A Hybrid Approach That May Facilitate the Repair of Traumatic Popliteal Artery Pseudoaneurysms.

PURPOSE: Traumatic popliteal pseudoaneurysms may occur in accidents or as an iatrogenic complication of a total knee arthroplasty. Complications often arise in open repair because of distorted anatomy. Up to 22% of the patients may suffer above-knee amputation. Endovascular treatment has proven to be an effective solution. However, the long-term performance of stents at the hinge point of the popliteal artery is questionable. We present a hybrid technique that was used successfully in 2 cases. TECHNIQUE: Our approach takes advantage of both open and endovascular techniques. At first, we apply a stent graft at the side of the injury to cover the arterial trauma and stop blood leakage to the aneurysm sac. This allows for a safer dissection and open repair. We clamp the artery proximally and distally, open the sac, extract the stent graft, and extend to a longitudinal arteriotomy. We then reconstruct the entire area with a standard in lay end-to-end anastomosis using a vein graft. This hybrid technique may reduce the risk of uncontrollable bleeding and allow for a safer nerve decompression. CONCLUSIONS: Repair of such injuries is technically demanding. A hybrid approach may reduce the risk of complications and offer excellent long-term outcomes. CLINICAL IMPACT: The hybrid approach to the treatment of traumatic popliteal pseudoaneurysms combines the advantages of both open and endovascular approaches. It may be possible to make an acute operation just as safe as an elective operation by implementing the proposed strategy. The procedure can be performed by surgeons of all levels, and patients may benefit from a safer surgical dissection with fewer complications and blood loss. This smart combination of standard techniques may prove invaluable in a hostile surgical environment where limb loss is likely.

Conservative treatment vs thrombus removal for Iliofemoral vein thrombosis in patients with congenital abnormalities of the inferior vena cava: a case report and systematic review of the literature.

Congenital abnormalities of the Inferior Vena Cava (IVC) should be suspected in cases of Deep Venous Thrombosis (DVT), especially in young patients, with no other risk factors and apparent causes. Currently, there is no guidance regarding the management of such patients. We report a case of Iliofemoral vein thrombosis in a young patient with congenital absence of the IVC that was successfully treated with catheter-directed thrombolysis (CDT) and perform a systematic review of the literature to identify evidence about the epidemiology, clinical presentation, management, and prognosis of this rare cause of DVT. A total of 42 studies reporting on 56 cases were included in the review. The mean age of the patients at the presentation of their first DVT episode is 23.6 years, 83.9% of patients were males, conservative management with anticoagulation was used in 68% of the reported cases, and thrombolysis was used in 32% of the cases. Only 10.7% of patients presented with PE potentially justified by the abnormal anatomy of the deep veins which makes the propagation of thrombi into the pulmonary arteries less possible. Comparing the long-term outcomes of the two treatment groups; 42.3% of the patients treated conservatively vs 15.4% of the patients treated with thrombolysis developed chronic symptoms (residual heaviness, pain, swelling, and cramping). 11.5% of patients who received conservative treatment developed post-thrombotic syndrome. None of the patients treated with thrombolysis developed post-thrombotic syndrome. There were no procedure-related complications and thrombolysis was well tolerated by the entirety of the thrombolysis treatment group. Recurrence of DVT occurred in 13% of the patients treated conservatively and in 7.7% of patients treated with thrombolysis. Thrombus removal by means of thrombolysis is the recommended treatment and can offer excellent short and long-term results. Anticoagulation with NOACs may be prescribed for life to prevent recurrence or for at least 6 months and then reconsidered following further evaluation of patients' bleeding risk. It may be of value to organise an international registry for such patients. Guidelines issued by the relevant scientific societies will then be able to make a clear recommendation about the management of such patients.

Hypogastric Preservation Using a Retrograde Endovascular Bypass in a Patient with Ruptured AAA and Concomitant Bilateral Common Iliac Aneurysms: A Feasible Option in the Acute Setting.

Preservation of the hypogastric circulation is of major clinical importance in cases of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Pelvic ischemia can be detrimental and significantly increase post-operative morbidity and mortality. However, the application of a side branch device or a bell-bottom graft is not possible in ruptured aortoiliac aneurysms (due to off-the-shelf unavailability and/or prolonged operative time) and in most cases pelvic circulation may have to be sacrificed. We report a case of a rAAA with bilateral common iliac artery (CIA) aneurysms that was successfully repaired with an aorto-uni-iliac (AUI) endograft, a cross-femoral bypass, and an inverted-U shaped contralateral EIA to IIA endovascular bypass. The procedure is described in detail and certain technical points are further discussed. The steps in cases where the aneurysm has ruptured are different compared to elective repairs and vascular surgeons need to be aware of certain pitfalls. This strategy may be feasible in the acute setting and permits preservation of the hypogastric circulation with the combination of standard techniques and grafts that are readily available in most institutions.

