Analysis of in-hospital analgesic pharmacotherapy costs and regimen and impact on postoperative pain-related function in degenerative lumbar intervertebral disc disease.

BACKGROUND: Pain medication may affect clinical and economic outcomes, and a detailed description of pain medication use is advocated in the literautre for better assessment of clinical outcomes of spine surgery, which otherwise clould be misleading. OBJECTIVES: To analyze the impact of in-hospital analgesic pharmacotherapy after spine surgery on subjective quality of life and pain relief in patients with degenerative lumbar intervertebral disc disease (DLIVD), and also to analyze pharmacotherapy costs. DESIGN: A single-center study included 50 patients with L5/S1 or L4/L5 DLIVD, eligible for spine surgery. INTERVENTION: Neurosurgery for DLIVD. MAIN ENDPOINTS: Outcomes in terms of postoperative pain and function were recorded prospectively using standardized questionnaires. Data for cost analysis and pharmcotherapy regimen were obtained retrospectively from case histories, doctors' request cards and hospital discharge summaries. RESULTS: Mean total pharmacotherapy cost amounted to €453.42±49.09. Mean pharmacotherapy cost amounted to €314.76±54.21 preoperatively, and €138.66±25.54 postoperatively. The greatest improvement in function and quality of life was in patients treated with non-opioids. CONCLUSION: This study supports the notion that analgesic pharmacotherapies could be differentiated in terms of overall impact on quality of life, and that pain-related distress might be the most relevant factor in this setting.

The use Prometheus FPSA system in the treatment of acute liver failure: preliminary results.

UNLABELLED: The preliminary outcomes of patients with acute liver failure treated with the Prometheus Fractionated Plasma Separation and Absorption (FPSA) system are presented herein. PATIENTS AND METHODS: The procedures were performed in 13 patients (4, intoxication by Amanita phalloides; 4, unknown reason; 3, acetaminophen intoxication; 1, Wilson disease, and 1, liver insufficiency after hemihepatectomy owing to metastases of colon adenocarcinoma). The patients were qualified for the procedure according to the King's College Hospital criteria. The patients' general status was assessed on basic of GCS, UNOS, and the 4-grade encephalopathy classifications. The procedures were performed with the Prometheus 4008H Fresenius Medical Care unit. RESULTS: The 29 procedures were of mean duration 6.5 hours. There were statistically significant reductions in total bilirubin, ammonia, and aminotransferase levels. In addition, the procedures corrected water, mineral, and carbohydrate disorders. One patient did not require liver transplantation. Seven patients received liver transplants: three patients with positive outcomes; two died due to septicemia within 30 days perioperatively, one died at 6 months after OLT owing to respiratory failure; and one, owing to hemorrhagic diathesis. Four patients did not receive a liver transplant because of lack of a organ, no consent for the surgery, or neoplastic disease with metastases. CONCLUSIONS: The Prometheus FPSA-System was an effective detoxication method for patients with acute liver failure. The system was useful as a symptomatic treatment before liver transplantation allowing a longer wait for a graft.

Orthotopic liver transplantation for fulminant hepatic failure.

This paper presents the results of liver transplantation for fulminant hepatic failure in 31 patients qualified as UNOS-1 class (extra-urgent indication for transplantation), operated from January 1989 to April 2005. Twenty-one patients (61.8%) survived the 3-month postoperative period. Three-year survival rate with good liver graft function was 52.9% (18 patients). Before the transplantation, eight patients (23.5%) underwent hepatic dialysis using Fractionated Plasma Separation and Adsorption (FPSA) with the use of a Prometheus 4008H System. Liver transplantation remains the only life-saving procedure for the treatment of fulminant liver failure, regardless of its cause.

Recurrence of primary sclerosing cholangitis in patients after liver transplantation.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease that progresses to end-stage liver disease. There are several specific problems related to the posttransplantation period in these patients. The aim of this study was to analyze a single center experience with 17 orthotopic liver transplantations (OLT) due to PSC. PATIENTS AND METHODS: Seventeen patients were included (10 men, 7 women). Actuarial patient and graft survival rates and the incidence of recurrent sclerosing cholangitis were determined at 1, 5, and 7 years. RESULTS: Fifteen patients received single grafts, whereas two patients required retransplants. Patients received either cyclosporine (n = 7) or tacrolimus (n = 10) based immunosuppression. The 1-, 5-, and 7-year patient survival rates were 80%, 60%, and 60%, respectively, whereas the graft survival rates were 88%, 65%, and 65%, respectively. Two patients had cholangiocarcinomas (CCA) diagnosed during OLT; both recurred within 6 months and had a fatal outcome. Two patients (12%) developed recurrent sclerosing cholangitis, as assessed by liver histology and imaging of biliary tree. CONCLUSIONS: Liver transplantation provides good patient and graft survival rates in cases affected with PSC. CCA is associated with poor recipient survival. Recurrent PSC occurs in approximately 12% of cases but does not significantly affect patient survival.

