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1.  Involuntary euthanasia of severely ill newborns: is the Groningen Protocol really dangerous? 
Hippokratia  2014;18(3):193-203.
Advances in medicine can reduce active euthanasia of newborns with severe anomalies or unusual prematurity, but they cannot eliminate it. In the Netherlands, voluntary active euthanasia among adults and adolescents has been allowed since 2002, when the so-called Groningen Protocol (GP) was formulated as an extension of the law on extremely premature and severely ill newborns. It is maintained that, at bioethical level, it serves the principle of beneficence. Other European countries do not accept the GP, including Belgium. Admissibility of active euthanasia is a necessary, though inadequate, condition for acceptance of the GP. Greece generally prohibits euthanasia, although the legal doctrine considers some of the forms of euthanasia permissible, but not active or involuntary euthanasia. The wide acceptance of passive newborns euthanasia, especially when the gestational age of the newborns is 22-25 weeks ("grey zone"), admissibility of practices within the limits between active and passive euthanasia (e.g., withholding/withdrawing), of "indirect active euthanasia" and abortion of the late fetus, the tendency to accept after-birth-abortion (infanticide) in the bioethical theory, the lower threshold for application of withdrawing in neonatal intensive care units compared with pediatric intensive care units, all the above advocate wider acceptance of the GP. However, the GP paves the way for a wide application of involuntary (or pseudo-voluntary) euthanasia (slippery slope) and contains some ambiguous concepts and requirements (e.g., "unbearable suffering"). It is suggested that the approach to the sensitive and controversial ethical dilemmas concerning the severely ill newborns is done not through the GP, but rather, through a combination of virtue bioethics (especially in the countries of the so-called "Mediterranean bioethical zone") and of the principles of principlism which is enriched, however, with the "principle of mutuality" (enhancement of all values and principles, especially with the principles of "beneficence" and "justice"), in order to achieve the "maximal" bioethical approach, along with the establishment of circumstances and alternatives that minimize or eliminate the relevant bioethical dilemmas and conflicts between the fundamental principles. Thus, the most appropriate/fairest choices are made (by trained parents and physicians), considering all interests involved as much as possible. Hippokratia 2014; 18 (3): 196-203.
PMCID: PMC4309136
Active euthanasia; newborn; neonatal; Groningen Protocol; bioethics; virtue ethics; principlism; beneficence; withholding; withdrawing
2.  Management and investigation of viral gastroenteritis nosocomial outbreaks: lessons learned from a recent outbreak, Greece, 2012 
Hippokratia  2014;18(3):204-208.
A nosocomial outbreak in a 740-bed hospital in Athens, Greece, was investigated in January-February 2012.
Recommendations on infection control measures were given and two case-control studies were conducted among patients (study A) and health care workers (HCWs) (study B). Compliance to control measures was evaluated.
The absence of a routine recording system of nosocomial-acquired gastroenteritis cases led to a 10 days delay in outbreak identification. In total, 63 gastroenteritis cases were identified; 30 HCWs and 33 patients. In the multivariable analysis of study A the disease incidence among patients was statistical significantly associated with a prior incident of vomitus in their room (OR=7.96, 95% CI=1.29-49.2). In study B, the incidence was associated with the history of direct contact with a symptomatic patient (OR=3.03, 95%CI 1.01-9.12). Twenty one (75%) of the symptomatic HCWs reported absence from work for a median of 2 days (range: 1-4). Seven (25.0%) continued to work despite being symptomatic. Only, 11.1% of patients were isolated or cohorted after developing symptoms. In-hospital virological testing was not feasible and one specimen sent to a university laboratory was positive for norovirus.
An appropriately designed protocol regarding the detection, the management and the laboratory investigation of nosocomial gastroenteritis outbreaks should be followed in order effective containment to be reassured. Hippokratia 2014; 18 (3): 204-208.
PMCID: PMC4309137
gastroenteritis; outbreak; nosocomial; hospital; norovirus
3.  Vascular access in hemodialyis patients - registry data 
Hippokratia  2014;18(3):209-211.
The use of arteriovenous fistula over a central venous catheter in hemodialysis patients is recommended whenever possible. It has become the gold standard among all the available permanent vascular accesses for hemodialysis as it is associated with less complications. The aim of our study was to analyze the type of vascular access in hemodialysis patients in our country, FYR of Macedonia and to see its association with other variables recorded by the National Renal Registry in 2009.
Material and methods:
Data were collected by 18 hemodialysis centers in the country. A total of 1,457 patients were analyzed. One hundred and ninety one patients were incident, and 164 out of 1,457 died during the year. Except for 9 patients, all the others had data on type of vascular access, as well as data on any vascular access intervention performed during the year.
