Medicina, Volume 45, Issue 8 (August 2009) – 10 articles

Objectives. To evaluate if the quality of services provided by family physicians and obstetricians/gynecologists at primary personal health care institutions of Kaunas city and access to it meet the needs and expectations of pregnant women.
Material and methods. Pregnant women visiting the selected health care institutions at their third trimester of pregnancy were asked to fill in the anonymous questionnaire. The study was conducted at two randomly selected maternity centers of Kaunas city and two family practices of Kaunas city where antenatal care was provided by family physicians. The questionnaires were given to 106 patients visiting family physicians (response rate was 88.7%) and to 202 patients visiting obstetricians/ gynecologists (response rate was 81.7%).
Results. Health services provided by family physicians and obstetricians/gynecologists met the expectations of pregnant women in respect of providing with information and communication. The patients of obstetricians/gynecologists significantly more often stated that they were very satisfied with patient-physician communication (P<0.05), they significantly more often understood explanations given by the physician (P<0.001) and claimed having sufficient knowledge about pregnancy (P<0.05), while the patients of family physicians significantly more often asserted that the physician helped them in preparation for childbirth (P<0.05). The patients of obstetricians/gynecologists significantly more often did not face any problems with access to services as compared to the patients of family physicians (z=3.0). Most of pregnant women stated that they were satisfied or very satisfied with the quality of health care at the health care facility providing them with antenatal care irrespective of the physician’s specialty.
Conclusions. The quality of antenatal health care provided by both family physicians and obstetricians/gynecologists and access to it satisfied the needs and expectations of the surveyed women. Correction of the limitations noticed, e.g., closer communication, more understandable explanations, more attention to preparation for childbirth, better work planning, could improve the quality of antenatal care provided by the family physicians. Full article

Ultrasound-guided transperineal prostate brachytherapy is now widely used modality in the treatment of prostate cancer. The overall prostate-specific antigen (PSA) progression-free survival at 10 years is 80–90% for low-risk patients. The results of long-term follow-up have showed better biochemical diseasefree survival after I-125 and Pd-103 brachytherapy than after conventional external-beam radiotherapy and similar survival after radical prostatectomy. The most commonly reported dosimetric quantifiers include D90 (the dose that covers 90% of the prostate volume outlined on postimplant computed tomography images) and V100 (the fractional volume of the prostate that receives 100% of prescription dose). The biochemical diseasefree survival correlates with the dose. In low-risk patients, achieving a D90 dose of 140–160 Gy might be adequate for prostate-specific antigen control. However, high-risk disease might require a D90 dose higher than 200 Gy. In the immediate posttreatment period, the most common complication is acute urinary retention. Urinary symptoms such as frequency, nocturia, and dysuria occur commonly and are documented in about 80% of patients complaining of symptoms 2–3 months after treatment. Late urinary complications of brachytherapy include urethral stricture and incontinence. Incontinence is rare and mainly occurs in patients who had transurethral resection of the prostate either prior or after brachytherapy. Rectal complications (proctitis, rectal bleeding) are rare after prostate brachytherapy. Brachytherapy like external-beam radiotherapy but 50–85%, and most patients’ sexual quality and function are preserved. Since July 2007, the real-time I-125 prostate brachytherapy has been started in Lithuania and Baltic countries at the Hospital of Kaunas University of Medicine. A total of 150 low-risk patients (≤T2a, Gleason ≤6, PSA ≤10) were treated by this method. Permanent prostate brachytherapy is an appropriate method for standard treatment of localized prostate cancer. Full article

Objective. To evaluate the functional outcome and pain control in patients after resection of humeral metastases.
Material and methods. A prospective randomized study of 24 cases of metastatic disease of the humerus with an associated pathologic fracture was carried out. The selected cases were divided into two groups based on the using methylmethacrylate cement for fracture fixation. Group 1 (n=12) included all cases in which the fracture was treated with bone cement augmentation. Group 2 (n=12) included all cases in which the fracture was treated without bone cement augmentation. Functional outcome was evaluated according to the American Musculoskeletal Tumor Society system.
Results. Good and excellent pain control was achieved in 95% of cases in both groups. Functional outcome after resection of humeral metastases and pathological fracture fixation was significantly better in Group 1. Total function in five patients (45%) accounted for 86% and in three patients (25%) for 83% of full normal upper extremity function, whereas in Group 2, total function in six patients (50%) accounted for 70% and in three patients (25%) for 83% of full normal upper extremity function. The rate of fixation failure was significantly greater in Group 2, where fixation instability was observed in 50% (n=6) of cases (P=0.03). There were no significant differences in complication rate (in 50% of cases, mechanical instability occurred after fixation with intramedullary nail and in 50% of cases after fixation with plates).
Conclusions. The introduction of bone cement as an adjunct to fixation of pathologic fracture improved clinical results and reduced the rate of fixation failure. Full article

