[Lung volume reduction (LVR) in severe emphysema: a multidisciplinary approach]. / Réduction de volume pulmonaire dans l'emphysème sévère: importance d'une prise en charge multidisciplinaire.

Most cases of emphysema are managed conservatively. However, in severe symptomatic emphysema associated with hyperinflation, lung volume reduction (LVR) may be proposed to improve dyspnea, exercice capacity, pulmonary functions, walk distance and to decrease long-term mortality. LVR may be achieved either surgically (LVRS) or endoscopically (EVLR by valves or coils) according to specific clinical criteria. Currently, the optimal approach is discussed in a multidisciplinary setting. The latter permits a personalized evaluation the patient's clinical status and allows the best possible therapeutic intervention to be proposed to the patient.

Massive Haematochezia due to Splenic Artery Bleeding into the Colon: Unusual Manifestation of Advanced Pancreatic Cancer.

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

[Understanding needs of people with Multiple Sclerosis. Perspective of patients and significant others in the German-speaking part of Switzerland]. / Bedürfnisse von Menschen, die an Multipler Sklerose leiden: Die Perspektiven von erkrankten Personen und ihren nächsten Angehörigen in der deutschsprachigen Schweiz.

Since there is no data available about the needs of people living with Multiple Sclerosis and significant others in Switzerland a questionnaire based cross sectional study was conducted with 878 patients and 615 family caregivers. This Swiss study used the addresses from the Swiss Multiple Sclerosis Society. The response rate was 35.2 % for patients and 70.1 % for significant others. Data analysis included descriptive and inferential statistics. Results showed that information needs are most important followed by consultation. 42.4 % of patients and 39.2  % of family caregivers need more information about alternative treatment options and 34.4 %, resp. 36.6  % about actual research results. For 39.5  % of patients, the possibility of using of their wheelchair in public is insufficient. Approximately a third of patients need more consultation in order to better manage cognitive impairment and fatigue. 30.9 % of family caregivers need more consultations in order to better manage their feelings of burden. Influencing factors of patients' need for consultation about fatigue are health status, quality of life, and anxiety. Patients' need for consultation about their management of cognitive impairment was influenced by health status, medication, and their ability of dealing with constraints and anxiety. The results showed that an enhancement of the quality of treatment and care based on patients' and family caregivers' needs are urgently needed.

Perforated Gallbladder into the Abdominal Wall.

Objective: Perforation of the gallbladder (PG) is a dreaded complication of an acute cholecystitis and is associated with increased morbidity and mortality. Cholecystocutaneous abscess (CCA) is an extremely rare complication. There is usually a history of cholecystolithiasis or neglected chronic gallbladder disease. We report a case of perforated gallbladder into the abdominal wall. Methods: A 65-year-old female, obese, was admitted to our department complaining of right upper quadrant abdominal pain. The diagnosis of acute cholecystitis was based on the clinical picture, laboratory test, and ultrasound findings. She was treated with oral antibiotics for 10 days and readmitted due to a painful, erythematous mass on the right subcostal region. An abdominal computed tomography showed the presence of a subparietal formation in communication with the gallbladder, and a gallbladder perforation was postulated. The treatment consisted of percutaneous drainage of the abdominal wall abscess followed by laparoscopic cholecystectomy in a two-stage protocol. Anatomical pathology analysis found chronic inflammation and excluded malignancy. The postoperative follow-up was uneventful. Discussion. This case demonstrates a very rare presentation of PG that created an abscess into the muscles of the abdominal wall. This kind of PG is rarely seen due to medicine improvements. When the conditions of the patient are good, rather than perform immediate surgery that could lead to serious complications, we propose a two-stage approach. Conclusion: CCA is a possible complication of gallbladder's pathology that all surgeons have to know. There is no standard baseline management for this pathology, due to the few numbers of cases and to the differences in the quality of the patients' illness. We suggest a two-stage approach with drainage of the abscess followed by laparoscopic cholecystectomy with abscess debridement.

