Estimating the impact of better management of glycaemic control in adults with Type 1 and Type 2 diabetes on the number of clinical complications and the associated financial benefit.

AIM: To estimate potential cost avoidance through modest and achievable improvements in glycaemic control in adults with Type 1 or Type 2 diabetes mellitus in the UK healthcare system. METHODS: The IMS Core Diabetes Model was used to examine the impact of improved glycaemic control (indicated by reduction in HbA1c level), in a representative cohort of adults with Type 1 or Type 2 diabetes. The cumulative incidence of microvascular and macrovascular complications was modelled across 5-year periods to a 25-year time horizon. Complication costs were applied to the data to estimate potential accrued cost avoidance. RESULTS: Significant cost avoidance of ~£340 m is apparent in the first 5 years, increasing to ~£5.5bn after 25 years of sustained improvement in control. The overwhelming majority of cost avoidance arises from reductions in microvascular complications. In people with Type 1 diabetes the greatest cost avoidance comes from a reduction in renal disease (74% of cost avoidance), while in people with Type 2 diabetes it is generated by a reduction in foot ulcers, amputations and neuropathy: 57% cost avoidance). Greater cost reduction is accrued more rapidly in people with higher starting HbA1c levels. CONCLUSION: Modest improvements in glycaemic control generate significant reductions in the incidence and, therefore, cost of microvascular complications in people with Type 1 or Type 2 diabetes. This study provides clear support for the premise that prioritized and sustained investment in early and better intervention can provide concrete financial benefits in both the short and longer term.

The contribution of a mobile mental health unit to the promotion of primary mental health in rural areas in Greece: a 2-year follow-up.

During the 2 years of the mobile mental-health unit's operation in Northwestern Greece, the referrals increased rapidly with 29.4% of patients never having received mental-health care before, while hospitalizations and relapses reduced significantly, indicating that community-oriented programs can contribute greatly to successfully addressing the needs of patients in remote rural areas.

Serum levels of E-selectin, ICAM-1 and VCAM-1 in colorectal cancer patients: correlations with clinicopathological features, patient survival and tumour surgery.

The serum concentrations of the cell adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were investigated in 63 patients with colorectal cancer and in 51 controls by an enzyme-linked immunosorbent assay (ELISA). Their relationship to clinicopathological variables and patient survival and changes in their levels after surgery were examined. Colorectal cancer patients showed significantly higher serum levels of E-selectin, ICAM-1 and VCAM-1 compared with healthy controls. There was a significant association between the serum levels of these molecules, disease stage and the presence of both lymph node and distant metastases. Both ICAM-1 and VCAM-1 levels correlated with serum E-selectin and carcinoembryonic antigen (CEA) levels. Serum levels of all three molecules decreased significantly after radical resection of the tumour. Elevated pre-operative E-selectin, ICAM-1 and VCAM-1 levels were significant prognostic factors, although not independent of stage, for patient survival. These findings suggest that serum concentrations of E-selectin, ICAM-1 and VCAM-1 may reflect tumour progression and metastasis. Since these markers are linked to CEA levels, it is uncertain whether their measurement will prove cost-effective in colorectal cancer management.

Circulating anti-CEA antibodies in the sera of patients with breast cancer.

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

General surgery in haemophiliac patients.

With improvements in medical technology, more and larger surgical procedures are performed in haemophiliac patients, but rarely reported in the surgical literature. A retrospective study from a 10 year period from one referral centre identified a total of 68 operations performed in haemophiliac patients. The levels of the defective factors were carefully monitored preoperatively and postoperatively, and replaced according to a standard formula. Special caution was taken to avoid any postoperative medication or procedures that could provoke haemorrhagic complications.Two patients suffered postoperative bleeding complications that were managed conservatively. Inhibitory factors were detected preoperatively in one case, and postoperatively in another, and were managed with aggressive replacement therapy. There was no mortality, and the overall morbidity rate was 6%. With adequate preoperative and postoperative monitoring of the clotting factors, meticulous haemostasis during surgery, careful postoperative nursing, and timely replacement therapy, haemophiliac patients can be operated with good results. Postoperative bleeding complications are rare, and usually amenable to conservative management.

