The Effect of Shift Working on Dietary Patterns of Healthcare Practitioners during the COVID-19 Pandemic: A Cross-Sectional Study

Background and Objectives: Health professionals' working schedules often do not allow them to follow a balanced way of life, and the nature of their work can affect their weight and eating habits. The aim of the present study is to shed some light on the impact of night shift working on the dietary practices of healthcare practitioners in Greece. Materials and Methods: This was a cross-sectional study. With the use of an administered questionnaire several parameters were assessed, including anthropometric characteristics, weight history, as well as nutritional habits of the same group of participants during night shifts and when at regular working hours. Moreover, nutritional beliefs of the subjects were recorded, as well as the level of adherence to the Mediterranean diet. Results: It was observed that in all food groups, including water, used to compare the nutritional patterns of the participants during night shifts and when working regular hours, statistical differences were noted (p = 0.001). Furthermore, the participants who reported a higher adherence to the Mediterranean diet and self-reported healthier nutritional habits, had a statistically lower weight compared to the participants that rarely followed the specific model or reported unhealthier eating routine (p = 0.010 and p = 0.015, respectively). Conclusions: We conclude that shift-working healthcare professionals are associated with disturbed eating behaviours leading to the high consumption of unhealthy food. The implementation of interventions that will concentrate on educating health workers on balanced nutrition and improving physical environment (i.e., food availability, healthier food choices) seems to be of great importance.

The Effect of Fat Supplementation on the Appearance of Symptoms Associated With Dumping Syndrome in Patients Having Undergone Gastric Surgery: Preliminary Results

BACKGROUND/OBJECTIVES

Data on the effect of dietary fat on dumping syndrome (DS) symptoms are limited. The aim of this study was to assess the effect of the addition of fat to a carbohydrate meal on the appearance of DS symptoms and glycemic response, in patients who had undergone gastric surgery.

SUBJECTS/METHODS

This was an interventional crossover study. Patients scheduled for gastric surgical procedures related to DS at two surgical units of two public hospitals (General University Hospital of Larissa and General Hospital of Larissa) were considered for study inclusion. Patients presenting symptoms suggestive of diagnosis (n = 12), after the ingestion of a carbohydrate meal, were used as both intervention and control groups. During the intervention process, a fat supplement was added to the carbohydrate meal that was previously used for diagnosis. Glycemic response and the amount and intensity of DS symptoms provoked by the two meals were assessed at both appointments.

RESULTS

Blood glucose levels were significantly lower in the group that consumed the added fat meal compared with the group that consumed the carbohydrate meal 60 minutes after ingestion (p = 0.028). Furthermore, a significant reduction was noted in the amount of late dumping symptoms (p = 0.021) and the intensity of both early and late dumping symptoms (p = 0.007 and p = 0.012 respectively), after fat addition.  Conclusions: Incorporating fat into a carbohydrate meal seems to attenuate postprandial blood glucose rises and reduce the amount and intensity of DS symptoms, in patients who had undergone gastric surgery.

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Pharmacogenetic Analysis of the MIR146A rs2910164 and MIR155 rs767649 Polymorphisms and Response to Anti-TNF Treatment in Patients with Crohn's Disease and Psoriasis

The clinical heterogeneity regarding the response profile of the antitumor necrosis factor (anti-TNF) in patients with Crohn's disease (CD) and psoriasis (PsO) is attributed, amongst others, to genetic factors that influence the regulatory mechanisms which orchestrate the inflammatory response. Here, we investigated the possible associations between the MIR146A rs2910164 and MIR155 rs767649 variants and the response to anti-TNF therapy in a Greek cohort of 103 CD and 100 PsO patients. We genotyped 103 CD patients and 100 PsO patients via the PCR-RFLP method, utilizing the de novo formation of a restriction site for the SacI enzyme considering the MIR146A rs2910164, while Tsp45I was employed for the MIR155 rs767649 variant. Additionally, we investigated the potential functional role of the rs767649 variant, exploring in silico the alteration of transcription factor binding sites (TFBSs) mapped on its genomic location. Our single-SNP analysis displayed a significant association between the rare rs767649 A allele and response to therapy (Bonferroni-corrected p value = 0.012) in patients with PsO, a result further enhanced by the alteration in the IRF2 TFBS caused by the above allele. Our results highlight the protective role of the rare rs767649 A allele in the clinical remission of PsO, implying its utilization as a pharmacogenetic biomarker.

Objective Measurements of Physical Function to Predict Survival in Patients with Metastatic Cancer

BACKGROUND/OBJECTIVES

Physician-reported performance status (PS) constitutes the established method for stratifying oncologic patients in therapeutic decision-making. Objective measurements of physical function may further refine prognostication.

