A deep learning system for detection of early Barrett's neoplasia: a model development and validation study

BACKGROUND

Computer-aided detection (CADe) systems could assist endoscopists in detecting early neoplasia in Barrett's oesophagus, which could be difficult to detect in endoscopic images. The aim of this study was to develop, test, and benchmark a CADe system for early neoplasia in Barrett's oesophagus.

METHODS

The CADe system was first pretrained with ImageNet followed by domain-specific pretraining with GastroNet. We trained the CADe system on a dataset of 14 046 images (2506 patients) of confirmed Barrett's oesophagus neoplasia and non-dysplastic Barrett's oesophagus from 15 centres. Neoplasia was delineated by 14 Barrett's oesophagus experts for all datasets. We tested the performance of the CADe system on two independent test sets. The all-comers test set comprised 327 (73 patients) non-dysplastic Barrett's oesophagus images, 82 (46 patients) neoplastic images, 180 (66 of the same patients) non-dysplastic Barrett's oesophagus videos, and 71 (45 of the same patients) neoplastic videos. The benchmarking test set comprised 100 (50 patients) neoplastic images, 300 (125 patients) non-dysplastic images, 47 (47 of the same patients) neoplastic videos, and 141 (82 of the same patients) non-dysplastic videos, and was enriched with subtle neoplasia cases. The benchmarking test set was evaluated by 112 endoscopists from six countries (first without CADe and, after 6 weeks, with CADe) and by 28 external international Barrett's oesophagus experts. The primary outcome was the sensitivity of Barrett's neoplasia detection by general endoscopists without CADe assistance versus with CADe assistance on the benchmarking test set. We compared sensitivity using a mixed-effects logistic regression model with conditional odds ratios (ORs; likelihood profile 95% CIs).

FINDINGS

Sensitivity for neoplasia detection among endoscopists increased from 74% to 88% with CADe assistance (OR 2·04; 95% CI 1·73-2·42; p<0·0001 for images and from 67% to 79% [2·35; 1·90-2·94; p<0·0001] for video) without compromising specificity (from 89% to 90% [1·07; 0·96-1·19; p=0·20] for images and from 96% to 94% [0·94; 0·79-1·11; ] for video; p=0·46). In the all-comers test set, CADe detected neoplastic lesions in 95% (88-98) of images and 97% (90-99) of videos. In the benchmarking test set, the CADe system was superior to endoscopists in detecting neoplasia (90% vs 74% [OR 3·75; 95% CI 1·93-8·05; p=0·0002] for images and 91% vs 67% [11·68; 3·85-47·53; p<0·0001] for video) and non-inferior to Barrett's oesophagus experts (90% vs 87% [OR 1·74; 95% CI 0·83-3·65] for images and 91% vs 86% [2·94; 0·99-11·40] for video).

INTERPRETATION

CADe outperformed endoscopists in detecting Barrett's oesophagus neoplasia and, when used as an assistive tool, it improved their detection rate. CADe detected virtually all neoplasia in a test set of consecutive cases.

FUNDING

Olympus.

[Prehospital postcardiac-arrest-sedation and -care in the Federal Republic of Germany-a web-based survey of emergency physicians]

BACKGROUND

This study evaluates the implementation of postcardiac-arrest-sedation (PCAS) and -care (PRC) by prehospital emergency physicians in Germany.

MATERIALS AND METHODS

Analysis of a web-based survey from October to November 2022. Questions were asked about implementation, medications used, complications, motivation for implementing or not implementing PCAS, and measures and target parameters of PRC.

RESULTS

A total of 500 emergency physicians participated in the survey. In all, 73.4% stated that they regularly performed PCAS (hypnotics: 84.7%; analgesics: 71.1%; relaxants: 29.7%). Indications were pressing against the respirator (88.3%), analgesia (74.1%), synchronization to respirator (59.5%), and change of airway device (52.6%). Reasons for not performing PCAS (26.6%) included unconscious patients (73.7%); concern about hypotension (31.6%), re-arrest (26.3%), and worsening neurological assessment (22.5%). Complications of PCAS were observed by 19.3% of participants (acute hypotension [74.6%]); (re-arrest [32.4%]). In addition to baseline monitoring, PRC included 12-lead-electrocardiogram (96.6%); capnography (91.6%); catecholamine therapy (77.6%); focused echocardiography (20.6%), lung ultrasound (12.0%) and abdominal ultrasound (5.6%); induction of hypothermia (13.6%) and blood gas analysis (7.4%). An etCO2 of 35-45 mm Hg was targeted by 40.6%, while 9.0% of participants targeted an SpO2 of 94-98% and 19.2% of participants targeted a systolic blood pressure of ≥ 100 mm Hg.

CONCLUSIONS

Prehospital PRC in Germany is heterogeneous and deviations from its target parameters are frequent. PCAS is frequent and associated with relevant complications. The development of preclinical care algorithms for PCAS and PRC within preclinical care seems urgently needed.

[In-hospital emergency care in the Federal Republic of Germany. A site survey of hospitals in the German Resuscitation Registry]

BACKGROUND

In contrast to prehospital care there is a lack of specifications for the organization and equipment of medical emergency teams for in-hospital emergency care.

OBJECTIVE

Evaluation of the organization, team composition, training, equipment and tasks of medical emergency teams in the Federal Republic of Germany.