Background. We evaluated efficacy and safety of recombinant granulocyte-colony stimulating factor (rGCSF) used as primary prophylaxis to prevent neutropenia and neutropenia-related complications induced by docetaxel and doxorubicin chemotherapy in patients with metastatic breast cancer.
Patients and methods. Three centers in Lithuania enrolled 36 patients who received rGCSF (5 μg/kg/d) on day 2 of each 21-day chemotherapy with docetaxel 75 mg/m2 and doxorubicin 50 mg/m2 (AT) starting in the first cycle. Treatment regimen was repeated for up to six cycles.
Results. Leukocytosis, bone pain, and headache were the most frequent adverse events, with incidence rates of 22%, 19%, and 8%, respectively. Adverse events were typical for rGCSF in this patient population. Overall incidence rate of febrile neutropenia was 14%. The mean duration of febrile neutropenia episodes across cycles was 2.14 days. Incidence of chemotherapy delay was 2%. There was no reduction in chemotherapy dose due to expected toxicity or side effects. Intravenous antibiotics for the treatment of febrile neutropenia were needed in 19% of cases. Quality-of-life assessment shows a significant improvement in emotional functioning and a significant decrease in pain score. The efficacy profile of rGCSF observed in the present study was comparable with that of other rGCSF products previously described in the published scientific literature.
Conclusions. The primary prophylaxis of neutropenia and its complications by rGCSF was safe and effective for women with metastatic breast cancer who received chemotherapy with docetaxel and doxorubicin. Full article

Chronic ischemic left ventricular dysfunction is present in number of clinical syndromes in which myocardial revascularization results in an improvement of left ventricular function, patients’ functional class, and their survival. Coronary arteriography is of limited value in diagnosis of viability. Noninvasive testing, traditionally nuclear imaging, stress echocardiography and (stress) electrocardiography have been the clinical mainstays for assessing myocardial viability as well as to detect myocardial ischemia. However, cardiovascular magnetic resonance is a rapidly emerging noninvasive imaging technique, providing high-resolution images of the heart in any desired plane and without radiation. Rather than a single technique, cardiovascular magnetic resonance consists of several techniques that can be performed separately or in various combinations during a patient examination. Whereas, no single cardiovascular magnetic resonance technique has a perfect, or near perfect, sensitivity and specificity, therefore, a combination of various cardiovascular magnetic resonance techniques are needed for the assessment of myocardial viability. The aim of this review article is to summarize our current understanding of the concept of myocardial viability, to discuss the clinical value of cardiovascular magnetic resonance (in particular the different cardiovascular magnetic resonance techniques to assess viability) for the evaluation of patients with coronary artery disease and chronic left ventricular dysfunction and to present the current place of cardiovascular magnetic resonance among other techniques for the assessment of viable myocardium. Full article

