Publications by authors named "Apostolos Komnos"

18 Publications

  • Page 1 of 1

Transmission Dynamics of SARS-CoV-2 during an Outbreak in a Roma Community in Thessaly, Greece-Control Measures and Lessons Learned.

Int J Environ Res Public Health 2021 03 11;18(6). Epub 2021 Mar 11.

Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, 41222 Larissa, Greece.

A COVID-19 outbreak occurred among residents of a Roma settlement in Greece (8 April-4 June 2020). The aim of this study was to identify factors associated with an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to evaluate the effectiveness of control measures implemented. Data were analyzed from individuals that were tested for SARS-CoV-2 during contact tracing, population screening or hospital visits. RT-PCR was used for the detection of SARS-CoV-2 in oropharyngeal samples. Risk factors for household secondary attack rates (SAR) and hospitalization with COVID-19 were examined using chi-square tests, Fisher's exact tests and logistic regression analyses. During the outbreak, 142 cases, 20 hospitalizations and 1 death were recorded, with a total of 2273 individuals tested. The risk of hospitalization was associated with age (OR: 1.04, 95% CI: 1.02-1.07) and Cycle threshold (Ct) values (OR for a decrease in Ct values by 1: 1.18, 95% CI: 1.07-1.31). Household SAR was estimated at 38.62% (95% CI: 32.50-45.01%). After the designation of an isolation facility for cases, household SAR declined from 74.42% to 31.03%. Household size was associated with the risk of infection (OR: 2.65, 95% CI: 1.00-7.07). The presence of COVID-19 symptoms among index cases was correlated with higher transmission (OR: 23.68, 95% CI 2.21-253.74) in multivariate analysis, while age was found to be associated with SAR only in univariate analysis. Roma communities can be particularly vulnerable to the spread of SARS-CoV-2. In similar settings, symptomatic cases are more important transmitters of SARS-CoV-2. Within these communities, immediate measures should be implemented to mitigate disease spread.
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http://dx.doi.org/10.3390/ijerph18062878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002111PMC
March 2021

Inadvertent direct pulmonary artery catheterization complicating the effort for subclavian venous cannulation and central venous catheter placement: A case report and review of the literature.

Int J Crit Illn Inj Sci 2020 Jul-Sep;10(3):143-147. Epub 2020 Sep 22.

Intensive Care Unit, General Hospital of Larissa, Larissa, Greece.

Subclavian access is commonly used in the intensive care unit (ICU) for central venous catheterization. Many complications have been reported during the placement of central venous catheters including pneumothorax, hemothorax, hematoma, and bleeding. The direct, through the thoracic wall, catheterization of pulmonary artery is a very rare one with only three previous reports in the literature. We report a patient who was catheterized for subclavian venous catheter placement, but the imaging techniques (chest X-ray and computed tomography with reconstruction of the images) revealed the direct positioning of the catheter into the pulmonary trunk, fortunately without other adverse events for the patient. Our case report in accordance with recent review of the literature strongly emphasizes the benefits of performing ultrasound-guided interventions in ICU.
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http://dx.doi.org/10.4103/IJCIIS.IJCIIS_94_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771621PMC
September 2020

Combination of thrombolytic and immunosuppressive therapy for coronavirus disease 2019: A case report.

Int J Infect Dis 2020 Aug 1;97:90-93. Epub 2020 Jun 1.

Intensive Care Unit, General Hospital of Larissa, Larissa, Greece.

In a proportion of patients, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a multisystem syndrome characterized by hyperinflammation, acute respiratory distress syndrome (ARDS), and hypercoagulability. A 68-year-old man with coronavirus disease 2019 (COVID-19) was admitted to the intensive care unit with respiratory failure, cytokine release syndrome (CRS), and skin ischemia - microthrombosis. Specific coagulation and inflammatory markers (D-dimer, ferritin, and C-reactive protein), along with the clinical picture, triggered the trial of recombinant tissue plasminogen activator (rt-PA) and tocilizumab. This was followed by resolution of the skin ischemia and CRS, while respiratory parameters improved. No major complications associated with rt-PA or tocilizumab occurred. The combination of rt-PA with targeted anti-inflammatory treatment could be a new therapeutic option for patients with COVID-19, ARDS, hyperinflammation, and increased blood viscosity.
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http://dx.doi.org/10.1016/j.ijid.2020.05.118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263262PMC
August 2020

Favorable Anakinra Responses in Severe Covid-19 Patients with Secondary Hemophagocytic Lymphohistiocytosis.

