The incidence of gestational diabetes mellitus before and after the introduction of HAPO diagnostic criteria.

INTRODUCTION: During the years 2014-2015 new diagnostic criteria for gestational diabetes mellitus (GDM) were gradually adopted by the Czech professional societies, which emerged from the results of the large prospective multicenter HAPO study (The Hyperglycemia and Adverse Pregnancy Outcome). The adoption of the new criteria was accompanied by concerns about the increase in the number of women with GDM. The paper deals with epidemiological results of GDM incidence in the first three years since the introduction of new criteria. METHODS AND RESULTS: In the years 2013-2014 GDM screening was performed at 1,594 pregnant woman at the General Teaching Hospital in Prague. According to that time valid diagnostic criteria (fasting glucose 5.6 mmol/g and/or 8.9 mmol/l in 60 min and/or 7.7 mmol/l in 120 min 75 g OGTT) GDM was found in 324, i.e. 20 % of women. In the years 2016-2018 were 2,629 pregnant women examined. GDM based on the new criteria (fasting blood glucose 5.1 mmol/l and/or 10 mmol/l in 60 min and/or 8.5 mmol/l in 120 min OGTT) was diagnosed in significantly less women - in 375, i.e. 14.3% (p < 0.0001). Overt diabetes, i.e. fasting glucose 7.0 mmol/l and/or 11.1 mmol/l in 120 min OGTT, was newly detected in 6 pregnant women, i.e. 0.2 %. Gestational diabetes was found in 62% cases based on repeated fasting fasting blood glucose and in 38% on the basis of higher blood glucose at 60 min and/or 120 min OGTT. GDM was significantly more prevalent in the age category over 30 years. Among women aged under 25 years GDM was present at 9.9%, aged 25-29.9 years at 9.6%, aged 30-34.9 years at 14.2% and aged 35 years at 18.6 %. Hypoglycaemia < 3.5 mmol/l experienced 2.9% of women during OGTT. When the screening in 2016-2018 was evaluated according to the previous diagnostic criteria, diabetes would be diagnosed in 16.2% of pregnant women. The result of the test would be falsely negative in 6% of all pregnant women, i.e. these women have repeatedly higher fasting glucose (5.1-5.5 mmol/l) according to the current criteria which was evaluated as physiological according to the previous criteria. However, in the HAPO, these values were already associated with a significant increase of complications. A total of 50% of women with GDM diagnosed according to the previous criteria would have a false positive result of OGTT (8.9-9.9 mmol/l in 60 min and/or 7.7-8.4 mmol/l in 120 min OGTT). These values are not considered to be significantly at risk under the new criteria. CONCLUSION: Our data do not confirm the increase in GDM incidence following the introduction of new diagnostic criteria which, according to current knowledge, better reflect the real risks of complications for the child and the mother. Applying the previous criteria has led to a number of false negative and positive results, so we consider the adoption of better-funded new criteria a step in the right direction. The incidence of diabetes was significant in all age categories and significantly increased in women over 30 years of age.

Pitfalls in screening for gestational diabetes in the Czech Republic - patient survey.

OBJECTIVE: The aim of our survey was to investigate gestational diabetes (GDM) screening policy in the Czech Republic with regards to the correct methodology of the screening. MATERIALS AND METHODS: 1100 anonymous questionnaires were distributed among patients of a tertiary level obstetric department from July 2015 to September 2015. RESULTS: 958 (87.0%) questionnaires were found eligible for analysis. 794 (82.9%) of participants had at least one risk factor for GDM development. The oGTT was performed in 751 (94.6%) women at risk of GDM and 153 (93.3%) women at low risk of GDM. From the 904 performed oGTT, 154 (17.0%) were performed completely by recommended standards. In the remaining cases, at least one deviation from standard was noted. The results of oGTT were provided by 364 (40.3%) of respondents. In this subgroup, 71 (19.5%) matched International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for GDM diagnosis. However, these women were often not those who were evaluated as screening positive by the office gynaecologist. CONCLUSION: The screening for GDM was frequently not performed in accordance with the national guidelines and the diagnostic criteria used were not uniform.