Microdysgenesis with abnormal cortical myelinated fibres in temporal lobe epilepsy: a histopathological study with calbindin D-28-K immunohistochemistry.

Microdysgenesis is a microscopic cortical malformation reported to occur with varying incidence in surgical lobectomies from patients with temporal lobe epilepsy (TLE). It may act as a substrate for the seizures. Four patients are reported with TLE, hippocampal sclerosis and cortical microdysgenesis which was also characterized by the presence of abnormal myelinated fibres running tangentially in the superficial cortical laminae and closely associated with abnormal clusters of neurones. Similar abnormal cortical fibres have been described in other malformations of cortical development including polymicrogyria and focal cortical dysplasia and it is therefore likely that these fibres represent part of the microdysgenetic malformation not hitherto reported. The possibility is discussed that they may also be of functional significance in terms of influencing local seizure propagation and the secondary cortical neuronal loss observed, predominantly affecting layer II. Studies of calbindin interneuronal populations showed preservation of these cells in the microdysgenetic cortex, when compared with non-malformed temporal lobes, despite an overall reduction in cortical neuronal density. In addition, prominent numbers of neurogliaform calbindin-positive nerve cells were observed in the microdysgenesis cases and the nature of these cells is speculated upon.

Carcinoid of the ampulla of Vater: presentation of a new case.

The appendix is the most common location for carcinoid tumors within the gastrointestinal tract. Carcinoid tumors of the ampulla of Vater is an extremely rare entity; only 71 cases of carcinoid of the ampulla of Vater have been reported in the literature to date. The clinical picture is non-specific, and endoscopy is the main diagnostic procedure; but large and deep biopsies are often needed to verify the histological nature of the tumor. Surgery is the treatment of choice. We report a new case of this rare tumor, and a review of the literature concerning the clinical findings, diagnosis, therapeutic challenge and results.

Malignant melanoma of the anorectal area. Report of two cases.

BACKGROUND/AIMS: Primary anorectal melanoma is a very rare malignant tumor with no more than 300 cases reported in the literature. METHODS: Two cases of anorectal melanoma are reported herein. RESULTS: Both patients, aged 44 and 74 years, presented at the outpatient department with anal bleeding, one after being treated for 3 months with antihemorrhoidal drugs. The diagnosis was established with proctoscopy and biopsy, and a palliative abdominoperineal resection in the presence of lymph node metastases was performed followed by chemotherapy with vindesine. Although the procedures were not curative, both patients had an uneventful postoperative recovery, and lived 4 years and 21 months, respectively, without bleeding problems albeit with the inconvenience of a colostomy. CONCLUSIONS: For the time being there is no convincing proof of the value of either types of proposed surgical management. We agree with those who believe that abdominal perineal resection has an advantage regarding the prognosis and quality of life.

Prognostic significance of circulating antibodies against carcinoembryonic antigen (anti-CEA) in patients with colon cancer.

OBJECTIVE: The discovery of antibodies against carcinoembryonic antigen (CEA) in patients with digestive cancers, in the late 1970s, initiated a number of studies on the role of these antibodies in patients with cancers of the GI tract. Our aim was to determine the prevalence and prognostic significance of the IgG and IgM anti-CEA antibodies in the serum of patients with colon cancer. METHODS: Using an enzyme-linked immunoassay, the sera of 58 colon cancer patients were examined for the presence of carcinoembryonic antigen (CEA) and for circulating antibodies against the CEA (anti-CEA). An inhibition assay was carried out for the determination of the specificity of the IgG and IgM anti-CEA antibodies. RESULTS: The CEA was elevated (> or =10 ng/ml) in only 12 patients (20.6%). Anti-CEA IgM and/or IgG antibodies were detected in 46 patients with colon cancer (79.1%). In the control group (n = 28), 10% of the individuals had detectable amounts of IgG and/or IgM anti-CEA antibodies. Patients with detectable amounts of circulating IgM anti-CEA antibodies (n = 14, 30.5%) had a statistically significantly better 2-yr survival compared to the rest of the patients (p = 0.017). The IgM anti-CEA antibodies can also be used as an independent prognostic factor in these patients (p = 0.0323). CONCLUSIONS: In this study, a high number of colon cancer patients have circulating anti-CEA antibodies in their sera. These may be used as diagnostic markers and as independent prognostic factors. In addition, the presence of these antibodies in the patients studied is associated with better prognosis and significantly increased 2-yr survival. It was also found that the anti-CEA antibodies (IgG and IgM) are more sensitive markers than CEA. These findings underline the biological importance of the anti-CEA antibodies and provide additional information on their potential use as markers of the immune status in patients with colon cancer.

