A mobile application for STEMI care optimization: pilot implementation project report

Background

In an effort to improve outcomes of STEMI patients, we developed a secure mobile application (app) to streamline real-time communication and coordination between multiple teams taking care of STEMI patients in a large health care system. The app includes multi-level alarm and notification systems, instant EKG transmission for quick interpretation, activation of the cardiac catheterization laboratory (CCL) after expert case review, secure video chat among team members facilitating clinical discussion, continuous updates on patients' clinical status and ambulance location tracking.

Purpose

One of the major shortcomings in STEMI system of care has been long delays in transfer of patients from non-PCI capable hospitals to a receiving center for primary PCI. To address the challenges of interhospital transfer, we designed a pilot project employing the app for STEMI transfer from a first contact hospital to our CCL. This report assesses the effect of the app on door-to-device time by comparing the key metric for STEMI transfer before (historic) and after app launch.

Methods

The pilot project involved key leadership stakeholders from Emergency Medicine and Nursing Departments at the referring hospital, CCL and our transfer center. During pilot period (July 2021 to January 2022) the referring center activated STEMI alarms using app activation in parallel with the previously established STEMI activation process via traditional phone calls to the transfer center. The built-in workflow redundancy was introduced to ensure the rapid and efficient, and at the same time, safe and reliable response to STEMI alert. In preparation for the pilot, more than 250 people were provisioned accounts, trained on their user-specific roles and scheduled in the app according to their schedules.

Results

A total of 40 suspected STEMIs were activated through the app during the pilot study; among them 30 cases were accepted for transfer and 10 rejected. After excluding patients who expired during transfer, were intubated, or had normal coronaries, final study population included 13 STEMI cases activated through the app. These cases were compared with 43 STEMIs activated through the traditional pathway from January 2019 to July 2021 before app launch. After implementing the app, the mean door-to-device time for STEMI transfer decreased from 120.3±48.3 to 91.8±15.4 min (P=0.002) (Figure 1). The significant improvement, 29 min (24%), of the key metric for interhospital transfer resulted in all STEMI cases meeting AHA goal of door-to-device time ≤120 minutes after the app launch. The respective percent of STEMI cases meeting the goal before app was 71% (Figure 2).

Conclusions

Implementation of a mobile app into STEMI workflow of a large urban healthcare system had a significant impact on the quality of care for transfer of STEMI patients, which has also helped bring our clinical practice closer to the AHA guidelines pertaining to the first door-to-device time.

Funding Acknowledgement

Type of funding sources: None.

[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]

BACKGROUND

The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín.

MATERIAL AND METHODS

Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method.

RESULTS

In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes.

DISCUSSION

High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes.

CONCLUSION

In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.

[Different impact of the laparoscopic and laparotomic approach on the immune response induced by surgical procedure]

INTRODUCTION

The laparoscopic approach has been adopted to treat gastrointestinal tract malignities over the last decade. This approach has become a routine method. The laparoscopic approach has been proven to provide better short-term results. Its long-term results are similar. There has also been research into the affection of the local and systemic immune reaction following surgical procedures. Available findings reveal demonstrably diminished negative impacts on the systemic immune response after laparoscopic procedures. The research papers dealing with local immunity are only experimental and their results are heterogeneous.

AIM

To give a literature review of the influence of a surgical procedure on the systemic and local immune response and to focus more closely on the comparison the immune response after laparoscopic and laparotomic approaches.

REVIEW

Authors provide a summary of current knowledge and studies which deal with the affection of the immune system by surgical procedures. The summary is dividend into parts discussing systemic and local immune responses. The role of macrophages is elaborated on in detail depending on the type of surgical approach. The results and the above-mentioned of experimental studies and their possible impact on clinical practice are subjected to critical analysis.

CONCLUSION

A great majority of studies support the hypothesis that the laparoscopic approach leads to less systemic immunosuppression and thus to the lower risk of the malignant spread of disease. Comparison of the impacts of laparoscopy and of open procedures on the local immune response has not been resolved yet.

