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Factors Associated with Difficult Neuraxial Blockade
No full textSpinal and epidural blocks are common practice in anesthesia and are usually used for various surgical or endoscopic procedures. Correct identification and puncture of the epidural or subarachnoid space determine the success or failure of the technique. Multiple attempts and difficult access to the epidural or subarachnoid space is a frequent problem in operating theaters and may be hazardous due to a number of possible acute or long-term complications. In addition, multiple punctures are associated with increased pain and patient discomfort. The aim of this study was to determine the factors associated with a difficult spinal or epidural block, dependent on the patient (age, gender, height, weight, body mass index, and quality of anatomical landmarks), the technique (type of blockade, needle gauge, and patient positioning), and the provider (level of experience). The study was conducted at the Department of Anesthesiology, Resuscitation, and Intensive Care Unit of University Hospital Osijek (Osijek, Croatia) and it included 316 patients who underwent a range of different surgical procedures in neuraxial blocks. There were 219 cases of first puncture success, while the overall success of neuraxial blocks was 97.5%. Five patients (1.6%) were submitted to the alternative technique, ie, general anesthesia. In three patients (0.9%), neuraxial block was partial so they required supplementation of intravenous anesthetics and analgesics. Furthermore, it was found that first puncture success was associated with younger age (P=0.007), lower weight (P=0.032), and body mass index (P=0.020). Spine deformity (P=0.015), poor identification of interspinous space (P=0.005), recumbent patient position during the puncture (P=0.001), and use of a paramedian approach were associated with first puncture failure. Adequate preoperative prediction of difficulties can help to reduce the incidence of multiple attempts, rendering the technique more acceptable and less risky to the patient, and consequently leading to improvement of medical care quality. The attending anesthesiologist should consider an alternative technique (general anesthesia or peripheral nerve block) for a patient if certain difficulties can be predicted
Cerebellar Glioblastoma Multiforme Presenting as Hypertensive Cerebellar Hemorrhage: Case Report
No full textBackground: Cerebellar glioblastoma multiforme (GBM) is rare and presents with increased intracranial pressure and cerebellar signs. The recommended treatment is radical resection, if possible, with radiation and chemotherapy. Clinical Presentation A 53-year-old man presented with hypertensive cerebellar bleeding and a 2-day history of severe headaches, nausea, vomiting, gait instability, and elevated blood pressure. Computed tomography (CT) showed a left cerebellar hematoma with no obstruction of cerebrospinal fluid and no hydrocephalus. CT angiography showed no signs of pathologic blood vessels in the posterior cranial fossa. The patient was observed in the hospital and discharged. Subsequent CT showed complete hematoma resorption. Two weeks later, he developed headaches, nausea, and worsening cerebellar symptoms. Magnetic resonance imaging (MRI) showed a 4-cm diameter tumor in the left cerebellar hemisphere where the hemorrhage was located. The tumor was radically resected and diagnosed as GBM. The patient underwent radiation and chemotherapy. At a follow-up of 1.5 years, MRIs showed no tumor recurrence. Conclusion Hypertensive cerebellar hemorrhage may be the first presentation of underlying tumor, specifically GBM. Patients undergoing surgery for cerebellar hemorrhage should have clot specimens sent for histologic examination and have pre- and postcontrast MRIs. Patients not undergoing surgery should have MRIs done after hematoma resolution to rule out underlying tumor
Povezanost il-1b i il-10 polimorfizama s rizikom i progresijom raka prostate u populaciji istočne Hrvatske
