The triad of erectile dysfunction, hypogonadism and the metabolic syndrome.

AIM: To identify the relationship of erectile dysfunction, hypogonadism and the metabolic syndrome in the context of men's health. METHODS: An Expert Panel Meeting was held in December 2006 in Vienna, Austria. In addition a comprehensive literature search was conducted. RESULTS: Men have a higher incidence of cardiovascular events than women of similar ages which has led to the belief that testosterone is a risk factor for cardiovascular disease in men. The latter hypothesis is no longer tenable. On the contrary, low testosterone levels are associated with (visceral) obesity, the metabolic syndrome, diabetes mellitus, cardiovascular disease and erectile dysfunction (ED). Testosterone therapy does not lead to an increased incidence of cardiovascular disease or events such as myocardial infarction, stroke or angina. Until recently (visceral) obesity, the metabolic syndrome, diabetes mellitus, cardiovascular disease and ED were viewed as more or less independent entities affecting the ageing male. It was not recognised that hypogonadism is a common denominator. With a more integrative approach to the health situation of middle-aged and elderly men, these conditions appear closely interrelated in their manifestations, hypothetically in their aetiology, diagnostic strategy and also their treatment. CONCLUSION: Improving sexual health is a portal to identify health hazards and improving men's health. Appropriate diagnosis and medical work up of men presenting with sexual symptoms may have the benefit of the diagnosing and treating other important conditions, such as obesity, diabetes, hypertension and hyperlipidaemia.

[7 advances in internal and general medicine--practical perspectives]. / Sieben Fortschritte in Innerer- und Allgemeinmedizin--praktische Perspektiven.

A popular new feature of the Van Swieten Congress' Annual Session is the update in General Internal Medicine. The following paper serves as a straight forward, if admittedly biased, guide for the practicing GP and general internist to seven of the presented clinically important advances in the last few years. The areas chosen are cholesterol, coronary artery disease, congestive heart failure, helicobacter pylori, osteoporosis, pneumonia, prevention, and finally thromboembolic disease.

Changes in professional development. Educating the gastroenterologist for the year 2000.

Recent changes in society, the practice in medicine, the health care delivery and new technologies will have a direct impact on the development of the medical profession. Thus, there is a need for more efficient, evidence-based and evaluated continuing medical education (CME) programs. But CME in one's own speciality interest is not enough. CME has to be extended into a broader context of continuing professional development (CPD) including personal, social and political aspects of medical practice. New methods have to concentrate on adult learning principles, individual needs and self-directed learning and have to promote performance-based assessment, outcome evaluation, communication skills, patient education and the use of computers and telecommunication technologies. All principles have to begin before entering medical school and then be continued and supported through a new medical curriculum from undergraduate to postgraduate training according to the 'lifelong learning' principle. All honorable gastroenterology, hepatology and endoscopy societies throughout the world should further define professionalism and develop leadership and management programs for their members. Nevertheless, every doctor always has a personal responsibility for lifelong learning.

Wilson's disease in patients presenting with liver disease: a diagnostic challenge.

BACKGROUND & AIMS: In patients with Wilson's disease presenting with liver involvement, the correct diagnosis is often missed or delayed. The aim of this study was to find an algorithm for diagnosis of this difficult patient group. METHODS: Clinical and laboratory findings of 55 patients with Wilson's disease were evaluated at diagnosis before treatment. Presenting symptom was chronic liver disease in 17 patients, fulminant hepatic failure in 5 patients, hemolysis in 3 patients, and neurological disease in 20 patients, and 10 patients were detected by family screening (siblings). Evaluation included neurological and ophthalmologic examination, routine laboratory tests, and parameters of copper metabolism including liver copper content in 43 liver biopsy specimens. RESULTS: In the whole group, serum ceruloplasmin level was <20 mg/dL in 73%, urinary copper excretion was increased in 88%, and liver copper content was elevated in 91% at diagnosis. Kayser-Fleischer rings were detected in 55%. In contrast to patients with neurological disease (90% Kayser-Fleischer rings, 85% low ceruloplasmin), only 65% of patients presenting with liver disease were diagnosed by these typical findings. Ceruloplasmin levels were lower in patients with Kayser-Fleischer rings or with neurological disturbances than in patients without these symptoms. CONCLUSIONS: The commonly used clinical and laboratory parameters are not sufficient to exclude the diagnosis of Wilson's disease in patients with liver disease of unknown origin.

Octreotide combined with goserelin in the therapy of advanced pancreatic cancer--results of a pilot study and review of the literature.