[Gastrointestinal stromal and other mesenchymal gastric tumors--laparoscopic management?]

INTRODUCTION

This study was aimed to evaluate a set of gastrointestinal stromal tumors (GIST) of the stomach managed with a laparoscopic technique (GIST).

MATERIALS AND METHODS

The study covers a period from January 1,2007 until December 31, 2009 during which 12 patients underwent the laparoscopic removal of stomach tumors in the Regional Hospital in Pardubice. In all cases tumors were removed completely in a laparoscopic way, including the healthy border of the stomach tissue. The defect created in the stomach wall was sutured laparoscopically as well. On completion the sufficiency of the sutures was reviewed gastroscopically.

RESULTS

No death was observed in our study. Two patients suffered from wound infection (secondary healing), one of them requiring repeat surgery owing to the excessive narrowing of the distal part of the stomach. The dehiscence of the laparoscopic suture or other intraabdominal complications was not observed. 3 patients underwent chemotherapy by Imitinib. During surveillance all patients were free of signs of tumor progression or local recurrence.

DISCUSSION

Gastric GISTs are very rare tumors but their incidence is increasing. At this time the consensus about the necessity of preoperative unambiguous differentiation between malignant or less malignant variants is not available. The strict differentiation is very difficult and the determination to choose a more radical surgical approach for more malignant variants is not clear-cut.

CONCLUSION

In case of gastric GIST the local removal of a tumor with the healthy border of the stomach tissue may be chosen as an adequate approach. Our results support this local surgical approach.

[Perilunar dislocation of the corpus in a patient with aplasia of the scaphoid]

Congenital aplasia of the scaphoid is a rare abnormality arising when the distal row of carpal bones is dislocated radially and proximally, the capitate replaces the scaphoid, and the lunate is triangular instead of quadrilateral in shape. The scaphoid bone which makes a functional bridge between the proximal and the distal row is a stabilising element under normal anatomical conditions. If it is absent, the carpus structure is disturbed and its radial part is prone to perilunar dislocation, because stability is provided only by the ligaments. However, a perilunar dislocation associated with aplasia of the scaphoid has not been described in the literature yet. In the case reported here, after arthroscopic examination ascertaining that the capsular ligaments are not interposed between the joints, the dislocation was managed by closed reduction and Kirschner wire transfixation for 8 weeks, and the wrist was immobilised with a below-elbow plaster splint for the same period. A 22-month follow-up did not show any signs of wrist instability or restriction in hand function.

[Chronic lunotriquetral instability of the wrist. Presentation of our method of treatment]

PURPOSE OF THE STUDY

One of the causes of pain on the ulnar side of the wrist is post-traumatic lunotriquetral (LTq) instability, which is difficult to detect on radiographs. For diagnosis, arthroscopic examination is most reliable. The methods for treatment of LTq instability include mere immobilization, ligament reconstructions and LTq joint stabilization with Kirschner's wires in acute conditions, and stabilization of the LTq joint by tenodesis or arthrodesis. In this study our method of treating chronic isolated injury to the lunotriquetral ligament is described.

MATERIAL

The group comprised 43 wrists with isolated lunotriquetral ligament injuries diagnosed by arthroscopy. In 19 patients with persisting complaints, stabilization was performed using our original method. At 4 months after surgery, the results were evaluated by the method of Green and O'Brien.

METHODS

Access to the LTq joint was gained through the fifth extensor compartment. At about 3 cm proximal to the ulnar head, one third of the extensor capri ulnaris (ECU) tendon was detached, without doing damage to the tendinous sheath on the ulnar head, and stretched distally up to the triquetrum-hamate joint level. Using a 3.2-mm drill, a tunnel was made on the dorsal side of the triquetrum, starting at the distal third of the ulnar side of the triquetrum and opening at the attachment site of the dorsal LTq ligament. In the middle part of the dorsal side of the lunate, a groove 4 mm deep and 6 mm long was made with a cutter and a two-suture Mitek anchor was inserted in its radial side. The graft was passed through the tunnel in the triquetrum, tightened up and inserted in the groove on the lunate, and sutured to the anchor. The rest of the tendon was reinserted to the ECU tendon. After suturing the dorsal structures and skin, a high plaster cast reaching up above the elbow was applied for 4 weeks, followed by application of a short plaster splint for another 2 weeks.

