Magdalena Roszak

Lower preoperative fluctuation of heart rate variability is an independent risk factor for postoperative atrial fibrillation in patients undergoing major pulmonary resection

OBJECTIVES The following study presents a special independent atrial fibrillation (AF) risk factor-preoperative fluctuation of heart rate variability (HRV), as well as other perioperative AF risk factors in patients qualified for pneumonectomy and undergoing pneumonectomy or lobectomy for lung cancer. METHODS The prospective study was performed in patients who had undergone anatomical resection for non-small-cell lung cancer. A total of 117 patients (92 men and 25 women) qualified for statistical research. In order to determine the risk factors, all patients were divided into two groups: Group A-98 patients without AF and Group B-19 patients with AF during the perioperative time. A number of different risk factors of AF have been analysed and further divided into preoperative, operative and postoperative. RESULTS Postoperative AF occurred in 19 patients (16%), all of them were male. The patients with higher short-term HRV parameters (SD1, RMSSD), slower mean heart rate and those with a lower fluctuation of HRV-related parameters (HRV Afternoon, Night, Day (A/N/D)) before the operation, were more prone to AF. Postoperative risk of AF was higher in patients with a higher number of ventricular ectopic beats before the operation, a higher number of supraventricular and ventricular ectopic beats and a higher maximal heart rate after the operation. Statistical analysis revealed that male gender and the extent of pulmonary resection, particularly left pneumonectomy, constituted significant risk factors. AF was more often observed in patients who had ASA physical status score of III, in comparison with ASAI and ASAII patients. CONCLUSIONS Along with other concomitant AF risk factors presented in this work, the evaluation of the fluctuation tendencies of HRV parameters should be taken into consideration before any major lung resection. The balance disturbance between the sympathetic and parasympathetic nervous systems is responsible for AF.

Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study

OBJECTIVES The pedicled intercostal muscle flap (IMF) is a high quality vascularized tissue commonly used to buttress the bronchial stump after pneumonectomy or bronchial anastomosis after sleeve lobectomy in order to prevent bronchopleural fistula formation. The evaluation of the viability of the muscle flap is difficult. The aim of this study was the assessment of the application of indicyanine green fluorescence for the evaluation of IMF perfusion. METHODS The study included 27 patients (10 males and 17 females), mean age 62.6 years (47-77 years). Indocyanine green fluorescence (ICG) was used for objective assessment of the IMF quality by a near-infrared camera system (Photodynamic Eye(®), Hamamatsu Photonics, Japan). The following factors that may have an impact on the quality of the IMF were assessed: age, gender, body mass index, comorbidities, IMF length and thickness and timing of the harvesting during the procedure. RESULTS The following surgical pulmonary resections with IMF harvesting were performed: 12 pneumonectomies, 2 sleeve lobectomies and 13 lobectomies. Intercostal muscle flap (IMF) was harvested before rib spreader insertion in 23 patients (85%) and at the end of the surgery in 4 patients (15%). The mean length and thickness of the harvested intercostal muscle were 19.9 ± 2.9 cm (range 13-24 cm) and 2.4 cm ± 0.7 cm (range 1.0-3.5 cm), respectively. Indocyanine green angiography showed ischaemia in the distal part of the muscle in all cases, despite the lack of obvious macroscopic signs. Median length of the ischaemic part was 4 cm (range 0.5-20 cm). The IMF length and thickness had a significant impact on the length of the ischaemic segment. In 24 patients, the ischaemic part of the muscle flap was severed. In 3 patients with the longest ischaemic segment (11, 13 and 20 cm), an alternative tissue was used to cover the bronchial stump. No major complications occurred. CONCLUSIONS Our preliminary results confirmed the simplicity and high efficacy of ICG in the assessment of intercostal muscle blood perfusion. ICG was superior to macroscopic evaluation and influenced surgical proceeding.

High costs as a slow down factor of thoracoscopic lobectomy development in Poland - an institutional experience.

