Postoperative delirium.

Postoperative delirium is a serious complication occurring mainly in patients over 65 years. This complication is common in the above mentioned age group and has been described in up to 50% of patients. Postoperative delirium has a significant impact both on postoperative morbidity and mortality. Systematic and early detection of at-risk patients is essential to reduce the risk of postoperative delirium. Targeted efforts are then developed in thus identified patients to reduce the risk factors for developing delirium. An individualized approach to anesthesia is adopted during the surgery. Procedures that contribute to reducing the risk of developing delirium are preferred in the postoperative period. If this complication does occur, it is primarily preferred to manage any potential cause of the condition using non-pharmacological procedures. Pharmacological interven- tion should be reserved only for patients with a hyperactive form of delirium. The aim of the article was to shed more light on measures that help to prevent the delirium and on the therapeutic procedures used.

Nutrition in open abdomen.

Open abdomen is known as a serious consequence of various intra-abdominal pathologies. Initially, patients often have a life-threatening condition, sepsis or septic shock. Severe stress related malnutrition, mineral and fluid imbalance develop as metabolic consequences. Intestinal fistulas also occur as a frequent complication in patients with open abdomen. In such patients, a comprehensive approach is needed, including rehabilitation, nutritional support using optimal formulas, and local care for the open abdomen. Our case report presents a patient with open abdomen and enterocutaneous fistulation. A complex nutritional approach in the course of the disease is described and its importance is discussed. Finally, a summary of nutritional care for open abdomen patients is provided based on current recommendations.

[Clostridium colitis at a surgical department]. / Problematika klostridiové kolitidy na chirurgickém pracovisti.

INTRODUCTION: The aim of our study was to identify risk factors associated with the development of Clostridium difficile colitis and determining the severity of clostridial colitis in a group of surgical patients. Identification of its predispositions is necessary for preventive interventions and effective treatment. MATERIAL AND METHODS: 51 patients diagnosed with clostridial colitis were included in our study. The inclusion criterion was based on laboratory detection of clostridial toxin in each patient. We analysed age, concomitant malignancy, recent surgical intervention, antibiotic and proton pump inhibitors treatment. The severity of clostridial colitis and its correlation to possible risk factors mentioned above was described and statistically evaluated. Non-parametric Fischer test was used for the statistical evaluation. RESULTS: We confirmed the importance of potential risk factors in the evaluated group of surgical patients with Cl. difficile colitis. The course of the disease was described as serious in 39.2% of patients in the study group. Recurrent attack of colitis was diagnosed in 4 patients, in 2 of them the second recurrence, in 1 patient the third relapse occurred. 2 patients with clostridial colitis evaluated in our group died, but the relation of their death to the clostridial GIT infection was not causal and the primary cause of death in both of them was multiple organ failure caused by serious comorbidities. We did not indicate any surgical intervention and no toxic megacolon developed in our study group. We did not detect any statistical correlation between the described risk factors and the severity of colitis. CONCLUSION: Clostridium difficile colitis needs to be recognised as a serious complication, especially in hospitalised patients. Its increased frequency and severity should not be underestimated. Although we can identify potential risk factors, we cannot exclude some of them completely (e.g. antibiotic and PPI treatment). On the other hand, a rational approach to antibiotic treatment in particular can be helpful in reducing the frequency and severity of clostridium difficile colitis.

[Arthroscopic findings concerning rotator cuff lesions and their operative management]. / Artroskopické nálezy lézí rotátorové manzety a jejich operacní lécba.

