Angiotensin receptor blockers provide better stroke protection than angiotensin converting enzyme inhibitors -a hypothesis with clinical and experimental support

Hippokratia 2005; 9(3):99-105

S.G. Chrysant
Oklahoma Cardiovascular and Hypertension Center University of Oklahoma, Oklahoma City, OK, USA

Abstract

Stroke is a major cause of death and disability and its incidence increases linearly with age and the level of systolic and diastolic blood pressure. Stroke, besides being a cause of long-term disability for the affected person, also imposes a significant burden on society and healthcare costs. Although good blood pressure control is very critical for stroke prevention, angiotensin receptor blockers (ARBs) may be superior to angiotensin converting enzyme inhibitors (ACEIs) for the same degree of blood pressure control. This hypothesis has clinical and experimental support. ARBs prevent stroke incidence by blocking the angiotensin II (AII), AT1 receptors preventing brain ischemia and allowing AII to stimulate the unoccupied AT2 receptors which improve brain ischemia. ACEIs, by reducing AII generation, are less effective in preventing stroke. This hypothesis provides evidence that AII plays an important role in the prevention of stroke. Certain ARBs like losartan and telmisartan possess additional properties which may play a role in stroke prevention, which is independent of AII. However, the most critical factor in stroke prevention is good blood pressure control irrespective of drug used.

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Adhesion molecules in cancer invasion and metastasis

Hippokratia 2005; 9(3):106-114

CH Golias, A Chralabopoulos, D Peschos, D. Maritsi, P. Charalabopoulos, A Batistatou
Physiology Dpt, Clinical Unit, Medical Faculty, University of Ioannina, Ioannina, Greece
Pathology Dpt, Medical Faculty, University of Ioannina, Ioannina, Greece

Abstract

For more than one hundred years the question "what defines which organs and when will be affected in case of a disseminated cancer" expressed by Paget remains basically unanswered, despite the bulk of published studies regarding the cancer behaviour. ?? 1944, Coman developed the theory of adhesion forces regarding the cancer problem. Nowadays, it is known that the interactions either among cells (cell-cell) or among cells and substratum components (cell-matrix) are mediated by some molecules, named adhesion molecules. Until now, more than a hundred of adhesion molecules have been identified. Research on physiology, biochemistry, genetics, and biology so in basic as in clinical level, attracts with intense interest the attention of many scientists. In the majority of the human cancers it has been clearly demonstrated that alterations in the adhesion forces are implicated in the invasion and metastasis process. Furthermore, an effort to establish a role of adhesion molecules as potential biomarkers in various human malignancies is attempted. Involvement of adhesion molecules in diagnosis, prognosis and treatment possibly has been implicated in many cases of human cancer. Adhesion molecules comprise of five known families; cadherins, integrins, immunoglobulin gene superfamily (IgSF), selectins, and CD44. In the present article a global approach of the whole subject is attempted. In addition, the role of some adhesion molecules in carcinogenesis is discussed in some detail.

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Renal transplantation in patients over 60 year old