RESULTS

Using the method of Green and O'Brien, we assessed pain, function (return to full activity), range of motion and grip strength. An excellent result was recorded in 48%, good in 42% and satisfactory in 10% of the patients; there were no poor results.

DISCUSSION

Our method gives better results than the published methods of tenodesis, because it secures stability of both the triquetrum and lunate bones. Also, these methods restrict motion to a lesser degree than LTq joint arthrodesis.

CONCLUSIONS

LTq instability of the wrist is a limiting condition for the patient's daily activities. It appears when, for gripping, the hand is positioned in dorsal flexion and ulnar duction. The diagnosis and therapy are complicated and only arthroscopy is reliable for LTq instability detection. The method described here provides an option for treating this disorder with good outcome and, in case of failure, does not interfere with a subsequent LTq joint arthrodesis.

[Haemothorax after blunt thoracic trauma]

BACKGROUND

Haemothorax is frequent consequence of blunt and penetrating thoracic trauma and is usually associated with pneumothorax. The occurence of haemothorax in blunt thoracic trauma patients is estimated between 25-75%. The reason of bleeding is impairment of intercostal arteries or lung parenchyma after trauma of the ribs. Uncontrolled bleeding is the main cause of the death. The article is focused on the treatment of this injury.

MATERIAL AND METHODS

There were enrolled 238 patients with thoracic trauma, who were admitted into our department, into the study. The average age of the patients was 42.5 years. The ISS > or = 16 were in 101 patients. Forty two patients were artefitially ventilated. Conservative treatment prevails, almost in 65%. Special care was indicated in patients with haemothorax (fluidotoraxem).

RESULTS

Clinically and based on other screening methods the presence of the fluid in thoracic cavity was in 131 patients. Surgical treatment (punction, drainage, videothoracoscopy and thoracotomy) was necessary in 47 (35.0%). Thoracotomy for the bleeding was indicated in seven cases (5.3 %).

CONCLUSION

In diagnostics and in treatment of the bleeding in thoracic trauma patients the most important factor is clinical status of the patient. Indication for thoracotomy must be unambigous. Massive haemotorax leads to restrictive ventilation disorder with decreased preload and can be activator of the haemocolaguation disorders. This fact decreases chance for the survival of the patient.

[Traumatic perforation of the duodenum--a case review]

A blunt duodenal injuries are rare in spite of high-energetic injuries are common in this time. The diagnostic is very difficult not only for the reason of the little experience with this type of the injury but in term of the duodenal anatomic localization too. On the other side just late injury Identification of the retroperitoneal part of the duodenum leads to rapid development of the fatal retroperitoneal phlegmon. The development of the clinical symptoms and results of the paraclinical equipment examinations during blunt injury of the upper abdominal part with consequent perforation of the posterior retroperitoneal segment of the duodenum is well-documented by means of the mentioned case. The development of the retroperitonal phlegmon was not noticed despite of the slight diagnostic delayed and defect in the duodenal wall was treated by suture of the perforation aperture. The early detection of the duodenal injury is necessary premise for the good choice of the adequate surgical treatment.

[Haemobilia, the rare case of bleeding into GIT]

AIM OF THE WORK

Bleeding into GIT is still serious problem with not low lethality. Especially, acute bleeding needs fast diagnostics and treatment. The aim of our work is to present the rare case of bleeding into GIT--haemobilia.

GROUP OF THE PATIENTS

There is presented casuistics of the patient who was successfully treated on our department for bleeding from erosion of cystic artery as a consequence of acute cholecystitis.

