Assessment to access to social and medical help- for homeless people in Cracow in the context to health problems

INTRODUCTION: Although homelessness is a worldwide problem also present in Poland and the Malopolska region, the data about it are not sufficient. AIM OF THE STUDY: Assessment of the general situation in Cracow and help options for homeless people. MATERIALS AND METHODS: A survey study conducted in 11 places offering refuge to homeless people in Cracow. RESULTS: In Cracow, there were 691 places to sleep in 11 institutions. Nine out of 11 were open all year long and most of them were available only for men. Five institutions offered meals, all of them had bathrooms, 7 places provided medical help. DISCUSSION: The expected number of homeless people in Poland and in Cracow seems to be underestimated. Basic needs of homeless people remain unsatisfied which decreases the possibility of transitioning out of homelessness. CONCLUSIONS: Help available for homeless people in Cracow needs improvements in all of the areas examined.

Comparison of analgesia, adverse effects, and quality of life in cancer patients during treatment of procedural pain with intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets.

AIM: Comparison of analgesia, adverse effects, and quality of life (QoL) of cancer patients in the treatment of procedural pain induced by nursing procedures with the use of intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets. METHODS: In adults with cancer with opioid tolerance and suffering procedural pain, intravenous morphine was used at an inpatient palliative medicine unit (20 patients) and fentanyl by intranasal (15 patients) and buccal routes (nine patients) at home. Five procedural pain episodes were examined: the Mini-Mental State Examination was used to assess cognitive function, the Brief Pain Inventory - short form (BPI-SF) to assess intensity and impact of pain on daily activities, a pain and adverse-effect questionnaire to assess the intensity of pain and adverse effects, and the European Organisation for Research and Treatment of Cancer QLQ-C15-PAL to assess QoL. RESULTS: All five procedural pain episodes were completed by 32 patients. Twelve patients stopped treatment due to death or referral to the hospital (four patients in each group), changes in the treatment of background pain (three patients), and intense drowsiness (one patient). Similar beneficial analgesic effects were observed in all patient groups. During fentanyl therapy, a smaller negative effect of pain on patients' activity, walking, and work (BPI-SF) was observed. Among adverse effects, fewer breaths (10-14 per minute) were observed in 17 patients and slight disturbances of consciousness in seven. For QoL, an improvement in emotional functioning, overall QoL, and fatigue was observed. Patients treated with intranasal and buccal fentanyl had higher physical functioning and were more active. CONCLUSION: In the treatment of procedural pain induced by nursing procedures in cancer patients, intravenous morphine and rapid-onset fentanyl show similarly high analgesic efficacy, with good tolerance of treatment and improvement in QoL.

Variations and angulation of the coronary sinus tributaries: Implications for left ventricular pacing.

BACKGROUND: Variations of the coronary sinus tributaries might result in difficulties in left ventricle electrode insertion during cardiac resynchronizing therapy. Morphometric features of tributaries, especially angulation of the coronary sinus tributaries, are crucial for coronary sinus procedures. METHODS: This study was carried out on 200 formaldehyde-fixed human hearts (22.0% females, mean age of 48.7 ± 15.6 years). RESULTS: The inferolateral aspect of the left ventricle was accessible from the coronary venous tree in 77.0% (in 35% from one, 29% from two, and 13.0% from three tributaries). The middle cardiac vein was present in all cases, with a diameter of 1.8 ± 0.5 mm, cannulation distance of 5.3 ± 3.2 mm, and angle of 82.0 ± 12.8°. The inferolateral vein of the left ventricle varied greatly in number: single in 63.5%, multiple in 30.5%. The ostium diameter for a single vein was 1.3 ± 0.5 mm, cannulation distance was 21.1 ± 9.8 mm, and the angle was 98.1 ± 13.5°. The left marginal vein was present in 39.5% with an ostium diameter of 0.9 ± 0.5 mm, cannulation distance of 46.0 ± 12.0 mm, and angle of 92.0 ± 13.4°. Finally, the oblique vein of the left atrium was present in 71.0% with a diameter of 1.3 ± 0.8 mm, cannulation distance of 27.2 ± 9.4 mm, and angle of 136.8 ± 16.6°. CONCLUSIONS: This study shows the clinically relevant morphometric characteristic of coronary sinus tributaries. The middle cardiac vein is the most constant among coronary veins. However, it is usually not suitable for left ventricular pacing. The inferolateral vein of the left ventricle is highly variable in number, but its morphology makes it a suitable target for left ventricular lead placement.

