[Glucose, Lactate, NGAL and Coefficient of Energy Balance in Synovial Fluid in Patients with Hip and Knee Prosthetic Joint Infection]. / Stanovení hladiny glukózy, laktátu, NGAL a KEB ve výpotku u infekcí TEP kolen a kyclí.

PURPOSE OF THE STUDY Laboratory methods are central to prosthetic joint infection (PJI) diagnosis. Most research teams focus on detection of specific inflammatory markers, causative pathogens, or on assessment of the tissue response. This study sought to determine the optimal cut-off values and diagnostic performance of selected synovial markers in relation to the diagnosis of hip or knee PJI. The studied markers were synovial level of glucose, lactate, coefficient of energy balance (CEB) and NGAL (neutrophil gelatinase-associated lipocalin). MATERIAL AND METHODS This prospective study includes 89 patients who underwent revision total knee or hip arthroplasty for septic or aseptic reasons in the period from 2014 to 2017. Among these 89 patients, there are 2 cases of prosthetic hip infection, 22 cases of prosthetic knee infection, 31 aseptic revision total hip arthroplasties and 34 aseptic revision total knee arthroplasties. The diagnostic characteristics of the studied methods were set in relation to the reference standard, the 2013 MSIS (Musculoskeletal Infection Society) criteria. The cut-off values were calculated using the ROC (receiver operating characteristic curve) analysis. RESULTS The synovial glucose test is considered positive if the glucose level drops below 2.65 mmol/L. The area under the curve is 0.813, sensitivity 75.0%, specificity 83.1%. The synovial lactate test is considered positive if lactate level rises above 8.87 mmol/L. The area under the curve is 0.882, sensitivity 70.8%, specificity 95.4%. Synovial NGAL is considered positive if its level exceeds 998 µg/L. The area under the curve is 1.000, sensitivity 100.0%, specificity 100.0%. CEB is considered positive if its value is lower than +4.665. The area under the curve is 0.883, sensitivity 91.7% and specificity 69.8%. Combining of these tests with other synovial markers does not improve the diagnostic performance of the studied tests. CONCLUSIONS The glucose and lactate levels and CEB undoubtedly reflect the presence of an inflammatory process in a prosthetic joint. However, the diagnostic characteristics of these tests are not better than those of other modern diagnostic techniques. As opposed to these tests, synovial NGAL shows excellent diagnostic performance. Nonetheless, the potential of this method shall be verified on larger cohorts of patients. Key words: prosthetic joint infection, periprosthetic infection, total knee arthroplasty, total hip arthroplasty, diagnosis, glucose, lactate, CEB, NGAL.

Optimal Route for Tranexamic Acid in Diabetics and Obese Patients Undergoing Primary Total Knee Arthroplasty - a Data from Randomized Study.

PURPOSE OF THE STUDY To determine the optimal strategy for tranexamic acid (TXA) administration in diabetic patients, smokers and obese patients (BMI > 30 kg/m2) undergoing primary total knee arthroplasty (TKA). MATERIAL AND METHODS The total of 400 consecutive patients indicated for primary TKA were randomised into 4 basic groups with different TXA administration regimens. Group 1 (IV1) had a single intravenous dose (15 mg TXA/kg) applied prior to skin incision. Group 2 (IV2) got two intravenous doses (15 mg TXA/kg): one prior to skin incision and one subsequently 6 hours after the first dose. Group 3 (TOP) had 2 g TXA in 50 ml of saline irrigated topically at the end of the surgery. Group 4 (COMB) combined IV1 and TOP regimens. We monitored the amount of total blood loss (TBL), haemoglobin drop, use of blood transfusions (BTs), and complications in each patient. Follow-up period was one year postoperatively. RESULTS In the group of diabetic patients (n = 87; 21.7%) the lowest TBL was observed in the order: IV1, IV2 > COMB > TOP. In the obese patients (BMI > 30 kg/m2; n = 242; 60.5%), TBL was significantly lower in the intravenous regimens (IV1: p = 0.002; IV2: p = 0.005, respectively) than in the TOP regimen. In the smoking patients (n = 30; 7.5%), TBLs were significantly lower in the order: IV1 > IV2 > COMB > TOP. DISCUSSION Individualised approach to prevention and therapy is a recent trend, also because comorbidities significantly affect the result of the intervention. In the case of diabetes, obesity and smoking, there is a proven link to early post-operative infections, mainly due to poorer innate immunity. It is conceivable, though, that the occurrence of infectious complications is also contributed to by larger hematomas or hemarthroses which are largely preventable. CONCLUSIONS In the diabetic and obese patients (BMI > 30 kg/m2), the combined topical/intravenous TXA application and two intravenous doses of TXA interventions were shown to be the most effective. However, no evidence of superiority of any of the TXA administration routes was obtained in the smokers. None of the TXA protocols was associated with a higher incidence of complications or early reoperation following TKA surgery. Key words: tranexamic acid, topical application, intravenous application, combined administration, diabetes, obesity, BMI, smoking, blood loss, hidden blood loss, total knee arthroplasty, complications.

[Short-Term Outcomes of Endoscopic Treatment of Inferior Calcar Calcanei in Patients with Plantar Fasciitis]. / Krátkodobé výsledky endoskopické ablace patní ostruhy u pacientu s plantární fasciitidou.

