New Frontiers in Electrocardiography, Cardiac Arrhythmias, and Arrhythmogenic Disorders

In recent decades, diagnosing, risk-stratifying, and treating patients with primary electrical diseases, as well as heart rhythm disorders, have improved substantially [...].

Assessment of the Learning Process After Introducing a New Liver Transplantation Procedure in a Center With Extensive Experience in Kidney Transplantation

BACKGROUND

Liver transplantation (LTx) is one of the most complex transplant procedures. The aim of the present study was to determine whether the learning process can be observed after the introduction of LTx in a center with extensive previous experience in renal transplantation.

METHODS

This retrospective analysis included 264 primary LTx procedures performed with the piggyback technique (2005-2016). The procedures were divided into 4 equal groups. The characteristics of the recipients, data related to the surgery, and the postoperative course and complications were analyzed.

RESULTS

We observed a significant reduction in surgical time and in the anhepatic phase duration between Group 1 and the other groups (median surgical time was 455 minutes vs 415 minutes, 410 minutes and 387 minutes, respectively, P < .05; median anhepatic phase duration was 75 min vs 60 min, 62 min, 60 min, respectively, P < .05). There was a decrease in the number of transfused blood units (median in Group 1 of 6 packs vs 3 packs in Group 4, P < .05) and a decrease in blood recovered from the operating field using the Cell Saver system (median in Group 1 of 1570 mL vs 1057 mL, 1123 mL, and 1045 mL, respectively, P < .05). A significant reduction in the number of hemorrhages was found (1.5% in Group 4 vs 13.6%, 10.6%, and 7.6% in the other groups P < .05). The remaining studied parameters were not statistically significant.

CONCLUSIONS

Extensive previous transplantation experience affected the lack of typical features of the learning process.

Donation and Transplantation of Kidneys Harvested From Deceased Donors Over the Age of 60 Years in the Upper Silesia Region

BACKGROUND

Population aging and shortage of organs for transplantation result in increasing numbers of kidneys retrieved from elderly donors. The aim of this study was to analyze donation of kidneys from donors after brain death (DBD) over the age of 60 years (≥60), comorbidities that affect decisions on retrieval, and early results of kidney transplantation.

METHODS

Ninety-six potential DBD ≥60 and 309 aged 40-59 years (40-59) reported in Upper Silesia, Poland, from 2004 to 2013 were enrolled in the study.

RESULTS

DBD >60 presented a higher rate of coexisting hypertension (53% vs 34%), limb ischemia (10% vs 1%), and past stroke (6% vs 1%) compared with DBD 40-59 (P < .05), but no differences were observed in serum creatinine concentration (85 vs 84 μmol/L), coexisting coronary disease (14% vs 6%), or diabetes (10% vs 4%). The decision of withdrawal from retrieval was more frequent in DBD ≥60 (16% vs 7%; P < .05). Twelve months after kidney transplantation, serum creatinine concentration was higher in recipients of kidneys from DBD ≥60 compared with DBD 40-59 (169 vs 138 μmol/L; P < .001). The survivals of recipients (93% vs 95%) and kidney grafts (90% vs 93%) as well as rates of proteinuria >1.0 g/24 h (6% vs 2%) did not differ between the groups.

CONCLUSIONS

A higher rate of comorbidities in potential kidney DBD ≥60 results in a lower retrieval rate in these donors. The function of kidneys harvested from DBD ≥60 12 months after transplantation is worse than those from DBD 40-59, but still acceptable.

Past Cardiovascular Episodes Deteriorate Quality of Life of Patients With Type 1 Diabetes and End-stage Kidney Disease After Kidney or Simultaneous Pancreas and Kidney Transplantation

BACKGROUND

The beneficial influence of kidney (KTx) or simultaneous pancreas and kidney transplantation (SPK) on quality of life (QOL) in patients with end-stage kidney disease caused by type 1 diabetes mellitus was confirmed in many studies. The aim of this study was to identify factors that influence QOL of patients in long-term follow-up after SPK or KTx.

METHODS

Twenty-seven SPK and 26 KTx patients with good function of transplanted organs at least 1 year after transplantation were enrolled into the analysis. To estimate QOL of the recipients the Kidney Disease and Quality of Life Short Form was applied.

RESULTS

Within the whole analyzed group, the necessity of exogenous insulin administration correlated (P < .05) with symptom/problem list (γ = -0.35), effects of kidney disease (-0.38), cognitive function (-0.47), sleep (-0.42), overall health (-0.47), physical functioning (-0.61), role-physical (-0.32), pain (-0.50), general health (-0.32), emotional well-being (-0.31), role-emotional (-0.36), social function (-0.33), energy/fatigue (-0.44), and the SF-12 physical composite (-0.44). History of cardiovascular episode correlated (P < .05) with symptom/problem list (γ = -0.59), effects of kidney disease (-0.46), burden of kidney disease (-0.56), sleep (-0.54), social support (-0.51), physical functioning (-0.55), role-physical (-0.70), pain (-0.60), general health (-0.57), emotional well-being (-0.45), role-emotional (-0.95), social function (-0.58), energy/fatigue (-0.59), SF-12 physical composite (-0.45), and SF-12 mental composite (-0.83).

CONCLUSIONS

Exogenous insulin administration and history of cardiovascular episode are the most important factors influencing QOL in patients after SPK or KTx, particularly worsening its physical components.

