A jump into the deep end - Women's strategies on the way to VBAC in Poland.

PROBLEM: In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BACKGROUND: Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AIM: This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC. METHODS: The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FINDING: Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. CONCLUSIONS: Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Cardiac Magnetic Resonance Findings in Patients Recovered from COVID-19 Pneumonia and Presenting with Persistent Cardiac Symptoms: The TRICITY-CMR Trial.

The prevalence and clinical consequences of coronavirus disease 2019 (COVID-19)-related non-ischemic cardiac injury are under investigation. The main purpose of this study was to determine the occurrence of non-ischemic cardiac injury using cardiac magnetic resonance (CMR) imaging in patients with persistent cardiac symptoms following recovery from COVID-19 pneumonia. We conducted a single-center, cross-sectional study. Between January 2021 and May 2021, we enrolled 121 patients with a recent COVID-19 infection and persistent cardiac symptoms. Study participants were divided into those who required hospitalization during the acute phase of SARS-CoV-2 infection (n = 58; 47.9%) and those non-hospitalized (n = 63; 52.1%). Non-ischemic cardiac injury (defined as the presence of late gadolinium enhancement (LGE) lesion and/or active myocarditis in CMR) was detected in over half of post-COVID-19 patients (n = 64; 52.9%). LGE lesions were present in 63 (52.1%) and active myocarditis in 10 (8.3%) post-COVID-19 study participants. The majority of LGE lesions were located in the left ventricle at inferior and inferolateral segments at the base. There were no significant differences in the occurrence of LGE lesions (35 (60.3%) vs. 28 (44.4%); p = 0.117) or active myocarditis (6 (10.3%) vs. 4 (6.3%); p = 0.517) between hospitalized and non-hospitalized post-COVID-19 patients. However, CMR imaging revealed lower right ventricular ejection fraction (RVEF; 49.5 (44; 54) vs. 53 (50; 58) %; p = 0.001) and more frequent presence of reduced RVEF (60.3% vs. 33.3%; p = 0.005) in the former subgroup. In conclusion, more than half of our patients presenting with cardiac symptoms after a recent recovery from COVID-19 pneumonia had CMR imaging abnormalities indicating non-ischemic cardiac injury. The most common finding was LGE, while active myocarditis was detected in the minority of patients. CMR imaging abnormalities were observed both in previously hospitalized and non-hospitalized post-COVID-19 patients. Further research is needed to determine the long-term cardiovascular consequences of COVID-19 infection and the optimal management of patients with suspected post-COVID-19 non-ischemic cardiac injury.

Analysis of mortality between 2019-2020 at the Neuroorthopedic and Traumatic Orthopedic Departments.

The number of deaths from skeletal injuries is still significant, but is declining with advances in emergency medicine. The adopted principles of emergency procedures and the availability of specialist centres enable the treatment to be effective. AIM: The aim of the study was to analyse the deaths of patients with spine and limb injuries who required surgery. MATERIALS AND METHODS: The analysis covered 22 deaths in the years 2019-2020. The assessment took into account: the cause of admission, the condition of the patient and comorbidities, the medical scales which were used to assess the possible risk of complications, the diagnostic correctness and qualification for surgical treatment, the waiting time for surgery and the cause of death and prior course of action. RESULTS: It can be stated that in 2019, the mortality rate was 0.21 (10 deaths out of 4658 hospitalized), in 2020, the mortality rate was 0.31 (12 deaths out of 3852 hospitalized). The mortality rate in the Department of Traumatic Orthopedics was: 0.30 in 2019 (8 deaths out of 2625 hospitalized) and 0.39 in 2020 (8 deaths in 2020 hospitalized). 10 patients with hip fractures (trochanteric and femoral neck) underwent surgery within 2.7 days (from 1 to 4 days). The causes of death within 1-9 days (average 4.86 days) from admission in this group were complex, and associated with the presence of chronic diseases, including: circulatory failure (9), septic shock (1), heart rhythm disturbances (7), renal failure (6), pulmonary congestion (4), hyperkalemia (1), coagulation disorders (1). In patients after spinal injury with quadriplegia, decompression (1), stabilization (1) and disc removal (1) were performed on the day of admission to the hospital. The patients were hospitalized in the ICU, and deaths occurred on days 9, 15 and 187 from admission due to respiratory and circulatory failure and sudden cardiac arrest. Patients after arthroplasty of the knee (1) and hip (2) were operated on day 2 from admission, and deaths occurred on day 4, 22 and 53 due to: sepsis (1), pulmonary embolism (1), respiratory failure in the course of pneumonia (1). CONCLUSIONS: The deceased were admitted in a serious general condition, burdened with numerous concomitant chronic diseases and their age ranged from 66 to 97 years. The surgical treatment was undertaken for life saving reasons but 5 of the deceased did not undergo surgery due to the extreme general condition leading to respiratory and circulatory failure.

