Experts' perspectives on the role of medical marijuana in oncology: A semistructured interview study.

BACKGROUND: Expansion of medical marijuana (MM) laws in the United States may offer oncology new therapeutic options. However, the scientific evidence for MM remains in infancy. This study qualitatively explored professional opinion around the role of MM in cancer care. METHODS: Semistructured interviews were administered to a sample of individuals with expertise at the interface of MM and oncology nationally. Key informant criteria included an oncologic clinical or research background and any of the following: publications, research, or lectures on cannabinoids or cancer symptoms; involvement in the development of MM dispensaries or legislation; and early adoption of state MM certification procedures. A gold standard, grounded, inductive approach was used to identify underlying themes. RESULTS: Participants (N = 15) were predominantly male, in their sixth decade, working in academic settings. Themes ranged from strong beliefs in marijuana's medical utility to reservations about this notion, with calls for expansion of the scientific evidence base and more stringent MM production standards. All participants cited nausea as an appropriate indication, and 13 of 15 pain. Over one-third believed MM to have a more attractive risk profile than opioids and benzodiazepines. CONCLUSIONS: Expert opinion was divided between convictions in marijuana's medicinal potential and guardedness in this assertion, with no participant refuting MM's utility outright. Emergent themes included that MM ameliorates cancer-related pain and nausea and is safer than certain conventional medications. Participants called for enhanced purity and production standards, and further research on MM's utility.

The response of weaned piglets to dietary valine and leucine.

Valine (Val) is considered to be the fifth-limiting amino acid in a maize-soyabean meal diet for pigs. Excess leucine (Leu) levels often occur in commercial diets, which may attenuate the effect of Val deficiency because of an increased oxidation of Val. The objective of the present experiment was to determine the effect of increasing concentrations of Leu on the response of young piglets to dietary Val. In all, 75 Large White×Landrace entire male pigs, 44 days of age and with a mean starting weight of 13.5 kg, were used. Three of these were sacrificed at the start to determine their mean initial chemical composition. A summit feed first limiting in Val was serially diluted with a non-protein diluent to produce a series of five digestible Val concentrations of 11.9, 10.1, 8.3, 6.6 and 4.8 g/kg, with a sixth treatment being added to test that the feeds were limiting in Val. Three identical Val series, each with six levels of Val, were supplemented with increasing amounts of Leu (23, 45 and 67 g/kg), thus 18 treatments in total. All pigs were killed at the end of the trial after 18 days for analysis of water, protein, lipid and ash in the carcass. The levels of Val and Leu and their interaction significantly influenced all the measurements taken in the trial. Daily gain in liveweight, water and protein, and feed conversion efficiency all increased with dietary Val content, whereas feed intake decreased as both Val and Leu contents increased. The deleterious effect of increased Leu on feed intake and growth was more marked at lower levels of Val. Supplementing the feed with the lowest Val content with additional Val largely overcame the effect of excess Leu. The efficiency of utilisation of Val for protein growth was unaffected by the level of Leu in the feed, the primary response to excess Leu being a reduction in feed intake. An intake of around 9 g Val/day yielded maximal protein growth during the period from 44 to 62 days of age in pigs of the genotype used in this trial.

[Nutritional deficiencies and supplementation after metabolic surgery]. / Nutritive Defizite und Supplementation nach metabolischer Chirurgie.

Increasing prevalence of morbid obesity in Germany is associated with an increasing number of bariatric surgical interventions.Based on the effectiveness of bariatric surgery with regard to a significant reduction of body weight and comorbidity as well as improvement of the quality of life compared with conservative measures, its value and impact has been substantially increased. Long-term metabolic deficits such as nutrient deficiencies can be considered the main risks of various restrictive, combined and malabsorptive procedures of bariatric surgery.The aim of this overview is to characterize metabolic complications after bariatric surgery and their prophylaxis, which require a temporary or permanent surveillance and, if necessary, effective supplementation.Bariatric surgical interventions such as gastric banding (GB) and sleeve gastrectomy (SG) can be subsequently associated with deficiencies related to B­vitamins whereas iron, folate, and vitamins B1, B12 and D deficiencies might be consequences of malabsorptive procedures such as biliopancreatic diversion, duodenal switch and Roux-en-Y gastric bypass.Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long follow-up investigations. The currently available guidelines of the American Association of Bariatric and Metabolic Surgery are the basis for the latest recommendations on supplementation and treatment in bariatric surgery.