CONCLUSION

Nowadays there is dominantly preferred endoscopic approach in diagnostics and treatment of the bleeding into GIT. But surgical approach is in some cases the only one method in treatment of these complications.

Standardisation of Parameters during Endovenous Laser Therapy of Truncal Varicose Veins - Experimental Ex-vivo Study

BACKGROUND

Vein shrinkage is a surrogate marker for successful laser treatment of varicose veins. However, many controversies still remain concerning the best laser parameters to use. The aim of this study was standardisation of intraoperative energy dosages and pull-back rates to achieve optimal clinical results.

DESIGN

Ex-vivo study in surgically removed saphenous trunks.

MATERIAL AND METHODS

Great saphenous veins were removed by Babcock stripping and irradiated with laser energy delivered by a laser diode emitting at 980 nm. In total, 279 vein segments (5 cm long) were treated using powers from 5-15 W. Vein segments were opened longitudinally and the circumference measured in the treated and untreated regions to assess thermal shrinkage.

RESULTS

The greatest shrinkage and minimum number of perforations was achieved using lower or medium power (8 to 12 W) with longer exposure to administer laser energy. The median percentage vein shrinkage was 50% (power 5 W), 45% (8 W), 40% (10 W), 45% (12 W) and 59% (15 W). When a higher power was used (15 W), the perforations were more frequent and carbonisation was marked.

CONCLUSIONS

Our data suggests that similar efficacy with fewer vein perforations may be obtained with low or medium power settings and increased exposure when undertaking laser obliteration of saphenous trunks. This may result in fewer adverse events such as ecchymosis following treatment in patients.

[Disorder of vertebral metastasis]

The aim of this article is putting near problems of treatment vertebral metastasis to professional public. Because of improving of imagine methods the diagnosis of this disorder is early making and that is way patient benefit of early initiation of adequate therapy. Authors of this paper rate literary studies concerning of therapeutic methods for treatment of vertebral metastasis and comper to their group of patients.

[New aspects in enteral nutrition in critical patients at the surgical intensive care unit]

INTRODUCTION

Nutritional support in critically ill patients has an impact on both prevention and treatment. Development of complications and organ failure can be prevented, good status of gut mucosa kept and positive nitrogen balance induced. Inflammatory response can be modulated.

NUTRITIONAL SCREENING

Patients undergoing major surgery should be actively screened for the nutritional risk level according to described parameters since it is considered to be very important for the postoperative period. Enteral nutrition (EN) versus parenteral nutrition (PN): Current study findings do not show any difference in mortality of critically ill patients with regard to the administration route. Inflammatory complications rate is significantly lower in EN patients. ESPEN Guidelines on Enteral Nutrition: The most recent recommendations for surgery patients are based on the evidence.

CONCLUSION

There is a need for an active nutritional screening to find patients in the risk. Other important points are the following: a progressive approach to early enteral nutrition combined with PN, multiprofessional cooperation and protocol implementation.

[Crossectomy doesn't improve outcome of endovenous laser ablation of varicose veins]

AIMS

Crossectomy (extended saphenofemoral or saphenopopliteal junction ligation) and stripping of refluxing saphenous trunk represent the basis of the traditional surgical therapy of varicose veins. Endovascular techniques of saphenous ablation are the mini-invasive alternatives of the radical surgical treatment. The objective of this study is the comparison of the endovenous laser ablation with and without crossectomy through open groin access.

MATERIAL AND METHODS

Retroprospective study compares the results of the group of patients treated with simple endovenous laser ablation (HVL - 329 limbs) and HVL completed with crossectomy (35 limbs). Both groups were comparable in terms of basic demographic and preoperative clinical data (p > 0.05). In both cohorts, subgroups with identical laser parameters were selected (p > 0.05). All procedures were performed according the same standard protocol, EVL patients received LMWH in the postoperative period. The results were evaluated by the comparison of CEAP clinical class pre and postoperatively, the percentage of recanalizations and also using the Kaplan-Meier life-table method.

