Brachial Plexus Schwannoma - Case Report and Literature Review.

Schwannoma as an extracranial nerve sheath tumor rarely affects brachial plexus. Due to the fact that brachial plexus schwannomas are a rare entity and due to the brachial plexus anatomic complexity, schwannomas in this region present a challenge for surgeons. We present a case of a 49-year-old female patient with a slow growing painless mass in the right supraclavicular region that was diagnosed as schwannoma and operated at our department. The case is described to remind that in case of supraclavicular tumors, differential diagnosis should take brachial plexus tumors, i.e. schwannomas, in consideration. Extra caution is also required on fine needle aspiration procedures or biopsies of schwannomas due to the possible iatrogenic injury of the nerve and adjacent structures. On operative treatment of schwannoma, complete tumor resection should be achieved while preserving the nerve.

Fine needle aspiration cytology of metastatic Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is uncommon cutaneous malignant neuroendocrine tumour of the elderly people with rapidly growing skin nodules found frequently on sun-exposed areas of the body. MCC is often an aggressive tumour with high tendency for local recurrence, lymph node involvement and distant metastases. This paper reports a case of metastatic MCC diagnosed by fine needle aspiration cytology (FNAC), flow cytometric deoxiribonucleated acid (DNA) analysis, pathohistology and electron microscopy. The cytological features in aspirate (stained with Papenheim and Papanicolaou staining) included increased cellularity, discohesive groups of small-to-medium size malignant cells with uniform, round-to-oval nuclei with moulding effect, fine chromatin, multiple micronucleoli and scanty cytoplasm. DNA flow cytometric analysis of the aspirate showed unexpected results for clinically aggressive behaviour of this tumour (the patient died after 21 months), and revealed that tumour contained diploid peak with DNA index of 1.1. The proliferation was high with elevated S-phase fraction (21%). The cytological diagnosis of possible metastatic MCC was confirmed by histological one as well as by electron microscopy presented the pathognomonic features for this tumour: dense-core neurosecretory granules with diameter of 100-250 nm surrounded by whorls of intermediate filaments. MCC provides an enormous challenge for the morphologist because of a wide range of differential diagnosis and for the clinician because this tumour has a highly malignant potential for local recurrence, nodal and distant spread and very often is combined with other tumours. Therefore it is important to perform FNAC of different lesions in the same patient because it can distinguish MCC from the other tumours.

Investigation of auditory brainstem function in elderly diabetic patients with presbycusis.

We performed brainstem auditory evoked potential (BAEP) examinations in 100 patients older than 60 years and having type I diabetes mellitus and presbycusis. The aim of our investigation was to compare the BAEP results of this group with those of healthy controls with presbycusis and to look for possible correlations between alteration of the auditory brainstem function and the aging of elderly diabetic patients. Absolute and interpeak latencies of all waves were prolonged significantly in the study group of diabetic patients. The amplitudes of all waves I through V were diminished in the study group as compared to those in the control group, with statistical significance present for all waves. Analysis of the latencies (waves I, II, I, and V), interpeak latencies (I-V), and amplitudes (I, II, III, and V) of BAEP revealed a significant difference between those of diabetics and those of healthy elderly controls with presbycusis. These data support a hypothesis that there is a brainstem neuropathy in diabetes mellitus that can be assessed with auditory brainstem response testing even in the group of elderly patients with sensorineural hearing loss.

Life threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy in multi-trauma patient with cervical spine injury.

Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance.

The optimal pediatric induction dose of propofol in combination with reduced-dose rocuronium and alfentanil for day-case tonsillectomy in children.

