Current knowledge and contemporary management of non-A non-B aortic dissections.

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection's location, extent, the aortic diameter, the associated complications and the patient's status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.

A Case of SARS-CoV-2 Clinical Relapse after 4 Negative RT-PCR Tests in Greece: Recurrence or Reinfection?

SARS-CoV-2 pandemic is the greatest public health concern of the year 2020. There are several worldwide reports of patients who have managed to recover from SARS-CoV-2 infection with negative PCR test results, that for unknown reasons convert back to positive PCR. We report a case of a patient in our hospital who developed positive PCR test results for SARS-CoV-2, after 4 consecutive results that were negative, along with a full-blown clinical syndrome of SARS-CoV-2 infection.

Clostridioides difficile infection in a patient with immunoglobulin A vasculitis: a triggering factor or a rare complication of the disease? A case-based review.

IgA vasculitis, formerly known as Henoch-Schonlein purpura (HSP), is the most common form of systemic vasculitis in children and is characterized by inflammation of the small vessels with typical deposition of IgA immune complexes. It is a leukocytoclastic type of vasculitis and is characterized by a tetrad of clinical manifestations: non-thrombocytopenia or coagulopathy-induced palpable purpura, arthritis, or arthralgia, gastrointestinal, and renal involvement. The exact cause of IgA vasculitis is not known yet, although infections, vaccinations and insect bites have been implicated in the appearance of the disease. The main risk factors for Clostridioides difficile infection (CDI) are previous CDI, age > 65 years old, pharmacologic agents (antibiotics, PPIs, histamine-2 receptor antagonists, glucocorticoids, and chemotherapy), prior hospitalization, the presence of co-morbidities, especially inflammatory bowel diseases and chronic kidney disease (CKD) and immunosuppression. Oral vancomycin or fidaxomicin are the gold standard of the therapy, with metronidazole being an alternative choice. The purpose of this study was to describe a case of IgA vasculitis and Clostridioides difficile infection to see whether there is any association between the two distinct clinical entities. Herein, we describe a 17-year old patient with IgA vasculitis and bloody diarrhea due to Clostridioides difficile infection and we discuss the co-existence of these two pathological conditions. The patient presented to the hospital with diffuse abdominal pain, nausea, vomiting, and two episodes of bloody diarrhea. Stools tested positive for Clostridioides difficile toxins, while he remained afebrile with hs-CRP = 1.5 mg/dL (normal range < 0.5 mg/dL). Direct immunofluorescence from the extremities' purplish eruption showed leukocytoclastic vasculitis with IgA deposition. Whether co-existence of the two above-mentioned distinct clinical entities is just a co-incidence or CDI is a triggering factor for IgA vasculitis remains to be elucidated in future large-scale studies.

Radial probe endobronchial ultrasound assisted conventional transbronchial needle aspiration in the diagnosis of solitary peribronchial pulmonary lesion located in the segmental bronchi.

