The role of reactive oxygen species in the pathophysiology of cardiovascular diseases and the clinical significance of myocardial redox

Acute and chronic excessive intracellular increase of reactive oxygen species (ROS) is involved in the development and progression of cardiovascular diseases. ROS are by-products of various oxidative physiological and biochemical processes. Sources of ROS are mitochondrial respiration, NADH/NADPH oxidase, xanthine oxidoreductase or the uncoupling of nitric oxide synthase (NOS) in vascular cells. ROS mediate various signaling pathways that underlie cardiovascular pathophysiology. The delicate equilibrium between free-radical generation and antioxidant defense is altered in favor of the former, thus leading to redox imbalance, oxidative stress, and increased cellular injury. An understanding of the pathophysiological mechanisms mediated by oxidative stress is crucial to the prevention and treatment of cardiovascular diseases.

The role of reactive oxygen species in myocardial redox signaling and regulation

Reactive oxygen species (ROS) are subcellular messengers in gene regulatory and signal transduction pathways. In pathological situations, ROS accumulate due to excessive production or insufficient degradation, leading to oxidative stress (OS). OS causes oxidation of DNA, membranes, cellular lipids, and proteins, impairing their normal function and leading ultimately to cell death. OS in the heart is increased in response to ischemia/reperfusion, hypertrophy, and heart failure. The concentration of ROS is determined by their rates of production and clearance by antioxidants. Increases in OS in heart failure are primarily a result of the functional uncoupling of the respiratory chain due to inactivation of complex I. However, increased ROS in the failing myocardium may also be caused by impaired antioxidant capacity, such as decreased activity of Cu/Zn superoxide dismutase (SOD) and catalase (CAT) or stimulation of enzymatic sources, including, cyclooxygenase, xanthine oxidase (XO), nitric oxide synthase, and nonphagocytic NAD(P)H oxidases (Noxs). Mitochondria are the main source of ROS during heart failure and aging. Increased production of ROS in the failing heart leads to mitochondrial permeability transition, which results in matrix swelling, outer membrane rupture, a release of apoptotic signaling molecules, and irreversible injury to the mitochondria. Alterations of "redox homeostasis" leads to major cellular consequences, and cellular survival requires an optimal regulation of the redox balance.

Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction.

STUDY DESIGN

Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines.

SETTING & STUDY POPULATIONS

Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms.

SELECTION CRITERIA FOR STUDIES

PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI.

DATA EXTRACTION

Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis.

ANALYTICAL APPROACH

Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses.

RESULTS

We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively.

LIMITATIONS

Practice variability in initiation of dialysis. Imperfect harmonization of data across studies.

CONCLUSIONS

Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.

gamma-H2AX: Can it be established as a classical cancer prognostic factor?

Double-strand breaks are among the first procedures taking place in cancer formation and progression as a result of endogenic and exogenic factors. The histone variant H2AX undergoes phosphorylation at serine 139 due to double-strand breaks, and the gamma-H2AX is formatted as a result of genomic instability. The detection of gamma-H2AX can potentially serve as a biomarker for transformation of normal tissue to premalignant and consequently to malignant tissues. gamma-H2AX has already been investigated in a variety of cancer types, including breast, lung, colon, cervix, and ovary cancers. The prognostic value of gamma-H2AX is indicated in certain cancer types, such as breast or endometrial cancer, but further investigation is needed to establish gamma-H2AX as a prognostic marker. This review outlines the role of gamma-H2AX in cell cycle, and its formation as a result of DNA damage. We investigate the role of gamma-H2AX formation in several cancer types and its correlation with other prognostic factors, and we try to find out whether it fulfills the requirements for its establishment as a classical cancer prognostic factor.

