Volume 76 (2022): Issue 3 (June 2022)

Lung cancer is the leading cause of cancer-related mortality worldwide. Early diagnosis of lung cancer is hampered by the absence of specific symptoms and the lack of a widely recognised cost-effective screening programme. Acquisition of a tumour tissue sample for morphological and molecular genetic examination is of paramount importance for cancer diagnosis. We describe diagnostic challenges for early-stage lung cancer and their possible current solutions. Liquid biopsy is a relatively new technology that was developed for evaluation of tumour-related circulating genetic material. Recent achievements in data processing provide more opportunities for wider implementation of Next Generation Sequencing (NGS) in clinical practice. This article summarises available data on the current and future role of liquid biopsy in the management of lung cancer. We also present an ongoing Latvian lung cancer study that focuses on integration of liquid biopsy with comprehensive clinical data utilising advantages of information technologies.

This study compared the reference intervals (RI) of B12 vitamin concentration in blood found in the literature with RIs extracted from data accumulated from a large number of patients by E. Gulbis Laboratory in Latvia. This paper investigated and demonstrated the possibility of using large amounts of random patient data to establish the RI for clinical laboratory tests. The blood level of B12 vitamin was selected as the model system for this study. The study used blind data for B12 blood level measurements from 132 379 patients accumulated in E. Gulbis Laboratory over a period of 15 years. In order to establish the reference intervals, the frequency distribution of log transformed B12 values was fit to a Gaussian distribution. The established B12 reference interval of 196 pg/ml and 942 pg/ml was found to be in good agreement with RIs reported elsewhere.

This retrospective single-centre study was conducted in an intensive care unit (ICU) in Pauls Stradiņš Clinical University Hospital (Rīga, Latvia) between 1 October 2020 and 30 April 2021. The aim was to assess the baseline clinical characteristics and their association with outcome for critically ill coronavirus disease 2019 (COVID-19) patients admitted to the ICU and requiring invasive mechanical ventilation (IMV). Demographic, clinical, laboratory, length-of-stay and mortality data were collected from medical records. In total, 66 critically ill patients admitted to the ICU were enrolled in this study. 77% were male, and the median age was 65.5 [57.0–70.8] years. Comorbidi-ties included obesity (67.2%), cardiovascular disease (63.6%) and type II diabetes (38.1%). Prone positioning was performed in most cases (68.2%) and one-third (34.8%) of patients required renal replacement therapy during their stay in the ICU. The median time to intubation after hospitalisation was eight [3.3–10.0] days. The median length-of-stay in the ICU was 12 [6.0–18.5] days and the overall mortality among all invasively ventilated patients in the ICU was 86%. In survivors, the duration of time between the onset of symptoms and hospitalisation, and time between the onset of symptoms and intubation, were found to be shorter than in non-survivors.

The aim of the study was to investigate how cerebral vasospasm, vasodilation and haemorrhage under artificial circulation conditions during cardiopulmonary bypass affect transcranial duplex ultrasonography measurements. A description of transcranial duplex ultrasonography and phantom development is provided. Measurements were made using a commercially available ultrasound system and cardiopulmonary bypass machine, water phantom and 32% glycerol solution with cornstarch. The experiments showed that the cerebral blood vessel condition in artificial circulation affects transcranial duplex ultrasonography measurement limit values. The most sensitive parameter for blood vessel condition changes is Peak Systolic Velocity (PSV) for which changes were observed in 100% of cases. The most insensitive was Time-Averaged Peak-Velocity (TAPV), and Minimum Diastolic Velocity (MDV) for which changes were observed in 83% of cases.

Degenerative joint diseases affect the elderly population, and advanced orthopaedic surgery offers novel solutions. The semi-sitting position is used during shoulder replacement surgery. There have been reports of transient and permanent neurological damage following surgery. We aimed to determine cerebral desaturation events (CDEs) during shoulder replacement surgery under general anaesthesia. This prospective, observational study was conducted at the Hospital of Traumatology and Orthopaedics. A cohort of 24 patients received combined plexus brachialis block and endotracheal anaesthesia. Their cerebral regional oxygen saturation index (rSO₂) and mean arterial blood pressure (MAP) were recorded and compared in predefined intervals: before induction, post-induction, after getting in a sitting position, after cementing, and after extubation. Hypotension was defined as the occurrence of any of the following: either a > 30% decline in MAP from the baseline or a MAP < 65 mmHg. CDEs were defined as a 20% reduction in frontal lobe oxygenation. Calculations were made using SPSS software (Version 14.0.2, SPSS Inc.). There was a significant correlation between MAP and rSO₂ after positioning, between MAP after intubation and rSO_2., and between MAP before intubation and rSO₂ at the end of surgery. One in three patients who experienced hypotension also experienced a CDE. rSO₂ fluctuations correlated with MAP.

