[Information on medical history in the emergency department : Influence on therapy and diagnostic decisions]. / Informationen zur medizinischen Vorgeschichte in der Notaufnahme : Einfluss auf Therapie- und Diagnostikentscheidungen.

BACKGROUND: The introduction of an electronic health record (EHR) or an emergency care data set (ECDS), as well as reforms in emergency medical care, is currently part of political debate in Germany. Currently, no data are available of how emergency departments could benefit from an ePA or NFD in Germany. The aim of this study was to determine if a patient's medical history has an influence on diagnostic and therapeutic decisions in the emergency department. METHODOLOGY: To answer this question, a descriptive observational study was conducted in an interdisciplinary emergency department with a study population of n = 96. RESULTS: For 55 patients (59%) neither a doctor's letter nor a drug list was found. However, in 48% of the patients who were admitted to the hospital via the emergency department, additions to the anamnesis record could be identified. Eight (9%) patients showed that therapy and/or diagnostic decisions should have been discussed or changed if the supplemented anamnestic information had been available in the emergency room. In addition, the study revealed that the duration of the anamnesis was prolonged in case of missing medical history (mean: 10-15 min, standard deviation: ±<5 min). In contrast to the patients with a medical history (mean: 5-10 min, standard deviation: ±<5 min). CONCLUSION: Based on the data stored in EHR and ECDS, therapy and diagnostic decisions could be made more reliably. In the absence of a medical history, the time required for medical history taking in emergency departments is significantly longer, which could be reduced by introducing EHR or ECDS.

[Efficacy and tolerability of pantoprazole in the treatment of gastroesophageal reflux disease]. / Schnelle Symptombefreiung und gute Verträglichkeit bei Patienten mit Refluxkrankheit. Datenanalyse der nicht interventionellen Studien PANTHER und PANDA mit Pantoprazol in Deutschland.

BACKGROUND: Proton pump inhibitors (PPI) are considered first-line therapies in the treatment of gastroesophageal reflux disease (GERD) and are prescribed frequently. METHODS: In two non-interventional trials 3040 patients with GERD were treated with 20 mg/40 mg pantoprazole per day. Symptoms were assessed by the investigators as well as the patients by means of the symptom questionnaire ReQuest at study start and after 1 week of treatment with pantoprazole. Data were pooled and analysed. RESULTS: At study start, 80% of patients had moderate/severe heartburn, 65% acid regurgitation, 20% painful swallowing and 32% suffered from moderate/severe steep dysfunction. After 1 week of treatment only 3.6% reported moderate/severe heartburn, 2.8% acid regurgitation, and 1.0% painful swallowing. Only 3.6% still suffered from sleep dysfunction. Improvement of symptoms was already observed after 1 to 2 days. CONCLUSION: Treatment with pantoprazole not only reliefs typical daily core symptoms but also improves the hitherto hardly noted sleep dysfunction and can, hence, bring a recovery of quality of life.

Collagen mRNA and fibronectin are increased in healing gastric ulcers in man.

The fibrillar collagens, types I and III, have been demonstrated in healthy human gastric mucosa as well as in the submucosa of gastric ulcer edges, where they were found to be remarkably increased. In order to verify the occurrence and activity of de novo collagen synthesis, we examined gastric biopsy specimens from six patients with antral ulcers and six normal controls. By means of in situ hybridization, using a 35-S-labelled RNA probe, we could identify the specific procollagen mRNA for type I collagen. Fibronectin was stained immunohistochemically employing specific polyclonal antibodies. In normal gastric mucosa, procollagen type I mRNA was expressed by only a very limited number of cells while at the ulcer edges the specific signal could be demonstrated in a large number of submucosal cells. Fibronectin as marker of newly built connective tissue was found to be markedly increased in the submucosa of healing gastric ulcers as compared to normal controls. These results suggest a substantial role of fibroneogenesis in the process of gastric ulcer healing.

Gastric cancer in pregnancy: do pregnancy, age or female sex alter the prognosis? Case reports and review.

