Baltic Journal of Clinical Medicine and Research

Reconstruction of Multiple Location Bedsores

Klinta Luīze Sprūdža — 2024-05-24

Keywords: Fillet flaps, Pressure sores, Reconstructive surgery, Spinal trauma

Introduction: Regress of a patient’s functional integrity due to spinal trauma is often complicated by the development of multiple bedsores. Reconstructive autograft surgery is used to maximise physiological and functional well-being.

Case description: A patient has a history of a spinal trauma suffered in 2018 with a lower paresis, leading to the development of bedsores – in the sacrum area, the greater trochanter area, the ischial tuberosity area. The patient was initially subjected to debridement and subsequently the formation of a lower extremity flap of the right leg was carried out. On 11.02.2021 a flap was prepared to the plantar surface of the right foot to the hip joint for a wide soft tissue flap on the front surface. The soft tissue was separated from the bone architecture, as well as the patella resection and tibia exarticulation in the knee, hip joint arthrotomy and femur exarticulation from acetabulum were carried out. After repeated debridement of ulcers, the flap is folded from the front surface of the right side across the right trochanter area, the sacrum area towards the left pelvis. The shape of the flap is created by adjusting it to the bedsored areas. At the end, flap fixing, drain insertion, application of aseptic bandage were carried out. Due to the dehiscence of perianal wounds caused by faecal contamination, a sigmostoma was formed on 04.03.2021.

Summary: A fillet flap creation with the right leg exarticulation was a reconstructive manipulation to improve the quality of life and health of the patient.

Conclusions: Late results reveal a successful scarring process. The patient is able to perform a lot of daily routines.

Multidisciplinary Treatment of Giant Prolactinoma in Young Adult

Jorė Rinkevičiūtė — 2024-05-24

Key words. giant prolactinoma, hyperprolactinemia, neurosurgery.

Introduction. Prolactinomas are characterized by their hormonal activity and size. Tumors above 4 cm are considered giant (they form less than 1% of all pituitary tumors), which are challenging to manage, because of extreme hyperprolactinemia and tumor tissue compressing optic chiasm and invading cavernous sinus [1].

Case Description. An 18-year-old male patient sought help from an ophthalmologist after two months of severe vision loss (VOS=0.01, VOD=0.1). In November 2021 performed exams, such as MRI and blood tests, showed further results: left optic nerve compression due to giant intrasellar lesion (61.5 cm³) with blood prolactin 358071.00 mU/I (norm – 89-365 mU/I), leading to diagnosis of giant prolactinoma.

Total tumor resection was technically impossible, so a combination of surgical and pharmacological therapy was chosen. First, the patient was treated with Cabergoline (2x/week) which decreased prolactin concentration to 107175.00 mU/I in two weeks, tumor shrank from 5.1x4.9x4.7 cm (61.5cm³) to 4.5x4.3x3.6 cm (36.5 cm³) and the patient regained his vision totally. Three weeks after diagnosis, routine microscopic transsphenoidal adenomectomy was performed to decompress optic chiasm and reduce hormone secreting mass. Surgeons removed tumor mass of 1.6 cm³. Histological findings confirmed the diagnosis of prolactinoma. Surgery led to a decreased prolactin concentration of 45977.97 mU/I. Due to still high levels of prolactin, Cabergoline treatment was continued, the dose increased from 0.25 micrograms to 0.25 milligrams two times a week. A year after, prolactin concentration gradually decreases, vision is normal and follow-up MRI shows only 3.3x2.1x1.8 (6.5 cm³) of tissue remnants. The patient continues the use of Cabergoline, now 1 milligram two times a week.

Summary. An 18-year-old male patient with giant prolactinoma showed a significant positive response to combined pharmacological and surgical therapy (decreased tumor size, prolactin secretion and optic nerve compression) in brief period.

Conclusion. Giant prolactinomas are known for their immense hormonal activity, which cannot be controlled with either only surgery or pharmacological treatment [2]. Despite general practice of conservative surgical prolactinoma treatment [3], this case displays the importance of combined surgical and pharmacological therapy.

