Cabbage and fermented vegetables: From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID‐19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS‐CoV‐2 binds to its receptor, the angiotensin‐converting enzyme 2 (ACE2). As a result of SARS‐CoV‐2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT₁R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID‐19. The nuclear factor (erythroid‐derived 2)‐like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT₁R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof‐of‐concept of dietary manipulations that may enhance Nrf2‐associated antioxidant effects, helpful in mitigating COVID‐19 severity.

Long-Term (≥25 Years) Kidney Allograft Survivors: Retrospective Analysis at a Single Center

INTRODUCTION

Despite great improvements in the short-term patient and kidney graft survival, the long-term morbidity and mortality in kidney transplant recipients still remains a significant problem. The aim of the study was to evaluate the impact of both donor and transplant recipient factors, as well as renal function indices on the very long-term (>25 years) kidney allograft survival.

MATERIAL AND METHODS

Retrospective analysis was performed on the data of 41 kidney transplant recipients (KTR), group A: follow-up = 25 years, 20 KTR, 10 male, mean age (mean [M] ± standard deviation [SD]): 34.6 ± 12.6 years, 14 living donors (LD), 6 cadaveric donors (CD); group B: follow-up > 25 years, 21 KTR, 16 male, mean age (M ± SD): 30.86 ± 12.37 years, 14 LD, 7 CD). Kidney graft origin, post-kidney transplantation diabetes mellitus, HLA compatibility, delayed graft function, and acute rejection episodes were also analyzed retrospectively. Statistical analysis with Mann-Whitney test and Kaplan-Meier survival analysis was performed (SPSS 20.0 for Windows).

RESULTS

The mean age of CDs was lower than that of LDs: CD mean age (M ± SD): 23.84 ± 16.26 years vs LD mean age: 52.75 ± 12.42 years (P < .001). Cadaveric kidney graft was associated with better renal allograft function 10, 15, and 25 years post kidney transplant. None of the other factors analyzed reached statistical significance between the 2 groups.

CONCLUSION

The age of the donor and the kidney graft origin are important co-factors of the very long-term kidney allograft survival.

The impact of wildfires on mental health of residents in a rural area of Greece. A case control population based study

Introduction

Psychopathological disturbances are common in the aftermaths of a disaster. The consequences of these disorders can be long lasting. In August of 2007 an intense and destructive wildfire broke out in the Peloponnesus peninsula in Greece.

Objectives

To investigate psychological and psychiatric morbidity in individuals who had experienced severe exposure to a wildfire disaster in a part of Greece and to indentify risk factors for the post disaster psychological problems.

Aims

To investigate a broader spectrum of mid-term psychological and psychiatric morbidity in victims, to evaluate the proportion of psychopathology that could be accredited to the disaster, to estimate the association of losses with different psychological symptoms, to indentify risk factors for psychopathology.

Methods

A Cross sectional case control study of adult population (18–65 years old). Data collected among others were demographic, Symptom Checklist 90-Revised for assessment of psychological difficulties, type and number of losses.

Results

Those damnified from the disaster scored significantly higher (p < 0.05) in the symptoms of somatisation, depression, anxiety, hostility, phobic anxiety, paranoia, and had significantly more symptoms (PST) and were more distressed by them (GSI) compared to controls. In addition risk factors for someone to be a psychiatric case were to be a victim from the fire, to have finished primary school, to be windowed and to have damages to his property.

Conclusions

Wildfires can cause considerable psychological symptoms in victims and there are reasons for public health policy makers to create services in order to help and improve the mental health of those affected.

Symptomatic retropharyngeal space lipoma. A patient with Madelung disease

BACKGROUND

Retropharyngeal space lipomas (RSL) are rare benign tumors of the head and neck region. They can, sporadically, occur as part of syndromic lipomatosis, such as Madelung disease. Symptoms are caused due to increasing pressure on surrounding structures. Description of case: We present a 64-year-old male patient with symptomatic RSL and symmetric lipomatosis, who was treated surgically.

CONCLUSION

RSL can grow to a large size before becoming symptomatic. Their diagnosis and treatment can be challenging due to their anatomical site, diverse symptomatology, and diffuse growth pattern. Imaging is necessary for diagnosis. In the vast majority of cases, RSLs are treated surgically with a favorable outcome. HIPPOKRATIA 2020, 24(2): 91-93.

Hepatic Artery Anatomic Variations and Reconstruction in Liver Grafts Procured in Greece: The Effect on Hepatic Artery Thrombosis

AIMS

Variations of the anatomy of donor hepatic arteries increase the number of arterial anastomoses during liver transplantation and, possibly, the incidence of hepatic artery thrombosis (HAT). In this study, we describe the arterial anatomic variations in liver grafts procured and transplanted by a single center in Greece, the techniques of arterial anastomosis, and their effect on the incidence of early HAT.

MATERIALS AND METHODS

From January 2013 to December 2017, the arterial anatomy of 116 grafts procured for liver transplantation were recorded, as well as the technique of arterial anastomosis and the incidence of early hepatic artery thrombosis (HAT <30 days).

RESULTS

A single hepatic artery was recorded in 72.41% of the procured grafts, an aberrant left hepatic artery (accessory or replaced) in 18 grafts (15.52%), and an aberrant right hepatic artery (accessory or replaced) in 17 grafts (14.66%), while other variations were observed in less than 1% of the procured livers. Of the 116 primary liver transplantations, 6 patients (5.17%) developed early HAT <30 days. Two of these patients (1.72%) had 1 anastomosis of the hepatic artery and 4 (3.45%) had 2 anastomoses due to anatomic variations.

CONCLUSIONS

Anatomic variations of the hepatic artery in liver grafts is a common finding and increase the incidence of early HAT but not to a degree to make these grafts unusable.

