The pathogenesis of arterial stiffness and its prognostic value in essential hypertension and cardiovascular diseases

Hippokratia 2009; 13 (2): 70-75

E Gkaliagkousi, S Douma

Abstract

The elasticity of a given arterial segment of the aorta and of big elastic arteries is not constant but depends on its distending pressure. As distending pressure increases, there is greater recruitment of inelastic collagen fibers and thereby a reduction in elasticity. It also depends on structural changes in the medial layer of the elastic arteries (mainly aorta and major arterial conduits), and is largely the result of progressive elastic fibre degeneration.Aortic Pulse Wave Velocity (PWV), is the most robust marker of arterial stiffness, however additional useful information can also be provided by the Central Augmentation Index (AIx C), and pulse pressure. The presence of systemic inflammation in cardiovascular disease and in particular in essential hypertension affects arterial stiffness and increases PWV. Some pharmacological and non-pharmacological interventions may improve arterial stiffness and thereby decrease PWV.

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Sarcoidosis: oral and perioral manifestations

Hippokratia 2009; 13 (2):119-121

AE Kolokotronis, MA Belazi, G Haidemenos, TK Zaraboukas, DZ Antoniades

Abstract

A 46-year-old white woman with lesions on the lower lip, perioral area and in the soft tissues of the oral cavity (gingivae and palate) was examined. The clinical signs were recorded, and incisional biopsies from the oral lesions were taken.The diagnosis of sarcoidosis was established by the histopathological evidence of typical non-caseating granulomas from tissue biopsy, supported by serum ACE- 57.9 U/L, blood calcium 16.83 mEq/L and 24-hrs urine calcium 600 mg).Oral lesions may be the first or the only sign of sarcoidosis in an otherwise healthy patient.

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Awareness during anesthesia: how sure can we be that the patient is sleeping indeed?

Hippokratia 2009; 13 (2): 83-89

G Kotsovolis, G Komninos

Abstract

Awareness during surgery is a very serious problem for the anesthetist and the patient as well. Such incidents are the cause for 2% of the legal claims against anesthetists while patients with intraoperative awareness experience describe it as the worst thing they have ever suffered from. Pain, anxiety and inability to react due to muscle paralysis often lead to the situation called posttraumatic stress disorder which demands psychiatric support. The fact that there are patients who report intraoperative experience, even several days after surgery, raises questions about the way the anesthetic drugs interfere with the mechanisms of memory and consciousness while, in bibliography, there are studies proving that even deeply anesthetized patients can be influenced by auditory stimuli without being able to recall them. Intraoperative monitoring of the anesthesia depth is important for the prevention of this problem. From all the available devices only the Bispectral Index Monitoring (BIS) has been proven to be effective for this purpose but the high cost per person and the low specificity in preventing awareness episodes do not allow its everyday use. The surgeon and especially the anesthesiologist must be aware of the risk factors, the prevention measures and the actions that must be taken after an awareness incident in order to minimize the unfortunate complications for both the patient and the doctors.

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Long term health consequences of polycystic ovarian syndrome: a review analysis

Hippokratia 2009; 13 (2): 90-92

A Daniilidis, K Dinas

Abstract

Polycystic ovarian syndrome (PCOS) is the commonest endocrinopathy among women of reproductive age with an estimated prevalence of about 10%. Type 2 diabetes, cardiovascular disease, endometrial cancer, breast cancer and ovarian cancer are some of the most important emerging issues regarding syndrome?s influence in women?s future well being. The aim of this review is to provide clear and up to date information, based on clinical evidence, in order to advise clinicians about the late consequences of the syndrome.

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Continuous subcutaneous insulin infusion versus multiple daily injections

Hippokratia 2009; 13 (2): 93-96

P Karagianni, Ch Sampanis, C Katsoulis, Gr Miserlis, S Polyzos, I Zografou, S Stergiopoulos, I Douloumbakas, Ch Zamboulis

