Others Are to Blame (Displacement in patients with drug-resistant epilepsy).

OBJECTIVE: To evaluate the defense mechanisms (DM) in patients with drug-resistant epilepsy and, to determine whether displacement is associated with seizures. SUBJECTS AND METHODS: Following an examination, 50 patients were diagnosed in accordance with the 2005 proposal of the International League Against Epilepsy and the definition of drug-resistant epilepsy from 2010. The neuropsychological examination used the Defense Style Questionnaire (DSQ-40). We measured the intensity of individual DMs. Mature DMs: sublimation, humor, suppression and anticipation; neurotic DMs: undoing, pseudo-altruism, idealization and reactive formation; and immature DMs: projections, passive aggression, acting out, isolation, devaluation, autistic fantasies, denial, displacement, dissociation, splitting, rationalization and somatization. The values were compared with 50 subjects without epilepsy. RESULTS: Patients with drug-resistant epilepsy use immature defensive styles significantly more (p=0.0010). Displacement have a positive correlation with frequency of seizure (p=0.0412). CONCLUSION: Blaming others is a characteristic of the behavior of patients with drug-resistant epilepsy, especially if they have seizures. As such, they may be less adaptable in a micro social environment.

Improved survival of incident patients with high-volume haemodiafiltration: a propensity-matched cohort study with inverse probability of censoring weighting.

BACKGROUND: Haemodiafiltration (HDF) is the preferred dialysis modality in many countries. The aim of the study was to compare the survival of incident patients on high-volume HDF (HV-HDF) with high-flux haemodialysis (HD) in a large-scale European dialysis population. METHODS: The study population was extracted from 47,979 patients in 369 NephroCare centres throughout 12 countries. Baseline was six months after dialysis initiation; maximum follow-up was 5 years. Patients were either on HV-HDF (defined as with ≥21 litres substitution fluid volume per session) or on HD if on that treatment for ≥75% of the 3 months before baseline. The main predictor was treatment modality. Other parameters included country, age, gender, BMI, haemoglobin, albumin and Charlson comorbidity index. Propensity score matching and Inverse Probability of Censoring Weighting (IPCW) were applied to reduce bias by indication and consider modality crossover, respectively. RESULTS: After propensity score matching, 1,590 incident patients remained. Kaplan-Meier and proportional Cox regression analyses revealed no significant survival advantage of HV-HDF. Results were biased by modality crossover: during the 5-year study period, 7% of HV-HDF patients switched to HD, and 55% of HD patients switched to HV-HDF. IPCW uncovered a statistically significant survival advantage of HV-HDF (OR 0.501; CI 0.366-0.684; p < 0.001). A higher benefit of HV-HDF for some subgroups was revealed, for example, non-diabetics, patients 65-74 years, patients with obesity or high blood pressure. CONCLUSIONS: This large-scale study supports the generalizability of previous RCT findings regarding the survival benefit of HV-HDF. Sub-group analysis showed that some sub-cohorts appear to benefit more from HV-HDF than others.

Changes in activated partial thromboplastin time and international normalised ratio after on-pump and off-pump surgical revascularization of the heart.

Surgical revascularization of the heart (CABG - coronary artery bypass grafting) is one way of treating coronary heart disease. Bleeding is one of the serious and frequent complications of heart surgery and can result in increased mortality and morbidity. Hemostasis disorder may be secondary consequences of surgical bleeding, preoperative anticoagulant therapy, and the use of cardiopulmonary bypass. Tests used for routine evaluation of the coagulation system are activated partial thromboplastin time (APTT) and international normalized ratio (INR). The study encountered 60 patients who were hospitalized at the Clinic for Cardiovascular Diseases, University Clinical Center Tuzla. Patients underwent elective coronary artery bypass heart surgery either with cardiopulmonary bypass (on-pump CABG) or without it (off-pump CABG). The aim of this study was to compare the changes in coagulation tests (APTT, INR) in patients who were operated on-pump and patients operated off-pump. Our study showed that the values of APTT and INR tend to increase immediately after surgery. Twenty-four hours after surgery these values are declining and they are approaching the preoperative values in all observed patients (p <0.05). Comparing APTT between the groups we found that postoperative APTT levels are significantly higher in the group of patients who underwent surgery with cardiopulmonary bypass (p <0.05). Changes in coagulation tests after surgical revascularization of the heart are more pronounced in patients who were operated with on-pump technique compared to patients operated off-pump technique.

Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy.

Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.

Survival of incident patients on high-volume online hemodiafiltration compared to low-volume online hemodiafiltration and high-flux hemodialysis.

BACKGROUND: Hemodiafiltration is becoming a preferred treatment modality for dialysis patients in many countries. The volume of substitution fluid delivered has been indicated as an independent mortality risk factor. The aim of this study is to compare patient survival on three different treatment modalities: high-flux hemodialysis, low-volume online HDF (oHDF) and high-volume oHDF. METHODS: Incident hemodialysis and oHDF patients treated in 13 NephroCare centers in Bosnia and Herzegovina, Serbia and Slovenia between January 1, 2007, and December 31, 2011, were included in this epidemiological cohort study. High-volume oHDF was defined as substitution volume higher than the median substitution volume infused, otherwise low-volume. Main predictor was treatment modality at baseline and in time-dependent model. Other predictors were age, gender, diabetes mellitus, cerebrovascular accident, arrhythmia, hemoglobin and C-reactive protein. RESULTS: Four hundred and forty-two patients were included in the study. Median substitution fluid volume was 20.4 L. Mean difference between the oHDF groups in substitution fluid volume was 8.3 ± 5.2 L [95 % confidence intervals (95 % CI) 7.1-9.5, p < 0.0001]. The unadjusted hazard ratios (HR) with 95 % CI compared to high-flux HD were 0.87 (0.5-1.5) for low-volume oHDF and 0.29 (0.13-0.63) for high-volume oHDF. After the adjustment for covariates, the HR for patients on low-volume oHDF remained statistically insignificant compared to high-flux HD (0.84; 95 % CI 0.46-1.53), while patients on high-volume oHDF showed a marked and significantly lower HR (0.29; 95 % CI 0.13-0.68) than patients on high-flux HD in baseline model. While this effect failed to reach significance in the time-dependent model (HR 0.477; 95 % CI 0.196-1.161), possibly due to an inadequate sample size here, the consistency of results in both models supports the robustness of the findings. After switching from high-flux hemodialysis to oHDF, mean hemoglobin and albumin levels did not change significantly. Mean erythropoietin resistance index (ERI) and erythropoiesis stimulating agents (ESA) consumption decreased significantly (p = 0.02, p = 0.03, respectively). CONCLUSIONS: The median substitution volume used in these three countries for post-dilutional oHDF is 20.4 L. oHDF is associated with significant reductions in ERI and ESA consumption. Only high-volume oHDF is associated with improved survival compared to high-flux hemodialysis.

Prognostic value of acute fluid collections diagnosed by ultrasound in the early assessment of severity of acute pancreatitis.

PURPOSE: To evaluate the prognostic value of acute fluid collections (AFC) diagnosed by conventional transabdominal ultrasound in the early assessment of severity acute pancreatitis (AP). METHODS: We studied 128 consecutive patients with AP between March 2006 and March 2011. The predictor was the number of AFC. Outcome measure was the occurrence of complications. Abdominal sonogram, contrast-enhanced CT, and pancreatitis-specific clinical and laboratory findings were performed. RESULTS: AFC were associated with complications (p < 0.0001), Balthazar grade (p = 0.004), Ranson score (p < 0.0001), and the majority of clinical, radiologic, and biochemical parameters for predicting complications of AP (p < 0.05). Univariate logistic regression also revealed significant association between the number of AFC and the occurrence of complications (OR 4.4; 95% CI 2.5-7.6). After the adjustment for covariates, AFC remained prognostic for complications and a cutoff point of >1 AFC was prognostic of their occurrence with 88% sensitivity and 82% specificity. CONCLUSIONS: AFC are related to the clinical course of AP and can predict its severity

What is the optimal treatment for appendiceal mass formed after acute perforated appendicitis.

We read with great interest the editorial article by Meshikhes AWN published in issue 25 of World J Gastroenterol 2011. The article described the advantages of emergency laparoscopic appendectomy compared with interval appendectomy as a new safe treatment modality for the appendiceal mass. The author concluded that the emergency laparoscopic appendectomy was a safe treatment modality for the appendiceal mass, and might prove to be more cost-effective than conservative treatment, with no need for interval appendectomy. However, we would like to highlight certain issues regarding the possibility of percutaneous catheter drainage to successfully treat the appendiceal mass, with no need for appendectomy, too.

