A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone.

AIM: To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD: A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS: Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION: The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.

Gastrostomy Under Paravertebral Block in High-Risk Patients with Esophageal Cancer - Two Case Reports.

Here we present two cases of gastrostomy insertion via laparotomy in patients with malignant esophageal disease. Patients were ASA (American Society of Anesthesiologists) physical status III and IV. The patients presented as very high risk for general anesthesia, so we decided to use unilateral left sided paravertebral block (PVB) on four thoracic levels along with contralateral local infiltration at the gastrostomy insertion site. We present two cases, one of them a 57-year-old male ASA III patient scheduled for a gastrostomy procedure due to esophageal cancer with infiltration of the trachea. We also present a case of a 59-year-old male patient, ASA IV status, scheduled for the same procedure due to advanced esophageal cancer with a fistula between the left main bronchus and the esophagus and metastases in the left lung. The paravertebral space was identified with the use of an 8 Hertz (Hz) linear ultrasound probe and a nerve stimulator. Paravertebral block was successfully used for insertion of a gastrostomy, thereby enabling adequate anesthesia and perioperative analgesia without hemodynamic or respiratory complications.

Giant Spinal Schwannoma in a 76-year-old Woman--A Case Report.

A schwannoma is a benign nerve sheath tumor composed of Schwann cells. Spinal schwannoma originates from dorsal roots of the spinal cord, causing symptoms due to the compression of neighboring structures. We present a patient with a low back pain and left L2 and L3 radiculopathy. Neuroimaging techniques (CT, MRI) showed a large expansive mass in the left lumbar paraspinal area. The tumor was removed totally by the posterior approach and was verified to originate from the left L2 spinal nerve root. The histopathological examination revealed typical findings of a schwannoma. The pain was resolved promptly after the surgery, however the patient's neurological condition wasn't improved. Surgical treatment was a final treatment, and no additonal therapy was necessary.

FACET ORIENTATION AND TROPISM: ASSOCIATION WITH ACCELERATED DEGENERATION OF STABILIZING STRUCTURES IN LOWER LUMBAR SPINE.

The influence of facet orientation and tropism on the process of spinal degeneration has been extensively studied during the last few decades, but there are still many controversies and conflicting results in this field of research. The biomechanical cause of accelerated degeneration of stabilizing structures in lower lumbar spine lies within the combination of several factors, but two most important ones are compressive load and more coronal facet orientation that offers less resistance against torsional loading. Axial rotation of lower lumbar spine is undoubtedly associated with higher strain in disc annulus, and enhanced range of secondary rotational movements may be even more significant for the progression of annular degeneration. Accordingly, more pronounced facet tropism could be having part in faster progression of disc degeneration in lower lumbar spine, as indicated by a number of recent studies. More sagittal facet orientation in patients with a higher facet osteoarthritis score at lower lumbar segments is very likely related to arthritic remodeling commonly seen in other synovial joints. There is also a possibility that it could be associated with the adaptation to partial loss of lumbar lordosis, as both coincide with advanced age.

Expression of genes responsible for the repair of mispaired bases of the DNA (MLH1) in invasive ductal breast carcinoma.

Breast cancer is a heterogeneous group of diseases determined and distinguished by cellular type, gene expression and clinical signs and symptoms. Identification of histological and biological markers is of great value in predicting the progression of tumor growth and anticipating the expected response to various treatment options. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific research we wanted to determine the involvement of the genetic polymorphisms of DNA mismatch repair system (MLH1 gene) and the subsequent development of breast carcinoma. This study included 108 patients who were surgically treated for invasive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava". The expression of the MLH1 gene was determined by immunohistochemical methods. The results showed that 82.9% of tumor cells expressed the MLH1 gene. Analysis of survival rate for patients with invasive ductal breast cancer showed a statistically significant (p = 0.043) correlation with the expression of MLH1 genes. The overall five year survival rate of our patients was 78.7%. These results indicate that there is a possible involvement of MLH1 gene in the progression and development of breast cancer.

Who is the patient? Disclosure of information and consent in anesthesia and intensive care (informed consent).

Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the practice, however with the vast advances in science and technology, numerous ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hippocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together represent the complete best interest of the patient. This is the basic goal of the "Informed Consent". The widening of legal boundaries regarding professional liability may consequentially lead to a "defensive medicine" and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evaluating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief explain all the necessary information a "reasonable" anesthesiologist would disclose to a "reasonable" patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient.