RESULTS

No thrombosis, nor pulmonary embolism were diagnosed in the post-operative period. During the follow-up (98% treated limbs), venous occlusion was observed in 88% of them (91.05 % in the endovenous group and 65.71% in the combined group). These differences are not statistically significant (p = 0.24). Same results were found using the Kaplan-Meier method (p = 0.086). Treatment significantly reduced CEAP clinical class in both groups but the results are better (C = 0.41 vs. 0.8) in the endovenous group (p = 0.004).

CONCLUSIONS

Endovenous ablation of the refluxing saphenous vein represents good alternative of crossectomy and stripping. Combination of both procedures is not effective and, on the contrary, can cause short and long-term complications.

[Blunt thoracic injury and the oxidation stress]

INTRODUCTION

Each injury is accompanied with the oxidation stress with an increase in the level of free oxygen radicals accompanied with a simultaneous decrease in the body's antioxidation capacity. The objective of the study: The objective of this study is to verify connection between the severity of an injury and the intensity of oxidation stress.

METHODS

126 patients with blunt chest injuries were evaluated during 33 months. The patients were divided into four groups, depending on the extent of trauma severity assessed by means of ISS (Injury Severity Score). Randomly selected patients in each group were administered--in addition to standard therapy--indomethacin in usual doses. Level of free oxygen radicals and the body's antioxidation capacity were observed. All tests were carried out at a significance level alpha of 0.05.

RESULTS

Practically all patients, regardless of their respective subgroups, experienced an increase in the level of free oxygen radicals accompanied with a simultaneous decrease in the body's antioxidation capacity.

CONCLUSION

The identified results display a connection between the severity of an injury and the intensity of oxidation stress.

[SIRS and serious blunt thoracic injuries]

INTRODUCTION

Serious blunt injuries are accompanied with the worsening of the mechanics of ventilation due to the chest and lung injuries alone as well as with a systemic inflammatory response (SIRS) that always affects the lungs. The development of an injury-induced respiratory failure is multifactorial and timely pharmacological intervention is likely to contribute to the treatment algorithm, thus improving prognosis in some patients with a serious chest trauma. THE OBJECTIVE OF THE STUDY: The objective of this study is to verify the efficacy of the pharmacological blockade of the systemic inflammatory response of the body (SIRS) in serious blunt chest injuries. The study also intends to identify whether the administration of indomethacin could reduce SIRS score and prevent multiorgan dysfunction and multiorgan failure.

METHODS

126 patients with blunt chest injuries were evaluated during 33 months. The patients were divided into four groups, depending on the extent of trauma severity assessed by means of ISS (Injury Severity Score). Randomly selected patients in each group were administered--in addition to standard therapy--indomethacin in usual doses. All tests were carried out at a significance level alpha of 0.05.

RESULTS

The onset of SIRS in the subgroup with indomethacin was statistically significantly postponed in groups I. and II. Groups ISS I to III showed a statistically markedly shorter time of SIRS duration in the subgroup with indomethacin. The first increase in inflammatory markers (acute phase proteins) was statistically significantly postponed in the group ISS I without the administration of indomethacin. Groups ISS II through IV did not show a statistically significant differences in the first onsets of inflammatory markers. The evaluation of all four groups did not detect any statistically significant differences in the duration of the inflammatory markers increase in the subgroup with indomethacin and in a control group. There was no statistical significance in the average time of ventilation support. An average hospitalization time was shorter in the subgroup ISS II with indomethacin. There was found statistically significant difference. Of the patients included in our file seven died during the monitored period. Lethality is thus 5.6%. A multiorgan failure was the cause of death in two patients in the non-indomethacin subgroup and in one patient in the indomethacin subgroup.

CONCLUSION

We proved that the factors that can be affected by the blockade of cyclooxygenase display statistically significant changes in subgroups with the administration of indomethacin. No changes were recorded with regard to acute phase proteins whose synthesis is not mediated by prostaglandins. The administration of indomethacin positively affects the development of SIRS, reduces and diminishes its effects as well as impact on the impaired body.

