Save the children by treating their mothers (PriVileG-M-study) - study protocol: a sequentially randomized controlled trial of individualized psychotherapy and telemedicine to reduce mental stress in pregnant women and young mothers and to improve Child's health.

BACKGROUND: As early as pregnancy, maternal mental stress impinges on the child's development and health. Thus, this may cause enhanced risk for premature birth, lowered fetal growth, and lower fetal birth weight as well as enhanced levels of the stress hormone cortisol and lowered levels of the bonding hormone oxytocin. Maternal stress further reduces maternal sensitivity for the child's needs which impairs the mother-child-interaction and bonding. Therefore, prevention and intervention studies on mental stress are necessary, beginning prenatally and applying rigorous research methodology, such as randomized controlled trials, to ensure high validity. METHODS: A randomized controlled trial is used to assess the impact of psychotherapy and telemedicine on maternal mental stress and the child's mental and physical health. Mentally stressed pregnant women are randomized to an intervention (IG) and a not intervened control group. The IG receives an individualized psychotherapy starting prenatal and lasting for 10 months. Afterwards, a second randomization is used to investigate whether the use of telemedicine can stabilize the therapeutic effects. Using ecological momentary assessments and video recordings, the transfer into daily life, maternal sensitivity and mother-child-bonding are assessed. Psycho-biologically, the synchronicity of cortisol and oxytocin levels between mother and child are assessed as well as the peptidome of the colostrum and breast milk, which are assumed to be essential for the adaptation to the extra-uterine environment. All assessments are compared to an additional control group of healthy women. Finally, the results of the study will lead to the development of a qualification measure for health professionals to detect mental stress, to treat it with low-level interventions and to refer those women with high stress levels to mental health professionals. DISCUSSION: The study aims to prevent the transgenerational transfer of psychiatric and somatic disorders from the mother to her child. The effects of the psychotherapy will be stabilized through telemedicine and long-term impacts on the child's and mothers' mental health are enhanced. The combination of psychotherapy, telemedicine and methodologies of ecological momentary assessment, video recording and bio banking are new in content-related and methodological manner. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00017065. Registered 02 May 2019. World Health Organization, Universal Trial Number: U1111-1230-9826. Registered 01 April 2019.

[Microscopic colitis: clinical presentation, treatment and outcome of 494 patients]. / Mikroskopische Kolitis: klinische Manifestation, Therapie und Outcome in 494 Patienten.

BACKGROUND: Collagenous colitis (CC) and lymphocytic colitis (LC) are chronic disorders characterized by watery diarrhea. AIM: To evaluate prospectively the clinical features, response to treatment and outcomes in a large group of patients with CC and LC. PATIENTS AND METHODS: Patients with histologically confirmed CC and LC were prospectively enrolled to complete a questionnaire on onset and duration of diarrhea, stool frequency and consistency, other gastrointestinal symptoms including weight loss, drug history, treatment success and concomitant diseases. RESULTS: A total of 494 patients (CC, n = 287, LC, n = 207) were available for analysis. The mean age at diagnosis was 65 in CC and 61 years in LC with a identically female predominance (76 % of patients) in both groups. Prior to diagnosis the mean duration of symptoms was 37 in CC and 23 months in LC. CC and LC patients share similar pattern of clinical symptoms. Concomitant autoimmune disorders were more common in CC patients (48.4 %) than in LC patients (29.6 %). Sustained clinical remission was reported by 35.5 % of CC and 38,6 % of LC, but more CC patients (47.7 %) received medication such as corticosteroids, antibiotics, bismuth or 5-aminosalicyclic than LC patients (16.9 %). 18.6 % of CC patients and 17.6 % of LC were regularly using NSAIDs. CONCLUSION: Collagenous and lymphocytic colitis are frequently diagnosed in elderly female patients. CC and LC share similar symptom pattern, but concomitant autoimmune disease were more common in CC than in LC patients.

The Churg-Strauss syndrome: diagnosed for the first time in a gastrectomy specimen.

The Churg-Strauss syndrome (CSS), first described in 1951 and characterised by eosinophilic inflammation and necrotising vasculitis in patients with asthma can in principle affect any organ. We report on a 47-year-old male patient, in whom the diagnosis of CSS was finally established for the first time on the basis of the histological work-up of a gastrectomy specimen. Endoscopic inspection had revealed a rigid gastric wall and a large irregularly shaped ulcer in the prepyloric antrum. Despite the fact that no carcinoma was demonstrable in the biopsy material, a gastrectomy was nevertheless performed since the endoscopic appearance was strongly suspicious for a carcinoma. The gastrectomy specimen revealed massive eosinophilic gastritis in combination with granulomas and necrotising vasculitis--localised mainly in the muscularis propria. In view of the subsequent information that the patient also suffered from asthma, the diagnosis of CSS (previously unrecognised) was established--for the first time--in the gastrectomy specimen.

