Hematological Indices Are Useful in Predicting Complications of Liver Cirrhosis.

BACKGROUND: Liver cirrhosis is the final stage of chronic liver disease. We aimed to evaluate non-invasive scores as predictors of complications and outcome in cirrhotic patients. METHODS: A total of 150 cirrhotic patients were included. Models for end-stage liver disease (MELD), albumin-bilirubin (ALBI) score, neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MoLR), and neutrophil-lymphocyte-albumin ratio (NLA) scores were tested in relation to the development of complications and mortality using receiver operating characteristic (ROC) curves. RESULTS: The ROC curve analysis showed (area under the curve) AUC values of NLR, NLA, ALBI, and MELD of 0.711, 0.730, 0.627, and 0.684, respectively, for short-term mortality. MELD, ALBI, and NLA scores showed a statistically significant correlation with hepatic encephalopathy (p = 0.000 vs. 0.014 vs. 0.040, respectively), and the MELD cut-off value of 16 had a sensitivity of 70% and a specificity of 52% (AUC: 0.671, 95% CI (0.577-0.765)). For the assessment of the presence of ascites, the AUC values for NLA and MoLR were 0.583 and 0.658, respectively, with cut-offs of 11.38 and 0.44. CONCLUSIONS: MELD, ALBI, and NLA are reliable predictors of hepatic encephalopathy. NLA and MoLR showed a significant correlation with the presence of ascites, and MELD, ALBI, NLR, and NLA have prognostic value to predict 30-day mortality in cirrhotic patients.

Microembolizations in the Arterial Cerebral Circulation in Patients with Atrial Fibrillation Ablation Using the Cryoballoon Technique-Protocol and Methodology of a Prospective Observational Study.

There is considerable uncertainty regarding the impact of microembolic signals (MESs) on neuropsychological abilities in patients receiving pulmonary vein isolation and beyond using the cryoballoon technique. We conducted the largest prospective observational study on this topic, providing insights into the gradual unmasking of procedure-related MESs and their impacts on neuropsychological outcomes. MESs were continuously detected periprocedurally using transcranial Doppler ultrasonography. Neuropsychological status was evaluated comprehensively using the CERAD Plus test battery, which consists of 11 neuropsychological subtests. Patients with atrial fibrillation were included in the study with an equal distribution (50:50) of paroxysmal or persistent presentations. Of 167 consecutive eligible patients, 100 were included within the study enrollment period from February 2021 to August 2022. The study, including the documentation of all follow-up visits, ended in November 2022. This paper focuses on describing the study protocol and methodology and presenting the baseline data.

Intestinal Ultrasonography as a Tool for Monitoring Disease Activity in Patients with Ulcerative Colitis.

Background: Ultrasonography is a noninvasive, inexpensive, and widely available diagnostic tool. In the last two decades, the development of ultrasound techniques and equipment has significantly increased the usage of intestine ultrasound (US) in the assessment of the gastrointestinal tract in patients with inflammatory bowel disease (IBD). Although current guidelines suggest routine utilization of US in patients with Crohn's disease, data regarding US usage in ulcerative colitis are still scarce. We aimed to assess the reliability of intestinal ultrasonography in the assessment of disease activity and extension of patients with ulcerative colitis. Methods: Fifty-five patients with a histologically confirmed diagnosis of ulcerative colitis, treated at University Clinical Center of Serbia in the period from 2019 to 2022 were included in this retrospective observational study. The data were obtained from the patient's medical records including history, laboratory, US, and endoscopy findings. US examined parameters were as following: bowel wall thickness (BWT), presence of fat wrapping, wall layer stratification, mesenteric hypertrophy, presence of enlarged mesenteric lymph nodes, and absence or presence of ascites. Results: Our results suggest that there is a strong correlation of BWT and colonoscopy findings regarding disease extension (r = 0.524, p=0.01, p < 0.05). Furthermore, our results have shown a statistically significant correlation of BWT with the Mayo endoscopic score (r = 0.434, p=0.01, p < 0.05), disease activity score (r = 0.369,p=0.01, p < 0.05), degree of ulcerative colitis burden of luminal inflammation (r = 0.366, p=0.01, p < 0.05), and Geboes index (r = 0.298, p=0.027, p < 0.05). Overall accuracy of US for disease extension and activity was statistically significant (p < 0.05). Conclusions: Our results suggest that US is a moderately accurate method for the assessment of disease activity and localization in patients with UC.

