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Objectives: The goal of this article is to investigate the correlation between sexuality and depression of cervical cancer (CC) patients. Methods: A bibliographical search was carried out in the databases CINAHL, PubMed, and Cochrane Library with the following terms in English for the years 2006 to 2017: sexuality, sexual function, sexual dysfunction, sexual problems, mood, depression, emotional distress, cervical cancer. Results: Fourteen studies were included. They present heterogeneity in the stage of the disease, the selected treatments, and their sample. From the studies, only 7 are evaluated as good methodologically. Sexual dysfunction and depression of CC patients persist for many years after treatments. The younger women, those who underwent radiotherapy, and those who had chronic fatigue, as an aftereffect of treatments, had increased depression. Women that underwent surgery and adjuvant therapy experienced the highest rates of depressive symptoms. There is a positive relationship between sexuality and depression in patients with CC. Conclusions: Sexuality and depression οf women with CC are affected by their therapies to a significant extent. There is a positive correlation between the two variables. The existing methodologically good studies are scarce, and for this reason the results cannot be generalized in all CC patients.

Background:\ud \ud Ensuring adequate knowledge about palliative care and positive attitudes towards death and dying are crucial educational aspects when preparing undergraduate nursing students to respond effectively to the complexities of care for people affected by a progressive, life-limiting illness. In undergraduate nursing education in Greece, the level of students' attained knowledge and developed attitudes towards palliative and end-of-life care remain unknown.\ud Purpose:\ud \ud To investigate undergraduate nursing students' knowledge about palliative care and attitudes towards death and end-of-life care, and explore demographic and academic factors as potential moderators of student knowledge and attitudes.\ud Methods:\ud \ud We conducted a descriptive, cross-sectional, questionnaire-based survey. We recruited 2nd, 3rd and 4th year undergraduate nursing students from the country's two University Faculties. Participants completed a demographic form, the Palliative Care Quiz for Nursing (PCQN), and the Frommelt Attitudes Towards Care of the Dying (FATCOD) questionnaire.\ud Results:\ud \ud The final sample was 529 students (response rate = 87.6%). Mean total PCQN scores revealed low levels of knowledge. Knowledge about pain/symptom management and psychosocial/spiritual care was insufficient. Mean total FATCOD scores indicated positive, liberal and supportive attitudes towards end-of-life care, with 60% of respondents keen to care for a dying person and their family. We noted less positive attitudes mainly in relation to student comfort with the care of a dying person and his/her imminent death. Academic parameters (year of study) and student demographic characteristics (older age) were the most significant moderators of both knowledge and attitudes. Greater knowledge about palliative care was a relatively weak, yet significant, predictor of more liberal attitudes towards care of the dying.\ud Conclusion:\ud \ud Our findings suggest that structured courses in palliative care can be a core part of undergraduate nursing education. Specific attention could be given to such areas patient-health professional communication, misconceptions and biases towards death and dying, and comfort in caring for the dying in order to prepare student nurses to psychologically deal with the sensitive and challenging process of death and dying.

Objective To evaluate effects of remote monitoring of adjuvant chemotherapy related side effects via the Advanced Symptom Management System (ASyMS) on symptom burden, quality of life, supportive care needs, anxiety, self-efficacy, and work limitations. Design Multicentre, repeated measures, parallel group, evaluator masked, stratified randomised controlled trial. Setting Twelve cancer centres in Austria, Greece, Norway, Republic of Ireland, and UK. Participants 829 patients with non-metastatic breast cancer, colorectal cancer, Hodgkin’s disease, or non-Hodgkin’s lymphoma receiving first line adjuvant chemotherapy or chemotherapy for the first time in five years. Intervention Patients were randomised to ASyMS (intervention; n=415) or standard care (control; n=414) over six cycles of chemotherapy. Main outcome measures The primary outcome was symptom burden (Memorial Symptom Assessment Scale; MSAS). Secondary outcomes were health related quality of life (Functional Assessment of Cancer Therapy—General; FACT-G), Supportive Care Needs Survey Short-Form (SCNS-SF34), State-Trait Anxiety Inventory—Revised (STAI-R), Communication and Attitudinal Self-Efficacy scale for cancer (CASE-Cancer), and work limitations questionnaire (WLQ). Results For the intervention group, symptom burden remained at pre-chemotherapy treatment levels, whereas controls reported an increase from cycle 1 onwards (least squares absolute mean difference −0.15, 95% confidence interval −0.19 to −0.12; P Conclusions Significant reduction in symptom burden supports the use of ASyMS for remote symptom monitoring in cancer care. A “medium” Cohen’s effect size of 0.5 showed a sizable, positive clinical effect of ASyMS on patients’ symptom experiences. Remote monitoring systems will be vital for future services, particularly with blended models of care delivery arising from the covid-19 pandemic. Trial registration Clinicaltrials.gov NCT02356081 .