[The alarming incidence of gestational diabetes mellitus using currently used and new international diagnostic criteria]. / Alarmující výskyt gestacního diabetes mellitus pri pouzití stávajících i nových mezinárodních diagnostických kritérií

OBJECTIVE: The aim of our study was to analyze the results of oral glucose tolerant test (oGTT) of pregnant woman with currently used Czech criteria for diagnosis of GDM, to find out the prevalence of GDM if the measurement of glycemia in 1 hour of oGTT is included and to compare the prevalence of GDM using the new IADPSG (International Association of Diabetes and Pregnancy Study Groups) criteria versus the currently used Czech criteria. DESIGN: Retrospective analysis. SETTINGS: Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital, Prague. METHODS: Data from the standard 75g 2-hour oral glucose tolerance test (oGTT) of 2567 pregnant females were analyzed using the currently recommended Czech cut-off values for plasma glucose at baseline and at2 hours of oGTT (5.6 and 7.7 mmol/l) and at baseline, 1 and2 hours oGTT (5.6, 8.9 and 7.7 mmol/l). The frequency of GDM using the Czech criteria was compared with the frequency of GDM using the novel IADPSG criteria (5.1, 10.0 and 8.5 mmol/l). Statistical analysis was done using the software GNU PSPP Statistical Analysis Software version 0.8.0-g0ad9f6. RESULTS: When using the current Czech criteria (at baseline and 2 hours of oGTT) GDM was diagnosed in 362 (14.11%) females. Inclusion of glycemia at 1 hour of oGTT increased the frequency of GDM to 571 (22.26%) females (p<0.00). With the novel IADPSG criteria GDM was diagnosed in 818 (31.89%) females (p=0.038). 503 females i.e. 19.61% and 394 females i.e. 15.36% (when glycemia at 1 h of oGTT included) respectively met the IADPSG but not the Czech criteria and thus were not treated for GDM. In contrast, 47 (1.83%) resp. 147 (5.73%) of tested women who met the Czech but not the IADPSG criteria received unnecessary diabetes treatment. CONCLUSION: The frequency of GDM is higher with the novel IADPSG criteria when compared with the currently used Czech recommendation. Switching to IADPSG criteria might help unravel hitherto unidentified cases of GDM and thus improve outcomes for females with GDM and their offsprings.

The branching pattern of villous capillaries and structural changes of placental terminal villi in type 1 diabetes mellitus.

Maternal diabetes is associated with changes of the placental structure. These changes include great variability of vascularity manifested by strikingly hypovascular as well as hypervascular terminal villi. In this paper, normal placental terminal villi and pathological villi of type 1 diabetic placentas were compared concerning the structure of villous stroma, spatial arrangement of villous capillary bed and quantitative assessment of capillary branching pattern. Formalin fixed and paraffin embedded specimens of 14 normal and 17 Type 1 diabetic term placentas were used for picrosirius staining, vimentin and desmin immunohistochemistry and confocal microscopy. 3D models of villi and villous capillaries were constructed from stacks of confocal optical sections. Hypervascular as well as hypovascular villi of diabetic placenta displayed changed structure of villous stroma, i.e. the collagen envelope around capillaries looked thinner and the network of collagen fibers seemed less dense. The desmin immunocytochemistry has shown that stromal cells of hypervascular as well as hypovascular villi appeared nearly or completely void of desmin filaments. In comparison with normal villi, capillaries of hypovascular villi had a smaller diameter and displayed a markedly wavy course whereas in hypervascular villi numerous capillaries occurred in reduced stroma and often had a large diameter. The quantitative assessment of capillary branching has shown that villous capillaries are more branched in diabetic placentas. It is concluded that type 1 maternal diabetes enhances the surface area of the capillary wall by elongation, enlargement of diameter and higher branching of villous capillaries and disrupts the stromal structure of terminal villi.

