[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.

[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.

[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.

[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.

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.

Vitamin supplementation during weight reduction--favourable effect on homocysteine metabolism.

Moderately elevated homocysteine concentrations, reflecting deficiency of some nutritional factors required for homocysteine metabolism (folate, vitamin B-6, vitamin B-12) and/or less severe genetic defects, are common in the general population. Several studies have indicated the role of homocysteine as an independent risk factor for vascular disease. A pilot study published recently suggested that plasma homocysteine levels increase during weight reduction in slightly overweight, otherwise healthy subjects (group A). We examined a comparable group of 13 overweight subjects (group B) using a standardised caloric intake and defined vitamin supplementation (Medyn: folate 0.2 mg/ vitamin B-68.0 mg/ vitamin B-120.010 mg three times the day orally) to determine the effect of weight reduction on serum homocysteine levels and to compare the results with those of the pilot study. Mean body weight declined from 87.0 +/- 20.2 to 84.2 +/- 20.1 kg (P < 0.05) in group A and 85.7 +/- 11.3 to 82.5 +/- 9.9 kg (P = 0.049) in group B. Serum homocysteine levels rose from 7.9 +/- 2.0 to 8.7 +/- 2.3 mumol/l (P < 0.0001) in group A and decreased from 8.19 +/- 1.73 to 7.35 +/- 0.88 mumol/l (P = 0.0022) in group B. No correlation was found between the changes in body weight and in homocysteine levels (r = 0.02 in group A, r = 0.18 in group B). Additionally, no correlation was found between serum folate levels and changes in homocysteine levels (r = 0.03 in group A, r = 0.09 in group B). The results suggest that an adequate oral vitamin-supplementation protects against increased homocysteine production during weight reduction.

[Intramural pseudodiverticulosis of the esophagus. Diagnosis on second look]. / Intramurale Pseudodivertikulose des Osophagus. Diagnose auf den zweiten Blick.

HISTORY: Case 1. A 56-year-old man had experienced increasing dysphagia for 6 months, accompanied by a weight loss of 20 kg. A stenosing oesophageal carcinoma was suspected. Case 2. A 82-year-old man had been suffering intermittently from nausea for some years but had maintained his weight (80 kg; height 173 cm). Endoscopy 4 months before this admission had revealed a duodenal ulcer; its treatment briefly improved the symptoms. INVESTIGATIONS, DIAGNOSIS AND TREATMENT: Endoscopy in case 1 detected a severe oesophageal stenosis which could not be passed, and its cause could not be ascertained despite biopsy, barium swallow and computed tomography. After bougie dilatation an endoscope was finally passed and the typical picture of oesophageal pseudodiverticulosis (OPD) seen. In case 2, endoscopy at first indicated only marked Candida oesophagitis. But after antimycotic treatment a second endoscopy revealed OPD. No treatment is known nor necessary since OPD causes no clinical symptoms unless there are complications. CONCLUSIONS: OPD, a rare condition, presents in various ways, both in its symptoms and at endoscopy. In case of oesophageal stenosis of unknown cause or Candida oesophagitis repeat endoscopy my be necessary to establish the true diagnosis: OPD should be included in the differential diagnosis.

Gastric ulcer healing in the rat: kinetics and localisation of de novo procollagen synthesis.

BACKGROUND AND AIMS: To gain further insight into the role of the extracellular matrix during healing of peptic ulcers, sequential changes of procollagen expression were studied over 30 days of ulcer healing. MATERIALS AND METHODS: Procollagens alpha 1 (I), alpha 1 (III), and alpha 1 (IV) RNA and their polypeptides were assessed in acetic acid induced rat gastric ulcers by in situ hybridisation and immunohistochemistry. RESULTS: Three days after ulcer induction, intense hybridisation signals were obtained with all probes, with procollagen alpha 1 (I) showing the highest transcript levels. Procollagen gene expression remained elevated up to day 15, but was reduced to initial low levels on day 30. Immunohistochemical staining documented increased deposition of the three procollagen types parallel to their respective transcript levels, again with type I showing the earliest and the most prominent deposits. The highest procollagen transcript levels were found in the intact submucosa surrounding the ulcer margins, followed by the muscularis propria and the serosa, with the lamina propria exhibiting the lowest transcript levels. CONCLUSION: The procollagens studied are regulated differentially at the transcriptional and post-transcriptional levels. The early onset and long duration of procollagen expression as well as the involvement of all layers of the gastric wall points to their central structural and functional role in gastric ulcer healing.

