Benefit of Contrast-Enhanced Ultrasound (CEUS) in the Follow-Up Care of Patients with Colon Cancer: A Prospective Multicenter Study.

PURPOSE: According to the German guidelines on colorectal cancer, unenhanced ultrasound is recommended for follow-up. On the other hand, ultrasound and radiology societies specify the use of contrast-enhanced ultrasound for ruling out liver metastases. Studies focusing on the follow-up of cancer patients are lacking. The goal of this multicenter study initiated by the German Ultrasound Society (DEGUM) was to determine the potential benefit of contrast-enhanced ultrasound in the follow-up of patients with colon cancer. MATERIALS AND METHODS: Follow-up patients with colon cancer (UICC > IIa) were investigated. As scheduled according to the German guidelines, unenhanced ultrasound was performed followed by contrast-enhanced ultrasound. All liver lesions were recorded. In case of additional metastases detected on contrast-enhanced ultrasound, contrast-enhanced CT, MRI or biopsy was performed to confirm additional liver metastases. RESULTS: A total of 45 liver metastases were detected in 26/290 patients (= 9 %) using unenhanced ultrasound. A further 28 metastases were detected on contrast-enhanced ultrasound in these 26 patients. In 18 patients showing no liver metastases, 40 additional metastases were detected on unenhanced ultrasound. This means that 44 patients with a total of 113 liver metastases were detected on contrast-enhanced ultrasound (p = 0.0006). CONCLUSION: Contrast-enhanced ultrasound should be recommended in the follow-up of patients with colon cancer in addition to unenhanced ultrasound - the up-to-date standard.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department]. / Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen: Diagnostische Herausforderungen in der Notfallaufnahme.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department]. / Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen. Diagnostische Herausforderungen in der Notfallaufnahme.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Google translate is not sufficient to overcome language barriers in neonatal medicine]. / Erste Erfahrungen mit Google Translate in der Neonatologie.

Language barriers hinder the interaction with patients and relatives. The use of language services increases knowledge, satisfaction and the use of medical care and thus improves patient's clinical outcome. The recommended use of professional interpreters (PI) is not always feasible. We tested an online translation tool as an alternative for PI for the transla-tion of standardized sentences from a neonatal doctor-/nurse-relative-interview.Translation of 20 sentences from a German neonatal intensive care unit parent information brochure to English, Portuguese and Arabic, using Google Translate (GT). Assessment of accuracy concerning grammar and content, in a second step simplification of all incorrect sentences, translation by GT and critical re-assessment and evaluation.An average of 42% of the sentences was correctly translated concerning grammar and content. The proportion of incorrectly translated sentences varied between 45-70%. By simpli-fication another 23% were translated correctly.Translations by GT were often incorrect in content and grammar. We suppose that the design of GT, which is a statistical translation engine, might be an explanation for this phenomenon. Presently, GT cannot guarantee unambiguous translations and cannot substitute PIs, only in particular circumstances, the use of GT or similar engines may be justified. For future use of electronic translation services, we suggest to compile a catalogue of sentences containing central information, which can be translated into defined foreign languages without misinterpretation or loss of information.

Neuroendocrine tumour, mucinous adenocarcinoma and signet-ring cell carcinoma of the appendix: three cases and review of literature.

Appendiceal neoplasms are relatively common tumours. Although these tumours are often associated with signs and symptoms of acute appendicitis, most appendiceal neoplasms are clinically silent. Appendiceal neoplasms are found in 0.7 to 1.4 per cent of all appendectomy specimens. The classification of these tumours is still confusing and precise treatment methods for these neoplasms remain unclear. First choice therapy of these neoplasms is still a surgical treatment and the type of operative procedure is determined by histology and metatstatic risk. Here, we report three cases of appendiceal neoplasms and make a short review of literature.

Clinical effects of STW 5 (Iberogast) are not based on acceleration of gastric emptying in patients with functional dyspepsia and gastroparesis.

STW 5, a herbal extract, is effective for the treatment of symptoms in patients with functional dyspepsia (FD). However, its mode of action is still unclear and a modulation of gastric motility is hypothesized. This multicentre, placebo-controlled double-blind study addressed the question of whether STW 5 accelerates gastric emptying in patients with FD and gastroparesis. One-hundred and three patients diagnosed with FD were randomly assigned to a treatment with either STW 5 or a liquid placebo for 28 days. The primary end point of the study was a change of a validated gastrointestinal symptom (GIS) score under treatment. Additionally, patients underwent a (13)C octanoic acid breath test for the assessment of the gastric half-emptying time (t(1/2)). Patients with prolonged t(1/2) were diagnosed with gastroparesis and requested to repeat the test at the end of treatment. A change of t(1/2) was defined a secondary study end point. t(1/2) was prolonged in 48.6% of patients in the STW 5 group and in 43.8% of the placebo group. During treatment, t(1/2) increased non-significantly in patients treated with STW 5 (+23 +/- 109 min; P = 0.51) and slightly accelerated among patients in the placebo arm (-26 +/- 51 min; P = 0.77) (P = 0.49). The improvement of the GIS (P = 0.08) and the proportion of patients with a treatment response (P = 0.03) were more pronounced in the STW 5 group. Our findings suggest that the clinical effects of STW 5 in patients with FD and gastroparesis are not directly mediated by an acceleration of gastric emptying. A clear-cut correlation with symptom improvement is still lacking.