OBJECTIVE: Tonsillectomy in children may be performed on a day-case basis. To achieve quality anesthesia and successful, fast recovery with minimal morbidity without the use of volatile anesthetic, the choice of drug combination has to be centered on one rapid- and short-acting hypnotic, opioid and non-depolarizing muscle relaxant. The aim of our study was to determine the optimal pediatric induction dose of propofol that by means of alfentanil and reduced-dose rocuronium allows the highest percentage of excellent intubating conditions. METHODS: One hundred and eleven children were randomized in three equal groups and included in prospective, double blind study. Anesthesia was induced with 2.0 (Group A), 2.5 (Group B) or 3.0 mg kg(-1) (Group C) of propofol proceeded by alfentanil (0.02 mg kg(-1)). Muscle relaxation was achieved with reduced-dose rocuronium (1.5x ED(95)) (0.45 mg kg(-1)). The intubating conditions were assessed using the four-point scoring system based on the difficulty of laryngoscopy, presence of vocal cord movement and the intensity of coughing. Neuromuscular transmission was monitored by means of acceleromyography with supramaximal train-of-four stimulation of the ulnar nerve by the frequency of 1Hz. RESULTS: Adequate intubating conditions were achieved in high percentages in all study groups (A = 94%, B = 95%, C = 98%) (P = 0.352). Significant higher differences of excellent and good intubating conditions, attributed to quality of laryngoscopy, movement of the vocal cords and intensity of coughing were observed in Group C (excellent = 94%, good = 4%) (B = excellent 80%, good = 18% and A = excellent 47%, good = 47%) (P = 0.0001). MAP decrease of 12% from the baseline occurred immediately only after 3.0 mg kg(-1) induction dose of propofol (80+/-7 mm Hg; A = 92 +/- 6, B = 88 +/- 9) (P = 0.005). CONCLUSIONS: Induction dose of 2.5 mg kg(-1) of propofol preceded by 0.02 mg kg(-1) of alfentanil in addition to reduced-dose rocuronium (0.45 mg kg(-1)) is the optimal pediatric induction dose of propofol for improving the most excellent intubating conditions without significant hemodynamic changes.

[Prevention of thromboembolism and survival after trauma]. / Tromboembolijska profilasksa i prezivljenje nakon ozljede.

AIM: Thromboembolism (TE) is a well-known and potentially fatal complication after injury and orthopedic surgery. Thromboembolic prophylaxis is generally recognized as a factor of significant interest concerning posttraumatic comorbidity and mortality. In this context, the aim of the study was to analyze hospital mortality 24 hours after injury, and to assess the proportion of fatal pulmonary embolism in overall hospital mortality. Finally, the purpose of the study was to explore the possible correlation between different prophylactic approaches and hospital mortality. METHODS: A retrospective-prospective study was conducted at the University Hospital of Traumatology, Zagreb, over a 14-year period (1988-2001). The study was based on documented clinical and autopsy findings and comprised all trauma patients admitted for hospital treatment. The overall and thromboembolic mortality were analyzed for each individual year during the study period. These two variables were compared and expressed as a proportion for each year. Further analysis included comparison of the data obtained between years and sequences of years. The modes of TE prophylaxis in various periods were analyzed as well. Differences in the mortality rates were tested for statistical significance. Results obtained for each period of time were compared and expressed as a function of different approaches to thromboembolic prevention. RESULTS: Results obtained in the study demonstrated a clear tendency towards the decrease in the overall mortality as well as in the mortality due to fatal pulmonary embolism. Mortality rates showed significant differences during the study period. The most prominent difference was found between the first and final year of investigation. In 1988, the overall mortality was 3.78% and TE mortality 2.05%, whereas in 2001 the respective rates were 1.17% and 0.3% (p < 0.001). A continuous significant mortality decrease in trauma patients was recorded for some years and sequences of years (p < 0.05). The proportion of TE fatality in the overall mortality was > 50% in 1988 and about 25% in 2001. Our results demonstrated a 70% reduction in the overall mortality and even 85% reduction in the fatal TE rate. Finally, a significant reduction of TE fatality by 55% independently of overall mortality reduction was observed. The decreasing mortality rate correlated with different approaches to TE prophylaxis during the 14-year-period. DISCUSSION: Thromboembolism accounted for a considerable proportion of the mortality rate in trauma patients during the study period. The observed dynamics, expressed as a 70% reduction in the overall hospital mortality and an 85% decrease in the fatal PE rate reflected significant improvement in trauma treatment. Further, independently of the overall mortality, TE mortality was reduced by more than 55%, which was obviously related to the changing approaches to TE prevention. At the beginning, physical methods of prophylaxis prevailed. Prophylactic anticoagulation with heparin was started sporadically around 1991 and have been enhanced over time. In 1995, it was included in the routine treatment of specific patient categories. Since 1998, low molecular weight heparin has become the gold standard in TE prophylaxis, with more prominent application in severe multiple injuries. With the recent approach, we have managed to overcome the controversies in the treatment of severe injuries, primarily concerning bleeding and TE, and achieved considerable improvement. CONCLUSION: A significant reduction in the mortality, especially due to fatal pulmonary embolism after injury, was clearly demonstrated. This could be explained by improvements in the management of trauma and organized TE prevention.