Glycemia and cardiovascular risk: challenging evidence based medicine

Hippokratia 2011; 15 (3): 199-204

K. Kitsios, A. Tsapas, P. Karagianni

Abstract

Optimal glycemic control is well known to reduce effectively the risk of micro vascular complications both in type 1 and type 2 diabetes mellitus. However the role of glycemic control in decreasing the risk of myocardial infarction and ischemic stroke, the leading causes of death in patients with diabetes, has been so far controversial. In this review, based on data recently reported from large interventional studies, we discuss the possible causal relationship between glycemia and cardiovascular outcomes in type 1 and type 2 diabetes. Strict glycemic control right from the diagnosis of the disease may be effective in reducing long term incidence of cardiovascular (CV) disease in both T1 and T2 diabetics. Nevertheless such a strategy could be potentially harmful for T2 diabetics with long duration of sub optimal glycemic control and already established CV complications. Treatment targets in these patients should be individualized taking into account other aspects of glycemic control and diabetes complications such as hypoglycemia and autonomic neuropathy.

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Socioeconomic evaluation of the treatment of ureteral lithiasis

Hippokratia 2011; 15 (3): 252-257

T. Rombi, A. Triantafyllidis, A. Fotas, T. Konstantinidis, S. Touloupidis

Abstract

Background and aim: This study attempts to estimate the socioeconomic differences between three major alternatives for the management of upper and lower ureteral lithiasis.
Material and methods: Two hundred and forty patients with upper and lower ureteral lithiasis, have been studied retrospectively, divided in six equal groups of forty. These patients have been treated either by extracorporeal shockwave lithotripsy (SWL), or with ureteroscopy with semirigid ureteroscope and the use of pneumatic lithoclast, or with ureteroscopy with flexible ureteroscope and the use of Holmium YAG Laser. For cost calculation, the reimbursement fee paid by insurance to the hospital was taken into account. For the estimation of the social burden, the length of hospital stay and the number of outpatient visits have been included as countable parameters.
Results: The percentage of effective stone removal for upper ureter was 81.0% for SWL, 62.5% for ureteroscopy with semirigid ureteroscope and the use of pneumatic lithoclast and, 82.5% for ureteroscopy with flexible ureteroscope and the use of Holmium YAG Laser. The same percentages for lower ureter were 82.5%, 92.5% and 97.5% respectively. The cost of stone removal for both the upper and lower ureter using extracorporeal lithotripsy was significantly higher compared to the other two procedures (median cost for upper ureter 828 € vs 474.50 € and 396 € respectively, and for lower ureter 826 € vs 396 € and 271 €, p<0.001). Regarding the social aspect, SWL is mainly an outpatient procedure, requiring a short hospital stay (for upper ureter 1.63 vs 2.48 and 2.45 respectively and for lower ureter 1.35 vs 2.43 and 2.13 days), but needing more and prevailing clinic visits (for upper ureter 1.43 vs 1.45 and 1 respectively and for lower ureter 1.45 vs 1.15 and 0.55 visitsgive numbers, compare), both in outpatient and in accident and emergency (A&E) department.
Conclusion: The increase in the expenses with regard to health management indicates the necessity of cost accounting the health programs including the medical procedures as a means to improve the relation between cost and benefit.

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Pregnancy-related low back pain

Hippokratia 2011; 15 (3): 205-210

P. Katonis, A. Kampouroglou, A. Aggelopoulos, K. Kakavelakis, S. Lykoudis, A. Makrigiannakis, K. Alpantaki

Abstract

Pregnancy related low back pain is a common complaint among pregnant women. It can potentially have a negative impact on their quality of life. The aim of this article is to present a current review of the literature concerning this issue. By using PubMed database and low back pain, pelvic girdle pain, pregnancy as keywords, abstracts and original articles in English investigating the diagnosis treatment of back pain during pregnancy were searched and analyzed Low back pain could present as either a pelvic girdle pain between the posterior iliac crest and the gluteal fold or as a lumbar pain over and around the lumbar spine. The source of the pain should be diagnosed and differentiated early. The appropriate treatment aims to reduce the discomfort and the impact on the pregnant woman's quality of life. This article reveals the most common risk factors, as well as treatment methods, which may help to alleviate the pain. Some suggestions for additional research are also discussed.

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Electrical Impedance Tomography: a new study method for neonatal Respiratory Distress Syndrome?