Perioperative Chemoprophylaxis οr Treatment for Extensively Drug Resistant Gram-Negative Bacteria in Patients Undergoing Liver Transplantation Based on Preoperative Donor/Recipient Surveillance Cultures: A Prospective Study

INTRODUCTION

The importance of preoperative donor/recipient colonization or donor infection by extensively drug-resistant Gram-negative bacteria (XDR-GNB) and its relation to serious post-transplantation infection pathogenicity in liver transplantation (LT) patients has not been clarified.

AIM

Prevention of postoperative infection due to XDR-GNB with the appropriate perioperative chemoprophylaxis or treatment based on preoperative donor/recipient surveillance cultures in LT patients, as well as their outcome.

MATERIALS AND METHOD

Twenty-six patients (20 male, 6 female) were studied (average preoperative Model for End-Stage Liver Disease score ≈15, range: 8-29) from January 2017 to January 2018. In all patients, blood, urine, and bronchial secretions culture samples as well as a rectal colonization culture were taken pre- and postoperatively, once weekly after LT, and after intensive care unit discharge. Recipients with positive XDR-GNB colonization and patients receiving a transplant from a donor with an XDR-GNB positive culture or colonization received the appropriate chemoprophylaxis one half hour preoperatively according to culture results. De-escalation of the antibiotic regimen was done in 2 to 5 days based on the colonization/culture results of the donor and recipient and their clinical condition. Evaluation for serious infection was done at 1 week and at 28 days for outcome results.

RESULTS

Fourteen out of 26 recipients (53.8%) were positive for XDR-GNB colonization preoperative, with 2/14 (14.28%) presenting serious infection due to the same pathogen. Intensive care unit length of stay was significantly longer in colonized with XDR-GNB patients (P < .0001). The outcome of colonized patients was 6/14 (42.8%) expired, but only in 2/14 (14.2%) was mortality attributable to infection.

CONCLUSION

Administering appropriate perioperative chemoprophylaxis and treatment may limit the frequency of XDR-GNB infections and intensive care unit length of stay and may improve the outcome in LT recipients.

Nucleos(t)ide analog(s) prophylaxis after hepatitis B immunoglobulin withdrawal against hepatitis B and D recurrence after liver transplantation

BACKGROUND/AIMS

Nucleos(t)ide analogs (NAs) have made a hepatitis B immunoglobulin (HBIG)-sparing protocol an attractive approach against hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, this approach is considered controversial in patients transplanted for HBV and hepatitis D (HDV) co-infection.

MATERIAL/METHODS

All patients transplanted for HBV/HDV cirrhosis were evaluated. After LT, each patient received HBIG + NAs and then continued with NAs prophylaxis. All patients were followed up with HBV serum markers and HBV DNA, while anti-HDV/HDV RNA was performed in those with HBV recurrence.

RESULTS

A total of 34 recipients were included (22 men, age: 46.7 ± 16 years). After HBIG discontinuation, NAs were received as monoprophylaxis (lamivudine [LAM]: 2, adefovir [AFV]: 1, entecavir: 9, tenofovir [TDF]: 12) or dual prophylaxis (LAM + AFV [or TDF]: 10 patients). Two (5.8%) of the 34 patients had HBV/HDV recurrence after HBIG withdrawal (median follow-up: 28 [range, 12-58] months). These 2 patients had undetectable HBV DNA at LT. Statistical analysis revealed that those with recurrence had received HBIG for shorter period, compared to those without recurrence (median: 9 vs. 28 months, P = 0.008).

CONCLUSIONS

We showed for the first time, to our knowledge, that maintenance therapy with NAs prophylaxis after HBIG discontinuation was effective against HBV/HDV recurrence, but it seems that a longer period of HBIG administration might be needed before it is withdrawn after LT.

Tigecycline for treatment of carbapenem-resistant Klebsiella pneumoniae infections after liver transplantation in the intensive care unit: a 3-year study

BACKGROUND

This 3-year prospective, observational, single-center study was undertaken to describe prescription, microbiology findings, tolerance, and efficacy of tigecycline for carbapenem-resistant Klebsiella pneumoniae (CRKP) infections after liver transplantation in the intensive care unit (ICU).

METHODS

All patients after liver transplantation treated with tigecycline for ≥3 days for CRKP infections in our ICU from January 1, 2010, to December 31, 2012, were studied. Patient characteristics, indication of treatment, bacteriology, and ICU mortality were collected. The main end points were clinical and microbiologic efficacy and tolerance of tigecycline.

RESULTS

Over the study period, 8 men and 2 women (18 CRKP isolates), aged 54.3 ± 7.7 years, were included in the study. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores on ICU admission were 13.7 ± 2.7 and 10 ± 2.2, respectively. In 7 isolates, tigecycline was prescribed for CRKP blood stream infection (BSI), in 6 for complicated intra-abdominal infection (IAI), in 2 for ventilator-associated pneumonia (VAP), in 2 for surgical site infection, and in 1 for urinary tract infection. In 4 cases, tigecycline was prescribed for secondary BSI followed by VAP and/or IAI. All isolates were susceptible to tigecycline, 83.4% to colistin, 44.5% to gentamicin, and 27.8% to amikacin. In 2 patients, tigecycline was prescribed as monotherapy. Three patients had clinical failure. The microbiologic response rate was 70%. Superinfection was detected in 5 patients, and Pseudomonas aeruginosa was the most frequently isolated pathogen. Tigecycline was generally well tolerated. The ICU mortality rate was 60% with attributable mortality rate 30%.

CONCLUSIONS

Our pilot study suggests that tigecycline shows a good safety and tolerance profile in patients with CRKP infections in the ICU after orthotopic liver transplantation. Limited therapeutic options for such infections leave physicians no choice but to use tigecycline for off-label indications such as urinary tract and blood stream infections.

