Genetic assessment of familial and early-onset Parkinson's disease in a Greek population

BACKGROUND AND PURPOSE

Although the first mutation associated with Parkinson's disease (PD) was identified several years ago in the alpha-synuclein (SNCA) gene in families of Greek and Italian ancestry, a more systematic study of this and other known PD mutations has not been performed in the Greek population.

METHODS

A genetic analysis in 111 familial or sporadic with early-onset (≤50 years, EO) PD patients was performed for the presence of the A53T SNCA mutation. In separate subgroups of these patients, further mutations in the SNCA, LRRK2, Parkin, PINK1 and DJ-1 genes were searched for. Additionally, a subgroup of familial cases was analysed for mutations in the glucocerebrosidase (GBA) gene.

RESULTS

In total, five patients (4.5% of our whole population) were identified with the A53T SNCA mutation, two with a heterozygote dosage mutation and one with a heterozygote point mutation in the Parkin gene, and seven patients (10.3% of our familial cohort) with GBA gene mutations.

CONCLUSIONS

The A53T mutation in the SNCA gene, although uncommon, does represent a cause of PD in the Greek population, especially of familial EOPD with autosomal dominant inheritance. GBA mutations in the familial cohort tested here were as common as in a cohort of sporadic cases previously examined from the same centres. For the remainder of the genes, genetic defects that could definitively account for the disease were not identified. These results suggest that further Mendelian traits that lead to PD in the Greek population remain to be identified.

MTHFR C677T polymorphism modifies the effect of HRT on metabolic parameters in postmenopausal women

OBJECTIVE

To assess the interaction of the MTHFR C677T polymorphism with changes in lipid and glucose metabolism effected by oral hormone replacement therapy (HRT) in postmenopausal women.

METHODS

In this open-label, prospective, interventional study, parameters of lipid and glucose metabolism, as well as homocysteine, were assessed in 97 postmenopausal women at baseline and 1 year after the initiation of HRT. Participants were stratified into three subgroups, according to the MTHFR C677T polymorphism (wild-type: CC genotype; heterozygous: CT genotype; homozygous for the mutant variable: TT genotype).

RESULTS

The TT genotype was associated with an elevation of total and low density lipoprotein (LDL) cholesterol, while CT and CC genotypes were associated with a reduction of total cholesterol and LDL cholesterol after 1 year of HRT (p = 0.032 for total cholesterol and p = 0.002 for LDL cholesterol). Women with the TT genotype had higher glucose levels in contrast to women with the CC genotype who had lower glucose levels after 1 year of HRT (p = 0.011). Additionally, CC carriers under HRT had a significant elevation of apolipoprotein A1 levels (p = 0.018), contrarily to CT and TT genotypes.

CONCLUSION

While HRT was associated with favorable changes in lipid and metabolic parameters in carriers of the CC genotype, this effect was not evident in carriers of the T allele. The MTHFR C677T polymorphism may modify the effect of HRT on lipid and metabolic parameters in postmenopausal women.

The proinflammatory mediator's production from ischemic brain during carotid endarterectomy

AIM

The aim of the study was to determine the quantity of produced mediators of inflammation (cytokines and eicosanoids), during carotid endarterectomy (CEA), which are factors of ischemic damage of the brain.

METHODS

Two groups (A and B) of 15 patients each, with internal carotid backpressure >30 mmHg were operated in our institution. We did not use a shunt in Group A during CEA and group B was operated upon with a shunt. Plasma concentrations of Interleukin-1b (IL-1b), Thromboxane B2 (TXB2), Prostaglandin E2 (PGE2) and tumor necrosis factor-a (TNFa) were measured by enzyme-linked immunosorbent assay (ELISA) technique.

RESULTS

We measured gradual increase of levels of IL-1b and TXB2 during cross-clamping and during reperfusion in group A (P<0.05). The levels of TNFa increased only during reperfusion (P<0.05). The concentration of IL-1b and TNFa remained almost stable in group B, whereas the concentration of TXB2 reduced but not significantly (P>0.05). The levels of PGE2 remained stable in both groups.

CONCLUSION

We should consider the increase of proinflammatory mediators during carotid cross-clamping when no shunt is used. The critical concentration of these mediators that threaten the brain's vitality is not yet detected. However, the clinical significance of this is unclear, since there were no perioperative strokes.

Effects of buflomedil on skin blood flow in patients with type 2 diabetes mellitus without overt micro- or macroangiopathy

AIM

The aim of this study was to assess the effects of buflomedil on the peripheral microcirculation in patients with type 2 diabetes mellitus (T2DM) without overt micro- or macroangiopathy.

METHODS

Twenty-three patients with T2DM were randomly assigned to receive buflomedil 600 mg/day for six months (N.=12) or no medication (N.=11). Skin blood flow in the lower limbs was assessed at baseline and after 3 and 6 months using Laser Doppler. We measured the following laser Doppler parameters: volume, flow and velocity.

RESULTS

In patients treated with buflomedil, there was a significant increase in volume (P=0.039) and a trend for an increase in both flow and velocity (P=0.097 for both parameters). In contrast, significant decreases in volume and flow were observed in the control group (P=0.045 and P=0.027, respectively) whereas velocity did not change (P=0.150).

