[Minimally invasive and O-arm assisted en bloc spinal tumor resections]. / Minimálisan invazív és O-arm asszisztált en bloc gerincdaganat-reszekciók.

BACKGROUND AND PURPOSE: The en bloc resection of spinal tumors is required in primary spine tumors and in selected cases of secondary spine tumors, where the primary disease is under control and long survival time is expected. Three cases are presented, applying O-arm assisted navigation or minimally invasive anterior approaches for en bloc tumor removal. METHODS: O-arm navigation assisted osteotomies were carried out to remove a Th.V. breast tumor metastasis en bloc, intact bony part of the Th.V. vertebra was spared. Vertebral corpectomies of a patient with L.IV. chordoma and of a patient with L.V. carcinoid were also performed using minimally invasive, microscope assisted, anterior approaches to the lumbar spine. RESULTS: No morbidity or local recurrence were detected in the patient with breast cancer 1 year after the operation. Nevertheless, new spinal metastasis were revealed 1 year after surgery despite the appropriate oncological treatment. The patient with L.IV. chordoma is still tumor free (last follow-up: 18 month after surgery), but post operatively detected lower limb paresis and gait disturbances are persisted. The posterior healthy bony parts of the spinal column remained intact, since only anterior approaches were used for en bloc L.IV. corpectomy. No morbidity or recurrence was detected in patient with L.V. carcinoid tumor on 1 year follow-up. CONCLUSION: Both the O-arm navigation assisted surgery and the minimally invasive anterior approaches to the spine can help to reduce surgical morbidity and to spare healthy bony structures of the spine. The later could play important role to provide long term spine stability. The presented new surgical technologies can be accepted only, if they produce at least the same oncological results on longer follow-ups as conventional surgical approaches.

[Treatment of osteomyelitis in diabetes mellitus. Case report]. / Diabetes mellitus talaján kialakult osteomyelitis kezelése.

The authors summarize the medical history of a patient with impaired healing of a wound in the sole of foot. The 63-year-old male patient had a second-degree burn in the sole of the left foot as he stepped on the hot concrete after taking off his slipper. On admission to our department, local wound management had already been started, his wound showed no healing tendency. Bilateral X-ray was performed of his left leg, osteomyelitis was not confirmed, soft tissue drainage was applied, and bacterial culture from the wound confirmed methicillin-resistant Staphylococcus aureus infection. After soaking the leg in water, phlegmon developed on the dorsal part of the foot and the patient had septic fever. X-ray was repeated, and osteomyelitis was confirmed. Enucleation of the hallux of the left foot and metatarsal resection were performed. Wound dressing was exchanged and wound toilette was applied daily, insulin therapy was modified after consultation with a diabetologist. 7 months after the surgery, the wound was completely healed, carbohydrate metabolism of the patient was controlled. Our case draws attention to the importance of informing the patients of potential complications - in this case of the diabetic foot and its proper care. Treatment of ulcer of the lower leg requires multidisciplinary care, which means that the diabetologist and the surgeon has to cooperate in the care of these patients, carbohydrate metabolism should be balanced and regular wound care is necessary. Orv Hetil. 2018; 159(42): 1727-1730.

[Minimally invasive, extrapleural-anterolateral approach to the spine]. / Minimálisan invazív, extrapleuralis, anterolateralis gerincfeltárás.

In spine surgery, minimally invasive approaches (MIS) are getting accepted and more popular worldwide during the last decades. It is due to the reduced intraoperative blood loss, decreased infection rate, less postoperative pain and earlier discharge from hospital compared to traditional approaches. The present paper puts forward a minimally invasive extrapleural approach to the thoracic spine that is not applied in Hungary. This new approach, in contrast to the standard costotransversectomy, provides direct visual control over the ventral surface of the dural sac. Furthermore, contrary to the transthoracic way, following minimally invasive extrapleural surgery thoracic drainage and intensive care are not necessary. The approach can be applied safely in treatment of ventral or ventrolateral pathologies of the thoracic spine.

Estimation of the severity of breathlessness in the emergency department: a dyspnea score.