No full textSingle nuclear polymorphisms (SNPs) in the promotor regions of cytokine genes included in angiogenesis may influence prostate cancer (PCa) development via regulation of the pathways of tumor angiogenesis. The aim of the present study was to investigate the association of IL-1β+3954 (rs1143634) and IL-10-1082 (rs1800896) polymorphisms with PCa risk and aggressiveness in eastern Croatian patients. One hundred twenty PCa patients and 120 benign prostatic hyperplasia (BPH) controls were genotyped using real-time PCR (LightCycler Instrument, Roche Diagnostics) and the melting curve analysis method. There was no significant difference in the frequency of genotypes for the two polymorphisms between PCa patients and controls (χ2=0.857, p=0.355 for IL-β1; χ2=0.026, p=0.872 for IL-10). Carriers of the IL-10-1082A>G variant were found to be associated with the Gleason score (GS)>7 (AA versus GA+GG, OR=3.47, 95% CI 1.11-10.88, p=0.033). There was no significant difference in the frequency of genotypes for the two polymorphisms and the presence of metastatic disease in PCa patients. These results suggest that tested SNPs associated with differential production of IL-1β and IL-10 are not risk factors for PCa and do not correlate with the presence of distant metastasis in eastern Croatians. We found that IL-10-1082 GA+/or GG carriers have a higher risk of developing PCa with GS>7 in eastern Croatians.Pojedinačni nuklearni polimorfi zmi (SNP) u promotorskim regijama gena citokina uključenih u angiogenezu, mogu utjecati na razvoj karcinoma prostate (PCa) regulacijom putova angiogeneze tumora. Cilj ove studije bio je istražiti povezanost IL-1b+3954 (rs1143634) i IL-10-1082 (rs1800896) polimorfi zama s rizikom i agresivnošću karcinoma prostate kod pacijenata iz istočne Hrvatske. 120 pacijenata s karcinomom prostate i 120 kontrola s benignom hiperplazijom prostate (BPH) genotipizirani su metodom lančane reakcije polimerazom u stvarnom vremenu (eng. real-time PCR) i analizom krivulje temperature taljenja pomoću tehnologije LightCycler (Roche Diagnostics). Nije bilo značajne razlike u učestalosti genotipova za dva polimorfi zma između PCa bolesnika i kontrola (c2=0,857, p=0,355 za IL-b1; c2=0,026, p=0,872 za IL-10). Utvrđena je povezanost nosioca IL-10-1082A>G varijante s GS>7 (AA u odnosu na GA+GG, OR=3,47; 95% CI 1.11 do 10,88, p=0,033). Nije bilo značajne razlike u učestalosti genotipova za dva polimorfi zma i prisutnosti metastatske bolesti u PCa bolesnika. Ovi rezultati sugeriraju da testirani SNP-ovi, povezani s različitom produkcijom IL-1b i IL-10, nisu čimbenici rizika za PCa i ne koreliraju s prisutnošću metastaza kod ispitanika u istočnoj Hrvatskoj. Otkrili smo da u istočnoj Hrvatskoj, nositelji IL-10-1082 GA +/ili GG genotipa imaju veći rizik razvoja PCa s GS>7
Usporedba kliničke značajnosti proinflamatornog proteina interleukina-6 u serumu i klasičnih tumorskih markera ukupnog psa, slobodnog psa i slobodni/ukupni psa prije biopsije prostate
No full textThe aim of the study was to clarify whether serum levels of proinflammatory cytokine interleukin-6 (IL-6) could be a useful marker in prostate diseases. Serum IL-6 was determined prior to prostate biopsy procedure in 82 patients with prostate adenocarcinoma (PCa), 25 patients with benign prostatic hyperplasia (BPH), 24 patients with high-grade prostatic intraepithelial neoplasia (PIN) and 17 patients with chronic prostatitis. Serum IL-6 levels were compared with total PSA (tPSA), free PSA (fPSA) and the free/total ratio (f/tPSA) serum levels. Statistically significant difference was not found in serum IL-6 levels among the four groups (p=0.088). However, the patients with poorly differentiated PCa with Gleason score (GS) 4+3=7 and >7 had significantly higher serum IL-6 levels than the patients with moderately differentiated PCa with GS 3+4=7 and 7 imali su značajno više razine serumskog IL-6 nego pacijenti sa srednje diferenciranim PCa s GS 3+4=7 i <7 (p=0.007). Rezultati sugeriraju da bi razina serumskog IL-6 mogla biti potencijalni korisni marker kod slabo diferenciranog PCa
Minimally Invasive Interventions in pain Management