Simultaneous restitution of matrix and cells in gastric ulcer: use of a combined in-situ hybridization and immunohistochemistry technique applicable to paraffin-embedded tissue.

The restoration of gastric tissue after ulceration involves cellular and matrix components. Our aim was to investigate the kinetics of collagen expression and cellular proliferation in an animal model of gastric ulcer. To demonstrate the expression of type I and IV collagen mRNAs by proliferating cells, a method combining in-situ hybridization and immunohistochemistry was devised. In order to avoid the disadvantages of radioisotopes, digoxigenin-labeled RNA-riboprobes were utilized and combined with single-step immunohistochemistry. This method proved sensitive enough to detect type I and IV procollagen mRNA transcripts in the submucosal area beneath the ulcer crater or adjacent to the ulcer rim. In addition, a subset of cells transcribing either procollagen type I or IV RNA was concomitantly positive for proliferating cell nuclear antigen by immunohistochemistry. Focal proliferation of cells simultaneously expressing extracellular matrix components may therefore occur in the gastric submucosa after ulceration, starting as soon as 3 days after the insult and continuing for several weeks. The devised method of combined in-situ hybridization and immunohistochemistry can be used with standard paraffin-embedded tissues, yields results within 2 days, and avoids radioisotopes.

[Intraductal ultrasound in the pancreaticobiliary duct system]. / Intraduktaler Ultraschall im pankreatobiliären Gangsystem.

BASIC PROBLEM AND OBJECTIVE OF STUDY: The power of resolution of conventional imaging methods is too low for the diagnosis of very small pancreaticobiliary tumours. High-frequency ultrasound transducers (20 MHz), adapted to the dimensions of the pancreaticobiliary systems (2 mm diameter), make intraductal ultrasound examination possible during endoscopic retrograde cholangiopancreatography (ERCP). In a prospective study the invasiveness and diagnostic value of intraductal ultrasound (IDUS) was compared with ERCP, endosonography (ES) and computed tomography (CT). PATIENTS AND METHODS: During ERCP in 51 consecutive patients an intraductal ultrasound transducer was introduced into the pancreaticobiliary duct system, the results being compared with those obtained with the other imaging modalities and histopathological findings, if available. RESULTS: IDUS of the pancreatic and bile duct systems is a rapid, simple and reliable method during ERCP and provides valuable additional information on periductal tissues. In the diagnosis of carcinoma of the pancreas its sensitivity was 75% (six of eight cases), that of ERCP 37% (3/8), ES 50% (4/8) and CT 37% (3/8). In the diagnosis of biliary tract tumour the sensitivity of the different modalities (in the above order) was 89% (8/9), 78% (7/9), 33% (3/9) and 33% (1/3). Specificity was 67% (2/3), 67% (2/3), 67% (2/3) and 33% (3/9); predictability 89%, 88%, 75% and 60%. CONCLUSIONS: The use of small ultrasound catheter transistor system in the biliary and pancreatic ducts, introduced during ERCP, is technically simple and has few complications. It is a valuable addition to ERCP in the precise diagnosis of small pancreaticobiliary lesions.

Expression of type I and IV collagen mRNAs in healing gastric ulcers--a comparative analysis using isotopic and non-radioactive in situ hybridization.

The sensitivity and practicability of in situ hybridization methods utilizing isotopic or non-radioactive labeling were compared. The aim of this study was to determine whether digoxigenin-labeled riboprobes are as sensitive as 35S-labeled probes to detect changes in type I and IV procollagen expression in an animal model of rat gastric ulcer. Both labeling and detection methods yielded similar results, with a superimposable signal distribution in the specimens. High levels of procollagen type I and IV transcripts were observed in spindle-shaped cells, presumably fibroblasts or myofibroblasts, localized in the ulcer base and rim. The increased expression of these collagen types suggests a remarkable upregulation of collagen expression during the healing of gastric ulcers. Liver tissue adhering to perforated ulcers displayed signals related to non-parenchymal cells, with hepatocytes demonstrating no detectable transcripts of type I or IV collagen genes. Due to the identical pattern of signal distribution by both hybridization techniques it is concluded that non-radioactive in situ hybridization is of value in monitoring highly expressed genes and yields results similar to those achieved with radioactive probes. In these cases, non-radioactive techniques are preferable because they are performed more rapidly and do not require handling of isotopes.