Rationale for a diagnostic chain in gestational breast tumor diagnosis

Due to the physiological tissue alterations of the breast during pregnancy and lactation the diagnosis of a breast tumor by palpation, imaging and fine-needle biopsy is difficult and often unreliable. The purpose of our study was to review the value of imaging (mammography and ultrasonography) and biopsy techniques in order to work out a reliable protocol for evaluating gestational tumors. We performed a retrospective analysis of 25 patients with clinical diagnosis of gestational breast tumors during a 4-year period from 1995 to 1999. Specimens were obtained by core biopsy for histological examination. Invasive breast cancer was diagnosed in five patients, malignant lymphoma of the skin in one patient. The tumors in the remaining 19 patients proved benign. The overall accuracy was 0.91 for conventional mammography, 0.76 for conventional and panoramic ultrasound and 0.48 for color-coded sonography. Mammography as the most reliable imaging method should be used to evaluate all patients in whom ultrasonographic findings are suspicious for tumor. Radiation phobia should not prevent the performance of mammography under these circumstances. Nevertheless, all pre-operative methods of diagnosing gestational breast tumors other than core biopsy are unreliable.

Tissue-specific modulation of cyclooxygenase-2 (Cox-2) expression in the uterus and the v. cava by estrogens and phytoestrogens

Cyclooxygenase 2 (Cox-2), an enzyme involved in prostaglandin production, is a key player in the development of pathologic changes, such as colorectal cancer, arteriosclerosis and thrombosis. In this study, we investigated the effects of estrogens, selective estrogen receptor modulators (SERMs), pure antiestrogens and phytoestrogens on the tissue-specific expression of Cox-2 in the uterus and the v. cava of ovariectomized female rats. Cox-2 expression could be detected in the uterine epithelium and in the endothelium of the v. cava. Cox-2 expression was time-dependently stimulated after administration of 17beta estradiol (E2) in the uterus. In the v. cava, E2 treatment resulted in a stimulated expression of the progesterone receptor (PR), a gene known to be regulated by E2, whereas Cox-2 was simultaneously down-regulated. Administration of the pure antiestrogen faslodex (Fas) had no effect on Cox-2 expression. In contrast, administration of tamoxifen (Tam) resulted in a decrease of Cox-2 expression in the v. cava but does not stimulate Cox-2 expression in the uterus. Interestingly, the same expression pattern of Cox-2 could be detected after dose-dependent administration of genistein (Gen). Here, down-regulation of Cox-2 could already be detected after administration of merely 0.5 mg/(kgBW) Gen, a dose where no effects on uterine weight were observed. In summary, our results demonstrate a reverse tissue-specific regulation of Cox-2 expression by estrogens in the v. cava and uterus indicating the existence of complex molecular mechanisms which have to be characterized in future studies. Remarkably, Tam and the phytoestrogen Gen, both share the ability to decrease the expression of Cox-2 in the v. cava without effecting its uterine expression. These observations may be of great importance with respect to potential beneficial or adverse effects of estrogens, SERMs and phytoestrogens on the cardiovascular tissue.

Combined determination of selected radiological and morphological variables relevant for dental age estimation of young adults

The mineralisation of third molars is one of the main criteria for dental age estimation of living subjects in criminal proceedings. Since the mineralisation of third molars is usually completed by the age of 19 or 20 years, this feature cannot be used to ascertain whether a person has attained the forensically relevant age of 21 years. This study examined whether determination based on an orthopantomogram of a combination of features relevant to dental age estimation of adults, supplies forensically useful information for ascertaining whether a person has attained 21 years of age. The features considered include the DMFT index of all permanent teeth, the DMFT index of all permanent teeth excluding third molars, the DFT index of third molars projecting beyond the occlusal plane, the eruption of third molars and the periodontal recession of second molars. A total of 650 conventional orthopantomograms of German subjects aged 18-30 years were evaluated. The statistical evaluation of our results was based on a discriminant analysis. It was carried out with two classes defined by two age groups: < or = 21 years and > 21 years. The probability of correct classification was 69.7% for males and 71.4% for females. It can be concluded that an evaluation of the variables reviewed in this paper does not by itself yield sufficient data to determine with the accuracy required in criminal proceedings whether a person has attained 21 years of age. The additional radiographic examination of the medial clavicular epiphyseal cartilage is recommended.

