Medicina, Volume 43, Issue 11 (November 2007) – 11 articles

Objectives. To determine the threshold values of Pediatric Index of Mortality 2 (PIM 2) score, Pediatric Trauma Score (PTS), and Glasgow Coma Scale (GCS) score for mortality in children after severe head injury and to evaluate changes in outcomes of children after severe head injury on discharge and after 6 months.
Material and methods. All children with severe head injury admitted to the Pediatric Intensive Care Unit of Kaunas University of Medicine Hospital, Lithuania, from January 2004 to June 2006 were prospectively included in the study. The severity of head injury was categorized according to the GCS score ≤8. As initial assessment tools, the PTS, postresuscitation GCS, and PIM 2 scores were calculated for each patient. Outcome was assessed according to Glasgow Outcome Scale on discharge and after 6 months.
Results. The study population consisted of 59 children with severe head injury. The group consisted of 37 (62.7%) boys and 22(37.3%) girls; the mean age was 10.6±6.02. The mean GCS, PTS, and PIM 2 scores were 5.9±1.8, 4.8±2.7, and 14.0±19.5, respectively. In terms of overall outcome, 46 (78.0%) patients survived and 13 (22.0%) died. All three scales appeared to be significant predictors of death. Threshold values for which potential mortality in children after severe head injury increased were 10.75 for PIM 2, 3 for PTS and 5 for GCS. PIM 2 score provided the best discrimination between survivors and nonsurvivors.
Conclusions. The threshold values for mortality in children after severe head trauma were PIM 2≥10.75%, PTS≤3 and GCS≤5, and these values were significant risk factors of death in severely head injured children. The changes in outcome for survivals on discharge and after 6 months were statistically significant. Full article

Ventral hernia is a common problem in general surgery practice. Incisional hernia can develop in 15–25% of patients after abdominal surgery. The aim of this study was to compare two different methods of incisional hernia surgery.
Materials and methods. A retrospective analysis of database of surgery department from 1997 to 2000 was performed. All patients were divided into two groups. The first group patients were operated using open suture repair (keel technique); the second group patients – using open mesh repair (onlay technique). Long-term follow-up was done by a mail questionnaire. A special questionnaire was sent to all patients. Postoperative evaluation included pain and discomfort in the abdomen, physical activity, and recurrence rate after operation. Statistical evaluation was conduced using descriptive analysis: the unpaired Student t test to compare parametric criterions between two study groups, Mann-Whitney U test to compare the unpaired nonparametric criterions between two study groups, and _X² test to investigate nonparametric criterions between these groups.
Results. A total of 202 patients (51 males, 151 females) with incisional hernia were operated during 1997–2000. One hundred seventy-one patients were in the keel technique group, and 31 patients in the onlay technique group. There were no significantly differences in age and sex between these groups. The hospitalization time was significantly longer in the open mesh repair group. The postoperative complication (wound seroma and suppuration) rate was significantly higher in the onlay technique group. One hundred sixty-one patients (79.7%) answered the questionnaire (133 in the keel technique group, 28 the in onlay technique group). The patients’ return to physical activity after surgery was significantly longer in the keel technique group. Forty-one patients (31%) had hernia recurrence in the keel technique group and 3 patients (11%) in the onlay technique group (P<0.05). There were no postoperative deaths in both groups.
Conclusions. The rates of postoperative therapeutic complications and hernia recurrence are significantly lower after open mesh repair surgery. Return to normal physical activity after surgery is significantly longer after open suture repair surgery. Full article

The aim of this study was to evaluate the need of the elderly for outpatient nursing and social services in Kaunas district.
Material and methods. The object of the study was elderly people (aged 65 years and more) living in Kaunas district. A questionnaire was used for interviewing. The sample was randomly selected from the lists of people registered at the primary health care centers (including outpatient departments and medical aid centers). A total of 390 inhabitants were investigated who represent all the elderly of Kaunas district. The independence of the respondents was evaluated by the standard tests (the Barthel Index and Mini-Mental State Examination).
Results. The respondents reported that 71.3% of them needed nursing and 58.2% social services. The need for the services was higher in older age group. The rural elderly reported higher need for social services (64.3%) than the urban elderly (49.6%). Less than half (45.9%) of respondents referred having problems visiting the general practitioner. Majority of the respondents (86.4%) pointed out that those who took care of them had no special medical training. Totally or almost totally dependent respondents (groups by Barthel Index) needed social (88.0%) and nursing (96.0%) services. Majority of respondents (79.2%) preferred to be cared at home.
Conclusions. More than half of the elderly needed both nursing and social services. The need for social services differently from nursing services was influenced by the living place of the respondents; the rural elderly needed services more than the urban elderly. Full article

