Delayed encephalopathy after acute carbon monoxide poisoning: a case study

Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a relatively rare inflammatory-associated neurometabolic complication. In this article, we present a case report of a 50-year-old male patient with a history of carbon monoxide poisoning. This acute poisoning, although successfully controlled during a stay in the intensive care unit of a local hospital, later led to persistent neurological symptoms. The patient was then treated in the inpatient unit of the rehabilitation clinic, where cognitive deterioration began to develop 20 days after admission. Subsequent examination using EEG and magnetic resonance imaging confirmed severe encephalopathy later complicated by SARS-CoV-2 infection with fatal consequences due to bronchopneumonia. Because currently there are no approved guidelines for the management of DEACMP, we briefly discuss the existing challenges for future studies, especially the application of rational immunosuppressive therapy already in the acute treatment phase of CO poisoning, which could prevent the development of a severe form of DEACMP.

Schizophrenia, Bipolar Disorder and Pre-Attentional Inhibitory Deficits

According to recent findings schizophrenia and bipolar disorder as separate disease entities manifest similarities in neuropsychological functioning. Typical disturbances in both disorders are related to sensory gating deficits characterized by decreased inhibitory functions in responses to various insignificant perceptual signals which are experimentally tested by event related potentials (ERP) and measured P50 wave. In this context, recent findings implicate that disrupted binding and disintegration of consciousness in schizophrenia and bipolar disorder that are related to inhibitory deficits reflected in P50 response may explain similarities in psychotic disturbances in both disorders. With this aim, this review summarizes literature about P50 in both schizophrenia and bipolar disorder.

Recent advances with 5-HT3 modulators for neuropsychiatric and gastrointestinal disorders

Serotonin (5-hydroxytryptophan [5-HT]) is a biologically active amine expressed in platelets, in gastrointestinal (GI) cells and, to a lesser extent, in the central nervous system (CNS). This biogenic compound acts through the activation of seven 5-HT receptors (5-HT_1-7 Rs). The 5-HT₃ R is a ligand-gated ion channel belonging to the Cys-loop receptor family. There is a wide variety of 5-HT₃ R modulators, but only receptor antagonists (known as setrons) have been used clinically for chemotherapy-induced nausea and vomiting and irritable bowel syndrome treatment. However, since the discovery of the setrons in the mid-1980s, a large number of studies have been published exploring new potential applications due their potency in the CNS and mild side effects. The results of these studies have revealed new potential applications, including the treatment of neuropsychiatric disorders such as schizophrenia, depression, anxiety, and drug abuse. In this review, we provide information related to therapeutic potential of 5-HT₃ R antagonists on GI and neuropsychiatric disorders. The major attention is paid to the structure, function, and pharmacology of novel 5-HT₃ R modulators developed over the past 10 years.

Baseline Difference in Quantitative Electroencephalography Variables Between Responders and Non-Responders to Low-Frequency Repetitive Transcranial Magnetic Stimulation in Depression

Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for depressive disorder, with outcomes approaching 45-55% response and 30-40% remission. Eligible predictors of treatment outcome, however, are still lacking. Few studies have investigated quantitative electroencephalography (QEEG) parameters as predictors of rTMS treatment outcome and none of them have addressed the source localization techniques to predict the response to low-frequency rTMS (LF rTMS). We investigated electrophysiological differences based on scalp EEG data and inverse solution method, exact low-resolution brain electromagnetic tomography (eLORETA), between responders and non-responders to LF rTMS in resting brain activity recorded prior to the treatment. Twenty-five unmedicated depressive patients (mean age of 45.7 years, 20 females) received a 4-week treatment of LF rTMS (1 Hz; 20 sessions per 600 pulses; 100% of the motor threshold) over the right dorsolateral prefrontal cortex. Comparisons between responders (≥50% reduction in Montgomery-Åsberg Depression Rating Scale score) and non-responders were made at baseline for measures of eLORETA current density, spectral absolute power, and inter-hemispheric and intra-hemispheric EEG asymmetry. Responders were found to have lower current source densities in the alpha-2 and beta-1 frequency bands bilaterally (with predominance on the left side) in the inferior, medial, and middle frontal gyrus, precentral gyrus, cingulate gyrus, anterior cingulate, and insula. The most pronounced difference was found in the left middle frontal gyrus for alpha-2 and beta-1 bands (p < 0.05). Using a spectral absolute power analysis, we found a negative correlation between the absolute power in beta and theta frequency bands on the left frontal electrode F7 and the change in depressive symptomatology. None of the selected asymmetries significantly differentiated responders from non-responders in any frequency band. Pre-treatment reduction of alpha-2 and beta-1 sources, but not QEEG asymmetry, was found in patients with major depressive disorder who responded to LF rTMS treatment. Prospective trials with larger groups of subjects are needed to further validate these findings.

