The Predominance of the Health-Promoting Patterns of Work Behavior and Experience in General Practice Teams-Results of the IMPROVEjob Study

This study aims to identify the distribution of the "Work-related behavior and experience patterns" (Arbeitsbezogenes Verhaltens-und Erlebnismuster, AVEM) in general practitioners and their teams by using baseline data of the IMPROVEjob study. Members of 60 general practices with 84 physicians in a leadership position, 28 employed physicians, and 254 practice assistants participated in a survey in 2019 and 2020. In this analysis, we focused on AVEM variables. Age, practice years, work experience, and working time were used as control variables in the Spearman Rho correlations and analysis of variance. The majority of the participants (72.1%) revealed a health-promoting pattern (G or S). Three of eleven AVEM dimensions were above the norm for the professional group "employed physicians". The AVEM dimensions "striving for perfection" (p < 0.001), "experience of success at work" (p < 0.001), "satisfaction with life" (p = 0.003), and "experience of social support" (p = 0.019) differed significantly between the groups' practice owners and practice assistants, with the practice owners achieving the higher values, except for experience of social support. Practice affiliation had no effect on almost all AVEM dimensions. We found a high prevalence of AVEM health-promoting patterns in our sample. Nearly half of the participants in all professional groups showed an unambitious pattern (S). Adapted interventions for the represented AVEM patterns are possible and should be utilized for maintaining mental health among general practice teams.

Antithrombotic therapy and assessment for bleeding diathesis in elective gastrointestinal endoscopy - Expert Opinion Statement on behalf of the Swiss Society of Gastroenterology

INTRODUCTION

180° view on general practitioners' leadership skills: practice-level comparisons of leader and staff assessments using data from the cluster-randomised controlled IMPROVEjob study

OBJECTIVES

Strong primary care leaders are needed to assure high quality services for patient populations. This study analysed general practitioners' (GP) leadership skills comparing practice-level self and staff assessments based on the full range of leadership model and the leader-member exchange (LMX).

SETTING

The questionnaire survey was conducted among German general practice leaders and their staff participating in the IMPROVEjob trial.

PARTICIPANTS

The study population comprised 60 German general practices with 366 participants: 84 GP practice leaders and 282 employees (28 physicians and 254 practice assistants).

PRIMARY AND SECONDARY OUTCOME MEASURES

Leadership skills of the practice leaders were measured using the Integrative Leadership Questionnaire (German Fragebogen für integrative Führung) and the LMX-7 questionnaire. Leaders rated themselves and practice staff rated their leaders. The data was analysed by paired mean comparisons on the practice level.

RESULTS

For most leadership dimensions, practice leaders rated themselves higher than their employees rated them. Differences were found for transformational leadership (p<0.001, d=0.41), especially for the dimensions 'innovation' (p<0.001, d=0.69) and 'individuality focus' (p<0.001, d=0.50). For transactional leadership, the dimension 'goal setting' differed significantly (p<0.01, d=0.30) but not the other dimensions. Scores for negative leadership were low and showed no differences between leaders and employees. Interestingly, employed physicians' rated their practice leaders higher on the two transformational ('performance development', 'providing a vision') and all transactional dimensions. The LMX-7 scale showed high quality relationships between leaders and employees.

CONCLUSIONS

This 180° analysis of GPs' leadership skills with self and employee ratings indicated good relationships. There is a potential to improve leadership regarding goal-setting, innovation and focusing on individual team members. These results allow for the development of targeted interventions.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00012677. Registered 16 October 2019.

Small Changes in Patient Arrival and Consultation Times Have Large Effects on Patients' Waiting Times: Simulation Analyses for Primary Care

(1) Background: Workflows are a daily challenge in general practices. The desired smooth work processes and patient flows are not easy to achieve. This study uses an operational research approach to illustrate the general effects of patient arrival and consultation times on waiting times. (2) Methods: Stochastic simulations were used to model complex daily workflows of general practice. Following classical queuing models, patient arrivals, queuing discipline, and physician consultation times are three key factors influencing work processes. (3) Results: In the first scenario, with patients arriving every 7.6 min and random consultation times, the individual patients' maximum waiting time increased to more than 200 min. The second scenario with random patient arrivals and random consultation times increased the average waiting time by up to 30 min compared to patients arriving on schedule. A busy morning session based on the second scenario was investigated to compare two alternative intervention strategies to reduce subsequent waiting times. Both could reduce waiting times by a multiple for each minute of reduced consultation time. (4) Conclusions: Aiming to improve family physicians' awareness of strategies for improving workflows, this simulation study illustrates the effects of strategies that address consultation times and patient arrivals.