SUBJECTS/METHODS

In this prospective observational study, 103 patients with metastatic cancer who were referred for systemic therapy initiation were evaluated. PS was evaluated using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and five objective physical function measurements (handgrip strength [HGS], chair stand test [CST], timed up and go [TUG] test, 4-m gait speed [GS] test, and short physical performance battery [SPPB] test). Overall survival and treatment complications were recorded from the medical records.

RESULTS

Patients with low PS according to ECOG-PS (hazard ratio [HR]: 3.80, 95% confidence interval [CI]: 1.84, 7.80), HGS (HR: 2.37, 95% CI: 1.24, 4.55), SPPB (HR: 3.43, 95% CI: 1.55, 7.57), GS (HR: 3.03, 95% CI: 1.44, 6.38), and TUG (HR: 5.16, 95% CI: 2.19, 12.14) had shorter overall survival after adjustment for sex, age, symptomatology, comorbidity, percentage of weight loss, and tumor localization.

CONCLUSIONS

Among the studied objective physical function measurements, HGS, SPPB, GS, and TUG were independent predictors of survival in a sample of patients with metastatic cancer, with TUG showing the highest effect size.

Pharmacogenetic analysis of canonical versus noncanonical pathway of NF-kB in Crohn's disease patients under anti-tumor necrosis factor-α treatment

OBJECTIVES

This study explores the potential of gene polymorphisms in the canonical and noncanonical NF-kB signaling pathway as a prediction biomarker of anti-tumor necrosis factor (TNF)α response in Crohn's patients.

MATERIALS AND METHODS

A total of 109 Greek patients with Crohn's disease (CD) were recruited, and the genotype of TLR2 rs3804099, LTA rs909253, TLR4 rs5030728, and MAP3K14/NIK rs7222094 single nucleotide polymorphisms was investigated for association with response to anti-TNFα therapy. Patient's response to therapy was based on the Crohn's Disease Activity Index, depicting the maximum response within 24 months after initiation of treatment.

RESULTS

Seventy-three patients (66.7%) were classified as responders while 36 as nonresponders (33.3%). Comparing allelic frequencies between responders and nonresponders, the presence of TLR2 rs3804099 T allele was associated with nonresponse (P = 0.003), even after stratification by anti-TNFα drugs (infliximab: P = 0.032, adalimumab: P = 0.026). No other association was identified for the rest of the polymorphisms under study. Haplotype analysis further enhanced the association of rs3804099 T allele with loss of response, even though the results were NS (P = 0.073).

CONCLUSION

Our results suggest that polymorphisms in the canonical NF-kB pathway genes could potentially act as a predictive biomarker of anti-TNFα response in CD.

Efficacy and safety of transpancreatic sphincterotomy in endoscopic retrograde cholangiopancreatography: a retrospective cohort study

Background

Difficult cannulation represents a common obstacle during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the efficacy and adverse events of transpancreatic sphincterotomy (TPS), and investigated potential associated confounders.

Methods

All patients referred to our department for ERCP during 2015-2020 were eligible if they had intact papilla and visceral anatomy. In addition to standard measures, TPS was combined with pancreatic stent placement. Apart from demographics, we retrieved data related to the indication, periampullary anatomy, necessity for TPS or fistulotomy, their outcomes and complications. Chi-square test was employed to investigate associations between TPS and independent variables. When significance was observed, the respective variables were inserted into a regression model.

Results

A total of 1082 individual patients were eligible, with an equal female: male ratio and a mean age of 72.7±15.82 years. Seventy-three patients (6.7%) underwent TPS, with a 95.9% successful cannulation rate. Papilla morphology or regional diverticulum did not affect the decision to perform TPS, though it was significantly associated with malignant common bile duct (CBD) obstruction as the ERCP indication (P=0.001). Considering adverse events, TPS did not increase the incidence of post-ERCP pancreatitis (PEP), though it affected bleeding (P=0.005). Regression analysis revealed a protective role of TPS against PEP (risk ratio [RR] 0.015, 95% confidence interval [CI] 0.23-5.05; P<0.001), while the aforementioned risk of hemorrhage was attributed to previous precut attempts (RR 3.02, 95%CI 1.42-6.43; P=0.004).

Conclusion

TPS combined with pancreatic stenting is an effective and safe modality in difficult cannulation cases and could be the first-choice alternative in malignant CBD obstruction.