Early change of prefrontal theta cordance and occipital alpha asymmetry in the prediction of responses to antidepressants

BACKGROUND

The study evaluated the effectiveness of EEG alpha 1, alpha 2 and theta power, along with prefrontal theta cordance (PFC), frontal and occipital alpha 1, alpha 2 asymmetry (FAA1/2, OAA1/2) at baseline and their changes at week 1 in predicting response to antidepressants.

METHOD

Resting-state EEG data were recorded from 103 depressive patients that were treated in average for 5.1 ± 0.9 weeks with SSRIs (n = 57) and SNRIs (n = 46).

RESULTS

Fifty-five percent of patients (n = 56) responded to treatment (i.e.reduction of Montgomery-Åsberg Depression Rating Scale score ≥ 50%) and 45% (n = 47) of treated subjects did not reach positive treatment outcome. No differences in EEG baseline alpha and theta power or changes at week 1 for prefrontal, frontal, central, temporal and occipital regions were found between responders and non-responders. Both groups showed no differences at baseline PFC, FAA1/2 and OAA1/2 as well as change of FAA1/2 at week 1. The only parameters associated with treatment outcome were decrease of PFC in responders and increase of OAA1/2 at week 1 in non-responders. There was no influence of the used antidepressant classes on the results. The PFC change at week 1 (PFCC) (area under curve-AUC = 0.75) showed only a numerically higher predictive ability than OAA change in alpha 1 (OAA1C, AUC = 0.64)/alpha 2 (OAA2C, AUC = 0.63). A combined model, where OAA1C was added to PFCC (AUC = 0.79), did not significantly improve response prediction.

CONCLUSION

Besides PFCC, we found that OAA1C/OAA2C might be another candidate for EEG predictors of antidepressant response.

Solitary Metastasis of Clear Renal Cell Carcinoma to Thyroid Gland: Three reported cases with review of the literature

Metastasis to the head and neck and more specifically to the thyroid gland from distant primary tumors is less common in comparison to the local regional metastasis of squamous cell carcinomas of the upper aero-digestive tract. Preoperative diagnosis of these cases can be difficult. The authors present three cases with distant solitary metastases of clear renal cell carcinoma to the thyroid gland with ambiguous mechanism of tumor spread to the thyroid. Solitary metastases of clear renal cell carcinomas are an uncommon variant of metastasis of this tumor and may imitate thyroid well differentiated carcinoma which most commonly affects the thyroid gland. Therefore, thorough endocrinological investigation of the thyroid gland is necessary. The recommended therapy of renal cell carcinoma metastasis includes surgical removal of all cancerous tissues - i.e. of the gland with the possibly infiltrated adjacent tissues, as well as removal of the affected lymph nodes - selective radical neck dissection. In our study, we discuss the clinical picture, pathology, diagnosis, differential diagnosis and prognosis together with literature review.

A 3-bp Deletion VK600-1E in the BRAF Gene Detected in a Young Woman with Papillary Thyroid Carcinoma

Papillary thyroid cancer (PTC) derived from follicular cells is a frequent thyroid tumor. The incidence of this type of malignancy is still growing worldwide. Several major genetic causes are recognized to cause PTC-mutations in the BRAF and RAS genes or rearrangements with the RET proto-oncogene. The most common genetic change found in PTC is a V600E mutation in the BRAF gene presented in 36-69 % of all PTC cases. For routine purposes, several methods were developed to selectively detect only this mutation. However, these methods miss other mutations in the BRAF gene located elsewhere. We focused on the analysis of the exon 15 of the BRAF gene by next-generation sequencing. Here we report a three nucleotide deletion VK600-1E in one patient and present this finding in the context of 13 previously described PTC cases with this deletion. Our patient is the second youngest one among the reported cases. Clinical features of PTC patients with VK600-1E are summarized. For the future, it is important to evaluate genotype-phenotype characteristics of patients with rare BRAF mutations and to follow up them for years.

