First experiences with a combined usage of veno-arterial and veno-venous ECMO in therapy-refractory cardiogenic shock patients with cerebral hypoxemia.

The use of extracorporeal membrane oxygenation (ECMO) is becoming a popular tool in the treatment of cardiogenic shock. We present two case reports where classical veno-arterial peripherally cannulated ECMO therapy proved insufficient with profuse cerebral hypoxemia. After augmenting the setting into veno-veno-arterial ECMO, we achieved a remarkable improvement of all oxygenation parameters. The simultaneous use of veno-venous and veno-arterial ECMO might display as a novel strategy to counteract the coronary and cerebral hypoxemia in veno-arterial ECMO therapy in patients with therapy-refractory cardiogenic shock or in combined cardiopulmonary failure. In this manuscript, the veno-veno-arterial ECMO setup is described in full detail and different venous cannulas are discussed.

[Catheter ablation of chronic atrial fibrillation using circumferential and complex linear lesions in the left atrium: modes of arrhythmia termination and long-term clinical outcome]. / Katetrová ablace pro chronickou fibrilaci síní metodou obkruzujících a komplexních lineárních lézí v levé srdecní síni. Ukoncení arytmie pri ablaci a dlouhodobé klinické výsledky.

OBJECTIVE: The aim of the article is to present the method and results of catheter ablation for chronic atrial fibrillation. METHOD: Catheter ablation for chronic atrial fibrillation was performed in 82 patients (18 females, aged 54 +/- 10 years), in 112 ablation procedures. Mean duration of the chronic phase of atrial fibrillation was 28 +/- 28 months. Before ablation, amiodarone was administered without effect to 74 (90%) patients, and was counter-indicated in 8 (10%) patients. Ablation strategy consisted of circumferential lesions around the pulmonary veins and of complex linear lesions in the left atrium. Full pulmonary vein antra isolation, and sinus rhythm restoration, or at least converting atrial fibrillation into the left atrial tachycardia, were the procedure end points. RESULTS: Sinus rhythm was restored by ablation at least in one of the ablation procedures in 43 (52%) patients. During the follow-up period spanning 17.3 +/- 11.6 months after the last ablation, stable sinus rhythm was achieved in 63 (77%) patients, of whom 38 (60%) had their sinus rhythm restored by ablation and another 14 (22%) their atrial fibrillation converted into the left atrial tachycardia. Of the 63 patients with stable sinus rhythm, class I or III antiarrhythmic medication has been maintained in 21 (33%) patients, and amiodarone has been taken by 13 (21%) patients. CONCLUSION: Catheter ablation of chronic atrial fibrillation is potentially highly effective in long-term restoration of sinus rhythm.

[Recurrent arrhythmias after catheter ablation of originally paroxysmal atrial fibrillation and results of repeat ablation]. / Recidivující arytmie po katetrové ablaci puvodne paroxyzmální fibrilace síní a výsledky opakované ablace.

AIMS: The aim is a description of the recurrent arrhythmias after previous ablation of paroxysmal atrial fibrillation (AF), and the results of a repeat catheter ablation. METHODS: A repeat ablation was performed in 76 patients (18 females, 54 +/- 11 years) in 96 procedures, which was 21% out of 362 patients, who had undergone the first ablation for a paroxysmal AF. The endpoints of the repeat ablation were re-isolation of the pulmonary veins (PV) and termination of a spontaneous or induced arrhythmia and restoration of a stable sinus rhythm (SR), and possibly achievement of noninducibility of any arrhythmia. RESULTS: Clinical left atrial tachycardia (LAT) was present in 10 (13%) patients before the first, and in 5 (25%) patients before the second repeat ablation. Arrhythmia arising from an arrhythmogenic PV due to the conduction recovery into the left atrium (LA) was found in 50 (66%) patients during the first, and in 7 (35%) patients during the second repeat ablation. Arrhythmias, predominantly of the reentry mechanism and originating in the LA free wall, were found in 26 (34%), respectively 13 (65%) during the first or the second repeat ablation. All arrhythmias from PVs were terminated by a PV encircling ablation. Substrate-related arrhythmias were terminated by ablation except for 2 (3%) patients during the first and 3 (15%) patients during the second repeat ablation. Persistent AF was mainly terminated via conversion into a LAT. In these cases, the ablation sites leading to the SR restoration were, similarly to the primary LATs, located predominantly in the LA anterior wall. During the 22 +/- 13 months follow-up, 68 (89%) patients were free of AF, 54 (71%) patients off the antiarrhythmic drugs and 14 (18%) patients with the class I or III antiarrhythmic drugs. CONCLUSION: AF associated with PV-LA re-connection dominated prior to the first repeat ablation, then the proportion of the substrate-related arrhythmias from the LA free wall increased. Clinical efficacy of the repeat ablation is high.

Poly (ADP-ribose) polymerase cleavage monitored in situ in apoptotic cells.

