Minimally-invasive pancreatic surgery in high volume centers in the Czech Republic - current status and possible implementations

INTRODUCTION

Minimally-invasive surgical methods have been becoming ever more common also in the segment of pancreatic surgery. The aim of this paper was to analyze the current state of minimally-invasive surgery in the Czech Republic and the justification and potential of implementing such procedures.

METHODS

Analysis of high volume centers using healthcare providers´ and payers´ data.

RESULTS

Thirteen pancreatic surgical centers meet the proposed criteria for being called a high volume center - a center of highly specialized care in pancreatic surgery based on the annual number of at least 17 major resections of the pancreas. According to data from healthcare payers, laparoscopy was used in 0.6%-65.7% of procedures in individual centers. However, these are not resection procedures. The centers themselves report a significantly smaller number of minimally-invasive pancreatic resection procedures. The actual numbers of minimally-invasive resection procedures in the current system are practically impossible to verify. The potential for implementing minimally-invasive pancreatic surgery in the Czech Republic can be estimated based on the identification of candidate patients.

CONCLUSION

Due to the fragmentation of this operative segment, its costs and small numbers of patients suitable for minimally-invasive pancreatic surgery even among high volume centers, the implementation rate of these methods is very slow. The need to centralize this segment of care appears to be very urgent from all points of view.

Laparoscopic liver resections - state of art

Progress had been made in the miniinvasive surgery in the past 30 years. Laparoscopic liver procedures were expanded from limited resections to major resection and complicated procedures. Miniinvasive approach offered better short-time results and similar oncological outcomes compared with open liver surgery. However, it is still challenging to perform some difficult procedures laparoscopically which requires a learning curve and accumulation of experiences in specialized centers.

[Iatrogenic biliary tract lesions requiring surgical reconstruction - presentation and classification of the lesions, their reconstruction and evaluation of the results]

INTRODUCTION

The incidence of biliary duct injuries requiring surgical reconstruction has stabilised between 0.30.7%. Biliary reconstruction in the hands of a trained hepatobiliary surgeon may lead to better short- and long-term outcomes in patients with this infrequent, but serious complication.

METHODS

This study presents a retrospective analysis of single surgeon experience with biliary injury repair during the period of 20072016. Extramucosal hepaticojejunostomy on the excluded segment of the jejunal loop was performed without the use of any transanastomotic drain. Immediate reconstruction of on-table recognised injuries was carried out; patients presenting with biliary leak were reconstructed early and patients presenting with biliary stricture underwent reconstruction depending on the degree of obstruction, presence of cholangitis and feasibility of endoscopic or percutaneous intervention. Postoperative complications were evaluated using Dindo-Clavien and ISGLS classification, and the effect of reconstruction was assessed according to McDonald criteria.

RESULTS

15 biliary reconstructions in 14 patients were performed during the study period. More than a half of the patients experienced some postoperative complication (53.33%); serious complication occurred in 2 patients. One patient (82 years old) died of non-surgical postoperative complications. Biliary leak occurred in three patients (20%), and deep surgical site infection (fasciitis) in four patients (33.33%). The average length of stay was 12.13 days. There was no revisional surgery during the index hospitalisation in any of the patients. There were two readmissions up to 90 days after biliary reconstruction (13.33%). The patients are currently followed up for an average of 4.01 years; compliance with follow-up is 100%. Successful reconstruction was achieved in 92.86% of patients; one patient required rehepaticojejunostomy (7.14%). According to McDonald criteria excellent results were accomplished in 6 patients (42.86%), good results in another 5 patients (35.71%) and 2 patients underwent percutaneous intervention on the reconstruction (14.28%).

CONCLUSION

When comparing results among various centres, we should take into account: 1. Experience of the centre/surgeon; 2. Case-mix (exact classification); 3. Timing of reconstruction; 4. Criteria for successful reconstruction; and 5. The length of follow-up. Patients in our centre who fulfil McDonald A and B criteria during the whole follow-up period are considered to have a successful repair. Reconstruction in McDonald C patients is also considered as a success by some authors, although this remains debatable as an early intervention on the reconstruction may be appropriate.Key words: cholecystectomy - bile duct injury - hepaticojejunostomy stricture.

Performance of CT ASPECTS and Collateral Score in Risk Stratification: Can Target Perfusion Profiles Be Predicted without Perfusion Imaging?

BACKGROUND AND PURPOSE

Endovascular trials suggest that revascularization benefits a subset of acute ischemic stroke patients with large-artery occlusion and small-core infarct volumes. The objective of our study was to identify thresholds of noncontrast CT-ASPECTS and collateral scores on CT angiography that best predict ischemic core volume thresholds quantified by CT perfusion among patients with acute ischemic stroke.

MATERIALS AND METHODS

Fifty-four patients with acute ischemic stroke (<12 hours) and MCA/intracranial ICA occlusion underwent NCCT/CTP during their initial evaluation. CTP analysis was performed on a user-independent platform (RApid processing of PerfusIon and Diffusion), computing core infarct (defined as CBF of <30% normal). A target mismatch profile consisting of infarction core of ≤50 mL was selected to define candidates with acute ischemic stroke likely to benefit from revascularization.

RESULTS

NCCT-ASPECTS of ≥9 with a CTA collateral score of 3 had 100% specificity for identifying patients with a CBF core volume of ≤50 mL. NCCT-ASPECTS of ≤6 had 100% specificity for identifying patients with a CBF core volume of >50 mL. In our cohort, 44 (81%) patients had an NCCT-ASPECTS of ≥9, a CTA collateral score of 3, or an NCCT-ASPECTS of ≤6.