Alarming decline in recognition of anatomical structures amongst medical students and physicians.

BACKGROUND: Insufficient anatomical training can put patients' safety at risk. The aim of this study was to assess the proficiency of medical students and physicians in identifying labeled anatomical structures. The second aim of the study was to evaluate factors that can affect this recognition. METHODS: An internet-based survey where participants had to correctly identify labeled anatomical structures on cadaveric specimens was designed. RESULTS: The study group included 1186 participants (58.7% females): 931 medical students and 255 medical graduates from all twelve Polish medical schools. The mean total survey score for the entire study group was 65.6%. Students gained significantly higher results than graduates (total: 67.3% vs. 59.5%, P<0.001); 331 (27.9%) participants did not pass the test (<60). There was a correlation observed between points gained in this survey and grade obtained in the gross anatomy course (P<0.001). Multivariable logistic regression found that participation in cadaver laboratory classes most strongly increases anatomical competencies (OR=5.30, 95%CI=1.20-23.40, P=0.03). Other significant factors boosting anatomical proficiency were membership in students' scientific clubs, being male, and having a high grade (≥80%) in initial gross anatomy course. The time since anatomy course completion was negatively correlated with the total survey score (OR=0.86, 95%CI=0.81-0.92, P<0.001). CONCLUSIONS: Anatomical knowledge of Polish medical students is moderate (<70%) and it significantly decreases with time. Anatomical structure recognition can be up to 25% lower in highly trained physicians when compared to pre-clinical medical students. This trend may be reversed by replacing subject-based anatomy courses with system-based (integrated) curricula at the undergraduate level or introducing short refresher anatomical courses during postgraduate training.

The median nerve penetrating through the radial head of the flexor digitorum superficialis muscle: Case report.

The forearm is a body region of numerous anatomical variations. Due to its favorable anatomy flexor digitorum superficialis muscle (FDS) is commonly used in tendon transfer surgeries. In this study a unique combination of abnormalities was found in a single forearm: the flexor digitorum superficialis muscle penetrated by the median nerve, one of the flexor digitorum superficialis tendons early division and absence of the palmaris longus muscle. Described variation potentially may lead to the clinical manifestation of the median nerve compression and should be also considered during FDS surgery.

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line.

Electric isolation of the left atrial appendage (LAA) and linear ablations in the area of the LAA base are gaining popularity. However, very little is known about the myocardial architecture and the presence of epicardial blood vessels within this region, which could significantly influence the course of such procedures. We examined 200 autopsied hearts (22.5% females, 46.7 ± 16.8 years old). The LAA isthmus (i.e., the line between the LAA ostium and the mitral annulus) was cut longitudinally. The myocardium was thickest at the LAA end of the isthmus (2.4 ± 0.7 mm) followed by its middle sector (2.1 ± 0.7 mm) inside the LAA, 5 mm from its ostium (1.9 ± 0.7 mm), and the mitral annulus end of the isthmus (1.8 ± 0.6 mm) (P < 0.0001). At least one artery was found in 96.5% of all samples (89.5% were single branched, 7% had two branches). The great cardiac vein was found in 77.0% and the left marginal vein in 2.5%. The artery was interposed between the endocardium and the great cardiac vein in 31.5% of cases. The smallest distance between the endocardium and the artery was 0.5 mm and between the endocardium and the vein was 0.7 mm. In total, we were able to distinguish fifteen different types of vascular arrangements within the LAA isthmus line in this study. The myocardium within the LAA isthmus is thickest at its LAA end. The left circumflex coronary artery branches are the most frequently-occurring vessels within the isthmus and are present in almost all cases, while the great cardiac vein is present in three quarters of hearts. Clin. Anat. 31:1024-1030, 2018. © 2018 Wiley Periodicals, Inc.

The influence of fixation on the cardiac tissue in a 1-year observation of swine hearts.