Gastrointestinal bleeding during anticoagulation with direct oral anticoagulants compared to vitamin K antagonists

Aim: Patients receiving oral anticoagulants with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) have an increased risk of gastrointestinal bleeding (GIB). We compared cases of GIB associated with VKAs and DOACs in terms of risk factors, scores, timing, location, severity, and outcome. Methods: Data from patients treated at a university hospital in Switzerland for GIB under VKA and DOACs between 2012 and 2018 were analyzed in this investigator-driven, retrospective, single-center study. Results: A total of 248 patients (110 males; median age, 80 years; 134 VKA, 114 DOAC) were included. No significant differences in age, weight or sex were observed. The propensity of the VKA group for risk factors such as comorbidities, interacting medications, or a high risk for bleeding (HAS-BLED score) was higher than that of the DOAC group. 56% of the VKA-treated patients had a supratherapeutic INR, and 25% in the DOAC group received an unlicensed dose. Significantly more patients in the DOAC group were not formally overdosed with OAC whilst receiving amiodarone compared to the VKA group (57% vs. 18%, respectively, p = 0.03). Latency between the documented start of oral anticoagulation and GIB was shorter in the DOAC group (median 3 months) than in the VKA group (median 23.5 months, p¡0.001). There were no differences in terms of location and severity of the GIB, length of hospitalization, or mortality. Conclusion: Patients taking VKAs displayed more risk factors for GIB than those taking DOACs. Treatment with DOACs was associated with early GIB and calls for increased vigilance during the first months after commencement. Co-medication with amiodarone appeared to be a risk factor for GIB in patients taking DOACs.

Job Satisfaction and Chronic Stress of General Practitioners and Their Teams: Baseline Data of a Cluster-Randomised Trial (IMPROVEjob)

Background: A high prevalence of poor job satisfaction and high chronic stress is documented for general practitioners (GPs) and non-physician practice staff from various countries. The reasons are multifactorial and include deficits in leadership, communication and workflows. This publicly funded study evaluates the effectiveness of the newly developed participatory, interdisciplinary, and multimodal IMPROVEjob intervention on improving job satisfaction among GPs and practice personnel. Here, we report the baseline characteristics of the participating GPs and practice assistants, focusing on job satisfaction and perceived chronic stress. Methods: The IMPROVEjob study was performed as a cluster-randomised, controlled trial (cRCT) with German GP practices in the North Rhine Region. The IMPROVEjob intervention comprised two leadership workshops (one for practice leaders only; a second for leaders and practice assistants), a toolbox with supplemental printed and online material, and a nine-month implementation phase supported by IMPROVEjob facilitators. The intervention addressed issues of leadership, communication, and work processes. During study nurse visits, participants completed questionnaires at baseline and after nine months follow up. The primary outcome was the change in job satisfaction as measured by the respective scale of the validated German version of the Copenhagen Psychosocial Questionnaire (German COPSOQ, version 2018). Perceived chronic stress was measured using the Trier Inventory of Chronic Stress (TICS- SSCS). Results: Recruitment of 60 practices was successful: 21 were solo, 39 were group practices. At baseline, n = 84 practice owners, n = 28 employed physicians and n = 254 practice assistants were included. The mean age of all participants was 44.4 (SD = 12.8). At baseline, the job satisfaction score in the total sample was 74.19 of 100 (±14.45) and the perceived chronic stress score was 19.04 of 48 (±8.78). Practice assistants had a significantly lower job satisfaction than practice owners (p < 0.05) and employed physicians (p < 0.05). In the regression analysis, perceived chronic stress was negatively associated with job satisfaction (b= −0.606, SE b = 0.082, p < 0.001, ICC = 0.10). Discussion: The degree of job satisfaction was similar to those in other medical professionals published in studies, while perceived chronic stress was markedly higher compared to the general German population. These findings confirm the need for interventions to improve psychological wellbeing in GP practice personnel.

Evaluating the Cost-Effectiveness of Early Compared with Late or No Biologic Treatment to Manage Crohn's Disease using Real-World Data

BACKGROUND AND AIMS

We evaluated the cost-effectiveness of early [≤2 years after diagnosis] compared with late or no biologic initiation [starting biologics >2 years after diagnosis or no biologic use] for adults with Crohn's disease in Switzerland.