PURPOSE OF THE STUDY: Our objective is to introduce our simplified, easy-to-use classification of rotator cuff (RC) lesions, describe the frequency of individual findings in a considerably large series of shoulder joints examined by arthroscopy, evaluate the results of the operative management of individual lesion types, and recommend optimal surgical approaches. MATERIAL: Over the course of 10 years (between October 1st, 2000 and December 31st, 2009), 756 arthroscopic operations on the shoulder joint were performed. RC lesions were identified in 516 cases. We categorized the lesions using our own classification. Patient characteristics were as follows: the mean age was 43 years, 69% of the patients were men, and the right shoulder was affected in 61% of the cases (with the dominant upper limb being affected in 71% of the cases). The patients were followed up for a minimum period of 6 months. METHODS: All operations were performed in the "beach-chair" position under general anesthesia or in an interscalenic block. The arthroscope was introduced into the shoulder joint through the "soft-spot". Continuous lavage via an arthroscopic pump was used. The glenohumeral joint was examined first; an examination of the subacromial space followed. Once the lesion type was identified, other procedures were performed. In standard situations, type I lesions were managed with ASK sub- acromial decompression (SAD). As to type II lesions, we initially performed open RC reconstruction with acromioplasty, which we later replaced with ASK-assisted RC reconstruction with SAD; we are currently managing these lesions with ASK RC reconstruction + SAD. As for type III lesions, we initially used to treat them with open RC reconstruction with acromio - plasty; we are now performing ASK-assisted RC reconstruction with mini-incision + SAD. We are trying to use "double-row" sutures in certain cases. The initial management of type IV lesions consisted of ASK palliative resection of RC remnants combined with SAD. Currently, we are performing partial muscle transfer of the intact subscapularis muscle tendon (Karas) or partial non-anatomical RC reconstruction (Burkhart). A combination of both methods described above was required in some cases. If delamination of the RC was found, partial reconstruction using the "double-layer" technique took place. Open acromioplasty was added during all operations. Type V lesions are managed with ASK palliative resection of RC remnants + SAD; when this approach proves unsuccessful, which is a rare phenomenon, resurfacing follows. The results were evaluated after 6 months using a modified Constant functional score. Besides clinical examination, self-assessment questionnaires filled in by the patients were also evaluated. RESULTS: Out of a total of 516 RC lesions, type I was the most prevalent (54%), followed by type V (16%). The prevalence of lesion types II, III and IV was about 10% each. In type I, the mean improvement measured by the Constant score was 36 points. As for type II, open reconstruction, ASK-assisted reconstruction and ASK reconstruction resulted in mean improvements of 31, 34, and 35 points, respectively. While open reconstruction of type III lesions was associated with a 27-point improvement on the Constant score, the use of ASK-assisted reconstruction resulted in a 29-point improvement. In type IV, the use of ASK palliative resection of RC remnants, muscle transfer (Karas), partial reconstruction (Burkhart), and a combination of the last two methods led to the mean 19-, 25-, 22-, and 22- point improvements respectively. Following ASK palliative resection, the mean Constant score improvement in type V lesions was 17 points, while the use of resurfacing, if performed, was associated with a 21-point improvement. DISCUSSION In type I lesions, favourable long-term outcomes are achieved through ASK SAD, which removes RC irritation within the narrowed subacromial space. RC reconstruction or sutures, which can be performed arthroscopically quite easily, are indicated in type II lesions. The situation is similar in type III lesions, where, from a technical point of view, reconstruction is facilitated by ASK-assisted reconstruction with mini-incision. Since type IV lesions are the most complex ones, the largest number of surgical management methods is described here. As for muscle transfer, the subscapularis and latissimus dorsi muscles are used most often, the latter requiring wider surgical access. Partial non-anatomical reconstruction is useful, too. New synthetic prostheses, as well as biosynthetic or biologic prostheses prepared with cultures of pluripotent stem cells, have been developed recently. Unlike some other authors, we prefer open surgery. Attempts at ASK reconstruction increase surgical time considerably, while the cosmetic effect is negligible if many ASK ports are used. Reconstruction is contraindicated in type V lesions; good outcomes are being achieved with ASK palliative resection of RC remnants (Apoil). Type I lesions are successfully managed with ASK SAD. The method of choice in type II lesions is ASK reconstruction. In type III lesions, we have been getting good results with ASK-assisted RC reconstruction with mini-incision. As for type IV lesions in older patients, we have good experience with muscle transfer of a part of the intact subscapularis muscle tendon (Karas); partial non-anatomial reconstruction (Burkhart) is deemed more beneficial in younger and more active patients. For anatomical reasons, a combination of both above-mentioned methods had to be used in some cases. ASK palliative resection of RC remnants, rarely followed by resurfacing when unsuccessful, remains the method of choice in treating type V lesions. Key words: shoulder arthroscopy, rotator cuff lesions, classification, subacromial decompression, reconstruction, open surgery, palliative resection, Constant Functional Score.

[Buried bumper syndrome (BBS) as a complication of percutaneous endoscopic gastrostomy]. / Buried bumper syndrom (BBS) jako komplikace perkutánní endoskopické gastrostomie.

"Buried bumper syndrome" is a less frequent but potentially serious complication of percutaneous endoscopic gastrostomy. We present case reports of two patients in whom buried bumper syndrome was diagnosed by means of X-ray examination and endoscopic examination. In both cases the original gastrostomy was surgically removed and classical gastrostomy was performed.

Effect of comorbidity on urinary neopterin in patients with breast carcinoma.

