Endoscopy in Barrett's oesophagus: adherence to standards and neoplasia detection in the community practice versus hospital setting.

OBJECTIVE: Potential process differences between hospital and community-based endoscopy for Barrett's oesophagus have not been examined. We aimed at comparing adherence to guidelines and neoplasia detection rates in medical centres (MC) and community practices (CP). DESIGN: Retrospective analysis. SETTING: All histologically confirmed Barrett cases seen over a 3-year period in six MC and 19 CP covering a third of all upper gastrointestinal endoscopies (n = 126,000) performed annually in Berlin, Germany. MAIN OUTCOME MEASURE: Rate of relevant neoplasia (high-grade intraepithelial neoplasia or more) in both settings in relation to adherence to standards. RESULTS: Of 1317 Barrett cases, 66% were seen in CP. CP patients had a shorter mean Barrett length (2.6 cm vs. 3.8 cm; P < 0.001) with fewer biopsies taken during an examination (2.5 vs. 4.1 for Barrett length

Protective effects of hydroxyethyl starch-deferoxamine in early sepsis.

The protective effects of hydroxyethyl starch-conjugated deferoxamine (HES-DFO), a macromolecular iron chelator, on the initial pathophysiological cascade in septic shock were evaluated following cecal ligation puncture (CLP) in rats. Animals were given an intravenous dose of 3.0 mL of either vehicle (HES) or HES-DFO immediately following completion of the CLP procedure. Animals were sacrificed 30, 60, 120, and 240 min following CLP, and samples of lung, kidney, bowel, and liver were collected for subsequent analysis of glutathione, myeloperoxidase, and evidence for lipid peroxidation based on measurement of thiobarbituric acid reactive substances and conjugated dienes. In addition, the endotoxin levels were determined in the plasma and histomorphological examination was conducted on tissue samples collected at each time point. At almost all time points, a reduction in lipid peroxidation was noted in the HES-DFO-treated rats (p < .05). Glutathione and myoloperoxidase levels were less affected. Lung tissue from animals receiving HEs demonstrated marked microatelectases, septal destruction, and splicing of basal membranes, which were greatly attenuated in animals having received HES-DFO. Similarly, tubulotoxic and mitochondrial damages observed in kidney samples from HES-treated animals were noticeably reduced in the animals having received the chelator. Liver and gut samples demonstrated unspecific inflammatory injury in both groups of animals. In summary, oxygen radical-mediated tissue damage occurs rapidly following CLP-induced sepsis. Based on histological and biochemical endpoints, treatment with the polymeric iron chelator, HES-DFO, significantly attenuates systemic oxidant injury, the degree of protection being most impressive in the lung and kidney.

Oral pH-modified release budesonide versus 6-methylprednisolone in active Crohn's disease. German/Austrian Budesonide Study Group.

OBJECTIVE: Corticosteroids are effective in acute Crohn's disease (CD). The present study assessed the effectiveness and safety of oral pH-modified release budesonide (BUD) in patients with active CD in comparison with 6-methylprednisolone (MPred). DESIGN: This was a prospective multicentre, randomized, double-blind, double-dummy study. METHODS: A total of 67 patients with active CD (CDAI > 150) were included. Patients were treated with 3 x 3 mg BUD (n = 34) or MPred (n = 33) according to a weekly tapering schedule (48-32-24-20-16-12-8 mg). The primary aim was remission of CD (CDAI < 150 and decrease by at least 60 points from baseline) after eight weeks. RESULTS: Baseline demographics, disease activity and localization of CD in the small bowel and the colon were similar in both treatment groups. On an intention-to-treat basis 19/34 patients in the BUD group (55.9%) and 24/33 patients in the MPred group (72.7%) were in remission after eight weeks (P = 0.237). Therapy failed in 15/34 patients (44.1%) of the BUD group and in 9/33 patients (27.3%) of the MPred group. The mean CDAI decreased from 262 +/- 50 to 118 +/- 69 in the BUD-group and from 262 +/- 81 to 95 +/- 61 in the Mored group (P = 0.183, final CDAI BUD vs. MPred). Steroid-related side effects appeared in 28.6% of the patients in the BUD group and in 69.7% of the patients in the Mored group (P = 0.0015). CONCLUSIONS: Oral pH-modified release budesonide (3 x 3 mg/day) is almost as effective as a conventional corticosteroid in patients with active CD but causes significantly less corticosteroid-related side effects.

