A multicenter, prospective, observational study examining the impact of risk factors, such as BMI and waist circumference, on quality of life improvement and clinical response in moderate-to-severe plaque-type psoriasis patients treated with infliximab in routine care settings of Greece.

BACKGROUND: Obesity has been associated with moderate-to-severe plaque psoriasis severity and PASI 75 response attainment of biologic therapies, but findings are inconsistent. OBJECTIVE: This study aimed to examine the association of body mass index (BMI) and waist circumference (WC) on disease severity, to identify potential patient characteristics associated with response attainment and to assess the impact of infliximab on the patients' health-related quality of life (HRQoL) among infliximab-treated patients in the routine care setting of Greece. METHODS: This was a multicenter, prospective, observational study of adult moderate-to-severe plaque psoriasis patients who had initiated treatment with originator infliximab within 2 weeks prior to enrolment. Postenrolment visits occurred at 14 ± 4, 30 ± 4 and 54 ± 4 weeks following treatment onset. RESULTS: Between October 2012 and June 2014, 136 eligible patients (62.5% males) with a median age of 48.6 years, BMI of 29.6 kg/m2 and WC of 107.0 cm at enrolment were recruited by 21 dermatology hospital/private offices. All patients had received prior psoriasis treatment(s); 62.5% were biologic-naïve. Mean baseline psoriasis area severity index (PASI) and Dermatology Quality of Life Index (DLQI) scores were 23.4 ± 13.6 and 15.0 ± 8.3, respectively. A low correlation was observed between WC at enrolment and baseline PASI [ρ = 0.324 (P < 0.001)]. Over a median 48.4 weeks of infliximab exposure, 89.3% of the per protocol set achieved a PASI 75 response. At 14, 30 and 54 weeks, the PASI 75 attainment rate was 66.4%, 74.8% and 76.6%, respectively; the clinically meaningful DLQI improvement (≥5 point decrease) rate was 68.9%, 75.7% and 69.8%, respectively. BMI category and abdominal obesity at enrolment did not impact PASI 75 or DLQI improvement rate attainment. CONCLUSION: In the routine care of Greece, infliximab reduced disease activity and improved the quality of life of moderate-to-severe psoriasis patients through 1 year of treatment, independent of their BMI and WC.

Efficacy of a new video-based training model in spinal surgery.

BACKGROUND: An important part of neurosurgical training is the improvement of surgical skills. Acquiring microsurgical skills follows a learning curve, influenced by specific exercises, feedback, and training. Aim of training should be rapid learning success. The study shows the way in which video-based training can influence the learning curve. METHODS: Over a period of 18 months (2011-2012) 12 residents were evaluated in spinal surgery (12 cases per resident) by a skilled evaluator based on different criteria. The evaluation criteria (exposition of important anatomy, intraoperative bleeding, efficacy of using bipolar cauterization) were weighted and added to a single quality-score. The participating residents were divided into two groups. Only one group (n = 5) received video-based training. RESULTS: Residents showed an individually different but explicit increase in microsurgical skills. The quality-score during the first surgery compared with the end point of the study demonstrated a faster improvement of surgical skills in the group with video-based training than in the group without special training. Considering all residents together, the video-training group displayed a steeper gradient of microsurgical success. Comparison of the single resident's microsurgical skills showed individual disparities. Various biases that influence the learning success are under examination. CONCLUSION: Video-based training can improve microsurgical skills, leading to an improved learning curve. An earlier entry of the learning curve plateau in the video-training group promotes a higher acquisition of surgical skills. Because of the positive effect, we plan to apply the video-based training model to other neurosurgical subspecialties, especially neurovascular and skull base surgery.

Simultaneous pancreas-kidney transplantation: initial results from a center in Greece.

AIM: The outcome of simultaneous pancreas-kidney transplantation (SPK) in type 1 diabetes has dramatically improved in recent years. We report the initial results of our SPK program. PATIENTS AND METHODS: From 2008 to 2010, we performed and prospectively obtained data on 4 SPKs in 4 type 1 diabetic patients with chronic renal failure. The recipients were 3 men and 1 woman, of overall mean age of 40.75 ± 4.78 years, mean time from diabetes diagnosis of 27 ± 15 years, and time on dialysis of 3.5 ± 0.57 years. All grafts were procured from multiorgan brain-dead donors of mean age 26 ± 8.16 years and mean body weight of 74 ± 4.34 kg. The pancreatic grafts were transplanted first into the right iliac fossa with mean cold ischemia times of 10.62 ± 3.09 hours for the pancreatic and 14.00 ± 2.97 hours for the renal grafts. Pancreas arterial inflow was re-established by an end-to-side anastomosis of an extension Y-graft to the recipient right iliac artery. The portal vein was sutured to the iliac vein directly. The exocrine secretions of the pancreas were managed by duodenojejunostomy extraperitoneally (n = 3) or intraperitoneally (n = 1). The ureteral anastomosis was performed using the Taguchi technique. RESULTS: After SPK, endocrine pancreatic function was immediately restored in all patients. Insulin administration was stopped within the first 24 hours after surgery. Two patients displayed delayed renal graft function necessitating dialysis for 9 and 23 days, respectively. The postoperative course was prolonged with a mean hospital stay of 82 ± 1 day. At a 31.75 ± 9.03 months follow up all patients are alive with functioning grafts. CONCLUSION: Our experience with SPK, although limited, has shown encouraging results over a short follow-up period.

