Survival and predictive factors of clinical outcome in patients with severe acquired brain injury.

BACKGROUND: Despite the many tools available to modern medicine, predicting the neurological and functional status of patients after severe brain injury remains difficult. AIM: This analysis evaluates the outcomes of patients with the most severe degree of cerebral function impairment. DESIGN: Retrospective cohort study. SETTING: Patients hospitalized in the long-term Intensive Care Unit (ICU) department in the Military University Hospital in Prague between 2015-2022. POPULATION: We analyzed patients with severe acquired brain damage from five distinct etiologies whose initial Glasgow Coma Scale (GCS) score was eight or less upon admission to ICU due to neurological damage. METHODS: Several parameters reflecting the patients' clinical status were evaluated. Overall survival after discharge from the ICU was calculated according to the Kaplan-Meier model with comparison between traumatic (TR) and non-traumatic (non-TR) etiologies. RESULTS: The analyzed cohort of 221 patients consisted of 116 patients of TR and 105 of non-TR etiology. There was no significant difference in overall survival between TR and non-TR groups. The length of hospitalization in the ICU was similar in both groups with a median of 94 days. The majority of patients had an improvement of GCS during the hospitalization with a median improvement of five points. GCS improvement occurred in the vast majority of patients regardless of TR or non-TR etiology. CONCLUSIONS: We did not observe a statistically significant difference in mortality or log-term neurological status between patients with severe brain injury of traumatic or non-traumatic etiology for the duration of our follow up. The majority of patients had improved GCS, were successfully decannulated, but remained disabled with severe limitations of functional independence. CLINICAL REHABILITATION IMPACT: The return of the patient to normal life is a rehabilitation challenge, regardless of the etiology of brain injury, and is extremely influenced by the level of development of neurorehabilitation programs in individual institutions, the severity of brain injury, and the individual motivation of the patient.

Intra and inter-rater variability in the construction of patient-specific musculoskeletal model.

BACKGROUND: Variations observed in biomechanical studies might be attributed to errors made by operators during the construction of musculoskeletal models, rather than being solely attributed to patient-specific geometry. RESEARCH QUESTION: What is the impact of operator errors on the construction of musculoskeletal models, and how does it affect the estimation of muscle moment arms and hip joint reaction forces? METHODS: Thirteen independent operators participated in defining the muscle model, while a single operator performed 13 repetitions to define the muscle model based on 3D bone geometry. For each model, the muscle moment arms relative to the hip joint center of rotation was evaluated. Additionally, the hip joint reaction force during one-legged stance was assessed using static inverse optimization. RESULTS: The results indicated high levels of consistency, as evidenced by the intra- rater and inter-rater agreement measured by the Intraclass Correlation Coefficient (ICC), which yielded values of 0.95 and 0.99, respectively. However, the estimated muscle moment arms exhibited an error of up to 16 mm compared to the reference musculoskeletal model. It was found that muscles attached to prominent anatomical landmarks were specified with greater accuracy than those attached over larger areas. Furthermore, the variability in estimated moment arms contributed to variations of up to 12% in the hip joint reaction forces. SIGNIFICANCE: Both moment arm and muscle force demonstrated significantly lower variability when assessed by a single operator, suggesting the preference for employing a single operator in the creation of musculoskeletal models for clinical biomechanical studies.

Does robotic TME bring difference in lymph node yield and quality of TME?

BACKGROUNDS: Oncological outcomes of the robotic low anterior rectal resection with total mesorectal excision (TME) are still under discussion. Few studies have proven that robotic TME (rTME) is a safe and equivalent method for treatment of rectal carcinoma. But there is almost no comparison between the rTME and conventional TME in terms of the number of lymph nodes obtained and the quality of the TME. METHODS: A single institution retrospective study was designed in a cohort of 261 patients. Cohort was divided into two groups depending on the type of surgery (rTME versus TME) and within these two groups, patients were divided according to whether they underwent neoadjuvant chemoradiation (nCHRT) or did not. The primary objective of the study was to compare obtained number of the lymph nodes in specimen. Secondary objectives were comparison of the quality of the TME and the number of positive circumferential resection margins. RESULTS: Results of the study have shown no significant difference in number of the lymph nodes obtained by the rTME and TME. There was no difference in the quality of the TME, neither in the group with the previous nCHRT nor in the group without a nCHRT. CONCLUSION: With results from the study we consider the rTME to be non-inferior to the conventional TME. Therefore, at least identical oncological results can be expected in patients treated by the rTME.

One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial.