[Comparison of coated and bare metallic stents in inoperable carcinomas of the oesophagus and cardia]

INTRODUCTION AND AIM

The authors discuss paliative treatment using coated and bare metallic stents in a prospective randomized study for inoperable oesophageal carcinomas. The aim of this study is to assess the following parameters in both treatment groups: duration of the stents functionality, survival rates, complications rates and histological findings.

METHODS

From 1999 to 2003, the total of 60 patients with oesophageal and cardial carcinomas were randomized. They had either bare (N-31 subjects) or coated (P-29 subjects) stents introduced. The patients were followed-up at one-month intervals.

RESULTS

No statistical differences between the groups were found when the above parameters were assessed.

DISCUSSION

The complications rate depended on the patients survival period in both stent types. Survival rates depended on the disease stage of the local tumorous process and on the individual patient's condition prior to the treatment.

CONCLUSION

The study showed that the metallic selfexpandible stents treatment method may become a widely used paliative procedure in patients with malignant dysphagia, however, it has not proved any differences in complication rates depending on the stent coating.

[Endoscopic solution of iatrogenic lesion of oesophagus]

The case report dissertates upon successful treatment of iatrogenic perforation of distal oesophagus with subcutaneous emphysema, pneumoperitoneum and pneumomediastinum. The endoclips and classic conservative treatment were used in therapy. The patient was treated 3 hours after the injury, no early or late complications related to perforation were noted.

[Pharmacologic prevention of SIRS (systemic inflammatory response syndrome) in severe thoracic injuries]

INTRODUCTION

Frequency and severity of the blunt chest injuries are increasing. Rather high letality is caused by the injury and following systemic inflammatory response.

OBJECTIVE

The aim of the study is to verify the efficacy of pharmacological blockade of the systemic inflammatory response syndrome (SIRS) in serious blunt chest injuries. The aim is also to find out if the administration of indomethacin as a cyclooxygenase inhibitor could prevent multiorgan dysfunction (MODS) and multiorgan failure (MOF).

MATERIAL AND METHODS

Patients were divided into 4 groups according to trauma severity (Injury Severity Score). The group I. contains patients with ISS up to 17. There is no premise of the SIRS development. In the group II. there were patients with ISS 18-30, which means polytrauma group due to new definition. In the group III. there were patients with ISS 31-40 (severe trauma). Group IV. contains critically injured patients (ISS 41 and higher). Some patients involved in our study were given indomethacin (as cyclooxygenase inhibitor in arachidonic acid cycle) together with standard therapy.

RESULTS

65 patients were included into study in last 14 months, 22 patients were given indomethacin. The group with indomethacin administration has later increase of inflammatory markers in groups III. and IV. This increase also takes less time in groups II. and III. Shorter time of mechanical ventilation support in group III. in patients with indomethacin was significant. SIRS is present in time of admission approximately in 44%. All patients have low antioxidants level. 5 patients died in our group, letality was 7.7%. All the died patients came from the subgroup without indomethacin, however only one death caused by MOF.

CONCLUSION

From the results of the first 14 months of the study we can conclude that certain number of patients with serious blunt thoracic trauma could benefit from indomethacin administration.

[Complications after ERCP and their treatment]

The aim of this article is to evaluate the occurrence of complications following diagnostic and therapeutic ERCP's and their treatment. It is based on data collected between January 1, 1998 and December 31, 2002, during which time period the Surgical Clinic in Pardubice completed 18 surgical procedures on patients experiencing post-ERCP complications. The article also provides an analysis of the individual types of complications, their specific surgical procedures, and the results. The discussion passage deals with the theoretical possibility of applying conservative treatment that is applicable in certain types of perforation occurrences, with special concern focused on the occurrence of fatal retroperitoneal phlegmona.