Carotid Endarterectomy Using a Flow-Reversal Technique in the Acute Period: A Novel Approach That May Reduce Intraoperative Cerebral Events.

Lesion manipulation during internal carotid artery (ICA) surgical dissection is the most crucial stage of carotid endarterectomy (CEA); a friable part of the carotid plaque or a thrombus may detach from the arterial wall, leading to cerebral embolism. Proximal protection devices used in carotid artery stenting reverse the blood flow to the brain eliminating, at least after their deployment, the chance of cerebral embolism. Based on the working principle of these devices, we propose a new approach to CEA making use of a flow-reversal technique, and we report its successful application in 2 high-risk patients with a soft and friable type 4 ICA plaque: a 62-year-old male patient presenting with crescendo transient ischemic attacks and a 61-year-old male patient presenting with a major stroke. Both were operated in the acute period. Once the reverse flow has been established, the surgeon can freely manipulate the carotid and perform a fast blunt dissection without the risk that the disturbance of the arterial wall may lead to cerebral embolism. A video recording of the procedure has been made and presented with this article. Despite the various limitations, including increased clamping time, transient intolerance to reverse flow, and increased blood loss, this technique may improve clinical outcomes, especially in symptomatic patients with friable plaque. A clinical trial is warranted to further study the results of the flow-reversal CEA.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review.

BACKGROUND: Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication. METHODS: A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded. RESULTS: In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery. CONCLUSIONS: Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.

Endovascular management of infected iliofemoral pseudoaneurysms - a systematic review.

We conducted a systematic review regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. 35 cases were identified, including 5 own. 22 pseudoaneurysms were located in the femoral area and 13 in the iliac vessels. The most commonly reported complaints were pulsatile groin mass (40 %), sepsis (37.1 %), active bleeding (31.4 %), and groin infection with purulent discharge (17.1 %). S. aureus (65.7 %) and Streptococcus species (22.9 %) were the most common microbes isolated. Factors for the development of infected pseudoaneurysms were intravenous drug use (20 %), infection of anastomosis in bypass surgery (22.9 %), cancer (14.3 %), history of multiple hip operations (14.3 %), renal transplantation (2.9 %), and obesity (5.7 %). The most commonly used covered stents were Viabahn (22.9 %),Jostent (17.1 %), Fluency (14.3 %), and Wallgraft (14.3 %). In 15 cases, surgical debridement and/or drainage was also performed.The mean follow-up was 15.8 months. There were only 2 cases of stent graft thrombosis (5.7 %). 2 patients required an open vascular bypass procedure at a later stage. One death was attributed to procedure-related complications (2.9 %). The infection rate of the deployed stent graft in follow-up was 3.4 %. Endovascular exclusion of an infected pseudoaneurysm with primary stent grafting and drainage may be an option in high-risk patients.
.

EndoVenous-assisted invaginated stripping of the great saphenous vein: A pilot and feasibility study.

Objective: By incorporating an endovascular component into Great Saphenous Vein stripping, EndoVenous-assisted Invaginated Stripping (EVIS) aims to make the procedure minimally invasive. A study was conducted to investigate the surgical intervention. Methods: Sketches and videos were used to illustrate the technical aspects of EVIS. A prospective cohort study included 20 patients with chronic venous insufficiency (CVI). Results: EVIS is performed as a day-surgery. Technical success was 100%, and no complications were recorded. The mean operative time was 45 minutes, intraoperative pain score was 4.8, post-operative pain was 2.5, 1.8, 1.2, 0.5 at 48 hours, 1, 4, and 12 weeks, respectively. The mean blood loss was 15 mL, and the mean length of the GSV strapped was 19 cm. The follow-up duplex showed a reduction in the diameter of the residual GSV stump. Conclusions: EVIS is a combination of standard techniques that may prove valuable in managing CVI.

Technology-assisted versus clamp-crush liver resection: a systematic review and meta-analysis.

