinetobacter baumannii. Nije bilo značajne razlike između VAT-a i VAP-a u odnosu na SAPS II i SOFAskor, vrijeme nastupa infekcije, trajanje terapije i mehanč~ke ventilacije, duljine boravka u JIL-u i ishodu liječenja. Zaključak: Pojavi respiratornih infekcija skloni su bolesnici s primarnim poremećajem svijesti i dugotrajno ovisni o respiratoru. Narušenost općeg stanja pridonosi nastanku infekcijskih komplikacija bolesnika, a antimikrobna terapija pogoduje selekciji i širenju rezistentnih uzročnika. Nesrazmjer u pojavnosti VAT-a i VAP-a posljedica je teškoća u dijagnostici tih stanja, izuzme li se radiološki nalaz, infekcije se ne razlikuju po utjecaju na tijek i ishod liječenja bolesnika.Objectives: The aim of this study was to determine the incidence of respiratory infections in mechanically ventilated patients, risk factors responsible for the occurrence of these infections, proportion of ventilator-associated tracheitis (VAT) and ventilator-associated pneumonia (VAP) in the total number of infections and the duration and outcome of patient treatment. Study design: Retrospective study. Participants and methods: The study included 106 mechanically ventilated patients treated in the ICU Clinic for Anaesthesiology from 1st January 2014 to 31st December 2016 in whom the treatment course was complicated by the onset of respiratory infection. The data were collected from medical records and statistically processed using MedCalc. Results: The incidence of respiratory infections was 8.5 per 1000 patient days and 20.1 per 1000 respirator days. Most patients (50 %) had a central nervous system (CNS) disorder at admission, 96 % prior antimicrobial therapy and all had invasive machine support. Of the total number of respiratory infections, 74% of patients had VAT and 26 % VAP. The cause of infection in 72 % of cases was Acinetobacter baumannii. There was no significant difference between VAT and VAP compared to SAPS II and SOFAscores, time of onset of infection, duration of therapy and mechanical ventilation, length of stay in the ICU and the outcome of the treatment. Conclusion: The occurrence of respiratory infections is common in patients with a primary disturbance of consciousness and long-term respiratory dependence. General state of impaired health contributes to the emergence of infectious complications in patients, and antimicrobial therapy favours the selection and dissemination of resistant agents. The disparity in the occurrence of VAT and VAP is a consequence of difficulties in diagnosing these conditions, and if radiological findings are excluded, infections are not different in terms of the course and outcome of the treatment

Antibiotic consumption and the prevalence of resistant microorganisms in the intensive care unit

Cilj istraživanja: Utvrditi obim potrošnje i kvalitativna obilježja propisivanja antimikrobnih lijekova u jedinici intenzivnog liječenja te utječe li način propisivanja i potrošnja tih lijekova na pojavnost bakterijske rezistencije. Nacrt studije: Presječna studija. Ispitanici i metode: Ispitanici su bolesnici liječeni u Jedinici intenzivnog liječenja Klinike za anesteziologiju i intenzivnu medicinu Kliničkog bolničkog centra Osijek tijekom 2015. i 2016. godine. Kriterij uključivanja jest primjena antimikrobnog lijeka neovisno o kliničkoj indikaciji. Relevantni podaci o kvalitativnim i kvantitativnim aspektima potrošnje lijekova i prevalenciji rezistentnih mikroorganizama prikupljeni su iz povijesti bolesti i mikrobiološkog protokola. Rezultati: Tijekom promatranog razdoblja liječeno je 1646 bolesnika i ostvareno 7 819 bolesničkih dana. Većina bolesnika (88,3 %) primala je antimikrobne lijekove, a čak 70 % bolesnika nije imalo znakova infekcije. Potonja je kod prijema bila utvrđena u 19,1 % bolesnika. Od 3 300 propisanih antimikrobnih lijekova, 60 % je bilo namijenjeno profilaksi ili preemptivnoj terapiji, dok je 28,1 % primijenjeno za liječenje utvrđene infekcije. Najčešće su propisivani amoksicilin s klavulanskom kiselinom, metronidazol i gentamicin, od rezervnih antibiotika kolistin. Među rezistentnim bakterijama najčešće su izolirani Acinetobacter baumannii, Klebsiella pnumoniae i meticilin-rezistentni Staphylococcus aureus. Zaključak: Tijekom boravka u Jedinici intenzivnog liječenja 90 % bolesnika dobivalo je antimikrobne lijekove. Više od dvije trećine bolesnika primalo je te lijekove u odsustvu infekcije, profilaktički ili preemptivno. Amoksicilin s klavulanskom kiselinom, gentamicin i metronidazol propisivani su u profilaksi i liječenju, dok su rezervni antibiotici namijenjeni liječenju infekcija rezistentnim uzročnicima. Dobiveni rezultati nisu ukazali na povezanost između potrošnje antimikrobnih lijekova i pojave bakterijske rezistencije.Objectives: To determine the extent to which antimicrobial drugs are consumed as well as qualitative features of antimicrobial drugs in the intensive care unit and to determine whether the manner in which these drugs are prescribed and consumed has any effect on the prevalence of bacterial resistance. Study design: Across sectional study. Participants and methods: The participants were patients treated in the intensive care unit of the Clinic for Anaesthesiology and Intensive Care in the Clinical Hospital Centre Osijek during 2015 and 2016. The inclusion criteria was the use of antimicrobial drug regardless of clinical indication. Relevant data about qualitative and quantitative aspect of consumption of drugs and the prevalence of resistant bacteria was collected from medical history of clinical diagnosis and microbiology protocols. Results: During the observation period, 1 646 patients were treated and 7819 patient days were achieved. The majority of patients (88.3 %) received antimicrobial drugs even in the absence of infection (70 %). Approximately 19.1 % of the patients were diagnosed with the latter at the moment of admission. From 3300 prescribed antimicrobial drugs, 60 % were intended for prophylaxis or pre-emptive therapy, while 28.1 % were used for the treatment of established infection. The most commonly prescribed drugs were amoxicilin with clavulanic acid, metronidazole, gentamicin, and colistin from the list of reserve antibiotics. Resistant bacteria that was most commonly isolated were Acinetobacter baumannii, Klebsiella pneumoniae and methicilin-resistant Staphylococcus aureus. Conclusion: Almost 90 % of patients were given antimicrobial drugs during their stay in the intensive care unit. More than two thirds of patients received medications prophylactically or preemptively even though the infection was absent. Amoxicilin with calvulanic acid, metronidazole and gentamicin were prescribed very often in prophylaxis or treatment, while reserve antibiotics were intended for the treatment of infection with resistant agents. The obtained results do not indicate a connection between the consumption of antimicrobial drugs and the appearance of bacterial resistance