Role of autophagy in gastric carcinogenesis

Gastric cancer represents a common and highly fatal malignancy, and thus a pathophysiology-based reconsideration is necessary, given the absence of efficient therapeutic regimens. In this regard, emerging data reveal a significant role of autophagy in gastric oncogenesis, progression, metastasis and chemoresistance. Although autophagy comprises a normal primordial process, ensuring cellular homeostasis under energy depletion and stress conditions, alterations at any stage of the complex regulatory system could stimulate a tumorigenic and promoting cascade. Among others, Helicobacter pylori infection induces a variety of signaling molecules modifying autophagy, during acute infection or after chronic autophagy degeneration. Subsequently, defective autophagy allows malignant transformation and upon cancer establishment, an overactive autophagy is stimulated. This overexpressed autophagy provides energy supplies and resistance mechanisms to gastric cancer cells against hosts defenses and anticancer treatment. This review interprets the implicated autophagic pathways in normal cells and in gastric cancer to illuminate the potential preventive, therapeutic and prognostic benefits of understanding and intervening autophagy.

The impact of COVID-19 pandemic on gastrointestinal diseases: a single-center cross-sectional study in central Greece

BACKGROUND

The current COVID-19 pandemic induced a suppressive environment for healthcare professionals and patients, especially during the lockdown period. Except for the direct burden of the COVID-19, collateral damage has been identified concerning other diseases. The aim of this study was to evaluate the potential impact of the lockdown on the non-COVID-19 patients' outcome in a tertiary gastroenterology department.

METHODS

Patients admitted to our department during the lockdown period (23 March- 4 May 2020) and during the respective previous year's timeframe were recruited. Sex, age, comorbidities, presenting symptoms, final diagnosis, therapeutic management, duration of hospitalization, and outcome were evaluated. A direct comparison was performed to investigate the potential impact of the lockdown on the duration of hospitalization and the final outcome.

RESULTS

A total of 161 patients were included to our analysis with 1:1 male:female ratio and mean age 70.86 years. Most of the cases experienced gastrointestinal tract bleeding, biliary stone disease manifestations, or gastrointestinal malignancy complications, and 85.1% were discharged. Fewer patients were hospitalized during the lockdown period (40%), whereas the duration of hospitalization was significantly longer (7.69±4.55 vs. 5.76±4.36 days). Binary logistic regression analysis and sensitivity analysis demonstrated that the quarantine was associated with increased prevalence of negative outcomes (odds ratio 5.21, 95% confidence interval 1.66-16.34; P=0.005), especially in cases with gastrointestinal malignancy and acute pancreatitis (P=0.045 and P=0.041, respectively).

CONCLUSION

The increase in the negative outcomes of common gastrointestinal diseases and the duration of hospitalization during the lockdown raise reasonable concerns regarding healthcare policies against further outbreaks.

Laparoendoscopic rendezvous may be an effective alternative to a failed preoperative endoscopic retrograde cholangiopancreatography in patients with cholecystocholedocholithiasis

Background:

Endoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy (LC), remains the standard way of management for patients with cholecystocholedocholithiasis. Laparoendoscopic rendezvous (LERV), a combined procedure for removing the gallbladder laparoscopically and clearing the common bile duct (CBD) endoscopically at the same time, could be an attractive alternative. The aim of this study was to compare LERV with classic ERCP in patients with cholecystocholedocholithiasis.

Methods:

886 patients with cholecystocholedocholithiasis were treated either with the LERV technique (90 patients), or with the 2-stage approach, which includes preoperative ERCP followed by LC (796 patients). The primary endpoint was any difference in the success of CBD cannulation and clearance; secondary endpoints were the detection of differences in morbidity (especially post-ERCP pancreatitis [PEP]), and the feasibility of the two approaches.

Results:

Successful cannulation of the CBD was more frequent with conventional ERCP compared with the LERV technique (89.8% vs. 75.5%, P=0.0001). LERV appears to be as effective as conventional ERCP for complete CBD clearance (85.5% vs. 82.8%, P<0.1). None of the patients in the LERV group had an episode of clinical PEP, whereas in the conventional ERCP group there were 23 episodes of PEP and one death. The median amylase level was higher in patients undergoing conventional ERCP group compared to patients in LERV group.

Conclusion:

Classic ERCP has a higher rate of successful CBD cannulation and a similar rate of CBD clearance compared to LERV.

The use of over-the-scope clip in the treatment of persistent staple line leak after re-sleeve gastrectomy: Review of the literature

Staple line leak after sleeve gastrectomy (SG) is a severe complication associated with increased mortality rates and the potential need for reoperation. We report the successful management of a re-SG staple line leak with the use of an endoscopic over-the-scope clip.

