CURRENT TREATMENT OPTIONS OF DUPUYTREN´S DISEASE

Dupuytren's disease (fibromatosis of the palmar fascia, benign neoplastic fibromatosis, Dupuytren's contracture) is a disease characterized by growth and successive contracture of single parts of the palmar aponeurosis. This condition is known and has been treated for several centuries. In the advanced stages of the disease, it leads to significant limitation of hand function, resulting in reduced quality of life of the patient. Dupuytren's disease (DD) is a life-long disease with a variable course and a heterogeneous clinical presentation. Therapy focuses on the clinical manifestations of the disease as well as on reduction of the functional limitation of the hand caused by the disease. In addition to conservative and surgical procedures, there are also some mini-invasive methods available. Treatment should be reserved for centres and experienced surgeons specialized in hand surgery.

SURGICAL TREATMENT OF MELANOMA

Malignant melanoma is a serious disease, the incidence of which rises. Since the most important treatment method is sufficient wide skin and subcutaneous tissue excision, plastic surgeon is often the only specialist who is able to close the resulting defect. This paper deals with recommendations and treatment options for malignant melanoma from the point of a plastic surgeon. The primary width of excised safety rim of healthy tissue with regards to the depth of melanoma invasion differs. Safety margin is 0.5 cm for melanoma in situ, 1 cm in Breslow up to 2 mm and 2 cm in Breslow over 2 mm. Furthermore, there is indication for sentinel lymph node biopsy, which should be performed in melanoma with Breslow over 1 mm, and in risky melanoma in Breslow above 0.75 mm. Every patient with stage IIB malignant melanoma and above according to TNM classification should undergo adjuvant therapy in a specialized centre. Ideal condition for the patient is a permanent and close cooperation between a dermatologist, oncologist and plastic surgeon, who supplement each other in diagnostics, therapy and follow up of the patients.

CURRENT CONCEPTS IN PERIPHERAL NERVE INJURY REPAIR

Even though reconstructive surgery of the nerves underwent significant progress due to experimental and clinical research over the past 40 years, injuries to the peripheral nerves still remain a great challenge for microsurgery. Literature results of these procedures are often evaluated as very good but the final result is often characterized by an achievement of only a useful and not full function, which is rather rare. It is not only a simple suture; the success is also based on functional regeneration and interconnection of the nerve fibres. This is limited by correct surgical technique, the age of the patient, delay from the time of injury and the mechanism or localization of the injury. Some injuries even now remain untreatable (such as the most severe brachial plexus injuries or long traction injuries of the peroneal nerve). Apart from standard neurolysis and epi- or perineural suture with or without nerve grafts, distal nerve transfers (in case of proximal injuries) and end-to-side neurorrhaphy (mainly in trauma of sensitive nerves) have recently been frequently used. The future is however based on influence of nerve regeneration at the cellular level using substances with growth potential. The main prerequisite of successful surgery is however early indication of surgical revision in a specialized centre.

Differential diagnosis of apneas in preterm infants

Clinically relevant apneas, which are common in preterm infants, may adversely affect later neuropsychological condition in this group of patients. Pharmacotherapy to stimulate respiratory functions may be unsuccessful. Polygraphic recording may help in the differential diagnosis of these clinically relevant events. Twenty-nine preterm neonates born before 36 weeks of gestational age were examined using polygraphic recording (respiration--two channels, perioral electromyography, oxygen saturation, heart rate, electroencephalography, electrocardiography, electrooculography). The examination was ordered by the attending physician after an unsuccessful treatment of apnea by Aminophylline, and it should contribute to the clarification of the causes of these events. In the course of the polygraphic examinations, altogether 63 episodes were recorded during which the pulse oximeter alarm signal was set off. In 42 cases, the alarm signal was set off in events during which SaO(2) fell below 85%. In the remaining 21 cases, the alarm signal was set off in episodes during which early bradycardia below 90/min occurred. The onset of apnea was very often associated with the phasic increase of the perioral electromyography and with electroencephalography arousal reaction. Because of suspicion that these apneas may be triggered by episodes of gastroesophageal reflux, the interruption of the Aminophylline treatment and setting up an antireflux regimen were recommended. These therapeutic measures had a positive effect: The frequency of alarm signals decreased within 48 h by a statistically significant 50%. In cases where the pharmacotherapy of apnea by stimulation of respiratory functions is not successful, differential diagnostic analysis should be performed. Polygraphy may contribute to the clarification of the causes underlying clinically relevant apneas in a view of newly described polygraphic signs. It is feasible to suspect, based on these signs, that gastroesophageal reflux is the cause for clinically significant apneas in that case.