PURPOSE OF THE STUDY The prospective study evaluates the short-term outcomes of endoscopic treatment of calcar calcanei in patients who underwent unsuccessfully more than 6 months of conservative therapy. MATERIAL AND METHODS Our study included 34 patients with refractory plantar fasciitis, in whom endoscopic treatment of inferior calcar calcanei with partial plantar fasciotomy was performed in the period from 01. 01. 2009 to 31. 07. 2015. The assessed parameters were the following: level of function, pain relief and patient satisfaction on the FAAM (Foot and Ankle Ability Measure) score and VAS (Visual Analog Scale) score with the minimum follow-up of 1 year. RESULTS A marked increase in the FAAM score from 39.2 preoperatively to 94.0 one year after the surgery and also a major pain relief on the VAS score from the initial 8 to the median 0 were observed. In total, 79.4% of patients were symptom-free one year after the surgery. The recurrence of calcar calcanei or ossification was seen on the radiograph taken one year after the surgery in 8 patients (23.5 %). DISCUSSION In our opinion, the most important outcome of our study is the considerable reduction in pain postoperatively (the median VAS score declined from 8 to 0 one year after the surgery) and concurrently a notable increase in the FAAM score (from 39.2 preoperatively to 94.0 one year after the surgery). Similar results of endoscopic partial fasciotomy were achieved also by some other authors. Therefore, this method can be considered validated. It has also been proven that the correlation between the calcar calcanei recurrence, or a higher BMI and recurrence of symptoms postoperatively is insignificant. CONCLUSIONS The endoscopic treatment of inferior calcar calcanei and plantar fasciotomy with denervation of fascial attachment is a fast, minimally invasive and safe method which brings very satisfactory results in the treatment of refractory plantar fasciitis. It is evidenced by subjective patient satisfaction, great function improvement, considerable pain relief after the surgery together with a minimum incidence of complications. Kew words:hindfoot, plantar heel pain, plantar fasciitis, arthroscopic treatment, short-term results.

Complications and mortality of surgical therapy for esophageal cancer: 10 years single center experience.

A single-center retrospective study the complication and mortality of surgical treatment of esophageal cancer 2006 to 2015 is presented. A total of 212 patients with esophageal cancer were operated at the First Department of Surgery University Hospital Olomouc, Czech Republic in the period between 2006 and 2015. Adenocarcinoma was histologically described in 127 patients (59.9%), squamous cell carcinoma in 82 patients (38.7%), and other types of carcinoma were described in 3 cases. According to the preoperative staging of esophageal cancer, the patients with early stage disease (T1-2N0M0) had primary surgery, while the patients with advanced stage (T3-4N0-2M0) were indicated for neoadjuvant chemoradiation with the surgery being performed subsequently. Transhiatal laparoscopic esophagectomy was performed in 183 patients, and Orringer esophagectomy in 4 patients. Thoracoscopic esophagectomy was performed in 17 patients and thoracotomy in 30 patients. Respiratory failure with the development of ARDS syndrome accompanied by multiple-organ failure occurred in 21 patients. Statistically significant association between mortality and ASA (p = 0.009) and between respiratory complications and ASA (p = 0.006) was demonstrated. The majority of patients who died were under 60 years of age (p = 0.039). Further, significant association between 30-day mortality and tumor stage (p = 0.021), gender (p = 0.022) and age (p = 0.018) was evident. A significant association between tumor stage and fistula in anastomosis, (p = 0.043) was observed. Esophagectomy is a procedure, which should be performed in specialized high-volume centers experienced in treatment of this serious malignancy and by certified oncology surgeons with long time experience in esophageal surgery.

[The effect of circulating tumor cells on the survival of patients with pancreatic cancer 5-year results]. / Vliv prukazu cirkulujících nádorových bunek na prezívání pacientu s karcinomem pankreatu - petileté výsledky.

INTRODUCTION: Pancreatic cancer (PDAC) is one of the most aggressive malignancies. Its incidence increases worldwide and, despite the developments in cancer research, mortality rates have not decreased. Poor prognosis of the disease is due to many factors, mainly late diagnosis. Distant metastases and peritoneal carcinomatosis are caused by hematogenous and lymphogenous spreading of the tumorous cells. One of the factors that may influence patient survival are so-called circulating tumor cells (CTCs). The aim of our work was to evaluate the possible influence of CTCs on the survival of patients with PDAC. METHOD: We included patients who underwent a radical or palliative surgical intervention at the First Department of Surgery of Medical Faculty and University Hospital in Olomouc between 1 January 2008 and 31 December 2012. The required samples for CTCs detection were taken from each patient. The detection of the CTCs was performed using real-time RT-PCR. The results were statistically processed and evaluated. RESULTS: We included 126 patients in total, of which 88 were treated radically and 38 received palliative treatment. Mean age was 63 years in patients with radical and 64 years in patients with palliative surgery. Mean survival time in radically treated patients was 29.6 months, in patients with palliative treatment the mean survival time was 8.5 months. The survival time of radically treated patients with CTCs was 27.2 months, without CTCs it was 33.8 months. CONCLUSION: We did not prove a statistically significant difference in survival between radically treated PDAC patients with and without detected CTCs in our work.Key words: pancreatic cancer - circulating tumor cells survival.

Esophageal cancer results of surgical treatment at the Department of Surgery I. at the University Hospital Olomouc.

