Point of care transthoracic echocardiography for the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and left ventricular dysfunction : Inferior vena cava and post-spinal anesthesia hypotension in elderly patients

In elderly patients with cardiac diseases, changes in cardiovascular physiology diminish cardiovascular reserve and predispose to hemodynamic instability after spinal anesthesia; hence, such patients could be at risk of postoperative complications. Additionally, transthoracic echocardiography (TTE) is used in clinical practice to evaluate cardiovascular hemodynamics. Therefore, we hypothesized that echocardiographic measurements could display significant diagnostic power in the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and reduced left ventricular ejection fraction (LV-EF). Therefore, sixty-one elderly orthopedic-trauma patients were recruited. Prior to spinal anesthesia a TTE examination was performed. The LV-EF, the stroke volume index (SVI), the peripheral vascular resistance (PVR), the LV filling pressures (E/Em ratio), the right ventricular function [tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV) and fractional area change (FAC)], as well as inferior vena cava (IVC) measurements, such as IVCCI (collapsibility index of the IVC) and dIVCmax (maximum diameter of IVC)-to-IVCCI ratio were assessed. Twenty-six out of sixty-one patients manifested hypotension. Preoperative dIVCmax-to-IVCCI ratio demonstrated the greatest performance amongst echocardiographic indices in predicting post - spinal anesthesia hypotension. The dIVCmax-to-IVCCI ratio < 48 had significantly higher diagnostic power than IVCCI > 0.28, FAC > 42, E/Em ratio < 9 and SVI < 32 (receiver operator characteristic curve analysis). The gray zone for the dIVCmax-to-IVCCI ratio (40-49) showed the lowest number of inconclusive measurements among echocardiographic variables. The preoperative dIVCmax-to-IVCCI ratio could be a reliable echocardiographic index to predict post - spinal anesthesia hypotension in elderly patients with left ventricular dysfunction.

Lung cancer invading the superior vena cava - surgical treatment. A short and up-to-date review

Lung cancer is one of the leading causes of cancer-related deaths worldwide. Superior vena cava syndrome (SVCS) is a rare but potentially life-threatening complication of lung cancer, occurring in approximately 5-10% of cases. There are difficulties in the process of surgical treatment of SVC infiltrated by lung tumors but the contribution of technological evolution and innovation is promising. At the same time, the amelioration of survival rates of patients subjected to surgical treatment is equally promising. The reported outcomes of surgical treatment for SVC invasion due to lung tumors vary depending on the extent of the tumor and the patient's overall health status. However, studies clearly suggest that surgical treatment can improve survival and quality of life in selected patients. The literature review showed that the surgical approach to lung cancer invading the SVC constitutes the most indispensable treatment which helps to achieve the long-term survival of patients.

Validation of parental stress scale in a Greek sample of mothers with infants from 0 to 12 months

Parenting an offspring is a rewarding, albeit challenging task, often accompanied by high levels of stress. It is important to accurately assess the stress associated with parenting, as severe forms of stress may affect the parent-child dyad and lead to poor child outcomes. The aim of this study was to translate and validate the Parental Stress Scale (PSS) in the Greek population. We implemented forward and back translation and conducted a pilot test. A total of 735 mothers (M_age  = 34.6) with infants aged 0-12 months completed the PSS, the Edinburgh Postnatal Depression Scale, and the Hospital Anxiety and Depression Scale. The Greek PSS-18 showed good internal consistency (Cronbach's α = .83) and adequate convergent validity. Results of exploratory and confirmatory factor analysis revealed two underlying factors: positive aspects of parenting and negative aspects of parenting. Our data confirm the validity of the Greek version of the PSS-18 in mothers with infants aged 0-12 months. The Greek version of the PSS-18 could be a useful tool for professionals and researchers who are interested in perinatal period and the aspects of parenthood.

Pain is vital in resuscitation in trauma

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

Mental health and psychosocial factors in young refugees, immigrants and Greeks: A retrospective study

Since 1989, Greece has accepted thousands of economic immigrants and more recently, since 2010, has been transformed to a host country for refugees mainly from countries at war. Refugees experience a number of serious traumas, i.e. death of family member or a close friend, physical, emotional or sexual abuse, and at the same time have to confront poverty, hostility and racism during and after the settlement in the host country. On the other hand, economic immigrants have mainly to face adaption difficulties in a host country including racism, poverty, different culture, bureaucracy. The aim of the current retrospective study was to examine the differences in psychopathology between immigrants, refugees and natives. We examined differences in psychiatric diagnoses and factors influencing their health status between four groups: (i) 90 files of children whose families referred to the Department of Child and Adolescent Psychiatry (DeCAP), University of Athens, during 2005-2009, (ii) 216 files of children whose families seek for help during 2010-2014. Immigrants who referred to the DeCAP during the first period were mainly economic immigrants, whereas immigrants of the second period were mainly refugees from countries in conflict. These data were matched with age and sex with 151 files of natives who referred to the DeCAP during the aforementioned decade: (iii) 72 Greek families who seek for help during 2005-2009, and (iv) 79 Greek families who seek for help during 2010-2014. The Greek comparison group consisted of children and adolescents whose parents were both Greek. Investigating the differences in psychiatric diagnoses (F) and factors influencing health status (Z) between the groups, young refugees received a greater number of Z compared to Greeks (2010-2014). The proportion of refugees who had at least two Z was greater than that of immigrants and Greeks 2010-20014. Regarding the psychiatric diagnoses, Greek sample after 2010 received a greater proportion of psychiatric diagnoses than refugees. These results highlight that refugee families seek for help mainly not for psychiatric reasons. This could reflect their different needs or their difficulty to have access in public health services comparing to immigrants and natives.

