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

Hippokratia 2009; 13 (1): 6-8

D. Vrochides, St. Paraskevas, V. Papanikolaou

Abstract

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

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Paraneoplastic bleeding disorder due to isolated hypofibrinogenemia: A case report

Hippokratia 2009; 13 (1): 52-54

Z. Cvetkovic, B. Cvetkovic, D. Celeketic, V. Libek, G. Perunicic-Pekovic

Abstract

An 80 years old male patient was admitted in our hospital with massive haematomas in the left forearm, chest and abdominal wall accompanied by intense back pain symptoms. Laboratory evaluation showed anemia, mild thrombocytopenia and elevated lactate dehydrogenase and alkaline phosphatase levels and normal concentrations of all the other biochemical parameters. Study of the coagulation status demonstrated prolonged thrombin time (TT), low fibrinogen levels – 0.98 g/l while plasminogen, antihrombin III(AT III) and protein C levels were found to be within normal range. Computed tomography scans of the head, chest and abdomen showed an enlarged infiltrative prostate, osteolytic bone lesions in vertebras L5-S1 and a large haematoma of the abdominal wall as the only pathologic findings. Very high levels of the prostate specific antigen indicated the possible existence of a prostate carcinoma with metastases to the vertebral column that resulted in elevated alkaline phosphate and lactate dehydrogenase levels. There were no signs of liver involvement and impaired hepatic synthetic function. Based on the results of the laboratory tests we concluded that the cause of the bleeding disorder in our patient was an acquired hypofibrinogenemia, which is a very rare paraneoplastic phenomenon. The patient was treated with daily transfusions of cryoprecipitate with no long-term improvement. Then the specific anti-tumor therapy (ciproteron acetate) was initiated, and two weeks later, fibrinogen concentration and TT returned to normal values.

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Non alcoholic fatty liver disease and metabolic syndrome

Hippokratia 2009; 13 (1): 9-19

P. Paschos, K. Paletas

Abstract

Non-alcoholic fatty liver disease (NAFLD) is a clinicopathologic entity increasingly recognized as a major health burden in developed countries. It includes a spectrum of liver damage ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), advanced fibrosis, and rarely, progression to cirrhosis. Recent studies emphasize the role of insulin resistance, oxidative stress and subsequent lipid peroxidation, proinflammatory cytokines, adipokines and mitochondrial dysfunction in the development and progression of NAFLD. Furthermore, accumulating evidence supports an association between NAFLD and metabolic syndrome. Although the data are mainly epidemiological, the pathogenesis of NAFLD and metabolic syndrome seems to have common pathophysiological mechanisms, with focus on insulin resistance as a key factor. This review summarizes the current knowledge on the epidemiology, pathophysiology and diagnosis of both NAFLD and metabolic syndrome and the findings that strongly support the association of nonalcoholic fatty liver disease as a possible component in the cluster of metabolic syndrome.

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Problems in diagnosis and treatment of tuberculosis infection

Hippokratia 2009; 13 (1): 20-22

V. Tsara, E. Serasli, P. Christaki

Abstract

Tuberculosis is still a major health problem in industrialized countries due to specific socioeconomic factors and there is the growing need of new rapid and accurate diagnostic methods, in order to achieve higher sensitivity and specificity compared to traditional methods of microscopic sputum examination and culture. Such methods, recently introduced, are nucleic acid amplification (NAA) tests, used directly on clinical specimens and blood tests (QuantiFERON-TB, T SPOT.TB test), measuring the IFN-? released by stimulated T cells. Furthermore, new drugs for the disease need to be developed, aiming to better treatment results and to prevention of Multiple Drug Resistance (MDR) cases. Critical aspects in the management of drug resistance cases should be the careful choices of drugs combination, the close follow up of the patients alongside with the patients adherence to therapy. The role of national and international tuberculosis programs is invaluable in TB control and therapy, as well as the collaboration of all the health system departments. However, most of the clinical problems that may arise are addressed by the International Standards for Tuberculosis Care- ISTC and these guidelines should be taken into consideration, at least until future research provides more promising diagnostic and therapeutic modalities for control of the disease.

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Enzymatic function of multiple origins regulates the progression of colorectal cancer and the development of metastases

Hippokratia 2009; 13 (1): 23-31

KA. Paschos, D. Canovas, NC. Bird

Abstract

Enzymes play a crucial role in the progression of colorectal cancer and the development of metastases. They facilitate malignant cell invasion through the degradation of the extracellular matrix, the rupture of the basement membrane and the derangement of cell-cell adhesion. Furthermore, they promote tumour cell migration and support the evolution of metastatic lesions in the liver and other organs, through multiple molecular mechanisms, including growth factor release and angiogenesis. Urokinase plasminogen activator system, matrix metalloproteinases, heparanase and autocrine motility factor constitute important enzymatic complexes which assist colorectal cancer growth, with potential clinical applications in the diagnosis and treatment of the disease.

