Dimitrios Dimitroulis

The Performance of Serum Inflammatory Markers for the Diagnosis and Follow-up of Patients With Osteomyelitis:

Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 109/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.

Associations between osteoprotegerin and femoral neck BMD in hemodialysis patients.

Numerous humoral factors are involved in the development of renal osteodystrophy, causing perturbations in bone mineral density (BMD) in patients with end-stage renal disease (ESRD). The RANKL/OPG cytokine system appears to mediate the effects of many of these factors on bone turnover, contributing to the pathogenesis of renal bone disease. The aim of this study was to evaluate the clinical and biochemical correlations of BMD measurements in patients on chronic hemodialysis. Fifty-four hemodialysis patients underwent measurement of BMD at the proximal femur and the lumbar spine (L2–L4). Intact parathyroid hormone (PTH), osteoprotegerin (OPG), sRANKL, and main bone biochemical markers were also measured in serum samples of all patients. BMD of the femoral neck was negatively correlated with OPG levels (r = 0.333, P = 0.014). OPG levels were significantly different among normal, osteopenic, and osteoporotic tertiles defined according to BMD of the femoral neck. The highest OPG levels were measured in the lowest T-score (osteoporotic) tertile and were higher than in the osteopenic and normal tertiles (P < 0.05). A threshold level for OPG at 21.5u2009pmol/l enabled the detection of osteoporotic patients with 76.5% sensitivity and 62.2% specificity. BMD values of trabecular bone-rich sites of the skeleton such as lumbar spine (L2–L4), trochanter, and Ward’ s triangle were inversely correlated with total ALP levels (P < 0.05). Hemodialysis patients with low BMD of the femoral neck demonstrated higher OPG levels than patients with normal BMD. Those with lumbar spine (L2–L4), trochanteric, and Wards triangle BMDs below the normal range presented higher total ALP levels. These results suggest that OPG and total ALP may be clinically useful markers in the detection of significant femoral neck and trabecular bone mineral deficit in hemodialysis patients, warranting further investigations.

Carotid ultrasound findings as a predictor of long-term survival after abdominal aortic aneurysm repair: a 14-year prospective study

PURPOSEnSeveral factors have been related to long-term survival after open abdominal aortic aneurysm (AAA) repair. The effect of carotid stenosis on outcome has not yet been examined. We performed an open prospective study to evaluate the prognostic significance of carotid stenosis on long-term survival of patients who had undergone elective operative repair of AAA.nnnMETHODSnTwo hundred eight patients who underwent elective open AAA repair in our department between March 1987 and December 2001 were included in the study. All patients were evaluated preoperatively with color duplex ultrasound (US) scanning of the carotid arteries, and were followed up with clinical examination and carotid duplex US scanning 1 month after the operation and every 6 months thereafter. Median duration of follow-up was 50 months (range, 5-181 months). Cardiovascular morbidity and mortality, as well as all causes of mortality, were recorded and analyzed with regard to traditional risk factors and carotid US findings.nnnRESULTSnTwenty-seven fatal and 46 nonfatal cardiovascular events were recorded. Both univariate and multivariate analysis showed that carotid stenosis 50% or greater and echolucent plaque were significantly associated with cardiovascular mortality and morbidity. Carotid stenosis was a stronger predictor of cardiovascular death than was ankle/brachial index. Age, hypercholesterolemia, coronary artery disease, and diabetes mellitus were also associated with higher mortality and morbidity from cardiovascular causes.nnnCONCLUSIONnPatients electively operated on for AAA repair and with stenosis 50% or greater and echolucent plaque at duplex US scanning are at significantly increased risk for cardiovascular mortality and morbidity. Carotid US can therefore be used to select a subgroup of patients with AAA who might benefit from medical intervention, including antiplatelet and lipid-lowering agents.