Object. To determine the prevalence and incidence of Staphylococcus aureus strains among preschool- and school-aged pupils and susceptibility of these strains to antimicrobial materials.
Material and methods. A study of 243 preschool- and 300 school-aged pupils was conducted during 2003– 2004. Identification of Staphylococcus aureus was made with plasmacoagulase and DNase tests. The resistance of Staphylococcus aureus to antibiotics, b-lactamase activity, phagotypes, and phage groups were determined. The isolated Staphylococcus aureus strains were tested for resistance to methicillin by performing disc diffusion method using commercial discs (Oxoid) (methicillin 5 mg per disk and oxacillin 1 mg per disk).
Results. A total of 292 (53.8%) Staphylococcus aureus strains were isolated and identified (113 (46.5%) from preschool- and 179 (59.7%) from school-aged pupils). The prevalence of Staphylococcus aureus strains among preschool-aged pupils varied from 46.5% to 47%. It increased to 59.0% (P>0.05) among schoolchildren aged from 11 to 15 years and to 73.0% (P<0.001) among schoolchildren aged from 16 to 19 years. Six methicillinresistant Staphylococcus aureus strains were isolated: two (1.8%) of them were from preschool-aged and four (2.2%) from school-aged pupils. The prevalence of Staphylococcus aureus strains with b-lactamase activity increased from 70.7 to 76.6% in preschool-aged pupils, and it varied from 72.0 to 79.0% in school-aged pupils (P>0.05). Staphylococcus aureus strains of phage group II (32.2–43.4%) were prevailing; nontypable Staphylococcus aureus strains made up 19.2–33.6%.
Conclusions. The prevalence of Staphylococcus aureus among preschool-aged children is 41.7 to 48.8%, and it increases among 9th–12th-grade pupils (73.0%, P<0.001). Some Staphylococcus aureus strains (2.1%) were resistant to methicillin. Staphylococcus aureus strains of phage group II (39.0%, P<0.05) are most prevalent among preschool- and school-aged pupils. Pupils were colonized with methicillin-resistant Staphylococcus aureus strains belonging to phage group III phagotype 83A and 77. Full article

Background. Various diagnostic utilities have been used in the diagnosis of strangulated obstruction. Despite this, there is no simple and reliable marker for it, and diagnosis in most cases is based on clinical, laboratory, and radiological investigations. The purpose of the present study was to assess D-dimer value in the diagnosis of strangulated obstruction.
Methods. A prospective study of 53 patients with small-bowel obstruction was conducted. Strangulated obstruction was present in 15 (28.3%) patients. Eight (53%) had intestinal necrosis, while 7 (47%) reversible ischemia. The blood samples were taken and analyzed with NycoCard Reader method with monoclonal antibodies specific for D-dimer neoantigens.
Results. In the presence of intestinal necrosis, there was a higher D-dimer level found than in the cases with reversible ischemia or simple small-bowel obstruction, although this difference did not reach statistically significant level. The D-dimer test had a sensitivity of 60%, specificity of 68%, positive predictive value of 43%, and negative predictive value of 81% in diagnosing strangulated obstruction.
Conclusion. In present series, D-dimer test was neither sensitive nor specific in diagnosing strangulation. Full article

