Embolisation of a high - flow renal arteriovenous fistula with the use of simultaneous transvenous and transarterial approach and balloon-assisted coil embolization

BACKGROUND

Renal arteriovenous fistula (RAVF) is a rare vascular malformation, which can be asymptomatic or may cause hemorrhage, hypokalaemic hypertension, heart failure and hematuria. Endovascular embolization is a minimally invasive method which can preserve renal parenchyma. In our case, balloon assisted coil embolization with simultaneous transvenous and transarterial approach was used. A remodelling balloon, which is routinely used in neurovascular procedures, was chosen in order to eliminate the risk of coil migration and preserve feeding artery and renal parenchyma.

CASE PRESENTATION

We present a case of successful balloon - assisted coil embolization of a high flow renal arteriovenous fistula in a 25-year-old male patient via simultaneous transarterial and transvenous approach with preservation of the feeding artery.

CONCLUSION

Endovascular embolisation is a safe and effective treatment of RAVFs with low risk of complications. Simultaneous transarterial and transvenous coil deployment with the use of a flow control balloon catheter can eliminate the risk of coil migration and coil protrusion into the parent artery with permanent RAVF occlusion and renal parenchyma preservation.

The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures

BACKGROUND

Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery.

METHODS

All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

RESULTS

An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)].

CONCLUSION

Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries

INTRODUCTION

As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS

All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS

A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION

The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

Prioritizing patients for hip fracture surgery: the role of frailty and cardiac risk

Introduction

The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h.

Methods

All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality.

Results

A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively.

Conclusion

Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.

Incidental Petrous Apex Cephalocele Presenting With Transient Global Amnesia: A Case Report and Rapid Literature Review

Transient global amnesia (TGA) constitutes a rare clinical entity that manifests with temporary memory without any other neurological manifestation. Several pathogenetic mechanisms have been implicated, including temporal hypoperfusion, venous congestion, and cortical spreading potentials. Accordingly, the only relevant imaging findings are hippocampal CA1 areas of restricted diffusion on diffusion-weighted images. In the current case report, we present the rare case of a patient with TGA associated with bilateral petrous apex cephalocele (PAC). A 63-year-old female presented with a single episode of transient memory. The brain MRI showed a bilateral PAC and an empty sella. The patient was neurologically intact upon examination and was conservatively managed. There was no symptom recurrence during the six months of follow-up. We hypothesize that the presence of the meningocele could be associated with the pathogenesis of TGA. To the best of our knowledge, this is the first case of a petrous apex meningocele presenting with TGA. Most previously reported patients were females in their fourth decade of life, usually presenting with headaches or incidentally. Almost half of the cases were bilateral, with an empty sella. Surgical treatment was reserved for symptomatic patients with cerebrospinal fluid leaks and excruciating trigeminal neuralgia. Patients with TGA may be associated with temporal lesions, including PAC. Likewise, PAC is an extremely rare clinical entity that could occasionally present with TGA.

Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample

BACKGROUND

The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay.

METHODS

All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model.

RESULTS

An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0.

CONCLUSION

Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.

Proximity superconductivity in atom-by-atom crafted quantum dots

Gapless materials in electronic contact with superconductors acquire proximity-induced superconductivity in a region near the interface1,2. Numerous proposals build on this addition of electron pairing to originally non-superconducting systems and predict intriguing phases of matter, including topological3-7, odd-frequency8, nodal-point9 or Fulde-Ferrell-Larkin-Ovchinnikov10 superconductivity. Here we investigate the most miniature example of the proximity effect on only a single spin-degenerate quantum level of a surface state confined in a quantum corral11 on a superconducting substrate, built atom by atom by a scanning tunnelling microscope. Whenever an eigenmode of the corral is pitched close to the Fermi energy by adjusting the size of the corral, a pair of particle-hole symmetric states enters the gap of the superconductor. We identify these as spin-degenerate Andreev bound states theoretically predicted 50 years ago by Machida and Shibata12, which had-so far-eluded detection by tunnel spectroscopy but were recently shown to be relevant for transmon qubit devices13,14. We further find that the observed anticrossings of the in-gap states are a measure of proximity-induced pairing in the eigenmodes of the quantum corral. Our results have direct consequences on the interpretation of impurity-induced in-gap states in superconductors, corroborate concepts to induce superconductivity into surface states and further pave the way towards superconducting artificial lattices.

Actinide Ion (Americium-241 and Uranium-232) Interaction with Hybrid Silica-Hyperbranched Poly(ethylene imine) Nanoparticles and Xerogels

The binding of actinide ions (Am(III) and U(VI)) in aqueous solutions by hybrid silica-hyperbranched poly(ethylene imine) nanoparticles (NPs) and xerogels (XGs) has been studied by means of batch experiments at different pH values (4, 7, and 9) under ambient atmospheric conditions. Both materials present relatively high removal efficiency at pH 4 and pH 7 (>70%) for Am(III) and U(VI). The lower removal efficiency for the nanoparticles is basically associated with the compact structure of the nanoparticles and the lower permeability and access to active amine groups compared to xerogels, and the negative charge of the radionuclide species is formed under alkaline conditions (e.g., UO2(CO3)34- and Am(CO3)2-). Generally, the adsorption process is relatively slow due to the very low radionuclide concentrations used in the study and is basically governed by the actinide diffusion from the aqueous phase to the solid surface. On the other hand, adsorption is favored with increasing temperature, assuming that the reaction is endothermic and entropy-driven, which is associated with increasing randomness at the solid-liquid interphase upon actinide adsorption. To the best of our knowledge, this is the first study on hybrid silica-hyperbranched poly(ethylene imine) nanoparticle and xerogel materials used as adsorbents for americium and uranium at ultra-trace levels. Compared to other adsorbent materials used for binding americium and uranium ions, both materials show far higher binding efficiency. Xerogels could remove both actinides even from seawater by almost 90%, whereas nanoparticles could remove uranium by 80% and americium by 70%. The above, along with their simple derivatization to increase the selectivity towards a specific radionuclide and their easy processing to be included in separation technologies, could make these materials attractive candidates for the treatment of radionuclide/actinide-contaminated water.