The authors present the results of surgical treatment of esophageal cancer at Department of Surgery I, University Hospital Olomouc between 20062016. The aim of the study was to use retrospective analysis to evaluate the results of patients operated for esophageal cancer and statistically evaluate the results based on the type of surgical approach (transhiatal, transthoracic). Method: A total of 240 patients with esophageal cancer were operated at Department of Surgery I between the beginning of 2006 and the end of 2016. We evaluated respiratory complications, the incidence of anastomotic fistula and complications based on the Clavien-Dindo classification of complications, based on the type of surgical approach selected (transhiatal or transthoracic esophagectomy). Results: The patient set included 207 men (86.3%) and 33 women (13.7%). The mean patient age was 60.4 years. The histological type was adenocarcinoma in 145 (60.4%) and squamous cell carcinoma in 90 (37.5%) patients; another type of carcinoma was observed in 5 cases. Transhiatal esophagectomy was performed in 194 patients (80.2%) (transhiatal laparoscopic in 190 and classic Orringer in 4 patients). Transthoracic approach was used in 46 patients (19.2%), thoracoscopic in 16, and thoracotomic in 30 patients. A gastric conduit was used in 236 patients and coloplasty was performed in 4 patients. The mean duration of surgery was 217 min for the transhiatal approach, 239 min for the thoracoscopic approach and 277 min for the thoracotomic approach. Total blood loss per patient was 562 ml on average for all the operated patients. Peri- or postoperative blood transfusions were administered to 148 patients. Lymphadenectomy was performed as part of the procedure in all patients; the mean of 16.1 lymph nodes were removed. The average hospital stay was 20.7 days. In the patient set, 30-day mortality included 12 patients (respiratory complications 10, MI 1, conduit necrosis 1) and 90-day mortality included 4 (multi organ failure during ARDS). Based on statistical analysis, the incidence of respiratory complications significantly correlated with ASA classification (p=0.0001) and Clavien-Dindo classification (p.

[Analysis of Costs Associated with Revision Total Knee Arthroplasty]. / Analýza nákladu spojených s reoperacemi TEP kolena.

PURPOSE OF THE STUDY No study has so far been published in the Czech Republic that would try to at least estimate the costs associated with revision total knee arthroplasties (TKA). The purpose of our study was to determine the total costs of primary and revision TKA for aseptic and septic failure and to determine the structure of costs, all with respect to a single workplace in the Czech Republic. MATERIAL AND METHODS The group included a total of 43 patients aged 55 to 82 years, of whom 23 (53.5%) with primary TKA implantation, 10 (23.3%) patients with revision surgery for aseptic failure, and 10 patients for septic failure of TKA. The costs of TKA were calculated retrospectively, factoring in all the items of reported care sent to the health insurance company system. The resulting costs reflected the appropriate payments in CZK based on the point value in the year concerned. RESULTS The average costs of uncomplicated primary TKA implantation amounted to CZK 136,279; the surgical treatment of aseptic failure of TKA was CZK 189,634; and the surgical treatment of septic failure of TKA was CZK 296,189. In all the evaluated cases, the highest cost item was the material of the implant (43.5 to 54.2% of the total costs), followed by the bed costs (19.8 to 21.6%), and the third highest cost item being the performance of surgery (13.6 to 16.5%). The costs of the physician's services represented 12.8 to 14.7% of the total costs and 23.6 to 33.8% of the costs of the implants. The costs associated with the treatment of infection by multiple-stage reimplantation were 5.4 times higher than when DAIR (revision surgery with debridement, irrigation, original implant retention) was used. The average costs of inpatient rehabilitation accounted for CZK 23,046 and the insurance company reimbursed on average CZK 33,544 for a 4-week therapeutic spa treatment. DISCUSSION The finding that the revision TKA is several times more expensive than the primary TKA and that the multiple-stage total knee reimplantation is the most expensive corresponds with the literature. In the Czech Republic, the dominant cost item is the cost of the implant, namely in the total costs of both the primary and revision TKA, with the revision implants in our study being on average 2.1 times more expensive than the implants used for primary implantation. Besides, the costs of implants also considerably differ across countries. The costs of the physician's services ranked 4th in the list of cost items, which does not correspond with the data reported in Western Europe or the US. Conversely, the least difference was observed in the costs of preoperative preparation and auxiliary examinations. CONCLUSIONS We have concluded in our study that the average costs of the total knee replacement for aseptic failure were 1.9 times higher than the costs of primary surgery. The average costs of treatment for septic failure (two-stage procedure) were 2.7 times higher compared to primary surgery. In case of aseptic failure, the costs of total knee reimplantation were 2.7 times higher compared to the replacement of only polyethylene liner in case of instability and osteosynthesis in case of periprosthetic fracture, with components retention. The costs of septic failure therapy were 5.4 times higher in multiple-stage reimplantation compared to revision surgery with debridement, irrigation and original implant retention. Key words: total knee arthroplasty; total knee replacement; revision total knee arthroplasty; aseptic failure; septic failure; cost analysis.

[The survival of patients with radically non-resectable pancreatic cancer]. / Prezívání pacientu s radikálne neresekabilním karcinomem pankreatu.

INTRODUCTION: Pancreatic cancer (PDAC) is one of the most aggressive malignancies. Its poor prognosis is due to a combination of various factors, mainly aggressive biology of the tumour, non-specific symptoms in early stages, their underestimation, prolonged time to diagnosis and late onset of treatment. The majority of patients are diagnosed in an advanced stage of the disease. Median survival of these patients ranges from 211 months. The most common consequences of locally advanced disease that require intervention include obstruction of the duodenum and biliary obstruction. The purpose of our study was to analyze the survival of patients with radically inoperable PDAC undergoing palliative surgery or exploration with biopsy, and to evaluate the influence of patient and tumour factors and treatment modalities on survival. METHODS: In our retrospective study we included all patients with radically inoperable PDAC undergoing a non-radical surgical intervention between 01 January 2006 and 31 December 2014. Patient age, histopathological findings, surgical and oncological treatment and survival were included in the analysis. The results were statistically processed and evaluated using IBM SPSS Statistics software version 22 (USA). RESULTS: 184 patients with radically inoperable PDAC, 105 males and 79 females, were included in our study. Mean age of the patients was 64 years and most patients presented with stage IV of the disease. Mean survival time was 7.04 months and median 4.7 months. CONCLUSION: We determined a statistically significant influence of the following factors on patient survival: sex, stage, presence of distant metastases at the time of surgery and oncological treatment administration. Mean and median survival of patients with radically inoperable tumours matches global statistics. KEY WORDS: pancreatic cancer - radically non-resectable - palliative surgery - survival.