Are the Intensive Care Units the Only Reservoir of Resistant Microorganisms?

Cilj istraživanja: Cilj rada je utvrditi učestalost i epidemiološka obilježja infekcija uzrokovanih rezistentnim mikroorganizmima te ispitati moguće čimbenike rizika odgovorne za kolonizaciju i pojavu infekcija tim uzročnicima. Nacrt studije: Presječno istraživanje. Ispitanici i metode: U istraživanje je uključeno 185 ispitanika liječenih u Jedinici intenzivnog liječenja (JIL) Klinike za anesteziologiju, reanimatologiju i intenzivnu medicinu tijekom 2016. i 2017. godine, kod kojih je bila potvrđena kolonizacija ili infekcija rezistentnim bolničkim mikroorganizmima. Demografski i klinički podatci o ispitanicima prikupljeni su iz povijesti bolesti i mikrobiološkog protokola. Rezultati: Prije dolaska u JIL, 49,2 % ispitanika bilo je kolonizirano, a 31,4 % njih inficirano rezistentnim uzročnikom. Najčešće je izoliran multiplorezistentan Acinetobacter baumannii. Kolonizaciju u JIL-u steklo je 60,5 %, a infekciju 59,4 % ispitanika. Osnovna bolest, kirurški zahvat i vrijeme boravka na odjelu pogodovali su kolonizaciji i infekciji prije dolaska u JIL, dok su kritično stanje, umjetni dišni put, strojna ventilacija, kirurške intervencije i vrijeme boravka u JIL-u rizični čimbenici odgovorni za pojavu kolonizacije i infekcije u JIL-u. Nije uočena razlika u pojavnosti infekcija između kirurških i ne-kirurških bolesnika. Zaključak: JIL-ovi nisu jedini rezervoari rezistentnih mikroorganizama. Dio bolesnika s drugih bolničkih odjela koloniziran je ili inficiran već pri dolasku u JIL, a dio stječe infekciju i kolonizaciju u JIL-u. Izolati su pretežito gram-negativne bakterije među kojima je najzastupljeniji Acinetobacter baumannii. Kolonizaciji i infekciji na odjelima i u JIL-u doprinose priroda i težina bolesti, izloženost invazivnim terapijskim postupcima i boravak u okruženju s visokom prevalencijom rezistentnih mikroorganizama.Objectives: The aim of this study is to identify the frequency and epidemiological characteristics of infections caused by multidrug-resistant microorganisms and examine possible risk factors responsible for colonisation and infections with these pathogens. Study design: Cross-sectional study. Participants and methods: The study included 185 participants treated in the ICU of the Clinic for Anesthesiology, Resuscitation and Intensive Care during 2016 and 2017, who were colonised or had infection caused by multidrug-resistant hospital microorganisms. The participants’ demographic and clinical data were taken from the medical records and microbiological protocol. Results: Prior to the admission at the ICU, 49.2% of the participants were colonised and 31.4% of them were infected by the resistant pathogen. The most common isolated pathogen was Acinetobacter baumannii. 60.5% of the participants were colonised at the ICU, 59.4% of them had infection prior to the admission at the ICU. Primary disease, surgical treatment and time spent in hospital ward favoured colonisation and infection prior to the admission at the ICU, while critical condition, artificial airway, mechanical ventilation, surgical intervention and time spent on ICU are considered risk factors responsible for colonisation and infection at the ICU. The difference between the incidence of infections between surgical and non-surgical patients was not found. Conclusion: ICUs are not the only reservoirs of resistant pathogens. A part of the patients is colonised or infected at the admission to the ICU, the other part got infected or colonised at the ICU. The isolates are usually Gram-negative bacteria. The most common is Acinetobacter baumanii. Colonisation and infection at hospital wards and ICUs are under the influence of the nature and severity of a disease, exposure to invasive therapeutic procedures and staying in surroundings with high prevalence of resistant microorganisms

