[The role of classical surgery in treatment of acute abdomen in oncological patients]. / Uloha klasickej chirurgie pri liecbe náhlych príhod brusných u onkologických pacientov.

Acute abdomen in patients with malignity may present itself as a first sign, or might manifest itself during therapy of diagnosed disease. Clinical picture might be modified by age of patients, comorbidity, and side effects of multimodal therapy. Authors analyze their group of patients, admitted to their department with malignant disease. They found out, that almost half of the patients was admitted urgently and had serious comorbidities. In operative therapy classical surgery dominated. Authors present in discussion causes of this unsatisfactory status, as well as literature references concerning urgent cases in different types of malignant diseases.

[The "pancreatic unit" in the treatment of severe necrotizing pancreatitis]. / "Pankreatická jednotka" v liecbe t'azkej nekrotizujúcej pankreatitídy.

The course of acute pancreatitis varies from mild, fortuitous forms to grave, life threatening disease. Approximately 80-90% of all forms are mild with low morbidity and mortality. The rest consist of severe, sometimes even fatal forms with present necrosis. It is active, conservative therapy which dominates, arising from new knowledge in interdisciplinary intensive care, together with enhanced possibilities of disease control. Capabilities of intensive care, elimination methods, endoscopy, interventional radiology, and other fields exceed abilities of surgical wards and thus require interdisciplinary approach. In accordance with international recommendations, the only way to meet these requirements is creation of specialized units dedicated to treatment of severe acute pancreatitis e.g. pancreatic units. Authors present their ideas of such pancreatic unit estabilished at their clinic. Professional experiences of authors come from 1350 patients being hospitalized with diagnosed acute pancreatitis throughout years 1990 to 2006.

Injuries of the intraabdominal organs at patients with polytrauma.

The authors analyse group of 77 patients with several injuries of the intraabdominal organs by polytrauma and intraabdominal continuing bleeding. The injuries were classified in compliance with the classification of the American Association for the Surgery of Trauma (AAST), 1994. At hemodynamically stable patients, the authors accept selective non-operative forms of treatment, however are aware of the risk of delaying the therapy of severe polytrauma. (Tab. 4, Fig. 2, Ref. 3.).

Stabilisation of thoracic wall in patients with chest injury.

The authors analyse a group of 38 polytraumatised patients with unstable thoracic injury who were subdued to internal surgical stabilisation of the thoracic wall during the period from 1st October 1994 to 30th September 2001. The average period of controlled pulmonary ventilation (CPV) was 3 days and the average period of hospitalisation at the Anaesthesiology and Intensive Care Department (AICD) was 10 days. In indicated cases, the authors recommend an active surgical approach in the treatment of patients with unstable thoracic injuries. (Tab. 2, Fig. 2, Ref. 3.).

[Treatment of gunshot wounds of the liver]. / Moznosti osetrenia strelného poranenia pecene.

The objective of the work was to draw attention to the rising trend of gunshot wounds of the abdomen with affection of the liver. The authors analyze their own group of five patients with gunshot wounds of the liver incl. one who died during the resuscitation operation, another one on the 15th day from complications, two recovered without sequelae, and the fate of one was unknown as he was referred to another department. In the discussion the authors deal with diagnostic methods, classification of hepatic injuries, indications for surgical revision, trends of expectation tactics, complications and in particular possible therapeutic procedures leading to arrest of haemorrhage and definite treatment.

[The current approach to liver injuries]. / Súcasný prístup k poraneniam pecene.