[Patient Satisfaction after Total Knee Arthroplasty. Analysis of Pre-Operative and Peri-Operative Parameters Influencing Results in 826 Patients]. / Spokojenost s náhradou kolena: analýza predoperacních a perioperacních parametru u 826 pacientu.

UNLABELLED: PURPOSE OF THE STUDY The aim of the study was, first, to assess satisfaction of our patients after primary total knee arthroplasty (TKA) at various intervals of follow-up. Second, a list of pre- and peri-operative factors with potential effects on patient satisfaction was analysed. The third objective was to identify conditions under which a result of replacement could be considered definite with a little probability of further unexpected development. A more detailed knowledge of unsatisfied patients may provide valuable information for use in pre-operative evaluation, indication for surgery, as well as in the surgery itself. MATERIAL AND METHODS This prospective study consisted of 826 patients who underwent primary TKA between September 2010 and March 2015 and had at least one complete post-operative examination. Our group included 296 men and 530 women. The average age at primary TKA was 68.9 (45-87). Primary osteoarthritis was the most frequent indication to surgery (82.6 %). The followup period ranged from 1 month to 3 years. On each follow-up examination, every patient received an original questionnaire with 24 questions concerning the course of their post-operative period (between the discharge from hospital and the planned follow-up). The patients assessed the degree of satisfaction with surgery outcomes on a scale ranging from "fully satisfied" to "dissatisfied" and expressed their overall satisfaction in percents. RESULTS At the final follow-up, 6.5% of the patients were not satisfied with the outcome. The patients' overall satisfaction was 90.2 % (i.e., responses to the question of how you were satisfied with surgery). Significantly more satisfied patients were among those with primary osteoarthritis. Their satisfaction was related to the level of the UCLA activity rating, feelings of uncertainty when walking and to the functional ability component of the KSS system. On the other hand, more dissatisfied patients were found among those with several previous operations, a higher ASA score or a higher number of risk factors (Charlson comorbidity score etc.). The duration of pre-operative complaints had no relation to post-operative satisfaction. Similarly, there was no relation between VAS-evaluated pain intensity before TKA and patient satisfaction after arthroplasty. Obesity and satisfaction were not inter-related either. DISCUSSION Assessment of satisfaction is one of the Patient Reported Outcome Measures (PROMs) used by patients to evaluate the effect of a therapeutic method. These instruments aid in assessing the degree to which the method has met the needs and expectations of patients. It is relevant to emphasise that subjective factors, such as expectation or satisfaction, do not depend on the therapeutic procedure only. Recent reports have shown that, in 10% to 30% of the patients, the TKA outcome has not met their expectations. More detailed studies draw attention to the fact that there are more dissatisfied patients after TKA than those after THA. When satisfaction with pain relief is considered, the number of dissatisfied patients is even lower (72%-86%). CONCLUSIONS An analysis of the patients' responses shows that the rate of satisfaction is high shortly after surgery but declines gradually thereafter. The overall satisfaction is stable about 12 months after the surgery. The number of dissatisfied patients or those reporting pain after TKA in our study is in agreement with the results reported in relevant literature. The associations found here will be used in preparing a tool for clinical outcome prediction. KEY WORDS: total knee arthroplasty, outcome evaluation, patient-reported outcome measures, satisfaction, dissatisfaction, pain after total knee arthroplasty, function after total knee arthroplasty.

The in vitro cytotoxicity of metal-complexes of porphyrin sensitizer intended for photodynamic therapy.

The sulphonated derivatives of porphyrins (e.g. TPPS4) are hydrophilic photosensitizers and have certain advantages like fully known structures and the possibility of synthetic production. The aim of this work was to study in vitro cytotoxicity and to compare the new photosensitizer MgTPPS4 with TPPS4 and its other metal-complexes (ZnTPPS4, PdTPPS4) on human skin melanom and mouse fibroblast cell lines. A photodynamic treatment was induced by light emitting diodes with three different total doses (1, 5 and 10J/cm(2)). For proper analysis and understanding of cell behavior after the administration of sensitizers, a complex battery of in vitro tests including the production of reactive oxygen species, the MTT viability test, a comet assay, a cell cycle and a type of cell death determination were used. We discovered that the most suitable photosensitizer is ZnTPPS4 because it had the biggest lethal influence on melanoma cells and the lowest lethal influence on fibroblast cells. The second most effective photosensitizer seemed to be MgTPPS4. On the basis of our results we can also assume that there is a higher accumulation of photosensitizer in a tumorous cell line. The higher concentration of photosensitizer and light dose resulted in more reactive oxygen species production and found more cells undergoing necrosis.

[Proximal gastrectomy for adenocarcinoma of the gastroesophageal junction in a selected set of patients immediate and long-term results]. / Proximální gastrektomie u selektovaných pacientu s adenokarcinomem gastroezofageální junkce, bezprostrední a dlouhodobé výsledky operacní terapie.

INTRODUCTION: The authors present the results of surgical resection in the form of proximal gastrectomy in a selected set of patients with adenocarcinoma of the gastroesophageal junction. The selection criteria included: ASA III-IV, internal comorbidities and elderly patients. METHODS: Between 2007 and 2015, 28 patients with adenocarcinoma of the gastroesophageal junction underwent proximal gastrectomy at the 1st Department of Surgery. The patient set consisted of 19 (67.8%) men and 9 (32.3%) women aged 5289 years with the median age of 72.5 years. Endoscopic examination revealed a tumour of the gastroesophageal junction, which was evaluated according to the Siewert classification: type I was present in 4 (16.7%) cases, type II in 12 (42.3%), and type III in 12 (42.3%). Histological analysis revealed adenocarcinoma in all cases. Proximal gastrectomy with lymphadenectomy was performed in all patients. Splenectomy was performed in eleven patients. The continuity of the gastrointestinal tract was ensured by esophagogastroanastomosis, and pyloromyotomy was performed as a standard procedure. Cryostatic examination revealed positive resection margins in the esophagus in five patients, which led to the resection of the distal esophagus from the right-sided thoracotomy. RESULTS: Injury to the biliary tract was observed in one case in the perioperative period, which was treated by hepaticojejunoanastomosis onto an excluded jejunal loop. The following complications were observed postoperatively: bleeding, respiratory complications, anastomotic dehiscence, laparotomy wound dehiscence, and inflammatory infiltration in the abdominal cavity. Thirty-day mortality was 10.7% in our patient set. CONCLUSION: Proximal gastrectomy with lymphadenectomy is an appropriate alternative for polymorbid patients with adenocarcinoma of the gastroesophageal junction and provides good short- and long-term results.Key words: cancer of gastroesophageal junction proximal gastrectomy complications of therapy.