[Visualization of the pancreatic ducts by ultrasound tomography in pancreatic diseases with bile duct obstruction]. / Pankreasgangdarstellung durch Ultraschalltomographie bei Pankreaserkrankungen mit Gallenwegsverschluss.

The sonographic findings in 274 patients with biliary obstruction and/or dilatation of the pancreatic duct of more than 4 mm were evaluated (128 common duct stones, 82 carcinoma of pancreas, 64 chronic pancreatitis). Carcinoma of the pancreatic head caused a greater degree of dilatation of the common bile duct (average diameter 18.3 mm) than did chronic pancreatitis (10.5 mm) or biliary stones (14.2 mm). Dilatation of the pancreatic duct greater than 4 mm occurred with approximately equal frequency with carcinomas (59%) and chronic pancreatitis (64%); it was found in only 1.6% of biliary duct stones. Dilatation of intra-and extra-hepatic bile ducts and hydrops of the gall bladder was significantly higher with carcinoma of the pancreas than in chronic pancreatitis.

A new oscillating saw for robotic aided surgery.

In this paper a brief description of a computer and robotic aided surgery system is given with a detailed overview of the necessity to develop special tools for robotic surgery. The application range of this robotic system has been specially focused on the orthopaedics field and, more particularly, on the execution of osteotomies. It was therefore necessary to develop a new saw device which would meet medical and--from the robot system point of view--mechanical as well as functional requirements. After describing the device which was developed on the basis of these requirements, a detailed comparative study of off-the-shelf oscillating saws and the new device is given at the end of the paper.

Intraoperative guidance in maxillofacial and craniofacial surgery.

The authors' experiences with intraoperative computer assisted guidance in interventions in oromaxillofacial and craniofacial surgery are reported. The guidance system SPOCS (Surgical Planning and Orientation Computer Systems, Aesculap, Germany) consists of an infrared light emitting system of diodes and camera, an imaging workstation and assorted freehand instruments. The software is an updated version of the well-known Viewing Wand software (ISG Technologies, Canada). In tests on phantoms, the system proved a mean accuracy of less than 1.5 mm. Within the last 15 clinical tests, the system has achieved an accuracy better than 3 mm which, at the moment, the authors estimate to be sufficient to proceed with its clinical evaluation. Using bone screws to register the patient's position, an accuracy in the range of less than 2 mm in relation to bony reference points has been achieved. By visualizing the tip of the instrument in real time, this technique allows surgical interventions, even in anatomically complicated situations, without endangering vital neighbouring structures. The 'offset' function of the software, by which the surgeon can elongate the tip of the instrument virtually, allows the surgeon to analyse structures before they are penetrated by the instrument as in a 'look ahead' operation. The authors expect computer assisted simulation and guidance systems to improve surgical quality and reduce the risks associated with surgical interventions.

StratomeX: Visual Analysis of Large-Scale Heterogeneous Genomics Data for Cancer Subtype Characterization.

Identification and characterization of cancer subtypes are important areas of research that are based on the integrated analysis of multiple heterogeneous genomics datasets. Since there are no tools supporting this process, much of this work is done using ad-hoc scripts and static plots, which is inefficient and limits visual exploration of the data. To address this, we have developed StratomeX, an integrative visualization tool that allows investigators to explore the relationships of candidate subtypes across multiple genomic data types such as gene expression, DNA methylation, or copy number data. StratomeX represents datasets as columns and subtypes as bricks in these columns. Ribbons between the columns connect bricks to show subtype relationships across datasets. Drill-down features enable detailed exploration. StratomeX provides insights into the functional and clinical implications of candidate subtypes by employing small multiples, which allow investigators to assess the effect of subtypes on molecular pathways or outcomes such as patient survival. As the configuration of viewing parameters in such a multi-dataset, multi-view scenario is complex, we propose a meta visualization and configuration interface for dataset dependencies and data-view relationships. StratomeX is developed in close collaboration with domain experts. We describe case studies that illustrate how investigators used the tool to explore subtypes in large datasets and demonstrate how they efficiently replicated findings from the literature and gained new insights into the data.