During apoptosis, the activation of a family of cysteine proteases, or caspases, results in proteolytic cleavage of numerous substrates. Antibody probes specific for neoepitopes on protein fragments generated by caspase cleavage provide a means to monitor caspase activity at the level of the individual cell. Poly (ADP-ribose) polymerase (PARP), a nuclear enzyme involved in DNA repair, is a well-known substrate for caspase-3 cleavage during apoptosis. Its cleavage is considered to be a hallmark of apoptosis. Here, we demonstrate that an affinity-purified polyclonal antibody to the p85 fragment of PARP is specific for apoptotic cells. Western blots show that the antibody recognizes the 85-kDa (p85) fragment of PARP but not full-length PARP. We demonstrate a time course of PARP cleavage and DNA fragmentation in situ using the PARP p85 fragment antibody and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) in Jurkat cells treated with anti-Fas. Furthermore, our results indicate that the p85 fragment of PARP resulting from caspase cleavage during apoptosis is rapidly localized outside the condensed chromatin but not in the cytoplasm.

Direct contracting: a Minnesota case study.

During 1996, HealthEast Care, Inc., a healthcare provider-owned and governed direct-contracting company, successfully responded to a request for proposal from the metropolitan Minneapolis-St. Paul-based Buyers Health Care Action Group (BHCAG), a coalition of self-insured employers, to provide healthcare services to members of BHCAG's Choice Plus health plan. HealthEast Care developed a care system proposal for BHCAG that balanced consumer and purchaser expectations with historical healthcare costs. Providers are reimbursed for contracted healthcare services according to a unique fee-for-service, budget-based payment model. BHCAG chose to contract with HealthEast Care and 23 other care systems in the metropolitan Minneapolis-St. Paul area and other parts of Minnesota to serve more than 117,500 Choice Plus enrollees.

Topometry of normal intrahepatic bile ducts.

This paper focuses on practical problems which may also prove to be of theoretical importance, by presenting a method of establishing an exact topometry of the intrahepatic bile ducts. Measurements were made on corrosive casts of the intrahepatic bile ducts from 13 human livers. On the basis of the topometric results presented it is possible to construct an adequate model by means of plastic tubes and to use it for the study of bile flow.

[Hernias in the abdominal wall]. / K problematike prietrzí v stene brusnej.

The authors emphasize the relapse frequency of the front abdominal wall hernias. Umbilical hernias, epigastric hernias, hernias in postoperative scars, as well as diastases of m. rectus abdominis are still not appropriately evaluated problem in surgery. Numeral surgical methods and procedures provide evidence of this fact. In spite of this, the relapses are frequent. In order to prevent relapses of hernias and to support the firmness of the abdominal wall, the authors use the corium graft technique. This study provides the description of the graft preparation. This surgical method was used in 54 patients, in whom no recurrence was recorded within the period of 1-3 years after surgery. The authors consider this procedure as being useful and effective. The methodical procedure is simple and economically advantageous, as autografts are ideal from the biological point of view. (Tab. 1, Fig. 6, Ref. 10.)

[History of the Surgery Clinic at the Slovak University Medical School in Bratislava during the war years (1941-1945)]. / K histórii Chirurgickej kliniky Lekárskej fakulty Slovenskej univerzity v Bratislave pocas vojnových rokov (1941-1945).

The aim of the present study was to contribute to a good and objective understanding of the development of the Department of Surgery of the Medical School in Bratislava over the war years of 1941-1945. After Prof. MUDr. Kostlivý had left Slovakia, his student, Prof. MUDr. Konstantín Cársky was appointed head of the Clinic of Surgery, as it was officially named. Already during the period of World War II, Prof. Cársky became a remarkable and reknown personality of the School of Medicine of the Slovak University in Bratislava. The first Slovak school of surgery developed under his guidance. On the basis of archival sources and documents, the paper presents statistical data concerning some aspects of the pedagogical activities of the Clinic of Surgery, its staffing, and the complicated process of competence growth, particularly appointments to the highest academic ranks.

Acute development of low T3 syndrome and changes in pituitary-adrenocortical function after elective cholecystectomy in women: some differences between young and elderly patients.

From two groups of female patients (young group: 15 patients aged less than 25 years; elderly group: 15 patients aged more than 65 years) who were subjected to cholecystectomy, blood samples were obtained on the day before surgery, on the day of surgery before premedication and after waking up from anaesthesia and also on days 1, 3 and 7 after surgery. In aliquots of sera the levels of TSH, ACTH, thyroxine (T4), triiodothyronine (T3), reverse triiodothyronine (rT3) and cortisol were estimated with the aid of radio-immunoassay (RIA). The differences between the young and elderly subjects were evaluated with the aid of four different statistical tests. Though no changes in the level of T4 were found, the level of T3 was significantly decreased and that of rT3 was significantly increased on Day 1 after surgery. However, the decrease of T3 was expressed more significantly in the young group and, in addition, an increase of rT3 in the same group was found even before premedication. The level of TSH showed a sharp increase at the end of surgery, which was expressed more in the young group. Though no differences between groups were observed in a sharp peak of the ACTH level during surgery, the increase of cortisol level in the elderly group was significantly higher and remained so during the post-operative period.