Hippokratia 2005; 9(3):115-118

G Vergoulas, Gr Miserlis, Th Eleftheriadis, I Ioannidis, S Patsalas, V Papanikolaou, G Imvrios, I Fouzas, P Papagiannis, D Takoudas
Organ Transplant Unit, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Background. There are controversial reports concerning the impact of age - related immune responses in renal transplant recipients. It has been suggested that, older age relates with lower acute and chronic rejection rate, reduced patient and graft survival and less aggressive immunosuppressive therapy is required. More recent reports refer increased recipient age as an independent risk factor for the development of chronic rejection and a higher incidence of acute rejection episodes. The purpose of this study was to present the experience of our centre with this particular group of patients, clarify their behavior after transplantation, and discuss possible treatment modalities.
Material. The period 1st Jan 1987 - 31st Dec 2003, among 801 kidney transplants, there were 23 recipients with age > 60 years at time of transplantation (mean age 63.47??3.00 years, range 60.5 - 70.5 years), 16 male and 7 female who received 19 cadaveric (CD) and 4 living related donor (LRD) grafts. Immunosuppression was steroids, MMF / azathioprine, CsA and ATG / basiliximab and mean donor age was 51.61?? 17.01 years (range 22.3 - 72.8 years). Initial hospital stay, blood pressure, lipid levels, delayed graft function (DGF), acute rejections (AR), patient and graft loss were recorded and cumulative patient and graft survival was calculated.
Results. During the follow up period there were 9 graft losses due to 8 deaths and 1 infection. Deaths were mainly due to cardiovascular and cerebrovascular accidents (75%) and to a lesser degree to infection (12.5%). The mean stay at 1st hospital admission was 32.60??29.16 days. There were 3 AR episodes (13.63%) and 11 cases with DGF (47.82%). The incidence of AR in pts with DGF and age > 60 years was 9.1 %. The cumulative patient and graft survival one and five years after kidney transplantation were 82.61 % and 74.61 % respectively. Abnormal high blood pressure and lipid levels were recorded in these patients.
Conclusions. The main cause of graft loss in patients with age > 60 years was death. There was no graft loss due to AR or chronic allograft nephropathy. The very high rate of DGF is probably due to high incidence of CD transplants, which caused a very prolonged 1st hospital stay. The low incidence of AR with or without DGF suggests deranged immune response.

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Treatment of malignant biliary obstruction using one metallic stent per patient

Hippokratia 2005; 9(3):119-123

N Vougiouklis, E Chartabilas, I Agorastos, ?? Akriviadis, G Chatzitheocharis, N Evgenidis, I Goulis, I Kountouras, N Mavroudis, G Mparaoutoglou, D Mpintoudis, N Nikolaidis, C Papanikolaou
Radiology Dpr, Hippokratio General Hospital, Thessaloniki, Greece

Abstract

Background: Drainage of malignant jaundice by percutaneously inserted stents is an established method in inoperab!e neoplasms. In a group of consecutive patients with malignant biliary obstruction, an attempt was made to drain the bile using only one metallic stent (MS) per patient. This study examines the results of this approach.
Patients and methods: In 23 men and 18 women (mean age 61.6 years) with obstructive jaundice caused by inoperable neoplasm, 43 shape-memory metallic stents (SMMS) were percutaneously inserted.
Results: In one case, two SMMS were used for the drainage of the two segmenta! ducts of the right hepatic lobe. In the remaining 40 patients, the stents were successfully released in the proper position in 38 patients and in an incorrect position in 2 patients. Their final length after their adjustment to the bile duct was increased by 20-30% resulting in protrusion of 8 MS into the duodenum. The serum bilirubin level before the intervention was 9 to 40 (mean 19.6) mg/dl while the lowest value after the drainage was 2 to 15 (mean 4.3) mg/dl. Serious complications were observed in 14,6 % of patients whilst the 30-day mortality was 5%. Seven patients underwent reintervention because of significant aggravation of jaundice.
Conclusion: Treatment of malignant biliary obstruction with the use of only one SMMS of considerable size is feasible and effective; the main drawback is the inability to accurately estimate the final position of the distal end of the stent.

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Diagnostic value of progestorone and CA-125 in the prediction of ectopic and abortive intrauterine gestations

Hippokratia 2005; 9(3):124-129

I Katsikis, D Rousso, A Piouka, D Farmakiotis, A Kourtis, V Koiou-Zournatzi, D Panidis
Division of Endocrinology and Human Reproduction, 2nd Dpt Obstetric & Gynaecology, Aritotle University of Thessaloniki, Thessaloniki, Greece

Abstract
Objective: The study was designed to investigate the predictive value of progesterone and CA-125 in the diagnosis of ectopic pregnancy (??) and inevitable miscarriage.
Methods: Forty women with ??, 20 with intrauterine (IU) abortive gestation and 20 regular pregnant women (controls) were studied. IU abortive and ?? were confirmed and treated by surgery. Serum progesterone and CA-125 levels were measured at the time of presentation and 24 hours after surgery.
Results: Women with ?? had significantly lower progesterone concentrations, compared to both women with IU abortive pregnancy and controls. Women with IU abortion had significantly higher CA-125 levels, compared to the other two groups. When using a progesterone concentration of less than 10.75 ng/ml as a cut-point for the diagnosis of ??, sensitivity, specificity, positive and negative predictive values were 85%. When using CA-125 concentration of more than 41.9 U/ml as a threshold for the diagnosis of IU abortive pregnancy, sensitivity was 80%, specificity 87%, the positive predictive value was 66% and the negative predictive value 93%.
Conclusion: The measurement of progesterone and CA-125 levels is useful in discriminating ectopic and intrauterine abortive from normal gestations.