Our purpose was to evaluate the relevance of repeat laterally directed sextant prostate biopsy for detection of prostate cancer in high-risk patients.
Material and methods. Our study included 195 men at high risk for prostate cancer (elevated prostatespecific antigen level and/or abnormal prostate detected by digital rectal examination). We consulted the patients in outpatient department of Kaunas University of Medicine Hospital during 2003–2007. We performed transrectal ultrasound-guided laterally directed sextant prostate biopsy in every patient. For the patients with benign histological findings and increased risk of prostate cancer, laterally directed sextant biopsies were repeated.
Results. Prostate cancer was detected in 30.3% of patients (59/195) on the first prostate biopsy, in 13.1% (11/84) on the second prostate biopsy, in 10.3% (4/39) on the third, and in 7.7% (1/13) on the forth biopsy. After all biopsies, prostate cancer was detected in 38.5% (75/195) of patients, and it differed significantly from the percentage of prostate cancer cases detected on the first biopsy (30.3%, P=0.04). We detected 78.7% (59/75) of all prostate cancer cases by the first laterally directed sextant prostate biopsy. The rest 21.3% (16/75) of cases we detected by repeat biopsies. The second laterally directed sextant prostate biopsy revealed additional 14.6% (n=11) of prostate cancer cases and increased the detection of prostate cancer to 93.3% (70/75). At the time of the first prostate biopsy, prostate cancer was diagnosed most frequently when patients had both risk factors: elevated prostate-specific antigen level and abnormal digital prostate examination; prostate cancer was diagnosed in 45.3% of these patients. The odds ratio to detect prostate cancer by the first biopsy in patients with elevated prostate-specific antigen level and abnormal digital prostate examination was 3.7, and odds ratio to detect prostate cancer by repeat biopsies was 4.7.
Conclusions. Repeat ultrasound-guided laterally directed sextant prostate biopsies reveal more cases of prostate cancer as compared to the first prostate biopsy. The majority of prostate cancer cases (93.3%) are detected by the first and second laterally directed sextant prostate biopsies. After the first negative prostate biopsy, we recommend to repeat prostate biopsy in high-risk patients. Full article

Cross-cultural tests and research instruments are broadly used to adapt questionnaires developed in different countries and cultures. The Nursing Outcomes Classification (NOC) – a comprehensive, standardized classification of patient outcomes – can be used to evaluate the results of nursing interventions.
Objective. To develop and test psychometrically the Lithuanian version of the Nursing Outcomes Classification Use Survey.
Material and methods. A Lithuanian version of the Nursing Outcomes Classification Use Survey was developed following traditional methodological procedures of research instrument translation and adaptation. The newly developed instrument was tested with a sample of 70 staff nurses from nursing and supportive care hospitals. The content and practical feasibility of the Lithuanian version of NOC was measured for its reliability and validity. Psychometric analysis was conducted with the statistical package SPSS 13.0 for Windows.
Results revealed a successful translation of NOC from English to Lithuanian with validity and acceptability of a shortened Lithuanian version (244 items instead of the original 330 items). Satisfactory internal consistency (Cronbach alpha >0.80 in 18 classes and in 6 classes out of 28 Cronbach alpha between 0.70 and 0.80) was defined, and stability in time was very good with a 7-day break between repeated translations (Spearman- Brown coefficient for the whole instrument was 0.806, ranging from 0.707 to 0.970). The majority of items in the Lithuanian version correlated with measurement class (correlation coefficients >0.40).
Conclusions. The Lithuanian version of Nursing Outcomes Classification Use Survey is a reliable, valid, and applicable to outcome identification in clinical practice and nursing research. Future research and further evaluation of the newly developed Lithuanian version of NOC is suggested. Full article

Background. Cervical pregnancy is a rare form of ectopic pregnancy, and the most effective method of its treatment is still under investigation. We would like to call attention to selective uterine artery embolization as an effective modern treatment method.
Case. A patient with suspected cervical pregnancy and 7-week amenorrhea was admitted to the hospital after unsuccessful use of emergency contraception. Transvaginal ultrasound showed gestational sack located 11 mm from the external cervical os. Crown-rump length was 11.2 cm, and the fetal heartbeat was present. The level of serum chorionic gonadotropin was 31 930 U/L. Treatment with systemic methotrexate was unsuccessful, and unilateral uterine artery embolization was performed followed by dilatation and curettage of the cervical canal. Three days after the procedure, sonographic examination showed contracted cervical canal. After a period of two months, normal uterine artery flow was registered by Doppler ultrasonography on both sides.
Conclusion. Uterine artery embolization in case of cervical pregnancy reduces the risk of bleeding and can be the method of choice when treatment with methotrexate fails. Unilateral embolization is effective when angiography shows unequal disposition of the arterial connections supplying the embryo. Full article