Nuclear targeting determinants of the phage P1 cre DNA recombinase.

The Cre DNA recombinase of bacteriophage P1 has become a useful tool for genomic manipulation in mice and other eukaryotes. Because Cre is of prokaryotic origin, the 38 kDa protein has been presumed to gain access to the eukaryotic nucleus simply because it is sufficiently small to pass through the nuclear pore by passive diffusion. Instead, we show here that Cre carries nuclear targeting determinants that efficiently direct Cre entry into the nucleus of mammalian cells. Fusions of Cre with green fluorescent protein (GFP) identified two regions that are necessary for nuclear localization. Region I contains a cluster of basic amino acids that is essential for nuclear localization and which resembles a bipartite-like nuclear localization signal. Region II exhibits a beta-sheet structure with which the bipartite motif may interact. However, neither region is by itself sufficient for nuclear localization. Nuclear transport in vitro with a 98 kDa GFP-Cre fusion protein shows that Cre does not gain access to the nucleus by passive diffusion, but instead enters the nucleus by means of an energy-dependent process. Thus, Cre is one of the few prokaryotic proteins that have been shown to carry determinants that allow it to target the eukaryotic nucleus.

Long-tract mitotic gene conversion in yeast: evidence for a triparental contribution during spontaneous recombination.

In Saccharomyces cerevisiae, spontaneous mitotic gene conversion at one site is statistically correlated with recombination at other loci. In general, coincident conversion frequencies are highest for tightly linked markers and decline as a function of intermarker distance. Paradoxically, a significant fraction of mitotic gene convertants exhibits concomitant nonreciprocal segregation for multiple and widely spaced markers. We have undertaken a detailed genetic analysis of this class of mitotic recombinants. Our results indicate that mitotic gene conversion in yeast is frequently associated with nonreciprocal segregation of markers centromere-distal to the selected site of conversion. In addition, distal markers are often found to be mosaic within the product colonies. These observations, and others described here, suggest that a percentage of gene conversion in vegetative yeast cells is coupled to a chromosome break and repair mechanism. This hypothesis was further tested using a strain trisomic for chromosome VII which was specially marked to detect homolog-dependent repair events. An association between mitotic gene conversion events and the production of broken chromosomes which are repaired by a homologous-pairing-copy mechanism was supported.

Long-term follow-up of collagenous colitis after induction of clinical remission with budesonide.

BACKGROUND: Budesonide (Entocort) is effective for the treatment of collagenous colitis. AIM: To assess the long-term outcome of patients after induction of clinical remission by budesonide treatment. METHODS: Fifty-one patients with chronic diarrhoea and histologically proven collagenous colitis were enrolled in randomized, placebo-controlled crossover trial using budesonide 9 mg daily for 6 weeks. Patients in clinical remission after either initial or crossover budesonide treatment were followed using standardized questionnaires. Clinical relapse was defined as five or more loose stools/day for at least 4 consecutive days. RESULTS: A total of 33 patients achieved clinical remission (85% per-protocol). During a median follow-up of 16 months, clinical relapse occurred in 20 patients (61%), after a median time of 2 weeks (range: 1-104, mean: 10 weeks). Patient age <60 years was identified as a significant risk factor for clinical relapse (OR = 7.4, P = 0.048). Budesonide was used for treatment of clinical relapse in 80% of patients achieving clinical response in all of them. CONCLUSIONS: Budesonide is effective in the treatment of collagenous colitis. Clinical relapses may occur in a considerable number of patients, particularly in those <60 years. Treatment of clinical relapse with budesonide appears to be an effective option.

Organization of the mouse ASGR1 gene encoding the major subunit of the hepatic asialoglycoprotein receptor.

The hepatic asialoglycoprotein receptor was the first of the mammalian lectins to be recognized and has been the subject of intense investigation for three decades. Yet, the precise biological role of this major hepatic endocytic receptor has remained elusive. We describe here the characterization of the mouse gene for the major subunit of this receptor (ASGR1) along with 3.5 kb of the upstream 5' region. The gene comprises eight coding exons, with the major transcript in liver displaying a single non-coding 5' exon. A minor hepatic transcript initiates 435 bp upstream of the major start and includes an additional 5' non-coding exon and intron. A minimal 600 bp proximal region of ASGR1 exhibits hepatic-specific promoter activity in HepG2 cells in vitro. These results provide the basis for more detailed genetic studies on the functional role of the hepatic asialoglycoprotein receptor in mammals.

