Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system. AIM: The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF. METHODS: All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed. RESULTS: Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%. CONCLUSION: Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.

Lumbar spondyloptosis after severe polytrauma: a case report.

A rare case of thoracolumbar spondyloptosis after a severe polytraumatic event is presented. Spondyloptosis accounts for a minor proportion of all spine trauma cases and is usually accompanied by complete neurological deficit. A 48-year-old man suffered severe polytrauma after having been hit by a truck at the work place. Radiographic scanning revealed multiple traumatic injuries and spondyloptosis at the L1/L2 level in coronal plane. However, despite extensive injuries, ASIA score was estimated as D. The patient underwent urgent multidisciplinary surgery due to severe head injuries. The next surgery was performed to stabilize the thoracolumbar segment and to preserve neurological functions. The surgery included implantation of transpedicular titanium screws via posterior approach. Good postoperative recovery was achieved during early postoperative rehabilitation at our Department, which was estimated as ASIA score D. In conclusion, prompt operative treatment to achieve neural integrity and early rehabilitation should be considered as the gold standard in such complicated injuries. Postoperative recovery largely depends on the quality of rehabilitation, which leads to improvement of patient self-care and normal social and psychological functions. In our case, the good preoperative neurological status of the patient also contributed to better postoperative outcome.

The quality of life of Croatian women after mastectomy: a cross-sectional single-center study.

BACKGROUND: Measuring the quality of life (QoL) of women with breast cancer is an important aspect of measuring treatment success. In Croatia, no QoL studies have been carried out with a focus on patients after mastectomy. The aim of this study was to examine QoL 1 month and 1 year after mastectomy. METHODS: This cross-sectional single-center study of quality of life was conducted in 101 patients, 50 of whom had undergone a mastectomy 1 month prior, and 51 of whom had undergone a mastectomy 1 year prior. The study was conducted from July 2015 to June 2016. The questionnaires used in the study were developed by the European Organisation for Research and Treatment of Cancer (EORTC). The questionnaire EORTC QLQ-C30 assesses the QoL of cancer patients, and the questionnaire EORTC QLQ-BR23 is a disease-specific breast cancer module. A chi square test, Fisher's exact test, Kolmogorov-Smirnov test, Student's t-test and Mann-Whitney U test were performed in the statistical analysis using the statistical program SPSS (Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.). RESULTS: Patients who had undergone a mastectomy a year earlier placed a higher value on their health state than did those who had undergone a mastectomy a month earlier. The most affected values of functional status on the EORTC QLQ-C30 scale were emotional functioning (37.5 [95% CI 33.3-61.6]) and sexual functioning (16.67 [95% CI 0-33.3]) 1 month and 1 year after mastectomy, respectively. The most affected symptoms on the EORTC QLQ-C30 scale were hair loss 66.67 [95% CI 33.3-100]) and fatigue 33.33 [95% CI 24-44]) 1 month and 1 year after mastectomy, respectively. CONCLUSION: In our study, both functional and symptom scales were more affected in women 1 month after mastectomy. QoL was considerably improved in women 1 year after the surgery compared to 1 month after mastectomy. The results of this study could contribute to the public awareness of the QoL of breast cancer patients.

POSTERIOR PENETRATING INJURY OF THE NECK: A CASE REPORT.

- A 45-year-old male patient was admitted to the emergency unit due to posterior stab wound of the neck. The knife was directed diagonally from the left to the right side of the neck in the dorsoventral axis. The patient was fully conscious upon admission with pain and paresthesia along the upper right extremity. The patient underwent computed tomography (CT) and CT angiography scan of the neck, which revealed the knife blade piercing the left sided neck muscles and through the intervertebral ligaments of the C IV/C V in direction to the contralateral internal carotid artery, vertebral artery and the C5 nerve root. The patient underwent an urgent surgery according to the radiographs. Electromyography was performed during the early postoperative care and revealed an acute lesion of the right-sided C5 nerve root. Postoperative follow-up magnetic resonance imaging revealed intact brachial plexus bundles at the site of injury. Symptoms of reduced muscle strength and limited range of motion of the upper right extremity prevailed. Penetrating neck injuries represent a rare entity of all trauma injuries. Meticulous preoperative radiographs revealed close proximity of the knife blade tip to the right-sided vertebral artery and common carotid artery. Limited abduction at the right shoulder during postoperative period correlated to the C5 nerve root injury.