The two hormone analogues octreotide and goserelin have been shown to decelerate growth of human pancreatic cancer in vitro and in vivo. The objective of this pilot study was to investigate the efficacy and toxicity of the combination of these two agents in patients with advanced pancreatic cancer. Octreotide was injected subcutaneously in dosages increasing weekly, starting with 50 micrograms twice daily, until the level of maintenance therapy of 500 micrograms three times a day was reached. In addition, 3.8 mg goserelin acetate was administered subcutaneously at monthly intervals. A median of 7 cycles (range 1-27 cycles) were applied; 13 out of 14 patients entered into the study were evaluable for response and all 14 were evaluated for toxicity. In one patient with initially non-resectable pancreatic cancer, systemic therapy yielded a partial remission lasting 9 months. The degree of tumour regression then allowed a consecutive macroscopic radical tumour resection followed by an additional 6 months of no evidence of disease while the same drug combination was continued. In an additional 9 patients, no change of disease was observed, in some cases for a remarkably long time (up to 27 months). Nevertheless, the objective response rate of 7% (95% confidence interval 0 +/- 21%) was low. In 5 patients a clear improvement in their performance status was seen soon after the start of therapy; 3 patients showed progression of the disease at first evaluation or earlier and 1 patient was not evaluable at the time of study assessment. According to the product-limit method of Kaplan and Meier, the time to progression was 3.0 +/- 1.8 months [median +/- asymptotic standard error (ASE)] and overall survival was 6.0 +/- 1.5 months (median +/- ASE). Toxicity was rare and only of mild to moderate degree. Overall, the regimen under investigation did not meet the criteria for sufficient antitumoural effectiveness. Nevertheless, this study reinforces the concept that pancreatic cancer is principally responsive to endocrine therapy and therefore the further investigation of hormonal manipulation seems worth while in the future.

Vinorelbine-induced neurotoxicity in patients with advanced breast cancer pretreated with paclitaxel--a phase II study.

Vinorelbine (VNB) shows high antitumoral activity in advanced breast cancer due to its high affinity for mitotic tubulin and differs from the other vinca alkaloids with regard to its low degree of neurotoxicity because of its low affinity for axonal tubulin. Preclinical data show the existence of different binding sites on tubulin for vinca alkaloids and paclitaxel (P), suggesting a lack of cross-resistance. Thus, VNB was chosen eligible for a phase II study to evaluate both the therapeutic efficacy and the toxicity of VNB in patients (pts) with advanced breast cancer failing first- or second-line chemotherapy with P. A total of 14 pts with advanced breast cancer pretreated with P were entered into the study. Therapy consisted of VNB at 30 mg/m2 diluted in 500 ml of normal saline given over 30 min after a minimal interval of 4 weeks since the last application of P. For the first four cycles, injections were repeated at 2-week intervals; thereafter they were repeated at 3-week intervals until evidence of progressive disease or severe toxicity developed. All but one pt was considered assessable for response and all pts were evaluable for toxicity. No objective response was observed; two pts showed no change in their disease. In four pts therapy had to be stopped because peripheral neurotoxicity increased from a pretherapeutic level after therapy with P from National Cancer Institute Common Toxicity Criteria (NCI-CTC) grade 1 (n = 3) and 2 (n = 1) to neurotoxicity grade 3 after 1, 2 (n = 2), and 3 cycles of therapy with VNB, respectively. In addition, constipation of grade 2 occurred in 10 pts. Hematologic toxicity was negligible. No other evaluable toxicity exceeded NCI-CTC grade 1. Both observations of this study, the complete resistance to VNB and the increase in peripheral neuropathy, let us assume the existence of a preclinically not anticipated but clinically relevant cross-resistance between these two spindle poisons and the presence of common functional targets. Therefore, P-pretreated pts should be excluded from consecutive VNB-containing therapies.

[Supportive therapy of pancreatic carcinoma]. / Supportive Therapie des Pankreaskarzinoms.

Due to the progressive clinical course and unchanged poor prognosis of pancreatic cancer supportive therapy has to focus on improvement of the quality of life. Pain control is best achieved with slow release opiates and by chemoablation of the coeliac plexus. Furthermore, management of anorexia with megestrol acetate and tumor-adapted enteral and parenteral nutritional therapy are discussed. The treatment of chemotherapy-induced side effects with haemopoetic growth factors and antiemetics is dealt with as well. Finally, the therapeutic principles of the management of post-pancreatectomy diabetes mellitus and postoperative steatorrhoea are pointed out.

[Pancreatic carcinoma--epidemiology and risk factors]. / Pankreaskarzinom--Epidemiologie und Risikofaktoren.