CONCLUSION

In conclusion, buflomedil appears to have a beneficial effect on the peripheral microcirculation in patients with T2DM.

Preoperative withdrawal of antiplatelet treatment in lower limb vascular patients prior to surgical management under epidural or spinal anaesthesia: an evidence based approach and systematic review

Antiplatelet drugs given to high risk patients for secondary prevention of cardiovascular disease are frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This is also the case for many patients undergoing lower limb vascular surgery via spinal or epidural anaesthesia. The aim of this study is to corroborate the clinician's decision for discontinuing or continuing the anti-platelet treatment in these patients perioperatively. We screened MEDLINE and Scopus (January 1980 - July 2007) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines according to Evidence Based Medicine rules. One randomized controlled trial, 2 meta-analyses, 1 prospective and 4 retrospective studies as well as 6 esteemed medical societies'" guidelines all conclude that there is no justification for the discontinuation of aspirin and NSAIDs prior to neuraxial anesthesia. However, for other antiplatelet drugs like ticlopidine, clopidogrel, abciximab, eptifabatide and tirofiban not enough data exist to support their continuation through the procedure. Therefore, their preoperative withdrawal is suggested 8 hours to 14 days prior, accordingly. The existing evidence does not justify the discontinuation of aspirin and NSAIDs before the intended procedure. Anesthesiologists and surgeons should be aware of the cardiovascular risks of withdrawal versus the non - evidence based benefit in hemorrhage complications.

Hemodynamic follow-up of iliofemoral venous thrombosis

AIM

The aim of this pilot study was to assess the venous hemodynamic changes after deep venous thrombosis (DVT) using air-plethysmography (APG) and to study the rate and magnitude of these changes in relation to those associated with the post-trombotic syndrome.

METHODS

Twenty limbs of 19 patients with acute iliofemoral thrombosis have been followed up with APG and Duplex scanning for 24 months. Patients were treated with anticoagulation and elastic stockings. The air-plethysmographic measurements of venous outflow and functional venous volume were measured on admission. These measurements, as well as venous reflux and calf muscle pump ejecting capacity, have been performer after one week, one month and 3, 6, 12, 18 and 24 months. The results were compared with similar measurements of 10 normal limbs and 10 post-thrombotic limbs with chronic venous ulcers. Duplex scanning was performed on admission, in six and 24 months.

RESULTS

Plethysmographic parameters showed a dramatic improvement in the first month, fast improvement after three months and slower improvement thereafter, with the exception of the development of marked venous reflux in five of the 20 limbs studied, in the first three months. Popliteal reflux was diagnosed in these limbs. Elastic compression protected the patent veins from overdistention and incompetence and contributed to the relatively good calf muscle pump function during the first year after DVT. By the end of the study no patient had post-thrombotic changes, but four patients needed elastic stockings in order to avoid edema.

CONCLUSIONS

The most important hemodynamic alterations occurred during the first three months after DVT. This is the crucial period during which conservative treatment needs to be improved. Further work is required in this field to study the effect of various newly emerging methods. The air-plethysmographic measurements described may become surrogate endpoints for testing different therapies.

The use of mice and rats as animal models for cardiopulmonary resuscitation research

Cardiopulmonary resuscitation (CPR) after the induction of cardiac arrest (CA) has been studied in mice and rats. The anatomical and physiological parameters of the cardiopulmonary system of these two species have been defined during experimental studies and are comparable with those of humans. Moreover, these animal models are more ethical to establish and are easier to manipulate, when compared with larger experimental animals. Accordingly, the effects of successful CPR on the function of vital organs, such as the brain, have been investigated because damage to these vital organs is of concern in CA survivors. Furthermore, the efficacy of several drugs, such as adrenaline (epinephrine), vasopressin and nitroglycerin, has been evaluated for use in CA in these small animal models. The purpose of these studies is not only to increase the rate of survival of CA victims, but also to improve their quality of life by reducing damage to their vital organs after CA and during CPR.

S-shaped ilio-mesenteric bypass in a young high risk patient

Symptomatic chronic mesenteric ischemia is a rare condition. Several surgical and endovascular techniques have been described, but treatment is individualized according to the conditions of each patient. We report a successful superior mesenteric artery revascularization by using an S-shaped retrograde polytetrafluoroethylene ilio-mesenteric bypass graft in a young overweight patient with a history of two abdominal vascular operations and several comorbidities.

Carotid artery disease in octogenarians: endarterectomy or stenting?

AIM

Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting (CAS) has emerged as a potential less invasive therapeutic alternative to patients who would otherwise be considered as high risk for open surgery. The aim of this review was to pool the most current studies of the growing body of literature in which outcomes of CEA or CAS are compared in octogenarians and non-octogenarians to determine the current safety and efficacy of these therapeutic procedures, due to a lack of randomized controlled trials.

METHODS

An electronic search of Medline, PubMed and Cochrane databases was supplemented by a review of bibliographies of relevant articles, as well as manual searches of relevant journals. Outcomes included 30-day stroke rate, death rate, combined stroke/death rate and myocardial infarction rate between octogenarians and non-octogenarians.