MATERIAL AND METHODS

Evaluation of a web-based survey of all hospitals participating in the German Resuscitation Register between February and March2020. The participants were asked about team composition; emergency equipment; type, content and scope of special training or further training as well as other additional tasks in the everyday clinical routine when participating in the medical emergency team. Hospitals with ≤ or >600 beds were compared.

RESULTS

A total of 21 (>600 beds: 10, 48%; ≤600 beds: 11, 52%) hospitals participated in the survey. Team composition requirements were present at 76% (n = 16; ≤600 beds: 8, 72% vs. >600 beds: 8, 80%), training requirements for medical emergency teams at 38% (n = 16; ≤600 beds: 4, 36% vs. >600 beds: 4, 40%) of hospitals, with a focus on cardiac life support (n = 6, 28%; ≤600 beds: 3, 27% vs. >600 beds: 3, 30%) and airway management (n = 4, 19%; ≤600 beds: 3, 27% vs. >600 beds: 1, 10%). A 12-lead electrocardiogram (n = 7, 33%; ≤600 beds: 1, 9% vs. >600 beds: 6, 60%; p = 0.02), video laryngoscope (n = 7, 33%; ≤600 beds: 2, 18% vs. >600 beds: 5, 50%), ventilator without (n = 7, 33%; ≤600 beds: 2, 18% vs. >600 beds: 5, 50%) or with the possibility of non-invasive ventilation was part of the standard equipment in n = 4, 19% (≤600 beds: 1, 9% vs. >600 beds: 3, 30%). A total of 85% (n = 18; ≤600 beds: 10, 100% vs. >600 beds 8, 72%), had additional tasks in the daily clinical routine. While clinics with >600 beds staffed medical emergency teams 100% of the time from the intensive care units, in clinics ≤600 beds medical emergency teams were deployed significantly more often in the emergency department (n = 5, 45%) and in the normal wards (n = 5, 45%, p = 0.03).

CONCLUSION

Training and equipment of medical emergency teams in the Federal Republic of Germany is heterogeneous. They should at least meet the standards commonly used in prehospital emergency medicine and include the availability of a portable 12-lead electrocardiogram, a ventilator with the possibility of noninvasive ventilation and a video laryngoscope. Regardless of the size of the hospital, continuous availability of all members of the medical emergency teams should be ensured.

Differences between manual CPR and corpuls cpr in regard to quality and outcome: study protocol of the comparing observational multi-center prospective registry study on resuscitation (COMPRESS)

Background

The effect of mechanical CPR is diversely described in the literature. Different mechanical CPR devices are available. The corpuls cpr is a new generation of piston-driven devices and was launched in 2015. The COMPRESS-trial analyzes quality of chest compression and CPR-related injuries in cases of mechanical CPR by the corpuls cpr and manual CPR.

Methods

This article describes the design and study protocol of the COMPRESS-trial. This observational multi-center study includes all patients who suffered an out-of-hospital cardiac arrest (OHCA) where CPR is attempted in four German emergency medical systems (EMS) between January 2020 and December 2022. EMS treatment, in-hospital-treatment and outcome are anonymously reported to the German Resuscitation Registry (GRR). This information is linked with data from the defibrillator, the feedback system and the mechanical CPR device for a complete dataset.

Primary endpoint is chest compression quality (complete release, compression rate, compression depth, chest compression fraction, CPR-related injuries). Secondary endpoint is survival (return of spontaneous circulation (ROSC), admission to hospital and survival to hospital discharge). The trial is sponsored by GS Elektromedizinische Geräte G. Stemple GmbH.

Discussion

This observational multi-center study will contribute to the evaluation of mechanical chest compression devices and to the efficacy and safety of the corpuls cpr.

Trial registration

DRKS, DRKS-ID DRKS00020819. Registered 31 July 2020.

CaRdiac Arrest Survival Score (CRASS) - A tool to predict good neurological outcome after out-of-hospital cardiac arrest

AIM

The aim of this study was to develop a score to predict the outcome for patients brought to hospital following out-of-hospital cardiac arrest (OHCA).

METHODS

All patients recorded in the German Resuscitation Registry (GRR) who suffered OHCA 2010-2017, who had ROSC or ongoing CPR at hospital admission were included. The study population was divided into development (2010-2016: 7985) and validation dataset (2017: 1806). Binary logistic regression analysis was used to derive the score. The probability of hospital discharge with good neurological outcome was defined as 1/(1 + e^-X), where X is the weighted sum of independent variables.

RESULTS

The following variables were found to have a significant positive (+) or negative (-) impact: age 61-70 years (-0·5), 71-80 (-0·9), 81-90 (-1·3) and > = 91 (-2·3); initial PEA (-0·9) and asystole (-1·4); presumable trauma (-1·1); mechanical CPR (-0·3); application of adrenalin > 0 - < 2 mg (-1·1), 2 - <4 mg (-1·6), 4 - < 6 mg (-2·1), 6 - < 8 mg (-2·5) and > = 8 mg (-2·8); pre emergency status without previous disease (+0·5) or minor disease (+0·2); location at nursing home (-0·6), working place/school (+0·7), doctor's office (+0·7) and public place (+0·3); application of amiodarone (+0·4); hospital admission with ongoing CPR (-1·9) or normotension (+0·4); witnessed arrest (+0·6); time from collapse until start CPR 2 - < 10 min (-0·3) and > = 10 min (-0·5); duration of CPR <5 min (+0·6). The AUC in the development dataset was 0·88 (95% CI 0·87-0·89) and in the validation dataset 0·88 (95% CI 0·86-0·90).