A comparative study of E-cadherin and stromelysin-3 expression in de novo and ex adenoma carcinoma of the colorectum.

An apparent exception to the colorectal adenoma-carcinoma carcinogenetic pathway is the so-called "de novo" carcinoma which has no evidence of adenoma in its vicinity. Despite the fact that they are often quite small, these lesions appear to be more aggressive (i.e., greater likelihood of lymph-node metastases) than carcinomas that clearly arise from surrounding adenomas exadenoma carcinoma. The purpose of the present comparative immunohistochemical study was to compare rates of cell adhesion molecule (E-cadherin) and protease [stromelysin-3 (ST-3)] expression in groups of de novo (n=64) and ex adenoma (n=42) lesions in order to see whether their more aggressive behavior is associated with decreased cell adhesion and increased protease expression. The rates of extensive ST-3 expression and decreased E-cadherin expression were significantly higher in the de novo group (P=0.014 and 0.005, respectively). Histopathologically, the de novo group also had a significantly higher percentage of cases with an infiltrative invasion pattern. These differences highlight the more aggressive phenotype of the de novo colorectal carcinoma and fit with their greater invasive potential.

Comparison of CD44 expression in early colorectal carcinomas of the de novo and ex adenoma types.

Small colorectal carcinomas without morphological evidence of origin from an adenoma have been called "de novo" carcinomas. As changes in the expression of the adhesion molecule CD44 and its variants have been described along the adenoma-carcinoma sequence in colorectal carcinoma, we compared patterns of CD44 expression in early de novo and ex-adenoma colorectal carcinomas by staining specimens from a group of early (pT1) colorectal carcinomas by immunohistochemistry for CD44 (standard and variant forms v3, v5, v6, v7, v7/8, v10). We evaluated carcinoma, adenoma (ex-adenoma cases), transitional mucosal areas and apparently nonneoplastic mucosa peripheral to the lesions (when present). A marked increase was seen in numbers and intensity of standard and variant forms of CD44 in carcinomatous areas compared with nonneoplastic mucosa in both groups, with no significant difference between the groups. However, adenoma areas of the ex-adenoma cases and the transitional mucosa of the de novo carcinomas had nearly identical staining patterns. Together with data from other molecular studies, this may be interpreted as evidence for an adenoma-type precursor lesion in so-called de novo colorectal carcinomas.

Stromelysin-3 expression in early (pT1) carcinomas and pseudoinvasive lesions of the colorectum.

Pseudoinvasion in colorectal adenomas is often difficult to distinguish from invasive carcinoma. Previous studies have indicated that expression of stromelysin-3 (ST-3), one of the metalloproteinase family of enzymes, may be useful for the identification of early invasive carcinoma. The goal of our study was to detect ST-3 expression in colorectal adenomatous polyps to see if it could be helpful for the differential diagnosis of pseudoinvasion vs. true invasion. We studied 25 polypectomy specimens which were divided histologically into 2 groups; the first consisted of 15 adenomas with invasive carcinoma, 8 of these carcinomas were more diffusely infiltrative (pT1), and 7 tended to be expansively invasive. The second group was composed of 10 adenomas with pseudoinvasion. A 35S labelled cDNA probe was used for in situ hybridization (ISH) and a monoclonal antibody (5ST-4A9) for immunohistochemistry (IHC). The distribution of ST-3 expression as detected by IHC and ISH was identical. All diffusely infiltrative carcinoma cases showed ST-3 expression, but only focally in 2 cases with marked lymphocytic infiltration. None of the expansive carcinoma or pseudoinvasion cases showed ST-3 expression. ST-3 expression seems to be an indicator of invasion, but a negative reaction for ST-3 does not rule out an expansive invasive neoplasm or a diffusely infiltrative invasive tumour with a dense lymphocytic reaction.

Quantitative investigations on the human entorhinal area: left-right asymmetry and age-related changes.

