Saliva cortisol levels and physiological parameter fluctuations in mild traumatic brain injury patients compared to controls.

BACKGROUND: Evidence suggests that fluctuations of cortisol and physiological parameters can emerge during the course of mild Traumatic Brain Injury (mTBI). OBJECTIVE: To investigate fluctuations of cortisol and physiological parametersduring the acute phase of mTBI in hospitalized patients. METHODS: 30 participants (19 patients with mTBI and 11 controls) were examined for saliva cortisol dynamics, heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP) and body temperature (BT) fluctuations for four consecutive days. Also, the participants completed the Athens Insomnia Scale and Epworth Sleepiness Scales, in order to check for sleep problems. RESULTS: Patients showed elevated levels of cortisol relative to controls (peak at 8 am and lowest levels at 12 am), as well as for most physiological parameters. MAP was significantly higher for patients throughout the measurement period, and BT was elevated for patients relative to controls at almost all measurements of the first and second day. Mean HR tended to track at non-significantly higher levels for the mTBI group. Patients' sleepiness and insomnia values (ESS and AIS) were initially significantly higher relative to controls but the difference dissipated by day 4. CONCLUSION: The increase in absolute values of cortisol and physiological parameters measurements, indicates that in the acute phase of mTBI, a stressful process is activated which may affect sleep quality as well.Supplemental data for this article is available online at at doi: 10.1080/00207454.2021.1951264.

Investigation of the Use of Circulating Long Non-coding RNA HOXA Transcript at the Distal Tip (LncRNA HOTTIP) as a Biomarker in Breast Cancer.

The critical need for new diagnostic and prognostic methods is highlighted by the fact that breast cancer continues to be the top cause of cancer-related deaths globally. Due to the dysregulation of long non-coding RNAs (lncRNAs) in numerous malignancies, they have become potential biomarkers in cancer. Recent research has focused on the lncRNA HOTTIP (HOXA transcript at the distal tip), which has a function in breast cancer metastasis and carcinogenesis. Until recently, HOTTIP had only been measured in cancer tissues and specimens. The aim of this study is to assess the amounts of the lncRNA HOTTIP in the blood serum of 46 breast cancer patients using real-time PCR analysis and identify the relationships between HOTTIP expression and several known clinical and pathological factors, including tumor grade, stage, lymph node involvement, hormone receptor status, and cell proliferation. The results of the study confirmed a positive relation of HOTTIP expression and breast cancer aggressiveness and metastatic behavior. The analysis results showed elevated HOTTIP values in stage III and T3/T4 tumors with multifocal characteristics and in lymph node involvement. Our findings raise the possibility of HOTTIP serving as a future prognostic biomarker for breast cancer patients.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy.

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery.

PURPOSE: To determine the perception of postoperative pain intensity between nurses and oncology patients undergoing major abdominal surgery. DESIGN: A prospective cross-correlation study with 173 oncology patients undergoing major abdominal surgery, such as hepatectomy or pancreatectomy. METHODS: Postoperative pain intensity was evaluated by clinical pain assessment tools such as critical-care pain observation tool (CPOT) and behavioral pain scale (BPS) recorded by the researcher, whereas the visual analog scale was completed by patients. Demographic and clinical data were recorded. FINDINGS: The Cronbach's α for CPOT and BPS was α = 0.738 for each. There was a significant correlation between CPOT and BPS (ρ = 0.796, P < .001), whereas the visual analog scale was correlated with CPOT and BPS (ρ = 0.351, P < .001 and ρ = 0.352, P < .001, respectively), showing that nurses did not underestimate patients' pain levels. CONCLUSIONS: The management of postoperative pain intensity after major abdominal surgery requires clinical comprehension by nurses to achieve the reduction or suppression of pain.

Phase II study of panitumumab combined with capecitabine and oxaliplatin as first-line treatment in metastatic colorectal cancer patients: clinical results including extended tumor genotyping.