[How Much Blood and What Components does the Patient need Intra- and Perioperatively?]. / Wie viel Blut und welche seiner Bestandteile benötigt der Mensch intra- und perioperativ? - neue wichtige Aspekte für den Allgemein-(Viszeral-)Chirurgen aus der Transfusionsmedizin und Hämostaseologie.

By the optimised availability of less expensive and safe red cell packs and other blood products over the last 20 years, numerous surgical interventions have become possible without any demand for comments on the precise need. However, a number of publications indicates that blood transfusion may also induce disadvantageous effects on the postoperative course by immunomodulation, which requires a rather restrictive indication for transfusion. Furthermore, demographic development leads to a decrease in that portion of the population with the potential for blood donation accompanied simultaneously by an increase of the percentage of older patients with more need of blood products during medical treatment. This makes blood-sparing measures necessary. In addition, costs for red cell packs have increased, in particular, for the generally compatible blood group 0 - an extra amount for rhesus negative blood. The present narrative review highlights, therefore, important news from the clinical transfusion medicine, immunohaematology and haemostaseology and their impact on daily transfusion practice. In this context, "blood management" is considered as one of the very effective blood-sparing measures, which focusses especially i) on the substitution of iron in case of depressed preoperative haemoglobin as well as ii) to elucidate disorders of coagulation by structured medical history and, subsequently, to balance possible need by a specific plan for substitution. Simultaneously, prospective studies are initiated to investigate how far the transfusion trigger of a patient can be lowered down to a still appropriate level. As far as consolidated findings are already available, they are described with regard to the single blood components and taking into account the cross-sectional guidelines of the "Bundesärztekammer" (Federal Physicians Chamber). Finally, initial evidence is provided characterising patient- and blood donor-specific, blood group-dependent features of a reasonable haemotherapy.

[Nutrient Deficiencies after Bariatric Surgery - Systematic Literature Review and Suggestions for Diagnostics and Treatment]. / Nutritive Defizite nach bariatrischer Chirurgie - systematische Literaturanalyse und Empfehlungen für Diagnostik und Substitution.

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered the main risks of metabolic surgery and its restrictive and malabsorbant surgical procedures. The aim of this compact short overview based on a selective literature search and our own clinical experience is to characterise the long-term metabolic complications, which are specific for the various bariatric procedures, and to refine the published guidelines for supplementation. Restrictive bariatric procedures can be associated with well-known surgical problems such as pouch dilatation or band migration, e.g., after gastric banding. After sleeve gastrectomy, emerging reflux disease can become a substantial problem. The most frequent deficiencies after restrictive procedures are related to B-vitamins whereas iron, folate, vitamin B1 and B12 and vitamin D deficiencies are associated with the malabsorptive procedure such as biliopancreatic diversion, duodenal switch and Roux-en-Y gastric bypass. Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical follow-up investigations. The currently available guidelines of German Society of Treatment of Obesity (CAADIP) of DGAV for supplementation should be known and followed, in particular, by the physicians who i) are exceptionally involved in medical care of obese people and ii) do it in full awareness of the obligatory postoperative clinical observation.

[Medical Rehabilitation in Gastrointestinal Oncology]. / Onkologische Rehabilitation bei gastrointestinalen Tumorerkrankungen.

