Correction to: Intraarticular application of autologous conditioned serum (ACS) reduces bone tunnel widening after ACL reconstructive surgery in a randomized controlled trial.

The Orthokine product used in the trial was donated by the manufacturer.

[Importance of standardized stepwise screening in patients with resistant hypertension]. / Vaznost sistemskog probira u algoritmu dijagnostike rezistentne hipertenzije.

Resistant hypertension (RH) is a condition that confers a high cardiovascular risk to the patient due to both persistent blood pressure elevation and the high prevalence of comorbidities and organ damage. Hypertension is defined as resistant (RH) to treatment when a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic and two other antihypertensive drugs belonging to different classes at adequate doses fails to lower blood pressure (BP) values to < 140 and 90 mm Hg, respectively. Prior to diagnosing a patient as having RH, it is important to document adherence and exclude white-coat hypertension, inaccurate measurement of BP, and secondary causes. Ambulatory BP monitoring (ABPM) has become an important tool in the diagnosis and follow-up of hypertensive patient, and it is even more important in the evaluation of those with resistant RH. Among patients with RH, it is very important to select patients with standardized stepwise screening: ABPM of resistant hypertensives has a circadian profile with a high proportion of nondipping. The possible reasons for the absence of dipping are sleep disturbance, obstructive sleep apnea, obesity, high salt intake in salt-sensitive subjects, orthostatic hypotension, autonomic dysfunction, chronic kidney disease, diabetic neuropathy, and old age. It seems reasonable to routinely use ABPM in the initial evaluation of all resistant hypertensive patients. In a significant number of these patients, ABPM will also be an essential tool in follow-up, especially regarding the possible effects of all therapeutic maneuvers that are devoted to bringing BP into the target ranges. The potential success of other therapeutic options such as renal denervation depends on the ability to select patients most likely to benefit.

Intraarticular application of autologous conditioned serum (ACS) reduces bone tunnel widening after ACL reconstructive surgery in a randomized controlled trial.

PURPOSE: Pro-inflammatory cytokines play a pivotal role in osteoarthritis, as well as in bone tunnel widening after ACL reconstructive surgery. A new treatment option is to administer autologous conditioned serum (ACS) containing endogenous anti-inflammatory cytokines including IL-1Ra and growth factors (IGF-1, PDGF, and TGF-ß1, among others) in the liquid blood phase. The purpose of this trial was to establish whether the postoperative outcome could be affected by intraarticular application of ACS. METHODS: In a prospective, randomized, double-blinded, placebo-controlled trial with two parallel groups, 62 patients were treated. Bone tunnel width was measured by CT scans, while clinical efficacy was assessed by patient-administered outcome instruments (WOMAC, IKDC 2000) up to 1 year following the ACL reconstruction in patients receiving either ACS (Group A) or placebo (Group B). We compared the levels and dynamics of IL-1ß concentrations in the synovial liquid and examined the correlation between the levels of IL-1ß at three different postoperative points. RESULTS: Bone tunnel enlargement was significantly less (6 months: 8%, 12 months: 13%) in Group A than in Group B (6 months: 31%, 12 months: 38%). Clinical outcomes (WOMAC, IKDC 2000) were consistently better in patients treated with ACS at all data points and for all outcome parameters, and there were statistically significant differences in the WOMAC stiffness subscale after 1 year. The decrease in IL-1ß synovial fluid concentration was more pronounced in the ACS group, and values were lower, to a statistically significant degree, in the ACS group at day 10. CONCLUSION: The intraarticular administration/injection of ACS results in decreased bone tunnel widening after ACL reconstructive surgery.

[Acute plastic bronchitis--case report]. / Akutni odljevni bronhitis--prikaz bolesnika.

Plastic bronchitis is a rare disorder characterized by formation and sometimes dramatic expectoration of bronchial casts. It may occur at any age, but most published cases refer to pediatric population. We report a case of an 81-year-old man hospitalized at intensive care unit, who presented with the appearance of plastic bronchitis type I. He had profuse expectoration of several pieces, a few cm long and up to 1 cm wide, of wormlike reddish-brownish "tissue". Histologically, it was a slimy purulent secretion with abundant fibrin and blood and with cytopathic effect of herpes virus. The pathogenesis of plastic bronchitis is not clear.

Reduced-dose rocuronium for day-case tonsillectomy in children where volatile anaesthetics are not used: operating room time saving.