The overall mean age was 58.8 ± 13.1 years. Eighty-nine percent of the non-incident patients (prevalent plus those who died during the year) had arteriovenous fistula, 10.6% central venous catheter and 0.2% vascular graft. When incident to non-incident patients were compared, incident patients were significantly older, had significantly higher mortality and significantly lower percentage of arteriovenous fistula. Patients with arteriovenous fistula had significantly longer dialysis vintage and significantly less deaths compared to those with central venous catheters.
The study showed that the number of non-incident hemodialysis patients with arteriovenous fistula in the country was high. The incident hemodialysis patients have high number of central venous catheters as vascular access for hemodialysis and significantly higher mortality compared to non-incident patients. Hippokratia 2014; 18 (3): 209-211.
PMCID: PMC4309138
vascular access; hemodialysis; arteriovenous fistula
4.  Nutrition assessment of children with advanced stages of chronic kidney disease-A single center study 
Hippokratia  2014;18(3):212-216.
Malnutrition is a major problem among children with Chronic Kidney Disease (CKD) and it is essential to be recognized as early as possible. Aim of our study was to assess the nutrition status of children with CKD.
Nutrition status of 30 children (1-16 years) with CKD stages IIIV and on peritoneal dialysis was evaluated. Malnutrition risk was assessed by Pediatric Digital Scaled MAlnutrition Risk screening Tool (PeDiSMART) score software.Anthropometry was expressed as Z-scores for age and sex. Phase angle (PhA) and body cell mass were assessed by bioelectrical impedance analysis (BIA). Three-day food intake was recorded and analyzed. Biochemical indexes were assessed.
Depending on the marker used for assessment 20-40% of our patients were malnourished. Intake/requirements ratio (median) was 86.5% for actual energy intake and 127% for actual protein intake. Multiple regression analysis has shown that the most determinant factor for Mid Upper Arm Circumference (MUAMC) was actual protein intake, Glomerular Filtration Rate (GFR) and age at diagnosis. PhA was mainly affected by GFR and energy intake. Statistically significant inverse correlation was found between PeDiSMART score and PhA (p=0.001), MUAMC (p=0.008) as well as protein intake (p=0.016).
A considerable proportion of children with advanced CKD are undernourished. Regular dietitian evaluation based on novel tools as PeDiSMART score and PhA may identify earlier patients at risk for malnutrition. Hippokratia 2014; 18 (3): 212-216.
PMCID: PMC4309139
malnutrition; anthropometry; phase angle; PeDiSMART score
5.  Evaluation of use of antibiotics without prescription among young adults in Albania case study: Tirana and Fier District 
Hippokratia  2014;18(3):217-220.
Self-medication is defined as the utilization of drugs to treat self-diagnosed disorders or symptoms, or the irregular or continuous use of a prescribed drug for chronic or repeated diseases or symptoms. The main problem with self-medication with antimicrobials is the emergence of pathogenic resistance. Antimicrobial resistance is an existing problem world-wide, mainly in developing countries. The aims and objectives of the study presented in this article are to evaluate the prevalence of purchase of antibiotics without prescription and appropriateness of use among adults and to determine the impact of the education level on the sensibility level over the use of antibiotics.
This was a questionnaire based study of 3 month duration. The study includes data from 350 young adults (182 men/172 women, mean age ± SD: 34.72 ± 13.7 years), who visited ten different pharmacies located in the city of Tirana and the "Olympus" Private Medical Clinic in Fier between December 2012 and March 2013. Also a part of questionnaires was distributed by e-mail.
The results of this study showed that out of 350 young adults, 273 (78.14%) of them used antibiotics as self medication. The most common reasons for self administration of antibiotics were fever 171 (29.23%), sore throat 170 (29.06%) and cough 83 (14.19%). In this study we observed that the most common source of information regarding self-medication is the pharmacy (community pharmacists) 166 (36.40%) and most common antibiotic used as self-medication is amoxicillin 70 (19.39%). Authors also determined the impact of education level over the use of antibiotics. The results showed that adults with low and medium education level (7.986% and 43.056% respectively) were most likely to use antibiotics as self-medication.
The findings from this study highlight the striking prevalence of self-medication among young adults in Albania and the lack of awareness about the risks associating their use. We recommend that a holistic approach must be taken to prevent this problem from escalating which would involve awareness and education regarding the implications of self medication, strategies to prevent the supply of medicines without prescription by pharmacies and strict rules regarding pharmaceutical advertising.Hippokratia 2014; 18 (3): 217-220.
PMCID: PMC4309140
Antibiotics; self medication; resistance; questionnaire study
6.  Low Density Lipoprotein transport in the normal human aortic arch 
Hippokratia  2014;18(3):221-225.
To understand the genesis and progression of atherosclerosis is essential to elucidate the blood flow and the transport of molecules in the cardiovascular system. The purpose of this computational study is to elucidate the relationship between low wall shear stress (WSS) - high site concentration of low density lipoproteins (LDL) and atherosclerotic sites in the normal human aortic arch under physiological flow and mass transport conditions.
