Treatment of COVID-19 pneumonia with low-dose radiotherapy plus standard of care versus standard of care alone in frail patients : The SEOR-GICOR IPACOVID comparative cohort trial.

PURPOSE: To assess the efficacy of lung low-dose radiotherapy (LD-RT) in the treatment of patients with COVID-19 pneumonia. MATERIALS AND METHODS: Ambispective study with two cohorts to compare treatment with standard of care (SoC) plus a single dose of 0.5 Gy to the whole thorax (experimental prospective cohort) with SoC alone (control retrospective cohort) for patients with COVID-19 pneumonia not candidates for admission to the intensive care unit (ICU) for mechanical ventilation. RESULTS: Fifty patients treated with LD-RT were compared with 50 matched controls. Mean age was 85 years in both groups. An increase in arterial oxygen partial pressure (PaO2)/fraction of inspired oxygen (PAFI) in the experimental LD-RT-treated group compared to the control group could not be found at 48 h after LD-RT, which was the primary endpoint of the study. However, PAFI values significantly improved after 1 month (473 vs. 302 mm Hg; p < 0.0001). Pulse oxymetric saturation/fraction of inspired oxygen (SAFI) values were also significantly higher in LD-RT-treated patients than in control patients at 1 week (405 vs. 334 mm Hg; p = 0.0157) and 1 month after LD-RT (462 vs. 326 mm Hg; p < 0.0001). All other timepoint measurements of the respiratory parameters were similar across groups. Patients in the experimental group were discharged from the hospital significantly earlier (23 vs. 31 days; p = 0.047). Fifteen and 26 patients died due to COVID-19 pneumonia in the experimental and control cohorts, respectively (30% vs. 48%; p = 0.1). LD-RT was associated with a decreased odds ratio (OR) for 1­month COVID-19 mortality (OR = 0.302 [0.106-0.859]; p = 0.025) when adjusted for potentially confounding factors. Overall survival was significantly prolonged in the LD-RT group compared to the control group (log-rank p = 0.027). No adverse events related to radiation treatment were observed. CONCLUSION: Treatment of frail patients with COVID-19 pneumonia with SoC plus single-dose LD-RT of 0.5 Gy improved respiratory parameters, reduced the period of hospitalization, decreased the rate of 1­month mortality, and prolonged actuarial overall survival compared to SoC alone.

Retroperitoneal abscess after urgent resection of the stomach in a geriatric patient treated with a surgical extraperitoneal approach - case report.

Retroperitoneal abscess after abdominal and retroperitoneal surgery is a relatively rare but serious complication that most often occurs as a result of a healing disorder in the postoperative period. The incidence is not high, in the literature the cases are mostly reported as case reports with a serious clinical course, high morbidity and mortality. The most important factor of effective treatment, after successful diagnosis by CT examination is rapid evacuation of the abscess and retroperitoneal drainage, in which mini-invasive surgical or radiological drainage dominate as methods of choice. Surgical drainage, burdened by higher morbidity and mortality is considered the last resort after failure of mini-invasive methods. In our case report, we present a case of retroperitoneal abscess, arising as a complication after gastric resection, which was evacuated and drained primarily surgically due to unsuitability for radiological intervention.

Early changes in osteochondral tissues in a rabbit model of post-traumatic osteoarthritis.

Concurrent osteoarthritic (OA) manifestations in bone and cartilage are poorly known. To shed light on this issue, this study aims to investigate changes in subchondral bone and articular cartilage at two time points after anterior cruciate ligament transection (ACLT) in a rabbit model. 2 (N = 16) and 8 (N = 10) weeks after ACLT, the subchondral bone structure, cartilage thickness, Osteoarthritis Research Society International (OARSI) score, fixed charged density (FCD), and collagen orientation angle were analyzed. OA related changes were evaluated by comparing the ACLT to the contralateral (C-L) and control knees. Already 2 weeks after ACLT, higher trabecular number in the medial femoral condyle and femoral groove, greater OARSI score in the femoral condyles, and thinner trabeculae in the lateral tibial plateau and femoral groove were observed in ACLT compared to C-L knees. Only minor changes of cartilage collagen orientation in the femoral condyles and femoral groove and smaller FCD in the femoral condyles, medial tibial plateau, femoral groove and patella were observed. 8 weeks post-ACLT, the surgical knees had thinner subchondral plate and trabeculae, and smaller trabecular bone volume fraction in most of the knee locations. OARSI score was greater in the femoral condyle and lateral tibial plateau cartilage. FCD loss was progressive only in the femoral condyle, femoral groove, and patellar cartilage, and minor changes of cartilage collagen orientation angle were present in the femoral condyles, femoral groove, and lateral tibial plateau. We conclude that ACLT induces progressive subchondral bone loss, during which proteoglycan loss occurs followed by their partly recovery, as indicated by FCD results.