CONCLUSIONS

Using an NCCT-ASPECTS of ≥9 or a CTA collateral score of 3 best predicts CBF core volume infarct of ≤50 mL, while an NCCT-ASPECTS of ≤6 best predicts a CBF core volume infarct of >50 mL. Together these thresholds suggest that a specific population of patients with acute ischemic stroke not meeting such profiles may benefit most from CTP imaging to determine candidacy for revascularization.

[Reverse strategy for synchronous colorectal liver metastases Therapeutic protocol completion, 3-year survival and progression pattern in 32 patients]

INTRODUCTION

Reverse, liver-first strategy is an alternative for patients with complicated liver metastases where disease progression would prove inoperable, or for patients with locally advanced pelvic disease where postoperative complications after primary tumour resection may lead to delayed treatment of metastatic disease.

METHODS

Retrospective unicenter analysis of 32 patients approached liver-first approach between 2011 and 2015. During this period reverse strategy was considered a preferred approach for all initially or potentially resectable synchronous colorectal liver metastases based on multidisciplinary team consensus.

RESULTS

26 patients (81.3%) completed their surgical plan (hepatectomy and primary tumour resection) but only 16 (50%) completed their oncosurgical plan (hepatectomy, primary tumour resection and full dose and length of perioperative or adjuvant systemic (bio)chemotherapy). Median overall survival was 50.5 months with the survival rate of 83.7% at 3 years. 20 patients (62.5%) progressed during the follow-up with median time to progression of 21.6 months. The liver was the most common site of recurrent disease followed by the lungs (65% and 20% of all recurrences, respectively).

CONCLUSION

While reverse strategy may allow complete tumour removal in the majority of patients, only half of them complete their oncosurgical plan even with the liver-first approach. The most problematic aspect of the liver-first strategy is the timing and length of perioperative (bio)chemotherapy. When deciding on preoperative chemotherapy in up-front resectable lesions one should take into account the risk of disease progression while on chemotherapy as well as the risks of complete radiologic response.

KEY WORDS

colorectal carcinoma reverse strategy liver-first approach liver metastases.

[Current status regarding surgical treatment of pancreatic cancer in the Czech Republic]

INTRODUCTION

The aim is to map the current situation in the surgical treatment of pancreatic cancer in the Czech Republic. This information has been obtained from surgical treatment providers using a simple questionnaire and by identifying the so called high volume centres. The information has been collected in the interest of organizing and planning research projects in the field of pancreatic cancer treatment.

METHOD

We addressed centres known to provide surgical treatment of pancreatic cancer. A simple questionnaire formulated one question about the total number of pancreatic resections, also separately for the diagnoses PDAC - C25, in the last two years (2014 and 2015). Other questions focused on the use of diagnostic methods, neoadjuvant therapy, preoperative assessment of risks, the possibility of rapid intraoperative histopathology examination, Leeds protocol, monitoring of morbidity and mortality including long-term results, and the method of postoperative follow-up and treatment. ÚZIS (Institute of Health Information and Statistics of the Czech Republic) was addressed with a request to analyze the frequency of reported total numbers for DPE, LPE, TPE and to do the same with respect to diagnosis C 25 for the last two years, available for the entire Czech Republic (2013, 2014).

RESULTS

Altogether 19 institutions were identified by the preceding audit, which reported more than 10 pancreatic resections annually; these institutions were addressed with the questionnaire. Sixteen institutions responded to the questions, 13 of them completely.

CONCLUSION

The majority of potentially radical surgeries for PDAC in the Czech Republic are carried out at 6 institutions. All of the institutions that participated in the survey collect data about morbidity and mortality and monitor their results.

KEY WORDS

pancreas cancer outcomes surgery.

[Evaluation in medical residency training programs]

BACKGROUND

For resident doctors the acquisition of technical and professional competence is decisive for the successful practice of their activities. Competency and professional development of resident doctors benefit from regular self-reflection and assessment by peers. While often promoted and recommended by national educational authorities, the implementation of a robust evaluation process in the clinical routine is often counteracted by several factors.

OBJECTIVE

The aim of the study was to test a self-developed digital evaluation system for the assessment of radiology residents at our institute for practicality and impact with regard to the radiological training.

MATERIAL AND METHODS

The intranet-based evaluation system was implemented in January 2014, which allowed all Radiology consultants to submit a structured assessment of the Radiology residents according to standardized criteria. It included 7 areas of competency and 31 questions, as well as a self-assessment module, both of which were filled out electronically on a 3-month basis using a 10-point scale and the opportunity to make free text comments. The results of the mandatory self-evaluation by the residents were displayed beside the evaluation by the supervisor. Access to results was restricted and quarterly discussions with the residents were conducted confidentially and individually.

RESULTS AND DISCUSSION

The system was considered to be practical to use and stable in its functionality. The centrally conducted anonymous national survey of residents revealed a noticeable improvement of satisfaction with the institute assessment for the criterion "regular feedback"compared to the national average. Since its implementation the system has been further developed and extended and is now available for other institutions.

Performance and Predictive Value of a User-Independent Platform for CT Perfusion Analysis: Threshold-Derived Automated Systems Outperform Examiner-Driven Approaches in Outcome Prediction of Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Treatment strategies in acute ischemic stroke aim to curtail ischemic progression. Emerging paradigms propose patient subselection using imaging biomarkers derived from CT, CTA, and CT perfusion. We evaluated the performance of a fully-automated computational tool, hypothesizing enhancements compared with qualitative approaches. The correlation between imaging variables and clinical outcomes in a cohort of patients with acute ischemic stroke is reported.