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Placental abruption and severe disseminated intravascular coagulopathy

Hippokratia 2005; 9(3):130-131

N Klearhou, A Daniilidis, K Stergiopoulos, M. Bougatsia, A Mamopoulos
3rd Dpt Obstetrics and Gynaecology, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

Abstract

We describe a case of a 39 year old Para I with Disseminated Intravascular Coagulation (DIC) following abruption of placenta at 29 weeks of gestation. She was operated four times and was transfused with 40 units of packed red cells, 43 units of fresh frozen plasma, 15 units of platelets and 36 units of cryoprecipitate. She presented with no history of thromboembolic disorders and there was no evidence of thrombophillia according to the laboratory investigations.

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Immune mediated sensorineual hearing loss in a myositis patient

Hippokratia 2005; 9(3): 132-133

P Boura, P Skendros, S Papadopoulos, J Kountouras
Division of Clinical Immunology, 2nd Dpt Internal Medicine, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

Abstract

An unusual case of an immune mediated sensorineural hearing loss in a myositis patient is described. ?24-year-o1d male deve1oped progressive sensorineural hearing loss (SNHL) and subsequently clinical p??ture compatible to acute myositis. He was ??positive. The diagnosis of myositis is based on clinical picture, aldolase levels and electromyogram (EMG) findings although, muscle biopsy was not performed due to the patient's refusal. Laboratory investigation for infectious myopathies, sarcoidosis as well as systematic vasculitides, Cogan syndrome or secondary myositis due to connective tissue disorders like systemic lupus or Sjogren syndrome was negative. He received high doses of steroids (1.5 mg/kg BW) and clinical status, CRP, aldolase levels and EMG findings were normalized, except for the SNHL where there was no improvement. During the follow-up period the patient had steady transaminasaemia. Although definite autoimmune liver disease was not confirmed by 1iver histology, azathioprine 100 mg daily was added, and transaminases declined to normal values. We conclude that, patients with inflammatory muscle disease and hearing disturbance should be considered to and investigated for immune mediated inner ear disease.

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Isolated tonsillar sarcoidosis mimicking malignancy: Diagnostic and therapeutic dilemmas

Hippokratia 2005; 9(3):134-137

G Fyrmpas, S Ereliadis, J Constantinidis, M Manthou, J Daniilidis
Dpt Otolaryngology, Head & Nech Surgery, AHEPA General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
Patholgy Dpt, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

Abstract

Background: Sarcoidosis is a multisystemic, granulomatous disease of obscure aetiology. Isolated tonsillar sarcoidosis is very rare and may mimic neoplasia.
Case report: We report a case of a 43 year old lady with isolated tonsillar sarcoidosis, whose clinical presentation was initially regarded as malignant tumour of the tonsil. The patient underwent tonsillectomy and received no further treatment. She remains free of symptoms one year following the diagnosis.
Discussion: Tonsillar sarcoidosis, in the absence of other systemic manifestations, may not be a straightforward diagnosis. ??n caseating granulomas, the histological hallmark of the disease, are non-specific and may be found in granulomatous processes of a known cause (e.g. tuberculosis). The diagnostic approach aims at supporting the clinical findings and revealing the true extent of the disease. Correct and timely diagnosis prevents delays in treatment and institution of contraindicated therapies (e.g. steroids for masqueraded tonsillar tuberculosis). Sarcoidosis should always be included in the differential diagnosis of asymmetric tonsils therefore histological examination of the tonsils is imperative. Patients suffering from sarcoidosis in the Head and Neck region need long term follow up. The initial diagnosis may change in the light of new symptoms and there may be a risk of developing malignant neoplasms in sarcoidosis.