Prognostic factors of local recurrence and survival after curative rectal cancer surgery: a single institution experience.

The aim of our study is to evaluate the importance of prognostic factors, both tumor-related and therapy related, and their impact on local recurrence rate of rectal carcinoma. It is also important to evaluate impact of chemoradiotherapy (CRT) on local recurrence rate and survival. We used the data of 514 patients with rectal carcinoma treated at Clinic of surgery at University Hospital Centre in Osijek, during the period from 2000 to 2007. Routine follow-up was carried out until March of 2012 or death. Median life expectancy for all patients who underwent surgery was 98 months. 47% of patients with resection without residual tumor (R0) did not develop local recurrence after median of observation of 90 months. 5-year survival rate for patients with R0 resection was 76.4%. The patients who had preoperative serum levels of carcinoembryonic antigen (CEA) within the normal range (< 5 microg/mL) had a significantly better prognosis with 5-year survival of 75.8%, than patients with elevated levels who had 5-year survival of 46.5%. Tumor stage had great influence on survival and was defined by UICC TNM (International Union against Cancer, Tumor Node Metastases) classification, 7th edition. 5-year survival rate was (93.5% for stage I, 87.4% for stage II, 58.2% for stage III, 8.1% for stage IV). Patients with low grade differentiation tumors had 5-year survival rate of 73.5%, and those with high-grade had 38.2%. We have found that preoperative CRT significantly reduces the rate of local recurrence (5.3% vs. 14.1%), but patients who were treated with preoperative CRT did not appear to benefit significantly in terms of their long-term prognosis, because there was no difference in overall survival between the patients who received preoperative radiochemotherapy and those who did not receive it (66.2% vs. 67.8%). It was found that the R-classification, anatomical extent of tumor described by the TNM classification of the UICC, tumor grade, and preoperative CEA serum level were prognostic factors that influenced survival.

Is postoperative cognitive decline after cardiac surgery associated with plasma beta amyloid 1-42 levels?

BACKGROUND: Postoperative cognitive decline following cardiac surgery is one of the frequently reported complications affecting postoperative outcome, characterized by impairment of memory or concentration. The aetiology is considered multifactorial and the research conducted so far has presented contradictory results. The proposed mechanisms to explain the cognitive decline associated with cardiac surgery include the neurotoxic accumulation of ß-amyloid (Aß) proteins similar to Alzheimer's disease. The comparison of coronary artery bypass grafting procedures concerning postoperative cognitive decline and plasmatic Aß1-42 concentrations has not yet been conducted. METHODS: The research was designed as a controlled clinical study of patients with coronary artery disease undergoing surgical myocardial revascularization with or without the use of a cardiopulmonary bypass machine. All patients completed a battery of neuropsychological tests and plasmatic Aß1-42 concentrations were collected. RESULTS: The neuropsychological test results postoperatively were significantly worse in the cardiopulmonary bypass group and the patients had larger shifts in the Aß1-42 preoperative and postoperative values than the group in which off-pump coronary artery bypass was performed. CONCLUSIONS: The conducted research confirmed the earlier suspected association of plasmatic Aß1-42 concentration to postoperative cognitive decline and the results further showed that there were less changes and lower concentrations in the off-pump coronary artery bypass group, which correlated to less neurocognitive decline. There is a lot of clinical contribution acquired by this research, not only in everyday decision making and using amyloid proteins as biomarkers, but also in the development and application of non-pharmacological and pharmacological neuroprotective strategies.

Personality Traits of Croatian University Students with Internet Addiction.

Specific personality traits may predispose individuals to various forms of addictive behaviors. This study aimed to investigate the association between personality traits of university students and Internet addiction (IA). A sample of 1051 university students was recruited from the largest university in Eastern Croatia. A structured anonymous questionnaire that included questions regarding students' sociodemographic information and Internet usage patterns, the Young Internet Addiction Test and Big Five Inventory served as a research tool. The study revealed that 1.0% of the studied sample expressed severe IA while 24.6% of study participants expressed some signs of addiction. The IA was detected in 576 (80.0%) students who used the Internet mainly for social networking, in 30 (78.9%) students who mainly used it for online gaming, and in 153 (52.2%) students who mainly used it for university assignments (p < 0.001). Higher neuroticism, higher extraversion, and higher openness to new experiences were connected with IA in general (p < 0.001). Higher neuroticism, higher extraversion, and higher openness to new experiences were significantly associated with addictive behavior during social networking (p < 0.001). Higher extraversion and higher openness to new experiences were significantly associated with addictive behavior during Internet usage for university assignments (p = 0.025), while there were no significant associations between specific personality traits and addictive behavior during online gaming (p = 0.059). Personality traits must be taken into account while developing programs and implementing interventions for preventing IA in the university student population.

