Information seeking behavior of patients with diabetes mellitus: a cross-sectional study in an outpatient clinic of a university-affiliated hospital in Athens, Greece.

BACKGROUND: The purpose of this study is to examine the information behavior of diabetic patients, a relatively unexplored field of diabetes care, including their needs for information, resources used, obstacles encountered and degree of satisfaction for diabetes-related information acquisition. METHODS: 203 patients (males: 110, type 2:172) followed-up in the outpatient Diabetes Clinics of a University-affiliated hospital in Greece were assessed, using a validated questionnaire. RESULTS: Patients identified diet (61.4%) and diabetic complications (41.9%) as "the most important" for their information needs and the treating physician (94.6%) for information resources. Internet importance and frequency of use ranked low. Main obstacles to information seeking were "lack of time" and "cost". Most patients (71.4%) stated they were "quite" or "very satisfied" with the current possibilities of information seeking. CONCLUSIONS: Diabetic patients' stated information needs and information sources, as well as main obstacles to obtaining information could potentially have important implications in designing a future information campaign.

The role of C-reactive protein in the prediction of the clinical severity of acute diverticulitis.

The aim of this study is to investigate the value of C-reactive protein (CRP) and of other laboratory parameters obtained during the initial evaluation of the patient in the prediction of the clinical severity of acute diverticulitis. The records of patients treated for acute diverticulitis at the Oulu University Hospital from December 2006 to December 2008 were retrospectively reviewed. Mild disease was defined when conservative treatment was successful. Severe acute diverticulitis was considered when percutaneous drainage of an abscess and/or surgery was necessary. From the 182 patients considered for analysis, 158 (87%) had mild disease, whereas 24 (13%) had severe. CRP (P = 0.034) and the Hinchey classification (P = 0.006) were shown to be independent risk factors for severe acute diverticulitis in the logistic regression analysis. The receiver operating characteristic curve showed that a CRP cutoff value of 170 mg/L significantly discriminated severe from mild diverticulitis (87.5% sensitivity, 91.1% specificity, area under the curve 0.942, P < 0.00001). CRP is a useful tool in the prediction of the clinical severity of acute diverticulitis. A mild episode is very likely in patients with CRP less than 170 mg/L. Those with higher CRP values have a greater probability to undergo surgical treatment or at least a percutaneous intervention.

Treatment of patients with metastatic renal cell carcinoma undergoing hemodialysis: case report of two patients and short literature review.

BACKGROUND: Renal cell carcinoma (RCC) may involve both kidneys. When bilateral nephrectomy is necessary renal replacement therapy is mandatory. Treating such patients with sequential therapy based on cytokines, antiangiogenic factors and mammalian target of rapamycin (mTOR) inhibitors is challenging. CASE PRESENTATION: The first case, a 50-year-old Caucasian female, underwent a radical right nephrectomy for RCC. Twelve years later she underwent a radical left nephrectomy along with total hysterectomy including bilateral salpingo-oophorectomy for RCC involving the right kidney and ovary. Hemodialysis was necessary because of bilateral nephrectomy. She relapsed with pulmonary metastases and enlarged mediastinal lymph nodes and received cytokine based therapy along with bevacizumab. Therapy was discontinued despite the partial response because of hemorrhagic gastritis. Therapy was switched to an antiangiogenic factor but the patient manifested a parietal brain hematoma and stopped therapy. Subsequently disease relapsed with malignant pleural effusion and pulmonary nodules and a mammalian target of rapamycin inhibitor was administered which was withdrawn only at patient's deteriorating performance status. The patient died of the disease 13 years after the initial diagnosis of RCC. CONCLUSION: Patients with RCC are in significant risk to manifest bilateral disease. Renal insufficiency requiring hemodialysis poses therapeutic challenges. Clinicians must be aware of the antiangiogenic factors' adverse effects, especially bleeding, that may manifest in higher frequency and more severe in this setting.

Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis.