Effect of curative versus palliative surgical treatment for stage III pancreatic cancer patients.

UNLABELLED: During the last decade, significant progress has been made in pancreaticoduodenectomy for patients with pancreatic carcinoma. Pancreatic resection performed by surgeons in tertiary referral centres is therefore justified, while the indications for pancreatic resection could be extended in patients with advance stages of disease. The aim of our study is to compare the effect of curative (pancreaticoduodenectomy) versus palliative surgery in patients with stage III pancreatic cancer, during a 20-years period. We retrospectively reviewed the charts of 58 consecutive patients with stage III ductal adenocarcinoma of the head of the pancreas. 23 patients underwent pancreatoduodenectomy with curative intent while the remaining 35 patients had surgery for palliative purposes (combined biliary and gastric bypass was performed in 83%). The hospital mortality rate was similar in both groups (4% vs 6%). 43% of patients undergoing pancreaticoduodenectomy had an uncomplicated post-operative course compared with 49% of patients undergoing palliative bypass. The length of surgical procedure and post-operative hospital stay in pancreaticoduodenectomy group were significant longer compared to those patients undergoing palliative bypass (p = 0.03 and p = 0.02 respectively). The overall actuarial survival was significantly (p < 0.01) longer in the group of patients who underwent pancreaticoduodenectomy compared with the group with palliative intent surgery. CONCLUSION: Pancreaticoduodenectomy with curative intent for stage III pancreatic cancer patients, could improve prognosis with similar peri-operative morbidity and mortality when compared with palliative bypass.

Long term effect of splenectomy on patients operated on for cancer of the left colon: a retrospective study.

OBJECTIVE: To find out if accidental splenectomy during colonic resection influences the survival of patients with colon cancer. DESIGN: Retrospective clinical study. SETTING: University hospital, Greece. SUBJECTS: Twenty-five patients with colonic cancer (13 Dukes' B and 12 Dukes' C) who had accidental splenectomy during resection of the left colon (n = 22) or the sigmoid (n = 3) between 1973 and 1990. Each study patient was matched with control patients for age, sex, Dukes' stage, grade, site of tumour, date, type of operation and number of blood transfusions. MAIN OUTCOME MEASURES: The five year actuarial and disease free survival estimated by the Kaplan-Meier product limit method. RESULTS: There were significantly more infective postoperative complications (6/25 compared with 0/25, p = 0.02) in patients who had a splenectomy. The incidence of metastases (p = 0.07) and the five-year disease free (p = 0.08) and overall survival (p = 0.1) were lower but not significantly so in patients who had a splenectomy compared with controls. CONCLUSIONS: Splenectomy significantly increases the number of infective postoperative complications in patients with colonic cancer. Although there was a trend for shorter disease-free survival after splenectomy, it seems that splenectomy had no impact on survival.

PTFE-vein composite grafts for critical limb ischaemia: a valuable alternative to all-autogenous infrageniculate reconstructions.

