Kaunas Clinics Research Articles

Acute Subdural Hematoma after Isolated Traumatic Brain Injury: Risk Factors and Prediction of Mortality

The aim of this study was to determine mortality and it‘s risk factors also prediction of lethal outcome in case of acute subdural hematoma after isolated traumatic brain injury (ITBI). Methods. A retrospective study of 162 patients after ITBI was carried out in Neurosurgical Intensive Care Unit (NITS) of Lithuanian University of Health Sciences Hospital (LUHSH) Kaunas Clinics (KC). Demographic (gender, age), clinical (pupil reaction to light, Glasgow Coma Scale (GCS) score, APACHE II scale score) and laboratory (white blood cell count, glycemia) data analysis on the first day after the injury was made. Conclusions. The mortality rate of acute subdural hematoma after isolated traumatic brain injury was 41 pct. Risk factors of mortality were estimated to be patient age ≥ 65 yrs, absence of pupil reaction to light, GCS 3-8, APACHE II score ≥ 16 points, white blood cell count ≥10,1 x 109/l and glycemia ≥5,6mmol/l. It was estimated the evident relation between predicted lethal outcome and real mortality when the risk of lethal outcome was higher than 25 pct.

KLIPPEL–FEIL SINDROMAS – VAIKO NEĮGALUMĄ LEMIANTI RETA ANOMALIJA

Disability includes health problems and personal activity restriction affects body functions or structures violations. Level of disability is a complex assessment of health status and self-loss in daily activities. Degree of disability is determined according to the level of disability determination criteria and procedure description. Basic working capacity assessed by reference to person‘s health status. It is important the early detection of level of disability that would help in time. Discusses the clinical case of a patient who came to LUHS Hospital Kaunas Clinics for suspected genetic syndrome. Patients phenotypic changes - chest deflection, spinal hemangioma and vertebral scoliosis. As well as recurrent respiratory tract infections with obstructive syndrome and bronchiolitis. Clinical features characteristic of Klippel-Feil syndrome, differentiated with occult spinal dysraphism. Provided data about disease symptoms, pathogenesis, diagnosis and the possible clinical manifestations. This case report contains a literature review of other reported cases and case analysis.

Postgraduate Cancer Education and Training in Lithuania: Harmonization According to the EU Rules.

The purpose of this article is to discuss Lithuanian postgraduate cancer education according to the data of 2013. In Lithuania, a specialization in an area called clinical oncology is absent; as independent specialities in oncology, there are both medical oncologists and radiation oncologists. These types of oncologists complete rigorous residency training in the clinics. Separate courses are provided in different residency programmes. Currently, there are two medical oncology and radiation oncology programmes for 3rd-, 4th- and 5th-year residents, one at the National Cancer Institute and another at the Lithuanian University of Health Sciences and Kaunas Clinics. Today, there are only 45 radiation oncologists and 56 medical oncologists licensed in Lithuania. This means that each radiation oncologist and medical oncologist is providing for 397 and 319 new cancer cases per year, respectively, or there are 0.3 practising in the major specialties of oncology per 10,000 population. Most other medical residency programmes expose their trainees to oncology for only 1 month either in the 1st or the 2nd year of residency. Due to the growing number of new cancer cases worldwide, these programmes have to be extended, especially for family and internal medicine residents. Lithuanian postgraduate cancer education and training is in the process of harmonization according to the EU rules. All the Lithuanian residency programmes are certificated by an independent public agency and are recognized by a number of countries, including all the countries of the EU.

Frequency of prenatal determination of 13, 18 and 21 trisomies and link with risk factors

The study was conducted in the Laboratory of the Hospital of Lithuanian University of Health Sciences Kaunas Clinic, in the Laboratory of Clinical Chemistry and Genetics and in the Department of Biology of Vytautas Magnus University. Abnormalities of number of chromosomes are diagnosed from amniotic fluid, which is taken by using an invasive prenatal method – amniocentesis, and modern diagnostic methods such as molecular cytogenetic analysis (FISH) and cytogenetic method, diagnosis of karyotype, by using G-staining method. In order to analyse the main risk factors that determine the frequency of Patau, Edwards and Down syndromes in the analysed group and to evaluate the variety of changeovers of chromosomes structure, the retrospective analysis of patient’s case records data was performed. The aforementioned patients were examined in the Hospital of Lithuanian University of Health Sciences Kaunas Clinic in 2007–2011. The received data is processed by using Statistical Package for Social Sciences (T-Test). The aim of the study is to evaluate, by using cytogenetic and molecular cytogenetic research methods, the frequency of prenatal trisomies determination of the thirteenth (13), the eighteenth (18), and the twenty first (21) chromosomes for the patients, who during 2007–2011 had genetic consultations in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics and to determine the connection between these trisomies and risk factors. During 2007–2011 1 156 patients were examined and 49 (4.2%) alterations of karyotype were determined, out of which 30 (61%) are related to Down syndrome, 14 (29%) to Edwards syndrome and 5 (10%) to Patau syndrome. After studying the data of questionnaires and case records, on the basis of the statistical reliability of data analysis, the influence of the main reproductive factors (abortions, contraceptives) and other risk or environmental factors (smoking, genetic diseases and use of medicines) to fetal anomalies was determined.

