The WFME global standards for quality improvement of postgraduate medical education: Which standards are also applicable in Germany? Recommendations for physicians with a license for postgraduate training and training agents

Background: In Germany, the (model) regulation for postgraduate medical education 2018, the professional codes of conduct of the regional medical councils and the health professions chamber laws of the federal states are the formal basis of postgraduate medical education, but say little about its structure, processes and results. The World Federation for Medical Education (WFME) has developed global standards for improving the quality of postgraduate medical education and published them in a revised edition in 2015. A German version which takes the specifics of medical training in Germany into account has not been published to date. Objective: The Committee for Postgraduate Medical Education (PGME) of the Society for Medical Education (GMA) has set itself the goal of firstly translating the WFME standards into German and secondly making recommendations for physicians with a license for post-graduate training (PLT) and training agents (TA) in clinics and practices which have been adapted to the German context. Methods: The WFME standards were translated into German by a working group of the GMA Committee for PGME, the terminology adapted to PGME in Germany and checked by an interdisciplinary panel of experts made up of 9 members of the committee. In a second step, the WFME basic standards and quality standards for PGME relevant to PLTs and TAs in Germany were iteratively determined by this panel of experts using the Nominal Group Technique (NGT) and compiled in the form of recommendations. Results: The translation of the WFME guidelines was approved by the expert group without any changes to the content, taking into account the terminological system of PGME in Germany. In a second step, 90 standards were identified which were considered helpful for PGME in Germany, especially for PLTs and TAs (such as development of a professional identity, a more patient-centered approach or support of self-directed learning). Care was taken to only give recommendations which can be influenced by PLTs and TAs. These standards have been summarized as recommendations to PLTs and TAs and take into account all chapters of the WFME standards. Conclusion: The WFME standards selected here are recommended to PLTs and TAs in clinics and practices to achieve high-quality PGME. Empirical longitudinal studies will be required to examine both the implementation and the results of applying the modified WFME criteria in Germany.

Will the Meikirch Model, a New Framework for Health, Induce a Paradigm Shift in Healthcare?

Over the past decades, scientific medicine has realized tremendous advances. Yet, it is felt that the quality, costs, and equity of medicine and public health have not improved correspondingly and, both inside and outside the USA, may even have changed for the worse. An initiative for improving this situation is value-based healthcare, in which value is defined as health outcomes relative to the cost of achieving them. Value-based healthcare was advocated in order to stimulate competition among healthcare providers and thereby reduce costs. The approach may be well grounded economically, but in the care of patients, "value" has ethical and philosophical connotations. The restriction of value to an economic meaning ignores the importance of health and, thus, leads to misunderstandings. We postulate that a new understanding of the nature of health is necessary. We present the Meikirch model, a conceptual framework for health and disease that views health as a complex adaptive system. We describe this model and analyze some important consequences of its application to healthcare. The resources each person needs to meet the demands of life are both biological and personal, and both function together. While scientific advances in healthcare are hailed, these advances focus mainly on the biologically given potential (BGP) and tend to neglect the personally acquired potential (PAP) of an individual person. Personal growth to improve the PAP strongly contributes to meeting the demands of life. Therefore, in individual and public health care, personal growth deserves as much attention as the BGP. The conceptual framework of the Meikirch model supports a unified understanding of healthcare and serves to develop common goals, thereby rendering interprofessional and intersectoral cooperation more successful. The Meikirch model can be used as an effective tool to stimulate health literacy and improve health-supporting behavior. If individuals and groups of people involved in healthcare interact based on the model, mutual understanding of and adherence to treatments and preventive measures will improve. In healthcare, the Meikirch model also makes it plain that neither pay-for-performance nor value-based payment is an adequate response to improve person-centered healthcare. The Meikirch model is not only a unifying theoretical framework for health and disease but also a scaffold for the practice of medicine and public health. It is fully in line with the theory and practice of evidence-based medicine, person-centered healthcare, and integrative medicine. The model offers opportunities to self-motivate people to improve their health-supporting behavior, thereby making preventive approaches and overall healthcare more effective. We believe that the Meikirch model could induce a paradigm shift in healthcare. The healthcare community is hereby invited to acquaint themselves with this model and to consider its potential ramifications.

Health as a Complex Adaptive System: a new dimension of patient care in internal medicine and general practice

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify health to be viewed as a CAS. In each patient, the current state of his health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help the patient to better understand his situation and to recognize possible next steps that may be useful for him to evolve toward more health by himself. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities to help patients to improve their health.

Applying a complex adaptive system's understanding of health to primary care

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify viewing health as a CAS. In each patient, the current state of health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help patients to better understand their situations and to recognize possible next steps that may be useful in order to evolve toward better health by themselves. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities for helping patients improve their health prospects.

Understanding the nature of health: New perspectives for medicine and public health. Improved wellbeing at lower costs

BACKGROUND

Current dilemmas of health care systems call for a new look at the nature of health. This is offered by the Meikirch model. We explore its hypothetical benefit for the future of medicine and public health. Meikirch model: It states: "Health is a dynamic state of wellbeing emergent from conducive interactions between individuals' potentials, life's demands, and social and environmental determinants." "Throughout the life course health results when an individuals' biologically given potential (BGP) and his or her personally acquired potential (PAP), interacting with social and environmental determinants, satisfactorily respond to the demands of life."

METHODS

We explored the Meikirch model's possible applications for personal and public health care.

RESULTS

The PAP of each individual is the most modifiable component of the model. It responds to constructive social interactions and to personal growth. If an individual's PAP is nurtured to develop further, it likely will contribute much more to health than without fostering. It may also compensate for losses of the BGP. An ensuing new culture of health may markedly improve health in the society. The rising costs of health care presumably are due in part to the tragedy of the commons and to moral hazard. Health as a complex adaptive system offers new possibilities for patient care, particularly for general practitioners.

DISCUSSION

Analysis of health systems by the Meikirch model reveals that in many areas more can be done to improve people's health and to reduce health care costs than is done today. The Meikirch model appears promising for individual and public health in low and high income countries. Emphasizing health instead of disease the Meikirch model reinforces article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations - that abandons the WHO definition - and thereby may contribute to its reinterpretation.