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Evaluation of popliteal arteries with CT angiography in popliteal artery entrapment syndrome

Hippokratia 2009; 13 (1): 32-37

S. Papaioannou, K. Tsitouridis, G. Giataganas, G. Rodokalakis, V. Kyriakou, CH. Papastergiou, M. Arvaniti, I. Tsitouridis

Abstract

Background: Popliteal artery entrapment is an uncommon clinical entity that occurs due to compression of the popliteal artery by adjacent muscle and tendinous structures. Early diagnosis should be established through a combined approach of careful physical examination and history-taking, duplex ultrasonography, and CT angiography. Patients and methods: We have studied retrospectively 16 patients of popliteal artery entrapment syndrome, 9 men and 7 women. All patients were scanned with a scanner Picker PQ 5000 after bolus injection of nonionic contrast medium and they all underwent a two-part examination first, with the knee in a neutral position, and, second, with the knee hyperextended. Results: At the second phase of the examination 3 patients showed normal findings, 10 patients have shown mild stenosis of the popliteal artery or more severe stenosis due to compression, 2 patients have exhibited bilateral stenosis and 1 patient has also showed popliteal venous compression Conclusion: CT angiography images and three-dimensional images are useful not only for depiction of the arterial changes but also identification of the abnormal anatomic structures responsible for the entrapment.

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Intravenous administration of iron sucrose for treating anemia in postpartum women

Hippokratia 2009; 13 (1): 38-40

C. Giannoulis, A. Daniilidis, T. Tantanasis, K. Dinas, J. Tzafettas

Abstract

Background: To compare the efficacy of oral and intravenous administration of iron supplements for treating postpartum anemia. Methods: One hundred and four anemic postpartum women were studied prospectively. The criteria for the diagnosis of anemia were Hb < 8 gr/dl and ferritine < 10?g/dl. They were randomised into two groups. Group A constisted of 78 women who received i.v. a total amount of 300 mg iron sucrose in three days. Group B consisted of 26 women, who received orally 800 mg iron proteinsuccinylate daily for four weeks. Results: At the end of the study, in group A the increase of Hb mean level was 4.6 gr/dl and of ferritin mean level was 105 mg/L. In group B the increase in hemoglobin mean level was 2.3 gr/dl and ferritin mean level was 68 mg/L. There was significant difference in the increase of hemoglobin level (p= 0.0001) and also in the increase in ferritin level (p=0.0004) between the two groups. Conclusion: Intravenous administration of iron sucrose seems to be safe and it helps postpartum women to recover early from anemia.

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Operative vaginal delivery in singleton term pregnancies: Short-term maternal and neonatal outcomes

Hippokratia 2009; 13 (1): 41-45

N. Prapas, I. Kalogiannidis, S. Masoura, E. Diamanti, A. Makedos, D. Drossou, G. Makedos

Abstract

Background: The rate of operative vaginal delivery has remained stable the last decade, however the rate of vacuum has increased against forceps application. Different maternal and neonatal outcomes have been proposed by many reports. The aim of the present study is to compare the short term maternal and neonatal outcomes between vacuum and forceps delivery.Material and methods: We conducted a medical record review of live born singleton, vacuum and forceps-deliveries. Maternal and delivery characteristics were recorded. Maternal and neonatal outcomes were also assessed. Out of 7098 deliveries, 374 were instrument assisted, 324 were conducted by vacuum (86.7%) and 50 by forceps (13.3%). Results: The incidence of 3rd degree lacerations and periurethral hematomas was similar between vacuum and forceps (3.4% vs. 2% and 0.3% vs 0% respectively), while perineal hematomas were more common in forceps compared with vacuum application (2% vs 0.3% respectively), albeit not significantly. The rate of neonates with Apgar scores ≤ 4 at 1 min was significantly higher after forceps compared with vacuum delivery (18% vs 5.2% respectively, p = 0.0003). The same observation was made concerning the neonatal intensive care unit (NICU) admissions (38% vs 11% respectively, p = 0.0001). The rate of neonatal trauma and respiratory distress syndrome did not differ significantly between the two groups. Conclusion: Results of the present study indicate that both modes of instrumental vaginal delivery are safe with respect to maternal morbidity and neonatal trauma. However, forceps application increases the risk of neonatal compromise consequently necessitating their admission in the NICU.