The numerical simulation couples the flow equations with the transport equation applying realistic boundary conditions at the wall in terms of blood-side concentration. The blood is considered to be non-Newtonian fluid obeying to the power law. Suitable mass transport conditions are specified at the wall.
Aortic arch walls are exposed to cholesterolemic environment although the applied mass and flow conditions refer to normal human geometry and normal mass-flow conditions. The luminal surface LDL concentration varies inversely with the WSS. Regions of high LDL luminal surface concentration do not necessarily co-locate to the sites of lowest WSS. Concave sides of the aortic arch exhibit, relatively to the convex sides, elevated concentration of the LDL. The area averaged normalized LDL concentration over the entire normal aortic arch is 1.267. The daughter aortic arch vessels exhibit, relatively to the main aorta, elevated LDL concentrations.
The near wall paths of the velocities might be the most important factor for the elevated LDL concentration at areas located either at the vicinity of bifurcations regions or at high curvature regions. Hippokratia 2014; 18 (3): 221-225.
PMCID: PMC4309141
LDL transport; wall shear stress; atherosclerosis; aortic arch; normal; human
7.  Therapeutic hypothermia in asphyxiated neonates with hypoxic-ischemic encephalopathy: A single-center experience from its first application in Greece 
Hippokratia  2014;18(3):226-230.
Therapeutic hypothermia has become an established therapy in asphyxiated neonates with evidence of moderate/severe hypoxic-ischemic encephalopathy. Herein, we describe our recent experience with total body cooling in asphyxiated neonates, which is the first relevant report in Greece.
Patients and Methods:
The medical records of all asphyxiated newborns treated with therapeutic hypothermia in our center between September 2010 and October 2013 were retrospectively reviewed. We recorded data related to neonatal-perinatal characteristics, whole body cooling and outcome.
Twelve asphyxiated neonates [median gestational age 38 weeks (36-40)] received whole body cooling (rectal temperature 33.5 ± 0.5 oC for 72 hours) during the study period for moderate (n=3) and severe (n=9) hypoxic-ischemic encephalopathy. Cooling was passive in 4 and active in 8 (66.7%) cases. Therapeutic hypothermia was initiated at the median age of 5 hours (0.5-11) after birth. Seven neonates survived (58.3%) to hospital discharge. On follow-up (7-35 months), neurodevelopment outcome was normal in 1 case, while 3, 1 and 2 subjects had mild, moderate and severe impairment, respectively.
Our initial experience with whole body cooling supports its beneficial effect in asphyxiated neonates. This treatment should be offered in all centers involved in the care of such neonates using either simple means (passive cooling) or automated cooling devices. Hippokratia 2014; 18 (3): 226-230.
PMCID: PMC4309142
neonatal encephalopathy; neonatal care; perinatal asphyxia
8.  Acute inflammatory arthritis in the elderly; Old flames, new sparks 
Hippokratia  2014;18(3):231-233.
The overall world prevalence of rheumatoid arthritis (RA) ranges from 0.5-1.0%. The annual incidence of RA in most European countries ranges from roughly 0.4 to >2.5 per 1,000 adults, increasing with age. A significant proportion of newly diagnosed cases will evolve into true erosive RA.
The aim of this cohort study was to study the characteristics of new developing, acute (<1 year), rheumatoid arthritis in an elderly (>65 years) population; its presenting features, accompanying manifestations and laboratory findings. One hundred twenty eight patients (103♀, 25♂) who presented to the rheumatology outpatients clinic with new-onset RA were included in the study. 42.2% of the patients had pre-existing osteoarthritis.
At presentation, 14.3% of the patients had systemic manifestations (fever, weight loss), 25.78% reported concomitant sicca symptomatology, and 50.9% were found to have abnormal haematological parameters (anemia and/or thrombocytosis). Clinical and laboratory parameters of the disease were analyzed and related to disease manifestations.. Haematological abnormalities were found to be associated both with increased inflammatory markers, as well as with increased titres of rheumatoid factor (RF), but not anti - cyclic citrullinated peptide (CCP) antibodies, in contrary to systemic manifestations which were not found to be related to the above mentioned parameters.
As the global population is becoming older, physicians will be challenged with the recognition and treatment of these conditions and their particular features in an increasing number of geriatric patients; within the context of the specific characteristics and comorbidities of this age group. Hippokratia 2014; 18 (3): 231-233.
PMCID: PMC4309143
Inflammatory arthritis; elderly; presentation; characteristics
9.  The effect of Antithrombin-III on routine hematological and biochemical parameters in an experimental animal model of skeletal muscle ischemia-reperfusion injury 
Hippokratia  2014;18(3):234-239.
Antithrombin III (AT-III) has been shown to attenuate the local and systemic harmful effects of skeletal muscle ischemia-reperfusion (I-R) injury. The aim of the present study was to monitor the fluctuation of routine hematological and biochemical parameters in an experimental animal model of tourniquet-induced skeletal muscle I-R injury and to investigate how these are influenced by the protective administration of AT-III.