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Mycophenolate mofetil late gastrointestinal toxicity causing chronic diarrhea after renal transplantation

Hippokratia 2005; 9(3): 138-140

G Vergoulas, A Avdelidou, K Ioannou, Th Eleftheriadis, Gr Miserlis, F Solonaki, N. Nikolaidis, O Gioulene, M Leontsini, A Papagiannis, D Takoudas
Organ Transplant Unit, Hippokratia General Hospital, Thessalonki, Greece

Abstract

Background: After the improvements in short and long - term patient and graft survival in kidney transplantation, the attention has been focused on the quality of life of renal transplant recipients. Chronic immunosuppression has been implicated for side effects that can compromise patients' quality of life. We describe two patients with chronic intractable diarrhoea due to late mycophenolate mofetil toxicity.
Case report: A man (VR) 40 years old with a living related donor and a woman (SV) 33 years old with a cadaveric donor presented intractable diarrhoea four years and three months and three years after transplantation respectively which caused a loss of 12 Kg and 8 Kg of their body weight respectively. The duration of the diarrhoea was about 25 months for VR and 18 months for SV with exacerbations and remittences during this period of time. Anti-diarrhoeic agents (loperamide and nifuroxazid) were used to control diarrhoea, as well as antibiotics(metronidazole,ciprofloxacin). The investigation of these patients started a few months after the initiation of the symptoms and included radiological examination of the large intestine, repeated bowel cultures for parasites and biopsy material from stomach, duodenum and large intestine during endoscopic examination.
Results and discussion: All the examination results were negative for malignancy, inflammatory bowel disease or malabsorption syndrome. MMF was converted to azathioprine (100 mg/d p.o) and the diarrhoea st???d in both patients. VR gained 5 kg and SV 4.5 kg weight during a less than two months period of time without any change in their serum creatinine levels.
Conclusion; Mycophenolate mofetil late gastrointestinal toxicity expressed as intractable diarrhoea exerts a negative influence on the quality of life of kidney transplant recipients and it must be always in the differential diagnosis of diarrhoea in renal transplant recipients. Convertion from mycophenolate mofetil (CellCept) to azathioprine is an easy to apply measure which stops diarrhoea and improves significantly the quality of life of these patients, without affecting graft's function.

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Assessment of olfactory and intanasal trigeminal function using electrophysiological and imaging techniques

Hippokratia 2005; 9(3):141-144

I Konstantinidis, Th Hummel
Smell & Taste Clinic, Otolaryngology Dpt, Carl Gustav Carus University Hospital of Dresden, Dresden, Germany

Abstract

Objective: The development of olfactory screening tests for the every day clinical practice was a useful tool for the assessment of olfactory and trigeminal function. These psychophysical tests have numerous advantages in the clinical utilization, but also important limitations. Subsequently, new techniques have been developed which rely less on the subjects' cooperation. The aim of this review is to describe the methods used to record and analyze olfactory and trigeminal event-related potentials (ERPs).
Methods: Odors are applied intranasaly by means of a special device called olfactometer. Stimulus presentation and recording of stimulus-linked ????segments typically are under computer control. Different techniques for the recording of olfactory system response have been developed: 1.Electro-olfactograms (???? which are electrical potentials of the olfactory epithelium that occur in response to olfactory stimulation, collected by an electrode placed in the olfactory cleft. 2. Event-related potentials which are EEG-derived poly-phasic signals, due to the activation of cortical neurons which generate electro-magnetic fields. 3. Imaging techniques include positron emission tomography (????, functional magnetic resonance imaging (FMRI), and magnetic source imaging (MSI).
Results: ERP olfactometry allows the investigation of subjects who have difficulties to respond properly (e.g., children, or aphasic, demented, unconscious, or inexperienced patients). It is also necessary for the diagnosis of olfactory deficits for medicolegal purposes. Olfactory dysfunction is an early symptom of some neurodegenerative diseases and the development of the techniques will be useful for the early diagnosis of these disorders. Conclusion: Olfactory ERPs are a validated means which allows the investigation of early components of olfactory information with a special focus on high temporal resolution. This technique is a useful tool in the study of subtle alterations in olfactory perception, odor memory, or odor aversion.

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