[Research and psychoanalysis: A controversial and complex relationship]

The connection between empirical research and clinical practice in the psychoanalytic area, as an approach where the psychoanalytic procedure and its results get objectified, continues to be controversial. Even if it is not so frequent, the significance of giving emphasis to the psychoanalytic areas in research, is evident through the literature review, as the benefits are supported to be many and substantial. To begin with, the empirical research is necessary in order for the psychoanalytic clinical theory to be strengthened in a wider scientifically accepted way and further developed, through the evaluation and the confirmation of what it entreats.3 Moreover, there is an important need of wide research, in order to evaluate the efficacy of the therapeutic techniques, as psychoanalytic therapeutic approaches are frequently adjudged incompetent and they are not form an option of the treatment of many psychiatric and emotional disorders, mainly because of the lack of findings concerning their efficacy. It is a fact though, that research in psychoanalytic areas cannot be conducted in the same way that can be conducted in different clinical interventions. It is essential to be conducted within the epistemological and theoretical environment that the psychoanalysis itself establishes, with main purpose -avoiding every objectification- the subjectification through intersubjectivity. On the other side, both the psychoanalytic thought and the psychoanalytic procedure, have proved to be significantly useful for the conduct of qualitative research and for the understating both of research findings and the way the research itself was carried out. The contribution of the psychoanalytic thought is highly important for the understanding of how the social data are being organized and constructed, as the unconscious has a crucial role in the construction of reality and in the way we perceive others and as a result in the construction of research data and the research environment. In addition, in the field of psycho-social research, the researcher is perceived to be himself part and the data and of the research procedure, as he always got influenced by the dynamics of the people or the group that he studies, operating himself as a "projective surface".

[Impulsivity as an immediate factor between addictive disorders and Attention Deficit-Hyperactivity Disorder]

Impulsivity is a behavior in everyday life of mentally healthy individuals. But in some cases the degree of impulsivity begins to create negative effects on one's life and acquires pathological connotation. Two clinical entities in which can be observed a high degree of impulsivity is Attention Deficit Hyperactivity Disorder (ADHD) and Addictive disorders. In these disorders, both impulsive act and impulsive choice are observed. According to some researchers, genetic factors are involved in the control of impulsivity. The impulsive choice, in the sense of delay discounting, may be an intermediate phenotype or endophenotype that contributes to vulnerability with respect to specific disorders in which impulsivity plays a central and decisive role. Another group of researchers argue that ADHD is one of the expressions of a more generalized disorder, known as reward-deficiency syndrome. In this syndrome, it is included increased frequency of addictive disorders. On the other hand, some researchers argue that ADHD in adolescence does not increase the likelihood of developing dependencies, when it is not accompanied by comorbidity of conduct disorders. Regarding the use of substances, there have been conflicting views in relation to etiopathogenesis of impulsivity observed in the addicted patients and whether this impulsivity precedes or follows the onset of substance use. The element that links ADHD with impaired preoccupation with gambling and has been studied most is also impulsivity. Some researchers theorize that ADHD mediates with the element of impulsivity in the development of disordered involvement with gambling in some patients. The positive correlation between impulsivity and addiction to gambling arises, whether behavioral scales or questionnaires about personality have been used. Moreover the higher measured impulsivity of the patient, the more serious are the symptoms of dependence. Abnormalities in neurotransmitter systems have been found both in patients with dependence on gambling, as well as in patients with impulsive behavior. It seems that impulsivity in these players is part of their personality and not a transient behavior. The variety of views that exists and the debate surrounding this issue reflects the multidisciplinary nature of the phenomenon of impulsivity, when found in dual diagnosis of Attention Deficit/Hyperactivity Disorder and Addictive Disorder. It is important for patients with ADHD or any form of addictive disorder, presenting for treatment, to assess the degree of their impulsivity and to investigate the possible comorbidity with other mental health problems, in which impulsivity plays a central role.