BACKGROUND: The demographic change of the human population comes along with an increasing aging, a rise of chronic diseases, particular carcinosis, as well as the need for prolonged working life times. This causes big challenges for the public health systems, primarily in the field of surgery. In this respect, oncological rehabilitation has an important supporting function. Its mission is to reintegrate the patient after surgery back into domestic, social and professional life. This article covers the most significant questions for rehabilitation of gastrointestinal oncology. PURPOSE: The aim of this study is to illustrate the legal foundations and routes to access oncological rehabilitation as well as to provide a survey of the contents of oncological rehabilitation with a special emphasis on gastrointestinal tumours. METHOD: We surveyed experience in clinical rehabilitation by means of an appropriate literature search. Key Findings and Conclusions: Oncological rehabilitation is anchored in social legislation. The terms of reference are different from those of an acute hospital. Apart from the treatment of numerous specific somatic problems, both psycho-oncological care and social-medical consultation and evaluation are centrally important tasks.

[From heparin to apixaban: anticoagulants cut both ways?]. / Vom Heparin zum Apixaban: Was bringen die "neuen Antikoagulanzien"?

BACKGROUND: Regarding anticoagulant therapies there has been a remarkable shift in recent years. The objective of this brief overview is to provide relevant information and guidelines on the advantages and disadvantages of novel anticoagulants addressing specifically the surgical disciplines. Hitherto, conventional anticoagulant therapy in patients with a high thrombosis risk was largely limited to heparins and vitamin-K antagonists (VKA). Their modes of action, the difficulties in managing VKAs (e.g., bridging therapy) and the risk of HIT (heparin-induced thrombocytopenia) associated with heparins are briefly discussed. Novel anticoagulants supposedly eliminate these obstacles. Fondaparinux (Arixtra®) is a fully synthetic pentasaccharide which acts like a heparin but has an increased half life. Fondaparinux has a diminished risk of HIT. However, no specific antidote is currently available for Fondaparinux. The novel oral anticoagulants (NOAC) dabigatran etexilat (Pradaxa®), rivaroxaban (Xarelto®) and apixaban (Eliquis®), also known as "direct" anticoagulants, act independently from antithrombin by inhibiting thrombin, as in the case of dabigatran, or by inhibiting factor Xa, as in the case of rivaroxaban and apixaban. It is assumed that they are suitable for long-term use and do not require laboratory monitoring. Nevertheless, clinical experience is very limited and caution rather than quick conclusions is necessary. Two major drawbacks are on the one hand the risk of drug accumulation in kidney and/or liver disease and, on the other hand, the lack of specific antidotes. In addition, interactions with other medication may have unexpected effects on serum drug levels. Therefore, the analysis of drug levels in the plasma may become necessary in subgroups of patients. DISCUSSION AND CONCLUSION: Studies establishing clear recommendations for the desirable and measurable reference range are needed. Similarly, evidence-based recommendations regarding perioperative prevention of thrombosis are required ("bridging": yes or no?). Irrespective of these issues, the authors predict a further expansion of the use of NOACs.

[Hernia repair at the groin - who undergoes which surgical intervention?]. / Leistenhernienreparation - Wo wird wie operiert?

BACKGROUND: Within the Guidelines of the European Hernia Society (EHS), there are disctinct statements about where and how inguinal hernia has to be surgically approached. In ASA-I and -II patients, it is recommended to perform the operation in an outpatient clinic setting. Male patients older than 30 years of age should undergo preferably surgical intervention using a mesh. In this context, there are two basic questions: "Are these recommendations already implemented in daily surgical practice (?)" and "Are these guidelines the road to success (?)", which are to be commented based on i) data from two registries, ii) data obtained in the surgical practice of the first author and iii) a selective literature search. MATERIAL AND METHODS: An analysis was made of prospectively obtained data from two German registries (Herniamed registry [H-med]; Quality Assurance Inguinal Hernia Registry [QIHR]) and a consecutive and representative patient cohort of a single surgical practice [Surg-Pract] specialised in hernia surgery. Main results and concluding remarks are discussed in light of data reported in the literature. RESULTS: Proportions of hernia repair in an outpatient clinic setting were substantially different among the 3 groups (as follows): H-med (22.3 %), QIHR (62.7 %), Surg-Pract (80.5 %) whereas the percentages of ASA-I and -II patients differed only slightly: H-med (83.4 %), QIHR (89.5 %) and Surg-Pract (88.3 %). Recurrency rates after 12 months were 0.6 % (QIHR) and 0.7 % (Surg-Pract), respectively. In Surg-Pract, for 30 % of hernia repairs, "only" suturing for reconstruction was used. CONCLUSION: In ASA-I and -II patients, a substantial proportion of individuals can be surgically treated in an outpatient clinic setting with no disadvantages regarding high surgical quality and favourable outcome. Data from the national H-med indicated a much lower percentage of such patients than internationally reported and, in addition, a disproportionately high rate of endoscopic procedures. Moreover, reimbursement for hernia repair in an outpatient clinic setting is much worse in Germany compared with international standards, and, interestingly, there is by a factor of 1/3 an above average number of hospital beds in Germany compared with the OECD countries.