Survival of living-related kidney graft recipients in the era of modern immunosuppressive treatment.

BACKGROUND AND OBJECTIVES: Currently, there is no consensus about immunosuppressive therapy following kidney transplantation. Acute rejection rates and allograft survival rates are the clinical outcomes traditionally used to compare the efficacy of various immunosuppressive regimens. Therefore, we conducted this study to evaluate whether patient survival rates improved in the era of modern immunosuppressive treatment during living-related kidney transplantation. DESIGN AND SETTING: Retrospective cohort study in a university-based tertiary internal medicine teaching hospital performed between 1999 and 2009 and patients followed up to 7 years. PATIENTS AND METHODS: Survival rates were assessed in 38 patients receiving basiliximab and mycophenolate mofetil (regimen A) and 32 patients receiving antithymocyte globulin and azathioprine (regimen B). The rest of the regimen (cyclosporine A and steroids) remained the same. A secondary end point was acute rejection episode. RESULTS: Seven-year survival rates were 100% and 72% (P=.001) and 7-year acute rejection-free survival rates were 82% and 53% (P=.03), in groups A and B, respectively. CONCLUSION: Long-term survival after living-related kidney transplantation has improved in the era of modern immunosuppressive treatment.

Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre.

AIM: To evaluate the efficacy of step-up approach to infected necrotising pancreatitis. METHODS: Retrospective analysis of 86 patients treated by step-up approach from 1989 to 2009. Infection was confirmed by examination of aspirated material or by presence of free pancreatic gas at contrast-enhanced computed tomography. Conservative treatment was initially attempted in all patients; percutaneous catheter drainage was performed when conservative therapy failed; surgery was planned only if no clinical improvement was observed. Primary outcome was mortality. RESULTS: Fifteen patients (17.4%) were successfully treated with conservative treatment only. Percutaneous catheter drainage was performed in 69 (80.2%). Eight patients (9.3%) died, two at week 1 without drainage or surgery and six after percutaneous catheter drainage and surgery. Eleven patients were converted to surgery (12.8%). Organ failure occurred in 59/86 (68.6%) and multiorgan failure in 25/86 (29.1%). Median (interquartile ranges) hospital stay and catheter dwell times were 13 (9-47) and 15 (7-34) days, respectively. There were 2.61 catheter problems and 1.68 catheter changes per patient. CONCLUSIONS: The step-up approach is an effective and safe strategy for the treatment of infected necrotising pancreatitis. Percutaneous drainage can avert the need for surgery in the majority of patients.

Comments on the article about correlation between computerized tomography and surgery in acute pancreatitis.

We read with great interest the article by Vege et al published in issue 34 of World J Gastroenterol 2010. The article evaluates the ability of contrast-enhanced computerized tomography (CECT) to characterize the nature of peripancreatic collections found at surgery. The results of their study indicate that most of the peripancreatic collections seen on CECT in patients with severe acute pancreatitis who require operative intervention contain necrotic tissue and CECT has a limited role in differentiating various types of collections. However, there are some points that need to be addressed, including data about the stage of acute pancreatitis in which CECT was done and the time span between CECT examination and surgery.

Rate of complications and conversions after laparoscopic and open cholecystectomy.

BACKGROUND AND OBJECTIVES: Although many advantages of laparoscopic method in regard to open one have been already proved, both surgical methods may cause a certain number of complications. The goal of the study is to answer the question: Is Laparoscopic Cholecystectomy (LC) safer and more satisfactory method than open cholecystectomy (OC) concerning number, type and seriousness of complications? DESIGN AND SETTING: Prospective, the research includes all patients in Bihac Cantonal Hospital during 2007, who had cholecystectomy, laparoscopic or open, because of the gallbladder calculosus. METHODS: The study has included 476 patients who had cholecystectomy and who satisfied standards for this study. Of the total number of patients, 293 of them had laparoscopic cholecystectomy and 183 open cholecystectomy. Total number of complications is established for each group of patients. RESULTS: The study has shown that there were more complications in patients operated by open method than in those operated by laparoscopic cholecystectomy (p < 0.0001). Intraoperative bleeding was found in 1.63% of patients with open and 0.68% with laparoscopic cholecystectomy. Postoperative collection in abdomen were found in 2.18% of patients with open and 1.02% with laparoscopic method. The most common complications for open cholecystectomy were: infection (2.73%), hematoma in the wound (2.73%) and urine retention (2.18%). CONCLUSION: It can be concluded that LC and OC are comparable procedures for the treatment of gall stone disease in terms of complications, results of this study demonstrate that LC is essentially a safe procedure with low complicatins, morbidity and mortality rate.