Hippokratia 2011; 15(3):211-215

I. Chatziioannidis, T. Samaras, N. Nikolaidis

Abstract

Treatment of cardiorespiratory system diseases is a procedure that usually demands data collection on terms of the anatomy and the operation of the organs that are under study. Electrical Impedance Tomography (EIT) is an alternative approach, in comparison to existing techniques. With EIT electrodes are placed in the perimeter of the human body and images of the estimated organ are reconstructed, using the measurement of its impendence (or resistance) distribution and determining its alteration through time, while at the same time the patient is not exposed to ionizing radiation. Its clinical use presupposes the correct placement of the electrodes over the perimeter of the human body, the rapid data collection and electrical safety. It is a low cost technique and it is implemented near the patient. It is able to determine the distribution of ventilation, blood supply, diffused or localized lung defects, but it can also estimate therapeutic interventions or alteration to assisted ventilation of the neonate. EIT was developed at the beginning of the 1980s, but it has only recently begun to be implemented on neonates, and especially in the study of their respiratory system function. The low rate of image analysis is considered to be a drawback, but it is offset by the potential offered for the estimation of lungs' function (both under normal and pathological conditions), since ventilation and resistance are two quite similar concepts. In this review the most important studies about EIT are mentioned as a method of estimating respiratory distress syndrome in neonates. In terms of the above mentioned development, it is supposed that this technique will offer a great amount of help to the doctor in his / her estimations of the cardiorespiratory system and to his / her selection of the best intervening strategies.

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Dietary interventions for primary allergy prevention in infants

Hippokratia 2011; 15 (3): 216-222

A. Mavroudi, I. Xinias

Abstract

Allergy prevention remains a vexing problem. Food sensitization frequently occurs early in life and is often the first sign of future atopic disease. Therefore, interventions to prevent food allergies and the development of the atopic phenotype are best made early in life. The results of studies regarding the effects of breast-feeding and the prevention of allergy remain inconclusive. Several factors in breast milk either induce or protect against food allergies. Probiotic and prebiotic supplemented whey hydrolysate formulas need further research in order to determine the future of this intervention in the prevention of food allergies. Several dietary manipulations in infancy, such as prolonged breast feeding, maternal avoidance diets during pregnancy and lactation, the use of hypoallergenic formulas, have been proposed as ways of altering the Th1/Th2 balance in infants, with varying degrees of success. Studies have examined whether food atopy can be prevented by controlling the intake of highly allergenic foods by a high-risk infant from a variety of sources, that is, both direct ingestion and indirect ingestion through the breast milk. The previous studies showed that in high risk infants who are unable to be completely breast fed, there is evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant cow's milk allergy ,while other studies reported that an antigen avoidance diet for high risk mothers is unlikely to reduce the atopic diseases in their children substantially, and that such a diet may adversely affect maternal and/or fetal nutrition.

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Current options in inguinal hernia repair in adult patients

Hippokratia 2011; 15(3):223-231

H. Kulacoglu

Abstract

Inguinal hernia is a very common problem. Surgical repair is the current approach, whereas asymptomatic or minimally symptomatic hernias may be good candidate for watchful waiting. Prophylactic antibiotics can be used in centers with high rate of wound infection. Local anesthesia is a suitable and economic option for open repairs, and should be popularized in day-case setting. Numerous repair methods have been described to date. Mesh repairs are superior to "nonmesh" tissue-suture repairs. Lichtenstein repair and endoscopic/laparoscopic techniques have similar efficacy. Standard polypropylene mesh is still the choice, whereas use of partially absorbable lightweight meshes seems to have some advantages.

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Network-centric Analysis of Genetic Predisposition in Diabetic Nephropathy

Hippokratia 2011; 15(3):232-237

A. Ntemka, F. Iliadis, NA. Papanikolaou, D. Grekas

Abstract

Diabetic nephropathy is a serious, long-term complication of diabetes and the leading cause of end-stage renal disease throughout the world. Although this disease is progressively imposing a heavier burden on the health care system, in many aspects it remains poorly understood. In addition to environmental influences, there is abundant evidence in support of genetic susceptibility to microvascular complications of nephropathy in diabetic patients. Familial clustering of phenotypes such as end-stage renal disease, albuminuria and kidney disease have been reported in large scale population studies throughout the world demonstrating strong contribution of inherited factors. Recent genome-wide linkage scans identified several chromosomal regions that are likely to contain diabetic nephropathy susceptibility genes, and association analyses have evaluated positional candidate genes under linkage peaks. In this review we have extracted from the literature the most promising candidate genes thought to confer susceptibility to diabetic nephropathy and mapped them to affected pathways by using network-centric analysis. Several of the top susceptibility genes have been identified as network hubs and bottlenecks suggesting that they might be important agents in the onset of diabetic nephropathy.