The recent COVID-19 pandemic has made important changes to the everyday practice of anaesthetists. Current research has shown that the virus spreads via respiratory droplets and aerosolisation. The aim of this study was to examine the extent of contact contamination, droplet spread and aerosolisation, which may occur with normal breathing and intubation in a mannequin study. In the first experiment, an Ambu bag was attached to the simulation mannequin’s trachea and an atomiser device was placed into the mannequin’s pharynx. This model simulated normal ventilation as 0.5 ml of luminescent fluid was sprayed through the atomiser. In the second experiment, the mannequin was intubated with a videolaryngoscope while spraying 0.5 ml of luminescent fluid through the atomiser, after which the laryngoscope was removed. The spread of the luminescent aerosol cloud after three full breaths, droplet spread and contact contamination were visualised using ultraviolet light. The extent of spread was evaluated using a 4-point Likert scale (0 to 3) by two observers. Each of the experiments was repeated five times. For the first experiment, aerosol formation, droplet spread and contact contamination were 2.5 (2–3), 1 (0–1), 0 (0–1) points. In the second experiment, aerosol formation, droplet spread and contact contamination were 0.5 (0–1), 1 (0–1), 3 (2–3) points, accordingly. Noticeable contact contamination occurs during laryngoscopy and removal of the laryngoscope, whereas droplet contamination with laryngoscopy and normal breathing is minimal. Normal breathing leads to significant aerosol formation.

Optimal preoxygenation (PO) prior to tracheal intubation reduces the risk of arterial desaturation and prolongs the period of safe apnoea. The common methods of PO are mask ventilation with 100% O₂ for 3–5 minutes or, alternatively, asking the patient to take eight deep breaths in a minute. Our study group conducted a prospective study to assess the impact of the most common risk factors on PO and to compare the efficiency of PO in patients undergoing elective and emergency abdominal surgery without premedication. PO was performed using mask ventilation with 6 l/min of 100% oxygen for 5 minutes. End-tidal oxygen (EtO₂) was documented in 30-second increments. We found that optimal PO (EtO₂ > 90%) was not achieved by almost half of the patients (46%) and that this was more common in the elective surgery group. Effective PO was not impacted by any of the evaluated risk factors for suboptimal oxygenation. Despite these findings, we believe that the identification of potential risk factors is crucial in the pre-anaesthesia stage, given the benefits of optimal PO.

Sepsis is among the leading causes of mortality globally. Blood purification techniques are evolving in sepsis therapy, aiming at pathogenic antigens and host cytokines. The aim of this study was to determine whether continuous renal replacement therapy (CRRT) with modified AN69ST membrane, brand name oXiris, improves the clinical course of adult patients with septic shock. The study had a retrospective, longitudinal, propensity score matching (PSM) design with two groups: treatment — CRRT started with oXiris, control — used ST150 filters only. Data from 636 patients were analysed. The oXiris and control groups included 40 and 57 patients, respectively. PSM left 19 patients in each group. Ten of 19 patients died in the oXiris group. Survival, CRRT duration, intensive care unit or hospital length of stay did not differ between the groups. The oX-iris group had a tendency for lower mortality in Gram-negative infection cases, though not statistically significant. During the first 72h of CRRT, both groups had improvement in noradrenaline requirement, arterial pressure and blood lactate. However, with oXiris treatment, increase of arterial pressure (TA) was greater during CRRT during the first 24h and there was a more significant decrease of noradrenaline infusion and lactate during the first 72 h. We concluded that in septic shock early CRRT with oXiris may be beneficial and that there might be decreased hospital mortality in the case of Gram-negative infection. Further larger studies are required.