Cell Host Microbe 2020 07 14;28(1):117-123.e1. Epub 2020 May 14.

4(th) Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, 124 62 Athens, Greece. Electronic address:

Dysregulation of inflammation is hypothesized to play a crucial role in the severe complications of COVID-19, with the IL-1/IL-6 pathway being central. Here, we report on the treatment of eight severe COVID-19 pneumonia patients-seven hospitalized in intensive care units (ICUs) in Greece and one non-ICU patient in the Netherlands-with the interleukin-1 receptor antagonist Anakinra. All patients scored positive for the hemophagocytosis score (HScore) and were diagnosed with secondary hemophagocytic lymphohistocytosis (sHLH) characterized by pancytopenia, hyper-coagulation, acute kidney injury, and hepatobiliary dysfunction. At the end of treatment, ICU patients had less need for vasopressors, significantly improved respiratory function, and lower HScore. Although three patients died, the mortality was lower than historical series of patients with sHLH in sepsis. These data suggest that administration of Anakinra may be beneficial for treating severe COVID-19 patients with sHLH as determined by the HScore, and they support the need for larger clinical studies to validate this concept.
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http://dx.doi.org/10.1016/j.chom.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221383PMC
July 2020

Causes and Risk Factors of Cerebral Ischemic Events in Patients With Atrial Fibrillation Treated With Non-Vitamin K Antagonist Oral Anticoagulants for Stroke Prevention.

Stroke 2019 08 25;50(8):2168-2174. Epub 2019 Jun 25.

Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.).

Background and Purpose- Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non-vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods- Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results- Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95-5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63-9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83-3.16), and CHADS-VASc score (OR, 1.72 for each point increase; 95% CI, 1.58-1.88) were associated with ischemic events. Among the CHADS-VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33-0.61). Conclusions- In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHADS-VASc score were associated with increased risk of cerebrovascular events.
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http://dx.doi.org/10.1161/STROKEAHA.119.025350DOI Listing
August 2019

Effect of integrin AV and B8 gene polymorphisms in patients with traumatic brain injury.

Brain Inj 2019 29;33(7):836-845. Epub 2019 Apr 29.

a Department of Neurology, Laboratory of Neurogenetics , University of Thessaly, University Hospital of Larissa , Larissa , Greece.

Α few genetic variants are associated with the outcome after traumatic brain injury (TBI). Integrins are glycoprotein receptors that play an important role in the integrity of microvasculature of the brain. To examine the role of integrin-AV () and integrin-B8 () tag single nucleotide polymorphisms (SNPs) on the outcome of patients with TBI. 363 participants were included and genotyped for 11 SNPs for and 11 for gene. SNPs were tested for associations with the 6-month outcome after TBI, the presence of a hemorrhagic event after TBI, and the initial TBI severity after adjustment for TBI's main predictors. The ITGAV CC and GG genotypes were associated with an unfavorable outcome after TBI, compared to the TT and AA genotypes, respectively. The ITGB8 CC and CC genotypes were associated with increased risk of any cerebral hemorrhagic event after TBI compared to GG and TT respectively. The ITGAV and were associated with the TBI's initial severity. ITGAV gene SNPs may be implicated in the outcome after TBI, as well as in the initial TBI severity, and also of ITGB8 gene SNPs in the risk of hemorrhagic event after a TBI.
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http://dx.doi.org/10.1080/02699052.2019.1606444DOI Listing
April 2020

Intravenous thrombolysis for acute ischemic stroke in Greece: the Safe Implementation of Thrombolysis in Stroke registry 15-year experience.

Ther Adv Neurol Disord 2018 28;11:1756286418783578. Epub 2018 Jun 28.

Department of Neurology, School of Medicine, University of Thessaly, Larissa, Greece.