Analysis of CD40 expression in breast cancer and its relation to clinicopathological characteristics.

Breast cancer is currently the most common cancer in women worldwide. For this reason, new biomarkers for better predicting response to treatment are needed. CD40, described as expressed in haematological and epithelial tumors, is linked to apoptosis and offers promise as a new predictive/ prognostic marker. We evaluated CD40 expression in formalin-fixed, paraffin-embedded samples from 181 breast carcinomas using immunohistochemical staining with CD40 antibody. Samples were divided according to hormone (oestrogen receptor /ER/, progesterone receptor /PR/) and her-2/neu status into groups: 1.Luminal A (ER+PR+her-2/neu-), 2. Luminal B (ER+PR+her-2/neu+), 3.Triple-negative (ER-PR-her-2/neu-) and 4. Her-2/neu (ER-PR-her-2/neu+). The results of CD40 staining were correlated with clinicopathological data. CD40 was found to be expressed in membrane, cytoplasm and nucleus. Normal ducts expressed cytoplasmic CD40 in 30% of cases, in breast tumor ducts in 53% of cases. CD40 was evaluated as an independent marker and significant positive correlation was found with Bcl-2 (p =0.002), early stage (p =0.016) and preoperative chemotherapy (p =0.043). There was higher overall survival for patients with cytoplasmic CD40 expression (0.05). Differences in expression of cytoplasmic CD40 between groups with different hormonal and her-2/neu status were statistically highly significant (p=0.00003). In groups with different hormonal status, a positive statistical correlation was found for the luminal A group with relapse (p=0.024) and stage (p=0.006). No correlation was found with age, disease onset, family history of cancer/ breast cancer, patient history, hormonal replacement therapy, menopausal status at onset of disease, adjuvant chemotherapeutic treatment or disease free survival. Nuclear expression of CD40 was found to be unrelated to any clinicopathological data. However, there was higher ratio of positive cases in cancer cases (83%) than in normal tissue (30%). In conclusion, cytoplasmic expression of CD40 is related to factors connected to better prognosis and suggest that CD40 may have potential as a new prognostic factor in breast cancer.

Pericyte coverage of fetoplacental vessels in pregnancies complicated by Type 1 diabetes mellitus.

Placentas from pregnancies complicated by Type 1 diabetes mellitus (DM 1) display altered vascular morphology and function. Here we studied the extent of pericyte coverage in microvessels of normal pregnancies and pregnancies complicated by DM 1. We used smooth muscle actin (SMA) as a marker for quantitation of pericyte coverage in placental capillaries. The extent of pericyte coverage around the vessel circumference was 38 ± 11% in normal vs. 33 ± 10% in DM 1 pregnancies. We found that there is no statistically significant difference in the extent of pericyte coverage around the capillary circumference between DM 1 and normal pregnancies.

Expression of adipokines and estrogen receptors in adipose tissue and placenta of patients with gestational diabetes mellitus.

The purpose of this study was to assess the expression profile of genes with potential role in the development of insulin resistance (adipokines, cytokines/chemokines, estrogen receptors) in subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and placenta of pregnant women with gestational diabetes mellitus (GDM) and age-matched women with physiological pregnancy at the time of Caesarean section. qRT-PCR was used for expression analysis of the studied genes. Leptin gene expression in VAT of GDM group was significantly higher relative to control group. Gene expressions of interleukin-6 and interleukin-8 were significantly increased, whereas the expressions of genes for estrogen receptors alpha and beta were significantly reduced in SAT of GDM group relative to controls, respectively. We found no significant differences in the expression of any genes of interest (LEP, RETN, ADIPOR1, ADIPOR2, TNF-alpha, CD68, IL-6, IL-8, ER alpha, ER beta) in placentas of women with GDM relative to controls. We conclude that increased expression of leptin in visceral adipose depot together with increased expressions of proinflammatory cytokines and reduced expressions of estrogen receptors in subcutaneous fat may play a role in the etiopathogenesis of GDM.