This clinical trial assessed the efficacy and toxicity of panitumumab combined with oxaliplatin and capecitabine as first-line treatment in KRAS exon 2 wild-type metastatic colorectal cancer (mCRC) patients. Patients with exon 2 KRAS wild-type mCRC received panitumumab 9 mg/Kg, oxaliplatin 130 mg/m2, and capecitabine 2000 mg/m2 repeated every 3 weeks. The primary endpoint was objective response rate (ORR, minimum 42 responses). We retrospectively assessed mutations in genes implicated in CRC with massively parallel sequencing; ERBB2 and EGFR amplification with fluorescence in situ hybridization, and tumor-infiltrating lymphocyte density. Among 78 patients enrolled, 45 (57.7%) completed 6 cycles. Most common grade 3-4 toxicities were skin rash (19.2%), diarrhea (18%), and neuropathy (6.4%). Among 5 (6.4%) potentially treatment-related deaths, 2 (2.6%) were characterized toxic. Objective response occurred in 43 (55.1%) of the patients (complete 6.4% and partial response 48.7%; stable 17.9% and progressive disease 7.7%), while 3.8% were non-evaluable and 15% discontinued their treatment early. Additional mutations in KRAS/NRAS/BRAF were found in 11/62 assessable (18%) tumors. After 51 months median follow-up, median progression-free (PFS) was 8.1 and overall survival 20.2 months, independently of KRAS/NRAS/BRAF or PI3K-pathway mutation status. Patients with TP53 mutations (n = 34; 55%), as well as those with left colon primary tumors (n = 66; 85%), had significantly better PFS, also confirmed in multivariate analysis. Although the clinical trial met its primary endpoint, according to the current standards, the efficacy and tolerability of the drug combination are considered insufficient. Extended genotyping yielded interesting results regarding the significance of TP53 mutations.ClinicalTrials.gov identifier: NCT01215539, Registration date: Sep 29, 2010.

Fast-Track Recovery Program After Major Liver Resection: A Randomized Prospective Study.

The objective of this study was to compare fast-track (FT) recovery protocol with the conventional one in patients treated with major liver resection by evaluating perioperative morbidity, length of hospitalization, and readmission rate. Sixty-two patients suffering from malignant liver tumors were surgically treated from May 2012 to April 2014. After randomization, they were prospectively divided into two groups: Group A patients (n = 32) followed FT recovery protocol and Group B patients (n = 30) were treated with the conventional (CON) protocol. Postoperative morbidity, readmission rate, and median hospital stay in the two groups were studied. Fast-track protocol was associated with a decreased complication (25%, p = .002), whereas the risk of postoperative morbidity was 2.4 times higher in patients treated with the CON protocol (60%, p = .002). Readmission rate was not significantly different between the two groups (6.25%, p = .35). Age (p = .382) and body mass index (p = .818) were not a suspending factor for following the FT protocol. Overall length of stay (postoperative days) in the FT group was (mean ± SD) 5.75 ± .5 and in the CON group was 13.5 ± 6.7 (p < .001). Fast-track recovery protocol seems to be safe and particularly efficient in patients undergoing major liver resections.

Abnormal distance of the extralaryngeal bifurcation point of the recurrent laryngeal nerve from the cricothyroid joint.

The extralaryngeal bifurcation point of the recurrent laryngeal nerve (RLN) is typically located in a mean distance of 0-2 cm from the cricothyroid joint (CTJ). In the presented case though, the left RLN was unexpectedly identified bifurcating in a mean distance of 7 cm from the left CTJ in a young woman with multinodular goiter during total thyroidectomy. The RLN was carefully exposed throughout its course for the avoidance of iatrogenic injury of the nerval structure. The operation was uneventful. The present manuscript aims to highlight a scarce anatomic variation and its implications for thyroidectomy. Rare anatomic variations of the RLN such as the presented one encumber thyroid surgery and represent a severe risk factor of RLN injury. Meticulous operative technique combined with surgeons' perpetual awareness concerning this peculiar anatomical aberration leads to an injury-free thyroid surgery.

Superiority of the sonication method against conventional periprosthetic tissue cultures for diagnosis of prosthetic joint infections.