Does simultaneously transplanted pancreas improve long-term outcome of kidney transplantation in type 1 diabetic recipients?

INTRODUCTION

Simultaneous pancreas-kidney transplantation (SPK) is an alternative to kidney transplantation (KTx) for type 1 diabetic patients with end-stage kidney disease. However, a fair comparison of SPK and KTx is difficult because of significant differences in donor, recipient, and transplantation procedure parameters. The aim of this study was to compare the early and long-term outcomes of SPK versus KTx in southwest Poland.

MATERIAL AND METHODS

Thirty-five diabetic dialysis patients who had SPK and 64 patients who had KTx were included in the analysis.

RESULTS

SPK recipients were younger (38±6 years versus 42±9 years) and received organs from younger donors (25±7 versus 43±12 years) compared to the KTx group. They had shorter kidney cold ischemia time (9±2 hours versus 22±7 hours) but worse HLA class II mismatches (1.4±0.6 versus 1.0±0.5). In the early postoperative period, three patients died from the SPK group and one patient died from the KTx group. Additionally, two SPK patients lost their pancreatic grafts, and five KTx patients lost their kidney grafts. One-year patient survival rates for the SPK and KTx groups were 88% and 98%, respectively, and 5-year, 81% and 93%, respectively. One-year kidney graft survivals rates for the SPK and KTx groups were 100% and 89%, respectively, and 5-years, 89% and 81%, respectively. One-year insulin-free survival among SPK patients was 90% and the 5-year survival rate was 76%. Excretory function of the transplanted kidneys was better among SPK group; however, the difference reached statistical significance only in posttransplant years 2 and 3: 63.5±20.1 versus 50.3±19.7 and 64.9±12.9 versus 51.6±21.8 mL/min/1.73 m2 for SPK and KTx, respectively.

CONCLUSIONS

Normoglycemia in SPK recipients did not improve patient survival at 5 years. The worse HLA compatibility in the SPK group did not lead to impaired kidney graft survival compared to KTx. Better kidney graft function among SPK recipients probably resulted from a more restrictive donor selection.

Donor-dependent risk factors for early surgical complications after simultaneous pancreas-kidney transplantation

INTRODUCTION

The success of simultaneous pancreas-kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK.

MATERIAL AND METHODS

Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study.

RESULTS

Donor age was older among recipients who lost their pancreatic grafts: 30.4±6.9 versus 24.1±6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3±5.7 versus 24.0±6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3±1.1 versus 23.2±2.5 kg/m2. P-PASS was higher in patients who lost their pancreatic grafts (17.6±2.1 vs 15.2±1.8) or died (15.3±1.9 vs 17.2±1.9), or lost pancreatic graft or died (15.2±1.8 vs 17.0±2.2) or with intra-abdominal infections (IAI; 17.1±1.7 vs 15.0±1.8). The incidence of donors≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P=.04). An higher rate of donors with P-PASS>16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P=.014) and serum sodium (odds ration, 0.91; P=.048) to be important predictors of IAI development.

CONCLUSION

Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

Biliary complications after orthotopic liver transplantation: a 5-year experience

INTRODUCTION

Biliary complications, particularly bile duct stenosis or leak, remain the "Achilles' heel" of orthotopic liver transplantation (OLT), significantly increasing the risk of graft loss and recipient death. The aim of the study was to retrospectively analyze biliary complications over a 5-year experience seeking to identify risk factors for these complications.

MATERIAL AND METHODS

Eighty-seven OLT performed in 84 recipients were included in the analysis. In all cases but one, we performed an end-to-end hepatic duct anastomosis with a 7-0 running suture under 2.5× magnification.

RESULTS

Biliary complications developed after 17.2% OLT: anastomosis site stenosis (10.3%), multiple stenoses (5.7%), or bile duct necrosis (1.1%). A bile leak was not observed. Two recipients died from biliary sepsis. Among the patients with biliary complications, there was an higher rate of hepatic artery problems (33.3% vs 2.7%; P<.01), and a longer anhepatic phase (85 vs 72 minutes; P<.01). We performed endoscopic treatment in 73% and percutaneous drainage in 6.6% of recipients. Good treatment results were achieved in 36.4% of cases with biliary complications whereas they were satisfactory in 27.3%. Five patients with biliary complications required re-transplantation.

CONCLUSIONS

A bile duct anastomosis performed end-to-end with a running suture under magnification decreased the risk of bile leakage after OLT. A prolonged anhepatic phase or an hepatic artery thrombosis or stenosis increased the risk of biliary complications after OLT.

Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation

BACKGROUND AND OBJECTIVES

Transfusion of autologous whole blood is one available method to reduce the need for allogenic blood transfusion. The objective of this study was to investigate the safety of transfusion of intra-operative autologous whole blood by monitoring plasma concentration of laboratory variables and adverse events after transfusion with the Sangvia(®) system.

MATERIALS AND METHODS

The clinical trial was designed as an open, prospective, multi-centre study, and a total of 20 patients undergoing primary hip arthroplasty were included. Systemic blood samples were taken and analysed preoperatively, at transfusion start and end and at 3, 6, 24 and 48 h after the transfusion.