CONCLUSION

The CaRdiac Arrest Survival Score (CRASS) represents a tool for calculating the probability of survival with good neurological function for patients brought to hospital following OHCA.

Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria

BACKGROUND

Criteria for endoscopic resection in patients with early gastric cancer (EGC) have been expanded recently by the National Cancer Centre (NCC). This study compared long-term outcomes in patients with EGC who underwent endoscopic treatment according to guideline criteria with those treated according to expanded criteria.

METHODS

Baseline and outcome data from patients undergoing curative endoscopic resection for EGC between January 1999 and December 2005 were collected from electronic medical records. Survival time hazard ratios and 95 per cent confidence intervals were calculated using the Cox proportional hazards model.

RESULTS

Of 1485 patients who had a curative resection, 635 (42.8 per cent) underwent resection according to traditional criteria and 625 (42.1 per cent) according to expanded criteria. There was no significant difference in overall survival between the groups.

CONCLUSION

Patients who have treatment following the expanded criteria have similar long-term survival and outcomes to those treated according to guideline criteria.

Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria

BACKGROUND

Criteria for endoscopic resection in patients with early gastric cancer (EGC) have been expanded recently by the National Cancer Centre (NCC). This study compared long-term outcomes in patients with EGC who underwent endoscopic treatment according to guideline criteria with those treated according to expanded criteria.

METHODS

Baseline and outcome data from patients undergoing curative endoscopic resection for EGC between January 1999 and December 2005 were collected from electronic medical records. Survival time hazard ratios and 95 per cent confidence intervals were calculated using the Cox proportional hazards model.

RESULTS

Of 1485 patients who had a curative resection, 635 (42.8 per cent) underwent resection according to traditional criteria and 625 (42.1 per cent) according to expanded criteria. There was no significant difference in overall survival between the groups.

CONCLUSION

Patients who have treatment following the expanded criteria have similar long-term survival and outcomes to those treated according to guideline criteria.

[Timing and concepts of surgical treatment of upper gastrointestinal haemorrhage]

BACKGROUND

Upper gastrointestinal bleeding is a frequently occurring clinical scenario with a potentially serious prognosis. In spite of excellent endoscopic results, the mortality rate after an insufficient endoscopic treatment is exception-ally high (12.5-36 %). It is crucial to recognise factors in which endoscopy reaches its limitations. Until now, no uniform guidelines and concepts concerning diagnosis and treatment as well as timing of surgical interventions, in particular, have been defined. The main goal of this study is to lower the morbidity and mortality rates after upper gastrointestinal bleeding, with potential risk stratification according to the literature and our own data. PATIENTS / MATERIAL AND METHODS: In a retrospectively designed study 220 patients were evaluated with upper gastrointestinal haemorrhage, who were hospitalised as emergencies from 1999 to 2002. Only those patients were accepted in the study who were examined within 48 hours endoscopically by oesophagogastroduodenoscopy. In order to exclude bleeding complications of a preceding endoscopic therapy, those patients were excluded who had been investigated by endoscopy in the past than 8 days.

RESULTS

After endoscopic evaluation of the bleed-ing activity of 33 Forrest I a / I b bleedings 5 patients and of 52 Forrest II a / II b / II c bleedings 6 patients had to undergo surgery. The haemoglobin content of conventionally treated patients was on average 10.3 mg / dL as compared to 8.4 mg / dL for the operated patients. The conventionally treated patients received an average of 3 red cell concentrates whereas the operated patients had 11 blood transfusions. The source of haemorrhage in the operated patients was located in bulbus duodeni (n = 7), cardia and fundus (n = 2) and the corpus (n = 2).

CONCLUSION

The evaluation of our own patient data including the experiences of other authors shows that a risk stratification is possible and meaningful. The indication for surgery thereby -depends on different factors: the comorbidity of the patient, the haemodynamic in- / stability, the number of necessary blood transfusions and the localisation of the bleeding source.

Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Total endoscopic resection of Barrett esophagus

Barrett's esophagus with high grade intraepithelial neoplasia is associated with disease progression at rates of greater than 10% per year. Endoscopic resection is a lower risk alternative to surgery for the management of high grade intraepithelial neoplasia and intramucosal cancer. Two endoscopic approaches have been used, namely localized resection of the lesion and total endoscopic resection of all Barrett's mucosa. The latter strategy removes all at-risk mucosa. Currently it is performed mainly using piecemeal endoscopic mucosal resection techniques. In recent years endoscopic submucosal dissection has been attempted to obtain en bloc resection. This review will describe the techniques of total endoscopic resection, and summarize the key published data.

