The use of indocyanine green for lateral lymph node dissection in rectal cancer-preliminary data from an emerging procedure: a systematic review of the literature.

INTRODUCTION: Lateral lymph node dissection (LLND) for rectal cancer is still not a widely established technique owing to the existing controversy between Eastern and Western countries and the lack of well-designed studies. The risk of complications and the paucity of long-term oncological results are significant drawbacks for further applying this technique. The use of indocyanine green (ICG) near-infrared (NIR) fluorescence for LLND appears as a promising technique for enhancing postoperative and oncological outcomes. This review aims to evaluate the emerging role of ICG during LLND and present the benefits of its application. MATERIALS AND METHODS: Systematic electronic research was conducted in PubMed and Google Scholar using a combination of medical subject headings (MeSH). Studies presenting the use of ICG during LLND, especially in terms of harvested lymph nodes, were included and reviewed. Studies comparing LLND with ICG (LLND + ICG) or without ICG (LLND-alone) were further analyzed for the number of lymph nodes and postoperative outcomes. RESULTS: In total, 13 studies were found eligible and analyzed for different parameters. LLND + ICG is associated with significantly increased number of harvested lateral lymph nodes (p < 0.05), minor blood loss, decreased operative time, and probably decreased urinary retention postoperatively compared with LLND-alone. CONCLUSIONS: The use of ICG fluorescence during LLND is a safe and feasible technique for balancing postoperative outcomes and the number of harvested lymph nodes. Well-designed studies with long-term results are required to elucidate the oncological benefits and establish this promising technique.

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology.

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.

Primary fallopian tube adenocarcinoma: preoperative diagnosis, treatment and follow-up.

Preoperative diagnosis of fallopian tube carcinoma is difficult due to the rarity and silent course of this neoplasm. We present herein the case of a 58-year-old woman with primary fallopian tube carcinoma that was diagnosed preoperatively on the basis of a positive for adenocarcinoma Papanicolaou vaginal smear, repeated episodes of vaginal bleeding, negative endocervical and endometrial curettage, characteristic features on ultrasonography and elevated CA-125 levels. The patient was treated by total abdominal hysterectomy, bilateral salpigno-oophorectomy and omentectomy. Pathologic confirmation of primary serous papillary adenocarcinoma of the left fallopian tube was made. Peritoneal washings were positive for malignancy. FIGO stage was considered as IIIb and the patient received six courses of combined carboplatin-taxol chemotherapy. At two years from onset of therapy the patient underwent a modified radical mastectomy and lymphadenectomy because of primary carcinoma of the right breast. The patient was started on tamoxifen therapy, which she is still taking. At 60 months after initial surgery, the patient is alive and well. In conclusion, our study suggests an association between fallopian tube carcinoma and breast cancer and a good response of the patient to platinum-based chemotherapy.

Primary postpartum haemorrhage due to a large submucosal nonpedunculated uterine leiomyoma: a case report and review of the literature.

The complications of leiomyomas during pregnancy are very rare and can be divided into those occurring during pregnancy, at delivery and in puerperium. We present an unusual complication of large submucosal nonpedunculated uterine leiomyoma in puerperium. The patient was a 32-year-old woman, gravida 2, para 1, who was admitted to our department from a private maternity clinic with a considerable drop in haemoglobin 23 hours after delivery of a healthy boy. The placenta had easily and spontaneously delivered. On admission to our department her haemoglobin was 6.3 g/dl. Pelvic examination disclosed the presence of fresh blood clots in the vaginal vault. A circular firm structure, 12 by 12 cm, was noted within the external cervical os. This mass was immovable. Total abdominal hysterectomy without salpingo-oophorectomy was immediately performed and the patient's postoperative course was uneventful. In conclusion, in this patient the uterine leiomyoma obstructed the cervical os and prevented the passage of lochia resulting in haematometra, uterine atony and subsequent serious uterine haemorrhage. In such cases ostetricians and gynaecologists should proceed immediately with surgical intervention to avoid a life-threatening situation.

Action of 25 microg 17beta-oestradiol vaginal tablets in the treatment of vaginal atrophy in Greek postmenopausal women; clinical study.