Purpose: The present study assesses the relationship between patient dignity in advanced cancer and the following variables: psychological distress, preparatory grief, and sociodemographic and clinical characteristics. Methods: The sample consisted of 120 patients with advanced cancer. The self-administered questionnaires were as follows: the Preparatory Grief in Advanced Cancer Patients (PGAC), the Patient Dignity Inventory–Greek (PDI-Gr), the Greek Schedule for Attitudes toward Hastened Death (G-SAHD), and the Greek version of the Hospital Anxiety and Depression Scale (G-HADS). Results: Moderate to strong statistically significant correlations were found between the 4 subscales of PDI-Gr (psychological distress, body image and role identity, self-esteem, and social support) with G-HADS, G-SAHD, and PGAC ( P < .005), while physical distress and dependency was moderately correlated with depression. Multifactorial analyses showed that preparatory grief, depression, and age influenced psychological distress, while preparatory grief, depression, and performance status influenced body image and role identity. Conclusions: Preparatory grief, psychological distress, and physical symptoms had significant associations with perceptions of dignity among patients with advanced cancer. Clinicians should assess and attend to dignity-distressing factors in the care of patients with advanced cancer.

Context The patient dignity inventory (PDI) is an instrument to measure dignity distressing aspects at the end of life. Objectives The aims of the present study were the translation of the PDI in Greek language as well as to measure its psychometric aspects in a palliative care unit. Methods A back-translation method was obtained at the Greek version. One hundred twenty advanced cancer patients completed the Greek version of the PDI, the Greek hospital anxiety and depression scale, the Greek schedule of attitudes toward hastened death (SAHD-Gr), and the Greek 12-item short form health survey. Results Confirmatory factor analysis failed to fit to the original instrument's structure and exploratory factor analysis was conducted revealing five factors ("Psychological Distress," "Body Image and Role Identity," "Self-Esteem," "Physical Distress and Dependency," and "Social Support"). The psychometric analysis of the PDI-Gr demonstrated a good concurrent validity, and the instrument discriminated well between subgroups of patients regarding age differences. Cronbach α were between 0.71 and 0.9 showing a good internal consistency. Conclusion The Greek version of the PDI showed good psychometric properties in advanced cancer patients, supported the usefulness of the instrument assessing the sense of dignity distressing aspects of the terminally ill cancer patients.

Effective symptom management is a critical component of cancer treatment. Computational tools that predict the course and severity of these symptoms have the potential to assist oncology clinicians to personalize the patient’s treatment regimen more efficiently and provide more aggressive and timely interventions. Three common and inter-related symptoms in cancer patients are depression, anxiety, and sleep disturbance. In this paper, we elaborate on the efficiency of Support Vector Regression (SVR) and Non-linear Canonical Correlation Analysis by Neural Networks (n-CCA) to predict the severity of the aforementioned symptoms between two different time points during a cycle of chemotherapy (CTX). Our results demonstrate that these two methods produced equivalent results for all three symptoms. These types of predictive models can be used to identify high risk patients, educate patients about their symptom experience, and improve the timing of pre-emptive and personalized symptom management interventions.

Background: There has been an international shift in health care, which has seen an increasing focus and development of technological and personalized at-home interventions that aim to improve health outcomes and patient-clinician communication. However, there is a notable lack of empirical evidence describing the preparatory steps of adapting and implementing technology of this kind across multiple countries and clinical settings. Objective: This study aimed to describe the steps undertaken in the preparation of a multinational, multicenter randomized controlled trial (RCT) to test a mobile phone–based remote symptom monitoring system, that is, Advanced Symptom Management System (ASyMS), designed to enhance management of chemotherapy toxicities among people with cancer receiving adjuvant chemotherapy versus standard cancer center care. Methods: There were 13 cancer centers across 5 European countries (Austria, Greece, Ireland, Norway, and the United Kingdom). Multiple steps were undertaken, including a scoping review of empirical literature and clinical guidelines, translation and linguistic validation of study materials, development of standardized international care procedures, and the integration and evaluation of the technology within each cancer center. Results: The ASyMS was successfully implemented and deployed in clinical practices across 5 European countries. The rigorous and simultaneous steps undertaken by the research team highlighted the strengths of the system in clinical practice, as well as the clinical and technical changes required to meet the diverse needs of its intended users within each country, before the commencement of the RCT. Conclusions: Adapting and implementing this multinational, multicenter system required close attention to diverse considerations and unique challenges primarily related to communication and clinical and technical issues. Success was dependent on collaborative and transparent communication among academics, the technology industry, translation partners, patients, and clinicians as well as a simultaneous and rigorous methodological approach within the 5 relevant countries. ©Eileen Furlong, Andrew Darley, Patricia Fox, Alison Buick, Grigorios Kotronoulas, Morven Miller, Adrian Flowerday, Christine Miaskowski, Elisabeth Patiraki, Stylianos Katsaragakis, Emma Ream, Jo Armes, Alexander Gaiger, Geir Berg, Paul McCrone, Peter Donnan, Lisa McCann, Roma Maguire. Originally published in JMIR Cancer (http://cancer.jmir.org), 14.03.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/)

BACKGROUND There has been an international shift in health care, which has seen an increasing focus and development of technological and personalized at-home interventions that aim to improve health outcomes and patient-clinician communication. However, there is a notable lack of empirical evidence describing the preparatory steps of adapting and implementing technology of this kind across multiple countries and clinical settings. OBJECTIVE This study aimed to describe the steps undertaken in the preparation of a multinational, multicenter randomized controlled trial (RCT) to test a mobile phone–based remote symptom monitoring system, that is, Advanced Symptom Management System (ASyMS), designed to enhance management of chemotherapy toxicities among people with cancer receiving adjuvant chemotherapy versus standard cancer center care. METHODS There were 13 cancer centers across 5 European countries (Austria, Greece, Ireland, Norway, and the United Kingdom). Multiple steps were undertaken, including a scoping review of empirical literature and clinical guidelines, translation and linguistic validation of study materials, development of standardized international care procedures, and the integration and evaluation of the technology within each cancer center. RESULTS The ASyMS was successfully implemented and deployed in clinical practices across 5 European countries. The rigorous and simultaneous steps undertaken by the research team highlighted the strengths of the system in clinical practice, as well as the clinical and technical changes required to meet the diverse needs of its intended users within each country, before the commencement of the RCT. CONCLUSIONS Adapting and implementing this multinational, multicenter system required close attention to diverse considerations and unique challenges primarily related to communication and clinical and technical issues. Success was dependent on collaborative and transparent communication among academics, the technology industry, translation partners, patients, and clinicians as well as a simultaneous and rigorous methodological approach within the 5 relevant countries.