[Prevention and treatment of infectious complications after pulmonary resection--part I]

Pulmonary complications are still the most frequent cause of morbidity and mortality after lung resections. One of the most significant ones are infectious complications, particularly pneumonia. Pneumonia is very often caused by residual atelectasis. We evaluated a group of 75 patients after lung resection focused on occurrence of these two significant complications. We emphasize the prevention of these complications and draw attention to the bronchoscopy and "breathing reeducation" (physical therapy).

DNA topoisomerase II-alpha in pulmonary carcinoid tumors

Fifty-four pulmonary carcinoid tumors of surgically treated patients were diagnosed according to modified Arrigoni histological criteria (WHO 1999). Forty-seven typical (TC) and seven atypical carcinoids (AC) formed the basic groups. Four subgroups were selected from the TCs and consisted of cases with higher tumor size (T2) or those associated with nodal involvement (N1), tumor satellites, and tumorlets. Subgroup tumors were regarded as affections with possible increased proliferation potential. The proliferate activity was examined immunohistochemically by topoisomerase II-alpha (clone SWT3D1) on paraffin material and calculated by the number of positive nuclei per 10 HPF. The topoisomerase expression was found to be statistically different in both principal groups made up of typical and atypical carcinoids with a mean value of 49 and 135 positive nuclei per 10 high power field in TC and AC, respectively. The remaining subgroups of the TCs associated with examined characteristics (larger tumor diameter, metastases, satellites, tumorlets) were not found to be statistically different. The topoisomerase II-alpha is a marker giving valuable information about the diagnosis of pulmonary typical and atypical carcinoids.

[Bacteriologic study of secretions of the lower respiratory tract after pulmonary resection]

Bacteriological monitoring of the low respiratory tract secretion was examined in 43 patients with lung resections. Three groups of cultivation results were evaluated: before operation, during operation and after operation in selected patients. There are two main reasons: 1. To prevent early infectious complications after operation, 2. To attempt treatment of the known bacteriological agent in time.

[Proliferative activity in pulmonary carcinoids]

AIM

On the basis of known Ki-67 dependence on tumor malignancy in some lesions, we compared this marker expression quantitatively in pulmonary typical and atypical carcinoid tumors and attempted to predict their biological behavior especially in cases associated with tumorous lymphadenopathy, satellites, and carcinoid tumorlets.

METHOD

Using material from surgically treated patients, we examined 54 cases of pulmonary carcinoids divided into five groups. 1. Forty-two typical carcinoids (TC), 2. Twelve atypical carcinoids (AC) diagnosed according to modified Arrigoni's criteria (Travis et al., 1998), 3. Thirty-two TC without metastases, satellites, and tumorlets (M, S, T), 4. Eight AC without M, S, T, and 5. Fourteen TC and AC associated with M, S, T. Groups 3, 4, and 5 were formed of cases selected from group 1 and 2. The proliferate activity was evaluated by Ki-67 (MIB-1, Immunotech France, 1:25). Its nuclear labeling was counted in more than 50 HPF and calculated as a number of positive nuclei in 10 HPF. The Fisher exact test was used for statistical analysis.

RESULTS

The Ki-67 nuclear expression was found in 19 (45%) out of 42 TC and in 9 (75%) out of 12 AC. In the set of TC without metastases (M, S, T), the Ki-67 positive labeling was found in 14 (44%) out of 32 cases (group III) and in six (75%) out of eight AC (group IV). In all TC and AC tumors with M, S, T (group V), the Ki-67 expression was encountered in 8 (57%) out of 14 cases. The Fisher exact test showed no significant difference between all examined groups.

CONCLUSION

No statistically significant difference was found in Ki-67 expression in pulmonary typical and atypical carcinoids. It appears to be a factor which can not be used for tumor prognosis prediction or adjuvant therapy indication in surgically treated patients.

Asymptomatic rupture of an aortoiliac aneurysm

The rupture of an abdominal aortic aneurysm is one of the most feared complications confronted by cardiovascular surgeons. Such ruptures are usually catastrophic, but in some instances the rupture is posterior and remains sealed. These chronic ruptures may manifest with any of a variety of clinical presentations. This report describes an uncommon presentation of a chronic rupture of an aortoiliac aneurysm in a patient with generalized aneurysmal disease. The rupture presented as an asymptomatic giant pulsatile mass in the patient's abdomen. The mass had developed over a period of several years. The literature is also reviewed.

