Femoral nerve block- or intravenous- guided patient control analgesiafor early physical rehabilitation after anterior cruciate ligament reconstruction in "fast-track" orthopedics: what is optimal?

Background and purpose: "Fast-track" orthopaedics characterizes early start of physical rehabilitation (PHR). Quality of mobilization depends on pain therapy success and preservation of motor function and muscle strength. Patient-control-analgesia (PCA), as an upgrade of continuous intravenous (IV) or regional analgesia (FB) makes the modern base in treatment of acute pain. The aim of the study was to determine more effective post-operative PCA-analgesia (IV-PCA vs. FB-PCA) for early PHR in "fast-track" orthopaedics. Materials and Methods: Prospective, observer-blinded study included 40 adults (bought gender, ASA I/II) scheduled for anterior cruciate ligament reconstruction (RACL). Spinal anaesthesia (12.5 mg, 0.5% levobupivacaine; G27-Pencil-Point) was performed in all patients. Patients were divided in two equal groups. In Group IV-PCA intravenous (fentanyl 0.5-1μg kg–1h–1), and in Group FB-PCA regional (femoral block: 0.125% levobupivacaine, 8 ml h–1) PCA-analgesia (Group IV-PCA: fentanil 10μg/8min/x6max; Group FB-PCA: 0.125% levobupivacaine, 8ml/30min/x3max) was established after surgery. Pain score (VAS) was assessed during 24-hours and accepted as satisfactory by 3. Diclofenac 75 i.v. was given in two doses, immediatelly and 12 hours after surgery. Paracetamol 1g was added intravenously if VAS was ³ 4. Start of early PHR was planned six hours after surgery. Result: FB- and IV-PCA provided equally effective analgesia during first 24-hours after RACL (VAS3). Early PHR was possible 6-hours after surgery in 85% of Group FB-PCA (Group IV-PCA=20%) (P=0,0001) due to significantly lower VAS 0,7+/–0,2 (Group IV-PCA=3,0+/–0,2)(P<0,0001). Residual motor block, presented in three patient (15%) with FB-PCA, disabled the onset of PHR.Additional analgesic dose wasmore need inGroup IV-PCA(40%) (Group FB-PCA=10%) (P<0,0001). Conclusion: FB-PCA allows more successful pain-free early PHR for orthopaedics "fast-track" ACL reconstruction compare to IV-PCA, excluding 15% of the FB-PCA patients in whom residual muscle weakness was present

Minimally invasive procedures in diagnosis of low back and radicular pain

Križobolja i lumboishijalgija su značajni zdravstveni problemi današnjice. Bolesnici s navedenim tegobama često izostaju s posla, a troškovi operacijskog liječenja iznimno su visoki. Adekvatna dijagnostika križobolje i lumboishijalgije podrazumijeva detaljno poznavanje anatomije kralježnice i živčanih struktura, kao i rukovanje pomičnim RTG uređajem. Svrha je ovih procedura primjenom kratkodjelujućeg lokalnog anestetika anestezirati pojedine živčane završetke, a u slučaju provokativne diskografije provocirati bol, kako bi se sa sigurnošću potvrdilo koje su anatomske strukture uzrok bolova. To je potrebno stoga što križobolju mogu uzrokovati različite bolesti kralježnice. Najčešće su degenerativne promjene u intervertebralnom disku, promjene malih zglobova, oštećeni sakroilijakalni zglob ili hernijacija diska. Shodno ovome, a ovisno o različitim anatomskim strukturama koje mogu biti izvor bolova, postoji više dijagnostičkih minimalno invazivnih procedura. Svaka dijagnostička procedura, s kojom se egzaktno utvrdi uzrok križobolje ili lumboishijalgije, bolesnika posljedično potvrđuje kao dobrog kandidata za minimalno invazivni terapijski zahvat.Low back and radicular pain make a significant health concern. They are also one of the leading, medically related, causes for missed work. Furthermore, expenses for surgery are often very high. Adequate diagnosis of low back and radicular pain involves detailed knowledge of the anatomy of the lumbar spine and the nerve structures, as well as handling with C-arm. The purpose of these procedures, with the use of short-acting local anesthetic, is to anesthetize specific nerve endings in order to verify which anatomical structures are true pain generators. This is important because low back pain can be caused by vast palette of spine disorders. The most common include degenerative intervertebral disc disease, changes in the zygapophyseal (facet) joints, damaged sacroiliac joint or disc herniation. Depending on the different anatomical structures that can cause the low back and radicular pain, one can use several minimally invasive diagnostic procedures. Each minimally invasive diagnostic procedure, with which we confirm the exact cause of low back pain or radicular pain, consequently predisposes patients for minimally invasive therapeutic intervention