Abstract

Background and aim: Continuous Subcutaneous Insulin Infusion (CSII) and Multiple Daily insulin Injections (MDI) are both strategies aiming to achieve a tight glycemic and metabolic control. However, the choice between them remains controversial. The aim of the present study was to compare the efficacy of MDI (three or more injections daily) with CSII on glycemic control in patients with Type 1 Diabetes Mellitus and assess satisfaction from treatment in the CSII group.
Material and Methods: Seventeen patients with Type 1 Diabetes Mellitus on CSII (previously on MDI) and 17 patients on MDI, matched for age, gender, BMI and duration of diabetes, were retrospectively studied. Glucosylated Hemoglobin A1c (HbA1c), frequency of hypoglycaemias (assessed as self reported episodes), BMI and total units of insulin per day were evaluated at baseline and after 6 months in both groups. CSII group completed a questionnaire concerning motive for treatment selection, advantages, deficiencies and inconvenience at the end of the study. Satisfaction from treatment was assessed with a scale from 0 to10.
Results: CSII group had more hypoglycaemic episodes at baseline than MDI group (16.2�2.8 vs 2.8�1.3, p < 0,001). HbA1c (8.4�0.5 before vs 7.3�0.4 after, p < 0.05) and total hypoglycaemic episodes per month (16.2�2.8 before vs 8.7�2.3 after, p < 0.05) significantly decreased in CSII group 6 months after baseline. On the contrary, total hypoglycaemic episodes per month were increased in MDI group (2.8�1.3 before vs 10.8 �2, 6 after, p < 0.05) in order to maintain HbA1c levels. No significant differences were observed in BMI in both groups. Total insulin demands were reduced in the CSII group (49.4�3.3 before vs 39.0�4.6 after, p < 0.05) and remained unchanged in MDI group. None of the patients discontinued CSII therapy, while overall satisfaction rate in this group was high. The main motive for CSII selection was frequent hypoglycaemic episodes and glucose fluctuations (10/17). The majority of patients expressed their wish for incorporating glucose trend indicator and/or continuous glucose measurement into pump and reducing pump size (15/17). Most commonly stated advantage was improved flexibility, followed by greater freedom and decreased sense of physical restrictions (10/17). Inconvenience mainly derived from alarm malfunction and catheter or needle occlusion and was reported from a minority of patients (4/17).
Conclusion: CSII group reported more hypoglycaemias than MDI group at baseline but 6 months later had significantly less hypoglycaemic events, while on the contrary, MDI group 6 months after baseline had more frequent and more severe hypoglycaemias. Although baseline hypoglycaemias are not equal between the two groups, we can assume that CSII group achieved less hypoglycaemic events along with significant reduction in HbA1c while utilising less insulin units

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Endotracheal and tracheostomy tube-related complications: imaging with three-dimensional spiral computed tomography

Hippokratia 2009; 13 (2): 97-100

I Tsitouridis, M Michaelides, V Dimarelos, M Arvaniti

Abstract

Aim: To present our experience from the use of three dimensional (3D) spiral computed tomography (CT) reconstructions for the detection of endotracheal and tracheostomy tube-related complications.
Material and Methods: The CT-scans of thirteen patients who were subjected to spiral computed tomography for the evaluation of possible tracheal complications due to the use of endotracheal or tracheostomy tubes were retrospectively studied. In each case, a spiral scan of the airways from the larynx to the main bronchi was performed. Axial images were reconstructed with the use of the following three-dimensional visualization methods: volume rendering (VR), tissue transition projection (TTP), shaded surface display (SSD) and virtual endoscopy (VE). Detected complications were subdivided into acute and late, according to the time of appearance (during presence of tracheal tube or after its removal, respectively).
Results: Six patients showed acute complications (wrong placement of the tube with compression of tracheal wall in three cases, perforation of tracheal wall in two cases, tracheal stenosis in one case). Seven patients showed late complications (tracheal stenosis in all cases). Three-dimensional reformatted images contributed significantly to the detection of both acute complications (position of tube in relation to tracheal wall), and late complications (number, position, length and degree of stenoses), providing a non-invasive evaluation of the outer tracheal wall and tracheal lumen.
Conclusion: Three-dimensional spiral CT reconstructions are a valuable adjunct of transverse images for the evaluation of trachea in cases of suspected tracheal tube-related complications.

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Outcome of laparoscopic sacrocolpopexy with anterior and posterior mesh