Analysis of VEGF, Flt-1, Flk-1, nestin and MMP-9 in relation to astrocytoma pathogenesis and progression.

Astrocytomas, particularly high grade astrocytoma, are brain tumors with potent angiogenic activity. Our immnunohistochemical study assessed vascular endothelial growth factor (VEGF), VEGF receptors (Flk-1, and Flt-1), the intermediate filamental protein nestin which plays a role in central nervous system development, and MMP-9, which belongs the family of matrix metalloproteinases implicated in tumor invasion and angiogenesis regulation. We investigated the expression of VEGF, its receptors, nestin and MMP-9 in astrocytomas and their correlation with tumor grade. We used paraffin-embedded samples from 66 patients, 29 with low grade (WHO-grade II) and 37 with high grade (WHO-grade III and IV) astrocytomas. Antibodies against VEGF, Flk-1, Flt1, nestin, CD34 and MMP-9 were used, followed by standard indirect immunohistochemical methods. Expression of Flt-1 and Flk-1 showed no significant differences between low and high grade tumor groups. Expression of VEGF and MMP-9 was increased in the high grade group (p equal to or less than 0.026 and 0.024). Nestin expression in tumor astrocytes and endothelial cells increased in high grade group (p same 0.007 and 0.003). Higher expression of VEGF in high grade astrocytomas may subsequently lead to activation of survival, angiogenesis and migration. Expression of nestin and MMP-9 also suggest their likely role in astrocytoma vascular development and proliferation.

Could changes in the regulation of the PI3K/PKB/Akt signaling pathway and cell cycle be involved in astrocytic tumor pathogenesis and progression?

The most frequent alterations found in astrocytomas are two major groups of signaling proteins: the cell cycle and the growth factor-regulated signaling pathways. The aim of our study was to detect changes in expression of the following proteins: the tumor suppressors PTEN, p53, and p21Waf1/Cip1, glial fibrillary acidic protein (GFAP, as a marker of astroglial differentiation), the phosphorylated form of protein kinase B/Akt (PKB/Akt), which is downstream to the epidermal growth factor receptor (EGFR), and MDM2, which degrades p53. Paraffin-embedded astrocytoma tissue samples from 89 patients were divided into low grade (grade I-II; 42 samples) and high grade astrocytomas (grade III-IV; 47 samples). Mouse monoclonal antibodies against GFAP, PTEN, PKB/Akt phosphorylated on serine 473, EGFR, p53, p21Waf1/Cip1 and MDM2 were used, followed by standard indirect immunohistochemical method. EGFR protein was detected in 29 % of low grade and in 60 % of high grade astrocytomas. The expression of phosphorylated PKB/Akt was found in roughly the same proportions: in 86% of low grade and in 79% of high grade astrocytomas. PTEN was not found in most of astrocytomas, 64% of low grade and 74% of high grade tumors showed no PTEN staining. Overexpression of the mutated form of p53 or loss of p53 expression, however, was found in about 63% in both groups of astrocytomas with no differences between them. GFAP expression was decreased in tumor astrocytes compared to normal astrocytes and this decreased with grading. GFAP positive tumor cells were detected in only 50% of low grade, and 32% of high grade astrocytomas. The level of MDM2 expression was similar in both grades. Loss of p21Waf1/Cip1 expression was shown in 20% of low and in 45% of high grade tumors. In the subgroup of high grade tumors with wild type p53, 86% showed p21Waf1/Cip1 expression, whereas in the subgroup of high grade tumors with altered p53, only 35% displayed p21Waf1/Cip1. We conclude that EGFR expression increases with astrocytoma grading. EGFR activation may subsequently lead to stimulation of the PKB/Akt survival pathway. PTEN defects may also participate in aggressive tumor behaviour through activation of the PKB/Akt pathway. The alteration of p53 supports the finding that the cell cycle regulation is also disrupted during development of astrocytomas. The changes in PTEN and p53 expression, and activation of PKB/Akt are events in the early stages of astrocytomagenesis. EGFR is one of the factors, which drives the progression of astrocytomas from low to high grade stage.