BACKGROUND-AIM: The aim of this study is to identify the long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS: Seven patients with chronic refractory pouchitis diagnosed by clinical, endoscopic and histological criteria received infliximab 5 mg/kg at 0, 2, and 6 weeks and thereafter every 2 months for 1 year. Three patients had fistulae (1 pouch-bladder, 2 perianal) and 4 extraintestinal manifestations (2 erythema nodosum, 2 arthralgiae). All patients were refractory to antibiotics and 3 to azathioprine. Crohn's disease was excluded after re-evaluation of the history and small bowel examination with enteroclysis or capsule endoscopy. Clinical response was classified as complete, partial and no response. Fistulae closure was classified as complete, partial and no closure. The pouchitis disease activity index (PDAI) was used as an outcome measure. All patients were followed up for 3 years after discontinuation of infliximab therapy. RESULTS: After 1 year of infliximab administration 5 patients had complete clinical response, 1 partial clinical response and 1 no response, while 2 out of the 3 patients with fistulae had a complete closure. The median PDAI dropped from 11 (baseline) (range, 10-14) to 5 (range, 3-8). Extraintestinal manifestations were in complete remission too. Three years after completion of therapy, all patients with complete clinical response at one year remained in remission. CONCLUSIONS: One year infliximab administration is associated with a long term benefit in patients with chronic refractory pouchitis following IPAA for UC.

DNA ploidy: a prognostic factor of response to chemotherapy and survival in metastatic gastric adenocarcinoma.

BACKGROUND: Metastatic gastric adenocarcinoma confers a dismal prognosis. Several prognostic factors are needed to distinguish patients that will benefit from chemotherapy. In this setting, the prognostic impact of DNA ploidy is still unclear. MATERIALS AND METHODS: The records of 61 patients with metastatic gastric adenocarcinoma were retrospectively reviewed. Response to chemotherapy and overall survival (OS) were assessed and correlated to tumour DNA ploidy index, which was calculated by cytometric image analysis. RESULTS: The median value of DNA ploidy index was 2.3. Patients with a low index responded better to chemotherapy than those with a higher index (p<0.01). Nevertheless, when the median value was used as a cut-off, no significant correlation of DNA ploidy index with response to chemotherapy (p=0.41) or OS (p=0.09) was observed. CONCLUSION: The prognostic role of DNA ploidy in metastatic gastric adenocarcinoma is still debatable. In this study, a low DNA ploidy index was associated with favorable prognosis; however, a suitable cut-off value is not yet available.

Prolonged survival after sequential multimodal treatment in metastatic renal cell carcinoma: two case reports and a review of the literature.

INTRODUCTION: In this case series and short review of the literature, we underline the impact of nephrectomy combined with sequential therapy based on cytokines, antiangiogenic factors, and mammalian target of rapamycin inhibitors along with metastasectomy on overall survival and quality of life in patients with metastatic clear cell renal carcinoma. CASE PRESENTATION: In the first of two cases reported here, a 53-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer and relapsed with a bone metastasis in his right humerus. He was treated with closed nailing and cytokine-based chemotherapy. For 5 years, the disease was stable and he had great improvement in quality of life. Subsequently, the disease relapsed in his lymph nodes, lung, and thorax soft tissue. He was then treated with antiangiogenic factors and mammalian target of rapamycin inhibitors. The disease progressed until September 2009, when he died of allergic shock during a blood transfusion, 9 years after the initial diagnosis of renal cell cancer.In the second case, a 54-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer. A year later, the disease progressed to his neck lymph nodes, and cytokine-based chemotherapy was initiated. While he was on cytokines, a solitary pulmonary nodule appeared and he underwent a metastasectomy. Nine months later, magnetic resonance imaging of his brain revealed a focal right occipitoparietal lesion, which was resected. After two years of active surveillance, the disease relapsed as a pulmonary metastasis and he was treated with an antiangiogenic factor. Further progressions presenting as enlarged axillary lymph nodes, chest soft tissue lesions, and thoracic spine bone metastases were sequentially observed. He then received a first-generation mammalian target of rapamycin inhibitor, an antiangiogenic factor, and later a second-generation mammalian target of rapamycin inhibitor and palliative radiotherapy. Ten years after the initial diagnosis of renal cell cancer, his disease is stable and he is on a third antiangiogenic factor and leads an active life. CONCLUSIONS: One multidisciplinary approach to patients with metastatic renal cell cancer combines nephrectomy, metastasectomy, and radiotherapy (when feasible) with medical therapy based on cytokines and targeted treatment employing agents inhibiting angiogenesis, other receptor tyrosine kinases, and mammalian target of rapamycin. This approach could prolong survival and improve quality of life.

Limits of infrainguinal bypass surgery for critical leg ischemia in high-risk patients (Finnvasc score 3-4).

BACKGROUND: The aim of the present study was to compare the early- and midterm outcomes after infrainguinal bypass surgery in the treatment of low- and high-risk patients with critical limb ischemia (CLI) (Finnvasc score 0-2 and 3-4, respectively), and to evaluate limits of infrainguinal bypass surgery in treatment of the latter group. METHODS: Two hundred seventy-four infrainguinal bypass procedures performed in 218 patients were retrospectively reviewed. The Finnvasc score (range: 0-4) was calculated by assigning one point to each of four preoperative risk factors, that is, coronary artery disease, diabetes, urgency of the procedure, and gangrene. Major outcome end points were survival, limb salvage, and amputation-free survival. RESULTS: Among 274 infrainguinal bypass procedures performed for CLI, 92 procedures (33.6%) were performed in patients with Finnvasc score 3-4. They had significantly lower leg salvage (at 3-year follow-up, 53.7 vs. 70.6%; log-rank: p = 0.004), survival (at 3-year follow-up, 49.7 vs. 69.7%; log-rank: p < 0.0001), and amputation-free survival (at 3-year follow-up, 27.7 vs. 53.1%; log-rank: p < 0.0001) compared with patients with Finnvasc score 0-2. Patients with Finnvasc score 3-4 and a preoperative serum creatinine level of >150 µmol/L had 1-year amputation-free survival of 12.5%, whereas patients with lower level of creatinine had 1-year amputation-free survival of 53.1% (p = 0.028). CONCLUSIONS: Infrainguinal bypass revascularization in CLI patients who present with Finnvasc score 3-4 can be considered at higher risk of poor intermediate outcome in terms of survival, leg salvage, and amputation-free survival. Poor outcome is particularly expected in patients with Finnvasc score 3-4 and renal failure. In this subgroup of patients, primary amputation should be considered.

Institutional results and meta-analysis of outcome after infrainguinal surgical revascularization in patients greater than 80 years old.

Our aim was to evaluate the outcome after infrainguinal bypass revascularization in patients greater than 80 years old with lower limb ischemia treated at our institution and to perform a meta-analysis of literature data to better estimate current postoperative results. Eighty-four infrainguinal bypass procedures were performed in 76 patients of at least 80 years of age. Major outcome end points included survival, limb salvage, and amputation-free survival. Systematic review and meta-analysis of literature data on immediate and late outcome in patients older than 80 years who underwent infrainguinal surgical revascularization have been performed. At 30 days, seven patients (8.3%) died and seven major amputations (8.3%) occurred. Kaplan-Meier estimates of survival at 1, 3, and 5 -years were 73.8, 59.8, and 43.1 per cent; leg salvage 78.9, 71.4, and 67.8 per cent; and amputation-free survival 58.3, 42.7, and 28.2 per cent, respectively. The mean survival was 4.6 ± 0.4 years. Only Finnvasc score greater than 2 was predictive of poor late amputation-free survival (at 5 years: 4.5 vs 42.3%; relative risk, 2.19; 95% confidence interval, 1.27 to 3.76). Eleven studies were additionally available for analysis. Pooled estimates of survival at 30 days, 1 year, and 5 years were 94.8, 86.0, and 47.6 per cent, respectively, and of leg salvage were 95.5, 84.7, and 84.1 per cent, respectively. Infrainguinal bypass in patients older than 80 years carries a significant operative risk and is associated with suboptimal long-term amputation-free survival, which is particularly poor among patients with a Finnvasc score greater than 2.

Pancreatic adenocarcinoma-associated polymyositis treated with corticosteroids along with cancer specific treatment: case report.

BACKGROUND: Adenocarcinoma of the pancreas only rarely is associated with inflammatory myopathy. In this setting, polymyositis may be treated with glucocorticoids in combination with cancer specific treatment. CASE PRESENTATION: We present the case of a 52-year-old man with stage IIA pancreatic tail adenocarcinoma who underwent surgical treatment and six months into therapy with gemcitabine he developed symmetrical, painful, proximal muscle weakness with peripheral oedema. Re-evaluation with imaging modalities, muscle histology and biochemistry conferred the diagnosis of polymyositis associated with pancreatic cancer progression. The patient was treated with glucocorticoids along with gemcitabine and erlotinib which resulted in complete remission within six months. He remained in good health for a further six months on erlotinib maintenance therapy when a new computer tomography scan showed pancreatic cancer relapse and hence prompted 2nd line chemotherapy with gemcitabine. CONCLUSIONS: Polymyositis associated with pancreatic cancer may respond to glucocorticoids along with cancer specific treatment.

One-year infliximab administration for the treatment of chronic refractory pouchitis.

AIM: To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis, following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS: Seven patients (4 females, 3 males) with chronic refractory pouchitis were included in an open study. Pouchitis was diagnosed by clinical plus endoscopic and histological criteria. Three patients also had fistulae (pouch-bladder in 1 and perianal in 2). Extraintestinal manifestations were also present in 4 patients (erythema nodosum in 2, arthralgiae in 2). All patients were refractory to standard therapy. Crohn's disease was carefully excluded in all patients after re-evaluation of the history and examination of the small bowel with enteroclysis or small bowel capsule endoscopy. Patients received Infliximab 5 mg/kg at 0, 2 and 6 weeks and thereafter every 2 months for 1 year. Clinical response was classified as complete, partial, and no response. Fistulae closure was classified as complete, partial, and no closure. The pouchitis disease activity index (PDAI) was also used as an outcome measure. RESULTS: Clinically, all patients improved. After 1 year of follow-up, 5 of the 7 patients had a complete clinical response, and 2 of the 3 patients with a fistula had complete fistulae closure. At the end of the follow-up period the median PDAI dropped from 11 (baseline) (range, 10-14) to 5 (range, 3-8). Extraintestinal manifestations were in complete remission at the end of the followup period as well. CONCLUSIONS: Our results indicate that infliximab may be recommended for the treatment of chronic refractory pouchitis complicated or not by fistulae following IPAA for UC.

Study of the microcirculation in hDAF transgenic rat livers xenoperfused with human blood.

BACKGROUND: The microcirculation was assessed in the livers of human decay accelerating factors (hDAF) and wild-type transgenic rats by fluorescent intravital microscopy, histology and histomorphology to determine the benefits of hDAF expression for the microcirculation of a rat liver xenograft perfused with human blood. METHODS: Male hDAF transgenic rats (group A; n = 20) and wild-type Sprague-Dawley rats (group B; n = 20) were xenoperfused with human blood, while other male wild-type Sprague-Dawley rats (group C; n = 10) were perfused with allogeneic blood. Following plasma and leukocyte staining with fluorescein sodium, and platelet staining with rhodamine, the right lobe of the liver was assessed by intravital microscopy, counting the numbers of perfused sinusoids and leukocytes adhering to the endothelium per mm(2), and calculating the acinar perfusion index (Pi). The liver underwent histological assessment at the end of each experiment. Mean +/- SEM values were calculated and the Mann-Whitney U-test was used for statistical analysis. RESULTS: The number of perfused sinusoids was higher in the group of hDAF rat livers (group A) and controls (group C) than in the group of non-transgenic rat livers perfused with human blood (group B) (P < 0.05), although only group C still had a significantly more perfused sinusoids than the other groups after 90 min of perfusion (P < 0.05). The acinar perfusion index was higher in groups A and C than in group B (P < 0.05); here again, only group C still had a significantly higher Pi than group B after 90 min of perfusion (P < 0.05). There was a massive accumulation of leukocytes that peaked after 5 min and persisted throughout the perfusion in all three groups. Histology showed portal and subendothelial hepatic vein hemorrhage, necrosis and inflammatory reaction, which were particularly evident in group B. CONCLUSION: In our study, rat livers transgenic for hDAF were better protected against early tissue damage by perfusion with human blood, but this did not result in a longer xenograft survival.