Ventriculo-meningitis or nosocomial meningitis/ventriculitis is a severe nosocomial infection that is associated with devastating neurological sequelae. The cerebrospinal fluid isolates associated with the infection can be Gram-positive or -negative, while the Enterococcus spp. is rarely identified. We report a case of a 68-year-old woman with a past medical history of insulin-dependent diabetes mellitus, hypertension, and coronary artery disease. She was admitted to the intensive care unit following a scheduled sphenoid wing meningioma resection. Her course was complicated with left middle cerebral artery pseudoaneurysm and hemispheric hemorrhage, and an arterial stent and external ventricular drainage catheter were placed. Neurological evaluation showed a minimal conscious state. She presented high fever on the 35th intensive care unit day. Cerebrospinal fluid was sampled and the external ventricular catheter was removed. Enterococcus faecalis was isolated from the culture specimen. The patient received targeted treatment with an ampicillin plus ceftriaxone combination, and a follow-up culture confirmed the pathogen’s eradication. Although she was considered cured, she had a prolonged intensive care unit stay and finally died in the ward two months after the completion of treatment. This case highlights the first reported use of this combination in a severe, non-endocarditis, invasive enterococcal infection, while the review discusses treatment options for nosocomial ventriculitis/meningitis.

The role of probiotics in the prevention of ventilator-associated pneumonia (VAP) remains inconclusive. The aim of this study was to assess the efficacy of a probiotic regimen for VAP prophylaxis in mechanically ventilated multi-trauma patients, intubated immediately after the injurious insult. In a randomized, placebo-controlled study enrolling multi-trauma patients, patients expected to require mechanical ventilation for >10 days were assigned at random to receive prophylaxis with a probiotic formula (n= 59) or placebo (n= 53). The probiotic formula was a preparation of Lactobacillus acidophilus LA-5 [1.75 x10(9) colony-forming units (cfu)], Lactobacillus plantarum (0.5 x10(9) cfu), Bifidobacterium lactis BB-12 (1.75 x109 cfu) and Saccharomyces boulardii (1.5 x10(9) cfu) in sachets. Each patient received two sachets twice daily for 15 days: one through the nasogastric tube and one spread on the oropharynx. The incidence of VAP was the primary endpoint. The incidence of other infections and sepsis, and the duration of hospital stay were the secondary endpoints. Administration of probiotics reduced the incidence of VAP [11.9% vs 28.3%, hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.13-0.92; P=0.034] and sepsis [6.8% vs 24.5%, odds ratio 0.22, 95% CI 0.07-0.74: P= 0.016]. Furthermore, probiotic prophylaxis reduced the time of stay in the intensive care unit (ICU) and the length of hospital stay. The prophylactic use of probiotics with a combination of enteral and topical application to the oropharynx had a positive effect on the incidence of VAP and sepsis, as well as on ICU and total hospital stay in patients receiving protracted mechanical ventilation. (C) 2021 The Authors. Published by Elsevier Ltd.

Acute motor sensory axonal neuropathy (AMSAN) is a severe form of Guillain–Barré syndrome, which typically is not related to ocular palsy, and is pathologically associated with antibodies against GM1 and GD1a gangliosides. We present a patient with a severe, drug-resistant form of AMSAN with ophthalmoplegia related to antiganglioside (anti-GD1a, -GD1b, -GM1) antibodies in the serum and cerebrospinal fluid, and with a poor long-term outcome. Rare cases of AMSAN with ophthalmoplegia are described in the literature. The present patient is a case of an unusual clinical phenotype of AMSAN, the characteristics of which warn of a serious clinical course that requires timely aggressive treatment.

Laparoscopic approach for suspected adrenal malignancies remains a controversial issue and it gets more controversial, when managing giant adrenal malignant tumors. The aim of this paper is to present five cases of patients with giant adrenal malignant tumors that underwent laparoscopic transabdominal lateral adrenalectomy in our department between 2010 and 2017. Literature is also reviewed in order to investigate the feasibility of laparoscopic resection in these cases.