No full textCilj je intervencijskih tehnika smanjenje boli djelovanjem na specifična, ograničena područja prijenosa bolnih signala bez nuspojava koje ima sistemska primjena analgetika. Svaka razina živcanog sustava može biti subjekt električne neuromodulacije s učinkom smanjenja kronične, a osobito neuropatske boli. Pažljivo probrani bolesnici mogu imati korist od implantacije sistema za intratekalnu isporuku lijekova, najčešće opioida s adjuvantnim lijekovima ili bez njih. Takvi su bolesnici već prošli uobičajenu konzervativnu analgetsku terapiju te su imali ili nedovoljno smanjenje boli ili neprihvatljive nuspojave. Opće je stajalište da je intratekalna i epiduralna primjena lijekova dobra opcija u liječenju karcinomske boli gdje su cesto potrebne više doze opioida, što za posljedicu ima teže nuspojave kao što su sedacija i konstipacija. Živčana blokada lokalnim anestetikom cervikalnih i lumbalnih simpatičkih vlakana dokazana je metoda liječenja kompleksnih regionalnih bolnih sindroma gornjih i donjih ekstremiteta. Kod osteoporotičnih bolesnika fraktura kralježaka često može biti uzrok akutne i kronične boli koja se uspješno liječi vertebroplastikom i kifoplastikom. Mehanička trauma živaca kao posljedica lateralne hernijacije diska, spondilolisteze, kemijske iritacije zbog curenja nukleusa pulpozusa i ozljede uzrokovane infektivnim agensima kao što je herpes zoster mogu inicirati kaskadu inflamatornih medijatora uključujući citokine koji uzrokuju i podupiru razvoj kronične boli. Zbog svega navedenoga foraminalna primjena steroida cesta je minimalnoinvazivna metoda liječenja ovih bolnih stanja.Interventional techniques that target specific nociceptive transmission sites can reduce pain without having the systemic impact that oral medications have on other organ systems. Neural blockade with local anaesthetic of nerve fibers in the cervical and lumbar sympathetic chain is a common therapeutic technique used in the treatment of complex regional pain syndrome of the upper and lower extremities. As patients age, bone and connective tissue components of the spine are subject to a wide array of degenerative processes that contribute to chronic pain, including but not limited to, vertebral fractures, disc herniations and ruptures, and hypertrophy and sclerosis of facets joints and ligamentum flavum. The most important interventional pain management target within the vertebral foramen is the dorsal root ganglion. The primary afferent neurons in the ganglion and the main link between peripheral nociceptors and the processing centres of the central nervous system. Injury of these nerves is common from mechanical trauma resulting from lateralized herniated disc or spondylolisthesis, chemical irritation from leakage of nucleus pulposus and injury caused by infectious agents such as herpes zoster. Electrical stimulation can provide effective analgesia by targeting various spinal targets including the spinal cord, nerve roots, and dorsal root ganglia. Destruction of specific spinal neural targets with either neurolytic solution or thermal probes provides long-term relief for a limited number of pain conditions
De novo slučaj djelomične trisomije 4p I djelomične monosomije 8p
No full textThe extent of clinical expression in cases of segmental aneuploidy often varies depending on the size of the chromosomal region involved. Here we present clinical and cytogenetic findings in a 5-month old boy with a duplication of a chromosomal segment 4p16.1®4pter and a deletion of a chromosomal segment 8p23.1®8pter. His karyotype was determined by applying classical GTG banding and FISH method (WHCR region, centromere 4, centromere 8, telomere 8p) as 46,XY,der(8)t(4;8)(p16.1;p23.1).ish der(8)t(4;8)(D8S504-,WHCR+,D8Z2+)dn. Parents are not related and have normal karyotypes, indicating de novo origin. We have compared similarity of the clinical features in our proband to other patients carrying only a duplication of the distal part of 4p or a deletion of distal part of 8p or similar combination described in the literature.Fenotip pacijenata s djelomičnom aneuploidijom često ima varijabilnu kliničku sliku ovisnu o veličini kromosomskog segmenta uključenog u translokaciju. Prikazane su kliničke citogenetičke osobitosti dječaka starog pet mjeseci s duplikacijom dijela kromosoma 4p16.1®4pter i s gubitkom dijela kromosoma 8p23.1®pter. Kariotip probanda određen je primjenom klasičnog GTG pruganja kromosoma i korištenjem FISH proba (lokus specifična proba za WHCR regiju, centromera 4, centromera 8, telomera 8p): 46,XY,der(8)t(4;8)(p16.1;p23.1).ish der(8)t(4;8)(D8S504–,WHCR+,D8Z2+)dn. Roditelji nisu u srodstvu i utvrđen im je normalan kariogram. Usporedili smo sličnost kliničkih osobitosti našeg pacijenta s ostalim pacijentima opisanim u literaturi koji imaju samo duplikaciju distalnog dijela 4p ili deleciju distalnog dijela 8p, ili sličnu kombinaciju nebalansiranog kariotipa