Jejunitis and brown bowel syndrome with multifocal carcinogenesis of the small bowel

This is the first report describing a case where prolonged, severe malabsorption from brown bowel syndrome progressed to multifocally spread small bowel adenocarcinoma. This case involves a female patient who was initially diagnosed with chronic jejunitis associated with primary diffuse lymphangiectasia at the age of 26 years. The course of the disease was clinically, endoscopically, and histologically followed for 21 years until her death at the age 47 due to multifocal, metastasizing adenocarcinoma of the small bowel. Multiple lipofuscin deposits (so-called brown bowel syndrome) and severe jejunitis were observed microscopically, and sections of the small bowel showed dense lymphoplasmacytic infiltration of the lamina propria as well as blocked lymphatic vessels. After several decades, multifocal nests of adenocarcinoma cells and extensive, flat, neoplastic mucosal proliferations were found only in the small bowel, along with a loss of the mismatch repair protein MLH1 as a long-term consequence of chronic jejunitis with malabsorption. No evidence was found for hereditary nonpolyposis colon carcinoma syndrome. This article demonstrates for the first time multifocal carcinogenesis in the small bowel in a malabsorption syndrome in an enteritis-dysplasia-carcinoma sequence.

Plasma histamine and tumour necrosis factor-alpha levels in Crohn's disease and ulcerative colitis at various stages of disease

Mast cells secrete numerous mediators and this study investigated plasma levels of histamine, and tumor necrosis factor alpha (TNF-α) in chronic inflammatory bowel disease (IBD). Plasma levels of histamine were determined in 68 patients with Crohn's disease (CD), 22 with ulcerative colitis (UC) and 13 controls. TNF-α levels were assessed in 29 CD patients, 11 UC patients, and in 11 controls. Plasma histamine levels in the control group were 0.25 ng (0.14 - 0.33) and showed no difference to CD (0.19 ng, 0.09 - 0.35) or UC (0.23 ng, 0.11 - 0.60). Significantly lower histamine levels were only found in CD patients on 5-aminosalicylic acid treatment (P ≤ 0.04). Plasma TNF-α levels in the control group were significantly lower 0.44 ml/m(2) (0 - 1.15) than in CD patients (4.62 ml/m(2), 1.82 - 9.22, P = 0.005) or UC (3.14 ml/m(2); 0.08 - 11.34, P = 0.01). In CD disease activity, fistula, and extraintestinal manifestations (EM) were associated with significantly higher plasma TNF-α values, but not the type of treatment. We concluded that in contrast to TNF-α, histamine levels were normal in CD and UC. There is no correlation with histamine and thus the proportion of TNF-α secreted from mast cells in the plasma in patients with IBD is less important.

Clinical practice and self-awareness as determinants of empathy in undergraduate education: a qualitative short survey at three medical schools in Germany

STUDY AIM

Physician empathy constitutes an outcome-relevant aim of medical education. Yet, the factors promoting and inhibiting physician empathy have not yet been extensively researched, especially in Germany. In this study, we explored German medical students' views of the factors promoting and inhibiting their empathy and how their experiences were related to their curricula.

METHODS

A qualitative short survey was conducted at three medical schools: Bochum University, the University of Cologne and Witten/Herdecke University. Students were invited to complete an anonymous written questionnaire comprised of open-ended questions inquiring about the educational content of and situations during their medical education that positively or negatively impacted their empathy. Data were analyzed through qualitative content analysis according to the methods of Green and Thorogood.

RESULTS

A total of 115 students participated in the survey. Respondents reported that practice-based education involving patient contact and teaching with reference to clinical practice and the patient's perspective improved their empathy, while a lack of these inhibited it. Students' internal reactions to patients, such as liking or disliking a patient, prejudice and other attitudes, were also considered to influence their empathy. Although each of the three schools takes a different approach to teaching interpersonal skills, no relevant differences were found in their students' responses concerning the possible determinants of empathy.

CONCLUSION

Providing more training in practice and more contact with patients may be effective ways of promoting student empathy. Students need support in establishing therapeutic relationships with patients and in dealing with their own feelings and attitudes. Such support could be provided in the form of reflective practice training in order to promote self-awareness. More research is needed to evaluate these hypothetical conclusions.

Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians

BACKGROUND

Empathy is an outcome-relevant physician characteristic and thus a crucial component of high-quality communication in health care. However, the factors that promote and inhibit the development of empathy during medical education have not been extensively researched. Also, currently there is no explicit research on the perspective of practicing physicians on the subject. Therefore the aim of our study was to explore physicians' views of the positive and negative influences on the development of empathy during their medical education, as well as in their everyday work as physicians.

METHOD

We administered a written Qualitative Short Survey to 63 physicians in seven specialties. They were able to respond anonymously. Our open-ended question was: "What educational content in the course of your studies and/or your specialist training had a positive or negative effect on your empathy?" We analyzed the data using thematic content analysis following Mayring's approach.

RESULTS

Forty-two physicians took part in our survey. All together, they mentioned 68 specific factors (37 positive, 29 negative, 2 neutral) from which six themes emerged: 1. In general, medical education does not promote the development of empathy. 2. Recognizing the psycho-social dimensions of care fosters empathy. 3. Interactions with patients in medical practice promote empathy. 4. Physicians' active self-development through reflective practice helps the development of empathy. 5. Interactions with colleagues can both promote and inhibit empathy through their role modeling of empathic and non-empathic behavior. 6. Stress, time pressure, and adverse working conditions are detrimental to empathy development.

CONCLUSIONS

Our results provide an overview of what might influence the development of clinical empathy, as well as hypothetical conclusions about how to promote it. Reflective practice seems to be lacking in current medical curricula and could be incorporated. Raising physicians' awareness of the psycho-social dimension of disease, and of the impact of peer influence and role modeling, seems promising in this regard, too. Stress and well-being seem to be closely related to physician empathy, and their modulation must take into account individual, social, and organizational factors. Further research should investigate whether or how these hypothetical conclusions can deepen our understanding of the determinants of physician empathy in order to help its promotion.

Subjective and objective olfactory abnormalities in Crohn's disease

The pathogenesis of Crohn's disease (CD) is still unknown, but the involvement of the olfactory system in CD appears possible. No study to date has systematically assessed the olfactory function in CD patients. We investigated the olfactory function in CD patients in active (n = 31) and inactive disease (n = 27) and in a control group of age- and sex-matched healthy subjects (n = 35). Subjective olfactory testing was applied using the Sniffin' Sticks test. For olfactory testing, olfactory event-related potentials (OERPs) were obtained with a 4-channel olfactometer using phenyl ethyl alcohol (PEA) and hydrogen sulfide (H(2)S). Carbon dioxide (CO(2)) was employed as control stimulus, and chemosomatosensory event-related potentials (CSSERPs) were registered. Results of the Sniffin' Sticks test revealed significantly different olfactory hedonic judgment with increased olfactory hedonic estimates for pleasant odorants in CD patients in active disease compared with healthy subjects. A statistical trend was found toward lower olfactory thresholds in CD patients. In objective olfactory testing, CD patients showed lower amplitudes of OERPs and CSSERPs. Additionally, OERPs showed significantly shorter N1- and P2 latencies following stimulation of the right nostril with H(2)S in CD patients in inactive disease compared with controls. Our study demonstrates specific abnormalities of olfactory perception in CD patients.