BACKGROUND: Off-pump coronary bypass surgery has become a widely used technique during recent years. However, limited data are available with regard to 1-year patency of bypass grafts implanted on the beating heart in unselected consecutive bypass surgery candidates. The aim of this study was to compare 1-year angiographic patency of bypass grafts done on the beating heart (off pump) with those done classically (on pump). METHODS AND RESULTS: The PRAGUE-4 trial randomized 400 consecutive nonselected cardiac surgery candidates into group A (on pump; n=192) and group B (off pump; n=208). One-year follow-up coronary angiography was done in 255 patients. The arterial graft patency after 1 year was 91% in both groups. Saphenous graft patency was 59% (on pump) versus 49% (off pump; P=NS). Saphenous graft patency per patient was lower in the off-pump group: 0.7 patent anastomosis per patient versus 1.1 patent anastomosis in the on-pump group (P<0.01). There were 46% on-pump patients with all grafts patent versus 52% off-pump patients (P=NS). Grafts anastomosed distally to collateralized chronic total occlusions of native coronary arteries remained patent in 100% on the left anterior descending artery compared with 23% on other arteries (P<0.0001). CONCLUSIONS: The patency of arterial coronary bypass grafts done on the beating heart is excellent and equal to grafts done on pump. The off-pump procedure in the unselected patient population results in fewer patent saphenous grafts per patient.

Use of recombinant activated factor VII in cardiac surgery for an effective treatment of severe intractable bleeding.

Experience gained with administration of supranormal-therapeutic doses (90 microg/kg) of recombinant activated factor VII in 7 cardiac surgery patients is presented. The patients were given recombinant activated factor VII postoperatively for intractable bleeding, 5 of them after surgical revision. Administration of recombinant activated factor VII was associated with significant reduction in blood loss (P < 0.05) and shortening of INR and aPTT in laboratory tests. None of the patients needed reoperation. Administration of recombinant activated factor VII proved highly effective in management of massive hemorrhage in cardiac surgery.

Off-pump versus on-pump coronary surgery: final results from a prospective randomized study PRAGUE-4.

BACKGROUND: Off-pump coronary artery bypass surgery is becoming increasingly popular despite the lack of sufficient evidence from randomized trials. The aim of our prospective, randomized, single-center study was to examine the role of off-pump revascularization among nonselected patients. METHODS: A total of 400 consecutive nonselected patients (mean age 63 years) scheduled for isolated coronary revascularization were randomized by a cardiologist into two groups: A (on-pump) and B (off-pump). The cardiac surgeon was allowed to change the operative technique at any time after randomization. The only exclusion criterion was an emergency procedure. The primary end point was any of the following within 30 days: death, myocardial infarction, stroke, or new renal failure requiring hemodialysis. The study was analyzed on the intention-to-treat principle. RESULTS: The primary end point occurred in 4.9% of patients in group A versus 2.9% in group B (not significant). Mortality was 1.1% in group A versus 2.0% in group B (not significant). Preoperative crossover occurred in 5.4% of patients in each group (not significant). Intraoperative conversion was necessary in 9.8% of patients in group B versus 1.1% of patients in group A (p < 0.001). Group B patients had fewer distal anastomoses (2.3 versus 2.7 in group A; p < 0.001), less blood loss (560 versus 680 mL; p < 0.001), lower postoperative creatine kinase MB levels (0.15 versus 0.56 microkat/L; p < 0.001) and lower total hospital costs (3,451 versus 4,387; p < 0.001). CONCLUSIONS: In our study off-pump technique was applicable in 85% of nonselected patients and is at least as clinically safe and effective as on-pump surgery.

Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia.

BACKGROUND: The expansion of coronary surgery on the beating heart without cardiopulmonary bypass has led to increasing interest in ultra-fast track anesthesia, allowing extubation of the patient in the operating theater. The techniques described to date combined general anesthesia with thoracic epidural analgesia. We report the routine application of a technique that allows immediate extubation in the majority of patients undergoing off-pump coronary artery bypass grafting without thoracic epidural analgesia. METHODS: Fast-track anesthesia using an ultra-shortacting opiate remifentanil, without epidural catheter insertion, was used in 160 unselected patients undergoing off-pump coronary artery bypass grafting (aged 43 to 83 years, mean 65 years). There were an average of 2.2 bypass procedures per patient, with the left internal mammary artery used in 93%. Contraindications to immediate extubation were (except for failure to meet standard extubation criteria) hemodynamic instability and persistent bleeding at the end of operation. Satisfactory postoperative pain control was achieved by continuous remifentanil (0.0125 to 0.05 microg x kg(-1) x min(-1)). RESULTS: Operating theater extubation within 10 minutes of the end of operation was feasible in 150 patients (94%). Five patients (3%) were extubated within 2 hours, and the remaining 5 patients (3%) were converted to standard anesthesia. There were no deaths during hospitalization. Major complications included myocardial infarction and transient ischemic attacks (2 patients each). No pulmonary complications were seen. Episodes of atrial fibrillation occurred in 21% of the patients undergoing operation. CONCLUSIONS: Immediate extubation is possible in most patients after off-pump coronary artery bypass grafting even without thoracic epidural analgesia. We believe this type of less invasive cardiac anesthesia is safe and promising.