RESULTS

Elevated values of complement activation and pro-inflammatory cytokines were seen in the intra-operatively collected blood but the impact on systemic levels were limited with low peak levels, systemic elevations before transfusion and normalization during the study period. Elevated levels of free haemoglobin and potassium were also detected in the intra-operatively collected blood, but systemic values were within reference values after the transfusion. No clinically relevant adverse event occurred during the study.

CONCLUSION

Inflammatory mediators and plasma haemoglobin were increased in intra-operatively salvaged and filtered blood compared to circulatory levels. Intra-operative retransfusion of autologous whole blood caused a transient systemic increase that normalized in the early postoperative period. There were no significant adverse events reported in the study. These data suggest that the Sangvia(®) system can be used for intra-operative collection and retransfusion of salvaged blood.

Impact of pancreas transplantation on the quality of life of diabetic renal transplant recipients

Simultaneous pancreas and kidney transplantation (SPKT) is considered to be the best method of treatment for patients with chronic renal failure (CRF) resulting from insulin-dependent diabetes mellitus (IDDM). The aim of the study was to compare the quality of life (QOL) of patients with IDDM and CRF subjected to SPK or kidney transplantation alone (KTA).

MATERIALS AND METHODS

We analyzed 21 patients after SPKT with good function of both grafts. The results were compared with 17 patients with functioning kidney grafts. Minimal observation time was 6 months. QOL was evaluated using Kidney Disease and Quality of Life Short Form (KDQOL-SF), which was sent to recipients by post. Results were presented as medians and interquartile ranges of calculated scored KDQOL-SF points.

RESULTS

Observation time was 30 months (range, 6-85). Analyzed groups did not differ as regards patient age at transplantation or duration of diabetes and dialysis treatment before transplantation. After SPKT patients reported higher QOL compared with KTA as regards symptom/problem list, 90.91 (86.36-95.46) versus 84.09 (75.00-90.91; P = .04), effects of kidney disease, 90.63 (84.38-93.75) versus 81.25 (68.75-82.14; P = .001); cognitive function, 93.33 (86.67-100.00) versus 80.00 (73.33-93.33; P = .03); overall health, 80.00 (70.00-90.00) versus 50.00 (50.00-70.00; P = .001); physical functioning, 90.00 (75.00-100.00) versus 80.00 (55.00-85.00; P = .03); and pain, 100.00 (90.00-100.00) versus 67.50 (45.00-90.00; P = .005), respectively.

CONCLUSION

SPKT had a positive impact on selected parameters of QOL among patients with IDDM and CRF compared to KTA.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION

Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation.

MATERIAL AND METHODS

A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months.

RESULTS

Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks.

CONCLUSION

All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Analysis of coagulation parameters in the early period after kidney transplantation

BACKGROUND

Hemorrhagic diatheses observed in patients with chronic renal failure result from platelet defects, vessel wall damage, and deficiency of II, VII, IX, and X clotting factors. In contrast, increased levels of fibrinogen and von Willebrand factor, as well as decreased plasma fibrinolytic activity, may lead to thrombotic complications in nephrotic syndrome. Successful kidney transplantation may reverse these disturbances. The aim of the study was to analyze plasma coagulation parameters in the early postoperative period.

MATERIALS AND METHODS

We studied 40 patients who received cadaveric kidney grafts in 2005 and 2006 for activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen, and D-dimer concentrations as well as antithrombin III and protein C and S activities. Blood was collected before surgery and on postoperative days 1, 7, and 14.

RESULTS

The APTT, PT, and fibrinogen values did not differ before and after transplantation. The activity of antithrombin III pretransplantation was 80.9% +/- 19.3%, increasing to 114.2% +/- 25.5% on postoperative day 14. The activities of protein C and S pretransplantation were 115.1% +/- 32.2% and 120.2% +/- 51.6%, respectively, increasing to 150.2% +/- 56.6% and 139.5% +/- 35.4%, respectively, on postoperative day 14. D-dimer concentrations increased from 252.3 +/- 312.0 ng/mL before transplantation to 951.5 +/- 1170.8 and 739.1 +/- 1049.8 ng/mL on postoperative days 7 and 14, respectively.

CONCLUSIONS

Kidney transplantation increased plasma clotting inhibitor activity in the early postoperative period. The high level of D-dimer observed postoperatively suggested increased thrombotic processes in these patients.

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients

BACKGROUND

Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy.

PATIENTS AND METHODS

Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision.

RESULTS

Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted.

CONCLUSION

Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

The Intrarenal Vascular Resistance Parameters Measured by Duplex Doppler Ultrasound Shortly After Kidney Transplantation in Patients With Immediate, Slow, and Delayed Graft Function

BACKGROUND

Evaluation of pulsatility (PI) and resistive (RI) indexes by duplex Doppler ultrasound shortly after kidney transplantation reflects the exacerbation of interstitial edema. The aim of study was to characterize factors that influence PI and RI in patients with immediate (IGF), slow (SGF), or delayed (DGF) kidney graft function.

