Bariatric Nutritional Intervention in Obese Patients with Compensated Liver Cirrhosis: A Four-Year Prospective Study.

BACKGROUND: Obesity and liver cirrhosis represent significant health challenges, often leading to various complications. AIMS: This prospective study aimed to investigate the impact of a four-year bariatric intervention, focusing on adherence to the Mediterranean Diet, on anthropometric, hematologic, and biochemical parameters in obese patients with compensated liver cirrhosis. Additionally, the study evaluated the concurrent contribution of weight loss to these health indicators. METHODS: The study involved 62 patients with compensated liver cirrhosis (mean age 65.87 ± 6 years) and 44 healthy controls (mean age 59.11 ± 8 years), all with a BMI > 30 kg/m2. Both groups underwent a weight loss intervention based on the Mediterranean diet, with a four-year follow-up. Anthropometric, biochemical and hematologic parameters were evaluated at several time points during the study and their statistical significance was assessed. RESULTS: Anthropometric parameters, including weight, BMI, waist and hip circumference, percentage of fat mass, and handgrip strength, exhibited significant improvements (p < 0.05), particularly within the first year of the intervention. Liver function tests and lipid profiles of the patients also showed significant enhancements (p < 0.05). Hematological and biochemical indices, such as hematocrit and ferritin, experienced discreet improvements in the patient cohort (p < 0.05). CONCLUSIONS: This study highlights the potential of a structured bariatric intervention rooted in the Mediterranean diet to positively influence the health of obese patients with compensated liver cirrhosis. The observed improvements in anthropometric, biochemical, and hematologic parameters, particularly within the first year of the intervention, suggest the importance of dietary modifications in managing the health of this patient population.

Recurrent episodes of acute pancreatitis due to duodenal gangliocytic paraganglioma: report of a case.

CONTEXT: Gangliocytic paraganglioma is a rare tumor, almost always located in the second portion of the duodenum, and manifested with upper gastrointestinal bleeding and abdominal pain. To date, only one case of duodenal gangliocytic paraganglioma presented with recurrent acute pancreatitis has been reported in the literature. CASE REPORT: We present a 72-year-old woman admitted to the hospital due to recurrent episodes of acute pancreatitis. Paraclinical examinations showed a polypoid mass in the second portion of duodenum which was removed surgically by local excision. The preoperative differential diagnosis was suggestive with gastrointestinal stromal tumor or adenoma. The histopathology examination revealed a duodenal gangliocytic paraganglioma. After a follow up period of seventeen months the patient remained without clinical evidence of tumor recurrence. CONCLUSION: Our case report draws attention to the need for including in our differential diagnosis of recurrent acute pancreatitis the mechanical obstruction of the pancreatic duct due to this tumor.

The Plague in Crete During the 19th Century.

The plague is one of the most dangerous infectious diseases that can affect mankind. The disease has caused countless pandemics over the centuries in many parts of the world, mainly Asia, Africa, and Europe, and has caused over 200 million deaths, making it one of the greatest scourges of mankind throughout the ages. Similar to the rest of Greece, Crete was affected for many years by the plague during the 19th century, which caused significant mortality, both in the cities and the countryside. The lack of doctors, the absence of organized health systems, the ignorance of the origin and modes of transmission, and the belief of the island's Muslim conquerors in destiny and God-given diseases made the spread of the plague very easy, while simultaneously making its control, with measures to protect public health, extremely difficult. This led to the repeated decimation of the island's population, with immeasurable social and economic consequences for its progression and future development.

First case of Whipple's disease successfully treated with tigecycline.

INTRODUCTION: Whipple's disease is a rare chronic infectious disease caused by Tropheryma whipplei. The infection mainly affects the small intestine of middle-aged patients, approximately three times more often in males than in females causing malabsorption and excessive weight loss but other organs may be affected as well. CASE REPORT: We describe a case of a 42-year-old woman with a history of chronic diarrhea and weight loss evolving for at least the last 6 years. The diagnosis of Whipple's disease was confirmed by histopathological examination of duodenal biopsy samples with Periodic acid-Schiff positive macrophages and by polymerase chain reaction technique detecting the DNA of Tropheryma whipplei. The patient was commenced on several antimicrobials including beta-lactams and co-trimoxazole but she did not improve. Finally, after-long lasting i.v. tigecycline 100 mg BID she was commenced on p.o. doxycycline along with hydroxychloroquine 200 mg TID for one year and after by p.o. doxycycline alone. DISCUSSION: The intriguing thing with this case was not only the natural resistance to co-trimoxazole but that the infection was controlled empirically with long-lasting i.v. tigecycline since several failed attempts to discontinue i.v. treatment followed. This might be due to erratic absorption of oral drugs due to gut inflammation. CONCLUSIONS: To our knowledge, this is the first case of Whipple's disease successfully treated with long-lasting induction parenteral tigecycline followed by p.o. doxycycline along with hydroxychloroquine for one year and after by p.o. doxycycline alone.

