[Suicide attempt by means of phenobarbital overdose. Effective treatment with continuous veno-venous hemodialysis]. / Phenobarbitalintoxikation in suizidaler Absicht. Kontinuierliche venovenöse Hämodialyse als effektive Therapie.

A 68-year-old woman tried to commit suicide using phenobarbital, which was initially prescribed for her dog that suffered from seizures. At admission she was unconscious and ventilated. Five days of intensive care therapy did not improve her state of consciousness. Subsequent continuous veno-venous hemodialysis accelerated the elimination of phenobarbital compared to endogenous elimination by a factor of five. The patient survived without sequelae. Detailed history taking and well-timed indication for dialysis were crucial.

Hepatic lesions in an elderly woman - cancer isn't always the answer.

Multiple hepatic lesions in an elderly woman usually suggest metastatic malignant disease, in most situations already beyond cure. However, we present the case of an 81-year-old female in whom histopathology verified granulomas and PCR proved hepatic tuberculosis. Tuberculostatic quadruple therapy resulted in complete remission. Isolated hepatic tuberculosis is rare, especially in HIV-negative subjects living in areas of low tuberculosis prevalence. This case highlights the need to histopathologically confirm malignancy as withholding therapy would have been deleterious in this curable patient.

[Medicinal prevention of gastrointestinal tumors: aspirin, Helicobacter and more?]. / Medikamentöse Prävention gastrointestinaler Tumoren: Aspirin, Helicobacter und mehr?

Despite the huge number of drugs on the market and recent advances in pharmacotherapy, only a few substances are available for the prevention of gastrointestinal tumors--most of which are not approved for this indication or not validated in appropriately designed randomized trials. General recommendations include lifestyle modifications such as avoidance of smoking, only moderate consumption of alcohol, regular physical exercise and a nutrition rich in fresh fruits and vegetables with limited meat. A global eradication therapy for Helicobacter pylori would be desirable to prevent gastric carcinoma, but this does not seem feasible from the socio-economic point of view. Therefore, at least patients at high risk should be screened and this pathogen eradicated, preferentially in their youth. Hepatitis B vaccination of newborns to prevent the development of hepatocellular carcinoma has already been established in Germany; a specific antiviral therapy should be offered to all patients with hepatitis B or C infections, taking into consideration the risks associated with this treatment. The use of non-steroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal malignancies cannot generally be recommended and should be restricted to patients at high risk and to clinical studies. However, the appropriate substance, dose and duration of NSAID therapy are still being debated.

Acetylsalicylic acid enhances antiproliferative effects of the EGFR inhibitor gefitinib in the absence of activating mutations in gastric cancer.

The epidermal growth factor receptor (EGFR) is highly expressed in gastric cancer indicating its suitability as a target for receptor tyrosine kinase (RTK) inhibitors. In the current study we explored the role of EGFR and its potential use as a therapeutic target in gastric cancer. First we analyzed 66 gastric cancer samples of Asian and Caucasian patients for the presence of EGFR mutations. No activating EGFR mutations were found and gefitinib alone was only weakly effective in gastric cancer cell lines. However, acetylsalicylic acid (ASA) significantly enhanced the inhibitory effects of gefitinib indicating synergistic action. Whole genome expression profiling indicated significant regulation of 120 genes in the case of co-administration of gefitinib and ASA (32 induced, 88 repressed) in gastric adenocarcinoma cells. Further analyses indicated that several important signalling pathways were effectively inhibited by simultaneous exposure to gefitinib and ASA. Our findings indicate that although gastric cancer does not seem to harbour mutations which render the cancer cells constitutively susceptible to gefitinib, the co-administration of ASA can strengthen RTK inhibitor activity in adenocarcinoma cells by EGFR activation. This is the first report of effective modulation of EGFR-inhibition activity in cancer.

Role of receptor tyrosine kinases in gastric cancer: new targets for a selective therapy.

Receptor tyrosine kinases (RTKs) such as the epidermal growth factor receptor family participate in several steps of tumor formation including proliferation and metastatic spread. Several known RTKs are upregulated in gastric cancer being prime targets of a tailored therapy. Only preliminary data exist, however, on the use of the currently clinically available drugs such as trastuzumab, cetuximab, bevacizumab, gefitinib, erlotinib, and imatinib in the setting of gastric cancer. Preclinical data suggest a potential benefit of their use, especially in combination with "conventional" cytostatic therapy. This review summarizes the current knowledge about their use in cancer therapy as well as new approaches and drugs to optimize treatment success.

Gastric electrical stimulation results in improved metabolic control in diabetic patients suffering from gastroparesis.