PURPOSE: To evaluate the clinical efficacy and safety of intravaginal application of 25 microg micronized oestradiol in postmenopausal women from the Greek population suffering from symptoms related to vaginal atrophy. MATERIALS AND METHODS: 91 women suffering from vaginal dryness, vaginal itching and dyspareunea were treated with 25 microg 17beta-oestradiol vaginal tablets. The duration of treatment was 12 weeks. During the first two weeks the women inserted one vaginal tablet intravaginally once daily. Thereafter, the women inserted one tablet twice per week with at least a 3-day interval between treatments to maintain therapeutic response for ten weeks. Efficacy was evaluated by the relief of vaginal symptoms and safety by the concentrations of serum oestradiol (E2) and follicular-stimulating hormone (FSH). Pretreatment and post-treatment findings were compared and each patient served as her own control. RESULTS: The rates of symptoms of vaginal dryness, vaginal itching and dyspareunea showed statistically significant differences over the course of the trial (Cochran Q test, p < 0.001). No one complained of vaginal dryness and vaginal itching after four and six weeks of treatment respectively, while in one patient the sensation of dyspareunea remained constant after the fourth week of treatment. Despite the statistically significant increase in blood oestradiol levels in relation to baseline values (ANOVA model of repeated measures, p < 0.001), these levels were within the normal range for postmenopausal women. Also, serum FSH levels were statistically significantly reduced from 47.4 mIU/ml at entry into the study to 45.5 mIU/ml after two weeks of treatment (dependent samples t-test, p < 0.003), but were clearly within the postmenopausal range. CONCLUSIONS: The twice-weekly local single treatment with vaginal tablets containing 25 microg of 17beta-oestradiol was effective and safe for the relief of symptoms related to atrophic vaginitis in postmenopausal women from the Greek population.

Mucinous cystadenoma of the ovary with functioning stroma and virilization in pregnancy: a case report and review of the literature.

Virilization caused by ovarian tumors with functioning stroma during pregnancy is extremely rare and has been reported in many ovarian tumors. In mucinous cystadenomas with maternal virilization during pregnancy the stromal cells responsible for the hormone secretion resemble lutein or Leydig cells and have been referred to as luteinized stromal cells. We present a case of a 30-year-old, gravida 2, para 1, woman who presented at approximately the 38th week of pregnancy with features of virilization. At the same time, a cesarean section was performed because of fetal distress and a male weighing 3,030 g without any gross abnormalities was delivered. A large tumor of the right ovary was detected and a right salpingo-oophorectomy was performed. Histopathologically, the tumor proved to be a benign mucinous cystadenoma. Masses typically resembling lutein stromal cells or Leydig cells of the testes or ovarian hilus were found in the wall of the cyst below the mucinous epithelium. No crystalloids of Reinke were identified. The stromal component of the tumor was characterized as functioning stroma with luteinized stromal cells. The glandular mucinous epithelium showed focal positivity for human chorionic gonadotrophin. The cytoplasm of the luteinized stromal cells reacted strongly and diffusely with antiserum for vimentin. Also, the cytoplasm of the luteinized stromal cells showed focal intense positivity for synaptophysin, and focal mild positivity for human chorionic gonadotrophin. Staining results for oestrogen and progesterone receptors were negative. In conclusion, we present an unusual case of clinical virilization during pregnancy associated with an ovarian mucinous cystadenoma with functioning stroma. The virilizing manifestations disappeared after removal of the ovarian neoplasm, supporting the perception that the functioning ovarian stroma was responsible for the androgen production.

Prenatal diagnosis of congenital cystic adenomatoid lung malformation: case report and review of the literature.

Congenital cystic adenomatoid malformation of the fetal lung is an extremely rare developmental abnormality characterized by excessive overgrowth of the terminal respiratory bronchioles at the expense of the saccular spaces. We present a case of a 33-year-old, gravida 2, para 1, woman with congenital cystic adenomatoid lung malformation-type II diagnosed by ultrasound at the 20th week of gestation. On the right side of the chest an area with a maximum diameter of 18.5 mm and with small cystic lesions was recognized. The maximum diameter of the cysts was 0.5 cm. There were no other fetal abnormalities. The pregnancy was terminated and the postmortem examination confirmed the ultrasonographic findings. The cysts had the appearance of bronchiolus-like structures and were lined with cuboidal and columar epithelium. Distended alveoli were present, while the airways were normal in structure. No other congenital anomalies were found. In conclusion, in this study we describe the ultrasonographic and pathologic findings of an unusual case of congenital cystic adenomatoid malformation of the fetal lung.