Radioactivity/Radionuclide (U-232 and Am-241) Removal from Waters by Polyurea-Crosslinked Alginate Aerogels in the Sub-Picomolar Concentration Range

The removal of radionuclide/radioactivity from laboratory and environmental water samples under ambient conditions was investigated via batch-type experiments using polyurea-crosslinked calcium alginate (X-alginate) aerogels. Water samples were contaminated with traces of U-232 and Am-241. The removal efficiency of the material depends strongly on the solution pH; it is above 80% for both radionuclides in acidic solutions (pH 4), while it decreases at about 40% for Am-241 and 25% for U-232 in alkaline solutions (pH 9). This is directly associated with the presence of the radionuclide species in each case; the cationic species UO22+ and Am3+ prevail at pH 4, and the anionic species UO2(CO3)34– and Am(CO3)2− prevail at pH 9. Adsorption on X-alginate aerogels is realized by coordination of cationic species on carboxylate groups (replacing Ca2+) or other functional groups, i.e., –NH and/or –OH. In environmental water samples, i.e., ground water, wastewater and seawater, which are alkaline (pH around 8), the removal efficiency for Am-241 is significantly higher (45–60%) compared to that for U-232 (25–30%). The distribution coefficients (Kd) obtained for the sorption of Am-241 and U-232 by X-alginate aerogels are around 105 L/kg, even in environmental water samples, indicating a strong sorption affinity of the aerogel material for the radionuclides. The latter, along with their stability in aqueous environments, make X-alginate aerogels attractive candidates for the treatment of radioactive contaminated waters. To the best of our knowledge, this is the first study on the removal of americium from waters using aerogels and the first investigation of adsorption efficiency of an aerogel material at the sub-picomolar concentration range.

Midterm Outcomes of Endoleak Type 2 Embolization after Endovascular Aortic Aneurysm Repair Using a Neurointerventional Approach

BACKGROUND

Type 2 endoleaks (T2ELs) have been considered a benign condition and intervention is recommended when they are associated to sac expansion. The aim of this study was to report on T2EL embolization midterm outcomes, using neurointerventional material.

METHODS

A single-center retrospective analysis of consecutive patients treated with transarterial embolization, using neurointerventional material, for T2EL after standard endovascular aortic aneurysm repair (EVAR) between January 01, 2017 and July 30, 2022, was undertaken. Primary outcome was technical success and secondary outcome was T2EL recurrence during follow-up.

RESULTS

Twenty six patients [92.3% males, mean age 73.9 ± 7.7 years] were included. The median time between EVAR and T2EL diagnosis was 12 months (range: 1-84 months). In 38.5% of patients, T2EL was detected at first month after EVAR. The time to embolization was 18 months (range: 1-96 months). In 42.3% of cases, a patent inferior mesenteric artery was suspected to relate to T2EL formation while in 42.3% of cases, a lumbar artery. Twelve procedures (38.4%) were performed using coils and Onyx and 13 (50%), using only Onyx. Technical success was 84.6%. The mean follow-up was 24 months (range: 1-60 months), including 20 patients. In 30% of cases, an T2EL recurrence was detected. Three patients (11.5%) underwent secondary embolization.

CONCLUSIONS

Transarterial embolization for T2EL, using neurointerventional material, provided acceptable technical success and T2EL recurrence rates at 2 years of follow-up. Longer follow-up data would further estimate the durability of the technique.

The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality

PURPOSE

Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

METHODS

All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS ≥ 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

RESULTS

After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

CONCLUSION

Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

The effect of SGLT-2i administration on red blood cell distribution width in patients with heart failure and type 2 diabetes mellitus: A randomized study

Background

Recent studies suggest that the pivotal mechanism of sodium glucose co-transporter-2 inhibitors (SGLT-2i) favorable action in patients with heart failure (HF) and type 2 diabetes mellitus (DM) is the stimulation of erythropoiesis via an early increase in erythropoietin (EPO) production which leads to hematocrit rise. Red blood cell distribution width (RDW) is a simple hematological parameter which reflects the heterogeneity of the red blood cell size (anisocytosis). Since, EPO has been also implicated in the pathophysiology of RDW increase, the current mechanistic study examined the effect of SGLT-2i administration on red blood cells size (RDW) in patients with HF and DM.

Methods

The present was a prospective single-center study. Patients (N=110) were randomly assigned to dapagliflozin (10 mg a day on top of antidiabetic treatment) or the control group. Inclusion criteria were: (a) age > 18 years, (b) history of type 2 DM and hospitalization for HF exacerbation within 6 months. The evaluation of patients (at baseline, 6 and 12 months) included clinical assessment, laboratory blood tests, and echocardiography. Data were modeled using mixed linear models with dependent variable the RDW index. In order to find factors independently associated with prognosis (1-year death or HF rehospitalization), multiple logistic regression was conducted with death or HF rehospitalization as dependent variable.

Results

An RDW increase both after 6 and after 12 months was observed in the SGLT-2i (dapagliflozin) group (p < 0.001 for all time comparisons), whereas RDW didn't change significantly in the control group. The increase in RDW was positively correlated with EPO, while negatively correlated with ferritin and folic acid (p < 0.005 for all). Baseline RDW was significantly associated with 1-year death or rehospitalization, after adjusting for group (SGLT-2i vs. control), age, gender, smoking and BMI at baseline.

Conclusion

RDW increased with time in patients with HF and DM who received SGLT-2i (dapagliflozin). The increased RDW rates in these patients may stem from the induction of hemopoiesis from dapagliflozin. Baseline RDW was found to be independently associated with outcome in patients with HF and DM.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Background

Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses.

Methods

This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders.

Results

A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia.

Conclusions

Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups.

Level of evidence: Therapeutic/Care Management, level III

Balloon-Assisted Coil Embolization and Balloon Angioplasty for Post Subarachnoid Hemorrhage Vasospasm: Initial Experience with Scepter Mini Balloon

The scope of this technical note is to report our experience with balloon remodeling for wideneck aneurysms and balloon angioplasty of post-subarachnoid hemorrhage vasospasm using the novel Scepter Mini balloon (SMB). Five cases were treated with balloon remodeling for aneurysmal subarachnoid hemorrhage, 2 of which were additionally treated with angioplasty due to post-bleeding vasospasm. All patients had their aneurysm located on parent vessels with a diameter smaller than 2 mm. Complete occlusion was noted in all aneurysms, and the patients had no short-term complications attributed to the catheterization. Additionally, we confirm the previously reported smooth navigation of the balloon through vessels with tortuous anatomy without catheter-induced vasospasm. Based on our experience, the SMB can be a safe and efficient device for applying the balloon remodeling technique for distally located wide-neck aneurysms and distal balloon angioplasty.

