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BACKGROUND: As in ulcerative colitis, there is an increased incidence of colorectal carcinoma in Crohn's disease. While carcinoma formation originating from ano-rectal fistulas is generally considered as a rare event there are different publications reporting on mucinous adenocarcinoma formation in association with a neovagina and rectovaginal fistulas. To the best of our knowledge this is the first description of a perianal mucinous adenocarcinoma arising in a patient after Crohn's disease proctocolectomy. CASE PRESENTATION: We report the case of a 50-year old female with a mucinous adenocarcinoma forming in the perineum eleven years after proctocolectomy for Crohn's disease. The patient was readmitted with perineal pain, leucocytosis and a perineal mass highly suspicious of abscess formation in the MRI-Scan. Histological examination revealed a mucinous adenocarcinoma. Exenteration including vagina, uterus and ovaries together with the coccygeal-bone was performed. CONCLUSION: Mucinous adenocarcinoma formation is a rare complication of Crohn's disease and so far unreported after proctocolectomy.

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BACKGROUND: Worsening renal function during hospital treatment is a substantial hazard, especially for elderly hospitalized patients. However, data concerning the prevalence and significance of potential risk factors is lacking. METHODS: All patients admitted during a 6-month observation period to a department of general internal medicine and geriatrics were enrolled. Patients <65 yrs old were excluded. Data was assessed using a retrospective analysis of patient charts; 343/583 charts provided sufficient data for the analysis. Renal function was estimated by the Cockcroft and Gault formula. Worsening renal function was defined as a decline to <66.7% of the initial value. Laboratory values at admission (serum albumin, sodium and potassium), activities of daily living at admission (ADL-score), established medical diagnosis and medication prior to and during in-patient treatment were included in the analysis of potential risk factors. RESULTS: Renal function worsened in 6.1% of patients included. Risk factors were prescription of loop diuretics, trimethoprim/sulfamethoxazole or non-steroidal antiphlogistics during hospitalization. Hypernatremia, lower serum albumin and lower ADL-score at admission also demonstrated an association with a decline in renal function. However, an established diagnosis of heart failure, diabetes and hypertension were not predictive. CONCLUSION: Reduced physiological resources to maintain fluid and sodium balance are more predictive for worsening renal function than medical diagnosis alone. ADL-score and serum albumin could help further to identify patients at risk. Non-steroidal antiphlogistics are still frequently prescribed during in-patient treatment, although they are significant risk factors for renal function decline.

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AIMS: To evaluate the quality of bedside estimation of glomerular filtration rate (GFR) in hospitalized elderly patients. METHODS: We evaluated common estimators of GFR in 29 women and 32 men aged 60 and older hospitalized in a geriatric ward: creatinine clearance (CCR), the Cockcroft-Gault formula (CG), the modification of diet in renal disease formula (MDRD), Baracskay formula (BAR), and a newly developed formula derived recently by us (GCM). Inulin clearance (CINU) was used to assess GFR. Exclusion criteria were mental illness and urinary incontinence. RESULTS: According to Bland and Altman accuracy and precision of all estimators were low and there was an underestimation of actual GFR: CCR 38.9 ml/min; CG 39.7 ml/min; MDRD 19.8 ml/min; BAR 34.0 ml/min, and GCM: 24.7 ml/min. The accuracy and precision of all methods were even lower in patients with a GFR of >90 ml/min and in patients with diabetes. In receiver-operating characteristics (ROC analysis) all formulas were superior to serum creatinine and overall MDRD disclosed the best results in detecting both a GFR of <90 ml/min and <60 ml/min. CONCLUSIONS: In general, estimation errors are large in an acute care setting. However, formula estimation is clearly superior to serum creatinine and CCR. MDRD gave the best results but may be replaced by the more simple CG and GCM formulas, whereas BAR was inferior.

