Medicina, Volume 45, Issue 1 (January 2009) – 11 articles

The aim of present study was to evaluate relationships between degree of portal hypertension, severity of the disease, and bleeding status in patients with liver cirrhosis. Patients and methods. All study patients with liver cirrhosis underwent hepatic venous pressure gradient measurements, endoscopy, clinical and biochemical evaluation. Liver function was evaluated according to Child-Turcotte-Pugh (Child’s) scoring system. Patients with decompensated cirrhosis (presence of severe ascites, acute variceal bleeding occurring within 14 days, hepatorenal syndrome, cardiopulmonary disorders, transaminase levels >10 times higher the upper normal limit), active alcohol intake, use of antiviral therapy and/or beta-blockers were excluded from the study.
Results. One hundred twenty-eight patients with liver cirrhosis (male/female, 67/61; mean age, 53.8±12.7 years) were included into the study. Etiology of cirrhosis was viral hepatitis, alcoholic liver disease, cryptogenic and miscellaneous reasons in 57, 49, 14, and 8 patients, respectively. Child’s stages A, B, and C of liver cirrhosis were established in 28 (21.9%), 70 (54.9%), and 30 (23.4%) patients, respectively. The mean hepatic venous pressure gradient significantly differed among patients with different Child’s classes: 13.8±5.3 mm Hg, 17.3±4.6 mm Hg, and 17.7±5.05 mm Hg in Child’s A, B, and C classes, respectively (P=0.003). The mean hepatic venous pressure gradient in patients with grade I, II, and III varices was 14.8±4.5, 16.1±4.3, and 19.3±4.7 mm Hg, respectively (P=0.0001). Since nonbleeders had both small and large esophageal varices, patients with large varices were analyzed separately. The mean hepatic venous pressure gradient in patients with large (grade II and III) varices was significantly higher than that in patients with small (grade I) varices (17.8±4.8 mm Hg vs 14.6±4.8 mm Hg, P=0.007). Thirty-four (26.6%) patients had a history of previous variceal bleeding; all of them had large (20.6% – grade II, and 79.4% – grade III) varices. In patients with large varices, the mean hepatic venous pressure gradient was significantly higher in bleeders than in nonbleeders (18.7±4.7 mm Hg vs 15.9±4.7 mm Hg, P=0.006).
Conclusions. Hepatic venous pressure gradient correlates with severity of liver disease, size of varices, and bleeding status. Among cirrhotics with large esophageal varices, bleeders have a significantly higher hepatic venous pressure gradient than nonbleeders. Hepatic venous pressure gradient measurement is useful in clinical practice selecting cirrhotic patients at the highest risk of variceal bleeding and guiding to specific therapy. Full article

Besides crystalloids, colloids are used for the treatment of hypovolemia and shock. They are high-molecular-weight proteins of bovine origin with properties of more rapid replacement of circulating blood volume. Iso-oncotic character provides the volume effect (»100%) close to the volume intravenously infused with the duration of action for 2–4 hours. Gelatin solutions are excreted with urine and feces in unchanged form without prolonged fixation in organism. Even in case of acute renal failure, gelatin peptides do not accumulate due to increased activity of proteolytic enzymes; therefore, they are the first-choice colloids. Gelatin solutions do not change coagulation as other colloids; just they may cause hemodilution as crystalloids do, so they are safe in case of hemorrhage and thrombocytopenia. There is a decreased risk of bleeding when gelatin solutions are used in surgery as compared with other colloids; in addition, they protect from hypotension due to vasodilatation in epidural or spinal analgesia. Gelatin solutions may cause compensatory hyperemia and increase of cardiac output, cardiac index, myocardial contractility, mean arterial blood pressure, and diuresis; in addition, oxygen delivery to the tissues improves. The dosage depends on clinical condition of a patient, and it is suggested to be 100–2000 mL and even more, for isovolemic hemodilution – 20 mL/kg of body weight. Adverse reactions such as anaphylactoid or anaphylactic to gelatin derivates are rare and similar to other colloids. Full article