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Lipopolysaccharide and hypoxia significantly alters interleukin-8 and macrophage chemoattractant protein-1 production by human fibroblasts but not fibrosis related factors

Hippokratia 2011; 15 (3): 238-243

T. Eleftheriadis, V. Liakopoulos, B. Lawson, G. Antoniadi, I. Stefanidis, G. Galaktidou

Abstract

Besides extracellular matrix production, fibroblasts are able to produce various cytokines. Their ubiquitous position makes fibroblasts appropriate cells for sensing various noxious stimuli and for attracting immune cells in the affected area. In the present study the effect of lipopolysaccharide (LPS) and cobalt chloride (CoCl2) on the above fibroblasts functions were evaluated in primary human skin fibroblasts cultures. Collagen, matrix metalloproteinase-1, tissue inhibitor of metalloproteinases-1, transforming growth factor-?1, interleukin-8 (IL-8) and macrophage chemoattractant protein-1 (MCP-1) were measured in fibroblasts culture supernatants. Fibroblasts proliferation and viability were assessed as well. Hypoxia inducible factor-1$ and the phosphorylated p65 portion of NF-kB were assessed in fibroblasts protein extracts. LPS and CoCl2 had a minor effect on fibrosis related factors in human primary fibroblasts, possibly due to the absence of interplay with other cell types in the used experimental system. On the contrary both LPS and CoCl2 increased significantly IL-8. LPS also increased considerably MCP-1, but CoCl2 decreased it. Thus LPS and CoCl2 induce a sentinel, nevertheless not identical, phenotype in primary human fibroblasts. The last disparity could result in different body response to infectious or hypoxic noxious stimuli.

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Are vascular disorders a common cause of erectile dysfunction in non hypogonadal, non neuropsychiatric patients?

Hippokratia 2011; 15(3):244-246

I. Vakalopoulos, P. Thanos, G. Gkotsos, D. Radopoulos

Abstract

Objectives: Pharmacological Color Duplex Ultrasonography (PCDU) is a technique used as an advanced investigation of erectile dysfunction (ED) causes. Aim of the study was to determine, if frequency of vascular disorders in ED patients justifies routine use of PCDU.
Materials and Methods: Seventy six patients aged 25-69 years with moderate to severe ED, free neuropsychiatric history and normal hormones were included in the study. The investigation consisted of basic ED work up and penile PCDU. Erection vascular parameters were determined.
Results: In the younger group (?45 years), 12% of patients demonstrated mild arterial insufficiency and none venous leakage, with only two patients not achieving hard erection. In the older group, 19.6% of patients demonstrated mild to moderate arterial insufficiency and 5.9% severe. Venous leakage was detected in 7.84%. Most patients (74.6%) achieved normal erection and 66.7% had normal PCDU parameters.
Conclusions: Vascular disorders were not found the primary cause of ED, especially among younger patients. PCDU is an advanced ED investigation, which should be applied only in vascular high risk cases.

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The use of fibrin sealant after total thyroidectomy for benign disease obviates the need for routine drainage. Results of a randomized controlled trial