Comparison of the results of liver transplantation for elective versus urgent indications.

The authors present an analysis of early and remote liver transplantation outcomes related to the presence of emergent indications among 196 of the 209 operations performed from 1989 to April 2003; namely 178 elective and 18 emergent transplantations. Perioperative mortality was 15%. The survival rate during the first 12 months was 79.8% and within 3 years 73.5% among patients operated on an elective basis (UNOS 3 and 2B). In contrast, patients with acute liver failure (UNOS 1 and 2A) showed rates of 45%, 50%, and 47%, respectively. Liver transplant outcomes depend primarily on the urgency of an operation. Longterm results are much better among patients operated on electively. Liver transplantation in patients with acute hepatic insufficiency is burdened with a high 45% mortality.

Results of liver transplantation according to indications for orthotopic liver transplantation.

OBJECTIVE: This study assessed the results of liver transplantation in patients with a variety of different indications. METHODS: From 1989 to April 2003, 209 orthotopic liver transplantations (OLTx) were performed on 196 patients, including 178 cases. The diagnoses were: PBC (n = 34); PSC (n = 13); elective postinflammatory cirrhosis in the course of hepatitis C (n = 29); hepatitis B (n = 16); postalcoholic cirrhosis (n = 23), autoimmune cirrhosis (n = 11); Wilson's disease (n = 6); cirrhosis of unknown etiology (n = 10); secondary biliary cirrhosis (n = 5); Budd-Chiari syndrome (n = 6); and benign liver neoplasms (n = 7). RESULTS: The 3-year survival rate in the group of patients transplanted electively was 74.1%. In other groups it was: PBC, 91.4%; PSC, 69.2%; hepatitis C, 69.6%; hepatitis B, 55.5%; postalcoholic cirrhosis, 80%; autoimmune cirrhosis, 81.8%; Wilson's disease, 57.1%; secondary biliary cirrhosis, 40%; Budd-Chiari syndrome, 66.6%; hemochromatosis, 100%; benign neoplasms of the liver, 87.5%; and liver cysts, 100%. CONCLUSIONS: Results of liver transplantation were closely related to the urgency of the procedure. Better results were achieved in patients operated upon routinely compared with in those operated upon emergently (74.1% vs 50%). The best results of liver transplantation were achieved in patients transplanted on a routine basis with a diagnosis of PBC (91.4%), autoimmunologic cirrhosis (81.1%), postalcoholic cirrhosis (80%), or hemochoromatosis (100%). Patients with liver insufficiency due to hepatitis B and Wilson's disease have an increased risk of graft destruction, and the rate of survival in these patients is significantly lower than in other patients.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation.

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

High-resolution 1H nuclear magnetic resonance spectroscopy analysis of bile samples obtained from a patient after orthotopic liver transplantation: new perspectives.

The liver is involved in many synthetic and metabolic functions. It takes part in the regulation of circulation, thermoregulation, and digestion. All liver functions are disturbed during harvesting, preservation, and transplantation. The assessment of graft function is still a matter of concern. Many methods including analysis of hepatic enzymes, ketone body ratio, and level of drug metabolites do not give complete and reliable information on graft function. Liver biopsy is still the best diagnostic tool, however, it is invasive, carrying the risk of complications. High-resolution proton spectroscopy of nuclear magnetic resonance was used for analysis of the bile sample obtained from a patient after orthotopic liver transplantation.

Resistance of gram-positive pathogens to antibiotics is a therapeutic challenge after liver transplantation: clinical experience in one center with linezolid.

BACKGROUND: Orthotopic liver transplantation has become an established therapeutic option for a large variety of fulminant and chronic liver diseases. Postoperative infections are the major cause of morbidity and the leading cause of mortality. The microbes responsible for these severe infections are predominantly gram-positive. METHODS: This article reviews results of linezolid therapy based on the clinical characteristics, microbial features, and outcomes of severe bacterial infections due to known or suspected resistant gram-positive species in selected liver allograft recipients. RESULTS: Among the 7 patients who received linezolid, methacillin-resistant Staphylococcus aureus. was isolated from 3, no pathogen from 2 patients, and serious pulmonary infection in 2 patients, 1 of whom had to be reintubated due to of respiratory failure. Cholangitis observed in 5 of 7 patients was caused by enterococci and staphylococci with septicemia in 1 subject. All patients demonstrated clinical improvement; microbiological eradication was observed in 4 patients. The majority of reported adverse events were mild or moderate in intensity. No potential drug interactions were observed between linezolid and concomitant medication. CONCLUSIONS: In the present study, linezolid proved to be effective and well tolerated. In summary, linezolid may represent an effective and safe antimicrobial agent for the treatment of infections due to susceptible and resistant gram-postive bacteria after solid organ transplantation.