[Attenuated psychosis syndrome: A new diagnostic category for further study in DSM-5]

In recent years an increasing number of studies focus on the issue of early diagnosis and intervention. At the same time, a large number of special service units for early psychosis have been established around the world especially in Australia, USA, UK, Germany etc. Recently, similar units operate in Greece also. The Diagnostic Manual of Mental Disorders of the American Psychiatric Association in its latest edition in 2013 (DSM-5), introduced the category "Attenuated Psychosis Syndrome" (APS) for people with early psychotic experiences in the section: "Conditions for further study '. This new category has specific criteria and describes a situation, in which a person displays psychotic symptoms in an attenuated form, with quite unaffected reality testing, but not qualifying a diagnosis of schizophrenic spectrum. The clinical expression of APS should be differentiated with several well known psychiatric disorders such as: brief psychotic disorder, schizotypal personality disorder, major depression with psychotic features, adolescence adjustment disorders, drug use, etc. The "Attenuated Psychosis Syndrome" occurs mainly in adolescence and in young adulthood. The mean percentage of transition to psychosis for these individuals is estimated at 36%, three years after the onset of initial symptoms, while the risk of transition to psychosis, although smaller, seems to remain up to ten years later. For some other individuals, transition to other psychiatric disorders occurs, such as depression with psychotic elements, or bipolar disorder, while a significant number of them will not transmit to even more serious disorders. At the biological level, studies focused in brain's neuroimaging, suggest significant volumetric differences among people at high risk for psychosis who later develop psychosis compared to those who don't, while studies of psychophysiological indicators or / and genetic markers show promising results for the identification of relevant parameters indicating the transition to psychosis. Αlthough an heterogeneous population, people with APS, show significant difficulties in social, professional and cognitive level, that should be therapeutically addressed. In an attempt to improve the clinical status of these individuals, to delay or even to prevent a psychotic episode, a series of interventions have been used by psychiatrists. These interventions include: (a) administration of drugs, especially atypical antipsychotics or antidepressants in low dosage, (b) administration of non-pharmaceutical supplements (e.g. omega-3 ), (c) psychotherapeutic interventions, mainly cognitive behavior therapy and (d) a combination of the above. Many questions need to be answered such as, the period of therapeutic intervention, identification of indicators (biological or/and clinical) that may determine the most suited for the APS individuals therapeutic interventions or, that may foresee, to prevent the transition to psychosis. Thus, the continuation of research in populations of APS individuals in multiple levels is necessary.

Structural and Theoretical Study of Strontium Borophosphate Glasses Using Raman Spectroscopy and ab Initio Molecular Orbital Method

Strontium borophosphate glasses of composition xSrO·(1 - x)·[0.68B₂O₃·0.32P₂O₅], 0.40 ≤ x ≤ 0.68, have been prepared by fast quenching of high-temperature melts and studied using Raman spectroscopy. In order to comprehend and confirm the obtained spectroscopic Raman data, crystalline compounds and glass-ceramics of analogous compositions were also prepared and studied. Also, ab initio molecular electronic structure theory was used to predict and confirm the experimental vibrational spectra The comparison between theoretical and experimental results showed a good overall agreement. The analysis has focused on a new detailed interpretation of the P-O-B Raman bands. Also, the analysis has revealed a divergent modification of the reported glasses near the meta-stoichiometry where the dominant species in the glass network were found to be borophosphate chains [BP₂O₉]^5-, pyrophosphate P₂O₇^4-, and orthophosphate PO₄^3- units.

Minimally invasive procedures

Minimally invasive procedures, which include laparoscopic surgery, use state-of-the-art technology to reduce the damage to human tissue when performing surgery. Minimally invasive procedures require small "ports" from which the surgeon inserts thin tubes called trocars. Carbon dioxide gas may be used to inflate the area, creating a space between the internal organs and the skin. Then a miniature camera (usually a laparoscope or endoscope) is placed through one of the trocars so the surgical team can view the procedure as a magnified image on video monitors in the operating room. Specialized equipment is inserted through the trocars based on the type of surgery. There are some advanced minimally invasive surgical procedures that can be performed almost exclusively through a single point of entry-meaning only one small incision, like the "uniport" video-assisted thoracoscopic surgery (VATS). Not only do these procedures usually provide equivalent outcomes to traditional "open" surgery (which sometimes require a large incision), but minimally invasive procedures (using small incisions) may offer significant benefits as well: (I) faster recovery; (II) the patient remains for less days hospitalized; (III) less scarring and (IV) less pain. In our current mini review we will present the minimally invasive procedures for thoracic surgery.

The radiographic effects of the scarf bunionectomy on rearfoot alignment

STATEMENT OF PURPOSE

Excessive pronation of the rearfoot has been implicated as a destabilizing force in the progression of hallux abducto valgus. Although the scarf bunionectomy has been shown to effectively correct the intermetatarsal angle associated with hallux valgus deformity, its effect on the rearfoot has yet to be established. The purpose of this case series is to demonstrate the effect of the scarf bunionectomy on rearfoot alignment.

METHODOLOGY

Medical records were reviewed to isolate patients who underwent unilateral or bilateral scarf bunionectomies (with or without akin osteotomy) who had complete medical records, follow-up of at least 12 months, and met the inclusion/exclusion criteria. Preoperative and postoperative radiographic measurements were analyzed at various postoperative time intervals. Standard deviations and statistical significance was obtained.

RESULTS

One hundred feet (71 patients) were included in this analysis. The long-term results of this study highlighted the scarf osteotomy's ability to affect the medial longitudinal arch by decreasing the intermetatarsal angle and lateral talar-first metatarsal angle. The talar declination and calcaneal inclination angle were not significantly altered with the scarf bunionectomy.