PATIENTS AND METHODS

PI and RI were measured in 200 transplanted patients at 2 to 4 days postoperatively. We excluded patients with acute rejection episodes within the first month. IGF, which was defined as serum creatinine <264 micromol/L at 3 days, SGF, which was defined as creatinine >264 micromol/L by day 3 with a maximum of one dialysis, and DGF, which was defined as more than 1 dialysis were observed in 33.3%, 41.5%, and 25.2% of patients, respectively. The examined donor parameters were age, hypotensive episodes, catecholamine infusion, central venous pressure, and glomerular filtration rate. The recipient factors were age, history of hypertension, diabetes mellitus, ischemic heart disease, and stroke. Additionally cold ischemia time (CIT), HLA mismatch, and PRA were analyzed.

RESULTS

The lowest PI and RI values were observed among patients with IGF (PI 1.37 [1.28 to 1.46]; RI 0.72 [0.69 to 0.74]); moderate values in SGF (PI 1.65 [1.52 to 1.78]; RI 0.78 [0.76 to 0.80]) and the highest values in DGF (PI 2.09 [1.83 to 2.35]; RI 0.83 [0.80 to 0.86]) differences that were highly significant. Hypotensive episodes and catecholamine infusion in the preharvest period had essential impacts on PI or RI values in the early posttransplant period. There was no significant correlation between PI or RI values and CIT. A slower ATN resolution was observed in DGF patients with higher PI values.

CONCLUSION

Ischemic injury, which occurred mainly prior to organ harvesting, played a dominant role determining intrarenal resistance in the early posttransplant period.

Early Donor Lymph Node Procurement and Local HLA Typing Reduce Cold Ischemia Time and Risk of Acute Tubular Necrosis in Cadaveric Kidney Transplantation

Prolonged cold ischemia time (CIT) is one of the most common causes of acute tubular necrosis (ATN) with consequent delayed graft function after kidney transplantation. The aim of the study was to analyze the impact of early donor lymph nodes (LN) procurement in combination with local or central HLA typing on CIT, on donor-recipient HLA mismatches, and on the early results of grafts. Two hundred six cadaveric procedures were performed from 2001 to 2004 including 86 cases out of 119 recipients who were matched locally and 60 cases out of 87 recipients who were matched centrally, wherein LN were obtained before kidney harvest. CIT was significantly shorter when LN were obtained before kidney harvesting both in local (13.6 vs 20.6 hours) and central (20.1 vs 27.7 hours) matching (both P < .001). ATN frequency was significantly lower in patients with LN obtained earlier (27.9%) when matched locally versus (35.0%) when matched centrally. Kidney graft function estimated at 12 months was similar in both groups. CIT longer than 19.5 hours predicted ATN occurrence with 57.7% sensitivity and 66.4% specificity. Local matching resulted in shortening CIT compared to central matching (15.5 vs 22.4 hours); however, the mismatch in HLA class I and HLA class II were significantly worse (HLA A + B 2.76 vs 2.45, HLA DR 1.21 vs 0.82). These discrepancies did not significantly influence the frequency of ATN (36.1% vs 40.0%) or the kidney graft function at 12 months.

Surgical Treatment of Urological Complications After Kidney Transplantation

Urological complications after kidney transplantation develop in 2.5% to 14.1% of recipients. The aim of the study was to analyze postoperative urological complications that required surgical treatment. Thirty-three urological complications developed in 30 among 321 patients (9.3%). Complications were divided into two groups: I, related to urine retention (60.6%); and II, related to urine leakage (39.4%). For 70% of group I, in patients a double pigtail ureteral stent was inserted; for 53.8% of group II, a vesicoureteric reanastomosis was performed. Good urine outflow was achieved in 90.0% of patients. Total early graft loss was 20% of patients. Urological complications related to stenosis or leakage can be treated with ureteral stent insertion or vesicoureteral reanastomosis. Hemorrhage or infection coexisting with a urological complication increased the risk of early graft loss. Long-term graft survival among patients after successful treatment of urological complications was similar to that of patients without them.

Surgically treated early complications after kidney transplantation

Early surgical complications after kidney transplantation (KTx) remain important clinical problems. The 35 patients in whom forty-six complications appeared within 1 month required surgical treatment. The causes were divided into four groups: bleeding and/or hematoma of the perigraft region (n = 22); urological complications (n = 9); simultaneous bleeding and/or hematoma and urological complications (n = 6); and others (n = 9). Among the 28 cases of hemorrhagic complication, the source of bleeding was not localized during the reoperation in 53.7% cases. Vascular anastomotic leakage was confirmed only in 7.1% of patients. The most common urological complications were stricture of (46.7% cases) and leakage at (26.7%) the vesicoureteral anastomosis. Within 3 months after KTx nephrectomy was performed in 27.5% of patients who had been previously operated for surgical complications compared to 4.6% patients without interventions. Among patients with a single reoperation the graft had to be removed in 20.0% compared with 44.4% for those with multiple reoperations. Localization of the bleeding source causing an early perigraft hematoma is not always possible. The most common early urological complication is a vesicoureteral stricture caused by edema. Surgical complications that appear within 1 month after KTx increase the risk of early graft loss.

[Management of early symptoms of acute septic hip in neonates and infants--conservative or surgical?]