[What the surgeon needs to know about basic new concepts of inflammation and their therapeutic consequences: sanitation of inflammation is not a passive but rather an active process regulated by lipid mediators]. / Was der Chirurg über grundlegend neue Konzepte zur Entzündung und deren therapeutische Konsequenzen wissen sollte: Die Ausheilung der Entzündung ist kein passiver, sondern ein durch Lipidmediatoren regulierter aktiver Prozess.

The acute inflammatory response as a physiological programme that protects the organism against injurious pathogens is characterised by highly regulated actions of pro- and anti-inflammatory mediators. Intensive investigations during the last decades have led to the identification of these mediators and their complex interplay as well as the design and development of anti-inflammatory therapies. However, the resolution of acute inflammation has long been considered to be a passive process. In consequence, little was known about the mechanisms which guide acute inflammation either to complete resolution, repair of inflamed tissue and restoration of normal function or to a chronic inflammatory process characterised by persistent signs of inflammation, tissue damage and impaired function. Predominantly during the last decade the so-called specialised proresolving mediators (SPM) have been identified. These essential fatty acid-derived mediators - lipoxins, resolvins, protectins, and maresins - terminate the acute inflammatory responses and stimulate their complete resolution. SPM possess both anti-inflammatory and proresolving activities in that they inhibit pro-inflammatory cytokines, limit infiltration of neutrophils, enhance macrophage uptake, and finally stimulate their non-phlogistic activation and clearance of apoptotic neutrophils and microbial particles. It has been demonstrated in multiple animal models of human inflammatory diseases that, e.g., atherosclerosis, diabetes, and inflammatory bowel diseases are caused by a decreased synthesis and/or an impaired signal transduction of the proresolving mediators. Future studies are warranted to clarify whether these proresolving lipid mediators will participate in healing human inflammatory diseases and their complications.

[Spectrum of microbial colonisation and resistance of a surgical ICU in a systematic comparison of the 10-year time period 1996-2005 using routine microbiological testing]. / Erreger- und Resistenzspektrum einer chirurgischen ITS im systematischen 10-Jahres-Vergleich 1996-2005 im Rahmen des mikrobiologischen Routinemonitorings.