Diagnostic Value of Non-invasive Scoring Systems in the Prediction of Esophageal Varices in Patients with Liver Cirrhosis-Single Center Experience.

Background and Objectives: Upper endoscopy is considered the gold standard for screening and diagnosis of esophageal varices (EV). Non-invasive methods for predicting EV have become a research hotspot in recent years. The aim of this study was to assess the role of non-invasive scores in predicting the presence of EV in patients with liver cirrhosis, and to determine the value of these scores in predicting the outcome of patients with cirrhosis presenting with acute variceal bleeding. Materials and Methods: A total of 386 patients with liver cirrhosis were included. The model for end-stage liver disease (MELD), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT), AST to platelet ratio index (APRI), fibrosis-4-index (FIB-4), fibrosis index (FI), King's Score, albumin-bilirubin (ALBI) score, and platelet-albumin-bilirubin (PALBI) score were calculated. The discriminatory capacities of the examined scores in predicting the presence of esophageal varices were tested using receiver operating characteristic (ROC) curves. Results: The ROC curve analysis showed (area under the curve) AUC values of ALBI and PALBI of 0.603, and 0.606, respectively, for the prediction of EV. APRI, MELD, PALBI, King's, FIB-4, and ALBI scores showed statistically significant correlation with EV bleeding (p < 0.05). AUC of APRI and MELD for predicting EV bleeding were 0.662 and 0.637, respectively. The AUC value of MELD in short-term mortality was 0.761. Conclusions: ALBI and PALBI scores had modest diagnostic accuracy of EVs in liver cirrhosis. APRI and MELD can be used as a reference index for the EV bleeding, and MELD score is best associated with short-term outcome in cirrhotic patients.

Hepcidin Is a Reliable Marker of Iron Deficiency Anemia in Newly Diagnosed Patients with Inflammatory Bowel Disease.

RESULTS: There was a high statistically significant difference between IBD patients and controls in levels of hepcidin (P < 0.01). Namely, serum hepcidin levels were significantly higher in the control group. There was no statistically significant correlation of serum hepcidin with CRP, Mayo score, or CDAI, respectively (P > 0.05). However, we have found a statistically significant negative correlation of sTfR and TIBC with hepcidin (P < 0.01). CONCLUSION: Results of our study suggest that hepcidin is a reliable marker of IDA in patients with IBD, and it could be used in routine clinical practice when determining adequate therapy in these patients.

Correlation of Patient-Reported Outcome (PRO-2) with Endoscopic and Histological Features in Ulcerative Colitis and Crohn's Disease Patients.

METHODS: A cross-sectional study was conducted in consecutive newly diagnosed patients with inflammatory bowel disease in a tertiary care referral center. The initial evaluation included patient-reported outcome for stool frequency subscore and rectal bleeding. Endoscopic activity was determined using the Mayo scoring system for ulcerative colitis and the Simple Endoscopic Score for Crohn's disease. Histopathological activity was assessed using a validated numeric scoring system. RESULTS: We included 159 patients (63 Crohn's disease with colonic involvement and 96 with ulcerative colitis). We found significant correlation between the Mayo endoscopic subscoring system and histology activity in ulcerative colitis, while no correlation was found in patients with Crohn's disease. Patient-reported outcome showed inverse correlation with endoscopic and histological activity in Crohn's disease (r s = -0.67; r s = -0.72), while positive correlation was found in ulcerative colitis (r s = 0.84; r s = 0.75). Interpretation and Conclusions. Patient-reported outcome is a practical and noninvasive tool for assessment of disease activity in ulcerative colitis patients but not in Crohn's disease.

Modified split tendon transfer of posterior tibialis muscle in the treatment of spastic equinovarus foot deformity: long-term results and comparison with the standard procedure.