Introduction Thoracoscopic (VATS) lobectomy after a decade of criticism is nowadays considered as a technically feasible, safe and oncologically proper operation. This approach has some advantages over conventional thoracotomy like: less postoperative pain, shorter hospitalization, fewer postoperative complications, better tolerance of adjuvant chemotherapy with comparable long-term survival rate. The VATS lobectomy is now generally accepted as an important alternative to open lobectomy in early-stage lung cancer. Aim In the study we analyzed all aspects of introducing video-assisted thoracoscopic surgery (VATS) lobectomy in our institution with special consideration of the costs of the procedure as a potential limiting factor of its widespread development. Material and methods The data of 212 consecutive patients with early stage lung cancer operated on during 2008-2011 were selected and analyzed. One hundred and eight patients underwent VATS lobectomy (VATS group) and 104 patients antero-lateral thoracotomy (thoracotomy group). Perioperative outcomes including operating time, blood loss during surgery, postoperative complication rate, length of hospital stay, and duration of chest tube drainage were assessed. The cost evaluation included: all direct theater costs, daily hospital costs, intensive care costs, pharmacy and disposable costs with special consideration of stapling device costs. Results The mean hospital stay after VATS lobectomy was significantly shorter than after thoracotomy, mean 7 days vs. 10 days (p < 0.0012). The complication rate and ICU admission rate were almost twice as high after thoracotomy than after VATS and were 46% vs. 23% (p < 0.0006) and 42% vs. 22% (p < 0.0027) respectively. Cost analysis showed significantly higher total costs of VATS lobectomy than after thoracotomy (median €2445 vs. €2047). Considerably higher theater costs for VATS compared to thoracotomy, median €1395 vs. €479, were caused mainly by endostapler costs, median €1069 vs. €161. Significantly higher hospital costs and ICU costs after thoracotomy did not compensate high theater costs of VATS lobectomy. Conclusions In Polish financial reality and potentially in other middle-income countries significantly higher costs of the procedure can limit widespread introduction of VATS lobectomy in clinical practice.

Comparative efficacy and usefulness of acebutolol and diltiazem for the prevention of atrial fibrillation during perioperative time in patients undergoing pulmonary resection.

BACKGROUND Postthoracic surgery atrial fibrillation (AF) is the most frequently occurring arrhythmia. Strategies for preventing AF have been amply evaluated, but currently there are no clearly defined guidelines for treatment of AF after thoracic surgery. METHODS The study was prospective and randomized controlled trial. Acebutolol and diltiazem versus placebo were compared, among 117 patients postpneumonectomy or lobectomy at the Thoracosurgery Clinic, Poznan University of Medical Sciences in Poland. Patients who were enrolled in the study were randomly assigned to one of the three groups: those who received acebutolol (Group 1) or diltiazem (Group 2) and compared with patients without antiarrhythmic drugs (Group 0). Each group consisted of 39 patients. The patients were continuously monitored postoperatively with 24 ECG (Holter monitor) in the intensive care unit. RESULTS In patients receiving acebutolol AF occurred in 5% compared with 23% of patients receiving diltiazem and 20% of patients receiving placebo (difference not statistically significant). CONCLUSIONS Acebutolol and diltiazem appear to have been non-effective for the treatment or prevention of AF. Side effects were mild. In comparison to diltiazem, however, acebutolol had a beneficial effect on the circulatory system. Patients who had received acebutolol proved to have had fewer tachycardia episodes and supraventricular ectopy during the postoperative period. It seems that acebutolol can be useful, especially in patients with sympathetic activity dominance.

Long-term renal outcome in children with OCRL mutations: retrospective analysis of a large international cohort

Background Lowe syndrome (LS) and Dent-2 disease (DD2) are disorders associated with mutations in the OCRL gene and characterized by progressive chronic kidney disease (CKD). Here, we aimed to investigate the long-term renal outcome and identify potential determinants of CKD and its progression in children with these tubulopathies. Methods Retrospective analyses were conducted of clinical and genetic data in a cohort of 106 boys (LS: 88 and DD2: 18). For genotype-phenotype analysis, we grouped mutations according to their type and localization. To investigate progression of CKD we used survival analysis by Kaplan-Meier method using stage 3 CKD as the end-point. Results Median estimated glomerular filtration rate (eGFR) was lower in the LS group compared with DD2 (58.8 versus 87.4 mL/min/1.73 m2, P < 0.01). CKD stage II-V was found in 82% of patients, of these 58% and 28% had moderate-to-severe CKD in LS and DD2, respectively. Three patients (3%), all with LS, developed stage 5 of CKD. Survival analysis showed that LS was also associated with a faster CKD progression than DD2 (P < 0.01). On multivariate analysis, eGFR was dependent only on age (b = -0.46, P < 0.001). Localization, but not type of mutations, tended to correlate with eGFR. There was also no significant association between presence of nephrocalcinosis, hypercalciuria, proteinuria and number of adverse clinical events and CKD. Conclusions CKD is commonly found in children with OCRL mutations. CKD progression was strongly related to the underlying diagnosis but did not associate with clinical parameters, such as nephrocalcinosis or proteinuria.