METHODS

We developed a Markov cohort model over the patient's lifetime, from the health system and societal perspectives. Transition probabilities, quality of life, and costs were estimated using real-world data. Propensity score matching was used to ensure comparability between patients in the early [intervention] and late/no [comparator] biologic initiation strategies. The incremental cost-effectiveness ratio [ICER] per quality-adjusted life year [QALY] gained is reported in Swiss francs [CHF]. Sensitivity and scenario analyses were performed.

RESULTS

Total costs and QALYs were higher for the intervention [CHF384 607; 16.84 QALYs] compared with the comparator [CHF340 800; 16.75 QALYs] strategy, resulting in high ICERs [health system: CHF887 450 per QALY; societal: CHF449 130 per QALY]. In probabilistic sensitivity analysis, assuming a threshold of CHF100 000 per QALY, the probability that the intervention strategy was cost-effective was 0.1 and 0.25 from the health system and societal perspectives, respectively. In addition, ICERs improved when we assumed a 30% reduction in biologic prices [health system: CHF134 502 per QALY; societal: intervention dominant].

CONCLUSIONS

Early biologic use was not cost-effective, considering a threshold of CHF100 000 per QALY compared with late/no biologic use. However, early identification of patients likely to need biologics and future drug price reductions through increased availability of biosimilars may improve the cost-effectiveness of an early treatment approach.

Escherichia coli bloodstream infection preceding the diagnosis of rectal carcinoma

Background:

Cancer is one of the major comorbidities in patients with sepsis, and conversely, bloodstream infections (BSI) may precede the diagnosis of colorectal malignancy, in particular when Streptococcus gallolyticus is isolated. We present the rare case of an Escherichia coli BSI preceding the diagnosis of rectal adenocarcinoma.

Case presentation:

A 56-year-old man with a history of ocular myasthenia gravis presented with fever and shaking chills, and was diagnosed with E. coli BSI of unknown origin. After a thorough history and examination, diagnostic workup revealed a rectal adenocarcinoma as portal of entry for E. coli BSI. The choice of definitive antibiotic treatment was complicated by the risk of myasthenia gravis exacerbation by several classes of antibiotics.

Conclusions:

In patients with E. coli BSI of unknown origin, clinicians need a high index of suspicion regarding underlying colorectal malignancies. This may permit earlier diagnosis in a potentially curable stage.

The Relevance of Vitamin and Iron Deficiency in Patients with Inflammatory Bowel Diseases in Patients of the Swiss IBD Cohort

BACKGROUND ANDAIMS

Vitamin and iron deficiencies are common in patients with inflammatory bowel disease (IBD) as a result of chronic intestinal inflammation, increase in demand, or dietary restrictions. Here, we assessed the frequency of complications in relation to deficiency of iron, folate acid, and vitamin B12 in patients enrolled in the nationwide Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS).

METHODS

A total of 2666 patients were included in the study, 1558 with Crohn's disease (CD) and 1108 with ulcerative colitis (UC).

RESULTS

Iron deficiency anemia was detected in 19.6% of CD patients and 21.6% of UC patients. In CD patients low BMI and nonsmoker status were positively associated with anemia. In both CD and UC, malabsorption syndrome, defined as failure of the GI tract to absorb 1 or more substances from the diet, was found to be significantly associated with anemia (6.2% and 3.8%, respectively) and current steroid use (40% CD, 52.7% UC). In CD patients with ileal (31.7% vs 20%) and colonic (29.9% vs 25%) disease location folate deficiency was significantly higher than in patients with ileocolonic CD or upper GI involvement. In CD patients, vitamin B12 deficiency was associated with the onset of stenosis and intestinal surgery (42.9% vs 32.8% and 46% vs 33% for patients with versus without B12 deficiency).

CONCLUSION

Our data indicate that due to frequent occurrence of deficiency states, regular monitoring and substitution of vitamins and iron are mandatory and may prevent long-term intestinal and extraintestinal complications in IBD patients.

Primary intestinal lymphangiectasia in an elderly female patient: A case report on a rare cause of secondary immunodeficiency

Protein loss via the gut can be caused by a number of gastrointestinal disorders, among which intestinal lymphangiectasia has been described to not only lead to a loss of proteins but also to a loss of lymphocytes, resembling secondary immunodeficiency. We are reporting on a 75-year-old female patient who came to our hospital because of a minor stroke. She had no history of serious infections. During the diagnostic work-up, we detected an apparent immunodeficiency syndrome associated with primary intestinal lymphangiectasia. Trying to characterize the alterations of the immune system, we not only found hypogammaglobulinemia and lymphopenia primarily affecting CD4+, and also CD8+ T cells, but also marked hypocomplementemia affecting levels of complement C4, C2, and C3. The loss of components of the immune system most likely was due to a chronic loss of immune cells and proteins via the intestinal lymphangiectasia, with levels of complement components following the pattern of protein electrophoresis. Thus, intestinal lymphangiectasia should not only be considered as a potential cause of secondary immune defects in an elderly patient, but can also be associated with additional hypocomplementemia.