Hippokratia 2011; 15(3):247-251

S. Sozen, O. Topuz, M. Tukenmez, M. Keceli

Abstract

Background: Drains are usually left after thyroid surgery to prevent formation of hematoma and seroma in the thyroid bed. This prospective randomized clinical trial was conducted to evaluate the necessity of drainage after total thyroidectomy for benign thyroidal disorders.
Methods: The patients were assigned randomly into two groups (group 1: with suction drain, group 2: fibrin glue). In the study, operating time, postoperative pain, the total amount of intramuscular analgesic administration, hospital stay, complications (such as wound infection, seroma, bleeding, hematoma, recurrent laryngeal nerve palsy or hypoparathyroidism), were recorded.
Results: The drained group (group 1) consisted of 2 men and 48 women with a mean age of 47.76±11.22 years. The nondrained (plus fibrin sealant)( group 2) (comprised of 10 men and 40 women with a mean age of 44.72±11.32 years. There was no significant difference in the gender, age, hormonal status and histopathological results of the patients between the two groups (P=0.18, P=0.36, P=0.28 and P=0.40, respectively). The operations performed were total thyroidectomy in all patients. Twenty-five patients (50%) in the non-drained group did not need intramuscular analgesic, whereas 15 patients (30%) did not in the drained group (P=0.01). In addition, the mean amount of intramuscular analgesic requirement was significantly less in the non-drained group than in the drained group (P=0.02). The complication rates were similar between the two groups. One case of hematoma (2%), two cases of seroma (4%) and three cases of transient hypoparathyroidism (6%) occurred in the non-drained group, whereas one case of hematoma (2%), two cases of seroma (4%), two cases of wound infections (4%) and two cases of transient hypoparathyroidism (4%) occurred in the drained group (P=0.69). No patient needed surgical revision or re-operation for any complication and all complications were successfully managed conservatively.
Conclusion: Routine drainage of thyroid bed following thyroid surgery may not be necessary. Not draining the wound results in lesser morbidity and decreased hospital stay.

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Bilateral asymptomatic giant renal artery aneurysm

Hippokratia 2011; 15 (3): 269-271

G. Ozkan, S. Ulusoy, H. Dinc, K. Kaynar, B. Sonmez, K. Akagunduz

Abstract
The incidence of renal artery aneurysm is very low. Approximately in 20% of these patients hypertension is observed. The diameter of aneurysm increases with accompanying complication rates. The most feared complication is rupture. The risk of rupture also increases with the diameter of aneurysm. We report an aneurysm with the biggest diameter reported in the literature. The patient had a 12 cm-diameter of aneurysm in one kidney and did not show any symptoms including hypertension until she was seventy years old.

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Scintigraphic evaluation of small intestinal transit in the streptozotocin induced diabetic rats

Hippokratia 2011; 15 (3): 262-264

G. Durmus-Altun, U. Vatansever, S. Arzu Vardar, S. Altaner, B. Dirlik

Abstract

Aim: Small intestine (SI) transit in the streptozotocin (STZ) induced diabetic rats were examined by using 99mTcmebrofenin scintigraphy.
Materials and methods: Wistar albino rats (mean body weight: 220±12 g) were studied for both control (n=10) and diabetes mellitus (DM) (n=10) groups. Diabetes was induced by a single intraperitoneal injection of streptozotocin (50 mg kg(-1) body weight. SI transit time was assessed by measuring arrival times of 99mTc-mebrofenin from duodenum to caecum.
Results: The mean transit time of 99mTc- mebrofenin was 67.8±11 min in control group. The mean transit time of SI was prolonged in STZ induced diabetic animals with (111.9±12.5, p=0.01). There was significant correlation between small intestinal transit time and blood glucose level (r: 0.73, p=0.01).
Conclusion: We observed that SI transit was prolonged in diabetic animals using 99mTc- mebrofenin, and additionally this technique is a readily available method for the detection of transit abnormalities in animal experiment.

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White Matter Lesions in Femoral Head Osteonecrosis patients: Manifestation of vascular disease or not?

Hippokratia 2011; 15 (3): 265-268

A. Dimitroulias, E. Tsironi, G. Hadjigeorgiou, N. Scarmeas, CH. Rountas, A. Zibis, K. Malizos

Abstract

Background: Osteonecrosis has been associated with the presence of white matter lesions. The objective of this study was to investigate the association between macro- and micro- vascular disease and white matter lesions.
Methods: Sixty-four patients with femoral head osteonecrosis were assessed during a cross sectional study in our university- based hospital. A vascular 'profile' was obtained for each patient and included measurement of plasma lipids, fundoscopic examination and common carotid artery triplex ultrasonography. All patients had brain MRI to assess for presence of white matter lesions. The two groups formed, with and without white matter lesions, were compared in order to define the association between white matter lesions and vascular disease.
Results: Patients without white matter lesions had more frequently corticosteroid induced osteonecrosis. There was no difference in the two groups with respect to intima media thickness and ApoB/ApoA1 ratio. Only one of our patients demonstrated retinopathy.
Conclusions: There is no evidence of concurrent macro- and micro- vascular pathology in young patients with white matter lesions and femoral head osteonecrosis. Cortisone appears to have a 'protective' effect against occurrence of white matter lesions.