Telomerase expression on aortic wall endothelial cells is attenuated in abdominal aortic aneurysms compared to healthy nonaneurysmal aortas

OBJECTIVEnLinear chromosomes carry specific DNA structures at their ends called telomeres. The latter shorten with each successive cell division making their length a marker of cell age. Telomerase prevents such telomere attrition by adding back telomeric repeats at the telomere ends, thus playing an important role in cell aging. On the other hand, an abdominal aortic aneurysm (AAA) represents an age-related degenerative disorder. The aim of the present study was to investigate a potential correlation of telomerase expression with AAA formation.nnnMETHODSnAortic wall tissue samples were collected from 49 patients (mean age, 63.8 ± 4.4 years) with AAAs during open elective repair and from 24 deceased organ donors as controls (mean age, 60.5 ± 3.9 years). Telomerase expression on endothelial cells was detected by immunohistochemistry. Associations of telomerase positivity with AAAs and epidemiologic and clinical variables were investigated.nnnRESULTSnTelomerase expression was significantly decreased in patients with AAAs (11 of 49; 22.4%) compared to controls (19 of 24; 79.2%; P < .001). This association persisted after adjustment for age, gender, coronary artery disease (CAD), hypercholesterolemia, hypertension and smoking (odds ratio, 0.47; 95% confidence interval, 0.14-0.58; P < .01.).nnnCONCLUSIONnPatients with AAAs have attenuated telomerase endothelial expression compared to controls, implying a protective role of telomerase against AAA formation. Further investigation of pathways involved in vascular aging may contribute to elucidation of AAA pathogenetic mechanisms.

Current trends in platelet transfusions practice: The role of ABO-RhD and human leukocyte antigen incompatibility.

Platelet transfusions have contributed to the revolutionary modern treatment of hypoproliferative thrombocytopenia. Despite the long-term application of platelet transfusion in therapeutics, all aspects of their optimal use (i.e., in cases of ABO and/or Rh (D incompatibility) have not been definitively determined yet. We reviewed the available data on transfusion practices and outcome in ABO and RhD incompatibility and platelet refractoriness due to anti-human leukocyte antigen (HLA) antibodies. Transfusion of platelets with major ABO-incompatibility is related to reduced posttransfusion platelet (PLT) count increments, compared to ABO-identical and minor, but still are equally effective in preventing clinical bleeding. ABO-minor incompatible transfusions pose the risk of an acute hemolytic reaction of the recipient that is not always related to high anti-A, B donor titers. ABO-identical PLT transfusion seems to be the most effective and safest therapeutic strategy. Exclusive ABO-identical platelet transfusion policy could be feasible, but alternative approaches could facilitate platelet inventory management. Transfusion of platelets from RhD positive donors to RhD negative patients is considered to be effective and safe though is associated with low rate of anti-D alloimmunization due to contaminating red blood cells. The prevention of D alloimmunization is recommended only for women of childbearing age. HLA alloimmunization is a major cause of platelet refractoriness. Managing patients with refractoriness with cross-matched or HLA-matched platelets is the current practice although data are still lacking for the efficacy of this practice in terms of clinical outcome. Leukoreduction contributes to the reduction of both HLA and anti-D alloimmunization.

Novel rescue procedure for inferior vena cava reconstruction in living-donor liver transplantation using a vascular graft recovered 25 h after donors' circulatory death and systematic review

Liver transplantation is a lifesaving treatment for patients suffering from end‐stage liver disease. Rarely, acute congestion of the inferior vena cava (IVC) is being encountered because of tumor compression. MELD allocation does not reflect severity of this condition because of lack of organ failure. Herein, a patient is being presented undergoing urgent living‐donor liver transplantation (LDLT) with IVC reconstruction for a fast‐growing hepatic epithelioid hemangioendothelioma (HEH). IVC reconstruction using a venous graft recovered from a 25‐h after circulatory‐death prior transplantation became necessary to compensate severe venous congestion. Additionally, a systematic review of the literature searching MEDLINE/PubMed was performed. Protocol and eligibility criteria were specified in advance and registered at the PROSPERO registry (CRD42013004827). Published literature of IVC reconstruction in LDLT was selected. Two reports describing IVC reconstruction with cryopreserved IVC grafts and one IVC reconstruction using a deceased after‐circulatory‐death‐donor IVC graft were included. Follow‐up was at 12 and 13 months, respectively. Regarding the graft recovery in the setting of living‐related donation, this graft remained patent during the nine‐month follow‐up period. This is the first report on the use of a venous graft from a circulatory‐death‐donor, not eligible for whole organ recovery. We demonstrate in this study the feasibility of using a size and blood‐group‐compatible IVC graft from a cold‐stored donor, which can solve the problem of urgent IVC reconstruction in patients undergoing LDLT.