Background: The diagnosis of peribronchial pulmonary lesions located in the tertiary bronchi, also known as segmental bronchi, as well as, the 4th order and 5th order segmental bronchi is very difficult. Histopathological specimens cannot be easily obtained by endobronchial biopsies (EBBX) due to the patent but small segmental bronchial lumen. The aim of the present study was to evaluate the diagnostic accuracy and safety of the novel technique with radial probe endobronchial ultrasound (R-EBUS) assisted conventional transbronchial needle aspiration (C-TBNA) in the diagnosis of solitary peribronchial pulmonary lesions located in segmental bronchi from 3th to 5th order. Methods: From December 2014 to December 2015, 16 patients with solitary peribronchial pulmonary lesions in the segmental bronchi from 3th to 5th order confirmed by computed tomography (CT) were enrolled. The lesions were located using radial probe endobronchial ultrasound (R-EBUS) to determine the sites of conventional transbronchial needle aspiration (C-TBNA), then, histopathological specimens were obtained using the technique of C-TBNA. The final pathological diagnosis was made based on the findings from the surgical specimens. Statistical analyses were performed for specimen results and complications. Results: On pathological evaluation, 14 of the 16 specimens were malignant, including 8 adenocarcinomas, 4 squamous cell carcinomas, and 2 small cell carcinomas, while 2 were non-malignant diseases. The diagnostic accuracy rate, sensitivity and missed diagnosis rates were 87.5%, 87.5% and 12.5%, respectively. When Combined the results of cytology with histologic samples obtained from C-TBNA the total diagnostic accuracy rate, sensitivity and missed diagnosis rate were 93.75%, 93.75% and 6.25%, respectively. There were 2 cases of bleeding complications >5 mL after C-TBNA, and both were resolved with endobronchial management. Conclusions: The combination of R-EBUS with C-TBNA was advantageous and safe for the diagnosis of solitary peribronchial pulmonary lesions located in the segmental bronchi. However, possible bleeding complications should be anticipated with needle aspiration. Further verification of this combined application should be investigated in larger clinical trials.

The cost of hospital treatment of advanced stage lung cancer patients in a developing South East European country.

Assessing the lung cancer treatment costs is necessary in order to estimate the budget impact of new interventions and therapeutic innovations. However, there are few studies regarding the use of resources and costs associated with treatment of lung cancer patients, not only in Serbia, but internationally. The aim of this paper was to assess the hospital costs of diagnosing and treating patients with stage IIIB and IV non-small cell lung cancer. Analysis of costs of care, services, medications and medical supplies, as well as of total hospital costs, was performed. Patients diagnosed with stage IIIB or IV NSCLC in the Institute during the year 2013 were enrolled in the study. A total of 187 patients with stage IIIB or IV NSCLC were analyzed. Total hospital costs were 506.970€, of which nearly two thirds was accounted to costs of services and medications. The mean cost per patient with adenocarcinoma was 3.075€, and for squamous cell lung carcinoma patient 1.943€. Statistically significant difference was shown when comparing mean hospital costs between patients in stage IIIB and stage IV adenocarcinoma, where this cost is higher in patients with stage IIIB. Mean hospital cost per female patient was nearly double as high that of the male patients, although without statistically significant difference. The mean cost for all adenocarcinoma patients was 1.317€, and for only four patients treated with TKI therapy 21.233€. This cost analysis could provide useful information in terms of budget impact of different lung cancer treatments and innovations in Serbia and corresponding developing countries.

Multiple metachronous and synchronous malignancies with lung and thorax involvement. Report of two cases.

Multiple primary malignant neoplasms (MPMN) is an uncommon phenomenon, while the diagnosis of such conditions is very significant. Considering that the strategy of the treatment is determined by the histological type of the tumor, practitioners should be alert in order to avoid malpractices in cases of multiple metachronous or synchronous malignancies. In this article we report two rare cases of MPMN. The first patient suffered from three metachronous malignant neoplasms, specifically tonsillar, lung and breast cancer, while the second patient was diagnosed with four synchronous and metachronous malignant tumors, including renal and lung cancer, basaloid carcinoma and melanoma. Such cases are extremely rare in the clinical practice and poorly described in the literature.

Lung cancer induced from chemotherapy a 20 years old case.

Lung cancer is diagnosed at a late stage although we have novel diagnostic tools. The association of smoking and other environmental factors are well known. However; there are cases where a malignancy is associated with previous radiation treatment. There is an association between radiotherapy treatment and cancer incidence. We present a case where lung cancer and laryngeal cancer was induced 20 years after radiation therapy of a hogkin lymphoma.

New hybrid method for trachea dilatation with rigid and flexible tools.