Liver regeneration in living-related donors after harvesting of liver segments II and III or II, III and IV.

BACKGROUND: CT-assisted volumetry permits an estimation of the volume of the graft in liver transplantation, as well as monitoring the donor's liver regeneration. The aim of the study was to observe the restitution of liver tissue in donors after harvesting of the liver fragment for living-related liver transplantation (LRLT). METHODS: The size of the whole liver and of segments II, III and IV was assessed by preoperative CT volumetry in 29 living-related liver donors. Segments II and III were harvested in 22 patients, segments II, III and IV in 6 patients. The remnant liver was assessed by CT volumetry on the 7th and 30th postoperative days. RESULTS: The correlation between the calculated volume of the graft and its weight was linear (r=0.56, p<0.04). Postoperative CT volumetry of the liver of living-related donors showed a different pattern of volume restoration (regeneration index) at both 7 and 30 days between donors who sacrificed segments II and III and those who sacrificed segments II, III and IV. The mean regeneration indexes were significantly higher in donors of segments II, III and IV as compared with donors of segments II and III (7 days, p<0.02; 30 days, p<0.05). DISCUSSION: It is possible that the donor's liver displays a different pattern of growth due to the alteration in blood supply to segment IV.

Lympho-epithelial interactions in rat thymus during pregnancy.

Alterations in the thymic epithelial cell activity were analysed during pregnancy and lactation in Wistar rats by examining the presence and in situ distribution of lymphoepithelial complexes formed by thymic nurse cells (TNC). TNC were identified in paraffin sections by their expression of MHC class II antigens, CD54 molecule and a neuromarker, protein gene product 9.5 (PGP9.5). On the first days of pregnancy (gestational days, GD) the number of PGP9.5+ TNC was found to decrease abruptly. On GD 14, a transient increase was noted in the number of PGP9.5+, MHC+, CD54+ TNC. Another increase was observed in the course of lactation, when the weight of the thymus reached the lowest values. While the increase in TNC numbers during lactation may be linked to the process of reconstruction of the thymic lymphoid population, the augmented activity of lymphoepithelial interactions on GD14 may be associated with thymic engagement in pregnancy-induced immune processes.

Histogenesis of the rat thymic medulla during first stages of development.

We investigated first stages of thymic medulla organisation in foetuses of Wistar strain rats. between 13th and 17th days of foetal life (GD). Medullary cells were identified by immunocytochemical localisation of neuron-specific enolase (NSE) as well as by traits of ultrastructure. The first thymic medullary precursor cells which were reactive for NSE were at first spread all over the thymic primordium. In the period of thymus colonisation by lymphoid cells, the following stages were distinguished in medulla organisation: (1) migration of NSE+ cells to the central portion of the thymus (GD 14-15), (2) small medullary epithelial patches, distributed within the thymus (GD 16), and (3) expansion of medullary patches into medullary compartment (GD 17). At the second and third stages of the medulla organisation, an increase in the number of NSE+ cells, followed by differentiation of their ultrastructure and increase in their biological activity were observed. We conclude that formation of medullary architectural pattern is controlled by interactions between maturing epithelial cells and developing lymphoid cells and by angiogenesis in the region.

[A case of IUD translocation to the peritoneal cavity--diagnostic procedures and treatment]. / Przypadek translokacji IUD do jamy otrzewnej--postepowanie diagnostyczno terapeutyczne.

The case of Cooper-T IUD translocation to peritoneal cavity diagnosed 5 years after its insertion is presented. Authors show diagnostic problems resulting from non typical complaints and incomplete documentation.

[Evaluation of the basis for elective appendectomy in gynecologic laparotomy]. / Ocena zasadnosci elektywnego usuniecia wyrostka robaczkowego w trakcie laparotomii ginekologicznych.

The usefulness of elective appendectomy in gynecological laparotomy has been discussed on the basis of data from 2157 operations. A high rate of pathology has been found in patients without any clinical manifestations including 56.6% inflammatory changes and 0.51% malignant neoplasmas. Elective appendectomy does not influence complications rate, duration of hospitalisation, excludes the need for future operation and may lower the costs of health care.

[Pros and cons of elective appendectomy in gynecologic laparotomy]. / Za i przeciw elektywnemu usuwaniu wyrostka robaczkowego w trakcie laparotomii ginekologicznych.

The problem of elective appendectomy still raises rational and emotional controversy among surgeons. Here is presented discussion and our opinion that strongly supports the idea of performing elective appendectomy during gynecological laparotomy.