CONCLUSION

This case series demonstrates that the scarf bunionectomy had significant effect on radiographic alignment of the bunion deformity and medial longitudinal arch over time. However, its effect on the rearfoot position was not statistically significant.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Series.

Lung cancer surgery: an up to date

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Management in child and adolescent psychiatry: how does it look in the Balkans?

This paper examines the situation of child and adolescent psychiatry in the following Balkan countries: Greece, Serbia, Bulgaria, Romania, Bosnia and Herzegovina, FYROM, and Montenegro. With the exception of Greece, these countries are new democracies, with their mental health services in a transitional stage of organization. Overall, they have initiated programmes to move psychiatric care towards deinstitutionalization, developing outpatient infrastructures to handle psychiatric disorders. Child psychiatry as a specialization is still less developed than adult psychiatry at a significant, albeit different degree among these countries. The number of mental health services offered to children and adolescents is deemed insufficient, and the type of services limited and lacking. This situation is also reflected in the small number of child psychiatrists and other mental health specialists for children and adolescents, as well as in the complete lack (Montenegro) or deficiency of special programmes and actions for children and adolescents. The same also applies to mental health legislation. Greece is the exception in the development of the entire spectrum of services, the number of specialists, and the establishment of an adequate legislation framework reinforced by the incorporation of all international treaties on children's rights; although the recent economic crisis has affected the country negatively, threatening with regression to pre-reformational practices. Children and adolescents in need of mental health care have been increasing in all countries. The effect of violent and sudden changes taking place in most countries is a major factor for the emergence of increased and stress-related psychopathology and psychosocial problems in children and families. In all countries, there is a significant development of nongovernmental organizations undertaking a large part of reformation work. There is also the disconcerting phenomenon of professional exhaustion and the migration of experts from their countries. Finally, there is the common need to develop educational programmes and related clinical practices in all degrees of prevention, promoting interdisciplinary cooperation, the biopsychosocial approach to understanding and dealing with mental health issues, as well as the development of cooperation among all institutions concerning children (education, health, etc.). All this should be reflected in a national plan to promote child mental health as the foundation upon which the necessary cooperation among Balkan countries would be established in order to promote research, the exchange of experiences, common practices, mutual understanding, and common interests.

Epilepsy and intellectual disability: does epilepsy increase the likelihood of co-morbid psychopathology?

Although epilepsy is particularly common among people with intellectual disability (ID) it remains unclear whether it is associated with an increased likelihood of co-morbid psychopathology. We therefore investigated rates of mental health problems and other clinical characteristics in patients with ID and epilepsy (N = 156) as compared to patients with ID but no epilepsy (N = 596). All participants were consecutive referrals to specialist mental heath services. Specialist clinicians agreed on the mental health diagnoses by applying ICD-10 clinical criteria using information gained from interviews with key informants and the patients. Bivariate and multivariate analyses showed that patients with epilepsy were more likely to live in residential housing and have severe ID in line with previous evidence. However, the presence of epilepsy was not associated with an increased likelihood of co-morbid psychopathology. On the contrary, rates of mental health problems, including schizophrenia spectrum, personality and anxiety disorders, were significantly lower among patients with epilepsy. The results are discussed in the context of mood-stabilizing and other psychotropic effects of anti-epileptic drugs in adults with ID and epilepsy, as well as possible diagnostic overshadowing.

Hydrolysis of 2-arachidonoylglycerol in Tetrahymena thermophila. Identification and partial characterization of a Monoacylglycerol Lipase-like enzyme

Tetrahymena thermophila is a model organism for molecular and cellular biology. Previous studies from our group showed that Tetrahymena contains major components of the endocannabinoid system, such as various endocannabinoids and FAAH. In mammalian cells the endocannabinoid 2-arachidonoylglycerol is inactivated mainly by MAGL. In this study we showed that 2-arachidonoylglycerol and 2-oleoylglycerol are hydrolyzed by the combined actions of MAGL and FAAH. MAGL-like activity was examined in the presence of FAAH specific inhibitors, URB597 or AM374 and showed optimum pH of 8-9, apparent K(M) of 14.1μM and V(max) of 5.8nmol/min×mg. The enzyme was present in membrane bound and cytosolic isoforms; molecular mass was determined at ∼45 and ∼40kDa. MAGL and FAAH could also inactivate endogenous signaling lipids, which might play an important role in Tetrahymena as suggested in mammals. Tetrahymena could be used as a model system for testing drugs targeting enzymes of the endocannabinoid system.