[Robot assisted endometrial cancer staging - evaluation the first 100 operations and comparing the first andthe last 30 operations]. / Robotem asistovaný staging karcinomu endometria - vyhodnocení prvních 100 operací a srovnání prvních a posledních 30 operací.

OBJECTIVE: To describe and evaluate our experience with robotically assisted laparoscopic staging of endometrial cancer in first hundred cases as compared with the first and last 30 cases of patients staged by this method. DESIGN: Comparative retrospective study. SETTING: Department of Obstetrics and Gynaecology, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Czech Republic. Institute of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Czech Republic. METHODS: The robotic centre at the Faculty Hospital in Olomouc was opened in August 2009 which enabled to perform robotically assisted laparoscopic staging of endometrial cancer. Retrospectively we evaluated the first hundred patients with the early stage of endometrial cancer who underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic/paraaortic lymphadenectomy using four-armed da Vinci S HD surgical robotic system. In the second stage of the evaluation we compared the first and the last 30 cases operated by the above mentioned minimally invasive approach. All cases were performed by two surgeons (P.R., D.P.), within the same institution in the course of learning this technique. Age, body mass index (BMI), clinical stage of disease, length of operation, nodal yield, blood loss, the pre-operative and post-operative hemoglobin concentration difference and operating complications were documented and compared. RESULTS: The first hundred patients were operated by the above mentioned minimally invasive method between September 2009 nad June 2014. All patients were between 33 and 85 years of age. The average age of the entire group of patients was 65 years of age, the average BMI reached 31.0 (ranging from 18.0 to 49.0), the operating times median was 206 minutes. The estimated median of blood loss was 100 ml. The conversion of robotic surgery to a laparotomy was recordedin 6 cases. When comparing the first and the last30 operated patients there was observed a statistically significant increase in BMI in the group of the last30 operations (29.5 vs. 33.0, p = 0.004) and there was a decrease in the number of conversions from 4 to 1.In particular, however, there was a statistically significant increase in the total number of the obtained lymph nodes in the group of the last 30 vs. the first30 patients (27 vs. 17), and the increase in the number of removed pelvic lymph nodes (21 vs. 17) and the paraaortic nodes (4 vs. 0). CONCLUSION: The robotically assisted laparoscopic staging is one of several possible surgical approaches in the treatment of patients with endometrial cancer and it can be performed adequately in this way. According to the results from our patients group it is a surgical modality with significantly low blood loss, safe even for patients with high BMI and age. The increasing erudition of the surgeon is linked to the shortening of the operating time, reducing the number of conversions and the higher yield of lymph nodes and a reduction in blood loss which was reflected in particular in the comparison of the pre-operative and post-operative hemoglobin difference.

[Assessment of Heavy/ Light Chain Pairs of Immunoglobulin (Hevylite assay) -  Benefit for Stratification of Multiple Myeloma?]. / Vysetrení páru tezkých/ lehkých retezcu imunoglobulinu (Hevylite assay) -  prínos pro stratifikaci mnohocetného myelomu?

BACKGROUND: The aim of the study was the comparison of two novel stratification models in multiple myeloma (MM), ie. according to Avet- Loiseau (A L) and according to Ludwig (L), based on the HLC r index (ratio of serum levels of involved- HLC/ uninvolved HLC, ie. HLC κ/ HLC  λ assessed using ie. nephelometric/turbidimetric technique using specific polyclonal antibodies on a Binding Site SPA(PLUS)) technique) and ß(2) microglobulin (ß(2) M) with selected prognostic factors (PF) of MM and staging systems according to Durie- Salmon (D S) and International Staging System (ISS). PATIENTS AND METHODS: In a cohort of 132 patients (94 with IgG and 38 with IgA type of MM) at the time of dia-gnosis, we assessed HLC r, select-ed PF and D S, ISS, A L and L stratification systems. RESULTS: Unlike in IgA isotype, in IgG isotype we found a significant relationship of HLC r to stratification according to D S and ISS with the difference between A and B substages according to D S (p = 0.049) and between ISS stages 1 vs. 3 (p = 0.001). In the IgG group, there was highly significant relationship of the depth of Hb and albumin decrease and ß(2) M increase to the results of stratification according to ISS, A L and L model (p < 0.0001), increase of LDH in the ISS system and A L, and creatinine according to ISS and L but not the relationship of the stages according to any of the stratification systems to the values of FLC r (ratio of serum free light chains κ/ λ of immunoglobulin), thrombocytes and Ca. In the IgA type, there was a significant relationship of the depth of the decrease of Hb, thrombocytes, albumin and increase of ß(2) M to the results of stratification according to ISS, A L and L and increase of creatinine in the case of ISS, but not of the values of FLC r, Ca and LDH in the case of any of the stratification systems. The degree of correlation of selected PF, especially of Hb, albumin and ß(2) M, event. of thrombocytes, LDH and creatinine to the stages according to ISS and to stage 1-3 according to A L and L model was in IgG vs IgA isotype significantly different (p < 0.0001- 0.030). Staging system according to ISS had proportional distribution of stages 1- 3, whereas in the A L model prevailed in IgA and IgG isotype risk category 2, ie. intermediate-risk (47.3 and 44.7%) and in the L model prevailed risk category 3, ie. high-risk (41.5 and 52.6%) with low count of category 1, ie. low- risk category (23.4 and 10.5%). McNemar- Bowker test of symmetry showed in both types of MM the highest concordance between the stratification according to D S and L in category 3, ie. high-risk (31.9 vs. 28.9%) with overall accord only in 53.2 and 42.1% and with significant shift in the case of IgG isotype only (p = 0.036). In IgG and IgA isotype there was an overall concordance in the distribution of categories 1- 3 according to ISS vs. A L (62.4 and 63.2%) but with significant shift of the stratification (p = 0.002 and 0.028). In the case of IgG and IgA isotype there was a close relationship between the models A L and L (64.5 and 81.6%) with significant stratification shift (p < 0.0001 and 0.030). CONCLUSION: The new stratification models for MM according to A L and L are easily practically applicable, with close relationship to principal PF but they need separate assessment of IgG and IgA isotypes of MM. The choice of optimal model for routine practice needs a validation study aimed at progression free survival and overall survival.

Immunoparesis in MGUS - Relationship of uninvolved immunoglobulin pair suppression and polyclonal immunoglobuline levels to MGUS risk categories.

Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic, potentially malignant condition. It has been established that annually approximately 1-2% of MGUS cases transforms into one of the malignant forms of monoclonal gammopathies. Progression risk factors include the quantity and type of M-protein, and namely the ratio of free light immunoglobulin chains (FLC). These factors, enable purposeful stratification of MGUS individuals. Some authors consider suppression of polyclonal immunoglobulin levels to be another progression factor. The aim of the study was to compare polyclonal immunoglobulin (PIg) levels with uninvolved heavy/light chain pair (HLC) levels in order to verify the degree of immunoparesis depending on MGUS risk category (0-3). The analyzed set consisted of 159 serum samples from MGUS patients (102 IgG, 57 IgA), who were stratified into 4 risk groups (0 - low, 1 - low-intermediate, 2 - high-intermediate and 3 - high risk of transformation). The results of analysis showed that with increasing degree of MGUS increases risk of immune paresis defined by decreasing levels of polyclonal immunoglobulins, ie. IgA and IgM in the case of IgG MGUS, respectively, IgG and IgM in case of IgA MGUS. Significant differences were also found when analyzing the levels of uninvolved HLC pairs IgG kappa (resp. IgG lambda) in IgG lambda (IgG kappa) dominant secretion. In the case of MGUS with IgA isotype, the results were similar. Discovery of the connection between the degree of immunosuppression and the level of MGUS risk contributes to our understanding of the relationship between biology, development and potential malignant transformation of MGUS. It is apparent that uninvolved HLC pair assay enables more reliable identification of at-risk MGUS patients than a simple quantitative assay for polyclonal immunoglobulins alone.

[Validity of the Morawietz classification for evaluation of periprosthetic tissue]. / Prínos Morawietzovy klasifikace k hodnocení periprotetických tkání.

PURPOSE OF THE STUDY A consensual classification of the periprosthetic interface membrane obtained at revision total joint arthroplasty was published by Morawietz et al. in 2006. Based on histomorphological criteria, four types of periprosthetic membrane were proposed: type I, aseptic failure; type II, septic failure; type III, combined type (carrying signs of both type I and II); and type IV, indeterminate type. The aim of this study was to find out whether and to what extent the Morawietz system would be suitable for use at an independent institution involved in the evaluation of periprosthetic membranes for a long time. Should it appear that the institution achieved an equally good or even better agreement between the clinical diagnosis and the histopathological finding, this consensus classification could be recommended for routine use. MATERIAL AND METHODS The samples of periprosthetic tissue evaluated in this study were obtained during surgery from the following groups of patients: 66 patients with aseptic loosening of total hip (THA) or knee arthroplasty, 15 patients with infection of THA, 16 patients with THA without any signs of aseptic loosening, osteolysis or infection; 8 patients with hip osteoarthritis and 8 patients with knee osteoarthritis. Sample collection and processing (for purposes of histomorphological evaluation and immunohistochemical staining) was performed according to the established protocol. The tissue samples evaluation was made by an experienced pathologist hand in hand with the method described in the original paper by Morawietz et al. For a more detailed tissue analysis, selected antibodies (CD4, CD8, CD20, IFN-γ and Hsp-60) were visualized by immunohistochemistry. RESULTS The majority of samples from aseptic reoperations were classified as membranes of the type I (79%) and III (16%). Specimens retrieved from septic cases were mostly classified as membranes of type II and III (60% together). The septic membranes showed a significantly higher expression of CD20 protein when compared with both the aseptic (p < 0.0001) and control THA samples (p = 0.003). The membranes retrieved from the surroundings of a stable THA without osteolysis and infection had lower expression levels of Hsp60 and IFN-γ, when compared with those from both aseptic and septic loosening. Finally, Hsp-60 expression was significantly higher in osteoarthritic tissue than in samples from stable THA (p = 0.041). DISCUSSION Morawietz et al. proposed a standardized classification system for evaluation of periprosthetic tissue. As any attempt at generalization of a complex issue, this proposal has certain shortcomings. One of these is poor detection of chronic and low-grade infections. A method that would improve the conventional counting of polymorphonuclear leukocytes is still being sought. In this connection, immunostaining for CD20 combined with an assessment of antimicrobial peptides may be a promising option. The supplementary specimen staining showed that pseudosynovial tissue is much more active in patients carrying infection and the least active in samples from stable THA in which certain tolerance and thus tissue homeostasis might be expected. CONCLUSIONS 1. In this study the distribution of findings classified according to the Morawietz system was similar to the results published in the original study from 2006. 2. The definition of an aseptic membrane (type I) in the Morawietz system meets the requirements of clinical practice (agreement, about 80%). 3. An increased sensitivity for infectious membrane detection can be achieved by using supplementary immunohistochemical staining effective particularly in chronic and low-grade infections. 4. Painless and stable THAs typically have very low expression levels of CD4, CD20 and Hsp-60 proteins, and interferon- -gamma (IFN-γ) as well. Key words: total hip arthroplasty, total knee arthroplasty, aseptic loosening, prosthetic joint infection, tissue analysis, membranes, CD receptors, Hsp-60 protein, IFN-γ.