Background: Intravenous thrombolysis (IVT) remains the only approved systemic reperfusion treatment for acute ischemic stroke (AIS), however there are scarce data regarding outcomes and complications of IVT in Greece. We evaluated safety and efficacy outcomes of IVT for AIS in Greece using the Safe Implementation of Thrombolysis in Stroke: International Stroke Thrombolysis Register (SITS-ISTR) dataset.

Methods: All AIS patients treated with IVT in Greece between December 2002 and July 2017 and recorded in the SITS-ISTR were evaluated. Demographics, risk factors, baseline stroke severity [defined using National Institutes of Health Stroke Scale (NIHSS)], and onset-to-treatment time (OTT) were recorded. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 3-month mortality rates. The efficacy outcomes evaluated a reduction in baseline NIHSS score at 2 and 24 h following IVT onset, 3-month favorable functional outcome [FFO; modified Rankin scale (mRS) scores of 0-1] and 3-month functional independence (FI; mRS-scores of 0-2). The safety and efficacy outcomes were assessed comparatively with previously published data from SITS national and international registries.

Results: A total of 523 AIS patients were treated with IVT in 12 Greek centers participating in the SITS-ISTR during the study period (mean age 62.4 ± 12.7; 34.6% women; median baseline NIHSS score: 11 points; median OTT: 150 min). The rates of sICH were 1.4%, 2.3%, and 3.8% according to the SIST-MOST, ECASS II, and NINDS criteria respectively. The median reduction in NIHSS score at 2 and 24 h was 3 [interquartile range (IQR): 1-5] and 5 (IQR: 2-8) points respectively. The 3-month FI, FFO and mortality were 66.5%, 55.6% and 7.9%. All safety and efficacy outcomes were comparable with available data from SITS-ISTR in other European countries.

Conclusions: Our study underscores the safety and efficacy of IVT for AIS in Greece. Additional action is necessary in order to increase the availability of IVT in the Greek population and to include more centers in the SITS-ISTR.
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http://dx.doi.org/10.1177/1756286418783578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048606PMC
June 2018

Predictors of Need for Critical Care Support, Adverse Events, and Outcome after Stroke Thrombolysis.

J Stroke Cerebrovasc Dis 2018 Mar 26;27(3):591-598. Epub 2017 Oct 26.

Intensive Care Unit, General Hospital of Larissa, Larissa, Greece.

Background: Results from trials and international registries exhibit heterogeneity regarding safety, efficacy, markers of prognosis, and markers of the need for critical care support after intravenous thrombolysis (IVT) for strokes. The purpose of our study was to indentify such markers after performance of comparisons among patients who received thrombolysis in our intensive care unit.

Materials And Methods: Our study included 124 patients who received IVT in accordance with international criteria. Outcome measures of univariate and regression analyses resulted from comparisons between groups of patients with or without the need for critical care support (advanced life support and neurocritical care interventions), groups of patients developing or not developing primary adverse events (symptomatic intracranial hemorrhage [SICH] and/or Death and/or Serious systemic bleeding and/or New stroke) and groups of patients with different main outcome variables (mortality, functional independence at 3 months).

Results: Our results suggested that higher severity scores (Simplified Acute Physiology Score II, National Institutes of Health Stroke Scale) correlated with the need for critical care support, primary adverse events, and main outcome variables, whereas older age was significantly associated with fewer adverse events. Hyperlipidemia, symptom-to-needle time, and vascular disease were associated with functional capacity at 3 months, whereas diabetes mellitus and vascular disease correlated with the need for critical care support.

Conclusion: Patients' age, hyperlipidemia, presence of vascular disease, Simplified Acute Physiology Score II (a novel marker), and National Institutes of Health Stroke Scale at 2 hours and at 7 days are independent predictors of the need for critical care support, adverse events, and clinical outcomes after thrombolysis.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.09.042DOI Listing
March 2018

Effect of angiotensin-converting enzyme tag single nucleotide polymorphisms on the outcome of patients with traumatic brain injury.