The paper presents 41 cases of acute hip sepsis in 36 patients, age ranging from 5 to 66 days. 32 cases were treated at the Institute of Polish Mother Hospital and 4 at the Pediatric Surgery Department of the Medical School of Łódź. In 40% of the cases multifocal infections were noted. Septic arthritis was diagnosed basing on clinical symptoms, lab tests, ultrasound screening, X-rays and immunoglobulin scyntigraphy. Patients were divided into three groups according to treatment: group 1 was administered antibiotics and immobilization was applied (16 patients--19 hips), group 2 had a biopsy, was administered antibiotics and immobilization (5 patients--6 hips), group 3 had an arthrotomy performed, wound drainage, casting was applied and antibiotics were administered (15 patients--16 hips). Immobilization was maintained by means of a cast or Koszla's harness. Patients were qualified for surgery basing on ultrasound investigation. After completion of various modes of treatment patients were followed at the outpatient clinic of the orthopedic department. A complete assessment was performed 3-6 years after the first symptoms appeared. A full clinical examination (ROM assessment), X-ray investigations were performed. Hip dysfunction was assessed basing on X-ray images according to the Ho Choi classification. Conservative treatment seems to be sufficient in early stages of septic arthritis, with only minor morphological pathologies visible on ultrasound examination. Early arthrotomy seems to be the method of choice in septic arthritis treatment. Aspiration of the hip may not be possible due to solid consistency of pus.

[Early results of high tibial osteotomy with the DERO system for osteoarthritis of the knee]

The authors present the surgical technique and early results after 14 wedge "minus" osteotomies and 5 wedge "plus" osteotomies performed in 16 (age ranging from 45 to 71 years) patients with osteoarthritis of the knee. Use of the DERO system for external stabilization of the knee allows early mobilization of the joint. According to the HSS scale in 15 cases (18 knees) a good result was achieved. Self-assessment of the results of treatment by the patients w\yielded good results in 12 cases and satisfactory in 3. All patients report greater ease of ambulation on flat terrain, across stairs, an increase in ROM and a decrease of pain symptoms. In one case a bad result was caused by infection of the surgical wound. In the observed group no infections, no reaction d\around the pins nor loosening of the bars was noted.

[Evaluation of methotrexate levels in biological fluids released from bone cement filling]

The authors present an analysis of methotrexate concentration in blood, urine and drainage liquid (both deep and superficial), as well as the results of biochemical analysis of blood and urine in a population of 42 patients treated surgically because of pathologic fractures of long bones. In 8 of the 42 patients chemotherapy was applied 14 days before the surgical procedure. Lithic lesions in the long bones were filled with cement with 2 g of methotrexate and further stabilisation was achieved by applying metal implants. The highest methotrexate concentrations were noted in deep drainage fluid and in blood. Methotrexate concentration reached its peak in body fluids 12-24 hours after the procedure, and fell to a minimum 48-72 hours post surgery. The lowest level of the drug compared to all body fluids was found to be in the blood. Only after 72 hours did it exceed the minimum required level of 0.05 umol/l. All biochemical markers in blood and urine except AspAT were found within normal range in all cases 72 hours post surgery. After 24-72 hours post-op a decrease in the number morphotic elements of blood was noted, particularly lymphocytes and thrombocytes.

Reconstruction of large defects of the roof of the hip joint using solid cortical spongy bone grafts

Background. A favorable outcome following revision hip arthroplasty is the result of several factors. One of the basic conditions is stable fixation of the endoprosthetic acetabulum in the physiological site with full bone support. It is difficult to meet this condition, however, in cases of upward migration of the primary endoprosthetic acetabular graft. This requires the supplementation of defects of various sizes present within the roof of the acetabulum during the revision procedure.<br /> Material. The author presents long-term results from the reconstruction of the roof of the hip joint using solid corticalspongy bone grafts in 36 operated patients.<br /> Results. Features of graft healing and full bone remodeling were found within 12 months in 21 operated patients, in whom solid bony autografts taken from the iliac ala had been used to fill the defects. The healing process in 13 patients, in whom solid frozen grafts taken from the bone bank had been used for plastic reconstruction of the roof of the hip joint, lasted 22 months. Unfavorable bony graft healing was observed in 2 patients, in whom full osteolysis of the graft had occurred, resulting in loosening of the acetabulum. Both patients were administered high doses of Encorton due to rheumatoid arthritis in the pre- and post-operation period.

[Morphology of a lithic lesion of the bone treated with cement filling with the addition of methotrexate]

The results of histopathologic examination of a lithic bony lesion and of the surrounding soft tissues obtained from a metastatic site from 2 patients are presented. Both patients had been previously treated surgically with a 40 g bone cement filling with 2 g of methotrexate. Revision surgical intervention was necessary because of loss of stability at the fracture site in a 68 year old female after with a metastasis from breast cancer after 8 weeks and in a 72 year old male with metastasis from cancer of the prostate after 10 weeks. During revision surgery the metal plates and the cement were removed. Tissues samples from the fracture site were taken for histopathologic examination. Fibrosis of connective tissue and haemosiderin accumulation were noted in the soft tissues surrounding the fractures site. Where there was direct contact between the bone cement and bone, necrosis of bone trabeculae and granuloma like bodies were noted. Revision surgery 10 weeks after the first procedure revealed more advanced bony necrosis. No cancerous tissue was observed in any of the cases.

[Dysphagia in the course of degenerative changes of the anterior wall of the cervical spine]

Diagnostics, differentiation and results of treatment for spondylogenic dysphagia in 8 male patients aged 50-69 (mean 57.7 years) have been presented. Non-steroid and steroid pharmacotherapy was successful in 6 patients. In 2 cases symptoms worsened and only surgical decompression of the esophagus was needed to eliminate dysphagia, persistent cough and hoarseness.