BACKGROUND: Dyspnea is a frequent complaint in emergency departments (ED). It has a significant amount of subjective and affective components, therefore the dyspnea scores, based on the patients' rating, can be ambiguous. Our purpose was to develop and validate a simple scoring system to evaluate the severity of dyspnea in emergency care, based on objectively measured parameters. METHODS: We performed a double center, prospective, observational study including 350 patients who were admitted in EDs with dyspnea. We evaluated the patients' subjective feeling about dyspnea and applied our Dyspnea Severity Score (DSS), rating the dyspnea in 7 Dimensions from 0 to 3 points. The DSS was validated using the deterioration of pH, base-excess and lactate levels in the blood gas samples (Objective Classification Scale (OCS) 9 points and 13 points groups). RESULTS: All of the Dimensions correlated closely with the OCS values and with the subjective feeling of the dyspnea. Using multiple linear regression analysis we were able to decrease the numbers of Dimensions from seven to four without causing a significant change in the determination coefficient in any OCS groups. This reduced DSS values (exercise tolerance, cooperation, cyanosis, SpO2 value) showed high sensitivity and specificity to predict the values of OCS groups (the ranges: AUC 0.77-0.99, sensitivity 65-100%, specificity 64-99%). There was a close correlation between the subjective dyspnea scores and the OCS point values (p < 0.001), though the scatter was very large. CONCLUSIONS: A new DSS was validated which score is suitable to compare the severity of dyspnea among different patients and different illnesses. The simplified version of the score (its value ≥7 points without correction factors) can be useful at the triage or in pre-hospital care.

[Changes in carbohydrate metabolism after kidney transplantation and their effects on cardiovascular risk]. / Vesetranszplantáció utáni szénhidrátanyagcsere-változások és annak hatásai a cardiovascularis rizikóra.

INTRODUCTION: Cardiovascular disease is the major cause of deaths after transplantation, with diabetes mellitus being the main risk factor in development. AIM: The aim of our study was to assess the prevalence of new onset diabetes mellitus in connection with the cardiovascular risk predicted by the HEART Score. METHOD: 44 patients were involved in our study; after overview of baseline data, OGTT was performed, followed by patient classification into the following groups: normal, impaired fasting glucose/impaired glucose tolerance, and new onset diabetes mellitus. Insulin resistance and kidney function were also assessed. RESULTS: Concerning baseline data, cold ischemic time (p = 0.016), body weight (p = 0.035), BMI (p = 0.025), and HbA1C (p = 0.0024) proved to be significantly different between normal and diabetic patients. Significant difference was found based on HOMA IR between the two groups 1.69±0.51 vs 6.46±1.42; p = 0.0017). Based on the HEART Score, patients with new onset diabetes mellitus were put into Group 3, which also reflects the risk which diabetes carries for the development of cardiovascular diseases. CONCLUSION: Cardiovascular risk can be decreased with increased allograft survival by early diagnosis and management of diabetes. Orv Hetil. 2017; 158(38): 1512-1516.

[Banff score changes in kidneys from marginal donors]. / Banff-score-változások a marginális donorokból származó veséknél.

INTRODUCTION: Despite an increase in the number of cadaver donors and the number of overall organ transplantations, the dramatic increase in the waiting list makes it necessary to reconsider donor criteria. AIM: The authors examined whether differences could exist in the function and/or morphology of transplanted kidneys originated from marginal and ideal donors one and five years after transplantation. METHOD: Kidney function and histopathologic findings were analysed and compared one and 5 years after transplantation in 97 patients having marginal donor kidneys and 178 patients who received ideal donor kidneys. RESULTS: Serum creatinine level was significantly higher (p = 0.0001) and estimated glomerular filtration rate was significantly lower (p = 0.003) in patients having marginal donor kidneys as compared to those with ideal donor kidneys 5 years after transplantation. Morphological changes in the transplanted kidneys such as tubulitis (p = 0.014) and interstitial inflammation (p = 0.025) were significantly more frequently present in patients with marginal donor kidneys than in those with ideal donor kidneys one year after transplantation. CONCLUSION: Despite an absence of differences in kidney function one year after kidney transplantation between patients having marginal and ideal donor kidneys, morphologic differences in the transplanted kidneys can be detected between the two groups of patients.

[Frequency of T-cell mediated rejection in new-onset diabetes after kidney transplantation]. / T-sejt-mediált rejectio gyakorisága vesetranszplantáció után, újonnan kialakult diabetes mellitusban.