Disability in Patients with Inflammatory Bowel Disease: Correlations with Quality of Life and Patient's Characteristics

BACKGROUND

Inflammatory bowel diseases may cause significant disability. However, little is known regarding the life domains where patients encounter most limitations.

OBJECTIVES

To assess patients' overall disability and determine the life domains where most restrictions were applied. Secondarily, we sought for possible relationships among disability, quality of life (HRQoL), and population characteristics.

METHOD

The study lasted for two years (2013-2015) and included 200 patients [52%  ulcerative  colitis  (UC)] from a referral centre. Disability was evaluated using the 36-item version of WHODAS 2.0 questionnaire. The influence of population characteristics on overall disability was assessed with linear regression.

RESULTS

Crohn's disease (CD) patients showed greater overall disability compared to UC (19.22 versus 15.01, p = 0.001), with higher scores in the domains of relationships, life activities, and participation. Disability was negatively associated with HRQoL (p < 0.001). Long activity, extensive disease, rural residence, and employment independently influenced the overall disability in both groups. Additionally, significant influence was recorded for lower education in the UC and for operation and celibacy in the CD group.

CONCLUSIONS

CD patients were facing more limitations compared to those with UC, especially in the domains of relationships, activities, and participation. Other than clinical factors, sociodemographic characteristics were also associated with increased disability.

Prevalence and Characteristics of Extra-intestinal Manifestations in a Large Cohort of Greek Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Extraintestinal manifestations [EIMs] are common in inflammatory bowel disease [IBD]. Data on epidemiology and risk factors of EIMs in IBD patients are limited. The aim of this study was to investigate the prevalence of EIMs in a large cohort of Greek IBD patients and identify risk factors for their development.

METHODS

The study population consisted of IBD patients, who were followed in eight tertiary Greek hospitals. Demographic and clinical characteristics of patients were analysed. The diagnosis of EIMs was based on standard criteria and on specialist consultation.

RESULTS

In total, 1860 IBD patients (1001 with Crohn's disease [CD], 859 with ulcerative colitis [UC]) were registered. Among them 615 [33.1%] exhibited at least one EIM; 238 patients [38.6%] developed an EIM before IBD diagnosis. An association between active IBD and presence of an EIM was established in 61.1% of the patients. Arthritic [peripheral arthritis], mucocutaneous [erythema nodosum], and ocular [episcleritis] were the most common manifestations. EIMs were more prevalent in females, patients with CD, smokers [for all p <0.0001], patients with extensive UC [p = 0.007], and patients with a previous appendectomy [p < 0.0001] or a major IBD-related surgery [p = 0.012].

CONCLUSIONS

About one-third of Greek IBD patients developed at least one EIM. Of those, more than one-third had their EIM diagnosed before IBD, and in about two-thirds it was related to disease activity. EIMs were more frequently present in females and patients with extensive UC in multivariate analysis.

An unusual case of Primary Effusion Lymphoma with aberrant T-cell phenotype in a HIV-negative, HBV-positive, cirrhotic patient, and review of the literature

Primary effusion lymphoma (PEL) is an unusual, human herpes virus-8 (HHV-8)-associated type of lymphoma, presenting as lymphomatous effusion in body cavities, without a detectable tumor mass. It primarily affects human immunodeficiency virus (HIV)-infected patients, but has also been described in other immunocompromised individuals. Although PEL is a B-cell lymphoma, the neoplastic cells are usually of the 'null' phenotype by immunocytochemistry. This report describes a case of PEL with T-cell phenotype in a HIV-negative patient and reviews all the relevant cases published until now. Our patient suffered from cirrhosis associated with Hepatitis B virus (HBV) infection and presented with a large ascitic effusion, in the absence of peripheral lymphadenopathy or solid mass within either the abdomen or the thorax. Paracentesis disclosed large lymphoma cells with anaplastic features consisting of moderate cytoplasm and single or occasionally multiple irregular nuclei with single or multiple prominent nucleoli. Immunocytochemically, these cells were negative for both CD3 and CD20, but showed a positive reaction for T-cell markers CD43 and CD45RO (VCHL-1). Furthermore, the neoplastic cells revealed strong positivity for EMA and CD30, but they lacked expression of ALK-1, TIA-1, and Perforin. The immune status for both HHV-8 and Epstein-Barr virus (EBV) was evaluated and showed positive immunostaining only for the former. The combination of the immunohistochemistry results with the existence of a clonal rearrangement in the immunoglobulin heavy chain gene (identified by PCR), were compatible with the diagnosis of PEL. The presence of T-cell markers was consistent with the diagnosis of PEL with an aberrant T-cell phenotype.

Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial

BACKGROUND

Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis.

OBJECTIVE

To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis.

SETTING

Controlled randomized trial, University/Teaching Hospital.

METHODS

: Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients.

RESULTS

Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02.

CONCLUSIONS

Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

Renal manifestations and complications of inflammatory bowel disease

Renal manifestations and complications are not rare in patients with inflammatory bowel disease (IBD) and may present as nephrolithiasis, amyloidosis, tubulointerstitial nephritis, and glomerulonephritis. Symptoms of renal impairment are not always specific and since the underlying bowel disease is preponderant, renal function deterioration may be underestimated. Additionally, medical treatment of patients with IBD such as aminosalicylates, cyclosporine, and tumor necrosis factor-α inhibitors can cause renal complications, although direct correlation to bowel disease is not always clear. The well-documented renal manifestations and complications of IBD, as well as the possible renal side effects of new drugs, emphasize the need for periodic evaluation of renal function. New markers of renal function may facilitate early diagnosis and unravel the complex mechanisms responsible for kidney damage. The purpose of this review is to summarize the renal manifestations and complications as well as the markers of renal function utilized in IBD, attempting to shed more light on the pathophysiology of renal damage in IBD.

Reduction of radiation doses to patients and staff during endoscopic retrograde cholangiopancreatography

BACKGROUND/AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a considerable radiation exposure for patients and staff. While optimization of the radiation dose is recommended, few studies have been published. The purpose of this study has been to measure patient and staff radiation dose, to estimate the effective dose and radiation risk using digital fluoroscopic images. Entrance skin dose (ESD), organ and effective doses were estimated for patients and staff.

MATERIALS AND METHODS

Fifty-seven patients were studied using digital X-ray machine and thermoluminescent dosimeters (TLD) to measure ESD at different body sites. Organ and surface dose to specific radiosensitive organs was carried out. The mean, median, minimum, third quartile and the maximum values are presented due to the asymmetry in data distribution.

RESULTS

The mean ESD, exit and thyroid surface dose were estimated to be 75.6 mGy, 3.22 mGy and 0.80 mGy, respectively. The mean effective dose for both gastroenterologist and assistant is 0.01 mSv. The mean patient effective dose was 4.16 mSv, and the cancer risk per procedure was estimated to be 2 × 10(-5).

CONCLUSION

ERCP with fluoroscopic technique demonstrate improved dose reduction, compared to the conventional radiographic based technique, reducing the surface dose by a factor of 2, without compromising the diagnostic findings. The radiation absorbed doses to the different organs and effective doses are relatively low.

Laparoendoscopic rendezvous: an effective alternative to a failed preoperative ERCP in patients with cholecystocholedocholithiasis

BACKGROUND

Although the ideal management of cholelithiasis and concomitant choledocholithiasis is controversial, the two-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] is the most popular treatment regimen worldwide. However, sometimes ERCP fails to solve the problem of choledocholithiasis preoperatively. The aim of this study was to evaluate the use of intraoperative ERCP using the laparoendoscopic "rendezvous" technique in patients in whom preoperative ERCP has failed or was not possible to attempt.

METHODS

Twenty-two patients (13 female, nine male), in whom ERCP failed or was not possible to be performed as a separate procedure before laparoscopic cholecystectomy, were treated with the one-stage approach of intraoperative ERCP during laparoscopic cholecystectomy using the so-called laparoendoscopic "rendezvous" technique.

RESULTS

The one-stage approach was completed successfully in a median time of 110 min (range = 75-160 min) in 21 cases; however, in two cases the wire introduced via the cystic duct could not be advanced through Vater's ampulla into the duodenum and the CBD was cannulated from the endoscopic route, in the usual way. There was no mortality or morbidity and most patients were discharged within 48 h after the procedure.

CONCLUSION

The laparoendoscopic "rendezvous" is a valuable alternative in treating patients with cholecystocholedocholithiasis. It appears to be a reliable method when preoperative ERCP fails to clear the CBD, while it also offers a one-stage solution to the problem.

Vascular endothelial growth factor in inflammatory bowel disease

BACKGROUND AND AIMS

Angiogenesis is an important component of tissue regeneration. As Inflammatory bowel disease (IBD) involves inflammation, ulceration, and regeneration of the intestinal mucosa, angiogenesis may be an integral part of IBD pathology. This study investigated the role of vascular endothelial growth factor in IBD.