INTRODUCTION: Split tendon transfer of tibialis posterior (SPOTT) is a treatment option for the hindfoot varus deformity in patients with cerebral palsy (CP). The purpose of this study was to present the long-term results of the newly modified SPOTT procedure developed by our senior author and compare it with the standard SPOTT technique in equinovarus foot deformity due to CP. METHOD: Our retrospective cohort study included patients with spastic foot deformity due to CP treated with the standard or modified SPOTT technique. Patients' age at the time of the surgery was ≥ five years with follow-up period of at least four years. Surgical outcomes were evaluated using Kling's criteria during the patient's last follow-up visit. RESULTS: The analysis included 124 patients (146 feet), where 105 feet were treated by the standard SPOTT technique and 41 feet by the modified SPOTT technique. Patients' median age at the time of the surgery was 11 years. Patients were followed-up for a median period of eight years during which the modified SPOTT technique showed significantly better surgical outcomes compared with the standard group (excellent/good results in 38 feet, 92.7%, vs. 79 feet, 75.2%, p = 0.02). Two groups of patients did not significantly differ in GMFCS level, age at the time of the surgery, or patient gender. There was similar distribution in CP patterns in the standard and modified groups; spastic hemiplegia was the most prevalent form, followed by spastic diplegia and spastic paraplegia. Overall, better surgical success was achieved in patients with GMFCS levels I-III (100%, 94.8%, and 69.8%, respectively). SPOTT procedure failure was frequently noticed in patients with GMFCS level IV (90.9%). CONCLUSION: The modified SPOTT procedure demonstrated efficiency and safety in patients with equinovarus foot deformity due to CP during the long-term follow-up. Compared with the standard procedure, the newly modified SPOTT technique showed significantly better surgical outcome, irrespective of the patients' gender, age, initial GMFCS level, and CP type.

The results of surgical treatment for pronation deformities of the forearm in cerebral palsy after a mean follow-up of 17.5 years.

AIM: This study evaluates the effects of three surgical procedures in the treatment of pronation deformities of the forearm in cerebral palsy patients; namely the transposition of pronator teres to extensor carpi radialis brevis muscle; and rerouting of the pronator teres muscle with or without pronator quadratus muscle myotomy. METHODS: Sixty-one patients, 48 male/13 female, with a mean age of 17 years (5-41 years) were treated between 1971 and 2011. Pronator teres transposition was performed in 10, pronator rerouting in 35, and pronator rereouting with pronator quadratus myotomy in 16 patients. Ranges of motion, and assessments using the Quick Dash, Mayo Scoring, and Functional Classification system of upper extremity, were made before and after surgery. Mean follow-up was 17.5 years (3-41 years). RESULTS: All three procedures led to significantly improved ranges of motion and upper limb function, with good/excellent results in 80 % of patients. Mean active supination improved from 10 ° (0-60 °) to 85 ° (30-90 °) (p < 0.001). There were significant improvements in Functional Classification system for the upper extremity scores (p < 0.003), Mean Quick Dash Scores improved from 58.41 (38.63-79.54) to 44.59 (27.27-68.18), and mean MEPS improved from 68 (30-85) to 84 (60-100) following surgery. All three techniques had statistically improved MEPS following surgery (p < 0.001); only the pronator teres muscle rerouting with pronator quadratus myotomy showed an improved Functional Classification system for the upper extremity score (p < 0.05); and only the pronator teres rerouting procedure showed an improved Quick Dash score (p < 0.05). There were no statistically significant differences in outcomes between different ages groups, and no significant differences between isolated pronator teres muscle rerouting were compared with those undergoing simultaneous treatment of carpal flexion and thumb adduction deformities (p > 0.05). CONCLUSION: Surgery is very effective in the management of pronation deformities of the forearm in patients with cerebral palsy. Isolated pronator teres rerouting is probably the most effective and simple technique. Adjunctive pronator quadratus myotomy does not lead to an improvement in the results and requires an additional surgical approach. There should be no age restriction to surgery, as all age groups appear to benefit from similar improvements in range of motion and upper limb function.

Superficial femoral artery aneurysm: a rare complication of wegener granulomatosis.

Wegener granulomatosis (WG) is a systemic disease of unknown etiology characterized by necrotizing granulomatous inflammation, tissue necrosis, and variable degrees of vasculitis, typically in small and medium-sized blood vessels. The classic clinical pattern is a triad involving the upper airways, lungs, and kidneys. However, large vessel aneurysm is an extremely rare finding in WG. We describe a 67-year-old Caucasian male with formerly proven WG who presented with a progressively growing superficial femoral artery aneurysm. Histologic findings revealed necrotizing granulomatous vasculitis involving this artery.