Purpose The aim of this study was to investigate the effectiveness of an educational intervention on home nursing care plans based on NANDA, Nursing Interventions Classification, and Nursing Outcomes Classification for registered nurses working at primary healthcare settings in Greece. Methods This is a quasi-experimental study without a control group. The sample consisted of 19 registered nurses. The study tool was a questionnaire administered pre- and post-educational intervention. Findings The intervention improved their skills on nursing diagnoses' nomination, proper formulation, and individualization of defining characteristics, but it did not improve them in desired outcomes formulation. Conclusions A significant effect of an educational intervention on nursing care plans was demonstrated. Implications for Nursing Practice Nurses' knowledge and attitudes are important for understanding and integrating documentation within the nursing process.

Context Risk profiling of oncology patients based on their symptom experience assists clinicians to provide more personalizedsymptom managementinterventions. Recent findings suggest that oncology patients with distinct symptom profiles can be identified using a variety of analytic methods. Objectives The objective of this study was to evaluate the concordance between the number and types of subgroups of patients with distinct symptom profiles usinglatent class analysisand K-modes analysis. Methods Using data on the occurrence of 25 symptoms from the MemorialSymptom AssessmentScale, that 1329 patients completed prior to their next dose of chemotherapy (CTX), Cohen'skappa coefficientwas used to evaluate for concordance between the two analytic methods. For both latent class analysis and K-modes, differences among the subgroups in demographic, clinical, and symptom characteristics, as well as quality of life outcomes were determined using parametric andnonparametric statistics. Results Using both analytic methods, four subgroups of patients with distinct symptom profiles were identified (i.e., all low, moderate physical and lower psychological, moderate physical and higher Psychological, and all high). The percent agreement between the two methods was 75.32%, which suggests a moderate level of agreement. In both analyses, patients in the all high group were significantly younger and had a highercomorbidityprofile, worse Memorial Symptom Assessment Scale subscale scores, and poorer QOL outcomes. Conclusion Both analytic methods can be used to identify subgroups of oncology patients with distinct symptom profiles. Additional research is needed to determine which analytic methods and which dimension of the symptom experience provide the most sensitive and specific risk profiles.

Introduction While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology (eSMART) study is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised controlled trial of oncology patients. Methods and analysis A total of 1108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal or haematological cancer will be recruited from multiple sites across five European countries. Patients will be randomised (1:1) to the ASyMS intervention (intervention group) or to standard care currently available at each site (control group). Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient-reported outcome measures at enrolment, after each of their CTX cycles (up to a maximum of six cycles) and at 3, 6, 9 and 12 months after completion of their sixth cycle of CTX. Outcomes that will be assessed include symptom burden (primary outcome), quality of life, supportive care needs, anxiety, self-care self-efficacy, work limitations and cost effectiveness and, from a health professional perspective, changes in clinical practice (secondary outcomes). Ethics and dissemination Ethical approval will be obtained prior to the implementation of all major study amendments. Applications will be submitted to all of the ethics committees that granted initial approval. eSMART received approval from the relevant ethics committees at all of the clinical sites across the five participating countries. In collaboration with the European Cancer Patient Coalition (ECPC), the trial results will be disseminated through publications in scientific journals, presentations at international conferences, and postings on the eSMART website and other relevant clinician and consumer websites; establishment of an eSMART website (www.esmartproject.eu) with publicly accessible general information; creation of an eSMART Twitter Handle, and production of a toolkit for implementing/utilising the ASyMS technology in a variety of clinical practices and other transferable health care contexts. Trial registration number NCT02356081. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2016-015016 © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Background Despite improvements in multimodality approach , overall survival of esophageal cancer (EC) is still very low. Because of the rarity of the disease and the lack of large prospective studies, several controversies exist regarding the optimal type of surgery and the use of adjuvant and neoadjuvant therapy. Traditionally, the debate for the extent lymphadenectomy is between transhiatal esophagectomy with 1-field lymphadenectomy (THE-1FL) and transthoracic esophagectomy with 2-field lymphadenectomy (TTE-2FL). The purpose of this study is to evaluate the effect of optimal patient selection for submission to each procedure, on overall survival.