Hepatic artery thrombosis after orthotopic liver transplantation: 3 patients with collateral formation and conservative treatment.

Hepatic artery thrombosis (HAT), a serious complication after orthotopic liver transplantation (OLT), can lead to patient death in the absence of revascularization or retransplantation. Herein we have presented clinical characteristics, imaging findings, and long-term outcomes of 3 OLT patients with HAT who were treated conservatively and developed hepatic arterial collaterals. These patients underwent transplantation due to hepatitis B cirrhosis, cryptogenic cirrhosis, or hepatitis C infection and alcoholic disease. They presented with bile duct stenosis and/or a bile leak at 1, 3, and 36 months after transplantation, respectively, and were treated with percutaneous drainage and stent placement, endoscopic retrograde cholangio-pancreatography (ERCP), or reanastomosis of the bile duct over a T tube. HAT was confirmed using multidetector computed tomography (MDCT) 3-dimensional (3D) angiography and Doppler sonography. They survive in good condition with normal liver function at 30, 50, and 42 months after OLT, respectively. Development of collateral arterial circulation to the liver graft was detected with MDCT 3D angiography and Doppler sonography. From our experience with 3 patients and a literature review, we believe that there are a number of patients who experience long-term survival after the diagnosis of irreversible HAT and the development of collaterals. Although this group is at high risk for sepsis and biliary complications, these are usually self-limiting complications due to improved treatment regimens. The development of collateral arterial flow may also be beneficial.

Imaging of complications of liver transplantation: multidetector computed tomography findings.

BACKGROUND: Liver transplantation is the treatment of choice for patients with end-stage liver disease; however, it is associated with a multitude of postoperative complications. Herein we have presented our experience with the application of multidetector computed tomography (MDCT) in the follow-up of liver transplant recipients. PATIENTS AND METHODS: Twenty-four liver transplantation patients were examined with triphasic hepatic computed tomography. Both symptomatic and asymptomatic patients were included in the study. Examinations were performed using a multidetector scanner. RESULTS: We documented seven cases of thrombosis, three stenosis, and two hepatic artery (HA) aneurysms. Portal vein (PV) stenosis and PV thrombosis were observed in two cases each. We observed one case of synchronous HA and PV stenosis; one inferior vena cava (IVC) and left renal vein thrombosis, and one IVC thrombosis. In three cases of HA obstruction we observed transplant neovascularization. One HA obstruction and one HA stenosis were accompanied by bilomas. Finally, we discovered three cases of hepatocellular carcinoma. CONCLUSION: In our experience MDCT as a single noninvasive examination, was a sensitive means to detect and evaluate vascular complications after liver transplantation, offering adequate information concerning the liver parenchyma, the rest of the abdomen, and to a lesser extent the biliary tract.

Three dimensional rotational angiography in surgical planning of aneurysm clipping.

BACKGROUND: Three-dimensional (3D) angiography is increasingly used in the diagnostics of brain aneurysms. Aim of the present study was to evaluate the accuracy of 3D angiograms with respect to its value for preoperative planning of aneurysm clipping. PATIENTS AND METHODS: The 3D angiograms of 42 patients with subarachnoid bleeding caused by aneurysm rupture of the anterior circle of Willis and the intradural carotid have been compared to intraoperative photographs of the aneurysms. RESULTS: Neighbouring vessels, aneurysm anatomy, arteries originating from the aneurysm wall were accurately shown decreasing the surgical risk of aneurysm clipping. CONCLUSIONS: The 3D images enabled a perfect preoperative planning through the operation by illuminating the aneurysm anatomy, neck localisation and shape and relation of the aneurysm to neighbouring vessels. Operative approach, use of an accurate clip and avoidance of clipping arteries close to the aneurysm have become predictable and safer by the use of 3D angiography.