Cytokines as biomarkers of inflammatory response after open versus endovascular repair of abdominal aortic aneurysms: a systematic review

The repair of an abdominal aortic aneurysm (AAA) is a high-risk surgical procedure related to hormonal and metabolic stress-related response with an ensuing activation of the inflammatory cascade. In contrast to open repair (OR), endovascular aortic aneurysm repair (EVAR) seems to decrease the postoperative stress by offering less extensive incisions, dissection, and tissue manipulation. However, these beneficial effects may be offset by the release of cytokines and arachidonic acid metabolites during intra-luminal manipulation of the thrombus using catheters in endovascular repair, resulting in systemic inflammatory response (SIR), which is clinically called post-implantation syndrome. In this systematic review we compared OR with EVAR in terms of the post-interventional inflammatory response resulting from alterations in the circulating cytokine levels. We sought to summarize all the latest evidence regarding post-implantation syndrome after EVAR. We searched Medline (PubMed), ClinicalTrials.gov and the Cochrane library for clinical studies reporting on the release of cytokines as part of the inflammatory response after both open/conventional and endovascular repair of the AAA. We identified 17 studies examining the cytokine levels after OR versus EVAR. OR seemed to be associated with a greater SIR than EVAR, as evidenced by the increased cytokine levels, particularly IL-6 and IL-8, whereas IL-1β, IL-10 and TNF-α showed conflicting results or no difference between the two groups. Polyester endografts appear to be positively correlated with the incidence of post-implantation syndrome after EVAR. Future large prospective studies are warranted to delineate the underlying mechanisms of the cytokine interaction in the post-surgical inflammatory response setting.

Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis

OBJECTIVE

Proximal embolic protection devices (P-EPD) and distal filters (DF) are used to prevent distal cerebral embolizations during carotid artery stenting (CAS). We compared their comparative effectiveness in regards to prevention of intraprocedural and periprocedural adverse events, including ischemic lesions (ipsilateral and contralateral), stroke, transient ischemic attacks (TIA) and death. We also compared the combination of the two neuroprotection strategies vs. a single strategy in regards to ischemic lesions and stroke.

MATERIALS & METHODS

This study was performed according to the PRISMA and MOOSE guidelines and eligible studies were identified through search of PubMed, Scopus and Cochrane Central. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity.

RESULTS

Twenty-nine studies involving 16,307 patients were included. There was a significant reduction in ischemic lesions with the use of P-EPD among observational studies (RR: 0.66 [0.45-0.97]). There were no statistically significant differences for the other outcomes between the two treatment groups.

CONCLUSIONS

There is a number of studies reporting outcomes on the comparison between P-EPD and DF for CAS. P-EDP can reduce distal embolization phenomena resulting into ischemic lesions when compared to DF based on the results from real-world studies. P-EPD was not superior however, in regards to periprocedural stroke, TIA and death. Further studies are anticipated to provide a clear answer to this debate.

Secondary hyperoxaluria: a risk factor for kidney stone formation and renal failure in native kidneys and renal grafts

Secondary hyperoxaluria is a multifactorial disease affecting several organs and tissues, among which stand native and transplanted kidneys. Nephrocalcinosis and nephrolithiasis may lead to renal insufficiency. Patients suffering from secondary hyperoxaluria, should be promptly identified and appropriately treated, so that less renal damage occurs. The aim of this review is to underline the causes of hyperoxaluria and the related pathophysiologic mechanisms, which are involved, along with the description of seven cases of irreversible renal graft injury due to secondary hyperoxaluria.

Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

BACKGROUND

Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair.

MATERIAL AND METHODS

A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications.

RESULTS

Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group.

CONCLUSIONS

Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.

Ureteral endometriosis: A systematic literature review

Introduction:

Ureteral endometriosis is a rare disease affecting women of childbearing age which presents with nonspecific symptoms and it may result in severe morbidity. The aim of this study was to review evidence about incidence, pathogenesis, clinical presentation, diagnosis, and management of ureteral endometriosis.

Materials and Methods:

PubMed Central database was searched to identify studies reporting cases of ureteral endometriosis. “Ureter” or “Ureteral” and “Endometriosis” were used as key words. Database was searched for articles published since 1996, in English without restrictions regarding the study design.

Results:

From 420 studies obtained through database search, 104 articles were finally included in this review, including a total of 1384 patients with ureteral endometriosis. Data regarding age, location, pathological findings, and interventions were extracted. Mean patients' age was 38.6 years, whereas the therapeutic arsenal included hormonal, endoscopic, and/or surgical treatment.

Conclusions:

Ureteral endometriosis represents a diagnostic and therapeutic challenge for the clinicians and high clinical suspicion is needed to identify it.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review

BACKGROUND

Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication.