Malignant Mesothelioma of the Tunica Vaginalis Testis. A Clinicopathologic Analysis of Two Cases with a Review of the Literature.

Paratesticular malignant mesothelioma is an extremely rare type of mesothelioma with only a limited number of reported cases. Its clinical differentiation is challenging, and its diagnosis is almost exclusively accidental. The major risk factor is exposure to asbestos, typically with a long latency between exposure and diagnosis. The current study presents the clinical data of two patients diagnosed with paratesticular malignant mesothelioma. We evaluated a large spectrum of risk factors in the patients histories. The histomorphological and immunohistochemical characteristics were analysed and put into the perspective of a broad differential diagnosis. Both cases of malignant epithelial mesothelioma of the tunica vaginalis testis clinically presented as unilateral hydroceles. Patients underwent surgery with the perioperative finding of a tumour. Radical inguinal orchiectomy was the treatment of choice for both patients. After comprehensive staging, the second patient underwent a second step of inguinal and pelvic lymph node dis- section. Follow-up visits revealed recurrence of the disease in the first patient. Resection of the tumour was performed. The histology confirmed the relapse of a tumour with identical features to those of the first tumour. Chemotherapy and radiotherapy were not indicated. Both patients are currently in complete remission. In conclusion, surgical treatment had a determinative role in the prognosis of these patients. Radical orchiectomy is the treatment of choice for localized disease. Lymph node dissection can be considered in the case of lymph node enlargement. There is a lack of evidence-based data for adjuvant chemotherapy and radiotherapy. Patients should be referred to experienced multidisciplinary cancer centres for a second opinion on histology, treatment, and a follow-up plan.Key words: mesothelioma - tunica vaginalis testis - hydrocele - asbestos exposure.

Preliminary study on serum paraoxonase-1 status and chemokine (C-C motif) ligand 2 in hospitalized elderly patients with catheter-associated asymptomatic bacteriuria.

Urinary tract infections (UTI) are common among elderly patients in residential care facilities, as well as in the hospital setting. Identifying new biochemical markers of UTI is an active line of research since UTI management is resource intensive. Paraoxonase-1 (PON1) forms part of the patient's immune system, the response-to-injury and inflammation. Our study sought to evaluate alterations in inflammation-related paraoxonase-1 (PON1) and chemokine (C-C motif) ligand 2 (CCL2) in patients with an indwelling catheter to assess their potential usefulness as biomarkers of infection. Patients (n = 142) who had had the urinary catheter removed and 100 healthy volunteers were recruited. In all participants we measured serum PON1 activity, PON1 concentration, CCL2, procalcitonin and C-reactive protein (CRP). Results indicated that patients had higher CCL2, CRP and procalcitonin concentrations than the control group, and lower paraoxonase activity. There were no significant differences in PON1 concentrations. When comparing the diagnostic accuracy of CRP, procalcitonin, CCL2 and the PON1-related variables in discriminating between patients with and those without UTI, we found a considerable degree of overlap between groups, i.e., a low diagnostic accuracy. However, there were significant inverse logarithmic correlations between serum paraoxonase activity and the number of days the urinary catheter had been in situ. Our results suggest that measurement of these biochemical variables may be useful in investigating complications of long-term use of these devices and help to improve the economic and clinical investment required in the management of the often-associated infection.