OBJECTIVES: Mivacurium, rocuronium, and vecuronium are neuromuscular blocking agents (NMB) commonly used in pediatric day-case anesthesia. Mivacurium is the most appropriate NMB for short surgical procedures where NMB drugs were required but is not available in all countries. AIM: We evaluated the operating room time minimization after reduced-dose rocuronium (0.45 mg x kg(-1)) during elective day-case tonsillectomy in children. METHODS/MATERIALS: One hundred and five children (6-9 years, ASA I/II status) scheduled for day-case tonsillectomy were included in prospective, double blind clinical study. Children were randomly divided in three equal groups. All children were premedicated (midazolam 0.25 mg x kg(-1) orally, EMLA). Anesthesia was induced (2.5 mg x kg(-1)) and maintained (0.1 mg x kg(-1) x min(-2)) by propofol and alfentanil (0.0015 mg x kg(-1) x min(-1)) and supplemented by inhalation mixture of 50% of O2/Air. Neuromuscular block was achieved by vecuronium (0.1 mg x kg(-1)) (V) or rocuronium in standard (0.6 mg.kg(-1)) (R) or reduced dose (0.45 mg x kg(-1)) (LD). Neuromuscular transmission was monitored by acceleromyography. Time analysis of NMB drugs action was performed. RESULTS: Time difference from the end of tonsillectomy to T90 neuromuscular block recovery was significantly shorter in LD Group (7.3 +/- 0.41 min), (V = 15.9 +/- 1.06, R = 16.0 +/- 1.7 min) (P = 0.0011). The onset time of neuromuscular block was prolonged in LD Group (LD=3.1 +/- 0.4, R = 1.3 +/- 0.4, V = 2.2 +/- 0.2 min) (P = 0.0039) without changing the intubating conditions. The maximum operation room time saving per each tonsillectomy was 37% in LD Group (Group V 21%, Group R 17%) (P = 0.0001). Low incidence of postoperative nausea and vomiting (PONV) 3-6% (0.4577) and good visual analog scale (VAS) score (< or =2) (0.5969) were found in all study groups 12 h after surgery. CONCLUSIONS: Reduced-dose rocuronium in addition with propofol and alfentanil in children where volatile anesthetics are not used effectively saves the operating room time during short elective surgical procedures, avoids delays in patient recovery, allows high level of acceptable intubating conditions, and improves the optimal surgical work. Low incidences of PONV as VAS score may achieved successfully.

A 10-year experience in the treatment of intraabdominal cerebrospinal fluid pseudocysts.

The aim of this retrospective study was to assess a ten-year experience in the treatment of rare complications of ventriculoperitoneal shunting--intraabdominal cerebrospinal fluid pseudocysts. At this time there are no data about incidence, clinical course and treatment of these complications in Croatia. Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. Retrospective data were obtained from 5 children with abdominal CSF pseudocysts, treated between 1996 and 2007. The incidence of intraabdominal CSF pseudocysts in our study is 2.9%. All patients were girls ranged in age from 4 to 12 years old (mean 8.8 years). In most cases etiology of hydrocephalus was congenital, idiopathic. Abdominal pain and distension were the most frequent clinical finding (4/5). Although infection has been reported as responsible for pseudocyst formation, we did not found it in our series. Laparotomy with cyst wall excision and catheter replacement was performed in 2/5 cases, and only cyst fluid aspiration with catheter replacement in 3/5 cases. Recurrence of the abdominal cyst was observed in one girl who was in terminal stadium of anaplastic ependymoma. It is our opinion that only catheter replacement and cyst fluid evacuation, as one of the treatment modalities, may be successful, even in large CSF intraperitoneal pseudocysts.

Relationship between polymorphonuclear leukocyte count in bronchoalveolar lavage fluid and bacterial content in Gram's stain and bacterial content in final microbiological report.

Eighty samples of bronchoalveolar lavage fluid (BALF) were obtained from the total of 48 patients (22 females and 26 males) and analyzed. Eighteen of those patients were organ transplant recipients. The relationship between polymorphonuclear leukocyte (PMN) count in direct sample and semi quantitative Gram-positive and Gram-negative bacterial content were analyzed in BALF samples. PMN count in direct sample and Gram-positive and Gram-negative bacterial content of the final microbiological report was compared as well. On the total number of samples PMN count in direct samples of BALF was statistically significant regarding the presence of Gram-positive bacteria in the same sample; it was nearly significant regarding the presence of Gram-negative bacteria; and it was statistically significant for the total bacterial content. If BALF samples are divided into those obtained from organ-transplant and those obtained from non-organ-transplant patients, positive, statistically significant relationship is found in the organ-transplant group, more specifically for the relationship between PMNs and total bacterial content. When PMN count in direct microbiological sample was compared with the results of the final microbiological report, statistically significant relationship was found neither with respect to all BALF samples, nor after dividing them into "organ-transplant" and "non-organ-transplant" group. We did not find differences caused by gender.

Life threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy in multi-trauma patient with cervical spine injury.

Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance.

The optimal pediatric induction dose of propofol in combination with reduced-dose rocuronium and alfentanil for day-case tonsillectomy in children.