Comparison of RIFLE and AKIN criteria in the evaluation of the frequency of acute kidney injury in post-liver transplantation patients

BACKGROUND

Acute renal dysfunction is presented quite often after orthotopic liver transplantation (LT), with a reported incidence of 12-64%. The "RIFLE" criteria were introduced in 2004 for the definition of acute kidney injury (AKI) in critically ill patients, and a revised definition was proposed in 2007 by the Acute Kidney Injury Network (AKIN), introducing the AKIN criteria. The aim of this study was to record the incidence of AKI in patients after LT by both classifications and to evaluate their prognostic value on mortality.

METHODS

We retrospectively evaluated the records of patients with LT over 2 years (2011-2012) and recorded the incidence of AKI as defined by the RIFLE and AKIN criteria. Preoperative and admission severity of disease scores, duration of mechanical ventilation, intensive care unit length of stay, and 30- and 180-day survivals were also recorded.

RESULTS

Seventy-one patients were included, with an average age of 51.78 ± 10.3 years. The incidence of AKI according to the RIFLE criteria was 39.43% (Risk, 12.7%; Injury, 12.7%; Failure, 14.1%), whereas according to the AKIN criteria it was 52.1% (stage I, 22.5%; stage II, 7%; stage II 22.55%). AKI, regardless of the classification used, was related to the Model for End-Stage Liver Disease score, the volume of transfusions, the duration of mechanical ventilation, and survival. The presence of AKI was related to higher mortality, which rose proportionally with the severity of AKI as defined by the stages of either the RIFLE or the AKIN criteria.

CONCLUSIONS

AKI classifications according to the RIFLE and AKIN criteria are useful tools in the recognition and classification of the severity of renal dysfunction in patients after LT, because they are associated with higher mortality, which rises proportionally with the severity of renal disease.

The effect of sorafenib on liver regeneration and angiogenesis after partial hepatectomy in rats

BACKGROUND

Liver regeneration is vital for the survival of patients submitted to extensive liver resection as a treatment of hepatocellular carcinoma (HCC). Sorafenib is a multikinase inhibitor of angiogenesis and cell division, both of which are integral components of liver regeneration. We investigated the effect of preoperative treatment with sorafenib, a drug used for the treatment of HCC, on liver regeneration and angiogenesis in healthy rats, after two-thirds partial hepatectomy (PH2/3).

METHODS

In total 48 Wistar rats received intragastric injections of sorafenib (30 mg/kg/d) or vehicle, underwent PH2/3, and were sacrificed at 48, 96 or 168 hours after that. The regenerative index of the liver remnant was studied, as well as the mitotic index. DNA synthesis and angiogenesis were estimated by immunohistochemistry for the Ki-67 and CD34 antigens, respectively.

RESULTS

Sorafenib reduced significantly the regenerative index at all time points but not the mitotic index at 48, 96 or 168 hours. Deoxyribonucleic acid (DNA) synthesis and angiogenesis were not affected significantly either.

CONCLUSIONS

Sorafenib, when administered preoperatively, reduces incompletely and transiently the regeneration of the liver after PH2/3 in rats. This could mean that sorafenib can be used as neoadjuvant treatment of patients with HCC prior to liver resection, but further experimental and clinical studies are needed to establish the safety of this treatment. Hippokratia 2015; 19 (3): 249-255.

Telbivudine is associated with improvement of renal function in patients transplanted for HBV liver disease

Recent studies showed that telbivudine in patients with hepatitis B virus (HBV) infection improved their glomerular filtration rate (GFR), but data regarding its impact on renal function in liver transplant (LT) recipients are very limited. We evaluated 17 consecutive recipients who received at baseline nucleos(t)ide analogue(s) (NAs) other than telbivudine for 12 months, and then they were switched to telbivudine prophylaxis for another 12 months. In each patient, laboratory data including evaluation of GFR (using MDRD and CKD-EPI) were prospectively recorded. The changes in GFR (ΔGFR) between baseline and after 12 months (1st period) and between telbivudine initiation and 24 months (2nd period) were evaluated. All patients remained serum HBsAg and HBV-DNA negative. GFR-MDRD at baseline, 12 months and 24 months were 72 ± 18, 67.8 ± 16 and 70.3 ± 12 mL/min, respectively, (P = 0.025 for comparison between 12 months and 24 months). ΔGFR at the 1st period was significantly lower, compared with ΔGFR at the 2nd period [mean ΔGFR-MDRD: -4.2 (range: -24-9) vs 2.5 (range: -7-22) mL/min, P = 0.013; mean ΔGFR-CKD-EPI: -4.2 (range: -19-10) vs 4.0 (range: -7-23) mL/min, P = 0.004], although the serum levels of calcineurin inhibitors were similar between the two periods. A second group of recipients (n = 17) who remained under the same nontelbivudine NA(s) for 24 months had a decline in the mean eGFR during the total follow-up period. In conclusion, we showed that telbivudine administration in LT recipients for HBV cirrhosis was effective and it was associated with significant improvement in renal function, but this remains to be confirmed in larger well-designed studies.

Appraisal of the peri-hospital management and evolving microbiology of peritonsillar abscess disease

OBJECTIVES

Peritonsillar abscess (PTA) is a common complication of tonsillitis, yet there is limited consensus regarding its management and epidemiology. Current issues include pre-hospital care provided by general practitioners (GP) in the community (ii) the lack of standardized protocols for in-patient management and (iii) the role of routine microbiology studies in patients with PTA. We performed a retrospective review of confirmed cases of PTA presenting to a west of Ireland tertiary referral center to evaluate the peri-hospital management and role of microbiology studies in such cases.