AIM: The aim of this study was to investigate the influence of formaldehyde-based fixation on dimension, weight and shape of cardiac tissue during a 1-year observation. MATERIALS AND METHODS: Seven measuring sites were permanently marked in 40 swine hearts prior to fixation. Four study groups (n = 10 each) were assembled that differed only in concentration and the type of fixative. The fixatives were 2%, 4% or 10% formaldehyde phosphate-buffered solution (FPBS) and alcoholic formalin. The samples were measured before fixation and then after fixation at 1 week, 3, 6 and 12 months. RESULTS: At the 3-month point, the 10% FPBS had caused significant changes in the smallest number of parameters, while the 2% FPBS affected the greatest number of dimensions. The most significant changes included chordae tendineae shrinkage and an increase in muscle thickness. After 6 months, the most significant changes were observed in 2% and 4% FPBSs and were also mainly associated with an increase in muscle thickness and chordae tendineae shrinkage. 1-year preservation compared to the baseline showed the most significant changes in muscle tissue thickness and hearth weight. The artery diameter decreased in long-term fixation in every tested solution. For atrial and angle measurements, 4% FPBS caused most significant changes among investigated fixatives. CONCLUSIONS: In all tested solutions, long-term fixation significantly changed cardiac tissue dimension compared to the nonpreserved samples. Short-term to 1-year fixation changes are smaller, but they should not be neglected. Different fixatives should be used depending on the character of the planned measurements.

Cardiac computed tomography compared with two-dimensional transesophageal echocardiography for the detection and assessment of atrial septal pouches.

The aim of this study is to compare the two-dimensional transesophageal echocardiography (2D-TEE) with multi-slice computed tomography (MSCT) and with autopsied material to evaluate the ability and precision of the imaging methods for the detection and assessment of septal pouch (SP). One hundred and fifty patients that underwent both 2D-TEE and MSCT and 50 autopsied human hearts were investigated. In MSCT, the interatrial septum was classified as a left SP in 37.3%, right SP in 3.3%, and patent foramen ovale (PFO) channel in 3.3%. In 2D-TEE, the interatrial septum was classified as a left SP in 39.3%, right SP in 11.3%, double SP in 4.7%, and PFO channel in 2.0%. The weighted kappa coefficient between MSCT and 2D-TEE in assessing the septum morphology was 0.59. The prevalence of the left SP is lower when it is evaluated by MSCT or 2D-TEE than by anatomical study, but this difference is insignificant (37.3% vs. 44.0%, p = 0.40, and 39.3% vs. 44.0%, p = 0.56, respectively). The prevalence of left SPs is lower when detected by MSCT or 2D-TEE than during autopsy, but the difference is statistically insignificant (37.3% vs. 44.0%, p = 0.40, and 39.3% vs. 44.0%, p = 0.56, respectively). Both 2D-TEE and MSCT are comparable techniques for detecting left-sided SPs with the insignificant lower prevalence of detecting left-sided SPs compared to autopsied material. However, TEE with the contrast seems to be superior over MSCT due to the possibility of unambiguous PFO channel detection. Therefore, TEE with contrast should be preferred over MSCT in the identification of left-sided SPs.

Mid-esophageal bicaval versus short-axis view of interatrial septum in two-dimensional transesophageal echocardiography for diagnosis and measurement of atrial septal pouches.

BACKGROUND: Recent studies suggest that the left-sided septal pouch (SP) may increase the risk of cryptogenic stroke and act as an arrhythmogenic substrate. The aim of this study was to compare two transesophageal echocardiography (TEE) projections of the interventricular septum: mid-esophageal bicaval and short-axis views toward evaluating their ability to detect SPs. MATERIALS AND METHODS: A total of 146 patients with both bicaval and short-axis TEE views were included in this study. The presence of SPs was determined, and they were evaluated for morphology. RESULTS: Irrespective of TEE projection view, the left SP was detected in 74 cases (50.7%), right SP in 16 cases (11.0%), and double in one case (0.7%). Agreement between both projections occurred in 119 cases (81.5%) with a weighted kappa coefficient of 0.68 (good agreement). We detected more left SPs from the bicaval view compared to the short-axis view; however, the observed difference was statistically insignificant (72 vs 59, P = .13). The detection of right SPs was higher in the short-axis view, but also statistically insignificant (9 vs 13, P = .38). Bland-Altman analysis revealed a significant difference in the left SP depth with higher values in the bicaval than short-axis view (systematic difference = 1.17 mm, LoA: -4.88-7.22 mm, P = .02, ICC = 0.58). CONCLUSIONS: The mid-esophageal bicaval view should be preferable over mid-esophageal short-axis view of interatrial septum for the diagnosis and measurement of the left SP.