Referances:

Subasinghe CJ, Somasundaram N, Sivatharshya P, Ranasinghe LD, Korbonits M. Giant Prolactinoma of Young Onset: A Clue to Diagnosis of MEN-1 Syndrome. Case Rep Endocrinol [Internet]. 2018 Aug 14 [cited 2023 May 3];2018:1–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30186640/
Cho EH, Lee SA, Chung JY, Koh EH, Cho YH, Kim JH, et al. Efficacy and Safety of Cabergoline as First Line Treatment for Invasive Giant Prolactinoma. J Korean Med Sci [Internet]. 2009 Oct [cited 2023 May 3];24(5):874. Available from: /pmc/articles/PMC2752771/
Song YJ, Chen MT, Lian W, Xing B, Yao Y, Feng M, et al. Surgical treatment for male prolactinoma: A retrospective study of 184 cases. Medicine [Internet]. 2017 [cited 2023 May 3];96(2). Available from: https://pubmed.ncbi.nlm.nih.gov/28079813/

Microbiological Findings, Infection Risk Factors and Complications Among Children after Tracheostomy

Marta Daina — 2024-05-24

Summary. Introduction. Bacterial infection of the respiratory tract is highly common among pediatric patients with tracheostomy, yet there is no wide knowledge about the prevalence of different airway microbes, the incidence of bacterial infection, infection risk factors, and complications.

The study aimed to analyze the prevalence of airway microbes, the incidence of bacterial infection, infection risk factors, and complications.

Methods. Retrospective data of officially reported cases were collected from 2018 to 2022 at Riga Children's Clinical University Hospital (RCCUH). Demographic factors, airway microbiological findings, tracheostomy-related complications, underlying conditions, and outcomes for 37 patients were gathered from the hospital's database Andromeda. The data were analyzed using MS Excel. This study received ethical approval from RSU Ethics Committee.

Results. Microbiological analyses were done in 78.3% (n=29) of the cases. Most cultures were obtained from airway aspirate. Altogether 46 different species of microbes were identified. The most frequently identified bacteria were Pseudomonas aeruginosa (in 72.4% of the cases; n=21) and Staphylococcus aureus (65.5%; n=19). Forty-eight percent (n=18) of the patients had respiratory tract infections that required hospitalization. Overall, there were 60 hospitalization episodes of which 51.6% (n=31) were caused by pulmonary bacterial infection, 25.0% (n=15) by non-bacterial infection, and 0.05% (n=3) because of local wound infection. The rest 18.3% (n=11) of hospitalization episodes were due to granulation tissue. The risk factor that showed the greatest significance in the development of bacterial infection was ventilator dependency. Formation of granulation tissue in the airways was found to be the most common complication among pediatric patients with tracheostomy.

Conclusion. This study summarizes the most common pathogens, risk factors, and complications, which should be considered while treating pediatric patients after tracheostomy. The results of this study demonstrate that P. aeruginosa and S. aureus have the highest prevalence among these patients. This research is currently used to develop guidelines for pediatric patients with tracheostomy care in RCCUH.

Keywords. Pediatric tracheostomy; Respiratory infections; Tracheostomy complications

Functional Outcome of Patients Following Intra-articular Tibal Plateau Fractures

Arnis Birze — 2024-05-24

Introduction. Tibial plateau fractures are injuries that often require surgical treatment due to their complexity. The management of these fractures can be challenging and may lead to complications and functional impairment, impacting daily activities significantly.

Aim of the study. The aim of this study was to evaluate of the functional outcome of patients with intra-articular tibial plateau fractures following surgical treatment and to compare the functional outcome between low-energy and high-energy trauma patients following surgical treatment of tibial plateau fractures.

Materials and methods. The study enrolled a total of 108 patients with proximal tibia fractures who were admitted to the Hospital of Traumatology and Orthopaedics between December of 2018 and December 2021. Among them, 88 patients (81,5%) underwent surgical treatment and were included in research groups. Fractures were evaluated using anteroposterior radiograph and computed tomography images and were categorized according to AO/OTA and Schatzker classifications. The patients were divided into two groups: Group A consisted of patients with low-energy trauma, and Group B included patients with high-energy trauma. Functional outcomes were assessed using the Lower Extremity Functional Scale (LEFS).

Results. The study assessed the functional outcome of 45 patients (51,1%) who underwent surgery between 11 and 43 months ago. Among them, Group A consisted of 30 patients with an average age of 54,4 years, and they achieved a mean LEFS score of 54,3 SD +/- 17. On the other hand, Group B included 15 patients with a mean age of 53,4 years, and their average LEFS score was 52 SD +/- 16,8. Statistical analysis using the Mann-Whitney test revealed no significant differences in the mean LEFS score between the two groups, U = 210,0, p = 0,718. When examining the individual activities covered within the LEFS assessment, there were no statistically significant differences observed between the two groups.

