The emersion of the new coronavirus SARS COV 2 (Severe Acute Respiratory SyndromeCoronavirus 2) was rapidly characterized as a pandemic by WHO. The majormanifestation of the virus is respiratory distress; however, the involvement of other organsshould not be overlooked. The kidney is one of the most important target organsof the specific virus with acute kidney injury (AKI) described in 5-36% of COVIDpositive patients and an average 25% within the severely ill.Purp ose: The purpose of this study was to consider the incidence of AKI in patientswith COVID 19 in our cohort and to better understand risk factors associated withAKI. Further, we wanted to investigate the impact of AKI on survival and in hospitalmortality.Methods: Patients admitted to Evagelismos General Hospital with confirmed COVID-19 infection from 11th March until 22th May were investigated. Patients 18 yearsold as well as transplanted patients were excluded from this study. AKI was definedaccording to the AKI criteria.Results : From 99 patients with COVID-19 infection, AKI occurred in 41 (41.4%).A total of 44 patients (44.4%) were admitted to Intensive Care Unit (ICU) and 31 ofthem (70.5%) developed AKI. Of the 44 patients with AKI, 16 (39%) required renalreplacement therapy. Hospital mortality, in total, was 16.2% (37% among patientswith AKI versus 0.02% among those without AKI, p=0.000).Conclusion: AKI was common among patients hospitalized with COVID 19. AKIwas associated with older age, clinical severity and existing CKD.
Radiographers or Radiological Technologists (RTs) as health professionals are calledupon to stand up to the circumstances and to modify practical applications to dealwith suspected and confirmed cases of Corona Virus Disease 19 (COVID-19). Theyperform chest X-ray examinations and Computed Tomography scans, which are keytools for diagnosing and monitoring patients with Severe Acute Respiratory SyndromeCoronavirus 2 (SARS-CoV-2). They are also an integral part of the departments ofMagnetic Resonance Imaging, Nuclear Medicine, Radiotherapy, Mammography, Orthopantomography- Cephalometric, Bone Density Measurement, and InterventionalRadiology – Hemodynamic. The purpose of this article is to provide RTs guidancethroughout the scope of their work and to keep the Hospital community informed.They are required to fully adhere to personal protective equipment (PPE) practices,such as the use of gloves, high-protection mask, special clothing, eye and feet protection.They should maintain safety distance and come into as little contact as possiblewith the patients. It is necessary to thoroughly disinfect and use protection for all theirwork components, stable or not. There should be separated spaces, in the presencesuspicious and confirmed cases, as well as the rational distribution of staff in theirworkstations and their continuous training and briefing. RTs are present in mediumand high-risk zones. As they are potential virus carriers in hospital units, PPE mustbe applied and strictly monitored. Moreover, workplaces should adapt to the currentprecautionary measures to ensure personal and occupational safety.
Aim: To observe changes in the nutritional status of patients during the acute postoperativedays following pancreaticoduodenectomy and to evaluate their influence onpostoperative complications.Methods: Nutritional status was assessed in 72 patients on the preoperative day beforesurgery and postoperative days (PD) 3 and 8, included measurements of bodycomposition by bioimpedance impedance analysis, biochemical values and musclefunction by maximum handgrip strength (HGS). The presence of postoperative complicationswas collected over 30 post operative days. Changes at PD were calculatedfor all variables. Non-parametric statistics were used and results are given as median(25th–75th quartiles).Results : Significant changes occurred on PD 3 in body weight +2.3 (0.8–3.6) kg, totalbody water +2.8 (1.1–5.9) l, extracellular water +2.5 (1.2–3.7) l, intracellular water+1.1 (-0.4–1.9) l, phase angle -1.0 (-1.2 to -0.7)°, C-reactive protein +58.0 (36.0–100.8)mg/l, serum albumin -12 (-16.5 to -10.0) g/l, and HGS -4.8 (-7.3 to -3.0) kg. Higher butno significant changes were observed at PD 3 in patients with postoperative complications(n=28) compared to those without (n=44). The hospital stay was longer inpatients with complications (12.5 days, p=0.005).Conclusion: Changes in body composition, biochemical values and muscle functionwere observed during the first 8 PDs. Changes at PD 3 did not influence significantlythe outcomes, but trends in body fluids and phase angle were found among patientswith postoperative complications.
