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.

Background: Despite the important advances in pregnancy and newborn follow-up, hypoxic-ischemic encephalopathy is still one of the prominent causes of newborn mortality and disability worldwide, and there is no sufficiently effective treatment for it yet. This study aimed to investigate whether the ozone injection, administered in a single-dose as a preconditioning agent before the hypoxia and in single and repeated doses on different days following the hypoxia, would affect the spatial memory performance of the rats in the Morris water maze test or on their apoptotic cell numbers.

Methods: The study consisted of 102 seven-day-old male Wistar baby rats randomly divided into five groups. Rats in all groups were induced with hypoxic-ischemic brain injury (HIBI) except for the Sham group, and 1.2 mg/kg ozone was administered intraperitoneally. For the apoptosis evaluation, eight rats from each of the first four groups were decapitated by cervical dislocation. Terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay was used for immunohistochemical quantification of apoptosis in the excised brains. Blood malondialdehyde (MDA) and superoxide dismutase (SOD) levels were measured in the blood samples collected through cardiac puncture. Fourteen-week-old rats underwent the Morris water maze test to test their long-term spatial memory.

Results: On apoptotic quantification in the right hemisphere using the TUNEL assay, the numbers of apoptotic neurons in the ozone preconditioning group (Group 3) and the group given ozone on the day of hypoxia (Group 4) were found to be significantly higher than the Sham group (Group 1), but significantly lower than the non-treatment group (Group 2) (p <0.001; p <0.001, respectively). Group 3 rats had the highest mean MDA level and SOD activity. Considering the platform finding times in the first four days of the tests, Group 4 had the shortest times after Group 1; and on Day 4, Group 4 found the platforms significantly sooner than Groups 2, 3, and 5 (p <0.001). Comparison of Groups 1 and 4 revealed significantly shorter times for Group 1 for each day except for Day 2.

Conclusions: Other studies have shown that controlled application of ozone would result in oxidative preconditioning and reduce the damage induced by reactive oxygen species through enabling adaptation to oxidative stress. Our study obtained remarkable and encouraging findings for ozone administration in HIBI by examining Group 4's performance in the first four days and the difference in its platform finding times between Day 1 and Day 4. HIPPOKRATIA 2021, 25 (2):56-62.

Background: Endograft infection complicating endovascular aneurysm repairs is infrequent and presents various symptoms and findings, the most common being abdominal pain, fever, fatigue, and gastrointestinal bleeding.

Description of the case: Α 75-year-old male patient with endovascular graft infection presented with a three-day history of fever and was initially misdiagnosed as a bacteremic urinary tract infection. Due to high surgical risk, a drainage tube was placed, and the patient was treated with intravenous antibiotics for three weeks and then with oral antibiotics for two months. On the six-month follow-up, there were no signs of infection recurrence.

Conclusion: Endovascular graft infections generally require antibiotic therapy combined with surgical debridement and revascularization. This case illustrates a successful alternative management strategy with percutaneous drainage of the aortic sac abscess combined with long-term oral antibiotic therapy. This case also underlines the high index of suspicion necessary for the accurate and timely diagnosis and management of endovascular graft infections. HIPPOKRATIA 2021, 25 (2) 91-93.

Background: Ocular involvement in patients with transfusion-dependent β-thalassemia is quite common, and its frequency differs among studies. This case series aimed to describe the ocular abnormalities occurring in β-thalassemia patients who need regular blood transfusions and receive iron chelation therapy.

Case series: This is a case series prospectively studied 32 β-thalassemia patients from Northern Greece receiving regular blood transfusions and iron-chelating therapy. Patients' average age was 35.5 years. Eighteen patients with major phenotypes and fourteen patients with intermedia type underwent comprehensive ophthalmic examination at the time of enrolment, including visual acuity evaluation, refraction and color vision tests, Amsler grid test, slit-lamp, and dilated-pupil fundus examination. Additionally, we performed visual field testing and optical coherence tomography in all patients and fluorescein angiography only in selected cases. After six months, patients' complete ophthalmic examination was repeated for any new ocular findings due to the disease process and iron chelation therapy. Ocular involvement was detected in 46.87 % of the patients. Lesions were most frequently seen in elderly patients with thalassemia major. Lens opacities were present in 21.8 %, and degeneration of the retinal pigment epithelium was described in 15.6 % of the patients, representing the commonest fundus alteration observed, followed by fundus atrophy. The most severe and vision-threatening condition described in this study was the presence of angioid streaks with choroidal neovascularisation. Six months follow-up of patients did not reveal any new ocular findings.

Conclusion: Early detection of severe ocular abnormalities is important in patients with thalassemia; thus, an ophthalmologic examination should be included at regular check-ups. An annual examination is currently indicated for asymptomatic patients, while in symptomatic and complicated cases, patients should be closely followed-up. HIPPOKRATIA 2021, 25 (2):79-82.

Background: Due to variable rates of colon carcinoma or advanced adenoma mimicking an acute diverticulitis episode, the necessity of colonoscopy to detect colon cancer or advanced adenoma remains to be explored. This study investigated the incidence and predictive factors of colon cancer or advanced adenoma following acute diverticulitis.

Methods: We evaluated retrospectively all consecutive patients with an episode of computed tomography-proven acute diverticulitis between June 2016 and August 2019. A follow-up colonoscopy was performed. Demographic and clinical parameters were recorded. Patients with clinically substantial colonic neoplasia (colon cancer or advanced adenoma) were classified as Group A, while Group B included patients without clinically significant colonic neoplasia. The incidence of clinically significant colonic neoplasia in acute diverticulitis patients was regarded as the primary outcome.

Results: The mean age of 233 patients with acute diverticulitis was 58.6 ± 12.7 years. Complicated diverticulitis was detected in 39 patients (16.7 %). Sixteen patients (6.9 %) were assigned to Group A and 217 patients (93.1 %) to Group B. The age of the patients in group A was significantly higher than in Group B (p =0.001). Age above 50 and 65 years was also significantly associated with clinically significant colonic neoplasia (p =0.015 and p =0.012, respectively). The other variables did not influence the development of clinically significant colonic neoplasia (p >0.05).

Conclusions: Colonoscopy examination following an episode of acute diverticulitis may not be recommended for all patients due to the rare occurrence of colon cancer or clinically significant colonic neoplasia in those younger than 50 years. HIPPOKRATIA 2021, 25 (2):69-74.