[Ureteroiliac artery fistula -- a rare cause of macroscopic haematuria]

INTRODUCTION

Since its first description in 1939 not more than approximately 80 cases of ureteroiliac artery fistulas have been reported. The incidence seems to increase with the number of endo-vascular and endo-urological interventions. Risk factors include pelvic vascular surgery and surgery for malignancy, irradiation and ureteral stenting. Due to the intermittent symptomatology, the preoperative diagnosis and planning of the therapeutic approach are often difficult.

CASE REPORT

We report the case of an ureteroiliac artery fistula caused by an iliac artery aneurysm following vascular surgery, and review the literature.

CONCLUSIONS

In case of preoperative diagnosis it is of great importance to coordinate the cooperation of urologists, vascular surgeons and radiologists in order to achieve the best treatment for the patient.

Die EXIT-Prozedur als anästhesiologische Herausforderung

The ex-utero intra-partum (EXIT) procedure enables the surgeon to perform invasive procedures in an infant during cesarean section before clamping the umbilical cord. Specific anesthesiological concepts are necessary for ensuring sufficient umbilical perfusion. We report the case of a 33-year-old female undergoing cesarean section in the 36th week of pregnancy because of a large fetal cervical tumor. The EXIT procedure was performed in order to secure the infant's airway during delivery. The anesthesiological management and interdisciplinary tasks are discussed in the literature review.

Do early injections of bulking agents following radical prostatectomy improve early continence?

Bulking agents belong to the treatment options of stress urinary incontinence in both genders for a long time, but early injection of bulking agents following radical prostatectomy to improve early continence is a new treatment modality and the results of the first years will be presented in this study. From 1996 to 2001, 55 incontinent patients, of whom 44 suffered from post-prostatectomy incontinence (PPI), have been treated by bulking agents in our clinic and evaluated later on, using a semistandardized questionnaire. Mean age was 65.5 years and the mean follow-up was 32 months. Of 44 patients with PPI, 29 suffered from incontinence of the third, 10 from incontinence of the second and 5 from incontinence of the first degree. We examined the influence of transurethral injection of bulking agents on direct postoperative continence (short-term results) and on continence at the time of follow-up (long-term results) (mean 32 month). An improved early continence (short-term result) was achieved in 30 patients. At follow-up, 19 patients were completely dry, 18 reported an improved continence. Especially the time of treatment, referring to radical prostatectomy, had a significant influence on treatment results with better results in the subgroup of 34 patients that have been treated early (mean 23 days) compared to 10 patients that received delayed treatment (mean 26 months) following radical prostatectomy. The preoperative degree of incontinence had a significant influence on short-term results, and not on long-term results. The amount of bulking material and the number of injections had no significant influence on short-term results, but repeated injections resulted in statistically worse long-term results. In summary, early transurethral injection of bulking agents is an effective and minimal invasive therapy option to improve early continence in patients with PPI. Time to improved continence due to training of the sphincter externus muscle cannot be shortened, but the quality of life during this time can be improved. In case of a severe lesion of the sphincteric muscle, continence cannot be improved for a longer period and the results are poor. In these cases, procedures like implantation of an artificial urinary sphincter may be required.

Esomeprazole 20 mg vs. pantoprazole 20 mg for maintenance therapy of healed erosive oesophagitis: results from the EXPO study

BACKGROUND

Following initial healing of erosive oesophagitis, most patients require maintenance therapy to prevent relapse.