β-Adrenergic blockade in patients with dementia and hip fracture is associated with decreased postoperative mortality

Purpose

Dementia, present in 20% of hip fracture patients, is associated with an almost threefold increase in postoperative mortality risk. These patients have a substantially higher incidence of cardiovascular, respiratory, and cerebrovascular mortality after hip fracture surgery compared to patients without dementia. This study aimed to investigate the association between beta-blocker therapy and postoperative mortality in patients with dementia undergoing hip fracture surgery.

Methods

This nationwide study included all patients in Sweden with the diagnosis of dementia who underwent emergency surgery for a hip fracture between January 2008 and December 2017. Cases where the hip fracture was pathological or conservatively managed were not included. Poisson regression analysis with robust standard errors was performed while controlling for confounders to determine the relationship between beta-blocker therapy and all-cause, as well as cause-specific, postoperative mortality.

Results

A total of 26,549 patients met the study inclusion criteria, of whom 8258 (31%) had ongoing beta-blocker therapy at time of admission. After adjusting for clinically relevant variables, the incidence of postoperative mortality in patients receiving beta-blocker therapy was decreased by 50% at 30 days [adj. IRR (95% CI) 0.50 (0.45–0.54), p < 0.001] and 34% at 90 days [adj. IRR (95% CI) 0.66 (0.62–0.70), p < 0.001]. Cause-specific mortality analysis demonstrated a significant reduction in the incidence of postoperative cardiovascular, respiratory, and cerebrovascular death within 30 and 90 days postoperatively.

Conclusion

Beta-blocker therapy is associated with decreased postoperative mortality in hip fracture patients with dementia up to 90 days after surgery. This finding warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01723-y.

Predictive Values of Preoperative Characteristics for 30-Day Mortality in Traumatic Hip Fracture Patients

Hip fracture patients have a high risk of mortality after surgery, with 30-day postoperative rates as high as 10%. This study aimed to explore the predictive ability of preoperative characteristics in traumatic hip fracture patients as they relate to 30-day postoperative mortality using readily available variables in clinical practice. All adult patients who underwent primary emergency hip fracture surgery in Sweden between 2008 and 2017 were included in the analysis. Associations between the possible predictors and 30-day mortality was performed using a multivariate logistic regression (LR) model; the bidirectional stepwise method was used for variable selection. An LR model and convolutional neural network (CNN) were then fitted for prediction. The relative importance of individual predictors was evaluated using the permutation importance and Gini importance. A total of 134,915 traumatic hip fracture patients were included in the study. The CNN and LR models displayed an acceptable predictive ability for predicting 30-day postoperative mortality using a test dataset, displaying an area under the ROC curve (AUC) of as high as 0.76. The variables with the highest importance in prediction were age, sex, hypertension, dementia, American Society of Anesthesiologists (ASA) classification, and the Revised Cardiac Risk Index (RCRI). Both the CNN and LR models achieved an acceptable performance in identifying patients at risk of mortality 30 days after hip fracture surgery. The most important variables for prediction, based on the variables used in the current study are age, hypertension, dementia, sex, ASA classification, and RCRI.

The mortality burden in patients with hip fractures and dementia

Purpose

Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population.

Methods

All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality.

Results

134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60–1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99–11.07), p < 0.001].

Conclusions

Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

Prevalence of diabetes and pre-diabetes in Greece. Results of the First National Survey of Morbidity and Risk Factors (EMENO) study

AIMS

To report the results of the first national Health Examination Survey (HES) on the prevalence of diabetes, its pharmacologic treatment and level of control, as well as pre-diabetes in Greece.

METHODS

Data were derived from the National Survey of Morbidity and Risk Factors (EMENO), in a randomly selected, representative sample of the adult Greek population. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age/sex distribution to the population. Non-response was adjusted by inverse probability weighting. Weighted prevalence estimates are provided.

RESULTS

A total of 4393 persons with HbA1c and/or fasting plasma glucose measurements were included. Total diabetes prevalence was 11.9% (95% CI: 10.9-12.9), known diabetes 10.4% (9.5-11.4), and unknown 1.5% (1.1-1.9), with considerable increase in older age groups and no difference between genders. Pre-diabetes prevalence was 12.4% (11.4-13.6). The majority of persons with known diabetes were receiving metformin. Of those with known diabetes (and measured HbA1c), 70.9% were well controlled (HbA1c <7.0%).

CONCLUSIONS

This first representative national HES showed high prevalence of diabetes in Greece, with low prevalence of unknown diabetes. Pre-diabetes prevalence is also substantial. These results will hopefully enable national authorities develop tailored and efficient strategies for disease prevention and management.

Adherence to the National Guidelines for Follow-Up Protocol in Subjects with Type 2 Diabetes Mellitus in Greece: The GLANCE Study

INTRODUCTION

Physician adherence, or lack therefore, to diabetes care and follow-up guidelines may be linked to the rates of achieving suboptimal glycaemic, blood pressure and lipid targets in people with type 2 diabetes mellitus (T2DM). In this cross-sectional study we evaluated physician adherence to the patient follow-up protocol (PFP) of the 2017 Hellenic Diabetes Association (HDA) guidelines and also assessed glycated haemoglobin (HbA_1c), blood pressure and lipid control achievement rates in the routine care setting in Greece.

METHODS

Eligible subjects were adults with T2DM receiving oral hypoglycaemic agents (OHAs) for ≥ 1 year who had ≥ 2 HbA_1c measurements in the previous year and an HbA_1c target < 7%. Overall adherence at the subject level was defined as the percentage of the 62 HDA PFP items that had been met during the past year.

RESULTS

Between June and December 2018, 601 eligible subjects (54.6% men; mean age 65.2 years; median T2DM duration 5.9 years, of whom 96.5% had ≥ 1 medical condition/comorbidity), were enrolled into the study by 53 hospital- and office-based endocrinologists, internists and general practitioners. The main OHAs prescribed at enrolment were metformin (91.0%), dipeptidyl peptidase-4 inhibitors (60.7%), sodium-glucose co-transporter-2 inhibitors (23.5%) and sulphonylureas (16.3%). Mean overall physician adherence to the PFP was 43.6%. Predictors of greater higher physicans' adherence were female sex (p = 0.026), > 3 medical conditions/comorbidities (p = 0.043) and diabetic complications (p < 0.001). HbA_1c, low-density lipoprotein-cholesterol, systolic/diastolic blood pressure and composite metabolic targets were achieved by 82.1, 57.0, 42.6 and 21.6% of subjects, respectively.

CONCLUSIONS

In Greek routine care, physician adherence to the PFP of the 2017 HDA guidelines is suboptimal. Future efforts should focus on identifying the barriers to an adequate adherence by physicians to the full PFP, with the aim to provide optimal patient care.