Endoscopic mucosal resection of Barrett's oesophagus containing dysplasia or intramucosal cancer

Barrett's oesophagus is premalignant. Oesophagectomy is traditionally regarded as the standard treatment option in the presence of high grade intraepithelial neoplasia or intramucosal cancer. However, oesophagectomy is associated with high rates of mortality and morbidity. Endoscopic ablative therapies are limited by the lack of tissue for histological assessment, and the ablation may be incomplete. Endoscopic mucosal resection is an alternative to surgery in the management of high grade intraepithelial neoplasia and intramucosal cancer. It is less invasive than surgery and, unlike ablative treatments, provides tissue for histological assessment. This review will cover the indications, techniques and results of endoscopic mucosal resection.

Radial EUS: the clinical impact of T staging

Endoscopic ultrasound staging of gastrointestinal and pancreaticobiliary cancers is important in guiding the choice of an appropriate treatment strategy such as endoscopic mucosal resection, surgery or palliative chemotherapy. This review will summarize the principles of endoscopic ultrasound T staging using a radial echoendoscope, elaborate on the accuracy rate in T staging, and discuss the clinical impact of endoscopic ultrasound T staging in the context of esophageal, gastric and pancreaticobiliary cancers.

Quality control of endoscopic ultrasound in preoperative staging of esophageal cancer

BACKGROUND AND STUDY AIMS

Endoscopic ultrasonography (EUS) is generally established as the most sensitive diagnostic tool for the assessment of locoregional tumor stage in esophageal carcinoma. It therefore has a crucial impact on the decision whether patients should undergo surgery as primary treatment or should receive neoadjuvant therapy. This study retrospectively evaluates the accuracy of EUS in tumor and nodal staging of prospectively evaluated patients with esophageal carcinoma in relation to tumor type, tumor grading, tumor site, and the influence of dilation.

PATIENTS AND METHODS

All 214 patients included in the study underwent surgery without neoadjuvant therapy and had tumor-free resection margins with no evidence of distant metastasis. EUS investigations were done at our Department of Interdisciplinary Endoscopy. EUS results were compared with the pathological findings.

RESULTS

EUS correctly identified T status in 141 patients (65.9 %). The sensitivity and specificity in relation to T status were 68.1 % and 98.2 % respectively for T1, 40.9 % and 83.4 % for T2, 84.3 % and 64.6 % for T3, and 14.3 % and 98.8 % for T4. The overall diagnostic accuracy of EUS in relation to N status was 64.5 % (n = 138); sensitivity and specificity for the diagnosis of N1 were 93.8 % and 20 %, respectively. Sixty-eight (80 %) of 85 pN0-staged tumors were overstaged as uN1. Dilation had a significant influence on the accuracy of EUS staging in advanced tumors ( P = 0.02), whereas tumor grading impacted on EUS staging in early tumors ( P = 0.01). Tumor site and tumor type did not show any influence.

CONCLUSIONS

Endosonographic staging of esophageal carcinoma is still unsatisfactory. An improvement in staging accuracy may be achieved by adding fine-needle aspiration biopsy (FNA) to EUS, because FNA improves N-stage accuracy, but it has no bearing on T-stage accuracy.

Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study

BACKGROUND AND STUDY AIMS

Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique.

PATIENTS AND METHODS

During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting.

RESULTS

A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3 %. In group B, the ES success rate using primary precut was 100 % at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B ( P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9 % in group A vs. 2.1 % in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation.

CONCLUSIONS

In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.

Endoscopic mucosal resection of early esophageal squamous cell cancer using the Duette mucosectomy kit

BACKGROUND AND STUDY AIM

Endoscopic mucosal resection (EMR) is a less invasive alternative treatment strategy to surgery for intramucosal esophageal squamous cell carcinoma (SCC). This study described our initial experience with the newly introduced Duette Multiband Mucosectomy Kit (Cook Ireland Ltd, Limerick, Ireland) for the treatment of extensive early esophageal SCC.

PATIENTS AND METHODS

Five patients with extensive early esophageal SCC, covering at least half of the circumference of the esophageal wall and measuring a mean of 2.8 cm longitudinally, underwent EMR after EUS staging.

RESULTS

EMR was successfully completed in one session in five patients. Post-EMR stricture occurred in four patients but was successfully treated with bougienage. One patient did not return for follow-up after bougienage and died from ischemic heart disease 3 months later. For the remaining four patients, there was no recurrence over a mean follow up of 14.7 months.

CONCLUSION

This new device obviates the need for repeated insertion of the endoscope during the process of ligation and resection and thus facilitates EMR of extensive SCC.

Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature

PURPOSE

This study was designed to evaluate the outcome of endoscopic polypectomy of malignant polyps with and without subsequent surgery based on histologic criteria.

METHODS

Consecutive patients with invasive carcinoma in colorectal polyps endoscopically removed between 1985 and 1996 were retrospectively studied. Patients with complete resection, grading G1 or G2, and absence of vascular invasion were classified as "low risk." The other patients were classified "high risk." Available literature was reviewed by applying similar classification criteria.

RESULTS

A total of 114 patients (59 males; median age, 70 (range, 20-92) years) were included. Median polyp size was 2.5 (0.4-10) cm. After polypectomy, of 54 patients with low-risk malignant polyps, 13 died of unrelated causes after a median of 76 months, 5 had no residual tumor at surgery, and 33 were alive and well during a median follow-up of 69 (range, 9-169) months. Of 60 patients with high-risk malignant polyps, 52 had surgery (residual carcinoma 27 percent). Five of eight patients not operated had an uneventful follow-up of median 57 (range, 47-129) months. Patients in the high-risk group were significantly more likely to have an adverse outcome than those in the low-risk group (P < 0.0001). Review of 20 studies including 1,220 patients with malignant polyps revealed no patient with low-risk criteria with an adverse outcome.