Urinary neopterin is increased in less than 20% of patients with breast carcinoma. Moderately increased neopterin concentrations are also known to accompany comorbid conditions commonly observed in patients with breast carcinoma, for example, diabetes mellitus or complications of atherosclerosis. In the present study, we evaluated the effect of the presence of comorbid conditions on urinary neopterin. A trend for higher neopterin concentrations was observed in patients with most of the comorbid conditions, but significantly higher neopterin was observed only in patients aged 70 years or older and in a heterogeneous group of patients with comorbidity other than diabetes mellitus, thyroid disorder, hyperlipidaemia, cardiac disorder or other malignancy. Significantly higher neopterin levels were noted in patients with two or more comorbid conditions. In conclusion, present data demonstrate an association between systemic immune activation reflected in increased urinary neopterin concentrations and age or presence of comorbid diseases in patients with breast carcinoma. A cumulative effect was observed with the presence of two or more comorbid conditions resulting in significantly increased urinary neopterin. These observations should be taken into account when interpreting the changes of parameters of systemic immune and inflammatory response in patients with breast carcinoma.

[Arthroscopic palliative resection of the rotator cuff in patients with unreconstructible lesions]. / Artroskopická paliativní resekce rotátorové manzety u nerekonstruovatelných lézí .

PURPOSE OF THE STUDY: The aim of this study is to present a simple rotator cuff lesion classification that provides guidelines as to their treatment, and to evaluate the results of palliative arthroscopic resection of rotator cuff residues known as unreconstructible lesions. In addition, our therapeutic approaches were ascertained in view of their applicability to the types of lesions studied. MATERIAL: In a five-year period (January 1, 2000 to December 31, 2004), a total of 181 arthroscopic procedures were performed on the shoulder joints of patients diagnosed with impingement or rotator cuff syndromes. In 130 cases, a tear or irritation of the rotator cuff was recorded. Rotator cuff lesions were categorized on the basis of our modification of the Gschwend classification. In 15 of the patients, in whom unreconstructible lesions were detected, arthroscopic palliative resection of rotator cuff residues was performed. The average age of these patients was 65 years, and they were followed up for 6 to 60 months. METHODS: All surgery was carried out in a "beach-chair" position, either under general anesthesia or with an interscalene brachial plexus block. The arthroscope was inserted through the "soft-spot". Continuous irrigation was provided with an arthroscopic pump. In the first place, the glenohumeral joint was explored, and resection of rotator cuff residues was performed via ventral and lateral ports. The procedure was completed by subacromial decompression and partial resection of the acromion. The results were evaluated by the Constant Functional Score, as modified by us. Clinical examination was supplemented with subjective information from questionnaires provided by the patients. RESULTS: In a total of 130 shoulder joints with rotator cuff tears examined by arthroscopy, type I lesions were found in 90, and these were treated by arthroscopic subacromial decompression. Twenty-five type II and type III lesions underwent open rotator cuff repair and 15 type IV and type V lesions were treated by palliative arthroscopic resection of residual rotator cuff lesions, using the Apoil method. These fifteen patients were followed up for 6 to 60 months and their outcomes were evaluated. No excellent results were achieved (Constant Score, 80-100 points), but this is implicit in the nature of a palliative operation. Good (65-79 points) and satisfactory (51-64 points) results were recorded in 11 (73.3 %) and four (26.7 %) patients, respectively. No poor results were found. The average improvement in Constant scores was 21 points. DISCUSSION: A total of 130 rotator cuff lesions diagnosed arthroscopically were categorized on the basis of a modified classification system. We will continue to treat type I lesions by arthroscopic subacromial decompression, which has provided good results, as reported in our previous study. We consider the arthroscopic repair of rotator cuff tears to be an optimal procedure for type II lesions; for type III lesions we will keep using open repair surgery. The most complex problem is presented by type IV lesions. While palliative arthroscopic resection of the rotator cuff is one option, muscle transfer has also shown satisfactory outcomes, as has partial reconstruction. The use of either allografts or cadaver grafts did not give good results. Type V lesions, in our opinion, are unambiguously indicated for palliative arthroscopic resection of the rotator cuff. Their treatment by the Apoil method and detailed evaluation of the outcomes are described here; the results of this study are in agreement with those reported in the relevant international literature. CONCLUSIONS: Good and satisfactory results were achieved by palliative arthroscopic resection of the rotator cuff, in combination with subacromial decompression, in patients with unreconstructible lesions. The average improvement in the Constant Functional Score was 21 points. This suggests that the method can be recommended for wider use in the future. However, exact diagnosis and correct indication, i.e., type V lesion, are essential.

Comparison of a novel ultra-performance liquid chromatographic method for determination of retinol and alpha-tocopherol in human serum with conventional HPLC using monolithic and particulate columns.