AIMS/HYPOTHESIS: Symptoms of gastroparesis possess a heavy impact on the quality of life; delayed gastric emptying may result in poor metabolic control in diabetics. Gastric electrical stimulation (GES) has recently been introduced as a treatment option in patients with drug refractory gastroparesis to increase the quality of life by alleviating nausea and vomiting frequencies. However, the effect of GES on metabolic control has not been assessed yet. METHODS: We performed a prospective single center study on the long-term effect (12 months) of continuous high-frequency/low-energy GES on symptoms, gastric emptying (measured scintigraphically), and metabolic control (HbA1c) in insulin-dependent diabetic subjects suffering from drug-refractory gastroparesis for more than one year. RESULTS: Seventeen (12 female, 5 male) patients entered the study; all were available for analysis at all time points. No therapy-associated adverse events occurred. Weekly vomiting and nausea frequencies decreased significantly at 6 and 12 months. Gastric retention rates improved significantly from 83 % (2 h) and 38 % (4 h) to 35 % (2 h)/14 % (4 h) and 25 % (2 h)/17 % (4 h) at 6 and 12 months, respectively. HbA1c values were lowered in all 17 subjects; initially, all HbA1c values were above 7.5 %; at 6 and 12 months, mean values had significantly decreased from 8.6 % to 6.2 % and 6.5 %, respectively. CONCLUSIONS/INTERPRETATION: Gastric electrical stimulation offers symptom control in diabetics with drug-refractory gastroparesis and decreases gastric retention. This study, for the first time, documents a positive effect of this therapy on metabolic control as indicated by HbA1c, a surrogate marker of the risk of diabetic complications.

Biological in vitro effects of fibrin glue: fibroblast proliferation, expression and binding of growth factors.

BACKGROUND: Fibrin glue is used in the endoscopic therapy of bleeding ulcerations. Accelerated closure of ulcers has been documented for this treatment in comparison with other injection techniques; the biological reason, however, remains unclear. METHODS: In an in vitro model the effects of fibrin glue on the expression and secretion of growth factors by gastric epithelial (AGS, KATO III) and mesenchymal cells (fibroblasts) as well as their proliferative response and their interaction were compared with those of other matrices. RESULTS: Native fibrin glue does not release vascular endothelial growth factor (VEGF) but is able to bind this growth factor in biologically relevant concentrations of 152.6 pg/mL. The addition of fibrin glue to a collagen type I matrix led to an increased proliferation rate of gastric wall fibroblasts. The transcription of VEGF and platelet-derived growth factor (PDGF) mRNA was significantly increased in epithelial cells. Co-culture of fibroblasts grown on fibrin glue containing matrix and epithelial cells resulted in an increased secretion of VEGF by both cell lines. CONCLUSIONS: Fibrin glue leads to increased proliferation of fibroblasts and local accumulation of VEGF. These findings might at least partly explain the accelerated closure of bleeding ulcers treated by fibrin glue injection.

[An unusual cause of dysphagia]. / Ungewöhnliche Ursache einer Dysphagie.

HISTORY AND ADMISSION FINDINGS: We report the case of a 79-year old male patient with progressive dysphagia 9 years after resection of an adenocarcinoma of the esophagus. The patient presented with cachexia and a weight loss of 10 kg within the last 10 weeks. He was unable to swallow solids and liquids. 6 weeks before he had suffered from pneumonia caused by aspiration. Two previously performed gastroscopic examinations had documented a stenosis of the anastomosis which was passed by the endoscope. Tissue specimens taken from the stenosis showed high-grade dysplasia. INVESTIGATIONS: Computed tomography of the thorax documented a stenosis of the esophagus with prestenotic dilatation and intraluminal food. There were no signs indicating local recurrence of the tumor such as transmural lesions. DIAGNOSIS, TREATMENT AND COURSE: Endoscopic examination showed an impacted foreign body measuring 2 x 4 cm which was be extracted. Extracorporeal inspection of this foreign body revealed it to be a dried apricot. After retaking the history, the patient was able to date the time of ingestion to have been three months earlier, shortly before his dysphagia had started. After extraction of the foreign body dysphagia resolved and the patient gained weight. CONCLUSION: Ingestion of foreign bodies or a food bolus may occur unnoticed on rare occasions and even large ones may remain undiagnosed despite repeated endoscopic examinations.

Spontaneous flow of bile through the human pancreatic duct in the absence of pancreatitis: nature's human experiment.