Pharmacogenet Genomics 2015 Oct;25(10):485-90

aLaboratory of Neurogenetics, Department of Neurology bDepartment of Neurosurgery, Faculty of Medicine, University Hospital of Larissa, University of Thessaly cIntensive Care Unit, General Hospital of Larissa dDepartment of Radiology, School of Medicine, University of Thessaly, Larissa eSecond Department of Neurology, School of Medicine, 'Attikon' University Hospital, University of Athens, Athens fSecond Department of Neurosurgery, Hippokration University Hospital gDepartment of Physiology, Aristotle University of Thessaloniki, Thessaloniki, Greece hInternational Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.

Background: Genetic variants appear to influence, at least to some degree, the extent of brain injury and the clinical outcome of patients who have sustained a traumatic brain injury (TBI). Angiotensin-converting enzyme (ACE) is a zinc metallopeptidase that is implicated in the regulation of blood pressure and cerebral circulation. ACE gene polymorphisms were found to regulate serum ACE enzyme activity.

Objective: The present study aimed to investigate possible influence of ACE gene region variants on patients' outcome after TBI.

Patients And Methods: In total, 363 TBI patients prospectively enrolled in the study were genotyped for five tag single nucleotide polymorphisms (SNPs) across the ACE gene. Using logistic regression analyses, tag SNPs and their constructed haplotypes were tested for associations with 6-month Glasgow Outcome Scale scores, after adjustment for age, sex, Glasgow Coma Scale scores at admission, and the presence of a hemorrhagic event in the initial computed tomography scan.

Results: Significant effects on TBI outcome were found for three neighboring tag SNPs in the codominant (genotypic) model of inheritance [rs4461142: odds ratio (OR) 0.26, 95% confidence interval (CI) 0.12-0.57, P = 0.0001; rs7221780: OR 2.67, 95% CI 1.25-5.72, P = 0.0003; and rs8066276: OR 3.82, 95% CI 1.80-8.13, P = 0.0002; for the heterozygous variants compared with the common alleles]. None of the constructed common tag SNPs haplotypes was associated with TBI outcome.

Conclusion: The present study provides evidence of the possible influence of genetic variations in a specific region of the ACE gene on the outcome of TBI patients. This association may have pharmacogenetic implications in identifying those TBI patients who may benefit from ACE inhibition.
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http://dx.doi.org/10.1097/FPC.0000000000000161DOI Listing
October 2015

Intraperitoneal microdialysis as a monitoring method in the intensive care unit.

Int Surg 2014 Nov-Dec;99(6):729-33

1 Homerton University Hospital, London, UK.

Studies on surgical patients provide some evidence of prompt detection of enteric ischemia with microdialysis. The purpose of the study was to measure intraperitoneal microdialysis values (glucose, glycerol, pyruvate, and lactate) in patients hospitalized in an intensive care unit (ICU) with an underlying abdominal surgical condition and to correlate these values with patients' outcomes. Twenty-one patients, 10 female, were enrolled in the study. The intraperitoneal metabolite values were measured for 3 consecutive days, starting from the first day of ICU hospitalization. Descriptive and inferential statistics were performed. The t-test, repeated measures analysis, Holm's test, and a logistic regression model were applied. Level of statistical significance was set at P = 0.05. Mean age of participants was 68.10 ± 8.02 years old. Survivors exhibited statistically significantly higher glucose values on day 3 (6.61 ± 2.01 against 3.67 ± 1.62; P = 0.002). Mean lactate/ pyruvate (L/P) values were above 20 (35.35 ± 27.11). All non-survivors had a mean three day L/P values greater than 25.94. Low L/P values were related to increased survival possibilities. High microdialysis glucose concentration, high L/P ratio and low glucose concentration were the major findings during the first three ICU hospitalization days in non-survivors. Intraperitoneal microdialysis may serve as a useful tool in understanding enteric ischemia pathophysiology.
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http://dx.doi.org/10.9738/INTSURG-D-13-00139.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254232PMC
March 2016

AQP4 tag single nucleotide polymorphisms in patients with traumatic brain injury.

J Neurotrauma 2014 Dec 10;31(23):1920-6. Epub 2014 Oct 10.