Background: Gender affects the clinical presentation of obstructive sleep apnea (OSA). The classic OSA symptoms, such as sleepiness, snoring, and apnea, are not so frequent in women. Objectives: To evaluate possible gender differences in questionnaires used for OSA prediction, such as the Epworth Sleepiness Scale (ESS), STOP, STOP Bang (SB), Berlin Questionnaire (BQ), Athens Insomnia Scale (AIS), and Fatigue Scale (FS). Methods: 350 males were matched with 350 women referred to a sleep clinic, according to OSA severity. All responded to the questionnaires and underwent a sleep study. Cardiovascular disease (CVD) patients were separately analyzed. Results: ESS did not differ between genders. SB was higher in males, whereas STOP, BQ, AIS, and FS were higher in females. BQ presented the highest sensitivity in both genders, whereas STOP exhibited the highest specificity in males and ESS in females. AIS and FS were more sensitive and SB more specific in females, whereas BQ was more specific in males. For severe OSA, the predictive values of SB and BQ were almost similar for both genders; however AIS and FS were higher in women. CVD patients presented higher scores, independent of gender, except for AIS, which was higher in females. Conclusion: Gender-specific evaluation of questionnaires is necessary to prevent OSA under-diagnosis.

Lung Cancer ManagementVol. 8, No. 3 EditorialOpen AccessBiopsy and rebiopsy for non-small-cell lung cancer: current and future methodsPaul Zarogoulidis, Christoforos Kosmidis, Varvara Fyntanidou, Zoi Aidoni, Kosmas Tsakiridis, Charilaos Koulouris, Nikolaos Michalopoulos, Anastasios Barmpas, Haidong Huang, Chong Bai, Wolfgang Hohenforst-Schmidt & Konstantinos SapalidisPaul Zarogoulidis*Author for correspondence: E-mail Address: pzarog@hotmail.comThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Christoforos KosmidisThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Varvara FyntanidouAnesthesiology Department, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Zoi AidoniThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Kosmas TsakiridisThoracic Surgery Department, 'Interbalkan' European Medical Center, Thessaloniki, Greece, Charilaos KoulourisThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Nikolaos MichalopoulosThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Anastasios BarmpasThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece, Haidong HuangDepartment of Respiratory & Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai, China, Chong BaiDepartment of Respiratory & Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai, China, Wolfgang Hohenforst-SchmidtSana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, 'Hof' Clinics, University of Erlangen, Hof, Germany & Konstantinos SapalidisThird Department of Surgery, 'AHEPA' University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, GreecePublished Online:17 Oct 2019https://doi.org/10.2217/lmt-2019-0006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit Keywords: bronchoscopycone beam CTconvex probe endobronchial ultrasoundCT-guided biopsyelectromagnetic navigationesophageal ultrasoundnon-small-cell lung cancerPET-CTradial endobronchial ultrasoundtransthoracic ultrasoundLung cancer is still predominately a disease with late-stage diagnosis and is the second highest cause of cancer death, after prostate cancer for males and breast cancer for females. In the last 5 years, there has been an effort to focus on prevention for smokers, with several lung cancer screening protocols being evaluated. In the last decade, the pharmaceutical industry has continued to investigate the genome of non-small-cell lung cancer and new emerging targeted treatments have been developed as a result. These novel therapies that have been developed were based on: EGFR mutation, anaplastic lymphoma kinase mutation, proto-oncogene B-Raf (BRAF), proto-oncogene tyrosine-protein kinase ROS-1 (ROS1) and PD-L1. Tyrosine kinase inhibitors (TKIs) were developed as drugs for EGFR, anaplastic lymphoma kinase mutation, ROS1- and BRAF-based therapies and immunotherapy was developed for PD-L1-based therapy [1–5]. There are currently different types of TKIs used as first-line treatment. However, these drugs can cause side effects including colitis, rashes or pneumonitis. These adverse effects have been shown to be associated with the effectiveness of the therapy. The more intense the adverse effects, the greater the resulting tumor reduction and metastasis control. Currently, we can adjust the dosage so that the adverse effects are minimized while also ensuring the therapy remains efficient. Moreover, drug resistance is usually observed in EGFR-positive patients when using TKIs because the mutation T790M is developed [1]. However, novel TKIs have been developed in order to overcome this. The main issue, until now, has been determining how to obtain the best possible sample that harbors the mutation. This can be achieved with tissue re-biopsy, or by blood sample [2,3]. Each method has its advantages and disadvantages. Re-biopsy is performed with an invasive technique, while a blood sample is easier to obtain. However, only with a tissue sample we can be 100% sure that a T790M can be found [3]. Immunotherapy can be administered alone as first-line treatment if PD-L1 expression ≥50% but it can also be administered as second-line treatment, indifferent of the PD-L1 