Ultrasound measurement of hyomental distance is promising as a predictor for difficult laryngoscopy in cases of difficult airway management. The aim of the study was to evaluate the prognostic value of ultrasound measurement of hyomental distance (HMD) for prediction of difficult laryngoscopy. Hyomental distance was sonographically measured in neutral (HMDn) and extreme head extension (HMDe) positions for fifty-six patients scheduled for elective surgery requiring tracheal intubation. Then the hyomental distance ratio (HMDR) was calculated. According to presence of difficult laryngoscopy assessed by the Cormack–Lehane (CL) score, patients were divided into a difficult laryngoscopy group (DL, n = 15) and easy laryngoscopy group (EL, n = 41). We calculated the sensitivity and specificity of HMDn, HMDe, and HMDR for difficult laryngoscopy. DL was present in 15 (27%) patients. We found a significant intergroup difference in HMDR between the DL and EL groups (1.12 ± 0.04 vs. 1.24 ± 0.06, respectively; p < 0.001). In contrast, we were not able to find a significant difference for HMDn and HMDr. HMDR had the highest sensitivity 86.7% and specificity 85.4% (p < 0.01) to predict difficult laryngoscopy, where the area under the curve was 0.939; p < 0.01 for HDMR < 1.2 cm. Moreover, we found that difficult laryngoscopy was associated with higher body mass index (BMI), with higher values in the DL group compared to EL patients (34.3 ± 9.1 vs. 28.5 ± 5.7 kg/m², respectively; p = 0.035). HMDR < 1.2 cm measured by ultrasound might have a good predictive value for prediction of difficult laryngoscopy.

Proximal femoral fractures are typical injuries in the elderly population. We conducted a retrospective study to estimate postoperative mortality and risk factors affecting patient outcomes at Tartu University Hospital. We retrospectively evaluated patients who were hospitalised in 2017 with a proximal femoral fracture diagnosis and who were operated (osteosynthesis, partial and total hip replacement). In the study we included 313 patients of 361 (219 women and 94 men). We did not find statistically significant difference between the choice of anaesthesia and mortality or between the time getting to the OR and mortality. Cognitive impairment and postoperative delirium were significantly associated with increased one-year mortality was 37% (p < 0.05). In the group of the patients who did not have postoperative delirium the overall mortality was 15%. 23% of the patients had preoperatively cognitive impairment, and 45.8% of them died in the first year after the operation (p < 0.001). Mortality of patients who did not have cognitive impairment was 14%. As the sample group of patients included in the study was small, further investigation should encompass a larger group in the future.

Teamwork is one of the most important aspects in medicine today. It is known that the operating room is the place where communication is most needed between doctors and other medical staff. The purpose of this study was to analyse the view of nurses towards collaboration between the physician and nurse in an anaesthesiology department depending on education and work experience. The study was conducted in three Lithuanian hospitals. The questionnaires “Jefferson scale of attitudes toward physician–nurse collaboration” and “Barriers of communication between doctors and nurses” were used. The statements of the questionnaires were rated using the Likert scale; the attitude was evaluated as positive when the assessment was more than median (2.5). The results were processed by SPSS Statistics 23.0 pack, using descriptive statistics and ANOVA, with statistically significant results when p < 0.05. A total of 138 nurses participated in this study, all female, aged 43.00 ± 12.48 years and with different education levels. According to the nurses, the most important aspects of teamwork were dominance of physicians (3.08 ± 0.65), nurse’s autonomy (3.46 ± 0.54), patient care (3.33 ± 0.56) and sharing knowledge and cooperation (3.33 ± 0.47) (F = 12.47; p < 0.001). Patient care and autonomy of nurses were most important aspects for nurses with higher education and short job experience, and physician dominance was the most important for nurses with a longer job experience and lower education level. Barriers to cooperation arising from environmental factors are the greatest drivers for ineffective teamwork.

Since the first liver transplantation at the Kaunas Clinic of the Hospital of Lithuanian University of Health Sciences (LUHS), in 2000, many changes have been implemented and an increasing number of cases led to the development of expertise. The aim of this article was to summarise 12-years out of liver transplantation experience. Data was obtained retrospectively from inpatient medical records at the Hospital of LUHS, Kaunas Clinic. All cases of liver transplantations from November 2009 to September 2021 were included (n = 96). The median age of transplant recipients was 50 years (IQR 46–56). Two-thirds of recipients were male (n = 66, 69%). The mean Model for End-Stage Liver Disease (MELD) score was 23 (SD 6). The most common indication for liver transplantation was hepatitis C virus-related end-stage liver disease (n = 24, 25%). Immediate extubation was performed with a median of 63% of cases (IQR 14.3–75.7%). We further compared data between the early (November 2009 – December 2015) and late phases (January 2016 – September 2021) of experience: the number of liver transplantation cases increased by 66% from 36 to 60), MELD scores stayed similar (an average of 22 vs 24, p = 0.282), and mean intraoperative time did not change significantly (543 minutes vs 496 minutes, p = 0.078). Liver transplantation has been gaining momentum in Lithuania. Increasing experience enables our centre to meet an increasing demand for liver transplantations.