Primary Enteric-Type Mucinous Adenocarcinoma of the Urethra in a Patient With Ulcerative Colitis

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in men. Mucinous adenocarcinoma of the urethra is extremely rare, and its biologic behavior is poorly understood. We present herein a rare case of mucinous urethral adenocarcinoma in a male patient with longstanding ulcerative colitis and multiple sclerosis. The patient presented with a voluminous pelvic mass; core biopsy of the lesion demonstrated a mucus-producing adenocarcinoma. Given the patients history of subtotal colectomy, preoperative diagnosis was oriented towards a rectal stump adenocarcinoma. The patient underwent a pelvic exenteration: surprisingly, histology marked the prostatic urethra as the primary lesion site.

Giant pancreatic incidentaloma: Report of a case and literature review

INTRODUCTIONnAsymptomatic lesions of the pancreas, referred to as incidentalomas, have appeared with increased frequency in recent years. Giant incidentalomas have rarely been reported in the literature.nnnPRESENTATION OF CASEnWe report herein a rare case of a giant cystic pancreatic incidentaloma measuring 12.7cm×8cm, which was found in an otherwise healthy male patient during a routine genitourinary imaging work-up. The patient underwent a distal pancreatectomy and splenectomy; the pathology report demonstrated a giant serous cystadenoma of the body and tail of the pancreas.nnnDISCUSSIONnThe management of pancreatic incidentalomas is challenging. While solid lesions almost always warrant surgery, there is ongoing debate concerning the management of cystic lesions that are found incidentally in the pancreas and have no clinical manifestations.nnnCONCLUSIONnWe report herein an interesting case of a voluminous incidental cystic pancreatic lesion. The appropriate approach and the decision whether to operate or not in such cases can be puzzling to the physician.

The clinical significance of apoptosis and M30 expression in colonic cancer progression

Abstract Background/aim: The aim of this study is to identify the significance of M30, an early apoptosis indicator, in colorectal cancer and its liver metastasis. Patients and methods: The expression of M30 was immunohistochemically estimated at colonic and liver metastatic tissues of 66 patients. The results were correlated to clinical and pathological features of the tumors. Results: High expression of M30 was observed in 15.5% of cases. No metastatic tissue showed expression of M30, while stage D tumors (metastasis included) showed a statistic significant lower expression of M30, when compared to earlier tumor stages. Conclusion: Low expression of M30 implies the development of resistance mechanisms against apoptosis, facilitating the progression of colon cancer.

Living donor liver transplantation in a patient with hepatic epithelioid haemangioendothelioma using a vena cava graft obtained twenty-four hours after cardiac arrest

Aim-BackgroundLiver transplantation is an acceptable therapy in selective patients with hepatic epithelioid haemangioendothelioma (HEH) and has been reported in absent or limited extrahepatic disease. The purpose of this paper is to present an interesting case of a new surgical technique involving the use of an inferior vena cava graft from a 24-hour deceased donor in a patient who underwent liver transplantation from a living donor.Case report-MethodsWe describe a 45-year-old woman with rapidly growing HEH and tumour involvement of all hepatic veins with obstruction of the inferior cava. The patient underwent living donor liver transplantation (LDLT). In view of the need for urgent liver replacement and the lack of banked vessels, we used a cava graft obtained from a blood-group matched man, who died twenty-four hours prior to LDLT. His cadaver was temporarily cold and stored in the Department of Pathology prior to his funeral. The recipient was put on mTOR inhibitor and carefully monitored.ResultsThe cava interpolate remained uneventfully open. Six months after surgery, the patient developed an asymptomatic partial thrombosis of 30% at interpolation which was treated with low molecular weight heparin. Eighteen months after the initial operation, the patient died due to diffuse disease recurrence.ConclusionsFollowing a review of the literature, this case emerges as the first description (new technique) of the use of a venous graft derived from a stored human cadaver, twenty-four hours after cardiac arrest. Questions arise as to whether the solution to technical surgical problems is the only safe and effective parameter in achieving the best treatment modality for similar cases.