INTRODUCTION: Knowledge on potentially pathogenic microbes including characteristics of their antibiotic resistance in septic patients as well as on the ward- and department-specific microbial spectrum can be considered essential for an efficient initiation of an adequate antimicrobial treatment, which turns out to become pivotal for patient outcome. Permanent changes in microbial patterns and antibiotic resistance can only be identified by a continuous investigation of various microbiological specimens. AIM: Based on the retrospective evaluation of prospectively collected data on microbiological investigations of the surgical ICU in 1996, 2002, 2004 and 2005, the short- and long-term changes by trend of microbial spectrum and antibiotic resistance following reorganisation and restructuring of the University Hospital from the more traditional pavillon-based system to a multidisciplinary complex building in 2003 were investigated. MATERIAL AND METHODS: Twice a week, routine microbiological testing of blood and urinary cultures as well as swabs from wound areas and endotracheal swabs were initiated in septic patients (suspect, manifestation) or in case of their clinical impairment. The microbial spectrum was sub-divided according to Gram-staining (Gram-positive/ -negative), various species and fungi with descriptive absolute and relative data values. -Various groups and time periods were statistically compared using χ² test as appropriate. P values < 0.05 were considered statistically significant. RESULTS: In total (n (Total) = 4 899), microbiological testing resulted in the detection of microbes in 699 and 833 blood and urinary cultures (14.3 % and 17 %, respectively) as well as 1 232 wound swabs (25.1 %) together with 2 135 samples from the endotracheal sites (43.6 %). During the short- (2002 vs. 2004) and long-term analyses (1996 vs. 2005), the proportion of Gram-positive microbes increased. Al-though Gram-positive bacteria can be considered the most frequent microbes for bacteriemia, there was a shift onto urinary and wound infections as well as pneumonias through the observation period. Despite the decreasing incidence of Enterococcus and the consistent proportion of MRSA, the increase of resistant Enterococcus strains (0 % vs. 43.2 %; P < 0.05) is critical. However, in the Gram-negative microbial spectrum there was an increase of the bacteraemia rate but a fall of the detection rate in wound and endotracheal swabs. In parallel, an increase of the detection rate of E. coli in blood (6.5 % vs. 45.5 %; P < 0.05) and endotracheal swabs (9.2 % vs. 16.2 %; P < 0.05) is associated with an increase of multiresistant Enterobacteriaceae strains (0 % vs. 30.7 %; P < 0.05). The portion of multiresistant strains of Pseudomonas with 31 % stayed the same through the 10-year time period. While Candida-based colonisation showed a decreased incidence (25 % vs. 15 %; P < 0.05) during the whole investigation period, there was a relative rise in the frequency of candidemia. CONCLUSION: ICU relocation from the pavillon-based system to a new complex clinic building was not associated with any significant alteration of the microbial spectrum on the surgical ICU. Increasing incidences of resistant Enterococcus and Gram-negative problematic microbes may indicate a general spread of multi-resistant microbes under the steady selecting pressure of a not always adequately initiated antibiotic / antimicrobial therapeutic regimen and underline the required but specific and selected microbiological screening.

A purging procedure for pantoprazole and 4-lumen catheters to prevent IV drug incompatibilities.

OBJECTIVE OF THE STUDY: The purpose of this prospective intervention study was to assess the number of patients with Y-site incompatibilities before and after implementation of quality improvement measures to prevent incompatibilities consisting of a focused instruction for pantoprazole as a drug frequently involved in incompatible drug pairs and of a recommendation to use 4-lumen instead of 3-lumen catheters to increase the number of available central infusion lines. SETTING: Cardiovascular intensive care unit where several standard operating procedures (SOPs) dealing with compatibility were already in place. METHOD: In a prospective intervention study, patients' IV medication was assessed for potential incompatibilities using a database containing compatibility information on approximately 60,000 drug pairs. In a first period, routine administration was monitored in 53 consecutive patients (control group). Then, quality improvement measures were implemented recommending a purging procedure before and after bolus administration of pantoprazole as a drug frequently causing incompatibilities in this setting. Additionally, the use of 4-lumen instead of 3-lumen catheters was suggested whenever considered useful by the responsible physicians. The monitoring was repeated during a second period in another 58 patients consecutively admitted to the same unit (intervention group). MAIN OUTCOME MEASURE: Overall number of patients with at least one incompatible drug pair and number of patients receiving incompatible pantoprazole combinations. RESULTS: The number of patients receiving incompatible pantoprazole combinations decreased from 15 of the 15 patients receiving pantoprazole (100.0%) in controls to 9/16 (56.2%) in the intervention group (P < 0.01). The overall number of patients with incompatibilities was not influenced by the intervention with 36/58 (62.1%) compared to controls with 38/53 (71.7%, P = 0.28). The fraction of central lines contributed by four lumen central catheters was larger due to the intervention (80/168 lines, 47.6%) compared to controls (16/184, 8.7%, P < 0.001). Only sporadically there were incompatible combinations of drugs governed by the already existing SOPs. CONCLUSION: In an intensive care setting with good SOP adherence, purging before and after administration decreased the respective incompatibility rate whereas the use of 4-lumen instead of 3- lumen catheters had not the expected benefit on separating drug pairs.