OBJECTIVES: to analyse the long-term results of primary composite bypass grafts comparing them to PTFE and vein grafts. DESIGN: a retrospective observational study. MATERIALS AND METHODS: between 1980 and 1996, 568 primary infrageniculate bypass procedures were performed; a saphenous-vein graft was used in 428 procedures, a PTFE graft in 44 and a composite PTFE-saphenous-vein graft in 96. Thirty-six composite grafts were below the knee and the remaining 60 extended more distally. Twenty-one bypass grafts from the latter group were sequential. Mean follow-up was 45.6 months. Five-year primary and secondary patency and limb salvage rates were compared by life-table analysis. RESULTS: cumulative 5-year primary patency for composite grafts was 58% and for saphenous-vein grafts 74%, while secondary patency rate was 75% and 82%, respectively (p <0.05). The 5-year limb salvage rate was 80% for composite grafts and 88% for saphenous-vein grafts (p >0.05). The primary and secondary patency and limb salvage rate for PTFE grafts was 24%, 31% and 40%, respectively. CONCLUSION: Composite grafts of PTFE and saphenous vein are significantly superior to PTFE graft alone and should be used in patients who lack sufficient length of saphenous vein.

Expression patterns of the novel catenin p120cas in gastrointestinal cancers.

p120cas is involved in signal transduction upon src or growth factor stimulation as well as in E-cadherin mediated cell adhesion and may play an important role in carcinogenesis. In this study, we evaluated immunohistochemically the expression and cellular localization of p120cas in 40 gastric, 43 colorectal and 20 pancreatic carcinomas, and examined the relationship between p120cas expression and pathological features. Altered p120cas expression was observed in 70%, 65% and 60% of gastric, colorectal and pancreatic cancers, respectively. The most common abnormality was of cytoplasmic expression associated with loss of membranous distribution found in 37% of gastric, in 25% of colorectal and in 25% of pancreatic cancers. Heterogeneous staining was noted in 15%, 19% and 20%, and complete loss of expression in 18%, 21% and 15% of gastric, colorectal and pancreatic cancers, respectively. There was no correlation between p120cas staining pattern and tumour grade or stage. Aberrant expression of p120cas which may reflect changes in signal transduction pathways occurs frequently in human malignancies.

Serum beta-endorphin levels in morbidly obese patients: the effect of vertical banded gastroplasty.

The associations between serum beta-endorphin levels and clinical and metabolic variables as well as beta-endorphin changes after surgically induced weight loss were investigated in 43 morbidly obese patients. A significant positive correlation between beta-endorphin and body weight, degree of body weight increase and ACTH was found preoperatively. Only body weight was independently associated with beta-endorphin levels. Twelve months following vertical banded gastroplasty, there was an extensive weight loss in all patients and improvement in their metabolic profile. A significant reduction in beta-endorphin levels which was proportional to the extent of weight loss was also observed.

Sex hormone changes in morbidly obese patients after vertical banded gastroplasty.

Serum sex hormone levels were measured preoperatively in 57 morbidly obese patients (19 men and 38 premenopausal women) and 12 months after vertical banded gastroplasty. In the male group, there was a significant decrease in estradiol and an increase in follicle-stimulating hormone (FSH), total testosterone and sex-hormone-binding globulin (SHBG). Among female patients, a significant decrease in estradiol, total and free testosterone and an increase in FSH and SHBG was found. Irregular menses present preoperatively in 5 women were corrected after successful weight loss. In conclusion, altered sex hormonal levels and gynecologic abnormalities associated with morbid obesity are corrected with adequate weight loss following vertical banded gastroplasty.

Surgery for renal artery aneurysms: a combined series of two large centers.

OBJECTIVE: To review the clinical features and results of surgical treatment of renal artery aneurysms from two large centers. PATIENTS AND METHODS: A retrospective analysis of 21 hypertensive patients with renal artery aneurysms operated in two centers during a 24-year period was performed. RESULTS: The presenting symptom was subcostal or flank pain in 8 (38%) and hematuria in 5 (24%) cases. A ring-like calcification was seen on plain X-ray in 6 (29%) cases. All patients were evaluated with renal angiography showing a saccular aneurysm in 13 cases (62%), fusiform in 5 (24%) and dissecting in 3 (14%) cases. All saccular aneurysms were treated with resection followed by reconstruction with vein patch in 10 cases, and with and end-to-end anastomosis in 3 cases. All fusiform and dissecting aneurysms were managed with resection and reconstruction using aortorenal bypass. There was no hospital mortality or significant morbidity. During a follow-up ranging from 6 months to 23 years, there was definite cure of hypertension in 14 (67%) patients and improvement of blood pressure levels in 4 (19%) patients. Three patients continued to be hypertensive. CONCLUSION: Surgery for renal artery aneurysms can be accomplished with good results and should be considered for patients with aneurysms greater than 2 cm, for aneurysms causing renovascular hypertension, significant stenosis, flank pain, or hematuria, for dissecting, expanding and thrombotic aneurysms, and in women with a potential for pregnancy. However, all aneurysms cannot and should not be treated surgically.