[Monoclonal gammopathy and primary hyperparathyroidism. Apropos of 2 cases and review of the literature]. / Gammapathie monoclonale et hyperparathyroïdie primitive. A propos de deux observations et revue de la littérature.

Frequency of primary hyperparathyroidism (HP) is increased in neoplasia. Though uncommon, both HP and monoclonal gammopathy are not exceptionally associated as seen in a literature review reporting 24 observations. The mechanism of this association remains unclear but does not seems coincidental. Association of hypercalcemia with gammopathy does not suggest systematically malignant hypercalcemia and implies the search for hyperparathyroidism. The authors report two patients presenting respectively a multiple IgD myeloma and an monoclonal gammopathy of undetermined signification associated with a parathyroid adenoma.

[Ki-1 positive non-Hodgkin's lymphoma disclosed by mucocutaneous ulcerations and glomerulonephritis]. / Lymphome non hodgkinien Ki-1 positif révélé par des ulcérations cutanéomuqueuses et une glomérulonéphrite.

Malignant lymphoma particularly of T phenotype can be associated with specific or non specific cutaneous lesions. These cutaneous manifestations can occur at the onset of the disease being sometimes the revealing sign or they can appear during the course of the lymphoreticular malignancies. Glomerulonephritis was also described in lymphoma. Ki-1 positive large cell lymphoma was recently identified. A new case is reported with lymphadenopathy and intestinal localisation revealed by cutaneous and mucosal ulcerations principally in the mouth and a focal segmental glomerulonephritis with endo- and extracapillary proliferation. The absence of lymphoma in cutaneous and renal lesions and the clinical presentation support the hypothesis of paraneoplastic manifestations, may be related to a vasculitis.

[Implication of emergency departments in the regulation of public hospitalizations]. / Place des services d'urgences dans la régulation des hospitalisations publiques.

PURPOSE: Emergency departments become a useful way to access to hospital care. Since these last years difficulties of hospitalization, mainly of the elderly, after visit to the emergency department, are on the increase. CURRENT KNOWLEDGE AND KEY POINTS: Emergency departments are an important mode of recruitment for hospital units, 4 patients to 10 are hospitalized from emergency departments. The difficulties of hospitalization starting at the emergency department are more important for the elderly. Actually, there are 2 type of hospital care, planed and non planed care. The development of observation units specific to the emergency departments allowed to resolve some of these difficulties. But they are limited by their small number of beds and the duration of hospitalization below to 36 h. Some hospitals developed polyvalent emergency short stay unit to hospitalize patients who visited emergency department without necessity to give them a specialized care. FUTURE PROSPECTS AND PROJECTS: This situation must allow us to purpose a better regulation of hospitalizations which includes emergency departments in a network system including the different hospital ways of taking care. A downstream way of care adapted to the emergency hospitalizations would be developed. This could include the emergency department, the observation unit and the emergency short stay unit in interface with internal medicine and general medicine units, geriatric unit and specialized units, all of them will be included in a town-hospital care network.

[Zona in 50 patients infected by human immunodeficiency virus. Clinical manifestations and prognostic value]. / Zona chez 50 malades infectés par le virus de l'immunodéficience humaine. Manifestations cliniques et signification pronostique.

Between January 1981 and April 1989, 50 patients infected with HIV were examined for herpes zoster. Herpes zoster enabled HIV infection to be detected in 23 patients (46 percent). It had only one localisation (involving contiguous dermatomes) in 37 patients, two localisations in 6 patients, three or four localisations in 1 patient each, and was disseminated in 5 patients. Localisations were mostly thoracic and cervicofacial. Herpes zoster was treated with acyclovir in 29 patients. All patients, treated or untreated, recovered from herpes zoster, but 9 of them (18 percent) had sequelae: pain in 8 and hypoacousia in 1. Herpes zoster recurred once in 8 patients and twice in 2. Among the patients with AIDS related complex 20 percent developed AIDS after herpes zoster at one year and 30 percent at two years. Among all the patients, the proportion of deaths after herpes zoster was 13 percent at one year and 34 percent at two years.

[Morbidity and mortality from acute drug poisoning in France]. / Morbidité et mortalité par intoxications médicamenteuses aiguës en France.