OBJECTIVE: To review the published evidence on technology-assisted liver resection regarding operative time, intraoperative bleeding, mortality, hospital stay, postoperative bile leak, and other outcomes. METHOD: A systematic review of clinical studies comparing liver resection using vessel sealing systems (VSSs-LigaSure), Cavitron Ultrasonic Surgical Aspirator (CUSA), or radiofrequency dissecting sealer (RFDS) with the conventional clamp-crushing technique (CC) was performed. Data for each modality were synthesized and individually compared with CC with the methodology of meta-analysis. RESULT: In all, 8 randomized controlled trials (RCTs) and 7 nonrandomized studies evaluating 1539 patients were included. Compared with CC, the VSS group (3 RCTs and 3 nonrandomized studies) had significantly lower blood loss by a mean of 109 mL (weighted mean difference [WMD] = -109; 95% confidence interval [CI] = -192, -26; data on 494 patients), lower risk for postoperative bile leak by 63% (odds ratio [OR] = 0.37; CI = 0.17, 0.78; 559 patients), and shorter total hospital stay by 2 days (WMD = -2.04; CI = -3.08, -1; 340 patients); no difference was noted for liver parenchyma transection time and mortality. No difference was noted between CUSA (4 RCTs and 1 nonrandomized study) or RFDS (3 RCTs and 3 nonrandomized studies) versus CC for any of the studied outcomes. CONCLUSION: Of the 3 modalities used in liver resection (VSS, CUSA, and RFDS), only VSS appeared to offer significant benefit over standard CC. However, the generalization of our findings is limited by the scarcity and clinical heterogeneity of the published studies. Large, well-designed and implemented RCTs are warranted to further investigate the usefulness of novel modalities used in liver resection.

Adhesive strips for the closure of surgical incisional sites: a systematic review and meta-analysis.

BACKGROUND: The authors evaluated the available evidence regarding the use of adhesive strips for the management of surgical incisions and compared them with sutures and other closure materials. Study design. Systematic review and meta-analysis of randomized controlled trials (RCTs). RESULTS: Twelve RCTs studying 1317 incisions in 1023 patients were included. No difference was found regarding the development of infection (odds ratio [OR] = 0.47; 95% Confidence interval [CI] = 0.12-1.85), dehiscence (OR = 1.22; 95% CI = 0.32-4.64), and overall cosmetic result (standardized mean difference = 0.01; 95% CI = -0.19 to 0.20). Closure with strips resulted in significantly lower incidence of redness (OR = 0.57; 95% CI = 0.37-0.89). The available data on pain, need for resuturing, swelling, patient satisfaction, and closure time with the use of strips could not be synthesized; however, regarding the latter 2 outcomes, application of strips seemed favorable. There was significant heterogeneity among the studies. CONCLUSIONS: The findings suggest that adhesive strips may be an efficient closure material for certain small-length incisions. Further research is warranted on outcomes such as dehiscence and the need for resuturing.

Risk factors for mesh-related infections after hernia repair surgery: a meta-analysis of cohort studies.

Mesh infection, although infrequent, is a devastating complication of mesh hernioplasties. The aim of this study was to systematically review and synthesize the available evidence on risk factors for synthetic mesh infection after hernioplasty. A systematic search was performed in PubMed and Scopus databases. The extracted data were synthesized with the methodology of meta-analysis. We identified six eligible studies that reported on 2,418 mesh hernioplasties. The crude mesh infection rate was 5%. Statistically significant risk factors were smoking (risk ratio [RR] = 1.36 [95% confidence interval (CI): 1.07, 1.73]; 1,171 hernioplasties), American Society of Anesthesiologists (ASA) score ≥3 (RR = 1.40 [1.15, 1.70]; 1,682 hernioplasties), and emergency operation (RR = 2.46 [1.56, 3.91]; 1,561 hernioplasties). Also, mesh infections were significantly correlated with patient age (weighted mean difference [WMD] = 2.63 [0.22, 5.04]; 2,364 hernioplasties), ASA score (WMD = 0.23 [0.08, 0.38]; 1,682 hernioplasties), and the duration of the hernioplasty (WMD = 44.92 [25.66, 64.18]; 833 hernioplasties). A trend toward higher mesh infection rates was observed in obese patients (RR = 1.41 [0.94, 2.11]; 2,243 hernioplasties) and in patients operated on by a resident (in contrast to a consultant; RR = 1.18 [0.99, 1.40]; 982 hernioplasties). Mesh infections usually resulted in mesh removal, and common pathogens included Staphylococcus spp., Enterococcus spp., and gram-negative bacteria. Patient age, ASA score, smoking, and the duration and emergency setting of the operation were found to be associated with the development of synthetic mesh infection. The heterogeneity of the available evidence should be taken under consideration. Prospective studies with a meticulous follow-up are warranted to further investigate mesh-related infections.

At what age do biomedical scientists do their best work?