Kidney graft outcomes in living-related transplantation have improved with substitution of basiliximab and mycophenolate mofetil for antithymocyte globulin and azathioprine: a single center retrospective cohort study.

BACKGROUND: Despite significant reduction in acute rejection rates and improvements in one year kidney allograft outcomes over the past decade, there is an overall lack of improvement in long-term allograft outcomes. We conducted this study to evaluate whether immunosuppressive regimens involving basiliximab and mycophenolate mofetil improved allograft outcomes in living-related kidney transplantation beyond the first year. METHODS: In a retrospective cohort study we analyzed kidney graft survival, acute rejection-free survival, kidney function, delayed graft function, and primary non-function in patients receiving an immunosuppressive regimen that included basiliximab and mycophenolate mofetil (group A), and compared to patients receiving antithymocyte globulin and azathioprine (group B). The rest of the treatment protocols remained the same, including cyclosporine A and steroids in both groups. RESULTS: Seven-year graft survival rates in groups A and B were 83% and 44%, respectively (p=0.005), 7-year acute rejection-free survival rates were 82% and 53%, respectively (p=0.03), kidney function was better (p=0.004) and its deterioration rate was lower (p=0.006) in patients receiving regimen A. In group A 1 primary non-function event was observed in contrast to 4 composite events of delayed graft function and primary non-function in group B (p>0.05). CONCLUSION: Long-term graft outcomes in living-related kidney transplantation have improved with substitution of basiliximab and mycophenolate mofetil for antithymocyte globulin and azathioprine in immunosuppressive protocols.

[Functional status of patients after lumbar disc herniation surgery]. / Funkcionalni status bolesnika nakon operacije lumbalne diskus hernije.

The aim of this study was to determine whether early rehabilitation from the first postoperative day after lumbar disc herniation surgery improved functional status of patients compared to the rehabilitation that started 3 weeks after surgery. Oswestry index was used for functional status assessment before surgery and after rehabilitation in 60 patients divided in 2 groups, i.e., early and control group of rehabilitation strated 3 weeks after surgery, 30 in each. Oswestry index values before surgery and after rehabilitation in the early rehabilitation group were 78.4 +/- 17 and 19.6 +/- 9.9, respectively (p < 0.0001) and in the control group the values were 79 +/- 13 and 37 +/- 14, respectively (p < 0.0001). The difference of Oswestry index before operation and after rehabilitation in the early rehabilitation group was 58.7 +/- 18.9, and in the control group 41.6 +/- 13.2 (p = 0.0001). Onset of rehabilitation from the first post operative day lead to better functional recovery compared to delayed rehabilitation 3 weeks after lumbar disc herniation surgery.

Percutaneous treatment for symptomatic pancreatic pseudocysts: Long-term results in a single center.

PURPOSE: The aim of the study was to present and evaluate the long-term results of percutaneous catheter drainage (PCD) in the treatment of symptomatic pancreatic pseudocysts (PPC). METHODS: We performed a retrospective analysis of 128 patients with 140 PPC treated by PCD from 01/01/1989 to 12/31/2008. All procedures were performed under ultrasound control. Surgical treatment was planned only in patients with failed PCD. The patients were followed up monthly with sonography for 12 months. The primary outcome was conversion rate to surgery. Secondary outcomes were disappearance of PPC, requirement for additional treatment, length of hospital stay, and catheter dwell time. RESULTS: During the follow-up, 42 of the 140 cysts (30%) recurred. 19/42 cysts were small and they were followed up without intervention and 23/42 cysts required further intervention. These patients were offered a second attempt but 5 patients declined it and they chose to undergo surgery. The remaining 18 patients underwent second PCD and 10 of them developed recurrence. All of them underwent third PCD and 6 of the 10 patients developed recurrences. Four and 2 of them necessitated surgery and follow-up, respectively. In total, 9 of the 128 patients (7%) underwent surgery during the study period. Medians (interquartile ranges) of hospital stay and catheter dwell time were 19 (14-23) and 23 (15-43) days, respectively. There were no complications related to the procedure. CONCLUSION: PCD is a safe and effective management for PPC, with low recurrence rates and complication rate and it can eliminate the need for surgery in majority of patients with PPC.