Anemia is an almost universal phenomenon (ninety five percent) among critically ill patients, especially if they stay in the ICU more than 3 days. Forty to fifty percent of such patients receive red blood cell transfusions. Blood loss (due to blood sampling), iron reduced availability and utilization and cytokine mediated bone marrow suppression account for this loss of red blood cell mass. Anemia is itself associated with worse outcomes, independently of the nature of underlying disease. Transfusion therapy nevertheless, probably is not the ideal solution as it is related to increased mortality and hospital infections. Both the degree of anemia and transfusion intensity could represent either causative influences or merely surrogate markers of severe illness, posing significant difficulties on the interpretation of investigational results. Currently, restriction of red blood cell transfusion threshold to 7g/l has become the standard practice. Following the famous TRICC trial which introduced the low threshold concept, the few predicted exceptions regarding sepsis, hemorrhage or cardiac disease were addressed with new studies. The results of these studies force towards the implementation of the restrictive strategy throughout the whole transfusion indications spectrum in the ICU, with the exception of the symptomatic coronary patients. In order to minimize transfusion intensity however, acute context care must be optimum, multidisciplinary treatment approaches and support being timely provided.
1. Overall survival (OS) results of a phase III randomized trial of standard-of-care therapy with or without enzalutamide for metastatic hormone-sensitive prostate cancer (mHSPC): ENZAMET (ANZUP 1304), an ANZUP-led international cooperative group trial. Testosterone suppression (TS) is the backbone of treatment for metastatic hormone-sensitive prostate cancer (mHSPC). Overall survival is improved by the addition of early docetaxel (DOC) or abiraterone to TS. The randomised phase 3 ENZAMET trial assessed the effects of enzalutamide (ENZA), a potent androgen receptor (AR) inhibitor, versus a nonsteroidal anti-androgen (NSAA: bicalutamide, nilutamide, or flutamide) in addition to SOC in mHSPC. Men (1125) with mHSPC were randomly assigned 1:1 to receive TS plus either ENZA (160 mg daily, by mouth, until clinical disease progression or prohibitive toxicity) or NSAA (conventional NSAA, by mouth until clinical disease progression or prohibitive toxicity). All participants were to receive standard background therapy with a LHRHA or surgical castration, as per standard of care. The choice of the LHRHA or surgical castration was at the discretion of the treating clinician. Randomization was stratified by: volume of disease (high vs low, according to CHAARTED); planned early DOC; planned anti-resorptive therapy, comorbidity score (ACE-27), and study site. The primary endpoint was overall survival. Subgroup analyses to assess possible modulation of the treatment effect were specified a priori and included planned early docetaxel (yes vs no) and volume of disease (high vs low). After a median follow-up of 33 months. Overall survival was prolonged by ENZA. At 3 years, 36% NSAA vs 64% ENZA were still on their assigned study treatment. Serious adverse events (regardless of attribution) within 30 days of study treatment occurred in 42% ENZA vs 34% NSAA, commensurate with the different durations of study treatment. ENZA significantly improved OS when added to SOC in mHSPC while the benefits appeared lower in those planned to receive early DOC.
We are all accustomed to face serum cholesterol as a potential threat for our health and so wish and try to have its levels as low as possible. So, in clinical practice we are rather indifferent or even satisfied when we find very low serum cholesterol levels -what we can call “hypocholesterolemia- in a certain individual. Is this practice right or it should be reevaluated? Since cholesterol is an important component of all cell membranes and its concentrations affect membrane permeability and fluidity it is highly probable that very low levels of it may disturb some cell functions and participate in the pathogenesis of diseases. Let’s start with a definition of the term, although this is not generally accepted. It can be described as a serum total cholesterol level under the fifth percentile of a general population adjusted for sex and age.1 In a less complicated manner it can be defined as less than 115 mg/dl. In a study of 7,000 healthy blood donors, a percentage of 7,8% were found to meet the criteria for hypocholesterolemia. Hypocholesterolemia may be congenital or acquired. Congenital conditions are either combined with low LDL- (low density lipoprotein) or low HDL- (high density lipoprotein) cholesterol levels.
