Η εξωτερική πολιτική του Ισαακίου Β΄ Αγγέλου (1185-1195) έναντι της Δύσης

Με την άνοδο στον θρόνο του Ισαακίου Β΄ (1185 - 1195) έχουμε κατ’ ουσίαν και την άνοδο μιας νέας δυναστείας στο Βυζάντιο, αυτής των Αγγέλων. Οι Άγγελοι φέρουν τρόπον τινά το μεγαλύτερο μερίδιο ευθύνης για την άλωση της Κωνσταντινούπολης από τους σταυροφόρους το 1204, γεγονός-τομή στη βυζαντινή ιστορία, το οποίο επηρέασε άρδην τις βυζαντινο-δυτικές σχέσεις. Η ήδη αυξημένη διείσδυση των Δυτικών στα βυζαντινά πράγματα στα χρόνια των Αγγέλων έγινε ανεξέλεγκτη μέσω της ακμής των ιταλικών παροικιών στην Πρωτεύουσα και των εμπορικών προνομίων που τους είχαν παραχωρηθεί. Ο Ισαάκιος Β΄ Άγγελος, επομένως, κλήθηκε να ανταποκριθεί σε έναν εξαιρετικά δύσκολο ρόλο, καθώς, από τη μία, η Δύση μπορούσε να αποτελεί ένα εχθρικό ή τουλάχιστον αναξιόπιστο μέτωπο και από την άλλη, έναν απαραίτητο σύμμαχο, προκειμένου το αποδυναμωμένο Βυζάντιο να ανταποκριθεί στις στρατιωτικές και ναυτικές του υποχρεώσεις. Η Δύση στα χρόνια αυτά φαινόταν να ισχυροποιείται συνεχώς και έπαψε να βρίσκεται στο παρασκήνιο. Ο Ισαάκιος Β΄ είχε αντιληφθεί την επικινδυνότητά της και προτιμούσε σαφώς μια αγαστή συνεργασία με όσους Δυτικούς συμμάχους μπορούσε να εξασφαλίσει εναντίον των λοιπών που τον αντιμάχονταν. Έτσι, κατάφερε να διατηρήσει καλές σχέσεις με την Ουγγαρία, τον οίκο του Μομφερά και τη Ρωμαιοκαθολική Εκκλησία. Στόχος του ήταν, βέβαια, να συμμαχήσει με ισχυρές ναυτικές δυνάμεις, προκειμένου να αντισταθμίσει τη δύναμη των δύο μεγάλων του αντιπάλων, του Νορμανδικού βασιλείου της Σικελίας και της Γερμανικής αυτοκρατορίας, οι οποίοι διέθεταν αξιόλογο στόλο. Κατάφερε νίκη εναντίον των Νορμανδών και έκλεισε ειρήνη μαζί τους, ενώ η αναστάτωση που του προκάλεσε η δίοδος της Γ΄ Σταυροφορίας και του Φρειδερίκου Βαρβαρόσσα μέσα από τα βυζαντινά εδάφη τον οδήγησε σε σπασμωδικές κινήσεις. Αφέθηκε, λοιπόν, στην πατρωνία της Βενετίας, της Γένουας και της Πίζας, των οποίων ο στόλος τού ήταν απαραίτητος, εφόσον η άλλοτε παντοδυναμία του Βυζαντίου στη Μεσόγειο χάρη στις πανίσχυρες ναυτικές του δυνάμεις είχε πλέον εκλείψει οριστικά. Η Βενετία εκμεταλλεύτηκε και με το παραπάνω την ευκαιρία που της δόθηκε. Ο Βυζαντινός αυτοκράτορας παραδόθηκε στις βενετικές αγκάλες οικειοθελώς προσβλέποντας στην εξυπηρέτηση των πρόσκαιρων αναγκών του και παραγνωρίζοντας εντελώς τη μακροπρόθεσμη ζημία που θα προκαλούσε η βενετική κηδεμονία. Τα μέσα διαπραγμάτευσης που διέθετε ήταν βεβαίως πενιχρά. Αυτό δεν δικαιολογεί, όμως, το γεγονός ότι προτίμησε τις εύκολες λύσεις. Οι υπόλοιπες κινήσεις του στην εξωτερική πολιτική δεν ήταν αρκετές για να υπερασπίσουν το πολύ ευάλωτο πλέον Βυζάντιο. Άφησε την ανασφάλειά του να κυριαρχήσει, δεν φύλαξε ικανοποιητικά τα νώτα του, προσφέροντας την Ανατολική Ρωμαïκή Αυτοκρατορία στο πινάκιο των Δυτικών πολεμιστών που κατέλαβαν την Κωνσταντινούπολη το 1204.Isaac’s II rise to the throne (1185-1195) marks the rise of a new dynasty in Byzantium, that of the Angels. The Angels bear in a way the greatest share of responsibility for the fall of Constantinople to the crusaders in 1204, a very important fact of byzantine history, which has greatly influenced Byzantine-Western relations. The already widespread penetration of the West into Byzantine reality became uncontrollable in the era of the Angels because of the prosperity of the Italian merchant quarters in the Capital and the commercial privileges granted to them. Isaac II Angelus, therefore, had to take an active role in an extremely difficult situation, since, on the one hand, the West could be a hostile or at least unreliable front and, on the other hand, it could also be a necessary ally in order for the weak Byzantium to meet its military and naval obligations. The West in those years seemed to be getting constantly stronger and ceased being in the background. Having realised that, Isaac clearly preferred a good cooperation with as many Western allies could secure against the others who were fighting him. Therefore, he managed to maintain good relations with Hungary, the Montferrat House and the Roman Catholic Church. His goal was to ally with powerful naval forces so that he could offset the power of his two major opponents, the Norman Kingdom of Sicily and the German Empire, who possessed a remarkable fleet. He achieved victory against the Normans and made peace with them, while the inconvenience caused by the passage of the Third Crusade and Frederick Barbarossa through the byzantine territory led him to careless actions. He let himself to the condescension of Venice, Genoa and Pisa, whose fleet was indispensable to him, since the former byzantine dominance of the Mediterranean thanks to its powerful naval forces had now ceased to exist. Venice, naturally, took advantage of the opportunity. The Byzantine emperor surrendered to the “Most Serene Republic” voluntarily looking to serve his temporary needs and completely neglecting the long-term damage caused by Venetian guardianship. His bargaining chips were of course insignificant. That does not justify, however, the fact that he preferred the easy solutions. The rest of his foreign policy agenda was not enough to defend Byzantium at its most vulnerable state. He felt insecure and did not cover his back, offering the Eastern Roman Empire to the Western warriors who occupied Constantinople in 1204