[ProVens® in the Therapy of Glaucoma and Ocular Hypertension]. / ProVens® v lécbe glaukomu a ocní hypertenze.

OBJECTIVE: To assess the effect of the ProVens® dietary supplement administration on intraocular pressure in patients with glaucoma and ocular hypertension. MATERIAL AND METHODS: The patients included in the trial were given the ProVens® dietary supplement once daily. One ProVens® tablet contains: 50 mg of maritime pine bark extract, 100 mg of green tea extract, and 3 mg of blueberry extract. The main ProVens® components are proanthocyanins from the bark of the maritime pine tree Pinus pinaster, polyphenols from green tea, and anthocyanins from blueberries. The total number of patients included in the trial was 46. Out of these, 35 patients were monitored for asymptomatic ocular hypertension and 11 patients for open-angle glaucoma treated with prostaglandin analogs. Intraocular pressure was measured by applanation tonometry in the beginning of the trial, after one month, and after three months of their inclusion in the trial, always at the same time of the day. RESULTS: In the group of patients with ocular hypertension, there was a statistically significant reduction in the intraocular pressure from the baseline values of 24.2 ± 2.1 mm Hg to 20.9 ± 2.5 mm Hg within the period of three months (p < 0.0001). In the group of patients with open-angle glaucoma, there was a statistically significant reduction of the intraocular pressure from the baseline values of 18.4 ± 3.2 mm Hg to 17.0 ± 3.1 mm Hg within the period of three months since the beginning of administration of the product (p = 0.022). When comparing both groups, we observed a significantly higher reduction in intraocular pressure (p = 0.0001) in the group of patients with ocular hypertension. In the whole group, no adverse effects were reported during the intake of this dietary supplement. CONCLUSION: Intake of the ProVens® dietary supplement containing proanthocyanins from the bark of the maritime pine tree Pinus pinaster together with a mixture of herbal antioxidants appears to be one of the methods of how to improve the control of intraocular pressure, particularly in patients with ocular hypertension. KEY WORDS: glaucoma, ocular hypertension, ProVens®, proanthocyanins, antioxidants, maritime pine bark extract.

[Surgical therapy of pancreatic cancer - 5 years survival]. / Resekabilní karcinom pankreatu 5leté prezití.

INTRODUCTION: The purpose was to identify 5-year survivors among a group of radically resected patients with pancreatic cancer and analyse the characteristics and factors associated with their 5-year survival. Single tertiary centre experience. METHOD: A prospectively maintained database of 155 pancreatic resections from January 2006 to June 2010 was scanned to identify patients after curative radical resections for pancreatic ductal adenocarcinoma. The clinical and pathological data was analysed retrospectively. The outcomes of the PDAC group were evaluated using Kaplan-Meier analysis (survival) with the Log-rank test and Cox regression analysis (evaluation of prognostic factors). Characteristics of the survivors were discussed. Significance level of 0.05 was used. Those factors were used as independent variables for Cox regression analysis whose significant effect on survival was shown based on Kaplan-Meier analysis. RESULTS: Among 155 patients undergoing a curative pancreatic resection, 73 had a pancreatic ductal adenocarcinoma. Fifteen patients (20.5%) after radical surgery survived over 5 years, 13 of whom are still alive. In the group of the survivors, the mean overall survival was 77.1 months (60110) and the median survival was 74 months. The mean relapse-free interval in the group of the survivors was 63.3 months (14110) with the median of 65 months. Factors associated with a longer survival included the absence of lymph node infiltration (p=0.031), uncomplicated postoperative course (p=0.025), absence of vascular invasion (p=0.017), no blood transfusions (p=0.015) and the use of postoperative therapy - predominantly chemotherapy (p=0.009). Significant independent predictors of survival included vascular invasion HR=2.239 (95%CI: 1.0934.590; p=0.028), postoperative chemotherapy HR=2.587 (95%CI: 1.3015.145; p=0.007) and blood transfusion HR=2.080 (95%CI: 1.0274.212; p=0.042). The risk of death was increased 2.2 times in patients with vascular invasion, 2.1 times in patients with transfusions, and finally 2.6 times in those with no chemotherapy. CONCLUSION: Factors associated with an improved overall survival included: the absence of lymph node infiltration, an uncomplicated postoperative course, absence of vascular invasion, no need of blood transfusions, and finally the use of postoperative chemotherapy. Vascular invasion, use of blood transfusions and postoperative adjuvant chemotherapy were significant independent prognostic factors of survival.

[Scaphoid excision and four-corner fusion using the variable angle locking intercarpal fusion plate for treatment of post-traumatic degenerative changes of the wrist]. / Excize clunkové kosti a ctyrrohá fúze zápestí pomocí VA-LIF v lécbe degenerativních poúrazových zmen zápestního kloubu.