Background: In elective open infrarenal aortic aneurysm repair the use of epidural anesthesia and analgesia may preserve splanchnic perfusion. The aim of this study was to investigate the effects of epidural anesthesia on gut perfusion with gastrointestinal tonometry in patients undergoing aortic reconstructive surgery. Methods: Thirty patients, scheduled to undergo an elective infrarenal abdominal aortic reconstructive procedure were randomized in two groups: the epidural anesthesia group (Group A, n=16) and the control group (Group B, n=14). After induction of anesthesia, a transanally inserted sigmoid tonometer was placed for the measurement of sigmoid and gastric intramucosal CO 2 levels and the calculation of regional-arterial CO 2 difference (ΔPCO 2 ). Additional measurements included mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), and arterial lactate levels. Results: There were no significant intra- and inter-group differences for MAP, CO, SVR, and arterial lactate levels. Sigmoid pH and PCO 2 increased in both the groups, but this increase was significantly higher in Group B, 20 min after aortic clamping and 10 min after aortic declamping. Conclusions: Patients receiving epidural anesthesia during abdominal aortic reconstruction appear to have less severe disturbances of sigmoid perfusion compared with patients not receiving epidural anesthesia. Further studies are needed to verify these results.

Objective The purpose of this study was to evaluate the impact of ATLS ® on trauma mortality in a non-trauma system setting. ATLS represents a fundamental element of trauma training in every trauma curriculum. Nevertheless, there are limited studies in the literature as for the impact of ATLS training in trauma mortality, especially outside the US. Design This is a prospective observational study. The primary end point was to investigate factors that affect mortality of trauma patients in our health care system. We performed a multivariate analysis for this purpose and we identified ATLS certification as a predictor of overall mortality. Following this finding we stratified patients according to the severity of injury as expressed by the ISS score and we compared outcome between those treated by an ATLS certified physician and those treated by non-certified ones. Main outcome measures Trauma volume and demographics of trauma patients, factors that affect mortality of traumatized patients and mortality between patients treated by ATLS ® certified and non-certified physicians. Results In total, 8862 trauma patients were included in the analysis. The majority of trauma patients (5988, 67.6%) were treated by a general surgeon, followed by those treated by an orthopedic surgeon (2194, 24.8%). There were 446 deaths in the registry but, 260 arrived dead in the Emergency Department and were excluded from the analysis. Multivariate analysis of the 186 deaths that occurred in the hospital revealed age, high ISS score, low GCS score, urban location of injury, neck injury and ATLS ® certification as factors predisposing to mortality. Cross tabulation of ATLS ® certification and ISS of the trauma patients shows that those treated by certified physicians died more often in all subcategories of ISS score ( p Conclusions In Greece, with no formal trauma system implementation, ATLS ® certified physicians achieve worse outcomes than their non-certified colleagues when managing trauma patients. We believe that these findings must be interpreted in the context of the National health care system. There is considerable room for improvement in our country, and further analysis is required.

The purpose of this study was to evaluate the incidence of TBI in Greece and to provide evidence on the epidemiologic characteristics of the disease.This is a prospective observational study initiated by the Hellenic Society of Trauma and Emergency Surgery. Thirty hospitals participated in the registry. All trauma patients requiring admission transfer to a higher level centre and those who arrived dead were included in the study. This report evaluated the epidemiologic characteristics of patients with brain trauma, the cause and the severity of the injury and the final outcome.Eight thousand eight hundred and sixty-two patients were included in the registry. Of them, 3383 had at least one brain injury. There were 2451 males and 932 females. Traffic accidents were the leading cause of TBI (54.1%), followed by falls (27.7%). The most affected age group was the 15-44 year olds (48.0%), but TBIs were more lethal in the 45-64 age group (17.8%). Interestingly, a 3.4% mortality was recorded if a TBI was present, even if ISS was relatively low (0-9 ISS group).TBI is a major element of trauma. Knowledge of the epidemiologic characteristics of the disease is imperative for adequate planning and future quality assessment.

Trauma is the most common cause of death to young people and many of these deaths are preventable [1]. The prediction of trauma patients outcome was a difficult problem to investigate till present times. In this study, prediction models are built and their capabilities to accurately predict the mortality are assessed. The analysis includes a comparison of data mining techniques using classification, clustering and association algorithms. Data were collected by Hellenic Trauma and Emergency Surgery Society from 30 Greek hospitals. Dataset contains records of 8544 patients suffering from severe injuries collected from the year 2005 to 2006. Factors include patients' demographic elements and several other variables registered from the time and place of accident until the hospital treatment and final outcome. Using this analysis the obtained results are compared in terms of sensitivity, specificity, positive predictive value and negative predictive value and the ROC curve depicts these methods performance.

The aim of this study is the application of the longitudinal data analysis in real medical data which are referred to the predicted death rate of patients who were hospitalized above four days in an Intensive Care Unit using four different scoring systems. Specifically, these systems estimate the acute disorders in the various organs of patients in combination with their age and history The random effects logistic regression model for binary outcomes was fitted and many useful conclusions were arisen concerning which variables are statistically significant. Also, missing values were replaced with five different ways. The results of both descriptive statistics and multilevel analysis reveal the statistically significant factors which are useful in their practical and clinical application.

Major decisions in the model building for ordinal regression involve the choice of the appropriate link function, as well as the decision for the explanatory variables to be included. This study aims to apply ordinal regression models to medical data used to describe the metabolic disorder alkalosis which is expressed in an Intensive Care Unit. Saturated and nested models are fitted with the use of five different link functions and stepwise methods are also applied. Differences involving variable selection and goodness of fit measures were observed and models were evaluated. A review of two well-known statistical software procedures for data analysis is also presented and useful conclusions are drawn.