The coincidence of gastric cancer and pregnancy is a rare event. By literature research of the last three decades only 31 cases from outside Japan were identified including two own patients. The analysis of these and another 61 cases from Japan revealed the same predominance of poorly differentiated diffuse carcinomas with peritoneal and lymphatic metastases as in other young patients (<40 years). The survival rate is not obviously affected by pregnancy, young age or female sex. Experimental and epidemiological data suggest a protective effect of oestrogen against the induction of (intestinal) gastric cancer, while the cancer growth itself seems to be enhanced. Oestrogen receptors (ER) are found in about 22% of gastric cancer cells, especially in the poorly differentiated type. In contrast to target organs like the breast, ER in gastric cancer seem to be a sign of tumour adaptation involving e.g. the pathway of the epidermal growth factor. The results of treatment with anti-oestrogen are controversial in experimental and clinical settings. Due to the very common epigastric complaints early diagnosis of gastric cancer is even more difficult in pregnancy, so that early gastroscopy is advisable in patients on risk. Main effort should be given, however, to primary prevention.

[Acute sigmoid diverticulitis--current diagnosis]. / Akute Sigmadiverticulitis--aktuelle Diagnostik.

Acute sigmoid diverticulitis may present in different forms. Firstly, symptomatic diverticulosis and acute diverticulitis have to be differentiated to allow for the proper selection of treatment. In the initial phase of diagnostic procedures in addition to clinical features a few laboratory data, plain X-ray films of the abdomen and abdominal ultrasound are helpful to obtain information about the potential presence of perforation, abscess, tumor masses and the structure of the colonic wall. Computed tomography is capable to answer most of the questions in the diagnostic work-up of acute diverticulitis. On the other hand, contrast barium enema provides little additional information and should be considered as contraindicated in acute diverticulitis. If at all, water-soluble contrast media should be employed. Endoscopy has its place in the differential diagnostic evaluation of severe bleeding and suspected tumor, but should be reserved for these limited indications.

[Effectiveness of screening colonoscopy in a community-based study]. / Die Vorsorgekoloskopie rettet Leben--Ergebnisse der Herner Vorsorgedatei.

In 2002 screening colonoscopy was introduced in Germany for the prevention of colorectal cancer (CRC) and CRC mortality. Individuals took part in a prospective study from October 2002 until September 2005 performed at a single centre for gastroenterology. Histopathological data, surgical-pathological stages and further follow-up events were recorded until 31st of December 2006. For screened individuals without symptoms, the data obtained were compared to those from age-matched patients who presented with clinical symptoms/signs and who underwent colonoscopy during the same period in time. A total of 5066 individuals underwent screening colonoscopy. In this group, colorectal cancer was detected in 46 individuals (0.9%). Endoscopic treatment was considered adequate for 21 cancers. In this group of 46 patients, 94.5% were classified into UICC stages I-II by pathological staging. In 504 screened individuals, colorectal polyps were detected (12.2%) and removed by polypectomy. Of these polyps, 16 were classified as cancer, 496 as adenomas and 1 as a carcinoid tumour. High grade dysplasia was noted in 41 polyps (8.3% of adenomas). In comparison, 4099 symptomatic patients underwent colonoscopy. In this group 100 cancers (2.4%) were detected. Advanced malignant tumours were noted in 39% of these; endoscopic treatment was feasible in 16% of the cancers. As of December 2006, cancer-related deaths were observed in 20% of symptomatic patients with CRC. Screening colonoscopy detects colorectal cancers in the early stages. Given the favourable prognosis in these stages, screening can reduce CRC-related mortality.

[Financial restrictions in health care systems could affect treatment quality of GERD-patients]. / Wachsender Kostendruck im Gesundheitswesen kann zu einer Beeinträchtigung der Behandlungsqualität bei Refluxpatienten führen.