Performance of dose calculation algorithms from three generations in lung SBRT: comparison with full Monte Carlo-based dose distributions.

The accuracy of dose calculation is a key challenge in stereotactic body radiotherapy (SBRT) of the lung. We have benchmarked three photon beam dose calculation algorithms--pencil beam convolution (PBC), anisotropic analytical algorithm (AAA), and Acuros XB (AXB)--implemented in a commercial treatment planning system (TPS), Varian Eclipse. Dose distributions from full Monte Carlo (MC) simulations were regarded as a reference. In the first stage, for four patients with central lung tumors, treatment plans using 3D conformal radiotherapy (CRT) technique applying 6 MV photon beams were made using the AXB algorithm, with planning criteria according to the Nordic SBRT study group. The plans were recalculated (with same number of monitor units (MUs) and identical field settings) using BEAMnrc and DOSXYZnrc MC codes. The MC-calculated dose distributions were compared to corresponding AXB-calculated dose distributions to assess the accuracy of the AXB algorithm, to which then other TPS algorithms were compared. In the second stage, treatment plans were made for ten patients with 3D CRT technique using both the PBC algorithm and the AAA. The plans were recalculated (with same number of MUs and identical field settings) with the AXB algorithm, then compared to original plans. Throughout the study, the comparisons were made as a function of the size of the planning target volume (PTV), using various dose-volume histogram (DVH) and other parameters to quantitatively assess the plan quality. In the first stage also, 3D gamma analyses with threshold criteria 3%/3mm and 2%/2 mm were applied. The AXB-calculated dose distributions showed relatively high level of agreement in the light of 3D gamma analysis and DVH comparison against the full MC simulation, especially with large PTVs, but, with smaller PTVs, larger discrepancies were found. Gamma agreement index (GAI) values between 95.5% and 99.6% for all the plans with the threshold criteria 3%/3 mm were achieved, but 2%/2 mm threshold criteria showed larger discrepancies. The TPS algorithm comparison results showed large dose discrepancies in the PTV mean dose (D50%), nearly 60%, for the PBC algorithm, and differences of nearly 20% for the AAA, occurring also in the small PTV size range. This work suggests the application of independent plan verification, when the AAA or the AXB algorithm are utilized in lung SBRT having PTVs smaller than 20-25 cc. The calculated data from this study can be used in converting the SBRT protocols based on type 'a' and/or type 'b' algorithms for the most recent generation type 'c' algorithms, such as the AXB algorithm.

Integration of the e-Learning into the medical university curricula.

OBJECTIVES: The aim of this contribution was to present the e-Learning introduction in the Slovak Medical University (SMU) with a focus on the implementation phase of the two blended courses - Healthcare Quality and Healthcare Professionals' Ethics. BACKGROUND: The introduction of the e-Learning was realized during the period 2008-2009 in the partnership of SMU and IBM Company, following strictly the project management approach. METHODS: The development of the e-module beta-versions was evaluated by the modules' authors using a structured interview. In a consequent pilot testing, the blended courses were evaluated by 23 students of the bachelor program in Rescue health care, and by 61 public health students at the master level program, respectively, using the standardized questionnaires. RESULTS: The tangible results included the documented SMU strategy for the e-Learning integration, six e-Learning modules and evaluation results. The authors' evaluation showed high scores for the experience in collaboration with IBM, as well as for the experience with the LMS environment. The students' evaluation showed a high acceptance of the e-Learning by both part-time and full-time students. The access to Internet was not recognized as a serious barrier. CONCLUSION: The first experience with the integration of the e-Learning into the curricula of the Slovak Medical University showed the advantage of the systematic approach. The experience with developing the strategy in an interdisciplinary/ intercultural team, the knowledge about specific characteristics of distance learning by the involved SMU staff, and the know-how and skills represented the important benefits. It was demonstrated that the blended learning is recommended as optimal for the education in medical environment (Tab. 4, Fig. 1, Ref. 22).

La función genuina de filtro del médico de atención primaria / The real filtering role played by the primary care physician

No disponible

No disponible

[Differential pressure as an independent factor of cardiovascular risk]. / La presión diferencial como factor independiente de riesgo cardiovascular.