METHODOLOGY

Retrospective chart review of 200 confirmed cases of peritonsillar abscess.

RESULTS

The annual incidence of PTA in the west of Ireland population was 14/100,000. Pre-hospital treatment given by Primary Care Physicians (PCP) was often deficient with 84 (42%) patients receiving no treatment prior to hospital referral. Needle aspiration was the most common technique used to drain the PTA 142 (71%). Anaerobes were isolated in 54 (27%) of cases demonstrating an increasing importance of these bacteria in PTA disease. Metronidazole with either benzylpenicillin 72 (36%), or co-amoxiclav 82 (41%), was the most common empiric antibiotics used. Successful treatment of all cases of PTA with the use of empiric antibiotics was achieved before results arising from microbiology became available.

CONCLUSION

The epidemiology of PTA is not well described. We have described the epidemiology for PTA disease in the west of Ireland population for the first time. Needle aspiration was the most common drainage technique used. Empiric antibiotic treatment based on clinical response is advised with antibiotics effective against aerobic and anaerobic bacteria recommended.

Hepatic artery thrombosis after orthotopic liver transplantation: 3 patients with collateral formation and conservative treatment

Hepatic artery thrombosis (HAT), a serious complication after orthotopic liver transplantation (OLT), can lead to patient death in the absence of revascularization or retransplantation. Herein we have presented clinical characteristics, imaging findings, and long-term outcomes of 3 OLT patients with HAT who were treated conservatively and developed hepatic arterial collaterals. These patients underwent transplantation due to hepatitis B cirrhosis, cryptogenic cirrhosis, or hepatitis C infection and alcoholic disease. They presented with bile duct stenosis and/or a bile leak at 1, 3, and 36 months after transplantation, respectively, and were treated with percutaneous drainage and stent placement, endoscopic retrograde cholangio-pancreatography (ERCP), or reanastomosis of the bile duct over a T tube. HAT was confirmed using multidetector computed tomography (MDCT) 3-dimensional (3D) angiography and Doppler sonography. They survive in good condition with normal liver function at 30, 50, and 42 months after OLT, respectively. Development of collateral arterial circulation to the liver graft was detected with MDCT 3D angiography and Doppler sonography. From our experience with 3 patients and a literature review, we believe that there are a number of patients who experience long-term survival after the diagnosis of irreversible HAT and the development of collaterals. Although this group is at high risk for sepsis and biliary complications, these are usually self-limiting complications due to improved treatment regimens. The development of collateral arterial flow may also be beneficial.

Infections related to renal transplantation requiring intensive care admission: a 20-year study

INTRODUCTION

The aim of this study was to evaluate infection complications as the reason for intensive care unit (ICU) admission among transplant recipients.

METHODS

We studied all renal transplant recipients with infectious complications admitted to our ICU from 1992 to 2012:44.3% of all renal transplant recipients admitted to ICU. The epidemiology and prognosis of infectious complications requiring ICU admission were evaluated with analysis of mortality factors.

RESULTS

The 22 men and 5 women included in this study showed a mean age of 42.7 ± 12.3 years. The Acute Physiologic and Chronic Health Evaluation II and Seguential Organ Failure Assessment scores on ICU admission were 20 ± 4.6 and 8.6 ± 3.9, respectively. The main infections complications requiring ICU admission were cytomegalovirus pneumonia (n = 15) and aspergillus pneumonia (n = 4). Sixteen patients required hemodialysis and 14, catecholamine support upon ICU admission owing to septic shock. The mortality rate among study patients was 62.9%, versus 26.5% for noninfectious renal transplant recipients requiring ICU admissions. Catecholamine support at ICU admission was independently related to mortality.

CONCLUSION

The mortality rate of renal transplant recipients admitted to ICU owing infection complications was higher than that of noninfected renal transplant patients. These data suggest that infections and septic shock in renal transplant recipients requiring ICU admission worsen their outcome significantly.

Infections after orthotopic liver transplantation in the intensive care unit

PURPOSE

The purpose of the study was to assess the characteristics and risk factors of infections in the early period after orthopic liver transplantation (OLT) among adult patients.

MATERIAL AND METHODS

We studied 75 patients who underwent OLT over 3 years from 2008 to 2010. We recorded all infections that developed during hospitalization in the intensive care unit (ICU) their outcomes, and the possible risk factors.

RESULTS

During the study period in 80 OLT we recorded 19 bloodstream infections (47.5%), 7 ventilator-associated pneumonias (VAP; 17.5%), and 14 intra-abdominal infections (35%). Among the 40 isolated microbes, 72.5% were Gram negative, 25% were Gram positive, and 2.5% were fungi. The median time to developing the infection was 4.95 days (range 2-10). Patients with infections showed longer durations of mechanical ventilation, longer lengths of ICU stay, and lower 1-year survivals.

Is epistaxis associated with arterial hypertension? A systematic review of the literature

Both epistaxis and hypertension are frequent problems in the adult population. The relationship between the level of arterial pressure and incidence of epistaxis in a patient with hypertension is a question that appears frequently in the clinical practice. A systematic review of the literature regarding the relation of arterial hypertension with epistaxis was performed through MEDLINE and EMBASE. All studies, whether examining the correlation of arterial pressure at presentation of a patient with nasal bleeding or the repercussion of episodes of epistaxis in hypertensive patients, were included in this review. Studies were evaluated independently by two reviewers according to a standard evaluation form. Overall, nine studies fulfilled our inclusion criteria. Five of them were single-group (patient) studies, while the remaining four included a control group. In eight studies, the patient group included patients with epistaxis, while one focused on hypertensive patients. Six out of nine studies agree that arterial pressure is higher at the time of epistaxis, as compared to the control group or to the general population. Seven out of nine studies conclude that there is cross-correlation between arterial pressure and the actual incident of epistaxis. The presence of high arterial blood pressure during the actual episode of nasal bleeding cannot establish a causative relationship with epistaxis, because of confounding stress and possible white coat phenomenon, but may lead to initial diagnosis of an already installed arterial hypertension.