In France, drugs are responsible for 40% of accidental poisonings in children and 80% of voluntary poisonings in adults. The annual incidence voluntary drug poisonings is evaluated at 4 per 1000 individuals. Their morbidity and severity have decreased considerably during the past 25 years. A toxic symptom is found in less of 50% of the cases. The fraction of patients hospitalized for drug poisoning mortality is low (0.1%), principally in adult voluntary poisoning. The benzodiazepins are responsible for 80% of the poisonings but they are much less toxic than barbiturates. The development of preventive actions and pharmacologic and toxicologic vigilance allowed to limit use of the most dangerous psychotropic drugs or to remove them from the market.

[Bacterial meningitis: factors related to the delay before appropriate antibiotic administration in the emergency department]. / Méningites bactériennes : facteurs associés au délai d'instauration d'une antibiothérapie adaptée aux urgences.

OBJECTIVES: We had for aim to check the appropriateness of our practices according to French guidelines (17th consensus conference, SPILF 2008) and to identify variables associated with the delay before appropriate measures were implemented. METHODS: Our retrospective observational study (2009-2011) focused on acute bacterial meningitis (ABM) in adults. Data was collected on a standardized questionnaire from medical charts and nurse reports. RESULTS: We included 31 adults presenting with ABM; 29 (93.5%) received ceftriaxone or cefotaxime in the emergency department. Indications for corticosteroids and brain imaging complied with guidelines in respectively 71.0% and 83.9% of cases. The median delays (IQR) were: admission/lumbar puncture (LP), 2h43 [1h09-5h57]; admission/antimicrobials, 3h21 [1h34-5h11]. The indication of suspected ABM in the admission letter was associated with earlier LP (P=0.01), and was almost significantly associated also with faster initiation of adequate antibiotic therapy (P=0.05). CONCLUSIONS: Suspicion of ABM mentioned in the admission letter was associated to a better management in the emergency department.

Prevalence of Barrett's esophagus in Northern Greece: A Prospective Study (Barrett's esophagus).

BACKGROUND: Barrett's esophagus(BE) is a premalignant condition associated with chronic gastro-esophageal reflux disease (GERD). As only a small proportion of BE progresses to malignancy, it is important to study BE prevalence to prevent adenocarcinoma. MATERIALS AND METHODS: Between January 2007 and December 2010, all consecutive individuals who underwent routine upper endoscopy were prospectively recruited. Patients referred for GERD were excluded from the study. Clinical and endoscopic data were collected. RESULTS: A total of 1,990 patients (mean age 47.48±13.4 years; 52.8% males) were included. Of them, 496 (24.9%) reported GERD. Erosive esophagitis (EE) was found in 221 participants (11.1%, 193 patients with LA grade A and 28 patients with LA grade B). Overall 31 of 1494 participants not reporting reflux symptoms (2.07%) suffered from silent GERD. BE was diagnosed in 75 participants (3.77%), four (5.3%) with long-segment BE and 71 (94.7%) with short-segment BE. Low-grade dysplasia was noticed in 1 patient with long-segment BE. Hiatal hernia (HH) was found in 196 patients (9.8%), and mean HH length was 3.22 ± 0.2 cm. BE was correlated to EE, GERD and the presence of HH (p= 0.0167, <0.001 and 0.017, respectively) whereas it was not associated with age, alcohol consumption and smoking (p= 0.057, 0.099 and 0.06, respectively). BE was not correlated with Helicobacter pylori infection (p=0.542). CONCLUSION: The prevalence of BE was 3.77% in a Greek population undergoing upper endoscopy not referred for GERD. Long-segment BE was very uncommon (0.2%) whereas 2.07% of patients not reporting symptoms suffered from silent GERD.

Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

Health-related quality of life in Greek chronic hepatitis C patients during pegylated interferon and ribavirin treatment.