Challenges for medical educators: results of a survey among members of the German Association for Medical Education

Background: Despite the increasing interest in medical education in the German-speaking countries, there is currently no information available on the challenges which medical educators face. To address this problem, we carried out a web-based survey among the members of the Association for Medical Education (Gesellschaft für medizinische Ausbildung, GMA).

Methods: A comprehensive survey was carried out on the need for further qualifications, expertise and the general conditions of medical educators in Germany. As part of this study, the educators were asked to list the three main challenges which they faced and which required urgent improvement. The results were analysed by means of qualitative content analysis.

Results: The questionnaire was completed by 147 of the 373 members on the GMA mailing list (response rate: 39%). The educators named a total of 346 challenges and emphasised the following areas: limited academic recognition for engagement in teaching (53.5% of educators), insufficient institutional (31.5%) and financial support (28.4%), a curriculum in need of reform (22.8%), insufficient time for teaching assignments (18,9%), inadequate teacher competence in teaching methods (18.1%), restricted faculty development programmes (18.1%), limited networking within the institution (11.0%), lack of teaching staff (10.2%), varying preconditions of students (8.7%), insufficient recognition and promotion of medical educational research (5.5%), extensive assessment requirements (4.7%), and the lack of role models within medical education (3.2%).

Conclusion: The medical educators found the biggest challenges which they faced to be limited academic recognition and insufficient institutional and financial support. Consequently, improvements should be implemented to address these issues.

The future of graduate medical education in Germany - position paper of the Committee on Graduate Medical Education of the Society for Medical Education (GMA)

The German graduate medical education system is going through an important phase of changes. Besides the ongoing reform of the national guidelines for graduate medical education (Musterweiterbildungsordnung), other factors like societal and demographic changes, health and research policy reforms also play a central role for the future and competitiveness of graduate medical education. With this position paper, the committee on graduate medical education of the Society for Medical Education (GMA) would like to point out some central questions for this process and support the current discourse. As an interprofessional and interdisciplinary scientific society, the GMA has the resources to contribute in a meaningful way to an evidence-based and future-oriented graduate medical education strategy. In this position paper, we use four key questions with regards to educational goals, quality assurance, teaching competence and policy requirements to address the core issues for the future of graduate medical education in Germany. The GMA sees its task in contributing to the necessary reform processes as the only German speaking scientific society in the field of medical education.

Mast cell tryptase levels in gut mucosa in patients with gastrointestinal symptoms caused by food allergy

BACKGROUND AND AIMS

Mast cells, which are important effector cells in food allergy, require a special histologic treatment for quantification in endoscopic gastrointestinal samples. The objective of this study was to investigate whether mast cell tryptase (T), a typical mast cell-associated marker, may help to detect patients with food allergy.

METHODS

Mast cell T was investigated from 289 colorectal samples of 73 controls, 302 samples from 43 patients with food allergy and gastrointestinal symptoms, and 72 samples from 12 patients with partial or complete remission of allergic symptoms. Endoscopically taken samples were immediately put into liquid nitrogen, mechanically homogenized by a micro-dismembrator with three homogenization steps and tissue T content (ng T/mg wet weight) was measured by fluoroenzyme immunoassay.

RESULTS

Tissue T levels from the lower gastrointestinal tract were significantly elevated (p < 0.0001) in patients with manifest gastrointestinal allergy (median: 55.7, range: 9.3-525.0) compared with controls (median: 33.5, range: 8.0-154.6). A subgroup of 12 patients with remission of allergy showed markedly decreased symptom scores and mucosal T levels after more than 1 year of antiallergic therapy (pretreatment median: 54.1, range: 37.0-525.0 and posttreatment median: 28.4, range: 19.8-69.1; p = 0.01).

CONCLUSIONS

High T levels in the gut of food-allergic patients support the role of stimulated mast cells or an increased mast cell number.

Normalized autofluorescence imaging diagnostics in upper GI tract: a new method to improve specificity in neoplasia detection

BACKGROUND & AIMS

This study was performed to improve the autofluorescence imaging (AFI) in the upper GI tract by applying a new method of normalized autofluorescence (NAFI) obtained via tri-modal imaging.

OBJECTIVE

NAFI may provide lower false positive rate to achieve ultimately better specificity at acceptable sensitivity.

PATIENTS AND METHODS

This is a prospective, controlled single-centre study. 18 patients with suspected esophagus or stomach cancer undergoing esophagogastroduodenoscopy (EGD) were enrolled between February and May 2010. After endoscopy each patient was assigned into one of two groups: (1) non-cancer, including inflammation; (2) cancer group. EGDs were performed using video white light endoscopy, followed by AFI/NAFI. The targeted biopsy samples were taken from the abnormal areas as well as from adjacent mucosa. NAFI was compared versus AFI for cancer diagnostics in terms of specificity and sensitivity.

RESULTS

NAFI detected all neoplastic lesions. WLE or NBI detected no additional neoplasia. The AFI displayed mucosal inflammation and carcinomas of esophagus and stomach as dark red color, the normal mucosa background was displayed as light green. The NAFI didn't differentiate inflamed tissue from normal in majority of cases, but in tumorous mucosa, the cancer areas were detected precisely. AFI shows 100% sensitivity but 50% specificity which correlates with previous literature data. On the other hand, NAFI demonstrated lower sensitivity (88%) but higher specificity compared to AFI (69%).

CONCLUSIONS

Measuring the NAFI instead of the AFI was found improving the specificity of cancer diagnosis. Use of fiber-optic endoscopes to analyze AFI and possible endoscopic and histological sampling error are the main potential limitations of this method.

[Integrative and personalized health care--requirements for a timely health-care system]

In medical and public debates, the concept "personalized" or "individualized" medicine (PM) is increasingly used for the orientation of medicine towards individual genetic, molecular and biological characteristics. However, this tunnel view neglects that the human "person" or "individual" encompasses more than just the molecular and biological side, and that patients increasingly call for a more holistic and more person-centred form of health care. Therefore the authors propose to extend the concept of PM in the framework of an integrative health-care concept, so that with respect to a modern and patient-centred health-care system not only the biological, but also the relevant psychological, mental, social, cultural, spiritual, and economic aspects of the human individual are accounted for in health care. The Faculty of Health of Witten/Herdecke University proposes the term "integrative and personalised health care" for such a holistic form of PM.