Results of an observational study in carotid surgery using absorbable suture material.

BACKGROUND: Absorbable sutures are not well accepted for reconstruction in high-pressure arterial segments because the suture line might break and aneurysmal changes could develop. This hypothesis was checked in the clinical setting of carotid surgery. METHODS: The morphology of the carotid artery was evaluated by color-coded ultrasound in four groups of patients: group A, 25 patients who underwent standard carotid endarterectomy and patchplasty, including a transverse plication for which absorbable sutures had been used; group B, 10 patients who underwent eversion endarterectomy and reinsertion using absorbable sutures; group C, 15 patients who underwent standard carotid endarterectomy and patchplasty without a transverse placation; group D, 20 patients who suffered from atherosclerotic disease but did not have previous carotid surgery or other carotid pathology. All operations had been performed at least 3 years earlier than the actual examination. RESULTS: Along the internal carotid artery, where an aneurysmal change would have been expected to occur, no differences in absolute size or calculated elliptical cross-sectional vessel area were found. Patients after eversion endarterectomy did not show signs of aneurysmal changes in the area of reinsertion at the carotid bifurcation. CONCLUSIONS: Even in the long-term, for this group of patients, no significant aneurysmal changes of arterial reconstructions in carotid surgery performed with absorbable sutures were observed.

Implementation of an artificial neuronal network to predict shunt necessity in carotid surgery.

In carotid surgery, it could be useful to know which patient will tolerate carotid cross-clamping in order to minimize the risks of perioperative strokes. In this clinical study, an artificial neuronal network (ANN) was applied and compared with conventional statistical methods to assess the value of various parameters to predict shunt necessity. Eight hundred and fifty patients undergoing carotid endarterectomy for a high-grade internal carotid artery stenosis under local anesthesia were analyzed regarding shunt necessity using a standard feed-forward, backpropagation ANN (NeuroSolutions); NeuroDimensions, Gainesville, FL) with three layers (one input layer, one hidden layer, one output layer). Among the input neurons, preoperative clinical (n = 9) and intraoperative hemodynamic (n = 3) parameters were examined separately. The accuracy of prediction was compared to the results of a regression analysis using the same variables. In 173 patients (20%) a shunt was used because hemispheric deficits or unconsciousness occurred during cross-clamping. With the ANN, not needing a shunt was predicted by preoperative and intraoperative parameters with an accuracy of 96% and 91%, respectively, where the regression analysis showed an accuracy of 98% and 96%, respectively. Those patients who needed a shunt were identified by preoperative parameters in 9% and by intraoperative parameters in 56% when the ANN was used. Regression analysis predicted shunt use correctly in 10% using preoperative parameters and 41% using intraoperative parameters. Intraoperative hemodynamic parameters are more suitable than preoperative parameters to indicate shunt necessity where the application of an ANN provides slightly better results compared to regression analysis. However, the overall accuracy is too low to renounce perioperative neuromonitoring methods like local anesthesia.

S-100B release during carotid endarterectomy under local anesthesia.

The neuronal protein S-100B has been found to be an indicator of cellular brain damage. The aim of the study was to evaluate whether cross-clamping of the carotid artery for carotid endarterectomy (CEA) under local anesthesia is associated with the same S-100B release pattern as during general anesthesia, where an increase in S-100B concentration in the jugular vein blood of 120% has been reported. In 45 consecutive patients undergoing CEA under local anesthesia, serum S-100B samples were drawn before surgery (T1), before carotid cross-clamping (T2), before cerebral reperfusion (T3), after reperfusion but before the end of surgery (T4), and 6 hr postoperatively (T5). At T1 and T5, blood samples were drawn only from the radial artery. Intraoperatively (T2-T4), samples were collected from the internal jugular vein additionally. S-100B levels were determined using an immunoluminometric assay (LIAISON) Sangtec 100; Sangtec, Bromma, Sweden). In eight patients, it was necessary to insert an intraluminal shunt because of signs of cerebral ischemia. In the remaining 37 patients, median carotid clamping time was 40 min. There were no neurological complications. There were no differences in baseline S-100B levels regarding gender and symptomatology. Median baseline (T1) and postoperative (T5) S-100B levels were identical (0.077 microg/L). All blood samples from the jugular vein showed significantly higher median S-100B levels than the corresponding arterial blood samples. Only slight increases of 13% and 18% were found during cross-clamping (T3) compared to the first intraoperative measurement (T2) in the venous and arterial samples, respectively, which was followed by decreases of 5% and 18%, respectively (T3-T4). S-100B release did not differ at any time point between patients who needed and patients who did not need a shunt, in either the arterial or the venous blood samples. During uncomplicated CEA under local anesthesia, there is no relevant increase of S-100B. These results are different from those reported when CEA is done under general anesthesia.