Hippokratia 2009; 13 (2): 105-109

P Xiromeritis, ML Marotta, N Royer, I Kalogiannidis, P Degeest, F Devos

Abstract

Aim: The assessment of the postoperative outcome following laparoscopic sacrocolpopexy using anterior and posterior mesh. Material and Methods: In the study were included one hundred and ten women (mean age 62 years with range from 34 to 78) who had laparoscopic sarcoplexy the period 2001-2005. They were contacted and completed postal questionnaires more than one year after surgery and had a follow up in the uro-gynaecology clinic.
Results: The median follow up was 21 months. Eighty-three of them (75.4%) answered the postal questionnaire. Good satisfaction was defined as complete disappearance of all genito-urinary symptoms. Moderate satisfaction was defined as a partial disappearance of symptoms, or de novo less annoying symptoms. Dissatisfaction was defined as no change in symptoms, and /or de novo important symptoms. The overall rate of good satisfaction was 74.7% (62/83), moderate satisfaction 15.6% (13/83), and only 9.6% (8/83) were not satisfied. There was no statistical difference among the six different groups (sacrocolpopexy only, plus TVT, plus TVT and hysterectomy, sacrocolpopexy and previous hysterectomy, sacrocolpopexy and TVT with previous hysterectomy), concerning the pre and post operative clinical signs and post operative symptoms. There was a statistically significant difference (p=0.038) regarding dissatisfaction and prolapse relapse between the group that had a previous total hysterectomy combining sacrocolpopexy with TVT and all other groups. The most frequent post operative symptoms were stress incontinence, dysuria and constipation. No severe complications and mesh erosion were observed, despite the two cases of mesh detachment.
Conclusions: Laparoscopic double synthetic mesh sacrocolpopexy seems to be a safe and effective treatment of genitourinary prolapse, with good overall long term outcomes and benefits of the minimal access approach. The presence of the remaining cervix after subtotal hysterectomy, seems to enhance the results of laparoscopic sacrocolpopexy.. Further randomised studies are needed to confirm our results and to compare this method to open and/or vaginal approach.

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The actual development of European Aviation Safety Requirements in Aviation Medicine: Prospects of Future EASA Requirements

Hippokratia 2009; 13 (2):106-109

J Siedenburg

Abstract

Common Rules for Aviation Safety had been developed under the aegis of the Joint Aviation Authorities in the 1990ies. In 2002 the Basic Regulation 1592/2002 was the founding document of a new entity, the European Aviation Safety Agency. Areas of activity were Certification and Maintenance of aircraft. On 18 March the new Basic Regulation 216/2008, repealing the original Basic Regulation was published and applicable from 08 April on. The included Essential Requirements extended the competencies of EASA inter alia to Pilot Licensing and Flight Operations. The future aeromedical requirements will be included as Annex II in another Implementing Regulation on Personnel Licensing. The detailed provisions will be published as guidance material. The proposals for these provisions have been published on 05 June 2008 as NPA 2008-17c. After public consultation, processing of comments and final adoption the new proposals may be applicable form the second half of 2009 on. A transition period of four year will apply. Whereas the provisions are based on Joint Awiation Requirement - Flight Crew Licensing (JAR-FCL) 3, a new Light Aircraft Pilot Licence (LAPL) project and the details of the associated medical certification regarding general practitioners will be something new in aviation medicine. This paper consists of 6 sections. The introduction outlines the idea of international aviation safety. The second section describes the development of the Joint Aviation Authorities (JAA), the first step to common rules for aviation safety in Europe. The third section encompasses a major change as next step: the foundation of the European Aviation Safety Agency (EASA) and the development of its rules. In the following section provides an outline of the new medical requirements. Section five emphasizes the new concept of a Leisure Pilot Licence. The last section gives an outlook on ongoing rulemaking activities and the opportunities of the public to participate in them.

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Hepatic focal nodular hyperplasia: when a benign lesion becomes “malignant”. Report of a case

Hippokratia 2009; 13 (2): 114-115

V Papanikolaou, D Vrochides, P Margari, D Giakoustidis, N Antoniadis, K Tsinoglou, E Akriviadis, D Takoudas

Abstract

In a 34 year-old woman complaining of right upper quadrant pain and having mildly elevated total bilirubin, the imaging investigation revealed a liver lesion with characteristics of focal nodular hyperplasia, measuring 3.8 cm, at the confluence of the hepatic veins. The mass was obstructing the left and middle hepatic veins and nearly obstructing the right hepatic vein. Dilation of the splenic vein with development of retropancreatic varices, splenomegaly and free abdominal fluid were also present. The patient underwent an uncomplicated left hemihepatectomy. Patient?s postoperative total bilirubin was normalized. Tomographic imaging three months after the liver resection revealed resolution of all the Budd-Chiari radiographic signs. This is a report of a case where a hepatic focal nodular hyperplasia, despite its benign nature, required extensive and urgent surgical intervention due to its location and potential dangers secondary to the development of portal hypertension.