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Percutaneous ultrasound-guided renal biopsy in children: a single centre experience

Hippokratia 2011; 15 (3): 258-261

N. Printza, J. Bosdou, A. Pantzaki, M. Badouraki, K. Kollios, CH. Ghogha, F. Papachristou

Abstract

Background and aim: The contribution of renal biopsy is of major importance in many renal diseases in children. In our study we aimed to evaluate retrospectively the indications, safety, efficacy and the spectrum of histopathological findings of percutaneous ultrasound-guided renal (PRB) biopsy during a 7 year period as well as to analyze specific groups of renal patients.
Patients and Methods: A total of 84 renal biopsies were performed in 81 children. Demographic data, clinical symptoms at presentation, indications for renal biopsy, laboratory findings, complications of the procedure and histological diagnosis were obtained from all patients who underwent PRB.
Results: The commonest indication for biopsy accounted was steroid resistant, steroid dependent or frequent relapsing idiopathic nephrotic syndrome (INS). Subcapsular hematoma presented 11% of the patients, but none of them needed blood transfusion. Adequate renal tissue sample was obtained in 97.7% of the renal biopsies. In 80% the histopathology revealed glomerular diseases. The most frequent types of biopsy-proven renal diseases were: focal segmental glomerulosclerosis (FSGS) (15%), IgA nephropathy (13.5%), minimal change disease (10%), various stages of lupus nephritis (8.5%), Henoch-Schonlein nephritis (7.5%), membranous glomerulonephritis (7.5%), mesangioproliferative glomerulonephritis (6%), post-infectious glomerulonephritis (6%), hemolytic uremic syndrome (5%), tubulointerstitial nephropathies (3.5%), acute tubular necrosis 2.5%. Among the 28 cases of INS, FSGS accounted for 43%. The leading histopathological pattern found in patients with recurrent episodes of gross haematuria was IgAN (84.5%). Among 7 cases of lupus nephritis, the observed histological types were: IV+V in 3/7, IIIA in 3/7 (43%) and IIB in 1/7.
Conclusions: Our study shows that percutaneous ultrasound guided renal biopsy is a safe, reliable and effective technique in children. It also provides updated information for childhood renal disease pattern.

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Oseltamivir-resistant influenza A pandemic (H1N1) 2009 virus in Northern Greece

Hippokratia 2011; 15 (3): 272-274

G. Gioula, A. Melidou, M. Exindari, N. Papoutsi, D. Chatzidimitriou, J. Dotis, M. Malisiovas

Abstract

Resistance to oseltamivir was observed to influenza A pandemic (H1N1) 2009 virus strains, isolated from two patients in North Greece. Investigations showed resistant viruses with the neuraminidase (NA) 275Y genotypes. Pandemic A (H1N1) 2009 virus should be closely monitored for emergence of resistant variants.

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Video capsule endoscopy findings in subacute superior mesenteric vein thrombosis

Hippokratia 2011; 15 (3): 275-277

P. Katsinelos, G. Chatzimavroudis, Ch. Zavos, I. Pilpilidis, K. Fasoulas, B. Papaziogas, J. Kountouras

Abstract

Background: Subacute superior mesenteric vein thrombosis is a rare ischemic intestinal disease which is often characterized by delayed diagnosis due to obscure clinical picture.
Case report: A 67-year-old woman who presented chronic abdominal pain with mild nausea due to superior mesenteric vein thrombosis was submitted to video capsule endoscopy. We describe, for the first time, the video capsule endoscopy findings in this patient.
Conclusion: We emphasize the role of this new technology in the diagnosis of suspected ischemic intestinal diseases.

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Identification of a mutation in the MTM1 gene, associated with X-linked myotubular myopathy, in a Greek family

Hippokratia 2011; 15 (3): 278-279

L. Fidani, P. Karagianni, C. Tsakalidis, G. Mitsiako, I. Hatziioannidis, V. Biancalana, N. Nikolaidis

Abstract

X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy, usually characterized by severe hypotonia and respiratory insufficiency at birth, in affected, male infants. The disease is causally associated with mutations in the MTM1 gene, coding for phosphatase myotubularin. We report a severe case of XLMTM with a novel mutation, at a donor splicing site (c.1467+1G) previously associated with severe phenotype. The mutation was also identified in the patient's mother, providing an opportunity for sound genetic counseling.

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