CONCLUSIONS

For patients with low-risk malignant polyps, endoscopic polypectomy alone seems to be adequate. In high-risk patients, the risk of adverse outcome should be weighed against the risk of surgery.

Long-term results of endoscopic removal of large colorectal adenomas

BACKGROUND AND STUDY AIMS

Endoscopic removal of large colorectal polyps has not been widely accepted. The aims of this study were to evaluate our longterm experiences justifying endoscopic resection technique as the treatment of choice.

PATIENTS AND METHODS

During a period of 12 years, 288 patients with a total of 302 polyps larger than 3 cm in diameter were treated endoscopically. 224 polyps were sessile and 78 pedunculated. Sessile polyps were removed using the piecemeal technique. Surgery was recommended in patients with unfavorable histology. Patients with favorable histology were followed up at 3 - 6 month intervals in the first year and then every 1 - 2 years.

RESULTS

A total of 184 patients with sessile polyps were followed up for at least 6 months. Recurrence rate of 166 benign polyps was 17 % (29/166). Only two patients had malignant recurrence. 8 of 18 patients with malignant polyps underwent surgery while 10 were unfit for surgery. 8 of these patients remained free of recurrence.

CONCLUSIONS

Previous concerns about endoscopic removal of large colorectal polyps are no longer justified. The results of this study showed that endoscopic resection of large colorectal polyps is safe and effective. In patients with high operative risk, endoscopic removal may be adequate.

Variceal bleeding and portal hypertension: has there been any progress in the last 12 months?

A review of the literature on the management of esophagogastric varices published in the last 12 months shows that the data are still quite conflicting. In the primary and secondary prophylaxis of variceal bleeding, beta-blockers are still the mainstay of pharmacotherapy. Measurement of the hepatic portal venous pressure gradient is considered to be a reliable parameter for successful reduction of portal pressure using medical therapy. However, intolerance of propranolol requiring discontinuation of therapy has been observed in approximately 30 % of patients. Patients' compliance with medication may represent another drawback of medical therapy. The role of endoscopic band ligation in secondary prophylaxis is now indisputable, especially in comparison with sclerotherapy. In the primary prevention of variceal bleeding, band ligation is beginning to have a competitive edge over pharmacological therapy. Acute variceal bleeding is no longer a frequent morbid emergency. Most cases of bleeding can now be managed successfully with band ligation and N-butyl-2-cyanoacrylate obliteration. N-butyl-2-cyanoacrylate has come into increasingly widespread use in the treatment of bleeding gastric fundal varices in which surgery or transjugular intrahepatic portosystemic shunting were previously regarded as the preferred therapies.

Lipid-induced changes in vascular smooth muscle cell membrane fluidity are associated with DNA synthesis

In the present study, we examined whether changes in the membrane fluidity of vascular smooth muscle cells (VSMCs) alter their DNA synthesis. For this purpose, the membrane fluidity of the cells was modulated after treatment of VSMCs with 1,2-dioleoyl phosphatidylcholine (PC). Treatment of VSMCs with 1,2-dioleoyl PC-rich medium containing 10% heat-inactivated human serum and 3 mg/ ml 1,2-dioleoyl PC for 24 h resulted in an increase in VSMC membrane fluidity at all temperatures from 15 degrees to 40 degrees C as well as a 51% inhibition of DNA synthesis, compared with untreated cells. Remarkably, enrichment of VSMCs with 1,2-dioleoyl PC/cholesterol-rich medium containing 10% human serum, 3 mg/ml 1,2-dioleoyl PC and 2 mg/ml cholesterol restored both membrane fluidity and DNA synthesis to the levels of untreated cells. The present findings show an inverse association between increased membrane fluidity and cellular DNA synthesis.

Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract

BACKGROUND

Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients.

PATIENTS AND METHOD

A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of >12 months.

RESULTS

Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone.

CONCLUSION

The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.

New mechanical puncture videoechoendoscope: one-step transmural drainage of a pseudocyst

A new mechanical puncture video echoendoscope (GF-UMD-240P 270 degrees image field parallel to the endoscope axis) has been used for puncture and drainage of a symptomatic pancreatic pseudocyst. It is equipped with a 2.8 mm working channel and an elevator allowing single step drainage with passage of a 7F nasocystic catheter.

Interventional endoscopic treatment of upper gastrointestinal bleeding - when, how, and how often

Acute upper gastrointestinal (GI) bleeding is still associated with high mortality. Reducing the rebleeding rate is the major challenge in therapeutic endoscopy. The following article describes the indications, techniques and limitations of endoscopic treatment of upper GI bleeding. Endoscopic techniques such as endoscopic sclerotherapy (EIS), endoscopic variceal ligation (EVL), cyanoacrylate obliteration, argon plasma coagulation (APC), and the application of hemoclip are described and compared concerning their efficacy. The pros and cons of "second-look" endoscopy are discussed.

Variceal bleeding and portal hypertension: still a therapeutic challenge?

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.