Objective. To analyze the dynamics of prevalence and severity of dental caries among 12- and 15-year-old schoolchildren in six regions of Lithuania.
Material and methods. A total of 5910 schoolchildren aged 12 and 15 years were examined. Dental caries was diagnosed according to the criteria of World Health Organization. The prevalence of dental caries was calculated by dividing the number of children with caries by the number of all children examined and expressed as percentage. Severity of dental caries was described by DMF-T index. DMF-T indices of individual persons as well as each age group were determined. Oral hygiene was evaluated by a simplified oral hygiene index. Fluoride concentration in Kretinga was 1.6–2.2 ppm; in the other regions, it varied between 0.2 to 0.4 ppm.
Results. The prevalence of dental caries among 12-year-olds was 88.4% in 1983 and 85.5% in 2005; among 15-year-olds, it was 95.5% and 92.9%, respectively. Mean DMF-T score decreased from 4.5 (in 1983) to 3.7 (in 2005) among 12-year-olds and from 6.4 (in 1983) to 5.6 (in 2005) among 15-year-olds. Oral hygiene index decreased from 1.69 in 1983 to 1.34 in 2005 among 12-year-olds and from 1.46 to 1.22 among 15-year-olds, respectively.
Conclusions. A tendency towards decrease in the prevalence and severity of dental caries was observed, when caries prevention program was running. Correlation between oral hygiene and DMF-T was observed in both age groups. Decreased prevalence and intensity of dental caries among 12- and 15-year-olds were associated with improved oral hygiene, usage of fluoride toothpaste, and fluoride content in drinking water. Full article

The aim of the study was to determine the association between coffee consumption and the risk of type 2 diabetes mellitus.
Material and methods. A case-control study included 234 cases with newly confirmed diagnosis of type 2 diabetes mellitus and 468 controls who were free of the disease in 2001. Cases and controls were matched by gender and age (±5 years). Data on age, education level, occupation status, marital status, family history of diabetes, lifestyle (dietary habits, smoking habits, coffee consumption, alcohol consumption, physical activity), and stress were collected via a questionnaire. Variables were retained in models as confounders when their inclusion changed the value of the OR by more than 10% in any exposure category. Conditional logistic regression to compute the odds ratio (OR), 95% confidence interval (CI), and P for trend was used.
Results. After adjustment for possible confounders (family history of diabetes, body mass index, eating speed, morning exercise, cigarette smoking, years of education, and stress), a statistically significant relationship was observed between type 2 diabetes mellitus and coffee consumption. Individuals consuming four or more cups of coffee per day were at lower risk of 2 diabetes mellitus (OR=0.51; 95% CI, 0.27–0.97) compared to those who consumed one or less than one cup of coffee per day.
Conclusion. Habitual coffee consumption of four or more cups per day might be related to the lower risk of type 2 diabetes mellitus. Full article

Objectives. To collect the data about the consumption of digoxin, evaluate the tendencies towards usage of this drug during 2004–2007, and to find departments, which cover the main part of digoxin consumption in a tertiary hospital. To evaluate the intensity of serum digoxin concentration measurements during 2005–2007.
Material and methods. Our study was carried out in a tertiary hospital with 2600 beds and 63 departments. Consumption of digoxin is expressed in defined daily doses per 100 occupied beds daily during 2004–2007. All serum concentration measurements in 2005–2007 were evaluated.
Results. The main consumers of digoxin in 2007 were the Units of Endocrinology, Pulmonology and Immunology, Cardiology II, Neurosurgical Reanimation and Intensive Care, Neurology, Eye Disorders I, Intensive Care Unit of Cardiology; they consumed 51.05% of total digoxin. In total, 58 digoxin measurements were performed in 2005, 89 in 2006, and 64 in 2007. The intensity of serum concentration measurements for digoxin is 1/147 (one measurement for 147 defined daily doses) in 2005, 1/89 in 2006, and 1/107 in 2007. These results show that intensity of serum digoxin concentration measurements is low.
Conclusions. Twenty-two out of the 63 departments cover 90% of digoxin consumption per year. The changes in digoxin consumption were not statistically significantly different in 2004– 2007. There was a tendency towards an increase in serum digoxin concentration measurements during the 3-year period. Digoxin concentration outside therapeutic ranges was established in about half of all cases in 2005–2006, but there was an increase in normal serum concentration in 2007. Full article