In this prospective observational study we present preliminary results of a modification of the translaryngeal tracheostomy technique that was introduced by Fantoni in 1997. The study was conducted in a five-bed surgical intensive care unit of a university teaching hospital. The study included 14 consecutive surgical patients (8 men, 6 women) who underwent a modified translaryngeal tracheostomy in a 6-month period. In our modification of the technique, we keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion, as reported in the classic subcricoid retrograde intubation technique. The technique that we use involves two medical doctors and a nurse. Mean patient age was 68.9 years (range: 31–85 years) and mean APACHE II score was 15.8 (range: 6–31). Mean operative time for the procedure was 15.2 min (range: 11.5–22 min). Eight of the patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in the same hospital stay. Five patients survived to be discharged from the hospital. The modified translaryngeal tracheostomy seems to be as reliable and safe as the original technique. In addition, the modified technique is faster and can be performed without the use of an endoscope.

Hemostasis in thyroid surgery is of utmost importance for a successful surgery and an uneventful postoperative course. The present article reports a single surgeon's 3-year experience in the use of the harmonic scalpel. The device was developed in the early 1990s and offered adequate and safe hemostasis for vessels up to 3 mm in width.This was a prospective observational study. Data sheets from all patients who had surgery by a single endocrine surgeon in the period from 1999 to 2004 were evaluated. Patients were divided into 3 groups based on the surgical technique used: group I comprised the conventional knot-and-tie technique, group II comprised the ligation of all but the superior thyroid vessels with a scalpel, and group III comprised patients in whom the device was used exclusively. The groups were compared in regard to surgical time, cost, and complication rate.A total of 272 patients were included in the study: 107 patients were included in group I, 77 in group II, and 88 group III. The surgical time of group I differed significantly compared with groups II and III (P.0001 in both cases). Surgical times between groups II and III did not differ significantly (P = .701).The use of the harmonic scalpel reduces surgical time, but it increases the cost of the surgery. It is our belief that by including in the absolute cost the time saved and the reduction in human resources needed, the use of the scalpel would prove to be economic.

Summary Chronic heart failure (HF) patients are submitted to non-cardiac surgery with an increased frequency owing to the advanced age of this group. Peri-operative adverse cardiac outcomes ensue as a result of preexisting cardiac disease which is aggravated by the anaesthetic manipulations and the surgical stress. The goal is to optimize preoperatively this fragile group of patients based on the contemporary guidelines for the management of patients with cardiac insufficiency. Pharmacological balancing remains the cornerstone for optimal results, although other modalities, invasive or not, contribute to improved outcome. The absence of strict guidelines for the preoperative management of these patients underlines the complexity and heterogeneity of the problem. Either way, chronic HF patients undergoing non-cardiac surgery constitute a difficult subset, and most probably an individualized approach will reduce postoperative cardiac complications and mortality.

To investigate whether apoptosis is a possible mechanism of brain dysfunction occurring in septic syndrome.Experimental prospective study.Laboratory of Surgical Research at the University of Athens.Male pathogen-free Wistar rats.Rats (n = 112) were subjected to sepsis by cecal ligation and puncture. Sham-operated animals (n = 40) underwent the same procedure but without ligation or puncture. Septic animals were either randomly divided (n = 62) in six groups and studied at 6, 12, 24, 36, 48, and 60 hrs after the operation or monitored (n = 50) for 48 hrs as a survival study group. Sham-operated animals were killed at 6, 12, 24, 36, 48, and 60 hrs after the procedure. Brain and cecum were then removed and postfixed in paraffin sections. Apoptosis was evaluated by light microscopy in hematoxylin and eosin-stained specimens and by transmission electron microscopy. In paraffin-embedded sections, immunostaining for bax, bcl-2, cytochrome c, and caspase-8 was done.In septic rats, increased apoptosis was detected in neurons of the CA1 region of the hippocampus, in choroid plexus, and in Purkinje cells of the cerebellum. Bax immunopositivity was found decreased after the septic insult (p =.03). Bax immunoreactivity was altered as the septic syndrome evolved; it was up-regulated in the early stages (6-12 hrs) and progressively decreased in the late phases (p =.001). Cytochrome c presented a similar regional pattern of expression and was found to be the sole gene marker carrying an independent prognostic role (p =.03). Both bcl-2 and caspase-8 expression remained at constant levels at all times evaluated.There is evidence that more neurons undergo apoptosis during sepsis than in normal brain tissue in certain sites where the blood-brain barrier is compromised. In this phenomenon, mitochondrial gene regulators such as bax and products such as cytochrome c seem to play important regulating and prognostic roles, respectively.

Purpose Caregiving burden affects the lives of family members providing care to patients with advanced cancer, with a host of factors possibly contributing to this. The aim of this study was to explore the effects of patient and caregiver variables on the perceptions of burden in families caring for a loved one living with advanced cancer in Greece. Methods A convenience sample of 100 pairs of patients receiving palliative radiotherapy for advanced cancer and their respective primary family caregivers were consecutively recruited at one radiotherapy centre. Patients and caregivers completed a set of questionnaires during face-to-face interviews. Correlational and multiple regression analyses were performed to identify potential predictors of caregiving burden. Results Caregiving burden was linked to both patient (gender, age, past surgery or chemotherapy treatment, depression and impact of cancer-related symptoms) and caregiver variables (gender, family status, education, place of residence, previous experience of care, employment status, difficulty of caregiving, anxiety and depression). In multiple regression analyses, caregiving burden was significantly predicted by caregivers' depressed mood, perceived difficulty of caregiving, family status, employment status, as well as by patients' past surgery, in a model that explained 49% of the total variance. Conclusions Greek family caregivers reporting greater depressive mood and difficulty with caregiving tasks, those married, those not employed, and those who cared for patients who had not undergone surgery were found at greater distress and disadvantage. Systematic assessment and intervention strategies are required to identify these vulnerable carers and help them cope when sharing in patient's cancer experience.