METHODS

A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded.

RESULTS

In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery.

CONCLUSIONS

Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.

Spontaneous isolated superior mesenteric artery dissection: Systematic review and meta-analysis

OBJECTIVES

Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease with an incidence of 0.06%. The purpose of the meta-analysis was to identify the outcomes associated with the various treatment options in the management of asymptomatic and symptomatic patients with SISMAD.

METHODS

Eligible studies were selected by searching PubMed, EMBASE, and Cochrane Library. Endpoints were outcome of asymptomatic patients treated conservatively, resolution of symptoms according to the treatment approach, rate of symptomatic patients switched from conservative to the endovascular and/or open repair, characteristics of the dissected lesion, and findings regarding the remodeling of superior mesenteric artery.

RESULTS

We identified 30 studies including 729 patients. Among them, 608 (83.4%) were symptomatic and were managed with conservative (438/72%), and/or endovascular (139/22.8%) and/or open treatment (31/5%). The remaining were asymptomatic and they were treated solely conservatively. A high rate of resolution of symptoms (92.8%) was noted for patients treated conservatively. Conversion from conservative treatment to either endovascular or open procedure was required in 12.3% and 4.4%, respectively. Resolution of symptoms was observed in 100% for those treated with open procedure and 88.8% for those treated endovascularly. The pooled rate of bowel ischemia in patients treated conservatively was 3.75% (95% confidence interval = 1.15-7.27). Complete remodeling was achieved in 32% and partial in 26% of those who were treated conservatively.

CONCLUSIONS

The majority of symptomatic patients with SISAMD were treated conservatively and showed an uncomplicated course and only a small percentage required conversion to endovascular or open repair. This might highlight the benign course of the disease.

Duplex Ultrasound versus Computed Tomography for the Postoperative Follow-Up of Endovascular Abdominal Aortic Aneurysm Repair. Where Do We Stand Now?

In the last decade, endovascular aneurysm repair (EVAR) has rapidly developed to be the preferred method for infrarenal abdominal aortic aneurysm repair in patients with suitable anatomy. EVAR offers the advantage of lower perioperative mortality and morbidity but carries the cost of device-related complications such as endoleak, graft migration, graft thrombosis, and structural graft failure. These complications mandate a lifelong surveillance of EVAR patients and their endografts. The purpose of this study is to review and evaluate the safety of color-duplex ultrasound (CDU) as compared with computed tomography (CT), based on the current literature, for post-EVAR surveillance. The post-EVAR follow-up modalities, CDU versus CT, are evaluated questioning three parameters: (1) accuracy of aneurysm size, (2) detection and classification of endoleaks, and (3) detection of stent-graft deformation. Studies comparing CDU with CT scan for investigation of post-EVAR complications have produced mixed results. Further and long-term research is needed to evaluate the efficacy of CDU versus CT, before CDU can be recommended as the primary imaging modality for EVAR surveillance, in place of CT for stable aneurysms.

A systematic review and meta-analysis for the management of Paget-Schroetter syndrome

OBJECTIVE

There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed.

METHODS

The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated.

RESULTS

Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis.

CONCLUSIONS

Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.

Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases

INTRODUCTION

Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made.

METHODS

Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate.

RESULTS

Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward.

CONCLUSIONS

Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.

Update on Surgical Management of Small Bowel Neuroendocrine Tumors

The widespread use of endoscopy and imaging in combination with the continuous update of the staging systems for neuroendocrine tumors has led to an increase in the incidence of small intestinal neuroendocrine tumors (si-NENs) globally. Despite high survival rates, severe complications may occur even in early stages due to the anatomic location of the primary site and the desmoplastic reaction. Surgery plays a central role in the management of patients with si-NENs. Excision of locoregional disease along with extensive lymph node dissection should be performed in fit patients, even in the presence of metastases. Multimodality treatment of liver metastases includes hepatectomy, ablative techniques and liver transplantation. Hormone therapy with somatostatine analogs is of high importance for symptomatic control; special caution should be exercised both pre- and intra-operatively. A multidisciplinary approach is essential in order to provide personalized therapeutics for patients with si-NENs. Clinical research and specialization in this field should be further encouraged.