Experimental shortening of the radius in the treatment of Kienböck's disease.

AIM: The aim of the research was to determine the smallest amount of loading on the lunate bone obtained by gradually shortening the radius in different ulnar variants as the potential treatment of Kienböck's disease. METHODS: The research was conducted on anatomic preparations of 20 upper extremities using only the distal part of the forearm and hand, placing them in exactly defined positions. A Fuji Prescale film was inserted in the open radiocarpal joint to measure pressure after compressing axially by changing the length of forearm in four stages by the gradual shortening of the radius. RESULTS: The greatest reduction of average pressure on the lunatum achieved by shortening the radius depended on ulnar variant. In ulnar variant 0, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (24% reduction). For ulnar variant -1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 2 mm (37% reduction). For ulnar variants -2, -3 and +1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (5%, 75% and 9% respectively). CONCLUSIONS: The pressure distribution in the distal radiocarpal joint is vital for healing, and shortening of the radius relieves the pressure on the lunate bone. The exact type of surgery and the amount of radial osteotomy depends on preoperative ulnar variant.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis.

AIM: Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODS: Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTS: There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONS: Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Epidemiologic data of malignant melanoma in Osijek-Baranya County (Eastern Croatia) during the period of 2000-2008.

During the past several decades there has been a substantial increase in the incidence of malignant melanoma worldwide. The highest incidences were reported in New Zealand and Australia. In Europe the northern countries generally have a higher incidence. The aim of this retrospective study was to provide the incidence and mortality for all patients with malignant melanoma diagnosed in Osijek-Baranya County, Eastern Croatia, during 2000-2008. In the past 30 years in the Republic of Croatia the incidence of melanoma increased by 337%. During the period of 2000-2006 in Osijek-Baranja County, the incidence of melanoma increased by 13%. The incidence of melanoma increases with age, but in past decades melanoma is more often diagnosed in people aged 25-40. The mortality between 2000 and 2008 increased by 18%. The incidence of melanoma generally increases equally in men and women. The most common localization of skin melanoma in males was trunk and in females the lower extremities. Presently, in Osijek-Baranya County melanoma is 15th on the list of malignant tumors and represent 2% of all malignant tumors. In New Zealand, Australia and European northern countries mortality is reduced, as result of earlier diagnosis and education of risk groups. Unfortunately, in Osijek-Baranya County, in a comparison with these countries, the mortality is higher although incidence is the same or lower.

Role of zinc in chronic gastritis.

Oxidative stress occurs in inflammation of gastric mucosa. The role of zinc in modulating oxidative stress has recently been recognized. Zn deficiency results in an increased sensitivity to oxidative stress and have a higher risk of musoca damage in inflammation. The aim of this study was to determine wheather chronic inflammation affects on the concentration of Zn2+ ions in gastric mucosa of patients with chronic gastritis. Forthy-three patients with chronic gastitis were enrolled. Patients were endoscoped. Histology and scoring of gastritis was performed following the guidelines of the updated Sydney system. Endoscopic finding of mucosa were scored according to a Lanza scoring system. The diagnosis of Helicobacter pylori (H. pylori) infection, histopathologic changes, intensity of inflammation and zinc concentration were determined from biopsies of gastric mucosa. The atomic absorption spectrophotometer was used to determine tissue concentrations of zinc. Twenty of 43 patients with chronic gastritis were uninfected by H. pylori. There was no statistically significant difference in tissue concentrations of zinc between H. pylori-positive and H. pylori-negative patients. From those infected patients 53.3% had chronic active gastritis. There was no statistically significant difference in tissue concentrations of zinc between patients with chronic active gastritis and patients with chronic inactive gastritis (p = 0.966). Zn in antrum showed positive correlation with density of H. pylori in antrum (Spearman' rho = 0.481, p = 0.020), negative correlation with density of H. pylori in corpus (Spearman' rho = -0.492, p = 0.017) and with zinc in corpus (Spearman' rho = 0.631, p =0.001). Tissue concentration of zinc was not affected by chronic inflammation of gastric mucosa in patients with chronic gastritis.