A two-dimensional proteomic profile of Tetrahymena thermophila whole cell lysate

Tetrahymena thermophila is a unicellular eukaryotic model organism used for a variety of biochemical, molecular and biological studies. According to its macronucleus genome sequence, it is expected to contain more than 27,000 protein-coding genes, although only a small proportion of them have information published specifically about them. Here, we present a reference map for whole cell lysate of T. thermophila obtained using two-dimensional gel electrophoresis (2-DE) combined with mass spectrometry. Although (2-DE) is one of the most efficient techniques for resolving complex protein mixtures and revealing the relative high-abundance proteins, it has not yet been applied generally to ciliates. In order to obtain qualitative protein samples for analysis, an appropriate homogenization method is required. Optimization of the homogenization method led to the analysis of nearly 4500 protein spots, the final identification of 375 different proteins using Mascot software and an additional 258 gene products using a newly developed web service, called Peptide Finder, resulting in a total of 631 different gene products that are considered to constitute the proteomic profile of the whole cell lysate of T. thermophila.

[Habits and problems of sleep in adolescent students]

The evaluation of sleep habits and sleep related problems in high school adolescent students in the Athens area and the assessment of these problems' relation to demographic and other variables was investigated by the Athens Insomnia Scale - 5 item version (AIS-5), which was administered to 713 adolescent Senior High School students in the Greater Athens Area. Data such as age, sex, school records, and time spent per week in school-related and extracurricular activities were collected. The sample's mean sleep duration was 7,5 hours, mean bedtime 12:20 am and wake-up time 7:15 am. Total sleep time was not affected by gender, but was influenced by time spent in various activities. Sleep complaints were related to delayed sleep, onset latency and insufficient total duration of sleep. Girls complained more than boys, while correlations showed that students with lower academic per formance and those in second grade were more likely to have higher AIS-5 scores. The results show that sleep time of high school students is dependent on practical matters such as school schedule and other activities, while sleep complaints are related to female gender, bad school performance as well as to the second grade. The difference between actual sleep time and sleep complaints should be considered when studying the sleep of adolescents.

[The concept of time and its relation to the psychoanalytic-psychotherapeutic setting]

Psychoanalysis is fundamentally related to time because it is an ef for t to understand how disturbances in the present are determined by events in the past. This paper represents an attempt to delineate the developmental line of time sense from birth to object constancy, concentrating on those maturational and environmental factors which determine psychotemporal adaptation in infancy and early childhood until the age of adolescence. Patients' distortions of time can frequently and readily be observed in clinical psychoanalysis reflecting both their psychopathology and their reactions to the temporal aspects of the psychoanalytic setting.

Expandable wallstents for treatment of tracheoesophageal fistulas of malignant origin

PURPOSE

To present our experience with endoscopic placement of esophageal endoprosthesis with self-expandable wallstents in patients with malignant tracheoesophageal fistulas.

PATIENTS AND METHODS

16 patients were retrospectively evaluated, in whom 16 stents were positioned at the esophagus because of tracheoesophageal fistulas: 12 of them suffered of malignant tumors of the esophagus and 4 of malignant tumors of the lung. All stents were placed with guide wire. We used self-expandable wallstents with internal silicon-basedcovering with flared ends, made of a stainless-steel alloy woven into a tubular mesh.

RESULTS

Stents were successfully places in all patients. No procedure-related mortality or significant morbidity occured. Two patients complained of transient swallowing discomfort, but none of them required any additional analgesia. Thirty-day mortality was nil. Immediate leak occlusion was obtained on erect contrast assessment after the procedure in all patients.

CONCLUSION

Self-expandable wallstents endoprosthesis in the esophagus for fistulas of malignant origin is an easy, well tolerated, safe and effective procedure without important complications or mortality.

Lung cancer: quality of life after surgery

PURPOSE

Lung cancer is the most common cause of cancer death in both men and women in our country. It has been estimated that there will be 6,000 lung cancer deaths every year in Greece. However, many patients with bronchogenic carcinoma also have coexistent obstructive lung disease. In these patients, preoperative prediction of functional status after lung resection is mandatory. The aim of our study was to determine the effect of lung resection on postoperative spirometric lung function.

PATIENTS AND METHODS

112 patients underwent spirometric pulmonary tests preoperatively, and at 3 and 6 months after their operation. The predicted postoperative forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) were calculated using the formula of Juhl and Frost: predicted postoperative FEV1 (or FVC)=preoperative FEV1(or FVC) x[1-(S x 0.0526)], where S=number of segments resected. Statistical significance was defined as a p value < 0.05.

RESULTS

The functional percentage losses at 6 months for lobectomies and pneumonectomies were 7.34% and 34.89% for FVC and 7.72%; and 32.53% for FEV, respectively. The linear regression analysis derived from the correlation between predicted and measured FEV1 resulted in 2 equations for lobectomy and pneumonectomy. The first, for lobectomy, was: FEV1POSTOP=0.00211 + 0.896660 x FEV1PREOP; and the second, for pneumonectomy, was: FEV1POSTOP=0.145 + 0.65318 x FEV1PREOP.

CONCLUSION

We conclude that our formulas are a reliable method for predicting postoperative respiratory function of the patients with lung cancer.