The Anatomy in Greek Iatrosophia during the Ottoman domination era.

The knowledge of Anatomy during the Ottoman domination in Greece has not been widely studied. Medical knowledge of the time can be retrieved from folk and erudite books called Iatrosophia. The majority of these books focused on empirical diagnostics and therapeutics. However, a small quota of these Iatrosophia includes important information about anatomy. The interest in anatomy appears only after the Neohellenic Enlightenment (1750-1821) and has been associated to the scholarly background of the 1821 revolution against the Ottomans. At the same time, anatomy has been discussed by various authors in diverse contexts. All in all, it appears that a consensus on the importance of anatomy has been established among Greek scholars in the late 18th century, leading to the translation of current anatomical knowledge to the contemporary language and literature.

Osteoclast: like giant cell undiferrentiated pancreatic tumor diagnosed by means of EUS guided FNA.

OBJECTIVE: Osteoclast-like giant cell tumours are rare abdominal malignant neoplasms mainly arising in the pancreas. Because of their rarity, clinical and cytopathology reports are very limited, and sonographic features have not been clearly specified ; these tumors are easily misdiagnosed by ultrasound as mucinous cystic tumors (MCTs)  or solid pseudopapillary neoplasms (SPNs). CASE STUDY: We report a case of osteoclast  like giant cell tumor arising in the pancreas of an 80 year old female patient offered by EUS-FNA cytology on direct and cell block slides. A biphasic pattern composed by a malignant mononuclear cell component and a giant cell component were hallmarks to the diagnosis. CONCLUSION: Our case highlights the performance of EUS-FNA in the diagnostic approach of  abdominal tumours and the significance of cell block method in the interpretation of osteoclast-like giant cell pancreatic tumour.

Effect of golimumab on health-related quality of life, other patient-reported outcomes and healthcare resource utilization in patients with moderate-to-severe ulcerative colitis: a real-world multicenter, noninterventional, observational study in Greece.

BACKGROUND AND AIMS: This real-world study assessed the impact of golimumab on health-related quality of life (HRQoL) and other patient-reported outcomes (PROs) in patients with ulcerative colitis over 12 months in Greece. METHODS: GO-LIFE was a noninterventional, prospective, multicenter, 12-month study. Patients who had moderately-to-severely active ulcerative colitis were naïve to antitumor necrosis factor (anti-TNFα) therapy and had failed previous conventional therapy. Patients received golimumab as per label. The primary endpoint was patients achieving inflammatory bowel disease questionnaire 32-item (IBDQ-32) remission at 12 months. Secondary endpoints, at 6 and 12 months, included patients achieving IBDQ-32 response; the mean change in the treatment satisfaction questionnaire for medication (TSQM) and the work productivity and activity impairment in ulcerative colitis (WPAI:UC) questionnaires; changes in healthcare utilization; patients achieving clinical response and remission; adherence rates and the percentage of patients who discontinued golimumab. RESULTS: IBDQ-32 remission was achieved by 76.9% of patients at 12 months. Mean changes in all TSQM and WPAI:UC domain scores at 12 months were statistically significant. Clinical remission was achieved by 49.4 and 50.6% of patients at 6 and 12 months, and clinical response by 59.3 and 56.8%, respectively. All patients but one (80/81) had high adherence (≥80%) to golimumab treatment over 12 months. Ulcerative colitis-related health care resource utilization was reduced during the follow-up period. CONCLUSIONS: In real-world settings, treatment with golimumab resulted in meaningful improvements in HRQoL and other PROs, and in disease activity at 6 and 12 months in patients with moderately-to-severely active ulcerative colitis who were naïve to anti-TNFa therapy.

Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial?