Evaluation of three purely polypropylene meshes of different pore sizes in an onlay position in a New Zealand white rabbit model

BACKGROUND

The aim of the study was to evaluate the influence of the pore size of a polypropylene mesh on the shrinkage and elasticity of the mesh-tissue complex and the inflammatory reaction to the implant in an open onlay hernia repair.

MATERIALS AND METHODS

Twenty-one 10 × 10 cm samples of polypropylene meshes of a different pore size (3.0 × 2.8 mm-PP3, 1.0 × 0.8 mm-PP1 and 0.6 × 0.5 mm-PP.5) were implanted in an onlay position in 21 New Zealand white rabbits. After 90 days of implantation the shrinkage, elasticity and foreign body reaction (FBR) were assessed.

RESULTS

The shrinkage of PP3 was 30.6 ± 4.3 %, PP1 49.3 ± 2.9 % and PP.5 49.5 ± 2.6 %. The shrinkage of PP3 was significantly lower (PP3 × PP1 p = 0.007, PP3 × PP.5 p = 0.005), PP1 and PP.5 were similar. The elasticity was similar. The strength of FBR in mesh pores was similar. The width of foreign body granuloma layers at the mesh-tissue interface was significantly reduced with increasing pore size (inner: PP3 10.1 ± 1.2; PP1 12.5 ± 2.9; PP.5 17.4 ± 5.2 and outer: PP3 21.2 ± 2.5; PP1 30.6 ± 6.3; PP.5 60.4 ± 14.9). All differences between the widths of granuloma layers were statistically significant (p < 0.010). One animal (PP1) was excluded because of a mesh infection.

CONCLUSIONS

Implantation of polypropylene mesh of a pore size of 3 mm in an onlay position is associated with a significant reduction of shrinkage in comparison to a 1 mm pore lightweight and 0.5 mm pore heavyweight mesh. A pore size increase to 3 mm is not sufficient for an improvement of mesh-tissue complex elasticity in comparison to a 1 mm pore lightweight and 0.5 mm heavyweight mesh. Polypropylene mesh with enlarged pores to 3 mm is associated with a similar strength of FBR in mesh pores and a reduced foreign body granuloma in comparison to a 1 mm pore lightweight and 0.5 mm pore heavyweight mesh.

Sensory disturbances, inhibitory deficits, and the P50 wave in schizophrenia

Sensory gating disturbances in schizophrenia are often described as an inability to filter redundant sensory stimuli that typically manifest as inability to gate neuronal responses related to the P50 wave, characterizing a decreased ability of the brain to inhibit various responses to insignificant stimuli. It implicates various deficits of perceptual and attentional functions, and this inability to inhibit, or "gate", irrelevant sensory inputs leads to sensory and information overload that also may result in neuronal hyperexcitability related to disturbances of habituation mechanisms. These findings seem to be particularly important in the context of modern electrophysiological and neuroimaging data suggesting that the filtering deficits in schizophrenia are likely related to deficits in the integrity of connections between various brain areas. As a consequence, this brain disintegration produces disconnection of information, disrupted binding, and disintegration of consciousness that in terms of modern neuroscience could connect original Bleuler's concept of "split mind" with research of neural information integration.

[Is pneumonectomy justified in the management of lung metastases?]

The authors discuss about questions of possibility pneumonectomy in concept of lung metastasis therapy. They analysed in detail indications, surgery, complications, survival and factors of survival. The authors also introduce case report of one patient with pneumonectomy in your group of patients.