[Exceptional bilocular inflammatory myofibroblastic pseudotumour (IMT) characterized by recurrent thoracic tumour growth and a rare (adult) second manifestation within the mesenteric tissue of the small intestine]. / Ungewöhnlicher bilokulärer inflammatorischer myofibroblastärer Pseudotumor (IMT), charakterisiert durch thorakales Rezidiv und seltene, da adulte, Zweitmanifestation im Dünndarmmesenterium.

BACKGROUND: Despite its rare occurrence, inflammatory myofibroblastic pseudotumour (IMT) is relevant in the differential diagnosis of intestinal lesions. By the mean of an extraordinary case report, tumour site and specific characteristics, finding of the correct diagnosis, therapeutic management, and outcome of extrapulmonary IMT is decribed based also on relevant references from the literature. CASE REPORT: A 39-year old man experienced a multifocal thoracic recurrence and abdominal metastasis of IMT 12 years after successful primary resection of pulmonary IMT. The intra-abdominal lesion localised in the jejunal mesenteric tissue was removed surgically (resection status, R 0) by segmental resection of the mid-jejunum (length: 80 cm) followed by jejunojejunostomy. Histology evaluation confirmed IMT. Thoracic surgeons advised against a surgical approach to the pulmonary and thoracic lesions because of their number and proximity to the superior vena cava as well as mediastinal infiltration. Despite receiving repeated advice from his physicians, the patient has not agreed to combined immunosuppressive treatment with cyclophosphamide and steroids, because of his desire for children. He underwent 5 months of systemic steroid treatment, starting in the third postoperative month, which he then chose to stop because of Cushing symptomatology. He agreed to a computed tomography (CT) scan follow-up 12 months after surgery, which revealed slight local progression of the remaining pulmonary lesion. Administration of a second steroid medication was initiated at a lower dose. No further CT scans were obtained. At present, he is consulting with an alternative medicine practitioner. CONCLUSION: This report documents a rarely described case of IMT at a jejunal mesenteric tumour site, interpreted as an uncommon late and extraordinary, metastatic, multifocal recurrence found 12 years (!) after surgical resection of the primary pulmonary tumour.

Comparison of the effects of two resistance training regimens on muscular and bone responses in premenopausal women.

SUMMARY: A 28-week resistance training with linear periodization was compared with an undulating model in 27 premenopausal women. In both groups, bone mineral density (BMD) was not changed but muscle strength increased, and there were changes in anthropometrical and muscle damage parameters, indicating that in this population, these models are similar concerning these variables. INTRODUCTION: This study seeks to compare the effects of resistance training with undulating versus linear periodization on BMD, muscle strength, anthropometrical variables, and muscle damage parameters in premenopausal women. METHODS: Twenty-seven females (39.6 +/- 0.41 years, mean +/- standard error), without osteopenia or osteoporosis and without calcium supplementation, were randomly assigned either to a linear periodization group (LPG, n = 14) or to an undulating periodization group (UPG, n = 13). The subjects were trained three times a week for 28 weeks. Lumbar spine and femoral neck BMDs were measured through dual-energy X-ray absorptiometry. Maximal and submaximal dynamic muscle strengths were measured through the 1-RM and 20-RM tests, respectively. Anthropometrical (body mass, skinfolds, and perimeters) and muscle damage parameters were assessed through serum creatine kinase (CK) and delayed-onset muscle soreness (DOMS). RESULTS: BMD remained unchanged in both groups, despite significant increases in maximal (LPG, 37-73%; UPG, 40-70%) and submaximal (LPG, 82-114%; UPG, 70-102%) muscle strength. The perimeter of the distal thigh was increased (about 1.7 cm) in both groups. CK and DOMS were greater in the first mesocycle than in the subsequent ones. After the 1st training session in each mesocycle, 24 and 48 h CK was increased as compared to pretraining values. CONCLUSIONS: The resistance training of 28 weeks increased muscle strength in both training groups with no difference in BMD or in the occurrence of muscle damage.