Left-Sided Atrial Septal Pouch is a Risk Factor for Cryptogenic Stroke.

BACKGROUND: The atrial septal pouch is an anatomic variant of the interatrial septum. The morphology of the left-sided septal pouch (LSSP) may favor blood stasis and predispose to thromboembolic events. The aim of this study was to determine the association between LSSP presence and cryptogenic stroke. METHODS: A total of 126 consecutive patients with cryptogenic stroke and 137 age-matched control patients without stroke were analyzed retrospectively. The presence and dimensions of LSSPs were assessed using transesophageal echocardiography. RESULTS: LSSP was present in 55.6% of patients with cryptogenic stroke and in 40.9% of those without stroke (P = .02). In univariate analysis, patients with LSSP were more likely to have cryptogenic stroke (odds ratio, 1.81; 95% CI, 1.11-2.95; P = .02). After adjusting for other risk factors using multiple logistic regression, the presence of an LSSP was found to be associated with an increased risk for cryptogenic stroke (odds ratio, 2.02; 95% CI, 1.19-3.41; P = .01). There were no statistically significant differences in size of the LSSP between patients with and those without stroke (P > .05). CONCLUSIONS: There is an association between the presence of an LSSP and an increased risk for cryptogenic stroke. More attention should be paid to clinical evaluations of LSSPs.

Comparative iTRAQ analysis of protein abundance in the human sinoatrial node and working cardiomyocytes.

Our objective was to assess the changes in protein abundance in the human sinoatrial node (SAN) compared with working cardiomyocytes to identify SAN-specific protein signatures. Four pairs of samples (the SAN and working cardiomyocytes) were obtained postmortem from four human donors with no evidence of cardiovascular disease. We performed protein identification and quantitation using two-dimensional chromatography-tandem mass spectrometry with isobaric peptide labeling (iTRAQ). We identified 451 different proteins expressed in both the SAN and working cardiomyocytes, 166 of which were differentially regulated (110 were upregulated in the SAN and 56 in the working cardiomyocytes). We identified sarcomere structural proteins in both tissues, although they were differently distributed among the tested samples. For example, myosin light chain 4, myosin regulatory light chain 2-atrial isoform, and tropomyosin alpha-3 chain levels were twofold higher in the SAN than in working cardiomyocytes, and myosin light chain 3 and myosin regulatory light chain 2-ventricular/cardiac muscle isoform levels were twofold higher in the ventricle tissue than in SAN. We identified many mitochondrial oxidative phosphorylation, ß-oxidation, and tricarboxylic acid cycle proteins that were predominantly associated with working cardiomyocytes tissue. We detected upregulation of the fatty acid omega activation pathway proteins in the SAN samples. Some proteins specific for smooth muscle tissue were highly upregulated in the SAN (e.g. transgelin), which indicates that the SAN tissue might act as the bridge between the working myocardium and the smooth muscle. Our results show possible implementation of proteomic strategies to identify in-depth functional differences between various heart sub-structures.

Porcine heart interatrial septum anatomy.

BACKGROUND: The left-sided atrial septal pouch (SP), a recently re-discovered anatomical structure within the human interatrial septum, has emerged as a possible source of thrombi formation and a trigger for atrial fibrillation, thereby potentially increasing the risk for ischemic stroke. In many studies, the swine interatrial septum has been used as model of the human heart. Also, possible new strategies and devices for management of the SPs may first be tested in this pig model. Therefore, in this study, we aimed to evaluate swine interatrial septum morphology and to compare it with the human analog, especially in the light of SP occurrence. METHODS: A total of 75 swine (Sus scrofa f. domestica) hearts were examined. The interatrial septum morphology was assessed, and SPs were measured. RESULTS: The most common variant of the interatrial septum was smooth septum (26.6%) followed by the patent foramen ovale channel and right SP (both 22.7%). No left or double SPs were observed. In 28.0% of all cases the fold of tissue (left septal ridge) was observed on the left side of the interatrial septum in the location where the left-sided SP should be expected. The mean length of the patent foramen ovale channel was 7.1±1.5mm. The mean right SP depth was 6.3±2.2mm, and its ostium width and height were 5.8±1.2 and 5.3±1.6mm, respectively. CONCLUSIONS: There are significant differences between human and porcine interatrial septum morphology that should be taken into account during experimental studies. The absence of the left SP in swine results in the inability to use porcine heart as an experimental model for left-sided SP management.