Sixty male Wistar rats were submitted to a 6-hour, tourniquet-induced, complete ischemia of the right hind-limb. Animals were divided into those receiving AT-III (dose, 250 IU/kg) 30 minutes before the reperfusion (group A, n=30) and those receiving placebo (group B, n =30). Another 10 animals were sham-operated (group C). White blood cell (WBC) and platelet (PLT) count, aspartate and alanine aminotransferases (AST and ALT), alkaline phosphatase (ALP), and γ-glutamyl transferase (γ-GT) were estimated in blood samples taken from the inferior vena cava at 3 different time points post-reperfusion (at baseline, at 30 minutes and at 4 hours) and groups A and B were compared using the Mann-Whitney U test.
There were no statistically significant differences between the AT-III and the placebo groups at 0, 30 minutes and 4 hours with regard to the WBC, ALT and γ-GT levels, however, there was a significant decrease of AST levels 4 hours post-reperfusion in the AT-III group compared to the placebo group (p=0.002). An increased PLT count and ALP levels 30 minutes post-reperfusion were also noted in the AT-III group compared to placebo (p<0.001; and p=0.001, respectively).
Of the routine hematological and biochemical parameters tested, AST was found to be significantly suppressed at 4 hours in the AT-III-treated animals, suggesting a possible beneficial effect of AT-III in mouse skeletal muscle I-R injury. The effect of AT-III on PLTs and ALP levels merits further investigation. Hippokratia 2014; 18 (3): 234-239.
PMCID: PMC4309144
Experimental study; lower limb; ischemia-reperfusion; skeletal muscle; antithrombin-III
10.  Endogenous subclinical hyperthyroidism may not lead to bone loss in premenopausal women 
Hippokratia  2014;18(3):240-244.
Osteoporosis is defined as the decrease in bone mineral density. It is a serious health problem showing the predisposed person with increased bone fracture risk. Hyperthyroidism is one of the major causes of secondary osteoporosis. The aim of this study was to assess bone mineral density in premenopausal women with endogenous subclinical hyperthyroidism.
A total of 168 subjects were included in this case-control study, of whom 86 and 82 participants were premenopausal women with subclinical hyperthyroidism and healthy premenopausal subjects, respectively. The patients with subclinical hyperthyroidism who were not receiving L-thyroxine treatment were included. The women in postmenopausal state or having chronic disease were excluded. The bone mineral densities of all subjects with dual energy X-ray absorptiometry were examined.
The Z scores (femur and L1-4) of the study group were -0.15 ± 1.15 and -0.23 ± 1.03, respectively. The Z scores of the control group were -0.39 ± 1.08 and -0.55 ± 0.98, respectively. The differences between the groups were not statistically significant (p=0.14, 0.34, respectively).
Our data suggest that contrary to exogenous subclinical hyperthyroidism, endogenous subclinical hyperthyroidism may not decrease bone mineral density in premenopausal women and it may not a risk factor for osteopenia or osteoporosis. Hippokratia 2014; 18 (3): 240-244.
PMCID: PMC4309145
Subclinical hyperthyroidism; bone mineral density; premenopausal women
11.  Observation of short-term catheter induced thrombosis in children treated with blood purification 
Hippokratia  2014;18(3):245-250.
No studies have assessed the safety of short-term catheter-induced thrombosis in children treated with blood purification. The aim of this study was to determine the incidence and evolution of thrombosis in the children.
One hundred nineteen (119) children treated with blood purification were enrolled. The data of baseline characteristics, coagulation status and type of catheters were recorded. Thrombosis- related symptoms and signs, ultrasound examinations of the right femoral veins were followed for 2 months. The relationship between associated risk factors (age, sex and type of catheters) and thrombosis was analyzed.
Of the 119 patients, 95 (79.8%) developed deep venous thrombosis (DVT) in the right external iliac veins. In only one patient it was clinically obvious. The incidence of thrombosis had no significant difference between the following subgroups: 1. Children under 6 years (14/15, 93.3%), 6-12 years (63/78, 80.7%) and above 12 years (18/26, 69.2%) (p=0.436); 2. Male (57/66, 86.3%) and female patients (38/53, 71.6%) (p=0.448); 3. Children catheterized with 8F (52/63, 82.5%) and 11F catheters (43/56, 76.7%) (p=0.435). Thrombolysis was achieved in 77 cases (77/80, 96.3%) with treatment of oral dipyridamole at one month and 80 cases (100%) at two months.
Children treated with blood purification through short-term femoral venous catheters have an increased risk of developing DVT, which is usually asymptomatic and good in prognosis. Hippokratia 2014; 18 (3): 245-250.
PMCID: PMC4309146
Deep venous thrombosis; femoral venous catheters; blood purification; hemoperfusion; children
12.  Computer-assisted evaluation of Mandibular Cortical Width (MCW) index as an indicator of osteoporosis 
Hippokratia  2014;18(3):251-257.
