[Uses and risks of drainage following elective colon resection. A prospective, randomized and controlled clinical study]

The results of a controlled randomized and prospective clinical study including 113 patients from March 1987 until August 1988 showed that prophylactic drainage in elective resection for cancer of the colon was not necessary. 60 patients received a drain, 53 patients were not drained. The drain turned out to be ineffective even concerning its expected function of draining intraabdominal fluid: its diagnostic and therapeutic value failed in clinical practice. The rate of surgical complications--i.e. anastomotic leakage, impaired wound healing and relaparotomy--was significantly higher in the drained group. In elective colon resection the use of a drain as a routine procedure cannot be recommended.

Quantification and classification of echographic findings in the thyroid gland by computerized B-mode texture analysis

Computerized B-mode image analysis was investigated in a pilot study to establish quantitative criteria for thyroid echography and to demonstrate the diagnostic accuracy of the procedure in thyroid disease. The ten per cent percentile of grey level distribution and entropy proved to be the most efficient statistical parameters. Computerized ultrasound detected all nodular lesions with an overall accuracy of about 85%. Standard diagnostic evaluation in nodular thyroid disease includes conventional ultrasound followed by needle biopsy to confirm the final diagnosis. However, in many cases, single needle biopsy is not sufficient to exclude malignant disease. Computer-aided ultrasound proved to be helpful for the identification of typical echographic characteristics in thyroid lesions with a high risk of malignancy. We suggest that needle biopsies be repeated in cases in which computerized analysis is positive, even when initial needle biopsy is negative.

[Protection of the pancreatico-digestive anastomosis following resection of the head of the pancreas by pancreatic duct occlusion with fibrin (-glue). Animal experiment and clinical experiences]

The pancreatico-digestive anastomosis is especially then endangered by dehiscence when, following resections due to carcinomas, a healthy lienal pancreatic rest has to be connected to the intestine. In the last years the pancreatic duct occlusion (PDO) with Prolamin proved to be possible for the elimination of the disturbing exocrine secretion. Apart from a strong exocrine fibrosis, a deterioration of the endocrine function results too. In animal experiments as well as clinically a simple and effective method for the protection of the pancreatico-digestive anastomosis could be developed by PDO with fibrin sealant (FS). Contrary to PDO with Prolamin a lower-grade, interstitial fibrosis under intact exocrine function is caused due to the short, 6 days at the most lasting blockade of the exocrine pancreatic secretion. Because of the high tryptic activity of the pancreatic juice 20,000 IU/ml Aprotinin were added to the fibrin sealant. So far this method was employed successfully in 36 patients within the scope of Whipple's operations due to pancreatic head carcinomas.

[The value of computer-assisted sonographic tissue characterization in focal lesions of the thyroid]

Thyroid lesions are a common observation in ultrasound examination. In most cases the differentiation of malignant and benign tissue is difficult. In this study 133 thyroid lesions were examined by an ultrasonographic tissue characterization system prior to surgery. The pathologic findings (29 cancers, 31 adenomas, 46 nodular goiters, 27 cysts) were examined with reference to the quantitative evaluation of the ultrasonic images (ROI method). The selected regions of interest (ROI) were analyzed with regard to the three most discriminating parameters. The overall accuracy of differentiation between malignant and benign thyroid nodules was 83.9%.

[Echographic localization diagnosis of enlarged parathyroid glands]

The authors report on their own experience with the localization of enlarged parathyroid glands by sonography. In a study of 248 patients with hyperparathyroidism, they obtained a sensitivity of 57% and a specificity of 81%, with an overall accuracy of 74%. These results are discussed in detail.

[Ileus of the small intestine caused by intestinal anisakiasis (herring worm disease)]

Two cases of anisaciasis caused by eating of improperly prepared herrings which were infested with larval nematodes are reported. The acute type with a stenosing process in the small intestinal wall existed in both cases which resulted in an ileus. Therapy was resection of the affected intestinal part with end-to-end-anastomosis. The morphological proof of larval nematodes, which penetrate from lumen into the eosinophilic granulomata, pseudotumours and eosinophilic microabscesses are important histological findings. It should be considered the possibility of a herring worm disease in the case of an acute abdomen caused by an inflammatory small bowel stenosis.

