Role of Contrast Enhanced Ultrasound (CEUS) in the Paediatric Population with Blunt Abdominal Trauma: A Prospective Study from a Single Center Experience for Paediatric Blunt Abdominal Trauma.

Aim:The aim of our study is to evaluate the diagnostic ability of contrast-enhanced ultrasonography (CEUS) in pediatric population with history of blunt abdominal trauma (BAT). Materials and methods: In an eight-year period (1/2012-1/2020), fifty-nine children (4-14 years old) were transferred to the Emergency Department with referred BAT. The initial imaging method was ultrasound scan (US). Thirty-two children were discharged in good condition 24 hours after their admission. The remaining 27, who had moderate to severe injuries and according to their laboratory tests and US results, were evaluated with CEUS and contrast-enhanced computed tomography (CECT). Results:Five children were confirmed with splenic injury, two with liver lacerations, one with liver lacerations and right kidney contusion, while in nineteen, no visceral pathology was found by US, CEUS and CECT. The CEUS and CECT were in complete agreement. On the contrary, unenhanced-US showed free peritoneal fluid in eleven children and possible parenchymal lesions in two children. In two of the patients with negative US-study, splenic contusions in CECT and CEUS were revealed. The CEUS study was also used as a follow-up method. Among the 27 patients, there were no adverse reactions from the CEUS contrast agent either at one-week and six-month follow-up, or after one-year period. Conclusion:Contrast-enhanced ultrasonography is an effective, easily performed, low cost and radiation free imaging method. It is ideal for both initial and follow up evaluation of trauma and thus, we encourage its usage in paediatric BAT cases.

Effects of anodal transcranial direct current stimulation on cognitive dysfunction in patients with progressive supranuclear palsy.

Progressive supranuclear palsy (PSP) is a tauopathy characterized by motor, neurobehavioral and disabling brainstem deficits. No disease-modifying therapeutic options exist. The therapeutic potential of transcranial direct current stimulation (tDCS) has been highlighted in studies on patients with other neurodegenerative diseases. Therefore, by drawing upon the limited tDCS literature on PSP, we conducted a pilot study in order to evaluate the effect of tDCS over motor and premotor cortex in patients with PSP, with a particular emphasis on cognitive dysfunction. Eight patients affected by PSP were included (4 males and 4 females with mean age 67.4±7.4 years, range: 55-80 years and mean disease duration: 4.6±3.3 years, range: 1-11 years). The mean Unified Parkinson's Disease Rating Scale Part III (UPDRS III) was 49±16.1 and the mean Hoehn & Yahr (H&Y) scale was 3.9±1 at baseline. All pharmacological treatments (L-dopa, pramipexole, rotigotine, rasagiline, amantadine) were maintained stable during the study. We aimed at evaluating along with the motor outcome (as it is reflected on a disease-specific rating scale), the post-tDCS cognitive status after the completion of the intervention. The clinical evaluation involved the PSP-Rating Scale, the UPDRS III and the Timed Up and Go test. Neuropsychological assessment focused on auditory-verbal memory and learning, episodic memory, visuo-motor coordination and speed of information processing, executive functions and verbal fluency (phonemic and semantic). Anodal tDCS was applied over primary motor and pre-motor cortices in 10 daily sessions. During the tDCS stimulation a constant current of 2 mA was delivered for 30 minutes. Clinical evaluations were performed at baseline, day 11, day 30 and at day 90. The PSP-Rating score (total and sections I & III) improved significantly on day 11 compared to baseline and similarly on day 30. A positive effect was also seen on action tremor. In addition to the global mental status improvement, patients showed increases in neuropsychological performance in the domains of visuo-motor co-ordination and processing speed, auditory-verbal learning, episodic memory,phonological and semantic fluency (access and retrieval from lexical memory, selective inhibition and lexical access speed). Our results suggest that tDCS has a beneficial effect on Progressive Supranuclear Palsy patients' bulbar and motor symptoms, cognitive dysfunction, as well as daily activities, which lasts beyond the duration of the treatment.

Contemporary antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: 1-year outcomes from the GReek AntiPlatElet (GRAPE) Registry.

