Atypical femoral fracture in a metastatic bone disease patient six months after discontinuation of denosumab received sequentially to previous bisphosphonate therapy - A case report.

Although, both bisphosphonates and denosumab are effective in reducing the risk of skeletal-related events in patients with metastatic bone disease, many concerns were being raised about the possible association between their use and atypical femoral fractures. A case of an atypical femoral fracture in a metastatic bone disease patient, six months after discontinuation of long-term zoledronic acid therapy and sequential treatment with denosumab is reported. After extensive laboratory and imaging examination, the fracture was classified as atypical and it was finally treated with discontinuation of denosumab, long cephalomedullary interlocking nailing and vitamin D administration. Sequential treatment with bisphosphonates and denosumab in patients with metastatic bone disease, may lead to an overlapping treatment effect, increasing bone suppression and the risk of atypical femoral fracture. In addition, discontinuation of denosumab may activate bone remodeling units in an area with microdamage accumulation in cortical bone caused by the previous bone suppression from the antiresorptive treatment. The activation of bone remodeling units may accelerate the occurrence of the atypical femoral fractures.

Atypical Femoral Fracture in a Patient without Bisphosphonate or Denosumab Exposure-A Case Report.

Introduction: Atypical femoral fractures (AFF) are associated with the use of bisphosphonates (BPs) or denosumab. However, few cases that meet the characteristics of these fractures, as established by the American Society of Bone and Mineral Research, have occurred in patients who have never used antiresorptive drugs. Case Report: We report a case of AFF in a 67-year-old woman who had never used antiresorptive medications. The history and comorbidities of the patient, the characteristics of the fracture, and the subsequent treatment are presented. Conclusion: AFFs may occur even in patients who have never been exposed to BPs or denosumab. The absence of antiresorptive osteoporosis therapy and the lack of radiographic focal periosteal reaction in the lateral femoral cortex, as in our case, can make it difficult to detect and prevent the disorder. Prolonged use of proton pump inhibitors and Vitamin D deficiency-related osteomalacia may contribute to the occurrence of these fractures. Further studies are required to accurately understand all inciting factors contributing to the development of AFFs.

Achilles and Patroclus: Lesser known Physicians of Homer's Iliad.

During the Trojan War, aside from the renowned Greek physicians, Machaon and Podalirius, sons of Asclepius, another two heroes, Achilles and Patroclus, are reported to have been capable of providing medical care to the wounded in the Greek camp.

John C. Carapanayiotis (1909-1999): the Greek radiologist and pioneer of physiatry in Greece

John C. Carapanayiotis was specialized in physical medicine and rehabilitation in the USA in 1948, at a time when the medical world in post-war Greece was ignorant of this specific medical specialty, and the political, economic and social backdrop was incapable of accepting and understanding the wealth of scientific knowledge that he was trying to introduce. At this point it should be noted that the specialty of Physical Medicine and Rehabilitation was established in Greece in 1973. John C. Carapanayiotis was a member of the American Congress of Physical Medicine during the 1950's. In the same period, he expressed interest, on behalf of the New York University, in the establishment of a Physical Therapy Clinic in Greece, which would be granted unlimited funding by the Marshal Plan. His efforts clashed constantly with the backward mentality of his time, with the entrenched conservatism and with the bureaucratic red tape. Unfortunately, he was far ahead of his time and was condemned to the same fate as all other visionaries and pioneers in the way that his knowledge and scientific background were not put into practice for decades to come.

Medical care in free-beseiged Missolonghi (1822-1826). Johann Jacob Meyer and the first military hospital.

During the siege of Missolonghi by the Ottomans the conditions of hygiene living, clothing and feeding of the vast majority of enslaved Greeks could be assessed as deprived and miserable. The humid climate and geophysical environment favored the outbreak of epidemics that further darkened an already unfavorable situation of the fighters and their families. Necessarily, the priority was to meet the military and economic needs and secondarily tackling public health issues, health care and medicine - social welfare. The inadequate infrastructure of nursing care, the limited number of health personnel and serious shortages into pharmaceutical material revealed the resolution of those doctors who provided their services during the siege. Johann Jacob Meyer, a famous Swiss philhellene, a man known as the first journalist in Greece, along with his Greek wife, contributed to the founding and organization of the first military hospital and to the improvement of the general health care during the siege of Missolonghi (1822-1826).

Hecamede: Homeric nurse of the battle-wounded in the Trojan War.

The Homeric epics present the 10-year lasting Trojan War, offering the description of battle wounds and medical care of injuries. Hecamede is referred by the Homer as a battlefield nurse who had knowledge of the treatment of bleeding battle wounds.

Focal, asymptomatic epididymal masses--B-mode and color Doppler sonographic evaluation. Case report.

We reported the case of an adult male with an extratesticular mass prove to be postoperative a chronic inflammatory process. The importance of B-mode and color Doppler sonography in the differential diagnosis and literature regarding epididymal nodules and tumors of the paratesticular structures (epididymis) is reviewed and discussed.

Evangelia Farmakidou (1890-1982): the first female Greek radiologist.

Evangelia (Lia) Farmakidou was the first female Greek radiologist. She was a distinguished physician with an open mind and depth of thought, multitalented, with integrity and an independent spirit. She was also one of the founding members of the Hellenic Radiological Society in 1933. She strived for the recognition of her chosen field in Greece as well as for the creation of the Radiology Department in the Medical School of the National and Kapodistrian University of Athens.

Focal hepatic lesion ultrasound-guided biopsies.

PURPOSE: To compare the results of pathologic and cytologic reports of specimens acquired from focal liver lesions using ultrasound-guided biopsy and to evaluate the necessity of performing both techniques in the same patient. MATERIALS AND METHODS: 21 patients were eligible for enrollment in the study. Specimens for both pathologic and cytologic examination were obtained from 16 lesions using a 17G needle guide in a single puncture attempt. In 2 cases the diagnosis was based on cytologic smears. In 3 cases only histologic sections were acquired. The needle was introduced under continuous ultrasonographic control using a freehand technique. A cytologist was present at all times. RESULTS: The diagnostic sensitivity of cytologic examination was 83.33% and that of histologic examination was 94.74%. Histology diagnosed all cases of benign lesions and was proved inconclusive in 1 patient. The diagnostic sensitivity and accuracy of both methods combined reached 100%. In 94.4% malignancy was immediately diagnosed by cytology. CONCLUSIONS: Combination of both methods should increase the sensitivity and accuracy in diagnosing focal liver lesions performing a safe minimally invasive technique.

Ultrasound as a first line screening tool for the detection of renal artery stenosis: a comprehensive review.

Renal artery stenosis (RAS) is the most common underlying medical condition in secondary hypertension among adults, representing about 5% of all cases of hypertension. Early diagnosis of RAS is an important clinical objective since interventional therapy may improve or cure hypertension and preserve renal function. Contrast angiography is the currently reference standard for the diagnosis of RAS; however, its invasive nature renders it unsuitable for screening purposes. Among screening tests used for the detection of RAS (computed tomography angiography, magnetic resonance angiography, radionuclide scanning), multiple studies have shown that color Doppler ultrasound (CDUS), although highly operator-dependent, can be an effective tool in the diagnosis of RAS. CDUS imaging is a simple, safe (noninvasive) and widely available technique; in addition, the procedure is painless and well tolerated by patients. In this concrete review we will underline the established color Doppler ultrasound criteria used for the detection of RAS, highlight their limitations and see how their combination may improve the diagnostic accuracy of this method.