1 Department of Neurology, Laboratory of Neurogenetics, University of Thessaly , University Hospital of Larissa, Larissa, Greece .

Accumulating evidence suggests that the extent of brain injury and the clinical outcome after traumatic brain injury (TBI) are modulated, to some degree, by genetic variants. Aquaporin-4 (AQP4) is the predominant water channel in the central nervous system and plays a critical role in controlling the water content of brain cells and the development of brain edema after TBI. We sought to investigate the influence of the AQP4 gene region on patient outcome after TBI by genotyping tag single nucleotide polymorphisms (SNPs) along AQP4 gene. A total of 363 patients with TBI (19.6% female) were prospectively evaluated. Data including the Glasgow Coma Scale (GCS) scores at admission, the presence of intracranial hemorrhage, and the 6-month Glasgow Outcome Scale (GOS) scores were collected. Seven tag SNPs across the AQP4 gene were identified based on the HapMap data. Using logistic regression analyses, SNPs and haplotypes were tested for associations with 6-month GOS after adjusting for age, GCS score, and sex. Significant associations with TBI outcome were detected for rs3763043 (OR [95% confidence interval (CI)]: 5.15 [1.60-16.5], p=0.006, for recessive model), rs3875089 (OR [95% CI]: 0.18 [0.07-0.50] p=0.0009, for allele difference model), and a common haplotype of AQP4 tag SNPs (OR [95% CI]: 2.94, [1.34-6.36], p=0.0065). AQP4 tag SNPs were not found to influence the initial severity of TBI or the presence of intracranial hemorrhages. In conclusion, the present study provides evidence for possible involvement of genetic variations in AQP4 gene in the functional outcome of patients with TBI.
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http://dx.doi.org/10.1089/neu.2014.3347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4238262PMC
December 2014

Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*.

Crit Care Med 2014 Mar;42(3):601-9

1Department of Internal Medicine, Ghent University, Ghent, Belgium. 2Attikon University Hospital, Athens, Greece. 3Critical Care Department, The Burns, Trauma, and Critical Care Research Center, The University of Queensland, Brisbane, QLD, Australia. 4Critical Care Department, Nord University Hospital, Marseille, France. 5Critical Care Department, General Hospital of Larisa, Larisa, Greece. 6Critical Care Department, Clinics of Constance, Constance, Germany. 7Department of Intensive Care, Mauriziano Hospital, Turin, Italy. 8Critical Care Department, Vall d'Hebron University Hospital, CIBERES, Universitat Autonoma de Barcelona, Barcelona, Spain.

Objective: We investigated the epidemiology of ventilator-associated pneumonia in elderly ICU patients. More precisely, we assessed prevalence, risk factors, signs and symptoms, causative bacterial pathogens, and associated outcomes.

Design: Secondary analysis of a multicenter prospective cohort (EU-VAP project).

Setting: Twenty-seven European ICUs.

Patients: Patients who were mechanically ventilated for greater than or equal to 48 hours. We compared middle-aged (45-64 yr; n = 670), old (65-74 yr; n = 549), and very old patients (≥ 75 yr; n= 516).

Measurements And Main Results: Ventilator-associated pneumonia occurred in 103 middle-aged (14.6%), 104 old (17.0%), and 73 very old patients (12.8%). The prevalence (n ventilator-associated pneumonia/1,000 ventilation days) was 13.7 in middle-aged patients, 16.6 in old patients, and 13.0 in very old patients. Logistic regression analysis could not demonstrate older age as a risk factor for ventilator-associated pneumonia. Ventilator-associated pneumonia in elderly patients was more frequently caused by Enterobacteriaceae (24% in middle-aged, 32% in old, and 43% in very old patients; p = 0.042). Regarding clinical signs and symptoms at ventilator-associated pneumonia onset, new temperature rise was less frequent among very old patients (59% vs 76% and 74% for middle-aged and old patients, respectively; p = 0.035). Mortality among patients with ventilator-associated pneumonia was higher among elderly patients: 35% in middle-aged patients versus 51% in old and very old patients (p = 0.036). Logistic regression analysis confirmed the importance of older age in the risk of death (adjusted odds ratio for old age, 2.1; 95% CI, 1.2-3.9 and adjusted odds ratio for very old age, 2.3; 95% CI, 1.2-4.4). Other risk factors for mortality in ventilator-associated pneumonia were diabetes mellitus, septic shock, and a high-risk pathogen as causative agent.