Several human characteristics that influence scientific research performance, including set goals, mental and physical abilities, education, and experience, may vary considerably during the life cycle of scientists. We sought to answer the question of whether high-quality research productivity is associated with investigator's age. We randomly selected 300 highly cited scientists (50 from each of 6 different biomedical fields, specifically immunology, microbiology, neuroscience, psychology-psychiatry, clinical medicine, and biology-biochemistry). Then, we identified the top 5 highly cited articles (within 10 yr after publication adjusted for the expansion of the literature) as first author of each of them. Subsequently, we plotted the distribution of the 1500 analyzed articles of the 300 studied scientists in the eight 5-year intervals of investigator's age during the year of article publication (21-25 to 55-60 yr of age), adjusted for person-years of contribution of each scientist in the various age groups. Highly cited research productivity plotted a curve that peaked at the age group of 31-35 yr of age and then gradually decreased with advancing age. However, a considerable proportion of this highly cited research was produced by older scientists (in almost 20% of the analyzed articles, researchers were older than 50 yr). The results were similar in another analysis of the single most cited article of each studied scientist. In conclusion, high-quality scientific productivity in the biomedical fields as a function of investigator's age plots an inverted U-shaped curve, in which significant decreases take place from around 40 yr of age and beyond.

Matching criteria in case-control studies in the field of antimicrobial resistance.

OBJECTIVE: We evaluated the available evidence from case-control studies in the field of antimicrobial resistance to identify the degree that matching was performed and the criteria used to do so. METHODS: We performed a systematic search of the PubMed database (articles archived by 08/2006) to identify relevant studies. Studies that used the individual matching technique were further analyzed. RESULTS: 115 case-control studies with a focus on antimicrobial resistance were identified: 28 regarding Acinetobacter baumannii, 25 regarding Pseudomonas aeruginosa, and 62 for other bacteria. Individual matching was performed in 32 (27.8%) out of the 115 studies. Age was the most frequently used matching criterion in 22 of 32 (69%) evaluated matched case-control studies, while sex was used in 11 (34%), presence of underlying illness in 8 (25%), site of infection in 5 (16%), and area of residence in 4 studies (12.5%). Other criteria were used in less than 10% of the studies. Analysis of data for matched pairs was performed in 18 of 32 (56.3%) studies that used a matched case-control design. DISCUSSION: The available evidence from the analyzed data from case-control studies in the field of antimicrobial resistance shows that individual matching is employed only in a proportion of such studies and only for a few characteristics, when it was used. Also, analysis for matched pairs was not used by almost a half of the relevant studies.

Bowel cleansing before bowel surgery: major discordance between evidence and practice.

Mechanical bowel cleansing (preparation) before colorectal surgery is commonly practiced, and medical care guidelines consent to this regimen. This has been an incontestable routine for surgeons for more than 100 years. However, during the last years, several randomized control trials and three meta-analyses led to the accumulation of enough evidence to conclude that no significant benefit is derived from this practice and thus, elective colorectal surgery can be safely done without mechanical bowel cleansing. Furthermore, several complications are attributed to mechanical bowel cleansing including anastomotic leakage, wound infections, and septic and non-septic complications that sometimes lead to the need for reoperation. Surgeons around the world may have to seriously reconsider the common practice of preoperative mechanical bowel cleansing. Despite the unquestionable practical value of mechanical bowel cleansing for bowel handling during anastomotic confection, we believe that current literature provides strong evidence that passed the line where this time-honored tradition may be finally called into question.

Epidemiology of constipation in Europe and Oceania: a systematic review.

BACKGROUND: We aimed to review the literature regarding the epidemiology of constipation in Europe and Oceania and the associated prevalence/risk factors. METHODS: Two reviewers performed PubMed searches and a hand search of references. A study was considered eligible for inclusion if it reported data about the prevalence of constipation in any population, free of other gastrointestinal disorders, in Europe and Oceania. Studies were evaluated for quality. Data regarding the setting, type of study, definition of constipation, study population, prevalence of constipation, factors associated with increased odds for constipation, and the female to male ratio, were collected. RESULTS: The 21 reviewed studies depict prevalence rates in 34 different population groups ranging widely from a low 0.7% to a high 81%. In the general population of Europe the mean value of the reported constipation rates is 17,1 % and the median value 16.6%. Among the studies conducted in Oceania, the mean value of constipation prevalence was 15.3%. Female gender, age and socioeconomic and educational class seem to have major effect on constipation prevalence. A number of various other risk factors are, less clearly, associated with constipation. CONCLUSION: This systematic review depicts the high prevalence and related risk factors of a disorder that decreases the health-related quality of life and has major economic consequences.

The top-ten in journal impact factor manipulation.