[Vienna classification of Crohn's disease: helpful or dispensable? A critical view]. / Wien-Klassifikation des Morbus Crohn: hilfreich oder verzichtbar? Eine kritische Standortbestimmung.

A short review of phenotypic classification of Crohn's disease is given. Pitfalls in a clinical system of disease classification into different phenotypes and limitations of the Vienna classification of Crohn's disease are discussed. The concept of distinctive patterns of disease "behaviour" is criticized. The disease behaviour is not a persistent phenomenon and changes in the long-term follow-up significantly. Factors not addressed in the Vienna classification but, of course, influencing presentation and progression of Crohn's disease such as influences of early childhood, smoking and use of non-steroidal anti-inflammatory drugs are mentioned. The need of the classification criterion "age" is questioned. It is criticized that the Vienna classification has (at least until now) no consequences for the management of Crohn's disease. Experimental treatment approaches follow the current genetic or microbiological hypotheses and do not consider the Vienna classification system. In view of the philosophy of science the need of phenotypic classification into subgroups, clarification of mechanisms and experimentation with drug treatments in the elaboration of disease causation is stressed. In recent years much progress has been made in clarifying Kirsner's "mysterious and multiplex" nature of inflammatory bowel disease. However, as physicians we have to focus on the "menace" of a chronic disease for the patient's life and not only to treat the hole of the patient with "biologicals" but rather to treat the whole patient in a bio-psycho-social approach.

[Contrast-enhanced "low MI real-time" sonography for the assessment of the malignancy of focal liver lesions]. / Kontrastmittelgestützte "Low-MI-Real-Time"-Sonographie zur Beurteilung der Dignität fokaler Leberläsionen.

PURPOSE: Contrast enhanced sonography using phase-inversion harmonic mode is a promising technique to detect and characterize hepatic lesions. Aim of the following study was to evaluate whether this technique can characterize liver tumors. MATERIAL AND METHODS: During January and December 2004, 46 patients with a solitary liver lesion were examined. The age of the 21 women and 25 men ranged between 37 and 82 years. The tumor size was between 8 mm and 14.5 cm. First conventional B-mode sonography and color-coded sonography were performed, followed by intravenous injection of the contrast agent SonoVue and continuous sonographic examination over 5 minutes using "low MI real-time" phase-inversion mode. The examination was video taped. The enhancement was evaluated qualitatively. RESULTS: Of the 21 malignant lesions, 20 could be correctly diagnosed as malignant. One of the malignant lesions was classified as benign. Of the 25 benign lesions, 21 could be classified correctly as benign, however, 4 lesions (2 hemangiomas, 1 adenoma, 1 teratoma) showed no enhancement in the portal and late phase and were incorrectly classified as malignant as well. CONCLUSION: Using pulse-inversion harmonic US with SonoVue, liver lesions showing an isoechoic or hyperechoic enhancement can be classified as probably benign. Further work up is necessary in case of little or no enhancement on delayed phase imaging.

[Pitfalls in contrast-enhanced liver sonography: consequences for the practice]. / Pitfalls in der kontrastverstärkten Lebersonographie: Konsequenzen für die Praxis.

Contrast-enhanced sonography performed as phase inversion harmonic imaging is a promising new technique for detection and characterization of hepatic foci. It has been reported that malignant liver tumors can be differentiated from benign entities with almost 100% sensitivity and that diagnosis of the type is possible with an accuracy of over 90%. The following report describes seven of our own cases and then compares the results we obtained with current knowledge, followed by a discussion. In summary, most hepatic lesions can be correctly characterized by supplemental use of enhanced sonography; practitioners should nevertheless be aware of atypical phenomena to be able to critically evaluate the findings.

[A consecutive study of patients with irritable bowel disease in two tertiary referral centers]. / Eine vergleichende Untersuchung zum Reizdarmsyndrom bei konsekutiven Patienten zweier internistischer Ambulanzen.