To assess the diagnostic accuracy of mandibular cortical width (MCW) as an indicator of the presence of osteoporosis.
Materials and methods:
The study included 343 women between 45-75 years of age. After informed consent, all subjects underwent dual energy X-ray absorptiometry (DXA) of the hip and the lumbar spine (L1 to L4) in order to establish a gold standard diagnosis of osteoporosis and an orthopantomogram (OPG).
From the initial subjects, 28 (8.2%) did not meet the inclusion criteria. In the final sample 315 patients were included, of whom 293 were postmenopausal (93.3%) and 22 perimenopausal (6.7%). Based on the DXA examination the sample was divided into three groups: a)normal controls (n=106), b)osteopenics (n=103) and c)osteoporotics (n=106). The MCW index was calculated by three different observers using the Emago image processing software. Inter - rater agreement was considered important since MCW was being tested as a possible screening tool for osteoporosis.
Comparisons of MCW values between normal controls, osteopenic and osteoporotic women in our sample showed that these values clearly differentiate between the three groups, especially between normal and osteoporotic subjects. Furthermore, the receiver operator characteristic curve (ROC) analysis showed this to hold true in real diagnostic terms, giving a threshold value of 3.24 for differentiating between normal and osteoporotic women.
With ROC values ranging between 0.80 and 0.87 we can reasonably assume that the MCW index is a reliable indication of the presence of osteoporosis in a patient. Hippokratia 2014; 18 (3): 251-257.
PMCID: PMC4309147
osteoporosis; panoramic radiographs; mandibular cortical width; dual energy X-ray absorptiometry; radiomorphometric indices
13.  Uterine artery embolization for treatment of symptomatic fibroids; a single institution experience 
Hippokratia  2014;18(3):258-261.
Uterine fibroids are the most common reproductive tract tumours in females. Uterine artery embolization (UAE) is a fertility-sparing procedure for treatment of symptomatic fibroids. We evaluated the efficacy and safety of UAE in the treatment of 118 patients with symptomatic uterine fibroids in a single Academic Centre in the West of Ireland to determine whether fibroid and uterine size affect clinical outcomes and complications.
This was a retrospective cohort of 118 patients who underwent UAE for treatment of symptomatic fibroids between November 2006 and August 2011. Diagnosis of fibroids in symptomatic patients was established by magnetic resonance imaging (MRI) and/or transabdominal ultrasonography (US). Three different embolic agents were used. All patients had at least one follow-up using MRI, at three and/or 12 months. A non-validated questionnaire was used to report patient satisfaction with regards to symptoms improvement on a yes-or-no basis.
Mean fibroid volume, uterine size and dominant fibroid size were significantly reduced at three months and one year follow-up (p = 0.00) and that was tallied with symptoms improvement (p < 0.05). Overall patient satisfaction at three months was 84% falling to 75.9% by 12 months (all p < 0.05). Few complications were reported (2.5%). No significant difference was observed in safety or efficacy for different embolic agents.
The study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids. Hippokratia 2014; 18 (3): 258-261.
PMCID: PMC4309148
Uterine fibroid embolization; menorrhagia; leiomyoma
14.  Alpha1-microglobulin as an early biomarker of sepsis-associated acute kidney injury: a prospective cohort study 
Hippokratia  2014;18(3):262-268.
Sepsis emerges as the leading risk factor for acute kidney injury (AKI) development in critically ill patients. Much effort has been invested so far on early diagnosis of AKI using promising biomarkers. This study aimed to determine whether urine alpha1-microglobulin (α1m), a lipocaline member previously used as an indicator of proximal tubular dysfunction, can early predict the development of sepsis-associated AKI (SAAKI) in critically ill patients.
A prospective, observational study was conducted in a single center Intensive Care Unit (ICU). Patients with normal renal function admitted to the ICU followed for sepsis and AKI development. Urine α1m levels were analyzed in pooled samples from 24-hour urine collections on sepsis onset and at various time points thereafter. The diagnostic performance of urine α1m was assessed using thenonparametriccalculation of the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.
Among 286 critically ill patients admitted to our ICU in a year, 45 patients with sepsis met the inclusion criteria. SAAKI developed in 16 septic patients (35.6%). Urine α1m levels were significantly elevated in all septic patients (average value of all samples on the day of sepsis: 46.02 ± 7.17 mg/l) and showed a trend to increase in patients who finally developed SAAKI. The AUC for SAAKI prediction according to α1m urine levels 24-hours before SAAKI onset was 0.739 (sensitivity 87.5%, specificity 62.07%, cutoff level 47.9 mg/l). Urine α1m 24-hours before SAAKI, serum creatinine on sepsis onset and Acute Physiology and Chronic Health Evaluation II (APACHE II) score on sepsis onset emerged as the most powerful independent predictors of SAAKI. The combination of these three parameters improved the AUC for SAAKI prediction to 0.944.