Willow (Salix L.) species are widely spread in Lithuanian natural dendroflora. Willow bark contains active substances known for anti-inflammatory properties and is known as a phytotherapeutic precursor of aspirin. Bark extracts are components of analgesic and antirheumatic preparations. Therapeutic effectiveness is associated with salicin (2-(hydroxymethyl) phenyl-β-D-glucopyranoside), which turns into salicylic acid. Increasing attention to natural preparations gives primary importance to research of plants. This study focused on 12 willow taxa and employed routine pharmacopoeia methods. High-performance liquid chromatography method was applied for the analysis of bark extractions. The investigation revealed that not all willow species accumulated a therapeutically sufficient amount of salicin. Bark samples were investigated after 1- and 2-year growth in autumn and spring. Salicin content ranged from 0.08 to 12.6%. Higher contents of active materials were determined in autumn and in 2-year-old willows. Certain willow taxa (Salix alba L., Salix mollissima L., Salix triandra L., Salix viminalis “Americana”, Salix dasyclados L.) possessed extremely low salicin amounts. In the second year, analysis covered 32 willow species. Results indicated striking differences in salicin amounts (from 0.04% in Salix viminalis “Americana” to 12.06% in Salix acutifolia). Willow species, plant age, and season should be considered when collecting medicinal plant material. The amount of salicylates in 2-year-old willow bark collected in autumn exceeded by 25% that in 1-year-old willow bark collected in spring. Bark of some analyzed willow species contained the amount of salicylates too low for using as anti-inflammatory or antipyretic remedy. Full article

The objective of this study was to compare TVT (tension-free vaginal tape) and TVT-O (tension-free vaginal tape obturator from inside to outside) procedures for the female surgical treatment of stress urinary incontinence: results, complications, and effectiveness after 1 year.
Material and methods. A prospective randomized study was carried out. The patients were followed up for 12 months. A total of 114 patients were operated on using TVT procedure and 150 patients – TVT-O procedure. There was no significant difference in age, body mass index, parity, menopausal status, and prolapse (no patients had cystocele greater than stage II) comparing both groups.
Results. The mean time in surgery was significantly shorter in the TVT-O group (19±5.6 min) as compared with the TVT group (27±7.1 min). No differences in the effectiveness of both procedures were found: TVT – 94.6% and TVT-O – 94.6% after one year, respectively. Hospital stay was significantly shorter in the TVT-O group (1.5±0.5 days) than in the TVT group (4.0±1.6 days). Significantly fewer complications were observed in the TVT-O group.
Conclusion. TVT and TVT-O operations are equally effective for the surgical treatment of female stress urinary incontinence. TVT-O group had shorter time in surgery and showed a lower rate of complications. Full article

Radiofrequency ablation of the slow pathway is an effective method of treatment in children with atrioventricular nodal reentrant tachycardia. The aim of our study was to evaluate anterograde conduction properties in children before and after radiofrequency ablation of the slow pathway and to determine the efficacy and safety of this method.
Material and methods. Noninvasive transesophageal electrophysiological examination was performed in 30 patients at the follow-up period (mean duration, 3.24 years) after radiofrequency ablation of the slow pathway.
Results. The slow pathway function was observed in 13 patients one day after ablation, in 26 patients during the follow-up period, and in 28 patients after administration of atropine sulfate. Atrioventricular node conduction was significantly decreased the following day after ablation and at the follow-up versus the preablation (165.2 [30.2] bmp and 146.3 [28.5] bpm versus 190.9 [31.4] bpm; P<0.001). The atrioventricular node effective refractory period prolonged significantly the following day after ablation and at the follow-up versus the preablation (319.3 [55.3] ms and 351.0 [82.1] ms versus 248.3 [36.6] ms; P<0.001). Effective refractory period of the fast pathway prolonged significantly as compared with the preablation (from 408.0 [60.4] ms to 481.2 [132.9] ms; P=0.005). The prolongation of effective refractory period of the slow pathway was more significant than effective refractory period of the fast pathway at the follow-up (P<0.001). Two late recurrences occurred; one patient had atrial tachycardia.
Conclusion. Children with atrioventricular nodal reentrant tachycardia can be effectively and safety cured by ablative therapy. The end-point during slow pathway ablation should be the abolition of tachycardia with preservation of dual atrioventricular nodal physiology. Full article