The Influence of Local Instillation of Fusidic Acid on the Development of Microbial Complications After Lung Resection

The efficacy of local instillation of fusidic acid in the prevention of post-surgical microbial complications during various types of lung resection was studied. Four hundred ninety two consecutive patients who underwent 504 thoracotomies for non-small cell lung carcinoma during April 1998-May 2004 were reviewed. The 290 patients of the first period who underwent 298 thoracotomies received a chemoprophylactic regimen of intravenous cefuroxime while the 202 patients of the second period who underwent 206 thoracotomies were additionally treated with fusidic acid, irrigated with local instillation into the pleural space, for the prevention of postoperative septic complications. Patients were followed postoperatively for development of septic complications (empyema and bronchopleural fistula) as well as of pneumonia and wound infection. Seventeen patients (5.7%) of the first period developed empyema and 13 fistula (4.4%), whereas only 2 patients (1.0%) of the second period developed empyema and fistula (OR = 5.876; 95% CI, 1.343- 25.716; P = 0.008 and OR = 4.193; 95% CI, 1.003-20.130; P = 0.034, respectively). Cases of pneumonia decreased, but not significantly, from 21 (7.0%) during the first period to 9 (4.4%) during the second period (OR = 1.613; 95% CI, 0.724-3.593; P = 0.257) while cases of wound infection decreased significantly from 19 (6.4%) to 2 (1.0%) (OR = 6.567; 95% CI, 1.513-28.510; P = 0.003). During the first period 23 pathogens were found from cases of empyema and 73 pathogens from cases of pneumonia and wound infection, whereas during the second period 3 and 18 pathogens were respectively found (OR = 5.3; 95% CI, 1.570-17.888; P = 0.003, and OR = 2.804; 95% CI, 1.628-4.838; P <0.001, respectively). These results indicate that local instillation of fusidic acid in the pleural space prior to lung resection seems effective in reducing the rate of septic complications as well as of wound infections.

Surgery in small cell lung cancer: when and why

Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. For many years, the diagnosis of SCLC was considered a contraindication for surgery because radiotherapy was at least equivalent in terms of local control, and the rate of resectability in SCLC patients was poor. When chemotherapy became the mainstay of treatment for SCLC, radiotherapy was its logical complement, and surgery was progressively abandoned. However, some centers continued to support surgery because experience suggested that in selected patients it was possible to achieve a long-term survival. In the search for predictors of long-term survival it became evident that the TNM staging system was effective for SCLC. The rationale for surgery in the context of SCLC is based on 3 factors: a) Several historical series of patients operated for limited-stage SCLC reported some long-term survivors, showing that cure could be achieved. b) After chemotherapy and radiotherapy, the rate of local relapse is 20%-30%. The assumption that surgical resection might be superior for local disease control has been suggested but not yet proved. c) The surgical intervention can precisely assess pathological (p) response to chemotherapy, identify carcinoids erroneously diagnosed as SCLC, and treat the non-small cell lung cancer (NSCLC) component of tumors with a mixed histology. Even if some controversies exist, it is accepted that surgery can be proposed as the first treatment in patients with T1 or T2 lesions with no evidence of lymph node involvement, followed by adjuvant chemotherapy. In more advanced stages of disease, chemotherapy should be the first step of treatment and surgery can be proposed to responding patients, before radical radiotherapy, depending on the p-stage of disease. Such an intensive multidisciplinary approach should be always employed in the context of controlled clinical trials.

Hearing and speech assessment of cleft palate patients after palatal closure. Long-term results

OBJECTIVE

The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty.

MATERIALS AND METHODS

We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity.

RESULTS

Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients.

CONCLUSIONS

Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.

Percutaneous stent placement in malignant cases of superior vena cava syndrome

PURPOSE

Superior vena cava (SVC) syndrome is caused by SVC stenosis or occlusion, frequently as a consequence of lung cancer or a mediastinal tumor. SVC syndrome is characterized by unpleasant symptoms and the condition usually leads to death if untreated. Treatment with radiation therapy and chemotherapy may produce an initial relief, whereas operations with bypass are associated with high mortality and morbidity. The PURPOSE of our study was to show the efficiency of percutaneous stenting in the SVC for relieving SVC syndrome secondary to malignant diseases.

PATIENTS AND METHODS

From January 1999 to March 2003, 17 patients with malignant SVC syndrome were evaluated at the "Metaxa" Cancer Hospital. Their caval stenoses were confirmed by means of computed tomography and venography. There were 15 males and 2 females with a median age of 62 years (range 47-79). The SCV syndrome was caused by malignant disease in all patients: bronchogenic carcinoma in 14 and lymphoma in 3. All patients underwent placement of a self-expandable (wallstent) endovascular (vena cava) prosthesis.

RESULTS

All procedures were successfully carried out without complications. The average time for wallstent placement was 37 min. There was no sign of bleeding and the wallstent was well positioned on chest roentgenograms. All patients, without exception, noticed an immediate improvement, with relief of dyspnea and rapid resolution of headache. Cyanosis disappeared over the first hour and swelling resolved gradually over the first 24 hours.

CONCLUSION

Percutaneous venous wallstent placement in the SVC is a simple, safe and effective technique to rapidly relieve SVC syndrome caused by malignant diseases.