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BACKGROUND: An increasing number of diagnostic procedures and shortened length of stay impede education for patients with diabetes mellitus attending an acute care unit. Therefore, an individualized approach to patient education may be more suitable. PATIENTS AND METHODS: The educational needs of inpatients with diabetes attending a department of general internal medicine were analyzed using a structured 5- to 10-minute interview. Within a period of 4 months, all patients with diabetes mellitus referred to the IVth Medical Department (speciality: geriatrics) were screened. Screening took place close to the day of admission. Following the screening interview, the interviewer initiated an individualized diabetes education according to the patient's needs and resources. The screening interview covered clinical data, functional limitations and disabilities, diabetes complications, patient's competence and motivation for further education. RESULTS: 205 patients with diabetes were seen (prevalence: 30.0%). 24 of them were newly diagnosed (prevalence: 3.5%). Overall, the screening revealed remarkable heterogeneity in patients with diabetes mellitus. 45 patients with previously known diabetes denied any diabetes education prior to hospital admission. Shorter diabetes duration, cognitive impairment, and treatment without insulin were significant and independent risk factors for missing diabetes education. Only 17.4% of patients on an insulin regimen prior to hospital admission performed no monitoring of blood glucose at home. Most patients holding their own blood glucose monitoring device performed daily measurements. Finally, 119 lessons of individual diabetes education were initialized in 73 patients (incidence: 17.4% of all admitted patients). CONCLUSION: Lack of education is common. As heterogeneity of patients with diabetes is striking, diabetes education has to be tailored to the individual needs and resources of the patients attending an acute care unit. Therefore, an individualized approach has proven to be suitable. In this context, a short structured interview is a useful tool for data assessment and scheduling of education lessons.

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CASE REPORT: A 71-year-old woman, suffering from spinal stenosis presented interstitial lung disease, albinism, and severe loss of visual acuity. On physical examination she showed tic-like automatism predominantly periorbital in the face and in the fingers. A computed tomography of the chest revealed typical findings of interstitial lung disease and additional mediastinal lymphomas and ground-glass attenuation in the lower regions of the lung. The findings of a transbronchial lung biopsy, presenting alveolar macrophages with ceroid-like material and platelet function studies proving slightly impaired platelet aggregation confirmed the clinical diagnosis of Hermansky-Pudlak syndrome. Sufficient pain control could be achieved without surgery and the patient was discharged home. 11 months after discharge, severe dyspnea and fever developed and finally the patient died of respiratory failure. CONCLUSION: The Hermansky-Pudlak syndrome is a rare cause of interstitial lung disease. In general, the lung disease presents in younger patients, but it may emerge in the elderly as well. Alveolar macrophages containing ceroid-like material are typical findings in BAL or lung biopsy. Furthermore impaired platelet aggregation and bleeding diathesis may be present. Both findings are useful to identify this rare disorder.

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This is a secondary analysis of data from a cross-sectional study to evaluate the diagnostic efficiency of cystatin C as a marker of the glomerular filtration rate in the elderly. Thirty patients (15 male, 15 female, mean age 75.4 +/- 7.1 years) attending a geriatric ward were enrolled. Exclusion criteria were previously diagnosed renal disease, dementia and heart failure (NYHA III or IV). Cystatin C in serum was determined by a particle-enhanced turbidimetric assay. Inulin clearance was assessed using a single-shot method. Also, Cockcroft-Gault formula was calculated. Twelve patients had a reduced glomerular filtration rate (<70 ml/min/ 1.73 m2). The mean values were 88.4 micromol/l (+/- 27.7) for serum creatinine, 1.57 mg/l (+/- 0.34) for cystatin C and 88.7 ml/min/1.73 m2 (+/- 34.6) for inulin clearance. Maximum efficiency was 0.73 for serum creatinine (cut-off limit 82 micromol/l), 0.67 for cystatin C (cut-off limit 1.63 mg/l) and 0.8 for Cockcroft and Gault estimation (cut-off limit 54 ml/min/1.73 m2). A receiver operating characteristics (ROC) analysis did not show any differences between the various methods. Therefore, cystatin C in serum may not improve the diagnostic efficiency in detecting a reduced glomerular filtration rate in the elderly. Furthermore, normal ranges for serum creatinine in the elderly might need to be adjusted.

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