Objective. The aim of this study was to establish and compare diagnostic accuracy (sensitivity, specificity, and diagnostic odds ratio) of plain x-ray, ultrasonography, bone scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI) in pediatric acute hematogenous osteomyelitis.
Material and methods. Analysis of patients’ data, hospitalized at the Department of Pediatric Surgery with suspected acute hematogenous osteomyelitis in the period of 2002–2008, was carried out prospectively. Inclusion criteria were age of 1–18 years, pain in bone area, fever, functional disorder, and (or) signs of infection. Plain x-ray, ultrasonography, bone scintigraphy, computed tomography, and magnetic resonance imaging were performed. The recommendations of Standards for Reporting of Diagnostic Accuracy were used in study design.
Results. A total of 183 patients were included into the study. Acute hematogenous osteomyelitis was diagnosed in 156 (85%) patients, and 27 (15%) had other diseases. A total of 169 early plain x-rays (median on the first day of hospital stay), 142 late x-rays (15th day of hospital stay), 82 ultrasonographies (second day), 76 bone scintigraphy (third day), 38 MRI scans (seventh day), and 17 CT (15th day) were performed. The sensitivity of ultrasonography was 0.55 (95% CI, 0.43–0.67); specificity, 0.47 (95% CI, 0.24–0.7); and diagnostic odds ratio, 1.08 (95% CI, 0.3–3.84). The sensitivity of CT was 0.67 (95% CI, 0.38–0.88); specificity, 0.5 (95% CI, 0.01– 0.98); and diagnostic odds ratio, 2.0 (95% CI, 0.02–172.4). The sensitivity of early x-ray was 0.16 (95% CI 0.1–0.23); specificity, 0.96 (95% CI, 0.78–1.0); and diagnostic odds ratio, 4.34 (95% CI, 0.63–186.3). The sensitivity of MRI was 0.81 (95% CI, 0.64–0.93); specificity, 0.67 (95% CI, 0.22–0.96); and diagnostic odds ratio, 8.67 (95% CI, 0.91–108.5). The sensitivity of late x-ray was 0.82 (95% CI, 0.75–0.88); specificity, 0.92 (95% CI, 0.62–1.0); and diagnostic odds ratio, 51.17 (95% CI, 6.61–2222.0). The sensitivity of bone scintigraphy was 0.81 (95% CI, 0.68–0.90); specificity, 0.84 (95% CI, 0.60–0.97); and diagnostic odds ratio, 22.30 (95% CI, 4.9–132.7).
Conclusions. Our analysis showed that late x-ray is the most valuable radiologic method in the diagnosis of acute hematogenous osteomyelitis, but bone scintigraphy and magnetic resonance imaging are the most valuable tests at the onset of the disease. Full article

During last decades, there are strengthening attitudes to optimize the treatment of Hodgkin’s lymphoma considering prognostic groups and risk factors. Based on the data of Vilnius University Clinics, a retrospective study was carried out, and treatment methods and outcomes of the patients treated during 1999– 2004 were analyzed. Medical histories of 114 patients younger than 60 years were reviewed. Median age was 28 years. In 83% of cases, classic nodular sclerotic Hodgkin’s lymphoma was diagnosed. Advanced-, intermediate-, and early-stage disease was diagnosed in 55%, 38%, and 7% of cases, respectively. The patients with early-stage disease underwent four ABVD chemotherapy courses; 88% of them underwent radiotherapy afterwards. The patients with intermediate-stage disease underwent 4–6 courses of ABVD or in minor cases (12% of patients with intermediate-stage disease) – 4 standard BEACOPP chemotherapy courses. After this treatment, 88% of patients with intermediate-stage disease underwent radiotherapy. Patients with advanced-stage disease underwent 8 escalate (44%) or standard BEACOPP (29%) chemotherapy courses. More than half of these patients (71%) underwent radiotherapy after chemotherapy. Patient follow-up median was 65 months. One hundred seven patients (94%) after primary treatment achieved complete remission, in 7 patients (6%) primary progression was observed, 12 patients (11%) relapsed, and 8 patients died. Overall survival and event-free survival in patients with early-stage disease was 100%. Overall survival in patients with early/intermediate- and advanced-stage disease was 95.1% and 84.0%, respectively. Event-free survival in patients with early/intermediate- and advanced-stage disease was 91.7% and 76.2%, respectively. In the groups of intermediate- and advanced-stage disease, the results of treatment were worse in the subgroup, which underwent extended-field radiotherapy (P<0.05). Overall survival in the group of patients with advanced-stage disease was the best who underwent ABVD scheme, but the event-free survival (70.6%) and disease-free survival (81.3%) in ABVD subgroup were worse compared to BEACOPP subgroup. According to our results, there was no statistically significant difference in survival of patients with advanced-stage disease who underwent or did not radiotherapy (P>0.05). Full article