expression [6]. Today, we can also administer immunotherapy as first-line treatment in combination with chemotherapy, indifferent of the PD-L1 expression [7]. Immunotherapy also has adverse effects, such as pneumonitis, orogonitis, vitiligo, dysregulation of the thyroid gland and hepatitis resurrection [8,9]. There have been cases where the tumor in patients with very high PD-L1 expression (≥90%) induced tumor necrosis to such a degree that the tumor melted within 24 h [10]. Before assessing the genome in a tissue sample, cells or blood, we should comment on the methods of biopsy and how to properly select for each patient.Pulmonary physicians had the bronchoscope for many years before the evolution of the ultrasound systems. For peripheral nodules, we can use the radial endobronchial ultrasound (EBUS), potentially combined with a C-arm in order to enhance the efficiency of the method [11,12]. Before the radial-EBUS, we used a C-arm for guidance of the biopsy forceps within the pulmonary parenchyma. However, this method was only efficient for large masses (≥3 cm). For pulmonary nodules, we can use electromagnetic navigation. There are currently different guidance systems on the market and, again, the addition of radial-EBUS and/or C-arm can enhance the efficiency of the electromagnetic navigation technique [11]. Cone beam computed tomography (CT) is another real-time navigation system that can be used with very high efficiency, by both the pulmonary physicians or the radiologists for masses and nodules [13,14]. Transthoracic ultrasound is another type of equipment that can be used either by the pulmonary physicians or the radiologists for peripheral large masses. CT-guided biopsy is another method for biopsy, but has limitations when compared with cone beam CT. Cone beam CT is real-time navigation, CT-guided biopsy is not. Moreover, neither of these techniques should be used for central lesions next to large vessels, for safety reasons. The real evolution for lung cancer staging became a reality with the convex probe EBUS (CP-EBUS) [15]. This endoscope can access those lymph node stations, which are proposed from the International Association for the Study of Lung Cancer (IALSC; CO, USA), within the mesothorax for proper lung cancer staging. It can safely puncture lymph node stations next to large vessels and, of course, access central masses which are surrounding central airways. The esophageal ultrasound (EUS) can be used to access lymph node stations like 7 and 4 L in the mediastinum, and every mass that is located paraoesophageal. In the case where a lymph node station within the mediastinum is so enlarged that it is touching the esophagus, it can be punctured with the EUS. Similarly, for CP-EBUS there are cases where a mass can be accessed with using the CP-EBUS through the esophagus. In some countries, the CP-EBUS is used to take biopsy from the left adrenal gland, especially in short patients (≤1.70 cm). The bronchoscope and CP-EBUS can use 19, 21 and 22G needles in order to acquire a sample. The larger the needle diameter, the larger the tissue sample. However, we should not forget that we cannot use the 19G needle in all lesions, since this could have serious adverse effects. Since the 19G needle has a larger diameter, it cannot be used to take biopsy from lymph node stations which are in close contact with large vessels. However, a 19G needle can be used for the EUS.For CT-guided biopsy, transthoracic ultrasound-guided biopsy and cone beam CT-guided biopsy, we can use larger core biopsy needles like 16 and 18G. Pneumothorax and hemothorax can occur in any case where needles are used. Forceps and specially designed brushes can also be used through endoscopes for endobronchial lesions. A very important factor is to assess our sample and, along with our pathology and cytology lab, perform the correct procedures in order to accurately use our sample. A cytology and pathology lab should work closely together in order to evaluate a biopsy material from a needle sample. Cell blocks produced from a needle biopsy are usually the best solution to evaluate both the cells and the tissue that are acquired with small G needles, like the 21 and 22G. We should use as little material as possible from one paraffin block to identify the cancer type so that we still have enough material left over to evaluate the different genes that might be expressed.It is very important to make the biopsy as convenient and safe as possible for a patient. For endoscopic techniques, sedation should always be used. There are cases where biopsies in small lymph nodes (≥5 mm) are required for proper lung cancer staging, and general anesthesia is necessary. Regarding techniques such as cone beam, transthoracic ultrasound and CT-guided biopsy, local anesthesia with lidocaine or xylocaine is enough. The status of the respiratory system is very important to consider when evaluating what type of anesthesia should be administered along with the proper biopsy method. Jet-ventilation is a respiratory model used where the respiratory rate is very high (>60) along with a very high tidal volume (>450). A catheter first enters the vocal cords and then the trachea while the patient is in deep sedation but is not intubated [16]. This model of respiration during an interventional procedure is excellent for patients with chronic obstruction pulmonary disease, because these