Urine α1m levels might help in the early prediction of SAAKI development and may prove useful biomarker. The pathogenetic implications of α1m in sepsis and SAAKI need further investigation. Hippokratia 2014; 18 (3): 262-268.
PMCID: PMC4309149
Acute kidney injury; Sepsis; Critically ill patients; Urinary biomarkers; alpha1-microglobulin
15.  Evaluation of potential salivary acetaldehyde production from ethanol in oral cancer patients and healthy subjects 
Hippokratia  2014;18(3):269-274.
Acetaldehyde has been implicated as a major factor in oral carcinogenesis associated with alcohol consumption. In this study, saliva samples from oral cancer patients and healthy individuals were incubated in vitro with ethanol in order to investigate factors which can influence salivary acetaldehyde production.
Materials and Methods:
A total of 66 individuals (40 males and 26 females, mean age 52 years) participated in the study. Participants were classified into three groups: Group 1 (oral cancer patients [n = 20]); Group 2 (poor dental health status [n = 25]) and Group 3 (good dental health status [n=21]). Every patient chewed a 1g piece of paraffin chewing gum for 1 minute then saliva samples were collected from all individuals. After in vitro incubation of the samples with ethanol, the levels of salivary acetaldehyde production was measured by head space gas chromatography. Kruskal-Wallis and Mann-Whitney tests and Spearman's Correlations analysis were performed for statistical analyses.
The salivary acetaldehyde production was significantly higher (p <0.0001) in both group 1 and group 2 when compared to group 3. However, there was no significant difference between group 1 and group 2. Poor dental health status, infrequent oral hygiene habits and dental visits, smoking and presence of a dental prosthesis were significant parameters for increased levels of salivary acetaldehyde production from alcohol. The evaluation of salivary acetaldehyde production after in vitro incubation with ethanol may be useful for early detection of oral cancer.
According to the results of this study, the significantly higher levels of salivary acetaldehyde production in oral cancer patients and individuals with poor dental health status may suggest a possible link between increased salivary acetaldehyde production and oral cancer. Improved oral hygiene can effectively decrease the level of salivary acetaldehyde production in oral cavity. Hippokratia 2014; 18 (3): 269-274.
PMCID: PMC4309150
Oral cancer; salivary acetaldehyde production; oral hygiene; dental health status
16.  Eosinophilic ascites, as a rare presentation of eosinophilic gastroenteritis 
Hippokratia  2014;18(3):275-277.
Eosinophilic ascites is the most unusual presentation of eosinophilic gastroenteritis (EGE), caused by edema and eosinophilic inflammation of the small bowel wall's serosal layer.
Case Report:
We report the case of a 37-year-old woman, who presented with diffuse abdominal pain, nausea, abdominal distension, moderate ascites and diarrhea of two weeks duration. The rest of physical and clinical examination was unremarkable, and her past medical history was uneventful. Magnetic Resonance Imaging showed the presence of ascites and diffuse thickening of small bowel wall, but did not detect a primary malignancy in the abdominal cavity; and no signs of portal hypertension or liver damage. Laboratory test results revealed essential peripheral blood eosinophilia, elevated serum IgE and marked increase of eosinophils in the abdominal fluid. Treatment with corticosteroids normalized laboratory tests results, and the ascites resolved immediately.
EGE is a rare entity and it should be kept in mind in patients of unexplained ascites. The absence of primary malignancy on imaging, coupled with marked increase of fluid esinophilia and immediate response to treatment with steroids, confirm indirectly the diagnosis of EGE. Hippokratia 2014; 18 (3): 275-277.
PMCID: PMC4309151
Eosinophilic gastroenteritis; ascites; corticosteroids; magnetic resonance imaging
17.  Primary retroperitoneal mucinous cystadenoma. A rare case with two cysts and review of the literature 
Hippokratia  2014;18(3):278-281.
Primary retroperitoneal mucinous cystadenoma is a rare neoplasm, with benign biological behavior. Delay in diagnosis and treatment of this tumor may be fatal for the patient, because of complications, such as rupture, infection and malignant transformation.
Case presentation:
We present a 23-year-old woman, who was admitted to the hospital because of a palpable abdominal mass and discomfort since 4 months. Computed Tomography and Magnetic Resonance Imaging scans were performed and showed two retroperitoneal cystic masses, which were excised by laparoscopy. Histological and immunohistochemical examination revealed that the inner surfaces of the cysts were lined by epithelium with features of mesothelial cells, in addition to ovarian mucinous cystadenoma. This is the 29th case and the second reported case with two contemporary cysts.
The origin of retroperitoneal mucinous cystadenomas is still unclear. Pathological and immunohistochemical findings proved that these tumors resemble ovarian mucinous cystadenomas but are unattached to the ovary and can arise at any location in the retroperitoneum. Surgical excision of the aforementioned tumors is the treatment of choice. Hippokratia 2014; 18 (3): 278-281.