Analysis of immediate ex vivo release of nitric oxide from human colonic mucosa in gastrointestinally mediated allergy, inflammatory bowel disease and controls

Nitric oxide (NO) is a local mediator in inflammation and allergy. The aim of this study was to investigate whether live incubated colorectal mucosal tissue shows a direct NO response ex vivo to nonspecific and specific immunological stimuli and whether there are disease-specific differences between allergic and chronic inflammatory bowel disease (IBD). We took biopsies (n=188) from 17 patients with confirmed gastrointestinally mediated food allergy, six patients with inflammatory bowel disease, and six control patients. To detect NO we employed an NO probe (WPI GmbH, Berlin, Germany) that upon stimulation with nonspecific toxins (ethanol, acetic acid, lipopolysaccharides), histamine (10(-8)-10(-4)M), and immune-specific stimuli (anti-IgE, anti-IgG, known food allergens) directly determined NO production during mucosal oxygenation. Non-immune stimulation of the colorectal mucosa with calcium ionophore (A23187), acetic acid, and ethanol induced a significant NO release in all groups and all biopsies. Whereas, immune-specific stimulation with allergens or anti-human IgE or -IgG antibodies did not produce significant release of NO in controls or IBD. Incubation with anti-human IgE antibodies or allergens produced a ninefold increase in histamine release in gastrointestinally mediated allergy (p<0.001), but anti-human IgE antibodies induced NO release in only 18% of the allergy patients. Histamine release in response to allergens or anti-human IgE antibodies did not correlate with NO release (r(2)=0.11, p=0.28). These data show that nonspecific calcium-dependent and toxic mechanisms induce NO release in response to a nonspecific inflammatory signal. In contrast, mechanisms underlying immune-specific stimuli do not induce NO production immediately.

Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial

BACKGROUND

Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking.

OBJECTIVE

Development of a training strategy for diagnostic upper endoscopy.

STUDY DESIGN

Prospective, randomized trial.

SETTINGS

A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed following a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators.

MAIN OUTCOME MEASUREMENTS

Time to reach the duodenum, pylorus, or esophagus.

RESULTS

All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different.

LIMITATIONS

Small sample size.

CONCLUSIONS

Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.

Mucin production determines sensitivity to bortezomib and gemcitabine in pancreatic cancer cells

The prognosis of pancreatic cancer remains disappointing due to a high intrinsic resistance against chemotherapeutic agents. Standard gemcitabine therapies have improved overall survival only marginally and recently, inhibition of the proteasome by the boronic acid derivative bortezomib has been introduced as a novel therapeutic strategy for solid and hematological malignancies including pancreatic cancer. The mucus-producing pancreatic cancer cell line Capan-1 was cultured under standard conditions and treated with different concentrations of gemcitabine or bortezomib. Mucus production was suppressed by siRNA-mediated silencing of apomucin genes. Cell proliferation was determined by 3H-thymidine incorporation and apoptosis was quantified after propidium iodide staining by flow cytometry. Apoptotic cell death was confirmed by TUNEL staining, determination of mitochondrial transmembrane potential and assessment of caspase 3/7 activity. NFκB-activity was determined by EMSA. The unfolded protein response (UPR) was further investigated by PCR, Western blotting and caspase 12 activity assays. Silencing of MUC4 significantly reduced expression of mucins for up to 5 days after transfection. While native cells showed an increased sensitivity to bortezomib treatment, silenced cells were more sensitive to gemcitabine treatment. Bortezomib induces mitochondrial damage in native cells and also activates the UPR by splicing of Xbp-1 and induction of CHOP, which is significantly reduced by silencing of MUC4. Our data suggest that mucinous pancreatic cancers are more sensitive towards proteasome inhibition by bortezomib and that alternative pathways of apoptosis are involved in cell death induction, while tumor cells with a low secretory activity show a better response to gemcitabine.

Long-Term Relapse-Free Survival by Interdisciplinary Collaboration in a Patient with Metastatic Pancreatic Cancer (UICC IV)

INTRODUCTION

The prognostic outlook for patients suffering from pancreatic cancer is generally poor. Particularly in cases of advanced and metastatic disease, long-term relapse-free survival may be achieved only in a few cases.

CASE REPORT

A 45-year-old patient presented with metastatic pancreatic cancer. Liver metastases had been intra-operatively confirmed by histology. Prior to initiating treatment, a portacath was surgically implanted. Subsequently, the patient received a weekly dose of 1,000 mg/m(2) gemcitabine combined with 2,000 mg/m(2) high-dose 5-fluorouracil as a 24-hour infusion for palliative treatment. As the patient was suffering from a stenosis of the ductus hepaticus communis, an endoprosthesis was primarily implanted. After 18 applications of chemotherapy during which only low toxic side effects such as nausea, vomiting and alopecia (NCI-CTC grade 1) presented, a partial remission of the primary tumor was observed. In the course of chemotherapy treatment, the carbohydrate antigen 19-9 tumor marker value normalized. Thus, the interdisciplinary tumor board of the University of Erlangen decided to perform a laparoscopy to evaluate the status of liver metastases after palliative chemotherapy treatment. Subsequently, the primary tumor could be completely resected (pT2, pN0, pM0, L0, V0, G2, R0); liver metastases were not observed. Eight years after the initial diagnosis, the patient is relapse-free, professionally fully integrated and presents with an excellent performance status.

CONCLUSION

Patients suffering from metastatic pancreatic cancer may benefit from treatment combinations with palliative intent. In singular cases, patients may even have a curative treatment option, provided a close interdisciplinary collaboration exists.

Cleaning of occluded pancreatic duct endoprostheses: a new indication for extracorporeal shock wave lithotripsy?

BACKGROUND

Pancreatic duct stenting is widely performed for bridging main pancreatic duct obstruction in patients with chronic pancreatitis. The major limitation is early stent occlusion, making regular stent exchange necessary.

OBJECTIVE

To date, no measures are available to prevent stent occlusion. The aim of this study was to evaluate the cleansing effect of shock wave application (SWA) on occluded pancreatic duct stents in vitro.

DESIGN

In vitro study.

PATIENTS

We analyzed occlusion rates of 25 plastic endoprostheses removed from 21 patients with chronic pancreatitis.

INTERVENTION

We administered 350 shock wave pulses every 10 mm along the prosthesis, which was stored in a latex balloon filled with gas-free physiologic saline solution, by using a pressure of 42 megapascals.