RESULTS

Randomized clinical trials or studies comparing CEA and CAS in the same study population were not identified. CEA and CAS outcomes, in octogenarians compared to younger cohorts, were evaluated in 10 and 5 studies, respectively. Analysis of data indicates no significant difference in adverse events reported in the two groups in the majority of studies of CEA, as opposed to the findings of CAS studies.

CONCLUSION

The current review supports the viewpoint that CEA remains the standard of care in octogenarians, towards which other procedures to prevent stroke should be compared. It also challenges the definition of the ''high-risk''/age blanket classification and suggests that until the longevity, safety and efficacy of CAS is established, wide applicability of CAS to such ''high-risk'' patients should be questioned and limited to ongoing controlled clinical trials.

Levosimendan improves the initial outcome of cardiopulmonary resuscitation in a swine model of cardiac arrest

BACKGROUND

Cardiac arrest remains the leading cause of death in Western societies. Advanced Life Support guidelines propose epinephrine (adrenaline) for its treatment. The aim of this study was to assess whether a calcium sensitizer agent, such as levosimendan, administered in combination with epinephrine during cardiopulmonary resuscitation, would improve the initial resuscitation success.

METHODS

Ventricular fibrillation was induced in 20 Landrace/Large-White piglets, and left untreated for 8 min. Resuscitation was then attempted with precordial compressions, mechanical ventilation and electrical defibrillation. The animals were randomized into two groups (10 animals each): animals in Group A received saline as placebo (10 ml dilution, bolus) + epinephrine (0.02 mg/kg), and animals in Group B received levosimendan (0.012 mg/kg/10 ml dilution, bolus) + epinephrine (0.02 mg/kg) during cardiopulmonary resuscitation. Electrical defibrillation was attempted after 10 min of ventricular fibrillation.

RESULTS

Four animals in Group A showed restoration of spontaneous circulation and 10 in Group B (P = 0.011). The coronary perfusion pressure, saturation of peripheral oxygenation and brain regional oxygen saturation were significantly higher during cardiopulmonary resuscitation in Group B.

CONCLUSIONS

A calcium sensitizer agent, when administered during cardiopulmonary resuscitation, significantly improves initial resuscitation success and increases coronary perfusion pressure during cardiopulmonary resuscitation.

Periodontal and atherosclerosis-induced diseases

AIM

This article reviews the available studies assessing the association between chronic inflammatory periodontal diseases with atherosclerosis-induced diseases, cardiovascular diseases, and their complications, using standard evidence based criteria.

METHODS

This study is based on a literature search using Medline medical database covering the period from 2001 to April 2006 and applying specific inclusion criteria. The authors reviewed randomized controlled trials, systematic reviews, narrative reviews and meta-analyses, which investigated the relationship of periodontal and cardiovascular diseases with clinically derived documentation. The critical evaluation of the studies was performed based on the Impact Factor of the journals, on which they were published.

RESULTS

On the basis of clinical aspects, the periodontitis-cardiovascular association was evaluated in 2 randomized controlled trials, 5 systematic reviews, 5 narrative reviews and 2 meta-analyses. The evidence linking periodontitis with an increased risk for cardiovascular disease and atherosclerosis is limited.

CONCLUSION

Current evidence supporting the causal, periodontitis-cardiovascular disease, association is weak. There is a clear need for new, well designed observational and intervention studies to confirm that thus far observed associations explore the validity of the associations in diverse populations, to establish whether they are causal in nature and determine potential benefits of periodontal intervention in reducing the risk for these medical conditions.

Comparative study of intravenous amiodarone and procainamide in the treatment of atrial fibrillation of recent onset

AIM

The aim of the present study was to compare the safety and efficacy of amiodarone and procainamide in the acute cardiology setting.

METHODS

The study population consisted of 223 patients with symptomatic atrial fibrillation (AF). After administration of digoxin for ventricular rate control, all patients who failed to restore sinus rhythm (SR) were randomized into 2 groups: group A (113 patients) were administered 300 mg amiodarone intravenously over 30 min and, in case of failure to restore SR, amiodarone of 20 mg/kg/24 h was administered intravenously. Group B (110 patients) were intravenously administered a bolus dose of 1 gm procainamide, at an infusion rate 50/mg/min, and, in case of failure to restore SR, 2 mg/min for the next 24 h.

RESULTS

The rate of cardioversion to SR was similar between amiodarone (81.4%) and procainamide (82.7%) (P=NS). Procainamide loading recorded faster cardioversion times than amiodarone loading (P=0.02), but there was no significant difference after that. Amiodarone caused a significant decrease on systolic blood pressure compared to procainamide for the first 18 h (P<0.001), and a significant decrease in the diastolic blood pressure for the first 6 h (P<0.001). Side-effects for either medication were sparse. The only real prognostic factor for successful cardioversion remains the size of left atrium.

CONCLUSION

Both drugs were equally effective in restoring SR, though procainamide acts quicker in the loading phase. Both medications are safe and side effects develop only in the maintenance phase.