PURPOSE OF THE STUDY: The aim of this study is to compare functional and X-ray results before and after four-corner arthrodesis using an angular stable dorsal circular plate in patients with post-traumatic degenerative changes of the wrist. METHODS: Nine consecutive patients with scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist, stage III, underwent scaphoid excision and four-corner fusion using angular stable plate fixation. The wrists were immobilised using a split for two weeks and then a removable wrist brace with assisted physiotherapy for four weeks. Minimal followup was 18 months. Clinical assessment before and after surgery included the wrist range of motion (ROM), grip strength, presence of pain, disabilities of the arm, shoulder and hand (DASH) scores, and radiographic findings of the carpal height and ulnar translation ratios. Differences were statistically tested. In addition, patients' satisfaction with functional outcomes was evaluated. RESULTS: In the post-operative period the patients experienced less pain during daily activities and had a better carpal height ratio than before surgery; these differences were statistically significant. In the other criteria, although showing better post-operative results, improvement was not statistically significant. Eight patients were satisfied with the final outcome. One patient required limited denervation of the wrist for pain relief. There was no non-union. DISCUSSION The functional outcomes (ROM, grip strength) in our patients at follow-up were fully comparable with the previously published studies. Although, by most postoperative treatment protocols, physical therapy is started at four to eight weeks of rigid fixation of the wrist, no non-union was found in our group of patients who had a shorter period of post-operative fixation. CONCLUSIONS: Four-corner arthrodesis of the wrist using angular stable dorsal circular plate fixation provides pain relief with acceptable preservation of the range of motion and no consolidation problems. Long-term follow-up and a larger group of patients would be necessary to confirm these hopeful results.

[Attainment of complete hematological remission is crucial for extended survival of AL amyloidosis patients with cardiac involvement]. / Dosazení kompletní hematologické remise je zásadní pro prodlouzení prezití nemocných s AL amyloidózou a srdecním postizením.

BACKGROUND: Symptomatic cardiac involvement is the most important prognostic factor in AL amyloidosis patients. Longterm survival is limited not only by cardiac involvement condition, but also by limited choice of treatment with unsatisfactory results. The aim of the present report is to assess the effect of achieved treatment response on survival of AL amyloidosis patients with symptomatic cardiac involvement under conventional treatment. MATERIAL AND METHODS: The monitored patient set consisted of 19 patients with systemic AL amyloidosis and symptomatic cardiac involvement, treated and monitored at the III. Clinic of Internal Medicine between 2004 and 2012. The male : female ratio was 17 : 2, and the age median was 64 (range 48 to 78 years). Thirteen patients died within the monitored period. Functional status was defined according to the NYHA classification, where five patients had class II involvement, 10 patients had class III involvement, and four patients had class IV involvement. Treatment response was assessed by the application of modified IMWG and ISA criteria; all patients were undergoing conventional treatment. Nine patients were treated by a combination of alkylating agents (alkeran, cyclophosphamide), six were treated by a combination treatment with thalidomide, and four were treated by a combination of bortezomib and dexamethasone. Data were analyzed with software SPSS v. 15 (SPSS, Inc., Chicago, USA). Log Rank Test was applied to survival evaluation. RESULTS: The statistical analysis included only 13 patients who underwent at least three months of treatment, where six patients attained complete remission (CR), four patients attained partial remission (PR), and three patients attained only stabilization of disease (SD). Significant difference in patient survival was found to be correlated with attained hematological response, where the patients who attained CR had median survival of 39 months vs 10 months in patients who attained PR or SD (p = 0.005). CONCLUSION: The results indicate that attainment of complete hematological remission is associated with significantly longer survival of AL amyloidosis patients with symptomatic cardiac involvement.

[The importance of cardiac bio-marker assay for the stratification and monitoring of AL amyloidosis patients -  single center experience]. / Význam stanovení kardiálních bio-markeru ve stratifikaci a sledování nemocných s AL amyloidózou -  zkusenosti jednoho centra.

INTRODUCTION: Cardiac involvement is a dominant prognostic factor in AL amyloidosis patients. A detailed assessment of the presence and degree of cardiac involvement utilizes an array of noninvasive investigation methods, particularly echocardiography and MRI; laboratory parameters include troponins and natriuretic peptides. Cardiac involvement detection aside, cardiac bio-markers are used as a relatively strong stratification and prognostic factor. OBJECTIVE: The presentation of cardiac bio-markers assay applications in AL amyloidosis patients at an individual treatment center. PATIENTS AND METHODS: The monitored patient set consisted of 22 patients with histologically confirmed AL amyloidosis, of whom 18 met the criteria for cardiac involvement. Levels of cardiac bio-markers troponin T (TnT) and Nterminal probrain natriuretic peptide (NT ProBNP) were determined in all patients. Risk stratification of the patients utilized the Mayo staging system which is based on both bio-markers assays; Log Rank Test was applied to survival evaluation. RESULTS: Median survival of patients with cardiac involvement stigmata was 10 months vs 60 months survival of patients without signs of cardiac involvement (p = 0.133). Of the 4 patients without cardiac involvement, 1 has shown positive levels of TnT and 2 positive levels of NT ProBNP. All cardiac involvement patients exhibited abnormal levels of NT ProBNP (median 4,752 ng/ l; 415.7- 35,000) as well as positive levels of TnT (median 0.0815 µg/ l; 0.02- 0.986). The application of the Mayo stratification system to the set had determined 2 patients at stage I, 5 patients at stage II and 15 patients at stage III. The median survival of the Mayo I + II group vs the Mayo III group was 60 vs 6 months (p = 0.015), revealing extremely limited survival of stage III patients. Assessment of TnT and NT ProBNP levels relative to treatment response shows that the degree of decrease in both markers depends on maximum treatment response -  respectively the attainment of a complete hematological remission. CONCLUSION: The results, although obtained from a limited set of patients, confirm a definitive benefit of the application of cardiac bio-markers assay in the diagnostic and therapeutic algorithm of AL amyloidosis patients. The Mayo stratification system utilizing the cardiac indicator values represents a robust tool for risk stratification of AL amyloidosis patients.