BACKGROUND: Symptomatic choledocholithiasis can be treated during pregnancy. Conceptus doses ranged from 0.1 mGy to 3 mGy in previous studies. OBJECTIVE: The objectives of the current study were to investigate whether the conceptus dose may exceed the threshold of 10 mGy in the case of a pregnant patient undergoing ERCP, and to provide data for the accurate assessment of a conceptus dose. DESIGN: Monte Carlo methodology and mathematical anthropomorphic phantoms were used to determine normalized conceptus dose data. Phantoms simulated pregnant patients of different body sizes and gestational stages. Monte Carlo simulations were performed to estimate the efficiency of external shielding. SETTING: University hospital. PATIENTS: Twenty-four consecutive patients. INTERVENTIONS: All patients underwent therapeutic ERCP. Exposure parameters and dose-area product were recorded during the procedures. MAIN OUTCOME MEASUREMENTS: The total dose-area product recorded during ERCP procedures ranged between 62 x 10(3) and 491 x 10(3) mGy . cm(2). RESULTS: Monte Carlo normalized conceptus dose data are presented as a function of kV(p), total filtration, gestational stage, and body mass index. The conceptus dose may exceed 10 mGy when the total dose-area product surpasses 130 mGy . cm(2). LIMITATIONS: Variations of conceptus location and size from the average. CONCLUSIONS: Conceptus dose from ERCP may occasionally exceed 10 mGy, the dose above which the analytical dose calculation is recommended. The use of external shielding is unnecessary because the associated dose reduction is negligible. The normalized dose data may be used for the accurate estimation of conceptus dose from an ERCP procedure performed on a pregnant patient, regardless of body size, gestational stage, operating parameters, and equipment used.

Patients' perceptions as an indicator of quality of care, in Greek patients with inflammatory bowel disease.

AIM AND METHOD: The chronic nature of inflammatory bowel disease (IBD) and its frequent relapses result to a considerable utilization of healthcare resources. Current approaches for the assessment of quality of care are based on the perception of the healthcare provider, which may be different from that of the healthcare user. The purpose of this study was to assess IBD patients' satisfaction, as an indicator of healthcare quality, with the use of a validated instrument (QUOTE-IBD). Ninety-five patients with IBD completed the GR-QUOTE-IBD questionnaire, for the assessment of patient's perception, regarding the quality of the perceived care. RESULTS: According to this evaluation suboptimal care was observed in the dimensions of accommodation, accessibility and information (mean values: 8.92, 8.94 and 8.95, respectively). In the subgroup analysis significant differences were observed in relation to patient's age groups and educational level. Differences were also noted in relation to the disease duration (longer and shorter than 5 years). CONCLUSIONS: The assessment of the quality of health care, based on patients' perception, revealed quality problems in the dimensions of accommodation, accessibility and information. According to subgroup analysis, disease type, educational status, age and disease duration play an important role in the formation of patients' expectations from the healthcare system.

Infliximab trough levels are decreasing over time in patients with inflammatory bowel disease on maintenance treatment with infliximab.

BACKGROUND: Infliximab trough levels (IFX-TLs) and antibodies to infliximab (ATIs) have been suggested as useful markers for the optimization of treatment in inflammatory bowel disease (IBD). We aimed to estimate the patterns over time of IFX-TLs and ATIs in IBD patients on maintenance treatment with IFX. METHODS: Two different measurements of IFX-TLs and ATIs were performed (ELISA; Eagle BioSciences) at a 10-month interval using serum samples of consecutive patients on maintenance treatment with IFX. Certain biomarkers [hemoglobin, erythrocyte sedimentation rate, C-reactive protein (CRP), platelets, albumin] measured at the same time as well as clinical disease activity and quality of life were assessed. RESULTS: Among a total of 86 IBD patients under maintenance treatment with IFX, 64 [49 Crohn's disease, 15 ulcerative colitis (UC), 42 men, mean age 44.2±15.2 years, 41 in combination therapy with immunomodulator, six in intensified dose], with two available measurements of IFX-TLs and ATIs (A and B), were included in the study. The median levels of IF-TLs were 5.07 (interquartiles range: 1.60-12.73) µg/ml in measurement A and 4.68 (1.19-7.83) µg/ml in measurement B (P<0.0001). Patients whose dose was intensified after the first measurement showed an increase in their median IFX-TLs from 1.47 to 8.5 µg/ml, whereas patients with stable IFX dose showed a significant reduction in the median IFX-TLs from 5.65 to 3.8 µg/ml (P<0.0001). In the logistic regression analysis, the decrease in IFX-TL was correlated significantly and independently with the increase in CRP [odds ratio 5.2 (1.4-19.0), P=0.01]. CONCLUSION: IBD patients on maintenance treatment with IFX show decreasing patterns of IFX-TLs over time associated with increasing patterns of CRP levels.