PURPOSE OF THE STUDY: The authors analyze their own three-year material within the treatment (both surgical and conservative) of the injury of liver. MATERIAL: During the given period 18 patients with the injury of liver were treated, of which 15 (83%) surgically and 3 (17%) conservatively. The group included 13 men (72%) and 5 women (28%), the average age at the time of injury was 30 years (range, 19-44 years). Ten patients (56%) suffered a blunt injury and 8 patients (44%) a penetrating injury, of which in 5 patients it was the case of a stab wound and in 3 patients a gunshot wound. METHODS: Indicated to operation were patients with a continuous intraabdominal bleeding, multiple organ injury of the abdominal cavity, simultaneous injury of diaphragm and gunshot wounds in the abdominal cavity. The method of treatment of the liver was determined by the extent of the injury. The authors accept the selective non-surgical treatment of hemodynamically stabilized patients which was developed on the basis of modern imaging methods. The condition of patients is also limited by the extent and severity of associated injuries. Hepatic injuries were classified according to American Association for the Surgery of Trauma, 1994. RESULTS: The average amount of hemoperitoneum in the patients operated on amounted to 1 550 ml. (200-4000) of blood, the average number of transfusion units 9 (4-20), the average duration of hospitalization at the intensive care unit was 7 (1-44) days and at the surgical department 10 (1-24) days. The average amount of hemoperitoneum according to Federle classification in the nonoperated on patients was 250 ml (200-375), the average number of transfusion units was 1.2 (1-2) of erythrocyte mass, the average duration of the stay in the intensive care unit of the surgical department was 2.3 (2-3) and at the surgical department 6.9 (6-8) days. Complications were recorded in 5 (28%) patients. During resuscitation 6 patients (33%) died due to hemorrhagic shock and in 2 (11%) patients we introduced during the resuscitation intracaval shunt. DISCUSSION: Non-surgical treatment has become a standard method of the treatment of a blunt hepatic, injury in the adult population and it is used in the extent of 50-82%. Failure of conservative treatment at present leads to a surgical intervention. Surgery is indicated in patients which continuously require transfusions, whose vital indicators have deteriorated and where there are evident growing signs of peritoneal irritation. CONCLUSION: Non-surgical treatment of blunt hepatic injuries should be initial in all patients with a secured hemodynamic stability. As it is impossible to find out in which patients non-surgical treatment will fail, the initial period of observation at the intensive care unit is a guarantee of a selective approach. If all its principles are observed the percentage of success of this treatment should exceed 90%.

Penetrating cardiac injury.

Penetrating cardiac injury is still a diagnostic problem at this time. The authors want to show the breadth of problems on the case histories of two patients. It is important to classify the patients according to their risk group, and then to proceed. In each suspicion of cardiac injury we started with thoracotomy. It is an important "life endangering thoracotomy in emergency room". The hypotension with abdominal symptoms was started with laparotomy. Transdiaphragmatic pericardiotomy is a helpful adjunct in the decision as to whether proceed to median sternotomy. (Tab. 2, Fig. 3, Ref. 7.)

[Resuscitation operations in patients with multiple injuries]. / Resuscitacné operácie u polytraumatizovaných pacientov.

The authors analyze a group of 15 patients with polytrauma during a 4-year period. The patients had the clinical signs of severe bleeding. Despite the complex resuscitation care, the patients died due to consequences of haemorrhagic shock already during the operation or very soon after operation. All patients were after initial resuscitation and diagnostic procedures (apparatus breathing, aggressive volumotherapy, proved continuous bleeding) performed for the use of further resuscitation actions, namely surgical control and stoppage of bleeding, surgical indications. This pathophysiological consideration is reflected also in the title of this study. The study further discusses the modern injury conception of resuscitation at a operating theatre which in frame of surgical intervention attempts to achieve homeostasis. At the same time, the surgical approach frequently must prefer the methods which enable the physiological stability on the behalf of incomplete solution of post-traumatic anatomic integrity. The definite solution can be possibly performed by subsequent operation. (Ref. 5.)

[Significance of monitoring of intracranial pressure in craniocerebral injuries.]. / Význam monitorovania intrakraniálneho tlaku pri kraniocerebrálnych poraneniach.

The authors extend the analysis of the previously published group of 26 patients with a craniocerebral injury during a 20-month period of monitoring of intracranial pressure by means of epidural approach by new techniques. Since 1996 they have implanted a technically upgraded intracranial pressure censor intraparenchymatosely and since 1998 intraventricularly in total in 27 patients with craniocerebral injury during 36-month period. The significance of continuous monitoring of intracranial pressure in indicated cases consists in the prevention and treatment of intracranial hypertension (medicaments, ventilation regimen, nursing care) as in craniocerebral injuries ther does not develop a direct relationship between the disorder of conscience and intracranial pressure. Key words: craniocerebral injuries, monitoring of intracranial pressure, intracranial hypertension.

[Injuries of diaphragm in our group of patients.]. / Urazy bránice v nasom klinickom materiáli.