Glioblastom maloga mozga kod starije osobe - prikaz slučaja

Cerebellar glioblastoma in the elderly is rare. Only 33 cases have been reported in the literature. We report on a 65-year-old male patient with cerebellar glioblastoma. Computed tomography scan revealed a posterior fossa tumor of 34x33x52 mm in size, with hydrocephalus. The patient presented with posterior fossa symptoms, ataxia, nausea and vomiting. He deteriorated rapidly and ventricular drainage was performed. When the patient\u27s condition improved, suboccipital median craniectomy was performed and the tumor was removed. Postoperative treatment included radiotherapy and temozolomide chemotherapy.Glioblastom maloga mozga je veoma rijedak. Dosad su u literaturi prikazana 33 bolesnika starije životne dobi s glioblastomom maloga mozga. Prikazan je slučaj muškarca u dobi od 65 godina. Kompjutorizirana tomografija maloga mozga pokazala je ekspanzivni proces maloga mozga veličine 34x33x52 mm. U kliničkoj slici je bila prisutna cerebelarna simptomatologija. Bolesnik je operiran u dva zahvata: najprije je zbog hipertenzijskog opstrukcijskog hidrocefalusa učinjena vanjska ventrikularna drenaža, a u drugom zahvatu medijalna subokcipitalna kraniektomija i ablacija tumora. Histopatološki nalaz je ukazao na glioblastom maloga mozga. Poslijeoperacijski je provedeno onkološko liječenje koje je uključivalo radioterapiju i kemoterapiju temozolomidom

Kvaliteta života bolesnika s epilepsijom - naša iskustva

A prospective study was carried out at the Zagreb University Hospital Centre to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and quality of life (QoL) in patients with epilepsy (PE), and its association with depressive symptoms and sexual dysfunction (SD). QoL was assessed by use of the Quality of Life in Epilepsy-31 Inventory (QOLIE-31), SD by the Arizona Sexual Experiences Scale (ASEX), and depressive symptoms by the Hamilton Rating Scale for Depression (HAM-D17). The study included 108 PE (women 63% and men 37% men), mean age 39.54±15.91 years. Focal type epilepsy was diagnosed in 14.8%, generalized type in 35.2%, and both types were present in 40.7% of study patients. Drug-resistant epilepsy (DRE) was present in 44/108 and vagus nerve stimulation (VNS) was implanted in 27/44 patients. The mean response on QOLIE-31 was 62.88±17.21 with no significant differences according to gender, type of epilepsy, and age. A statistically significantly lower QoL was found in the ‘Overall QoL’ domain (35-55 vs. <35 age group). Patients taking both types of AEDs had a significantly lower QoL compared to those on newer types of AEDs. Higher QoL was associated with less pronounced depressive symptoms (p=0.000). Significant correlations were found between lower QoL and SD (p=0.001). In 27 patients with DRE having undergone VNS, a favorable effect of VNS implantation on the QoL and mood was observed as compared with 18 patients without VNS (p=0.041).Provedeno je prospektivno istraživanje u KBC-u Zagreb s ciljem procjene povezanosti epilepsije, antiepileptičkih lijekova (antiepileptic drug, AED) i kvalitete života (quality of life, QoL) u bolesnika s epilepsijom, kao i učestalosti depresije i seksualne disfunkcije (SD). QOLIE-31 (Quality of Life in Epilepsy-31 Inventory) je primijenjen za procjenu QoL-a, ASEX (Arizona Sexual Experiences Scale) za SD i HAM-D17 (Hamilton Rating Scale) za depresiju. Uključeno je 108 bolesnika s epilepsijom (63% žena, 37% muškaraca; srednja dob 39,54±15,91 godina). Žarišnu epilepsiju imalo je 14,8% i generaliziranu 35,2% bolesnika, dok je obje vrste epilepsije imalo 40,7% bolesnika. Farmakorezistentnu epilepsiju (drug-resistant epilepsy, DRE) imalo je 44/108 bolesnika, a kod njih 27/44 ugrađen je stimulator vagusnog živca (vagus nerve stimulation, VNS). Srednji odgovor na QOLIE-31 bio je 62,88±7,21 bez značajnih razlika u odnosu na spol, vrstu epilepsije i dob. Statistički značajno niži QoL nađen je u domeni ‘Sveukupni QoL’ (dobna skupina 35-55 godina u odnosu na dobnu skupinu <35). Bolesnici koji su uzimali obje vrste AED imali su značajno niži QoL u usporedbi s onima na novijim AED. Viši QoL bio je povezan s manje izraženim simptomima depresije (p=0,000). Pronađene su značajne korelacije između nižeg QoL-a i SD (p=0,001). U bolesnika s DRE utvrđen je pozitivan utjecaj ugradnje VNS-a na QoL i raspoloženje (27 bolesnika s VNS-om u usporedbi s 18 bolesnika bez VNS-a, p=0,041)