Evaluation of the results of posterior approach in thoracic disc herniation surgery.

The incidence of symptomatic intervertebral disc hernias in the thoracic segment is estimated at 1 case per million people per year, which is about 0.25-0.75% of all symptomatic intervertebral disc hernias and 0.15-1.85% of operative intervertebral disc diseases. AIM: The aim of the study was to assess the results of the surgical treatment of symptomatic discopathy in the thoracic spine through the posterior approach. MATERIALS AND METHODS: The results of the surgical treatment of 52 patients (35 women, 17 men) with symptomatic thoracic disc herniation in the Department of Neuroorthopedics in the years 2012-2019 were analyzed retrospectively. The neurological and functional status of patients before and after the surgery was assessed, as well as the average duration of the surgery and hospitalization, perioperative complications, intraoperative blood loss and the number of reoperations. Radiculopathy and myelopathy were the main indications for surgery. RESULTS: The largest group included patients operated on in the 5th and 6th decades of life, with women being the majority (67%). Hernia of the distal thoracic spine, i.e. Th10-Th11-Th12-L1, was most often operated on. According to the Frankel scale, the largest number of patients (47 before the surgery and 48 after the surgery) were qualified for groups D and E. As regards the WISCI scale the largest group of patients was classified as level 20. The rate of complications was 7%, the rate of neurological complications was 5.2% and the rate of reoperations was 3.5%. CONCLUSIONS: The vast majority of discopathies in the thoracic spine occur at lower levels, i.e. Th10-Th11-Th12-L1. The analysis of the functional status after the surgery of thoracic discopathy based on 2 scales showed a greater usefulness of the WISCI scale than the Frankel scale. A larger number of patients changed the group after surgery in the WISCI scale than in the Frankel scale. Therefore, we can conclude that the WISCI scale is more accurate in assessing the functional state of patients operated on due to thoracic discopathy.

Surgical treatment of thoracic disc herniation.

Symptomatic thoracic disc herniation is estimated on 1 person per million per year. 70% of all thoracic disc herniation cases are asymptomatic. This condition is often undiagnosed in regard to misguided clinical manifestations. Surgical treatment of symptomatic thoracic disc herniation is major challenge for spine surgeons because of the fact that thoracic spine has special anatomical conditions. Historically, posterior approach with laminectomy was treatment by choice, but this method was abandoned for some time, because of the high risk of postoperative complications. During last years we observe development of new approaches and advanced techniques e.g. microsurgical pedicle-sparing transfacet approach, costotransversectomy, extracavitary approach, minimal invasive thoracoscopic or endoscopic discectomy, but posterior approach is still broadly applied.

Updated overview of evidence on optimal antithrombotic therapy in patients with atrial fibrillation undergoing percutanous coronary intervention.

Selection of the optimal peri- and postprocedural antithrombotic regimen in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is a common clinical problem which may pose a challenge to medical practitioners. This systematic review summarizes the updated evidence on this topic. Non-vitamin K oral anticoagulants (NOACs) at standard doses are the preferred option in most of post PCI patients with AF, except those few with a clear indication for a vitamin K antagonist (VKA). Reduced NOAC doses should be considered in dabigatran- or rivaroxaban-treated patients with a high bleeding risk, which prevail over concerns about stent thrombosis or ischemic stroke. There is insufficient evidence to favor one NOAC over another in this setting. In the early post stenting period, triple therapy comprising a NOAC, clopidogrel and aspirin is recommended. Timing of post PCI aspirin cessation should be based on a careful analysis of the bleeding and ischemic risk. There is only low quality evidence regarding the optimal approach to elective or urgent/emergency PCI procedures in patients requiring oral anticoagulation. It is suggested that there is no need of interruption of VKA and PCI procedure should be performed via radial artery access with a lower dose of unfractionated heparin. On the other hand, NOACs are usually stopped before elective PCIs, while urgent/emergency procedures may be performed with the addition of low-dose parenteral anticoagulation.

Intradural disc herniation - report of two cases.

Intradural disc herniation is a very rare condition, which occurs in up to 0.3% cases of all disc herniations. It mostly develops at L4-L5 level, which is caused by the presence of strong adhesions between the posterior longitudinal ligament and dura mater. These rare cases are included in the classifications, however, they are associated with diagnostic difficulties, both in physical examination and in the image visible in magnetic resonance. REPORT OF 2 CASES: The presented patients were treated in the Neuroortopedic Department within the last two years. Despite previous examinations, the final diagnosis of intradural disc herniation occurred only during the surgery. CONCLUSIONS: Rarely occurring hernias of the intervertebral disc require increased vigilance among surgeon's spine physicians. Preoperative diagnosis of intradural lesion would make it possible to develop a better surgical strategy.