patients tend to experience rapid increases in PCO2 during an endoscopic procedure. Positron emission computed tomography can indicate where to puncture within a large mass in order to obtain live cancer cells. Large masses, especially squamous cell carcinoma, tend to experience tumor necrosis and develop abscesses, meaning false-negative results are often given. This imaging technique provides information regarding the staging of lung cancer, it identifies suspicious lymph nodes of the mesothorax and provides us with the first information of the extent of the disease until the CP-EBUS verifies this information. Medical thoracoscopy is another technique which a pulmonary physician or a thoracic surgeon can perform. We can easily visualize the pleura and perform large tissue biopsies and, if necessary, perform pleurodesis [17]. Rapid on-site evaluation is another technique that provides information within the biopsy procedure, regarding whether the material that we obtained was sufficient for diagnosis. Moreover, it provides information on whether we have lung cancer in the site that we punctured; small cell or non-small-cell lung cancer, or distant metastasis. This technique has its limitations, since we might have false negative in cases of lymphoma [15]. Whenever we suspect lymphoma, thoracoscopy should be preferred. Large 19G core biopsies from endoscopic techniques might sometimes provide us with the diagnosis of lymphoma but we still have false-negative results in some patients [18,19].Another noninvasive method of rapid on-site evaluation is elastography, in which we use the color and strain ration in order to have a real-time tissue evaluation [20]. It allows us to know if a lesion or a lymph node is benign or malignant and where exactly to puncture within the lesion in order to obtain the best sample. When drug resistance occurs with disease relapse in patients that are EGFR positive and are under TKIs, we need to obtain a new sample, either tissue or cytology, to investigate whether we have T790M mutation. Current medical opinion suggests that we should re-biopsy the cancer site if it relapses, if a new lesion occurs or if a lymph node is enlarged [2,21]. Finally, the method of biopsy should be chosen based on the safety of the patient and our first choice should be to obtain tissue sample.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/References1. Domvri K , Zarogoulidis P , Darwiche K et al. Molecular targeted drugs and biomarkers in NSCLC, the evolving role of individualized therapy. J. Cancer 4(9), 736–754 (2013). Crossref, Medline, CAS, Google Scholar2. Zarogoulidis P , Rapti A , Sardeli C et al. Re-biopsy after relapse of targeted therapy. T790M after epidermal growth factor mutation, where and why based on a case series. Respir. Med. Case Rep. 21, 171–175 (2017). Medline, Google Scholar3. Sundaresan TK , Sequist LV , Heymach JV et al. 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A new and safe mode of ventilation for interventional pulmonary medicine: the ease of nasal superimposed high frequency jet ventilation. J. Cancer 9(5), 816–833 (2018). Crossref, Medline, Google Scholar17. Yap KH , Phillips MJ , Lee YC . Medical thoracoscopy: rigid thoracoscopy or flexi-rigid pleuroscopy? Curr. Opin. Pulm. Med. 20(4), 358–365 (2014). Crossref, Medline, Google Scholar18. Yu L , Chen K , Xu Y et al. The value of EUS in combination with cytological, flow cytometry, and gene rearrangement in the diagnosis of gastrointestinal lymphoma. Hematol. Oncol. 35(3), 303–309 (2017). Crossref, Medline, CAS, Google Scholar19. Zarogoulidis P , Huang H , Bai C et al. Endobronchial ultrasound convex probe for lymphoma, sarcoidosis, lung cancer and other thoracic entities. A case series. Respir. Med. Case Rep. 22, 187–196 (2017). Medline, Google Scholar20. Huang H , Huang Z , Wang Q et al. Effectiveness of the benign and malignant diagnosis of mediastinal and hilar lymph nodes by endobronchial ultrasound elastography. J. Cancer 8(10), 1843–1848 (2017). Crossref, Medline, Google Scholar21. Zarogoulidis P , Gaga M , Huang H , Darwiche K , Rapti A , Hohenforst-Schmidt W . Tissue is the issue and tissue competition. Re-biopsy for mutation T790: where and why? Clin. Transl. Med. 6(1), 6 (2017). Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited ByModified Biopsy Assessment for Endobronchial Ultrasound in Diagnosis of Peripheral Lung Neoplasms1 June 2022 | Creative surgery and oncology, Vol. 12, No. 1PD-L1 and standardized uptake value expression in lung cancer: a possible connection for efficient early lung cancer treatmentPaul Zarogoulidis, Chrysanthi Sardeli, Vagelis Christakidis, Wolfgang Hohenforst-Schmidt, Haidong Huang, Christoforos Kosmidis, Anastasios Vagionas, Sofia Baka, Kosmas Tsakiridis, Eleni-Isidora Perdikouri, Konstantinos Romanidis & Konstantinos Sapalidis18 March 2021 | Biomarkers in Medicine, Vol. 15, No. 7 Vol. 8, No. 3 Follow us on social media for the latest updates Metrics History Received 25 August 2019 Accepted 10 September 2019 Published online 17 October 2019 Published in print December 2019 Information© 2019 Paul ZarogoulidisKeywordsbronchoscopycone beam CTconvex probe endobronchial ultrasoundCT-guided biopsyelectromagnetic navigationesophageal ultrasoundnon-small-cell lung cancerPET-CTradial endobronchial ultrasoundtransthoracic ultrasoundFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/PDF download