Anatomy of the mitral subvalvular apparatus.

OBJECTIVES: To characterize morphologic variations in the papillary muscles and tendinous cords of the left ventricle and ventricular zones of the mitral valve leaflets. METHODS: A total of 100 autopsied human hearts from healthy donors with classical mitral valve type were investigated. RESULTS: In 1 heart, only 1 group of papillary muscles was found, and in the remaining 99%, we could distinguish 2 groups of muscles: Superolateral (SLPM) and inferoseptal papillary muscle (ISPM) groups. The SLPM group had 1 papillary muscle (75.8%), 2 in 20.2%, and >3 in 4.0%. In the ISPM group, the muscle percentages were 38.4%, 36.4%, and 25.2%, respectively. The apex of at least 1 papillary muscle was situated higher than the plane of the opened anterior leaflet (AML) in 47.5% and 50.5% for the SLPM and ISPM groups, respectively. The number of strut cords arising from the SLPM group was 0 (2.0%), 1 (50.5%), 2 (33.3%), 3 (12.1%), and 4 (2.0%), and from the ISPM group was 0 (6.1%), 1 (52.5%), 2 (35.4%), or 3 (6.1%). Cords to left ventricular outflow tract were present in 14 specimens. Muscular cords were found in eight hearts. In all hearts specimens AML had rough and clear zones. The classical zones (rough, clear, and basal) in the posterior mitral leaflet were observed in 38.4%. CONCLUSIONS: There is a high variability in the papillary muscles and tendinous cords in the mitral valve complex. Proper nomenclature, simple classification, and the most common variants for papillary muscle groups and tendinous cords were presented.

Spatial relationship of blood vessels within the mitral isthmus line.

Aims: The aim of this study was to assess the spatial relationship of blood vessels and the thickness of the atrial wall within the mitral isthmus line. Methods and results: A total of 200 randomly selected autopsied adult human hearts (Caucasian) were examined. The mitral isthmus line was cut longitudinally and the thickness of the left atrial wall was measured. The blood vessels within the isthmus were identified and their relationship with the endocardial surface (ES), mitral annulus (MA), and the left inferior pulmonary vein (LIPV) ostium was assessed. The mean myocardial thickness in the upper, middle, and lower 1/3 of the mitral isthmus section were 1.9 ± 1.0, 3.0 ± 1.5, and 2.7 ± 1.3 mm, respectively. The great cardiac vein (GCV) was present within the isthmus in 98.0%, the left circumflex artery (LCx) in 57.0%, and the Marshall vein in 35.0% of all hearts. The GCV was located 4.5 ± 2.2 mm from the ES, 7.3 ± 5.3 mm from the MA, and 24.3 ± 7.3 mm from the LIPV. The LCx was situated 3.8 ± 2.3 mm from the ES, 7.9 ± 5.1 mm from the MA, and 25.3 ± 8.0 mm from the LIPV. We were able to detect eight different patterns of GCV and LCx mutual arrangement within the mitral isthmus line. Conclusion: The myocardium is the thinnest in the upper 1/3 sector, and the blood vessels are mainly located in the middle and lower 1/3. In 49.1%, the LCx is situated at a distance of less than 3 mm from the ES. In 55.3%, the LCx is located between the GCV and ES of the left atrium.

Morphologic variability of the mitral valve leaflets.