Nuclear reprogramming and adult stem cell potential

Cell-based therapy may represent a new strategy to treat a vast array of clinical disorders including neurodegenerative diseases. Recent observations indicate that adult somatic stem cells have the capacity to contribute to the regeneration of different tissues, suggesting that differentiative restrictions are not completely irreversible and can be reprogrammed. Cell fusion might account for some changed phenotype of adult cells but it seems to be biologically irrelevant for its extreme rarity. Other experimental evidences are compatible with the hypothesis of wide multipotency of well-defined stem cell populations, but also with transdifferentiation and/or dedifferentiation. Further studies on nuclear reprogramming mechanisms are necessary to fulfil the promise for developing autologous cellular therapies.

Hepatocyte function during experimental use of a bioartificial liver

The aim of the present study was to compare the function of fresh versus cryopreserved hepatocytes in an experimental bioartificial liver system (BAL), especially designed to reproduce clinical parameters. Our BAL consists of a pump, a plasma reservoir, a membrane oxygenator, and a hollow fiber module loaded with 5 x 10(9) isolated porcine hepatocytes, either fresh (n = 5) or cryopreserved (n = 5). In the present setting, the system was isolated and perfused for 6 hours with recirculating plasma obtained from pigs with ischemic liver failure (toxic plasma). The following parameters were studied at 0 and 6 hours: oxygen consumption by the hepatocytes in the bioreactor, hepatocyte viability, as well as plasma concentrations of AST, LDH, ammonia, urea, and total bilirubin. MEGX concentrations were measured following injection of lidocaine into the system 30 minutes after initiation of plasma recirculation. Compared to cryopreserved cells, fresh hepatocytes showed higher viability at both time points studied (P <.05). Furthermore, during BAL sessions, ammonia levels were reduced while urea, AST, and LDH levels were increased with both preservation types (P <.05). Total bilirubin levels increased only during sessions with cryopreserved hepatocytes. After lidocaine administration, both fresh and cryopreserved hepatocytes were capable of producing MEGX; however, fresh-cell bioreactors produced significantly more MEGX at both 30 and 60 minutes after lidocaine administration. Oxygen consumption was significantly higher by fresh-cell bioreactors both before and after BAL use. In conclusion, hepatocytes in the BAL bioreactor showed preservation of important metabolic functions, when perfused with homologous toxic plasma. Fresh cells appeared to respond better than did cryopreserved ones.

Structural and optical characterization of pyrolytic carbon derived from novolac resin

The structural and optical properties of technologically interesting pyrolytic carbons formed from cured novolac resin and cured novolac/biomass composites were studied by X-Ray Diffraction Analysis (XRD), and Fourier Transform Infrared (FTIR), Raman and Photoluminescence (PL) spectroscopy. Pyrolysis of the cured materials took place at temperatures in the range 400-1000 degrees C. The most important weight loss, shrinkage and structural changes of pyrolyzed composites are observed at temperatures up to 600 degrees C due to the olive stone component. In the same temperature range, the changes in pyrolyzed novolac are smaller. The spectroscopic analysis shows that novolac pyrolyzed up to 900 ( degrees )C has less defects and disorder than the composites. However, above 900 ( degrees )C, pyrolyzed novolac becomes more disordered compared to the pyrolyzed composites. It is concluded that partial replacement of novolac by olive stone in the composite materials leads to the formation of a low cost, good quality product.

Mykotisches Aneurysma der infrarenalen Aorta

The mycotic aneurysms of the infrarenal aorta (MAIA) are extremely rare and the associated morbidity and mortality is very high. The classification of infected aneurysms considers four types: a) true mycotic aneurysms, b) secondary mycotic aneurysms due to bacterial arteritis, c) infected preexisting abdominal aortic aneurysms and d) post-traumatic infected false aneurysms. The prognosis of true MAIA’s is better than the other forms of infected aneurysms. The standard treatment includes the resection of the aneurysm and infectious surrounding tissues and the restoration of the flow using ex situ (axillobifemoral) bypass or in situ replacement with autologous vein or a rifampicine-bonded graft. We present a case of mycotic aneurysm of the infrarenal aorta and a brief discussion of the alternative treatments from the relevant literature.

'On-line' alterations of contralateral jugular blood gas profile during carotid clamping

The aim of this work was to record the metabolic status of the brain (pH, PCO(2) and PO(2)) during carotid endarterectomy (CEA), with the use of an intravascular multiparameter sensor (Paratrend 7) via retrograde catheterization of the contralateral jugular vein. Twenty-four patients with ASA grades II and III scheduled for CEA were included in the study. After induction of anesthesia, the contralateral internal jugular vein was punctured retrogradely and the sensor was introduced. During clamping, pH became persistently more acidotic (7.34-7.31; p < 0.05), PCO(2) was elevated (43.2-46.8 mm Hg; p < 0.05) while most of the patients showed a non-significant decrease in PjvO(2)/SjvO(2) (jv = jugular venous). Correlation with clamping time or stump pressure was not significant. Unclamping was followed by a short period (5- 9 min) of decrease in pH and elevation of PCO(2) (7.30-7.22; p < 0.05, and 48.0-52.5 mm Hg; p < 0.05, respectively). PjvO(2) was significantly elevated (51.8-58.0 mm Hg; p < 0.001) after the restoration of flow. The study suggests that local CO(2) creates conditions for compensation of flow after the application of a carotid clamp. We consider that this monitoring technique, after further validation, may provide useful information.

A survey of 14 computed tomography scanners in Greece and 32 scanners in Italy. Examination frequencies, dose reference values, effective doses and doses to organs

A survey of examination frequencies, dose reference values, effective doses and doses to organs involving 14 scanners from Greece and 32 scanners from Italy was carried out for the years 1999 and 2000. Examination frequencies per scanner and per year were found to be 3590 for Greece and 4520 for Italy. For the types of examinations considered, CDTI(W) and DLP measurements were taken. Also scan lengths used for the same types of examinations were monitored. For the same types of examinations effective doses were calculated by two methods, and it was found that their mean values ranged from 13.1 mSv for thoracic spine to 1.6 mSv for the brain examinations. From the data of the 14 Greek laboratories, doses to organs were calculated and it was found that the thyroid receives 50.2 +/- 19.8 mGy during a cervical spine examination while the gonads receive 17.8 +/- 6.9 mGy during a routine pelvis examination.

Screening transvaginal uterine ultrasonography for identifying endometrial pathology in postmenopausal women

BACKGROUND

During the last decade, transvaginal ultrasonography (TVS) has become a widely-used technique for the evaluation of endometrial histology. The purposes of this study were to compare transvaginal sonographic evaluation of the endometrium with histology obtained by endometrial biopsy in asymptomatic postmenopausal women and to determine whether screening transvaginal sonography might be useful in the evaluation of postmenopausal women.

MATERIALS AND METHODS

The study included 59 unselected asymptomatic postmenopausal women who attended the outpatients' clinic for annual cervical cytology at Ioannina University Hospital, Greece. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy.

RESULTS

In the 43 women with a histopathological diagnosis of normal endometrium/inadequate for assessment/atrophy, the mean endometrial thickness was 5.1 +/- 3.3 mm (range 0.8-13.8 mm) whereas the corresponding value in the 16 women with abnormal findings was 17.6 +/- 4.3 mm (range 9.4-24.6 mm) (p<0.001). If a 9-mm cut-off limit was used for endometrial thickness, the sensitivity, specificity and positive predictive value were 100%, 90.69% and 80%, respectively.

CONCLUSION

TVS is a sensitive test for determining endometrial disease in asymptomatic postmenopausal women. However, well-designed studies should be conducted, completed, analysed and validated before a mass-screening program using TVS is implemented.

Transvaginal uterine ultrasonography compared with endometrial biopsy for the detection of endometrial disease in perimenopausal women with uterine bleeding

BACKGROUND

Almost 70% of all gynecological consultations in perimenopausal women are related to irregular uterine bleeding. In this prospective study, we compared endometrial assessment by transvaginal ultrasonography (TVS) in perimenopausal women with irregular uterine bleeding to histological assessment and tested whether the TVS was effective as a diagnostic tool for the detection of endometrial pathology in these women.

MATERIALS AND METHODS

Eighty consecutive perimenopausal women complaining of irregular uterine bleeding participated in the study. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy. The ultrasonographic results were compared with the histological diagnosis obtained from the endometrial biopsy.

RESULTS

Sixty-seven out of 80 women (83.7%) had normal histological findings, whereas 13 (16.3%) had abnormal findings. No endometrial cancer was diagnosed in this cohort of women. In the 67 women with a histological diagnosis of normal endometrium, mean+/-SD endometrial thickness was 10.5+/-4.0 mm (range 4.0-18.5 mm), whereas the corresponding value in the 13 women with abnormal findings was 18.7+/-3.8 mm (range 13.5-22.5 mm). If a 13 mm cut-off limit was used for endometrial thickness, which would include all abnormal cases, the sensitivity, specificity and positive predictive values were 100%, 71.64% and 40.62%, respectively.

CONCLUSION

TVS can identify women with perimenopausal bleeding in which the likelihood of endometrial pathology is high and in which tissue sampling should be performed. Thus, TVS can be a primary method of selecting women with perimenopausal bleeding who must be further investigated with more invasive methods such as endometrial biopsy.

Incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm or occlusive disease

BACKGROUND

The aim of this study was to compare the incidence of abdominal and incisional hernias in patients with abdominal aortic aneurysm (AAA) versus patients with aortoiliac occlusive disease (AOD).

PATIENTS AND METHODS

The study included retrospectively 121 patients, who underwent elective aortic surgery due to AAA (n = 63) or AOD (n = 58) in the period between January 1998 and January 2000. The patients were examined for the presence of abdominal hernias upon admission, as well as for the development of incisional hernias on follow-up.

RESULTS

The incidence of inguinal hernias was significantly higher in the group AAA (21/6-33.3%) compared to the group with AOD (6/58-10.3%) (p < 0.01). The incidence of other abdominal wall hernias (umbilical, epigastric or miscellaneous hernias) was also significant higher in AAA group. Furthermore, the incidence of inguinal hernias was significantly higher in the subgroup of patients with an aneurysm diameter more than 6 cm (41.5% vs 18.2%, p < 0.05). The mean follow-up of the patients was 1.7 +/- 0.3 years. 7 cases of incisional hernia were noted in the AAA group (11.1%) and only 2 cases in the AOD group (3.4%) (p < 0.05). The size of the aneurysm had no influence on the incidence of incisional hernias in the AAA group.

CONCLUSION

We conclude that there seems to be an increased incidence of abdominal wall hernias as well as postoperative incisional hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease.

Screening transvaginal uterine ultrasonography for identifying endometrial pathology in postmenopausal women

BACKGROUND

During the last decade, transvaginal ultrasonography (TVS) has become a widely-used technique for the evaluation of endometrial histology. The purposes of this study were to compare transvaginal sonographic evaluation of the endometrium with histology obtained by endometrial biopsy in asymptomatic postmenopausal women and to determine whether screening transvaginal sonography might be useful in the evaluation of postmenopausal women.

MATERIALS AND METHODS

The study included 59 unselected asymptomatic postmenopausal women who attended the outpatient clinic for annual cervical cytology at Ioannina University Hospital Greece. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy.

RESULTS

In the 43 women with a histopathological diagnosis of normal endometrium/inadequate for assessment/atrophy, the mean endometrial thickness was 5.1 +/- 3.3 mm (range 0.8-13.8 mm) whereas the corresponding value in the 16 women with abnormal findings was 17.6 +/- 4.3 mm (range 9.4-24.6 mm) (p<0.001). If a 9 mm cut-off limit was used for endometrial thickness, the sensitivity, specificity and positive predictive value were 100%, 90.69% and 80%, respectively.

CONCLUSION

TVS is a sensitive test for determining endometrial disease in asymptomatic postmenopausal women. However, well-designed studies should be conducted, completed, analysed and validated before a mass-screening program using TVS is implemented.

Application of European Commission reference dose levels in CT examinations in Crete, Greece

The purpose of this study was to apply European Commission reference dose levels (EC RDLs) to routine CT examinations. The dosimetric quantities proposed in the European Guidelines (EG) for CT are weighted computed tomography dose index (CTDI(w)) for a single slice and dose-length product (DLP) for a complete examination. Patient-related data as well as technical parameters for brain, chest, abdomen and pelvis examinations were collected for four CT scanners in the Euromedica Medical Center. Computed tomography dose index (CTDI) measurements were performed on each scanner and CTDI(w), DLP and effective dose E were estimated for each type of examination for a random sample of 10 typical patients. Mean values of CTDI(w) had a range of 27.0-52.0 mGy for brain and 13.9-26.9 mGy for chest, abdomen and pelvis examinations. Mean values of DLP had a range of 430-758 mGy cm for brain, 348-807 mGy cm for chest, 278-582 mGy cm for abdomen and 306-592 mGy cm for pelvis examinations. Mean values of E were 1.4 mSv for brain, 10.9 mSv for chest, 7.1 mSv for abdomen and 9.3 mSv for pelvis examinations. Results confirm that the Euromedica Medical Center meets EC RDLs for brain, abdomen and pelvis examinations, in terms of radiation dose and examination technique. As far as chest examination is concerned, although CTDI(w) of each scanner is within proposed values, the DLP is consistently exceeded, probably because of the large irradiation volume length L. It is anticipated that a reduction of L, or product mAs, or their combination, will reduce DLP without affecting image quality.

Alterations in carbon dioxide release during abdominal aortic clamping for aneurysmal or occlusive repair

BACKGROUND

Application and removal of an infrarenal aortic clamp is associated with changes in oxygen consumption, especially when collateral perfusion is limited. Carbon dioxide production during abdominal aortic clamping is expected also to change. The aim of this study was to evaluate the alterations of CO2 release during abdominal aortic surgery.

METHODS

DESIGN

prospective study.

SETTING

University Hospital, Greece.

PATIENTS

17 patients undergoing abdominal aortic aneurismal (AAA) repair and 8 patients undergoing repair of aortoiliac occlusive disease.

INTERVENTION

intraoperative record or calculation of PaCO2, PetCO2, PECO2, VD, VDalv, and VCO2. Patients with aneurysms were randomly divided to have constant ventilation (group AA) or modified ventilation to preserve normocapnia (group AB) during clamping. Ventilation was kept constant in the occlusive patients group (group OD).

RESULTS

Patients with AAA showed a significant decrease of VCO2 during clamping and an elevation after unclamping in both groups (AA and AB), with no difference of statistical importance between them. During clamping, PetCO2/ PaCO2 ratio was decreased and VDalv was increased especially in group AA, while unclamping produced the opposite effect. Occlusive patients showed insignificant alterations.

CONCLUSIONS

Our results suggest that, the calculated alveolar dead space is only an indicator of the true V/Q in patients with AAA, because it is strongly dependent on the CO2 load to the lungs, which is markedly altered in the same period. The modification of ventilation during clamping based only on PetCO2 and not on arterial sampling, could possibly lead to hypercarbia in these patients.