UNLABELLED: Background - Aims: Chronic hepatitis C (CHC) can cause a series of neuropsychiatric symptoms, whereas the currently approved treatment for this disease often induces similar symptoms as well. The aim of the present study was to compare Greek CHC patients' health-related quality of life (HRQoL) with that of healthy controls, to identify any possible relationships between HRQoL and demographic and laboratory parameters and to study the fluctuation of HRQoL during therapy and follow-up. PATIENTS AND METHODS: Ninty nine patients with CHC and 91 healthy controls were enrolled in the study. ALT, viral load, HCV genotype, fibrosis stage by liver biopsy and BMI, were determined at baseline. All patients completed the SF-36 quality of life questionnaire, which was self-administered, before treatment. They were treated with pegylated interferon alpha2-a or alpha-2b and ribavirin for 24 or 48 weeks and evaluated in the middle of therapy, at the end and six months after treatment cessation. SF-36 questionnaire was also completed in each evaluation. RESULTS: Patients' HRQoL was found to be below that of healthy controls in all SF-36 scales before treatment. There was a significant negative association between history of drug abuse and general health and a positive association between age and mental health. Multivariate analysis revealed that history of drug abuse seemed to play a significant role in bodily pain and general health of patients, as well as age did in vitality and mental health. The course of patients' HRQoL showed that in the middle of treatment values in all SF-36 scales were below those of baseline and they returned to pretreatment levels at the end of therapy. However, at the end of the six month follow-up period, an improvement in almost all scales compared to baseline was noted. CONCLUSION: Our results showed that a) Greek CHC patients' HRQoL was worse than that of healthy individuals and fluctuated significantly during treatment b) A history of drug abuse and age can independently affect HRQoL c) During treatment values of HRQoL are worsened possibly due to interferon-a treatment and d) In the long-term treatment results in improvement of HRQoL.

Transfer of atopy following bone marrow transplantation.

BACKGROUND: Bone marrow transplantation is an optimal treatment of acute leukemia and aplastic anemia. Allergic manifestations in recipients long after bone marrow transplantation have been reported. A case involving transfer of atopy manifested as food allergy-induced-atopic dermatitis is reported. METHODS: The donor and the patient were investigated by prick tests and RAST to the same food allergens. Single blind, oral challenge to egg documented food allergy in the recipient. RESULTS: A 5-year-old boy without history of atopy developed severe atopic dermatitis after bone marrow transplantation from his HLA-identical sister for acute lymphoblastic leukemia. The patient's course had been marked previously by acute graft versus host disease and cytomegalovirus infection. Immunoallergic evaluation showed an exquisite sensitization to egg, peanut, and soybean. Total IgE was 6400 KIU/L. Concomitantly, the donor showed the same sensitizations. Absolute avoidance resulted in the regression of atopic dermatitis. Subsequently, new sensitization to wheat flour, Dermatophagoides pteronyssinus, birch, and plantain pollens was detected. The donor developed asthma. CONCLUSIONS: This case gives evidence of the transfer of sensitization from donor to recipient. The passive transfer of memory cells within the bone marrow inoculum is a possible mechanism. The current concept of allergy supports down regulation of Th1 cells to the benefit of Th2 cells. Additional deregulation induced by acute graft versus host disease, cytomegalovirus infection, and immunosuppression is possible.

Diagnosis and pathogenesis of the anaphylactic and anaphylactoid reactions to anaesthetics.

Immediate adverse reactions to anaesthetics have an immune mechanism in more than 50% of the cases. They are mainly due to muscle relaxant drugs. A prospective evaluation of tryptase, histamine and serotonin for diagnosing anaphylaxis to anaesthetics was performed over 2 years. The sensitivity of each marker was at 60-70% and it reached 80% when combining tryptase and histamine. Specific IgE have been already observed in serum from patients allergic to muscle relaxant, thiopentone, morphine, phenoperidine, propofol and radio-contrast media. However, the recent progress in the identification of drug epitopes by Sepharose-solid drug phase IgE radioimmunoassay has to be reconsidered as non-specific binding of hydrophobic drugs such as propofol to hydrophobic serum IgE has been observed recently in patients with drug allergy. In addition, association of drugs such as propofol and muscle relaxant may potentiate the mediator release by a non-elucidated mechanism.

Epstein-Barr virus lymphoproliferative disease of donor origin after kidney transplantation: a case report.

A case of an Epstein-Barr virus (EBV)-associated B lymphoproliferative disorder presented as a renal transplant obstruction is reported. The diagnosis was made from histology, immunohistochemistry, and EBV expression studies. Cytogenetic analysis showed the tumor to be of donor origin and revealed chromosomal translocation 46, XY, inv (1)(p35; q41), involving the EBV insertion site 1(1p35) and transforming growth factor beta 2(1q41) loci.