MAIN OUTCOME MEASUREMENTS

After SWA, the occlusion rate was measured again, and the cleansing rate was calculated in comparison with the native prosthesis.

RESULTS

The mean (± SD) occlusion rate was significantly reduced (64.7 ± 28.7 [15%-100%]) before SWA vs 9.8 ± 25.3 [0-100%]) after SWA; P = .038). In 16 of 25 prostheses (64%), cleaning was complete. Four of the remaining 9 prostheses (16%) showed satisfactory cleaning of 95%, on average. Residual clogging material was found mainly at the duodenal tip and the middle of the stent. No significant association was found between patient-related or stent-related parameters and the cleansing effect of SWA.

LIMITATIONS

In vitro study design.

CONCLUSION

SWA is effective in cleaning occluded pancreatic endoprostheses in vitro. Prolongation of stent placement seems possible if regular SWA is performed. Extracorporeal shock wave lithotripsy therefore might become a new indication for patients under treatment with pancreatic endoprostheses.

The measurement of leukotrienes in urine as diagnostic option in systemic mastocytosis

Clinical symptoms of patients with mastocytosis may include skin reactions, but also gastrointestinal symptoms with hyperacidity and dysmotility (e.g. ulcer, diarrhea, pain). They are mostly caused by mediators derived from activated mast cells. In order to investigate the impact of leukotrienes on the clinical symptoms excretion of leukotriene B4 (LTB4) and leukotrienes C4-D4-E4 (cysteinyl-leukotrienes) into urine was studied in 9 patients with indolent systemic mastocytosis divided into a group with high and low intensity of symptoms and in 11 healthy volunteers. Leukotriene excretion was determined by ELISA and correlated with methylhistamine excretion. Patients with systemic mastocytosis with high and low intense symptoms showed significantly higher urinary excretion of cysteinyl-leukotrienes than controls. There was a positive correlation of cysteinyl-leukotriene excretion and urinary methylhistamine excretion. LTB4 excretion was also significantly increased in patients with systemic mastocytosis compared to healthy volunteers. No correlation of urinary LTB4 excretion with urinary methylhistamine was observed. The present study demonstrates that urinary excretion of LTB4 and cysteinyl-leukotrienes LTC4-D4-E4 is clearly enhanced in indolent systemic mastocytosis Hence, determination of leukotriene excretion into urine can be used as a tool in the diagnostic and in the therapeutic monitoring of systemic mastocytosis.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions.

METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded.

RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%.

CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.

Palliative first-line therapy with weekly high-dose 5-fluorouracil and sodium folinic acid as a 24-hour infusion (AIO regimen) combined with weekly irinotecan in patients with metastatic adenocarcinoma of the stomach or esophagogastric junction followed by secondary metastatic resection after downsizing

BACKGROUND

The aim of this retrospective study was to evaluate the efficacy and safety of weekly high-dose 5-fluorouracil (5-FU)/folinic acid (FA) as 24-h infusion (AIO regimen) plus irinotecan in patients with histologically proven metastatic gastroesophageal adenocarcinoma (UICC stage IV).

MATERIAL/METHODS

From 08/1999 to 12/2008, 76 registered, previously untreated patients were evaluable. Treatment regimen: irinotecan (80 mg/m²) as 1-h infusion followed by 5-FU (2000 mg/m²) combined with FA (500 mg/m²) as 24-h infusion (d1, 8, 15, 22, 29, 36, qd 57).

RESULTS

Median age: 59 years; male/female: 74%/26%; ECOG ≤1: 83%; response: CR: 1%, PR: 16%, SD: 61%, PD: 17%, not evaluable in terms of response: 5%; tumor control: 78%; median OS: 11.2 months; median time-to-progression: 5.3 months; 1-year survival rate: 49%; 2-year survival rate: 17%; no evidence of disease: 6.6%; higher grade toxicities (grade 3/4): anemia: 7%, leucopenia: 1%, ascites: 3%, nausea: 3%, infections: 12%, vomiting: 9%, GI bleeding of the primary tumor: 4%, diarrhea: 17%, thromboembolic events: 4%; secondary metastatic resection after downsizing: 16 patients (21%), R-classification of secondary resections: R0/R1/R2: 81%/6%/13%, median survival of the 16 patients with secondary resection: 23.7 months.

CONCLUSIONS

Combined 5-FU/FA as 24-h infusion plus irinotecan may be considered as an active palliative first-line treatment accompanied by tolerable toxicity; thus offering an alternative to cisplatin-based treatment regimens. Thanks to efficient interdisciplinary teamwork, secondary metastatic resections could be performed in 16 patients. In total, the patients who had undergone secondary resection had a median survival of 23.7 months, whereas the median survival of patients without secondary resection was 10.1 months (p≤0.001).

Predictive factors of mortality after PEG insertion: guidance for clinical practice

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is considered the preferred route for long-term enteral feeding. The aim of this study was to determine predictors of an increased mortality risk after PEG insertion.

METHODS

A retrospective study was conducted during a 13-year period in the gastroenterology department of Erlangen University Hospital. The authors completed a questionnaire with details of demographic data, diagnosis, indication for PEG, type of tube, and cause of death. Patients were contacted regularly at scheduled appointments.

RESULTS

In total, 787 patients (574 male [72.9%]) underwent PEG placement by the pull technique. The main underlying disease was malignant (75.6%). By the end of the study period, 614 patients had died. The average survival time was 720 days. The 30-, 60-, 90-day and 1-, 3-, and 5-year mortality rates amounted to 6.5%, 9.8%, 13%, 32.1%, 59.3%, and 69.8%, respectively. Predictive factors of increased 30-day mortality were higher age, lower body mass index (BMI), and the presence of diabetes mellitus. The presence of all 3 variables served as an indicator to detect high-risk patients, with a sensitivity of 0.80 and a specificity of 0.64.

CONCLUSION

Mortality predictors for patients after PEG insertion are higher age, lower BMI, and the presence of diabetes mellitus. To avoid unnecessary and dangerous examinations in high-risk patients, the above-mentioned predictive factors of mortality should be checked before PEG placement.

Hemodynamic efficacy of sequential hemoclip application using the Olympus HX-110/610 reloadable clipping device in spurting bleedings

BACKGROUND

Hemoclip application in GI-hemorrhage has proven to be effective. Clinical experience shows that multiple clips are frequently necessary. In 2005, an easily reloadable clip-applicator was introduced. We evaluated the hemodynamic efficacy of this new device.