Short-term stimulation of vascular smooth muscle cells with platelet-derived growth factor (PDGF)-BB and angiotensin II induces

Growth factors such as the platelet-derived growth factor (PDGF)-BB and angiotensin II (Ang II) have been shown to induce vascular smooth muscle cell (VSMC) proliferation after long stimulation periods. Little is known though, about the effects of PDGF-BB and Ang II on VSMC proliferation after short stimulation periods. The purpose of our study was to examine whether a short term (3-60 min) stimulation of VSMC with PDGF-BB or Ang II is sufficient to induce cell proliferation. Incubation of VSMC with Ang II (100 nM) or PDGF-BB (50 ng/ml) caused a significant increase in [3H]thymidine incorporation starting after a 3-min stimulation, while the cell counts required 32 and 8 h of stimulation, respectively. Mitogen-activated protein kinase activation reached a maximum at 5-10 min of PDGF-BB or Ang II stimulation. This study demonstrates that the growth-promoting effects of PDGF-BB and Ang II are strongly dependent on the length of the stimulation period and that while prolonged stimulation periods (>8-32 h) result in VSMC proliferation, short ones (3-60 min) result only in [3H]thymidine incorporation without an increase in cell count, a fact of considerable pathophysiological significance, considering that the time kinetics of growth factors in the VSMC microenvironment have not as yet been clarified.

Cholera toxin treatment of vascular smooth muscle cells decreases smooth muscle alpha-actin content and abolishes the platelet-derived growth factor-BB-stimulated DNA synthesis

The second messenger cyclic AMP regulates diverse biological processes such as cell morphology and cell growth. We examined the role of the second messenger cyclic AMP on rat aortic vascular smooth muscle cell (VSMC) morphology and the intracellular transduction pathway mediated by platelet-derived growth factor beta-receptor (PDGF-Rbeta). The effect of PDGF-BB on VSMCs growth was assessed by [(3)H]-thymidine incorporation. Tyrosine phosphorylation of PDGF-Rbeta, PLC-gamma1, ERK1 and ERK2, p125(FAK) and paxillin as well as Sm alpha-actin was examined by the chemiluminescence Western blotting method. Actin mRNA level was quantitated by Northern blotting. Visualization of Sm alpha-actin filaments, paxillin and PDGF-Rbeta was performed by immunfluorescence microscopy. Cholera toxin (CTX; 10 nM) treatment lead to a large and sustained increase in the cyclic AMP concentration after 2 h which correlated with change of VSMC morphology including complete disruption of the Sm alpha-actin filament array and loss of focal adhesions. Treatment of VSMCs with CTX did not influence tyrosine phosphorylation of p125(FAK) and paxillin but decreased the content of a Sm alpha-actin protein. Maximal decrease of 70% was observed after 24 h of treatment. CTX also caused a 90% decrease of the actin mRNA level. CTX treatment completely abolished PDGF-BB stimulated DNA-synthesis although PDGF-Rbeta level and subcellular distribution and translocation was not altered. Furthermore CTX attenuated the PDGF-BB-induced tyrosine phosphorylation of the PDGF-Rbeta, PI 3'-K, PLC-gamma1 and ERK1/2 indicating an action of cyclic AMP on PDGF-beta receptor. We conclude that although cyclic AMP attenuates the PDGF-Rbeta mediated intracellular transduction pathway, an intact actin filament may be required for the PDGF-BB-induced DNA synthesis in VSMCs.

Green tea compounds inhibit tyrosine phosphorylation of PDGF beta-receptor and transformation of A172 human glioblastoma

The effect of the green tea compounds 2-(3,4-dihydroxyphenyl)-3, 4-dihydro-2H-1-benzopyran-3,5,7-triol (catechin), epicathechin (EC), epigallocathechin-3 gallate (EGCG), epicathechin-3 gallate (ECG) and catechin-3 gallate (CG) on the tyrosine phosphorylation of PDGF beta-receptor (PDGF-Rbeta) and on the anchorage-independent growth of A172 glioblastoma cells in semisolid agar has been investigated. Treatment of A172 glioblastoma with 50 microM CG, ECG, EGCG and 25 microM Tyrphostin 1296 resulted in an 82+/-17%, 77+/-21%, 75+/-8% and 55+/-11%, respectively (mean+/-S.D., n=3) inhibition of the PDGF-BB-induced tyrosine phosphorylation of PDGF-Rbeta. The PDGF-Rbeta downstream intracellular transduction pathway including tyrosine phosphorylation of phospholipase C-gamma1 (PLC-gamma1) and phosphatidylinositol 3'-kinase (PI 3'-K) was also inhibited. Spheroid formation was completely inhibited by 50 microM ECG, CG, EGCG and by 25 microM Tyrphostin 1296. We conclude that catechins of the green tea possessing the gallate group in their chemical structure act as anticancer agents probably partly via their ability to suppress the tyrosine kinase activity of the PDGF-Rbeta.

