Hippokratia最新文献

Background: Most outcome-predictive models for COVID-19 patients use hospital admission data, offering a spontaneous mortality risk estimation. We aimed to elaborate on a tool that could be applied repeatedly, thus being more suitable for these patients' rapidly changing clinical course.

Methods: In this prospective study, we evaluated 560 samples derived from 156 patients hospitalized for COVID-19 in a single center. Age >61 years, male sex, comorbidities >2, need for intensive care unit admission, lactate dehydrogenase (LDH) >408 U/L, Neutrophil/Lymphocyte Ratio (NLR) >17, C-reactive protein (CRP) >10 mg/dl, and D-dimers >3,200 ng/ml were incorporated in an eight-scale score (MaD-CLINYC) after optimal scaling, ridge regression, and bootstrapping, which was documented to correlate with outcome independently of one or more samples analyzed, day from admission at sampling, and need for delivery. Validation process was performed over 574 samples derived from three centers.

Results: The developing and the validation cohort Area under Curve (AUC) was 0.90 (95 % Confidence Interval: 0.82-0.98) and 0.91 (0.88-0.94), respectively (p =0.822). A MaD-CLINYC score ≥4 had 75 % sensitivity and 81 % specificity to predict fatal outcome.

Conclusions: MaD-CLINYC score is a powerful, feasible, easy-to-use, dynamic tool to assess the risk of the outcome, thus assisting clinicians in close monitoring and timely decisions in COVID-19 hospitalized patients. HIPPOKRATIA 2021, 25 (3):119-125.

Background: Our understanding of the pathophysiology and management of intracranial aneurysms (IAs) continuously advances. This case-control study analyzed the demographics of patients with IAs and the morphological Digital Subtraction Angiography (DSA) characteristics of ruptured and unruptured IAs.

Methods: Two patient groups with saccular ruptured and unruptured IAs eligible for coiling were prospectively analyzed during a 3-year period. Patient groups were compared regarding gender, age, arterial vasculature side, anatomical location, diameter, preoperative DSA appearance, aneurysmal and anatomical Circle of Willis variations (CWV) co-existence.

Results: One hundred and three patients with ruptured and eighty-six patients with unruptured IAs were studied. Anterior communicating and internal carotid artery IAs were the dominant locations: 42.7 % and 23.3 % in ruptured and 29 % and 41.9 % in unruptured IAs, respectively. The female-to-male ratio was 1.78 in ruptured and 2.44 in unruptured IAs (p =0.317), while the rupture was more frequent in younger patients (p =0.034). Angiographically, smaller diameter (p =0.01), abnormal morphology (p =0.0001), and co-existence of CWV (p =0.016) were reported in ruptured IAs. Location at bifurcation/trifurcation (p =0.487) and the co-existence of additional or mirror IA did not differ significantly (p =0.879).

Conclusions: On DSA, ruptured and unruptured IAs differed in size, morphology, and co-existence of CWV; findings that may favor the treatment of specific unruptured IAs. However, a higher level of evidence is needed to include all these factors in the treatment decision process, provide patient-oriented treatment and reliably identify unruptured IAs at greater risk. HIPPOKRATIA 2021, 25 (3):100-107.

Background: Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

Methods: We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

Results: Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

Discussion: After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

Conclusion: Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Background/aim: Acute pancreatitis is a common gastrointestinal condition worldwide with variable severity and complications. Alcohol and gallstones are the leading causes of acute pancreatitis, while pancreatic ischemia is uncommon. Although venous thrombosis, especially adjacent to the inflamed pancreas, is a common complication of acute pancreatitis, arterial thrombosis secondary to pancreatitis has rarely been described. On the other hand, arterial thromboembolic events, secondary to cardiovascular diseases, are a rare cause of pancreatic ischemia. Herein, we present an interesting case of acute ischemic pancreatitis secondary to aortic atheromatosis complicated with multi-organ infarcts.

Description of the case: An 80-year-old male patient presented with nausea, abdominal pain, and vomiting accompanied by peripheral edema and ascites. Clinical, laboratory, and imaging investigation showed acute moderate to severe pancreatitis with multiple splenic and renal infarcts. An intraluminal free-floating aortic thrombus, secondary to atheromatosis of the descending aorta, was the cause of the complications. A conservative approach was successfully implemented, including supportive measures, antiplatelets, and vasodilators.

Conclusion: Identification of acute pancreatitis' cause, especially in the setting of a systemic disease like atheromatosis, is a challenging task and of great importance, given the implications on treatment decision-making and prevention of recurrent episodes. HIPPOKRATIA 2021, 25 (3):138-140.

Background: Neuroendocrine neoplasm (NEN) of the cystic duct (CD) is an extremely rare entity, with misty clinical manifestation and incidental, in most cases, diagnosis. Due to its rarity, several dilemmas arise concerning the optimal treatment of this type of malignancy.

Case description: We report two cases of histologically confirmed NENs of the CD from our institution. Furthermore, we present a literature review focusing on the treatment type and likelihood of recurrence. The two patients underwent laparoscopic cholecystectomy (CCE) due to cholelithiasis and were both diagnosed with well-differentiated Grade 1 (G1) NEN. The first patient did not undergo further treatment as the surgical margins were clear. Regarding the second patient, complementary resection of the CD remnant was performed since the histopathological diagnosis indicated positive surgical margins. Active postoperative surveillance was suggested, and both patients remain disease-free to date. In the literature, we identified 22 previous cases of NENs of CD. Since there are still no standard guidelines, various surgical plans were adopted, varying from simple CCE to hepatic lobectomy and Roux en Y hepaticojejunostomy. Postoperative surveillance is reported for up to four years. Regardless of the implicated treatment plan, no patient was diagnosed with recurrent malignancy and the mortality rate was very low (1/22).

