Early internationalization of students in a German medical school in the former German Democratic Republic.

The growing influence and importance of internationalization in higher education, especially in medical education, inspired anatomists at Columbia University New York, USA and at the Martin Luther University Halle-Wittenberg, Germany, to start a novel international preclinical collaboration project. As part of the anatomy dissection course a group of volunteer medical students from Halle dissected selected areas of the human body with the help of an English, illustrated, iPad-run dissection script (American Dissector). Meanwhile the rest of the students worked with a traditional German text-based dissector. Additionally, participating German students were matched with US students, with whom they connected via video-conferencing and discussed subjects like differences between their health care systems, structure and content of the anatomy course and the differences in their medical education systems. Questionnaires were sent for feedback and checklists confirmed dissection findings. Results indicated that the American Dissector was successfully shared internationally. The majority (62%) found it easier to find structures using the American Dissector compared to the standard dissector and also 62% needed the atlas two times less when using the American Dissector. Furthermore, students enjoyed their interaction with their international peers and the vast majority (77%) wished there were more interactions like this in the medical curriculum. This publication describes an approach to embed internationalization in the preclinical medical curriculum based in the gross anatomy course in a German Medical school, located in East Germany. Considering its history as a former German Democratic Republic faculty this is a meaningful step towardglobalization of medical education in this part of Germany.

Malignant peritoneal mesothelioma with mimicry of pseudomyxoma peritonei in a patient with a history of perforated sigmadiverticulitis.

We describe a 57-year-old man who presented with diffuse abdominal pain, abdominal enlargement, vomitus, dyspnea and a weight loss of 30 kg within 6 months. These acute symptoms were preceded by an episode of ascites and an acute sigmadiverticulitis 7 months ago. Ultrasonography and computed tomography were suggestive of pseudomyxoma peritonei. However, malignant mesothelioma peritonei was diagnosed by open surgery with biopsy for histological examination. Despite R-2-resection of the tumor and following open hyperthermic intraperitoneal chemotherapy with initial remarkable recovery the patient died 5 months after therapeutical intervention. Malignant peritoneal mesothelioma is an extremely rare tumor with great diagnostic and therapeutic difficulties. We report a case including diagnostical work up and the medical surgical therapy of this disease.

Uncommon metastasis of a glioblastoma multiforme in liver and spleen.

A case of a glioblastoma multiforme is presented. Craniotomy was performed with total resection of the right temporal tumor. Postoperatively, the patient received adjuvant radiotherapy, but 6 months after therapy he developed severe nausea and weight loss. Recurrence of an intracranial tumor in the right temporal region with nodules in the liver and spleen were detected by CT scan. Fine-needle biopsies of the liver confirmed the diagnosis of a glioblastoma metastasis with characteristic immunohistochemical staining for glial fibrillary acidic protein. This rare case of an intracerebral glioblastoma metastasizing to liver and spleen was managed by systemic chemotherapy.

[Graves ophthalmopathy and ocular myasthenia]. / Basedow-Ophthalmopathie und okuläre Myasthenie.

BACKGROUND: An 18-year-old woman presented with thyrotoxic symptoms - right sided lid retraction and exophthalmus. She complained of diplopia on lateral gaze. Laboratory investigations confirmed Grave's disease with hyperthyroidism and TSH receptor antibodies. PATIENTS AND METHODS: Her clinical symptoms improved after thyrostatic and steroid therapy. However, diplopia recurred 2 weeks after withdrawal of steroid therapy and a ptosis of the left lid appeared for the first time. RESULTS: A positive Tensilon test and electromyographic findings confirmed the diagnosis of myasthenia gravis with a predominantly ocular manifestation. Diplopia and ptosis improved with oral pyridostigmine. CONCLUSIONS: The coexistence of myasthenia gravis should be taken into consideration in the management of patients with Graves' ophthalmopathy.

Pitfall: a pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss.

A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm.

Cytokine and low-level nitric oxide prestimulation block p53 accumulation and apoptosis of RAW 264.7 macrophages.

Nitric oxide causes apoptotic cell death in RAW 264.7 macrophages. The cellular response to the NO donor S-nitrosoglutathione (GSNO) comprises an apoptotic morphology and DNA fragmentation, which largely depends on the accumulation of the tumor suppressor gene product p53. Pre-treatment of macrophages with LPS, IFN-gamma in the presence of NG-monomethyl-L-arginine (NMMA) imparts resistance to apoptotic cell death, normally elicited by exogenously-supplied GSNO. Similarly, pre-treatment with low-dose GSNO (25-200 microM) conferred resistance from a second exposure to a higher dose of GSNO (1 mM). Protection is comprehended at the level of blocked p53 accumulation. Upregulation of protective mechanisms in response to non-lethal NO concentrations or by LPS, cytokine pre-stimulation may redirect the ability of nitric oxide to upregulate p53 and to initiate macrophage apoptosis, thereby modulating cellular susceptibility towards NO-intoxication.