Presynaptic Dopaminergic Imaging Characterizes Patients with REM Sleep Behavior Disorder Due to Synucleinopathy

OBJECTIVE

To apply a machine learning analysis to clinical and presynaptic dopaminergic imaging data of patients with rapid eye movement (REM) sleep behavior disorder (RBD) to predict the development of Parkinson disease (PD) and dementia with Lewy bodies (DLB).

METHODS

In this multicenter study of the International RBD study group, 173 patients (mean age 70.5 ± 6.3 years, 70.5% males) with polysomnography-confirmed RBD who eventually phenoconverted to overt alpha-synucleinopathy (RBD due to synucleinopathy) were enrolled, and underwent baseline presynaptic dopaminergic imaging and clinical assessment, including motor, cognitive, olfaction, and constipation evaluation. For comparison, 232 RBD non-phenoconvertor patients (67.6 ± 7.1 years, 78.4% males) and 160 controls (68.2 ± 7.2 years, 53.1% males) were enrolled. Imaging and clinical features were analyzed by machine learning to determine predictors of phenoconversion.

RESULTS

Machine learning analysis showed that clinical data alone poorly predicted phenoconversion. Presynaptic dopaminergic imaging significantly improved the prediction, especially in combination with clinical data, with 77% sensitivity and 85% specificity in differentiating RBD due to synucleinopathy from non phenoconverted RBD patients, and 85% sensitivity and 86% specificity in discriminating PD-converters from DLB-converters. Quantification of presynaptic dopaminergic imaging showed that an empirical z-score cutoff of -1.0 at the most affected hemisphere putamen characterized RBD due to synucleinopathy patients, while a cutoff of -1.0 at the most affected hemisphere putamen/caudate ratio characterized PD-converters.

INTERPRETATION

Clinical data alone poorly predicted phenoconversion in RBD due to synucleinopathy patients. Conversely, presynaptic dopaminergic imaging allows a good prediction of forthcoming phenoconversion diagnosis. This finding may be used in designing future disease-modifying trials. ANN NEUROL 2024;95:1178-1192.

Whole brain pattern of iron accumulation in REM sleep behavior disorder

Isolated REM sleep behavior disorder (iRBD) is an early stage of synucleinopathy with most patients progressing to Parkinson's disease (PD) or related conditions. Quantitative susceptibility mapping (QSM) in PD has identified pathological iron accumulation in the substantia nigra (SN) and variably also in basal ganglia and cortex. Analyzing whole-brain QSM across iRBD, PD, and healthy controls (HC) may help to ascertain the extent of neurodegeneration in prodromal synucleinopathy. 70 de novo PD patients, 70 iRBD patients, and 60 HCs underwent 3 T MRI. T1 and susceptibility-weighted images were acquired and processed to space standardized QSM. Voxel-based analyses of grey matter magnetic susceptibility differences comparing all groups were performed on the whole brain and upper brainstem levels with the statistical threshold set at family-wise error-corrected p-values <.05. Whole-brain analysis showed increased susceptibility in the bilateral fronto-parietal cortex of iRBD patients compared to both PD and HC. This was not associated with cortical thinning according to the cortical thickness analysis. Compared to iRBD, PD patients had increased susceptibility in the left amygdala and hippocampal region. Upper brainstem analysis revealed increased susceptibility within the bilateral SN for both PD and iRBD compared to HC; changes were located predominantly in nigrosome 1 in the former and nigrosome 2 in the latter group. In the iRBD group, abnormal dopamine transporter SPECT was associated with increased susceptibility in nigrosome 1. iRBD patients display greater fronto-parietal cortex involvement than incidental early-stage PD cohort indicating more widespread subclinical neuropathology. Dopaminergic degeneration in the substantia nigra is paralleled by susceptibility increase, mainly in nigrosome 1.

Cell-tak coating interferes with DNA-based normalization of metabolic flux data

Metabolic flux investigations of cells and tissue samples are a rapidly advancing tool in diverse research areas. Reliable methods of data normalization are crucial for an adequate interpretation of results and to avoid a misinterpretation of experiments and incorrect conclusions. The most common methods for metabolic flux data normalization are to cell number, DNA and protein. Data normalization may be affected by a variety of factors, such as density, healthy state, adherence efficiency, or proportional seeding of cells. The mussel-derived adhesive Cell Tak is often used to immobilize poorly adherent cells. Here we demonstrate that this coating strongly affects the fluorescent detection of DNA leading to an incorrect and highly variable normalization of metabolic flux data. Protein assays are much less affected and cell counting can virtually completely remove the effect of the coating. Cell-Tak coating also affects cell shape in a cell line-specific manner and may change cellular metabolism. Based on these observations we recommend cell counting as a gold standard normalization method for Seahorse metabolic flux measurements with protein content as a reasonable alternative.

Efficiency of 123I-ioflupane SPECT as the marker of basal ganglia damage in acute methanol poisoning: 6-year prospective study

CONTEXT

Investigate whether ¹²³I-ioflupane SPECT (DaT SPECT) has the potential as a marker of basal ganglia damage in acute methanol poisoning.

METHODS

Prospective, single-centre, cohort study of patients with confirmed methanol poisoning was conducted. DaT SPECT was performed twice with semi-quantification using DaTQUANT^TM and MRI-based volumetry was calculated. Specific binding ratios (SBR) of striatum, caudate nucleus, and putamen were correlated with laboratory parameters of outcome, volumetric data, and retinal nerve fibres layer (RNFL) thickness measurements.

RESULTS

Forty-two patients (mean age 46.3 ± 4.2 years; 8 females), including 15 with MRI-detected putamen lesions (group I) and 27 patients with intact putamen (group II), underwent DaT SPECT. Volumetry was calculated in 35 of the patients assessed. SBR values for the left putamen correlated with putamen volume (r = 0.665; p < 0.001). Decreased bilateral SBR values were determined for the striatum and the putamen, but not for the nucleus caudate, in group I (p < 0.05). Significant correlation was observed between the SBR of the posterior putamen and arterial blood pH (r = 0.574; p < 0.001) and other toxicological parameters of severity of poisoning/outcome including serum lactate, glucose, and creatinine concentrations (p < 0.05). The SBR of the posterior putamen positively correlated with the global RNFL thickness (p < 0.05). ROC analysis demonstrated a significant discriminatory ability of SBR of the posterior putamen with AUC = 0.753 (95%CI 0.604-0.902; p = 0.007). The multivariate regression model demonstrated that arterial blood pH, age, and gender were the most significant factors associated with SBR of the posterior putamen.

CONCLUSION

DaT SPECT demonstrates significant potential for the diagnosis of methanol-induced basal ganglia damage.

MRI-guided voxel-based automatic semi-quantification of dopamine transporter imaging

PURPOSE

Functional imaging with 123I-FP-CIT SPECT suffers from poor spatial resolution resulting in partial-volume effect, which affects the subsequent semi-quantification. Definition of regions of interest for semi-quantification is further subject to user's experience and inter-observer variability. The aim of this work has been to develop an automatic method for definition of volumes of interest and partial-volume correction using patient-specific MRI and providing complete contrast recovery in striatal region.

METHOD

The method consists of spatial pre-processing (image segmentation and multi-modality registration), partial-volume correction (performed by region-based voxel-wise technique), and calculation of uptake indices in striatal structures. Anthropomorphic striatal phantom was used to optimize the method and to assess linearity, accuracy, and reproducibility. The method was tested on 58 patient datasets and compared with clinical assessment and BasGan software.

RESULTS

The method works automatically. The output is highly linear regarding changing striatal uptake. Complete contrast recovery is achieved using 6.5 mm FWHM. Accuracy is better than 0.15 in terms of RMSE between measured and true uptake indices. Reproducibility is better than 5% for normal uptake ratio. The method outperformed clinical assessment in all measures. With patient data, it provided results closer to BasGan (RMSE 0.9) than to clinical assessment (RMSE 1.9) and fairly correlated with both.

CONCLUSION

The proposed method provides complete recovery of striatal contrast under given acquisition and reconstruction conditions. It reduces intra- and inter-observer variability, accurately defines volumes of interest, and effectively suppresses partial-volume effect. It can be reproduced using publicly available software.

Comparative study of the substantia nigra echogenicity and 123I-Ioflupane SPECT in patients with synucleinopathies with and without REM sleep behavior disorder

OBJECTIVES

Hyperechogenicity of the substantia nigra (SN) and abnormal dopamine transporter-single-photon emission computed tomography (DAT-SPECT) are biomarkers commonly used in the assessment of prodromal synucleinopathy. Our goals were as follows: (1) to compare echogenicity of SN in idiopathic rapid eye movement (REM) behavior disorder (iRBD), Parkinson's disease (PD) without RBD (PD-noRBD), PD with RBD (PD + RBD), and control subjects; and (2) to examine association between SN degeneration assessed by DAT-SPECT and SN echogenicity.

PATIENTS/METHODS

A total of 61 subjects with confirmed iRBD were examined using Movement Disorders Society-unified PD rating scale (MDS-UPDRS), TCS (transcranial sonography) and DAT-SPECT. The results were compared with 44 patients with PD (25% PD + RBD) and with 120 age-matched healthy subjects.

RESULTS AND CONCLUSION

The abnormal SN area was found in 75.5% PD, 23% iRBD and 7.3% controls. Median SN echogenicity area in PD (0.27 ± 0.22 cm²) was higher compared to iRBD (0.07 ± 0.07 cm²; p < 0.0001) and controls (0.05 ± 0.03 cm²; p < 0.0001). SN echogenicity in PD + RBD was not significantly different from PD-noRBD (0.30 vs. 0.22, p = 0.15). Abnormal DAT-SPECT was found in 16 iRBD (25.4%) and 44 PD subjects (100%). No correlation between the larger SN area and corresponding putaminal binding index was found in iRBD (r = -0.13, p = 0.29), nor in PD (r = -0.19, p = 0.22). The results of our study showed that: (1) SN echogenicity area in iRBD was higher compared to controls, but the hyperechogenicity was present only in a minority of iRBD patients; (2) SN echogenicity and DAT-SPECT binding index did not correlate in either group; and (3) SN echogenicity does not differ between PD with/without RBD.

Mitochondria-targeted compounds in the treatment of cancer

Mitochondria are highly dynamic organelles involved in many cellular functions. Beyond their central role in metabolism, they also take a part in maintaining calcium homeostasis, cell death, immunity, and ROS production. Changes in these functions have been shown to be crucial for the adaptation and survival of cancer cells. Mitochondria, therefore, constitute a promising target for the development of novel anticancer agents. The triphenylphosphonium (TPP+) moiety has been widely used to target molecules into mitochondria. TPP+ derivatives of a variety of conventional cytostatic drugs, natural substances, metformin, antioxidants or a range of newly synthesized molecules have shown promising results against cancer cells. In this review, we discuss biochemical differences between cancer cells and normal cells with a specific focus on mitochondria, and how mitochondrially targeted molecules can be used to selectively affect mitochondrial function in normal and cancer cells. We summarize the published data on mitochondrially targeted anticancer agents and propose future research avenues.

Metabolic cooperation in the ovarian follicle

Granulosa cells (GCs) are somatic cells essential for establishing and maintaining bi-directional communication with the oocytes. This connection has a profound importance for the delivery of energy substrates, structural components and ions to the maturing oocyte through gap junctions. Cumulus cells, group of closely associated GCs, surround the oocyte and can diminished the effect of harmful environmental insults. Both GCs and oocytes prefer different energy substrates in their cellular metabolism: GCs are more glycolytic, whereas oocytes rely more on oxidative phosphorylation pathway. The interconnection of these cells is emphasized by the fact that GCs supply oocytes with intermediates produced in glycolysis. The number of GCs surrounding the oocyte and their age affect the energy status of oocytes. This review summarises available studies collaboration of cellular types in the ovarian follicle from the point of view of energy metabolism, signaling and protection of toxic insults. A deeper knowledge of the underlying mechanisms is crucial for better methods to prevent and treat infertility and to improve the technology of in vitro fertilization.

Operationalising resilience for disaster medicine practitioners: capability development through training, simulation and reflection

Resilience has in recent decades been introduced as a term describing a new perspective within the domains of disaster management and safety management. Several theoretical interpretations and definitions of the essence of resilience have been proposed, but less work has described how to operationalise resilience and implement the concept within organisations. This case study describes the implementation of a set of general resilience management guidelines for critical infrastructure within a Swedish Regional Medical Command and Control Team. The case study demonstrates how domain-independent guidelines can be contextualised and introduced at an operational level, through a comprehensive capability development programme. It also demonstrates how a set of conceptual and reflective tools consisting of educational, training and exercise sessions of increasing complexity and realism can be used to move from high-level guidelines to practice. The experience from the case study demonstrates the value of combining (1) developmental learning of practitioners' cognitive skills through resilience-oriented reflection and interaction with dynamic complex open-ended problems; (2) contextualisation of generic guidelines as a basis for operational methodological support in the operational environment; and (3) the use of simulation-based training as part of a capability development programme with increasing complexity and realism across mixed educational, training and exercise sessions. As an actual example of a resilience implementation effort in a disaster medicine management organisation, the study contributes to the body of knowledge regarding how to implement the concept of resilience in operational practice.

Neoadjuvant Hypertermic Isolated Limb Perfusion in Treatment of Undifferentiated Spindle Cell Sarcoma of Lower Limb with Achieved Complete Pathologic Response

BACKGROUND

Hyperthermic isolated limb perfusion uses therapeutic effect of hyperthermia in the bounded compartment of the limb together with increased concentration of chemotherapy effect than what would be achieved in systemic application. Gold standard was melphalan (Alkeran) in combination with tasonermin (Beromun, tumor necrosis factor alpha). The efficacy of this combination has been demonstrated in limb soft tissue sarcomas and in patients with limb isolated bulky disease of malignant melanoma.

CASE

We describe a case of a 65-year-old female patient with undifferentiated spindle-cell sarcoma treated by a multidisciplinary team at the 2nd Surgical Clinic of Cardiovascular Surgery and Clinic of Oncology General University Hospital in Prague and at the Department of Orthopaedics Na Bulovce Hospital with the aim of preserving the limb despite the advanced disease. The patient underwent hyperthermic isolated limb perfusion with tasonermin and melphalan with partial response on magnetic resonance imaging. Subsequent wide resection was done with complete pathological remission according to histological examination maintaining a fully functional limb. The patient is followed without signs of recurrence.

CONCLUSION

Hyperthermic isolated limb perfusion with tasonermin and melphalan is an important part of a multimodal approach in the treatment of extremity sarcomas with a high percentage of responses that increase the percentage of limbs retaining resections. Multidisciplinary team should consider this option in patients with localized limb sarcomas and should be performed in specialized centers with experience in this procedure. This work was supported by project Progres Q28-LF1. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.

Laparoscopic treatment of bowel perforation after blunt abdominal trauma (BAT) in children

Minimally invasive techniques have now become standard for the treatment of many surgical conditions in children. There are a few studies that describe the utility of laparoscopy in BAT in children. In this article, we describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma, both with bowel perforation. In both cases, the perforation was identified and closed, one laparoscopically with an ongoing suture, the second jejune perforation was closed by laparoscopic-assisted techniques. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We hypothesize, that diagnostic laparoscopy provides important information for the treatment of children with abdominal trauma and is accompanied by improved diagnostic accuracy, reduction of nontherapeutic laparotomy rates, and a reduction of morbidity. Minimally invasive surgery in children after BAT is suitable for hemodynamic stable patients, could improve pain scores, cosmetic effect, shorter hospital stays, shorter operative times and shorter return to school/activities. However, at any point in the patients care, in case the unstable hemodynamic is encountered, exploratory laparotomy is the procedure of choice.Key words: miniinvasive surgery blunt abdominal trauma - laparoscopy bowel perforation.

[Isolated Perfusion of the Upper Extremity with TNF-α - Double Venous Cannulation]

BACKGROUND

The authors present a technical variation of the standard cannulation for cardiopulmonary bypass perfusion during hyperthermic isolated limb perfusion (ILP) procedures in selected patients with unresectable soft tissue sarcoma or malignant melanoma.

PATIENTS

Of 55 ILP procedures performed at our institution since the procedure was established in 2009, nine were performed at the upper extremity. Standard single venous cannulation was used in five cases, and extended, double venous cannulation in the last four. The standard technique for brachial vein cannulation in a small compartment of the upper extremity entails a problematic and longer perfusion of the upper extremity. This is due to the lower flow rate in the venous system and relatively large surface area with respect to weight. We present a simple technique based on a "Y" cannulation of the venous system via the deep brachial vein and superficial venous system via the basilic vein, delivering a 20% increase in flow rate in the extracorporeal circulation. Faster heating of the upper extremity and a stable thermal environment throughout upper-extremity ILP are essential for successful treatment.

CONCLUSION

Extended technique of venous cannulation for extracorporeal circulation setting, due to their advantages, became standard in the upper limb ILP procedure at our institution.Key words: isolated limb perfusion - malignant melanoma - soft tissue sarcoma - upper limb - extracorporeal circulation The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 8. 1. 2017Accepted: 15. 1. 2017.

[Hyperthermic Isolated Limb Perfusion Combined with Tasonermin - a Perfusion Leakage Monitoring Technique]

BACKGROUND

Hyperthermic isolated limb perfusion is used to treat irresectable extremity malignancies. It is based on the following principle - the perfusion of the extremity is isolated from systemic circulation and connected to an extra-corporal circuit via which a very high concentration of a chemotherapeutic agent is administered into the blood compartment of the extremity. In some cases, treatment efficiency can be improved using tasonermin (a TNF-α agent). By itself, tasonermin can cause severe health complications in patients if leakage into systemic circulation results in a level that exceeds the maximally tolerated dose. Therefore, it is important to monitor for leakage during the whole operation.

METHOD

Leakage monitoring was performed by a nuclear medicine method based on the measurement of activity of a gamma-emitting radiotracer detected by a scintillation probe located over the heart. An amount of radiotracer that resulted in a basal level of measured signal was first administered into the systemic circuit followed by the administration of a second, one order of magnitude higher amount of radiotracer into the perfusion circuit. Leakage, when it occurred, increased the count rate detected over the heart, and the mathematical relation between leakage level and count rate increase was derived.

RESULTS

In our department, the method was tested and optimized during isolated limb perfusion without using a TNF-α agent. Then, accreditation for the use of TNF-α was granted. Since then, the method has been used to monitor leakage in all cases of isolated limb perfusion with TNF-α. All isolated limb perfusion operations with TNF-α passed without complications. The radiation burden was almost negligible for both the patient and medical staff.

CONCLUSION

The method described in this report represents a reliable method for perfusion leakage monitoring when using TNF-α in our department.Key words: perfusion - isolated limb - TNF-α - leakage - monitoring - nuclear medicine - radiopharmaceuticalsThe authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 16. 6. 2016Accepted: 21. 6. 2016.

Effect of storage duration on the rheological properties of goose liquid egg products and eggshell membranes

In practice, goose eggs are increasingly used and, therefore, the rheological properties have to be known for processing. The eggs of geese (Landes Goose, Anser anser f. domestica) were stored for one, 2, 3, 4, 6, and 8 wk at a constant temperature 4°C. First of all, the egg quality parameters were described in terms of egg weight, egg weight loss, egg shape index, yolk height, albumen height, yolk index, albumen index, and Haugh units. In the next step the rheological behavior of liquid egg products (egg yolk, albumen, and whole liquid egg) was studied using a concentric cylinder viscometer. Flow curves of all liquid egg products exhibited non-Newtonian shear thinning behavior. This behavior can be described using the Herschel-Bulkley model and for technical application using the Ostwald-de Waele model. The effect of the storage duration on the rheological behavior is different for the different liquid egg products. With the exception of very low shear rates, the viscosity of the egg yolk as well as of the whole liquid egg decreases with storage time. At lower shear rates there is a tendency toward increased albumen viscosity with storage duration. The storage duration also affects the mechanical properties of the eggshell membrane. This effect has been evaluated in terms of the ultimate tensile strength, fracture strain, and fracture toughness. All these parameters increased with the loading rate, but decreased during the egg storage. These mechanical phenomena should be respected, namely in the design of the egg model for the numerical simulation of the egg behavior under different kinds of the mechanical loading.

Effect of the loading rate on compressive properties of goose eggs

The resistance of goose (Anser anser f. domestica) eggs to damage was determined by measuring the average rupture force, specific deformation and rupture energy during their compression at different compression speeds (0.0167, 0.167, 0.334, 1.67, 6.68 and 13.36 mm/s). Eggs have been loaded between their poles (along X axis) and in the equator plane (Z axis). The greatest amount of force required to break the eggs was required when eggs were loaded along the X axis and the least compression force was required along the Z axis. This effect of the loading orientation can be described in terms of the eggshell contour curvature. The rate sensitivity of the eggshell rupture force is higher than that observed for the Japanese quail's eggs.

Excess of free fatty acids as a cause of metabolic dysfunction in skeletal muscle

Obesity is often associated with metabolic impairments in peripheral tissues. Evidence suggests an excess of free fatty acids (FFA) as one factor linking obesity and related pathological conditions and the impact of FFA overload on skeletal muscle metabolism is described herein. Obesity is associated with dysfunctional adipose tissue unable to buffer the flux of dietary lipids. Resulting increased levels and fluxes of plasma FFA lead to ectopic lipid deposition and lipotoxicity. FFA accumulated in skeletal muscle are associated with insulin resistance and overall cellular dysfunction. Mechanisms supposed to be involved in these conditions include the Randle cycle, intracellular accumulation of lipid metabolites, inflammation and mitochondrial dysfunction or mitochondrial stress. These mechanisms are described and discussed in the view of current experimental evidence with an emphasis on conflicting theories of decreased vs. increased mitochondrial fat oxidation associated with lipid overload. Since different types of FFA may induce diverse metabolic responses in skeletal muscle cells, this review also focuses on cellular mechanisms underlying the different action of saturated and unsaturated FFA.

The role of 99mTc-MIBI SPECT/low dose CT with 3D subtraction in patients with secondary hyperparathyroidism due to chronic kidney disease

OBJECTIVE

The aim of the present work was to assess the incidence of parathyroid glands hyperplasia or adenoma in patients with various stages of chronic renal insufficiency using 99mTc-methoxyisobutylisonitrile (MIBI) SPECT and 3D subtraction technique with 99mTc-pertechnetate (Tc).

SUBJECTS AND METHODS

Sixty one patients underwent hybrid SPECT with low-dose CT of the parathyroid glands and thyroid SPECT scintigraphy. Thirty six patients were with chronic kidney disease (CKD) without renal failure (RF) and 25 patients underwent peritoneal dialysis or hemodialysis. In each patient, two SPECT studies were performed - an early and a late one with low dose of CT with MIBI injection. Additional SPECT was performed on another day with Tc. SPECT studies were evaluated visually using volume rendering method and semi-quantitatively by 3D subtraction of Tc SPECT from early MIBI SPECT.

RESULTS

From all 61 patients, 40/61 (66%) findings were positive, 7/61 (12%) inconclusive, and 14/61 (23%) negative. Solitary lesions were detected in 22 patients. More than one lesion was found in 18 patients.

CONCLUSION

The incidence of secondary hyperparathyroidism was detected in 40/61 patients (66%) with chronic kidney disease using scintigraphy and 16 patients (40%) from them underwent surgery. MIBI SPECT/low dose CT with 3D dual - tracer subtraction (MIBI-Tc) method is an effective tool for preoperative detection of the parathyroid glands hyperplasia or adenoma.

Prevention of neural tube defects by folic acid - awareness among women of childbearing age in Slovakia

BACKGROUND

Folic acid deficiency plays a central role in the aetiology of many congenital anomalies including neural tube defects. Protective effect of folic acid on embryo may be acquired only if taken periconceptionally.

OBJECTIVES

The aim of the study was to investigate the awareness about folic acid among women of childbearing age in Bratislava, Slovakia.

METHODS

There were 130 respondents involved in the research (106 pregnant women, 24 female students of medical faculty). Using questionnaire we acquired following data: pregnancy details, interest in diet before and during pregnancy, recommendations regarding nutrition and supplementation pre- and post-conception, knowledge about folic and other acid in 2004 and 2009.

RESULTS

More than half of the respondents knew the sources of folic acid. The interest in the nutrition facts of the food dropped from 91 % to 58.5 %. The number of pregnant women advised about correct nutrition and folic acid supplementation before and during pregnancy increased from 16 % to 37 %. Planning the next gravidity with folic acid supplementation became greater than 21 % (38 % in 2009). Nevertheless, only 46 % of these women believed that proper food content with folic acid may prevent congenital anomalies. In a group of students planning to take folic acid periconceptionally the number raised up to 62.5 %.

CONCLUSION

The results revealed low knowledge about the effect of folic acid on developing embryo among women of childbearing age. Effective intervention programs are needed with the aim to improve periconceptional intake of folic acid in 2004 and 2009. The results in both periods show low knowledge about this essential vitamin (Tab. 1, Fig. 8, Ref. 31).

Biliary atresia - a new derivative method?

BACKGROUND

Biliary atresia is a progressive cholangiopathy in neonates of unknown origin. Surgical intervention - Kasai portoenterostomy - is the only treatment possible. However, only liver transplantation can be considered a definitive solution even in cases of favourable post-operative course, i.e., after bile passage has been recreated.

OBJECTIVES

The authors set out to identify ways to optimize the operative treatment in biliary atresia patients. In particular, their objective was to identify a suitable bile derivation area outside porta hepatis, thereby simplifying the surgical procedure of the following liver transplantation.

METHODS

The research was conducted from 2006 to 2010 on a set of 30 corrosive casts prepared by the Institute of Anatomy, Medical Faculty, Comenius University Bratislava. The research consisted of an analysis of individual tubular structures of the liver parenchyma, particularly the bile vessels. The authors explored the latter's position and branching out, as well as their relationships in different segments, and their availability in surgical exploration.

RESULTS

The analysis of the corrosive casts resulted in selecting an area in liver segments II and III suitable for creating a new type of hepatoenterostomy. The area is sufficiently distant from porta hepatis, conveniently accessible to the surgeon, and has a broad bile duct branch. This type of anastomosis would preserve the anatomic situation in the porta hepatis area intact for the following transplantation.

CONCLUSION

While the results of the experiment warrant some optimism, authors will have to wait until this type of derivation operation is applicable in practice. The authors continue their research by performing anastomosis in an animal model (Fig. 5, Ref. 18)

Higher insulin sensitivity in vegans is not associated with higher mitochondrial density

BACKGROUND/OBJECTIVES

Vegans have a lower incidence of insulin resistance (IR)-associated diseases and a higher insulin sensitivity (IS) compared with omnivores. The aim of this study was to examine whether the higher IS in vegans relates to markers of mitochondrial biogenesis and to intramyocellular lipid (IMCL) content.

SUBJECTS/METHODS

Eleven vegans and 10 matched (race, age, sex, body mass index, physical activity and energy intake) omnivorous controls were enrolled in a case-control study. Anthropometry, bioimpedance (BIA), ultrasound measurement of visceral and subcutaneous fat layer, parameters of glucose and lipid homeostasis, hyperinsulinemic euglycemic clamp and muscle biopsies were performed. Citrate synthase (CS) activity, mitochondrial DNA (mtDNA) and IMCL content were assessed in skeletal muscle samples.

RESULTS

Both groups were comparable in anthropometric and BIA parameters, physical activity and protein-energy intake. Vegans had significantly higher glucose disposal (M-value, vegans 8.11±1.51 vs controls 6.31±1.57 mg/kg/min, 95% confidence interval: 0.402 to 3.212, P=0.014), slightly lower IMCL content (vegans 13.91 (7.8 to 44.0) vs controls 17.36 (12.4 to 78.5) mg/g of muscle, 95% confidence interval: -7.594 to 24.550, P=0.193) and slightly higher relative muscle mtDNA amount (vegans 1.36±0.31 vs controls 1.13±0.36, 95% confidence interval:-0.078 to 0.537, P=0.135). No significant differences were found in CS activity (vegans 18.43±5.05 vs controls 18.16±5.41 μmol/g/min, 95% confidence interval: -4.503 to 5.050, P=0.906).

CONCLUSIONS

Vegans have a higher IS, but comparable mitochondrial density and IMCL content with omnivores. This suggests that a decrease in whole-body glucose disposal may precede muscle lipid accumulation and mitochondrial dysfunction in IR development.

[Metformin: the overlap of diabetology and oncology]

Type 2 diabetes moderately increases predisposition for manifestation of tumor disease. Both drugs stimulating insulin secretion (insulin secretagogues) and insulin injection therapy also moderately increases risk of tumor manifestation (OR approx 1.3). According to some reports pyoglitazon therapy could be of increased risk of bladder cancer. On the other hand, hundreds of study on isolated cells, experimental animal models and retrospective studies in patients have shown preventive effect of metformin therapy on manifestation tumors of pancreas, breast, colorectum, liver, endometrium and ovary. More over, the prognosis of diabetic cancer patients on metformin therapy seems be better, than in diabetics without metformin treatment. These data are promising for future use of metformin for prevention and therapy of some malignant tumors.

[Complications resulting from osteosynthesis in children after supracondylar fractures of the humerus]

INTRODUCTION

The authors carried out the analysis of the causes for re-operations after percutaneous osteosynthesis of supracondylar fractures of the humerus in children.

MATERIALS AND METHODS

The authors evaluated the complications of osteosynthesis of supracondylar fractures in children hospitalized at the Clinic of Pediatric Surgery, University Hospital in Bratislava, for a 5-year period between 2007 and 2011. From the total number (395) of supracondylar fractures, 372 were treated as closed reduction and percutaneous transfixation.

RESULTS

32 (8.6%) of supracondylar fractures that were treated as closed reduction and osteosynthesis were indicated for re-operation - 8 times for signs of lesion n. ulnaris, 7 times for migration of Kirschner wires, 17 times for non-anatomical status or osteosynthesis failure. In case of lesions of nervus ulnaris, Kirschner wires were eliminated from the ulnar side and replaced either with intramedullary descendently introduced Kirschner wire to the ulnar condyle (the first option) or with three divergent Kirschner wires from radial side (the second option). In case of failed osteosynthesis, reosteosynthesis was performed using three Kirschner wires (two parallel or divergent from the radial side and one through the medial epicondyle).

CONCLUSION

During the period monitored, the introduction of a differentiated approach in the treatment of supracondylar fractures of the humerus in children according to the type of fracture and the degree of displacement has significantly reduced the number of reoperations. Subsequently, it is important to notice that the decreased number of reosteosynthesis can be also assigned to the fact that the initial operation is not necessarily carried out as an urgent one (e.g. by a surgical team on night duty), but can be postponed and performed by an experienced traumatological team next day.

V/P scan in diagnosis and follow-up of pulmonary embolism in 15-25-year-old females in relation to hormonal contraception use

BACKGROUND

An analysis of medical records of young females who were examined in our department during a five-year period (2005-2009) on suspicion of pulmonary embolism (PE) in relation to hormonal contraception (HC).

MATERIAL AND METHODS

The patient sample included 86 young females aged 15-25 (mean 21) years who underwent a ventilation/ perfusion scintigraphy (V/P scan). Seventeen of them were examined repeatedly. Altogether, 114 scintigraphic examinations were performed. Lung perfusion scintigraphy was performed using a planar gamma camera (Mediso MB 9200) in 4 projections following 100 MBq 99mTc--MAA i.v. application with 81 mKr ventilation scintigraphy concurrently.

RESULTS

1. Among 57/86 (66%) patients on HC, 24 (42%) had scintigraphic signs of PE. 2. 11/57 (19%) of them had clinical signs of deep venous system thrombosis of the lower limbs that were confirmed by sonography. 3. Leiden mutation was found in 9/24 (37%) patients with PE. 4. Among 29/86 (34%) females not taking HC, PE was detected in only 3 patients (10%). 5. 10/17 (59%) repeatedly examined females had permanent post-embolic residual changes of lung perfusion.

CONCLUSIONS

In our group of patients who underwent a P/V scan, 42% of those on HC were diagnosed with PE on scintigraphy, compared to 10% of those not taking HC. Among the patients with PE, there were 10/24 (42%) young females with persistent post-embolic changes. Our study indicates that the well-known risk of venous thromboembolism related to the use of HC needs to be considered as a cause of PE even among very young females. In our experience, prevention of these life-threatening conditions in patients with a family history of venous thromboembolism consists of timely examination of their thrombotic profile and selection of appropriate contraception.

[Fracture-separation of the distal humeral epiphysis in a four-month-old infant: case report]

We report the case of a 4-month-old infant with fracture-separation of the distal humeral epiphysis diagnosed on the basis of X-ray examination. Closed reduction was performed under ultrasound guidance. The effect of reduction was checked by computer tomography and magnetic resonance imaging and, under general anaesthesia, the arm was immobilised using a collar-and-cuff. Subsequently, percutaneous osteosynthesis with two 1.2-mm Kirschner wires through the radial condyle was carried out. The fracture was allowed to heal in a normal elbow position with plaster cast for 5 weeks. The duration of immobilisation had to be prolonged and removal of the wires postponed because the infant acquired a respiratory infection; the usual time for fracture union is 3 weeks. At 23 months after injury the outcome was excellent and the baby remained registered for a long-term follow-up.

[Epidemiology of neural tube defects]

INTRODUCTION

Neural tube defects represent group of congenital diseases with relatively high incidence in population. Authors assess world and Slovak literature and statistical facts about the epidemiology of NTD and compare them with their own results of retrospective study performed in Children's Hospital, Bratislava.

MATERIALS AND METHODS

List of patients consists of 250 children (106 boys, 144 girls): X-ray images showing lumbo-sacral part of vertebral column were evaluated retrospectively (X-ray of native abdomen, urological tract or skeleton). Authors assessed presence or non-presence of spina bifida on images, without relation to age, gender or diagnosis of patients.

RESULTS

From the total number of 250 radiograms, 72 findings were positive (36 boys and 36 girls), 160 images were negative, 18 were unsuitable for evaluation due to low image quality. The highest diagnostic capture was from urological images - 40% of all positive findings. Incidence of spina bifida in Children's Hospital concluded from X-ray images is quite high - 28.8%.

CONCLUSION

According to the data from National Centre of Health Statistics the incidence of open caudal neural tube defects in Slovakia is under 5 per 10 000 live-born children at present time. However the occurrence of occult spina bifida is not known exactly. The high rate of spina bifida presented herein (28%) can be caused by relatively low number of evaluated radiograms. Also the fact that children were not only healthy ones and data were obtained from the western part of Slovakia as well. In conclusion we can say that after accidental finding of caudal neural tube defect consecutive diagnostics should be performed in clinical positive cases - genetics, MRI and consultation with specialists to decide for the optimal follow up of the patient.

[Type II bile duct cyst or accessory gall bladder?]

Choledochal and bile duct's cysts are well known, their morphological classification and also operative management had been described in detail. The most frequent are cysts' types I. and IV., in which the operation consists of cyst's resection and biliary tract reconstruction. Authors summarize nowadays knowledge and present case of 21-months old girl, who was diagnosed of choledochal cyst accidentally. She was operated on electively; the operative finding verified 2 cystic lesions with own bile ducts joined to choledochal duct. The proximal cyst had 3 diverticles and thus mimicked a choledochal cyst type IV. on the preoperative examinations. The resection of both cystic lesions was done. This is a unique case of biliary tract malformations.

Devastating injury of the groin with vascular lesion

A 13-year-old girl suffered an injury of the left inguinal region in October 2002. The mechanism of the injury was a fall off a merry-go-round with subsequent trailing by the iron frame, which resulted in devastation of the soft tissues and vessels of her left groin. The patient was transported to the Department of Paediatric Surgery in a state of haemorrhagic shock. A part of the iron frame was still sticking out of her groin. Emergent surgery and haemostasis was followed by reconstructive vascular surgery. Vascular ischaemic-reperfusion syndrome appeared 8.5 hours after the injury. A second episode of haemorrhagic shock developed on the 6th post-operative day, after a dislodgement of an arterial thrombus from a small artery, which was not obvious during the surgery. The situation required emergent wound exploration and surgical control of the bleeding. A third episode of haemorrhagic shock developed on the 9th post-operative day, after an excessive administration of heparin. This time no surgical bleeding was detected during wound exploration. The last episode of haemorrhagic shock appeared 6 months later, during the patient's menarche. She was ashamed to tell her parents about her heavy bleeding for several days. Authors of this article conclude that it is not necessary to increase the dose of Heparin above 20 mcg/kg/hour, even though the value of aPTT is not as high as we would expect. We should expect also the possibility of severe bleeding due to menarche on the anticoagulant therapy in adolescent female patients. Authors also consider both arterial and deep venous reconstructions to be adequate methods of treatment in case of extensive devastating injury of the groin region in the adolescent period (Fig. 5, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

[Osseous bridge after physeal-injury to the distal tibia with spontaneous resolution]

The risk of osseous bridge development after certain types of physeal injury is well established. Once formed, the bridge continues to grow and results in a progressive deformity. The authors present an unusual case of a five-year-old girl who had a Salter-Harris Type-IV fracture of the distal tibial epiphyseal plate, with subsequent osseous bridge formation and deformity development. The bridge resolved spontaneously in 16 months, and joint mechanical axis alignment was gradually restored with normal growth of the distal tibia. Key words: physis, paediatric fractures, bony bridge, growth arrest.

[Use of allogenous material in the management of spina bifida aperta]

AIM

"Conditio sine qua non" in the management of open neural tube defects includes closure of all layers with as minimum as possible tension left within the suture region, in order to prevent early, as well as long-term postoperative complications. In extensive fascial defects, the authors used the Gore-Tex patch as an alternative to myofascial or fasciocutaneous flaps.

PATIENTS AND METHODS

From January 2004 to January 2008, 23 patients suffering from open spina bifida underwent surgery in the Bratislava Pediatric Surgery Centre. In 17 subjects, the fascia was sutured following a myofascial release, in 2 subjects the suture was secured with tissue adhesive. In 4 subjects, the Gore-Tex patch was implanted to secure the "tension free" plasty; the Gore-Tex Dual Mesh was used in 2 subjects as well as the Gore-Tex Spinal.

RESULTS

Two subjects, who had the Gore-Tex Dual Mesh implanted, developed sequestration of the implant during the late postopertive period. Upon reoperation, the authors removed the Gore-Tex Dual Mesh in the both subjects. However, they found a firm fibrous membrane, which was considered sufficient to protect the dural sac. On the contrary, the both subjects who had the Gore-Tex Spinal implanted, healed with no complications recorded.

CONCLUSION

Based on the experience, the Gore-Tex Dual Mesh, although implanted lege artis, does not appear a suitable material for fascia replacements in open spina bifida plastic procedures. Further experience will give more evidence, whether Gore-Tex Spinal would be a suitable alternative, however, the courses in the 2 subjects have hitherto been encouraging.

[Later age diaphragmatic hernia]

INTRODUCTION

Congenital diaphragmatic hernia (CDH) is usually diagnosed antenatally or through the neonatal period at present. It is also used to treat and manage CDH in this date. However in rare cases CDH could be presented after finished neonatal period with non-specific and misleading symptoms. The aim of our presentation is to analyze the patients with late - presenting and diagnosed CDH.

METHODS

During period 1996-2006 we operated on 54 children with CDH, 12 of them with late - presenting CDH, age variance was 9 months and 6 years. The spectrum of symptoms was from asymptomatic CDH (2 patients), mild respiratory (4 patients) and gastrointestinal symptoms (4 patients), combination of respiratory and gastrointestinal symptoms (2 patients) and finally the symptomatology of bowel incarceration (2 patients).

RESULTS

Seven children presented with another associated malformations (m. Down, congenital heart failure, hydrocephalus, anorectal atresia). All 12 patients were operated on with a good results. The operation was composed of reposition of the herniated part of gastrointestinal tract (without need of resection) and diaphragmatic plastic. Two patients were reoperated on - once because of diaphragmatic relaxation and the second one due to consecutive heart operation.

CONCLUSION

Congenital diaphragmatic hernia could be presented with chronic and non-specific respiratory or gastrointestinal symptoms. Time to time, presentation of diaphragmatic hernia as "acute abdomen" could be seen. The operation is indicated, also in asymptomatic patients as a prevention of life-threating events.

[Symptomatic Meckel's diverticulum in children]

Meckel's diverticulum (MD) is the most frequent anomaly of the small intestine, usually asymptotic. Complications of MD in children are usually bleeding and inflammation. Signs are non specific and diagnostics is prolonged. Scintigraphy is the method for the verification of bleeding from MD. A positive finding is the indication for exploration using laparoscopic or classic approach. In patients with bleeding of the MD, the literature presents, that there is usually gastric mucosa. The authors present patients with bleeding and the microscopic picture of the MD was intestinal mucosa with bleeding.

[Occlusive ileus caused by intestinal duplication]

State with progressive development of intestinal obstruction may leads to the misinterpretation of acute gastroenteritis in infant period. After passing of newborn period the differential diagnosis is not easy. Loss of time which leads to the correct diagnosis is ufavourable for patient because of worsening of the condition. The authors present a case review of 5 months old girl in whom cystoid intestinal duplication caused complete ileo-coecal occlusion. Associated diagnosis in our patient were anus perinealis ventralis and diverticulum Meckeli. The treatment of enteral duplication and Meckel's diverticulum was done in one stage surgery.

[Stoma procedures in the congenital digestive tract malformations]

The authors analyze options for intestinal stoma procedures for congenital digestive tract malformations. A primary anastomosis is considered the principal procedure, however, the authors advice against its risky performance. Although a stoma being the ultimate treatment option, indications for stoma procedures should be considered carefully and the procedure should be performed on time, to avoid any potential later pathology development in the anastomosis. The authors compare and critically assess the following principal three types of the stoma procedures: 1. The modified Gross procedure; 2. The Bishop-Koop Roux Y anastomosis; 3. The Santulli-Blanc Roux Y anastomosis. The authors do not favour any of the above and they stress out that for each individual malformation, its own optimal procedure should be selected and performed.

Tethered spinal cord syndrome--the importance of time for outcomes

OBJECTIVES

Tethered spinal cord syndrome is a relatively uncommon disorder of the medullary spine, usually associated with other congenital diseases of the caudal end of the spinal cord. However, it often remains unrecognised and due to its progressive character has serious consequences for those affected.

METHODS

We analysed a group of 22 patients, treated for TTS during the period from 1990 to 2005, focussing on the time period between the onset of symptoms and their treatment. The initial data from the year 1998 already pinpointed this time-lag as a crucial prognostic factor for outcomes.

RESULTS

Nine of the 22 treated patients showed an improvement of symptoms, 2 of them ad integrum. Eleven remained unchanged, without further progress and 2 patients worsened after surgery or despite it. Our results showed a direct correlation between the time-lag and the outcome of therapy. The average time span between recognition of disease and operation in those patients whose symptoms improved was about 16.7 months, whereas for those who remained unchanged it was 52.4. In the patients who worsened it was 54 months.

CONCLUSION

Virtually all patients operated within the first year showed a subsequent improvement of symptoms. Only 25 % of patients operated at a later stage achieved some measure of improvement. Time is a relevant factor for success.

Perinatal traumatism with gastroschisis

Authors analyse 11 cases of perinatal traumatism in a group of 110 patients with gastroschisis during a period of 25 years. They point out its causes and consequences. To minimize perinatal traumatism, it is necessary to conduct suitable prenatal and perinatal management. In spite of preferring Caesarean section there are no differences between vaginal and Caesarean delivery when the delivery is properly managed (Tab. 1, Fig. 3, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

MCNP-based computational model for the Leksell Gamma Knife

We have focused on the usage of MCNP code for calculation of Gamma Knife radiation field parameters with a homogenous polystyrene phantom. We have investigated several parameters of the Leksell Gamma Knife radiation field and compared the results with other studies based on EGS4 and PENELOPE code as well as the Leksell Gamma Knife treatment planning system Leksell GammaPlan (LGP). The current model describes all 201 radiation beams together and simulates all the sources in the same time. Within each beam, it considers the technical construction of the source, the source holder, collimator system, the spherical phantom, and surrounding material. We have calculated output factors for various sizes of scoring volumes, relative dose distributions along basic planes including linear dose profiles, integral doses in various volumes, and differential dose volume histograms. All the parameters have been calculated for each collimator size and for the isocentric configuration of the phantom. We have found the calculated output factors to be in agreement with other authors' works except the case of 4 mm collimator size, where averaging over the scoring volume and statistical uncertainties strongly influences the calculated results. In general, all the results are dependent on the choice of the scoring volume. The calculated linear dose profiles and relative dose distributions also match independent studies and the Leksell GammaPlan, but care must be taken about the fluctuations within the plateau, which can influence the normalization, and accuracy in determining the isocenter position, which is important for comparing different dose profiles. The calculated differential dose volume histograms and integral doses have been compared with data provided by the Leksell GammaPlan. The dose volume histograms are in good agreement as well as integral doses calculated in small calculation matrix volumes. However, deviations in integral doses up to 50% can be observed for large volumes such as for the total skull volume. The differences observed in treatment of scattered radiation between the MC method and the LGP may be important in this case. We have also studied the influence of differential direction sampling of primary photons and have found that, due to the anisotropic sampling, doses around the isocenter deviate from each other by up to 6%. With caution about the details of the calculation settings, it is possible to employ the MCNP Monte Carlo code for independent verification of the Leksell Gamma Knife radiation field properties.

Penile block in children, our first experience

Penile block has been in use in penile surgery as a technique for perioperative analgesia for 25 years. The authors reintroduced penile block on the Department of Paediatric Anaesthetics and Intensive Care at the University Children's Hospital in Bratislava, Slovakia in June 2004 after 8 years. This prospective open observational study presents their experience with penile block for elective penile surgery in 96 paediatric patients (Tab. 3, Ref. 14).

[Paresis of the femoral nerve in pelvic extraperitoneal hematoma--case reports and literature review]

The authors describe two rare cases of femoral nerve paresis in pelvic extraperitoneal hematoma in children. The first case was a 13-year-old girl, with no trauma in her medical history, in whom the paresis was suspected to have inflammatory or tumorous etiology; the other case was a 14-year-old boy injured during playing football. In both patients, extraperitoneal pathology of the pelvis was evident clinically and was shown in CT scans; paresis of the femoral nerve was demonstrated by EMG. In both cases, surgical intervention revealed a hematoma causing neuropathy. This was removed and, within a year of first sign appearance, both patients were free from neurological symptoms. The authors consider early surgery to be a decisive factor in the course of this neurological complication, as the regeneration of nerve structures took nearly a year despite the adolescent age of the patients. No reports of similar conditions in children treated at the same institution were found in the relevant international literature.