Intravenous colistin in the treatment of sepsis from multiresistant Gram-negative bacilli in critically ill patients

INTRODUCTION: The increasing prevalence of multiresistant Gram-negative strains in intensive care units (ICUs) has recently rekindled interest in colistin, a bactericidal antibiotic that was used in the 1960s for treatment of infections caused by Gram-negative bacilli. We conducted the present observational study to evaluate the efficacy of intravenous colistin in the treatment of critically ill patients with sepsis caused by Gram-negative bacilli resistant to all other antibiotics. PATIENTS AND METHOD: Critically ill patients with sepsis caused by Gram-negative bacilli resistant to all antibiotics with the exception of colistin were treated in the six-bed ICU of a trauma hospital. Diagnosis of infection was based on clinical data and isolation of bacteria, and the bacteria were tested with respect to their susceptibility to colistin. Clinical response to colistin was evaluated. RESULTS: Twenty-four patients (mean age 44.3 years, mean Acute Physiology and Chronic Health Evaluation II score 20.6) received 26 courses of colistin. Clinical response was observed for 73% of the treatments. Survival at 30 days was 57.7%. Deterioration in renal function was observed in 14.3% of 21 patients who were not already receiving renal replacement therapy, but in only one case did this deterioration have serious clinical consequences. CONCLUSION: The lack of a control group in the present study does not allow any definite conclusions to be drawn regarding the clinical effectiveness of colistin. On the other hand, this drug has an acceptable safety profile and its use should be considered in severe infections with multiresistant Gram-negative bacilli

European guidelines for the diagnosis, treatment and follow-up of breast lesions with uncertain malignant potential (B3 lesions) developed jointly by EUSOMA, EUSOBI, ESP (BWG) and ESSO

Introduction: Breast lesions of uncertain malignant potential (B3) include atypical ductal and lobular hyperplasias, lobular carcinoma in situ, flat epithelial atypia, papillary lesions, radial scars and fibroepithelial lesions as well as other rare miscellaneous lesions. They are challenging to categorise histologically, requiring specialist training and multidisciplinary input. They may coexist with in situ or invasive breast cancer (BC) and increase the risk of subsequent BC development. Management should focus on adequate classification and management whilst avoiding overtreatment. The aim of these guidelines is to provide updated information regarding the diagnosis and management of B3 lesions, according to updated literature review evidence. Methods: These guidelines provide practical recommendations which can be applied in clinical practice which include recommendation grade and level of evidence. All sections were written according to an updated literature review and discussed at a consensus meeting. Critical appraisal by the expert writing committee adhered to the 23 items in the international Appraisal of Guidelines, Research and Evaluation (AGREE) tool. Results: Recommendations for further management after core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB) diagnosis of a B3 lesion reported in this guideline, vary depending on the presence of atypia, size of lesion, sampling size, and patient preferences. After CNB or VAB, the option of vacuum-assisted excision or surgical excision should be evaluated by a multidisciplinary team and shared decision-making with the patient is crucial for personalizing further treatment. De-escalation of surgical intervention for B3 breast lesions is ongoing, and the inclusion of vacuum-assisted excision (VAE) will decrease the need for surgical intervention in further approaches. Communication with patients may be different according to histological diagnosis, presence or absence of atypia, or risk of upgrade due to discordant imaging. Written information resources to help patients understand these issues alongside with verbal communication is recommended. Lifestyle interventions have a significant impact on BC incidence so lifestyle interventions need to be suggested to women at increased BC risk as a result of a diagnosis of a B3 lesion. Conclusions: These guidelines provide a state-of-the-art overview of the diagnosis, management and prognosis of B3 lesions in modern multidisciplinary breast practice