Congenital diaphragmatic hernia associated with esophageal atresia, tracheoesophageal fistula, and truncus arteriosus in a premature newborn

The occurrence of coexisting congenital diaphragmatic hernia (CDH) and esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is extremely rare and is considered highly lethal. The combination of CDH with EA/TEF and truncus arteriosus communis (TAC) has not been reported in the literature to date. The authors describe a premature neonate with this association.

[Are there any new procedures for treating necrotising enterocolitis in neonates with very low birth weight?]

OBJECTIVE

To evaluate some perinatal and neonatal risk factors of occurrence of necrotising enterocolitis (NEC) and the current possibilities of treatment.

DESIGN

A retrospective data analysis.

SETTING

Mother and Child Care Institute, Prague.

METHODS

The clinical course in 28 neonates treated for NEC on the worksite of the authors in the period 1999-2003. Only neonates with NEC in the second and third Bell's stages were included in the group.

RESULTS

From a group of 14,275 neonates born during the reference period, NEC was diagnosed in 28 neonates. In all cases, they were neonates with very low birth weight (VLBW). The average gestation age was 26.6 weeks (the range was 23-35; the median was 25.5); the average birth weight was 822 grams (the range was 340-1,490g; the median was 735). Incidence was between 1.08 and 2.37/1,000 live births (the average was 1.94). On the average, NEC occurred on the 17th day after birth (the range was 5-59; the median was 14). 14 neonates (50%) in the acute stage of NEC were operated on; 9 children (32%) were only treated conservatively. In eight children at the acute stage, who were operated on, divided ileostomy was created; in four children, a T-drain was used for removal of the intestinal content and an abdominal drain was used for this purpose in one child. Repeated surgery was necessary in five children. Of the conservatively treated ones, five children recovered as a result of conservative treatment and four children died as a result of fast progression of NEC without surgical treatment. All the children treated for patent ductus arteriosus (PDA) with Indometacin died. The overall mortality in the group was 39.3% (11 children died).

CONCLUSION

Prematurity seems to be the common denominator of the occurrence of NEC. Treatment of NEC in highly immature neonates with birth weight below 1,500g requires comprehensive cooperation of a neonatologist and a children's surgeon. Resection of a necrotic intestine with creation of a stomy remains a standard procedure, which is followed in unstable neonates with a localised form of the illness. Prevention of premature birth, antenatal steroids, frequent feeding (trophic feeding) and the corresponding correction of water management seem to be a reasonable strategy to reduce the incidence of NEC. The resulting incidence, mortality, the time of the occurrence of NEC and the therapeutic procedures are within the limits stated in the international literature.

[Further development of neonates with severe pneumopathy]

OBJECTIVE

To assess the risk and the degree of possible unfavourable development in neonates with bronchopulmonal dysplasia and with congenital diaphragmatic hernia.

DESIGN

Longitudinal monitoring of the mental, motoric and neurological development until the age of 2 years. Comparison of the findings with the result of polygraphic examination carried out at the expected time of birth.

METHODS

The following children were monitored: a) 38 children with bronchopulmonal dysplasia born between the 24th and 33rd post-conception weeks; b) 18 children with congenital diaphragmatic hernia, of whom 3 children were born between the 34th and 36th post-conception weeks, while the remaining 15 children were born on the expected date. All children underwent polygraphic examinations (EEG - 8 channels, respiration, EKG, EOG and EMG) between the 38th and 42nd post-conception weeks. During the 1st and the 2nd years, their psychomotoric development and neurological status were repeatedly evaluated according to Bayley and Vlach, respectively.

RESULTS

Up until the 2nd year of life, approximately 2/3 of the children in both monitored groups were developing favourably or satisfactorily. However, the development of the remaining 1/3 was not favourable: The children were mentally or motorically retarded and/or cerebral palsy developed in them. The polygraphic examination in the neonatal period predicted the favourable or unfavourable development of the monitored children with high probability.

CONCLUSION

The study showed that in accordance with the data stated in the literature, the development of neural functions is seriously affected in a relatively high percentage of neonates with severe pneumopathy. Neonatal polygraphy can contribute to timely determination of the prognosis for these children. Children with serious neonatal pneumopathies need to be provided with dispensary care on a long-term basis, and professional consultancy and intervention programmes need to be ensured for them.

[The first experience with linezolide in treatment of nosocomial septic condition in premature neonates]

OBJECTIVE

Nosocomial infections caused by the coagulase-negative staphylococci are among the most frequent complications in an intensive care unit for neonates. The authors describe three cases of successful treatment of this complication in which the new antibiotic Linezolide was used.