MATERIAL/METHODS

We prospectively compared the new clipping device (Olympus HX 110/610) in a validated experimental setting using the compactEASIE®-simulator for GI bleeding. The artificial blood circulation system in the simulator was connected to a pressure transducer. Four investigators of different endoscopic experience (1000-6000 endoscopies) treated 12 bleeding sources each, with up to 6 clips for each bleeding location. Pressures were recorded to objectify the additive effects of sequential clip application on the reduction in vessel diameter. The intervention was abandoned if a maximum measurable pressure of 300 mmHg was achieved.

RESULTS

Hemoclip application led to a significant increase of peak pressure (91±100 mmHg, p<0.001) and mean pressure (95±99 mmHg, p<0.001), representing a significant reduction in vessel diameter. Pooled data showed a significant stepwise increase in mean and maximum system pressure, resulting in reduction of vessel diameter up to the fifth hemoclip. On average, 5 clips (range 1-6) were used. More experienced endoscopists achieved a higher increase in mean pressure (167 and 118 mmHg vs 72 and 23 mmHg, p<0.05). Mean reloading time was 39 seconds (19-49 sec).

CONCLUSIONS

Sequential application of multiple hemoclips led to an increasing effect, comparable to the results of previous clinical trials. The number of hemoclips applied correlated inversely, but not significantly, with the endoscopist´s experience. Expensive single-use clips appear dispensable in view of the short reloading time.

Efficacy of contrast-enhanced US versus CT or MRI for the therapeutic control of percutaneous radiofrequency ablation in the case of hepatic malignancies

PURPOSE

The goal of this study was to assess the informative value of contrast-enhanced ultrasound after radiofrequency ablation (RFA). Patients who had undergone RFA of malignant liver tumors were followed up with contrast-enhanced sonography (CEUS), computed tomography (CT) and/or magnetic resonance tomography (MRI), and the outcomes were compared.

MATERIALS AND METHODS

76 patients undergoing 194 RFAs for 118 hepatic neoplasms (n = 55 HCC, n = 63 metastases) in the course of a 7-year period were examined post-interventionally using CEUS and CT or MRI. During follow-up (gold standard of evaluation), contrast agent rim accumulations with a diameter greater than 5 mm and a growth rate of at least 25 % were counted as a recurrence.

RESULTS

CEUS-CT comparison group: A total of 65 scan pairs were compared. In 54 cases (83.1 %) the findings were the same with either method. In 7 cases (10.8 %) CEUS confirmed the correct diagnosis, and in 2 cases (3.1 %) only CT was correct. In 2 cases (3.1 %) both methods yielded incorrect results. Diagnostic accuracy (DA): CEUS 93.8 %, CT 86.2 %. CEUS-MRI comparison group: In 23 cases (88.5 %) of a total of 26 scan pairs, the findings were the same for both CEUS and MRI. In 3 discordant cases only CEUS confirmed the correct diagnosis (3 cases, 11.5 %). Diagnostic accuracy DA (n = 26): CEUS 100 %, MRI 88.4 %.

CONCLUSION

CEUS performs equally to CT and MRI in the follow-up of patients treated for liver tumors by RFA.

Modern enteroscopic interventions and characterization of nonmalignant postsurgical biliary anastomosis by double-balloon endoscopy

BACKGROUND

Endoscopic access to strictured biliodigestive anastomoses often is difficult and may require percutaneous transhepatic biliary drainage or reoperation.

METHODS

Push- or push-and-pull enteroscopy was used to diagnose disease and treat 24 postsurgical patients with suspected strictured biliodigestive anastomosis. Endoscopic retrograde cholangiography and biliary interventional procedures were used. Endoscopic accessibility, diagnosis of disease, therapeutic success, and complication rates were investigated at a single tertiary university gastroenterology center.

RESULTS

Push enteroscopy reached biliary enteroanastomoses in 5 of the 24 patients (20.8%), whereas push-and-pull enteroscopy found choledocho- or hepaticojejunostomies in 17 of the remaining 19 postsurgical patients (89.4%). In all, successful enteroscopic intervention was achieved for 21 of the 24 patients (87.5%), whereas only 3 patients had to undergo percutaneous cholangiodrainage (12.5%). Cicatricially changed biliodigestive anastomoses were found in 14 of 21 patients (66.6%) including a mucosal type stricture in 7 patients (50%), an intramural type stricture in 5 patients (35.7%), and a ductal type stricture in 2 patients (14.2%). The remaining seven patients (33.3%) were normal. Enteroscopic interventions at strictured biliodigestive anastomosis included ostium incision for 8 (57.1%) and endoprosthesis insertion for 13 (92.8%) of the 14 patients, with prompt resolution of cholestasis and cholangitis. The major complications for the 24 patients involving 68 double-balloon enteroscopy (DBE) examinations comprised 2 perforations (8.3% per patient), 1 mild peritonitis (4.1%), and 1 cholangitis (4.1%), whereas minor complications were experienced by up to 20.8% of the patients.

CONCLUSIONS

Modern interventional enteroscopy yields a high rate of successful interventions for strictured biliodigestive anastomosis, requires ostium incision for mucosal and intramural types of strictures, and helps to reduce percutaneous approaches.

[A comparative study of the hepatic transit time (HTT) of different ultrasound contrast agents in patients with liver metastases and healthy controls]

PURPOSE

Liver metastases lead to a shortening of the HTT of an echo enhancer. Studies using SonoVue™ also showed a shortening of the HTT in healthy controls. Hence the HTT depends on the applied contrast agent. We examined whether the HTT of SonoVue™, Luminity™ und Levovist™ is useful to discriminate between patients with and without liver metastases.

MATERIALS AND METHODS

We compared the arteriovenous HTT of Levovist™, Sonovue™ und Luminity™ in 20 patients with liver metastases and in 15 controls. An Acuson Sequoia™ ultrasound system was used. The HTT results from the difference of the arrival time of the microbubbles in the hepatic artery and a hepatic vein.

RESULTS

Using Levovist™ six patients and three controls had to be excluded from further analysis. The arrival time was undetectable. The mean HTT values in healthy controls were: Levovsit™ 14.75 sec (SD ± 2.53 sec), SonoVue™ 9.27 sec (SD ± 2.41 sec) and Luminity™ 9.2 sec (SD ± 2.34 sec). In patients the mean HTT values were: Levovist™ 9.89 sec (SD ± 1.04 sec), SonoVue™ 6.28 sec (SD ± 2.41 sec) and Luminity™ 6.33 sec (SD ± 1.37 sec). Using a cut off of 8 sec for SonoVue™ and Luminity™, the sensitivity to exclude liver metastases was 75% and 80%.