Possible mechanisms of direct cardiovascular impact of GLP-1 agonists and DPP4 inhibitors

Diabetes mellitus is a leading cause of cardiovascular morbidity and mortality worldwide. Traditional antidiabetic therapies targeting hyperglycemia reduce diabetic microvascular complications but have minor effects on macrovascular complications, including cardiovascular disease. Instead, cardiovascular complications are improved by antidiabetic medications (metformin) and other therapies (statins, antihypertensive medications) ameliorating insulin resistance and other associated metabolic abnormalities. Novel classes of antidiabetic drugs have proven efficacious in improving glycemia, while at the same time exert beneficial effects on pathophysiologic mechanisms of diabetes-related cardiovascular disease. In the present review, we will present current evidence of the cardiovascular effects of two new classes of antidiabetic medications, glucagon-like peptide 1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP4) inhibitors, focusing from mechanistic preclinical and clinical investigation to late-phase clinical testing.

Clinical Characteristics of Patients with co-Existent Diabetic Peripheral Neuropathy and Depression: A Systematic Review

Objectives Both diabetic peripheral neuropathy and depression have significant implications on patients’ quality of life, management and outcomes. We aimed to evaluate all available evidence concerning patients with co-existent diabetic peripheral neuropathy and depression, and describe their clinical characteristics, in order to promote early recognition and management.

Methods Systematic search of PubMed for studies providing data on patients with diabetic peripheral neuropathy and depression. The primary outcome was to evaluate all available evidence related to characteristics of diabetes, diabetic peripheral neuropathy and depression. Secondary study outcomes included comorbid conditions and complications in these patients.

Results Final analysis included 24 studies with data on 205 patients. Most patients were adults between 18–65 years of age. Mean HbA1c value was above 8% and most patients were treated with insulin. Neuropathy was predominantly painful and most patients with available data were considered to have major depressive disorder. In addition to diabetic peripheral neuropathy and depression, diabetes-related complications were recorded in 43 patients, the most common being autonomic neuropathy, retinopathy and nephropathy. The most frequently reported comorbidities were weight loss (72 patients), impotence (60 patients), hypertension (23 patients) and coronary artery disease (22 patients).

Conclusions The present study describes the characteristics of patients with co-existent diabetic peripheral neuropathy and depression, aiming for prompt detection, prevention of further deterioration and improvement of patient outcomes. Available evidence shows that the majority of these patients are adults, with painful peripheral neuropathy and with insulin-treated and inadequately controlled diabetes.

Diet, life-style and cardiovascular morbidity in the rural, free living population of Elafonisos island

BACKGROUND

There are about 70 small islands in the Aegean and Ionian Sea, of less than 300 Km2 and 5000 inhabitants each, comprising a total population of more than 75,000 individuals with geographical and socioeconomic characteristics of special interest. The objective of the present study was to assess lifestyle characteristics and the state of cardiovascular risk of the population of a small Eastern Mediterranean island, Elafonisos.

METHODS

PERSEAS (Prospective Evaluation of cardiovascular Risk Surrogates in Elafonisos Area Study) is an ongoing, population-based, longitudinal survey of cardiovascular risk factors, life-style characteristics and related morbidity/mortality performed in a small and relatively isolated island of the Aegean Sea, named Elafonisos. Validated, closed-ended questionnaires for demographic, socio-economic, clinical and lifestyle characteristics were distributed and analyzed. The MedDietScore, a validated Mediterranean diet score was also calculated. In addition, all participants underwent measurement of anthropometric parameters, blood pressure and a full blood panel for glucose and lipids.

RESULTS

The analysis included 596 individuals who represented 74.5% of the target population. The mean age of the population was 49.5 ± 19.6 years and 48.2% were males. Fifty participants (8.4%) had a history of cardiovascular disease (CVD). The rates of reported diabetes, hypertension, and hypercholesterolemia were 7.7%, 30.9% and 30.9% respectively, with screen-detection of each condition accounting for an additional 4.0%, 12.9%, and 23.3% of cases, respectively. Four hundred and seven individuals (68.3%) were overweight or obese, 25% reported being physically inactive and 36.6% were active smokers. The median MedDietScore was 25 [interquartile range: 6, range 12-47] with higher values significantly associated with older age, better education, increased physical activity, absence of history of diabetes and known history of hypercholesterolemia.

CONCLUSIONS

Obesity and traditional risk factors for CVD are highly prevalent among the inhabitants of a small Mediterranean island. Adherence to the traditional Mediterranean diet in this population is moderate, while physical activity is low. There seems to be a need for lifestyle modification programs in order to reverse the increasing cardiovascular risk trends in rural isolated areas of the Mediterranean basin.

Expert consensus on the rational clinical use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors

Two proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, evolocumab and alirocumab, have recently been approved by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of hypercholesterolemia. These fully human monoclonal antibodies selectively block PCSK9, thus permitting the low-density lipoprotein (LDL) receptor to effectively recycle to the surface of liver cells. The administration of these antibodies leads to robust LDL cholesterol (LDL-C) lowering by 50-60% on top of maximum hypolipidemic treatment. At least 4 randomized, placebo-controlled studies are under way and will address the question of whether the administration of these PCSK9 inhibitors is associated with a significant reduction of cardiovascular events. Because of the high cost associated with the use of these medications it is very important to consider which patients may gain the most benefit, at least until the results of outcome studies are available. In this Consensus paper, 34 clinicians/scientists define 3 groups of patients that should be currently considered as candidates for the use of these novel drugs. These include: 1a. Adults with established cardiovascular disease and LDL-C≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 1b. Adults with diabetes and established cardiovascular disease or chronic kidney disease or target organ damage and LDL-C ≥100 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe, 2. Adults with familial hypercholesterolemia (FH) without established cardiovascular disease and LDL-C ≥130 mg/dL while on lifestyle modifications and maximally tolerated hypolipidemic treatment, i.e. high-intensity statin + ezetimibe (evolocumab is also indicated in children above 12 years with homozygous FH), and 3. Adults at high or very high cardiovascular risk who are statin intolerant and have an LDL-C ≥100 and ≥130 mg/dL, respectively, while on any tolerated hypolipidemic treatment.