Trachea stenosis is observed either in benign or malignant situations. In cancer malignancy a tumor might obstruct the central airway in three different ways. Again granuloma tissue is usually observed after intubation or stent placement in order to manage a benign malformation of the trachea. In any case there are several tools and techniques that can be used either with surgery or endoscopically to manage such situation. We will focus on a hybrid technique in order to ventilate the patient while performing endoscopic management of granuloma tissue.

Esophagus lyomyoma diagnosed with convex endobronchial ultrasound (EBUS).

Esophageal lyomyoma are rare benign tumors of the esophagus and they remain usually undiagnosed until local compression symptoms occur in the esophagus. Gastroscopy or esophageal ultrasonography (EUS) are usually the methods of choice for diagnosis. Moreover; surgery is the solution for this entity. In our case we present diagnosis of esophageal lyomyoma using convex probe endobronchial ultrasound (EBUS) with a fine needle aspiration of 22G.

Deep accidental hypothermia accompanied with cardiac arrest after alcohol and drug poisoning treated with extracorporeal life support.

Deep accidental hypothermia is an unusual clinical entity in developed countries. We report a case of a 30 year old male Caucasian patient with accidental severe hypothermia who was transferred to the emergency department of our hospital after prolonged exposure in the urban city's night environment cold as a result of alcohol and drugs abuse. The patient was found unconscious in the first early hours from onlookers. The time that the patient remained unconscious is unknown. During the transfer to the hospital because of cardiac arrest cardiopulmonary resuscitation began. In the emergency department an extracorporeal life support system (ECLS) was implanted under cardiopulmonary resuscitation in order to achieve hemodynamic stabilization and rapid and safe rewarming. The patient's rewarming lasted 6 hours. The patient was extubated the next day.

Aerosol Immunotherapy with or without Cisplatin for metastatic lung cancer non-small cell lung cancer disease: In vivo Study. A more efficient combination.

Lung cancer is the leading cause of cancer death after prostate cancer for males and breast cancer for females. There are novel therapies in the past five years such as; tyrosine kinase inhibitors and most recently in the last two years immunotherapy. Immunotherapy is currently being investigated if it can be administered alone or in combination. Previously we have investigated whether immunotherapy compounds can be produced as aerosols, and in the current study we investigated the safety and efficiency independently of the programmed death-ligand 1. The aerosol administration of both cisplatin and nivolumab is possible. The combination of the two drugs has a synergistic effect and therefore should be considered an option. Time of administration for immunotherapy is also very important.

Monitoring changes in quality of life in patients with lung cancer under treatment with chemotherapy and co administration of zoledronic acid by using specialized questionnaires.

Background: Due to the severity of the primary disease in patients with lung cancer, quality of life (QoL) is often overlooked. Factors that form QoL should be taken in consideration when planning the appropriate treatment and determining therapy targets, because of the increasing frequency of bone metastasis leading to high levels of pain. Purpose of this study is to assess quality of life in patients with lung cancer, before and after treatment combined with zoledronic acid. Methods and materials: QoL was assessed in 80 patients (49 males-31 females), of which 45 developed bone metastasis. Prior and post treatment (with co administration of zoledronic acid) seven reliable scales: Pittsburgh Sleep Quality index (PSQI), Epworth Sleeping Scale (ess), Dyspnea Scale (ds), Fatigue Severity Scale (FSS), Brief Pain Inventory (BPI), Fact-G scale for sleep quality and EQ-5D for general health condition. Results: Statistically positive correlations were verified between PSQI-DS, PSQI-FSS, BPI-ESS, DS-FSS, DS-BPI and BPI-FSS (p<0,005) prior and post treatment. Patients sleep quality was improved, pain levels decreased and betterment in quality of life was marked (p<0,001). Although significant decrease in fatigue levels was observed (p<0,001) there has been an increase in dyspnea symptoms (p<0,001). Conclusions: Significant improvement was apparent when zoledronic acid was co administered in any treatment in patients with lung cancer. Sleep quality, fatigue and pain parameters also improved, with no positive impact on the symptoms of dyspnea.