Aim: To assess the efficacy of infliximab in ulcerative colitis (UC) patients who had failed therapy with adalimumab or golimumab. Methods: Retrospective analysis of prospectively acquired data of all anti-TNF naive patients with moderate to severe UC who received adalimumab or golimumab in 4 tertiary referral centres. Patients with primary non response or secondary loss of response to adalimumab or golimumab received therapy with infliximab. Clinical response and remission rates were assessed at week 14 and 54 after initiation of infliximab. Results: Between September 2015 and September 2017, 29 of 58 (50%) anti-TNF naive patients with moderate to severe UC failed therapy with adalimumab (n=38) or golimumab (n=20). Twenty one of 29 (72.4%) patients were primary non responders and 8 (27.6%) patients lost response to adalimumab or golimumab. All these 29 patients received infliximab, while 15 (51.7%) were on concomitant azathioprine therapy. Eighteen (62.1%) and 10 (34.5%) patients showed clinical response and clinical remission at week 14 respectively, while 14 (48.3%) patients were on clinical remission at week 54 after initiation of infliximab. Azathioprine co-administration at the start of infliximab was associated with a greater proportion of patients achieving clinical remission at week 54 (10 of 15 patients on combination therapy vs 4 of 14 patients on infliximab monotherapy, p=0.04). Conclusions: A significant proportion of anti-TNF naive patients with moderate to severe UC who have failed 1st course therapy with subcutaneous anti-TNF agents can achieve clinical response and/or remission with 2nd course therapy with infliximab.
Background: We present the application of a modern telemetric method that records and monitors Intracranial Pressure (ICP) over long periods in patients with possible intracranial hypertension. Methods: A telemetric devise (Raumedic, Neurovent P-tel) was surgically implanted in six (6) patients. Three (3) patients with inconclusive diagnosis of idiopathic intracranial hypertension, two (2) patients with possible diagnosis of aqueduct stenosis and one (1) patient with Normal Pressure Hydrocephalus. All patients underwent a 3-day ICP recording within the nursing unit. Two more recordings were obtained over a period of 2-6 months at outpatient base. Results: All patients had an uncomplicated post-operative course. Analysis of the data excluded the diagnosis of idiopathic intracranial hypertension in two patients. Contrary in four patients data confirmed elevated ICP values and subsequently three of them underwent shunts implantation, while one patient refused further neurosurgical treatment. Conclusions: The telemetric device could be safely implanted in selected patients. It could provide long-term ICP recordings, which are necessary to confirm diagnosis and guide to the appropriate treatment.
Conventional aortic valve replacement in patients with porcelain aorta can be technically challenging and is even sometimes seen as contraindication. Trans-aortic valve implantation has been proposed as an alternative to other trancutaneous routes of implantation and is feasible when there is a small healthy area in the right anterolateral aspect of the ascending aorta. Herein we report an interesting case of combined transaortic valve implantation and off-pump coronary artery bypass grafting in a patient with severe aortic stenosis, severe ostial left main coronary artery disease and porcelain aorta.