Potentially Inappropriate Prescribing in Elderly Outpatients in Croatia
No full textThe purpose of this study was to determine the prevalence of inappropriate prescribing to the elderly and to identify possible gender-related differences in prescribing certain potentially inappropriate medications (PIMs) to outpatients by using large administrative prescription database. Medications prescribed for elderly outpatients (≥ 65 years) in Primorsko-Goranska County, Croatia, who received five or more different drugs simultaneously in 2010, were analyzed. The prevalence of potentially inappropriate drugs prescribed to the elderly was assessed using the new comprehensive protocol developed by authors Mimica Matanović and Vlahović-Palčevski. A total of 62.4 % of patients received at least one
medication with unfavorable benefit/risk ratio in the elderly. Female patients were given inappropriate medications in a significantly higher percentage than men (69.3 % vs. 50.5 %; p65 years and receiving five or more drugs was potentially inappropriate. Elderly women were prescribed PIMs more often than men. Drugs of concern in female patients were benzodiazepines, antidepressants, and nonsteroidal anti-inflammatory drugs (NSAIDs). In male patients, there was a significantly higher proportion of possible interactions with warfarin, theophylline, and medications affecting the cardiovascular system, such as ACE inhibitors and amiodarone
First Guidelines of Croatian Interest Group in Diagnosing and Treating pain Conditions of Cervical and Thoracic Spine Using Minimally invasive procedures
No full textBolni sindromi vratne i prsne kralježnice važni su javnozdravstveni problemi. Troškovi operacijskog liječenja iznimno su visoki, a radno sposobni ljudi s ovim bolestima često svakodnevno izostaju s posla. Kroničnu vratobolju najčešće uzrokuju degenerativne promjene malih zglobova. Cervikobrahijalni sindrom najčešće uzrokuje hernijacija vratnoga intervertebralnog diska. Svaka minimalno invazivna dijagnostička procedura, koja se radi s ciljem identifikacije izvora boli, bolesnika istodobno predodređuje za specifični minimalno invazivni terapijski zahvat. Ako su vratobolja ili bol u prsnoj kralježnici uzrokovane degenerativnim promjenama malih zglobova, tada se, nakon pozitivnih dijagnostičkih blokova, primjenjuju procedure radiofrekventne neuroablacije. Kod boli u vratnoj kralježnici uzrokovanih degenerativnim promjenama intervertebralnog diska bolesnicima se preporučuju intradiskalne dekompresije. U slučajevima kada su akutna vratobolja i radikularna bol bez mišićne slabosti uzrokovane stenozom spinalnog kanala, bolesniku se preporučuju epiduralne steroidne injekcije. Svrha je minimalno invazivnih terapijskih procedura primjenom kortikosteroida i kratkodjelujućega lokalnog anestetika te primjenom radiofrekventne struje bolesnika na duže vrijeme osloboditi boli te mu poboljšati kvalitetu života.Pain syndromes originating from cervical and thoracic spine remain to be a major public health problem. Medical expenses in general and surgical procedures associated with overall care for the neck and thoracic pain are high and growing. Furthermore, these two chronic pain conditions are also leading causes for missed workdays. Chronic pain syndromes originating from cervical spine are most commonly caused by degenerative changes of the facet joints. Cervicobrachial syndrome is most commonly caused by herniated discs. Diagnostic controlled blocks, performed in order to identify the source of pain, often predetermine patient for further therapeutic minimally invasive interventions. If the chronic pain