Stent Grafts for Acute Traumatic Injury of the Thoracic Aorta: A Single-Centre Experience.

OBJECTIVES: The presented study reveals the single centre experiences with the minimally invasive endovascular repair for acute traumatic thoracic aortic lesions in the care of multitrauma patients. METHODS: We reviewed ten patients with acute traumatic thoracic aortic lesions treated with a thoracic aortic stent graft between April 2001 and December 2006. The prospective collected data included age, sex, injury severity score, type of endovascular graft, endovascular operation time, length of stay, length of stay in the intensive care unit, and mortality. Followup data consisted of contrast-enhanced spiral computed tomography at regular intervals. RESULTS: All patients (m:f 5:5; median age, 46 years; interquartile range [IQR], 29-68.5 years) suffered severe traumatic injury, the median Injury Severity Score was 39.5 (IQR 37.3-43). All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 90 min (IQR, 65-120 min). The overall hospital mortality was 20% (n = 2), and all deaths were unrelated to the aortic rupture or stent placement. No incidence of paraplegia was present. No intervention-related mortality occurred during a median follow-up of 14.7 months (IQR, 9.7-55.8 months). CONCLUSION: The endovascular approach to acute traumatic thoracic aortic lesions is feasible, safe, and effective in multitrauma patients. The low endovascular therapy-related morbidity and mortality in the postoperative period is encouraging. The results seem to be favorable to those published of open emergency repair.

Occupation-related vascular disorders of the upper extremity--two case reports.

Hypothenar hammer (HH) syndrome and vibration-induced white finger (VWF) syndrome are the main occupation-related vascular diseases of the upper extremity. The clinical presentation is similar to that of Raynaud's phenomenon. The characteristic history will lead to the appropriate diagnosis being confirmed by angiographic features in HH and by functional tests in VWF. While in HH the underlying cause, which is mostly thought to be an aneurysm of the ulnar artery, might be cured surgically, in VWF only medical treatment offers relief from the symptoms. The knowledge of these entities is necessary to suspect such disorders so that further exposure to risk factors like repetitive hypothenar trauma or work with vibrating hand-held tools can be avoided, which is of great importance for the overall prognosis of these patients.

Endovascular repair of aneurysm after previous surgical coarctation repair.

OBJECTIVES: Late aneurysm formation has been reported after every type of surgical coarctation repair, with rupture of such aneurysms being responsible for approximately 7% of all deaths. Secondary surgical repair carries a significant mortality and morbidity. According to the positive experience with endovascular therapy of atherosclerotic thoracic aortic aneurysms, it is worthwhile to evaluate the concept of minimally invasive endovascular stent grafting for secondary repair of postsurgical aneurysms. METHODS: Data were collected prospectively on consecutive patients who presented with postcoarctation false aneurysms. RESULTS: Since 1999, in a cohort of 46 endovascularly treated patients with thoracic aortic pathologies, 3 patients with postcoarctation false aneurysms underwent endoluminal stent-graft placement. All of these procedures were technically successful without 30-day or 1-year procedure-related mortality. After a mean follow-up of 19 months (range, 7.8-33.5 months), all aneurysm remain excluded without endoleak. CONCLUSIONS: According to the current limited experience of small series and short periods of follow-up, the endoluminal repair seems to be a promising alternative to redo operations for postsurgical thoracic aneurysms associated with coarctation repair. Long-term follow-up is required to assess the durability of the stent-graft treatment.