The case of rear complicated homozygous hypercholesterolemia treated by a direct adsorption of lipoprotein apheresis procedure is presented in this article. In total, 30 sessions of direct adsorption of lipoprotein apheresis were performed on a 14–16-year-old patient from June 2004 to December 2006. Blood flow rate was 30–70 mL/min. Central and ulnar veins were punctured. Lipid levels were measured before and after lipid apheresis during each session throughout the study period. The mean decrease in total cholesterol level was 26.4–71.2% compared to baseline, low-density lipoprotein cholesterol – 31.9–72.2%, lipoprotein (a) – 56.6–90.9%, apolipoprotein B – 26.4–60.0%. Clinical procedures were completely uneventful. The last 26 sessions were performed in a day unit. Full article

The high morbidity and mortality in patients with serious heart failure is a therapeutic challenge for current medicine. The leading cause of left ventricular dysfunction remains ischemic heart disease. Coronary artery bypass surgery is a treatment of choice in moderate-to-severe ischemic cardiomyopathy. The scarcity of completed prospective randomized clinical trials and high surgical risks create significant uncertainty concerning the optimal current treatment strategy. The role of imaging techniques of assessment for myocardial viability based on current guidelines may be very important in clinical decision-making. Present paper reviews some of the relevant literature concerning surgical treatment of ischemic cardiomyopathy and current evidence-based recommendations on this method of treatment. In advanced heart failure, coronary revascularization alone is an insufficient treatment modality. In the presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be considered at coronary artery bypass grafting surgery. One of the most common mechanisms of ischemic mitral regurgitation is Carpentier’s type IIIb dysfunction, in which an undersized mitral anuloplasty might be helpful. Surgery of left ventricular shape and volume restoration leads to improvement of left ventricular function in patients with ischemic cardiomyopathy. When the results from three ongoing prospective randomized studies – the Surgical Treatment for Ischemic Heart Disease trial, Heart Failure Revascularization trial, the PET and Recovery Following Revascularization-2 trial – determining outcome of revascularization versus medical therapy are available, clinicians will have reliable data for making decisions concerning the optimum treatment strategy. At present, the choice of management still remains based on the data obtained from available retrospective trials or the state of art in the field. Full article

Objectives. The aim of this study was to investigate the prevalence of erectile dysfunction, its severity, and other sexual function domains in hypertensive and normotensive Qatari’s men and to estimate the association between hypertension and predictors of erectile dysfunction.
Material and methods. A matched case-control study was conducted at the primary health care clinics during a period from May to October 2006. Four hundred twenty-five hypertensive patients and 425 age-matched normotensive attendants of primary health care clinics, aged 30– 75 years, were approached for the study. Of them, 296 hypertensive participants (74%) and 298 normotensive men (70.1%) gave their consent to participate in it. The mean age of the hypertensive participants was 54.8±11.5 years as compared to nonhypertensive participants with a mean age of 54.5±12.1 years. Face-to-face interviews were based on a questionnaire that included variables on age, sociodemographic status, educational level, occupation, cigarette smoking, and blood pressure. Hypertension was defined as mild for systolic blood pressure (SBP) 120–139 mmHg and diastolic blood pressure (DBP) 80–89 mmHg; moderate for SBP 140–159 mmHg and DBP 90–99 mmHg; and severe for SBP >160 mmHg and DBP >100 mmHg. All patients completed a detailed questionnaire addressing their general medical history, with special emphasis on hypertension (i.e., duration of hypertension, type of treatment, and presence of any complications). Sexual function was evaluated with the International Index of Erectile Function (IIEF).
Results. Of the 296 hypertensive patients, 196 participants reported erectile dysfunction (66.2%), while among the 298 nonhypertensive participants, only 71 had erectile dysfunction (23.8%). Of the hypertensive participants studied, 25% had severe, 29.1% had moderate, and 12.1% had mild erectile dysfunction. The percentages of various sexual activity domains were highly significant and at higher risk among hypertensive patients than normotensive men (P<0.001). Frequency and severity of erectile dysfunction increased with advancing age.
Conclusions. Our results have shown that the prevalence of erectile dysfunction was significantly higher in Qatari hypertensive men than in normotensive men. Age, level of education, diabetes mellitus, occupation, and duration of hypertension were considered statistically significant predictors of erectile dysfunction. Erectile dysfunction was more common in hypertensive individuals receiving antihypertensive treatment. Full article