AIMS: To directly compare the efficacy and safety of pantoprazole 40 mg VS. omeprazole 20 mg in patients with gastroesophageal reflux disease (GERD). MATERIAL AND METHODS: 915 Patients suffering from symptomatic GERD B-D (Los Angeles classification) were included in a double-blind randomized multicenter clinical trial and treated with either pantoprazole 40 mg od or omeprazole 20 mg od for six weeks. Primary efficacy criterion was the first time to reach normal symptoms as assessed by the questionnaire ReQuest-GI. RESULTS: Compared to omeprazole 20 mg, pantoprazole 40 mg achieved a significantly faster rate of symptom relief (p = 0.0298). Thus, as assessed with the ReQuest questionnaire, patients treated with pantoprazole 40 mg experienced relief from the 7 leading GERD symptoms 2 days earlier than those treated with omeprazole 20 mg. Long-lasting sustained relief from symptoms was also achieved earlier with pantoprazole than with omeprazole; in patients treated with pantoprazole, the daily symptom load was lower than in those treated with omeprazole. After 6 weeks of treatment, over 90 percent of patients were free from symptoms in both treatment groups (93.7 % in the pantoprazole, vs. 91.8 % in the omeprazole group, PP). Both medications were well tolerated. CONCLUSIONS: GERD patients treated with pantoprazole 40 mg experience a significantly faster relief from their leading symptoms than those treated with omeprazole 20 mg.

[Laparoscopic versus open appendectomy: which factors influence the decision between the surgical techniques?]. / Laparoskopische vs. offene Appendektomie: Welche Faktoren beeinflussen die Wahl der Operationsmethode?

BACKGROUND: Although in hospitals focussing on minimal invasive surgery laparoscopic appendectomy (LA) is widely practiced as method of choice in patients with acute appendicitis, the decision for the laparoscopic or the conventional technique (OA) is usually ensued by individual viewpoints. Aim of this prospective observation study was to analyse the decision algorithm for both procedures in patients with the presumptive diagnosis "appendicitis". PATIENTS AND METHODS: Between January 1996 and July 2001 512 patients with the presumptive diagnosis "acute appendicitis" underwent surgery and, assigned by intention-to-treat, were subdivided in a laparoscopic (I) and a conventional group (II). The choice of surgical procedure was analysed with regard to patient characteristics (age, gender, comorbidity), severity of appendicitis (clinical manifestation, preoperative inflammation signs), surgeon (clinical experience) and daytime (during the day, in the evening, at night). Furthermore, the outcome of either method was related to postoperative diagnosis, perioperative morbidity, analgesia, length of hospital stay and cosmetic results. RESULTS: In group I 265 patients and in group II 247 patients underwent surgery. Conversion from LA to OA was necessary in 6.4 %. Group I consisted of significantly more female (67.9 % vs. 45.7 %) and younger patients (21 yrs. vs. 30 yrs.) with less medical history as well as minor severity of tissue inflammation and significantly lower preoperative serum inflammation parameters (leukocytes (1000/ml): 10.6 +/- 4.3 vs. 13.5 +/- 4.9; CRP (mg/l): 2.3 +/- 3.3 vs. 5.6 +/- 7.5, I vs. II: p < 0.001). In group I more patients underwent surgery during day-time as well as by more laparoscopic-experienced surgeons. In the postoperative histopathologic evaluation there were significantly fewer cases with complicated appendicitis (33.2 % vs. 52.2 %, p < 0.001). Additionally, patients after LA revealed a lower postoperative complication rate (9.3 % vs. 18.3 %), length of hospital stay (median 3 vs. 4 days) and duration of analgesia (2.1 +/- 1.8 vs. 4.1 +/- 7.1 days). CONCLUSIONS: Important factors for decision algorithm between a laparoscopic or an open appendectomy include severity of appendicitis, gender, day-time as well as the surgeon's individual laparoscopic experience. With appropriate indication for each technique, both procedures are of equal value in the treatment of acute appendicitis. Furthermore the positive patient selection for laparoscopic appendectomy contributed to a better postoperative outcome in this study.