DESIGN

Analysis of three clinical cases.

SETTING

Mother and Child Care Institute, Prague.

METHODS

Description of cases of nosocomial sepsis in 3 immature neonates where the usual treatment of multiresistant strains of coagulase-negative staphylococci, based on the use of Vankomycin, was not successful.

CONCLUSION

Administration of Linezolide proved to be very effective in all of the described cases. In spite of the high effectiveness and relative safety of this preparation, its precise role in the treatment of infection-related complications caused by coagulase-negative staphylococci has not yet been established. For the time being, we recommend administering this preparation only in strictly indicated cases after the usual therapy fails.

[Pseudo-hydrothorax in peripheral venous catheterization in an extremely premature neonate--case report]

The authors describe very rare complication (pseudopleural effusion) after peripheral venous cannulation (Introcan-W 24G3/4 through v. axilaris) in extremely premature newborn with birth weight 600 grams, which lead to worsening of patient's respiratory insufficiency. Ultrasonographic examination confirmed extrapleural process without necessity of surgical intervention. Cannula extraction and infusion interruption were followed by spontaneous regression of the complication, thereafter artificial ventilation was discontinued and baby was discharged.

[Effect of natural surfactant on mortality and morbidity in neonates with a birth weight below 1500 grams]

OBJECTIVE OF STUDY

Evaluation of the natural surfactant in treatment of the respiratory distress syndrome (RDS) on the mortality and morbidity of neonates with a birth weight lower than 1500 g.

TYPE OF STUDY

Retrospective analysis of data.

SETTING

Department:perinatological centre, Institute for Mother and Child, Prague.

METHOD

A total of 442 neonates with birth weights under 1500 g were evaluated. During period I/1994-XII/1998 271 neonates were analyzed (Group A). The results of the total neonatal mortality and morbidity were compared with results of care provided to 171 patients during I/1989-XII/1993 before introduction of the surfactant. Surfactant therapy was used in 134 patients of group A (9%) with RDS who met the standard indication criteria. The initial surfactant dose (Alveofact R Boehringer Ingelheim, GFR) depended on the ventilation parameters and was 50 mg/kg and in severe forms of RDS 100 mg/kg. The total cumulative dose did not exceed 200 mg/kg. The data were assembled in a database used in the Institute for the Care of Mother and Child and evaluated using the statistical programme EpiInfo (CDC, USA).

RESULTS

In the group of neonates with a birth weight lower than 1000 g 110 neonates in group A were evaluated and 61 in group B. Surfactant was administered to 77 infants of the treated group (70%). Statistically significant differences were recorded: in the total mortality (A: 29 vs. B: 79%, p < 0.0001, the number of neonates who died during UPV (A: 32% vs. B: 80%, p < 0.0001), incidence of PVH-IVH grade I-IV (A: 29% vs. B: 67%, p < 0.0001). In the group of neonates with a birth weight of 1000 to 1499 g 161 children were evaluated in group A and 110 in group B. Alveofact was administered to 57 neonates of the treated group (35%). Statistically significant differences were recorded: in the total mortality (A: 4%, vs. B: 31%, p < 0.0001), the number of neonates who died during UBPV (A: 7% vs. B: 45%, p < 0.0001), incidence of perintraventricular grade I-IV (A: 11% vs. B: 35%, p < 0.0001), incidence of patent ductus arteriosus (A: 6% vs. B: 15%, p < 0.02), incidence of pneumothorax (A: 7% vs. B: 18%, p < 0.01) and in the incidence of posthaemorrhagic hydrocephalus (A: 2% vs. B: 11%, p < 0.01). There was a statistically significant difference in the incidence of BPD to the disadvantage of group A (A: 16% vs. B: 8%, p < 0.01).

CONCLUSION

The study confirmed the favourable effect of the introduction of surfactant in the treatment of RDS and on the general mortality and morbidity of neonates with a birth weight below 1500 g.

[Extracorporeal membrane oxygenation in the treatment of severe pulmonary hypertension in a neonate after surgery for laparoschisis]

The authors describe the case of newborn with laparoschisis in whom severe idiopathic pulmonary hypertension during postoperative period developed and initiation of extracorporeal membrane oxygenation (ECMO) to maintain circulatory stability and adequate oxygenation was necessary. ECMO was performed for 75 hours with maximum extracorporeal support up to 50% of cardiac output (Biomedicus pump BP 50, Jostra oxygenator M8). Patient was successfully weaned and switched to conventional ventilation and nitric oxide inhalation with consequent extubation. No bleeding complications were observed during ECMO in connection with surgical repair of laparoschisis.