Symptoms of Depression and Anxiety Are Independently Associated With Clinical Recurrence of Inflammatory Bowel Disease

BACKGROUND & AIMS

We examined the relationship between symptoms of depression and anxiety and clinical recurrence of inflammatory bowel disease (IBD) in a large patient cohort. We considered the progression of depression and anxiety over time.

METHODS

We collected clinical and treatment data on 2007 adult participants of the Swiss IBD study (56% with Crohn's disease [CD], 48% male) performed in Switzerland from 2006 through 2015. Depression and anxiety symptoms were quantified by using the Hospital Anxiety and Depression Scale. The relationship between depression and anxiety scores and clinical recurrence was analyzed by using survival-time techniques.

RESULTS

We found a significant association between symptoms of depression and clinical recurrence over time (for all patients with IBD, P = .000001; for subjects with CD, P = .0007; for subjects with ulcerative colitis, P = .005). There was also a significant relationship between symptoms of anxiety and clinical recurrence over time in all subjects with IBD (P = .0014) and in subjects with CD (P = .031) but not ulcerative colitis (P = .066).

CONCLUSIONS

In an analysis of a large cohort of subjects with IBD, we found a significant association between symptoms of depression or anxiety and clinical recurrence. Patients with IBD should therefore be screened for clinically relevant levels of depression and anxiety and referred to psychologists or psychiatrists for further evaluation and treatment.

Monitoring colonoscopy withdrawal time significantly improves the adenoma detection rate and the performance of endoscopists

BACKGROUND AND STUDY AIMS

The recommended minimum withdrawal time for screening colonoscopy is 6 minutes. Adenoma detection rates (ADRs) increase with longer withdrawal times. We aimed to compare withdrawal times and ADRs of endoscopists unaware of being monitored vs. aware.

PATIENTS AND METHODS

Seven experienced gastroenterologists prospectively performed 558 screening colonoscopies during a 9-month period in a Swiss University hospital. Colonoscopy withdrawal times were first measured without the gastroenterologists’ knowledge of being monitored (n = 355 colonoscopies) and then with their knowledge (n = 203 colonoscopies).

RESULTS

The median withdrawal time when gastroenterologists were unaware of being monitored was 4.5 minutes (interquartile range [IQR] 4 – 5.5 minutes) without intervention and 6 minutes (IQR 4 – 9 minutes) with intervention, increasing significantly to 7.3 minutes (IQR 6.5 – 9 minutes) and 8 minutes (IQR 7 – 11 minutes), respectively, when they were aware of being monitored (P < 0.001 both for colonoscopies with and without intervention). The ADR increased from 21.4 % when the gastroenterologists were unaware of being monitored to 36.0 % when they were aware (P < 0.001). In the multivariate regression model, the endoscopists knowing they were being monitored was the strongest factor associated with ADR (odds ratio 4.417; 95 % confidence interval [CI] 2.241 – 8.705; P < 0.001).

CONCLUSIONS

Colonoscopy withdrawal time in unmonitored gastroenterologists is shorter than recommended and increases with awareness of monitoring. ADR significantly increases when gastroenterologists are aware of being monitored. Implementation of systematic monitoring, and analysis of withdrawal time and ADR for each endoscopist may help to increase the ADR.

[Functional diarrhea - pathophysiology, investigation and treatment]

The most important reason for functional diarrhea in clinical practice is diarrhea-predominant irritable bowel syndrome (IBS) which is characterized by chronic intermittent diarrhea and abdominal pain. The pathophysiology underlying IBS is complex and includes visceral hypersensitivity, abnormal gut motility and autonomous nervous system dysfunction as well as genetic and psychosocial factors. Treatment should be tailored to the individual's symptoms and involves general measures, pharmacological treatments, dietary interventions, psychotherapy and complementary and alternative approaches. The following manuscript will give an overview over pathophysiology, reasonable investigations and treatment of IBS.

Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial

BACKGROUND

In patients undergoing routine upper EGD, propofol is increasingly used without pharyngeal anesthesia because of its excellent sedative properties. It is unclear whether this practice is non-inferior in regard to ease of endoscopic intubation and patient comfort.

OBJECTIVE

To assess the relevance of local pharyngeal anesthesia regarding the ease of EGD performance in patients sedated with propofol as monotherapy.

DESIGN

Randomized, double-blind, placebo-controlled, non-inferiority trial.

SETTING

One community hospital and one university hospital in Switzerland.

PATIENTS

We enrolled 300 consecutive adult patients undergoing elective EGD.

INTERVENTION

Pharyngeal anesthesia with 4 squirts of lidocaine spray versus placebo spray immediately before propofol sedation.

MAIN OUTCOME MEASUREMENTS

Number of gag reflexes (primary endpoint), number of intubation attempts, and degree of salivation during intubation (secondary endpoints) assessed by the endoscopists and staff.

RESULTS

In the lidocaine group, 122 patients (82%) had no gag events, and 25 patients had a total of 39 gag events, whereas in the placebo group 104 patients (71%) had no gag events, and 43 patients had a total of 111 gag events. The rate ratio of gagging with quasi-likelihood estimation of placebo compared with lidocaine was 2.85 (95% confidence interval [CI], 1.42-6.19; P = .005). In adjusted logistic regression analysis, the odds ratio for gagging for placebo pharyngeal anesthesia compared with lidocaine was 1.9 (95% CI, 1.03-3.54). The number of intubation attempts and the degree of salivation were similar in both groups. Two patients in the placebo group experienced oxygen desaturation and needed short-term mask ventilation.

LIMITATIONS

The level of sedation and possible long-term side effects of pharyngeal anesthesia were not assessed.

CONCLUSION

Topical pharyngeal anesthesia reduces the gag reflex in patients sedated with propofol even though it does not seem to have an influence on the ease of the procedure and on patient or endoscopist satisfaction in adequately sedated patients.

Budesonide is effective in adolescent and adult patients with active eosinophilic esophagitis

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by dense tissue eosinophilia; it is refractory to proton pump inhibitor therapy. EoE affects all age groups but most frequently individuals between 20 and 50 years of age. Topical corticosteroids are effective in pediatric patients with EoE, but no controlled studies of corticosteroids have been reported in adult patients.

METHODS

We performed a randomized, double-blind, placebo-controlled trial to evaluate the effect of oral budesonide (1 mg twice daily for 15 days) in adolescent and adult patients with active EoE. Pretreatment and posttreatment disease activity was assessed clinically, endoscopically, and histologically. The primary end point was reduced mean numbers of eosinophils in the esophageal epithelium (number per high-power field [hpf] = esophageal eosinophil load). Esophageal biopsy and blood samples were analyzed using immunofluorescence and immunoassays, respectively, for biomarkers of inflammation and treatment response.

RESULTS

A 15-day course of therapy significantly decreased the number of eosinophils in the esophageal epithelium in patients given budesonide (from 68.2 to 5.5 eosinophils/hpf; P < .0001) but not in the placebo group (from 62.3 to 56.5 eosinophils/hpf; P = .48). Dysphagia scores significantly improved among patients given budesonide compared with those given placebo (5.61 vs 2.22; P < .0001). White exudates and red furrows were reversed in patients given budesonide, based on endoscopy examination. Budesonide, but not placebo, also reduced apoptosis of epithelial cells and molecular remodeling events in the esophagus; no serious adverse events were observed.

CONCLUSIONS

A 15-day course of treatment with budesonide is well tolerated and highly effective in inducing a histologic and clinical remission in adolescent and adult patients with active EoE.

Colon Capsule Endoscopy compared to Conventional Colonoscopy under routine screening conditions

Background

Nodular regenerative hyperplasia (NRH) has been recently recognized as an emergent cause of liver disease in HIV-infected patients. NRH may cause non-cirrhotic portal hypertension with potentially severe consequences such as refractory ascites, variceal bleeding and hypersplenism. Obliteration of the small intrahepatic portal veins in association with prothrombotic disorders linked to HIV infection itself or anti-retroviral therapy seem to be the causes of NRH and thus the term HIV-associated obliterative portopathy has been proposed.

Case Presentation

Here we describe a case of a HIV-infected patient with biopsy-proven NRH and listed for liver transplantation (LT) because of refractory ascites and repeated upper gastrointestinal bleedings. A transjugular intrahepatic portosystemic shunt was placed as a bridge to LT and did not improve liver function. However, anticoagulant therapy with low-molecular-weight heparin (LMWH) was associated with rapid improvement in the liver condition and allowed to avoid LT in this patient.