UNLABELLED: Essentials The comparative efficacy and safety of antiplatelet agents in 'real life' is not clear. We recruited acute coronary syndrome patients receiving percutaneous coronary intervention. At 1-year follow-up, prasugrel offers better anti-ischemic protection than clopidogrel. Prasugrel and ticagrelor are accompanied by more frequent bleeding events. SUMMARY: Background The comparative efficacy and safety of antiplatelet treatment outside randomized trials is not clear. Objectives To investigate long-term efficacy and safety in 'real-life' acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI) with contemporary use of clopidogrel, prasugrel and ticagrelor. Methods In a prospective, observational, multicenter cohort study, 2047 patients were recruited into the GReek AntiPlatElet (GRAPE) Registry and were followed-up for 1 year for major adverse cardiovascular events (MACE, a composite of death, non-fatal myocardial infarction, urgent revascularization and stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] classification). Results Exposure to clopidogrel, prasugrel and ticagrelor by PCI occurred in 959, 363 and 717 patients, respectively. After adjustment, the rate of MACE (primary outcome endpoint) was lower in prasugrel-treated patients (4.4%) than in clopidogrel-treated patients (10.1%) (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.30-0.91), although not significantly different between ticagrelor (6.8%) and clopidogrel groups (HR, 0.78; 95% CI, 0.54-1.12). Any type of BARC-classified bleeding (secondary outcome endpoint) was more frequent in prasugrel-treated patients (51.2%) than in clopidogrel-treated patients (37.6%) (HR, 1.61; 95% CI, 1.33-1.95) and more frequent in ticagrelor-treated patients (56.9%) than in clopidogrel-treated patients (HR, 1.81; 95% CI, 1.55-2.10). An adjusted comparison between prasugrel and ticagrelor-treated groups did not reveal differences in any outcome measure. After adjustment, the death rate was more reduced by novel agents in comparison with clopidogrel (2.9% vs. 6.2%). Conclusions In ACS/PCI patients, prasugrel offered better anti-ischemic protection than clopidogrel, whereas use of both novel agents is accompanied by more frequent bleeding events.

Transcranial magnetic stimulation but not MRI predicts long-term clinical status in cervical spondylosis: a case series.

STUDY DESIGN: Case series. OBJECTIVE: To compare transcranial magnetic stimulation (TMS) and magnetic resonance imaging (MRI) findings between patients who underwent surgery for cervical spondylotic myelopathy and those with spondylosis who were not operated upon, and to correlate these findings with clinical functionality at follow-up. SETTING: Private practice. METHODS: Of 16 consecutive patients with cervical spondylosis 8 underwent surgery (group I) and 8 were treated conservatively (group II). We compared TMS and MRI findings between these groups and we correlated central motor conduction times (CMCTs) and MRI-measured sagittal and parasagittal diameters of the spinal canal at baseline evaluation, with clinical functionality at 2-year follow-up. RESULTS: Group I CMCTs at the lower limbs correlated significantly with modified-JoA 2 years post surgery (r=-0.71, P<0.05), but MRI-measured diameters did not. In group II baseline TMS was unrevealing, contrary to significant spinal stenosis disclosed by MRI. The condition of none of these patients deteriorated at 2 years. CONCLUSIONS: CMCTs at the lower limbs, but not cervical spinal canal diameters, correlate with long-term functional outcome following surgical or conservative treatment.

Docetaxel plus oxaliplatin in combination with capecitabine as first-line treatment for advanced gastric cancer.

OBJECTIVE: In the present phase II study, we evaluated the efficacy and safety of a docetaxel-oxaliplatin-capecitabine combination as a first-line treatment in patients with advanced gastric cancer. PATIENTS AND METHODS: A total of 27 patients (18 males) with histologically confirmed inoperable gastric adenocarcinoma were recruited. Docetaxel was given (50 mg/m(2) i.v.) on day 1 followed by oxaliplatin (75 mg/m(2) i.v.) also on day 1. Capecitabine (2,750 mg/m(2)) was given orally as two daily divided doses from days 1 to 7. Cycles were repeated every 2 weeks. All patients had measurable disease and 18 of them had a performance status (WHO) of 0. RESULTS: A total of 240 treatment cycles were administered. All patients were evaluable for toxicity. Four patients who discontinued treatment early (having received only 3 chemotherapy cycles) were included as non-responders in an intention-to-treat response analysis. Complete response, partial response, stable disease and progressive disease were observed in 4 (15%), 12 (44%), 3 (11%) and 8 (30%) patients, respectively. The observed response rate was 59%, and the disease control rate (complete response + partial response + stable disease) was 70%. At the time of analysis, 6 patients were still alive and the median survival was 18.0 months. The most common grade III/IV toxicities observed were neutropenia (5%), diarrhea (2%), palmar-plantar erythrodysesthesia (2%) and neurotoxicity (1%). All other toxicities were mostly of grade I/II and easily manageable. CONCLUSION: The combination of docetaxel, oxaliplatin and capecitabine in the described mode of administration represents a relatively active and well-tolerated regimen in patients with advanced gastric cancer and warrants further evaluation.