Respiratory Syncytial Virus Uses CX3CR1 as a Receptor on Primary Human Airway Epithelial Cultures

Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory disease in infants, but no vaccine or effective therapy is available. The initiation of RSV infection of immortalized cells is largely dependent on cell surface heparan sulfate (HS), a receptor for the RSV attachment (G) glycoprotein in immortalized cells. However, RSV infects the ciliated cells in primary well differentiated human airway epithelial (HAE) cultures via the apical surface, but HS is not detectable on this surface. Here we show that soluble HS inhibits infection of immortalized cells, but not HAE cultures, confirming that HS is not the receptor on HAE cultures. Conversely, a “non-neutralizing” monoclonal antibody against the G protein that does not block RSV infection of immortalized cells, does inhibit infection of HAE cultures. This antibody was previously shown to block the interaction between the G protein and the chemokine receptor CX3CR1 and we have mapped the binding site for this antibody to the CX3C motif and its surrounding region in the G protein. We show that CX3CR1 is present on the apical surface of ciliated cells in HAE cultures and especially on the cilia. RSV infection of HAE cultures is reduced by an antibody against CX3CR1 and by mutations in the G protein CX3C motif. Additionally, mice lacking CX3CR1 are less susceptible to RSV infection. These findings demonstrate that RSV uses CX3CR1 as a cellular receptor on HAE cultures and highlight the importance of using a physiologically relevant model to study virus entry and antibody neutralization.

Respiratory syncytial virus (RSV) is the second most common infectious cause of infant death worldwide. Despite this great clinical impact, no effective antivirals or vaccines against RSV are available. Here we find that the RSV attachment (G) glycoprotein uses CX3CR1 as a receptor on primary human airway epithelial (HAE) cultures, an excellent model of RSV infection of the human lung. The G protein contains a CX3C motif and we find that this region is critical for its role in infection of HAE cultures, but not of immortalized cells. Furthermore, we find that antibodies against the G protein neutralize RSV infection of HAE cultures differently from immortalized cells. These insights suggest that HAE cultures should be used to quantify neutralizing antibodies, including during vaccine development, that the CX3CR1 interaction with the RSV G protein could be a target for antiviral drug development, and that the G protein should be considered for inclusion in vaccines.

Splenic Lymphangioma

Splenic lymphangioma is a rare malformation of the splenic lymphatic channels, mostly seen in children. It is characterized by the presence of cysts, resulting from increases in the size and number of thin-walled lymphatic vessels that are abnormally interconnected and dilated. The condition may be restricted to the spleen, but in most cases it involves multiple organs (systemic lymphangiomatosis). The clinical picture is variable; small lesions are often incidentally detected through imaging studies, while larger lesions can result in compression of organs, causing pain or rupture even after minor trauma. Therefore, splenic lymphangiomas should be considered in the differential diagnosis of splenomegaly or left upper quadrant pain even among adults and should be immediately treated with splenectomy; delay in the therapeutic intervention can lead to life-threatening complications.

Diabetes treatment in patients with renal disease: Is the landscape clear enough?

Diabetes is the most important risk factors for chronic kidney disease (CKD). The risk of CKD attributable to diabetes continues to rise worldwide. Diabetic patients with CKD need complicated treatment for their metabolic disorders as well as for related comorbidities. They have to treat, often intensively, hypertension, dyslipidaemia, bone disease, anaemia, and frequently established cardiovascular disease. The treatment of hypoglycaemia in diabetic persons with CKD must tie their individual goals of glycaemia (usually less tight glycaemic control) and knowledge on the pharmacokinetics and pharmacodynamics of drugs available to a person with kidney disease. The problem is complicated from the fact that in many efficacy studies patients with CKD are excluded so data of safety and efficacy for these patients are missing. This results in fear of use by lack of evidence. Metformin is globally accepted as the first choice in practically all therapeutic algorithms for diabetic subjects. The advantages of metformin are low risk of hypoglycaemia, modest weight loss, effectiveness and low cost. Data of UKPDS indicate that treatment based on metformin results in less total as well cardiovascular mortality. Metformin remains the drug of choice for patients with diabetes and CKD provided that their estimate Glomerular Filtration Rate (eGFR) remains above 30 mL/min per square meter. For diabetic patients with eGFR between 30-60 mL/min per square meter more frequent monitoring of renal function and dose reduction of metformin is needed. The use of sulfonylureas, glinides and insulin carry a higher risk of hypoglycemia in these patients and must be very careful. Lower doses and slower titration of the dose is needed. Is better to avoid sulfonylureas with active hepatic metabolites, which are renally excreted. Very useful drugs for this group of patients emerge dipeptidyl peptidase 4 inhibitors. These drugs do not cause hypoglycemia and most of them (linagliptin is an exception) require dose reduction in various stages of renal disease.

Metabolic effects of renal denervation

In the present review article we address the issue of the potential effect of renal sympathetic denervation (RSD) on metabolic states associated with resistant hypertension. So far, there is an established pathophysiological background denoting that abnormalities in glucose metabolism especially in obese patients and in those with sleep apnea are constantly accompanied by increased sympathetic firing, as assessed by markers of sympathetic activity. Since resistant hypertension is also characterized by enhanced sympathetic activity, it seems logical and biologically plausible, that RSD might favorably influence impaired glucose metabolism, sleep disorders and increased body adiposity beyond BP lowering. Despite the limited evidence from clinical trials, there are promising data suggesting that RSD indeed ameliorates glucose metabolism-related measures in resistant hypertension. Well-designed randomized trials recruiting a larger number of patients with hypertension, and focused on metabolic parameters, may refine the role of RSD as a potential intervention to treat dysmetabolic states associated with hypertension.

Rectal extranodal Rosai-Dorfman disease diagnosed by EUS-FNA: a case report and review of the literature

Rosai-Dorfman disease (RDD), also known as "sinus histiocytosis with massive lymphadenopathy," only rarely involves the gastrointestinal (GI) tract. Therefore, this unusual site of presentation can be challenging for the pathologist. We present a case of RDD manifesting as a rectal submucosal mass associated with rectal bleeding in a 54 year old woman. The diagnosis was made on cytologic preparations obtained through endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and subsequently confirmed by biopsy. To our knowledge, this is the first time extranodal RDD of the GI tract has been diagnosed by EUS-FNA. A review of previously published cases of GI RDD is presented to increase awareness of this exceptional presentation.