OBJECTIVES: To confirm that high differential pressure (DP) supposes greater risk of ischaemic cardiopathy and to assess whether it is also an independent risk factor of suffering a cerebrovascular accident. DESIGN: An analytical, observational, retrospective and longitudinal study with historic cohorts. SETTING: Urban population of about 18 000 inhabitants. PARTICIPANTS: 300 patients aged between 15 and 75 with hypertension of > or =2 years evolution, who have had their blood pressure taken by nurses 4 or more times (excluding casualty) and have not suffered a cardiovascular event (CVE), whether coronary accident, cerebrovascular accident or peripheral vasculopathy. MAIN MEASUREMENTS: The history relating to cardiovascular risk was recorded: lipaemia, obesity, tobacco dependency, diabetes mellitus, left ventricular hypertrophy (LVH). These factors were considered present if their diagnosis preceded the CVE diagnosis. They were placed in 2 groups, depending on the degree of differential pressure: "high" if >60 mm Hg and "not high" if (3/4)60 mm Hg. They were analysed for intention to treat over 10 years, with the appearance or not of a CVE as a response variable. RESULTS: 300 participants (73.3% women), 150 exposed to risk and 150 not exposed. The initial analysis showed significant differences between the 2 groups for age (P<.0001), diabetes (P<.0001), and LVH (P<.001). After logistic regression, the OR of suffering LVH was 2.38 (95% CI, 1.19-4.74) in the group with high DP; the OR of ischaemic cardiopathy, 2.84 (95% CI, 1.16-6.96); and of cerebrovascular accident, 2.70 (95% CI, 1.09-6.68). There were no significant differences for peripheral arteriopathy. CONCLUSIONS: DP was confirmed as an independent factor of cardiovascular risk and, despite the limitations of the study, it was pointed to as a possible independent factor of cerebrovascular risk.

La presión diferencial como factor independiente de riesgo cardiovascular / Differential pressure as an independent factor of cardiovascular risk

Objetivo. Confirmar que la presión diferencial alta supone más riesgo de cardiopatía isquémica y valorar si también es factor de riesgo independiente de padecer un accidente cerebrovascular. Diseño. Estudio longitudinal, analítico y observacional, retrospectivo de cohortes históricas. Emplazamiento. Población urbana de aproximadamente 18.000 habitantes. Participantes. Se incluyó en el estudio a 300 pacientes de 15 a 75 años de edad con hipertensión de 2 años de evolución o más, en los que constaban 4 o más determinaciones de presión arterial por enfermería (excluyendo urgencias) y que no habían padecido un episodio cardiovascular (ECV): coronariopatía, accidente cerebrovascular o vasculopatía periférica. Mediciones principales. Se registraron los antecedentes asociados a riesgo cardiovascular: dislipemia, obesidad, tabaquismo, diabetes mellitus e hipertrofia ventricular izquierda, y se consideraron presentes si su diagnóstico precedía al del ECV. Se realizó una clasificación en 2 grupos en función del grado de presión diferencial: alta si superaba los 60 mmHg (pacientes expuestos) y no alta si era >= 60 mmHg o inferior (pacientes no expuestos). Se realizó un análisis por intención de tratar durante 10 años señalando la aparición o no de ECV como variable de respuesta. Resultados. De los 300 participantes (un 73,3% mujeres), 150 se consideraron expuestos y 150 no expuestos. El análisis inicial mostró diferencias significativas entre ambos grupos respecto a la edad (p < 0,0001), presencia de diabetes (p < 0,0001) y de hipertrofia ventricular izquierda (p < 0,001). Tras la regresión logística, la odds ratio para padecer un ECV fue 2,38 (intervalo de confianza [IC] del 95%, 1,19-4,74) en el grupo de presión diferencial elevada. Para la cardiopatía isquémica la odds ratio fue de 2,84 (IC del 95%, 1,16-6,96) y para el accidente cerebrovascular, de 2,70 (IC del 95%, 1,09-6,68). Para arteriopatía periférica no hubo diferencias significativas. Conclusiones. Se confirma la presión diferencial como factor independiente de riesgo cardiovascular y se apunta, a pesar de las limitaciones del estudio, la posibilidad de que también sea un factor independiente de riesgo cerebrovascular