[Obstetrical aspects of peripartum cardiomyopathy]. / Porodnické aspekty peripartální kardiomyopatie.

OBJECTIVE: The authors demonstrate a case report of the peripartum cardiomyopathy that occurred at a so far healthy woman after the delivery by the caesarean section. SUBJECT: Case report. SETTING: Department of Obstetrics and Gynecology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague. METHODS: The gravidity of a 28-year old primipara, gemini, was finished by the caesarean section because of cardiologic (benign cardiac extrasystoles) and obstetric (gemini clashing position) indication. After the delivery a heart failure started to develop. The diagnosis was closed as peripartum cardiomyopathy. The clinical state of patient stabilized after initiating adequate therapy, the follow up has been still going on. RESULTS: Peripartum cardiomyopathy is a rare disease that occurs as a left ventricular cardiac failure in pregnant women or in woman in childbed. Etiology of the disease is unknown, the disease management requires collaboration among obstetricians, cardiologists, anesthesiologists and neonatologists. Prognosis is uncertain.

[Massive pulmonary embolism after delivery by cesarean section]. / Masivní plicní embolie po porodu císarským rezem.

OBJECTIVE: To give an overview of the preventive and therapeutic measures in thromboembolic disease in association with pregnancy and delivery. SUBJECT: Case report. SETTING: Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General Faculty Hospital, Prague. SUBJECT AND METHOD: The surgical treatment of massive pulmonary embolism in a patient after delivery by caesarean section. CONCLUSION: Surgical embolectomy still has its place in the treatment of pulmonary embolism in the early phase of critical cases, when thrombolysis is contraindicated, and mechanical disintegration with the catheter is unsuccessful. In such cases it is the only one possibility of saving the patient. However, prevention of thromboembolic disease remains of primary importance.

Dynamic study of the distribution of microcirculatory blood flow in multiple splanchnic organs in septic shock.

OBJECTIVES: To study dynamic distribution of microcirculatory blood flow in multiple splanchnic organs during septic shock; to test the hypothesis that changes in microcirculatory blood flow in splanchnic organs correlate with changes in regional flow during septic shock. DESIGN: A prospective, controlled, animal study. SETTING: Animal laboratory in a university medical center. SUBJECTS: Nine anesthetized and mechanically ventilated domestic pigs. INTERVENTIONS: Systemic flow (cardiac output) was measured with thermodilution and regional (superior mesenteric artery) flow with transit time flowmetry. Local blood flow (microcirculatory flow) was continuously measured in splanchnic organs (gastric, jejunal, and colon mucosa, liver, and pancreas) and the kidney with multichannel laser Doppler flowmetry. Septic shock was induced with fecal peritonitis. After 240 mins of sepsis, intravenous fluids were administered to alter hypodynamic shock to hyperdynamic septic shock. MEASUREMENTS AND MAIN RESULTS: In this severe septic shock model, systemic and regional flows decreased by approximately 50% during the first 240 mins. Similar reductions were recorded in microcirculatory flow in the mucosa of the stomach (-41%; p < .001) and colon (-47%; p < .001). In the jejunal mucosa, on the other hand, flow remained virtually unchanged. Microcirculatory flow was also significantly decreased in the liver (-49%; p < .001), pancreas (-56%; p < .001), and kidney (-44%; p < .001). Administration of intravenous fluids at 240 mins was followed by three-fold increases in systemic and regional flows (approximately 70% above baseline). In the jejunal mucosa, flow also increased significantly above baseline (42%; p < .001), whereas in the stomach and the colon, it barely reached baseline. Kidney blood flow increased to baseline, whereas pancreas and liver flows remained 26% (p < .05) and 34% (p < .001), respectively, below baseline. CONCLUSION: Changes in microcirculatory blood flow in the splanchnic organs are heterogeneous, both in early hypodynamic and in hyperdynamic septic shock, and cannot be predicted from changes in systemic or regional flows. Microcirculatory blood flow in the jejunal mucosa remains constant during early septic shock, whereas pancreatic blood flow decreases significantly more than regional flow.