Multimedia and interactivity in distance learning of resuscitation guidelines: a randomised controlled trial

ABSTRACT The aim of the study was to conduct a comparative analysis of three forms of knowledge transfer online, taking into account the long-term knowledge growth rate and the satisfaction of students surveyed in respect to distance learning. The cohort of participants for this survey were students of the first degree, studying in the Emergency Medical Services. The authors created three e-learning courses in basic and advanced resuscitation procedures. The level of course participants’ satisfaction was analysed, as well as the knowledge growth rate measured three times: 7, 30 and 90 days, respectively, after finishing the course. The level of satisfaction in all the groups surveyed was comparable. The growth rate for knowledge was the highest in group C in the second and third survey, respectively (30 and 90 days after the end of the course), and a significant difference in favour of course C was demonstrated one month after finishing classes.

Using a Virtual Learning Environment as a Key to the Development of Innovative Medical Education

Abstract This article shows the organization of distance learning, particularly the idea of b-learning, combining the accomplishment of classes carried on in the traditional way and via computers. The authors present learning activities related to complementary education herein. Some of these course types may be successfully adapted to an e-learning background. The models and structure of the university virtual environment for distance learning are described. These illustrate a new approach to creating a virtual space for medical and technical studies where e-learning courses are created to be used for distance education, which allows students to be taught more effectively. The projected virtual courses for different groups of students ensure individualization of students’ work, which could be a relevant element for creating the shortest path of development of professional competencies. This paper further includes a brief overview of technologies used to build interactive elements into learning mate- rials. The authors present the use of interactive elements in medical education based on examples of certain selected games and animations.

Educational Multimedia Materials in Academic Medical Training

Abstract This article presents an overview of generally available applications for creating multimedia and interactive educational materials, such as presentations, instructional videos, self-tests and interactive repetitions. With the use of the presented tools, pilot materials were developed to support the teaching of biostatistics at a medical university. The authors conducted surveys among students of faculties of medicine in order to evaluate the materials used in terms of quality and usefulness. The article presents the analysis of the results obtained.

Implementation of e-learning portal for academic education and lifelong learning

Distance education is entering the area of university education with increasing strength, particularly including lifelong learning. Distance education requires a well-structured organisation and resource management tools, namely an e-learning portal. Universities which are still at the beginning of the portal implementation process may encounter numerous technical and organisational issues. This article was created with a view of educational centres in which the portal is implemented with scarce financial resources by several academic employees having little experience in the field. The authors point to several key issues, such as: analysis of the schools needs in terms of distance education server resources, choice of portal in terms of technology, supported standards or functions necessary for proper course and lastly, user management. The article also mentions the often-underestimated aspect of portal management. The authors further present the capabilities of computational clouds, their deployment in the academic environment and their use in distance learning. Such a solution is extremely rare, particularly in Eastern and Central European countries.

Creating Digital Question Databases: Use of Self-Tests in Teaching Medical Subjects

Abstract Enhancement of teaching using digital materials is rapidly entering the world of medical studies. Creation of a self-learning environment supported with self-tests is received well, or even enthusiastically, among students. On the other hand, there is a relatively large group of opponents among university teachers, who do not see the need for changes in teaching and testing methodology to be made. This attitude may be surfacing as a result of anxiety connected with implementing new technologies in teaching medical subjects, as well as the belief that implementing new technologies does not have an immediate effect on learning quality. The authors of this article attempt to demonstrate that a thoughtful choice of e-learning platform facilitates the process of implementing online learning and testing aids in medical faculties. The second part of the article presents initial results of studies concerning the efficiency of learning enhanced with self-tests. Our analysis details the results of exams in pathophysiology taken by students of the medical faculty at the Poznan University of Medical Sciences. After the course, an evaluation survey was completed by 195 students concerning the quality of teaching with the use of the OLAT (Online Learning and Training) e-learning portal. It showed that students had positive attitudes toward learning with the use of online materials, particularly with regard to the use of self-tests, which allowed students to check their knowledge independently in exam-like conditions. The article that follows is targeted at those teachers who are interested in implementing a self-study and electronic knowledge evaluation environment for their courses, not necessarily in medical subjects.