[The significance of cytokines and extracellular matrix for stomach ulcer healing]. / Die Bedeutung von Zytokinen und extrazellulärer Matrix für die Magenulkusheilung.

The healing process of gastric ulcers is regulated by many factors. Cytokines play a central role in the different stages of healing. In the early stage of inflammation, TNF-alpha and interleukins regulate cell-migration and -proliferation. In the ulcer's base revascularisation is stimulated by b-FGF, collagen synthesis by TGF-beta. The reepithelialization is mediated by EGF, which accelerates ulcer healing in animal models, while TGF-alpha is involved in mucosal protection. The extracellular matrix (ECM) is important for the stability and quality of the ulcer scar, as known from dermatological experiments. An increase of collagen types I and III in healing gastric ulcers was demonstrated recently, which might illuminate the particular role of ECM proteins for the gastric ulcer healing process.

[Antiphospholipid antibody syndrome as the cause of clinical rapidly progressing vasculopathy]. / Antiphospholipid-Antikörpersyndrom als Ursache einer klinisch rasch progredienten Vaskulopathie.

HISTORY AND ADMISSION FINDINGS: For 3 weeks a 54-year-old man had been unsuccessfully treated with antibiotics for ulcerating tonsillitis with fever, weight loss, occasional headaches, and hypertension. A year before he had suffered a transitory cerebral ischaemic attack. On admission he had a fever of 38.6 degrees C, blood pressure of 185/100 mmHg and a nonspecific 2/6 apical systolic murmur. INVESTIGATIONS: Erythrocyte sedimentation rate was 100/120 mm, C-reactive protein 1.5 mg/dl, serum creatinine 2.45 mg/dl, urinary protein 0.8 g/d. Tests for antinuclear antibodies (ANCA) against neutrophil granulocytes and for native DNA antibodies were negative, as were serological tests for Coxsackie virus, Cytomegalovirus and Epstein-Barr virus. Sonography and computed tomography revealed thrombosis along the entire aortic wall, renal artery stenosis and a contracted left kidney. Transoesophageal echocardiography demonstrated small thrombi on the aortic valve leaflets. Coloscopy showed ulcerative colitis. TREATMENT AND COURSE: The patient was anticoagulated. Local cold produced livedo reticularis. Tests for cardiolipin antibodies in serum and a skin biopsy provided the diagnosis of antiphospholipid antibody syndrome (APS). As the skin biopsy showed vasculitis, immunosuppressive treatment was started. This stabilized the condition and he was discharged to be followed by his general practitioner. CONCLUSION: APS can cause complex symptoms in many organs, but effective treatment (anticoagulation, corticosteroids, immunosuppressives) is available, as this case demonstrates.

[Identification of procollagen mRNA in chronic active hepatitis B]. / Identifikation von Prokollagen-mRNAs bei chronisch aktiver Hepatitis B.

In situ hybridization is a tool for staining intracellular procollagen mRNAs with specific probes. Our study shows the amounts of procollagen mRNAs of types I and III to be increased in liver biopsies of five patients with chronic active hepatitis B as compared with five healthy controls. Parallel staining employing anti-smooth-muscle-actin antibodies was able to identify myofibroblast-like cells at the same localization where procollagen mRNAs were found. Consequently, these transformed Ito-cells might be the procollagen-producing cells.

Distribution of collagen types I, III, and IV in peptic ulcer and normal gastric mucosa in man.

The quality of peptic ulcer healing does not only mean complete epithelial restitution of the mucosal surface but also adequate repair of the underlying connective tissue. To obtain more information about the metabolism of extracellular matrix proteins in gastric mucosa and submucosa, we investigated biopsy specimens from six patients with antral peptic ulcers and six normal controls by staining of collagen types I, III, and IV with an immunofluorescence technique. In normal mucosa we found a certain amount of collagen types I and III in equal distribution and almost no collagen type IV. In contrast, there was a remarkable increase of collagen types I and III in peptic ulcers predominantly located at the ulcer edges. These results are compatible with the view that extracellular matrix proteins play some part in the ulcer healing process.