The prevalence of genetic and serologic markers in an unselected European population-based cohort of IBD patients.

BACKGROUND AND AIM: The aetiology of inflammatory bowel disease (IBD) is unknown, but it has become evident that genetic factors are involved in disease susceptibility. Studies have suggested a north-south gradient in the incidence of IBD, raising the question whether this difference is caused by genetic heterogeneity. We aimed to investigate the prevalence of polymorphisms in CARD15 and TLR4 and occurrence of anti-Saccharomyces cerevisiae (ASCA) and antineutrophil cytoplasmic antibodies (pANCA) in a European population-based IBD cohort. METHODS: Individuals from the incident cohort were genotyped for three mutations in CARD15 and the Asp299gly mutation in TLR4. Levels of ASCA and pANCA were assessed. Disease location and behaviour at time of diagnosis was obtained from patient files. RESULTS: Overall CARD15 mutation rate was 23.9% for CD and 9.6% for UC patients (P < 0.001). Mutations were less present in the Scandinavian countries (12.1%) versus the rest of Europe (32.8%) (P < 0.001). Overall population attributable risk was 11.2%. TLR4 mutation rate was 7.6% in CD, 6.7% in UC patients and 12.3% in healthy controls (HC), highest among South European CD patients and HC. ASCA was seen in 28.5% of CD patients with no north-south difference, and was associated with complicated disease. pANCA was most common in North European UC patients and not associated with disease phenotype. CONCLUSION: The prevalence of mutations in CARD15 varied across Europe, and was not correlated to the incidence of CD. There was no association between mutations in TLR4 and IBD. The prevalence of ASCA was relatively low; however related to severe CD.

Role of ASCA and the NOD2/CARD15 mutation Gly908Arg in predicting increased surgical costs in Crohn's disease patients: a project of the European Collaborative Study Group on Inflammatory Bowel Disease.

BACKGROUND: NOD2/CARD15, the first identified susceptibility gene in Crohn's disease (CD), is associated with ileal stenosis and increased frequency of surgery. Anti-Saccharomyces cerevisiae antibody (ASCA), a serological marker for CD, is associated with ileal location and a high likelihood for surgery. We hypothesized that the presence of ASCA and NOD2/CARD15 mutations could predict increased health care cost in CD. METHODS: CD patients in a prospectively designed community-based multinational European and Israeli cohort (n = 228) followed for mean 8.3 (SD 2.6) years had blood drawn for measurement of ASCA (IgG, IgA), Arg702Trp, Gly908Arg, and Leu1007fsinsC. Days spent in the hospital and the costs of medical and surgical hospitalizations and medications were calculated. RESULTS: The median duration of surgical hospitalizations was longer in Gly908Arg-positive than -negative patients, 3.5 and 1.5 days/patient-year (P < 0.01), and in ASCA-positive than -negative patients, 1.1 and 0 days/patient-year (P < 0.001). Median surgical hospitalization cost was 1,580 euro/patient-year in Gly908Arg-positive versus 0 euro/patient-year in -negative patients (P < 0.01), and 663 euro/patient-year in ASCA-positive versus 0 euro/patient-year in -negative patients (P < 0.001). Differences in cost of medications between groups were not significant. The effect of Gly908Arg was expressed in countries with higher Gly908Arg carriage rates. ASCA raised surgical costs independently of the age at diagnosis of disease. Arg702Trp and Leu1007fsinsC did not affect the cost of health care. CONCLUSIONS: Since CD patients positive for Gly908Arg and ASCA demonstrated higher health care costs, it is possible that measurement of Gly908Arg and ASCA at disease diagnosis can forecast the expensive CD patients.

Aberrant function of myeloid-derived suppressor cells (MDSCs) in experimental colitis and in inflammatory bowel disease (IBD) immune responses.