INTRODUCTION: New-onset diabetes is one of the most common complications after kidney transplantation. AIM: The aims of the authors were to examine the frequency of new-onset diabetes mellitus in kidney transplanted patients receiving cyclosporine A (n = 95) and tacrolimus (n = 102) and to analyze the occurrence of T-cell mediated rejection in these two groups of patients. METHOD: Age, laboratory results, renal function and histological findings were evaluated one year after kidney transplantation. Histological evaluation was performed according to the 2007 modification of the Banff 1997 classification. RESULTS: New-onset diabetes developed in 12% of patients receiving cyclosporine A-based immunosuppression and in 24% of patients taking tacrolimus (p = 0.002). Uric acid level (p = 0.002) and the age of the recipient (p = 0.003) were significantly different in the new-onset diabetic and non-diabetic groups, while renal function showed no significant difference. Evaluation of tissue samples revealed a significant difference in T-cell mediated rejection between the new-onset diabetic and non-diabetic groups (13 vs. 8 patients; 37% vs. 6%; p = 0.001). CONCLUSIONS: The results indicate an early development of the pathological effect of new-onset diabetes after kidney transplantation on the morphology of the renal allograft.

Validation of artificial intelligence application for dental caries diagnosis on intraoral bitewing and periapical radiographs.

OBJECTIVES: This study aimed to assess the reliability of AI-based system that assists the healthcare processes in the diagnosis of caries on intraoral radiographs. METHODS: The proximal surfaces of the 323 selected teeth on the intraoral radiographs were evaluated by two independent observers using an AI-based (Diagnocat) system. The presence or absence of carious lesions was recorded during Phase 1. After 4 months, the AI-aided human observers evaluated the same radiographs (Phase 2), and the advanced convolutional neural network (CNN) reassessed the radiographic data (Phase 3). Subsequently, data reflecting human disagreements were excluded (Phase 4). For each phase, the Cohen and Fleiss kappa values, as well as the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of Diagnocat, were calculated. RESULTS: During the four phases, the range of Cohen kappa values between the human observers and Diagnocat were κ=0.66-1, κ=0.58-0.7, and κ=0.49-0.7. The Fleiss kappa values were κ=0.57-0.8. The sensitivity, specificity and diagnostic accuracy values ranged between 0.51-0.76, 0.88-0.97 and 0.76-0.86, respectively. CONCLUSIONS: The Diagnocat CNN supports the evaluation of intraoral radiographs for caries diagnosis, as determined by consensus between human and AI system observers. CLINICAL SIGNIFICANCE: Our study may aid in the understanding of deep learning-based systems developed for dental imaging modalities for dentists and contribute to expanding the body of results in the field of AI-supported dental radiology..

Percutaneous Spine Fusion Combined with Whole-Body Traction in the Acute Surgical Treatment of AO A- and C-Type Fractures: A Technical Note.

BACKGROUND: A diminished level of pain following the operation and shortened hospitalization are the distinct advantages of minimally invasive spine surgery (MISS). However, manipulating the spine with additional MISS tools (e.g., distraction and compression devices) is often cumbersome. Our paper draws attention to a cost-free, fast, indirect decompression method that can be used in the acute treatment of thoracolumbar spine fractures. The presented method involves ligamentotaxis by whole-body traction in the operating room combined with percutaneous spine fixation. METHODS: Fifteen patients with thoracolumbar injuries A type and C type (without distraction) by AO classification were operated sequentially with the combination of whole-body traction and percutaneous minimally invasive spine fixation. Data were analyzed retrospectively. RESULTS: A total of 139 screws were implanted into 70 segments in 6 female and 9 male patients. The average clinical follow-up was 16 months. Average preoperative traumatic kyphosis was 17 degrees, and an average postoperative kyphosis was 1.8 degrees. The fractured vertebrae's height gain was an average of 11.0 mm (range 3.9-21.9 mm) ventrally and an average of 5.4 mm (range 1-11.2 mm) dorsally after the surgeries. The spinal canal space narrowing showed an average 6.5 mm improvement postoperatively. Operative time averaged 2 hours and 34 minutes, and blood loss averaged 250 mL (range 150-400 mL). No neurologic complications and wound healing problems were observed. CONCLUSIONS: The combination of MISS and whole-body traction provided successful anatomical correction in thirteen of the fifteen cases of compression type thoracolumbar fractures without extensive surgical exploration.

Cerebral Microbleeds May Be Less Detectable by Susceptibility Weighted Imaging MRI From 24 to 72 Hours After Traumatic Brain Injury.