[The effect of treatment method for tibial fracture on tibial bone mineral density]

Bone mineral density (BMD) has been measured above malleolar fracture site and within femoral neck in 17 patients treated conservatively and in 17 patients treated surgically. The BMD was taken 3 months after injury. BMD at the fracture site decreased in patients treated conservatively by 20 +/- 3% and by 17 +/- 4% in those operated on. BMD within the femoral neck of the extremity involved decreased by 5% regardless of the mode of treatment. The results achieved indicate no significant difference in BMD in both groups of patients.

[Use of bone cements with added methotrexate for stabilization of pathologic fractures and filling of long bone defects in cases of neoplasm metastasis]

Preliminary results of surgical treatment in 24 patients with pathologic fractures or metastatic long bone defects impending fracture are presented. Fourteen females and 10 males aged 36-72 years with femoral (18 cases), tibial (4 cases) or humeral (2 cases) involvement were followed-up for 6-48 months. In 12 patients the pain ceased or decreased, 3 patients occasionally required non narcotic analgesics, in 9 cases the pain continued. All patients with lower extremity involvement were able to ambulate with an aid of walking sticks, 2 patients with humeral fracture resumed activities of daily living. Nine patients with multiple metastases to the lungs and spine died on average 15 months after surgery. The longest survival rate was found in patients with kidney cancer-19 months, ovary cancer-17 months and breast cancer 15 months. No postoperative complications were found. In 2 patients fracture fixation lost their stability after 8 and 10 weeks due to excessive weight bearing.

[Atypical recipient and longterm results of kidney transplantation]

In their study authors compared the results of renal transplantations in a group of 51 patients with relative contraindications to a remaining group of 413 patients. Congenital anomalies or previously performed operations of urinary tract, previous renal transplantations, laparotomies, peritoneal dialysis, extreme atherosclerosis of the aorta and iliac arteries were regarded as relative contraindications. Results of the treatment do not differ considerably in both groups of patients what confirms the necessity of renal transplantations in difficult recipients.

[Surgical treatment of different forms of renovascular hypertension]

24 patients with renovascular hypertension were operated from 1995 to 1997. Patients were divided into three groups: group I-atherosclerotic stricture of renal arteries with or without aorta stenosis (13), group II-fibromuscular dysplasia (8), group III-stricture of vascular anastomosis after renal transplantation (5). All patients were disqualified from PTA. Operations of reanastomosis of renal arteries to aorta or prosthesis and TEA dominated in group I, the operation of choice in groups II and III was plastic procedure with patch or venous graft. Authors conclude that surgical treatment of renovascular hypertension is an efficient method of treatment in case of disqualification from PTA and the way of reconstruction should be dependent on the reason of renovascular hypertension.

[Primary retroperitoneal tumors--course, diagnosis and treatment results]

36 patients with primary retroperitoneal tumors (PRT) were studied. In 15 cases (41.7%) tumours were found incidentally. Ultrasound examination seems to be the golden standard for finding asymptomatic retroperitoneal neoplasms. High percentage of malignancy (72.2%-26 cases), mesenchymal texture of tumors and late detection of the disease caused by its occult clinical course are the frequent reasons of inoperability (11 patients-30.5%).

[The role of intracellular activation of enzymes in pathogenesis of acute pancreatitis--literature review]

Pathophysiology of acute pancreatitis (AP) is not full clear to present-day. Current review shows an importance of experimental models of AP with observations of intracellular changes during early stages of disease. One of the actual opinion suggest that abnormality in intracellular transport, secretion with intracellular activation of enzyme protein plays an important role in evolution of AP. These events further start cascade reactions and lead to autodigestion of pancreas.

[Surgical treatment for complicated clavicle fracture]

A review of 78 patients (43 males, 25 females), aged 17-62, operated on for complicated fracture of the clavicle served to present indications and surgical techniques for this treatment. The use of a metal plate allows for stable fixation of the fracture, thus further management of patients with concomitant thoracic, pulmonary, or spinal injuries does not require plaster cast immobilization. Inaccurate fracture fixation with compression screw as being unstable necessitates plaster cast immobilization. Coexisting shoulder dislocation has been primarily managed surgically.

[Early results of treatment for a comminuted articular fracture of the calcaneus using a "DERO" fixator]

The method of treatment for comminuted articular fracture of the calcaneus with the use of a "Deroo" fixator is presented. A "Deroo" eliminates the need for the cast, allows for an early active foot mobilization in the first post-operative day, prevents muscular atrophy. Crosby and Fitzgibbons classification served to assess clinical and radiological results; in 5 cases they were rated excellent, in 10 good, in 5 fair and in 7 cases results were poor.

A comparison of the clinical usefulness of CA 19-9 and CA 50 in the diagnosis and monitoring of gastrointestinal cancers

We compared serum levels of CA 19-9 and CA 50 in 108 patients with malignant neoplasms of the stomach, pancreas, liver, and colon with the serum levels in 60 patients with benign gastrointestinal diseases, and 10 healthy subjects. Increased serum levels of CA 19-9 and CA 50 were found in 51.8 and 62% of the cancer patients, respectively. The results of CA 19-9 and CA 50 assays in the nonneoplastic group showed less specificity. False positive results were noted in 11.7% of CA 19-9 tests and in 31.6% of CA 50 tests. We concluded that in gastrointestinal cancer, the CA 19-9 test should be performed initially. CA 50 determination can be useful, but the lower specificity of the test should be taken into consideration. CA 50 should be recommended only for postoperative monitoring, especially in patients with normal CA 19-9 serum levels.

[Mechanical properties of tissue generated as a result of fascia lata grafted into an articular cartilage defect of the knee joint (experimental observations)]

In 64 sheep knees crushing strength and elastic recovery of the tissue generated on the basis of fascia lata grafted into articular cartilage defect in the knee after active motion and load has been assessed. The newly generated tissue is characterized by increasing in time thickness, deformability and elastic recovery the greater the deeper the defect was. Primarily, the new tissue is able to carry smaller loads but after 26 weeks is capable of carrying much greater loads then the cartilage; it has also better plastic and elastic properties.

[Treatment of the deformities associated with hypoplasia or agenesis of the sacral bone]

On the basis of follow-up of 5 children treated because of the deformities associated with sacral agenesis or hypoplasia as well as on the literature the authors came to the conclusion that congenital dislocation of the hip, clubfoot and flatfoot are the most common. The aim of the treatment is to prepare the child for walking before the end of the first year of life. Since the deformities mentioned are resistant to conservative treatment they require a very sophisticated surgery with the constant adjustment of the operating plan in every stage of the management. The type of hip surgery should be selected individually.

[A case of sacral agenesis coexisting with Goldenhar syndrome]

A case of two coexisting embryopathies has been described. The deformities within the sacral bone and systemic anomalies led to the diagnosis of sacral agenesis; Goldenhar syndrome has been differentiated with other disturbances of branchial arches formation.

[Morphological evaluation of fascia lata tissue implantation for chondral defects in the knee joint of sheep under active motion and load]

Experiments carried out on 64 knees of 32 Lein sheep with superficial and deep chondral defects of the patella and femoral condyles covered by autogenic fascia lata grafts indicate that under active motion and load the grafted tissue after 6 weeks is thinner, fragile and lustreless. Quantitative and qualitative deterioration of collagen fibers, almost complete atrophy of elastic fibers and increase in number of cells and vessels is observed under microscope. After 9 weeks remodeling of the fascia occurs which thickens and increases in number of fascicular collagen fibres, after 12 weeks the foci of neochondrogenesis can be found. After 26 weeks a new hyaline like cartilage is generated surrounded by connective tissue containing fascicular collagen and elastic fibers. At this point remodeling is not yet completed.

QT interval prolongation and increased plasma catecholamine levels in patients with mitral valve prolapse

The heart rate corrected QT interval (QTc) and plasma catecholamine (CA) and norepinephrine (NE) levels were measured in 15 symptomatic patients with idiopathic mitral valve prolapse (MVP) and in 19 control subjects. MVP patients showed longer mean QTc and were divided into two groups: group A normal QTc (greater than 440 msec) and group B prolonged QTc (less than 440 msec). In supine resting conditions CA levels were as follows: group A 0.420 +/- 0.035 ng/ml and group B 0.619 +/- 0.104 ng/ml (p less than 0.05); both were greater than control values (0.348 +/- 0.017 ng/ml, p less than 0.005). NE levels were as follows: group A 0.350 +/- 0.031 ng/ml and group B 0.376 +/- 0.052 ng/ml (NS); both were greater than control values (0.242 +/- 0.025 ng/ml, (p less than 0.05). When a standing position was assumed, CA and NE levels increased significantly in all groups but this was most marked in group B as compared to control levels (CA: 1.039 +/- 0.123 ng/ml versus 0.625 +/- 0.037 ng/ml; NE: 0.737 +/- 0.076 ng/ml versus 0.504 +/- 0.031 ng/ml) (p less than 0.001 and p less than 0.05, respectively). Thus the longest QTc was observed in patients with MVP who had the highest levels of CA and NE, in both supine and standing positions. These data may account, in part, for the occurrence of severe ventricular arrhythmias in some patients with MVP and may offer a rationale for adrenergic blockade in that subset of patients with MVP and markedly prolonged QTc.

Hypertrophic cardiomyopathy in Friedreich's ataxia: symmetric or asymmetric?

We evaluated 15 patients with Friedreich's ataxia (FA) to define the incidence of myocardial involvement and the type of cardiomyopathy observed. All patients with FA had either ECG, vectocardiographic or echocardiographic abnormalities, suggesting some degree of myocardial involvement. In contrast to reports indicating that asymmetric septal hypertrophy (ASH), often obstructive, is associated with FA, symmetric, concentric hypertrophic cardiomyopathy (SCH) was the predominant abnormality (sixty-seven percent of patients). Echocardiograms should be performed periodically in all FA patients since this technique allows the detection of cardiac hypertrophy.