Conclusions

Thus, this case underscores the relation between thrombophilia and HIV-associated NRH and emphasizes anticoagulant therapy as possible treatment.

Serum protein electrophoresis: an underused but very useful test

Serum protein electrophoresis is used in clinical practice to identify patients with multiple myeloma and other serum protein disorders. It is an inexpensive and easy-to-perform screening procedure. Electrophoresis separates serum proteins based on their physical properties and identifies morphologic patterns in response to acute and chronic inflammation, various malignancies, liver or renal failure, and hereditary protein disorders. For gastroenterologists, the use of serum protein electrophoresis may be helpful in the diagnosis of both common diseases with unusual presentations and rare disorders with typical presentations. Therefore, it represents an ideal screening tool.

Effect of yacon (Smallanthus sonchifolius) on colonic transit time in healthy volunteers

BACKGROUND

Yacon is a root crop which contains high amounts of fructooligosaccharides (FOS). The aim of this study was to investigate the effects of yacon syrup on colon transit time in healthy volunteers.

METHODS

In a placebo-controlled, double-blind study yacon was administered to 16 healthy individuals (8 males, 8 females) in a dose of 20 g daily (equal to 6.4 g FOS) in a 2-week crossover design. Each period was interrupted by a 2-week wash-out phase. Transit time was assessed by a radio-opaque marker technique.

RESULTS

Transit time (mean +/- SEM) through the gastrointestinal tract was significantly decreased from 59.7 +/- 4.3 to 38.4 +/- 4.2 h (p < 0.001). Yacon was well tolerated with an excellent side effect profile. Bloating is not an uncommon side effect observed with FOS, but bloating-related disturbances were not significantly more often reported with yacon compared to placebo. Stool frequency increased from 1.1 +/- 0.1 to 1.3 +/- 0.2 times per day and the consistency showed a tendency for softer stools as assessed by a numerical depicted stool protocol. Neither parameter did, however, reach statistical significance.

CONCLUSION

Yacon markedly accelerates colonic transit in healthy individuals. Further studies are needed in constipated patients to confirm these preliminary data. Due to the low caloric content of yacon, the root could be a useful treatment in constipated diabetics or obese patients.

Two-marker protein profile predicts poor prognosis in patients with early rectal cancer

The aim of this study was to establish an immunohistochemical protein profile to complement preoperative staging and identify rectal cancer patients at high-risk of adverse outcome. Immunohistochemistry was performed on a tissue microarray including 482 rectal cancers for APAF-1, EphB2, MST1, Ki67, p53, RHAMM, RKIP and CD8⁺ tumour infiltrating lymphocytes (TILs). After resampling of the data and multivariable analysis, the most reproducible markers were combined and prognosis evaluated as stratified by pT and pN status. In multivariable analysis, only positive RHAMM (P<0.001; HR=1.94 (1.44–2.61)) and loss of CD8⁺ TILs (P=0.006; HR=0.63 (0.45–0.88)) were independent prognostic factors. The 5-year cancer-specific survival rate for RHAMM+/TIL− patients was 30% (95% CI 21–40%) compared to 76% (95% CI: 66–84%) for RHAMM−/TIL+ patients (P<0.001). The 5-year cancer-specific survival of T1/T2/RHAMM+/TIL− patients was 48% (20–72%) and significantly worse compared to T3/T4/RHAMM−/TIL+ patients (71% 95% CI 56–82%); P=0.039). Stratifying by nodal status, only N+/RHAMM+/TIL− patients demonstrated a significantly worse prognosis than N0/RHAMM+/TIL− patients (P=0.005). Loss of CD8⁺ TILs was predictive of local recurrence in RHAMM+ tumours (P=0.009) only. RHAMM and CD8⁺ TILs may assist in identifying early stage rectal cancer patients facing a particularly poor prognosis and who may derive a benefit from preoperative therapy.

Cystic and solid lesions of the pancreas

More than 95% of malignant tumours of the pancreas are exocrine carcinomas. The exocrine carcinomas have to be distinguished from benign serous cystadenomas and tumours, the latter including mucinous cystic neoplasms, serous cysts, and solid pseudopapillary neoplasms. Cystic lesions have to be separated from pseudocysts, which are the most common cysts. Pseudocysts are due to extensive confluent autodigestive tissue necrosis caused by alcoholic, biliary, or traumatic acute pancreatitis. This review focuses on the classification of the different types of solid and cystic lesions based on histological criteria. The various imaging procedures are also discussed, along with their strengths and limitations.