Early intracellular signalling pathway of ethanol in vascular smooth muscle cells

1. ERKs belong to MAP kinase family and are activated by several growth and stress factors. Although ethanol has been shown to modulate ERK1 and ERK2 (p44(mapk) and p42(mapk)) activity, it can also act as an antiproliferative agent in various mammalian cells. Since the nature of the antiproliferative effect of ethanol in VSMCs has not been defined, we examined its effects on growth and on early intracellular events normally induced by growth factors in VSMCs. 2. Measurement of cytosolic Ca(2+) and pH in cell monolayers was performed using fura-2/AM and BCECF/AM, respectively. The effect of ethanol on VSMCs growth was assessed by [(3)H]-thymidine incorporation, by cell counting and by determination of the caspase 3 activity. Stimulation of ERK1 and ERK2 was examined by the chemiluminescence Western blotting method. The expression of c-fos was quantitated by Northern blotting. Determination of inositolphosphates was performed after labelling of VSMCs with myo-[2-(3)H]-inositol and separation of inositolphosphates by HPLC. 3. Ethanol (0.3 - 1.0% v v(-1), 17 - 170 mM) induced a dose-dependent maximal stimulation of p44(mapk)/p42(mapk) at 30 min and expression of c-fos mRNA with a maximum at 120 min. Intracellular events upstream to MAP kinase, like an increase in [Ca(2+)](i), activation of the Na(+)/H(+) exchanger and formation of phosphoinositol metabolites were also markedly activated by ethanol. Treatment of VSMCs with ethanol for 3 - 5 min induced an increase in DNA synthesis whereas treatment of the cells for more than 30 min was toxic. Caspase 3 activity was not modulated by ethanol treatment of VSMCs. 4. We may postulate that the activation of these mitogenic signals including the elevation of DNA synthesis reflects a cell effort to protect itself against the toxic effects of ethanol.

Evidence that lipoproteins are carriers of bioactive factors

We recently demonstrated that the mitogenic effect of LDL (100 microg/mL) as well as its early intracellular signaling pathway are mediated by a pertussis-toxin (PTX)-sensitive G(i) protein-coupled receptor that is independent from its classical receptor and involves activation of extracellular response kinases (ERK1/2) (also known as p44(mapk)/p42(mapk)). In the present study we examined whether LDL-adherent factors may be responsible for some of the effects of LDL. The term "signaling activity" is used to characterize fractions that cause an increase in intracellular free Ca(2+) concentration or stimulate ERK1/2 and c-fos mRNA expression. LDL, HDL, and VLDL stimulate ERK1/2 with the following order of potency: LDL>HDL>VLDL. After delipidation of LDL with chloroform/methanol/water mixtures a PTX-sensitive signaling activity was found in one fraction arbitrarily called LDL-F. After further analysis of LDL-F compounds by high pressure liquid chromatography, a PTX-sensitive signaling activity was detected only in the fraction with a retention time of 33 minutes (arbitrarily called LDL-F33). Similarly, after separation of sphingosine-1-phosphate (SPP) and sphingosylphosphorylcholine (SPC) by high pressure liquid chromatography, a PTX-sensitive signaling activity was found in the fractions 33 and 33 to 35, respectively. These findings demonstrate that the effects of LDL-F33 are mimicked by similar fractions collected from SPP/SPC, hence suggesting that these LDL-adherent molecules are possibly closely related to SPP/SPC. A PTX-sensitive signaling activity was also detected in HDL and HDL-F33. Therefore, LDL and other lipoproteins may function as carriers for bioactive phospholipids thereby contributing to the development of coronary artery disease. Our findings support a new research concept that may contribute in elucidating cellular mechanisms promoting coronary artery disease.

Lysophosphatidic acid stimulates protein kinase C isoforms alpha, beta, epsilon, and zeta in a pertussis toxin sensitive pathway in vascular smooth muscle cells

The natural phospholipid lysophosphatidic acid (LPA) has been characterized as an important vascular smooth muscle cell (VSMC) mitogen whose effects are mainly mediated by pertussis toxin (PTX)-sensitive guanosine triphosphate (GTP)-binding protein (Gi-protein). Protein kinase C (PKC) isoforms play an important role in intracellular signaling cascades and in growth of VSMC. In the present study we investigated the effect of LPA on activation of PKC isoforms alpha, beta, epsilon, and zeta in VSMC by Western blot of cytosolic and membrane fractions. Furthermore, we examined the role of PKC activation on LPA-induced growth of VSMC using PKC inhibitor 19-27. Stimulation of VSMC by 5 microg/mL LPA for 10 min increased the amount of PKC alpha, beta, epsilon, and zeta in the particulate fraction by 689%, 285%, 424%, and 510%, respectively, and returned to control level after 30 min. Correspondingly, the amount of PKC alpha, beta, epsilon, and zeta in the cytosolic fraction decreased by 32%, 94%, 44%, and 95%, respectively, compared to control. Furthermore, we could show that LPA-induced activation of PKC alpha, beta, epsilon, and zeta isoforms was PTX sensitive. Incubation of VSMC with nonspecific PKC inhibitor 19-27 (10 micromol/L) for 24 h resulted in a 30% inhibition of LPA-induced DNA synthesis as measured by [3H]thymidine incorporation. In conclusion, in VSMC LPA stimulated translocation of PKC isoforms alpha, beta, epsilon, and zeta in a PTX-sensitive manner. Furthermore stimulation of PKC might be critically involved in LPA-induced mitogenesis in VSMC.

