Medical sciences

Folia Medica Cracoviensia


Folia Medica Cracoviensia | 2019 | vol. 59 | No 4 |


I n t r o d u c t i o n: Infective endocarditis (IE) is a potentially life-threatening condition. According to current ESC (European Society of Cardiology) guidelines, the use of antibiotic prophylaxis should only be reserved for specific dental procedures with interruption of consistency of the oral mucosa such as extractions and should be reserved for patients with the highest risk of developing IE. The aim of this study was to assess the knowledge of need for IE prophylaxis in defi ned clinical settings among Polish dentists.

Ma t e r i a l a n d Me t h o d s: A specially self-designed internet questionnaire was created concerning the topic of infective endocarditis prophylaxis in specifi c clinical scenarios for patients undergoing dental extractions during outpatient visits. Th e survey was made available to the dentists via internet and was active in March 2018.

R e s u l t s: There were 352 Polish dentists who completed the survey. Antibiotic prophylaxis for IE during dental extractions was used in 93% of cases with prior IE, 89% with artifi cial heart valve, 69% with biological valve, 28% with pacemaker, 54% with coronary stent, 73% with cyanotic heart defect, 58% with diabetes mellitus, 20% after prior myocardial infarction and 54% with heart valve disease. There was a significant relationship between the time of working as a physician (>15 years) and more outdated or improper IE prophylaxis (p = 0.04).

C on c l u s i o n s: The management of patients for infective endocarditis prophylaxis undergoing dental extractions is suboptimal. Antibiotic therapy is overused in some clinical scenarios and on the other hand underutilized in those recommended by the current ESC guidelines.

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The abducens nerve is characterized by a long intracranial course and complex topographical relationships. Anatomical knowledge may help to understand both the etiology and clinical symptoms of abducens nerve palsy. Typically, the single trunk of the abducens nerve travels on both sides. However, occasionally different variants of unilateral or bilateral duplications of the abducens nerve may be observed. Th e presented paper is a detailed anatomical description of bilateral duplication of the abducens nerve, with atypical appearance of the nerve in the cavernous sinus and normal distribution within the lateral rectus muscle on both sides of one cadaver. On the right side both trunks of the abducens nerve fused within the subarachnoid space and pierced the dura mater together. On the left side both trunks of the duplicated abducens nerve pierced the dura mater separately, entered the petrous apex separately and fused just below the petrosphenoidal ligament. Within the cavernous sinus the nerve divided once again into two filaments, which reunited into one trunk aft er crossing the horizontal segment of the intracavernous part of internal carotid artery. Th e orbital segments of the abducens nerve showed a typical course on both sides. Duplication of the abducens nerve is anatomical variation which should be taken into account during diagnostic and surgical procedures performed within the petroclival region and cavernous sinus.

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B a c k g r o u n d: The aim of the study was to evaluate the usefulness of the modified Peyton’s four-step approach in the teaching of cardiac auscultation and to determine students’ perception of Peyton’s four-step approach.

Me t h o d s: The opinion of the participants on the usefulness of the modifi ed four-step approach was attained through the use of anonymous questionnaires, voluntarily completed by students, and on the basis of semi-structured interviews conducted with a subset of students. 187 second-year students of our 6-year long curriculum were enrolled. They attended an obligatory Laboratory Training of Clinical Skills course. The average group size was 16 students.

R e s u l t s: The survey findings identified that 88.1% of participants found it helpful in developing their understanding of cardiac auscultation. 89.8% of all participants claimed that the new modified four-step approach facilitated memorization. The modified Peyton’s four-step method allows for better organization of classes in the opinion of 87.6% students. The advantages of the method were noticed by the majority of students.

C on c l u s i o n s: The modified Peyton’s four-step approach in the teaching of cardiac auscultation under laboratory conditions was perceived by students to be a comprehensible method that facilitates understanding and memorization. Th is approach allows for improved organization of classes. From the student’s perspective this method allows one to master the technique of cardiac auscultation in the classroom, through the increased demand of the participants’ attention, activity and involvement.

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Knowledge of uterine fibroids has existed since the time of Hippocrates. However, there are still wide gaps in the understanding of its pathogenesis. No single theory explains the background of uterine fibroid pathology, which affects more than 50% of women worldwide. By contrast, a newly depicted cell type called telocytes was only recently identified in the past twenty years. Th ese cells have evoked ambivalent opinions in the scientific community. The unique features of telocytes coupled with experimental evidence by numerous researchers and our hypotheses and conceptions are discussed in this review. We emphasize the main telocyte interactions in the context of the uterine fibroid architecture. This review reveals the pivotal role of telocytes, describing their contacts with smooth muscle cells, fibroblasts, vessels and nerves, inflammatory cells and stem cells. Our data are based on the latest publications and our own results.