Savižudiškam elgesiui įtakos turintys veiksniai: socialinės-demografinės charakteristikos bei psichikos sutrikimai

Aims and objectives of the study: To collect data on sociodemographicand psychiatric anamnesis and manifestationof psychiatric disorders in suicide attempt survivors.Methodology and materials: The survey took place in Emergency and Psychiatric departments of the Hospital of Lithuanian Universityof Health Sciences Kaunas Clinics and the Psychiatric Hospital division of Republican Hospital of Kaunas from October of 2012 till September of 2013. The survey and the accompanying study were approved by Kaunas regional bioethics committee. The 150 participants of the survey were adult patients who had been admitted to the Emergency department at the Hospital of Lithuanian University of Health Sciences Kaunas Clinics after a suicide attempt. These patients underwent psychiatric assessment and were subsequently hospitalized in either the Psychiatric department of HLUHS Kaunas Clinics or the Psychiatric unit of Kaunas Republican Hospital due to risk of repeated suicide attempts. Patients who agreed to participate in the survey answeredquestions from the survey questionnaire during the first three days following their suicide attempt. Statistical analysis of collecteddata was performed using IBM SPSS Statistics version 19.Results: 150 adult suicide survivors participated in the survey of whom 59.3% (n=81) were women and 40.7% (n=69) were men. Women were more statistically significant than men (p=0.022) in the survey. Division according to age among survey participants was as follows: 18 to 24 y/o – 20.7% (n=43), 25 to 34 y/o – 21.3% (n=32), 35 to 49 y/o – 24.7% (n=37), 50 y/o and older – 25.3% (n=38). According to the percentage, the dominant group was the 18 to 24 year-olds, but differences in distribution among age groups are too small to be statistically significant. Stress-related and neurotic disorders (F40-F49) were diagnosed in 41.3% of participants,alcohol related mental and behavioural disorders (F10) – 24%, affective disorders (F30-F39) – 23.3%, personality disorders(F60-F69) – 20.0%, Schizophrenia and delusional disorders (F20-F29) – 16.7%. Comorbidity of mental disorders was found in 27.3% of participants. Conclusions: there were more women than men among patients who attempted a suicide. The majority of participants had been diagnosed with mental disorders and had attempted suicide in the past. The most popular means of attempted suicide is intentional self-poisoning with prescription medication. Stress-related and neurotic disorders was the dominant diagnosis among participants.

Impedance plethysmography as an alternative method for the diagnosis of peripheral arterial disease

Background and objectiveIn the diagnosis of peripheral artery disease (PAD), the ankle-brachial index (ABI) is considered as the standard, and other noninvasive methods have received too little attention. Therefore, the aim of the study was to determine the diagnostic accuracy of impedance plethysmography in diagnosing PAD and to compare this method with other methods. Materials and methodsA total of 66 patients with a mean age of 76.1±9.6 years who had been treated for various cardiovascular diseases at Kaunas Clinical Hospital during 2011–2012 were enrolled into the study. All the patients were screened for PAD. Impedance plethysmography was performed with a new-generation Niccomo™ device. The receiver operating characteristic analysis was employed to determine the diagnostic accuracy of 4 parameters of impedance plethysmography: crest time (CT), crest width (CW), pulse amplitude (Pampl), and alternating blood flow (ABF). ResultsThere were a significant correlation between the ABI and the CT (r=−0.699, P<0.001), between the ABI and the ABF (r=0.552; P<0.001), and between the ABI and the Pampl only among men (r=0.652; P<0001). No correlation was found between the ABI and the CW. Among all the parameters, the CT had the highest sensitivity and specificity (73.2% and 96.0%, respectively). Other parameters had the following sensitivities and specificities: ABF, 61.0% and 96.0%; and Pampl, 90.0% and 20.0%, respectively. ConclusionsImpedance plethysmography, especially its parameter CT, is an alternative noninvasive method in diagnosing PAD and could be used for the screening of patients with PAD.