AIM

To compare endoscopic and symptomatic remission rates over 6 months' maintenance therapy with esomeprazole or pantoprazole (both 20 mg once daily) in patients with healed erosive oesophagitis.

METHODS

Patients with symptoms of gastro-oesophageal reflux disease and endoscopically confirmed erosive oesophagitis at baseline were randomized to receive esomeprazole 40 mg or pantoprazole 40 mg for up to 8 weeks. Patients with healed erosive oesophagitis and free of moderate/severe heartburn and acid regurgitation at 4 weeks or, if necessary, 8 weeks entered the 6-month maintenance therapy phase of the study.

RESULTS

A total of 2766 patients (63% men; mean age 50 years) received esomeprazole 20 mg (n = 1377) or pantoprazole 20 mg (n = 1389) and comprised the intention-to-treat population. Following 6 months of treatment, the proportion of patients in endoscopic and symptomatic remission was significantly greater for those receiving esomeprazole 20 mg (87.0%) than pantoprazole 20 mg (74.9%, log-rank test P < 0.0001). Esomeprazole 20 mg produced a higher proportion of patients free of moderate to severe gastro-oesophageal reflux disease symptoms and fewer discontinuations because of symptoms than pantoprazole 20 mg (92.2% vs. 88.5%, P < 0.001).

CONCLUSIONS

Esomeprazole 20 mg is more effective than pantoprazole 20 mg for maintenance therapy following initial healing of erosive oesophagitis and relief of gastro-oesophageal reflux disease symptoms.

White biotechnology for green chemistry: fermentative 2-oxocarboxylic acids as novel building blocks for subsequent chemical syntheses

Functionalized compounds, which are difficult to produce by classical chemical synthesis, are of special interest as biotechnologically available targets. They represent useful building blocks for subsequent organic syntheses, wherein they can undergo stereoselective or regioselective reactions. "White Biotechnology" (as defined by the European Chemical Industry [ http://www.europabio.org/white_biotech.htm ], as part of a sustainable "Green Chemistry,") supports new applications of chemicals produced via biotechnology. Environmental aspects of this interdisciplinary combination include: Use of renewable feedstock Optimization of biotechnological processes by means of: New "high performance" microorganisms On-line measurement of substrates and products in bioreactors Alternative product isolation, resulting in higher yields, and lower energy demand In this overview we describe biotechnologically produced pyruvic, 2-oxopentaric and 2-oxohexaric acids as promising new building blocks for synthetic chemistry. In the first part, the microbial formation of 2-oxocarboxylic acids (2-OCAs) in general, and optimization of the fermentation steps required to form pyruvic acid, 2-oxoglutaric acid, and 2-oxo-D-gluconic acid are described, highlighting the fundamental advantages in comparison to chemical syntheses. In the second part, a set of chemical formula schemes demonstrate that 2-OCAs are applicable as building blocks in the chemical synthesis of, e.g., hydrophilic triazines, spiro-connected heterocycles, benzotriazines, and pyranoic amino acids. Finally, some perspectives are discussed.

Akzeptanz der Gesundheitstelematik bei ihren Anwendern

The user acceptance of health telematics in medical care plays a critical role in mediating the success of its implementation. Model assumptions evolving from different fields such as industry, health care and medical psychology are presented, and various perspectives for patients and providers involved in these models are highlighted. The impact of health telematics on health care results from four components: (a) the improvement of work characteristics and communication processes, (b) the enhancement of diagnostic and treatment quality via telematics, (c) technical and economic advantages and (d) communication tools for patient. The evidence concerning clinical, economic and psychosocial criteria within these domains is reviewed according to the published literature. Despite the fact that a considerable benefit of health telematics has been shown in individual studies, the evidence concerning the improvement of health care, the improvement of work and communication processes as well as concerning its clinical and cost effectiveness is still scarce. It is recommended to further integrate health telematics and health service research.