BACKGROUND AND AIMS: Myeloid-derived suppressor cells (MDSCs) encompass a novel population of suppressor cells and a potential candidate for cell-based therapies in inflammatory diseases. Herein, we investigated their immunomodulatory properties in experimental inflammatory colitis and T cell-mediated immune responses in inflammatory bowel disease (IBD) patients. METHODS: MDSCs (defined as CD14-HLA-DR-/lowCD33+CD15+) numbers were determined in peripheral blood (PB) from IBD patients. PB MDSC function was assessed in vitro. Experimental colitis was induced upon 2,4,6-trinitrobenzene sulfonic acid (TNBS) treatment and MDSCs were characterized by flow cytometry. The in vivo suppressive potential of bone marrow (BM)-derived MDSCs (BM-MDSCs) was tested by using both depleting and adoptive transfer strategies. RESULTS: MDSCs were enriched in the periphery of IBD patients during active disease. TNBS colitis induced amplification of MDSCs, particularly of the granulocytic (Ly6G+) subset during the effector phase of disease. Of interest, BM-MDSCs potently suppressed CD4+ T cell responses under steady state but failed to control colitis-associated immune responses in vivo. Mechanistically, under the colonic inflammatory milieu MDSCs switched phenotype (decreased proportion of Gr1high and increased numbers of Gr1low) and downregulated CCAAT/enhancer-binding protein beta (CEBPß) expression, a critical transcription factor for the suppressive function of MDSCs. In accordance with the murine data, human CD33 + CD15+ MDSCs from peripheral blood of IBD patients not only failed to suppress autologous T cell responses but instead enhanced T cell proliferation in vitro. CONCLUSIONS: Our findings demonstrate an aberrant function of MDSCs in experimental inflammatory colitis and in IBD-associated immune responses in vitro. Delineation of the mechanisms that underlie the loss of MDSCs function in IBD may provide novel therapeutic targets.

Factors associated with disease evolution in Greek patients with inflammatory bowel disease.

BACKGROUND: The majority of Crohn's disease patients with B1 phenotype at diagnosis (i.e. non-stricturing non-penetrating disease) will develop over time a stricturing or a penetrating pattern. Conflicting data exist on the rate of proximal disease extension in ulcerative colitis patients with proctitis or left-sided colitis at diagnosis. We aimed to study disease evolution in Crohn's disease B1 patients and ulcerative colitis patients with proctitis and left-sided colitis at diagnosis. METHODS: 116 Crohn's disease and 256 ulcerative colitis patients were followed-up for at least 5 years after diagnosis. Crohn's disease patients were classified according to the Vienna criteria. Data were analysed actuarially. RESULTS: B1 phenotype accounted for 68.9% of Crohn's disease patients at diagnosis. The cumulative probability of change in disease behaviour in B1 patients was 43.6% at 10 years after diagnosis. Active smoking (Hazard Ratio: 3.01) and non-colonic disease (non-L2) (Hazard Ratio: 3.01) were associated with behavioural change in B1 patients. Proctitis and left-sided colitis accounted for 24.2%, and 48.4% of ulcerative colitis patients at diagnosis. The 10 year cumulative probability of proximal disease extension in patients with proctitis and left-sided colitis was 36.8%, and 17.1%, respectively (p: 0.003). Among proctitis patients, proximal extension was more common in non-smokers (Hazard Ratio: 4.39). CONCLUSION: Classification of Crohn's disease patients in B1 phenotype should be considered as temporary. Smoking and non-colonic disease are risk factors for behavioural change in B1 Crohn's disease patients. Proximal extension is more common in ulcerative colitis patients with proctitis than in those with left-sided colitis. Among proctitis patients, proximal extension is more common in non-smokers.

Assessing health-related quality of life in patients with inflammatory bowel disease, in Crete, Greece.