Randomized clinical trial of folate supplementation in patients with peripheral arterial disease.

BACKGROUND: The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD). METHODS: Individuals with PAD were randomly assigned to receive 400 microg folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF) (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle : brachial pressure index (ABPI) and pulse wave velocity (PWV). Secondary outcomes were changes in plasma inflammatory markers. RESULTS: Plasma tHcy was significantly reduced in folic acid and 5-MTHF groups compared with controls: median difference: - 2.12 (95 per cent confidence interval - 3.70 to - 0.75) micromol/l (P = 0.002) and - 2.07 (-3.48 to - 0.54) micromol/l (P = 0.007) respectively. ABPI improved significantly: median difference 0.07 (0.04 to 0.11) (P < 0.001) and 0.05 (0.01 to 0.10) (P = 0.009) respectively. Brachial-knee PWV (bk-PWV) decreased significantly in individuals receiving 5-MTHF and tended to be reduced in those taking folic acid compared with controls: median difference: - 1.10 (-2.20 to - 0.20) m/s (P = 0.011) and - 0.90 (-2.10 to 0.00) m/s (P = 0.051) respectively. Plasma levels of inflammatory markers were not affected. CONCLUSION: Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.

Homocysteine and peripheral arterial disease: systematic review and meta-analysis.

OBJECTIVE: To evaluate homocysteine (Hcy) levels in patients with peripheral arterial disease (PAD) as compared to unaffected controls, and to review the clinical effects of therapy aimed at lowering homocysteine in PAD patients. METHODS: MEDLINE, EMBASE and Cochrane databases were searched from 1950 to December 2007. We selected observational studies and trials that evaluated Hcy levels in patients with PAD compared to unaffected controls. We also included trials on the effect of Hcy-lowering therapy (folate supplementation) in PAD patients. Continuous outcomes were pooled in a random effects meta-analysis of the weighted mean difference between comparator groups. RESULTS: We retrieved 33 potentially suitable articles from our search. Meta-analysis of 14 relevant studies showed that Hcy was significantly elevated (pooled mean difference +4.31micromoll; 95% C.I. 1.71, 6.31, p<0.0001 with significant heterogeneity) in patients with PAD compared to controls. As all 14 studies consistently demonstrated raised plasma Hcy levels in PAD patients, the significant heterogeneity in this meta-analysis probably arises from differences in the degree of Hcy elevation. The effect of folate supplementation on PAD was tested in eight clinical trials but clinically important end points were inconsistently reported. CONCLUSION: Patients with PAD have significantly higher Hcy levels than unaffected controls. However, we did not find any robust evidence on clinically beneficial effects of folate supplementation in PAD.

"Hemosuccus pancreaticus"--primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection.

There is a broad spectrum of causes for upper gastrointestinal (GI) bleeding that can be stopped by various approaches. On the basis of the report of an extraordinary case, the favorable minimally invasive approach of applying fibrin glue and histoacryl/lipiodol to the vascular basis of a bleeding pseudoaneurysm leading to "Hemosuccus pancreaticus" as a rare cause of recurrent bleeding in the upper GI tract and dangerous complications in the case of chronic pancreatitis is described. There were recurrent bleeding episodes within the upper GI tract in a 40-year-old female patient. Her medical history was significant for chronic pancreatitis and pseudocyst. Abdominal ultrasound plus duplex ultrasonography revealed a pseudoaneurysm within the tail of the pancreas as the cause of "Hemosuccus pancreaticus". Ultrasound guidance was used to repeatedly apply 2 ml of fibrin glue and 2 x 2 ml of the mixture of lipiodol and histoacryl to the basis of the pseudoaneurysm which led to complete and permanent cessation of the bleeding. Immediate and follow-up control duplex ultrasonographies (up to one year) demonstrated sufficient exclusion of the pseudoaneurysm but a preservation of the lienal artery with no disturbance of the blood perfusion in the splenic parenchyma. In conclusion, this is one of the first reports of the successful cessation of recurrent bleeding into a pseudocyst out of pseudoaneurysm ("Hemosuccus pancreaticus") by an ultrasound-guided transcutaneous fibrin glue and histoacryl/lipiodol application, which 1. is recommended as an alternative but feasible and safe therapeutic tool, 2. can provide sufficient and permanent cessation of bleeding but preserve the perfusion of the natural vessel as an initial step in the possible therapeutic algorithm, and 3. can avoid, in case of success, more invasive approaches such as angiography-guided embolization with coils or implantation of a prosthesis and even open surgical intervention, in particular, in high-risk patients.