Allicin release under simulated gastrointestinal conditions from garlic powder tablets employed in clinical trials on serum cholesterol

The failure of five recent clinical trials to show significant reduction in elevated serum cholesterol by a single brand of allicin-standardized garlic powder tablets is in contrast to many prior positive studies with the same brand. The hypocholesterolemic activity of garlic is mainly due to allicin, a compound that is produced by the acid-sensitive garlic enzyme, alliinase, only after tablet consumption. Therefore, the allicin-releasing ability of ten lots of these tablets--manufactured over the same years that the positive and negative clinical trials were conducted (1989-1997)--was determined under simulated gastrointestinal dissolution conditions, as defined by U.S. Pharmacopeia Method 724A. It was found that the older lots were more resistant to acid-disintegration (2.5 h vs. 1.3 h, P < 0.001) and that they released three times as much allicin (44% vs. 15 % of their potential, P < 0.001) as the newer lots. A second brand of tablets employed in a recent negative trial released no detectable amount of allicin, while a third set of tablets with high allicin release was used in a trial that gave positive effects. Hence, the persons involved in the recent negative clinical trials probably received considerably less allicin than did those in the older positive studies, possibly accounting for much of the discrepancy in the outcomes. In conclusion, clinical trials using garlic powder tablets to assess any effect of garlic that might be related to allicin, as most are, cannot be considered valid for garlic when the trial shows no effect, unless the expected allicin release from the tablets has at least been determined under standardized drug release conditions (USP 724A).

Evaluation of fetal heart monitoring in the first stage of labor

OBJECTIVE

To evaluate the usefulness of continuous electronic fetal heart rate (FHR) monitoring in the first stage of labor.

METHODS

A total of 814 pregnant women in labor without identifiable risk factors was divided into two groups. In group A (468 cases), continuous FHR monitoring began in the earliest phase of the first stage of labor (cervical dilatation < or = 4 cm), while in group B (346 cases) it began when the cervical dilatation was > 4 cm. Initial FHR tracings were normal in all 814 cases. The fetal monitoring findings were analyzed at 10-min intervals, and comparisons were made between the two groups concerning FHR findings and their correlation with the state of the newborns.

RESULTS

No significant difference was found between the two groups in the incidence of repetitive variable decelerations (1.9% and 1.7%, respectively); sporadic variable decelerations (9.2% and 8.7%, respectively); persistent repetitive late decelerations that resulted in Cesarean section (1.1% and 1.4%, respectively); or sporadic late decelerations (8.3% and 8.1%, respectively). One newborn from each group required intensive neonatal care.

CONCLUSIONS

The same tracing sufficiency of fetal stress was observed in the two groups. However, the manner of labor supervision in group B seemed to be more beneficial, because of greater maternal comfort, a lower necessity for personnel, lower consumption of cardiotocographic materials and the possibility of labor induction for more women. Since fetal monitoring is widely used, it is preferable to start continuous FHR monitoring when the dilatation of the cervix approximates 4-5 cm (second phase of the first stage of labor) without risk of fetal loss.

Patient dose, image quality and radiographic techniques for common X ray examinations in two Greek hospitals and comparison with European guidelines

The radiographic technique factors and the quality of each radiographic image for three common examinations (chest PA, pelvis AP and lumbar spine LAT) were compared with the European criteria and entrance surface dose (ESD) was measured for each radiograph in two Greek hospitals. The measurements were carried out using calibrated LiF thermoluminescence dosemeters. The patients were selected so that their weight was close to 70 +/- 10 kg and their height to 170 +/- 10 cm. Effective dose values were calculated using a PC-based Monte Carlo program. All four X ray rooms in the survey achieved mean doses well below the European reference doses. However the mean doses in the X ray rooms differed by a factor of about 3.

Intercomparison of TL dosimetry (DIMOND programme)

During DIMOND CA, a thermoluminescence dosimetry intercomparison has been performed, in order to ensure that all participants measure the same dose. After the calibrating and annealing procedures, 50 TLD pellets (in groups of five) of each participating country were sent to the coordinator to be irradiated with 'unknown' radiations (blind test). The irradiation conditions (8 different set-ups, one for each group of pellets per participant) were (i) one gamma irradiation (60Co), at air kerma in the range of 0.3 to 50.0 mGy, (ii) seven X ray irradiations, at air kerma in the range of 0.3 to 50.0 mGy, with tube potential in the range of 40 to 150 kV and a variety of filter combinations. Ten pellets (two groups) were used for background and transport dose evaluation. After measuring the TLDs, the participants sent the results to the coordinator for intercomparison. Irradiating set-up conditions, evaluated doses, as well as comparison of mean values with the 'true' nominal doses are presented and discussed.

Continuous contralateral jugular acid-base and blood gas monitoring during carotid endarterectomy

BACKGROUND

The aim of this study is to evaluate the intravascular multiparameter sensor Paratrend 7 (P7) for continuous acid-base and blood gas monitoring after retrograde jugular catheterization during carotid endarterectomy.

PATIENTS AND METHODS

We studied 11 patients with history of smoking (72.7%), coronary artery disease (72.7%), hypertension (100%), diabetes mellitus (55.5%) and TIA's and/or nondisabling stroke (90.9%). The contralateral internal jugular vein was punctured retrogradely and the calibrated P7 sensor was introduced. The sensor was removed after surgery. The P7 provides continuous graphical display of pH, pCO2, and pO2, while temperature, oxygen saturation, HCO3 concentration and base excess are displayed numerically.