MR features of gastrointestinal stromal tumors

We report on two patients presenting with gastrointestinal stromal tumors (GIST). The important tumor size and the marked tissular hypersignal seen on T2-weighted magnetic resonance images (MRI) should be considered as magnetic resonance (MR) features strongly indicating diagnosis of GIST.

Esomeprazole 40 mg administered intravenously has similar safety and efficacy profiles to the oral formulation in patients with erosive esophagitis

BACKGROUND/AIMS

An intravenous formulation of esomeprazole has been developed for use in patients where oral administration is not appropriate. This study evaluated safety after 1 and 4 weeks, and efficacy after 4 weeks' esomeprazole 40 mg once daily treatment, administered via an intravenous injection, intravenous infusion or orally, in patients with erosive esophagitis.

METHODS

In this double-blind, multi-centre study, patients with endoscopically confirmed erosive esophagitis (Los Angeles grade A-D) were randomized to receive 1 week's treatment of esomeprazole 40 mg once daily, via a 3-min injection, a 30-min infusion or orally, followed by 3 weeks of open treatment with oral esomeprazole 40 mg once daily. Safety variables were evaluated following 1 and 4 weeks' esomeprazole treatment. Healing rates at 4 weeks were estimated.

RESULTS

Intravenous and oral esomeprazole were equally well tolerated during the first week, and after 4 weeks' treatment. The 3 treatment groups showed similar levels of healing following 4 weeks' treatment with esomeprazole (injection + oral: 79.7%; infusion + oral: 80.2%; oral alone: 82.6%).

CONCLUSIONS

Esomeprazole 40 mg administered via an intravenous injection, intravenous infusion or orally administered for 1 week, followed by 3 weeks of oral dosing, is well tolerated and provides effective healing of erosive esophagitis.

Evolution versus constitution: differences in chromosomal inversion

We compared the chromosomal breakpoints of evolutionary conserved and constitutional inversions. Multicolor banding and human-specific bacterial artificial chromosomes were applied to map the breakpoints of constitutional pericentric inversions on human chromosomes 2 and 9. For the first time, we present a high-resolution analysis of the breakpoint regions, which are characterized by gene destitution, co-localization with fragile sites, multitude repeats as well as pseudogenes and, remarkably, a large sequence homology to the opposite breakpoint. In contrast, evolutionary inversion breakpoints lack such extensive cross-hybridizing regions and are often associated with fragile sites of the genome and low-copy repeats. These molecular characteristics gave evidence for different types of inversion formation and indicate that evolutionary inversions cannot originate from constitutional inversions like those of chromosomes 2 and 9. Finally, the constitutional inversion breakpoints were investigated on three different great ape species and on four test persons each bearing the same cytogenetically determined inversion on chromosomes 2 and 9, respectively. Our data indicate the existence of different molecular breakpoints for the two variant chromosomes.

Glucocorticoid receptor heterozygosity combined with lack of receptor auto-induction causes glucocorticoid resistance in Jurkat acute lymphoblastic leukemia cells

Glucocorticoids (GC) induce apoptosis in malignant lymphoblasts, but the mechanism of this process as well as that of the clinically important GC resistance is unknown. We investigated GC resistance in Jurkat T-ALL cells in which ectopic GC receptor (GR) restores GC sensitivity, suggesting deficient GR expression. Jurkat cells expressed one wild-type and one mutated (R477H) GR allele. GR(R477H) ligand-binding-dependent nuclear import, as revealed by live-cell microscopy of YFP-tagged GR, was unaffected. Transactivation and transrepression were markedly impaired; however, GR(R477H) did not act in a dominant-negative manner, that is, did not prevent cell death, when introduced into a GC-sensitive cell line by retroviral gene transfer. Contrary to another GR heterozygous, but GC-sensitive, T-ALL model (CCRF-CEM), Jurkats expressed lower basal GR levels and did not auto-induce their GR, as revealed by 'real-time' RT-PCR and immunoblotting. Absent GR auto-induction could not be restored by transgenic GR and, hence, was not caused by reduced basal GR levels. Thus, inactivation of one GR gene results in haploinsufficiency if associated with lack of GR auto-induction.