Retinol and alpha-tocopherol are biologically active compounds often monitored in blood samples because of their evident importance in human metabolism. In this study a novel ultra-performance liquid chromatographic (UPLC) method used for determination of both vitamins in human serum has been compared with conventional HPLC with particulate and monolithic C(18) columns. In UPLC a sub-two-micron particle-hybrid C(18) stationary phase was used for separation, in contrast with a five-micron-particle packed column and a monolithic column with a highly porous structure. Methanol, at flow rates of 0.48, 1.5, and 2.5 mL min(-1), respectively, was used as mobile phase for isocratic elution of the compounds in the three methods. Detection was performed at 325 nm and 290 nm, the absorption maxima of retinol and alpha-tocopherol, respectively. Analysis time, sensitivity, mobile-phase consumption, validation data, and cost were critically compared for these different chromatographic systems. Although cost and mobile-phase consumption seem to make UPLC the method of choice, use of the monolithic column resulted in almost the same separation and performance with a slightly shorter analysis time. These methods are alternatives and, in routine laboratory practice, more economical means of analysis of large numbers of biological samples than use of a traditional particulate column.

[Arthroscopic subacromial decompression--personal experience and results]. / Artroskopická subakromiální dekomprese--vlastní zkusenosti a výsledky.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the outcomes of a comparatively new surgical technique--the arthroscopic subacromial decompression, justify its use and give reasons for refraining from open acromioplasty after Neer. The evaluated clinical sample comprised a relatively large group of patients, the biggest one presented so far in the Czech literature. The authors point out the benefits of this procedure and on the basis of the outcomes recommend its further use. MATERIAL: In the period of January 1999 through November 2001 we performed arthroscopic subacromial decompression for primary or post-injury impingement syndrome in 63 shoulders in 61 patients (average age 43.6 years). In the time interval of 6-24 months we followed up all the patients. The group did not include the patients with stabilization or suture of the rotator cuff performed in one step. METHODS: The surgery was performed in the "beach-chair" position of the patient with the arthroscope introduced through the "soft-spot". First the glenohumeral joint was examined and subsequently the shaver was applied in the subacromial region from the lateral port. In most of the patients we performed apart from soft-tissue subacromial decompression also a partial resection of the acromion. Evaluation of the outcomes was based on the modification of the Constant's functional score and questionnaires filled in by patients. RESULTS: In the time interval of 6-24 months we followed up all the patients. In 42 patients (66.7%) the result was excellent (80-100 points after Constant), in 18 patients (28.6%) the result was good (65-79 points) and in 2 patients (3.2%) a fair result (51-64 points) was achieved. Poor result (45 points) occurred only in one patient. Total improvement in the Constant score amounted on average to 27 points. DISCUSSION: The group of patients was first of all compared with our previously evaluated group of 32 patients after an open acromioplasty after Neer where we achieved only 68% of excellent and good results. Better results were achieved with a more aggressive approach and a larger resection of the acromion. Our group was the biggest group so far evaluated in the Czech literature. In comparison with other authors (Podskubka, Procházka) we achieved better results. However, these authors used UCLA score for evaluation. In comparison with foreign authors (Rockwood, Copeland, Ellman, Orljanski, Delej, Weissinger) our results were similar or better. Our experience is similar to that of the mentioned authors. CONCLUSIONS: Total improvement in the Constant's score by 27 points on average and 95% of excellent and good results justify further use of this considerate method (cosmetic effect, the possibility of immediate physiotherapy, less pain, elimination of the detachment of the deltoid muscle) with a reasonable indication and sufficient scope of the resection of the acromion.

[Autotransfusion in patients with total hip or knee endoprosthesis.]. / Autotransfuze u pacientu s plánovanou implantací totální endoprotézy kycelního nebo kolenního kloubu.

Authors in their paper explain the term autotransfusion, they compare advantages and disadvantages of autologous and homologous transfusion. Perioperative and postoperative blood loss was compared and number of transfused units was recorded in group of 573 patients undergoing total hip or knee replacement. 34.2% of patients had autotransfusion. Authors describe preparation of autotransfusion and its application. They evaluate possible complications of homologous and autologous transfusions and also discuss economical aspects and summarize indications and contraindications of autotransfusion. Finally, they try to make recommendations in order to select optimal and sub-optimal patients undergoing total hip or knee replacement for autotransfusion. Key words: blood transfusion, autologous transfusion, total hip replacement, total knee replacement, perioperative and postoperative blood loss, complications of transfusion, indications for autotransfusion.