Indications, Safety, Efficacy and Survival Benefit of Intraperitoneal Chemotherapy in Patients With Advanced Gastric Cancer.

BACKGROUND/AIM: Advanced gastric cancer remains a significant concern for the medical community mostly due to the locoregional extension of the disease. Most commonly, stomach neoplasms are resectable, but not curable, due to the elevated percentage of peritoneal dissemination after gastrectomy and extensive lymph node dissection. Locoregional intraperitoneal chemotherapy plays a pivotal role in overall survival and prognosis of patients with advanced gastric cancer and shows a high probability of peritoneal dissemination after gastrectomy. In this review, we aimed to collect and present literature data concerning intraperitoneal chemotherapy in advanced stages of gastric cancer as well as evaluate the safety and survival benefit of the procedure. MATERIALS AND METHODS: We conducted a survey including all randomized controlled trials and clinical trials that were published in the last 30 years. The keywords used were: advanced gastric cancer, intraperitoneal chemotherapy and peritoneal carcinomatosis. We searched for clinical trials in Pubmed, Embase databases and the Cochrane library. Inclusion criteria were: patients with advanced gastric cancer with no macroscopical signs of peritoneal dissemination, who were treated with D2 gastrectomy and received one or more cycles of intraperitoneal chemotherapy. The final review included 20 articles. RESULTS: The safety of intraperitoneal chemotherapy, as well as the survival benefit of patients were evaluated. The majority of articles denoted that intraperitoneal chemotherapy is a safe procedure without severe or lethal complications. The majority of complications were hematological while non-hematologic complications were also noted. A survival benefit with statistically significant results (p<0.05) was observed in 6 out of 10 randomized controlled trials. CONCLUSION: Intraperitoneal chemotherapy for advanced gastric cancer is a safe procedure with promising results regarding survival benefit and prognosis. Further patient evaluation is required in order to standardize the type of chemotherapeutic agent and the sufficient dose and cycles for the most appropriate results.

Admissions due to vaccine preventable diseases in a large paediatric intensive care unit in Greece over a 10-year period.

AIM: Childhood immunisation is an important preventive measure. However, care givers may delay routine immunisations or seek exemptions from state vaccine mandates. Vaccine refusal creates barriers on vaccine coverage and leads to morbidity and mortality. METHODS: Our study reviews morbidity and mortality from vaccine preventable diseases (VPDs) in a large paediatric intensive care unit in Greece over a 10-year period. RESULTS: During the study period, 73 cases of VPDs were recorded, corresponding to 3.5% of total paediatric intensive care unit admissions. Influenza was the most prevalent VPD, followed by pneumococcal disease, measles, pertussis and meningococcal disease. Most patients (83.3%) were unvaccinated for the admission's VPD. Outcome was unfavourable for 31.9% of the patients (17 children died, 6 developed chronic impairment). CONCLUSION: Absent or incomplete vaccination may result in serious morbidity and mortality from preventable diseases. Strengthening vaccination strategies are needed to improve individual protection as well as herd immunity.

Aberrant internal carotid artery in the middle ear: the duplication variant.

Vascular variants concerning the internal carotid artery (ICA) at the skull base level are rare. Correct workup and diagnosis in case of suspicion of such a variant are important as it mimics glomus tumours and could complicate myringotomy or middle ear surgery. We report a case of a 39-year-old woman presented with a 6-month history of right pulsatile tinnitus and aural fullness. Ear microscopy examination revealed a pale red pulsatile mass anterior to the umbo. Radiological assessment using CT and MRI/magnetic resonance angiography confirmed the diagnosis of an aberrant ICA. Interestingly, a duplication of the ICA was demonstrated, in which the enlarged inferior tympanic artery presented as the aberrant ICA, whereas a narrower collateral hypoplastic native ICA was also present. A conservative approach with regular follow-up appointments was recommended.

Rescue Decompressive Craniectomy in Children with Severe Traumatic Brain Injury.

Decompressive craniectomy (DC) is considered a rescue therapy in patients with traumatic brain injury (TBI) with increased intracranial pressure (ICP). In this retrospective study, we examined the impact of craniectomy on ICP in children with severe TBI and their neurological outcome. A total of 14 patients were enrolled. Peak ICP was significantly lower (31 ± 2.9 to 19 ± 4.6, p < 0.001) and minimum cerebral perfusion pressure (CPP) higher (41 ± 10.5 to 58 ± 11.4, p < 0.001) postcraniectomy. The survival rate was 71%. However, 57% of our cohort had a poor neurological outcome at 6 months postinjury. In conclusion, although rescue DC was effective in controlling ICP and CPP, the long-term neurological outcome remained poor.