Objectives. To confirm that high differential pressure (DP) supposes greater risk of ischaemic cardiopathy and to assess whether it is also an independent risk factor of suffering a cerebrovascular accident. Design. An analytical, observational, retrospective and longitudinal study with historic cohorts. Setting. Urban population of about 18 000 inhabitants. Participants. 300 patients aged between 15 and 75 with hypertension of >=2 years evolution, who have had their blood pressure taken by nurses 4 or more times (excluding casualty) and have not suffered a cardiovascular event (CVE), whether coronary accident, cerebrovascular accident or peripheral vasculopathy. Main measurements. The history relating to cardiovascular risk was recorded: lipaemia, obesity, tobacco dependency, diabetes mellitus, left ventricular hypertrophy (LVH). These factors were considered present if their diagnosis preceded the CVE diagnosis. They were placed in 2 groups, depending on the degree of differential pressure: "high" if >60 mm Hg and "not high" if ¾60 mm Hg. They were analysed for intention to treat over 10 years, with the appearance or not of a CVE as a response variable. Results. 300 participants (73.3% women), 150 exposed to risk and 150 not exposed. The initial analysis showed significant differences between the 2 groups for age (P<.0001), diabetes (P<.0001), and LVH (P<.001). After logistic regression, the OR of suffering LVH was 2.38 (95% CI, 1.19-4.74) in the group with high DP; the OR of ischaemic cardiopathy, 2.84 (95% CI, 1.16-6.96); and of cerebrovascular accident, 2.70 (95% CI, 1.09-6.68). There were no significant differences for peripheral arteriopathy. Conclusions. DP was confirmed as an independent factor of cardiovascular risk and, despite the limitations of the study, it was pointed to as a possible independent factor of cerebrovascular risk

Effects of water use on arsenic release to well water in a confined aquifer.

Field-based experiments were designed to investigate the release of naturally occurring, low to moderate (< 50 microg/L) arsenic concentrations to well water in a confined sandstone aquifer in northeastern Wisconsin. Geologic, geochemical, and hydrogeologic data collected from a 115 m2 site demonstrate that arsenic concentrations in ground water are heterogeneous at the scale of the field site, and that the distribution of arsenic in ground water correlates to solid-phase arsenic in aquifer materials. Arsenic concentrations in a test well varied from 1.8 to 22 microg/L during experiments conducted under no, low, and high pumping rates. The quality of ground water consumed from wells under typical domestic water use patterns differs from that of ground water in the aquifer because of reactions that occur within the well. Redox conditions in the well can change rapidly in response to ground water withdrawals. The well borehole is an environment conducive to microbiological growth, and biogeochemical reactions also affect borehole chemistry. While oxidation of sulfide minerals appears to release arsenic to ground water in zones within the aquifer, reduction of arsenic-bearing iron (hydr)oxides is a likely mechanism of arsenic release to water having a long residence time in the well borehole.

[Arterial embolisms in the extremities]. / Embólie do artérií koncatín.

The authors discuss the causes of development of embolism into the peripheral vessels. The most frequent site of embolism in the lower extremity is the a. femoralis communis and a. poplitea, in the upper extremity the brachial and cubital artery. Frequently a premonition of myocardial infarction is involved which was not reflected in ECG changes but was confirmed on autopsy. The most frequent source of embolization into the periphery is atrial fibrillation. The success of treatment depends on early surgical intervention (embolectomy), local thrombolysis and postoperative administration of anticoagulants. Late removal of the embolus causes local and general changes, loss of the extremity and increases the morbidity and mortality.

Instability of lipoprotein(a) in plasma stored at -70 degrees C: effects of concentration, apolipoprotein(a) genotype, and donor cardiovascular disease.