OBJECTIVES: We investigated the nature of illness behavior and the meaning of emotional deficiencies during childhood in patients with irritable bowel diseases (IBS). DATA: A consecutive study in two tertiary referral centers was conducted with 48 patients suffering from irritable bowel diseases (IBS) and 91 patients with inflammatory bowel disease (IBD). METHODS: The diagnosis of IBS was made by following the Manning criteria, a positive diagnosis of IBD was established through physical, endoscopic and radiologic examinations and was confirmed histologically. Psychological data were obtained by structured psychiatric interviews and psychological self-report measures (GBB). RESULTS: We found that the rate of physician visits given in the course of the disease, is increased for those having irritable bowel disease (IBS). These patients are dissatisfied with the physicians and prone to psychophysiological complaint. In the daily routine and in occupation they are more impaired than those with inflammatory disease. This finding emphasizes in particular that patients with irritable bowel diseases (IBS) have experienced emotional deficiencies in childhood as an after effect of loss, divorce of the parents etc. CONCLUSIONS: Implications for doctor-patient relationship and the necessity for epidemiological studies in Germany are discussed.

Impaired health-related quality of life in inflammatory bowel diseases: psychosocial impact and coping styles in a national German sample.

BACKGROUND: The purpose of this study is to give a detailed survey of the disease-specific and generic quality of life (HRQOL) of adult patients suffering from inflammatory bowel disease (IBD) in Germany. METHODS: 1322 patients suffering from IBD were examined in a cross-sectional study. A questionnaire assessing disease-specific and generic quality of life, coping, and hopelessness was sent to members of the German Crohn/Colitis association. RESULTS: Compared to the general population, the generic HRQOL in IBD patients is significantly reduced. Active coping has a negative influence on patients' generic physical HRQOL during an active phase (beta = -0.31), while this association is not present in the case of patients in remission (beta = -0.02, interaction: P = 0.0003). Depressive coping is strongly and negatively associated with assessment of the physical (beta = -0.39, P < 0.0001) and mental (beta = -0.66, P < 0.0001) HRQOL. Disease-specific burdens are mainly reported in the physical dimension. CONCLUSION: The pattern of psychosocial impact of disease in German IBD patients is largely congruent with the one observed in the USA and Canada, but shows some specific differences. The a priori unexpected finding that active coping was associated with poor HRQOL in active IBD status illustrates the importance of considering different determinants of HRQOL in terms of their mutual interaction.

Diagnosis of symptomatic intestinal metastases using transabdominal sonography and sonographically guided puncture.

OBJECTIVE. We studied the sonographic findings of symptomatic intestinal metastases and the use and safety of subsequent sonographically guided 22-gauge fine-needle aspiration or 18-gauge core biopsy. CONCLUSION. Symptomatic intestinal metastases can be diagnosed by transabdominal sonography. Extensive hypoechoic segmental bowel wall thickening with loss of stratification and intussusception can be observed. Sonographically guided fine-needle aspiration or 18-gauge core biopsy performed at the end of the examination allows definite diagnosis and is a safe procedure.

[Pyostomatitis vegetans and Crohn's disease. A specific association of 2 diseases]. / Pyostomatitis vegetans und Morbus Crohn. Eine spezifische Assoziation zweier Krankheiten.

HISTORY AND CLINICAL FINDINGS: A 27-year-old man was referred to the dermatological out-patient clinic because of inflammatory changes in the oral mucosa of unknown cause. 5 months earlier he had been diagnosed as having Crohn's disease of the terminal ileum. On both sides of the buccal mucosa there were rough erythematous vegetations and disseminated miliary abscesses, which extended to the labial gingiva and the soft palate. Further physical examination was unremarkable. INVESTIGATIONS: Several inflammatory parameters were increased: C-reactive protein 100 mg/l, erythrocyte sedimentation rate 55/88 mm, eosinophilic cationic protein 35.8 ng/ml (normal range 2.3-16 ng/ml). White cell count was normal (7,25/nl), with a lymphocytopenia of 11.9%. There was no eosinophilia. Haemoglobin was reduced to 11.6 g/dl and the platelets raised to 526/nl. Smears of the oral mucosa showed no fungal, viral or bacterial infection. Biopsy revealed leucocytic microabscesses in the epithelium, granulation tissue and flat ulcerations with adjoining superficial necrotic zones. DIAGNOSIS, TREATMENT AND COURSE: The clinical and histological picture as well as the association with Crohn's disease (CD) suggested pyostomatitis vegetans (PV). The PV was treated with disinfectant mouth washes which improved the subjective findings. Budesonide was given for CD. CONCLUSION: PV is a rare and usually isolated condition, but it can also occur in association with a chronic gastrointestinal disease such as ulcerative colitis and Crohn's disease. The diagnosis of PV indicates a thorough gastroenterological investigation.

[What is the onset of primary biliary liver cirrhosis?]. / Wie beginnt die primäre biliäre Leberzirrhose?