[Cushing syndrome with occult ectopic ACTH production]

A 19-year old patient was admitted to our hospital with the typical stigmata of a prolonged Cushing's syndrome. He presented first at another hospital with elevated ACTH values and the diagnosis of pituitary Cushing's syndrome was made. A partial hypophysectomy was performed, but neither this nor a therapy with ketokonazole could influence the cortisol levels. Because of this background the diagnosis of ectopic ACTH-production was established. Since we were not able to locate a source of ACTH, we recommended a bilateral adrenalectomy, after which the symptoms of Cushing's syndrome disappeared within a few months. About one year after the operation a CT-scan demonstrated an intrapulmonary mass, which was removed surgically. There were neither signs of local infiltration nor of lymphogenic metastasis. The histological and immunhistochemical diagnosis was typical of bronchial carcinoid with ACTH-production. The follow up so far did not reveal a recurrence.

Role of mitogen-activated protein kinase in the angiotensin II-induced DNA synthesis in vascular smooth muscle cells

The activation of mitogen-activated protein (MAP) kinase and increase in intracellular free calcium concentration ([Ca2+]i) are discussed in reference to activation of different protein kinases and growth of vascular smooth muscle cells (VSMCs). The aim of the present study was to investigate the role of angiotensin (Ang) II-induced increase in [Ca2+]i for activation of 44-kD/42-kD MAP kinase (p44mapk/p42mapk) and DNA synthesis in VSMCs. Experiments were performed by chelation of [Ca2+]i by the intracellular chelator 1,2-bis-(o-amino-5-methylphenoxy)ethane-N,N,N',N'-tetraacetic acid tetraacetoxymethyl ester (MAPTAM). Ca2+ was measured by the fura 2 method. MAP kinase activation was determined by the Western blotting method. DNA synthesis was determined by measurement of [3H]thymidine incorporation into the cell DNA. Treatment of VSMCs with 20 micromol/L MAPTAM for 30 minutes resulted in a complete abolishment of the maximal Ang II-induced increase at 10 seconds. Ang II phosphorylated the p44mapk/p42mapk in a time-dependent manner, showing a maximum at 3 minutes. In MAPTAM-treated cells, the maximal phosphorylation of MAP kinase isoforms was shifted to 5 minutes, and dephosphorylation was delayed compared with untreated cells. In concordance with this finding, the induction of the MAP kinase phosphatase-1 was markedly impaired in MAPTAM-treated cells. Ang II induced a 2.3-fold increase in [3H]thymidine incorporation into DNA synthesis in untreated cells. This effect was not reduced in MAPTAM-treated cells. Treatment of the cells with PD 98059 (10 micromol/L), a MAP kinase kinase inhibitor, caused 85% inhibition of the Ang II-induced activation of MAP kinases but did not inhibit the Ang II-induced DNA synthesis. In conclusion, the Ang II-induced stimulation of the MAP kinase is a Ca2+-dependent process. Furthermore, blockade of the Ang II-induced stimulation of the early intracellular events, such as increase in [Ca2+]i or phosphorylation of the MAP kinase, is not accompanied by an inhibition of the Ang II-induced DNA synthesis.

Inhibition of glycosphingolipid synthesis by threo-1-phenyl-2-decanoylamino-3-morpholino-1-propanol (PDMP) and the modulation of IL-1beta-stimulated expression of inducible nitric oxide synthase in rat aortic smooth muscle cells

1. The composition of glycosphingolipids is altered in atherosclerotic tissue. In order to study the possible modulation of interleukin-1beta (IL-1beta)-induced expression of inducible nitric oxide synthase (iNOS) by endogenously synthesized glycosphingolipids, we investigated rat aortic vascular smooth muscle cells (VSMC) grown in the presence of the inhibitor of glycosphingolipid synthesis, threo-1-phenyl-2-decanoylamino-3-morpholino-1-propanol (PDMP). 2. Depletion of glycosphingolipids by PDMP (20-30 microM) was demonstrated by thin-layer chromatography of D-[1-(14)C]-galactose- or L-[-U14C]-serine-labelled glycosphingolipids. Nitrite generation was measured by the diaminonaphthalene assay, nitric oxide was determined by the oxyhaemoglobin technique and iNOS protein was detected by immunocytochemistry. 3. In VSMC grown in the presence of PDMP, the glycosphingolipid content was reduced by 30-50%. In PDMP-treated VSMC, IL-1beta (3 micro ml[-1])-stimulated release of nitrite (135 +/- 4 nmol mg(-1) protein 48 h[-1]) was significantly increased as compared to IL-1beta-stimulated control cells (40 +/- 3 nmol mg(-1) protein 48 h(-1); n = 6, P < 0.001). Similarly, IL-1beta (3 micro ml(-1), 36 h)-stimulated release of nitric oxide was higher in PDMP-treated VSMC (6.1 +/- 0.5 nmol mg(-1) protein h[-1]) as compared to untreated cells (2.0 +/- 0.6 nmol mg(-1) protein h(-1); n = 3, P < 0.01). These findings were confirmed by the demonstration of increased expression of iNOS protein (14.9 +/- 1.2% vs 6.4 +/- 0.2%; n = 4, P < 0.001), as shown by immunocytochemistry. 4. Evidence is presented that endogenous glycosphingolipids are important modulators of cytokine-induced iNOS expression. In view of an altered glycosphingolipid profile in atherosclerotic arteries, these mechanisms might be of relevance for the pathogenesis of atherosclerosis and restenosis subsequent to vessel injury.