Studies on the metabolism and excretion of benzyl isothiocyanate in man

1. Both after ingestion of benzyl isothiocyanate (BITC), a compound with antibacterial properties, and after consumption of garden cress known to contain BITC, the metabolite N-acetyl-S-(N-benzylthiocarbamoyl)-L-cysteine was identified in the urine of volunteers by comparative chromatography. 2. The chemical structure of the metabolite was confirmed by elemental analysis and by comparison of the i.r. and 1H-n.m.r. spectra with those of the synthetic product. 3. On average 53.7% of the dose of BITC was excreted as this metabolite by the renal route. 4. The metabolite was excreted rapidly, appearing with maximum concentrations some 2-6 h after dosing and being essentially complete 10-12 h after administration.

[Pancreatic duct occlusion in resection treatment of chronic pancreatitis and cancer of the head of the pancreas. A 3-year follow-up study]

The original aims of pancreatic duct occlusion (PDO) were reduction of early complication rate after pancreas resection, influence on clinical symptoms by elimination of exocrine tissue and preservation of B-cell function in the remaining pancreas. As a result of a 3-years study in patients with chronic pancreatitis and carcinoma in whom a Whipple's operation with and without PDO had been carried out the evaluation of PDO was estimated. The PDO has a high value in pancreas head resections because of carcinoma. Similar is the importance in the reduction of clinical symptoms in patients with chronic pancreatitis. A protective effect could not be observed neither in patients with chronic pancreatitis nor with carcinoma. On the other hand there was no additional damage by PDO, as the comparison with patients without PDO has shown.

A thirty-year review of maternal mortality in Oklahoma, 1950 through 1979

Oklahoma's Maternal Mortality Committee has been active since 1941. During the 30-year period 1950 through 1979, the committee reviewed in detail 75.9% of the pregnancy-related deaths that occurred in Oklahoma. The maternal mortality ratio in 1950 was 95.1/100,000 live births, and for 1979 it was 8.1/100,000 live births, a decrease of 91.5%. The risk of death from childbearing remained greater for black women than for American Indian or white women throughout the three decades. For American Indian women, the risk of death associated with pregnancy has decreased and is almost equal to the risk for white women. The Maternal Mortality Committee estimated that two thirds of Oklahoma's maternal deaths were preventable. The proportion of deaths judged preventable did not vary substantially during the study period. We conclude that maternal mortality in Oklahoma can be reduced to fewer than three deaths per 100,000 live births. Intensive monitoring and investigation of deaths and their causes by local maternal mortality committees continues to be an important mechanism for obtaining information to assist health workers in the prevention of deaths.

[Status of clinical pancreas transplantation]

Since 1977 and especially within the latest 5 years there was a volatile development in the pancreas transplantation. If we had only 60 transplants between 1966-1977, prevalent duodeno-pancreas-transplants, the cases rose to 215 up to 1982 and to 447 transplantations between 1983 to 1985. Altogether there were 722 pancreas transplants, up to November, 15, 1985 registered. Before 1977 only 2 patients had a 1 year function rate of the transplant and of the 447 transplantations within the latest 3 years 201 transplants functioned more than 12 months. That was a 1-year function rate of 45% in contrast to 3% before 1977. The clear improvement of the results in pancreas transplantation can be attributed to operative aspects and to the employment of Cyclosporine A. The segmental pancreas transplantation with duct occlusion and intestinal or external drainage of the duct system were the most sure operative procedures. The combination of Azathioprine and Cyclosporin A brought with a 1-year function rate of 54% better results in comparison to the singular application of Azathioprine (22%) and Cyclosporin A (41%). The simultaneous pancreas-kidney transplantation had a 1-year function rate of 39%, the pancreas transplantation after kidney of 31% and the pancreas transplantation alone of 20%.

Pharmacokinetic studies of alizarin in man

Alizarin, a constituent of the madder root, is employed in phytotherapy to prevent recurrences of calcium-containing urinary stones. Pharmacokinetic studies were carried out in human subjects during the development of a pharmaceutical product containing alizarin. After giving a single oral dose of 210 mg of alizarin there were two maxima in the serum concentration curves, the first at 2-4 h and the second at 6-8 h. Alizarin and its glucuronide conjugate were detected in both maxima by TLC. The mean elimination half-life was 12 h. The amounts excreted in the urine within 6 days ranged from 18.1 to 36.3%, and the amounts in the faeces from 21.6 to 33.0% (total recovery: 40-60%). In bile from a patient who had undergone cholecystectomy only 0.6% of the dose was recovered. To exclude any possibility that alizarin might be bound to calcium ions in bone, bone trephine specimens were examined from patients with oxalate stones who had previously been treated with alizarin for several years. No alizarin was detectable in these samples. When alizarin is mixed with fresh human faeces and incubated anaerobically it undergoes rapid bacterial decomposition. This in vitro experiment indicates that when alizarin is given orally a large proportion is broken down by bacterial action in the intestine.