Purpose: A former rodent study showed that cerebral traumatic microbleeds (TMBs) may temporarily become invisible shortly after injury when detected by susceptibility weighted imaging (SWI). The present study aims to validate this phenomenon in human SWI. Methods: In this retrospective study, 46 traumatic brain injury (TBI) patients in various forms of severity were included and willingly complied with our strict selection criteria. Clinical parameters potentially affecting TMB count, Rotterdam and Marshall CT score, Mayo Clinic Classification, contusion number, and total volume were registered. The precise time between trauma and MRI [5 h 19 min to 141 h 54 min, including SWI and fluid-attenuated inversion recovery (FLAIR)] was individually recorded; TMB and FLAIR lesion counts were assessed. Four groups were created based on elapsed time between the trauma and MRI: 0-24, 24-48, 48-72, and >72 h. Kruskal-Wallis, ANOVA, Chi-square, and Fisher's exact tests were used to reveal differences among the groups within clinical and imaging parameters; statistical power was calculated retrospectively for each comparison. Results: The Kruskal-Wallis ANOVA with Conover post hoc analysis showed significant (p = 0.01; 1-ß > 0.9) median TMB number differences in the subacute period: 0-24 h = 4.00 (n = 11); 24-48 h = 1 (n = 14); 48-72 h = 1 (n = 11); and 72 h ≤ 7.5 (n = 10). Neither clinical parameters nor FLAIR lesions depicted significant differences among the groups. Conclusion: Our results demonstrate that TMBs on SWI MRI may temporarily become less detectable at 24-72 h following TBI.

1-D blood flow modelling in a running human body.

In this paper an attempt was made to simulate blood flow in a mobile human arterial network, specifically, in a running human subject. In order to simulate the effect of motion, a previously published immobile 1-D model was modified by including an inertial force term into the momentum equation. To calculate inertial force, gait analysis was performed at different levels of speed. Our results show that motion has a significant effect on the amplitudes of the blood pressure and flow rate but the average values are not effected significantly.

PARP inhibition protects mitochondria and reduces ROS production via PARP-1-ATF4-MKP-1-MAPK retrograde pathway.

Oxidative stress induces DNA breaks and PARP-1 activation which initiates mitochondrial reactive oxygen species (ROS) production and cell death through pathways not yet identified. Here, we show the mechanism by which PARP-1 influences these processes via PARylation of activating transcription factor-4 (ATF4) responsible for MAP kinase phosphatase-1 (MKP-1) expression and thereby regulates MAP kinases. PARP inhibitor, or silencing, of PARP induced MKP-1 expression by ATF4-dependent way, and inactivated JNK and p38 MAP kinases. Additionally, it induced ATF4 expression and binding to cAMP-response element (CRE) leading to MKP-1 expression and the inactivation of MAP kinases. In contrast, PARP-1 activation induced the PARylation of ATF4 and reduced its binding to CRE sequence in vitro. CHIP-qPCR analysis showed that PARP inhibitor increased the ATF4 occupancy at the initiation site of MKP-1. In oxidative stress, PARP inhibition reduced ROS-induced cell death, suppressed mitochondrial ROS production and protected mitochondrial membrane potential on an ATF4 and MKP-1 dependent way. Basically identical results were obtained in WRL-68, A-549 and T24/83 human cell lines indicating that the aforementioned mechanism can be universal. Here, we provide the first description of PARP-1-ATF4-MKP-1-JNK/p38 MAPK retrograde pathway, which is responsible for the regulation of mitochondrial integrity, ROS production and cell death in oxidative stress, and may represent a new mechanism of PARP in cancer therapy since cancer stem cells development is JNK-dependent.

Detecting hypovolemia in postoperative patients using a discrete Fourier transform.

In the present paper, an attempt was made to find waveform-derived variables that would be useful for a more precise diagnosis of hypovolemia. In attempting this, arterial blood pressure graphs of 18 hypovolemic postoperative patients were analysed using a discrete Fourier transform. Using a paired samples t-test, the amplitude of the first harmonic (A1) is shown to be significantly higher in normovolemic cases than in hypovolemic ones (p < 0.001). Based on the values of A1, a preliminary study was performed in which an additional group of 14 hypovolemic and 14 normovolemic patients were categorized into hypovolemic and normovolemic groups using logistic regression. The method proved to be successful in identifying hypovolemic patients: the prediction was correct in 80% and wrong only in 20%, indicating that A1 is potentially a useful parameter in detecting hypovolemia.