MATERIALS AND METHODS

Sixty-two patients with acute ischemic stroke and MCA or ICA occlusion undergoing multidetector CT, CTA, and CTP were retrospectively evaluated. CTP was processed on a fully operator-independent platform (RApid processing of PerfusIon and Diffusion [RAPID]) computing automated core estimates based on relative cerebral blood flow and relative cerebral blood volume and hypoperfused tissue volumes at varying thresholds of time-to-maximum. Qualitative analysis was assigned by 2 independent reviewers for each variable, including CT-ASPECTS, CBV-ASPECTS, CBF-ASPECTS, CTA collateral score, and CTA clot burden score. Performance as predictors of favorable clinical outcome and final infarct volume was established for each variable.

RESULTS

Both RAPID core estimates, CT-ASPECTS, CBV-ASPECTS, and clot burden score correlated with favorable clinical outcome (P < .05); CBF-ASPECTS and collateral score were not significantly associated with favorable outcome, while hypoperfusion estimates were variably associated, depending on the selected time-to-maximum thresholds. Receiver operating characteristic analysis demonstrated disparities among tested variables, with RAPID core and hypoperfusion estimates outperforming all qualitative approaches (area under the curve, relative CBV = 0.86, relative CBF = 0.81; P < .001).

CONCLUSIONS

Qualitative approaches to acute ischemic stroke imaging are subject to limitations due to their subjective nature and lack of physiologic information. These findings support the benefits of high-speed automated analysis, outperforming conventional methodologies while limiting delays in clinical management.

[Colon cancer - evaluation of complications and risks of planned resections]

INTRODUCTION

Resection procedures for colorectal cancer are burdened with a relatively high number of complications. The aim of this study is to define risk factors associated with the development of postoperative complications based on retrospective data analysis.

MATERIAL AND METHODS

From January 1 st 2007 to December 31st 2012, 1093 patients underwent surgery for colorectal cancer. Retrospectively, we selected a group of 406 patients who underwent planned, elective colon resection for colon cancer. Open surgery was performed in 158 patients (38.9%), laparoscopic resection in 248 patients (61.1%). Based on initial staging of the disease, there were 85 patients (20.9%) in stage I, 137 patients (33.8%) in stage II, 110 patients (27.1%) in stage III and 74 patients (18.2%) in stage IV. Postoperative complications were evaluated according to Clavien - Dindo classification.

RESULTS

Grade I complications were observed in 34 patients (8.4%), grade II in 25 patients (6.2%), grade III in 43 patients (10.6%), grade IV in 7 patients (1.7%) and grade V in 8 patients (2.0%). The highest incidence of complications was observed in left colon resection procedures (41.1%), open resections (39.8%), procedures lasting longer than 301 minutes (50%), patients older than 81 years (41.6%) and in procedures performed by the youngest, less experienced surgeon (40.6%).

CONCLUSION

Our results confirmed that the type and approach of surgical procedure, patients age and surgeons experience are risk factors associated with a higher incidence of postoperative complications. High-risk surgical patients should be operated on by experienced surgeon who regularly performs a high number of resection procedures.

Diffusion-weighted imaging with dual-echo echo-planar imaging for better sensitivity to acute stroke

BACKGROUND AND PURPOSE

Parallel imaging facilitates the acquisition of echo-planar images with a reduced TE, enabling the incorporation of an additional image at a later TE. Here we investigated the use of a parallel imaging-enhanced dual-echo EPI sequence to improve lesion conspicuity in diffusion-weighted imaging.

MATERIALS AND METHODS

Parallel imaging-enhanced dual-echo DWI data were acquired in 50 consecutive patients suspected of stroke at 1.5T. The dual-echo acquisition included 2 EPI for 1 diffusion-preparation period (echo 1 [TE = 48 ms] and echo 2 [TE = 105 ms]). Three neuroradiologists independently reviewed the 2 echoes by using the routine DWI of our institution as a reference. Images were graded on lesion conspicuity, diagnostic confidence, and image quality. The apparent diffusion coefficient map from echo 1 was used to validate the presence of acute infarction. Relaxivity maps calculated from the 2 echoes were evaluated for potential complementary information.

RESULTS

Echo 1 and 2 DWIs were rated as better than the reference DWI. While echo 1 had better image quality overall, echo 2 was unanimously favored over both echo 1 and the reference DWI for its high sensitivity in detecting acute infarcts.

CONCLUSIONS

Parallel imaging-enhanced dual-echo diffusion-weighted EPI is a useful method for evaluating lesions with reduced diffusivity. The long TE of echo 2 produced DWIs that exhibited superior lesion conspicuity compared with images acquired at a shorter TE. Echo 1 provided higher SNR ADC maps for specificity to acute infarction. The relaxivity maps may serve to complement information regarding blood products and mineralization.

[Anterior cruciate ligament injuries in children and adolescents in our patient group]

PURPOSE OF THE STUDY

Today arthroscopy remains the principal method in both the diagnosis and the therapy of knee injuries also in children and adolescents because serious knee ligament injuries, including those to the anterior cruciate ligament (ACL), are not rare in childhood. According to many authors, consequences of knee instability in children are more serious than in adults.

MATERIAL AND METHODS

In 713 patients treated by arthroscopy for knee joint injuries at our department between 2000 and 2010, ACL injury ranked fifth among knee injuries and was found in 85 patients (12%). All patients in this group were under 19 years of age. The average age at the time of arthroscopic surgery was 15 years and 3 months. The patients were followed up at regular intervals for the symptoms and signs of anterior knee instability. Skeletal maturity achieved by the final follow-up (in 2010) was recorded in 69 (82%) of them.

RESULTS

Of the 85 patients with ACL injury, 50 subsequently underwent ACL reconstruction. This procedure was used only when they achieved skeletal maturity. Correlation between pre-operative clinical diagnosis and arthroscopic findings was found only in 52% of the patients.