Υπόβαθρο: Η ποιότητα ζωής των ασθενών με καρκίνο σχετίζεται με τις διαδικασίες της νόσου και της θεραπείας κατά τρόπο αμφίδρομο και πολυπαραγοντικό. Οι μεταβολές της αντίληψης των ασθενών για τους παράγοντες που συμβάλλουν στην ποιότητα ζωής τους κατά τη διάρκεια χημειοθεραπείας δεν έχουν μελετηθεί επαρκώς, παρότι αποτελούν σημαντικό προγνωστικό παράγοντα. Επιπρόσθετα, οι σύντροφοι ασθενών με καρκίνο συμβάλλουν στην επικοινωνία μεταξύ του ασθενή και της θεραπευτικής ομάδας και ταυτόχρονα μετέχουν στη λήψη αποφάσεων και στην παροχή φροντίδας. Παρότι τόσο στην κλινική πράξη όσο και στα πλαίσια ερευνητικών μελετών, καλούνται να παρέχουν την εκτίμησή της για την ποιότητα ζωής των συντρόφων τους που νοσούν, ο βαθμός κατά τον οποίο η εκτίμησή τους σχετίζεται με το βίωμα των ασθενών δεν έχει μελετηθεί. Σκοπός: Οι στόχοι της παρούσας μελέτης ήταν: α) Η εκτίμηση της ποιότητας ζωής ασθενών με καρκίνο του πνεύμονα που υποβάλλονται σε χημειοθεραπεία, β) η εκτίμηση της ποιότητας ζωής των ασθενών αυτών από τους συντρόφους τους, και γ) η σύγκριση των εκτιμήσεων της ποιότητας ζωής των ασθενών και των συντρόφων τους γι’ αυτήν. Μέθοδος: Μέσω διαδικασίας σκόπιμης δειγματοληψίας, μελετήθηκαν 40 ζευγάρια, εκ τον οποίων ο ένας ήταν ασθενής με πρόσφατη διάγνωση καρκίνου πνεύμονα, που ελάμβανε για πρώτη φορά χημειοθεραπεία. Η συλλογή των δεδομένων έγινε με τη συμπλήρωση των ίδιων ερωτηματολογίων από τους ασθενείς και τους συντρόφους τους, σε χωριστά δωμάτια, την ίδια ημέρα, σε τρεις διαφορετικές χρονικές στιγμές: πριν από τον πρώτο χημειοθεραπευτικό κύκλο, στο μέσο της χημειοθεραπείας και μετά τον τελευταίο χημειοθεραπευτικό κύκλο. Τα ερωτηματολόγια που χρησιμοποιήθηκαν στη μελέτη είναι: European Organization for Research and Treatment of Cancer EORTC QLQ-C30 και LC13, Quality of Life Patient Version Scale και Partner Relationship Inventory Form IA και Form IB. Τα μετρικά χαρακτηριστικά των κλιμάκων ήταν ικανοποιητικά. Αποτελέσματα: Τα κυριότερα ευρήματα της μελέτης ήταν α) η επιδείνωση της ποιότητας ζωής των μελετηθέντων ασθενών σε οργανικό, ψυχολογικό και κοινωνικό επίπεδο σύμφωνα με τους ίδιους και τους συντρόφους τους κατά τη διάρκεια της χημειοθεραπείας (p

Aim: The aim of this study was to detect circulating anti-carcinoembryonic antigen antibodies (anti-CEA) in breast cancer patients and to evaluate their clinical and prognostic significance. Methods: Fifty-two breast cancer patients and 28 controls were included in this study. Detection of anti-CEA antibodies was performed using a modified enzyme linked immunoassay (ELISA). Sensitivity, specificity and usefulness index of anti-CEA antibodies were compared to those of CEA. The correlation of anti-CEA antibodies with survival and recurrence-free survival was tested with univariate and multivariate analysis. Results: Anti-CEA was present in 57% of breast cancer patients and in 11% of controls. The sensitivity and usefulness index of anti-CEA were significantly better than those of CEA. The specificity of anti-CEA antibodies was less than that of CEA, the difference not being statistically significant. Anti-CEA antibodies were an independent statistically significant, favourable factor in recurrence-free survival. Conclusion: Anti-CEA antibodies circulate in breast cancer patients. They could be used as a more sensitive tumour marker than CEA. Their presence is associated with improved recurrence-free survival. These results should be confirmed in a larger series.

Objective: To evaluate Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II scoring systems in a single intensive care unit (ICU), independent from the ICUs of the developmental sample; and to compare the performance of APACHE II and SAPS II by means of statistical analyses in such a clinical setting. Design: Prospective, cohort study. Setting: A single ICU in a Greek university hospital. Patients: In a time interval of 5 yrs, data for 681 patients admitted to our ICU were collected. The original exclusion criteria of both systems were employed. Patients

To present a new technique of end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent.We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity.There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality.This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.