CONCLUSION

The mean HTT values of all contrast agents were shorter in patients. Levovist™ showed a longer HTT in patients and controls than Luminity™ and SonoVue™. Levovist™ showed the best separation between patients and controls but some patients and controls had to be excluded. The HTT could still be a useful tool to exclude liver metastases but the HTT depends on the contrast agent and the applied contrast technique.

Cortisone replacement therapy in endocrine disorders - quality of self-care

OBJECTIVE

Some endocrine disorders make cortisone replacement therapy (CRT) mandatory. Patients need to be well informed about the therapy and to be able to adapt the dose in case of stress, trauma or surgery. It is unknown where the patients mainly get their information from and what their preferences in learning about the disease are, as well as what their ideas are on how to improve the knowledge transfer.

STUDY DESIGN

We used an anonymized questionnaire to evaluate these objectives as well as the patients' present state of knowledge.

PATIENTS AND METHODS

A total of 338 patients with Addison's disease, hypopituitarism or adrenogenital syndrome (mean age 39.8 +/- 21.1 years, mean duration of disease 11.4 +/- 10.8 years) took part in the study.

RESULTS

Spoken information by doctors is the main source of information for the patients (89%). Apart from counselling by physicians, journals of self-help groups (66%), brochures/guidebooks (60%) and the Internet (45%) are important sources of information. Asked for suggestions for further improvement of knowledge transfer, information available on paper is still the first choice (65%). 51.9% of the questions about CRT were answered correctly. 24% of the patients reported hospitalizations because of Addisonian crisis.

CONCLUSION

Information transfer by doctors is the main source of information for the patients. The low patient numbers make the development of structured education programmes unlikely. Given that only the half of the answers in the 'knowledge' section of the questionnaire were correct, the available media could contribute to the improvement of information transfer.

Clinical significance of lymphoid hyperplasia of the lower gastrointestinal tract

Lymphoid hyperplasia of the intestine has been associated with multiple diseases and symptoms. This study was undertaken to analyze the number and topographical distribution of the lymphoid follicles. A total of 302 adult consecutive patients were enrolled when they underwent elective colonoscopy. Standardized pictures from terminal ileum and colon were taken using video colonoscopes. In each picture, the number, size, and mucosal elevation of lymphoid follicles were analyzed in relation to histological and immunological findings and medical history. Lymphoid hyperplasia was found to be most extensive in the terminal ileum and cecum. Patients with untreated gastrointestinally mediated allergy (GMA) showed the highest number of lymphoid follicles per visible field in the terminal ileum ( P < 0.001) and cecum ( P = 0.003) vs. the control group. Patients with infectious colitis also showed a high number of lymphoid follicles per endoscopic visible field in the transverse colon ( P = 0.020). The presence of lymphoid hyperplasia is a frequent finding during colonoscopy. It may indicate an enhanced immunological mucosal response to antigenic stimulation such as GMA or infection.

Palliative first-line treatment with weekly high-dose 5-fluorouracil as 24h-infusion and gemcitabine in metastatic pancreatic cancer (UICC IV)

BACKGROUND

The aim of this study was to evaluate the efficacy and toxic side effects of combined gemcitabine plus weekly high-dose 5-Fluorouracil (5-FU) as 24h-infusion in patients with metastatic pancreatic cancer (UICC IV) as validation group of an earlier phase II study. Primary endpoints were to assess the response and tumour control rate.

MATERIAL/METHODS

This study comprised 60 prospectively registered patients with metastatic pancreatic cancer (UICC IV). A locally advanced disease was defined as exclusion criteria. The treatment schedule was weekly gemcitabine (1.000 mg/m(2)) as a 0.5h-infusion combined with 5-FU (2.000 mg/m(2)) as a 24h-infusion on day 1, 8 and 15 every 28 days.

RESULTS

Response rate (CR+PR) was achieved in 7% of the patients, tumour control rate (CR+PR+SD) was achieved in 59%. Median time-to-progression was 4 months, median overall survival was 7.3 months (95% CI 5.4-9.1). The median survival of patients with normal CEA value was 10.6 months (95% CI 7.8-13.4); with a normal CA 19-9 median survival was 10.1 months (95% CI 4.6-15.7) and with ECOG performance status 0 median survival was 10.1 months (95% CI 8.6-15.3). As higher grade toxicity (grade 3/4) leukopenia (15%), anaemia (10%) and thrombopenia (5%) were observed. Nausea and diarrhea (grade 3/4) occurred in 5% of the patients and vomiting in 2%.

CONCLUSIONS

The administration of gemcitabine and 5-FU as a 24h-infusion is feasible and offers good tumour control rate accompanied by tolerable toxicity. The subgroup of patients with a good performance status (ECOG 0) and tumour markers within the normal range benefit from the gemcitabine combination therapy.

Neoadjuvant treatment with weekly high-dose 5-fluorouracil as a 24h-infusion, folinic acid and biweekly oxaliplatin in patients with primary resectable liver metastases of colorectal cancer: long-term results of a phase II trial

BACKGROUND

In 2003 Wein et al. published data after a short median follow up (23 months). Here we report on the long-term results.

MATERIAL/METHODS

The patients (n=20) received a neoadjuvant treatment regimen comprising biweekly 85 mg/m2 oxaliplatin (L-OHP) (2h-infusion, d 1, 15, 29 qd 57) and 500 mg/m2 calcium folinic acid (FA) (1-2h-infusion, d 1, 8, 15, 22, 29, 36 qd 57) followed by 2600 mg/m2 5-Fluorouracil (5-FU) (24h-infusion, d 1, 8, 15, 22, 29, 36 qd 57). Two cycles of chemotherapy were administered, with a third being added when the treatment was well tolerated. Thereafter, curative resection of the liver metastases was attempted.

RESULTS

After neoadjuvant therapy, imaging procedures revealed complete remission in 2 patients (10%) and partial remission in 18 patients (90%). Diarrhea (Common Toxicity Criteria toxicity grade 3) was observed in 6 patients (30%) as main symptom of toxicity, followed by vomiting in 3 patients (15%). Higher grade sensomotoric neuropathy did not present. The curative resectability rate (R0) was 80%. In 9 out of 18 patients (50%) undergoing surgical intervention minor postoperative complications occurred. No postoperative mortality was observed. Over a median follow up of 45,5 months the median survival of all patients is 3.0 years and the 5-year overall survival rate is 40%. The 5-year disease-free survival rate is 25%.

CONCLUSIONS

Neoadjuvant treatment with 5-FU combined with FA and L-OHP proved to be highly effective and well tolerated. Disease-free survival rates and median overall survival rates are promising.