Short-term fluctuations of plasma NT-proBNP levels in patients with new-onset atrial fibrillation: a way to assess time of onset?

OBJECTIVE: The objective of this study was to characterise short-term kinetics of plasma amino-terminal pro-B natriuretic peptide (NT-proBNP) levels in patients with new-onset atrial fibrillation (AF) without heart failure. DESIGN: Prospective cohort study. SETTING: Emergency departments and inpatient services of three large community hospitals. PATIENTS: 31 consecutive patients with new-onset atrial fibrillation (<24 h before presentation) persisting at least 48 h, without evidence of heart failure. MAIN OUTCOME MEASURES: Plasma NT-proBNP levels were obtained at presentation and then 6, 12, 18, and 24 h after presentation. A final sample was obtained 48 h after onset of AF. RESULTS: Mean plasma NT-proBNP levels and 95% CIs (pg/ml) during the 48-h period following onset of AF were: 0-6 h: 636 (395 to 928), 6-12 h: 1364 (951 to 1778), 12-18 h: 1747 (1412 to 2083), 18-24 h: 1901 (1549 to 2253), 24-36 h: 1744 (1423 to 2066) and 36-48 h: 1101 (829 to 1373). Mean time to peak NT-proBNP levels was 16.7 (0.7) h; 29 patients reached their peak levels within 24 h. The mean peak NT-proBNP level was significantly higher than those obtained at 0-6 h and at 36-48 h after onset of AF (p<0.001 for both). There was no correlation between ventricular rate and plasma NT-proBNP levels during any time period after onset of AF. CONCLUSION: In patients with new-onset AF but no clinical or radiographic evidence of heart failure, plasma NT-proBNP levels rise progressively to a peak during the first 24 h and then rapidly fall. This pattern may serve as an aid to assess the time from AF onset.

The prognostic impact of allopurinol in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

Oxidative stress has been shown to increase after acute myocardial infarction and during coronary reperfusion. Allopurinol inhibits xanthine oxidase, an enzyme involved in reperfusion injury. In this study, 40 patients with ST elevation myocardial infarction and symptoms' onset 3-12 h, who underwent primary coronary intervention, were administered either allopurinol (loading dose 400 mg followed by 100 mg for 1 month--group A, 21 patients), or placebo (group B). Allopurinol resulted in a more effective ST-E recovery (P<0.05 for all comparisons) and lower peak values of troponin I (P=0.04), CPK (P=0.01) and CK-MB (P=0.03). After 1-month follow-up period, 13% lower incidence of major adverse cardiac events (P=0.002) was also observed in group A, whereas no significant differences in the EF were detected between the groups studied. In our study population, allopurinol administration was beneficial concerning tissue reperfusion, myocardial injury and clinical outcomes.

The diagnostic value of earlier and later components of Vestibular Evoked Myogenic Potentials (VEMP) in multiple sclerosis.

AIM OF THE STUDY: To evaluate the ability of VEMP to disclose spatial dissemination of Multiple Sclerosis. MATERIALS AND METHODS: Forty-six MS patients with auditory and/or vestibular symptoms were studied. Patients were divided in two groups. Group 1 included 24 patients with brainstem MRI findings, and Group 2 included 22 patients without MRI findings. VEMP and BAEP have been recorded and assessed. RESULTS: Abnormal p13n23 wave was observed in 50%, while unilateral absence or bilateral delay of the n34p44 in 43% of the patients. The overall diagnostic value considering abnormal cases suggested by both first and second VEMP waves was increased to 71%. Statistically significant differences revealed between patients and controls for p13 latency (p=0.018). The p13n23 was abnormal in 7 patients, although MRI scanning did not reveal brainstem lesions. In 9 out of 18 MS patients suffering from unilateral hearing loss, n34p44 was present in the unaffected ears and absent in the affected side, although p13n23 was normal. CONCLUSION: Abnormal VEMP imply the presence of lesions undetected by MRI neuroimaging, which verifies the diagnostic value of the method. Unilateral absence of n34p44 complex was related with sensorineural hearing loss, supporting the hypothesis that n34p44 is of cochlear origin.

A tumor-like manifestation of extrapulmonary tuberculosis in a hemodialysis patient.