Conclusions. Our research findings suggest that, in patients with tibial plateau fractures resulting from low-energy and high-energy trauma, there is no significant difference in post-operative functional outcomes, as per the Schatzker classification of these fractures. This suggests that relying solely on the Schatzker classification may not be adequate for predicting functional outcomes. Factors beyond the appearance of the fracture on anteroposterior radiographs seem to wield substantial influence in determining functional outcomes.

Keywords. Tibial plateau fracture; Functional outcomes; Schatzker classification.

Changes in concentration of carbon dioxide and temperature in university classrooms

Rūta Kauce — 2024-05-24

This study aims to observe variations in temperature, relative humidity, and carbon dioxide concentrations in university classrooms without mechanical ventilation throughout the day. Over three days, two classrooms in Riga Stradiņš University, equipped solely with natural ventilation, were evaluated for variations in indoor air quality. Observations were recorded using the Aranet4 sensor during actual study sessions with varying numbers of occupants, and ventilation periods marked by window operations. The recorded parameters were compared with established indoor air quality guidelines. The results showed that the relative humidity remained within the ideal range (40%-60%) throughout the observation period. Indoor temperature varied between 18 °C to 26 °C, with noticeable increases during practical study sessions and decreases during ventilation periods. The carbon dioxide levels consistently exceeded the safe limit of 1000 ppm during all study sessions, with the time taken to exceed this threshold being directly proportional to the number of occupants. The findings underline the need for strategic ventilation interventions and classroom arrangements, considering occupancy and room size to promote healthier learning environments. Further research incorporating occupant surveys and including diverse educational settings is recommended.

Multisystem Inflammatory Syndrome in Children (MIS-C) with Involvement of Cardiovascular, Respiratory, and Gastrointestinal System: A Case Report

Estere Moorlata — 2024-05-24

MIS-C is a rare complication after COVID-19 that develops because of a dysregulated immune response with an excessive inflammatory response. The definition of MIS-C is based on the following criteria: age of 0-19 years, presence of fever for more than 3 days, involvement of more than two organ systems, elevated inflammatory markers, evidence of COVID-19 infection, and exclusion of differential diagnosis.

This is a case of a 7-year-old female patient who presented to the emergency department with complaints of fever, headache, jaundice, fatigue, and nausea for two days. Physical examination revealed icterus, abdominal pain, hepatomegaly, and palmar erythema. Laboratory results showed leucopenia 3.29 x10 3 /uL, thrombocytopenia 58 x103 /uL, prolonged prothrombin time 48.2 %, INR 1.55, high ferritin 3278 ng/mL, bilirubin 117.34 umol/L, ALT 2003.11 U/L, AST 2224.82, LDH 1165 U/L, D-dimers 4.63 mg/L FEU, creatinine 31.85 umol/L, CRP 50.57 mg/L and NT-ProBNP 504.4 pg/ml. Ultrasonography showed polyserositis, ascites, pericholecystitis, hepatolienal syndrome, fluid accumulation in pleural space, pericardial effusion, tricuspid, and mitral valve insufficiency. It was found that the patient has SARS-CoV-2 spike (s) protein antibodies and IgG against adenovirus. Differential diagnosis of adenovirus associated acute hepatitis was excluded. Thereafter patient was diagnosed with MIS-C with involvement of liver, lungs, and heart. Treatment with immunoglobulins, furosemide, spironolactone, low dose methylprednisolone and aspirin was started. After 12 days of hospitalization patient’s condition normalized and she was discharged home with recommended follow-up.

The diagnosis of MIS-C is challenging due to the wide variety of clinical and laboratory manifestations. The initiation of immunoglobulin therapy is crucial for recovery of patient and should not be delayed as soon as there’s a diagnostic suspicion.

The Impact of the COVID-19 pandemic on primary headache disorders with a particular focus on migraine disorders

Nils Pöhlmann — 2024-05-24

Keywords. Migraine, primary headache disorders, COVID-19, Pandemic,

Objectives. The goal of this research work is to identify “real life” changes of headache days (MHD) and headache intensity of migraineurs during the pandemic, and to demonstrate exact pandemic specific headache-triggers considering the social, economic, and occupational consequences of the COVID-19 Pandemic.