[Thyreopathy in primary care]

Thyroid gland disorders, as the core of all endocrinopathies, affect 5-7% of the population of the Czech Republic, with women being affected 6-8 times more often than men. Clinically, thyreopathies are divided into hormonal production disorders and morphology disorders. Thyroid hormones fT3, fT4 and TSH serum levels determine the diagnosis of a thyroid gland disorder. Primary hypothyreosis is characterized by reduced fT4 and increased TSH. Low T3 syndrome is a protective reaction of the organism and is associated with conversion of T4 into hormonally inactive triiodothyronine (rT3). Primary hyperthyreosis is characterized by higher fT4 and low TSH levels. Acute thyreoiditis: Inflammatory signs and normal thyroid function, anti-TPO as well as anti-TG are not elevated. Subacute thyreoiditis is manifested as an inflammation, normal anti-TPO and anti-TG, sometimes also hyperthyreosis. Chronic thyreoiditis, Hashimoto's struma is among the most frequent causes ofhypothyreosis in the Czech Republic and it is diagnosed through high anti-TPO and anti-TG levels and higher TSH. Thyreoidal adenomas and carcinomas are clinically usually euthyroid. Determination of tumour markers - thyreoglobulines in papillary and follicular carcinomas and calcitonin in medullar carcinoma that requires genetic assessment (determination of germinal mutations, usually with PCR)--is essential.

The anatomical relationship between the saphenous nerve and the great saphenous vein

OBJECTIVE

Damage to the saphenous nerve (SN) has been a known complication during varicose vein surgeries. We tested whether a better knowledge of the anatomy of the SN and the great saphenous vein (GSV) can prevent such damage.

METHODS

We conducted a morphological and histological examination on 86 limbs from 43 cadavers in order to analyse the anatomical interrelation between the SN and the GSV in the lower leg and we also measured the distance between the nerve and the vein in a sample of 42 sections from three parts of the lower leg.

RESULTS

The anatomical relationship between the SN and the GSV is varied and the two structures run close to each other so a better knowledge of their anatomy in itself proved insufficient in preventing damage to the SN.

CONCLUSION

However, in the case of endovenous laser therapy and radiofrequency ablation tumescent anaesthesia decreases the risk of damage to the SN.

BRAFV600E mutation in the pathogenesis of a large series of papillary thyroid carcinoma in Czech Republic

BACKGROUND

Activating point mutation of the BRAF gene, the most common genetic alteration reported in papillary thyroid carcinomas (PTC), has been associated with poor prognostic characteristics.

AIM

Our objective was to determine the frequency of BRAFV600E mutation in PTC tumor tissues from the period 1960-2007 and to correlate it with clinicopathological parameters.

SUBJECTS AND METHODS

DNAs were extracted from 242 PTCs, 23 sporadic medullary carcinomas, one anaplastic carcinoma and 6 poorly differentiated carcinomas. The presence of BRAFV600E mutation was determined using single strand conformation polymorphism method and verified by direct sequencing.

RESULTS

BRAFV600E mutation was detected in 81 of 242 PTCs (33.5%), in one of 6 poorly differentiated carcinomas (16.7%) and in anaplastic carcinoma. BRAFV600E mutation was much less frequent in the follicular variant compared to classical variant and mixed follicular- classical variant of PTCs (p=0.001). BRAFV600E mutation was significantly associated with presence of nodal metastasis (p=0.029), more advanced TNM stage (p=0.014) and recurrence of disease (p=0.008). The mutation correlated with a higher age at diagnosis (p=0.049) and with a greater tumor size (p=0.041). Multivariate analysis confirmed these findings. The prevalence of BRAFV600E mutation before 1986 was significantly lower than after it (p=0.008).

CONCLUSIONS

Our data suggest that BRAFV600E mutation is associated with high-risk clinicopathological characteristics of PTC and worse prognosis of patients. The frequency of the mutation significantly varied during the observed period but rather because of the different age distribution of patients in particular periods than as a consequence of Chernobyl accident.

[Evaluation of neoadjuvant chemo-radiotherapy with locally advanced rectal cancer by comparing tumour volume before and after treatment]

BACKGROUND

Neoadjuvant chemotherapy is a standard preoperative therapeutical procedure with locally advanced rectal adenocarcinoma. The aim of the study was to compare the tumour volume reduction before and after the oncological therapy in relation to the change in the CEA value and to the outcome of the histopathological evaluation of response to the treatment.