BACKGROUND: There is considerable evidence to suggest that plasma lipoprotein(a) [Lp(a)] concentration is a cardiovascular risk factor. Confusing results in epidemiologic studies, however, suggest that the effects of storage should be further investigated. The influence of the assay method, the initial plasma Lp(a) concentration, and the apolipoprotein(a) [apo(a)] genotype are all factors that should be considered. METHODS: Blood was obtained from 65 survivors of premature myocardial infarction and 95 age-matched controls. The plasma samples were stored in sterile conditions at -70 degrees C for 5 years in the presence of antioxidant and antiproteolytic substances. Plasma Lp(a) was measured by immunoturbidimetry, and apo(a) alleles were determined by pulsed-field gel electrophoresis and Southern blotting. RESULTS: Plasma Lp(a) was significantly higher in patients. The mean kringle number for the smallest isoform was also lower in patients than in controls, but no differences were found in the distribution of the largest isoform. All patients and controls were heterozygotes. During storage, mean Lp(a) decreased significantly in samples from patients (-23%; P <0.001) but not in samples from controls (-9%; P, not significant). This was not related to the kringle number and was limited to samples with initial plasma Lp(a) concentrations between 41 and 345 mg/L. CONCLUSIONS: Plasma Lp(a) from patients is less stable than Lp(a) from controls, and the difference is not related to distribution of apo(a) genotypes but may be concentration-dependent. Differential sample stability may complicate the interpretation of several studies.

Polymorphisms in human apolipoprotein(a) kringle IV-10 and coronary artery disease: relationship to allele size, plasma lipoprotein(a) concentration, and lysine binding site activity.

Elevated plasma levels of lipoprotein(a) [Lp(a)] represent a major independent risk factor for the development of atherosclerosis. The kringle IV type 10 of apolipoprotein(a) [apo(a)] is the primary lysine binding site (LBS) of Lp(a) and is associated with lesion formation in transgenic mice. The purpose of this study was to search for mutations in the apo(a) kringle IV type 10 which could alter the LBS activity of Lp(a) from patients with coronary artery disease. We found the DNA region of kringle IV type 10 of apo(a) to be mutable but relatively well preserved in the Spanish population. We identified a novel mutation which probably leads to a truncated form of apo(a) in a patient heterozygous for the mutation and with low lysine binding activity and low plasma Lp(a) concentration. Two other mutations have been previously identified in humans, the substitutions W81R and M75T. The W81R was not found in our sample, but the M75T mutation was present in 43% of patients with coronary artery disease and 23% of age-matched controls. The genotype TT conferred a significant risk for myocardial infarction (odds ratio 2.53). This association was not due to linkage disequilibrium with kringle IV repeats. The M75T polymorphism was not associated with the LBS function of apo(a), but it influenced plasma Lp(a) concentration.

Strategy-making capability and performance of Slovak acute hospitals.

BACKGROUND: Research of strategic management issues in the environment of Slovak Health Care System generally and in the environment of secondary health care providers partially is a relatively new approach of last decade. In continuity with research of western authors this pilot study approaches a specific area of strategic management that is strategy-making capability and its relationship to performance of hospitals. AIM: Main goal of authors was to apply framework developed by Hart and test relationship of strategy making capability and performance in Slovak Acute Hospitals. Two hypotheses were developed for that purpose. METHODS: To conduct a test of both hypotheses a combination of three instruments was used. First was a set of 17 questionnaire items to tap the five strategy-making modes. Second was another set of 8 questionnaire items to tap the four perceived performance dimensions. Third was a current classification of Slovak acute hospitals and their levels. In summary data on twenty-five questionnaire--items were mailed to Chief Executive Officers (CEO) of 81 Slovakian acute hospitals within a larger survey co-ordinated by Ministry of Health. Data were collected via a questionnaire survey of top managers from selected acute Slovak hospitals within December 1999--February 2000. The sample was chosen from the list of acute care hospitals in the 1999 Report of the Slovak Institute for Health Care Information and Statistics. RESULTS: Being aware of certain limitations in such a construct results indicate that hospitals with higher level of strategy-making capabilities might outperform those with lower level of this capability. (Tab. 5, Ref. 21.).