INTRODUCTION: Diagnosis of periprosthetic infections is challenging. The aim of this study was to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of sonication fluid of the explanted prostheses. METHODS: We prospectively enrolled 114 patients undergoing revision hip or knee arthroplasty because of loosening of the prostheses, at our institution, between July 2012 and July 2016. Patients' medical history and demographic characteristics were recorded. The explanted hardware was separated in sterile containers and sonicated under sterile conditions. At least five samples of periprosthetic tissue were sent for culture and histological examination. We compared the culture of samples obtained by sonication of explanted hip and knee prostheses with conventional culture of periprosthetic tissue for the microbiological diagnosis of prosthetic joint infection. RESULTS: Infectious Diseases Society of America guidelines were used for the definition of prosthetic joint infection. Sixty-one patients had periprosthetic infection and 53 aseptic loosening (73 hip prostheses and 41 knee prostheses). The sensitivity of sonication fluid culture was 77.04%, and the sensitivity of conventional tissue cultures was 55.73% (p value = 0.012). The specificities of the two methods were 98.11 and 94.34%, respectively. The sensitivity of the histopathological examination of the periprosthetic tissue was 72.10%. There were 17 patients with PJI where the isolated pathogen was detected in SFC but not in PTC, while in five cases the pathogen was detected only in PTC. There were nine patients where no bacteria were detected by any microbiological method and the diagnosis was based on clinical and histological findings, according to the guidelines. CONCLUSIONS: The sonication method represents a reliable test for the diagnosis of prosthetic joint infections with a greater sensitivity and specificity than the conventional periprosthetic tissue cultures.

Anomalous origin of the right colic artery from the right gastroepiploic artery during complete mesocolic excision: a rare case report.

Complete mesocolic excision (CME) is a standardized surgical procedure for colonic cancer that requires ample knowledge of the anatomical patterns of the colic arteries. Variations of the colic vessels encumber both surgical and endovascular techniques. In the presented case below, the right colic artery was incidentally detected emerging from the right gastroepiploic artery, during CME. Surgeons should be always aware of this variation in order to perform safe abdominal surgeries and sufficient resection of the regional lymph nodes with a view to minimizing the probability of recurrence of disease when encountering colonic cancer.

The ligament of Parks as a key anatomical structure for safer hemorrhoidectomy: Anatomic study and a simple surgical note.

Hemorrhoids are a common anal disorder which affects both men and women of all ages. One out of ten patients with hemorrhoidal disease, requires surgical treatment. Unfortunately though, hemorrhoidectomy is closely related to complications that can be present early or late postoperatively. In the present manuscript, the safe surgical technique which emphasizes to the identification of the key anatomical structure of the ligament of Parks (Trietz's muscle) is adequately described. A total of 200 patients with grades III and IV hemorrhoids, underwent Milligan-Morgan or Ferguson's hemorrhoidectomy. The mucosal ligament of Parks was identified to all patients and was used as a key anatomical structure through the excision of the hemorrhoids. Its identification guides surgeons during the operation and reduces the major problem of postoperative complications. Finally, since the mucosal ligament of Parks represents a constantly identifiable landmark, it allows simple and reliable identification of the internal sphincter muscle and minimizes the probability of postoperative complications.

Anatomic variation of the relation between the facial nerve and the retromandibular vein during superficial parotidectomy: A rare case report.

INTRODUCTION: Identification and preservation of the facial nerve (FN) is a major challenge when performing parotidectomy. Anatomic variations of the relation between the FN and the retromandibular vein (RMV) pose a high risk of nerve injury and bleeding during the operation. PRESENTATION OF CASE: An unusual anatomic variation of the relation between the FN and the RMV was unexpectedly detected during superficial parotidectomy. The operation was uneventful. A meticulous review of the recent literature was conducted as well. DISCUSSION: Variations of the relation between the FN and the RMV are mainly identified during the operation, since when performing parotidectomy, surgeons typically detect all the FN branches by locating the RMV. Such kind of variations, are not as rare as considered and their presence complicates parotid surgery and increases the potentiality of nerve injury and hemorrhage. CONCLUSION: Surgeons' deep knowledge and perpetual awareness concerning the probable anatomic variations of the relation between the FN and the RMV combined with detailed exposure of the operative field and of the relationship between these adjacent anatomical structures lead to safe parotid surgery.

Leiomyomatosis peritonealis disseminata: A case report and meticulous review of the literature.

INTRODUCTION: Leiomyomatosis peritonealis disseminata (LPD) is a peculiar benign clinical disorder characterized by proliferation of peritoneal and subperitoneal nodules. LPD is a difficultly diagnosed benign disease that rarely degenerates into malignancy. PRESENTATION OF CASE: A 40-year-old Caucasian female with vaginal bleeding proceeded to our institution for elective excision of abdominal and pelvic masses which were firstly considered as leiomyosarcomas. The histologic diagnosis of the mass lesions revealed smooth muscle benign cells. This is the first case of LPD reported in Greece. A meticulous review of the literature was conducted as well. DISCUSSION: The differential diagnosis of LPD is difficult due to its clinical resemblance with peritoneal carcinomatosis or metastatic lesions and with benign metastasizing leiomyoma (BML) as well. Etiological factors, pathophysiology and clinical manifestations which lead to a safe diagnosis of LPD are adequately described. CONCLUSION: Surgeons' thorough knowledge concerning this rare clinical condition is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate treatment and the minimization of the probability of malignant transformation of LPD.