Conclusions: In this multicenter cohort study, ventilator-associated pneumonia did not occur more frequently among elderly, but the associated mortality in these patients was higher. New temperature rise was less common in elderly patients with ventilator-associated pneumonia, whereas more episodes among elderly patients were caused by Enterobacteriaceae.
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http://dx.doi.org/10.1097/01.ccm.0000435665.07446.50DOI Listing
March 2014

Nursing Activities Score as a predictor of family satisfaction in an adult intensive care unit in Greece.

J Nurs Manag 2014 Mar 17;22(2):151-8. Epub 2013 Jul 17.

Department of Critical Care Medicine, General Hospital of Larissa, Larissa, Greece.

Aim: To study family satisfaction with care in an Intensive Care Unit (ICU) and its association with nursing workload estimated by the Nursing Activities Score (NAS).

Background: Few previous studies have investigated the association between workload in ICUs and family satisfaction.

Methods: Family Satisfaction ICU 24 (FS ICU-24) questionnaires were distributed to 161 family members (106 respondents). Questionnaires' score, NAS measurements and Simplified Acute Physiology Score II (SAPS-II) data were analysed.

Results: The mean total level of family satisfaction was equal to 80.72% (± 9.59). Family members were more satisfied with the level of care compared with decision making. NAS values revealed a shortage of nurses in the morning shift. Moreover, there was a statistically significant positive correlation between NAS and total satisfaction after adjusting for age, length of stay and SAPS-II.

Conclusions: Improvements in clinical practice require the measurement of care quality which particularly includes family satisfaction. Our results indicated that family members were less satisfied with decision making.

Implications For Nursing Management: Nurse managers should plan for the successful involvement of family members in the decision-making process. Higher levels of nurse staffing might improve the care provided.
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http://dx.doi.org/10.1111/jonm.12089DOI Listing
March 2014

Cerebral perfusion pressure, microdialysis biochemistry and clinical outcome in patients with traumatic brain injury.

BMC Res Notes 2011 Dec 14;4:540. Epub 2011 Dec 14.

General Hospital of Larissa, Larissa, Greece.

Background: Traumatic Brain Injury (TBI) is a major cause of death and disability. It has been postulated that brain metabolic status, intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are related to patients' outcome. The aim of this study was to investigate the relationship between CPP, ICP and microdialysis parameters and clinical outcome in TBIs.

Results: Thirty four individuals with severe brain injury hospitalized in an intensive care unit participated in this study. Microdialysis data were collected, along with ICP and CPP values. Glasgow Outcome Scale (GOS) was used to evaluate patient outcome at 6 months after injury. Fifteen patients with a CPP greater than 75 mmHg, L/P ratio lower than 37 and Glycerol concentration lower than 72 mmol/l had an excellent outcome (GOS 4 or 5), as opposed to the remaining 19 patients. No patient with a favorable outcome had a CPP lower than 75 mmHg or Glycerol concentration and L/P ratio greater than 72 mmol/l and 37 respectively. Data regarding L/P ratio and Glycerol concentration were statistically significant at p = 0.05 when patients with favorable and unfavorable outcome were compared. In a logistic regression model adjusted for age, sex and Glasgow Coma Scale on admission, a CPP greater than 75 mmHg was marginally statistically significantly related to outcome at 6 months after injury.

Conclusions: Patients with favorable outcome had certain common features in terms of microdialysis parameters and CPP values. An individualized approach regarding CPP levels and cut -off points for Glycerol concentration and L/P ratio are proposed.
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http://dx.doi.org/10.1186/1756-0500-4-540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275520PMC
December 2011

Effect of pravastatin on the frequency of ventilator-associated pneumonia and on intensive care unit mortality: open-label, randomized study.