Simultaneous pancreas-kidney transplantation: initial results from a center in Greece

AIM

The outcome of simultaneous pancreas-kidney transplantation (SPK) in type 1 diabetes has dramatically improved in recent years. We report the initial results of our SPK program.

PATIENTS AND METHODS

From 2008 to 2010, we performed and prospectively obtained data on 4 SPKs in 4 type 1 diabetic patients with chronic renal failure. The recipients were 3 men and 1 woman, of overall mean age of 40.75 ± 4.78 years, mean time from diabetes diagnosis of 27 ± 15 years, and time on dialysis of 3.5 ± 0.57 years. All grafts were procured from multiorgan brain-dead donors of mean age 26 ± 8.16 years and mean body weight of 74 ± 4.34 kg. The pancreatic grafts were transplanted first into the right iliac fossa with mean cold ischemia times of 10.62 ± 3.09 hours for the pancreatic and 14.00 ± 2.97 hours for the renal grafts. Pancreas arterial inflow was re-established by an end-to-side anastomosis of an extension Y-graft to the recipient right iliac artery. The portal vein was sutured to the iliac vein directly. The exocrine secretions of the pancreas were managed by duodenojejunostomy extraperitoneally (n = 3) or intraperitoneally (n = 1). The ureteral anastomosis was performed using the Taguchi technique.

RESULTS

After SPK, endocrine pancreatic function was immediately restored in all patients. Insulin administration was stopped within the first 24 hours after surgery. Two patients displayed delayed renal graft function necessitating dialysis for 9 and 23 days, respectively. The postoperative course was prolonged with a mean hospital stay of 82 ± 1 day. At a 31.75 ± 9.03 months follow up all patients are alive with functioning grafts.

CONCLUSION

Our experience with SPK, although limited, has shown encouraging results over a short follow-up period.

Hepatitis B prophylaxis post liver transplantation with newer nucleos(t)ide analogues after hepatitis B immunoglobulin discontinuation

Newer nucleos(t)ide analogues (NUCs) have better resistance profiles making hepatitis B immunoglobulin (HBIG)-sparing protocol an attractive prophylactic approach against hepatitis B virus (HBV) recurrence after liver transplantation (LT). We evaluated the risk of HBV recurrence after withdrawal of HBIG in patients who had been under HBIG plus NUCs after LT. Stable patients without HBV recurrence after LT while receiving combination of HBIG plus NUCs for at least 12 months were eligible for HBIG discontinuation. The patients were at low risk for HBV recurrence (only 4.5% had detectable HBV DNA at the time of LT, and 32% had HBV/hepatitis D virus co-infection). All patients were followed up with HBV serum markers, HBV-DNA, and evaluation of renal function, including glomerular filtration rate. Forty-seven recipients discontinued HBIG and were maintained on newer NUCs. Median follow-up post-HBIG withdrawal was 24 months (range: 6-40 months). Twenty-eight (60%) patients continued on lamivudine in combination with adefovir dipivoxil (n = 23, 82%) or tenofovir (n = 5, 18%); 10 (21%) and 9 (19%) of the 47 patients continued on tenofovir and entecavir monoprophylaxis, respectively. Although 3 (6.3%) patients developed detectable hepatitis B surface antigen, all of them had undetectable HBV DNA and no clinical manifestations of HBV recurrence. Renal function was similar between the different groups of patients. In conclusion, maintenance therapy with newer NUCs after discontinuation of HBIG prophylaxis was effective, but further studies in larger cohorts with longer follow-up are needed.

Idiopathic temporal bone encephalocele

Meningoencephaloceles are herniations of brain tissue through dehiscences of the skull base. These skull defects are either acquired (otologic infection, trauma, surgery, neoplasia) or spontaneous. Spontaneous temporal bone meningoencephaloceles are quite rare conditions, usually congenital in origin presenting during childhood, and only occasionally idiopathic presenting during adulthood. We present a case of temporal bone meningoencephalocele of adult onset. The patient was treated with exploratory mastoidectomy, amputation of the herniated cele and closure of the defect with temporalis fascia and an inferiorly based pedicled muscular flap. No reconstruction of the bony defect was performed, as the layered closure was considered adequate. Twelve months' follow-up revealed no relapse of the condition or postoperative complications.

Newborn hearing screening: a regional example for national care

Congenital Permanent Childhood Hearing Impairment (PCHI) is known to have a negative effect on language acquisition, cognitive development and social integration. Since 2000 our department has implemented a UNHS program in the West of Ireland. We describe our experience and detail our results to date. All neonates born from October 2000 to November 2007 were screened using a 2-stage protocol. Transient evoked oto-acoustic emissions (TEOAEs) were used to screen all neonates, followed by automated auditory brainstem response (AABR) in those who did not pass TEOAE, and all neonates at audiological risk. 26,281 babies were born over the eight year period. 25,742 underwent the screening process, achieving a coverage rate of 98%. The prevalence of PCHI in the population tested was 1.21/1000 live births (31/25,731). Our results show that a hospital based 2-stage UNHS protocol using TEOAEs and AABR is accurate, feasible and effective.