BACKGROUND: Health Related Quality of Life (HRQoL) is an important outcome measure in Inflammatory Bowel Disease (IBD). The aim of our study was to assess HRQoL in a population of 135 Greek patients with IBD. METHODS: A cohort of 135 patients with IBD, 81 with ulcerative colitis (UC) and 54 with Crohn's disease (CD) were enrolled in our study. Demographic and disease-related data were recorded. HRQoL was assessed by a disease-specific and a generic questionnaire, IBDQ and SF-36, respectively. Disease activity was assessed by Harvey-Bradshaw Index and the Colitis Activity Index for CD and UC patients, respectively. RESULTS: Among all variables recorded in our study, only disease activity had a significant effect on HRQoL. Patients with active disease scored significantly lower on both IBDQ and SF-36 when compared to those in remission. Only two among the four IBDQ dimensions, bowel and systemic, had significant ability in distinguishing best patients in remission from those with active disease. CONCLUSIONS: IBD has a negative impact on HRQoL. Patients with active disease are more impaired than patients in remission. In our population of patients bowel and systemic dimensions had a predominant value in patients' perception of quality of life. Patients in our study using the same instrument scored higher than previously reported.

Primary biliary cirrhosis and autoimmune cholangitis are not associated with coeliac disease in Crete.

BACKGROUND: An increased prevalence of coeliac disease in patients with primary biliary cirrhosis has been recently reported. However, in other studies the association has not been confirmed. There have been no formal attempts to systematically evaluate patients with autoimmune cholangitis for coeliac disease. METHODS: Sera from 62 patients with primary biliary cirrhosis, 17 with autoimmune cholangitis and 100 blood donors were screened for anti-gliadin, anti-endomysial, anti-reticulin, and IgA class antibodies to guinea pig liver-derived tissue transglutaminase. Eighteen untreated coeliacs served as methodological controls. Analyses were performed by using the chi2 and Fischer's exact tests. RESULTS: Anti-gliadin antibodies were detected in 21% of patients with primary biliary cirrhosis, 35% of patients with autoimmune cholangitis, and 3% of controls (p < 0.001). IgA class gliadin antibodies positivity was more pronounced in patients with Scheuer's stage III-IV disease (p < 0.05). Anti-transglutaminase antibodies were detected in 10% and in 18% of patients with primary biliary cirrhosis and autoimmune cholangitis respectively (p < 0.001). Anti-reticulin and anti-endomysial antibodies were negative in all patients. Duodenal biopsies were performed in 59% and 71% of patients with primary biliary cirrhosis and autoimmune cholangitis respectively, tested positive for at least one antibody class. No histological features of coeliac disease were found. CONCLUSIONS: We were unable to demonstrate an increased risk of coeliac disease in patients with primary biliary cirrhosis and autoimmune cholangitis. Our results confirm the previously reported high prevalence of false-positive anti-gliadin and guinea pig liver-derived anti-tissue transglutaminase antibodies in patients with chronic liver disease.

Effect of octreotide on apoptosis-related proteins in rat Kupffer cells: a possible anti-tumour mechanism.

BACKGROUND: Octreotide may prolong survival in patients with hepatocellular carcinoma, through an as yet unidentified mechanism. Kupffer cells play a key role in antitumour activity. Kupffer cell apoptosis is of major importance for the maintenance of this antitumour activity. MATERIALS AND METHODS: We studied the in vitro effects of octreotide in the RNA expression of apoptotic and antiapoptotic proteins in isolated rat Kupffer cells, before and after exposure to lipopolysaccharide (LPS). Apoptotic and antiapoptotic gene expression was assessed using a semi-quantitative multiplex RT-PCR measuring bax, bcl-xS, bcl-2 and bcl-xL. LICE (caspase-3) mRNA was used as a measure of apoptosis. RESULTS: Unstimulated Kupffer cells exhibited increased proapoptotic gene expression in a time-dependent manner, paralleled by a similar increase of LICE. LPS stimulation decreased the expression of proapoptotic bax and bcl-xS mRNA without effecting the antiapoptotic proteins. A decrease of LICE expression became significant at 48 hours. Octreotide showed a reduction of proapoptotic proteins, accompanied by an early increase and a late reduction of antiapoptotic proteins and a net decrease of LICE expression. A combination of LPS and octreotide produced a similar effect with the exception of a late increase of LICE expression, probably caused by a late increase of bax and bcl-xS. CONCLUSION: LPS and octreotide reverse the observed increased apoptosis of cultured Kupffer cells by influencing both proapoptotic and antiapoptotic proteins. Therefore, the antitumour effect of octreotide in hepatocellular carcinoma may, in part, be explained by its antiapoptotic effect on Kupffer cells.

Unexpected toxicity after low-dose docetaxel treatment of a cancer patient with clinically latent HCV-positive hepatic cirrhosis.