DISCUSSION

The problem of anterior knee instability in children and adolescents still remains unsolved. Although surgical procedures for ACL reconstruction in skeletally immature patients have been described, most of the authors support the option of ACL reconstruction at the age of skeletal maturity. This view is also maintained by our team.

CONCLUSIONS

The aim of this study was to draw attention to ACL injuries and resulting knee instability in children and adolescents.

Clinical assessment of standard and generalized autocalibrating partially parallel acquisition diffusion imaging: effects of reduction factor and spatial resolution

BACKGROUND AND PURPOSE

PI improves routine EPI-based DWI by enabling higher spatial resolution and reducing geometric distortion, though it remains unclear which of these is most important. We evaluated the relative contribution of these factors and assessed their ability to increase lesion conspicuity and diagnostic confidence by using a GRAPPA technique.

MATERIALS AND METHODS

Four separate DWI scans were obtained at 1.5T in 48 patients with independent variation of in-plane spatial resolution (1.88 mm(2) versus 1.25 mm(2)) and/or reduction factor (R = 1 versus R = 3). A neuroradiologist with access to clinical history and additional imaging sequences provided a reference standard diagnosis for each case. Three blinded neuroradiologists assessed scans for abnormalities and also evaluated multiple imaging-quality metrics by using a 5-point ordinal scale. Logistic regression was used to determine the impact of each factor on subjective image quality and confidence.

RESULTS

Reference standard diagnoses in the patient cohort were acute ischemic stroke (n = 30), ischemic stroke with hemorrhagic conversion (n = 4), intraparenchymal hemorrhage (n = 9), or no acute lesion (n = 5). While readers preferred both a higher reduction factor and a higher spatial resolution, the largest effect was due to an increased reduction factor (odds ratio, 47 ± 16). Small lesions were more confidently discriminated from artifacts on R = 3 images. The diagnosis changed in 5 of 48 scans, always toward the reference standard reading and exclusively for posterior fossa lesions.

CONCLUSIONS

PI improves DWI primarily by reducing geometric distortion rather than by increasing spatial resolution. This outcome leads to a more accurate and confident diagnosis of small lesions.

[Treatment of sequelae after Monteggia lesions in childhood]

PURPOSE OF THE STUDY

To review the current methods of operative management of post-traumatic chronic radial head dislocation in chronic Monteggia lesions in children.

MATERIAL AND METHODS

Post-traumatic chronic dislocation of the proximal radius usually occurs following missed or ineffectively treated Monteggia fractures. The radial head is usually dislocated anteriorly. We performed open reduction of the radial head, reconstruction of the annular ligament and corrective osteotomy of the ulna in eleven patients. Three of our patients underwent ulnar lengthening via gradual distraction using an Ilizarov external fixator. This procedure was used in nine boys and five girls who were treated for complications following Monteggia lesions between 2000 and 2009. The average age at the time of surgery was 8 years and 4 months, the average injury-to-surgery interval was 19 months, and a prerequisite for surgery was a normal concave articular surface of the proximal radius. The patients were followed up for an average of 28 months and, at final follow-up, all were fully active and had no pain or instability.

RESULTS

The complications included: non-union of the ulnar osteotomy site in two patients, residual radiocapitellar subluxation in two patients, and one patient had revision surgery. Nine patients showed a full range of motion, two had a loss of extension, and three had a mean loss of pronation of 20 degrees and a mean loss of supination of 20 degrees.

DISCUSSION

The Monteggia lesion is a rare fracture in childhood, but its sequelae can be serious. So far a unified therapeutic approach has not been proposed. Most authors prefer reconstruction surgery. Our results are in full agreement with the published data.

CONCLUSIONS

The operative treatment of consequences after Monteggia fractures in children has a relatively high rate of complications and unpredictable results. Indications for reconstruction involve a normal articular surface of the radial head and a normal alignment of the radius and ulna. Key words: Monteggia fracture, consequences, reconstruction surgery, childhood.

Cerebral CT perfusion using an interventional C-arm imaging system: cerebral blood flow measurements

BACKGROUND AND PURPOSE

CTP imaging in the interventional suite could reduce delays to the start of image-guided interventions and help determine the treatment progress and end point. However, C-arms rotate slower than clinical CT scanners, making CTP challenging. We developed a cerebral CTP protocol for C-arm CBCT and evaluated it in an animal study.

MATERIALS AND METHODS

Five anesthetized swine were imaged by using C-arm CBCT and conventional CT. The C-arm rotates in 4.3 seconds plus a 1.25-second turnaround, compared with 0.5 seconds for clinical CT. Each C-arm scan had 6 continuous bidirectional sweeps. Multiple scans each with a different delay to the start of an aortic arch iodinated contrast injection and a novel image reconstruction algorithm were used to increase temporal resolution. Three different scan sets (consisting of 6, 3, or 2 scans) and 3 injection protocols (3-mL/s 100%, 3-mL/s 67%, and 6-mL/s 50% contrast concentration) were studied. CBF maps for each scan set and injection were generated. The concordance and Pearson correlation coefficients (ρ and r) were calculated to determine the injection providing the best match between the following: the left and right hemispheres, and CT and C-arm CBCT.

RESULTS

The highest ρ and r values (both 0.92) for the left and right hemispheres were obtained by using the 6-mL 50% iodinated contrast concentration injection. The same injection gave the best match for CT and C-arm CBCT for the 6-scan set (ρ = 0.77, r = 0.89). Some of the 3-scan and 2-scan protocols provided matches similar to those in CT.

CONCLUSIONS

This study demonstrated that C-arm CBCT can produce CBF maps that correlate well with those from CTP.

[Tricalcium phosphate mixed with autologous bone marrow in the treatment of benign cystic bone lesions in children]

PURPOSE OF THE STUDY

To test the hypothesis that the application of tricalcium phosphate (TCP) mixed with autologous bone marrow can achieve better and faster healing of benign bone lesions than the application of tricalcium phosphate granules alone.