[Ileocecal Crohn disease with sigmoid involvement]

This report concerns 14 patients with Morbus Crohn and inflammatory conglomerat tumors between ileo-coecum and sigma. In the case of primary affliction of the ileo-coecum and secondary involvement of the sigma (group A), it is generally sufficient to perform an ileo-coecal resection and suture over the sigma, if a fistula is present. In case of Morbus Crohn afflicting primarily the sigma (group B) or simultaneous involvement of ileo-coecum and sigma (group C), a double resection is necessary. It was always possible to demonstrate the presence of an ileo-sigmoidal fistula by means of barium enema and mostly possible with barium meal or enteroclysis. We consider preoperative colonoscopy with graduated biopsies to be absolutely necessary to determine the exact stage of the illness. Fistulas can be more accurately demonstrated by radiogram than endoscopically.

[The influence of viscosity-increasing pharmaceutic aids on the liberation of the peptide gonadotropin releasing hormone (GnRH) in solution]

The in vitro liberation of the peptide hormone GnRH from polymer solutions was studied as a function of the viscosity of the polymer solutions. The liberation experiments were performed with a flow through dialysis apparatus. From solutions of dextran, carboxymethylcellulose, hydroxyethylcellulose, and polyvinylpyrrolidone the release of GnRH is prolonged whereas the release of GnRH from highly viscous solutions of methylcellulose and polyacrylic acid is not. The delivery process was found to be diffusion-controlled in solutions of dextran, carboxymethylcellulose, and hydroxyethylcellulose. In solutions of polyvinylpyrrolidone the diffusion-controlled prolongation of the GnRH release is additionally influenced by binding of the peptide to the polymer. The results imply that in these polymer solutions the diffusion coefficient of GnRH does not obey the classical relation D approximately 1/eta which is often used to predict liberation from viscous solutions. Thus, the measured macroscopic viscosity of the polymer solutions is not relevant for the diffusion-controlled prolongation of the in vitro release of GnRH. This phenomenon can be explained by the obstruction effect and the microviscosity of the polymer solutions. The described rapid and simple method can be applied for the quantitative determination of the prolonged release in polymer solutions based on diffusion-controlled processes and is useful in the comparison of the efficacy of various polymeric additives. Furthermore the method allows the quantitative proof of the decrease of diffusion in viscous low-molecular solutions and the proof of prolongations of delivery due to the binding of the investigated drug to the polymer.

CT guided percutaneous fine-needle biopsy of the pancreas

147 CT guided fine-needle biopsies of the pancreas were carried out on 141 patients (45 malignant tumours, 79 chronic pancreatitis and pancreas without lesions, respectively). In 23 pseudocysts a malignant lesion could be excluded. By analysing the remaining 124 biopsies (non-cystic targets) an overall accuracy of 79%, a sensitivity of 71% and a specificity of 84% in differentiating between benign and malignant lesions were obtained. By excluding 12% of biopsies with no diagnostic material, an overall accuracy of 90% might be recorded. The comparison between the number of aspirates per examination and the cytological diagnoses would indicate that a minimum of four aspirates is required for satisfactory results.

Incidences of antibodies to hepatitis B, herpes simplex and cytomegalovirus in prostitutes

The 170 prostitutes registered by the local public health authority (165 female, 5 male; ages 17-61) were serologically investigated by ELISA and CFT for the presence of hepatitis B virus (HBV) markers (n = 170), anti-CMV (n = 118) and anti-HSV 2 antibodies (n = 117). 4.7% (1.2%) were found to be HBs- (HBe-)antigen carriers; 1.2% revealed an acute hepatitis B (seroconversion of anti-HBc or IgM-anti-HBc highly positive); 17.1% presented a past and resolved hepatitis B (anti-HBs positive). These rates exceeded those of 125 female age-matched control persons considerably, out of whom only 2.4% (0.8%) presented HBs-(HBe-) antigen and 3.2% anti-HBs antibodies. 90% of the prostitutes investigated proved to be anti-CMV IgG (1.7% IgM) antibody positive and were compared to healthy blood donors (47% IgG, 0% IgM-anti-CMV antibody carriers) and other CMV risk groups: pregnant women 56 (13), patients in hemodialysis 61 (0), hemophiliac patients 69 (0), patients after kidney transplantation 90 (16) and after open-heart surgery 87 (4) % anti-CMV IgG (IgM) antibody carriers. An AIDS patient suffered from simultaneous HBV and CMV infections. The risk of HSV 2 infection is among prostitutes (38.5% seropositives) five times as high as among female age-matched control persons (7.2% seropositives, n = 125). These results confirm that prostitutes must be regarded as a risk for the spread of hepatitis BV and CMV- and HSV 2-caused diseases in the population.