Clinical and patohistological factors affecting the 5 year survival rate in a population of Croatian women with invasive ductal breast carcinoma.

Breast carcinoma falls into a heterogeneous group of diseases which can be determined by various prognostic factors. The identification of clinical and histopathologic factors is of great value in predicting the progression of tumor growth and survival outcome. Due to a high degree of cell proliferation in breast tumors and high genetic instability of these tumors, as a consequence of defective DNA repair mechanisms, chemotherapy as a treatment option often renders very successful results. During our scientific study of the expression of genes responsible for mismatch repair of DNA in cells of invasive ductal carcinoma we also compared the patient survival rate with the major prognostic factors. This study included 108 patients who were surgically treated for invasive breast cancer at the Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital "Dubrava". The overall survival rate was compared to factors such as initial tumor stage, regional lymph node involvement and distant metastasis. The overall five year survival rate of our patients was 78.7%. Patients without the presence of distant metastasis, a lower rate of local lymph node involvement and a lower. tumor stage statistically had a longer overall survival period. It is important that physicians recognize the various clinico-pathohistological factors in patients with breast carcinoma. This study confirms that this prognostic factors determine the type of treatment required and most important, the patient overall survival period.

Gastric tube ulcer perforating the pericardium after subtotal esophagectomy.

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature.

Quality of life after the Sweedish adjustable gastric band procedure.

The term "quality of life" usually describes factors that have an impact on living conditions within the society or on an individual. Generally, the term quality of life refers to the level of the welfare of individuals or group of people. Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health and as such is one of the most common pathological conditions of modern society. Almost 10-25% of adult population in Europe, 1/3 population in the USA and 20% of population in Croatia are affected by obesity. In this prospective study we included 30 patients who underwent Sweedish adjustable gastric band procedure (SAGB) (Johnson & Johnson) procedures without complications during the first year of the postoperative period. Body mass index (BMI) was in female patients 40,52174 kg/m2 and in male patients 46,71429 kg/m2. Prior to the surgical procedures 13 patients (43.33%) experienced worse health conditions. Health conditions were equl in 17 patients. The treatment was ineffective in 5 patients (16.67%). In 5 patients health conditions were equal. 6 patients (20%) had good quality of life, 11 patients (36.67%) very good and only 3 patients (10%) had excellent quality of life after the procedure. We noticed body weight reduction in all patients. The quality of life was improved in all patients, except for one 28 years old woman. Body weight loss and quality of life after the procedure are in positive correlation which means that significant body weight loss leads to improved quality of life. Our conclusion is that SAGB is a quality method in obesity treatment which improves quality of life.

Immediate breast reconstruction in relation to women's age.

A modern approach to breast cancer treatment after mastectomy includes immediate breast reconstruction (performed simultaneously with the mastectomy). The understanding of factors that influence women's decisions and appreciation of their satisfaction is as important as the knowledge of medical efficiency of the selected treatment. The influence of women's age on opinion making for immediate breast reconstruction was researched in a monocentric prospective study (N = 102). Methods included questionnaires, interviews and medical documentation reviews. Women comply breast reconstruction with silicone implants and autologous tissue equally. Analyzing age distribution it is evident that women age 35-50 and older than 65 would agree to reconstruction with silicone implants more often. This can be explained by the fact that younger women expect to have better shaped breasts after reconstruction then prior to the same, while older women tend to avoid breast reconstruction using muscle flaps because they are more demanding and also require longer hospitalization.

Prognostic performance of the Simplified Acute Physiology Score II in major Croatian hospitals: a prospective multicenter study.

AIM: To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals. METHODS: A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2×2 classification tables, and Hosmer-Lemeshow tests. RESULTS: The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE]=0.012; 95% CI=0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: χ(2) =584.4; P<0.001 and C statistics: χ(2)(8) =313.0; P<0.001) in the group of patients included in the study. CONCLUSION: The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA): changes and updates of chapter 7.0: treatment of patients with MRSA infection]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA): izmjena i dopuna poglavlja 7.0.: lijecenje bolesnika s MRSA - infekcijom.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and as well in Croatia. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. In the meantime, several new possibilities appeared in the treatment of patients with MRSA infections in Croatia, so the Chapter 7.0 Treatment of patients with MRSA infections is changed and updated according to the new treatment possibilities. The rest of the Guidelines was not changed.