PATIENTS AND METHODS

In the years 2004-2008, 274 rectal cancer patients were evaluated, of which 64 underwent neoadjuvant CRT with subsequent surgery and had also completed other inclusion criteria. The tumour volume before and after the CRT, percentage reduction in the tumour volume and the relation to the change in the CAE value and the histopathological evaluation were evaluated.

RESULTS

The distance between the anus and the tumour was from 3 to 15 centimetres, the average value being 8.1 centimetres. In 5 cases the tumour was not histologically found in the resected specimen. Average value of the CEA value before the CRT was 18.12 ng/ml, range 0.7-98.1 ng/ml, after the CRT the average value was 7.00 ng/ml, range 0.5-18.7 ng/ml. The average tumour volume before CRT was 32.48, range 10.3-88.5, after the CRT the average volume was 20.13, range 4.7-55.1.

CONCLUSION

A relation between the change in the T value and the volume reduction before and after the CRT of statistical significance has been proven in this group of patients. This relation however has not been proved in the N value change. Only in one-third of the evaluated patients was there a positive change in both T and N classification. No relation between the CEA value and the tumour volume change has been proven.

[Open pleural window at treatment of the advanced thoracic empyema: 20 high-risk patients' treatment experience]

The aim of the retrospective clinical study was the analysis of the 20 high-risk patients operated in our department within years 2000-2008 by the modified Eloesser procedure for the serious thoracic empyema.

MATERIAL AND METHODS

We have analyzed the data of the 17 men and 3 women. The most important objectives were the cause of the disease, type of procedure, perioperative mortality, length of stay and subsequent procedures. The underlying disease was the malignant intrathoracic disease in 40%, diabetes mellitus was found in 25%. The cause of empyema was pleuropneumonia in 45%, postresectional empyema occurred in 35%.

RESULTS

There were two perioperative deaths (10%), remaining patients were all dismissed in a stabilized condition the 22nd postoperative day at average. Six subsequent reconstructive procedures were performed. There was no early death for the postpneumonectomy empyema.

CONCLUSION

In case of the serious pleural empyema in a high-risk patient is the modified Eloesser procedure safe and life saving surgical operation. The timing of the procedure and correct indication for surgery are essential.

Somatic mutations in the RET proto-oncogene in sporadic medullary thyroid carcinomas

The frequency and prognostic relevance of RET proto-oncogene somatic mutations in sporadic medullary thyroid carcinoma (MTC) remain controversial. In order to study somatic mutations in the RET proto-oncogene in sporadic MTCs found in the Czech population and to correlate these mutations with clinical and pathological characteristics, we investigated 48 truly sporadic MTCs by sequencing classical risk exons 10, 11, 13, 14, 15 and 16. From the 48 tumors studied, 23 (48%) had somatic mutation in the RET proto-oncogene in exons 10, 11, 15 or 16. The classical somatic mutation Met918Thr in exon 16 was only found in 13 tumors (27%). In five cases, multiple somatic mutations and deletions were detected. A statistically significant correlation between the presence of somatic mutation with more advanced pathological TNM stages was observed. Other clinical and pathological characteristics did not show any statistical significant association with the presence or absence of somatic mutation.

[Robotic procedures in the colorectal surgery]

PURPOSE

The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was developed specifically to compensate the technical limitations of laparoscopic instruments, such as two-dimensional vision, misalignment of hands and instruments, limited dexterity of instruments inside the patient, and fixed instrument tips. The da Vinci system provides a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom.

METHODS

These advantages can be applied in the field of colorectal surgery, and that's why we are reporting 45 cases that underwent robotic colorectal surgery. We concluded that the da Vinci system may be useful in surgical procedures, such as splenic flexure takedown, dissection of the inferior mesenteric artery with identification of the nervous plexus, and dissection of a narrow pelvis. The major drawbacks of robotic systems are high cost, and a lack of tactile sensation and tensile feedback to the surgeon, who must depend on visual cues to estimate the tension exerted on tissue by the robotic arms.

RESULTS

In conclusion, robotic colorectal surgery can be performed safely and effectively, using the da Vinci surgical system, because this system has more dexterity and flexibility than conventional laparoscopic instruments. However, prospective randomized studies are necessary to evaluate the preservation of sexual and voiding function, as well as the oncological and functional (pelvic floor disorders) outcomes of this approach.