One hundred years ago E. L. Opie proposed two distinct hypotheses to address the pathogenesis of gallstone-induced pancreatitis. These hypotheses appear mutually exclusive. The first predicts that impediment to the flow of pancreatic juice causes pancreatitis (the pancreatic duct obstruction hypothesis), whereas the second predicts that bile flow into the pancreatic duct behind an impacted gallstone would trigger the onset of acute pancreatitis (the common-channel hypothesis). One of the more convincing arguments against the latter hypothesis is the observation that bile, when experimentally perfused through the pancreatic duct of dogs, does not induce pancreatitis. This experimental situation had spontaneously developed in the patient we describe here: a biliopancreatic fistula had permitted the continuous flow of bile through a large portion of the pancreas, which was associated with cholangitis but had apparently never led to pancreatitis. This patient's case would suggest that in humans, just as in experimental animals, bile flow through the pancreatic duct is not necessarily involved in the onset of gallstone-induced pancreatitis and lends further support to Opie's pancreatic duct obstruction hypothesis.

Dynamics and localization of activin A expression in rat gastric ulcers.

BACKGROUND: Activin A, the homodimer of the activin/inhibin betaA subunit, has been shown to participate in cutaneous wound healing. In this study we intended to determine its part in gastric ulceration. METHODS: Activin A expression was studied by immunohistochemistry and in situ hybridization in acetic-acid-induced chronic gastric ulcers in rat. The dynamics of this process were also assessed by quantitative real time RT-PCR and RNase protection assays (RPA). The effects of different doses of this cytokine on epithelial and mesenchymal cell proliferation were quantitated in vitro. RESULTS: Low amounts of activin A and its mRNA were expressed by epithelia, endothelia and fibroblasts in intact gastric tissue. Granulation tissue of gastric ulcers and gastric glands adjacent to the ulcer rim expressed markedly increased amounts of activin protein as well as activin/inhibin betaA mRNA. RPA and RT-PCR studies revealed a more than 3-fold increase in the relative abundance of this mRNA. Activin A did not affect the proliferation rate of fibroblasts and epithelial cells in vitro. CONCLUSIONS: Activin A participates in gastric ulcer healing in a similar fashion as in cutaneous wounding. Its expression on protein and mRNA level is markedly increased in ulcer base and rim.

Deep brain stimulation of the centre median-parafascicular complex in patients with movement disorders.

The centre median-parafascicular (CM-Pf) complex of the thalamus is considered to be a possible target for deep brain stimulation (DBS) in patients with movement disorders. In a prospective study on the effect of CM-Pf DBS versus somatosensory thalamic DBS on chronic neuropathic pain, three of 12 patients had additional movement disorders. Bifocal quadripolar electrodes were implanted by computed tomography guided stereotactic surgery under local anaesthesia contralaterally to the side of the pain for test stimulation. Two of the three patients with movement disorders had permanent implantation of CM-Pf electrodes. During test stimulation of the left CM-Pf complex for several days, a 67 year old woman received no benefit with respect to the neuropathic pain, but the choreoathetotic movements of her right foot ceased. As the pain syndrome was not improved, she decided not to have permanent implantation. A 74 year old man with postzoster neuralgia and allodynia enjoyed excellent relief from his pain with chronic CM-Pf DBS. In addition, improvement in the tremor at rest was noted. A 72 year old man had sustained reduction in his stump dyskinesias. Further evaluation of the possible role of the "forgotten" central and medial thalamic nuclei in the treatment of movement disorders may be warranted.

Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy.

OBJECTIVES: Surgical treatment of complex cervical dystonia and of cervical dyskinesias associated with cervical myelopathy is challenging. In this prospective study, the long term effect of chronic pallidal stimulation in cervical dystonia and on combining the technique with spinal surgery in patients with severe cervical dyskinesias and secondary cervical myelopathy is described. METHODS: Eight patients with a history of chronic dystonia who did not achieve adequate benefit from medical treatment or botulinum toxin injection participated in the study. Five patients had complex cervical dystonia with tonic postures and phasic movements. Three patients had rapidly progressive cervical myelopathy secondary to severe cervical dyskinesias and dystonia in the context of a generalised movement disorder. Quadripolar electrodes were implanted in the posteroventral lateral globus pallidus internus with stereotactic CT and microelectrode guidance. In the three patients with secondary cervical myelopathy, spinal surgery was performed within a few weeks and included multilevel laminectomies and a four level cervical corporectomy with spinal stabilisation. RESULTS: Improvement of the movement disorder was noted early after pallidal surgery, but the full benefit could be appreciated only with a delay of several months during chronic stimulation. Three months after surgery, patients with cervical dystonia had improved by 38% in the severity score, by 54% in the disability score, and by 38% in the pain score of a modified version of the Toronto western spasmodic torticollis rating scale. At a mean follow up of 20 months, the severity score had improved by 63%, the disability score by 69%, and the pain score by 50% compared with preoperatively. There was also sustained amelioration of cervical dyskinesias in the three patients who underwent spinal surgery. Lead fractures occurred in two patients. The mean amplitude needed for chronic deep brain stimulation was 3.8 V at a mean pulse width of 210 micros, which is higher than that used for pallidal stimulation in Parkinson's disease. CONCLUSIONS: Chronic pallidal stimulation is effective for complex cervical dystonia and it is a useful adjunct in patients with cervical dyskinesias and secondary cervical myelopathy who undergo spinal surgery.