OBJECTIVES: The rapid development of surgical and less-invasive percutaneous mitral valve repair procedures has increased interest in mitral valve anatomy. We characterize the morphologic variability of the mitral valve leaflets and provide the size of their particular parts. METHODS: We studied 200 autopsied human hearts from white individuals without any valvar diseases. We measured the intercommissural and aorto-mural diameters of the mitral annulus and identified the leaflets and their scallops. We also noted the base and the height of the inferoseptal commissure, superolateral commissure, anterior mitral leaflet, and posterior mitral leaflet with their scallops. RESULTS: Variations in posterior mitral leaflet were found in 55 specimens (27.5%), and variations in anterior mitral leaflet were found in 5 hearts (2.5%). The most common variations included valves with 1 accessory scallop between P3 and inferoseptal commissure (7%), accessory scallop between P1 and superolateral commissure (4%), connections of P2 and P3 scallops (4%), connections of P1 and P2 scallops (3%), and accessory scallop in anterior mitral leaflet (2.5%). CONCLUSIONS: In all cases, the mitral valve is built by 2 main leaflets with possible variants in scallops (29.5%). The variations are largely associated with posterior mitral leaflet and are mostly related to the presence of accessory scallop. Anatomically, the anterior mitral leaflet is not divided into scallops, but could have an accessory scallop (2.5%). Understanding the anatomy of the mitral valve leaflets helps with the planning and performing of mitral valve repair procedures. Variations in scallops may affect repair procedures, but unfortunately cannot be predicted by any of the annular sizes.

Persistent left superior vena cava.

Persistent left superior vena cava (PLSVC) is the most common congenital malformation of thoracic venous return and is present in 0.3 to 0.5% of individuals in the general population. This heart specimen was dissected from a 35-year-old male cadaver whose cause of death was determined as non-cardiac. The heart was examined and we found a PLSVC draining into the coronary sinus. The right superior vena cava was present with a small-diameter ostium. An anomalous pulmonary vein pattern was observed; there was a common trunk to the left superior and left inferior pulmonary veins (diameter 17.8 mm) and an additional middle right pulmonary vein (diameter 2.7 mm) with two classic right pulmonary veins. The PLSVC draining into the coronary sinus had led to its enlargement, which could have altered the cardiac haemodynamics by significantly reducing the size of the left atrium and impeding its outflow via the mitral valve.

Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents.

BACKGROUND: The aim of this study is to provide a morphometric description of the left-sided septal pouch (LSSP), left atrial accessory appendages, and diverticula using cardiac multi-slice computed tomography (MSCT) and to compare results between patient subgroups. METHODS: Two hundred and ninety four patients (42.9% females) with a mean of 69.4±13.1years of age were investigated using MSCT. The presence of the LSSP, left atrial accessory appendages, and diverticula was evaluated. Multiple logistic regression analysis was performed to check whether the presence of additional left atrial structures is associated with increased risk of atrial fibrillation and cerebrovascular accidents. RESULTS: At least one additional left atrial structure was present in 51.7% of patients. A single LSSP, left atrial diverticulum, and accessory appendage were present in 35.7%, 16.0%, and 4.1% of patients, respectively. After adjusting for other risk factors via multiple logistic regression, patients with LSSP are more likely to have atrial fibrillation (OR=2.00, 95% CI=1.14-3.48, p=0.01). The presence of a LSSP was found to be associated with an increased risk of transient ischemic attack using multiple logistic regression analysis after adjustment for other risk factors (OR=3.88, 95% CI=1.10-13.69, p=0.03). CONCLUSIONS: In conclusion LSSPs, accessory appendages, and diverticula are highly prevalent anatomic structures within the left atrium, which could be easily identified by MSCT. The presence of LSSP is associated with increased risk for atrial fibrillation and transient ischemic attack.

Residua of thymus in the mediastinum - clinical aspects - cadaveric study.

The main goal of this study was to investigate possible residua of thymic tissue in 100 adult cadavers with no thoracic pathology known before, by dissection of standard locations of thymic tissue in perithyroid, periaortic, peritracheal and retrotracheal spaces, as well as areas located next to the course of phrenic, vagus and left recurrent laryngeal nerves. Thus obtained tissue samples were studied by two pathologists independently. The remnants of the thymic tissue were found in 61 out of 100 specimens studied. It means that residua of ectopic thymic tissue is common, which may have a huge impact on the results of treatment of many diseases i.e. myasthenia gravis in course of thymoma.