Variable discrimination and asymmetric preferences in laboratory tests of reproductive isolation between cichlid colour morphs.

Mating behaviour affects reproductive isolation and phenotypic differentiation. In Lake Tanganyika, the cichlid fish Tropheus moorii diversified into numerous, currently allopatric colour variants. Allopatric isolation is periodically interrupted by dispersal and secondary contact during lake level fluctuations, making long-term differentiation partly dependent on assortative mating. Laboratory experiments with two moderately distinct morphs revealed assortative female preferences in one (Nakaku), but random mate choice in the other morph (Mbita). No discrimination was apparent between two subtly differentiated morphs (Chimba and Moliro). Tested against each other in a previous study, the highly distinct Moliro and Nakaku exhibited strong assortative preferences. The correlation between colour pattern similarity and mate discrimination suggests that allopatry and philopatric behaviour are less crucial for the maintenance of differentiation between highly distinct morphs than for more similar morphs. Interestingly, the asymmetric isolation in one pair of morphs is congruent with a pattern of unidirectional mitochondrial introgression between populations.

Insulin-like growth factor I improves aspects of mycophenolate mofetil-impaired anastomotic healing in an experimental model.

BACKGROUND: Patients taking immunosuppressants after transplantation may require intestinal surgery. Mycophenolate mofetil (MMF) has been found to impair the healing of colonic anastomoses in rats. This study examined whether insulin-like growth factor (IGF) I prevents MMF impairment of anastomotic healing. METHODS: Sixty-three rats were divided into three groups (MMF, MMF/IGF and control). Animals underwent a sigmoid colon anastomosis with a 6/0 suture, and were killed on days 2, 4 and 6 after surgery. Investigations included bursting pressure measurement, morphometric analysis, and assessment of mucosal proliferation by 5-bromo-2'-deoxyuridine and Ki67 immunohistochemistry of the anastomoses. RESULTS: The leak rate was three of 21, one of 20 and two of 20 in the MMF, MMF/IGF-I and control groups respectively. Anastomotic bursting pressures were significantly lower in the MMF group than in the control group on days 2 and 4, but there was no significant difference by day 6. Values in the MMF/IGF-I and control groups were similar. Colonic crypt depth was significantly reduced in MMF-treated animals on days 2 and 4, but this impairment was attenuated by IGF-I on day 4. Similarly, IGF-I reduced the negative impact of MMF on mucosal proliferation on days 2 and 6. CONCLUSION: Exogenous IGF-I improves some aspects of MMF-impaired anastomotic healing.

Determinants of hepatic function in liver cirrhosis in the rat. Multivariate analysis.

We investigated the determinants of hepatic clearance functions in a rat model of liver cirrhosis induced by phenobarbital/CCl4. Aminopyrine N-demethylation (ABT), galactose elimination (GBT), and serum bile acids (SBA) were determined in vivo. The livers were then characterized hemodynamically: intrahepatic shunting (IHS) was determined by microspheres and sinusoidal capillarization by measuring the extravascular albumin space (EVA) by a multiple indicator dilution technique. The intrinsic clearance was determined by assaying the activity of the rate-limiting enzymes in vitro. Hepatocellular volume (HCV) was measured by morphometry. ABT and SBA, but not GBT, differentiated cirrhotic from normal liver. IHS ranged from normal to 10%; all cirrhotic livers showed evidence of sinusoidal capillarization (reduced EVA). The cirrhotic livers showed a bimodal distribution of HCV, HCV being decreased in 50% of the cirrhotic livers. Multivariate analysis showed EVA and portal flow to be the main determinants of microsomal (ABT) and cytosolic (GBT) clearance function; SBA, by contrast, were determined solely by IHS. We conclude that sinusoidal capillarization is the main determinant of hepatic clearance, while serum bile acids reflect intrahepatic shunting. These findings emphasize the importance of alterations of hepatic nutritional flow to explain reduced clearance function in cirrhosis of the liver.

Inhibition by alkyl-lysophospholipids of tritiated thymidine uptake in cells of human malignant urologic tumors.