Public knowledge of head and neck cancer

Studies show 60% of patients with newly diagnosed Head & Neck Squamous Cell Cancer in Ireland, present with advanced disease. A poor level of knowledge and awareness among the public of Head & Neck Cancer, is an important consideration in the often delayed presentation for medical attention in many of these cases. Our study surveyed 200 members of the public to assess their knowledge and awareness of Head & Neck Cancer. One hundred and forty (70%) of respondents had never encountered the term "Head & Neck Cancer". One hundred and forty six (73%) failed to identify excessive alcohol consumption as a risk factor. Less than 100 (50%) would have concern about persisting hoarseness or a prolonged oral ulcer. An urgent need exists to raise awareness of Head & Neck Cancer among the public in Ireland.

Hepatitis C and liver transplantation

Cirrhosis due to chronic hepatitis C is the leading indication for liver transplantation in Europe, United States and Japan. Reinfection after liver transplantation is universal and chronic liver disease develops in at least 70% of patients at 3 years, with an accelerated course compared to the nontransplant setting. These facts underscore the need for a better understanding of hepatitis C infection and the various treatment modalities. This paper attempts a brief review of the scope of the disease, as well as the different treatment modalities, with special emphasis given to orthotopic liver transplantation.

Liver transplantation with grafts from septuagenarians

BACKGROUND

The purpose of this study was to evaluate our experience with orthotopic liver transplantation (OLT) using grafts from septuagenarians.

PATIENTS AND METHODS

Seventeen adult patients underwent transplantation with grafts from donors 70 years of age or older during an 8-year period.

RESULTS

The median donor age was 73 years (range, 70-83). Eleven (64.7%) donors had experienced at least 1 hypotensive period and received vasoactive drugs. Median cold and warm ischemia times were 7.25 hours and 35 minutes, respectively. Two recipients underwent retransplantation because of dysfunction or primary nonfunction. Morbidity rate was 47% and hospital mortality rate was 23.5%. After a median follow-up of 34.5 months (range, 3-84 months), 5 additional patients died. Median patient survival was 17 months (range, 0-84 months). One-, 3-, 5-, and 7-year cumulative survival rates were 69.7%, 57.5%, 46.2%, and 23.3%, respectively. Only graft dysfunction (P = .042) was observed to be an independent predictor of survival upon multivariate analysis.

CONCLUSIONS

Although grafts from septuagenarians allow for expansion of the donor pool, long-term recipient survival is inferior to that encountered with younger donors.

Impact of double-j ureteric stent in kidney transplantation: single-center experience

We retrospectively evaluated the use of double-j stent and the incidence of urological complications in 2 groups of patients who received a kidney transplant. From January 2005 to September 2007 we studied 172 patients receiving kidney transplants, 65 and 107 from living and cadaver donors, respectively. From the 172 patients, a total of 34 were excluded due to ureterostomy or Politano-Leadbetter ureterovesical anastomosis. Another 21 patients were excluded from the study due to graft loss due to acute or hyperacute rejection, cytomegalovirus (CMV) infection, or vascular complication. The remaining patients were divided into 2 groups: group A (44 patients) and B (73 patients) with versus without the use of a double-j-stent, respectively. The 2 groups were comparable in terms of donor and recipient gender, ischemia time, and delayed graft function. We failed to observes significant differences between the 2 groups in mean hospital stay (23 +/- 9 and 19 +/- 9), urinary leak (2.3% and 4.1%), and urinary tract infection (20.4% and 19.2%), among groups A and B, respectively. The only difference observed concerned the gravity of the urinary leak; no surgical intervention was needed among the double-j stent group versus 2 patients demanding ureterovesical reconstruction in the nonstent group. In conclusion, our data suggested that the routine use of a double-j stent for ureterovesical anastomosis neither significantly increased urinary tract infection rates, nor decreased the incidence of urinary leaks, but may decrease the gravity of the latter as evidenced by the need for surgical intervention.

Hepatic focal nodular hyperplasia: when a benign lesion becomes "malignant". Report of a case

In a 34 year-old woman complaining of right upper quadrant pain and having mildly elevated total bilirubin, the imaging investigation revealed a liver lesion with characteristics of focal nodular hyperplasia, measuring 3.8 cm, at the confluence of the hepatic veins. The mass was obstructing the left and middle hepatic veins and nearly obstructing the right hepatic vein. Dilation of the splenic vein with development of retropancreatic varices, splenomegaly and free abdominal fluid were also present. The patient underwent an uncomplicated left hemihepatectomy. Patients postoperative total bilirubin was normalized. Tomographic imaging three months after the liver resection revealed resolution of all the Budd-Chiari radiographic signs. This is a report of a case where a hepatic focal nodular hyperplasia, despite its benign nature, required extensive and urgent surgical intervention due to its location and potential dangers secondary to the development of portal hypertension.

Transplantation for type 1 diabetes mellitus. Whole organ or islets?

Two types of transplants are offered to patients with complicated insulin dependent diabetes mellitus: a) whole pancreas transplantation, b) pancreatic islet transplantation. A total of 29000 whole pancreas transplantations and 1500 islet transplantations have been performed worldwide until today. Patient survival for whole pancreas recipients is 85% five years after transplantation, whereas very few islet studies focus on patient survival. Graft survival for whole pancreas recipients is 90%, 70% and 45%, at one, five and ten years after transplantation respectively. On the other hand, only 44% of islet recipients are still insulin free, one year after engraftment. If the definition of a successful islet transplantation is not insulin independence but production of C-peptide, then 80% of the same islet recipients have a functioning graft by the end of the first post-transplant year. It is a known fact that whole pancreas transplantation has significant complications. The most common complications after whole organ transplantation include technical failures, acute rejection and CMV infection, whereas islet transplantation is associated with portal vein thrombosis, bleeding, emergency exploratory laparotomy, liver steatosis and rapamune-induced mouth ulcers. The cumulative cost of a whole organ transplantation is about ?40,000. On the other hand, the cumulative cost of a pancreatic islet transplant is estimated to be higher than ?120,000. Whole organ transplantation halts the late complications of diabetes, namely vasculopathy, retinopathy, nephropathy and neuropathy. Although similar claims are made for islet transplantation, its impact on long-term diabetic complications is possible but not proven. Currently, in North America, lean young donors are utilized for whole organ transplants, whereas overweight or older donors are utilized for islet transplants. In conclusion, although islet transplantation is an extremely promising therapy and probably the way of the future, whole organ transplant is still the gold standard according to evidence-based medicine.