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Toxic adenoma of the thyroid gland and Wolff-Parkinson-White syndrome

Hippokratia 2009; 13 (2): 116-118

M Naco, E Celiku, A Llukacaj, J Shehaj, R Kameniku

Abstract

We report the case of a 17-year-old girl with toxic adenoma scheduled for surgery – right lobectomy and isthmectomy of thyroid gland. During the examination before surgery, patient was diagnosed for the first time as having with Wolff – Parkinson – White (WPW) syndrome. In the operating room, after the induction of anesthesia, the electrocardiogram showed wide QRS complex tachycardia with a rate of 180 beats/min, which was diagnosed as paroxysmal supraventricular tachycardia. The patient was treated immediately with antiarrhythmic drugs: adenosine iv three times (at doses of 6 mg, 12mg, 12mg bolus) and esmolol iv twice (at doses 28.5 mg). This approach resulted in disappearance of the delta wave and tachycardia for the whole surgery period. In this case report we discuss the role of induction of anesthesia and presence of toxic adenoma in a patient with WPW.

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Severe migratory Angioedema due to ACE inhibitors use

Hippokratia 2009; 13 (2): 122-124

G Peltekis, D Palaskas, M Samanidou, A Fragakis, K Alexopoulos, A Kotsani, I Vogiatzis, E Kyrmizakis

Abstract

Angioedema due to use of angiotensin-converting enzyme inhibitors (ACEIs) is a rare side-effect but is seen more often because of the increase in the use of these drugs due to their effectiveness and good tolerance in the treatment of hypertension and congestive heart failure. Other types of angioedema, which should be included in the differential diagnosis, are the hereditary type, which results from deficiency of C1 esterace inhibitor and the allergic angioedema.Angioedema is a potentially life-threatening condition when it is located to the mucosal and submucosal layers of the upper airway. Some times an angioedema case can be very severe, resistant to the usual treatment and even rarely fatal. The last eight months, six patients with angioedema due to ACEIs (5 cases) or angiotensin II receptor blockers (1 case),were examined and hospitalized at our department. We describe the case of a 65year old woman with severe migratory angioedema of the tongue, the floor of the mouth and the oropharynx, which was rather resistant to the usual treatment.

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Mesangioproliferative glomerulonephritis in an infant with Prader-Willi syndrome

Hippokratia 2009; 13 (2): 125-126

N Printza, E Bersos, D Zafeiriou, M Leontsini, M Stamou, F Papachristou

Abstract

Prader - Willi syndrome (PWS) is a neurobehavioral disorder characterized mainly by neonatal hypotonia, dysmorphic features, hypogonadism, mental retardation and behavioral problems. The PWS has not been associated with renal complications.We report the case of an infant with Prader-Willi syndrome due to loss of the paternal copy of chromosome 15q11.2-13, who presented with severe proteinuria and microscopic hematuria. Renal biopsy revealed mesangioproliferative glomerulonephritis (MPGN). The early onset of the primary MPGN in this infant make us consider a possible association between the deficiency of the paternally expressed genes from the 15q11-q13 region and the renal disease.

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Matrix metalloproteinases and cardiovascular diseases

Hippokratia 2009; 13 (2): 76-82

A Papazafiropoulou, N Tentolouris

Abstract

Matrix metalloproteinases (MMPs) are extracellular enzymes that are important in many physiologic and pathologic processes. Their activity is regulated mainly by tissue inhibitors of metalloproteinases (TIMPs). MMPs expression is related with the classical cardiovascular risk factors as well as with inflammation. They play a central role in atherosclerosis,plaque formation, platelet aggregation, acute coronary syndrome, restenosis, aortic aneurysms and peripheral vascular disease. Many studies have shown that commonly prescribed antihypertensive medications, glitazones and statins may influence MMPs activity. The aim of the review is to present literature data on the role of MMPs and their inhibitors in cardiovascular disease.we discuss the role of induction of anesthesia and presence of toxic adenoma in a patient with WPW.

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Myopic traction maculopathy: Study with Spectral Domain Optical Coherence Tomography and review of the literature

Hippokratia 2009; 13 (2): 110-113

V Konidaris, S Androudi, P Brazitikos

Abstract

Aim: To describe the tomographic findings of a case of myopic traction maculopathy using Spectral Domain Optical Coherence Tomography (SD-OCT) and present the results of its surgical intervention.
Design: Observational case report and review of the literature.
Methods: A 61-year-old male with metamorphopsia was examined clinically and with the use of SD-OCT. The diagnosis of myopic traction maculopathy was made. The patient underwent pars plana vitrectomy with removal of the vitreomacular adhesions, the epiretinal and the internal limiting membrane.
Results: Visual acuity increased by two Snellen lines, metamorphopsia disappeared, macular morphology was improved and myopic traction maculopathy was resolved. Conclusions: Imaging with SD-OCT is capable of documentation and measurement of the early stages of myopic traction maculopathy. Moreover, vitrectomy was beneficial for the visual and anatomic outcome of the patient.

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