Three-dimensional plant architecture and sunlit-shaded patterns: a stochastic model of light dynamics in canopies

Background and Aims Diurnal changes in solar position and intensity combined with the structural complexity of plant architecture result in highly variable and dynamic light patterns within the plant canopy. This affects productivity through the complex ways that photosynthesis responds to changes in light intensity. Current methods to characterise light dynamics, such as ray-tracing, are able to produce data with excellent spatio-temporal resolution but are computationally intensive and the resultant data are complex and high dimensional. This necessitates development of more economical models for summarising the data and for simulating realistic light patterns over the course of a day. Methods High-resolution reconstructions of field-grown plants are assembled in various configurations to form canopies, and a forward ray-tracing algorithm is applied to the canopies to compute light dynamics at high (1 minute) temporal resolution. From the ray-tracer output, the sunlit or shaded state for each patch on the plants is determined, and these data are used to develop a novel stochastic model for the sunlit-shaded patterns. The model is designed to be straightforward to fit to data using maximum likelihood estimation, and fast to simulate from. Key Results For a wide range of contrasting 3D canopies, the stochastic model is able to summarise, and replicate in simulations, key features of the light dynamics. When light patterns simulated from the stochastic model are used as input to a model of photoinhibition, the predicted reduction in carbon gain is similar to that from calculations based on the (extremely costly) ray-tracer data. Conclusions The model provides a way to summarise highly complex data in a small number of parameters, and a cost-effective way to simulate realistic light patterns. Simulations from the model will be particularly useful for feeding into larger-scale photosynthesis models for calculating how light dynamics affects the photosynthetic productivity of canopies

Axillary lymphadenopathy at the time of COVID-19 vaccination: ten recommendations from the European Society of Breast Imaging (EUSOBI).

Unilateral axillary lymphadenopathy is a frequent mild side effect of COVID-19 vaccination. European Society of Breast Imaging (EUSOBI) proposes ten recommendations to standardise its management and reduce unnecessary additional imaging and invasive procedures: (1) in patients with previous history of breast cancer, vaccination should be performed in the contralateral arm or in the thigh; (2) collect vaccination data for all patients referred to breast imaging services, including patients undergoing breast cancer staging and follow-up imaging examinations; (3) perform breast imaging examinations preferentially before vaccination or at least 12 weeks after the last vaccine dose; (4) in patients with newly diagnosed breast cancer, apply standard imaging protocols regardless of vaccination status; (5) in any case of symptomatic or imaging-detected axillary lymphadenopathy before vaccination or at least 12 weeks after, examine with appropriate imaging the contralateral axilla and both breasts to exclude malignancy; (6) in case of axillary lymphadenopathy contralateral to the vaccination side, perform standard work-up; (7) in patients without breast cancer history and no suspicious breast imaging findings, lymphadenopathy only ipsilateral to the vaccination side within 12 weeks after vaccination can be considered benign or probably-benign, depending on clinical context; (8) in patients without breast cancer history, post-vaccination lymphadenopathy coupled with suspicious breast finding requires standard work-up, including biopsy when appropriate; (9) in patients with breast cancer history, interpret and manage post-vaccination lymphadenopathy considering the timeframe from vaccination and overall nodal metastatic risk; (10) complex or unclear cases should be managed by the multidisciplinary team

Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging

Abstract This article summarises the information that should be provided to women and referring physicians about breast ultrasound (US). After explaining the physical principles, technical procedure and safety of US, information is given about its ability to make a correct diagnosis, depending on the setting in which it is applied. The following definite indications for breast US in female subjects are proposed: palpable lump; axillary adenopathy; first diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women; suspicious abnormalities at mammography or magnetic resonance imaging (MRI); suspicious nipple discharge; recent nipple inversion; skin retraction; breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy; abnormalities in the presence of breast implants; screening high-risk women, especially when MRI is not performed; loco-regional staging of a known breast cancer, when MRI is not performed; guidance for percutaneous interventions (needle biopsy, pre-surgical localisation, fluid collection drainage); monitoring patients with breast cancer receiving neo-adjuvant therapy, when MRI is not performed. Possible indications such as supplemental screening after mammography for women aged 40–74 with dense breasts are also listed. Moreover, inappropriate indications include screening for breast cancer as a stand-alone alternative to mammography. The structure and organisation of the breast US report and of classification systems such as the BI-RADS and consequent management recommendations are illustrated. Information about additional or new US technologies (colour-Doppler, elastography, and automated whole breast US) is also provided. Finally, five frequently asked questions are answered. Teaching Points • US is an established tool for suspected cancers at all ages and also the method of choice under 40. • For US-visible suspicious lesions, US-guided biopsy is preferred, even for palpable findings. • High-risk women can be screened with US, especially when MRI cannot be performed. • Supplemental US increases cancer detection but also false positives, biopsy rate and follow-up exams. • Breast US is inappropriate as a stand-alone screening method

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

Abstract: We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as “high-risk” or B3 lesions). Finally, seven frequently asked questions are answered

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic