Cytokine Plasma Levels in Breast Cancer Patients, Before and After Surgery.

Studying the levels of cytokines in the plasma of patients could be valuable in guiding immunotherapy policies. We assessed the plasma levels of 4 major cytokines [interferon (IFN)-ß, interleukin-2 (IL-2), tumor necrosis factor alpha (TNF-α), transforming growth factor beta (TGF-ß)] collected from 19 patients with ductal breast cancer (BCa), before surgery (BS) and 5 days after surgery (AS). The ratio AS/BS was also calculated and correlated with histopathological variables and tumor-infiltrating lymphocyte (TIL) density. The IFN-ß and TNF-α levels were significantly higher in BCa patients, BS and AS, than healthy controls (P < 0.02). High IL-2 levels BS were linked with node involvement (P = 0.02), and marginally with HER2 expression (P = 0.08), while high TNF-α levels were linked with high PgR expression (P = 0.02). Increasing IFN-ß, IL-2, and TNF-α levels were noted AS, which was more evident in patients with larger tumors. The TGF-ß levels were significantly lower in BCa patients (P < 0.007). Linear regression analysis showed a direct association of IFN-ß levels AS (P = 0.02, r = 0.52) and of TNF-α AS/BS-ratio (P = 0.001, r = 0.72) with TIL-density. It is suggested that although effector immune response is evident in the majority of early stage BCa patients, removal of the primary tumor further unblocks such responses.

Biliary tract injuries after lap cholecystectomy-types, surgical intervention and timing.

Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy (LC). Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries. Bile duct injury (BDI) is a severe and potentially life-threatening complication of LC. Several series have described a 0.5% to 0.6% incidence of BDI during LC. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.

The histological and immunohistochemical aspects of bile reflux in patients with gastroesophageal reflux disease.

Introduction. The pathogenesis of GERD is strongly related with mixed acid and bile reflux. Benign and malignant esophageal and gastric lesions have been associated with synergetic activity between those parameters. Bile reflux causes reactive gastropathy evaluated with Bile Reflux Index (BRI). The aim was to investigate if the sequence: bile reflux-intestinal metaplasia-GERD-esophagitis, is associated with apoptotic/oncogenetic disturbances. Materials/Methods. Fifteen asymptomatic subjects and 53 GERD patients underwent gastroscopy with biopsies. The specimens examined histologically and immunohistochemically for p53, Ki-67, Bax, and Bcl-2. Results. Elevated BRI score detected in 47% (25/53) of patients with GERD and in 13% (2/15) of controls (P = 0.02). Severe esophageal lesions were significantly more common in BRI (+) patients (14/25) compared to BRI (-) ones (P = 0.0049). Immunohistochemical analysis did not show associations between BRI score and biomarker expression. Conclusions. Bile reflux gastropathy is associated with GERD severity, but not with oncogene expression or apoptotic discrepancies of the upper GI mucosa.

Evaluation of guide wire cannulation technique in elderly patients with choledocholithiasis.

AIMS: Post-ERCP pancreatitis is the most frequent complication of ERCP. We aimed to evaluate guide-wire cannulation as compared to conventional contrast-assisted cannulation with regard to the rate of post-ERCP pancreatitis (PEP) in elderly patients with choledocholithiasis. METHODS: Patients aged 80 years or over with known choledocholithiasis, who were referred to ERCP in one single district hospital from January 2005 to March 2008 were reviewed retrospectively. RESULTS: During this period, 246 ERCPs were performed in 217 patients. In 82 procedures (37.0%) deep cannulation of the biliary tree was achieved by means of a contrast-assisted procedure, whereas in the remaining 135 attempts a guide wire was used. Among the 64 patients older than 80 years, cannulation was accomplished in 25 by contrast visualization of the biliary tree and in 39 by means of the guide-wire. In the overall population of 217 patients, PEP occurred in 11 patients (5%), 10 and 1 case, respectively, for each of the two procedures (p = 0.00042). In the elderly patients, PEP occurred in 5 out of 25 patients after contrast filling of the bile duct, and in 1 out of 39 patients after the guide-wire utilization (p = 0.021). Cannulation was successful in 201 of 217 patients (92.6%), and in 57 of the 64 elderly patients (89%) (36 with guide wire, p = 0.42). Bleeding occurred in 5 patients (2.3%) and perforation in one (0.46%). CONCLUSION: The guide-wire seems to reduce the incidence of pancreatitis in the elderly compared to conventional contrast but does not improve the success rate for cannulation.

The significance of histological evidence of bile reflux gastropathy in patients with gastro-esophageal reflux disease.

BACKGROUND: Synergetic activity between acid and bile has been associated with extensive esophageal mucosal damage in patients with gastro-esophageal reflux disease (GERD). Reflux of bile causes injury to gastric mucosa evaluated with an established histological index (bile reflux index, BRI). The aim of the study was to investigate the role of bile reflux in patients with GERD using the BRI. MATERIAL/METHODS: Fifteen asymptomatic subjects and 53 patients with GERD underwent upper gastrointestinal endoscopy with biopsies taken from the gastric antrum, body, cardia, and lower esophagus. The updated Sidney system was used for histological examination and BRI was calculated according to the findings in the antrum. RESULTS: BRI was elevated in 25/53 GERD patients (47%) and in 2/15 15 controls (13%) (OR: 5.8, 95%CI: 1.2-28.3). Elevated BRI was noted in 72% (13/18) of the patients with severe esophagitis (grade B or C) or Barrett's esophagus, whereas it was present in 34% (12/35) of those with mild or no lesions (OR: 5, 95%CI: 1.4-17.3). Additionally, 5 of the 6 patients detected with intestinal metaplasia (IM) at the cardia (83%) and 9 of the 12 patients with IM of the antrum (75%) had elevated BRI. CONCLUSIONS: Bile reflux gastropathy is present in a significant proportion of patients with GERD and associated with disease severity. The elevated BRI in such patients highlights the role of duodeno-gastro-esophageal reflux as an additional factor in the pathogenesis of GERD.

Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study.

BACKGROUND: Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods. MATERIALS AND METHODS: Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions. RESULTS: Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04). CONCLUSION: Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.

Enterobius Vermicularis infection of the appendix as a cause of acute appendicitis in a Greek adolescent: a case report.

Gastrointestinal infection due to Enterobius vermicularis occurs worldwide and is considered to be the most common helminth infection. The simple presence of E. vermicularis in the appendix usually produces symptoms of acute appendicitis. The association of this parasitic infestation with acute appendicitis varies from 0.2%-41.8% worldwide. We present a case of a 15 year old female with enterobiasis of appendix presented with clinical features of acute appendicitis. The appendix was surgically removed and the specimen was pathologically diagnosed to contain of E. vermicularis in non-inflamed and histologically normal appendix. Even if this condition is not uncommon in the Greek population, to the best of our knowledge this is the first report presented in the English literature.

De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate.

OBJECTIVE: To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP). DESIGN: Prospective observational study. SETTING: Multidisciplinary intensive care unit. PATIENTS AND PARTICIPANTS: VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 +/- 1.2 vs. 22.7 +/- 6.3 days) and hospital (23.7 +/- 2.8 vs. 29.8 +/- 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 +/- 1.6 vs. 22.4 +/- 6.4 days) and hospital (23.1 +/- 4.4 vs. 29.9 +/- 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 +/- 1.1 vs. 23.2 +/- 6 days) and hospital (23.8 +/- 2.4 vs. 29.8 +/- 11.4 days) stay (p < 0.05). CONCLUSIONS: For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de-escalation therapy.

Both early-onset and late-onset ventilator-associated pneumonia are caused mainly by potentially multiresistant bacteria.

OBJECTIVE: To compare the causative pathogens of early-onset and late-onset ventilator-associated pneumonia (VAP) diagnosed by bronchoalveolar lavage quantitative cultures. Most previous reports have been based on endotracheal aspirate cultures and gave uncertain findings. DESIGN: Prospective evaluation of consecutive patients with clinical suspicion for VAP. SETTING: Multidisciplinary intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: During a 3-year period 473 patients with clinical suspicion of VAP entered the study. Diagnosis of VAP was confirmed by cultures of bronchoalveolar lavage (> 10(4) cfu/ml) specimens in 408 patients. INTERVENTIONS: Protected bronchoalveolar lavage samples were taken. Initial antibiotic therapy was modified upon bronchoalveolar lavage culture results. MEASUREMENTS AND RESULTS: Among 408 patients 191 had early-onset (< 7 days mechanical ventilation) and 217 late-onset (> or = 7 days) VAP. Potentially multiresistant bacteria, mainly Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), were the most commonly isolated pathogens in both types of VAP. No difference was noted in the contribution of potentially multiresistant pathogens (79% vs. 85%), P. aeruginosa (42% vs. 47%), or MRSA (33% vs. 30%) between early-onset and late-onset VAP. Initial antibiotic therapy was modified in 58% of early-onset VAP episodes and in 36% of late-onset VAP episodes. No difference in mortality was found between the two types of VAP. CONCLUSIONS: Both early-onset and late-onset VAP were mainly caused by potentially multiresistant bacteria, most commonly P. aeruginosa and MRSA. Antimicrobial agents against these pathogens should be prescribed empirically, at least in our institution.