Study of postprandial lipaemia in type 2 diabetes mellitus: exenatide versus liraglutide

Therapeutic approaches based on the actions of the incretin hormone GLP-1 have been widely established in the management of T2DM. Nevertheless, much less research has been aimed at elucidating the role of GLP-1 in lipid metabolism and in particular postprandial dyslipidemia. Exenatide and liraglutide are two GLP-1 receptor agonists which are currently available as subcutaneously administered treatment for T2DM but their chronic effects on postprandial lipaemia have not been well investigated. The aim of this study is to examine the effect of treatment with either liraglutide or exenatide for two weeks on postprandial lipaemia in obese subjects with T2DM. This study was a single-center, two-armed, randomized, controlled 2-week prospective intervention trial in 20 subjects with T2DM. Patients were randomized to receive either liraglutide or exenatide treatment and underwent a standardized meal tolerance test early in the morning after 10 h fast at baseline (visit 1, beginning of treatment) and after a two-week treatment period (visit 2). Exenatide and liraglutide both appear to be equally effective in lowering postprandial lipaemia after the first administration and after a two-week treatment. The mechanisms which lead to this phenomenon, which seem to be independent of gastric emptying, are yet to be studied.

Endovascular treatment of ruptured dissecting posterior inferior cerebellar artery aneurysms

Dissecting aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin from vertebral artery (VA) are very rare. Although rare, they associated with a high risk of rebleeding and they present a therapeutic challenge. This study reviewed the clinical presentations, angiographic characteristics of dissecting aneurysms of the PICA and to assess the clinical and angiographic outcomes of patients who underwent endovascular treatment. Ten patients with ten dissecting aneurysms who underwent endovascular treatment were identified in the clinical records of a single medical center from January 2000 to December 2010. The mean follow-up duration was 2.8 years. All patients presented with subarachnoid hemorrhage (SAH). They all underwent endovascular treatment, which included occlusion of the dissected segment and the parent artery after detailed angiographic evaluation of the vascular anatomy, and test occlusion of the PICA. In all patients the endovascular treatment was successfully completed without procedure related complications. Long-term follow-up studies in seven out of ten patients showed complete occlusion of the aneurysm with no new neurologic deficits. The clinical outcome was good in eight cases, whereas two patients with poor clinical condition at admission died during their initial hospital stay. Endovascular occlusion of the parent vessel and the dissected segment is relatively safe treatment option for dissecting aneurysms of the PICA distal to its origin.

Correlation between mesenteric fat thickness and serum apolipoproteins in patients with peripheral arterial occlusive disease

BACKGROUND

Visceral fat possesses the most detrimental potential for cardiovascular morbidity through the release of adipokines, as well as metabolic and proinflammatory mediators, which adversely affect metabolic and vascular homeostasis. Among the different types of visceral adipose tissue, mesenteric fat is considered particularly detrimental, due to its close proximity to the portal circulation, affecting directly the liver, which is the main regulator of body metabolic homeostasis. Mesenteric fat can be reliably estimated using abdominal ultrasonography, the only available imaging method able to depict individual mesenteric leaves. Aim of the present study was to investigate the correlation of mesenteric fat thickness (MFT) with serum apolipoprotein levels in patients undergoing digital subtraction angiography in a single center.

METHODS

35 male patients with peripheral arterial disease were examined. After careful examination of the periumbilical area, the mesenteric leaves were identified. The maximal distance between each pair of sequential leaves was measured, and the mean value of the three thickest leaves was determined as the mesenteric fat thickness. Six apolipoprotein fasting serum concentrations were measured using a Luminex proteomics platform (xMAP Multiplex immunoassay): apolipoprotein A-I (apoAI), apolipoprotein A-II (apoAII), apolipoprotein B (apoB), apolipoprotein C-II (apoCII), apolipoprotein C-III (apoCIII) and apolipoprotein E (apoE).

RESULTS

MFT correlated with apoAII and apoB serum concentrations. The correlations with apoAII and apoB remained significant following correction for BMI. No correlations were noted between MFT and serum apoAI, apoCII, apoCIII or apoE levels before or after adjustment for BMI.

CONCLUSIONS

Our study indicates that MFT is significantly correlated with the concentration of atherogenic low density lipoproteins particles, as well as with apoAII, a determinant of free fatty acids levels. No correlation was observed between mesenteric fat thickness and very low density lipoprotein or chylomicron particles concentration.

Reversible cerebral vasoconstriction syndrome: treatment with multiple sessions of intra-arterial nimodipine and angioplasty

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe headache with or without additional neurological symptoms and reversible cerebral vasoconstriction. Unruptured aneurysms have been reported in some cases with RCVS. We describe a severe case of a 50-year-old woman with RCVS presenting as cortical subarachnoid hemorrhage. Cerebral angiogram demonstrated the typical angiographic findings of RCVS and two very small unruptured aneurysms of the left internal carotid artery. The patient was treated with calcium channel blockers and the two aneurysms were successfully treated endovascularly. On day 16 the patient developed new focal neurological symptoms (severe paraparesis) and was successfully treated with intraarterial nimodipine and angioplasty in multiple sessions.

Femoral stem displacement in a patient suffering recurrent dislocations after hip hemiarthroplasty: case report

Displacement of the femoral component during attempt to closed reduction of a dislocated hip arthroplasty is an exceptionally rare, catastrophic event, which renders operative management obligatory. We report the proximal migration of a femoral stem during attempt to closed reduction in a patient with recurrent postoperative dislocations after hip hemiarthroplasty, and describe successful management by conversion to a standard total hip arthroplasty, retaining the same stem in the existing cement mantle. This illustrative case is reported not only as an extremely rare event, but also to highlight and discuss pitfalls and efficient measures in the management of this complex issue.

Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience

OBJECTIVE

This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally.

METHODS

Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems.

RESULTS

On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period.

CONCLUSION

Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.

Prevalence of overweight and abdominal obesity in Greek children 6-12 years old: Results from the National Epidemiological Survey

OBJECTIVE

To provide estimates of overweight (OW), obesity (OB) and abdominal obesity (AO) in a sample of children throughout the whole of Greece.

MATERIAL AND METHODS

This epidemiological, cross-sectional survey examined 3,140 children aged 6-12 y (1,589 boys and 1,551 girls) who were selected by stratified sampling through household family members of Greek adolescents attending school. Participants reported data on height, weight and waist circumference (WC). BMI and Waist-to-Height ratio (WHtR) were calculated. AO was estimated using WC and WHtR.

RESULTS

Overall prevalence of OW including OB was 31.2% in boys and 26.5% in girls, while OB prevalence was 9.4% and 6.4% respectively. The prevalence of AO based on WC (AO-WC), was similar in girls (14.2%) and boys (12.5%) while the prevalence of AO, based on WHtR (AO-WHtR), was higher in boys than in girls (25.6% vs 20.0%, p<0.0001). With increasing age, the prevalence of OW and OB decreases in both genders, and AO-WHtR only in girls. Rates of OW were significantly more prevalent in Greeks than in immigrants.