PMCID: PMC4309152
Primary; retroperitoneal; mucinous; cystadenoma
18.  A unique case of ruptured ectopic pregnancy in a patient with negative preg-nancy test - a case report and brief review of the literature  
Hippokratia  2014;18(3):282-284.
Despite the major advances made in the diagnosis and management of ectopic pregnancies in the last two decades, an accurate diagnosis can sometimes still be quite challenging, since it relies on the combination of ultrasound findings and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements.
Case presentation:
This paper describes the case of a 36-year-old woman of Caucasian origin who was admitted to the emergency department of our clinic with clinical symptoms of hemorrhagic shock in combination with two negative pregnancy tests done by her at home and a negative urine test which was performed on her admission to the hospital. Quantitative measurement of β-hCG in the serum of the patient was 13 mIU/mL. On admission, right tubal pregnancy was diagnosed on ultrasound and she underwent an emergency laparotomy due to signs of hemodynamic shock.
It is sometimes a considerable challenge to identify a patient with an ectopic pregnancy at risk of rupture. This case of ectopic pregnancy which was followed by a negative pregnancy test illustrates the magnitude of the difficulties involved in the diagnosis of ectopic pregnancy. It also demonstrates the need to maintain a high clinical index of suspicion and to undertake careful clinical examination of the patient on the basis of the clinician's diagnostic research. Hippokratia 2014; 18 (3): 282-284.
PMCID: PMC4309153
Ectopic pregnancy; hemorrhagic shock; beta human chorionic gonadotrophin; β-hCG
19.  Cervical mass as the presenting manifestation of hepatocellular carcinoma 
Hippokratia  2014;18(3):285-287.
Hepatocellular carcinoma is one of the most common cancers in the world due to its association with chronic hepatitis infections. Amongst the most usual metastasis of hepatocellular carcinoma are the lymph nodes, the lungs and the bones. Soft tissue metastases are extremely rare.
Case presentation:
Herein, we report the case of a 73-years-old male patient who presented with cervical and upper extremities muscle pain along with paresthesias and a palpable mass on the cervical region.
This unusual clinical manifestation along with the above-described rare presentations of hepatocellular carcinoma must be taken into account, especially among patients with chronic hepatitis infections. Hippokratia 2014; 18 (3): 285-287.
PMCID: PMC4309154
Hepatocellular carcinoma; soft tissue metastasis; cervical metastasis
20.  Is the treatment of hearing loss in rheumatoid arthritis effective? 
Hippokratia  2014;18(3):288.
PMCID: PMC4309155
rheumatoid arthritis; hearing loss; intratympanic application; corticosteroids; methotrexate
21.  Pharmaceutical innovation: impact on expenditure and outcomes and subsequent challenges for pharmaceutical policy, with a special reference to Greece 
Hippokratia  2014;18(2):100-106.
Over the recent decades, advances in healthcare technology have led to significant improvements in the quality of healthcare and in population health. At the same time, technological change in healthcare, rising national income and expansion of insurance coverage have been acknowledged as the main determinants of the historical growth in health spending in industrialized countries. The pharmaceutical sector is of particular interest as it constitutes a market characterized by rapid technological change and high expenditure growth rates. The purpose of this article is to provide an overview of research findings on the impact of pharmaceutical innovation on pharmaceutical expenditure growth, total health expenditure and population health outcomes and to bring forward the challenges that arise for pharmaceutical policy in Greece.
PMCID: PMC4201392  PMID: 25336869
Pharmaceutical technology; innovation diffusion; drug costs; pharmaceutical economics; Greece
22.  Effect of Different Analgesics on Pain Relief During Extracorporeal Shock Wave Lithotripsy 
Hippokratia  2014;18(2):107-109.
Background/aim: The aim of this study was  to compare  three drugs for pain relief during shock wave lithotripsy (SWL).
Materials and Methods:
Seventy six male patients that were treated for renal stones with SWL were included in this study. They were randomized into four groups. A different treatment protocol was used for each group.  Intramuscular (IM) diclofenac 75mg was given in group 1 (n=20), dexketoprofen, 50mg, IM in group 2 (n=20) and hyoscine 10 mg plus paracetamol 500mg, orally in group 3 (n=20). In group 4 (control, n=16) saline solution   was given 30 min before SWL. Pain during SWL was assessed using the 10-score linear visual analogue pain scale (VAS) and was compared among groups. Age, weight, height, body mass index (BMI), stone size, stone location, duration of SWL, total shock waves performed and mean energy level (kV) for each patient were recorded. A p value of <0.05 was considered statistically significant.
The mean patients’ age was 45.4 ± 12.9 years. The highest VAS value was observed in Group 4 (8.4 ± 1), and the lowest  in Group 1 (6.25 ± 2.2).  Statistically significant  difference was noted  only when Group 1 and Group 4 were compared. The remaining groups provided similar results and there were no significant statistical differences according to VAS values. Other parameters were similar  in all groups.