MATERIAL AND METHODS

The prospective study included two groups, each consisting of 10 patients, treated for benign cystic bone lesions at the Department of Paediatric Surgery, Orthopaedics and Trauma Surgery from July 1, 2008 to June 30, 2010. The bone cysts involved non-ossifying fibroma, enchodroma, fibrous dysplasia, aneurysmal bone cyst and juvenile bone cyst. One group was treated using ChronOS(TM) Beta-Tricalcium Phosphate (Synthes GmbH, Switzerland) granules mixed with autologous bone marrow harvested during surgery (BM group). The other (CH group) received treatment with ChronOS granules alone. Relevant clinical data were obtained from all 20 patients treated for one of the bone cyst forms mentioned above. The patients were followed up till the end of 2010.

RESULTS

TCP application was a one-step procedure in both groups. In the BM group, bone regeneration ad integrum (Neer 1) was achieved, with only an occasional very small residue of the cyst seen on radiographs (Neer 2). None of the patients reported any problems, not even at 6 months after surgery. In the CH group, two patients required further surgical treatment because of insufficient bone healing (Neer 3) and two other patients reported pain persisting at the site of the lesion at 6 months post-operatively. In these patients TCP was used to fill a defect after excochleation of an aneurysmal bone cyst or fibrous dysplasia. The rest of the patients showed satisfactory healing.

DISCUSSION

The main objective of the use of synthetic biocompatible materials in surgical treatment of benign bone cysts requiring filling of the lesion is to reduce the post-operative stress of paediatric patients as much as possible. Although our first results were not statistically significant to give unambiguous support to our hypothesis that lesions would heal better with the use of synthetic tricalcium phosphate mixed with autologous bone marrow, there is plenty of evidence that further development of cell technologies will result in a more exact definition of bone substitute materials in both their components, i.e., well-defined cells and non-biological scaffolds close in structure to inorganic compounds of bone, i.e., biodegradable osteoinductive materials.

CONCLUSIONS

The patients with benign bone lesions treated by TCP mixed with autologous bone marrow showed neither recurrent disease nor complications. The group treated with TCP alone had recurrent lesions in two and persisting pain also in two patients. Other complications were not recorded.

Oral manifestations of diabetes mellitus and influences of periodontological treatment on diabetes mellitus

The aim of this review was to describe and determine the oral manifestation of DM and influences of periodontological treatment on DM. Diabetes mellitus (DM) is one of the most serious diseases of metabolism. Long-term consequences of hyperglycemia are very heterogeneous, and affect practically all tissues and organs of organism. Classical signs and symptoms of DM are polyphagia, polyuria, polydipsia, physical weakness, and decreased immunity against infections. Untreated and fully developed DM results in numerous complications, of which the most serious include nephropathies, retinopathies, myopathies, neuropathies, cardiovascular diseases, bad wound healing and disorders of microvascularity and macrovascularity. Oral manifestations of DM are of different types and they affect various tissues of this region. Summarizing and comparing the literature data were used to obtain these goals. From the etiopathogenetic viewpoint, we can state that the so far best-investigated oral complication is that of diabetic periodontitis and its consequences, including early teeth loss. Uncontrolled hyperglycemia deteriorates the periondontal status to the extent of developing into a clinical picture of diabetic periodontitis. On the other hand, it is to be noted that not all researchers have confirmed that the treatment of periodontitis brings about a statistically important improvement in diabetic markers, mainly HbA1c. It is necessary to continue in these studies (Ref. 34).

[Synthetic biocompatible degradable material for juvenile bone cyst treatment]

PURPOSE OF THE STUDY

Owing to advances in operative techniques and biotechnology, bone replacement biocompatible materials have recently come into focus for orthopaedic and trauma surgeons. Bone lytic lesions, such as tumorous bone defects, diseases simulating cancer, chronic inflammatory lesions or skeletal injuries, often require stabilisation of the skeleton and treatment of the bone affected. Juvenile bone cysts are benign lytic lesions posing a threat to bone compactness in childhood. They are benign, fluid containing bone cavities, lined with a membrane consisting of thin vascularised connective tissue with scattered osteoclast-like cells. These cysts are usually diagnosed between; five and twenty years of age outside this age range their occurrence is rare.

MATERIAL

The group comprised the patients treated for juvenile bone cysts at the Department of Paediatric Surgery, Orthopaedics and Traumatology between 2001 and 2007. In the 2001-2003 period, 24 patients were treated with Depo-Medrol. Between January 2005 and December 2007, 31 patients with the same diagnosis were treated by minimally invasive application of chronOs Inject.

METHODS

The aim of the study was to compare these two methods of juvenile cyst therapy, i.e., the most widely used method of repetitive Depo-Medrol applications against the novel method based on filling the cyst with chronOs Inject, a synthetic biocompatible resorbable material. An alternative hypothesis assumed that the new method would result in fewer necessary operations in patients with juvenile cyst and better treatment outcomes, as evaluated by Neer's criteria for bone cyst therapy.

RESULTS

A total of 20 surgical interventions were performed in 18 patients treated by chronOs Inject and 100% cyst healing without necessity of additional surgery was achieved. Of the 24 patients treated with Depo-Medrol, 12 patients (50%) showed cyst healing wit no further surgery required. A total of 69 applications were needed.