Point-Based Visualization for Large Hierarchies.

Space-filling layout techniques for tree representations are frequently used when the available screen space is small or the data set is large. In this paper, we propose an efficient approach to space-filling tree representations that uses mechanisms from the point-based rendering paradigm. We present helpful interaction techniques and visual cues that tie in with our layout. Additionally, we relate this new layout approach to common layout mechanisms and evaluate the new layout along the lines of a numerical evaluation using the measures of the Ink-Paper Ratio and overplotted%, and in a preliminary user study. The flexibility of the general approach is illustrated by several enhancements of the basic layout, as well as its usage within the context of two software frameworks from different application fields.

The Design Space of Implicit Hierarchy Visualization: A Survey.

Apart from explicit node-link representations, implicit visualizations and especially the Treemap as their frontrunner have acquired a solid position among the available techniques to visualize hierarchies. Their advantage is a highly space-efficient graphical representation that does not require explicit drawing of edges. In this paper, we survey the design space for this class of visualization techniques. We establish the design space along the four axes of dimensionality, edge representation, node representation, and layout by examining existing implicit hierarchy visualization techniques. The survey is completed by casting some light into regions of the design space that have not yet been explored. Our design space is not a mere theoretical construct, but a practically usable tool for rapid visualization development. To that end, we discuss a software implementation of the introduced design space.

[Dysplasia and carcinoma in situ of the pancreatic duct epithelium]. / Dysplasie und Carcinoma in situ des Pankreasgangepithels.

Histopathologic aspects of metaplasia, dysplasia and carcinoma in situ of the pancreas are described and diagnostic difficulties discussed. Morphological lesions of the pancreatic ducts were studied in 200 control autopsy cases, and in 85 clinical cases with primary pancreatic carcinoma. The following groups of morphologic lesions can be differentiated with sufficient reliability: normal ductepithelium, metaplasia and hyperplasia; mild and moderate epithelial dysplasia; severe dysplasia including carcinoma in situ; invasive ductal/ductular carcinoma. Important for a reliable diagnosis are good specimens and good histological sections. Severe dysplasia including carcinoma in situ in areas surrounding invasive carcinomas as well as isolated severe dysplasia herald a high risk of progressive tumor disease for the patient.

[The TNM classification of pancreas cancer]. / TNM-Klassifikation des Pankreaskarzinoms.

According to the TNM-System classification for the cancer of pancreas 331 subjects were collected. Some important factors were associated with the survival time of patients, i.g. the localization, the size and the histological type of tumors. It is well known that when distant metastases are found, only a palliative operation is possible while metastases in the regional lymph nodes are considered as a critical moment of the treatment of this disease. Teamwork is strongly recommended between the surgeon and pathologist to achieve better results as it is presented by classification. Following this fact it is possible to determine accurately the actual stage of any cancer of pancreas. As a result of the present findings it should be suggested to establish comparable and standardised programs for the treatment of pancreatic cancer.

[Pathogenetic correlation between chronic pancreatitis and pancreatic carcinoma]. / Uber pathogenetische Wechselbeziehungen zwischen chronischer Pankreatitis und Pankreaskarzinom.