The incidence of pancreatic cancer has increased steadily over the past decades throughout the world. Pancreatic cancer is the fifth leading cause of death from cancer in the western world. In 1991 1074 Austrians died of pancreatic cancer. Over 80% of cases occur in the age group of 60-80 year olds. The incidence is higher in men than in women by a ratio of about 1.5 to 1. There is strong evidence that pancreatic cancer risk is increased with cigarette smoking, increasing protein intake and fat consumption and nonalcoholic chronic pancreatitis. A reduction in the incidence of pancreatic cancer will only be achieved through selected prevention programmes.

[Helicobacter pylori and the mouth cavity--overview and perspectives]. / Helicobacter pylori und die Mundhöhle--Ubersicht und Perspektiven.

In view of the possibility of reinfection after successful treatment and the pitfalls in eradicating Helicobacter pylori (H. pylori) from gastric mucosa, it is of great interest to identify natural reservoirs for this organism, other than the stomach. This review discusses the results of investigations as to whether H. pylori can be harboured in the microaerobic environment of dental plaques in saliva. Only few data are available on the prevalence of H. pylori in the mouth. Data from conventional microbiological technique studies are contradictory, with the prevalence varying from 3.4% to 100%. Different diagnostic procedures were used to identify H. pylori, but only a few seem to be reliable enough to detect H. pylori in clinical samples taken from the mouth. Moreover, insufficient information is provided on the role of hygienic conditions in the investigated oral cavity and the existence of gingival or periodontal disease. The mechanisms of oral colonisation with H. pylori are still unknown. Human periodontal disease is associated with a complex microflora in which more than 350 microbial species can be encountered. The periodontal pocket may be important as a natural reservoir for H. pylori, because it can provide microaerobic conditions. Recently reported molecular techniques such as the highly sensitive and specific polymerase chain reaction (PCR) may help to clarify the prevalence of oral carriage of H. pylori in future.

[Diagnosis of Helicobacter pylori infection]. / Diagnostik der Helicobacter pylori-Infektion.

A number of direct (histology, specific culture) and indirect (serology, urease test, breath test) diagnostic tests for Helicobacter pylori (H. pylori) are available. The gold standard for H. pylori presence or absence is still histology (tissue stained by Giemsa) without or in combination with specific culture. For routine practice a combination of histology (two antral and two body biopsies) and the urease test (one antral and one body biopsy specimen) is recommended in patients undergoing upper GI endoscopy. The reaction velocity of the urease test can be semi-quantitatively graded and, thus, allows a rough estimate of the grade and the activity of gastritis. The simplest and least expensive non-invasive method is serologic testing for IgG and/or IgA antibodies. Latex-agglutination methods are "quick tests", useful for screening purposes. ELISA based tests accurately quantitate the amount of antibody (titer) present and are a promising tool for assessing the efficacy of H. pylori eradication treatment. 13 C/14 C-urea breath tests are reliable non-invasive methods for the diagnosis of ongoing H. pylori infection.

[Helicobacter pylori: clinical pictures of an infectious disease with pathogen persistence]. / Helicobacter pylori: Krankheitsbilder einer Infektionskrankheit mit Erregerpersistenz.

It is the aim of this paper to provide survey of the very fast developing field of medical research on Helicobacter pylori which includes as different branches as gastroenterology, pharmacology or microbiology. After examination of the several diseases, pathological mechanisms, the diagnostical techniques and the therapeutical regimens, the authors of this study favorize an early indication for eradication of helicobater pylori. Since research on Helicobacter pylori is divided into many fields, there is the attempt to come to a clear and more rational point of view concerning therapeutical strategies and management of the infection. It is another focal point to emphasize the important role that chronical gastritis induced by Helicobacter pylori plays as an important risk factor for gastric carcinoma.

Upper gastrointestinal endoscopy findings in patients with long-standing bulimia nervosa.

Bulimia nervosa, an eating disorder now recognized with increasing frequency, is receiving growing attention because of purported complications. Recent claims of a high frequency of erosions, ulceration, and bleeding in the esophagus, ascribed to repeated, self-induced vomiting, prompted us to investigate by endoscopy the upper gastrointestinal mucosa in 37 consecutive patients with long-standing bulimia nervosa. The endoscopic appearance of esophageal and gastric mucosa was normal in 23 patients. Signs of mild esophagitis observed in eight patients were not related to the duration or severity of bulimic behavior or to symptoms of gastroesophageal reflux; two of these eight patients had sliding hiatal hernias. The remaining six patients were found to have superficial mucosal erythema in the stomach or duodenum, but none showed actual erosions, ulcers, or bleeding. Our observations suggest that, in contrast to reports by others, mucosal injury consequent to chronic, self-induced vomiting in patients with bulimia nervosa is relatively infrequent and limited.