[Gastrointestinal motility--physiology and methods of measurement]

The development of modern investigation procedures has been the cornerstone to understand the normal gastrointestinal motility. According to its physiological functions the stomach can be divided into a proximal and distal portion, which fulfill completely different tasks. In the fasted state the motility pattern of the small intestine is highly organized into a distinct and cyclic recurring of peristalsis (= Interdigestive Migrating Motor Complexes). After food ingesting this pattern is temporarily abolished and replaced by a band of random contractions (= fed pattern). Colonic contractility exhibit tonic and phasic contractions. During the day and in irregular intervals high amplitude propagated contractions occur which are sometimes associated with mass movements through the colon. To measure pressure activity in the intestine manometry has been established. Various pressure sensors are used to measure gastrointestinal contractility during fasting and after food intake. The transit process of the entire gastrointestinal tract reflects the overall gastrointestinal motor activity and is quantified at the best scintigraphically. For daily practice a simple but nevertheless reliable method to assess cursorily the colonic transit is the radiopaque marker method.

Role of free fatty acids in regulating gastric emptying and gallbladder contraction

The limited effectiveness of orlistat, an inhibitor of gastrointestinal lipases, in inhibiting fat digestion is not completely understood. Therefore we studied the effect of orally and duodenally administered orlistat on gastric emptying, cholecystokinin (CCK) secretion, and gallbladder contraction. In healthy males, gastric emptying of solids and fat were quantified scintigraphically, gallbladder contraction by ultrasound and CCK release by radioimmunoassay. Three studies were performed: (1) oral and (2) duodenal orlistat with a fat-containing meal, and (3) duodenal orlistat with a fat-free meal. Gastric emptying rates of solids and fat (T50% accelerated by 16 and by 22%, p < 0.05, respectively) were significantly faster after duodenal perfusion of orlistat; gallbladder contraction and CCK release were reduced under these conditions (p < 0.005, respectively). With oral orlistat no significant effect was documented on these parameters. We conclude that fat hydrolysis is essential in the regulation of fat-induced gastric emptying and gallbladder contraction.

[Chronic constipation]

Complaints of chronic constipation may substantially impair the quality of life of a patient. The disease feeling is shaped not only by objective parameters but also by subjective perceptions. This is along-considered into the so-called Rome-III-criteria. In the majority of the patients no distinct pathology can be found. A smaller group of patients however exhibit isolated or in combination a slow colonic transit or a pelvic floor dysfunction. Secondary extraintestinal causes are to be looked for particularly during a first clinical evaluation. Apart from general clinical investigations if necessary combined with a colonscopy, specific function tests (transit measurements, defecography) may be applied. Different laxative agents are the primary cornerstone of treatment. In selected cases biofeedback training or even surgical intervention can be successfully adopted.

Pharmacokinetics and pharmacodynamic effects of an oral ghrelin agonist in healthy subjects

CONTEXT

An oral formulation of EP01572, a peptidomimetic growth hormone secretagogue, was studied. An oral delivery system would be preferable in many of the possible therapeutic indications of ghrelin agonists such as EP01572.

OBJECTIVES

Our objective was to establish the pharmacological profile and the GH-releasing activity of increasing oral doses of EP01572 in healthy volunteers. In addition, the pharmacokinetics and pharmacological effects of EP01572 were investigated after intraduodenal (ID) administration.

SETTING

This study was a single-center escalating dose study with oral and ID applications.

SUBJECTS AND METHODS

In the first part, EP01572 was given orally to 36 male subjects; the treatment consisted of one oral dose of either EP01572 or placebo (0.005, 0.05, and 0.5 mg/kg body weight). Six subjects received two additional oral doses of EP01572: 0.125 and 0.25 mg/kg body weight. In the second part, the following treatments were performed in a randomized order: 1) administration of a bolus of saline (placebo) to the small intestine; 2) ID administration of a bolus of EP01572 at 0.2 mg/kg body weight; 3) ID perfusion of a bolus of EP01572 at 0.35 mg/kg body weight; and 4) ID perfusion of a bolus of EP01572 at 0.5 mg/kg body weight.

RESULTS

The oral and ID administration of EP01572 induced a rapid and dose-dependent increase in plasma drug concentrations and a potent GH release in healthy male volunteers.

