Comparison of Two Sternal Closure Techniques Based on Risk Factors: A Prospective, Observational Study

Background. Stainless steel wires are still commonly used as a sternum closure technique. However, it can cause fatal complications due to rupture and dehiscence. It was anticipated that the sternal Cable System (Pioneer Surgical Technology Inc., Marquette, MI, USA) could provide a better sternal fixation and reduce the possible complications. Materials and Method. A total of 100 patients (57 male, 43 female) at high risk of dehiscence were included in this prospective observational study. Among those with EuroSCORE value of 4 and above, patients with chronic lung disease, chronic kidney disease, diabetes mellitus, obesity, smoking, body mass index, advanced age, and resurgery were operated in two separate centers. Standard steel wires ( n : 51) used for sternotomy were compared with the sternal cable ( n : 49). Early and late sternal dehiscence rates were compared in the study. The relationship between risk factors causing dehiscence and both methods was assessed statistically. Results. Early dehiscence rates were 6.4% in those closed with a sternal cable ( n : 3) and 11.8% in those closed with a sternal wire ( n : 6) ( p < 0.05 )). In risky patients, body mass index was the most determining parameter in terms of sternum dehiscence risk. Conclusion. In risky patients, we recommend the sternal cable system as a good and reliable closure technique to achieve a more stable and compact sternum.

An unnoticed reason of renal failure: Acute phosphate nephropathy

Acute Phosphate Nephropathy is a clinical and pathological finding characterized by acute and subsequent chronic renal failure following the use of intestinal cleansers containing sodium phosphate. The pathophysiology of Acute Phosphate Nephropathy occurs due to the increase of sodium and water absorption in the proximal tubules due to hypovolemia, and the accumulation of calcium phosphate load in the distal tubules in the collector and distal canals. Renal biopsy findings include acute and chronic tubular damage with tubular and interstitial calcium phosphate deposits. Prevention of Acute Phosphate Nephropathy can be achieved by hydration before and after the use of calcium phosphate in risky patients, minimizing the sodium phosphate dose, and having 12-hour intervals between sodium phosphate applications. In this article, we aimed to present the patients who used sodium phosphate for colonoscopy and developed Acute Phosphate Nephropathy.

T-tube enterostomy in neonates with perforated necrotizing enterocolitis as an alternative option

Background: The use of T tube enterostomy (TTES) as an alternative option for stoma in neonatal emergency is known long time ago.Methods: We introduced T-tube ileostomy as technical innovation in our institution as a way of treatment for intestinal perforation in low birth weight premature neonates.Results: In this study 14 neonates underwent TTES procedures at university-based pediatric surgery and neonatology department. 11 (78.6%) patients treated with TTES, discharged home. Three babies (22.4%) died in postoperative course. One of them developed recurrent severe fulminant NEC ileostomy was created and kept on TPN but died after 2 weeks due to septicaemia. The two others were dysmorphic with metabolic diseases.Conclusions: T tube is effective in selected cases of necrotizing enterocolitis (NEC) because of its simplicity in application and removal. But it could not replace the formal stoma in general, its advantages are saving one more time exposure to surgery in those risky patients, Author recommend the use it in cases of post NEC intestinal perforation and extreme low birth weight neonates.

Improving patient care after a suicide attempt

Objectives: Improving the care that patients receive after a suicide attempt will reduce the risk of a subsequent suicide attempt. We described how care for these patients can be improved and identified the available guidelines. Methods: We reviewed the literature on crisis and aftercare, psychosocial assessment, risk assessment, brief contact interventions, and brief interventions. Results: People who have made a suicide attempt are at increased risk of suicide, and the period immediately after discharge from hospital is particularly risky. Patients require an empathic response at their first point of contact, comprehensive psychosocial assessment, effective discharge planning, rapid and assertive follow-up, and coordinated care in the subsequent months. Conclusions: Empathic and effective care that begins in the emergency department and extends through to community care is imperative. Enough is known about the risks of inadequate care and the key ingredients of effective care to proceed with changes to Australia’s healthcare response to a suicide attempt.

Defensive medicine in the emergency department. The clinicians’ perspective

The overuse of medical services is regarded as a growing problem in Western countries, accounting for up to 30% of all delivered care, and carrying a higher risk of morbidity and mortality. One of the leading drivers toward medical overuse is the so-called defensive medicine, which is commonly defined as ordering of tests, procedures, and visits, or, at variance, avoidance of high-risk patients or procedures, aimed to reduce exposure to malpractice liability. Defensive medicine may increase the amount of care provided to the patients (<em>i.e.</em>, additional tests or therapies), change care or setting of care (<em>i.e.</em>, patients referred to another specialist or another healthcare facility), or impair the optimal care (<em>i.e.</em>, refusing risky patients). Some studies seem to confirm a large utilization of defensive medicine in the emergency departments. This article tries to analyze some key points capable to pave the way to a consistent reduction of defensive medicine, thus defining a hierarchical list of priorities, keeping the patient’s health always at the center of the matter.