Objective. The aim of the study was to collect the data on incidence rates, pathogens of nosocomial infections, and antimicrobials for treatment of nosocomial infections.
Material and methods. Data were collected between March 2003 and December 2005 in five pediatric intensive care units using a modified patient-based HELICS protocol. Nosocomial infection was identified using the Centers for Disease Control definitions. All patients aged between 1 month and 18 years that stayed in the units for more than 48 hours were eligible for inclusion in this study.
Results. A total of 1239 patient admissions and 7601 patient-days were evaluated. In 169 children (13.6%), 186 nosocomial infections occurred. The incidence density was 24.5 per 1000 patient-days, the incidence rate – 15.0 per 100 admissions. The highest incidence density was observed in the 6–12-year age group (31.2 per 1000 bed-days). Nosocomial infection rates per 1000 device-days were 28.8 for ventilator-associated pneumonia, 7.7 – for bloodstream infection, and 3.4 – for urinary tract infection. The most common site of infection was respiratory tract (58.8%). Secondary bacteremia developed in 18 (10.6%) patients. Haemophilus influenzae (20.1%), Acinetobacter spp. (14.2%), and Staphylococcus aureus (17.6%) were the most frequently isolated microorganisms. The most common antimicrobials used were first- and second-generation cephalosporins 74 (31.0%) and broad-spectrum penicillins 70 (29.3%).
Conclusions. In Lithuanian pediatric intensive care units, the incidence rates of nosocomial infections were comparable to the available data from other countries, except for the ventilatorassociated pneumonia rate, which was relatively high. H. influenzae, Acinetobacter spp., and S. aureus were the most prevalent pathogens. The first- and second-generation cephalosporins and broad-spectrum penicillins were the most common antimicrobials in the treatment of nosocomial infections Full article

Background. Cerebral cavernous angiomas remain as one of the most negotiable and controversial topics in neurological and neurosurgical practice. We present statistical evaluation of initial presentation, preoperative neurological findings, surgical complications, and outcome of surgically treated patients with intracerebral cavernous angiomas.
Methods. During 1997 to 2004, 87 patients (41 men, 46 women) with intracerebral cavernous angiomas underwent surgical treatment in the tertiary referral center, and these were included into the present uncontrolled clinical study. The mean age of the patients at the time of operation was 42.4 years, and the mean duration of illness was 120.5 days. All patients underwent preoperative magnetic resonance imaging, and pre- and postoperative clinical examination. The clinical course was documented using the Karnofski performance scale. A simplified version of Engel’s classification of the outcome of the patients with chronic seizures was applied.
Results. The most common clinical presentation of cavernous angiomas was seizures, significant part of which was chronic. No association was found between lesion location by cerebral lobes and clinical presentation by seizures. No significant differences in the likelihood of presenting with hemorrhage between supratentorial and subtentorial lesions were detected. In addition, no associations were found between size of cavernoma and the initial presentation of cavernoma by an extralesional hemorrhage or chronic seizures. In the group of patients presenting with headache, sporadic seizures, or intracerebral hemorrhage, good postoperative outcome was achieved in 83% of the patients. Of the patients who underwent operation for seizure control, significant seizure reduction or elimination after surgery was observed in 79% of the patients.
Conclusions. Microsurgical removal of cavernous angiomas and surrounding hemosiderin plate tends to significant reduction or elimination of epileptic seizures and improved postoperative neurological status. Full article

Aim of the study. To determine the associations between the source of infection and antibiotic resistance in patients with Pseudomonas aeruginosa bacteremia.
Material and methods. A retrospective analysis of 50 patients with Pseudomonas aeruginosa bacteremia was carried out. If sepsis was suspected, blood culture was incubated in an automatic system BACTEC 9240. Then bacteria were identified, and their antibiotic resistance was estimated by disc diffusion method. If Pseudomonas aeruginosa strains were resistant to three or more antibiotics, they were considered as multidrug-resistant.
Results. The origin of bacteremia was confirmed in 33 (66%) patients. Lower respiratory tract was the predominant source of Pseudomonas aeruginosa bacteremia (81.8%, n=27) as compared with infection of wound (39.4%, n=13), urinary tract (15.2%, n=5), and drain or cerebrospinal fluid (9.1%, n=3) (P<0.05). Eighteen percent (n=9) of strains, which caused bacteremia, were resistant to ceftazidime; 38% (n=19), to piperacillin; 22% (n=11), to imipenem; 26% (n=13), to meropenem; 24% (n=12), to ciprofloxacin; 40% (n=20), to gentamicin; and only 8% (n=4), to amikacin. Multidrug-resistant Pseudomonas aeruginosa strains were more frequently isolated if a source of infection was wound comparing to a source of other localization (61.5%, n=8 and 20.0%, n=4, respectively; P<0.05). Resistance of Pseudomonas aeruginosa strains to imipenem was associated with resistance to ciprofloxacin (13.2%, n=5 and 50.0%, n=6, retrospectively; P<0.05), but resistance to meropenem – both to ciprofloxacin and amikacin.
Conclusions. The predominant source of Pseudomonas aeruginosa bacteremia was lower respiratory tract, and multidrug-resistant strains caused bacteremia more frequently if a source infection was wound. Pseudomonas aeruginosa resistance to carbapenems was associated with resistance to ciprofloxacin and resistance to meropenem – also to amikacin. Resistance of strains to ceftazidime and piperacillin was associated with resistance to gentamicin. Full article