Arterioportal fistula: a rare cause of portal hypertension and abdominal pain.

Esophageal varices are commonly caused by portal hypertension secondary to cirrhosis. We report the case of a 71-year-old woman who presented with esophageal variceal bleeding due to portal hypertension caused by an arteriovenous fistula. The fistula, which was probably brought about by a liver biopsy performed 18 years previously, was complicated by bleeding. Since this event, the patient has reported right upper quadrant pain. Embolization resulted in elimination of the varices as well as abdominal discomfort.

Deactivation of thalamocortical activity is responsible for suppression of parkinsonian tremor by thalamic stimulation: a 99mTc-ECD SPECT study.

Four patients with Parkinson's disease (PD) achieved excellent improvement of their unilateral tremor by chronic deep brain stimulation (DBS) of the contralateral ventral intermediate (Vim) nucleus of the thalamus. Repeated measurements of cerebral blood flow were obtained 14 days apart off and on stimulation using 99mTc-ECD SPECT. Subjects were scanned at rest and the data were compared with those of normal healthy volunteers. During stimulation, there were highly significant deactivations in the motor area and supplementary motor area on the electrode side and in the prefrontal area and the anterior cingulum bilaterally. No cerebellar deactivation was detected. We conclude that the mechanism responsible for suppression of parkinsonian tremor by thalamic stimulation is deactivation of thalamocortical activity.

Remodeling of extracellular matrix in gastric ulceration.

The quality of ulcer repair remains crucial for the stability of the injured tissue and for preventing recurrence. Therefore, we studied the temporo-spatial expression of the fibrillar and basement membrane collagens (types I, III, and IV), the collagenase MMP-2 as well as its inhibitor TIMP-1 before and after oral administration of basic fibroblast growth factor (b-FGF) over 30 days in acetic acid-induced rat gastric ulcers. The alterations and the exact location of the mRNA transcripts and their precipitated proteins were visualized by means of radioactive in situ hybridization and immunohistochemistry. Our data show that hybridization signals of procollagen I could first be identified 2 hours after ulcer induction. After 12 hours the ulcer was established and the mRNA was enhanced at the ulcer margin. After 24-48 hours the other procollagen transcripts were detected and all were further upregulated over the mesenchymal cells of all gastric layers up to 21 days, then declined at 30 days. In contrast, MMP-2 became prominent after 48 hours and up to 21 days. TIMP-1 was enhanced at 72 hours. After oral administration of b-FGF the transcriptional activity of the procollagens and MMP-2 was not significantly altered, while ulcer diameter was significantly reduced. We conclude that the early onset and long duration of collagens' expression points to their central structural and functional role in gastric ulcer healing. MMP-2 seems to be involved in both active ulceration and ECM remodeling. The timing of TIMP/MMP expression may be critical for proper restoration of gastric wall integrity.

Expression of decorin and biglycan in rat gastric tissue: effects of ulceration and basic fibroblast growth factor.

BACKGROUND: The small chondroitin/dermatan sulphate proteoglycans decorin and biglycan participate in organizing the network of collagen fibrils and interact with non-collagenous matrix proteins. In addition, via interactions with cytokines they are directly or indirectly involved in signalling, growth and cell differentiation. We aimed to analyse their expression in normal gastric tissue and during gastric ulcer healing. METHODS: Proteoglycan expression was studied by immunohistochemistry and in situ hybridization in acetic acid-induced gastric ulcers in rat during early phases and during chronic ulceration. The effects of treatment with an acid stable mutein of FGF-2 (bFGF) were also studied. RESULTS: In normal gastric tissue, both proteoglycans were most strongly expressed in the submucosal layer. However, some epithelial cells were positive for biglycan and, surprisingly, also for decorin. In the early phase after ulcer induction exclusively decorin became induced in the muscularis mucosae, while biglycan became detectable in this layer only after 2 weeks. There was no up-regulation of either proteoglycan in other layers, nor could an effect of FGF-2 treatment be seen. CONCLUSIONS: The expression of decorin could be observed for the first time in epithelial cells. Decorin, but not biglycan, appears as an early phase reactant in the muscularis mucosae in accordance with its putative role during angiogenesis and the prevention of apoptosis.