Minimally invasive procedures in treatment of low back and radicular pain

Križobolja i lumboishijalgija značajni su javnozdravstveni problemi modernoga doba. Troškovi operacijskog liječenja često su iznimno visoki, a radno sposobni ljudi s ovim bolestima često izostaju s radnoga mjesta. Minimalno invazivno liječenje križobolje i lumboishijalgije podrazumijeva detaljno poznavanje anatomije kralježnice i živčanih struktura, kao i rukovanje pokretnim RTG uređajem. Križobolju i lumboishijalgiju mogu uzrokovati degenerativne promjene u intervertebralnom disku, promjene zigapofizealnih (fasetnih) zglobova, oštećeni sakroilijakalni (SI) zglob ili hernijacija diska, kao najčešći uzrok stenoze spinalnog kanala. Svaka minimalno invazivna dijagnostička procedura, s kojom se egzaktno potvrdi uzrok križobolje ili lumboishijalgije, bolesnika posljedično predodređuje za specifični minimalno invazivni terapijski zahvat. Kod bolova u slabinskoj kralježnici uzrokovanih degenerativnim promjenama u intervertebralnom disku bolesniku se preporučuje jedna od metoda anuloplastike. Ako je križobolja uzrokovana degenerativnim promjenama fasetnih zglobova ili promjenama u SI zglobu, tada se primjenjuju procedure radiofrekventne neuroablacije. U slučajevima kada su križobolja i lumboishijalgija uzrokovane stenozom spinalnog kanala, bolesniku se preporučuju epiduralne steroidne injekcije ili perkutana laserska dekompresija diska. Svrha je ovih procedura, primjenom dugodjelujućih kortikosteroida i kratkodjelujućeg lokalnog anestetika, te primjenom radiofrekventne struje ili primjenom energije lasera, bolesnika na duže vrijeme osloboditi bolova i tako mu poboljšati kvalitetu života, a istovremeno prevenirati ili barem odgoditi velik operacijski zahvat.Low back and radicular pain make a significant health concern in our days. Expenses for this kind of surgery are often very high. Furthermore, these two conditions are also one of the leading, medically related, causes for missed work. Minimally invasive treatment of low back and radicular pain involves detailed knowledge of the anatomy of the lumbar spine and the nerve structures, as well as handling with C-arm. Degenerative changes in the intervertebral disc, changes in the zygapophyseal (facet) joints, damaged sacroiliac joint or disc herniation can all cause low back pain. Each minimally invasive diagnostic procedure, with which we confirm the exact cause of low back pain or radicular pain, consequently predisposes patients for minimally invasive therapeutic intervention. When low back pain is caused by degenerative changes in the intervertebral disc, the patient is recommended a method of annuloplasty. If the pain in the lumbar spine is caused by degenerative changes of facet joints or changes in SI joint, patient can be offered radiofrequent neuroablative procedures. In cases where the low back and radicular pain are caused by spinal stenosis patients are advised epidural steroid injections or percutaneous laser disc decompression. The purpose of these procedures, with the use of long-acting corticosteroids and short-acting local anesthetic, together with the use of radio frequent or laser energy is to relieve the patients from their pain. This way we improve their quality of life and, at the same time, prevent or at least postpone major surgery

The Clinical Benefit of Percutaneous Transhepatic Biliary Drainage for Malignant Biliary Tract Obstruction

Percutaneous transhepatic biliary drainage (PTBD) is a decompression procedure for malignant proximal biliary obstruction. In this research, over a six-year period, 89 patients underwent PTBD procedure for jaundice caused by malignant disease to restart chemotherapy or for palliative intent. Clinical outcomes after PTBD procedure in the two groups of patients, according to the adequate bilirubin decline (ABD) needed for subsequent chemotherapy, are presented in this paper. Survival and logistic regression were plotted and compared using Kaplan&ndash;Meier survival multivariate analysis with a long-range test. Results were processed by MEDCALC software. In the series, 58.4% (52/89) of patients were in good performance status (ECOG 0/1), and PTBD was performed with the intention to (re)start chemotherapy. The normalization of the bilirubin level was seen in 23.0% (12/52), but only 15.4% (8/52) received chemotherapy. The median survival time after PTBD was 9 weeks. In patients with ABD that received chemotherapy, the median survival time was 64 weeks, with 30-day mortality of 27.7%, and 6.4% of death within 7 days. The best outcome was in patients with good performance status (ECOG 0&ndash;1), low bilirubin (&lt;120 &micro;mol/L) and LDH (&lt;300 &micro;mol/L) levels and elevated leukocytes at the time of the procedures. PTBD is considered in ABD patients who are candidates for chemotherapy