[Auricular flutter associated with an interatrial septal aneurysm submitted to radiofrequency ablation]

We present the case of a young man who began with type I atrial flutter, he had no response to antiarrhythmic drugs. The echocardiogram showed an atrial septal aneurysm in the region of the fossa ovalis. We performed an electrophysiologic study which showed an atrial flutter with atrial rate of 257 bpm, and 2:1/3:1 AV conduction. The flutter waves were negatives in leads II, III and a VF (type I atrial flutter). An endocardial mapping was obtained in order to localize the area of slow conduction. It was located in the isthmus of atrial tissue bounded by the inferior vena cava and the tricuspid valve annulus in the low posterior septal right atrium. In this area we applied radiofrequency energy in 10 occasions but the arrhythmia was not suppressed. With atrial pacing we achieve a concealed entrainment and then resumption of atrial flutter after cessation of pacing. After another 6 applications of radiofrequency in this same area in sinus rhythm, we paced the atrium without inducing any form of arrhythmia. He was asymptomatic 15 days later, but one month after the ablation, the flutter reappeared, we performed a second successful radiofrequency ablation. In this time he was asymptomatic.

[Radiofrequency ablation in idiopathic ventricular tachycardia originating in the right ventricle]

We present the case of a 10-year-old boy, with structurally normal heart who began two years before admission, with sustained monomorphic ventricular tachycardia with heart rate of 280 bpm and LBBB morphology, AQRS + 60 degrees, with pallor and diaphoresis. The tachycardia was treated with xylocain. He was also treated with propaphenone, verapamil, and amiodarona, in spite of these, he continued with this type of arrhythmia 2 or 3 times a month. We performed an electrophysiologic study which showed ventricular tachycardia originated in the right ventricle infundibulum. We took an endomyocardial biopsy, which was normal. He was scheduled for percutaneous catheter ablation of the tachycardia by radiofrequency energy. During the procedure the ventricular tachycardia appeared spontaneously, we mapped the most early ventricular activation and then in sinus rhythm, this site was pace mapped and resulted in similar pattern of clinical ventricular tachycardia. We identified the site of origin of the ventricular tachycardia in the posterior region of the right ventricle infundibulum, delivering radiofrequency, changing to sinus rhythm. Then we paced the apex of the right ventricle without inducing any form of arrhythmia. He is asymptomatic four months later.

Mother-daughter interaction and adherence to diabetes regimens

This study explores the relationship of mother-daughter interaction to adherence to treatment plans among diabetic adolescents. Fifty mother-daughter dyads discussed conflict issues and feelings, problems, and concerns related to diabetes. Discussions were analyzed using the Hill Interaction Matrix and modified Beavers-Timberlawn Family Evaluation Scales. Interview questionnaires provided information on adherence, feelings, problems and concerns, parental supervision, adjustment, and family life. The less adherent the adolescent, the more emotionally charged the interaction, the more directly confrontive mother and daughter were, and the less efficient they were at negotiating issues. The adolescent's statements about herself confirmed observations that poor adherers, more than good adherers, had difficulty discussing feelings, problems, and concerns with their mothers (r = -0.51, P less than or equal to 0.001). Poor adherers reported believing less strongly that adherence would delay/avoid complications (r = 0.51, P less than or equal to 0.001), became more anxious about seeing a disabled diabetic person (r = -0.29, P less than or equal to 0.29), and worried more about future health (r = -0.27, P = NS). No relationships were found between adherence and adolescent-physician rapport. Many adolescents were not engaging in good self-care behaviors, were quite concerned about future health, perceived mothers to be very concerned, hesitated telling peers about their illness, and did not share deeper illness-related concerns with their closest nondiabetic friends.