PATIENTS AND METHODS

The VEGF plasma (pVEGF) and serum (sVEGF) levels were assessed in patients with ulcerative colitis (UC; n=50) or Crohn's disease (CD; n=44) and in healthy controls (n=23). The immunohistochemical expression of VEGF was also assessed in surgical material from 11 patients with active IBD.

RESULTS

Overall the sVEGF levels ranged from 30-899 pg/ml (median 200 pg/ml) and were significantly higher than the pVEGF levels (range 20-80 pg/ml, median 30 pg/ml). pVEGF levels were significantly lower in patients with active and quiescent CD than in healthy controls. Despite the lower pVEGF levels noted also for patients with UC, the difference was not significant. sVEGF levels were also reduced in patients with IBD, but the difference was not significant. No association of pEGF/sVEGF with beta-thromboglobulin and platelet factor 4 levels (markers of platelet activation) was noted. On immunohistochemistry VEGF was not expressed in the inflammatory component (lymphocytes and macrophages), the fibroblasts, or the muscular layer of the intestinal wall. The intestinal epithelium was negative in CD, while a cytoplasmic reactivity was noted in UC and normal controls.

CONCLUSION

As VEGF is a vascular and epithelial cell survival factor, the defective VEGF response ability, confirmed here for patients with CD, may be a key element in the pathology of the disease. The pathology of UC, however, seems not to be VEGF dependent.

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.

Resistance to activated protein C, factor V leiden and the prothrombin G20210A variant in patients with colorectal cancer

OBJECTIVE

The aim of our study was to determine the frequency of resistance to activated protein C (APC), factor V Leiden (FVL) and the prothrombin G20210A variant in patients with colorectal cancer.

METHODS

74 patients with colorectal cancer and 192 colonoscopically selected controls were prospectively investigated for the presence of APC resistance, FVL and the prothrombin G20210A variant. APC resistance was measured as the ratio of activated partial thromboplastin times with and without APC (APC sensitivity ratio, APC-SR). The FVL and prothrombin G20210A variant were detected by a polymerase-chain-reaction-based technique.

RESULTS

FVL was detected in the heterozygous form in 4 of 74 cancer patients (5.4%) and in 7 of 192 controls (3.6%; p > 0.5, odds ratio: 1.51). After excluding patients and controls with FVL, APC-SR was below 2 in 6 of 70 cancer patients (8.5%) and in 1 of 185 controls (0.5%; p < 0.01, odds ratio: 17.25), and the mean value of APC-SR was significantly lower in cancer patients than the respective level of controls (2.8 vs. 3.7, p < 0.001). The G20210A mutation in the prothrombin gene was found in the heterozygous form in 2 of 74 patients with colorectal cancer (2.7%) and in 5 of 192 colonoscopically control subjects (2.6%; p > 0.5, odds ratio: 1.03).

CONCLUSIONS

These findings suggest that patients with colorectal cancer have a high frequency of resistance to APC but no significant differences in the frequency of the FVL or G20210A mutation of the prothrombin gene compared to colonoscopically selected controls.

Angiogenic interactions of vascular endothelial growth factor, of thymidine phosphorylase, and of p53 protein expression in locally advanced gastric cancer

The assessment of the angiogenic profile of tumors may become an important tool as a guide for the inclusion of novel drugs and molecular therapies into the standard chemoradiotherapy policy. Several studies have shown the prognostic importance of microvessel density (MVD) and of angiogenic factor expression in operable gastric cancer. In the present study we investigated, with immunohistochemistry the MVD, the expression of vascular endothelial growth factor (VEGF) and of thymidine phosphorylase (TP) expression, as well as the nuclear expression of p53 protein, in a series of patients with locally advanced inoperable gastric cancer. A strong association of VEGF with TP expression was noted (P = 0.005), and tumors coexpressing these factors had a statistically higher MVD (P = 0.0001). Nuclear p53 accumulation was also related to a high MVD (P = 0.004), and this was independent of VEGF or TP expression. Microvessel density showed a bell-shaped association with prognosis; cases with an intermediate MVD exhibit a favorable outcome (P < 0.05). A trend of nuclear TP expression to define a group of patients with poorer prognosis was noted (P = 0.06), while none of the remaining variables showed any significant association. The immunostaining results allowed the grouping of the angiogenic profile in four major categories: 1) highly vascularized tumors with VEGF and/or TP expression (about 36% of cases); 2) highly angiogenic tumors with p53 nuclear accumulation and low VEGF/TP expression (7% of cases); 3) poorly vascularized tumor with low VEGF/TP and negative nuclear p53 staining (32% of cases); 4) poorly vascularized tumors with TP expression (7% of cases). Specific therapies targeting hypoxia, VEGF, or TP expression as well as p53 gene therapy have entered clinical experimentation or are already available for clinical use. Using the suggested markers more than 80% of locally advanced gastric carcinomas can be grouped in different categories according to their angiogenic profile. Such a categorization may be useful for phase III trials on novel therapies targeting the major angiogenesis-related features studied here.