Resistant vasospasm in subarachnoid hemorrhage treated with continuous intraarterial nimodipine infusion.

Cerebral vasospasm complicating aneurysmal subarachnoid hemorrhage is a well-known medical entity. The delayed ischemic neurological deficits (DIND) as a result of vasospasm remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options, either medical or interventional, fail to reverse vasospasm, continuous intraarterial infusion of nimodipine through catheters directly into the spastic arteries presents a promising treatment modality. Of 73 patients with aneurysmal subarachnoid hemorrhage between 2008 and 2009, a total of 27 had Hunt and Hess grades of 4 and 5. Fifteen percent of them showed refractory vasospasms and were treated with continuous nimodipine infusion via catheters in both internal carotid arteries. We present the method's indications and possible complications.

Transorbital impalement injury with massive intracranial lesion not detected by cranial CT scan.

An extraordinary case of transorbital penetration injury is presented. A 24-year-old male patient was involved in a fight and was pushed against a shelf. He immediately lost consciousness and was brought to hospital. A cranial computed tomogaphy (CT) scan showed a hemorrhage and brain edema over the left hemisphere with orbital roof fracture. A decompressive craniectomy was performed. Intraoperatively, an orbital roof fracture with penetration of the frontobasal dura could be seen which could not be explained by the trauma mechanism. The postoperative magnetic resonance imaging (MRI) with susceptibility-weighted image (SWI) showed two injury tracks from the orbit through the brain which appeared to be penetration injuries. The forensics department was consulted and penetration by a falling candleholder was found to be the cause of the injuries. In this case, the cranial CT alone did not show any indication of a penetration injury. Only MRI revealed the penetration track, which stresses the diagnostic value of this modality and especially the SWI in cases where the trauma mechanism does not correspond to the injury shown in the CT scan.

Outcome of craniocerebral gunshot injuries in the civilian population. Prognostic factors and treatment options.

AIM: Gunshot wounds to the head are rare in Europe. They may be inflicted by low-velocity handguns, captive bolt guns and tear gas cartridges and mostly result from suicide attempts. The experience of neurosurgeons with this kind of traumatic injury is decreasing; the aim of this study was therefore to analyse prognostic factors which help to decide whether or not to operate and to discuss treatment options. METHODS: Thirty patients with gunshot head injuries treated in our hospital from 1993 to 2008 were retrospectively evaluated. Glasgow Coma Scale (GCS) score, pupil reactivity, lesion localisation, number of bone fragments, intracranial pressure (ICP), midline shift, hypotension, and dural penetration were analysed for their prognostic value. Surgically and non-surgically treated patients were evaluated separately. Complications were registered. RESULTS: A low GCS of 3-8, fixed pupils, >2 bone fragments, bilobar or posterior fossa/brainstem lesions and ICP >45 mmHg were indicators of a poor prognosis. CONCLUSION: Patients with a GCS of 3-8 and two non-reactive pupils should not be operated. If one or both of the pupils are reactive, surgery should be performed irrespective of the GCS score, except in patients with translobar/transventricular wounds. Even if there are no clear contraindications to surgery, the outcome is expected to be poor in patients with a low GCS score, midline shift >10 mm, >2 bone fragments in the brain, and a bilobar, posterior fossa/brainstem or ventricular lesion and ICP >45 mmHg. When surgery is performed the wound and the missile or bone track should be debrided meticulously, the wound and dura should be closed in a watertight fashion and antibiotic prophylaxis as well as tetanus serum should be given.

Impact of an anesthesia discharge scoring system on postoperative monitoring after circumcision in children: a randomized trial.

BACKGROUND: Ambulatory surgery in children, combined with new anesthetic methods, leads to shorter hospital stays and an increase in patient and parental satisfaction. AIM: Aim of the study was to determine the feasibility and safety of transferring children directly to the ward without a previous stay in a post anesthesia care unit (PACU), after undergoing circumcision for phimosis under regional anesthesia and non-opioid analgesia. METHODS: 187 healthy children undergoing circumcision were studied in a randomized manner. After surgery, children who met predefined inclusion criteria in the operating room were randomly assigned to one of two groups. Children in the first group (Group A) bypassed the PACU and were admitted directly to the ward, after undergoing assessment using the White and Song scoring system. Children in the second group (Group B) were first transferred to a PACU and then to the ward. The children in Group A who did not meet the criteria of the White and Song scoring system represent the level of risk associated with direct transfer to the ward and no PACU stay. Recovery in the PACU and the ward, parental satisfaction, number of readmissions and the number of parental contacts for medical problems after discharge were recorded and compared between the two study groups. RESULTS: 157 children were randomly assigned into two groups (79 children in Group A and 78 in Group B). Demographic data, the duration of surgery, and recovery in the PACU or the ward were similar for the two groups. No readmissions were observed and most parents were very satisfied with the procedure. CONCLUSION: Children undergoing circumcision do not routinely require admission to a PACU and if the appropriate criteria are met, it is safe to transfer them directly to the ward.