CONCLUSIONS

Overweight and obesity in Greek children is very prevalent, particularly in boys, comparable with that reported for Mediterranean European countries. Abdominal obesity also appears high. Preventive and treatment strategies are urgently needed to combat this national epidemic.

Comparative study of the immunohistochemical expression of metalloproteinases 2, 7and 9between clearly invasive carcinomas and "in situ" trophoblast invasion

KEYWORDS

Matrix metalloproteinases (MMPs) are endopeptidases considered to participate in the transient invasive property of trophoblastic cells during embryo implantation and placentation. The same molecules play an important role in the invasive and metastatic potential of cancer cells. The aim of this study was to compare the immunohistochemical expression of MMP2, 7and 9between clearly invasive carcinomas and "in situ" trophoblast invasion in an effort to illuminate their distinct roles in uncontrolled and controlled invasion. <br />We performed an immunohistochemical analysis of 45 clearly invasive carcinomas of various organs (colorectal, gastric, breast, pulmonary, renal) and 40 first trimester gestation specimens (before the 9th week of gestation). The markers expression was evaluated semiquantitavely, seperately in cancer parenchymal and gestational trophoblastic cells as well as cancer stromal and decidual cells, according to apercentage scale (0 %, 50% of cells) and according to staining intensity (0, +, ++, +++). <br />MMP9 was expressed more often in the malignant parenchymal as well as in the malignant stromal component of carcinomas than in the trophoblastic (p=0, 0118) and decidual (p=0,017) component of gestations respectively. Although all carcinomas and almost all gestation specimens stained for MMP2 and MMP7, the immunostaining for both molecules was statistically more extensive and intense in trophoblasts and decidual cells by comparison to cancerous elements.<br />In conclusion, although there seems to be adirect link between cancer invasion and MMP9 immunohistochemical expression, the role of MMP2 and MMP7 appears to be more complicated underlining the complexity of the mechanisms involved in cancer spreading.

Significance of estrogen receptor 1 (ESR-1) gene imbalances in colon and hepatocellular carcinomas based on tissue microarrays analysis

Estrogen receptor alpha-encoded by ESR1 gene-overexpression correlates with prognosis and response to specific chemotherapy in breast adenocarcinoma cases. Mechanisms of ESR-1 deregulation in carcinomas remain under investigation. To analyze ESR1 in carcinomas of different histogenesis. Using tissue microarray technology, 172 primary carcinomas including breast ductal adenocarcinomas (n=60), hepatocellular carcinomas (n=52), and colon adenocarcinomas (n=60) were cored and re-embedded in three paraffin blocks. Initial diagnosis was based on liquid based cytology (LiquiPrep/ThinPrep). Immunohistochemistry and fluorescence in situ hybridization were performed. Quantitative evaluation of ER-a protein levels was assessed by applying digital image analysis. ER-a overexpression was observed in 41/60 (68.3%), 23/52 (44.2%) and 4/60 (6.6%) cases, respectively. ESR1 gene multiple copies were confirmed in 13/60 (21.6%) breast adenocarcinomas, but high amplification only in 8/13 (62.8%). Allelic absence was identified in 3/52 (5.7%) hepatocellular carcinomas, whereas colon adenocarcinomas demonstrated gene gains in 5/60 (8.3%) cases referred to chr 6 aneuploidy and not to amplification. ER-a overall expression was associated strongly to ESR1 gene copies only in breast carcinoma (P=0.036). ESR-1 gene overexpression happens frequently in breast cancer, but only a subset of them are high amplified cases correlated to increased response rates in hormonal therapy (tamoxifen). Absence of this mechanism in hepatocellular and colon carcinomas maybe is a negative factor for applying this therapy. This is a pattern of histo-genetic depended targeted therapeutic strategy.

Endovascular treatment of very small intracranial aneurysms

Object

Endovascular treatment of very small aneurysms poses a significant technical challenge for endovascular therapists. The authors review their experience with a series of patients who had intracranial aneurysms smaller than 3 mm in diameter.

Methods

Between 1995 and 2006, 97 very small aneurysms (defined for purposes of this study as < 3 mm in diameter) were diagnosed in 94 patients who were subsequently referred for endovascular treatment. All patients presented after subarachnoid hemorrhage, which was attributed to the very small aneurysms in 85 patients. The authors reviewed the endovascular treatment, the clinical and angiographic results of the embolization, and the complications.

Results

Five (5.2%) of the 97 endovascular procedures failed, and these patients underwent craniotomy and clip ligation. Of the 92 aneurysms successfully treated by coil embolization, 64 (69.6%) were completely occluded and 28 (30.4%) showed minor residual filling or neck remnants on the immediate postembolization angiogram. Complications occurred in 7 (7.2%) of 97 procedures during the treatment (3 thromboembolic events [3.1%] and 4 intraprocedural ruptures [4.1%]). Seventy-six patients were followed up angiographically; 4 (5.3%) of these 76 showed angiographic evidence of recanalization that required retreatment. The clinical outcomes for the 76 patients were also graded using the Glasgow Outcome Scale. In 61 (80.3%) cases the outcomes were graded 4 or 5, whereas in 15 (19.7%) they were graded 3. Seven patients (7.4%) died (GOS Grade 1), 2 due to procedure-related complications (intraoperative rupture) and 5 due to complications related to the presenting subarachnoid hemorrhage.

Conclusions

Endosaccular coil embolization of very small aneurysms is associated with relatively high rates of intraprocedural rupture, especially intraoperative rupture. With the advent of more sophisticated endovascular materials (microcatheters and microguidewires, soft and ultrasoft coils, and stents) endovascular procedures have become feasible and can lead to a good angiographic outcome.

Clinical and microbiological effects of adjunctive, locally delivered chlorhexidine on patients with chronic periodontitis

OBJECTIVE

The impact of a locally delivered chlorhexidine chip (Periochip) on clinical and microbiological parameters of chronic periodontitis requires further documentation. The aim of the present study was to investigate the effects of the chip as an adjunct to mechanical treatment of chronic periodontitis.

METHODS

Fifty patients with chronic periodontitis were randomized into two groups. The test group (n = 25) received scaling and root planing and adjunctive Periochip in four pockets. The control group (n = 25) received scaling and root planing only. Clinical indices (probing depth, probing attachment level, bleeding on probing) were assessed at baseline, three and six months. Subgingival samples were analyzed at baseline, three weeks, three and six months after treatment for levels of eight bacterial species using "checkerboard" DNA-DNA hybridization.