Alkyl-lysophospholipids (ALP) inhibited the uptake of [3H]thymidine by cells from a variety of human urologic tumors in vitro. Cells of prostate carcinomas, a seminoma, various bladder carcinomas and teratocarcinomas showed proliferation rates that were 10% of those of the controls when incubated with some ALP for longer than 24 hours. Concentrations as low as 1 microgram ALP/ml medium (10(6) tumor cells) were effective. Antitumor action increased after incubation for 2-5 days. Morphologic studies showed tumor cell death after incubation periods of this length. Equivalent concentrations of conventional cytostatic drugs used in anticancer chemotherapy protocols did not cause greater inhibition of [3H]thymidine uptake by tumor cells in vitro. Human embryonic fibroblasts were not sensitive to ALP, whereas cytostatic drugs completely inhibited their proliferation at comparable doses.

[Acute lower gastrointestinal bleeding--an evidence-based algorithm for diagnosis and treatment]. / Die akute untere gastrointestinale Blutung--Therapieformen, Abklärungs-Richtlinien und -Algorithmus.

Novel means to locate and treat lower gastrointestinal bleeding (lGB) allow to reduce the rate of required surgical interventions and help to limit the extend of resection. The risk stratification of patients with lGB is the primary step of our recommended treatment algorithm. Accordingly, risk stratifying instruments, which are only partly validated up to now, are gaining significance in lGB. Whereas, gastro-duodenoscopy and colonoscopy prior to angiography or scintigraphy are established diagnostic tools, capsule enteroscopy offers a novel approach to hemodynamic stable patients with lGB that are difficult to localize. With its every increasing sensitivity, Angio-Computer Tomography is likely to replace scintigraphy and diagnostic angiography in the very near future. In addition, recent advances in superselective microembolisation have been shown to have the potential rendering surgical interventions in a majority of patients with acute lGB unnecessary. The extend of required surgical resection is largely dependent on the success to localize the bleeding source of prior diagnostics. Only if the source is identified, a limited segmental resection should be performed. Should surgery be required, we suggest to maintain the effort to localize the bleeding, either by prior laparoscopy and/or by intraoperative entero-colonoscopy. Eventually, if the source of bleeding remains unclear total colectomy with ileorectal anastomosis represents the procedure of choice in patients with acute lGB.

Mycophenolate mofetil impairs healing of left-sided colon anastomoses.

INTRODUCTION: Inadequate healing and consequent leakage from bowel anastomoses are a significant cause of postoperative morbidity and mortality. Immunosuppressive drugs are known to disturb healing processes and to impair the mechanical stability of bowel anastomosis. Mycophenolate mofetil (MMF) is an immunosuppressive agent that selectively inhibits the proliferation of T and B lymphocytes and has been shown to be effective in preventing allograft rejection after organ transplantation. Adverse effects are few; however, nothing is known in regard to possible adverse effects of MMF administration on the healing of bowel anastomosis. The aim of the present study was to evaluate the effect of systemic MMF administration on the healing of colon anastomoses in rats. METHODS: Rats underwent laparotomy, division of the left colon, and sigmoidostomy. MMF (25 mg/kg) or vehicle was administered intraperitoneally in two groups (n=21 per group) 3 days before surgery and then once daily until euthanization (7 animals per group; 2, 4, and 6 days after surgery). Bursting pressure measurements, histologic evaluation, morphometric analysis, mucin and collagen staining, and BrdU immunohistochemistry of the anastomotic site were performed. Furthermore, matrix protein expression at the anastomotic site was determined by collagen I and fibronectin Western blots. RESULTS: Administration of MMF significantly decreased anastomotic bursting pressure postoperatively. Accordingly, histology, mucin staining, and BrdU immunohistochemistry and measurements of the colonic crypt depth showed more extended inflammation, a significantly lower proliferation rate, and a significantly thinned mucosal layer in the MMF-treated groups when compared to control animals, whereas matrix synthesis at the anastomotic site was not different. CONCLUSIONS: The administration of the immunosuppressive agent MMF significantly impairs healing and mechanical stability of colon anastomosis in rats during the early postoperative period. MMF act to disturb host reparative processes mainly by impairment of reparative colonic epithelium proliferation and less by a disturbance of matrix synthesis.