DISCUSSION

An impetus to introduce the novel method of juvenile cyst treatment stemmed from the unsatisfactory results of the previous treatment with repetitive Depo-Medrol applications requiring additional open surgery and spongioplasty to fill the cyst. For filling cysts and other benign bone defects jeopardizing bone stability, such as deep metaphyseal fibrous defect, non-ossifying fibroma, enchondroma or fibrous dysplastic lesion, synthetic tricalcium phosphate in the form of chronOs granules was used, but without the possibility of minimally invasive percutaneous application. As soon s the resorbable chronOs Inject became available, the minimally invasive method of filling cysts with this material was adopted.

CONCLUSIONS

The results showed that, in the patients treated by the chronOs Inject method, the outcomes achieved were significantly better than those in the patients treated with Depo-Medrol. The difference was in the number of operations needed, which were significantly fewer in the chronOs Inject method, as well as in the overall treatment outcome, with significantly more frequent excellent results in the chronOs Inject method.

[Modern radiotherapy in the complex management of soft tissue and bone sarcomas in adults--current overview and the author's experience]

Soft tissue sarcomas and primary bone tumours constitute very heterogenic group. Gold treatment standard is surgery in most of them. Nowadays the combination surgery with radiotherapy is preferred, because thanks new radiotherapeutic technology is possible to apply very high dose of radiation which necessary for local control of these tumours. The goal of our article is to describe new possibilities of radiotherapy, including neoadjuvant and adjuvant setting, intraoperative radiotherapy, interstitial brachytherapy and the combination with surgery. But very important is multidisciplinary cooperation to until recently in prognostic bad group of patients, concentration these patients to centers with modern technique and clinical experience with treatment of soft tissue sarcomas and bone tumours.

Perfusion MRI (Tmax and MTT) correlation with xenon CT cerebral blood flow in stroke patients

BACKGROUND

While stable xenon CT (Xe-CT) cerebral blood flow (CBF) is an accepted standard for quantitative assessment of cerebral hemodynamics, the accuracy of magnetic resonance perfusion-weighted imaging (PWI-MRI) is unclear. The Improved PWI Methodology in Acute Clinical Stroke Study compares PWI findings with Xe-CT CBF values in patients experiencing symptomatic severe cerebral hypoperfusion.

METHODS

We compared mean transit time (MTT) and Tmax PWI-MRI with the corresponding Xe-CT CBF values in 25 coregistered regions of interest (ROIs) of multiple sizes and locations in nine subacute stroke patients. Comparisons were performed with Pearson correlation coefficients (R). We performed receiver operating characteristic (ROC) curve analyses to define the threshold of Tmax and absolute MTT that could best predict a Xe-CT CBF <20 mL/100 g/minute.

RESULTS

The subjects' mean (SD) age was 50 (15) years, the median (interquartile range [IQR]) NIH Stroke Scale score was 2 (2-6), and the median (IQR) time between MRI and Xe-CT was 12 (-7-19) hours. The total number of ROIs was 225, and the median (IQR) ROI size was 550 (360-960) pixels. Tmax correlation with Xe-CT CBF (R = 0.63, p < 0.001) was stronger than absolute MTT (R = 0.55, p < 0.001), p = 0.049. ROC curve analysis found that Tmax >4 seconds had 68% sensitivity, 80% specificity, and 77% accuracy and MTT >10 seconds had 68% sensitivity, 77% specificity, and 75% accuracy for predicting ROIs with Xe-CT CBF <20 mL/100 g/minute.

CONCLUSION

Our results suggest that in subacute ischemic stroke patients, Tmax correlates better than absolute mean transit time (MTT) with xenon CT cerebral blood flow (Xe-CT CBF) and that both Tmax >4 seconds and MTT >10 seconds are strongly associated with Xe-CT CBF <20 mL/100 g/minute. CBF = cerebral blood flow; DBP = diastolic blood pressure; DEFUSE = Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution; DWI = diffusion-weighted imaging; EPITHET = Echoplanar Imaging Thrombolytic Evaluation Trial; FOV = field of view; ICA = internal carotid artery; IQR = interquartile range; MCA = middle cerebral artery; MTT = mean transit time; NIHSS = NIH Stroke Scale; PWI = perfusion-weighted imaging; PWI-MRI = magnetic resonance perfusion-weighted imaging; ROC = receiver operating characteristic; ROI = region of interest; SBP = systolic blood pressure; SVD = singular value decomposition; Xe-CT = xenon CT.

[The technological screening of beers, made in Slovak Republic, in the view of forensic alcohology]

The questions connected with forensic alcohology are closely bounded with the legal norms and actual production of alcoholic beverages, incl. the breweries. The presented work, dealing with the beers being made in Slovak republic, had been stipulated by the Slovak Society of Forensic Medicine, in the aim to inform the forensic experts about the beers being produced in the country mentioned.

Paratuberculosis and avian tuberculosis infections in one red deer farm studied by IS900 and IS901 RFLP analysis

As the attempt to eradicate paratuberculosis in one red deer (Cervus elaphus) farm failed, all 167 red deer of different age groups were slaughtered and examined by culture for mycobacteria, and the farm was closed down. Spleen and hepatic lymph nodes, mediastinal lymph node, ileocecal lymph node, and ileum were collected from each animal and examined (a total of 835 organs). Neither tuberculosis lesions nor pathognomic signs of paratuberculosis were detected. Among all microscopically negative for mycobacteria organs, Mycobacterium avium subsp. paratuberculosis alone was isolated from 165 organs, M. a. avium alone from 41 organs, and both pathogens from four organs. M. a. paratuberculosis alone was detected in 71 red deer, M. a. avium alone in 13 red deer and both pathogens in 18 red deer. Using standardised RFLP methods, three IS900 RFLP types B-C1, B-C16, and B-C32 were identified among 40 M. a. paratuberculosis isolates and four IS901 RFLP types N-B1, N-B3, N-B4, and P-B3 among 17 M. a. avium isolates.