The evolution of the role of liver transplantation in treating alcoholic cirrhosis in Greece

BACKGROUND

Liver transplantation represents the main treatment for alcoholic cirrhosis. The goal of this article is to review the results of liver transplantation for alcoholic cirrhosis in Greece over the last 2 decades.

METHODS

Among 247 patients who underwent liver transplantation between 1991 and 2007, 34 (13.7%) experienced alcoholic cirrhosis as the primary diagnosis. We reviewed their demographic data, stage of liver disease, and outcomes regarding survival via a Kaplan-Meier curve. Also we analyzed the causes of death and the postoperative complications.

RESULTS

Mean Model for End-Stage Liver Disease (MELD) score was 18.4. Other diagnoses included hepatitis C virus (HCV; 23.5%), hepatitis B virus (HBV; 14.7%), and hepatocellular carcinoma (8.8%). Eleven patients died the most frequent causes being primary graft nonfunction (n = 3), hepatic artery thrombosis (n = 2), sepsis (n = 2), and portal vein thrombosis (n = 2). Complications included rejection (32.4%), infection (26.5%), hepatic graft dysfunction (11.8%), and recurrent HCV, recurrent HBV, and renal failure (8.8% each). Recurrence of alcoholism was observed in 3 patients (8.8%) with mild effects on liver function tests. There has been a significant increase in the number of liver transplantations for alcoholic cirrhosis in the last 6 years, namely 25 patients versus 9 in the previous 10 years.

CONCLUSIONS

We observed a significant increase in the frequency of alcoholic cirrhosis leading to liver transplantation in the last several years 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.

Cyclosporine enhances liver regeneration: the role of hepatocyte MHC expression and PGE2--a study relevant to graft immunogenicity

AIM

We have investigated CsA induced liver hyperplasia to explore the potential effects on the immunogenicity of the regenerating liver within the clinical context of rejection after transplantation.

MATERIALS AND METHODS

Flow cytometry analysis of hepatocytes, isolated 48 hours after 2/3 partial hepatectomy (PH2/3) or sham operation in rats, was performed to determine the effect of CsA on DNA synthesis and MHC molecule expression. The possible role of PGE2 was evaluated by the administration of SC-19220, an EP1-PGE2 receptor antagonist.

RESULTS

CsA augmented liver regeneration and this was partially attenuated by SC-19220. The moderate expression of class I MHC expression, as well as the very low class II MHC expression detected in normal hepatocytes by flow cytometry was augmented after PH2/3 and reduced by CsA. The CsA-mediated decrease of hepatocyte immunogenicity was not SC-19220 dependent.

CONCLUSIONS

It is proposed that the enhancing effect of CsA on hepatocyte proliferation is by means of an indirect mechanism that can be attributed to a) reduced immunogenicity of the regenerating liver as a result of inhibition of class I and II MHC hepatocyte expression and b) increased PGE2 synthesis in the liver mediated by its action on EP1 receptor.

Liver transplantation outcomes in patients with cirrhosis and hepatocellular carcinoma: experience of a single center in a viral hepatitis endemic area

Our center has performed 205 orthotopic liver transplantations (OLT) in 201 patients. Hepatocellular carcinoma (HCC) was discovered in 32 (15%) patients, 5 of whom were diagnosed incidentally in recipient explants. The main underlying diagnosis was viral hepatitis (n = 28; 87.5%). Most patients (17; 53.1%) were diagnosed as having Child class B cirrhosis. Single tumors measuring <3 cm were diagnosed in 29 (90.6%) patients. Downstaging chemoembolization was performed in 7 (21.8%) patients. Preoperative aFP levels were normal in 20 (62.5%) patients. In the rest (n = 12; 37.5%), aFP levels normalized immediately after the OLT. In the latter group, 2 patients had a delayed (2 years) postoperative increase in aFP levels; both patients had tumor recurrence in the graft. All patients with hepatitis B received antiviral treatment with HBIG and lamivudine. There were 9 deaths (28.1%) in the immediate postoperative period (<30 days). One-year survival rate was 62.5% (n = 20). Actuarial 5-year survival rate was 55%, and actuarial 10-year survival rate was 40%. In conclusion, OLT has become the standard treatment for patients diagnosed with HCC in a population that shows cirrhosis most of the time to be secondary to viral hepatitis, provided that recipients are selected according to the size of the neoplasm and that they receive adequate antiviral prophylaxis.

Management of a giant ruptured hepatocellular adenoma. Report of a case

This report describes a rare case of a young woman with massive intra-abdominal bleeding due to a giant ruptured hepatocellular adenoma. The patient had never used oral contraceptive pills and she was urgently operated for haemorrhage control in another hospital where the left hepatic artery was also ligated. After haemodynamic stabilization in the ICU and because of a complicated postoperative course (signs of intraabdominal sepsis) she was transferred to our hospital and a left lobectomy was performed. We present the case and comment on the preferred treatment modalities of hepatocellular adenomas.