The total nerve cell numbers in the right and in the left human entorhinal areas have been calculated by volume estimations with the Cavalieri principle and by cell density determinations with the optical disector. Thick gallocyanin-stained serial frozen sections through the parahippocampal gyrus of 22 human subjects (10 female, 12 male) ranging from 18 to 86 years were analysed. The laminar composition of gallocyanin (Nissl)-stained sections could easily be compared with Braak's (1972, 1980) pigmentoarchitectonic study, and Braak's nomenclature of the entorhinal laminas was adopted. Cell-sparse laminae dissecantes can more clearly be distinguished in Nissl than in aldehydefuchsin preparations. These cell-poor dissecantes, lamina dissecans externa (dis-ext), lamina dissecans 1 (dis-1) and lamina dissecans 2 (dis-2), were excluded from nerve cell number determinations. An exact delineation of the entorhinal area is indispensable for any kind of quantitative investigation. We have defined the entorhinal area by the presence of pre-alpha cell clusters and the deeper layers of lamina principalis externa (pre-beta and gamma) separated from lamina principalis interna (pri) by lamina dissecans 1 (dis-1). The human entorhinal area is quantitatively characterized by a left-sided (asymmetric) higher pre-alpha cell number and an age-related nerve cell loss in pre as well as pri layers. At variance with other CNS cortical and subcortical structures, the neuronal number of the entorhinal area appears to decrease continuously from the earliest stages analysed, although a secular trend has to be considered. The asymmetry in pre-alpha cell number is discussed in the context of higher human mental capabilities, especially language.

Differentiation of focal foveolar hyperplasia from hyperplastic polyps in gastric biopsy material.

Our objective was to investigate the question as to whether focal foveolar hyperplasia and hyperplastic polyp can be differentiated in forceps biopsy material from the stomach. Morphometric determination of the height of the epithelium layer in forceps biopsy specimens was obtained from 35 hyperplastic polyps, and forceps biopsy material was obtained from 25 focal foveolar hyperplasias. The diagnosis of hyperplastic polyp was confirmed by subsequent polypectomy. The medians and scatter range of the epithelial layer height were calculated. Using the t-test for independent samples the question was examined as to whether there is any statistically significant difference between hyperplastic polyps and focal foveolar hyperplasia in terms of the parameter "height of the foveolar epithelial layer." The measurements revealed that the average height of foveolar epithelial cells in hyperplastic polyps is 37.70 microns +/- 7.41 microns. In the case of focal foveolar hyperplasia, the corresponding figure was only 24.26 microns +/- 5.11 microns. This difference was statistically highly significant (p < 0.0001). In conclusion, focal foveolar hyperplasia and hyperplastic polyp of the gastric mucosa can readily be differentiated on the basis of architectural and cytological criteria, even in forceps biopsy material. Since the hyperplastic polyp very probably does not evolve from focal foveolar hyperplasia, and the latter is not a pre-neoplastic condition or lesion, it is proposed that focal foveolar hyperplasia should no longer be referred to as "gastric polyp," which would avoid unnecessary follow-up examinations and possibly even surgery.

Primary hepatic cancer and liver cirrhosis. Autopsy study covering fifty years.

Autopsy reports from 1931 to 1980 were used to study the incidence of liver cirrhosis (LC) and the association between LC and hepatocellular carcinoma (HCC) in our area (Wuppertal, Germany). An increase in LC and in LC with HCC has occurred since World War II, with HCC being most frequently associated with postnecrotic cirrhosis. The prevalence of HCC in men with LC was highest (13.5%) in 1966-1970, whereas the prevalence of HCC with LC in women rose abruptly to a peak (11.8%) during the last 5 years of the study. Possible etiological factors for the association between LC and HCC are discussed.

Clinical course of collagenous colitis over a period of 10 years.

AIM: The aim of this study was to evaluate the long-term outcome of patients with collagenous colitis 10 years after the diagnosis. PATIENTS AND METHODS: In 1989/1990, 65 patients were diagnosed to have collagenous colitis. Initially and after an interval of ten years these patients were asked to complete a questionnaire including onset and duration of diarrhea, stool frequency and consistency, other gastrointestinal symptoms including weight loss, drug history, treatment response and concomitant diseases. RESULTS: Questionnaires from 47 patients (72.3 %) (female 40; mean age 68 years, range 41 - 95 years) were available for analysis. After a follow-up of ten years, 11 patients (23.4 %) had persistent diarrhea with no change of frequency and consistency compared to baseline. Four patients (8.5 %) showed a reduction of diarrhea frequency of at least 50 %. Diarrhea was resolved in 23 patients (48.9 %) during the follow-up period. Of those, 20 patients received anti-inflammatory treatment. After a complete resolution of diarrhea during the long-term follow-up, 9 patients (19.2 %) showed recurrence of diarrheal symptoms. None of the patients developed any malignancies of the GI-tract. CONCLUSION: The long-term outcome of CC is benign with a resolution of diarrhea in up to 50 % of patients receiving anti-inflammatory treatment. About 30 % of patients may experience persistent diarrhea even 10 years after diagnosis. Our data confirm that CC is a chronic disorder with a variable course of symptoms during a long-term follow-up.