Oximetry of the brain

Background. Devices allowing direct assessment of brain tissue oxygenation have showed promising results in clinical studies. However, estimation of brain oximetry still has some challenges. The aim of our study was to estimate the feasibility to monitor cerebral oximetry for neurosurgery patients in the Operating Room and in the Neurosurgery Intensive Care Unit, possible basic disturbances for the study and early results. Materials and methods. The prospective trial took place in a tertiary university setting – the Neurosurgery Department of the Lithuanian University of Health Sciences Hospital (Kaunas Clinics). The monitoring was performed with an INVOS® Cerebral / Somatic Oximeter, which is based on near-infrared spectroscopy. The monitoring places were the Operating Room, later the Neurosurgery Intensive Care Unit and for some patients the regular Neurosurgery Ward. All patients had acute open or closed traumatic brain injury and had undergone neurosurgery. Results. 52 patients were included in the study, while 36 operations were performed after traumatic brain injury with successful monitoring. Preoperatively GCS ranged from 3 to 15 (average 10.2 ± 4.6), all patients had no hypotension ranged from 214 mmHg to 112 mmHg (average 148.0 ± 26.6), the mean arterial pressure ranged from 155 mmHg to 61 mmHg (average 106.0 ± 21.8), only two patients had hypoxia with SpO2 of 86% and 76%, other values averaged 96.7% ± 4.3% . Hemoglobin preoperatively ranged from 162 g/l to 82 g/l (average 133.7 ± 17.9). The va­ lues of cerebral oxygenation preoperatively in the Operating Room were 42–96% (average 74.8 ± 10.8), and one patient with cerebral oxy­ genation of 15% bilaterally before surgery died in 24 hours after the surgery (normal values vary from 58 to 82%). The values varied from to 15–95% in the period of the operation. The biggest difference of cerebral oxygenation between brain hemispheres was registered as 42% and 68% before the intubation, 60% (±8.8) and 76% (±4.0) during the operation, 64% (±4.9) and 80% (±5.3) in the Intensive Care Unit. 13 patients died, 17 were discharged with GCS of 13–15 and 6 patients with GCS of 8–12. Conclusions. Monitoring of regional cerebral oximetry for neurosurgery patients can be performed, despite of its limitations: surgery or application of the Mayfield holder in the frontal region of the head, intra­ operative transcranial Doppler monitoring

Complications of thrombolysis in an intensive care unit

Background. Thrombolysis is often the only way in treating people with life-threatening conditions, like acute myocardial infarction (AMI), pulmonary embolism (PE) and acute ischemic stroke (AIS). Complications of thrombolytic therapy are not rare and have clear influence in the quality of life, hospital stay, outcomes and mortality. Most common complications are intracranial hemorrhage, severe injection site, nose, vaginal bleeding and peripheral hematomas. Methods and materials. A retrospective study took place in the Department of Intensive Care, Hospital of Lithuanian University of Health Sciences Kaunas Clinics. Medical data of 83 patients, who underwent treatment with thrombolytic drugs in the period of 2007–2011, were analyzed. All patients were treated with intravenous infusion of Alteplase. Inclusion criteria were as follows: • AMI, AIS or PE treatable with thrombolytic therapy. Results. 72.3% (n = 60) of patients experienced massive PE, 13.3% (n = 11) AMI and 14.4% (n = 12) AIS. There were 8.43% (n = 7) of patients who had bleeding complications – 2.4% (n = 2) experienced nose bleed during or shortly after thrombolytic therapy, 3.6% (n = 3) had injection site bleeding and 1.2% (n = 1) experienced multiple skin hemorrhages. 11.7% (n = 7) of patients in the group of massive PE were thrombolised during CPR and only one of them experienced bleeding to the pleural cavity. There were no internal or external bleeding observed neither in AMI nor in AIS groups. In-hospital mortality after thrombolytic therapy was 20.5% (n = 17). Conclusions. Thrombolytic therapy very often is the only way in treating acute, life-threatening diseases, like acute myocardial infarction, pulmonary embolism or acute ischemic stroke. Intracranial hemorrhage, injection site, nose, vaginal bleeding and peripheral hematomas are the most common complications of thrombolysis. Risk factors should be evaluated before starting the thrombolytic therapy. Data of our hospital experience do not dramatically differ from worldwide data.

Femoral neck fractures in Lithuania and Sweden. The differences in care and outcome

Hip fractures constitute a serious and common health problem from both individual and public health perspectives. Unified data collection and comparison between countries is recognised as an effective tool for care improvements. However, the variation in patients' demography, treatment methods and other local cultural aspects in different countries should be considered. The aim of our study was to compare femoral neck fracture patients treated in Kaunas and Lund, concerning functional outcome and quality of life. We investigated 99 patients treated by arthroplasty in Kaunas Clinics and 117 patients in Lund University Hospital. Patients were investigated according to the National Swedish Hip Fracture Register model and were followed up for a period of four months after the injury. The patient's place of residence, mobility, complaints of pain and additional hospital stay were recorded. The EQ-5D questionnaire was used to evaluate quality of life. Patients in Kaunas were significantly younger, had lower ASA grade and were more mobile before trauma and at four moths follow-up. However, when comparing quality of life at four months follow-up between the institutions, Lund patients reported significantly better self care, felt less pain and discomfort, and had less symptoms of anxiety and depression. The difference observed in quality of life rating between institutions might be related to local cultures of the countries and should be considered when comparing the data.