Introduction. Colonic metastasis following curative surgery for renal cell carcinoma has rarely been described in the literature. Case Presentation. We present a case of a 64-year-old man who previously had a left nephrectomy for renal cell carcinoma. Five months post-operatively the patient presented with microscopic intestinal bleeding and anemia. Colonoscopic surveillance revealed a metastatic lesion in the ascending colon, and a right hemicolectomy was subsequently performed. Discussion. Colonic metastasis following resection for renal cell carcinoma is a rare entity, as evidenced by its lack of description in the literature. Imaging scans, such as computed tomography, have little diagnostic value and an increased medical suspicion is warranted for prompt diagnosis.

A number of experimental protocols have been used to try to reproduce the clinical scenarios of hemorrhagic shock. The present study reports on an experimental swine model of controlled hemorrhagic shock that incorporates microdialysis monitoring for the evaluation of tissue perfusion and oxygenation. The aim of our study was to provide a reproducible, accurate, and reliable model for the testing and evaluation of therapeutic interventions in the area of hemorrhagic shock.Landrace swine (n = 8) were subjected to controlled hemorrhagic shock, with a mean arterial pressure of 35 ± 5 as the endpoint. Six more pigs were used as the control group. Microdialysis monitoring of the tissue lactate/pyruvate ratio was used. The mean arterial pressure, heart rate, hematocrit, hemoglobin, and lactate/pyruvate ratio measurements were obtained just before (phase A) and 30 min after (phase B) hemorrhage in the study group; the control group underwent the same measurements at the corresponding points.The mean arterial pressure, hematocrit, and hemoglobin were lower (P0.05) in the study group than in the control group at phase B and compared with the values for the study group at phase A. Also, the lactate/pyruvate ratio and heart rate were greater (P0.05) in the study group than in control group at phase B and compared with the values for the study group at phase A.This model of hemorrhagic shock is effective and correlates with the clinical parameters of tissue oxygenation, as documented by microdialysis.

Introduction Intramuscular myxoma is a rare benign soft tissue tumor. The lack of specific symptoms and widely used laboratory tests makes the diagnosis quite difficult. We present a case of an Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level. To the best of our knowledge, there have not been any reported cases of an association of Intramuscular myxoma with tumor markers in the literature. Case presentation A 45-year-old Caucasian woman presented to our department for resection of a mass in her left groin area, discovered incidentally on a triplex ultrasonography of her lower extremities. The diagnosis of Intramuscular myxoma was confirmed on histopathology after the complete surgical excision of the tumor. On laboratory examination, the serum level of carbohydrate antigen 19.9 was found to be elevated, but it returned to normal six months after resection of the mass. Conclusion Carbohydrate antigen 19.9 is a tumor marker that increases in a variety of malignant and benign conditions. After the exclusion of all other possible reasons for carbohydrate antigen 19.9 elevation, we assumed a possible connection of carbohydrate antigen 19.9 elevation and Intramuscular myxoma, an issue that requires needs further investigation.

Transanal excision of rectal polyps with laparoscopic instrumentation and a single incision laparoscopic port is a novel technique that uses technology originally developed for abdominal procedures from the natural orifice of the rectum. Transanal endoscopic microsurgery (TEM) is a well established surgical approach for certain benign or early malignant lesions of the rectum, under specific indications. Our technique is a hybrid technique of transanal surgery, a reasonable method for polyp resection without the need of the sophisticated and expensive instrumentation of TEM which can be applied whenever endoscopic or conventional transanal surgical removal is not feasible.

Administration of immuno-enhanced nutritional support may decrease postoperative morbidity, mortality, and infectious complications in cancer patients. The aim of this study was to verify that perioperative enteral diet, enriched with the nutrients arginine, ribonucleic acid (RNA), and omega-3 fatty acids improves outcomes of head and neck cancer patients undergoing major surgery. Forty patients with squamous cell carcinoma of the head and neck were studied. Group 1 received no preoperative nutritional support, whereas Group 2 received an oral formula with nutrients arginine, RNA, and omega-3 fatty acids. After surgery, Group 1 received a standard enteral formula, whereas Group 2 received an enriched enteral formula. Albumin (g/dl), prealbumin, fibrinogen, CRP, Il-6, and TNFa were measured 5 days before and 8 days after surgery. No statistically significant difference was observed for all the evaluated markers between postoperative and preoperative levels for both groups. The rate of complications was significantly reduced in the total number of patients receiving immunonutrition and in the particular subgroup of well-nourished patients receiving an immuno-enhanced diet. Perioperative enteral immuno-enhanced feeding in head and neck cancer patients undergoing major surgery may influence the postoperative outcomes by reducing the frequency rate of infections and wound complications. Nutr Cancer

Background Trauma is a leading cause of death worldwide and a major health problem of the modern society. Trauma systems are considered the gold standard of managing patients with trauma. An integral part of any trauma system is a trauma registry. In Europe, and particularly in Greece, trauma registries and systems are in an embryonic stage. In this study, we present an attempt to record trauma in Greece. Methods The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. In succeeding meetings of the representatives, the reporting form was developed and the inclusion criteria were defined meticulously. Inclusion criteria were defined as patients with trauma requiring admission, transfer to a higher level center, or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic database, and analyzed. Results Thirty-two hospitals receiving patients with trauma participated in the country, representing 40% of the country's healthcare facilities and serving 40% of the country's population. In 12 months time, (October 2005 to September 2006), 8,862 patients were included in the study. Of them, 66.9% were men and 31.3% were women. The compilation rate of the reporting forms was surprisingly high, considering that the final reporting form included 150 data points and that there were no independent personnel in charge of filling the forms. Conclusions Trauma registries are feasible even in health care systems where funding of medical research is sparse.