Conclusion: We propose that cholecystectomy with ligation of the CD proximal to its junction with the common hepatic duct is an adequate oncological treatment for G1 NENs of the CD. When preoperative or perioperative suspicion for malignancy is made, a frozen section of the CD should be sent for pathological examination to confirm radical resection (R0). Nevertheless, there is a need for further research that could validate our findings. HIPPOKRATIA 2021, 25 (3):141-144.

[This corrects the article on p. 278 in vol. 15, PMID: 22435031.].

Background: Advances in perinatology and medical technology have pushed the limits of viability to unprecedented extremes, leading to a growing population of NICU "graduates" with a wide range of health issues. Although survival rates from 22 weeks of gestation onwards have improved over the last 30 years, the incidence of disabilities remains the same. Providing intensive care to a high-risk population with significant mortality and morbidity raises the fundamental conflict between sanctity and quality of life. Potential severe handicap and need for frequent tertiary care inevitably impact the whole family unit and may outweigh the benefit of survival. The aim of this study is to explore and summarize the ethical considerations in neonatal care concerning perivable birth.

Methods: Eligible studies published on PubMed were included after a systematic search using the PICO methodology.

Results: Forty-eight studies were systematically reviewed regarding guidelines, withholding or withdrawing treatment, parental involvement, and principles applied in marginal viability. As periviable birth raises an array of complex ethical and legal concerns, strict guidelines are challenging to implement.

Conclusions: Active life-sustaining interventions in neonatology should be balanced against the risk of putting infants through painful and futile procedures and survival with severe sequelae. More evidence is needed on better prediction of long-term outcomes in situations of imminent preterm delivery, while good collaboration between the therapeutic team and the parents for life-and-death decision-making is of utmost importance. HIPPOKRATIA 2021, 25 (1):1-7.

Background: Comprehensive geriatric assessment (CGA), as a complex diagnostic process, allows medical specialists to recognize the capabilities and limitations of the patient in older age. This study aimed to evaluate the prevalence and severity of deficits typical of seniors and find relationships between CGA results and selected factors.

Methods: A cross-sectional questionnaire study was performed in Krakow among patients aged 65 years and over visiting their general practitioners (GPs). CGA was conducted using eight scales: the Activities of Daily Living (ADL), Mini-Mental State Examination, Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, Timed Up and Go Test, Mini Nutritional Assessment Short Form, Clinical Frailty Scale, and Athens Insomnia Scale.

Results: Four hundred and thirty-eight patients, aged between 65 and 96 years, were examined. Most of them received high scores in the assessed aspects. The most common abnormalities were sleep disorders (42 %), symptoms of frailty (33 %), and depressive tendency (32 %). Age correlated with every aspect assessed in CGA and worsened as patients grew older (in all cases p <0.05). Male gender reduced the chance of depressive disorders [odds ratio (OR) =0.6 (0.39-0.92); p =0.02]. The strongest association was found between ADL and IADL scales [OR =153.56 (34.86-676.48); p <0.001].

Conclusions: Even though patients who attended general practices were functioning well in everyday life, after analysis, they manifested deficits in some areas of CGA. The most widespread problems in the geriatric population were depressive symptoms, frailty, and insomnia, and that is why GPs should ask about sleep and mood disorders during visits and assess the occurrence of frailty. HIPPOKRATIA 2020, 24(4): 173-181.

Background: In the setting of the oral-gut-liver axis, microbiome dysbiosis has been associated with decompensated cirrhosis progression. However, little is known on salivary microbiome profiles in stable decompensated patients.

Methods: We studied patients with stable decompensated cirrhosis (n =28) and matched healthy controls (n =26). There were five patients (17.8 %) with hepatocellular carcinoma (HCC). Microbiomes of the 54 salivary samples were profiled through next-generation sequencing of the 16S-rRNA region in bacteria.

Results: The two study groups (patients and controls) did not differ significantly concerning their baseline characteristics. The most abundant phyla were Firmicutes, Bacteroidetes, Proteobacteria, and Fusobacteria. Proposed dysbiosis ratio Firmicutes/Bacteroidetes was lower in patients than in controls (range: 0.05-2.54 vs. 0.28-2.18, p =0.4), showing no statistical significance. Phylum Deinococcus-Thermus was detected only in controls, while Phylum Planctomycetes only in patients. A-diversity analysis indicated low diversity of salivary microbiome in decompensated patients and patients with HCC, who presented specific discriminative taxa. On principal coordinate analysis (PCoA), the patients' and controls' salivary microbiomes clustered apart, suggesting differences in community composition (PERMANOVA test, p =0.008). Boruta wrapper algorithm selected the most representative genera to classify controls and patients (area under the curve =0.815).

Conclusions: Patients with stable decompensated cirrhosis of various etiology and history of complications have decreased diversity of their salivary microbiome. PCoA and Boruta algorithm may represent useful tools to discriminate the salivary microbiome in patients with decompensation. Further studies are needed to establish the utility of salivary microbiome analysis, which is easier obtained than fecal, in decompensated cirrhosis. HIPPOKRATIA 2020, 24(4): 157-165.