THE IMPACT OF COLISTIN ON RENAL FUNCTION IN CRITICAL PATIENTS

Cilj istraživanja: Utvrditi utjecaj kolistina na bubrežnu funkciju kritičnih bolesnika, učestalost i težinu bubrežnog oštećenja, čimbenike koji, uz kolistin, doprinose nastanku akutne bubrežne ozljede (ABO) te utjecaj potonje na klinički ishod. Nacrt studije: Opservacijsko retrospektivno istraživanje. Ispitanici i metode: Istraživanjem je obuhvaćeno 58 bolesnika hospitaliziranih u JIL-u Klinike za anesteziologiju i intenzivnu medicinu tijekom dvogodišnjeg razdoblja. Kriterij uključivanja ciljana je terapijska primjena kolistina. Demografski i klinički podatci o ispitanicima prikupljeni su iz povijesti bolesti. Rezultati: Kolistin je bio primijenjen za liječenje mikrobiološki potvrđene infekcije. U više od 70 % bolesnika primijenjen je sustavno, a u 80 % slučajeva u kombinaciji s drugim antibioticima. Udarnu dozu primilo je pet ispitanika, medijan doze održavanja iznosio je 6, kumulativne doze 41 milijun IU, a medijan trajanja liječenja 7 dana. ABO je utvrđena kod 12 ispitanika, između 2. i 14. dana terapije, s ravnomjernom zastupljenošću stadija 1, 2 i 3. Nije potvrđeno da trajanje terapije, doza kolistina i prisutnost sepse značajno utječu na pojavnost ABO. Smrtnost u ispitanika s ABO iznosila je 75 %. Zaključak: U većine ispitanika kolistin je primijenjen sustavno u kombinaciji s drugim antibioticima, a u manjem broju slučajeva inhalacijski kao jedino antimikrobno sredstvo. Iako očigledni, porast koncentracije kreatinina, sniženje klirensa i glomerularne filtracije tijekom primjene kolistina nisu dosegli statističku značajnost. U ispitanika s poznatom ABO kolistin nije izazvao dodatno pogoršanje bubrežne funkcije. ABO nastala tijekom primjene kolistina vjerojatno je posljedica udruženog djelovanja više čimbenika među kojima valja istaknuti latentni poremećaj bubrežne funkcije u sklopu kritične bolesti.Objective: The aim of this research was to assess the infl uence of colistin on renal function in critical patients, the frequency and severity of renal dysfunction, factors that, along with colistin, contribute to the onset of acute kidney injury (AKI), and the effects of AKI on clinical outcome. Study design: Observational retrospective study. Participants and Methods: The study included 58 patients hospitalized at the Intensive Care Unit of the Department of Anesthesiology and Intensive Care over a two-year period. The inclusion criterion was targeted therapeutic use of colistin. Demographic and clinical data on patients were collected from their medical records. Results: Colistin was used for targeted treatment of microbiologically confi rmed infections. In more than 70% of patients, it was administered systematically, and in 80% of cases in combination with other antibiotics. Five patients received a loading dose of colistin, the median maintenance dose was 6 million IU, the cumulative dose was 41 million IU, and median duration of treatment was 7 days. AKI was established in 12 subjects between the 2nd and 14th day of therapy, with a uniform representation of injuries of the 1st, 2nd and 3rd degree. The duration of therapy, doses of colistin and sepsis were not proven to significantly affect the incidence of AKI. The mortality rate in AKI patients was 75%. Conclusion: In most subjects, colistin was administered systematically in combination with other antibiotics, and in few cases inhaled as the only antimicrobial agent. Although apparent, the increase of creatinine concentration, reduction of clearance and glomerular filtration during the administration of colistin did not reach statistical significance. In the subjects with known AKI, colistin did not induce further aggravation of renal function. AKI resulting from the use of colistin is probably a consequence of the combined effect of several factors, one of which is latent renal dysfunction as part of the critical illness

Aplasia Cutis Congenita in a Newborn Child Associated with Two Fetus Papyraceous

Aplasia cutis congenita (ACC) is a rare inborn lesion, presenting with absence of skin. The etiology is unknown and is probably not attributable to a single cause but to a combination of genetic factors. Multiple causes have been suggested for ACC: syndromes and teratogens, intrauterine infection – varicella zoster virus, herpes simplex virus – fetal exposure to cocaine, heroin, alcohol, or antithyroid drugs. The most common site is the scalp. We report a case with multiple lesions on the trunk, resembling an instance with ACC group 5. This form of ACC occurs in association with the in utero death of a twin or more (in this case triple) fetus. Histological findings are available in very few reports. Therapy options depend on the characteristics of the lesion, but conservative treatment is usually chosen.</p