RESULTS

The targeted difference of probing depth of 2 mm between groups was not observed. Both treatments resulted in improvement of clinical indices and non-statistically significant differences were observed between the two groups at any time point, with the exception of bleeding on probing at three months (ANOVA, p < 0.05). No major differences were observed concerning levels of important periodontal pathogens (Mann-Whitney test, p < or = 0.05).

CONCLUSIONS

In this small, six-month, phase 4 trial, no differences in mean probing depth reduction or "red-complex" periodontal pathogens were detected for patients with chronic periodontitis treated with adjunctive chlorhexidine chip (single administration) as compared to patients treated with scaling and root planing alone.

Prevalence of tetM, tetQ, nim and bla(TEM) genes in the oral cavities of Greek subjects: a pilot study

AIM

To investigate the prevalence of tetM, tetQ, nim and bla(TEM) antimicrobial resistance genes in subgingival and tongue samples of Greek subjects.

MATERIALS AND METHODS

Fifty-four subjects participated in the present study. Participants each contributed with one pooled subgingival sample from the mesiobuccal surface of the four first molars and one sample from the tongue. Samples were analysed using polymerase chain reaction for tetM, tetQ, nim and bla(TEM) genes using the primers and conditions described previously. Subjects were stratified according to periodontal status (health, gingivitis or periodontitis). Intake of any antibiotic for medical or dental reasons during the previous 12 months was also recorded (self-reported). Comparisons within and between groups were performed by applying non-parametric tests (z-test with Bonferroni corrections).

RESULTS

A high prevalence of tetM, tetQ and bla(TEM) genes was detected in both tongue and subgingival samples (48.1-82.2%). No differences were observed across genes between periodontally healthy, gingivitis or periodontitis cases, and no statistical correlation was observed between the presence of the bla(TEM) gene and the intake of beta-lactams during the last 12 months (Fisher's exact test, p>0.05).

CONCLUSIONS

Findings from the present study suggest a high prevalence of tetM, tetQ and bla(TEM), but not nim resistance genes in subgingival and tongue samples from Greek subjects.

Endovascular treatment of intracranial microarteriovenous malformations

Object

Microarteriovenous malformations (micro-AVMs) are an uncommon subgroup of brain AVMs defined by a nidus measuring < 1 cm in diameter. The clinical features, angiographic characteristics, and outcomes in patients with micro-AVMs who had been treated endovascularly after presenting with hemorrhage were reviewed to identify common features affecting prognosis.

Methods

Between 1997 and 2006, 25 patients (12 females and 13 males) with 26 micro-AVMs were treated. Twenty-four patients presented with intracerebral hematoma and 1 with subarachnoid hemorrhage only. All patients underwent CT on admission, diagnostic cerebral angiography, and 1 session of endovascular treatment during the acute phase.

Results

Procedure-related complications occurred in 3 patients (12%), which caused temporary hemiparesis in 1 (4%) and no clinical sequelae in 2 patients (8%). Complete nidus obliteration was achieved at the end of the embolization in 22 (84.6%) of 26 lesions. Two recurrences were evident on follow-up angiography 6 months postembolization, resulting in a complete obliteration rate of 77% (20 of 26 lesions) after a single treatment. Late angiography was performed in 12 patients, and no further recurrences were identified.

Conclusions

Immediate complete obliteration of a micro-AVM with a high permanent cure and low morbidity rates was accomplished using endovascular treatment. Early embolization after bleeding should be considered as an alternative to resection.

Epidemiological survey for the prevalence of overweight and abdominal obesity in Greek adolescents

This study was designed to provide estimates of overweight (OW), obesity (OB), and abdominal OB (AO) in a representative sample of adolescents throughout the whole of Greece. A total of 14,456 adolescents aged 13-19 years (6,677 boys and 7,779 girls) had direct measurements (height, weight, waist circumference (WC)) taken at school during 2003. The overall prevalence of OW including OB in the population studied was 29.4% in boys and 16.7% in girls. OB prevalence was also higher in boys than in girls (6.1% vs. 2.7%), whereas prevalence of AO was higher in girls than in boys (21.7% vs. 13.5%). Rates of OW, OB, and AO were significantly more prevalent in the Greek than in the foreign male population (immigrants). OW% in adolescent girls was independently associated with smoking and alcohol consumption. The prevalence of OW and OB in Greek adolescents is high, particularly in boys, comparable with that reported for most Mediterranean European countries. AO, mainly in adolescent girls, also appears high. Preventive and treatment strategies are urgently needed to combat this OB epidemic in Greece.

Outcomes of kidney transplantation in Greek and Albanian patients: a single centre experience

BACKGROUND AND AIM

It has been reported that racial and ethnic (genetic make up), as well as socioeconomic differences may affect the results of kidney transplantation. Socioeconomic factors are quite difficult to differentiate from genetic factors. It is not surprising that a group with poorer access to health care, less private insurance and less income does less well with serious medical problems. The aim of this study was to compare the outcomes of kidney transplantations in Greek (G) and Albanian (A) patients.

PATIENTS AND METHODS

Twenty nine transplanted patients of Albanian ancestry were matched with 29 Greek patients retrospectively. Their mean age was 34 (G) and 31 (A) years, there were 21 men and 8 women in each group (G, A) and they received 26 kidneys from living related donors and 3 kidneys from cadaveric donors respectively. Arterial blood pressure (ABP), body weight (BW), serum creatinine, serum total protein and albumin, total cholesterol, HDL-cholesterol and triglycerides, 24 hour proteinuria were measured on 7th, 15th postoperative day, 1st , 3rd , 6th month and 1st year after transplant. BMI was calculated before and 1 year after transplantation and acute rejection episodes were recorded too. Methylprednizolone (MP), cyclosporine (CsA) dose /kg BW were calculated at baseline, 1, 3, 6, 12 months after transplant. Cumulative patient and graft survival at 1 and 5 years were calculated too.

RESULTS

Patient survival at 1 and 5 years was 100% / 93.1% and 100% /93.1% respectively (p: NS). Graft survival at 1 and 5 years was 100% / 93.10% and 93.75% / 86.45% respectively (p: NS). BW (but not BMI) and total cholesterol levels in Greek patients were higher compared to those of Albanian patients during the 1st post transplant year (p: 0.044 and p: 0.021 respectively). MP dose in A patients was higher during the first year (p: 0.05).

CONCLUSION

Patients and graft survival do not present difference between G and A patients. There is significant difference on cholesterol profile between G and A patients. A larger number of transplants are possibly needed to allow us to draw firm conclusions.