Crit Care Med 2011 Nov;39(11):2440-6

Department of Critical Care Medicine, University Hospital of Larissa, Larissa, Greece.

Objective: To investigate whether the use of pravastatin reduces the frequency of ventilator-associated pneumonia and whether it is related to favorable outcomes in critical care patients.

Design: Two-center, two-arm, randomized, open-label, controlled trial.

Setting: University Hospital and General Hospital of Larissa, Greece.

Patients: Consecutive patients were recruited from the intensive care units of the two hospitals. Patient inclusion criteria included mechanical ventilation and intensive care unit stay of >48 hrs.

Interventions: The two arms consisted of treatment plus oral pravastatin sodium (40 mg) (n = 71 patients, pravastatin group) and treatment without pravastatin (n = 81 patients, control group). Treatment was started after randomization and ended 30 days later.

Measurements And Main Results: Ventilator-associated pneumonia frequency and intensive care unit mortality at 30 days and at the end of intensive care unit stay were measured. Adverse events related to statin treatment in the intensive care unit were documented. Sixteen patients (22.5%) in the pravastatin group and 28 (34.5%) in the control group (p = .11) presented pneumonia during the 30-day treatment period in the intensive care unit. There was an indication for increased probability of being free from ventilator-associated pneumonia during the 30-day treatment period in the pravastatin group compared to the control group (p = .06) and significantly increased probability during the whole intensive care unit period of stay (p = .04) in the pravastatin group compared to the control group in the subgroup of patients with Acute Physiology and Chronic Health Evaluation scores of ≥ 15. Six patients (8.45%) in the pravastatin group and 16 (19.85%) in the control group died during the 30-day treatment period (p = .06), whereas 10 (14.1%) patients in the pravastatin group and 24 (29.1%) patients in the control group died during the whole period of intensive care unit stay (p = .03). Pravastatin group patients with Acute Physiology and Chronic Health Evaluation scores of ≥ 15 had significantly increased probability of survival compared to controls during the 30-day treatment period (p = .04). Creatine kinase and hepatic function enzyme levels during the whole study period were not significantly different between the pravastatin group and control group.

Conclusion: This study provides evidence that pravastatin may favorably affect the outcome of critical care patients.
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http://dx.doi.org/10.1097/CCM.0b013e318225742cDOI Listing
November 2011

Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas.

J Crit Care 2012 Feb 23;27(1):83-8. Epub 2011 Jun 23.

Intensive Care Unit, General Hospital of Larissa, Greece.

Purpose: The aim of our study was to investigate the roles of cerebral perfusion pressure (CPP) and microdialysis marker values on the clinical outcome of patients with spontaneous intracerebral hematoma.

Materials And Methods: Twenty-seven patients (18 men; mean ± SD age, 54.17 ± 10.05 years; 9 women, mean ± SD age, 65.00 ± 4.24 years) with a GCS of 8 or less upon admission were included in this study. After a 6-month follow-up period, a linear regression model was applied to evaluate the outcomes using the Glasgow Outcome Scale (GOS).

Results: Of the 27 patients, 16 died within the first 6 months after discharge from the hospital. Six patients had a favorable prognosis after 6 months. In the patients who had a favorable outcome (GOS = 4 or GOS = 5), the CPP was above 75.46 mm Hg, and intracranial pressure was below 14.21 mm Hg. No patient with a favorable prognosis had a lactate-pyruvate (L/P) ratio greater than 37.40. An inverse linear relationship was found among the L/P ratio, the CPP, and patient outcome.

Conclusion: The L/P ratio and CPP were found to be related to patient outcome. In addition, a CPP greater than 75.46 mm Hg and an L/P ratio lower than 37.40 mm Hg were related to a favorable outcome.
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http://dx.doi.org/10.1016/j.jcrc.2011.04.004DOI Listing
February 2012

Angiotensin-converting enzyme tag single nucleotide polymorphisms in patients with intracerebral hemorrhage.

Pharmacogenet Genomics 2011 Mar;21(3):136-41

Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, Larissa, Greece.