We report a case with unexpected toxicity after low-dose docetaxel chemotherapy. The patient had a history of clinically latent HCV-positive hepatic cirrhosis when she presented with inoperable pulmonary adenocarcinoma. She was recruited in a protocol combining standard radiotherapy (RT) with docetaxel (30 mg/m2 week). On day 7, after the 1st docetaxel infusion, grade III neutropenia (980 neutrophils), grade II platelet toxicity (90,000/ml) and lymphopenia (486/ml) had developed. Chemotherapy and RT were interrupted and the neutrophil counts were partially restored (1400/ml), while the platelet counts were back to normal (140,000/ml) and the lymphocyte counts were further reduced (320/ml), on day 15. Bilateral leg oedema and hair loss appreared. On day 21, there was a full restoration of neutrophil counts (1890/ml), while there was persistent lymphocytopenia (300/ml). Alopecia grade III was now evident. Dysphagia grade II complicated with fungal oropharyngeal infection appeared on day 24 (24 Gy of RT). One more dose of docetaxel of 30 mg/m2 was given on day 36 Grade II neutropenia (1050/ml) and grade III platelet toxicity (48,000/ml) were observed 14 days after the second docetaxel dose, while dysphagia grade II appeared once again. After a one-week delay, RT was continued to a total dose of 54 Gy. Liver function tests remained unchanged throughout the treatment. Post-RT CT-scan of the chest and upper abdomen showed complete response of the lung lesion. We suggest that, when docetaxel is chosen to treat cancer patients with HCV-positive hepatic cirrhosis, a starting dose schedule reduced by at least 50% should be considered before escalating to the standard dose.

Increasing incidence of cholangiocarcinoma in Crete 1992-2000.

BACKGROUND: There have been recent reports of an increased incidence of cholangiocarcinoma. PATIENTS AND METHODS: Patients with cholangiocarcinoma, resident on the island of Crete, diagnosed between 1992 and 2000, were studied. Case ascertainment was enhanced by collaboration of the pathology departments and all gastroenterologists of Crete in providing relevant data. A specially designed patient protocol was used. Crude incidence rates are presented. RESULTS: During the 9-year period 7 patients were diagnosed with cholangiocarcinoma of the intrahepatic ducts, 17 with Klatskin and 16 patients with extrahepatic ducts carcinoma. A steady incidence increase of cholangiocarcinoma, irrespective of location, was shown. The estimated incidence rate per three-year period progressively increased from 0.998 to 2.329 and 3.327 per 100,000 for the periods 92-94, 95-97 and 98-2000, respectively. Median survival time was 8.5 months. No significant difference was seen between survival according to the location of cholangiocarcinoma. CONCLUSION: A steady incidence increase of cholangiocarcinoma cases in Crete during the time-period 1992-2000 was shown.

Validation and results of a questionnaire for functional bowel disease in out-patients.

BACKGROUND: The aim was to evaluate and validate a bowel disease questionnaire in patients attending an out-patient gastroenterology clinic in Greece. METHODS: This was a prospective study. Diagnosis was based on detailed clinical and laboratory evaluation. The questionnaire was tested on a pilot group of patients. Interviewer-administration technique was used. One-hundred-and-forty consecutive patients attending the out-patient clinic for the first time and fifty healthy controls selected randomly participated in the study. Reliability (kappa statistics) and validity of the questionnaire were tested. We used logistic regression models and binary recursive partitioning for assessing distinguishing ability among irritable bowel syndrome (IBS), functional dyspepsia and organic disease patients. RESULTS: Mean time for questionnaire completion was 18 min. In test-retest procedure a good agreement was obtained (kappa statistics 0.82). There were 55 patients diagnosed as having IBS, 18 with functional dyspepsia (Rome I criteria), 38 with organic disease. Location of pain was a significant distinguishing factor, patients with functional dyspepsia having no lower abdominal pain (p < 0.001). Significant factors distinguishing between IBS and functional dyspepsia were relief of pain by either antacids or defecation (19% vs 71% and 66% vs 0% respectively). Awakening from pain at night was also a factor distinguishing between IBS and organic disease groups (26% vs 61%, p < 0.01). CONCLUSIONS: This questionnaire for functional bowel disease is a valid and reliable instrument that can distinguish satisfactorily between organic and functional disease in an out-patient setting.