Opening Aeolus' Bag of Winds: Acute Abdominal Pain in a Severely Immunosuppressed Patient.

BACKGROUND: Necrotizing enterocolitis (NE) is a necrotizing disease mostly of the ileocecal region. It is a severe and potentially life-threatening complication that can affect patients undergoing chemotherapy for lymphoma. We analyze a case of NE that occurred in a patient with non-Hodgkin's lymphoma during chemotherapy with concurrent HIV infection. CASE REPORT: We present a case of a 37-year-old woman who was admitted to our emergency department because of acute abdominal pain. Her medical history included HIV infection and B-cell immunoblastic lymphoma. For the latter, the patient was receiving rituximab cyclophosphamide hydroxydaunorubicin oncovin vincristine prednisone (R-CHOP) regimen. A complete blood count showed a low leukocyte count (40/mm³) and a low neutrophil count (32/mm³). An exploratory laparotomy with midline incision was performed. Intraoperatively, the cecum and the proximal part of the ascending colon were found to be edematous with the mesocolon being extremely gelatinous without macroscopically identified ischemia. Histopathology revealed a nonspecific infarction necrosis of the bowel wall with multiple ulcerations in the cecum, but no evidence of major vessel thrombosis. The patient had an uneventful postoperative course and was discharged in good condition on the 10th postoperative day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first reported case of NE in a patient with acquired immune-deficiency syndrome who developed the syndrome during an episode of severe neutropenia and was treated surgically. The decision to operate should be balanced between the clinical and laboratory status as well as the operative risk. Physicians should be aware of this complication of chemotherapy, especially in severely immunosuppressed patients, because it could be triggered just by an episode of neutropenia.

An Uncommon Complication of a Common Procedure.

Constant, safe and reliable endovascular access is necessary for patients' diagnosis and treatment. Endovascular access is possible with a variety of means, including central and peripheral venous catheters. Peripheral catheterization is an extremely common medical procedure and is considered risk-free or associated with minimal complications. Still potentially serious complications can occur. Authors describe a rare case of peripheral catheter migration at left pulmonary artery in an immunosuppressed patient.

Concept of the aortic aneurysm repair-related surgical stress: a review of the literature.

OBJECTIVE: Abdominal aorta aneurysm (AAA) is a serious threat for human life. AAA repair is a high-risk procedure which results in a severe surgical stress response. We aim to give a conceptual description of the underlying pathophysiology of stress after surgical repair of AAA. METHODS: The MEDLINE/PubMed database was searched for publications with the medical subject heading "surgical stress" and keywords "abdominal aortic aneurysms (AAA)", or "cytokines" or "hormones" or "open repair (OR)" or "endovascular repair (EVAR)". We restricted our search to English till 2012 and only in cases of abdominal and thoracoabdominal aneurysms (TAAA). RESULTS: We identified 93 articles that were available in English as abstracts or/and full-text articles that were deemed appropriate for our review. CONCLUSIONS: Literature highlights no statistical significance for early acute TNF-α production in EVAR and no TNF-α production in OR. IL-6 and IL-8 levels are higher after OR especially when compared with those of EVAR. IL-10 peak was observed during ischemic phase in aneurysm surgical repair. Cortisol and epinephrine levels are higher in OR patients in comparison to EVAR patients. Finally, the incidence of systemic inflammatory response syndrome was significantly higher in OR than EVAR patients.

Treatment paradigms for ductus arteriosus aneurysms in adults.

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature.

Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases.

INTRODUCTION: Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made. METHODS: Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate. RESULTS: Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward. CONCLUSIONS: Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.

Music meets surgery: two sides to the art of "healing".

BACKGROUND: The effect of music in the operating room is not fully understood. Through a systematic review the authors aim to give a conceptual presentation of the effect that music has on the pre- and postoperative course of surgical patients and on the effectiveness of the surgical work performed by both physicians and staff. METHODS: The search was conducted both on the basis of the Medical Subject Headings (MeSH) tree and as a text search using the Medline database (1946 to December 2011). The main search heading was "music in operating room" with the accessory keyword "surgery." The selection criteria specified the English language and the availability of abstracts or full-text articles. From 85 articles listed with the corresponding search, 28 were relevant and enrolled for the review. RESULTS: Patients exhibit lower anxiety levels before and during surgery when hearing music and a significant reduction in analgesia and sedation requirements has been observed. Music was found to reduce the heart rate, blood pressure, and muscle effort of surgeons while at the same time increasing the accuracy of surgical tasks. Surgeons who played a musical instrument were found to perform surgical tasks faster. On the other hand, anesthesiologists report that music is associated with difficulties communicating and offering a stable level of sedation. The most appropriate music in the operating room seems to be the classical type. CONCLUSIONS: Music in the operating room can have beneficial effects on patients by decreasing stress, anxiety, and the demand for analgesic and anesthetic drugs. For the surgical staff, music is considered to be distracting. For the surgeon, music can increase the speed and accuracy of task performance.

A pathological fracture and a solitary mass in the right clavicle: an unusual first presentation of HCC and the role of immunohistochemistry.

Hepatocellular carcinoma (HCC) is an aggressive malignant tumor that occurs throughout the world. Μetastases from hepatocellular carcinoma (HCC) were generally considered to be rare in the past, because the carcinoma had an aggressive clinical course. In our era, has been reported that extra-hepatic metastases occur in 13.5%-41.7% of HCC patients and this is considered as terminal-stage cancer. The prognosis for patients at this stage continues to be poor due to limited effective treatment. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals. We present here an extremely infrequent case of a patient, without known liver disease, in which the presenting symptom was a pathological-in retrospect-fracture of his right clavicle which wasn't properly evaluated, until he presented a bulky mass in the region 6 months later. For our patient, the added diagnostic difficulty alongside the unknown liver disease, has been that the clavicular metastases was the first presentation of any metastatic disease, rather than the more common sites of HCC spread to adjacent lung or lymph nodes.

Surgery via natural orifices in human beings: yesterday, today, tomorrow.

BACKGROUND: We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. METHODS: Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated. RESULTS: The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable. CONCLUSIONS: NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

H1N1v influenza vaccine in Greek medical students.

BACKGROUND: We sought to investigate the penetration of the H1N1v vaccine in Greek medical students, as well as their approach to the vaccination. METHODS: A survey was conducted among the students of the University of Athens, School of Medicine, 1 month after the initiation of the vaccination programme. Participants were asked to fill in a questionnaire regarding their status of vaccination and their approach to the H1N1v vaccine. RESULTS: We handed a questionnaire to 1000 students (out of 1700 officially enrolled in the medical school) and retrieved 922 answers. Only 74 (8%) medical students had been vaccinated and 78 (9%) planned to (probably or definitely) do so in the future, while 641 (67%) would (probably or definitely) not get vaccinated. The highest coverage was among the sixth year students (37/234, 16%). The most common reasons for not having received the vaccine were perception of the disease as mild (387/848, 46%), and concern regarding long-term adverse events (370/848, 44%). Thirty percent (258/848) of the students doubted the vaccine's effectiveness, and 197 (23%) worried about possible short-term adverse events. One hundred and thirty-three respondents (16%) believed the whole story is a conspiracy while 102 (12%) reported to have had the flu. Almost half (43%) of the participants considered their knowledge on the subject inadequate. CONCLUSION: Our findings confirmed the low penetration of the H1N1 vaccine in Greece, as in most European countries, even in medical students. Better education of the students and the public might aid in increasing the immunization rates.