[Characteristics of the aged surgery patient]. / Zvlástnosti chirurgického pacienta v stareckom veku.

In 32 old people selected at random (16 men and 16 women) indicators of the water and mineral salt balance were investigated as well as renal and hepatic functions, nutritional status, serum insulin, thyroxine and triiodothyronine and in 12 also changes after operation. The findings indicate that it is necessary to ensure clinical and biochemical monitoring as well as proper preparation of old people for a planned surgical operation. Old people must be always considered critical patients and it is important to provide extra preoperative and postoperative care.

[Adrenal tumors and surgical approaches to the adrenal glands]. / Nádory nadobliciek a operacné prístupy k nadoblickám.

In 1987 at the First Surgical Clinic in Bratislava four patients with adrenal tumours were operated. Hormonally inactive tumours are, however, diagnosed late on account of their latent growth. To the diagnosis of tumours sonography and computed tomography contributed in a major way. Adrenal tumours must be radically removed, sometimes even with surrounding organs (kidney, spleen, pancreas). Malignant tumours have a very adverse prognosis.

[Carcinoma of the large intestine and cholecystectomy]. / Karcinóm hrubého creva a cholecystektómia.

The authors draw attention to the high incidence of carcinoma of the large intestine in conjunction with cholecystectomy. The increased incidence of this disease was observed in patients after cholecystectomy (17.69%). The authors processed data from a group of 260 patients with colorectal carcinoma during the ten-year period from 1979 to 1988, in 46 with cholelithiasis during previous period cholecystectomy was performed, i.e. in 17.69%. It is assumed that the stimulating effect in carcinogenesis of the large intestine are changes in the bile acid metabolism occurring after cholecystectomy. Hitherto valid indications for cholecystectomy do not change, however, but make us consider these relationships in clinical practice and call for further analyses.

[Diagnostic and therapeutic problems in carcinoma of the esophagus and cardia]. / Pohl'ad na diagnosticko-terapeutickú problematiku karcinómu pazeráka a kardie.

The authors describe their experience with the treatment of 180 patients with tumours of the oesophagus and cardia, during a 13-year period, at the Surgical Clinic, Medical Faculty, Comenius University, Bratislava. Most frequently the tumorous process was in the median portion of the oesophagus. A radical operation could be performed only in 27.2% of patients. The reason was that frequently the tumours were already very advanced when the patients were admitted to the surgical department; that means: late diagnosis. This explains also the short postoperative survival. The authors analyze the reasons for the above described facts and submit their concept of the diagnostic and therapeutic approach to the problem of carcinoma of the oesophagus and cardia.

[Pancreatic fistulas]. / Pankreatické fistuly.

The authors analyze the causes, diagnostic and therapeutic procedure in internal pancreatic fistulae. Based on the case-histories of two patients, they demonstrate the importance of ERCP, fistulography, pleurography as well as of surgical tactical procedures. They describe conservative and surgical treatment and their indications.

[Metastasizing melanoma]. / K problematike metastázovania melanómu.

The complexities of diagnosing melanoma metastases are discussed. More accuracy can be attained with the aid of USG, CT, NMR and scintiscans of the liver. The LDH test appears to be the most effective in cases of metastases developing in the liver. A case of melanoma metastases in the gallbladder is analyzed.

[Forms of the compression syndrome in nodular and retrosternal struma in advanced age]. / Formen des Kompressionssyndroms bei Knoten- bzw. Retrosternalstruma im fortgeschrittenen Alter.

65 cases with a partially retrosternally localized nodular goitre and with compression syndrome (CS) are discussed. The most often (45 patients) registered complaints are breathing difficulties because of tracheal compression, in 8 further patients bad deglutination prevailed over dyspnoe, 3 patients with a compression of the jugular veins showed oedematous face, cyanosis and other signs testifying for stasis of the superior vena cava. Compression of the cervical truncus sympathicus was the cause of Horner's syndrome in 5 patients, in one person thyroid malignancy led to a coarse voice via infiltration of the recurrent nerve. In an additional group were 10 persons with a partially retrosternally localized recurrent nodular goitre, they were subjected to reoperation. In conclusion, 1. the therapy of choice of a CS is strumectomy 2. a consequent postoperative therapy with thyroid preparations is postulated.

Iodothyronines in human bile.

Bile was collected from 7 patients after cholecystectomy with routine T-tube drainage of bile duct postoperatively. In all patients reported, the total volume of bile collected was more than 500 ml which was considered to be close to the volume of bile excreted by the liver during the 24 h collection period. The excretion of total thyroxine (T4), triiodothyronines (T3 and rT3) and diiodothyronines (3,3'-T2, 3,5-T2 and 3'.5'-T2) was estimated with the aid of specific radioimmunoassay described previously. It was found that the total amount of T4 corresponded to its content in about 100 ml plasma, while corresponding figures for triiodothyronines were about 1000-1500 ml and these for diiodothyronines about 10-15 liters. It was concluded that in man the biliary excretion of iodothyronines appears to be of much less importance for their total body balance than in rats.