Completion pneumonectomy for lung cancer

PURPOSE

Completion pneumonectomy is a trully challenging operation associated with increased mortality and morbidity. The aim of this study was to present a series of 18 patients who underwent completion pneumonectomy for lung cancer during a 15-year period and to evaluate the postoperative outcomes and long-term results.

PATIENTS AND METHODS

Between January 1985 and December 2000,18 patients underwent completion pneumonectomy for lung cancer; 10 for local recurrence ,6 for second primary lung tumor and 2 for lung tumors in patients who had previously been operated on for benign disease.

RESULTS

No intraoperative deaths occurred. Postoperative mortality and morbidity were 11.11% and 33.33%, respectively. The median operational time was 212.7 minutes. The mean blood loss during the procedure was 1.042,5 ml. The complication rate was 33.33%. The 5-year survival was 18.75% for all patients. The 5-year survival was 25% for the local recurrence group and 50% for the primary lung cancer group. The 5-year survival of the patients in the second primary tumor group has not been reached yet.

CONCLUSION

Completion pneumonectomy can be performed with an acceptable operative mortality rate and offers a second chance for cure to patients with lung cancer. Although complications are common ,they can successfully be managed with proper understanding of them.

Incisional metastasis after cervical mediastinoscopy: a case report

The risk of iatrogenic tumor seeding from mediastinoscopy is low. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature.

Thoracoscopy, bronchoscopy and mediastinoscopy in the staging of lung cancer

PURPOSE

To estimate the benefit of Video-Assisted Thoracoscopy (VAT) in the staging of patients with lung cancer.

PATIENTS AND METHODS

Between October 1998 and January 2001 VAT was used in 250 patients with histologically proven lung cancer. They were staged by more conventional techniques including magnetic resonance imaging (MRI), bronchoscopy, and mediastinoscopy.

RESULTS

As a result of VAT 30 patients were upstaged and spared a thoracotomy receiving neo-adjuvant chemotherapy at that point. In 40 patients the procedure was converted into an open thoracotomy and a curative resection was performed during the same session. The remaining 180 patients were deemed inoperable and they received chemotherapy and radiation treatment.

CONCLUSION

VAT enhanced our bronchoscopic and medistinoscopic findings. It was especially useful in assessing the extent of invasion of various thoracic structures amenable to surgical removal "en block" with the tumor, and in differentiating simple contact of the tumor with an intrathoracic structure from tumor invasion. In addition, it allowed access and sampling of lymph nodes in spaces not easily accessible by mediastinoscopy.

Prevalence of migraine in schoolchildren and some clinical comparisons between migraine with and without aura

OBJECTIVES

To determine the prevalence of migraine and its association with age, gender, and social class and to find out whether or not the headache and nonheadache characteristics differ between children with migraine, with and without aura, using the diagnostic criteria of the International Headache Society for childhood migraine.

DESIGN

Population-based study in two stages comprising an initial screening questionnaire followed by telephone interviews of children with symptoms.

SETTING

Eighteen kindergarten and 39 primary and secondary schools in Thessaloniki and its semiurban areas.

SUBJECTS

Four thousand children, aged 4 to 15 years, representing a random sample of 5% of schoolchildren in Thessaloniki and its semiurban areas.

MAIN OUTCOME MEASURES

(1) The prevalence of migraine, (2) the connection of migraine with social class, (3) differences in the occurrence of individual symptoms between migraine with and without aura.

RESULTS

The results of the present study show that migraine prevalence was 6.2% (95% confidence interval [CI], 5.4 to 7.0). The estimated prevalences of migraine with and without aura were 2.8% (95% CI, 2.3 to 3.4) and 3.4% (CI, 2.8 to 4.0), respectively. The prevalence of migraine increased with age and it was found to be almost equal in boys and girls aged 7 to 9 years or younger, but in older age groups the prevalence was higher in girls than in boys. The data showed no evidence that connected migraine with social class. It also showed that except for the aura, the headache (e.g., frequency, duration, location, quality, and severity) and nonheadache (e.g., nausea, vomiting, phonophobia, and photophobia) characteristics were no different between children with migraine, with and without aura. In conclusion, our findings indicate that migraine is a common underdiagnosed cause of severe recurrent headache in children. The findings show that childhood migraine is not connected with social class and varies with age and gender, and that except for the aura, both migraine with and without aura are so similar in their headache and nonheadache clinical characteristics that a common pathogenesis is plausible.

Anterior dislocation of the elbow in a child with congenital posterior dislocation of the radial head. A case report

A 9-year-old boy presented with anterior dislocation of the left elbow associated with a long-standing posterior dislocation of the radial head. Lack of full extension of the elbow joint was reported since birth. The dislocated elbow was reduced. No treatment was undertaken for the dislocated radial head. Radiographic evidence of dysplasia of the contralateral radial head provided a significant diagnostic criterion of a congenital malformation.

Giant cell fibroblastoma: an entity or a reactive phenomenon?