Mice lacking cannabinoid CB1-, CB2-receptors or both receptors show increased susceptibility to trinitrobenzene sulfonic acid (TNBS)-induced colitis

This study was performed to assess whether mice lacking the cannabinoid receptor CB1, CB2 or both receptors show increased susceptibility to TNBS colitis in comparison to wildtype mice. Previously, activation of CB1 and CB2 receptors showed attenuation of TNBS colitis in mice. The aim of the study was to investigate the susceptibility of three mouse strains CB1-, CB2- and CB1+2 double knockout mice in the model of TNBS colitis. The different knockout mice were given each a single enema with TNBS 7 mg, volume 150 microl (in 50% ethanol solution) on day 1. Control group (C57BL/6 mice) received the same concentration of TNBS enema and each strain received vehicle application of 150 microl 50% ethanol solution. After a 3-day period, the animals were sacrificed and their colon excised. A scoring system was used to describe macroscopical and histological changes. Messenger RNA-expression of TNF-alpha and IL-1beta as pro-inflammatory markers was measured by RT-PCR. All three knockout strains showed increased susceptibility to TNBS colitis quantified by macroscopical and histological scoring systems and pro-inflammatory cytokine expression in comparison to the TNBS control group (wild type C57BL/6 animals). Mice lacking the CB1-, CB2-receptor or both receptors showed aggravation of inflammation in the model of TNBS colitis. Lacking of both cannabinoid receptors did not result in potentiation of colitis severity compared to lacking of each CB1 or CB2, respectively. These results suggest that the endocannabinoid system may have tonic inhibitory effects on inflammatory responses in the colon.

The Virtual Family--development of surface-based anatomical models of two adults and two children for dosimetric simulations

The objective of this study was to develop anatomically correct whole body human models of an adult male (34 years old), an adult female (26 years old) and two children (an 11-year-old girl and a six-year-old boy) for the optimized evaluation of electromagnetic exposure. These four models are referred to as the Virtual Family. They are based on high resolution magnetic resonance (MR) images of healthy volunteers. More than 80 different tissue types were distinguished during the segmentation. To improve the accuracy and the effectiveness of the segmentation, a novel semi-automated tool was used to analyze and segment the data. All tissues and organs were reconstructed as three-dimensional (3D) unstructured triangulated surface objects, yielding high precision images of individual features of the body. This greatly enhances the meshing flexibility and the accuracy with respect to thin tissue layers and small organs in comparison with the traditional voxel-based representation of anatomical models. Conformal computational techniques were also applied. The techniques and tools developed in this study can be used to more effectively develop future models and further improve the accuracy of the models for various applications. For research purposes, the four models are provided for free to the scientific community.

The Virtual Family--development of surface-based anatomical models of two adults and two children for dosimetric simulations

The objective of this study was to develop anatomically correct whole body human models of an adult male (34 years old), an adult female (26 years old) and two children (an 11-year-old girl and a six-year-old boy) for the optimized evaluation of electromagnetic exposure. These four models are referred to as the Virtual Family. They are based on high resolution magnetic resonance (MR) images of healthy volunteers. More than 80 different tissue types were distinguished during the segmentation. To improve the accuracy and the effectiveness of the segmentation, a novel semi-automated tool was used to analyze and segment the data. All tissues and organs were reconstructed as three-dimensional (3D) unstructured triangulated surface objects, yielding high precision images of individual features of the body. This greatly enhances the meshing flexibility and the accuracy with respect to thin tissue layers and small organs in comparison with the traditional voxel-based representation of anatomical models. Conformal computational techniques were also applied. The techniques and tools developed in this study can be used to more effectively develop future models and further improve the accuracy of the models for various applications. For research purposes, the four models are provided for free to the scientific community.

The pan-deacetylase inhibitor panobinostat inhibits growth of hepatocellular carcinoma models by alternative pathways of apoptosis

Inhibition of deacetylases represents a new treatment option for human cancer diseases. We applied the novel and potent pan-deacetylase inhibitor panobinostat (LBH589) to human hepatocellular carcinoma models and investigated by which pathways tumor cell survival is influenced. HepG2 (p53wt) and Hep3B (p53null) responded to panobinostat treatment with a reduction of cell proliferation and a significant increase in apoptotic cell death at low micromolar concentrations. Apoptosis was neither mediated by the extrinsic nor the intrinsic pathway but quantitative RT-PCR showed an upregulation of CHOP, a marker of the unfolded protein response and endoplasmic reticulum stress with subsequent activation of caspase 12. Dependent on the p53 status, a transcriptional upregulation of p21(cip1/waf1), an increased phosphorylation of H2AX, and an activation of the MAPK pathway were observed. In a subcutaneous xenograft model, daily i.p. injections of 10 mg/kg panobinostat lead to a significant growth delay with prolonged overall survival, mediated by reduced tumor cell proliferation, increased apoptosis and reduced angiogenesis in tumor xenografts. Panobinostat increased the acetylation of histones H3 and H4. Panobinostat is a well tolerated new treatment option for HCC that activates alternative pathways of apoptosis, also in p53-deficient tumors.

Adherence to Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea: Impact of Patient Education after a Longer Treatment Period

<i>Background:</i> Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA) but it is often cumbersome so that adherence to CPAP therapy is limited. <i>Objectives:</i> We evaluated adherence to CPAP therapy after an additional educative intervention in OSA patients after a longer treatment period. <i>Methods:</i> A short patient information program covering many aspects of symptoms, consequences and treatment of OSA was created, and standardized information sessions were developed to be given by an experienced sleep physician to >6,000 participants of patient support group meetings throughout Germany. They also received a booklet containing the essential information of the lectures. Of the 526 randomly selected members of these support groups receiving the anonymized questionnaire by mail, 475 CPAP patients sent the questionnaire back. Of these CPAP patients, 243 participated in a lecture und and had received a booklet (information group) and 232 CPAP patients had not attended a lecture (control group). <i>Results:</i> In the information group, a significantly higher daily usage of CPAP devices (6.9 ± 0.9 h/day) was reported compared with the control group (5.7 ± 1.3 h/day; p < 0.001). Furthermore, the score in the Epworth Sleepiness Scale (ESS) was found to be significantly lower in the information group (median ESS = 6, interquartile range, IQR, 4–8 vs. median = 11, IQR 8–13; p < 0.001). <i>Conclusions:</i> Patients who attended our short information program showed a higher daily usage and a lower subjective daytime sleepiness. These results suggest that patients on CPAP therapy may benefit from education even after a longer treatment period.