Spinal cord infarction after tumor removal surgery of the thoracic region - a case report.

Spinal cord infarction is very rare condition and usually occurs in the thoracic region of the spine. The etiology is often unknown and patophysiology can be diverse. The stroke may occur while performing a surgical procedure, but it is also found in vascular diseases, for example dissecting aneurysms, vasculitis and vascular malformations. A CASE REPORT: The authors present the case of a 62 year old woman admitted to the Neuroortopedics department due to metastasis of papillary renal carcinoma to the spine. During physical examination no neurological deficits were found. However magnetic resonance imaging revealed pathological tissue covering the left pedicle of the Th9 vertebra, penetrating the spinal canal, and compressing the spinal cord. The patient was qualified to the surgery and underwent tumor removal and transpedicular stabilization of the spine. The operation proceeded on schedule, without complications. After the operation the patient did not have any neurological deficits. In the first 24 hours post-surgery paresis of the lower limbs appeared, which rapidly deepened until the right limb was paralyzed. Due to the lack of improvement after administration of solumedrol, and suspicion of hematoma at the surgical site, the patient was qualified for reoperation. Intraoperatively there was no compression of the spinal cord, nonetheless, after being awaken from surgery, no active movements were found in the left lower limb. Magnetic resonance imaging was performed and revealed spinal cord infarction in its ventral part extending from Th9 to Th12. CONCLUSIONS: Even in procedures where no surgical complications appeared it should be noted that the rare risk of spinal cord infarction exists.

Brachial Plexus Root Avulsion Injury with Occipital Condyle Fractures. Case Study.

Avulsion injuries of the brachial plexus with occipital condyle fractures are very rare and usually result from motor vehicle accidents. This paper presents an analysis of the case of a 24-year-old male patient who sustained both these injuries in a car accident. Computed tomography revealed a fracture of the right occipital condyle and a magnetic resonance scan showed spinal nerve disruption at the C3-C7 level on the left. The patient underwent conservative treatment.

Analysis of Reasons for Failure of Surgery for Degenerative Disease of Lumbar Spine.

BACKGROUND: In the aging society, there is a growing number of patients with advanced degenerative disease of the spine. These patients frequently require surgical treatment. This paper aims to analyse the reasons for failure of surgery for degenerative disease of the lumbar spine. MATERIAL AND METHODS: Histories of patients operated on by one group of surgeons in the Neuroorthopaedic Department of "STOCER" in 2014 and 2015 due to degenerative disease of the lumbar spine were analysed retrospectively. Out of the cohort, patients who had undergone a revision surgery were selected for the study and divided into two groups: group A (60) of patients previously operated on in another centre and group B (47) of patients previously operated on in "STOCER". The reasons for failure of the surgery were analysed in detail based on history, physical examination, imaging studies and surgery reports. RESULTS: Surgery was performed in 601 patients, of whom 107 patients had been previously operated on. The most frequent reasons for revision surgery of the same motor segment were recurrent disc herniation, inadequate decompression and inappropriate surgical technique. In the group of patients who had implants inserted to stabilise the spine, the revision surgery in most cases was due to adjacent segment disease. CONCLUSIONS: Use of implants and spinal fusion is always associated with a risk of complications and is frequently independent of the surgeon. 2. In order to reduce the rate of revision surgeries, it is important to perform complete decompression and select an adequate surgical technique.

Malocclusions and craniofacial anomalies in a child with velo-cardio-facial syndrome.

Velo-Cardio-Facial syndrome (VCFS), also called 22q11.2 microdeletion syndrome, is a rare pathology. The syndrome is caused by 22q11.2 deletion, recognized as one of the most frequent pathogenic human microdeletions. The scope and severity of the phenotypic expression of 22q11.2 microdeletion is characterised by high variability, although cleft palate and congenital conotruncal malformations are among the clinical features often associated with that syndrome. In the presented case of a boy patient with submucous cleft palate and congenital cardiac defect, 22q11.2 microdeletion was identified at the age of 13 months. In the presented paper particular emphasis was placed on the issue of dental and orthodontic care in patients with changes in the oral cavity and the craniofacial area, as well as on the possibilities of treatment and prophylaxis. The necessity to perform a thorough examination of the oral cavity in infants was also underlined as a vital element of clinical assessment, in particular in the case of co-occurring structural defects of internal organs.