Sepsis is a major cause of death and the most common cause of death among critically ill, non-ICU patients. Dexmedetomidine (DEX), an <alpha>2 adrenergic receptor agonist, presents sympatholytic action in certain parts of the brain with anxiolytic, sedative, and pain killing effects. Additionally, through the activation of <alpha>7 nicotinic acetylcholine receptor receptors, DEX reduces cytokine transcription and inhibits inflammation, rendering it beneficial during septic conditions. Moreover, there is a lot of interest in designing experimental sepsis models, where the administration of DEX is evaluated for its impact on multiple systems. This review focuses on experimental studies published between 1999 to March 2019 that were using DEX administration in sepsis in vivo models. From these, 36 articles were selected and summarized. Overall results show evidence that DEX may decrease mortality and inhibit inflammation, as it enhances the activity of the immune system while reducing its systemic reaction and lowering cytokine concentrations. Moreover DEX succeeds to alleviate heart injury during sepsis, acting beneficially for microcirculation and shows a neuroprotective role by inhibiting apoptotic pathways. In addition, DEX appears to have a protective role for liver and spleen as well as a beneficial role for the function of lungs and kidneys as it reduces sepsis-induced injuries and apoptosis in intra-abdominal experimental sepsis models.

Heart malignancies are rare and difficult to diagnose at early stage. Usually they are discovered when they present disease symptoms. CT of the thorax with contrast, MRI of the thorax, endobronchial ultrasound (EBUS) or echocardiography (transthoracic and/or transesophageal) and fluorodeoxyglucose positron emission tomography-CT (FDG-PET-CT) can be used to diagnose this entity. We present a rare heart sarcoma and our diagnostic algorithm.