Influence of methionine-enkephalin and morphine on myoelectric activity of small bowel

Enkephalins, naturally occurring peptides with powerful opiatelike effects, have recently been detected throughout the tissues of the alimentary tract, but their role is unknown. This study was designed to compare the effects of methionine-enkephalin (met-enkephalin) and morphine on the myoelectrical pattern of the small bowel. Five conscious dogs were prepared with electrodes spaced 25 cm apart along the entire small intestine. Spike activity and slow waves were recorded with a Beckman Dynograph. Records were obtained in fasted conditions and following a meat meal or intravenous infusion of caerulein while animals received intravenous infusion of either met-enkephalin or morphine in various doses (range 10-160 microgram/kg . h). Met-enkephalin at a dose of 40 microgram/kg . h caused a significant decrease in spike activity and in the frequency of bursts of the interdigestive myoelectric complexes (IMC), whereas morphine almost doubled the frequency of the IMC. Met-enkephalin in dogs given food or infused with caerulein significantly decreased the fed-type spike activity of the small bowel, whereas morphine did not affect it. The effects of met-enkephalin and morphine on the intestinal myoelectrical pattern can be reversed by naloxone, an opioid antagonist, suggesting that they are mediated by separate opioid receptors.

Effect of somatostatin on myoelectrical activity of small bowel

Somatostatin, a growth hormone-release inhibiting hormone, has been found to be a powerful inhibitor of gastric and pancreatic secretion as well as of hormone release in the digestive system. This study was undertaken to determine the influence of somatostatin on the myoelectrical activity pattern of the small bowel. Three conscious dogs were prepared with electrodes spaced 25 cm apart along the entire small intestine. Intravenous infusions of somatostatin were administered in various doses (0.6--5.0 microgram/kg.h) while spike activity and slow waves were recorded under fasting conditions, after a meat meal, or during intravenous infusion of gastrin, caerulein, or insulin. Somatostatin at a dose of 0.6 microgram/kg.h almost doubled the frequency of the interdigestive myoelectric complex. Somatostatin in fed dogs caused a dose-dependent decrease of the normal fed spike activity, and at higher doses it induced a pattern like that seen in fasting animals. The slow-wave frequency in both fasted and fed conditions was not changed significantly. We conclude that somatostatin given under basal conditions increases the frequency of the interdigestive complex and, when administered after feeding, converts the fed-type pattern to the fasted-type pattern. It may therefore play a promoting role in initiating the interdigestive myoelectric complex.

Effect of methylated prostaglandin E2 analogue on insulin secretion in man

Previous studies of the effect of E series prostaglandins /PGs/ on insulin secretion gave conflicting results in animals and little information in man. This study was designed to determine the effect of methylated PGE2 analogue /15/S/- 15-methyl PGE2 methyl ester/, given orally, intraduodenally or intravenously, on insulin secretion, both under basal conditions and in response to intraduodenal or intravenous administration of glucose in 22 male volunteers. Methylated PGE2 kept basal serum insulin level unchanged, but significantly reduced insulin response by 15 +/- 6 microunits/ml to intravenous glucose pulse injection /0.1 g/kg/ or by 45 +/- 11 microunits/ml to intraduodenal glucose infusion /0.5 g/kg-hr/. Blood glucose level was unaffected in tests with intraduodenal methylated PGE2, but in tests with intravenous administration it was significantly reduced. These studies demonstrate that methylated PGE2 analogue given orally, intraduodenally or intravenously results in a potent suppression of insulin response to glucose challenge.

Cyclic AMP and bicarbonate responses of the dog pancreas to vasoactive intestinal peptide (VIP) and secretion

The effects of secretin (3 CU per kilogram) and vasoactive intestinal peptide (VIP; 8 mug per kilogram) on bicarbonate and cyclic AMP secretions in pancreatic juice (with pancreatic duct perfusion) and on pancreatic tissue cyclic AMP were investigated as a function of time in 13 anesthetized dogs. The peptides were given by rapid intravenous injection. Even 30 sec. after peptide administration, tissue cyclic AMP levels were elevated, reaching peak values within the first minute and a second peak at about 3 min. Bicarbonate and cyclic AMP secretions in pancreatic juice started with a lag of 1 min. after peptide injection. Following the injection of VIP, peak pancreatic response developed within the first 5 min. and the pancreatic response actually disappeared after 15 min., whereas secretion evoked by secretin was sustained for at least 30 min. The mean +/- S.D. observed maximal bicarbonate response to VIP (100 +/- 49 muEq./5 min.) was about one sixth of the maximum output following secretin (592 +/- 181 muEq./5 min.). Increases in pancreatic tissue and juice cyclic AMP caused by VIP were significant (p less than 0.05) at 1 and 4 min.; however, they were but moderate if compared with the rise achieved by secretin. The results presented confirm previous reports that VIP is a secretin-like partial agonist of pancreatic bicarbonate secretion and are compatible with the hypothesis that both secretin and VIP elicit canine pancreatic bicarbonate secretion via the second messenger system of cyclic AMP.

Effect of motilin on pancreatic secretion

Motilin and secretin were compared in regard to their effects on pancreatic bicarbonate and protein secretion in conscious dogs provided with chronic pancreatic fistulas. Dose-response analysis showed that maximal bicarbonate response to motilin was about 5% of that to secretin and maximal protein response was about 35% of that to caerulein. The interaction of these two peptides showed that motilin is a potent inhibitor of secretin-induced bicarbonate secretion. Since motilin is released by duodenal alkalinization and inhibits pancreatic bicarbonate secretion, it is possible that this peptide is involved in the feedback mechanism of inhibition of pancreatic secretion by alkaline pancreatic juice present in the duodenum.