In thoracic and abdomen surgeries the injury of diaphragm is often neglected. Clinical symptoms vary and in patients with polytrauma they are usually disguised. The authors analyze a group of 9 patients with polytrauma with the injury of diaphragm during a five-year period (from 1 September 1993 to 31 August 1998) specifying diagnostic possibilities and stressing the necessity to revise the diaphragm in laparotomy or thoracothomy for associated injuries. The prognosis of the injury is given by associated injuries. Key words: injury of diaphragm, polytraumatic patient.

[Topical issue of the injury of liver.]. / Aktuálna problematika poranenia pecene.

The authors analyse their own 10-year clinical material (1 August 1987-31 July 1997). In the course of this period they operated on 40 patients for the injury of liver. The indications were persisting intra-abdominal bleeding, multiple injuries of organs in the abdominal cavity, simultaneous injuries of diaphragm and gunshot wounds of abdomen. Injuries were classsified according to AAST, the range of organ injury - liver. The treatment of liver was determined by the extent of the injury. In their surgical strategy the authors prefer suture of hepar by collagenous stripes (Parenchymaset, Braun) with sufficient drainage, but they also used resection or packing in dilaceration injuries. Patients with injuries of hepatic veins and retrohepatic inferior vena cava died in the course of resuscitation surgery despite the introduction of en-docaval shunt. The authors accept selective non-surgical treatment of hemodynamically stabilised patients which has been developed thanks to modern visualisation methods. However, such treatment implies a risk of delayed management of significant associated injuries. The fate of patienst is also limited by the extent and seriousness of associated injuries. Key words: liver injury, surgical and non-surgical treatment.

[Early treatment of unstable chest in patients with multiple injuries.]. / Vcasné osetrenie nestabilného hrudníka u polytraumatizovaných pacientov.

The authors analyze a group of 11 patients with unstable chest injuries who were subjected in 1994-1996 to internal surgical stabilization of the chest wall. They compare them with a group of 11 consecutive patients from the previous period who were treated by artificial pulmonary ventilation. The basic indicator for evaluation of both groups was the necessary length of assisted ventilation which had an impact on all important parameters, complications and mortality of patients with this injury. Patients in the group with surgical stabilization of the chest wall needed on average three days of assisted ventilation and their mean time spent in the resuscitation department was 10 days. On the other hand, patients in the ventilated group needed on average 15 days of assisted ventilation and spent 25 days in the resuscitation department. The authors recommend in indicated cases an active surgical approach to the treatment of patients with unstable chest injuries. Key words: polytrauma, unstable chest injury, stabilization of the chest wall.

[Monitoring of the intracranial pressure in craniocerebral injuries.]. / Monitorovanie intrakraniálneho tlaku pri kraniocerebrálnych poraneniach.

The authors analyzed a group of 26 patients with serious craniocerebral injuries during a 20-month period, where the total mortality was 26 %. The majority of injuries was contracted during traffic accidents and the most frequent CT finding on admission was traumatic subarachnoidal haemorrhage and contused and haemorrhagic foci in the brain. As during craniocerebral injuries no direct relationship develops between impairment of consciousness and intracranial pressure the authors recommend continuous assessment of the intracranial pressure. It is important for prevention and treatment (medicamentous, ventilation regimen and nursing care) of intracranial hypertension. Key words: craniocerebral injury, monitoring of intracranial pressure, intracranial hypertension.

[Thoracoabdominal operations in patients with multiple injuries.]. / Torakoabdominálne výkony u polytraumatizovaných pacientov.

The authors analyze during a two-year period a group of 58 patients with multiple injuries, including a thoracoabdominal injury, with a total mortality of 29 %. The dominating injury was damage of the chest and the most frequent surgical procedure negative pressure drainage of the pleural cavity, as described by Büllau. 82% of the surgical procedures were performed during the acute stage of treatment of the multiply injured patient (unstable patient) within 8 hours after admission to hospital. If peroperative coagulopathy develops, the authors recommend intraabdominal packing, closure of the abdominal cavity and after the patient's stabilization (haemodynamics, ventilation, milieu intérieur) definitive surgical treatment. Key words: polytrauma, peroperative coagulopathy, intraabdominal packing, definitive surgical treatment.

A simple method to identify alcohol and other drug use in pregnant adults in a prenatal care setting.