Simultaneous Transcatheter Aortic Valve Implantation and Infrarenal Aortic Aneurysm Repair for Severe Aortic Stenosis and Abdominal Aortic Aneurysm: Report of 2 Cases and Literature Review

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population. Both conditions have adverse outcomes, if not adequately managed. No clear recommendations are available in the literature until today, in regards of the management sequence making thus the decision-making challenging. We report 2 cases of AAA and significant AS treated with endovascular aortic repair (EVAR) and transcatheter aortic valve implantation (TAVI) during the same procedure and a review of the literature on this topic. Based on our experience, the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential.

Outcomes of endosutured aneurysm repair with the Heli-FX EndoAnchor implants

OBJECTIVE

Endovascular aneurysm repair has gained field over open surgery for the treatment of abdominal aortic aneurysm. However, type Ia endoleak represents a common complication especially in hostile neck anatomy that is recently faced using endoanchors. We conducted a systematic review and meta-analysis to collect and analyse all the available comparative evidence on the outcomes of the endosuture aneurysm repair in patients with or without hostile neck in standard endovascular aneurysm repair.

METHODS

The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the prospective and retrospective studies reporting primary use of the Heli-FX EndoAnchor implants were considered eligible for inclusion in this study. The main study outcomes (technical success of endoanchor implantation, incidence of type Ia endoleak, aortic stent graft migration and the percentage of patients who presented regression or expansion of aneurysm sac throughout the follow-up) were subsequently expressed as proportions and 95% confidence intervals.

RESULTS

Eight studies with a total of 968 patients were included in a pooled analysis. The technical success of the primary endoanchor fixation was 97.12% (95%CI: 92.98-99.67). During a mean six months follow-up period, a pooled rate of 6.23% (95%CI: 0.83-15.25) of the patients developed a persistent type Ia endoleak despite the primary implantation. Migration of the main graft was reported in five studies, in which a 0.26% (95%CI = 0.00-1.54) of the patients required an additional proximal aortic cuff. Regression of the aneurysm sac was observed at 68.82% (95%CI: 51.02-84.21). An expansion of the aneurysm sac was found in 1.93% (95%CI: 0.91-3.24) of the participants. The overall survival rate was 93.43% (95%CI: 89.97-96.29) at a mean six months follow-up period.

CONCLUSIONS

Endosuture aneurysm repair with the Heli-FX EndoAnchor implants seems to be technically feasible and safe either for prevention or for repair of intraoperative type Ia endoleak. Despite the primary implants of endoanchors, few cases of persistent type Ia endoleak and migration are still conspicuous. Long-term follow up is needed to determinate the role of this therapeutic option in the treatment of aortic aneurysms.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

gamma-H2AX: A potential biomarker in breast cancer

Histone H2AX undergoes phosphorylation as an answer to DNA double-strand breaks, which in turn are part of the oncogenic procedure. The detection of gamma-H2AX can potentially serve as a biomarker for transformation of normal tissue to premalignant and consequently to malignant tissues. The aim of this study was to evaluate the clinical significance of gamma-H2AX expression in breast cancer. Gamma-H2AX expression in tissues from 110 breast cancer patients was analyzed by immunohistochemistry and correlated with clinicopathological variables. Greater tumor size, higher grade, and the number of affected lymph nodes are significantly associated with greater values of gamma-H2AX. In addition, gamma-H2AX differs significantly among patients' International Federation of Gynecology and Obstetrics stage. Higher values of estrogen receptor and progesterone receptor are significantly associated with lower gamma-H2AX values. In conclusion, a positive association between gamma-H2AX expression and infaust histopathological parameters was observed.