[Periosteal tethering of growth plates in long bones (focal fibrocartilaginous dysplasia)]

PURPOSE OF THE STUDY

Another three cases of periosteal tethers (focal fibrocartilaginous dysplasia) are reported. Until now only 54 children affected by this entity were described. Analysis of these three cases concerning clinical appearance, x-ray deformity, preoperative and histologic findings and the end-results of the own method of surgical treatment was undertaken to categorise the proper diagnosis.

MATERIAL

The studied group involved distal posteromedial femoral lesion (Boy aged 11 months, Epiphysis-diaphysis angle 68 degrees, femoro-tibial angle 27 degrees). Another case with proximal tibial lesion on the lateral side (Boy aged 18 months, Epiphysis-diaphysis angle 75 degrees, femoro-tibial angle 18 degrees). Third case with proximal tibial lesion, localised typically medially (Boy aged 17 months, Epiphysis-diaphysis angle 70 degrees, femoro-tibial angle 19 degrees).

METHODS

All three cases were routinely followed for short time, before surgical correction was performed. AP and lateral x-rays were undertaken. Surgical correction involved curretage of the lesion and a half-circumferential excision of the periost between the lesion and the physis. Short-term immobilisation followed. In no case an osteotomy was needful.

RESULTS

Limited surgical approach consisting of curretage and periost excision resulted in slow but full correction of the long bone angulation. In the distal femoral lesion the normal value of limb axis was achieved in 9 years, in proximal and lateral tibial lesion in 7 years and in proximal and medial tibial lesion in 3 years. Persisting shortening of the limb length was found only in femoral lesion involving 10 millimetres. Histologic findings comprised areas of dense fibrous tissue, of fibrocartilage and of sclerotic bone. Bacterial cultivation was negative.

DISCUSSION

It seems, that there is almost no difference between clinical, x-ray and preoperative findings of periosteal tethers and focal fibrocartilaginous dysplasia. A real fibrous band between the cortical lesion and the physis was not found in this study, however the periost was roughened and adhered firmly to the bone. Limited surgical exposure consisting of curretage and half-circumferential excision of periost quaranteed in all three cases full correction of the former deformity.

CONCLUSION

Osteotomy is not an absolutely necessary surgical solution in these cases.

Comparison of enzyme immunoassay and mouse bioassay for determining paralytic shellfish poisoning toxins in shellfish

Sixty shellfish samples (mussel [Mytilus edulis], queen scallops [Chlamys opercularis] and king scallops [Pecten maximus]), collected during routine surveillance for paralytic shellfish poisoning (PSP) toxins conducted by the UK Ministry of Agriculture, Fisheries and Food and the Scottish Office Agriculture, Environmental Fisheries Department, were analysed for contamination with PSP toxins by mouse bioassay (MBA), and by a competitive direct enzyme immunoassay (Ridascreen Saxitoxin ELISA). Using the MBA as the reference method (detection limit: 350 micrograms kg-1), no false negative results out of a total of 45 MBA-positive samples and one false positive result out of a total of 15 MBA-negative samples were obtained by ELISA. The correlation coefficient for MBA-positive samples (n = 45) was 0.78. At the regulatory level for PSP toxins (800 micrograms kg-1), 39 of the samples were correctly determined by ELISA to be above or below this level, toxicity was overestimated in two samples, and underestimated in four samples.

Enzyme immunoassay for the detection of isoxazolyl penicillin antibiotics in milk

Polyclonal antibodies were raised against isoxazolyl penicillins in rabbits after immunization with a cloxacillin-human serum albumin conjugate. The antisera were tested in direct and indirect competitive enzyme immunoassays (EIAs), using glucose oxidase or horseradish peroxidase conjugates of oxacillin, cloxacillin, or dicloxacillin, respectively, as the labelled antigen. The relative cross-reactivities of each test system with oxacillin, cloxacillin, and dicloxacillin, determined from the amount of antibiotic required for 50% inhibition of labelled antigen binding, were dependent on the antibiotic used as the labelled antigen. Other beta-lactam antibiotics did not cross-react in these test systems. In a direct EIA using a cloxacillin-horseradish peroxidase conjugate, cloxacillin and dicloxacillin in milk were detected at levels of 10 and 30 ng ml-1; the average recoveries at these levels were 102 and 84%, respectively.

Early diagnosis of congenital dislocation of the hip

In this prospective study, 35,550 neonates were examined shortly after birth by a team of orthopaedic surgeons. They diagnosed 775 unstable or dislocated hips in 656 babies; there were two teratological dislocations. Treatment was first with a Frejka pillow and, if this failed to give a normal hip, a Pavlik harness at three months. Early clinical examination did not identify 21 infants who were found to have subluxation or dislocation of the hip at the three-month review. The number of missed cases declined during the study, however, reflecting the increasing experience of the examiners. One case of avascular necrosis occurred in the group treated from birth and one in the late-diagnosed group. Open reduction was necessary only in the two teratological dislocations. Experienced examiners are needed for accurate clinical diagnosis; and treatment should be started before the baby is discharged from the maternity ward.

[Bone Reconstruction of Autolyzed Antigen-free Allogenic /AAA/ Bone in Children and Adolescents with Benign Bone Tumours.]