The purpose of this study is to investigate the effect of ultrasound energy used during phacoemulsification on corneal structure, which is the most important refractive part of the eye. This will be achieved with the comparison of preoperative and postoperative parameters related to corneal thickness and endothelium and their correlation with clinical, intrasurgical and imaging diagnostic findings. Methods: This is a clinical prospective study conducted in Evangelismos G.H.A. The patients’ enrollment was based on detailed medical history assessment, medication records as well as meticulous slit lamp examination, tonometry, best corrected visual acuity evaluation and thorough fundoscopy. Nuclear cataract sclerosis was evaluated with Lens Opacities Classification System III, and patients were scheduled for surgery. Preoperatively, with the use of specular microscopy (Tomey EM-3000; Tomey, Tennenlohe, Germany), central corneal thickness and several endothelial indices were recorded. The same measurements took place the 1st, 7th and 30th postoperative day. All the surgical operations were done without complications. Results: statistical analysis from preoperative and postoperative data showed that central corneal thickness, although elevated during the 1st and 7th postoperative day, did not present statistical significant difference in the final evaluation, with a mean elevation of only 3,9μm. Endothelial cell density levels though were reduced in all postoperative measurements (p<0,001). The final percentage endothelial cell loss was18,58%, with the most profound loss being accounted in the first postoperative week. Corneal edema and endothelial cell loss were correlated with poor visual acuity, reduced corneal curvature, increased nuclear sclerosis and prolonged time of ultrasound metrics. Conclusion: the use of confocal microscopy is a useful tool in pointing significant differences of corneal structure after uneventfull cataract phacoemulsification. The evaluation of a larger cohort of patients and a prolonged follow up procedure could give further information concerning corneal alterations after surgery. Key words: cataract, phacoemulsification, cornea, lens, endothelium, ultrasound, confocal microscopy List of Abbreviations: CCT: central corneal thickness, SD: standard deviation, CV: coefficient of variation, , ECD: endothelial cell density, ECL%: endothelial cell loss%,
Despite the undeniable progress in the development of new effective drugs against malignant and non-malignant hematological diseases, allogeneic hematopoietic stem cell transplantation (HSCT) remains the only therapeutic option with long lasting curative potential. Continuous research for the last fifty years has repeatedly shown that HLA compatibility between recipient and donor constitutes the most decisive factor for successful engraftment and higher rates of overall survival. Unfortunately, a fully HLA matched donor is in many cases precluded, therefore the identification of better tolerated HLA mismatches has always been and still remains an important research objective. In this review we recapitulate current knowledge on how HLA- (i.e. locus, resolution level, directionality, number etc.) as well as non-HLA factors (i.e. disease stage, recipient age, graft source etc.) may impact the overall effect of HLA incompatibility on HSCT outcome, with the aim to offer an overview on potentially “permissive” HLA mismatches.
Renal Oncocytomas are rare benign renal masses. They can be easily mistaken for Renal Cell Cancers and patients usually undergo a radical nephrectomy. We present a case of a female patient who was admitted with a large mass originating from the right kidney. The results from the CT (stellate scar) and the angiography (spoke-wheel pattern) were consistent with Renal Oncocytoma, but still a radical nephrectomy was performed. This decision was made due to the inability of the current diagnostic procedures to safely differentiate Renal Oncocytomas from Renal Cell Cancers
In these guidelines, ESC and EACTS provide recommendations for revascularization of stable coronary artery disease (SCAD), non-ST-segment elevation acute coronary syndrome (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and revascularization in patients with different risk factors. The authors underline the importance of the interaction between cardiologists, cardiac surgeons, and referring physicians for choosing the best possible revascularization approach. Herein we represent the key messages of the recently published 2018 guidelines.