Continuous measurements of microcirculatory blood flow in gastrointestinal organs during acute haemorrhage.

Hypoperfusion of splanchnic organs is an important contributor to the development of multiple organ failure after major surgery and trauma. During general anaesthesia and surgery we compared changes in systemic haemodynamics and regional blood flow with changes in the distribution of microcirculatory flow (MBF) in multiple splanchnic organs in pigs exposed to acute haemorrhage. Seven pigs (25 kg) were bled to a mean arterial pressure of 40 mm Hg; 180 min later the shed blood was retransfused. MBF was measured in the intestinal mucosa (stomach, jejunum, colon), pancreas, liver and kidney using a six-channel laser Doppler flowmeter. Cardiac output was measured by thermodilution and superior mesenteric artery flow by ultrasonic flowmetry. During haemorrhage, MBF in the gastric and colon mucosa and flow in the liver and kidney decreased to a similar extent to regional and systemic flows (30-50%). In contrast, MBF in the jejunal mucosa remained virtually unchanged and flow in the pancreas decreased significantly more than systemic and regional flows (60%, P < 0.05). We conclude that: (1) changes in the distribution of MBF in the gastrointestinal tract during acute haemorrhage are heterogeneous and cannot be predicted from changes in systemic or regional haemodynamics; (2) MBF in the jejunal mucosa did not decrease during haemorrhage, indicating that autoregulation of blood flow in the mucosa remained intact during shock; and (3) MBF in the pancreas decreased significantly more than systemic and regional flows during shock, suggesting that the pancreas is particularly vulnerable to haemorrhage.

[Lipids and atherosclerosis of the peripheral vessels]. / Lipidy a ateroskleróza periferních cév.

The authors present a review of information on the incidence éf obliterations of peripheral vessels, incl. their own experience, with a group of diabetic patients. Attention is paid to the pathophysiology of affections of peripheral vessels. In the final part data on the relationship of lipids or their fractions and the development of obliteration of peripheral vessels are presented.

Effects of sodium nitroprusside and phenylephrine on blood flow in free musculocutaneous flaps during general anesthesia.

BACKGROUND: Hypoperfusion and necrosis in free flaps used to correct tissue defects remain important clinical problems. The authors studied the effects of two vasoactive drugs, sodium nitroprusside and phenylephrine, which are used frequently in anesthetic practice, on total blood flow and microcirculatory flow in free musculocutaneous flaps during general anesthesia. METHODS: In a porcine model (n = 9) in which clinical conditions for anesthesia and microvascular surgery were simulated, latissimus dorsi free flaps were transferred to the lower extremity. Total blood flow in the flaps was measured using ultrasound flowmetry and microcirculatory flow was measured using laser Doppler flowmetry. The effects of sodium nitroprusside and phenylephrine were studied during local infusion through the feeding artery of the flap and during systemic administration. RESULTS: Systemic sodium nitroprusside caused a 30% decrease in mean arterial pressure, but cardiac output did not change. The total flow in the flap decreased by 40% (P < 0.01), and microcirculatory flow decreased by 23% in the skin (P < 0.01) and by 30% in the muscle (P < 0.01) of the flap. Sodium nitroprusside infused locally into the flap artery increased the total flap flow by 20% (P < 0.01). Systemic phenylephrine caused a 30% increase in mean arterial pressure, whereas heart rate, cardiac output, and flap blood flow did not change. Local phenylephrine caused a 30% decrease (P < 0.01) in the total flap flow. CONCLUSIONS: Systemic phenylephrine in a dose increasing the systemic vascular resistance and arterial pressure by 30% appears to have no adverse effects on blood flow in free musculocutaneous flaps. Sodium nitroprusside, however, in a dose causing a 30% decrease in systemic vascular resistance and arterial pressure, causes a severe reduction in free flap blood flow despite maintaining cardiac output.