The autopsy material from the Institute of Pathology of the Faculty of Medicine of the Humboldt University (Charité) in Berlin for the years 1970 to 1984 was analyzed with respect to the presence of pancreatic carcinoma and a long history of chronic, non-obstructive pancreatitis. A total of 20,515 adult sections were reviewed. 331 (1.6%) of these had carcinoma of the exocrine pancreas. 75 pancreata were dissected in tail-to-head direction into 10 blocks. In 12 (16%) of them a chronic non-obstructive pancreatitis or pancreatic scarring as a result of pancreatitis could be demonstrated histologically. The possibility of a relationship between pancreatitis and pancreatic carcinoma is considered, in particular with respect to pre-malignant changes and latency of the latter. Comprehensive analysis and evaluation of the present study material, together with a critical evaluation of the literature, support the viewpoint that long-term, chronic pancreatitis and pancreatic carcinoma have a common pathogenic basis and that chronic pancreatitis may be regarded as an antecedent event for the neoplasm.

[Duct-oriented classification of exocrine pancreatic carcinoma]. / Gangorientierte Klassifikation der exokrinen Pankreaskarzinome.

Histogenetic classification was applied to 416 cases of human exocrine pancreas carcinoma. Fundamental importance was attributed, in that context, to duct-associated histogenesis. A distinction was, therefore, made between ductal and ductular pancreas carcinomas. Invasive ductal carcinomas were subdivided by three categories: highly stromatous classical adenocarcinoma with poor prognosis, invasive ductal carcinoma with further differentiation (myxoma, squamous carcinoma, pleomorphous macrocellular and parvicellular types), and variations with specific differentiation (serous, mucinous tumours) with good prognosis. Invasive ductular carcinomas were subdivided by terminal non-papillary adenocarcinoma with protracted illness, ciliary adenocarcinoma, microglandular adenocarcinoma, ductulo-acinous tumour with excellent prognosis, and oncocytic carcinoma. These should be distinguished from intermediary cells with cellular transformation and neoplastic differentiation, such as adenocarcinoma with hepatocellular differentiation and mixed tumours (exocrine and endocrine) with alternatingly predominant cell spectra. Determination of prognostically differentiated tumours types is considered to be an indispensable prerequisite for adequately adjusted effective therapy. This appears to be the only approach which promises progress for the future.

[Endoscopic papillotomy in the treatment of choledocholithiasis--technic, indications, results]. / Endoskopische Papillotomie (EPT) zur Behandlung der Choledocholithiasis-Technik, Indikationen, Ergebnisse.

UNLABELLED: Endoscopic papillotomy (EPT) has good short- and long-term results in the non-operative treatment of common bile duct stones. Advantages are low risk, short hospital stay and short unfit to work. On the basis of the literature and own experiences that derive from 2,500 EPT the author discusses preparation, technique, indications, contraindications, complications, and results of the procedure. EPT successfully had been performed in 98.3% of cases. All bile duct stones could be removed in 92%. INDICATIONS: choledocholithiasis 2013 (456 with gallbladder in situ, 24 with acute biliary pancreatitis), benign papillary stenosis 125, papillary carcinoma 57, other indications 305. COMPLICATIONS: 4.6% (115); bleeding 36, pancreatitis 36, cholangitis/stone impaction 30, retroduodenal perforation 13; urgent operation 1.2% (30), mortality 0.5% (12).

[Lesions of the pancreatic duct epithelium and histogenesis of exocrine pancreatic carcinomas]. / Pankreasgangepithelläsionen und Histogenese des exokrinen Pankreaskarzinoms.