Perioperative management with glucose solution and insulin.

The objective of this study was to analyze how preoperative glucose treatment influences the blood glucose level as a measured exponent of surgical stress and to establish the best postoperative replacement considering glucose solutions and insulin. This prospective clinical trial involved 208 non-diabetic patients with normal glucose tolerance, who underwent major surgical procedures and needed 24 hours ICU monitoring postoperatively. Patients were randomly given 5% glucose solution (1000 mL) one day before surgery or after overnight fasting. Group A and group B were randomized to be given 5 different kinds of postoperative replacement with cristalloids and insulin. None of the patients from group A or group B were given glucose solutions during surgical procedures. Blood glucose levels were measured 14 times from the preoperative period until 24 hours after admission to the ICU and the main outcome measure was blood glucose level. All patients had a statistically significant increase in blood glucose levels in comparison to basal levels (p < 0.05) in all measurements. All data were processed with descriptive statistics, chi-square test, parametric ANOVA test and ANOVA test with repeated measure, non parametric Kruskal-Wallis test and Mann-Whitney U-test. Statistically significant change was accepted with p < 0.05. Preoperative glucose infusion decreased metabolic and endocrine response only during surgery; the smallest increase of postoperative blood glucose level was noticed after administering postoperative non-glucose crystalloid solutions; there is no clinical evidence that one specific postoperative replacement is better than the other; there is no clinical evidence that postoperative use of insulin can decrease or attenuate surgical induced insulin resistance.

[A patient with 16 liter blood loss during radical prostatectomy]. / Bolesnik koji je tijekom radikalne prostatektomije izgubio 16 litara krvi.

Radical prostatectomy is the treatment of choice for localized prostate neoplasm. Bleeding is a common problem during this operation. Massive bleeding can occur in case of injury of one of the hypogastric vein branches during lymphadenectomy or transection of the dorsal vein plexus. We present a 67-year-old patient that lost 16 liters of blood during the operation. In order to restitute the lost blood volume and prevent the low cardiac output and hypoxia, the patient was administered crystalloids, colloids, blood and blood derivatives. The patient received epinephrine, norepinephrine and dopamine to maintain mean arterial pressure above 55 mm Hg. After stopping surgical bleeding, stabilization of the coagulation system was achieved and further nonsurgical bleeding prevented by aprotinin and recombinant factor VIla. Timely volume restitution, not only with blood and blood components, was crucial to prevent the consequences of hemorrhagic shock. With pharmacological interventions, by aprotinin and recombinant factor VIIa in particular, we can act prophylactically and therapeutically to stop nonsurgical bleeding. Multimodal therapeutic procedures, promptly administered in massive bleeding, can improve the survival prognosis.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA)]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA).

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and in Croatia as well. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. Guidelines include recommendations for measures in prevention of MRSA spread, role of hospital management, rational use of antibiotics, measures in a case of outbreak, treatment of infections and brief review of community-acquired MRSA. At the end, appendices concerning hospital audit, algorithms of laboratory diagnosis, patient information and form for national MRSA surveillance were added.

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study.

AIM: To analyze the hemodynamic and respiratory effects of propofol on patients undergoing gastroscopy and colonoscopy. METHODS: In this prospective study, conducted over a period of three years, 1,104 patients referred for a same day GI endoscopy procedure were analyzed. All patients were given a propofol bolus (0.5-1.5 mg/kg). Arterial blood pressure (BP) was monitored at 3 min intervals and heart rate and oxygen saturation (SpO2) were recorded continuously by pulse oximetry. Analyzed data acquisition was carried out before, during, and after the procedure. RESULTS: A statistically significant reduction in mean arterial pressure was demonstrated (P < 0.001) when compared to pre-intervention values, but severe hypotension, defined as a systolic blood pressure below 60 mmHg, was noted in only 5 patients (0.5%). Oxygen saturation decreased from 96.5% to 94.4 % (P < 0.001). A critical decrease in oxygen saturation (< 90%) was documented in 27 patients (2.4%). CONCLUSION: Our results showed that propofol provided good sedation with excellent pain control, a short recovery time and no significant hemodynamic side effects if carefully titrated. All the patients (and especially ASA III group) require monitoring and care of an anesthesiologist.