Ultrasound evaluation of extracranial carotid artery lesions in Parkinsonian patients.

The purpose of this investigation was to determine the atherosclerotic changes in patients with vascular parkinsonism and in patients with idiopathic Parkinson's disease, in order to evaluate the possible influence of the extracranial pathology of carotid arteries in developing lacunar cerebral infarcts. Degree of stenosis and plaque morphology of the extracranial part of carotids in both group of patients were evaluated by color Doppler flow imaging ultrasound investigation and the results were compared. We selected two matched groups of patients with parkinsonism: 22 patients with vascular parkinsonism, and 28 with idiopathic Parkinson's disease.The atherosclerotic changes found in patients with Parkinson's disease showed mild carotid lesions with mostly stable calcified plaques and lesser risk for embolic cerebral intravascular events contrary to the higher degree of carotid stenosis found in patients with vascular parkinsonism with mostly mixed plaques prone to embolization. Therefore, we suggest performing ultrasonographic examination of the extracranial part of carotid arteries in all patients with parkinsonism to assess risk of vascular accidents originating from carotid lesions. That would enable adequate treatment of parkinsonism and prevent further occurrence of intracranial vascular changes.

Secondary hypertension due to isolated interrupted aortic arch in a 60-year-old person--one-year follow up.

Interrupted aortic arch (IAA) is a congenital defect characterized by loss of luminal continuity between the ascending and descending aorta1. It is a rare malformation with an estimated incidence of perinatally diagnosed cases of 3 per million live births3. The condition is considered extremely rare in adults. However, its true prevalence in this population is unknown. We have found 30 case reports of IAA in adults in literature, 5 of whom were older than 50 years. Four of them had type A IAA. Arterial hypertension is a typical co-morbidity. In this report we describe a 60-year-old male patient who had a type A asymptomatic IAA. Although we initially suspected the aortic coarctation, further invasive procedures revealed complete interruption of the aortic arch just distal to the origin of the left subclavian artery. The patient underwent surgical repair, followed by full recovery and near-normalization of blood pressure.

Retrorenal fat predicts grade C pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula after pancreaticoduodenectomy is one of the most severe complications with mortality rates as high as 45%, and the prediction of most severe form of fistula (grade C) is crucial for successful management of patients who are to undergo cephalic pancreatoduodenectomy. It has been found that the amount of abdominal fat may predict grade C postoperative pancreatic fistula. In this study, we analysed the value of retrorenal fat thickness in the prediction of grade C pancreatic fistula. METHODS: A total of 140 patients who underwent pancreaticoduodenectomy were retrospectively analysed. Retrorenal fat thickness and intra-abdominal fat, expressed as total fat area, visceral fat area and subcutaneous fat area, were determined from computed tomography slices using the known range of attenuation values (-190 to -30). Blood loss, operating time, pancreatic texture and main pancreatic duct diameter as well as body mass index were also analysed. RESULTS: Retrorenal fat thickness (P = 0.0004), duct diameter (P = 0.0008), subcutaneous fat area (P = 0.023) and total fat area (P = 0.014) were found to be significant predictors of grade C pancreatic fistula. CONCLUSION: Although retrorenal fat tissue thickness may seem robust, it is a simple measure that can be used to predict the most severe grade of pancreatic fistula after pancreaticoduodenectomy.

Esomeprazole versus pantoprazole for healing erosive oesophagitis.

The aim of this study was to compare the efficacy of esomeprazole and pantoprazole with regard to healing and relief from gastroesophageal reflux disease-related symptoms. I this multicentre, randomized, single-blind study 180 patients (ITT population) diagnosed with endoscopically proven GERD grade A,B,C received esomeprazole (40 mg once daily (o.d.), n = 90) orpantoprazole (40 mg o.d., n = 90). Healing and relief from GERD-related symptoms were assessed at first and final visit (after 4 or 8 weeks of treatment). Esomeprazole 40 mg provided significantly greater healing than pantoprazole 40 mg after 4 weeks of treatment in patients with EE (77.8% vs. 72.2%). Esomeprazole-treated patients were healed after up to 8 weeks of treatment similar those treated with pantoprazole (92.2% vs. 91.1%). The proportion of heartburn-free days was similar in patients treated with esomeprazole and to those treated with pantoprazole.