Aim of the study The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals. Methods The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational. Results In total 8862 patients were included in the study in 12 months time. Of them 68.7% ( n =6084) were male, aged 41.8±20.6 (mean±S.D.) and 31.3% were female ( n =2778), aged 52.7±24.1 (mean±S.D.). The mean duration of treatment in the emergency room department was 1h and 28min. Of the total number of patients, 2312 (26.1%) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident. Conclusions Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered.

Heart failure (HF) is a major cause of perioperative morbidity and mortality in noncardiac surgery. Preoperative optimisation of these patients is, thus, of utmost importance. Levosimendan seems promising for patients undergoing cardiac surgery; however, its safety and efficacy in HF patients undergoing noncardiac surgery have not been evaluated.To evaluate the effects of prophylactic preoperative levosimendan administration on left ventricular function in HF patients undergoing noncardiac surgery.HF patients with ejection fraction30%undergoing elective noncardiac surgery in 2005 were included in this prospective study. Patients were admitted to our surgical intensive care unit one day preoperatively. Under continuous haemodynamic monitoring, the treatment protocol consisted of an initial loading dose (24 microg/kg) for ten minutes followed by a continuous 24-hour infusion (0.1 microg/kg/min) at the end of which patients underwent surgery. Echocardiography was performed before infusion (day 0) and on the 7th postinfusion day (day 7). Measurements included left ventricular ejection fraction (LVEF), velocity time integral(VTI), pre-ejection period (PEP), ejection time (ET),maximum (Pmax) and minimum P(min) transvalvular aortic pressure gradient, and maximum (Vmax) and minimum V(min) aortic velocity.Twelve consecutive patients were enrolled. Levosimendan resulted in a significant increase in LVEF,VTI, P(max), P(min), V(max), and V(min) (p0.01) and, moreover, a significant reduction in PEP, ET, and PEP/ET (p=0.04) on day 7 compared with day 0 values. No adverse reactions,complications or mortality occurred during 30-day follow-up.Prophylactic preoperative levosimendan treatment may be safe and efficient for perioperative optimisation of heart failure patients undergoing noncardiac surgery.

To evaluate the impact of the perioperative administration of norepinephrine on the perfusion of the esophageal graft. This is an experimental study. Six swine underwent transhiatal esophagectomy; the stomach was used to replace the resected esophagus. We provoked hemorrhagic shock to the animals and then we administered noradrenaline to restore the blood pressure. We monitored the graft perfusion perioperatively using the technique of microdialysis. In all animals, the graft experienced severe hypoperfusion after the administration of noradrenaline that was statistically significant. Our data support the hypothesis that norepinephrine should be used with extreme caution in the perioperative setting after esophagectomy. Further studies, however, will be required to evaluate the clinical significance of this finding.

Background Apoptosis represents a physiological clearance mechanism in human tissues. The role of apoptosis has not been examined in normal lung cell populations, such as alveolar macrophages and polymorphonuclear cells. What is the percentage, as well as the role, of apoptosis in the alveolar microenvironment of the healthy human lung? Patients and methods Bronchoalveolar lavage was obtained from 21 volunteers without lung disease. The specimens were analyzed using: Annexin V binding, DNA laddering, light microscopy and immunohistochemistry for bcl-2 expression. Results Apoptosis of the total bronchoalveolar lavage cell population was 51.2%. Both alveolar macrophages and polymorphonuclear cells had a high apoptotic rate (62.1% and 48.3%, respectively) as determined by Annexin V binding. These findings were further confirmed using morphological criteria for apoptosis and gel electrophoresis for DNA fragmentation. In the majority of the individuals examined, (8 out of 21), the bcl-2 gene was expressed in the lymphocyte population mainly. Conclusions The percentage of apoptosis in lung cells of healthy humans is high. Apoptosis plays a key role in normal lung cell death. It appears to be the mechanism that opposes cell proliferation by eliminating, aged or damaged cells thus facilitating the process of lung remodeling.

Purpose Descending necrotizing anterior mediastinitis (DNAM) is a severe infectious disease with a very high mortality rate. The aim of this study was to define the impact of several clinical factors on survival. Patients and Methods Between 1985 and 2002, 27 patients were managed for DNAM, 11 with combined transthoracic mediastinal and cervical drainage (group A) and 16 with a less aggressive surgical approach, such as cervical drainage and transcervical mediastinal drainage (group B). The records of all patients were statistically analyzed for the impact of several clinical factors on survival. Results Although patients in group A were admitted to the hospital faster, treated with antibiotics as outpatients earlier, and operated on much sooner after hospital admission compared with the patients in group B, multivariate analysis revealed that early combined transthoracic mediastinal and cervical debridement and drainage was the only favorable factor for survival in patients DNAM patients (odds ratio = 9.99; 95% confidence interval = 1.02 to 97.49). Conclusions Less extensive surgical approaches (ie, thoracic drainage without cervical drainage or combined cervical and subxiphoid thoracic drainage) led to unsatisfactory results and high reoperation rates. In contrast, early, aggressive combined cervical and thoracic drainage proved to be an effective method for managing DNAM.