Comparison of Ankle-Brachial Index in Patients With and Without Atrial Fibrillation

The aim of this study was to compare the ankle-brachial index between patients with atrial fibrillation (AF) and those without atrial fibrillation. A total of 286 patients admitted to the Departments of Neurology or Cardiology, Kaunas Clinical Hospital, during 2008-2010 and referred for a consultation with an internist and/or a cardiologist were included in this study. All patients had at least one prevalent cardiovascular disorder and were screened for diagnosis of permanent AF based on medical records and electrocardiogram and evaluated for the ankle-brachial index (ABI). Peripheral artery disease (PAD) was defined as an ABI of <0.9 assessed by using a 5-MHz Doppler ultrasound device. The patients with permanent AF had a significantly lower ABI compared with the patients without AF (P<0.001). Binary regression analysis revealed that permanent AF was associated with PAD (OR, 2.5; 95% 1.5-4.2). The likelihood of having an ABI of <0.9 increased with each additional risk factor: AF (OR, 2.2; 95% CI, 1.3-3.8), stroke (OR, 2.3; 95% CI, 1.3-4.2), age of >69 years (OR, 2.4; 95% CI, 1.3-4.7), and myocardial infarction (OR, 2.4; 95% CI, 1.1-5.5). Nearly one-fourth (24.5%) of all patients with an ABI of <0.9 did not report any PAD-specific symptoms. The patients with cardiovascular disorders and permanent atrial fibrillation were found to have a significantly lower mean ankle-brachial index and higher prevalence of peripheral artery disease compared with cardiovascular patients without atrial fibrillation. The patients who were found to have a lower ankle-brachial index and permanent atrial fibrillation were older and often had several cardiovascular diseases (angina pectoris, stroke, myocardial infarction, or hypertension).

Diffusion-weighted magnetic resonance imaging of cervical cancer

Background. Diffusion-weighted magnetic resonance imaging (DW–MRI) has been employed in the diagnostics of malignant tumors of abdomen and pelvis relatively recently. Nowadays, there exists a particular interest in adaptation DW–MRI for assessing the response of tumors to chemoradiaton therapy. The aim of our study was to compare the mean value of the apparent diffusion coefficient (ADC) in a healthy cervix, cancer-affected cervix and a cervix after chemoradiation therapy, as well as to identify the ADC range typical of cervical cancer. Materials and methods. The study enrolled 108 female patients who underwent pelvic MRI in the Lithuanian University of Health Sciences Kaunas Clinics Hospital in 2008–2010. The study group consisted of 65 patients in whom cervical cancer had been clinically suspected and confirmed by biopsy before MRI examination. All these patients underwent pelvic MRI twice: before the chemoradiation therapy and 6 months after the therapy. The control group consisted of 43 patients in whom cervical cancer had been not suspected and MRI was performed because of other pelvic diseases. Results. The mean ADC value of the study group (0.658 ± 0.118 × 10–3 mm2/s) was lower than of the control group (1.171 ± 0.143 × 10–3 mm2/s) (t = 20.315, p = 0.03). The ADC threshold value of 0.945 × 10–3 mm2/s was defined, differentiating the cancer-affected cervical tissue from the normal. The mean ADC value of the patients who responded to chemoradiation therapy (1.111 ± 0.138 × 10–3 mm2/s) increased and in those who did not respond it remained lower (0.733 ± 0.073 × 10–3 mm2/s) (t = 9.518, p = 0.04). The ADC threshold value of 0.830 × 10–3 mm2/s was defined, differentiating the residual tumor tissue from the healthy cervical tissue after chemoradiation therapy. Conclusions. The ADC value in the case of cervical cancer was significantly lower than in the non-affected cervical tissue. The ADC value increases after effective chemoradiation therapy and becomes closer to the coefficient value of non-affected cervical tissue, but still remains lower. The 0.945 × 10–3 mm2/s ADC threshold was detected while differentiating between cancer-affected and normal cervical tissues, while the ADC threshold was 0.830 × 10–3 mm2/s when differentiating between residual tumor tissue and healthy cervical tissue after chemoradiation therapy at a high sensitivity and specificity. Keywords: diffusion-weighted magnetic resonance imaging, apparent diffusion coefficient, cervical cancer, chemoradiation therapy