The authors describe in detail the preparation of six batches of human AAA/autolyzed antigen-free allogenic bone/ prepared in 1985 to 1988. This bone was administered to a total of 48 children and adolescents aged 6 to 19 years. It was used to fill cavities after metaphyseal connective tissue bone defects /31 x/, solitary bone cysts /10 x/, enchondromas /5 x/ and fibrous dysplasia /2 x/. The observation period was 2 years and 2 months to 5 years and 9 months. The mean volume of the cavities was 21 ml. In all patients the X-ray pictures were evaluated in a chronological sequence and changes on the host s bones in the cavity and the inserted AAA bones were described, and finally also changes of the entire bone complex with incorporated AAA implants. The results were arranged in tables. On the host's bones a periosteal reaction was observed in the area surrounding the focus, the entire cavity was covered with a soft shadow, there was sclerosis of the margins and bottom of the bone bed and gradual diminution of the bone defect from the sides and bottom of the bed. On the AAA bones the following observations were of interest: the connection of AAA bone with the surrounding newly formed bone, less clearly defined outlines of the AAA bone, loss of identity of the AAA bone. Sclerosis or elimination of the AAA bone were not observed. In three patients with batch 5 a "halo" effect was observed. On the entire complex with incorporated AAA bones the following were investigated: sclerosis of the entire portion of the bone, then regression and diminution of sclerosis, differentiation of the corticalis and medullary cavity and formation of a normal bone structure without signs of previous treatment. Preparation of six different batches of AA bone revealed that: 1.The spongious parts are more readily and more rapidly incorporated than the cortical part which is only partly demineralized. 2.Gelatinization with LiCI had a favourable effect on the incorporation of thus prepared implants. X-ray investigation revealed that the course of incorporation and reconstruction of these bones has the following specific features: 1.Reconstruction begins as a rule by the periosteal reaction of the host and its shift above the gap has a favourable effect on healing of the defect. 2.Two months after operation the cavity is covered by a soft shadow when the newly formed vessels and mesenchymal cells of the host infiltrate into the focus. 3.Activation of the bed is manifested by its greater density, sclerotization and by gradual diminution of the volume of the cavity. The greater density is not necessarily associated with diminution of the size of the cavity. 4.Bone implants are connected to the newly formed bone without passing through the stage of densi fication and sclerotization. The newly formed bone infiltrates them, absorbs and replaces the bone proper without signs of the previous stage of scle rosis, as observed in patients with frozen allogenic bones. 5.After incorporation of AAA implants further bone reconstruction takes place, as known from the healing of fractures or bone gaps. Key words: demineralized bone, AAA bone, benign bone tumors, reconstruction of bone transplant.

[Clinical and ultrasonic diagnosis of congenital hip dislocation (dynamics of changes in early therapy)]

The authors present part of their prospective epidemiological study of congenital dysplasia of hip joints within which newborns were examined by ultrasonogram prior to the beginning of the therapy. Apart from the standard examination in the frontal plane after Graf they examined on principle also the ultrasonographic stability by the dynamic test after Schuler as well as by the application of the probe anteriorly with the simultaneous provocation according to Palmén. The authors have processed pathological ultrasonographic findings in 53 newborns (64 hip joints). The technique of the examination by ultrasound from the anterior approach is explained in detail. The comparison of both dynamic tests has shown that the examination from the anterior approach is considerably more sensitive than Schuler's dynamic test and also fully correlates with the clinical finding. It is a fact that the shift of the head in the flexion dorsally represents the most important component of the movement in unstable hip joint during provocation, it is far more noticeable than the lateralization of the head or the shift in the cranial direction. After achieving ultrasonographic stability the classical Graf method is sufficient for the registration of residual changes on the acetabular rim. The follow-up of patients until their complete healing has shown a surprisingly rapid remodellation of hip joints. The whole complex of clinically unstable hip joints has been divided into subgroups according to Graf classification. In type IIc or IId on the basis of ultrasonographic examination from the anterior approach the stable joints from the ultrasonographic viewpoint have been distinguished from unstable ones. The follow-up carried out in short intervals has shown that of longest duration is the remodellation of total dislocation and, on the contrary, of shortest duration is the healing of joints in the IIc or IId type. An absolute majority of affected hip joints have become normal until 3rd month of the age. The complex does not include two patients with teratological dislocation, the incidence of which has been determined in our study by the ratio of 2 cases in 35,550 of timely examined newborns. The role of the factor of spontaneous stabilization cannot be in this part of the study completely discounted. However, herewith we present part of an accomplished epidemiological study where the number of timely diagnosed patients including late diagnoses corresponds to the number of dislocations and subluxations determined within the conventional late diagnosis.

Examination of bile acid negative feedback regulation in rats

Recent data obtained using cultured rat hepatocytes showed that bile acids do not inhibit bile acid synthesis, whereas cholesterol concentrations vary in parallel with bile acid synthesis (Davis et al. (1983. J. Biol. Chem. 258: 4079-4082). This led us to re-evaluate in vivo experiments upon which the consensus that bile acid synthesis is primarily regulated by bile acid "negative feedback" is based. Infusion of taurocholate into either the jugular vein or duodenum of bile-diverted rats stimulated biliary cholesterol secretion and bile flow, but it did not inhibit bile acid synthesis. The lack of an inhibitory effect was evident using several different infusion rates of taurocholate. Even at the greatest rate of taurocholate infusion (25 mumol/(100 g.hr] there was no significant inhibition of bile acid synthesis. In contrast, infusing mevinolin (1 mg/hr), a potent competitive inhibitor of HMG-CoA reductase, almost completely inhibited bile acid synthesis and biliary cholesterol secretion. Since mevinolin did not affect bile flow, these results cannot be ascribed to bile secretory failure. Thus, while these studies suggest that taurocholate may not regulate bile acid synthesis directly via negative feedback, cholesterol is likely to act as a positive effector of bile acid synthesis.

[Transient infarct-like ECG findings in cholecystectomy]

It is reported on the appearance of transient infarction-like electrocardiographic changes in a 49-year-old female patient which developed during a cholecystectomy after cardiac arrest due to a considerable loss of blood. The ECG normalised within 7 minutes, neither accompained nor followed by any pathologic ion displacements in the systemic blood or by enzyme changes (GOT, GPT).