Though pulmonary tuberculosis (TBC) remains the commonest clinical presentation, extrapulmonary TBC is an increasingly important clinical problem. Among the extrapulmonary sites, primary liver tuberculosis seems to be an extremely rare location. Fewer than 100 cases of TBC hepatic abscesses have been reported whereas most of them have been originated from other sites, usually the lung and the gastrointestinal track. Therefore, in the absence of any particular symptom this infrequent location may lead to a delayed or missing diagnosis. The present study reports the difficulties in early diagnosis of an extrapulmonary TBC case, as it happened to a 53-year-old man with diabetic nephropathy who started on regular hemodialysis for 5 months. In such "atypical presentations" the clinicians should bear in their mind the possibility of the TBC occurrence, which usually responds well to the conventional antituberculous therapy.

Using vestibular evoked myogenic potentials to localise brainstem lesions. A preliminary report.

BACKGROUND: Vestibular Evoked Myogenic Potentials (VEMPs) are saccular responses to acoustic stimuli. They can be recorded from the sternocleidomastoid muscle ipsilaterally to the stimulated ear. Their reflex arc includes the ipsilateral vestibular nuclei. OBJECTIVE: To determine the usefulness of VEMPs in localising brainstem lesions. METHODS: We used VEMPs, Blink Reflex (BR) and Brainstem Auditory Evoked Responses (BAERs) to evaluate six patients presenting with acute ischaemic or haemorrhagic brainstem lesions, or basilar dolichoectasia. RESULTS: MRI in patient one revealed a dorsolateral medullary infarct on the right. VEMP amplitude was reduced ipsilaterally. The R2 BR component was delayed bilaterally upon stimulation of the affected side. Patients two and three had suffered a left lateral lower pontine infarct and a right lateral lower pontine haemorrhage. In patients four and five, MRA revealed dolichoectasia of the basilar artery exerting pressure on the lower lateral pons. VEMP amplitude was reduced ipsilaterally. Patient six had an ischaemic lesion in the right upper lateral pons. The R1, R2i and R2c BR components were delayed ipsilaterally. BAERs waves IV and V were absent on the right. VEMPs were normal. CONCLUSIONS: VEMPs are affected by lesions of the lateral lower pons and upper medulla. Our results suggest that they may be a useful addition in the localisation of such lesions.

Octreotide: a therapeutic option for idiopathic intracranial hypertension.

PURPOSE: To study the effects of octreotide, a somatostatin analogue, in patients with Idiopathic Intracranial Hypertension (IIH). METHODS: We performed a prospective, open-label study of the effect of Octreotide on 26 patients with symptoms and signs of IIH, investigated by brain MRI and lumbar puncture. Octreotide was administered subcutaneously, at an initial dose of 0.3 mg/day; and was gradually increased until headache was relieved (upper-dose limit: 1 mg/day). Treatment with octreotide at 1 mg/day was administered for a maximum of six to eight months and afterwards the dose was gradually tapered. Patients were followed prospectively every month for three years. CSF opening pressure was measured before the treatment was started and again in the first follow-up examination, on month one. In all follow-up visits the presence of papilledema was evaluated by fundoscopy; visual fields and visual acuity were also examined. RESULTS: Overall 24/26 patients improved significantly (92%). Headache was relieved within days (1-10, median 7 days). Papilledema subsided in all 24 patients, in up to two months (35 to 68, median 45 days). Visual disturbances, initially presenting in 20 of our patients, improved in 18 (90%). The mean reduction in CSF pressure after treatment was 20.72A+/-10.7 cmH2O (range 2 to 48). Patients were followed for three years after cessation of treatment. No recurrence of papilledema, or any other symptoms, has been observed. CONCLUSIONS: Octreotide resulted in a significant and sustained improvement of IIH in our patients. These results suggest that it may be an effective alternative to existing treatments for IIH.

The role of breastfeeding and passive smoking on the development of severe bronchiolitis in infants.

AIM: Bronchiolitis is an acute infectious disease of the lower respiratory tract which causes the obstruction of bronchioles in children younger than 2 years. The aim of this study was to investigate the effect of passive smoking alone and in conjunction with breastfeeding on the severity of acute bronchiolitis in infancy and the duration of hospitalisation. METHODS: We studied 240 consecutive infants aged from 6 to 24 months (137 boys and 103 girls) median age 14 months, who required hospital admission for acute bronchiolitis at the Paediatric Department of Democritus University Hospital, Alexandroupolis, Greece. The outcomes of interest were the severity of bronchiolitis and the duration of hospitalisation. RESULTS: Among the entire cohort, 122 (50.8%) children presented a severe attack of bronchiolitis. In multivariate regression analysis adjusting for confounding factors, breastfeeding for less than four months (aOR=6.1, 95% CI=3.4-10.7), exposure to environmental tobacco smoke (aOR=2.2, 95% CI=1.1-3.6) and their combination (aOR=16.2, 95% CI=6.0-34.3) showed significant association with severe bronchiolitis and prolonged hospitalisation. Passive smoking did not increase the risk of severe bronchiolitis, when infants breastfed for more than four months (aOR=1.9, 95% CI=0.8-5.1). CONCLUSION: In conclusion, exposure to environmental tobacco smoke worsens the symptoms and the prognosis of bronchiolitis, while breastfeeding seems to have a protective effect even in children exposed to environmental tobacco smoke.