[Pneumoperitoneum as occasional finding in chronic dialysis patients--laparotomy or conservative non-operative approach?]. / Das Pneumoperitoneum als Zufallsbefund bei chronischen Dialysepatienten--zwingende Indikation zur Laparotomie oder mögliche konservative Therapie?

Free air of unknown origin within the abdominal cavity is a serious problem, which in the majority of cases indicates the perforation of a hollow organ. In two cases, we report on i) detection of free air subdiaphragmatically by coincidence during follow-up investigation of an interstitial pulmonary disease (chest X-ray) in a 67-year old patient with chronic renal insufficiency, and ii) diagnostic of pneumoperitoneum (3 times as primary diagnosis) in a 63-year old multimorbid female (with chronic renal insufficiency) with recurrent, but unspecific epigastric symptoms over a time period of 5 years. The following investigations such as endoscopy, contrast enema, and abdominal ultrasound did not detect a perforation as most likely cause. The first patient was discharged after clinical observation, laboratory and ultrasound follow-up for 5 days. In the second case, neither explorative laparoscopy during the second clinical observation period nor laparotomy for required cholecystectomy because of cholecystitis could appropriately clarify the origin. In conclusion, the detection of a pneumoperitoneum in asymptomatic patients or subjects with unspecific abdominal symptoms requires always clinical monitoring and instrumental diagnostic, consisting of endoscopy in the upper gastrointestinal tract, contrast enema of the colon and abdominal and/or thoracal computed tomography, to definitely exclude perforation. In addition, ultrasound as third column detects early low amounts of fluid and is the suitable method for short-term follow-up. The cause of pneumoperitoneum, particularly in asymptomatic patients, can not be found in every case. Under these circumstances, non-operative treatment is favored.

Immunomodulation by perioperative administration of n-3 fatty acids.

It has been increasingly reported that administration of n-3 fatty acids is beneficial in patients with inflammatory processes. This effect is most likely caused by different biological characteristics, including an immunomodulating effect of the products derived from n-3 fatty acids through eicosanoid metabolism. The aim of this study was to investigate the effect of perioperative administration of n-3 fatty acids on inflammatory and immune responses as well as on the postoperative course of patients with extended surgical interventions of the abdomen. In particular, the effect of n-3 fatty acids on interleukin-6 release and on granulocyte/monocyte function (HLA-DR expression) was studied. There was a downregulation of the inflammatory response, and, simultaneously, a smaller postoperative immune suppression in the n-3 fatty acid group. In addition, we observed shorter postoperative periods in the intensive care unit and on the regular medical wards as well as lower rates of severe infections. The results suggest that perioperative administration of n-3 fatty acids may have a favourable effect on outcome in patients with severe surgical interventions by lowering the magnitude of inflammatory response and by modulating the immune response.

Complications of local dental anesthesia and anatomical causes.

Anatomical descriptions usually include only the average topographical relationships, but the anatomical structures particularly in the head region display great variability. This is one of the essential causes underlying side effects and complications of local dental anesthesia. In examinations of intravascular needle placement in over 6000 local anesthetic injections in the jaws, positive blood aspiration occurred most frequently (5.8%) at the mandibular foramen. The close proximity to the cerebral vessels explains the frequency of severe side effects. Anatomical studies on the course of the maxillary artery and its branches as well as the course of the nerve demonstrate that unexpected anatomical constellations can lead to both anesthetic failure and dramatic side effects.