The bad prognosis of exocrine pancreas carcinoma manifests itself by a high incidence of recidivation, early metastasis formation and a low 5-year survival rate of 1-2% on an average has not essentially been improved in recent times although progress is evident in diagnosis as well as in surgical, radiological and cytostatic therapy. The unfavourable course of illnesses is due to the symptomless early phase rather than the existing diagnostic potential. Thus, a recording, standardization and definition of pancreatic duct atypias is a necessity for optimizing the pattern of examinations. Topographically, the structure of pancreatic parenchyma may be classified by 1) interlobular ducts; 2) intralobular ducts; 3) intercalated ducts; 4) centroacinar cells, and 5) acinar cells. Based on this matrix, entities of varying diagnostic relevance may be derived, i.e. 1) orthological histiomorphological tissue formations; 2) hyperplastic epithelial changes; 3) metaplastic epithelial formations; and 4) atypical hyperplasias. Beyond this, there are numerous indications of a redifferentiation of numerous pancreatic cell types, primarily of acinar cells. The close relationships between ductal and acinar cells may be subsumed as a terminal ductulo-acinar intercalated duct complex. Against the background of chronic pancreatitis and corresponding length of history (< 6.5 years), cancer may develop in up to 16% of cases. On the molecularbiological level, point mutations of the K-ras gene, a mutation or deletion of the p53 suppressor gene and an excess production of the c-erbB-2 protooncogene are found in a great number of pancreatic carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histogenetic classification of exocrine pancreatic carcinomas]. / Histogenetische Einteilung der exokrinen Pankreaskarzinome.

The structures of normal ductal and ductular epithelium were compared with cytological peculiarities of pancreas carcinoma. This provided the basis on which to propose histogenetic classification of exocrine pancreas carcinoma. Most of the pancreas carcinomas are adenocarcinomas and originate from small lateral ductules. Preneoplastic ductal alterations, such as proliferation of ductal epithelium, adenomatous dysplasia, and light-cell transformation, may be topographically distinguished from ductular changes, including centroacinic hyperplasia, oncocytic transformation, microglandular metaplasia, ductulo-acinic metaplasia, hepatocellular metaplasia, and peri-insular metaplasia. The close correlations that exist between ductular and acinic cells may be summarised under the cover term of terminal ductulo-acinic intercalated duct complex. Dysplasia is generally accompanied by decline in neutral glycosaminoglycans and occurrence of unsubstituted sialomucin of the embryonic type.

[Neuroendocrine system and its tumors]. / Neuroendokrines System mit seinen Tumoren.

The original classification of neuroendocrine tumours proposed by Pearse was based on a common embryologic origin in the neuroectoderm. The term, carcinoid, literally means carcinoma-like, was coined in 1907 to describe the histologic similarity of these tumors to carcinomas on the one hand and their generally indolent biologic behaviour on the other hand. Neuroendocrine tumours represent a group with complex biological, histological, ultrastructural and immunocytochemical properties. This concept was replaced by another classification based on results of modern techniques (electron microscopy, immunocytochemistry, molecular and DNA analyses). This permits a more reliable classification of tumours, that can be used to determine their biological behaviour and prognosis.

[Acute pancreatitis--etiology, pathological anatomy and pathogenesis]. / Akute Pankreatitis--Atiologie, pathologische Anatomie und Pathogenese.

Acute pancreatitis is a disease characterized by abdominal pain, low-grade fever, abdominal tenderness and rigidity, and moderate elevation of the white blood cell count. A widely used revised classification of pancreatitis is that proposed in 1984 at Marseille. It only distinguishes between acute and chronic pancreatitis. In 61 cases were 40 men and 21 women. The mean age in the total series was 52.5 years. The etiology of the acute condition was alcoholism in 32.8% and biliary tract disease in 23%. In 9.8% the acute pancreatitis is associated with alimentary tract diseases (adipositas, hyperlipidemia). The severity of acute pancreatitis is pathological anatomy determined by three stages. In pathogenesis the process of digestion is caused by activated pancreatic enzyme with acinar cell injury. The acinar cell is normally protected from the action of its own enzymes by elaborate intracellular compartmentation of enzymes. Acute pancreatitis is triggered by pancreatic phospholipase A leading to necrosis of lipolytically active fat cells with release of membrane-toxic fatty acids with following destruction of adjacent tissue. Fat necrosis initiates an acute inflammatory reaction with immigration of granulocytes and liberation of kinins, which activate pancreatic enzyme. Pancreatic enzymes are similar to lysosomal enzymes with regard to substrate specificity. Activation will be also triggered by lysosomal enzymes of necrotic acinar cells.