Glucocorticoid-induced apoptosis and glucocorticoid resistance: molecular mechanisms and clinical relevance

The ability of glucocorticoids (GC) to efficiently kill lymphoid cells has led to their inclusion in essentially all chemotherapy protocols for lymphoid malignancies. This review summarizes recent findings related to the molecular basis of GC-induced apoptosis and GC resistance, and discusses their potential clinical implications. Accumulating evidence suggests that GC may induce cell death via different pathways resulting in apoptotic or necrotic morphologies, depending on the availability/responsiveness of the apoptotic machinery. The former might result from regulation of typical apoptosis genes such as members of the Bcl-2 family, the latter from detrimental GC effects on essential cellular functions possibly perpetuated by GC receptor (GR) autoinduction. Although other possibilities exist, GC resistance might frequently result from defective GR expression, perhaps the most efficient means to target multiple antileukemic GC effects. Numerous novel drug combinations are currently being tested to prevent resistance and improve GC efficacy in the therapy of lymphoid malignancies.

Chemokine-receptor expression on T cells in lung compartments of challenged asthmatic patients

BACKGROUND

The interaction of chemokines with their receptors strongly influences the migration of leucocytes.

OBJECTIVE

In order to assess the contribution of these molecules to the local recruitment of T cells in bronchial asthma, we analysed the expression of 14 chemokine receptors on lung-derived T cells.

METHODS

Chemokine-receptor expression by T cells derived from the peripheral blood, the bronchoalveolar lavage fluid and the bronchial mucosa was analysed by flow cytometry and immunohistochemistry. Expression profiles in healthy and mildly asthmatic individuals were compared, the latter prior and after segmental allergen provocation.

RESULTS

Compared with peripheral blood, alveolar T cells expressed significantly more CCR2, CCR5, CCR6, CXCR3 and CCR4. However, no differences were observed between healthy controls and unchallenged asthmatics. In patients developing significant inflammatory responses following specific allergen challenge, a marked increase in the percentage of CCR4+ and CCR7+, and reduced numbers of CXCR3-bearing alveolar T cells were detected. Following specific allergen challenge, chemokine-receptor expression profiles of T cells from the alveolar space and the mucosa or the submucosa were similar, excluding a particular subcompartmentalization of the chemokine/chemokine-receptor system.

CONCLUSION

The expression of certain chemokine receptors by lung T cells suggests a contribution to the physiological recruitment of T cells to the lungs, both in healthy controls and unchallenged mild asthmatics. However, strong allergen-induced airway responses were associated with a specific chemokine-receptor profile, suggesting the involvement of certain chemokine receptors in the pathogenesis of allergic bronchial inflammation.

Ciclosporin-Monitoring bei Patienten mit chronischer Uveitis

BACKGROUND

Cyclosporine (CsA) is a widely used drug in the treatment of posterior uveitis. Whereas treatment with CsA has considerably improved the visual prognosis of uveitis patients, the therapeutic benefits of CsA are partially outweighed by its adverse effects, most notably nephrotoxicity and hypertension. Recently, monitoring the CsA 2-h postdose level (C(2)) has been recommended as the most sensitive assay and predictor of clinical outcome in transplantation.

PATIENTS AND METHODS

This prospective clinical trial included 15 patients with posterior uveitis who received oral CsA (5 mg/kg BW b.i.d.). The relationship of C(2) to C0 blood levels was analyzed and correlated with clinical safety and efficacy.

RESULTS

A high intrapatient and interpatient variability was observed regarding the C0 values depending on several factors including comedication and intestinal resorption. C(2) values corresponded to control measurements of intraocular inflammation.

CONCLUSIONS

C(2) monitoring offers a simple and accurate alternative for clinical monitoring of CsA. It allows the dose of CsA to be individualized effectively for each patient.