Identification of women who use alcohol and other drugs while pregnant must occur as early as possible during the course of prenatal care so that interventions can be applied that may decrease the effects of alcohol and other drugs use on the newborn infant. This method for screening pregnant adults (a separate method is used for pregnant teenagers) who come for prenatal care is designed to be incorporated into the routine medical history interview and physical examination performed in all new prenatal patients. It explains how to ask pregnant women directly about alcohol and other drug use and how to determine the significance of their use. Common risk factors for alcohol and other drug use in pregnant women are described. Use of a Risk Assessment Worksheet is suggested as a means to determine which women may need further evaluation for possible alcohol and other drug use. Ways to ask pregnant women about continuing use at subsequent prenatal visits are also mentioned. Finally, suggested criteria for referring alcohol- and other drug-using women identified by this method for treatment of chemical dependence are supplied.

Adolescent psychiatric inpatients' risk of suicide attempt at 6-month follow-up.

Adolescent inpatients (of whom 48 were admitted for a suicide attempt, 33 were admitted for suicidal ideation, and 53 had no history of clinically significant suicidal ideation or attempt), were interviewed while in the hospital and then followed up 6 months later. Of the 134 patients followed up, 13 (9.7%) had made a suicide attempt. The vast majority of those who attempted suicide had been suicidal while in the hospital (12/13 or 92.3%). Other risk factors for suicidal behavior include major depression at intake, affective disorder with nonaffective comorbidity, a depressive disorder that continued through follow-up, death of a relative, and family financial problems. Suicidal inpatients, particularly those with chronic and recurrent affective illness, are at substantial risk for making a suicide attempt within 6 months of discharge. At follow-up, an even higher proportion showed attempts or suicidal ideation with a plan (N = 36 or 26.8%), with risk factors similar to those noted above. More intense outpatient or partial hospital interventions as a transition from the inpatient environment may be necessary to reduce the rate of recidivism among suicidal adolescents.

The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study.

OBJECTIVE: The presence of guns in the home, the type of gun, and the method of storage were all hypothesized to be associated with risk for adolescent suicide. DESIGN: Case-control study. SUBJECTS: The case group consisted of 47 adolescent suicide victims. The two psychiatric inpatient control groups were 47 suicide attempters and 47 never-suicidal psychiatric controls, frequency-matched to the suicide victims on age, gender, and county of origin. SETTING: The cases were a consecutive community sample, whereas the inpatients were drawn from a university psychiatric hospital. MAIN OUTCOME MEASURE: Odds of the presence of guns in the home of suicide victims (cases) relative to controls. RESULTS: Guns were twice as likely to be found in the homes of suicide victims as in the homes of attempters (adjusted odds ratio, 2.1; 95% confidence interval, 1.2 to 3.7) or psychiatric controls (adjusted odds ratio, 2.2; 95% confidence interval, 1.4 to 3.5). Handguns were not associated with suicide to any statistically significantly greater extent than long guns. There was no difference in the methods of storage of firearms among the three groups, so that even guns stored locked, or separate from ammunition, were associated with suicide by firearms. CONCLUSIONS: The availability of guns in the home, independent of firearms type or method of storage, appears to increase the risk for suicide among adolescents. Physicians should make a clear and firm recommendation that firearms be removed from the homes of adolescents judged to be at suicidal risk.

Reliability and validity of the structured interview for personality disorders in adolescents.

The Structured Interview for the DSM-III Personality Disorders was administered to 23 currently affectively ill adolescents and their parents. Interviews were videotaped and rerated; interrater agreement was moderate (weighted K = 0.49; unweighted K = 0.59). Moreover, there was evidence of convergent validity for Cluster II traits and disorders (borderline, histrionic, narcissistic), insofar as these diagnoses were associated with higher scores on the novelty-seeking subscale of the Tridimensional Personality Questionnaire as predicted. Cluster II patients tended to have higher rates of attention deficit disorder and bipolar disorder, and higher rates of suicidal gestures among second-degree relatives. Some difficulty was encountered differentiating symptoms of affective illness from those of personality disorder and in deciding when personality traits were impairing enough to call them disorders. Reliability may be improved by: (1) interviewing patients when out of affective episode; and (2) using standardized functional impairment criteria for differentiating personality style from disorder. Additional work is advocated to learn if personality disorders are precursors, epiphenomena, or the consequences of affective disorder.

Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients.

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.