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Childhood and parental obesity in the poorest district of Greece

Hippokratia 2009; 13 (1): 46-48

P. Malindretos, E. Doumpali, M. Mouselimi, N. Papamichail, CH. Doumpali, O. Sianaba, G. Orfanaki, A. Sioulis

Abstract

Background and aim: Childhood obesity represents a rising threat in southern Europe. It is widely accepted that childhood obesity is an important risk factor for the appearance of obesity in adulthood. Our aim was to estimate the prevalence of obesity in school aged children living in one of the poorest districts of Europe, as well as to estimate the association between the frequency of obesity observed in these children and their parents. Material and methods: We examined and calculated the body mass index (BMI) in 107 children aged 12.2 �0.78 years. BMI was adjusted for age and sex and it was correlated with children parents’ weight status. Results: Obesity was diagnosed in 16% of the children. The relationship between children’s and their parents weight status was very strong. In 40% of the obese parents, their children were found to be obese also (p < 0.001). Conclusion: In the present study a strong relationship between children weight status and their parents’ weight status was confirmed. Additionally, this correlation was proven at a district with very low house income. Knowing that it is easier to prevent obesity, rather than to cure it, our aim should be, when a child is brought to the doctor,independently of the cause, to assess both the child as well as its parents’ weight status.

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Methicillin resistant staphylococcus aureus thoracic spondylitis late after cervical spine surgery

Hippokratia 2009; 13 (1): 49-51

PP. Tsitsopoulos, D. Zevgaridis, I. Anagnostopoulos, J. Harms, P. Tsitsopoulos

Abstract

Background: Spondylodiscitis is a known and serious complication of spinal surgery. A rare case of a late and remote thoracis spondrylitis due to methicillin resestant staphylococcus aureus following cervical surgery is presented. Case report: A 50 year-old-male was treated for cervical degenerative disease via a combined anterior and posterior cervical approach (discectomy with fusion and laminectomy). Three years later a cervical epidural abscess was formed which wad treated successfully conservatively. After 18 months he developed spondylitis of the second thoracic vertebra. The patient was further treated surgically via a dorsolateral extracavitary thoracic approach. Laboratory analysis revealed Methicillin Resistant Staphylococcus Aureus (MRSA) spondylitis sensitive to linezolid. Inflammation markers declined and clinical symptoms ameliorated. At 12-month follow-up the patient did not show any evidence of recurrence of the infection. Conclusions: A high rate of suspicion must be maintained in patients presenting with signs of spinal infection and neurological impairment even many years after the initial operation. Optimal investigation and outcome require close clinical monitoring and a well coordinated multidisciplinary approach.

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Sonographic evaluation of epignathus

Hippokratia 2009; 13 (1): 55-57

I. Tsitouridis, D. Sidiropoulos, M. Michaelides

Abstract

Epignathus is extremely rare form of teratoid tumor arising from the palate or pharynx in the region of basisphenoid (Rathke’s pouch), filling the buccal cavity and protruding from the mouth. This tumor usually causes death in neonatal life because of its location and because surgical removal is often impossible. Prenatal sonographic diagnosis is important for genetic counseling, obstetric management and in some cases neonatal surgery. We present a case of epignathus originating from the hard palate in a female child delivered at gestational week 33 by caesarian section due to increasing hydramniosis.

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Permanent unilateral blindness associated with peripartum cardiomyopathy

Hippokratia 2009; 13 (1): 58-60

TM. Liakakos, M. Daskalaki, K. Sfakianoudis, B. Votteas, M. Liakakos

Abstract

Peripartum Cardiomyopathy (PPCM) is a rare and ominous disease manifested in the peripartum period of women with complications concerning different organic systems. We describe a case of peripartum cardiomyopathy which was complicated with acute permanent unilateral blindness, further documented embolic retinal artery occlusion as a consequence of PPCM. This is a quite unusual event with PPCM, since to our knowledge there is no previously reported case with PPCM as the sole associated factor. The purpose of our paper is to emphasize that thromboembolism of the central retinal artery, seems to be compatible with peripartum cardiomyopathy and that, peripartum blindness, may be attributed to the cardiomyopathy diagnosis.

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A case of idiopathic bursal synovial chondromatosis resembling rheumatoid arthritis

Hippokratia 2009; 13 (1): 61-63

O. Kiritsi, K. Tsitas, G. Grollios

Abstract

Primary synovial osteochondromatosis is an unusual condition, which generally involves otherwise normal joints. Joints commonly affected in descending order of frequency are knee, hip, glenohumeral joint, elbow and ankle, though any articulation may be involved. Synovial osteochondromatosis has been also encountered in tendon sheaths and periarticular bursa. We report a case with the clinical findings, radiographic features, surgical and histological data of primary subacromial-subdeltoid bursa synovitis. X-ray radiographs of the right glenohumeral joint as well as CT and MRI of the right shoulder zone were performed. A soft tissue mass around the lateral margin of the proximal humerus without evidence of any calcification/ ossification or erosion of the adjacent cortex was detected on both X-Rays and CT images. Multiple nodules of almost equal size appeared that were isointense on T1-weighted spin-echo images and slightly hyperintense on T2 weighted spin-echo images compared with the signal intensity of the surrounding skeletal muscles. The main differential diagnosis was pigmented villonodular synovitis, rheumatoid arthritis with rice bodies and secondary synovial osteochondromatosis. Based on the results of all modalities the diagnosis of primary synovial chondromatosis of subdeltoid/ subacromial bursa was concluded.

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