The cytoprotective effect of prostaglandin E2 on taurocholate-induced erosions in gastric mucosa of the rat. Light microscopic, morphometric and scanning electron microscopic investigations

The morphological changes associated with the cytoprotective effect of prostaglandin E2 (PGE2) following sodium-taurocholate (NaTC) erosive injury in the gastric mucosa were investigated in male rats. A single topic application of NaTC (80 mMol) induced multiple gastric erosions in all animals. Application of 200 micrograms PGE2/kg body weight prior to NaTC treatment led to a significant 90% decrease in the lesion-score in PGE2-protected animals. Light microscopic morphometric studies of the mucus-producing cells in the fundus mucosa were carried out. Within the PGE2-protected animals a significant increase was observed in the length of zones of the mucus-producing cells at the surface and in the foveolae (both PAS-positive and alcian-blue-positive cells). Compared to the NaTC-injured animals, this increase amounted to 8.1% for the PAS-positive, and 6.1% for the alcian-blue-positive zone. Compared to the untreated controls, these values were 4.7% and 3.2% respectively. In the scanning electron microscope we observed a characteristic explosive release of mucus and damage of the cell's surface membranes in the NaTC-treated animals. The PGE2-protected rats showed a predominance of exocytosis of mucus vesicles which formed a characteristic mucus network at the surface membrane. Our investigations suggest that the cytoprotective effect of PGE2 may, in part, be due to an increase in mucus production and to a modification of mucus adherence at the cell membrane.

Relationship between insulin secretion and pancreas morphology in subjects with chronic pancreatitis

In order to investigate whether a relationship exists between in vivo insulin secretion and islet mass, 8 patients suffering from severe chronic relapsing pancreatitis were studied before and after pancreatectomy by glucose-glucagon-test (per os 1.75 g glucose; i.v. glucagon 0.01 mg/kg b.w.) and by intravenous glucose-tolerance-test (iGTT) (i.v. glucose 0.33 g/kg b.w.). Postoperative in vitro assessments of pancreatic insulin and alpha-amylase content were performed, and morphometric studies were carried out. Patients were characterized by reduced c-peptide secretion when compared with healthy subjects. The c-peptide response to the glucose-glucagon-test correlated well with the morphometrically estimated exocrine and islet tissue mass (P less than 0.05) and with the content of insulin and amylase in the tissue. The findings suggest that in subjects suffering from severe chronic relapsing pancreatitis the maximal insulin response might represent a parameter for the patient's islet mass.

Pharmacokinetic studies with silymarin in human serum and bile

Six subjects were given orally 560 mg of silymarin (silibinin 240 mg = 8 Legalon 70 dragees). The serum concentration curves and urinary excretion of silibinin, the principal constituent of silymarin, were measured. The maximum serum concentrations were low, ranging from 0.18 to 0.62 microgram/ml. The same was true of renal excretion, which amounted to only 1-2% of the silibinin dose over 24 hours. However, after giving 140 mg of silymarin (silibinin: 60 mg) to patients who had undergone cholecystectomy, bile collected from the T-tube drains was found to contain maximum silibinin concentrations of between 11 and 47 micrograms/ml. Though the dose was four times lower than in the previous experiments, these concentrations were approximately 100 times higher than in the serum. Because complete collection of bile from these patients was impossible and because it was not possible to collect individual samples in the time interval from 12-24 h, the conventional pharmacokinetic parameters required for bioavailability studies could not be calculated. However, computation of the value for AUC0-24 and for "mean time" (MT) provided data which enabled bioavailability comparisons to be made. A study in which the absorption of Legalon 35 and Legalon 70 dragees was compared provides an example for such bioavailability investigations in the bile.