Background: Prostate cancer is considered to be highly sensitive to changes in radiation therapy dose per fraction, specifically to hypofractionation. An increase in the fractionation dose could cause a higher increase to the prostate than to the normal tissues leading to better disease control with less toxicity. Here we present the results of a randomized trial comparing mild hypofractionation to conventional fractionation after a median of 3,6 years follow up. Patients and Methods: 139 patients were randomized to receive either hypofractionated radiotherapy with 2,25 Gy/fr to a total of 72 Gy (arm 1) or conventionally fractionated treatment with 2Gy/fr to a total of 74 Gy (arm 2). 72 patients were assigned to arm 1 and 67 to arm 2. Results: After a median follow up of 3,6 years, 23 patients (31,9%) from arm 1 developed grade≥ 2 acute genitourinary toxicity and 21 (31,3%) from arm 2 (p=0,79). The corresponding values from gastrointestinal were 15 (20,8%) and 12 (17,9%) (p=0,6). For late toxicity from GU, 8 patients (11,1%) developed grade≥ 2 symptoms in arm 1 and 7 (10,4%) in arm 2 (p=0,92). late GI toxicity grade≥ 2 was observed in 8 (11,1%) patients in arm 1 and 8 (11,9%) in arm 2 (p=0,88). In multivariate analysis, hormone therapy was significantly associated with late GI events, while acute toxicity from both GU and GI was a prognostic factor of late adverse reaction. Conclusion: No difference in the toxicity profile could be identified between hypofractionation and conventional fractionation. Our schedule of 2,25Gy/fr seems safe and tolerable by the patients with acceptable rates of acute and late toxicity.

Background and Objectives: The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. Methods and Materials: Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Results: Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11–1.35), I2 = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09–1.09), I2 = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. Conclusion: The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small.

Pancreatic cancer is still diagnosed at a late stage although we have novel diagnostic tools. Pancreatic cancer chemotherapy treatment resistance is observed and therefore novel treatments are in need. Anti-cancer stem cell therapy, combination of chemotherapy and/or radiotherapy with immunotherapy, proteins/enzymes and gene therapy are currently under evaluation. Targeted treatment with tyrosine kinase inhibitors is also administered and novel inhibitors are also under evaluation. In the current review we present recent data from our search within the year 2018.

Introduction: Non-small cell lung cancer is still diagnosed at a late stage although we have new diagnostic equipment such the radial endobronchial ultrasound, convex probe endobronchial ultrasound, and electromagnetic navigation. The diagnostic techniques have been upgraded with rapid on-site evaluation (ROSE) and currently from 2014 real-time elastography is being evaluated as a ROSE technique. Areas covered: A thorough search was performed on PubMed and Scopus with the following key words: elastography, strain ratio, convex probe EBUS, endoscopic ultrasound (EUS), elastography. In the current mini review, we will focus on published data regarding elastography with the convex probe endobronchial ultrasound in two different systems and comment on this future ROSE technique. Elastography, strain ratio, and factors such as(I) margin (indistinct or distinct); (II) shape (oval or round); (III) short-axis size less or more than 1 cm; (IV) presence or absence of central hilar structure (CHS); (V) echogenicity (homogeneous or heterogeneous); and (VI) presence or absence of coagulation necrosis sign are presented in our review based on published literature. Expert opinion: Current data indicate that we can have up to 93% sensitivity and specificity of real-time elastography and strain ratio for the evaluation of benignancy and malignancy; however, sample biopsy is still necessary. For now, we can only reduce the number of punctures.

The radial endobronchial ultrasound (EBUS) and convex EBUS are the excellent diagnostic tools for the investigation of a nodule and diagnosis-staging lung cancer "

We designed this experimental study with a view to evaluate the effects of dexmedetomidine (DEX) on cardiac performance and systemic and peripheral hemodynamics in healthy and early-stage endotoxemia swine models. Our study hypothesis was that DEX can ensure hemodynamic stability during the course of endotoxemia. Thirty-two male pigs (25–27 kg) were assigned into four groups: (1) no intervention (group A), (2) DEX 0.8 μg/kg was administered in non-septic animals (group B), (3) sepsis induced by intravenous Escherichia coli endotoxin (group C) and (4) DEX 0.8 μg/kg was administered in septic animals (group D). Hemodynamic parameters such as heart rate, mean blood pressure, central venous pressure, pulmonary artery pressures, pulmonary artery occlusion pressure, pulmonary vascular resistance and cardiac output were continuously recorded. Central venous oxygen saturation was also measured in order to obtain a complete evaluation of cardiovascular response to sepsis. Heart rate was decreased, whilst mean arterial pressure decrease was alleviated after DEX administration in septic animals. In addition, central venous pressure was stable in animals with sepsis after DEX infusion. Sepsis dramatically elevated pulmonary function indicators but DEX succeeded in ameliorating this effect. The important decrease measured in central venous oxygen saturation in both sepsis groups reflected the decreased perfusion of tissues that takes place at the end of early sepsis. Our findings support the hypothesis that DEX has beneficial effects on heart rate and pulmonary artery pressure, whilst reduction in systemic blood pressure occurs at acceptable levels.