Title: Correlation of serum and urine midazolam levels with observed level of consciousness after discontinuation of midazolam sedation in the intensive care unit Marilena Papadaki1, Maria Pratikaki2, Achilleas Giannopoulos1, Theodora Ntaidou1, Eleftheria Mizi1, Marios Kougias1, Georgios Bouboulis1, Aikaterini Sarri1 and Charikleia S Vrettou1 1 1st Department of Intensive Care, Evangelismos Hospital, University of Athens Medical School, 45-47 Ipsilantou Str., 106 76 Athens, Greece 2 Department of Clinical Biochemistry, Evangelismos Hospital, Athens, Greece Introduction: Continuous infusion of midazolam is related to prolonged activity and delayed awakening in the critically ill. Serum benzodiazepine levels can be helpful in differentiating residual benzodiazepine activity from other causes of impaired level of consciousness (LOC) [1]. Although benzodiazepine levels can also be measured in the urine, the relationship between serum and urine levels with the observed LOC has not been studied in clinical practice. Objectives: To investigate the correlation between serum and urine benzodiazepine levels in the critically ill and their correlation with the observed level of consciousness estimated with the Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness Score (FOUR score). Patients and Methods: This prospective observational study involved patients admitted to a 30 bed General Intensive Care Unit, who were intubated and mechanically ventilated, with GCS prior to intubation > 8. Midazolam infusion was discontinued for at least 12 hours before sampling. Serum and urine sampling and clinical evaluation to calculate the GCS and FOUR score were done simultaneously. Gathered data included age, sex, weight and height, reason for admission to intensive care, renal function, daily fluid balance, daily and hourly urine output, liver function, serum proteins, hemoglobin and the application of renal replacement therapy. Serum benzodiazepine measurements were performed on the Integra system (Roche), which is suitable for semiquantitative detection of benzodiazepines in the serum. Urine benzodiazepine levels were measured with the Cobas C501 system, which is suitable for semiquantitative detection of benzodiazepines in human urine. The Scientific and Ethics committee of Evangelismos hospital approved the study protocol. Results: Twenty patients were included in the study, 10 male and 10 female. Reasons for ICU admission were septic shock (n=7), respiratory failure and ARDS (n=7), and acute surgery and trauma (n=6). Patients’ age ranged from 20 to 90 years old (median 66 years) and their weight from 45 to 160 Kg (median 77.5 Kg). The SOFA score ranged from 4 to 15 (median 8). The GCS score from 3 to 14 (median 7) and the FOUR score from 3 to 15 (median 10). Six patients were on continuous veno-venous haemodiafiltration (CVVHD) at sampling time. Serum benzodiazepine levels correlate moderately with the GCS (R =-0.496, p=0.026) and better with the FOUR score (R =-0.685, p=0.001), but did not correlate with measured levels in the urine (R =-0.029 p=0.904), even when patients without AKI were analysed separately (n= 12, R = 0.173, p=0.572). Figure 1 presents the scatter plot of measured urine and serum benzodiazepine levels in our sample. Conclusions: In patients treated in the intensive care unit, after discontinuation of midazolam sedation, the LOC (GCS and FOUR score) correlate significantly with the benzodiazepine levels measured in the serum. Urine benzodiazepine levels do not correlate with serum levels or with the observed LOC and therefore cannot be helpful in the differential diagnosis of drowsiness or coma in this population. References: (1) Rosich Andreu et al. Intensive Care Medicine Experimental 2015, 3(Suppl 1):A330
Objective: Immunophenotype has been correlated with molecular aberrations in several studies. The aim of this study was the discovery of immunophenotypic features related to mutations in AML and MDS patients connected to prognostic factors. Moreover, an effort to evaluate a method for the detection of the most common NPM1 mutations of exon12 and Internal Tandem Duplications (ITD) mutations of FLT3 gene by flow cytometry was performed. Method: Patients with de novo myeloid neoplasms [ AML and MDS (AML-M3 patients were excluded)] were included. FLT3/ITD/TKD and NPM1 mutations were detected by PCR and fragment analysis. The immunophenotypic analysis was performed by multi-dimensional flow cytometry (FC) with a standardized panel of monoclonal antibodies on peripheral blood or bone marrow samples. Nucleophosmin Antibody and CD135 were used for the mutations immunophenotypic detection. Results: NPM1 and/or FLT3 mutations correlated with low or no expression of more immature cells markers such as CD34, CD117, HLADR, as well as higher expression of more mature markers such as CD11b. The higher expression of CD33 should be mentioned as well. The presence of NPM1mut and FLT3/ITD does not seem to be detectable by FC at least using these two monoclonal antibodies. The presence of CD7 aberrant lymphoid marker’s expression was associated with FLT3mut, NPM1wt genotype. CD56 or CD2 positivity was found only in patients’ samples negative for NPM1 and/or FLT3 mutations. Conclusions: Certain immunophenotype findings including the presence of aberrant lymphoid markers may be indicative of the presence of mutations in NPM1 and FLT3 linked to prognosis.