A considerable part of the scientific community is, at least to some degree, involved in the "impact factor game". Editors strive to increase their journals' impact factor (IF) in order to gain influence in the fields of basic and applied research and scientists seek to profit from the "added value" of publishing in top IF journals. In this article we point out the most common "tricks" of engineering and manipulating the IF undertaken by a portion of professionals of the scientific publishing industry. They attempt to increase the nominator or decrease the denominator of the IF equation by taking advantage of certain design flaws and disadvantages of the IF that permit a degree of artificial and arbitrary inflation. Some of these practices, if not scientifically unethical, are at least questionable and should be abandoned. Editors and publishers should strive for quality through fair and thoughtful selection of papers forwarded for peer review and editorial comments that enhance the quality and scientific accuracy of a manuscript.

Article and journal impact factor in various scientific fields.

BACKGROUND: We tried to provide the scientific community with data to answer the following simple question: What proportion of publications in the various scientific fields is published in journals with impact factor above the median and mean values of the distribution of journal impact factor? METHODS: We analyzed and compared the distribution of the impact factor data reduced to the unit of science publication, the article. We calculated the proportion of articles published in journals with impact factor above the journal mean impact factor, journal median impact factor, and article mean impact. RESULTS: For all categories examined, at the article level, the mean impact factor was higher than the median (by 13.7% to 500% for the various scientific categories). The mean impact factor of journals was considerably lower than the mean impact factor of articles (by 0.3 to 6.4 units). The proportion of articles that were published in journals with impact factor above the journals' median impact factor was well above 50% in 17 of 19 scientific fields examined (all except mathematics and computer science). SIGNIFICANCE: Our analysis shows that in most scientific fields examined, it is quite easier to publish an article in the top 50% of journals (based on impact factor calculations) than it is for the article to be included in the top 50% of published articles (based on the assumption made regarding the article' impact factor).

E-meducation.org: an open access medical education web portal.

BACKGROUND: Internet can serve in opening the door to a brand new world of high quality medical information. However, the chaotic size of data available in the WWW is often misleading. We sought to provide the world medical community with a web portal that may be used as a clearinghouse providing the outlet for dissemination of high quality WWW educational products. METHODS: Directories of the relevant WWW resources have been compiled and others are being currently under development to cover most medical fields. A custom-built medical search engine was created. Really Simple Syndication (RSS) feeds and video sharing services were reviewed for their quality and were presented along with case-based educational presentations through a user-friendly web portal interface. A directory of guidelines database is currently under development. RESULTS: The educational portal "e-meducation" available at http://www.e-meducation.org/ has been launched in December 2006 and at the moment, provides links to more than 800 educational web-pages, more than 2100 clinical practice guidelines, 32 news feeds, and 14 educational videos. The web site also hosts 40 case-based presentations and a custom medical search engine. CONCLUSION: Based on the incorporation of simple and tested educational strategies such as case based instruction and interactive learning, e-meducation.org aims to become a prototype platform that offers a more convenient interface to existing products, resources and medical contents.

Endovascular Management of Infected Iliofemoral Pseudoaneurysms: A Case Series.

The treatment of infected iliofemoral pseudoaneurysms is challenging and controversial. We present our experience regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. Our experience with 5 cases showed that stent grafting combined with antibiotic therapy and provisional drainage may be a safe and effective option in patients with cancer, patients with history of multiple hip revisions, and drug-addicted users. In our small case series, the reinfection rate was null and no covered stent thrombosis occurred. These results are fairly encouraging, but further studies with longer follow-up in a larger number of patients are needed to confirm the efficacy and durability of the technique.

Medical training in Greece: A crisis in progress.

OBJECTIVES: We sought to evaluate the opinions of medical students and graduates regarding the quality of medical education in Greece. METHODS: Two online questionnaires concerning the undergraduate medical education and specialty training respectively were distributed. RESULTS: Regarding the quality of undergraduate medical education, 52.1% of participants replied favorably while clinical training was found satisfactory by 45.1. Dissatisfaction rates with research opportunities and support from tutors reached 88.4 and 83.3%, respectively. The majority (75.3%) supported the introduction of examinations for commencing specialty training. 52.3% of physicians were satisfied with the quality of specialty training. The most common complaint was the absence of a formal educational program. 67.2% of participants were dissatisfied with working conditions during their specialty training, with 70.1% working >60 h per week. Physicians practicing medical specialties were more satisfied with the quality of specialty training than those practicing surgical specialties (odds ratio: 1.43; 95% confidence limits: 1.09-1.87) and were less likely to work for >60 h per week (odds ratio: 0.66; 95% confidence limits: 0.48-0.9). CONCLUSION: Opinions expressed in this survey highlight the need for reforming medical education in Greece.