Diffuse esophageal spasm: a malfunction that involves nitric oxide?

OBJECTIVE: As recently suggested, nitric oxide (NO) may play an important role in the regulation of esophageal motility, being partly responsible for the latency period and latency gradient between the onset of a swallow and contractions of esophageal circular smooth muscles. Diffuse esophageal spasm appears to be a classical example in which the mechanisms normally responsible for the physiologic timing of the contractions occurring in the esophageal body after swallowing are disturbed. METHODS: Five patients (one male and four female; age, 18-48 years) with symptomatic esophageal spasm were give glyceryl trinitrate (GTN) intravenously in gradually increasing doses or L-arginine on two separate occasions and underwent manometric measurements of esophageal motility after wet swallows, using a multilumen perfused catheter system (Synetics Medical, Stockholm, Sweden). The amplitude, duration, and propagation of the contractions and the latency period were analyzed, using specially designed software. Additionally, during the GTN infusion period arterial blood pressure was measured every 5 min, RESULTS: GTN infusion given at a dose of 100 to 200 micrograms/kg-h intravenously caused the occurrence of and a dose-dependent elongation of the latency period after swallowing. The mean amplitude of the contractions did not show any significant alterations, whereas the mean duration of the contractions decreased significantly, from 11.2 +/- 4.8 sec to 5.4 +/- 0.8 sec. These effects were accompanied by significant alleviation of symptoms during swallowing. Interestingly, no adverse side effects such as headache or flush were observed at any dose of GTN. The blood pressure did not show any changes during the studies in any of the five patients. Administration of L-arginine (300 mg/kg-h intravenously) did not cause any significant alterations of motility pattern or alleviation of dysphagia. CONCLUSIONS: 1) NO may play an important role in the control of human esophageal motility, being involved in the mechanisms responsible for the timing of propulsive contractions in the body after swallowing; 2) GTN may to be of benefit in the treatment of diffuse esophageal spasm in symptomatic patients; and 3) patients with diffuse esophageal spasm may have a malfunction in endogenous NO synthesis and/or degradation.

[Drug interactions. Mechanisms and clinical relevance]. / Arzneimittelinteraktionen. Mechanismen und klinische Bedeutung

During the last few years 3 important drugs (terfenadine, mibefradil, cisapride) had to been withdrawn from the market because of serious drug-drug interactions. Polypragmacy, not only in advanced age, is often applied. Consequently the possibility of pharmacokinetic and/or pharmacodynamic drug interactions has always to be taken into account which can cause adverse effects, therapeutic failures, hospital admissions and extra costs. Clinically relevant interactions can be observed especially on the level of drug metabolism and transport. Both pharmacokinetic processes can be induced or inhibited by numerous agents. Taking proton pump inhibitors as an example it could be shown that the various compounds can differ in their interaction potential.

Myofibroblast-like cells produce mRNA for type I and III procollagens in chronic active hepatitis.

In chronic active hepatitis the rate of collagen biosynthesis is largely determined by intracellular mRNA concentrations. To localize procollagen mRNA-producing cells, we investigated biopsy specimens from five patients with hepatitis B surface antigen-positive chronic active hepatitis and five patients without liver disease by in situ hybridization. We used type I and III procollagen cDNAs for transcription to (35S)-labeled probes. Parallel sections were stained with anti-actin monoclonal antibodies. Our results show that cells in which collagen synthesis is ostensibly enhanced can be localized by in situ hybridization of procollagen mRNAs. These cells were also anti-actin-positive in parallel sections and were localized in areas of inflammatory cell infiltration and necrosis. We conclude that myofibroblast-like cells may express procollagen mRNAs in chronic active hepatitis. Moreover, in situ hybridization may be a valuable diagnostic tool for providing additional morphologic information on the degree of fibrogenesis activity.