Neuropeptides in inflammatory bowel disease: an update.

SUMMARY: : Extrinsic and intrinsic neurons of the gut contain multiple neuropeptides, which through complex interactions modulate mucosal defense, inflammation, and repair in response to injury. Initial changes of the neurovascular peptidergic system may represent normal protective mechanisms against tissue injury, whereas subsequent alterations of neurovascular regulation may contribute to the pathogenesis and maintenance of the inflammatory state. Multiple interactions between sensory neurons, the immune system and growth factors appear to exist, and there is also a marked plasticity of the neurovascular peptidergic system with changes in the synthesis, release, binding, and degradation of peptides during inflammatory processes. A delicate and closely regulated balance between proinflammatory (e.g., SP, VIP, NPY) and antiinflammatory neuropeptides (e.g., CGRP, somatostatin, bombesin) seems to exist in the gastrointestinal tract. Disturbances of this balance might contribute to the pathophysiology of inflammatory bowel disease. In our overview, we will describe the results of studies in animal models of experimental inflammation and focus on the potential insight they provide in understanding the pathophysiology of inflammatory conditions of the bowel such as IBD. Knowledge with respect to these regulatory systems might provide novel insights into the inflammatory process and potentially expand the available therapeutic approaches in the management of IBD.

Alkyl-lysophospholipids inhibit the growth of hypernephroid carcinomas in vitro.

Synthetic alkyl-lysophospholipids (ALPs) inhibit the proliferation of human hypernephromas in vitro. Cells of ten different tumors were incubated with 4 ALPs for periods of more than 24h. Eight of ten cell lines showed proliferation rates below 1% of the controls after cultivation. One microgram of ALPs per 10(6) tumor cells was effective, in some experiments a dose response relation was found for even lower concentrations. Equivalent concentrations of cytostatic drugs did not show reproducible higher antitumor effects in vitro. In two of the tested cell lines ALPs did not show any reproducible tumor growth inhibition, whereas at least some of the cytostatic drugs revealed slight cytostatis.

Growth inhibition of malignant hypernephroma cells by autologous lysophospholipid incubated macrophages obtained by a new method.

In order to obtain pure human macrophages, mononuclear cells from peripheral blood were cultured on teflon membranes and the non-adherent lymphocytes removed. After 24 hours, all remaining adherent cells were detached from the membranes with 100% viability. They showed all the morphological and cytochemical characteristics of human monocytes. Within 10 days of cultivation they differentiated into monolayers of pure macrophages. Untreated macrophages of this origin showed only limited cytostatic effects on autologous hypernephroma cells in vitro. After preincubation with different alkyl-lysophospholipids they revealed a tumor growth inhibition capability of up to 90%.

Keratinocyte growth factor promotes healing of left-sided colon anastomoses.

BACKGROUND: Inadequate healing and consequent leakage from bowel anastomoses are a significant cause of postoperative morbidity and mortality. Systemic application of keratinocyte growth factor (KGF) has been shown to promote mucosal healing in models of colitis in rats and mice. The aim of the present study was to evaluate the effect of systemic KGF administration on healing of colonic anastomoses in rats. METHODS: Rats underwent laparotomy, division of the left colon, and sigmoido-sigmoidostomy. KGF (5 mg/kg) or vehicle were administered intraperitoneally in two groups (n = 30 per group) 12 hours prior to surgery, and then once daily until sacrifice (6 animals per group; 2, 4, 7, 12, and 21 days after surgery). Bursting pressure measurements, histologic evaluation, morphometric analysis, mucin and collagen staining, and hydroxyproline measurements of the anastomotic site were performed. RESULTS: Administration of KGF significantly increased anastomotic bursting pressure on postoperative days 2, 4, and 7 by 34%, 49%, and 19%, respectively. Histology, mucin staining, and measurements of the colonic crypt depth showed markedly less extended inflammation with an increased acidic mucin content and a significantly thickened mucosal layer in the KGF treated group when compared with vehicle-treated animals. CONCLUSIONS: KGF promotes healing of colonic anastomoses in rats during a 1-week postoperative period following large bowel surgery. KGF may be acting to accelerate host reparative processes as well as to enhance protection of the anastomotic wound bed by increased colonic epithelium proliferation, increased mucus production, and reduction of the inflammatory activity at the anastomotic site.