An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece

OBJECTIVES

Information about the epidemiology of acute upper gastrointestinal bleeding (UGIB) in southern Europe is very limited and especially in Greece non-existent. Our study sought to determine the current epidemiology of acute UGIB (incidence, mortality and case fatality) in the prefecture of Heraklion-Crete.

DESIGN/METHODS

From February 1998 to February 1999, we prospectively obtained data on all patients with acute UGIB in the prefecture of Heraklion-Crete. All patients who were permanent residents of the prefecture of Heraklion, aged 16 years and over with acute UGIB were included in the study.

RESULTS

During this period, 353 cases of acute UGIB were included in the study. The overall incidence of acute UGIB is 160/100,000 adults per year with a male-to-female ratio of 1.7 and a mean age 66.2 +/- 17.1 years. The incidence rises from 30 in those aged under 30 years to 609 in those aged over 75 years. The overall population mortality was 9/100,000 adults per year. Overall case fatality during hospitalization was 5.6%. All deaths occurred in patients older than 60 years. One or more comorbid illnesses were noted in 61% of cases. Recent intake of non-steroidal anti-inflammatory drugs (NSAIDs) was reported in 49% of the cases. The most common recorded diagnoses were erosive disease in 108 (30.5%) patients, duodenal ulcer in 97 (27.4%) and gastric ulcer in 75 (21.2%). Rebleeding occurred in 41 patients (12%). Twelve patients (3.3%) had surgery during hospitalization.

CONCLUSIONS

The overall annual incidence of acute UGIB in the prefecture of Heraklion-Crete is one of the highest reported in Europe and increases appreciably with age. Both population mortality and case fatality are slightly lower compared to those reported in most previous studies.

Resistance to activated protein C and low levels of free protein S in Greek patients with inflammatory bowel disease

OBJECTIVE

Patients with inflammatory bowel disease (IBD) frequently suffer from thromboembolic events. A recently identified mechanism for thrombophilia, the poor anticoagulant response to activated protein C, has been suggested as one of the leading risk factors for thrombosis. The aim of this study was to evaluate the frequency of thrombophilic abnormalities, including activated protein C-resistance (APCR), in Greek patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

Forty-eight patients with UC, 36 with CD, and 61 matched healthy controls (HC) were studied. Cases with presence of lupus anticoagulant, use of anticoagulants or heparin, and pregnancy were excluded. Disease activity in CD was evaluated by use of the Crohns Disease Activity Index (CDAI) score and in UC by the Truelove-Witts grading system. Plasma levels of protein C, free protein S, antithrombin III (AT-III), activated protein C resistance (APCR), and fibrinogen were determined in IBD patients, as well as in HC. All the cases and controls with abnormal APCR were further studied by genetic testing for the factor V Leiden mutation.

RESULTS

Mean fibrinogen levels in UC and CD patients were significantly elevated (p<0.0001), compared with HC. The mean values of free protein S, as well as mean APCR, were significantly lower in UC and CD patients than in the HC (p<0.0001). Seven (five UC and two CD) of 84 IBD patients (8.3%) and three of the HC (4.9%) had the factor V Leiden mutation. No significant difference was observed for the other thrombophilic parameters. Fibrinogen levels and profound free protein S deficiency were found related to disease activity.

CONCLUSIONS

Thrombophilic defects are common in Greek patients with IBD and they could interfere either in the disease manifestation or in the thrombotic complications.

Oral administration of recombinant human granulocyte macrophage colony-stimulating factor in the management of radiotherapy-induced esophagitis