Acute subdural hematoma in the elderly; clinical and CT factors influencing the surgical treatment decision.

OBJECTIVE: Acute subdural hematomas (aSDH) are severe traumatic brain injuries. Older patients have a higher mortality rate. In the present study the computed tomography (CT) and neurological deficits caused by aSDH were used as prognostic factors to define the outcome and surgical treatment indication in older patients. METHODS: The affect of the Glasgow Coma Scale (GCS) score on initial presentation, pupil abnormalities, parenchymal lesions, SDH-thickness, midline shift and intracranial pressure (ICP) in the outcome of older patients (>or=65 years old) admitted to our hospital between 1993 and 2006 with aSDH was evaluated. The outcome was assessed with the Glasgow Outcome Scale (GOS). The data were collected retrospectively. Statistical analysis was performed with Chi-square test and ANOVA. RESULTS: Older patients have a high mortality after aSDH. A low GCS score (3-8), pupil abnormalities, the presence of contusions and subarachnoid bleeding, midline shift>aSDH thickness as well as a highly elevated ICP>40 mmHg are unfavorable factors in the prognosis of aSDH. CONCLUSION: Patients with a GCS of 13-15 can be observed clinically (the expected outcome is very good). Comatose patients (GCS 3-8) with bilateral dilatation of the pupils should not be operated (very high mortality rate). If the GCS score is <13 and both pupils or only one are reactive to light and the midline shift<10 mm, surgery is indicated. If the midline shift is >10 mm and aSDH thickness>midline shift, surgery is also indicated. If in the same patient group midline shift>SDH thickness and ICP>40 mmHg, surgery is not indicated.

Preoperative evaluation of living kidney donors with multidetector computed tomography angiography.

OBJECTIVE: The purpose of this study was to determinate the accuracy of multidetector computed tomography (MDCT) angiography for imaging evaluation of renal anatomic variants among potential living renal donors for surgical planning. MATERIALS AND METHODS: Two hundred twenty-three living kidney donors underwent MDCT angiography (MDCTA) in our institution over the last 2 years. The examination was performed with a 4-detector scanner, including scanning before and after power injection of nonionic contrast material during the arterial, nephrographic, and excretory phases. Scans were reconstructed for three-dimensional (3D) images using MIP, MPR, VRT, and CPR techniques. RESULTS: Arterial variants, including supernumerary renal arteries, were present in 140 subjects: 11 presented luminal stenosis; 10 had calcifications within the vessel wall; 3 had renal artery aneurysms; 2 had obstructions; and 1 had angulation of the renal artery. Calcifications were associated with luminal stenosis (4 subjects) or no pathology (6 subjects). Venous variants were present in 4 subjects, including 3 retroaortic renal veins and 1 left renal vein draining into the retrohepatic portion of the IVC. Incidental findings were 3 renal infarcts. CONCLUSION: MDCTA and urography are a minimally invasive, fast method to detect and classify a variety of anatomic anomalies among potential living renal donors relevant to surgical planning.

Vertebral artery decompression in a patient with rotational occlusion.

We report a patient who suffered drop attacks during head reclination. Computer tomography of the cervical spine demonstrated a stenotic right vertebral artery at C4/5. However, Doppler ultrasonography of the vertebral artery showed no abnormality. Angiography confirmed complete occlusion of the left vertebral and a stenosis of the right vertebral artery. Dynamic angiography indicated occlusion of the stenotic region on the right side during reclination of the head. Surgery using a posterior approach with decompression of the vertebral artery, lead to an excellent outcome and the patient left the hospital without any symptoms. Therefore, in patients with drop attacks and normal ultrasonography, a stenosis of the vertebral artery caused by a spondylophytic compression could still be the cause. At worst, the stenosis could lead to brain infarction if left untreated. Dynamic angiography is crucial for the diagnosis and surgical decompression has excellent results.

Immunophenotypic analysis of the p53 gene in non-melanoma skin cancer and correlation with apoptosis and cell proliferation.