Characteristics of Bordetella pertussis infection among infantsand children admitted to paediatric intensive care units in Greece: A multicentre, 11-year study.

AIM: To describe children with pertussis who required intensive care. METHODS: This is a retrospective analysis of pertussis admissions to all (six) national intensive care units in Greece from 2003 to 2013. RESULTS: A total of 31 children were included, 28 of whom were younger than 12 months old. Cough was the most prominent symptom, being present in 27 of 31 (87%) patients, and on admission, only 7 (22.6%) satisfied the case definition. Mechanical ventilation was initiated in 13 (42%) patients. Six patients died because of respiratory failure (two) or multi-organ system failure (four). The patients who died had significantly higher white blood cell counts (WBC) (77 800-31 600, P = 0.031) and neutrophils (29 016-12 795, P = 0021) than those who survived and lower minimum values of serum sodium (125-133, P = 0002). They also had a longer duration of hospitalisation prior to their paediatric intensive care unit admission (6-1 days, P = 0022). Three patients were diagnosed with pulmonary hypertension, and only one of them survived. Age, gender and immunisation status did not differ between survivors and non-survivors. Two patients received exchange blood transfusion, and survival benefit was not apparent. CONCLUSION: Young infants are at risk of severe pertussis, resulting in serious complications or death. Elevated WBC and low serum sodium are associated with higher mortality. Despite advances in life support and treatment of organ failure in childhood critical illness, pertussis still has substantial mortality.

Effectiveness of 7.5% hypertonic saline in children with severe traumatic brain injury.

PURPOSE: Hyperosmolar therapies aim at controlling increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the effect of 7.5% hypertonic saline (HTS) on ICP and cerebral perfusion pressure (CPP) in children with severe TBI. MATERIALS AND METHODS: Medical records of patients 14 years or younger with severe TBI, admitted in the pediatric intensive care unit of "Aghia Sophia" Children's Hospital, Athens, Greece, during 2009 to 2015, and received HTS apart from mannitol were retrospectively reviewed. The ICP and CPP pre-HTS and 30, 60, and 120 minutes post-HTS infusion were evaluated. Furthermore, the presence of adverse effects, the long-term neurological outcome, and survival were recorded. RESULTS: Twenty-nine patients requiring in total 136 HTS infusions were analyzed. The ICP was significantly reduced and CPP elevated at 30, 60, and 120 minutes postinfusion; and furthermore, postadministration ICP and CPP were predominantly within acceptable limits. No significant adverse effects were recorded and most of the patients survived, however, one third had severe neurological impairment at 6 months postinjury. CONCLUSIONS: In our study, 7.5% HTS infusion as a second-tier osmotic therapy was associated with significant reduction of ICP and increase of CPP in children with severe TBI.

Antibiotics versus placebo or watchful waiting for acute otitis media: a meta-analysis of randomized controlled trials.

BACKGROUND: Recommendations on withholding antibiotics in children with acute otitis media (AOM) have been inadequately implemented in clinical practice. OBJECTIVES: We evaluated the role of prescribing antibiotics for AOM. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) that were retrieved from searches performed in the PubMed and Cochrane databases, and compared antibiotic treatment with placebo or watchful waiting (delayed antibiotic treatment if clinically indicated) for patients with AOM. RESULTS: We identified seven trials comparing antibiotic treatment with placebo (all double-blinded) and four trials comparing antibiotic treatment with watchful waiting (two investigator-blinded and two open-label) trials, all of which involved children (6 months to 12 years). Clinical success was more likely with antibiotics than comparator treatment in: placebo-controlled trials [seven RCTs, 1405 patients, risk ratio (RR) = 1.11, 95% confidence interval (CI) = 1.05-1.18]; watchful waiting trials (four RCTs, 915 patients, RR = 1.18, 95% CI = 1.07-1.32); and all trials combined (11 RCTs, 2320 patients, RR = 1.13, 95% CI = 1.08-1.19). Similarly, persistence of symptoms 2-4 days after treatment initiation was less likely with antibiotics in: placebo-controlled trials (four RCTs, 1014 patients, RR = 0.75, 95% CI = 0.64-0.88) and all trials combined (five RCTs, 1299 patients, RR = 0.68, 95% CI = 0.54-0.85). Diarrhoea was more likely with antibiotics (seven RCTs, 1807 patients, RR = 1.50, 95% CI = 1.16-1.95). No differences between the compared treatments were found regarding other effectiveness and safety outcomes. CONCLUSIONS: Antibiotic treatment is associated with a more favourable clinical course in children with AOM, compared with placebo, and also compared with watchful waiting. However, safety issues and the rather small treatment effect difference render the consideration of additional factors necessary in relevant clinical decision making.