The medical records of 49 consecutive patients with primary biliary cirrhosis of the liver were screened for informations about medical examinations during the years before the diagnosis was established. In 15 cases previous medical reports could be found. Evidence of liver disease (slight elevation of transaminases and gamma-GT) was documented up to 18 years before the diagnosis was proven. In 6 patients liver biopsies had been performed: normal 1 x, fatty liver 1 x, fibrosis 1 x, non-specific hepatitis 1 x, chron. pers. Hep. 2 x. The characteristic increase of alkaline phosphatase often occurred within a few months. Antimitochondrial antibodies became positive independent of the beginning of cholestasis. It can be concluded that early stage primary biliary cirrhosis must be considered in patients with long standing slight elevation of liver enzymes even without cholestasis when other causes can be excluded.

[Diagnosis of pleural effusions and atelectases: sonography and radiology compared]. / Diagnostik von Pleuraergüssen und Atelektasen: Sonographie und Radiologie im Vergleich.

In a prospective study it was shown that chest ultrasonography is superior to conventional x-ray diagnosis of recumbent patients in diagnosing pleural effusion and lung atelectasis. In 110 supine radiographs we found a sensitivity of 47% and a specificity of 71% for right pleural effusions and a sensitivity of 55% and a specificity of 93% for left pleural effusions in comparison to 110 sonographic examinations. The results of supine radiographs in detection of atelectasis were less efficient: sensitivity for the right side: 7%; sensitivity for the left side: 13.5%. Hence, the knowledge of chest ultrasonographic diagnosis can improve the interpretation of supine radiographs.

[Color-coded Doppler sonography of primary and secondary liver tumors]. / Farbcodierte Dopplersonographie (FD-Sonographie) primärer und sekundärer Lebertumoren.

50 Patients with 78 focal liver lesions were examined via colour-coded Doppler system to study the vascularity of metastatic lesions and primary benign and malignant liver tumours. According to the amount of detectable colour Doppler signals, tumour vascularity was graded into 4 types. Metastases (n = 40) and cavernous haemangiomas (n = 12) seemed to be avascular with no evidence of increased vascularity (Type I/II). Conversely primary liver cancer (PLCA) (n = 7) and focal nodular hyperplasia (FNH) (n = 16) mainly produced arterial Doppler signals within the tumour (Type III/IV). AV shunts and partial portal vein thrombosis could be demonstrated in PLCA. Doppler colour flow imaging for detection of tumour vascularity may thus add to the specificity of ultrasonic tumour diagnosis.

[Echogenic splenic lesions--incidence and differential diagnosis]. / Echoreiche Milzprozesse--Häufigkeit und Differentialdiagnose.

In order to estimate the incidence and clinical relevance of echogenic focal lesions in the spleen, 121,372 ultrasound investigations from seven laboratories were evaluated. Ninety-two cases with echogenic lesions in the spleen were reviewed (incidence: 3.2 to 14.2 of 10,000 patients). Differential diagnosis included neoplastic tumors (17.4%; five metastases, three lymphomas, seven hemangiomas, one lymphangiomatosis), vascular disorders (17.4%: bleeding, infarct) and inflammatory focal lesions (8.7%; abscess, calcifications). Follow-up studies showed no change in size and pattern in a further 17.4% of the lesions, indicating benign disorders. Thirty patients suffered from a malignant condition with splenic metastasis or lymphomas in eight cases. In a further five patients, it was possible to confirm echogenic hemangiomas. There are no specific echographic patterns which differentiate hemangiomas from malignant tumors.

Mediastinal lymph node staging with transesophageal echography in cancer of the lung.

Transesophageal echography (TEE) was used prospectively to study mediastinal lymph node enlargement in 23 patients with cancer of the lung. The findings were validated blindly by comparison with computed tomography (CT, n = 23) and pathological N classification after curative surgery (n = 9). Lymph nodes larger than 1 cm were defined as pathologically enlarged. In the upper mediastinum, 22% (8 vs 36), in the lower mediastinum including the subaortic region 112% (37 vs 33) and in the hilar region 67% (6 vs 9) of enlarged lymph nodes diagnosed by CT were detected by TEE. A pathological study in 9 patients demonstrated true positive findings in 2 vs 1, true negatives in 4 vs 5, false positives in 3 vs 2 and false negatives in 0 vs 1 comparing TEE with CT. From these preliminary data, we conclude that TEE, although still experimental, is equal or superior to CT in detecting enlarged nodes in the lower mediastinum, specifically in the aortopulmonary window but clearly inferior in the upper mediastinum and the hilar region. Additional information on central tumors and infiltration of the heart or great vessels can be clarified. In addition, data on hemodynamics and cardiac status can be obtained. TEE seems to be a promising tool in the preoperative staging of lung cancer.