Chromosomal instability in flat adenomas and carcinomas of the colon.

Flat adenomas are flat or slightly elevated dysplastic lesions of the colorectal mucosa, mostly with a tubular architecture. Compared with polypoid adenomas of similar size, flat adenomas show a higher frequency of high-grade dysplasia and rapid submucosal invasion. The aim of this study was to survey whether flat colorectal lesions differ in their pattern of chromosomal aberrations from their polypoid counterparts. Six flat adenomas and 12 flat carcinomas were analysed by comparative genomic hybridization (CGH) and the pattern of chromosomal aberrations was compared with a previously published series of 112 polypoid adenomas and 82 polypoid carcinomas. In addition, multiplex ligation-dependent probe amplification (MLPA) for identifying DNA copy number changes of 25 individual genes on chromosome 20 was performed on 14 flat and 15 polypoid tumours. With CGH, flat adenomas showed on average 1.8 gains (range 1-4) and 3.2 losses (range 0-4), and the flat carcinomas 4.5 gains (range 0-8) and 3.5 losses (range 1-6). In both adenomas and carcinomas, high frequencies of 20q gain (83% and 92%, respectively) and 18q loss (83% and 92%, respectively) were found. This correlation between 20q gain and 18q loss had previously been observed in a subgroup of polypoid colorectal tumours. Both flat and polypoid colorectal tumours with 20q gains by CGH showed similar patterns of copy number ratios for the individual genes tested. TOP1, BCL2L1, and E2F1 had median copy number ratios of 2 or higher, while ZNF217 had a ratio around 3. In conclusion, flat adenomas and carcinomas of the large intestine show a similar pattern of chromosomal aberrations to that observed in a specific subgroup of polypoid lesions. The transcription factor ZNF217 is an important candidate for driving the 20q gain.

Segmental genomic replacement by Cre-mediated recombination: genotoxic stress activation of the p53 promoter in single-copy transformants.

Genotoxic stress results in transcriptional activation of the p53 promoter. To gain more detailed information on genotoxic induction of the p53 promoter at a uniform genomic locus, we have developed an efficient strategy for replacing a defined genomic segment in mouse NIH 3T3 cells with exogenous transfected DNA using a 'double lox' targeting strategy mediated by Cre DNA recombinase. The strategy utilizes a pair of heterospecific lox sites engineered both into the genome and onto the targeting DNA. This allows direct replacement of genomic DNA by a Cre-catalyzed double crossover event. p53-CAT reporter constructs were site-specifically placed into the genomic target 20-fold more efficiently by double lox recombination than by Cre-mediated single crossover insertional recombination, and the absolute frequency of site-specific double lox targeting exceeded the frequency of transformation due to random illegitimate recombination of transfected DNA into the genome. Resulting targeted single-copy integrants of the p53-CAT reporter show strong genotoxic induction by mitomycin C, and a dynamic range of induction that exceeds that seen in transient transfection assays. The double lox strategy is generally applicable to Cre-mediated genomic targeting in any cell and should be of particular utility in the site-specific targeting of DNA into embryonic stem (ES) cells for the production of gene-modified mice.

Colorectal mini-de novo carcinoma: a reality in Germany too.

BACKGROUND AND STUDY AIMS: Based on Japanese case studies, we examined whether colorectal mini-de novo carcinoma also occurs outside Japan. We defined mini-de novo carcinomas as carcinomas infiltrating the submucosa, with a maximum diameter of 10 mm, and with no evidence of precursive adenomatous tissue. PATIENTS AND METHODS: Between 1988 and 1994, we diagnosed carcinomas of this type in polypectomy and surgical resection specimens from 155 patients. These mini-de novo carcinomas did not differ from carcinomas arising from adenomas in terms of patient age (median 67.1 years), sex distribution (men: women 0.96:1), or location--they occurred primarily in the sigmoid (53%) and rectum (27.3%). RESULTS: Most of the mini-de novo carcinomas were macroscopically of the polypoid type (59.4%); flat, elevated carcinomas were also relatively frequent, including those with a central concave depression (21.9%) and those without a depression (12.3%). Histologically, all of the lesions without exception were adenocarcinomas (grade 1: 28.4%, grade 2: 65.8%, grade 3: 5.8%). There was carcinomatous invasion of submucosal lymphatic or blood vessels in 20%. CONCLUSIONS: Our analysis shows that colorectal mini-de novo carcinoma is not a purely Japanese phenomenon, and that these carcinomas are being diagnosed with increasing frequency as the awareness of their existence and macroscopic growth characteristics increases.