In conclusion, this study shows that reducing the pain with a single dose injection of intramuscular diclofenac sodium before SWL is superior compared to others.
PMCID: PMC4201393  PMID: 25336870
shockwave lithotripsy; diclofenac sodium; dexketoprofen; hyoscine-N-butyl bromide plus paracetamol
23.  Health Professionals’ knowledge and attitude towards the Umbilical Cord Blood donation in Greece 
Hippokratia  2014;18(2):110-115.
In the last years a major emphasis is laid on the Allogeneic Transplantation of Blood Stem Cells from the Umbilical Cord Blood with a simultaneous development of Umbilical Cord Blood bank. The attitude and knowledge of Health Professionals is vital to the success of this attempt as it affects significantly the promotion of Umbilical Cord Blood donation. The aim of present study is the examination of Health Professionals’ knowledge and attitudes towards Umbilical Cord Blood in Greece.
Material and Methods:
The study was conducted from April 25th 2012 to May 7th 2012. The sample consisted of 109 Health Professionals from 3 provincial hospitals and 2 hospitals in Thessaloniki. In order to collect the data, a questionnaire was used. The questionnaire was designed by the researcher and a group of experts to serve the mission of the present study. From the 130 questionnaires sent, 109 were completely answered (response rate 84%).
Of those who participated to the research, 23.9% were physicians, 34.9% were midwives, and 34.8% were nurses. As far as the Health Professionals’ knowledge on the Umbilical Cord Blood is concerned, only 15.6% of the participants declared to be quite or well informed on the collection methods and the usage of Umbilical Cord Blood. The vast majority of the participants (89%), declared that a well-organized program on a continual training is very essential. 93.5% of the participants declared that in the last 5 years received no or very little training regarding the collection, storing and transplantation of Umbilical Cord Blood.
Although according to a relevant research health professionals are considered by the public as the most credible source of information about Umbilical Cord Blood, their level of knowledge on the usage and storing of Umbilical Cord Blood is inadequate. The present study indicates the necessity of creation or reinforcing of effective programs of continual training with the use of technology (i.e. Internet).
PMCID: PMC4201394  PMID: 25336871
Blood Stem Cells; Umbilical Cord Blood; transplantation
24.  Circumcision – A new approach for a different cosmetic result 
Hippokratia  2014;18(2):116-119.
To assess the difference in aesthetic result after a non-religious circumcision with classic Johnston’s technique and a new proposed technique.
Materials and methods:
A total of 76 children were circumcised (not for religious purposes) in a period of 6 years using the classic Johnston’s technique (50 patients) and a new proposed technique (26 patients). Parents of circumcised children were interviewed three months after the operation. The aesthetic result was scored by both the parents and the patients as bad, acceptable, good or very good. Scores between the two groups were compared.
No major complications were encountered. The aesthetic result score between the two groups had a statistically significant difference (Mann Whitney U Test, p<0.0005). Children being circumcised with the new technique and their parents were more satisfied with the aesthetic result three months after the operation.
In communities in which religious circumcisions are being performed relatively rare, the aesthetic result of a classic method may seem awkward to the patient and his family. Therefore, circumcision being performed for non religious reasons necessitates an acceptable aesthetic result. Our technique fulfills this prerequisite. Hippokratia 2014; 18 (2):116-119.
PMCID: PMC4201395  PMID: 25336872
circumcision; technique; cosmetic
25.  Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongue 
Hippokratia  2014;18(2):120-124.
The presence of neck metastases represents one of the most important prognostic factors for carcinomas of the anterior tongue, the five-year survival rate being under 20% in patients with regional metastases. The aim of this study was to demonstrate the efficacy of prophylactic selective neck dissection in patients without detectable nodal metastases.
Materials and Methods:
A matched case-control study with prospective follow up was conducted in ENT Department of Coltea Clinical Hospital for 86 patients with T1-T2N0 stage carcinoma of the anterior tongue surgically treated between January 2000 and January 2005 with or without concurrent selective supraomohyoid neck dissection (SND). The patients were divided in two groups, comparable in age and sex distribution. Descriptive statistics, risk of recurrences, Kaplan Maier five-year survival curves and the global and specific mortality rates were performed using EpiInfo software. The level of significance was established at p<0.05.
After a mean follow-up time of 90.5 months, for all variables considered as outcomes of SND efficacy evaluation, significance differences (p < 0.05) were registered between groups: the frequency of patients who developed neck metastases was lower in the group of subjects who underwent prophylactic selective neck dissection; the all-cause mortality rate at the end of the follow-up period was three times lower in SND study group compared with controls; the specific mortality rate due to regional recurrences was five times lower in test-group compared with controls.
Our study suggest that prophylactic selective neck dissection could be indicated for patients with T1-T2N0 carcinomas of the anterior tongue in order to increase both overall and free of recurrence survival time, respectivelly.
PMCID: PMC4201396  PMID: 25336873
Anterior tongue carcinoma; N0 neck; neck dissection

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