Attenuation of intestinal ischemia/reperfusion induced liver and lung injury by intraperitoneal administration of (-)-epigallocatechin-3-gallate

The aim of this study was to evaluate the effect of ( - )-epigallocatechin-3-gallate (EGCG), a natural antioxidant, on liver and lungs after warm intestinal ischemia/reperfusion (I/R). Thirty male Wistar rats were equally divided into a sham-operation group, an intestinal I/R group and an intestinal I/R group pretreated with EGCG intraperitoneally. Intestinal ischemia was induced by occlusion of the superior mesenteric artery for 60 min followed by reperfusion for 120 min. Immediately after reperfusion, liver, lung and blood samples were collected and analyzed. Results showed that intestinal I/R increased the levels of aspartate (AST) and alanine (ALT) transaminase in serum to 987 and 752 IU/l, respectively. Malondialdehyde (MDA) increased in liver to 1.524 nmol/g in the group subjected to intestinal I/R compared to 0.995 nmol/g in the sham operation group. MDA was also increased in lungs to 1.581 nmol/g compared to 0.896 nmol/g in the sham operation group. Myeloperoxidase (MPO) increased in liver, after intestinal I/R, to 5.16 U/g compared to 1.59 U/g in the sham operation group. MPO was also increased in lungs to 3.89 U/g compared to 1.65 U/g in the sham operation group. Pretreatment with EGCG decreased serum levels of AST and ALT to 236 and 178 IU/l, respectively. It also decreased mean MDA levels in liver and lungs to 1.061 and 1.008 nmol/g, respectively, and mean MPO levels in liver and lungs to 1.88 and 1.71 U/g, respectively. Light microscopy and transmission electron microscopy examinations showed significant alteration in liver and lungs and protection of liver and lung parenchyma in the animals treated with EGCG.

Silent sinus syndrome, a case presentation

"Silent Sinus Syndrome" is a quite rare condition of otherwise asymptomatic maxillary sinusitis that presents with enophthalmos. Despite the fact that the "Silent Sinus Syndrome" presents with enophthalmos, these patients are finally treated by the otorhinolaryngologist, who should be familiar with this condition, in order to facilitate prompt diagnosis and treatment. We present the case of a 33 year old man with enophthalmos and no other associated symptom that was caused by chronic rhinosinusitis. Functional endoscopic sinus surgery was the treatment of choice. No reconstruction of the orbital floor was performed. One year follow up, following surgical treatment revealed an excellent result.

Association of repeat polymorphisms in the estrogen receptors alpha, beta, and androgen receptor genes with knee osteoarthritis

Genetic factors have been shown to play an important role in the etiology of osteoarthritis (OA). To elucidate the possible role of genetic variation in the estrogen receptors alpha and beta (ER-alpha, ER-beta) and androgen receptor (AR) genes with knee OA, the -1174(TA)(n), c.1092+3607(CA)(n), and c.172(CAG)(n) repeat polymorphisms of ER-alpha, ER-beta, and AR genes were studied. A case-control cohort of 158 patients with idiopathic knee OA and 193 controls were used. A significant difference was observed in the frequency distribution of -1174(TA)(9-25) and c.1092+3607(CA)(13-27) repeat polymorphisms of the ER-alpha and ER-beta genes between OA patients and controls (p<0.005 and p<0.0001, respectively). A significantly increased odds ratio (OR) for knee OA was observed in individuals having long alleles (LL) genotype for ER-alpha gene and LL and one short and one long allele (SL) genotypes for ER-beta gene compared to individuals with the short alleles (SS) genotype (95% CI 1.03-3.5; p=0.04 and CI 2.4-8.3 and 2.5-7.5; p < 0.001, respectively). When ORs were adjusted for various risk factors, it was observed that women with LL genotypes for ER-beta and AR genes showed significantly increased risk for OA development (p=0.002 and 0.001). An association between c.1092+3607(CA)(13-27) and c.172(CAG)(8-34) repeat polymorphisms of the ER-beta and AR genes and knee OA was found in individuals of Greek descent.

The frequency and distribution of mast cells in pleomorphic adenomas of salivary glands

AIM

To investigate whether the frequency and distribution of mast cells (MCs) in pleomorphic adenomas (PAs) of major and minor salivary glands justifies the suggestion that there exists an association between MCs and mucoid stromal changes in PAs.

METHODS

The material consisted of 22 cases of pleomorphic adenoma (eight arising in major and 14 in minor salivary glands) and a control group represented by five cases of monomorphic adenoma (MA). Representative 3-microm thick, paraffin-embedded sections were stained with H&E and Azur A. Computer-aided image analysis was performed in order to evaluate the relative surface area occupied by epithelial and connective tissue components, as well as the absolute number of MCs.

RESULTS

According to our findings, PAs from minor salivary glands contain significantly greater numbers of mast cells compared with tumours from major glands. Additionally, the distribution of MCs within the stromal connective tissue appeared not to be random.

CONCLUSION

It is possible that differences in the pattern of connective tissue might influence the actual concentration of MCs and that these differences are responsible for the observed variations between major and minor gland PAs.

Oral manifestations of papular-purpuric 'gloves and socks' syndrome due to parvovirus B19 infection: the first case presented in Greece and review of the literature

Papular-purpuric 'gloves and socks' syndrome (PPGSS) is a novel, rare, self-limited dermatosis initially described in 1990. It is characterized by painful, pruritic edema and erythema, rapidly evolving to papular-purpuric lesions on the distal extremities, in a gloves-and-socks distribution, accompanied by fever and oral lesions such as petechiae, vesiculopustules and small erosions. Parvovirus B19 has been implicated in most cases as the etiological factor. Herein we present the first case of PPGSS in a 42-year-old Greek man with von Willebrand disease. On admission the patient was febrile, and presented acral edema and erythema rapidly followed by purpuric lesions on the same sites, and palatal petechiae. Complete remission of the exanthem occurred 7 days after hospitalization. Clinical and laboratory evaluation including serologic tests and PCR, confirmed the presence of parvovirus B19. Review of the existing literature on this novel syndrome and its association with parvovirus B19 is also presented.