Radiation-induced esophagitis often results in treatment interruption, which may severely affect the probability of control of the local disease in patients undergoing chest radiotherapy (RT). No effective regimen that would reduce the incidence and severity of this complication has been identified up to now. Although acceleration of oral mucosal healing using topical recombinant human granulocyte macrophage colony-stimulating factor (rhGM-CSF) has been reported, the mechanism of such an interaction remains obscure. Effective topical application of rhGM-CSF for the treatment of radiation-induced esophagitis has never been reported in the past. In pharmacological studies, we observed that glycerol exerts a remarkable stabilizing effect on rhGM-CSF immunoreactivity. After studying the kinetics of esophageal emptying with nuclear imaging, we proposed a rhGM-CSF regimen that could be applied for topical treatment of esophagitis during RT. The regimen was applied for 5 consecutive days in a cohort of 36 patients undergoing chest RT, immediately after the documentation of grade 3 esophagitis. RT was not interrupted. Mucosal biopsies were performed endoscopically and examined immunohistochemically. Regression of dysphagia to grade 0/1 was observed in 19 of 36 (52%) patients, whereas grade 2 dysphagia persisted in 12 of 36 (33%) patients. Progression of dysphagia was seen in 5 of 36 (14%) patients. Recurrence of severe esophagitis within 5-8 days after rhGM-CSF therapy was observed in 7 of 31 (22%) patients with initial response to rhGM-CSF. Four of these patients presented significant improvement of symptomatology after additional rhGM-CSF medication. In immunohistochemical studies, active intraepithelial neovascularization and thymidine phosphorylase and vascular endothelial growth factor overexpression were observed in the damaged epithelium, which was not accompanied by macrophage or neutrophil infiltration. We conclude that rhGM-CSF topical therapy (p.o. administration) exerts a significant therapeutic effect against RT-induced esophagitis. The rhGM-CSF mucosa healing effect is probably due to its direct angiogenic activity and/or to the potentiation of the activity of other angiogenic factors released by the damaged epithelium.

Appendectomy, tonsillectomy, and risk of inflammatory bowel disease: case-controlled study in Crete

PURPOSE

Appendectomy has been suggested as a possible protective factor in ulcerative colitis and as a risk factor in Crohn's disease. Tonsillectomy has also been associated with Crohn's disease. We performed a case-controlled study to investigate these associations in a homogeneous Greek population.

METHODS

One hundred thirty-four consecutive cases of ulcerative colitis and 76 cases of Crohn's disease were included in the study. For each inflammatory bowel disease patient and a corresponding healthy control subject, matched for gender, age, and educational level, a standard record on various risk factors was completed by interview. The association between disease status and risk factors was assessed by Pearson's chi-squared test and the independent contribution of each risk factor was analyzed by means of logistic regression analysis.

RESULTS

Appendectomy had been performed in 11 (8.2 percent) patients with ulcerative colitis, in 18 (13.4 percent) of their matched healthy control cases, in 19 (25.0 percent) patients with Crohn's disease, and in 10 (13.2 percent) of their matched healthy control cases. Odds ratio for development of ulcerative colitis after appendectomy was 0.6 (95 percent confidence interval, 0.26-1.27). Odds ratio for Crohn's disease was 2.2 (95 percent confidence interval, 0.94-5.12). Odds ratio for development of ulcerative colitis or Crohn's disease after tonsillectomy was 0.95 (95 percent confidence interval, 0.49-1.82) and 3.29 (95 percent confidence interval, 1.29-8.37), respectively. The logistic regression analysis showed that appendectomy and tonsillectomy have no independent association with the risk of developing ulcerative colitis, whereas in Crohn's disease both appendectomy and tonsillectomy have positive associations. Well-established risk factors, such as family history and smoking status, were also verified in this study.

CONCLUSIONS

This case-control study, using multivariate logistic regression analysis, showed a less pronounced association between ulcerative colitis and appendectomy than previous reports. Our data also support the conclusion that tonsillectomy is a risk factor for developing Crohn's disease.

Hypofractionated radiotherapy with concurrent 5-fluorouracil radiosensitisation for recurrent or locally advanced colorectal cancer. A phase II study

In a pilot study we treated 19 patients suffering from recurrent or locally advanced inoperable colorectal cancer, with concurrent hypofractionated radiotherapy (4-5 Gy/fraction, 2 fractions per week) and 5-fluorouracil bolus, 1 hour before RT at doses of 300 mg/m2. For 16 patients treated with radical intent the Normalised Total Dose for alpha/beta = 10 Gy ranged between 56-74 Gy (median 62 Gy). The schedule used was very well tolerated. Moderate grade II haematological toxicity was observed in 11% of cases and diarrhoea grade II/III resulting in 2-4 weeks treatment delay was observed in 26% of cases. One case with bowel perforation and one with painful subcutaneous fibrosis was observed during 12-27 months of follow-up. Out of 16 patients treated with radical intent 4 (25%) showed complete response and the overall response rate was 56% (9/16). The one-year symptom-free survival was obtained in 11/16 (69%) radically treated patients. It is concluded that hypofractionated radiochemotherapy with 5-fluorouracil for recurrent or locally advanced colorectal cancer is an effective regimen and has acceptable acute and late toxicity. Further investigation is required.