Objectives: Studies investigating the association between angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and the risk of intracerebral hemorrhage (ICH) have provided conflicting results. Moreover, it is possible that the ACE I/D polymorphism may not represent the functional variant of the gene. The objective of this study was to clarify the influence of the ACE gene region on the risk of ICH by genotyping tag polymorphisms along ACE gene in two independent ethnically different cohorts.

Methods: We included 250 Greek and 169 Polish unrelated patients with ICH and 250 Greek and 322 Polish normal controls in the study. To cover the majority of the genetic variability across the extended ACE gene region, we identified five tag single nucleotide polymorphisms (rs4343, rs4461142, rs7221780, rs8066276, rs8066114) from the HapMap using a pairwise tagging approach and an r2 greater than or equal to 0.8. Single nucleotide polymorphisms and haplotypes were analyzed for associations with ICH risk, ICH subtype (lobar/nonlobar), and age of disease onset using logistic and Cox regression models. Correction for multiple comparisons was carried out.

Results: In the Polish cohort, we observed a trend toward an association between the rs4461142 and the age of ICH onset (hazard ratio 0.50, 95% confidence interval 0.27-0.90, P=0.02). A common haplotype (GTCTC) also showed a trend for increased ICH risk in the Polish cohort (odds ratio 0.19, 95% confidence interval 0.04-0.85, P=0.02). These results were not replicated in the Greek cohort.

Conclusions: Our results did not provide clear evidence for a role of ACE gene in the development of ICH.
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http://dx.doi.org/10.1097/FPC.0b013e328343ab15DOI Listing
March 2011

Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial [ISRCTN50308308].

Crit Care 2004 Aug 28;8(4):R268-80. Epub 2004 Jun 28.

Genimatas General Hospital, Athens, Greece.

Introduction: This randomised, open-label, observational, multicentre, parallel group study assessed the safety and efficacy of analgesia-based sedation using remifentanil in the neuro-intensive care unit.

Methods: Patients aged 18-80 years admitted to the intensive care unit within the previous 24 hours, with acute brain injury or after neurosurgery, intubated, expected to require mechanical ventilation for 1-5 days and requiring daily downward titration of sedation for assessment of neurological function were studied. Patients received one of two treatment regimens. Regimen one consisted of analgesia-based sedation, in which remifentanil (initial rate 9 microg kg(-1) h(-1)) was titrated before the addition of a hypnotic agent (propofol [0.5 mg kg(-1) h(-1)] during days 1-3, midazolam [0.03 mg kg(-1) h(-1)] during days 4 and 5) (n = 84). Regimen two consisted of hypnotic-based sedation: hypnotic agent (propofol days 1-3; midazolam days 4 and 5) and fentanyl (n = 37) or morphine (n = 40) according to routine clinical practice. For each regimen, agents were titrated to achieve optimal sedation (Sedation-Agitation Scale score 1-3) and analgesia (Pain Intensity score 1-2).

Results: Overall, between-patient variability around the time of neurological assessment was statistically significantly smaller when using remifentanil (remifentanil 0.44 versus fentanyl 0.86 [P = 0.024] versus morphine 0.98 [P = 0.006]. Overall, mean neurological assessment times were significantly shorter when using remifentanil (remifentanil 0.41 hour versus fentanyl 0.71 hour [P = 0.001] versus morphine 0.82 hour [P < 0.001]). Patients receiving the remifentanil-based regimen were extubated significantly faster than those treated with morphine (1.0 hour versus 1.93 hour, P = 0.001) but there was no difference between remifentanil and fentanyl. Remifentanil was effective, well tolerated and provided comparable haemodynamic stability to that of the hypnotic-based regimen. Over three times as many users rated analgesia-based sedation with remifentanil as very good or excellent in facilitating assessment of neurological function compared with the hypnotic-based regimen.

Conclusions: Analgesia-based sedation with remifentanil permitted significantly faster and more predictable awakening for neurological assessment. Analgesia-based sedation with remifentanil was very effective, well tolerated and had a similar adverse event and haemodynamic profile to those of hypnotic-based regimens when used in critically ill neuro-intensive care unit patients for up to 5 days.
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http://dx.doi.org/10.1186/cc2896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522854PMC
August 2004