Introduction: Lung cancer is diagnosed at advanced stage due to lack of early disease symptoms. Currently we have several different biopsy techniques such as; radial endobronchial ultrasound, convex probe endobronchial ultrasound, electromagnetic navigation, ct guided biospy and transthoracic ultrasound biopsy. Novel therapies such as; immunotherapy is being used for non-small cell lung cancer in the everyday clinical practice as first and second line treatment. Programmed ligand-1 is essential in order to administer immunotherapy as first line treatment. Patients and Methods: Two thousands and two patients were included in our study where programmed ligand 1 was evaluated with DAKO technique and BIOCARE®. Cell blocks were obtain with convex probe ebus-tbna 22G needle. Results: The Deming regression between DAKO and BIOCARE clone revealed an amazingly strong linear relationship as the coefficient of determination indicated (R2=0.999) and the variance ratio close to 1 (0.978), proving that both techniques can equally well be substituted for each other. The regression coefficient equals to 1 and the intercept hardly differs from 0 (0.936). In practice, this relationship permits adopting the economically affordable BIOCARE clone for further medical considerations. Conclusion: No statistical difference was observed between DAKO and BIOCARE®, therefore we propose that both techniques can be used in order to investigate the expression of programmed ligand 1 with safety. PD-L1 expression was higher in the central mass instead of the lymphnodes.

Background and Objectives: Among HIV infection symptoms, sensory neuropathy (HIV-SN) remains a main cause of suffering, with incidence varying from 13–50%. So far, numerous pharmacological and non-pharmacological treatments have been tested, although few evidence-based analgesic options are available. We conducted an up-to-date systematic review and meta-analysis of the literature in order to evaluate the efficacy and safety of pharmacologic and non-pharmacologic treatments for pain control, in patients with HIV neuropathy. Materials and Methods: We searched MEDLINE, EMBASE, Scopus/Elsevier, The Cochrane Central Register of Controlled Trials (CENTRAL), USA Clinical Trials registry, and The International Web of Science up to April 2019. All randomized controlled trials evaluating efficacy and safety of non-pharmacologic and pharmacologic therapies were included. Efficacy was defined as pain reduction during the study period. Safety was estimated from adverse events. A meta-analysis was performed whenever possible. Results: 27 randomized controlled trials (RCTs) were included for analysis (7 evaluating non pharmacologic interventions, 20 pharmacologic therapies). Non-pharmacologic studies (n = 742) involved seven different therapeutic modalities. Only Acupuncture/Moxibustion showed pain reduction over placebo, Gracely Pain Scale Mean (SD): Acu/Moxa 0.85 (0.12), placebo 1.10 (0.09), p = 0.05. Pharmacologic studies, involving 2516 patients revealed efficacy for capsaicin 8% over placebo (mean difference −8.04 [95% CI: −14.92 −1.15], smoked cannabis (where pooling data for meta-analysis was not possible) and recombinant Nerve Growth Factor. Conclusion: Despite various modalities for pain control in HIV-SN, strongest evidence exists for capsaicin 8% and smoked cannabis, although of low methodological quality. Among non-pharmacologic modalities, only Acu/Moxa gave a marginal beneficial effect in one study, possibly limited by inherent methodological flaws.