Pyloric duplication: ultrasound appearance.

This paper reports a case of pyloric duplication, an extremely rare abnormality usually discovered during infancy. Clinical findings involved mainly symptoms of obstruction and radiological evaluation included abdominal US, plain radiography and CT imaging. Pyloric duplication was diagnosed by US and confirmed by CT scans and surgery. This case shows that when the sign of two-layer pattern is present in US scans, a conclusive diagnosis for alimentary tract duplications can be reached and there is no need for further radiological evaluation.

Hypocalcemic heart failure in thalassemic patients.

Hypocalcemic cardiomyopathy in primary or secondary hypoparathyroidism is usually refractory to conventional treatment of cardiac failure. We report the case of a thalassemic patient with severe cardiac failure that might have been attributed to several factors, such as hemosiderosis, hypomagnesemia, and hypocalcemia, refractory to conventional cardiac therapy. Cardiac echocardiography showed impaired biventricular performance, and laboratory analyses revealed hypoparathyroidism due to hemosiderosis. When concomitant treatment of heart failure and calcium supplementation was initiated, correction of hypocalcemia resulted in clinical and laboratory improvement, providing strong evidence in support of our hypothesis about hypocalcemic myocardiopathy.

Neurophysiological monitoring of brainstem function in a patient with Wallenberg syndrome, using Vestibular Evoked Myogenic Potentials.

PURPOSE: We evaluated the use of Vestibular Evoked Myogenic Potentials (VEMPs) in the assessment of neural function, following medullary lesions. METHODS: A 54-year-old male presented with symptoms and signs typical of right lateral medullary (Wallenberg) syndrome. He underwent brain MRI and three successive neurophysiological investigations, which included VEMPs, Brainstem Auditory Evoked Responses (BAERs) and the blink reflex. RESULTS: VEMPs amplitude on the left (unaffected) side was 256.8 microv in the first investigation and remained approximately equal to that value in the following two ones. Their amplitude on the right (affected) side was 37.9 microv, 154.2 microv and 235.2 microv correspondingly. At the same time vertigo, diplopia and nystagmus gradually improved. Right blink reflex comprised a normal R1, but delayed R2 ipsilateral and R2 contralateral responses, which remained unaltered during the follow-up period. Brain MRI disclosed a right dorsolateral medullary infarct. CONCLUSIONS: VEMPs amplitude progressively increased, parallel to the improvement of vestibular symptoms. The blink reflex evolved differently, while BAERs were not affected. As the three evoked responses are mediated by separate neural circuits, they provide information on different aspects of brainstem function. Thus, VEMPs seem to be a useful method that complements existing ones in the assessment of brainstem lesions.

Transfusional hemosiderosis and combined chelation therapy in sickle thalassemia.

Although the indications for transfusions in sickle cell syndromes are well listed, and chronic transfusion has become practicable since the recent advances in chelation therapy have essentially eliminated the risk of secondary iron overload, multi-transfused, non-compliant to long-term chelation therapy patients confront the complication of iron overload and secondary hemosiderosis. In thalassemia major patients, combined therapy with desferrioxamine and deferiprone has maximized tissue iron removal and may reduce the overall occurrence of hemosiderotic heart failure. Despite this, safety and contradictions of chelating agents are still controversial. The aim of this report is to present the results of this combination in a long-term transfused sickle beta-thalassemic patient suffering from severe heart failure and liver dysfunction.

Reversal of heart failure in thalassemia major by combined chelation therapy: a case report.

In patients with thalassemia major (TM) who are non-compliant with long-term desferrioxamine (DFO) chelation, survival is limited mainly because of cardiac complications of transfusional hemosiderosis. Combined chelation therapy with DFO and deferiprone has maximized the efficacy of the therapy and reduced cardiological complications. The aim of this report is to present the results of this combination in a desperate case of heart failure.