The histological and immunohistochemical features of four tumors displaying the characteristic pattern of Giant Cell Fibroblastoma (GCF) are presented. Three of them were found in association with classical and/or myxoid dermatofibrosarcoma protuberans, while the fourth tumor was a retroperitoneal malignant hemangiopericytoma where foci with features of GCF were found. Typical sinusoidal spaces and the bizarre mononuclear and multinucleated cells in close association to blood vessels presenting a wide spectrum of lesions of their walls are also described. These last changes led us to believe that GCF-like lesions might not always characterize an entity but could often represent a host reaction of the connective tissue to locally aggressive or malignant tumors.

Changing trends in the treatment of zygomaticomaxillary complex fractures: a 12-year evaluation of methods used

PURPOSE

The efficacy of the current methods for the treatment of fractures of the zygomaticomaxillary complex was evaluated.

PATIENTS AND METHODS

One thousand two hundred seventy-seven patients with fracture of the zygomaticomaxillary complex and 196 patients with fractures of the zygomatic arch that were admitted between 1984 and 1995 were evaluated. One thousand one hundred fifty surgical procedures were performed, and in 401 cases, no operative treatment was considered necessary. The Gillie's approach was used in 514 cases, intraosseous wiring in 89 cases, bone plate osteosynthesis in 322 cases, Roger-Anderson pins in 180 cases, antral packing in 17 cases, and elevation with a hook in 28 cases.

RESULTS

The best results were achieved with the use of semirigid fixation with miniplates applied at one or more sites of the fractured complex, occasionally used in combination with other methods such as Roger-Anderson pins.

CONCLUSIONS

Semirigid fixation with miniplates offers the most reliable method available today for the treatment of zygomatico-orbital complex fractures and has practically replaced every other method in our institution. The increased cost and occasionally the necessity to remove the hardware are the main disadvantages of the method.

Cystic angiomatosis of bone with massive osteolysis of the cervical spine

The case of a 2 1/2-year-old boy with diffuse cystic angiomatosis of bone is presented. No evidence of visceral involvement was recorded. The clinical, radiographic and histologic findings during the course of the disease process are discussed. At the age of 15 years the patient died of neurologic alterations developed due to massive osteolysis and collapse of the cervical spine, and severe dyspnoea, secondary to persistent bilateral pleural effusions.

Management of nocturnal enuresis in children with desmopressin and bladder physiotherapy

In the last 2 years, 29 children with nocturnal enuresis were treated in the outpatient departments of the Departments of Urology and Pediatric Surgery of the Aristotle University, Thessaloniki. There were 22 boys and 7 girls aged 7 to 12 years. The clinical examination was normal in all cases. All children had undergone various treatments with no beneficial effect, and relapses had occurred. The patients were given desmopressin (DDAVP) nasal drops in combination with bladder physiotherapy; 77% were cured after 12 months. Physiotherapy improves the percentage of cures as the functional capacity of the bladder increases.

Ectopic bone formation in a child with a head injury: complete regression after immobilisation

A girl aged 3 years was struck by an automobile and admitted to hospital unconscious with a head injury and a right hemiparesis. Pelvic and left femoral fractures were managed with skin traction. Three weeks after the injury the range of motion of the right hip joint was reduced and movements were painful. Radiographic examination two weeks later revealed heterotopic bone formation around the hip joint. Immobilisation was the only treatment offered. One year after injury, the ectopic ossification around the hip had resolved spontaneously, and she was able to walk independently.

Soft tissue angiomyolipoma. A case report

A unique case of angiomyolipoma developed in the deep soft tissues of the lower extremity of a 79 year old woman is presented. The initial tumor was misinterpreted as an ordinary lipoma and the recognition of the entity was accomplished only in the recurrent tumor and after the re-evaluation of the slides from the former tumor. The extensive fibroplasia and the bizarre appearance of many proliferating fibroblasts found in the recurrent tumor have been attributed to local host reaction and degenerative changes. However, these changes may create an alarming histologic pattern to the tumor, which need to be differentiated from a lipo- or leiomyosarcoma.

Abdominoscrotal hydrocele

Hydrocele is among the commonest inguinal anomalies in children. One of its most unusual variants is the abdominoscrotal hydrocele, of which no more than 22 cases have been reported in the world literature. The present case is the first one in our country. In this patient the coexistence of small bilateral scrotal hydrocele and cystic abdominal mass at the right side is described. Abdominoscrotal hydrocele is an unusual cause of lower abdominal cystic tumour in association with an inguinoscrotal hydrocele in infancy.

Internal fixation of hip osteotomy in children. Successful healing in 26 children without postoperative casting

We assessed the necessity of postoperative casting when a plate was used for fixation of a proximal femoral varus osteotomy. 26 children without postoperative immobilization were compared to 17 children with a cast. No complications were encountered in either group of children and all osteotomies showed similar healing. Our findings indicate that plate fixation provides adequate stability for healing of the osteotomy.

Torsion of spermatocele and aplasia of the vas deferens. A case report

Torsion of a spermatocele combined with aplasia of the vas deferens is described. The purpose of this case report is that this rare condition should not be omitted from the differential diagnosis of the acute scrotum in childhood. The authors also support that the term "spermatocele" could be used in the non semen producing age of childhood, based upon the non age-dependent pathologic criteria.