Material and methods. This study included 222 migraineurs currently undergoing treatment at the West German Headache Center. The “pen-paper” survey consisted of 37 questions (dichotomic questions, even/uneven Likert scales, Perceived Stress Scale (PSS), open questions) and compared physical, intellectual, psychological, psychosocial, financial, and professional variables before and during the COVID-19 pandemic, with consequent changes of MHD frequency and intensity in our patient collective.

Results. 2/3 of patients experienced consistent and 1/3 of patients an increase in headache days and headache intensity during the Pandemic. The MHD increased significantly from 14,2±10,1 to 15,3±10,0 (p=<0,01).

Significant correlations between an increase in 1:MHD or 2:Headache-Intensity were found with: Age(2:p=.016;r_s=-.168), no spouse(1:p=.049;r_s=-.138), COVID-19 cases in private environment(1:p=.035;r_s=.146), reduced physical performance(1:p=.023;r_s=-.161), temporary (forced) work reduction(1:p=.023;r_s=-.170), Homeschooling(1:p=.013;r_s=.220), “Home Childcare”(1:p=.007;r_s=.240; 2:p=.011;r_s=.227), fear of own infection(1:p<.001;r_s=.267; 2:p=.002;r_s=.217), fear of infection of others(1:p=.042;r_s=.140), fear of financial hardship(1:p=016;r_s=.170; 2:p=.013; r_s=.177), fear of loneliness(2:p=.005;r_s=.198), fear of meeting people(1:p<.001;r_s=.248; 2:p=.003;r_s=.205), 1:p=.024;r_s=-.158), more conflicts with own children(1:p=.013;r_s=.216; 2:p=.004;r_s=.251), PSS(2:p=.003;r_s=.222). Additionally, the second COVID-19 wave demonstrated a significant worsening of migraine headache compared to the first wave.

Conclusions. Beyond the actual infection, the COVID-19 Pandemic negatively affects the lives and disease experiences of migraineurs. Pandemic-specific stress, worries, fears, as well as various physical and psychological factors caused an increase in migraine headaches in our patients. Only the optimistic feeling of being able to cope well with the pandemic correlated positively with a reduction in MHD.

The Relationship Between Personality Factors and Cooperation Level of Adult Patients During Invisalign Treatment: a Pilot Study

Dāniels Beļajevs — 2024-05-24

Objectives. Patient cooperation level is crucial factor in orthodontic treatment success. There is no clear evidence, how personality traits affect patients' cooperation during orthodontic treatment with clear aligners. The aim of this study is to assess the relationship between the personality traits of an adult patient and cooperation level for treatment with aligners.

Materials and methods. This prospective cohort study evaluated 22 patients, who were in orthodontic treatment with Invisalign clear aligners. Assessments were performed at 6 months and 12 months of the treatment. Assessment involved administration of a general data questionnaire, personality test, intraoral scanning and cooperation questionnaire. Patients personality traits were assessed through the validated Big Five Personality Inventory (BFI) analogue test in the Latvian language[1]. Patient cooperation was assessed by evaluating clinical fitting of aligners to dental arches and comparison of the planned and achieved movements for the upper 1^st premolar expansion (%). Premolar expansion ≤60% and/or aligners did not fit in more than one sextant, considered as insufficient motivation level. Questionnaire and scan results were compared with BFI test results by non-parametric statistical analysis. Data were analyzed in the SPSS. P-value less than 0.05 considered reliable.

Results. 12 patients were cooperative and 10 patients compliance level was considered insufficient. Noncompliant patients had higher scores for neuroticism (p = 0.04). Neuroticism was associated with increased number of missed appointments, non-correspondence of the actual aligner number and planned aligner number, inability to control the financial level. The neuroticism level negatively correlated with the achieved movements of the upper premolars (r = - 0.49, p < 0.05). Higher scores in extraversion were associated with complaining about treatment and worse hygiene scores. Higher scores in conscientiousness were associated with ability to control financial level and parents participation in treatment process. Openness was positively correlated with desire to inform family about the start of the treatment. Neither of personality traits were correlated with other extrinsic motivation factors.

Conclusions. Assessment of the personality traits by the Big Five Personality Inventory could be used for prediction of the patient’s cooperation during treatment with clear aligners.

1 Viktorija Perepjolkina; Promocijas darbs "Daudzdimensionālas personības aptaujas izstrāde un validizācija Latvijas pieaugušo izlasē"; promocijas darba vadītājs: Viesturs Reņģe; aizstāvēšanas datums un vieta: 01.04.2014., LU PPMF;