[Gestational diabetes--a model trial. The effect of alloxan diabetes on the spectrum of fatty acids in the blood, liver and brain in laboratory rats]. / Gestacní diabetes--modelová studie. (Vliv aloxanového diabetu na spektrum mastných kyselin v krevním séru, v játrech a v mozku u laboratorního potkana).

In alloxan-induced diabetic rats (Wistar, females, age 3-4 months of postnatal life) the large spectrum of fatty acids in blood serum, brain cortex, medulla oblongata and liver was studied. The fatty acids, using gas chromatography, were detected as methyl esters and the methods were published previously (Smídová and al. 1994). Alloxan (Merck) administered i.p., 140 mg/kg body weight, caused immediately elevation (three times) of blood sugar levels. On the 13th day the rats were killed. The results are as follows: a) In blood serum alloxan diabetes of cca two weeks duration caused a significantly increased participation of saturated FA and decreased participation of both polyunsaturated FA (n-3 and n-6). b) In brain cortex no differences between controls and diabetic rats in the indicated groups of FA were found. c) In the medulla oblongata an increased participation of polyunsaturated fatty acids n-6 was established. d) In hepatic tissue the increased participation of saturated FA as well as a decreased participation of FA n-6 was described. Analysing the main groups of FA we found especially in n-3 and n-6 FA several significant changes in single FA (a smaller pool of arachidonic acid in blood serum as well as in liver, decreased participation of docosahexaenoic acid in the brain cortex, etc.). The purpose and possible consequences of such changes are discussed.

Effects of extradural anesthesia on microcirculatory blood flow in free latissimus dorsi musculocutaneous flaps in pigs.

Free musculocutaneous flaps are used frequently in plastic surgery to reconstruct soft-tissue defects after radical cancer surgery and trauma. Despite improved surgical techniques, some of these flaps fail due to insufficient blood supply. Extradural anesthesia causes both sensory (pain relief) and sympathetic (vasodilatation) block that may be advantageous in free-flap surgery. This hypothesis, however, has not yet been studied. An experimental model in pigs was developed in which clinical conditions for anesthesia and microvascular surgery on the lower extremity were simulated as closely as possible. The effects of extradural anesthesia as well as phenylephrine infusion, combined with general anesthesia, on central hemodynamics and on microcirculatory blood flow in skin and muscle of the latissimus dorsi free flap were studied. After surgery, seven animals received extradural anesthesia during stable normovolemic conditions and another seven during mild hypovolemia (10 percent blood loss). The extradural block was objectively evaluated using the temporal summation test. Thirty minutes after induction of extradural anesthesia, the animals received an intravenous infusion of phenylephrine 1 microgram/kg per minute over a period of 15 minutes. Multichannel laser-Doppler flowmetry was used to measure microcirculatory blood flow in skin and muscle of the free flap as well as in control skin and muscle on the same extremity simultaneously. In normovolemic animals, extradural block caused a 10 percent decrease in mean arterial pressure and cardiac output and an approximately 20 percent decrease in microcirculatory blood flow in both the skin and muscle of the flap (all changes were nonsignificant). In slightly hypovolemic animals, however, extradural anesthesia caused a significant decrease in cardiac output (31 percent, p < 0.01), mean arterial pressure (24 percent, p < 0.01), and in mean blood flow in the flap muscle (22 percent, p < 0.05) and skin (20 percent, p < 0.05). During phenylephrine infusion, mean arterial pressure increased significantly (p < 0.05) in both hypovolemic and normovolemic animals, while cardiac output and microcirculatory blood flow in the flap remained almost unchanged. Extradural anesthesia does not improve microcirculatory blood flow in free musculocutaneous flaps in pigs. It causes a significant decrease in cardiac output, mean arterial pressure, and microcirculatory blood flow in slightly hypovolemic animals. During phenylephrine infusion, the microcirculatory blood flow in free flaps slightly improves due to the increase in mean arterial pressure. We suggest that extradural anesthesia for microvascular surgery should be used with great caution until human data are available.