OBJECTIVE: Tonsillectomy in children may be performed on a day-case basis. To achieve quality anesthesia and successful, fast recovery with minimal morbidity without the use of volatile anesthetic, the choice of drug combination has to be centered on one rapid- and short-acting hypnotic, opioid and non-depolarizing muscle relaxant. The aim of our study was to determine the optimal pediatric induction dose of propofol that by means of alfentanil and reduced-dose rocuronium allows the highest percentage of excellent intubating conditions. METHODS: One hundred and eleven children were randomized in three equal groups and included in prospective, double blind study. Anesthesia was induced with 2.0 (Group A), 2.5 (Group B) or 3.0 mg kg(-1) (Group C) of propofol proceeded by alfentanil (0.02 mg kg(-1)). Muscle relaxation was achieved with reduced-dose rocuronium (1.5x ED(95)) (0.45 mg kg(-1)). The intubating conditions were assessed using the four-point scoring system based on the difficulty of laryngoscopy, presence of vocal cord movement and the intensity of coughing. Neuromuscular transmission was monitored by means of acceleromyography with supramaximal train-of-four stimulation of the ulnar nerve by the frequency of 1Hz. RESULTS: Adequate intubating conditions were achieved in high percentages in all study groups (A = 94%, B = 95%, C = 98%) (P = 0.352). Significant higher differences of excellent and good intubating conditions, attributed to quality of laryngoscopy, movement of the vocal cords and intensity of coughing were observed in Group C (excellent = 94%, good = 4%) (B = excellent 80%, good = 18% and A = excellent 47%, good = 47%) (P = 0.0001). MAP decrease of 12% from the baseline occurred immediately only after 3.0 mg kg(-1) induction dose of propofol (80+/-7 mm Hg; A = 92 +/- 6, B = 88 +/- 9) (P = 0.005). CONCLUSIONS: Induction dose of 2.5 mg kg(-1) of propofol preceded by 0.02 mg kg(-1) of alfentanil in addition to reduced-dose rocuronium (0.45 mg kg(-1)) is the optimal pediatric induction dose of propofol for improving the most excellent intubating conditions without significant hemodynamic changes.

Huge multinodular goiter with mid trachea obstruction: indication for fiberoptic intubation.

Goiter or thyromegaly is one of the most common causes of mid tracheal obstruction (external compression or stenosis), which may be associated with difficult larynx visualization and/or difficult airway management, depending on the goiter size, type and ingrowth into the surrounding tissue. Iodine deficiency disorders are still one of the most common causes of goiter in the population of the African continent. These patients with goiter generally present for medical examination at an advanced stage of the disease. Mallampati test, thyromental distance and inter-incisor gap appear to provide the optimal combination for prediction of difficult visualization of the larynx. Video laryngoscopy examination of the subglottic region and inspection of tracheal deviation in the presence of tracheal compression without detected stenosis of the trachea is a standard and preferred technique in comparison with direct laryngoscopy. Intubation can be performed when vocal cords are visualized. The major difficulty on intubation is encountered in only 5.3% of patients with goiter. Large goiter need not always be associated with a higher incidence of difficult endotracheal intubation. Only two predicting factors for difficult airway assessment were identified in these patients: cancerous goiter (especially if compressive signs are present) and Cormack and Lehane grade III/IV. The indication for fiberoptic intubation is tracheal compression or initial tracheal stenosis. Conventional tracheostomy has to be performed in goiter patients with identified tracheomalacia and/or high degree or tracheal stenosis.

Difficult airway management with bonfils fiberscope in case of emergency: acute abdomen with ileus.

This clinical report describes an emergency case of a 49-year-old man, ASA E III status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of difficult intubation (Mallampati test Class III, short thyro-mental (< 6 cm) and sterno-mental distance (<10 cm) with limited mouth opening (inter-incisor gap < 3 cm) were associated with significant comorbidity (rheumatoid arthritis, heart disease, obesity (body mass index 32.6 kg m-2), cervical spine mobility and generalized vascular disease). A specialist experienced in airway management decided on one attempt of Bonfils fiberoptic intubation as primary intervention and urgent tracheotomy, if needed, as secondary intervention. Immediately after assuming supine position on the operating table, the patient lost consciousness and cardiac arrest developed. Successful intubation with oxygenation was followed by cardiopulmonary resuscitation. Upon stabilization of the patient's vital functions, urgent surgery was performed. In the emergency case presented, we succeeded quickly to secure the airway with Bonfils fiberoptic intubation, which allowed for appropriate oxygenation and starting resuscitation. The high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands.

Reversal of thrombocytopenia and bleeding tendency in a preterm neonate with recombinant activated factor VII: case report.

A male neonate, born at 26 weeks of postmenstrual age, with intracranial hemorrhage grade IV and thoracic drainage for artificial tension pneumothorax on day 6 of his life is presented. Despite prior transfusions, the preprocedural hemogram showed marked anemia and thrombocytopenia. To reverse thrombocytopenia and to avoid volume overload, the patient was administered 110 microg kg(-1) of recombinant activated factor VII (rFVIIa) and drainage of the pneumothorax was performed uneventfully.