Hands actively participate in daily activities of a human; therefore, hands are the most vulnerable parts of the human body. People injure hands so often because namely hands are in the closest position to the dangerous equipment. According to the data of various authors, the injuries of hands and fingers make even 30–75% of all industrial traumas, and burns of hands account for about 6% of all traumas of hands. The aim of the study was to compare the effectiveness of active surgical treatment method with conservative treatment method, applied for the treatment of deep dermal partial skin thickness burns of the hands, wrists, and forearms of distal third.
Materials and methods. A total of 49 patients with burned hands participated in the perspective study of random sample (totally 79 hands). All these patients were treated in the Department of Plastic and Reconstructive Surgery, Hospital of Kaunas University of Medicine, during the period of 2001–2005. The patients were assessed after 3, 6, and 12 months.
Results. Applying conservative method of treatment of deep partial skin thickness burns, the frequency of infectious complications was increased. In order to evaluate the state of scar, we applied the scale of Vancouver and analyzed the pigmentation of a scar, its height, flexibility, and color. After statistical analysis had been performed, we determined that more changes of skin were seen in the group, which received active surgical treatment (P<0.05).
Conclusions. Statistically significantly fewer complications were in the group of active surgical treatment in the early (fewer infectious complications, smaller area of unnaturalized autograft) and in the late (scars were less rough, with less changes of pigmentation) postoperative periods Full article

Objective. Noninvasive diagnosis of coronary artery disease in patients with left bundle branch block is challenging. Multislice computed tomography can be useful in this population; however, quality of images depends on the patterns of myocardial contractions. We investigated the influence of left bundle branch block on image quality of multislice computed tomography coronary angiography.
Materials and methods. Multislice computed tomography coronary angiography was performed in 30 patients with left bundle branch block and 30 patients without conduction disturbances. Image quality of each coronary segment was visually assessed and rated on a five-point scale (1=highest quality).
Results. Average image quality score in the best cardiac cycle phase did not differ significantly between groups (1.71±0.59 in the left bundle branch block group vs. 1.60±0.57 in the control group, P=0.46). In the left bundle branch block group, a significantly lower image quality score was observed in end-systolic cardiac phase (2.67±0.6 vs. 2.22±0.65 in the control group, P=0.007), whereas no difference was demonstrated in mid-diastolic phase (1.73±0.6 vs. 1.69±0.66 in the control group, P=0.81). After image assessment in multiple cardiac phases, an increase in image quality score was higher in the left bundle branch block than in the control group (0.2±0.17 vs. 0.11±0.14, P=0.003). A negative correlation was observed between image quality score and both the heart rate and heart rate variability in both groups (P<0.001).
Conclusion. A nonsignificantly lower overall image quality of multislice computed tomography coronary angiography was demonstrated in the left bundle branch block group. In the presence of left bundle branch block, image quality in the end-systolic phase was significantly lower. Image assessment in multiple phases increased overall image quality and is therefore advisable in patients with left bundle branch block. Increased heart rate and heart rate variability worsened image quality in both groups. Full article

The aim of the study was to evaluate growth pattern of small- and appropriate-for-gestationalage children and to identify prenatal and postnatal risk factors for short stature and development of components of metabolic syndrome. A total of 109 small- and 239 appropriate-for-gestational-age infants were enrolled in the study. Within 24 hours after birth and at 2, 5, 9, 12, 18, 24 months, and 6 years of age, anthropometric data were recorded for study children. Cord blood samples from study infants were collected, and insulin-like growth factor-1 (IGF), IGF-binding protein-3, and leptin levels were measured. Birth weight and height (P<0.001) and insulin-like growth factor-1, IGF-binding protein-3, and leptin levels (P<0.05) were lower in children born small for gestational age vs. children born appropriate for gestational age. At 2, 5, 12, 18, and 24 months and 6 years of age, children born small for gestational age remained shorter and weighed less (P<0.001). Waist-to-hip ratio, heart rate at 6 years of age and gain in body mass index from birth up to 6 years of age was higher in children born small for gestational age. Height gain during the first year of life was mainly influenced by birth length and target height. Maternal weight before pregnancy and cord leptin levels were the most significant factors influencing postnatal weight gain during the first years of life.
Conclusions. During the first 6 years of life, children born small for gestational age remained shorter and lighter. A greater catch-up in body mass index and tendency towards central pattern of fat distribution during the first years of life might be predisposing factors for the development of long-term metabolic complications in these individuals. Full article