[Antibiotic prophylaxis of infectious complications in gynecologic surgery]. / Antibiotická profylaxe infekcních komplikací v gynekologické operative.

Infections are still the most frequent postoperative complications and one of the limiting factors of successful gynaecological surgery. In recent years information on successful anti-microbial chemoprophylaxis is increasing and is associated with reduced postoperative inflammations, febrile morbidity and early complications. Views differ above all as regards indications for the use of antibiotic prophylaxis and the selection of a suitable antibiotic. Data in the literature differ also as regards achieved results. The submitted work had the objective to test on a representative group the success and rationality of medicamentous prophylaxis in gynaecological surgery and to contribute to a clearer view on controversial points. 203 women admitted to the Second Gynaecological and Obstetric Department of the First Medical Faculty Charles University and General Faculty Hospital Prague for elective abdominal or vaginal hysterectomy on account of a benign indication were divided into three groups which did not differ from the demographic or medical aspect. In group A (53 women) for prophylaxis two doses of Augmentin were used (combination of amoxycillin with clavulanic acid) i.v., patients in group M (50 women) had three doses of Mandol (Cefamandol) i.m., and in control group K (100 patients) no antibiotics were administered prophylactically. The authors investigated the postoperative course and evaluated some parameters in relation to possible postoperative infectious complications. The results proved unequivocally that prophylaxis with Augmentin reduces significantly the postoperative infectious morbidity (11.5%), febrile morbidity (5.6%) and the incidence of early infectious complications (3.8%) after abdominal or vaginal hysterectomy, as compared with the control group (35%, 31% and 11% resp.). Prophylaxis with Cefamandol reduced only in few parameters postoperative complications, but in general did not lead to a significant improvement of the postoperative course nor to a reduction of postoperative inflammatory complications. Similar results were obtained when only complications after abdominal hysterectomy were evaluated. The results of bacteriological examination confirmed the expected differences in the spectrum of efficacy of the two antibiotics on the most common microbial flora in the given area, i.e. a high sensitivity of Augmention to enterococci and bacterioids and resistance of these bacteria to Mandol. These results can be considered one of the reasons of different results of the two antibiotics. Prophylaxis with amoxycillin/clavulanic acid was found to be safe, very effective and financially feasible prevention of postoperative infectious complications after abdominal and vaginal hysterectomy. It led to a significant increase in the number of cases without any complications, when compared with the control group.

[Cytodiagnosis and premature birth in light of the Bethesda system]. / Cytodiagnostika a predcasný porod ve svetle Bethesda systému.

1. Evaluation of cytological cervico-vaginal smears by the Bethesda system enlisted cytodiagnostics among important laboratory methods which can be used also in risk pregnancies. 2. Vaginal cytology makes it possible to test at the same time the hormonal situation during pregnancy, which reflects the placental function, and to evaluate also the vaginal biocenosis. 3. The authors provided evidence that the large number of superficial cells on the cytological smear (more than 10%) is associated with low oestriol and pregnandiol levels which are warning signs of the approaching termination of pregnancy. 4. By the action of microorganisms on the vaginal epithelium typical morphological changes develop in the cell nucleus and in the cytoplasm. By polychromatic staining also the causal agents of inflammations and infections threatening the mother and foetus are apparent. 5. The authors assume that cytological examination and evaluation according to the Bethesda system should be included in the complex of antenatal examinations also in women without clinical symptoms of premature delivery or without signs of vaginal infection.