BACKGROUND:Chronic Obstructive Pulmonary Disease (COPD) has been associated with major perioperative morbidities or mortalities, especially in surgical patients receiving general anesthesia. The severity of the COPD and the degree of bronchial hyperreactivity can determine the perioperative anesthetic risk; therefore they have to be assessed by a thorough preoperative evaluation in order to give the rationale on which to decide for optimum anesthetic management. OBJECTIVE:Aim of the study was to assess the predictive applicability of exhaled Nitric Oxide (NO) in smoking surgical population with COPD, on the basis of morbidity and mortality. METHODS:A prospective, observational study was undertaken in 70 smoking patients diagnosed with COPD scheduled for laparotomy surgery under general anesthesia COPD was evaluated with the GOLD Classification of Air Flow Limitation, the Modified MRC Dyspnoea Scale (mMRC), the BODE Index score and the 6 Minutes Walk Distance (6MWD) using spirometry parameters. All patients were observed for presenting perioperative and postoperative respiratory complications. A cut off value of 19 ppb was determined for fractional exhaled nitric oxide measured at expiratory flow of 50 mL/s (FENO50) to differentiate patients poor prognosis from those with favorable outcome. RESULTS:Patients with severe COPD had high BODE index score as well as FENO50. Elevated FENO50 is significantly related to multiple complications (p = 0.004) and postoperative cough (p < 0.001). Patients from the high FENO50 group that were not treated with steroids had a statistically significant higher incidence of extra hospital care need (p < 0.001). Increased FENO50 and ABCD classification are both related with the presentation of multiple complications (Odds ratio = 2.5, 95% CI 1.1 to 5.7, p = 0.028 for ABCD and Odds ratio = 6.39, 95% CI 1.33 to 30.5, p = 0.020 for FENO50). Increased FENO50 and ABCD are related with extra hospital care (p = 0.001 and p = 0.002 respectively) and combined with corticosteroid administration could predict the necessity for extra hospital care (Odds ratio 4.09, 95% CI 1.1 to 15.3, p = 0.036 for corticosteroid treatment, odds ratio 2.4, 95% CI 1.1 to 5.1, p = 0.029 for ABCD and odds ratio 7.93, 95% CI 1.7 to 35.3, p = 0.007 for FENO50). CONCLUSION:The FENO50 may identify high risk smoking surgical patients with COPD receiving general anesthesia. Perioperative and postoperative complications in COPD smoking patients undergoing abdominal surgery can be predicted using not only ABCD GOLD 2011 classification but also the FENO50 as a preoperative marker.

Apneic oxygenation; pulmonary and cardiovascular effects Kolettas A, Grosomanidis V, Fyntanidou B, Kotzampassi K, Kolettas V, Theodosiadis P, Karakoulas K, Mitos G, Aidoni Z, Vasilakos D Apneic oxygenation is an adjunct „ventilation‟ technique that involves insufflation of oxygen at varying flows through a catheter that is inserted through the endotracheal tube and is positioned above the carina. Apneic oxygenation improves gas exchange efficiency and preserves the arterial oxygenation at an acceptable level. The understanding of the mechanism that is responsible for the sustained high alveolar and blood oxygenation levels requires the substantial knowledge of the physiology regarding the transport and exchange of alveolar gases. Application of apneic oxygenation may be necessary in some clinical situations, in which no movement of the chest or the lungs may be desirable, such as during cardiothoracic surgery or during some radiological procedures, in order to eliminate respiratory motion artifacts. Moreover, it is used during the apnea test for the diagnosis of brain death, to ensure an adequate arterial oxygenation. Under ideal conditions, apneic oxygenation could theoretically be sufficient to provide enough oxygen for survival for a longer time period. However, accumulation of carbon dioxide would remain the limiting factor. Hypercapnia and subsequent acidosis are responsible for most of the respiratory and cardiovascular effects of apneic oxygenation. Apneic oxygenation is an alternative technique, which contributes to the maintenance of oxygenation during apnea by intratracheal insufflation of oxygen at different flow rates. Oxygen is insufflated through a catheter that is inserted through the endotracheal tube and is positioned just above the trachea bifurcation at a flow ranging between 2L/min and 10L/min. A modified apneic oxygenation technique is represented by the endobrochial apneic oxygenation. In this case oxygen is insufflated through a catheter that is inserted through a double lumen endotracheal tube and is placed in one of the two major bronchus. Besides oxygenation maintenance, carbon dioxide accumulation cannot be avoided. However, if high flow rates are used, carbon dioxide removal can be partly enhanced.