BACKGROUND: Sunlight precipitates a series of genetic events that lead to the development of skin cancers such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The p53 tumour suppressor gene, which plays a pivotal role in cell division and apoptosis, is frequently found mutated in sunlight-induced skin tumours. OBJECTIVE: To investigate the immunoreactivity of the p53 gene in non-melanoma skin cancers and to correlate its expression with apoptotic and cell proliferation markers. METHODS: We analysed 35 non-melanoma tumours including 19 BCCs and 16 SCCs from sun-exposed skin areas. p53 protein expression was studied immunohistochemically using the DO7 monoclonal antibody against wild-type and mutant p53 forms. The percentage of p53-immunopositive nuclei was measured by image analysis. Cell proliferation and apoptosis were also assessed by image analysis following Ki-67 immunostaining and application of the TUNEL method on paraffin sections, respectively. RESULTS: The percentage of p53-expressing cells varied from 3.5 to 90 in BCCs (median value 54.4%) and from 3.7 to 94 in SCCs (median value 40.3%). The mean value of Ki-67-positive cells was comparable in both groups of tumours with a mean value of 40.6% in BCCs and 34.6% in SCCs. Conversely, the TUNEL assay showed sporadic staining of apoptotic cells within the tumours with a mean value of 1.12% in BCCs and 1.8% in SCCs. p53 protein expression was correlated positively with cell proliferation (r = 0.75, P = 0.000001) and negatively with apoptosis (r = -0.23, P = 0.05). CONCLUSION: p53 immunoreactivity was high in the majority of the skin carcinomas examined and correlated positively with cell proliferation and negatively with apoptosis. The p53 protein overexpression appears to be related to an inactivated protein resulting from mutations of the p53 gene or other unclear molecular mechanisms.

Actinic granuloma successfully treated with acitretin.

Actinic granuloma is a rare skin disorder that develops in an area of actinic elastosis. The pathogenesis of the disease is obscure but the most accepted hypothesis implicates the solar radiation as the triggering factor. Typically the disease presents in middle-aged individuals with significant past sun-exposure and involves mainly the sun-exposed skin. It manifests as asymptomatic annular patches with elevated borders and central atrophy and shows little tendency to regression. Several treatments have been tried with variable success. We present a 74-year-old male who consulted our department for annular atrophic plaques involving his forehead and nose, present for 8 months and insidiously spreading but otherwise asymptomatic. A biopsy confirmed the clinical suspicion of actinic granuloma and excluded other possibilities. Our patient was commenced on acitretin 25 mg/day and showed a remarkable improvement within a year; the lesions stopped spreading and almost disappeared.

Routine psychosocial assessment of women in the antenatal period: frequency of risk factors and implications for clinical services.

Routine psychosocial assessment was introduced at an Australian public hospital's antenatal clinic in 2001. After modification, this assessment consists of 12 questions together with the Edinburgh Depression Scale (EDS). Data are reported for responses to these questions from over 2,000 English-speaking women presenting to the clinic in a 12-month period. These 12 questions and the EDS were categorised into seven risk domains, with 12% of the women (n = 260) having three or more of these risk domains. Referral information to one of our two clinical services shows that 6.7% of women assessed in the antenatal clinic become clients having face-face counselling, and a further 7.2% have just telephone contact with this specialist perinatal mental health service. This information should prove useful for services considering implementing routine psychosocial assessments (or "screening") in the antenatal period.

Metastatic low-grade inflammatory myofibroblastic tumor (IMT) in the central nervous system of a 29-year-old male patient.

A case of myofibrosarcoma (IMT) of the brain and lung as well as the spinal cord is described. A 29-year-old male patient presented with fever (40 degrees C), malaise, vomitus, meningism and leukocytosis. Computer tomography identified a bleeding in the left frontal lobe. A bleeding angioma was suspected and an operation was performed. The histological examination could not reveal an exact diagnosis. Eight months after complete recovery from the first bleeding, the patient had a second intracranial temporo-occipital bleeding on the right side which has been removed operatively. A new lesion was seen in the left parietal white matter of the brain. A growing cavernoma was suspected and resection of the lesion was planned. Pre-operatively the patient suffered from hemoptysis and fever. The X-ray of the chest showed a pulmonary lesion in the left lower lobe. In the CT of the chest a large tumor in the left lower lobe of the lung and additionally a cystic structure in the mediastinum was seen. The histological examination of this tumor identified an inflammatory myofibroblastic tumor (IMT). The left parietal lesion has been resected after the thoracic operation. The brain lesions were estimated to be metastases of the IMT of the lung. In the further clinical history the patient developed a large spinal cord metastasis of the thoracic spine. The metastatic development of the tumor reported in this case is unusual. The current therapy of these tumors consists of complete tumor resection and further clinical controls. However, due to the localization and the extension of some lesions in the present case, the complete resection has not been possible. There is no proven role of chemotherapy and radiation therapy. The patient died due to the pulmonary deterioration.