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B a c k g r o u n d: Near Infrared Spectroscopy (NIRS) is considered a reliable assessment method of a balance between cerebral oxygen demand and supply. One of forms of anaesthesia applied during extensive abdominal surgical procedures is the epidural anaesthesia. Its application in addition to the general anaesthesia is a commonly accepted form of anaesthesia in patients undergoing abdominal surgery. The aim of this study was to verify the hypothesis that epidural blocks may have eff ects on cerebral saturation in patients undergoing abdominal surgery under general anaesthesia.

M e t h o d s: Cerebral saturation was monitored intrasurgically. Reduction of cerebral oxymetry by over 25% in relation to the baseline, or cerebral oxymetry value below 50% was considered clinically significant.

R e s u l t s: One hundred and one (101) subsequent and non-randomised patients, age between 35 and 84 years (mean 64 ± 10) qualifi ed for major abdominal surgeries were enrolled. In 14 (13.9%) patients of 101 enrolled a clinically signifi cant reduction of cerebral saturation was observed. In 50 (49.5%) of the enrolled patients, the epidural anaesthesia was applied along the general anaesthesia. A clinically signifi cant reduction of cerebral saturation was observed in 9 of them. No statistically significant association was found between the application of epidural anaesthesia and development of cerebral desaturation.

C o n c l u s i o n: The application of epidural anaesthesia caused no clinically significant reduction of cerebral saturation during the general anaesthesia in course of major abdominal surgical procedures.

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I n t r o d u c t i o n: A high neutrophil-to-lymphocyte ratio (NLR) has been reported to be a strong biomarker of inflammation.

A i m: We sought to evaluate the impact of NLR on long-term all-cause and cardio-vascular (CV) mortality in hemodialysis (HD) patients.

Ma t e r i a l a n d Me t h o d s: A total of 84 chronic kidney disease (CKD) stage 5 patients with 54 of them on HD, with a median age of 61.5 (51.3–74.8) years were enrolled. The association between NLR and clinical biomarkers was investigated. Multivariable Cox regression analysis was used to find significant predictors of all-cause and CV mortality at follow-up.

R e s u l t s: The median NLR (interquartile range) was 3.0 (2.1–4.1). Patients with NLR ≥3.9 (the highest tertile) had higher five-year all-cause mortality then remaining patients (53.6% vs. 30.4%; p = 0.039). On the contrary, only a trend towards increased CV mortality was observed (25.0% vs. 42.9%; p = 0.10). NLR ≥3.9 was a significant predictor of all-cause mortality at five years [hazard ratio (95%CI): 2.23 (1.10– 4.50); p = 0.025] in Cox regression model adjusted for age, gender, and diabetes status. Similarly, while using NLR as continuous variable a significant association between NLR and all-cause mortality was confirmed even after adjustment for covariates [hazard ratio per 1 unit increase (95%CI): 1.26 (1.06–1.51); p = 0.009] with the area under the receiver operating characteristic (ROC) curve of 0.64. Correlations between NLR and WBC, concentration of fibrinogen, albumin were observed.

C o n c l u s i o n s: Asymptomatic inflammation measured by NLR showed an association with long-term all-cause mortality in stage 5 CKD patients, even while white blood cell count was in the normal range.

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Spigelian hernia (SH) is a rare ventral interstitial hernia occurring through a defect in the transversus abdominis aponeurosis (Spigelian fascia). Spigelian fascia is found between the lateral border of the rectus abdominis muscle and the semilunar line, which extends from the costal cartilage to the pubic tubercle. In other words, Spigelian line is where the transversus abdominis muscle ends in an aponeurosis characterized by a congenital or acquired defect in the Spigelian aponeurosis. Pediatric cases of SH are either congenital or acquired due to trauma, previous surgery or increased intra-abdominal pressure. SH in combination with ipsilateral cryptorchidism may constitute a new syndrome, as such cases are extremely rare in the literature Th is new syndrome is characterized by the following congenital, ipsilateral disturbances: SH, absence of inguinal canal and gubernaculum and the homolateral testis found within the Spigelian hernia sac (a hernia sac containing undescended testis). Th e aim of this study is to emphasize some typical fi ndings of this specifi c entity, and, hence, the necessity for a thorough investigation of the origin of the SH.

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I n t r o d u c t i o n: Induction of labor is an intervention in the obstetrics, which aim is to achieve cervical ripening and stimulate contractions of uterus before beginning of labor. The purpose of our study was to evaluate efficacy of combinations of vaginal misoprostol, intracervical dinoprostone and Foley catheter at term with regard to mode of delivery and rate of emergency C-sections due to birth asphyxia.

Ma t e r i a l a n d Me t h o d s: 403 singleton pregnant women, who underwent pharmacological labor induction at term, were reviewed. Patients were divided into 2 main cohorts due to beginning of induction algorithm: vaginal misoprostol (66) or intracervical dinoprostone (337) consisting of 3 subgroups — PGE2 alone (184), PGE2+Foley catheter (125), PGE2+Foley catheter+PGE1 (28).