Energy and redox status, and carbon allocation in one- to three-year-old spruce needles.

Metabolite pools were determined in lyophilized homogenates of one- to three-year-old needles from 13-year-old spruce trees. These were exposed in open-chambers for five consecutive years to SO(2) (30 microg m(-3)) and O(3) (50 to 180 microg m(-3)), singly and in combination. The samples were taken shortly before bud break (mid-March). The energy (ATP/ADP) and redox status (NAD(P)H/NAD(P)) increased with needle age. This increase was most pronounced in needles exposed to both pollutant gases. To evaluate carbohydrate metabolism, levels of starch, sugars (sucrose, fructose, glucose), sugar phosphates (dihydroxyacetone phosphate, glyceraldehyde 3-phosphate (triose phosphates, TP), fructose 6-phosphate, fructose 2,6-bisphosphate: F2,6BP) and 3-phosphoglyceric acid (PGA) were measured. The concentrations of starch, glucose, fructose and TP on a dry weight basis increased with needle age, while those of sucrose and F2,6BP decreased. Interestingly, the total amount of soluble sugars remained constant in needles from control chambers and large fluctuations mainly occurred after a single application of the pollutants. Needles from fumigated trees generally showed somewhat lower starch and sugar, and fructose 6-phosphate levels. The content of TP increased with needle age while that of sucrose and F2,6BP decreased. This inverse behavior was even more prominent in the presence of both pollutants and is discussed in the context of recent knowledge on the regulation of carbon partitioning. There was a significant increase in the ratio of TP/PGA in samples from the combined exposure treatments. This also indicates an increase in the redox charge and corroborates the data on both the redox status of the pyridine nucleotide system and the significantly increased ATP/ADP ratio. The results are indicative of a switch in metabolism, from anabolic to predominantly catabolic reactions, which is most pronounced in the samples fumigated with both O(3) and SO(2). The data are compared to those obtained from naturally exposed trees in the southern Black Forest (Kälbelescheuer/Haldenhof, near Freiburg, Germany).

[2-year evaluation of a cooperation model between a surgical university clinic and a general hospital]. / 2-Jahresbilanz eines Kooperationsmodells zwischen einer Chirurgischen Universitätsklinik und einem Spital der Grundversorgung.

INTRODUCTION: On 1 January 1998 a cooperation between an university hospital and a peripheral general hospital was initiated with the aim of reducing waiting lists and health care costs. Surgical patients initially referred to the Department of Visceral and Transplantation Surgery of the University of Bern (Inselspital) were evaluated and selected in the outpatient clinic for an operation in the peripheral hospital Grosshöchstetten. The operation and postoperative care in Grosshöchstetten was performed by a team from the university department according to the standard concept also utilized at the university hospital. RESULTS: The 574 patients referred to the university and operated on in Grosshöchstetten during a 2-year period had a morbidity rate of 3.5%, a reoperation rate of 1.0% and a mortality rate of 0.15%. The mean hospital stay was 6.3 days. The quality evaluation performed by questionnaires to patients and physicians showed an overall satisfaction rate of 95%. The cooperation resulted in reduction of the overall costs in both hospitals, and the patients' involved health insurances profited from substantially lower costs per case. CONCLUSIONS: Health care costs in both hospitals as well as the waiting list at the university hospital were markedly reduced during this 2-years trial, with an overall satisfaction rate of 95%. This form of cooperation of an university with a peripheral hospital represents a new and valuable model for effective reduction of health care costs.