Frontline Intensive Chemotherapy Brings Survival Benefit In Young, Risky Patients With Follicular Lymphoma: Pair-Matched Analysis From The Czech Lymphoma Study Group (CLSG) Database

Background Follicular lymphoma (FL) is a disease with very heterogeneous course ranging from the indolent forms to rapidly progressive cases with poor outcome. Optimal therapy in FL patients with high tumor burden is immunochemotherapy (R-CHOP is the most frequent regimen used), followed by maintenance treatment. Data from randomized prospective studies (PRIMA) showed poorer outcome in those with high risk disease in terms of lower CR rate, higher risk of relapse and lower efficacy of maintenance therapy. Data comparing up-front intensive approach in younger fit patients and R-CHOP are limited. Aim To analyze long term results of intensive treatment protocol (R-sequential chemotherapy) in comparison with age, FLIPI and maintenance delivery matched (R-CHOP) controls. Methods Here we analyzed data of 48 prospectively enrolled FL patients who were treated by sequential (R-SQ) chemotherapy with or without up-front autologous stem cell transplant (ASCT) as a part of stratified risk adapted treatment in one institution. For R-SQ regimen were indicated patients<65 years with INT-FLIPI (with at least 2 additional risk factors: bulk and/or elevated B2M>3mg/L and/or thymidine kinase>15 IU/L) or HIGH-FLIPI patients (irrespective of additional risk factors). R-SQ protocol consists of alternating three cycles of etoposide-doxorubicine regimen (PACEBO), one methotrexate-ifosfamide regimen (IVAM), and one cycle of high dose cytarabine regimen (HAM). Remission was consolidated with 6th cycle of chemotherapy (PACEBO) in INT-FLIPI patients (n=22, 46%) or with ASCT with BEAM-200 conditioning (n=26, 54%) in HIGH-FLIPI patients. Maintenance immunotherapy was applied for historical reasons in 24 patients (50%). Controls were randomly selected from the Czech Lymphoma Study Group (CLSG) database from 626 cases with confirmed FL grade I to IIIa, treated with R-CHOP. Pair matching was performed on 1:3 basis, controls were matched by age, FLIPI and rituximab maintenance application. In the end, we analyzed intensive SQ-group (n=44) and standard control R-CHOP-group (n=144). Maintenance therapy was delivered to 24 patients (50%) in R-SQ group and to 72 patients (50%) in R-CHOP-group (P=1.00). Results Median age of SQ-group was 47.6 years compared to 48.7 years in R-CHOP (P=0.44), FLIPI index was equally distributed: INT-FLIPI (43% vs 43%), HIGH-FLIPI (57% vs 57%, P=1.00). Treatment response quality was higher in SQ-group than in R-CHOP-group: CR/CRu 93.8% vs 70%, PR 6.2% vs 23% and SD/PD 0% vs 8% respectively (P=0.01). During the follow-up, (median 3.5 and 6.1 years in R-CHOP and SQ-group respectively, P<0.01) 10 patients (20.8%) relapsed or progressed in the R-SQ-group, and 41 (29%) in the R-CHOP-group (P=0.01). Only two of 48 patients (4.2%) died in the R-SQ-group, whereas twelve (8.7%) died in the R-CHOP-group (P=0.03). Five-year progression-free survival (PFS) was superior in the R-SQ-group with 78.5% (95% CI 0.66-0.91) survival compared to 53.8% (95% CI 0.43-0.65, P=0.005, HR=0.37) in the R-CHOP-group. Five-year overall survival (OS) was 100% in the R-SQ-group and 91.9% (95% CI 0.86-0.97, P=0.027, HR=0.18) in the R-CHOP group. When analyzing patients who received maintenance therapy, we found no difference in OS (P=0.13), but there was still significant difference in 5-year PFS in favor of the R-SQ-arm (88.4% and 58.2%, P=0.034). Conclusions In risky FL patients, intensive front-line therapy brings about 24% advantage in CR rate, about 25% higher 5-year PFS (reduces risk of relapse/progression by 62%) and about 10% advantage in 5-year OS (reduces risk of death by 82%). Maintenance immunotherapy application overshadows OS but not PFS advantage of intensive chemotherapy. Finally, in younger physically fit risky patients, more intensive induction regimen leads to superior disease control a remission duration compared to standard R-CHOP. Acknowledgment Supported by grants: LF-2013-004, IGA NT12193-5/2011 and PRVOUK-27/LF1/1. We would like to thank to all referring physicians: Jan Pirnos (Ceske Budejovice), Katerina Kubackova (FN Motol), Lucie Barsova (Liberec), Petr Kessler (Pelhrimov), Jitka Jakesova (Pribram), Milan Lysy (Usti n. Labem), Jindra Ciberova (Znojmo), Dagmar Adamova (Opava), Milan Matuska (Ostrava), Martin Brejcha (Novy Jicin). Disclosures: Trneny: Roche: Honoraria, Research Funding.