R e s u l t s: Comparison of maternal age, presence of cervical dilation and parity revealed no major differences between cohorts. Eff ectiveness of labor induction with misoprostol, dinoprostone and dinoprostone followed by Foley catheter were respectively 90.9%, 51.3%, and 82.8%. Addition of PGE1 was effective in 83% of patients with negative response to PGE2 followed by Foley catheter. There was no statistically significant diff erence in rate of C-sections between dinoprostone and misoprostol cohorts, C-section due to birth asphyxia were insignificantly more frequent in PGE1 than in PGE2 cohort. Efficacy in the subgroup administered only dinoprostone was significantly higher in 40th than in 41th (p = 0.016).

C o n c l u s i o n s: Intracervical dinoprostone seems to be safer, but less effective in labor induction than vaginal misoprostol. Following PGE2 by other methods increased efficacy of induction in this cohort.

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I n t r o d u c t i o n: Stress is an ubiquitous phenomenon in the modern world and one of the major risk factors for cardiovascular disease. Th e aim of our study was to evaluate the effect of various acute stress stimuli on autonomic nervous system (ANS) activity, assessed on the basis of heart rate (HRV) and blood pressure (BPV) variability analysis.

Ma t e r i a l s a n d M e t h o d s: The study included 15 healthy volunteers: 9 women, 6 men aged 20– 30 years (23.3 ± 1.8). ANS activity was assessed by HRV and BPV measurement using Task Force Monitor 3040 (CNSystems, Austria). ECG registration and Blood Pressure (BP) measurement was done 10 minutes at rest, 10 minutes aft er the stress stimulus (sound signal, acoustic startle, frequency 1100 Hz, duration 0.5 sec, at the intensity 95 dB) and 10 minutes aft er the cold pressor test. The cold pressor test (CPT) was done by placing the person’s hand by wrist in ice water (0–4°C) for 120 s.

R e s u l t s: Every kind of stress stimulation (acoustic startle; the CPT) caused changes of HRV indicator values. The time domain HRV analysis parameters (pNN50, RMSSD) decreased aft er acoustic stress and the CPT, but were signifi cantly lower after the CPT. In frequency domain HRV analysis, significant differences were observed only aft er the CPT: (LF-RRI 921.23 ms2 vs. 700.09 ms2; p = 0.009 and HF-RRI 820.75 ms2 vs. 659.52 ms2; p = 0.002). The decrease of LF-RRI and HF-RRI value aft er the CPT was significantly higher than after the acoustic startle (LF-RRI 34% vs. 0.4%, p = 0.022; HF-RRI 19.7% vs. 7% ms2, p = 0.011). The decreased value of the LF and HF components of HRV analysis are indicative of sympathetic activation. Nonlinear analysis of HRV indicated a significant decrease in the Poincare plot SD1 (p = 0.039) and an increase of DFAα2 (p = 0.001) in response to the CPT stress stimulation. Th e systolic BPV parameter LF/HF-sBP increased signifi cantly aft er the CPT (2.84 vs. 3.31; p = 0.019) and was higher than aft er the acoustic startle (3.31 vs. 3.06; p = 0.035). Signifi cantly higher values of diastolic BP (67.17 ± 8.10 vs. 69.65 ± 9.94 mmHg, p = 0.038) and median BP (83.39 ± 8.65 vs. 85.30 ± 10.20 mmHg, p = 0.039) were observed in the CPT group than in the acoustic startle group.

C on c l u s i o n s: Th e Cold Pressor Test has a greater stimulatory eff ect on the sympathetic autonomic system in comparison to the unexpected acoustic startle stress. Regardless of whether the stimulation originates from the central nervous system (acoustic startle) or the peripheral nervous system (CPT), the final response is demonstrated by an increase in the low frequency components of blood pressure variability and a decrease in the low and high frequency components of heart rate variability.

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Editorial office


Redaktor Naczelny
Dr hab. Krzysztof Gil, prof. UJ

Zastępca Redaktora Naczelnego
Prof. Andrzej Surdacki

Sekretarz Redakcji
Prof. Beata Kuśnierz – Cabala

Prof. Benjamin Chain (London, UK),
Prof. Paul Enck (Tübingen, Germany),
Prof. Tomasz Grodzicki (Kraków, Poland),
Prof. Kalina Kawecka-Jaszcz (Kraków, Poland)
Prof. Maciej Małecki (Kraków, Poland),
Prof. Janusz Marcinkiewicz (Kraków, Poland),
Prof. Franz H. Messerli (New York, USA),
Prof. Jacek Musiał (Kraków, Poland),
Prof. Wiesław Pawlik (Kraków, Poland),
Prof. Jacek J. Pietrzyk (Kraków, Poland)
Prof. Władysław Sułowicz (Kraków, Poland)
Prof. Piotr Thor (Kraków, Poland)
Prof. Jerzy A. Walocha (Kraków, Poland)

Redaktor techniczny
Danuta Ambrożewicz


Adres redakcji
ul. Czysta 18
31-121 Kraków

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