The Effect of Intra-articular Injection of Autologous Microfragmented Fat Tissue on Proteoglycan Synthesis in Patients with Knee Osteoarthritis

Osteoarthritis (OA) is one of the leading musculoskeletal disorders in the adult population. It is associated with cartilage damage triggered by the deterioration of the extracellular matrix tissue. The present study explores the effect of intra-articular injection of autologous microfragmented adipose tissue to host chondrocytes and cartilage proteoglycans in patients with knee OA. A prospective, non-randomized, interventional, single-center, open-label clinical trial was conducted from January 2016 to April 2017. A total of 17 patients were enrolled in the study, and 32 knees with osteoarthritis were assessed. Surgical intervention (lipoaspiration) followed by tissue processing and intra-articular injection of the final microfragmented adipose tissue product into the affected knee(s) was performed in all patients. Patients were assessed for visual analogue scale (VAS), delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and immunoglobulin G (IgG) glycans at the baseline, three, six and 12 months after the treatment. Magnetic resonance sequence in dGEMRIC due to infiltration of the anionic, negatively charged contrast gadopentetate dimeglumine (Gd-DTPA2−) into the cartilage indicated that the contents of cartilage glycosaminoglycans significantly increased in specific areas of the treated knee joint. In addition, dGEMRIC consequently reflected subsequent changes in the mechanical axis of the lower extremities. The results of our study indicate that the use of autologous and microfragmented adipose tissue in patients with knee OA (measured by dGEMRIC MRI) increased glycosaminoglycan (GAG) content in hyaline cartilage, which is in line with observed VAS and clinical results

Prenatal selenium status, neonatal cerebellum measures and child neurodevelopment at the age of 18 months

Objectives: The aim of this study was to evaluate the association of maternal blood selenium (Se) levels and cord blood Se levels with neonatal cerebellum measures and child neurodevelopment at the age of 18 months. Moreover, to investigate whether the neonatal cerebellum measures could be used as a potential biomarker for selenium homeostasis during pregnancy. Study group and methods: The study population consisted of 205 mother-child pairs from Croatian Mother and Child Cohort. Maternal blood and cord blood were obtained at delivery and selenium level was analyzed by Inductively Coupled Plasma Mass Spectrometry. Cranial ultrasonography examination was performed on 49 newborns – cerebellum length and width have been measured. Neurodevelopmental assessment of cognitive, language and motor skills were conducted on 154 children, using The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), at the age of 18 months. Results: The mean levels of selenium in maternal blood and cord blood were 92.6 ng/g and 97.0 ng/g, respectively. Maternal blood selenium levels were moderately and negatively correlated (r = −0.372 ; p = 0.008) with cerebellum length, while cord blood selenium levels were positively correlated with cerebellum width (r = 0.613 ; p = 0.007) among female children group. Maternal blood selenium levels were weakly and positively correlated (r = 0.176 ; p = 0.029) with child's cognitive abilities. Conclusion: To the best of our knowledge, our study is the first one investigating the association between neonatal brain measures and selenium levels in mother-child pairs. Our results indicate that prenatal selenium intake correlated with cerebellum length and width measured by cranial ultrasonography. Hence, cerebellum may be used as a potential biomarker and a target “organ” for early detection of possible adverse effects of prenatal status to various micronutrients

Personalized medicine in modern radiology, neurology, neurosurgery, orthopedics, anesthesiology, physical medicine and rehabilitation and pediatrics: Model of the St. Catherine Hospital

CILJ: Prikazati primjenjivost personalizirane medicine u svakodnevnom kliničkom radu Specijalne bolnice Sv. Katarina kao regionalnom centru izvrsnosti i lideru u primjeni inovativnih metoda dijagnostike i liječenja. METODE: Liječnici različitih specijalnosti: radiolozi, neurolog, neurokirurg i vertebrolog, ortopedi, fizijatar, anesteziolog te molekularni biolog, medicinski biokemičar i pedijatar, u ovome su radu na konkretnim primjerima naveli osnovne principe primjene personalizirane medicine u svome svakodnevnom kliničkom radu kritički se pri tome osvrćući na relevantne radove o navedenoj temi publicirane u recentnoj medicinskoj literaturi. ZAKLJUČCI: Nedvojbeno je da će načela personalizirane medicine odrediti smjernice razvoja dijagnostičkih i terapeutskih postupaka. Isto tako, stanična terapija, liječenje matičnim stanicama, stanično reprogramiranje, tkivni inženjering ili genska terapija postati će metode izbora u liječenju niza bolesti koje smo do sada više ili manje bezuspješno liječili standardnim metodama i postupcima