RESULTS

Mean duration of carotid cross-clamping was 17.0 +/- 6.2 min. Mean stump pressure was 50.2 +/- 12.9 mmHg. Intraluminal shunting was not used in any operation. All sensors were easily inserted. During clamping, pH became persistently more acidic (7.31 to 7.28; p < 0.05), pCO2 was elevated (44.7 to 49.8 mmHg; p < 0.05) while, in the majority of the patients, there was a non significant decrease in pjvO2/SjvO2. Declamping was followed by a short period of decrease of pH and elevation of pCO2 reminiscent of wash out phenomena. PjvO2 was significantly elevated (53.8 +/- 5.2 to 59.0 +/- 5.8 mmHg; p < 0.001) after the restoration of flow. In one case, P7 was diagnostic for unsuccessful endarterectomy.

CONCLUSIONS

P7 is useful during carotid endarterectomy providing continuous and "on-line" information on brain metabolism. It is a simple and powerful technique, which should be further investigated.

Routine obstetrical ultrasound at 18-22 weeks: our experience on 7,236 fetuses

OBJECTIVE

This study aimed at examining the detection rate of congenital abnormalities by using routine ultrasonography at 18-22 weeks of gestation.

METHODS

The sample included 7,236 fetuses. A detailed sonographic examination was performed in each fetus and a neonatal evaluation or pathology examination was made to confirm the prenatal findings.

RESULTS

The total prevalence of fetal abnormalities in our sample was 2.24% (162/7,236). There were 29/162 (17.9%) fetuses with CNS abnormalities, 27/162 (16.7%) fetuses with gastrointestinal abnormalities, and 28/162 (17.3%) fetuses with urinary tract abnormalities. There were also 31/162 (19.1%) fetuses with cardiovascular abnormalities, 26/162 (16.0%) with malformation of the limbs and musculoskeletal system, and 21/162 (13%) fetuses with other various abnormalities. The overall sensitivity in detecting fetuses with congenital abnormalities was 80.25% (130/162). The sensitivity per system was 93.1% (27/29) for CNS, 45.2% (14/31) for cardiovascular system, 85.2% (23/27) for gastrointestinal system, 85.7% (24/28) for urinary system, 84.6% (22/26) for musculoskeletal system, and 95.2% (20/21) for the rest of the abnormalities detected. We performed 40 pregnancy terminations in the group of malformed fetuses. Among the fetuses considered as normal, 1.7% had chromosomal abnormalities.

CONCLUSIONS

The results indicate that routine sonographic examination at 18-22 weeks of gestation can detect the majority of congenital abnormalities. More experience is needed for the examination of the cardiovascular system, where the sensitivity was particularly low (14/31 or 45.2%).

Carbon tetrachloride modulates the rat hepatic microsomal UDP-glucuronyl transferase activity and membrane fluidity

Modulations in rat hepatic microsomal UDP-glucuronyl transferase activity have been observed during carbon tetrachloride (CCl4) poisoning, with a large decrease in the enzyme cooperatively and increase in the membrane fluidity, occurring 30 min after administration. The results strengthen the possibility that an increase in microsomal membrane fluidity may be an early key event in liver injury induced by CCl4.

Reduced dialysis of nitrofurantoin and hydrocortisone acetate from methylcellulose solutions

Factors affecting reduction in the permeation rate of nitrofurantoin and hydrocortisone acetate from methylcellulose solutions through a cellulose membrane were investigated. The factors evaluated were the effect of polymer agglomeration and whether the drugs formed a complex with the polymer. The influence of polymer agglomeration was evaluated by dynamic dialysis studies of nitrofurantoin dissolved in solutions of methylcellulose 400 cps, which agglomerates, and in methylcellulose 50 cps, which does not exhibit this behavior. Dialysis rates of this drug were measured as a function of polymer concentration, ionic strength, heating time prior to measurement, and temperature. The effect of polymer agglomeration on the permeation rates of hydrocortisone acetate was studied by varying the ionic strength of the drug-polymer solution. Complex formation studies were conducted for both drugs by the equilibrium dialysis method. Polymer agglomeration caused a substantial reduction in the dialysis rate of both drugs in methylcellulose 400 cps solutions. There was less reduction in the dialysis rate of nitrofurantoin with increased polymer concentration of methylcellulose 50 cps solutions, which was attributed to the increase in the bulk viscosity of the solution. There was no evidence of complex formation of the drugs with the polymers.

Colorimetric determination of penicillins and related compounds in intravenous solutions by nickel (II)-catalyzed hydroxamic acid formation

Solutions of ampicillin, carbenicillin, methicillin, oxacillin, penicillin G, and cephalothin in 5% dextrose were analyzed by nickel(II)-catalyzed hydroxylaminolysis. The reactions of these antibiotics were complete within 20 min at room temperature. Under the analytical conditions, molar absorptivities of the ferric-hydroxamate complexes ranged from 830 to 1005 liters/mole/cm. Coefficients of variation for the analysis of these antibiotics in 5% dextrose were typically less than 3% at concentrations of 1 mg/ml. Oxacillin was analyzed by the same method in normal saline and/or lactated Ringer solutions. The method also was applied to the analysis of chloramphenicol in aqueous solutions. Only ampicillin showed a significant decrease in concentration in 48 hr.

[Volvulus of the gall bladder. Report of one case (author's transl)]

A case of torsion of the gallbladder is presented. Torsion of the gallbladder is uncommon and should be remembered in right upper quadrant acute abdomens, especially in elderly, asthenic individuals.