Screening for children's depression symptoms in Greece: the use of the Children's Depression Inventory in a nation-wide school-based sample.

The objective of this study is to determine the level of depressive symptoms among a sample of Greek children aged 8-12 years, as measured by the Greek Children's Depression Inventory (CDI), as well as to examine CDI's psychometric properties. A nationwide school-based sample of 650 children was initially recruited and depressive symptoms were assessed with the CDI among 538 children who provided all relevant information. Statistical evaluation included assessment of CDI internal reliability, test-retest reliability, determination of age, gender and socioeconomic status (SES) effects. Based on the distributions of CDI scores observed in this normative sample, a recommended cutoff score, identifying a high probability of serious levels of depressive symptoms that need to be further evaluated, was defined. Internal reliability and test-retest reliability were satisfactory and the expected associations with age and gender were observed. High SES was correlated with significantly less depression symptoms. The prevalence of depressive risk, when the cutoff point of 19 or 13 was taken as threshold, was much lower than those obtained from studies in other countries. The cutoff point of 15, corresponding to 90th percentile of the present sample, may be used as a screening threshold for further assessment. The present results are encouraging providing evidence about the psychometric properties of the CDI and implications for child mental health promotion planning in Greece. Further validation of the CDI against other measures and psychiatric diagnoses is needed.

Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials.

BACKGROUND: Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis. OBJECTIVE: We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis. METHODS: We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment. RESULTS: Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations. CONCLUSION: Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.

Prevalence of genotypic resistance to nucleoside analogues, nonnucleoside analogues, and protease inhibitors in HIV-infected persons in Athens, Greece.

The objective was to study the prevalence of genotypic resistance to nucleoside analogues (NRTIs), nonnucleoside analogues (NNRTIs), and protease inhibitors among HIV-1-infected persons in Athens, Greece. Patients followed at two HIV units were examined for prevalence of emergence of antiretroviral resistance mutations (ARMs) in this observational study where complete therapy history was available. All mutations were recorded according to the October/November 2005 IAS-USA Drug Resistance Mutations Figures. A total of 234 patients underwent genotypic testing of 2069 followed (1987-2004). The most frequent ARMs of each drug category were to NRTIs at codons M184V [present in 149 tests (63.6%)], M41L [79 (33.8%)], K70R [66 (28.2%)], M184VI [58 (24.8%)], T215YF [53 (22.7%)], D67N [82 (35.0%)], T215Y [72 (30.8%)], K219Q [47 (20.1%)], K219E/Q [54 (23.1%)], and L210W [49 (20.9%)], respectively. The most prevalent mutations related to NNRTIs were K103N [present in 59 tests (25.2%)], G190A [50 (21.4%)], and Y181C [48 (20.5%]. Mutations in the protease gene showed that the ARM at residue L63P was the most prevalent present in 119 samples (50.9%). L90M (26.5%) was among the most frequently observed single key protease mutations in our series, although variables of V82 and I54 amino acid substitutions were more frequent. M184V (63.6%) and K103N (25.2%) were the most frequent mutations related to NRTIs and NNRTIs, respectively.

Comparison of utility of blood cultures from intravascular catheters and peripheral veins: a systematic review and decision analysis.

Blood cultures are sometimes obtained from intravascular catheters for convenience. However, there is controversy regarding this practice. The authors compared the diagnostic test characteristics of blood cultures obtained from intravascular catheters and peripheral veins. Relevant studies for inclusion in this review were identified through PubMed (January 1970-October 2005) and the Cochrane Central Register of Controlled Trials. Studies that reported clear definitions of true bacteraemia were included in the analysis. Two reviewers independently extracted the data. Six studies were included in the analysis, providing data for 2677 pairs of blood cultures obtained from an intravascular catheter and a peripheral venipuncture. A culture obtained from an intravascular catheter was found to be a diagnostic test for bacteraemia with better sensitivity (OR 1.85, 95 % CI 1.14-2.99, fixed effects model) and better negative predictive value (almost with statistical significance) (OR 1.55, 95 % CI 0.999-2.39, fixed effects model) but with less specificity (OR 0.33, 95 % CI 0.18-0.59, random effects model) and lower positive predictive value (OR 0.41, 95 % CI 0.23-0.76, random effects model) compared to a culture taken by peripheral venipuncture. In a group of 1000 patients, eight additional patients with true bacteraemia would be identified and 59 falsely diagnosed as having bacteraemia by a blood culture obtained from an intravascular catheter compared to results of the peripheral blood culture. Given the consequences of undertreating patients with bacteraemia, the authors believe that, based on the available evidence, at least one blood culture should be obtained from the intravascular catheter.