Evaluation of cerebrovascular reserve capacity in symptomatic and asymptomatic internal carotid stenosis with transcranial Doppler

Cerebrovascular reserve capacity (CVRC) is a hemodynamic parameter indicating the brain's capacity to overcome ischemia. Transcranial Doppler (TCD) is a useful device to measure CVRC, with high availability and low cost. The aim of the study is to investigate asymptomatic patients with affected CVRC, who could benefit from CEA. One hundred and forty five consecutive patients (60 symptomatic and 65 asymptomatic), with internal carotid artery (ICA) stenosis >70 % and 20 healthy individuals without internal carotid stenosis underwent TCD-inhalation CO(2) tests in order to measure the CVRC in both hemispheres of each patient. CVRC between asymptomatic and symptomatic patients were significantly different in the 95 % confidence interval (CI) as well as the mean CVRC value in contralateral carotid artery. The correlation between CVRC in the carotid artery with stenosis and the existence of symptoms is significant at the 0.01 level. Additionally, symptoms and CVRC of the contralateral carotid artery are also significant at the 0.05 level and CVRC values in asymptomatic patients and the control group at the 0.01 level. None of the covariant factors, except the age, are significantly correlated with CRVC. CVRC could be an early mark-index to evaluate the risk of stroke in this group of patients and to design their therapeutic approach.

The profile of patients receiving public and private surgical services in Greece during the economic crisis: a comparative study

Background

International experience has shown that deterioration of healthcare services is a common consequence of socio-economic crises. Exact mechanism of this deterioration varies with respect to particularities of each healthcare system, government and administrative policies and local epidemiological conditions. The aim of the present study was to evaluate the effect of Greek economic crisis on the profile and the satisfaction rates of patients seeking surgical services in public and private hospitals.

Methods

A questionnaire-based survey concerning healthcare quality and patients' satisfaction was conducted at a private and a public (university) hospital. Patient demographics alongside with patient satisfaction before and after treatment were quantified and compared.

Results

Significant differences between private and public sector patients were found concerning nationality, socio-economic status and medical conditions. Private sector patients are younger, of a higher socio-economic status and admitted for elective rather than urgent medical conditions. Patient expectations before treatment are lower for public sector concerning a variety of markers but patient satisfaction is similar.

Conclusions

Even in the years of financial crisis, Greek patients seem to be satisfied by the quality of the healthcare services in both public and private hospitals. Despite the limitations of our study regarding the selection of the population, we believe that the findings might generate more meticulous research on the field hoping that juxtaposed discussions will sensitize policy makers.

Neutrophil Gelatinase Associated Lipocalin (NGAL) as a Biomarker. Does It Apply in Abdominal Aortic Aneurysms? A Review of Literature

Neutrophil gelatinase associated lipocalin (NGAL) as a protein derived from neutrophils has recently been the field of investigation in a wide range of diseases (renal disease, coronary artery disease, etc). The MEDLINE/PubMed database was searched for publications with the medical subject heading "NGAL" and keywords "Abdominal aortic aneurysm (AAA)," "biomarker," and "growth". We restricted our search to date. In this review, we included 38 articles and abstracts that were accessible and available in English. An effort to further explain the role of NGAL within AAA has been made. NGAL seems to be a hopeful marker for the pathogenesis and the progression of abdominal aortic aneurysms (AAAs), which has significant morbidity and mortality rates.

The effect of exercise on coagulation and fibrinolysis factors in patients with peripheral arterial disease

Peripheral arterial disease is a widely prevalent atherosclerotic occlusive disorder. Symptoms commence with exercise-induced pain in the lower extremities, known as claudication. Despite the fact that exercise has been shown to improve fibrinolytic profile some patients, the effect of exercise on coagulation and fibrinolysis cascades in claudicants has not been comprehensively defined. Literature search in English language yielded 13 studies of exercise on claudicants, including 420 patients. Claudicants tend to have a higher coagulation activity at rest compared to healthy individuals, a trend that persists even after exercise. Post-exercise coagulation activity of claudicants is increased when compared to their respective baseline levels, but it is so in a non-consistent manner. From the available data, it has been suggested that claudicants have a functional and effective fibrinolytic mechanism in place, operating continuously at a relatively higher activity level compared to healthy individuals. Fibrinolysis seems to be activated by exercise; a positive outcome with a prolonged effect as shown by a few of the studies. A final conclusion whether coagulation or fibrinolysis activity is affected mostly by exercise type and intensity in claudicants could not be answered. All conclusions regarding the effect of exercise on the coagulation and fibrinolysis mechanisms should be taken under cautious consideration, due to the limited number of studies, the small number of patients and the different exercise strategies employed in each study. Further randomized studies with similar exercise protocols could provide safer conclusions in the future.

Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.