Surgical anatomy of double pyramidal lobe on total thyroidectomy: a rare case report.

Double pyramidal lobe is a scarce anatomical variation of the thyroid gland. Its presence impinges on the completeness of total and subtotal thyroidectomy and the postoperative treatment. Surgeons should be always aware of this variation in order to perform sufficient resection of the thyroid gland and minimize the possibility of recurrence of benign and malignant thyroidopathies.

Prognostic Evaluation of Epidermal Growth Factor Receptor (EGFR) Genotype and Phenotype Parameters in Triple-negative Breast Cancers.

BACKGROUND: Epidermal growth factor receptor (EGFR) aberrations have been implicated in the pathogenesis of triple-negative breast cancer (TNBC) but their impact on prognosis and, therefore, druggability, remain controversial. Herein, we studied EGFR aberrations at different molecular levels and assessed their prognostic impact in patients with operable TNBC treated with adjuvant anthracycline-based chemotherapy. MATERIALS AND METHODS: We evaluated the prognostic impact of EGFR gene status by fluorescent in situ hybridization (FISH), EGFR coding mutations by Sanger and next-generation sequencing, relative EGFR messenger RNA (mRNA) levels by qPCR (upper quartile) and EGFR and p53 protein expression by immunohistochemistry (IHC), in 352 centrally-assessed tumors from an equal number of TNBC patients. RESULTS: Approximately 53.5% of the tumors expressed EGFR, 59.3% p53 and 35.9% both EGFR and p53 proteins; 4.1% showed EGFR gene amplification and 4.4% carried EGFR mutations. The latter were located outside the druggable kinase domain region and presented at low frequencies. Amplification and mutations overlapped only in one case of glycogen-rich carcinoma. EGFR and CEN7 copies were higher in tumors from older patients (p=0.002 and p=0.003, respectively). Patients with amplified tumors (n=11) had excellent prognosis (0 relapses and deaths). Upon multivariate analysis, high EGFR copies conferred significantly favorable disease-free survival (HR=0.57, 95% CI 0.36-0.90, Wald's p=0.017) and high CEN7 copies favorable overall survival (HR=0.49, 95% CI=0.29-0.83, Wald's p=0.008). Patients with EGFR-/p53+ and EGFR+/p53- tumors had significantly higher risk for relapse than those with EGFR-/p53- and EGFR+/p53+ tumors (HR=1.73, 95% CI=1.12-2.67, Wald's p=0.013). CONCLUSION: EGFR gene amplification and mutations are rare in TNBC, the latter of no apparent clinical relevance. Surrogate markers of EGFR-related chromosomal aberrations and combined EGFR/p53 IHC phenotypes appear to be associated with favorable prognosis in patients with operable TNBC receiving conventional adjuvant chemotherapy.

Comparative Evaluation of Pain, Stress, Neuropeptide Y, ACTH, and Cortisol Levels Between a Conventional Postoperative Care Protocol and a Fast-Track Recovery Program in Patients Undergoing Major Abdominal Surgery.

BACKGROUND: Fast-track (FT) postoperative protocol in oncological patients after major abdominal surgery reduces complications and length of postoperative stay compared to the conventional (CON) protocol. However, stress and pain responses have not been compared between the two protocols. OBJECTIVES: To compare stress, pain, and related neuropeptidic responses (adrenocorticotropic hormone [ACTH], cortisol, and neuropeptide Y [NPY]) between FT and CON protocols. METHOD: A clinical trial with repeated measurements was conducted (May 2012 to May 2014) with a sample of 63 hepatectomized or pancreatectomized patients randomized into two groups: FT ( n = 29) or CON ( n = 34). Demographic and clinical data were collected, and pain (Visual Analog Scale [VAS] and Behavioral Pain Scale [BPS]) and stress responses (3 self-report questions) assessed. NPY, ACTH, and cortisol plasma levels were measured at T1 = day of admission, T2 = day of surgery, and T3 = prior to discharge. RESULTS: ACTHT1 and ACTHT2 levels were positively correlated with self-reported stress levels (ρ = .43 and ρ = .45, respectively, p < .05) in the FT group. NPY levels in the FT group were higher than those in the CON group at all time points ( p ≤ .004); this difference remained significant after adjusting for T1 levels through analysis of covariance for age, gender, and body mass index ( F = .003, F = .149, F = .015, respectively, p > .05). CONCLUSIONS: Neuropeptidic levels were higher in the FT group. Future research should evaluate this association further, as these biomarkers might serve as objective indicators of postoperative pain and stress.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature.

INTRODUCTION: Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak. PRESENTATION OF CASE: Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well. DISCUSSION: This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation. CONCLUSION: Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons' perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

Prevalence and geographic variation of abdominal obesity in 7- and 9-year-old children in Greece; World Health Organization Childhood Obesity Surveillance Initiative 2010.

BACKGROUND: In children, abdominal obesity is a better predictor of the presence of cardiovascular risk factors than body mass index (BMI)-defined obesity. We aimed to evaluate the prevalence of abdominal obesity in the Greek pediatric population and to assess the impact of residence on the prevalence of both BMI-defined and abdominal obesity. METHODS: In the context of the Childhood Obesity Surveillance Initiative of the World Health Organization (WHO) Regional Office for Europe, a national representative sample of 7.0-7.9 and 9.0-9.9-year-old children was evaluated (n = 2,531 and 2,700, respectively). Overweight and obesity according to BMI were estimated using both the WHO and International Obesity Task Force cut-off points. Abdominal obesity was defined as waist circumference/height ratio >0.5. RESULTS: The prevalence of abdominal obesity did not differ between 7-year-old boys and girls (25.2 and 25.3%, respectively; p = NS). Among 9-year-old children, abdominal obesity was more prevalent in boys than in girls (33.2 and 28.2%, respectively; p = 0.005). Among normal weight and overweight children, the prevalence of abdominal obesity was 1.6-6.8 and 21.8-49.1%, respectively. The prevalence of abdominal and BMI-defined obesity did not differ between children living in the mainland, in Crete and in other islands except in 7-year-old girls, where the prevalence of BMI-defined obesity was highest in those living in Crete, intermediate in those living in other islands and lowest in those living in the mainland. In 9-year-old boys and in 7- and 9-year-old girls, the prevalence of abdominal obesity was highest in children living in Athens and lowest in children living in Thessaloniki, whereas children living in other cities and in villages showed intermediate rates. The prevalence of abdominal obesity in 7-year-old boys and the prevalence of BMI-defined obesity did not differ between children living in cities and villages. CONCLUSIONS: The prevalence of pediatric abdominal obesity in Greece is among the highest worldwide. Boys and children living in the capital are at higher risk for becoming obese. Given that abdominal obesity is more prevalent than BMI-defined obesity and appears to be more sensitive in identifying cardiovascular risk, measurement of waist circumference might have to be incorporated in the screening for childhood obesity.

Congenital peritoneal encapsulation of the small intestine: A rare case report.

INTRODUCTION: Peritoneal Encapsulation (PE) is a scarce congenital malformation, characterized by a supplementary peritoneal membrane that covers all or a part of the small intestine. PRESENTATION OF CASE: PE was unexpectantly discovered in a young woman during laparotomy for bowel obstruction. There were no specific pre-operative indications of this malformation. The operation was uneventful. DISCUSSION: PE is a very rare congenital anatomical anomaly that is difficultly identified pre-operatively. PE is mainly asymptomatic, but in some cases, like in the presented one, PE presents with small bowel obstruction. Surgeons should be aware of this malformation and suspect it when encountering a patient with small bowel obstruction without other etiological factors. CONCLUSION: Knowledge of this peculiar congenital anomaly is pivotal, so that accurate diagnosis and appropriate management of it are direct and efficient.

Langer's axillary arch.

Langer's axillary arch is usually asymptomatic and difficult to detect preoperatively. When present, it is important for surgeons operating in the axillary region, to identify correctly the relevant anatomy. Simple surgical division is curative and necessary in order to achieve exposure of the axillary contents, lymphatic dissection, and neurovascular preservation.