The effect of vertical banded gastroplasty on glucose-induced beta-endorphin response.

BACKGROUND: beta-Endorphin is an endogenous opioid involved in the regulation of food intake and obesity as well as in insulin metabolism. In this study, we investigated glucose-induced beta-endorphin, insulin, and glucose responsiveness in morbidly obese patients and the effect of surgically induced weight loss. METHODS: Thirty-two healthy, nondiabetic, morbidly obese patients (body mass index over 40 kg/m2) and 32 normal-weight controls were studied. Serum levels of beta-endorphin, insulin, and glucose were measured under basal conditions and during an oral glucose tolerance test (OGTT) before and 12 months following vertical banded gastroplasty. RESULTS: Preoperative basal levels of beta-endorphin, insulin, and glucose and their responses during OGTT in obese patients were significantly higher compared with those of controls. After surgery, basal beta-endorphin, insulin, and glucose levels decreased significantly compared with preoperative values. Postoperative basal insulin and glucose levels were similar to those in controls, while beta-endorphin levels remained significantly higher than those of controls. A significant reduction in total responses of beta-endorphin, insulin, and glucose during OGTT was also observed; however, postoperative beta-endorphin and insulin responses remained significantly higher than in controls. CONCLUSION: Morbidly obese patients have an increased glucose-stimulated response of beta-endorphin, insulin, and glucose which is partially corrected with weight loss following vertical banded gastroplasty.

Aberrant E-cadherin expression associated with loss of differentiation and advanced stage in human pancreatic cancer.

E-cadherin is a cell-cell adhesion molecule involved in tumour invasion and metastasis. We evaluated E-cadherin expression immunohistochemically in 43 formalin-fixed, paraffin-embedded specimens of pancreatic cancer and investigated its relationship to histopathological features. In non-cancerous pancreatic cells E-cadherin immunoreactivity was localized at the cell membrane, particularly at the intercellular junctions. Abnormal E-cadherin expression was found in 18 (42%) cases. A significantly higher proportion of poorly-differentiated tumours (71%) showed abnormal E-cadherin expression compared with moderately (50%) and well (19%) differentiated tumours (P = 0.037). There was a significant correlation between abnormal E-cadherin expression and lymph node involvement (P = 0.013), the presence of distant metastases (P = 0.034) and advanced tumour stage (P = 0.025). These findings suggest that loss of normal E-cadherin expression is involved in the progression of pancreatic cancer.

Revascularization of the limbs using vein grafts after vascular injuries.

We report on 32 patients with vascular injury of a limb undergoing a total of 41 revascularization procedures with interposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated venous injury in four, and an isolated arterial injury in 19 cases. Eighteen per cent of patients with arterial injuries had normal distal pulses on initial examination. Preoperative arteriography was performed in 12 cases, and intraoperative arteriography in four. All venous injuries were diagnosed at operation. In most cases, the contralateral greater saphenous vein was used for grafting. Four patients had postoperative thrombosis after arterial reconstruction resulting in below knee amputation in two cases. Two patients suffered from postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of a superficial femoral vein repair. It is concluded that revascularization of arterial and venous injuries of the extremities with interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in viable limbs.

Anomalous inferior vena cava complicating abdominal aortic aneurysmectomy.

Variations in the site and course of the inferior vena cava (IVC), although relatively infrequent, can have important surgical implications, especially during surgery for abdominal aortic aneurysm. We report two cases of left-sided IVC encountered during aneurysmectomy. In both cases, the anomaly was not detected during preoperative ultrasound examination, but was identified by CT scan in one case. Careful mobilization of the IVC and left iliac vein allow retraction of the IVC to the right, after which the aneurysm can be approached in the usual manner.