syndromes of the cervical and thoracic spine are caused by degenerative facet joints, patient can be offered neuroablative procedures using radiofrequency. In patients suffering from chronic cervical and thoracic pain caused by painful intervertebral disc minimally invasive intradiscal decompression procedures can be performed. In cases where the neck pain and radicular pain are caused by the central and foraminal spinal stenosis patients are advised epidural steroid injections. The purpose of above advised procedures, using steroids, local anesthetics and RF current, is to relieve patients’ pain, allow optimal physical therapy, and improved functional capacity, consequently providing a better quality of lif
Djelomična monosomija 2p i djelomična trisomija 4p uslijed očeve translokacije t(2;4)(p25.1;q31.3)
No full textClinical features in patients with segmental aneuploidy often vary depending on the size of the chromosomal segment involved. Monosomy 2p is usually observed as a part of more complex syndromes among probands of balanced reciprocal translocation carriers. Patients with dup4q syndrome have variable clinical features, which are both related to the size of duplicated segment of the 4q and specific associated monosomy. Clinical findings of our patient were compatible with those previously reported in dup4q and del2p patients. Herein are presented the clinical and cytogenetic findings in a 4-year-old female with an unbalanced karyotype 46,XX,der(2)t(2;4)(p25.1;q31.3)pat. Clinical phenotypes of 2p;4q translocation cases are variable, because the involved breakpoints vary case-by-case. We also compare similarity of the clinical features of our proband and other patients carrying either duplication of the distal part of 4q and patients carrying a deletion of distal part of 2p as described in the literature. To our knowledge, this is the first case of partial trisomy 4q accompanied with partial monosomy 2p.Klinička slika pacijenta s djelomičnom aneuploidijom ovisi o veličini kromosomskog segmenta uključenog u translokaciju. Monosomija 2p često je dio složenih sindroma u potomaka nositelja uravnotežene recipročne translokacije. Pacijenti sa sindromom dup4q imaju promjenjivu kliničku sliku koja ovisi o veličini dupliciranog segmenta 4q i specifičnoj pridruženoj monosomiji. Klinička slika nače pacijentice podudara se s kliničkom slikom več objavljenih pacijenata s dup4q i del2p. Prikazani su klinički i citogenetički nalazi četvrogodišnje djevojčice sa nebalasiranim kariotipom 46, XX,der(2)t(2;4)(p25.1;q31.3)pat. Fenotipovi slučajeva translokacije 2p;4q su promjenjivi jer točke loma variraju od pacijenta do pacijenta. Usporedili smo sličnost kliničkih nalaza naše pacijentice s ostalim pacijentima opisanim u literaturi koji imaju ili duplikaciju distalnog dijela 4q ili deleciju distalnog dijela 2p. Ovo je prva pacijentica s djelomičnom trisomijom 4q povezana s djelomičnom monosomijom 2p
Stereotactic Radiotherapy for Vestibular Schwannoma
No full textBackground - Vestibular schwannomas (acoustic neuromas) are common benign tumours that arise from the Schwann cells of the vestibular nerve. Management options include observation with neuroradiological follow-up, microsurgical resection and stereotactic radiotherapy.
Objectives - To assess the eJect of stereotactic radiotherapy compared to observation, microsurgical resection, any other treatment modality, or a combination of two or more of the above approaches for vestibular schwannoma.
Search methods - We searched the Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; Web of Science; CAB Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 24 July 2014.
Selection criteria - Randomised controlled trials (RCTs) exploring the eJicacy of stereotactic radiotherapy compared with observation alone, microsurgical resection or any other possible treatment or combination of treatments in patients with a cerebellopontine angle tumour up to 3 cm in diameter, presumed to be a vestibular schwannoma.
Data collection and analysis - We used the standard methodological procedures expected by The Cochrane Collaboration.
Main results - No studies met the inclusion criteria for this review