CONCLUSIONS

This study showed that EP01572 was active with regard to stimulation of GH release in humans after oral and ID administration.

Effect of CCK-1 receptor blockade on ghrelin and PYY secretion in men

Cholecystokinin (CCK), peptide YY (PYY), and ghrelin have been proposed to act as satiety hormones. CCK and PYY are stimulated during meal intake by the presence of nutrients in the small intestine, especially fat, whereas ghrelin is inhibited by eating. The sequence of events (fat intake followed by fat hydrolysis and CCK release) suggests that this process is crucial for triggering the effects. The aim of this study was therefore to investigate whether CCK mediated the effect of intraduodenal (ID) fat on ghrelin secretion and PYY release via CCK-1 receptors. Thirty-six male volunteers were studied in three consecutive, randomized, double-blind, cross-over studies: 1) 12 subjects received an ID fat infusion with or without 120 mg orlistat, an irreversible inhibitor of gastrointestinal lipases, compared with vehicle; 2) 12 subjects received ID long-chain fatty acids (LCF), ID medium-chain fatty acids (MCF), or ID vehicle; and 3) 12 subjects received ID LCF with and without the CCK-1 receptor antagonist dexloxiglumide (Dexlox) or ID vehicle plus intravenous saline (placebo). ID infusions were given for 180 min. The effects of these treatments on ghrelin concentrations and PYY release were quantified. Plasma hormone concentrations were measured in regular intervals by specific RIA systems. We found the following results. 1) ID fat induced a significant inhibition in ghrelin levels ( P < 0.01) and a significant increase in PYY concentrations ( P < 0.004). Inhibition of fat hydrolysis by orlistat abolished both effects. 2) LCF significantly inhibited ghrelin levels ( P < 0.02) and stimulated PYY release ( P < 0.008), whereas MCF were ineffective compared with controls. 3) Dexlox administration abolished the effect of LCF on ghrelin and on PYY. ID fat or LCF significantly stimulated plasma CCK ( P < 0.006 and P < 0.004) compared with saline. MCF did not stimulate plasma CCK release. In summary, fat hydrolysis is essential to induce effects on ghrelin and PYY through the generation of LCF, whereas MCF are ineffective. Furthermore, LCF stimulated plasma CCK release, suggesting that peripheral CCK is the mediator of these actions. The CCK-1 receptor antagonist Dexlox abolished the effect of ID LCF, on both ghrelin and PYY. Generation of LCF through hydrolysis of fat is a critical step for fat-induced inhibition of ghrelin and stimulation of PYY in humans; the signal is mediated via CCK release and CCK-1 receptors.

Effects of a preload on reduction of food intake by GLP-1 in healthy subjects

BACKGROUND/AIMS

Glucagon-like peptide-1 (GLP-1) inhibits food intake in animals and humans. Whether GLP-1 interacts with other satiety signals to modulate food intake is unknown. We investigated therefore in healthy volunteers the potential interactions of GLP-1 with signals from the stomach in regulating food intake.

METHODS

Three sequential, double-blind, crossover studies were performed in male subjects: (1) 12 subjects underwent four experiments (preloads) 20 min before meal intake; (2) 12 volunteers received intravenous (i.v.) GLP-1 (0.9 pmol/kg/min) or saline; (3) subjects received i.v. GLP-1 or saline (control) together with a preload of either 400 ml water or 400 ml protein shake. The effect of these treatments on food intake and feelings of hunger was quantified. Subjects were free to eat and drink as much as they wished.

RESULTS

GLP-1 induced a reduction in food and calorie intake (p < 0.005) compared to controls. If combined with a protein preload, the inhibitory effect of GLP-1 on food intake was markedly increased (p < 0.001). Furthermore, a decrease in hunger feelings and an increase in satiety feelings was documented.

CONCLUSION

GLP-1 interacts with signals from the stomach to modulate energy intake in humans. The signal is only initiated by nutrient-based distension, but not with gastric distension of the fundus alone.

[Portal vein thrombosis in a young patient with severe abdominal pain: a case report]

Wir berichten über einen Patienten mittleren Alters mit gürtelförmigen Oberbauchschmerzen, bei welchem nebst einer chronischen zusätzlich eine subakute Thrombose der kavernös transformierten und stark verkalkten Portalvene duplexsonographisch und computertomographisch nachgewiesen wurde. Eine Vollliqueminisierung und anschliessende Marcoumarisierung führte zur Besserung der Symptomatik.

Effect of intravenous esomeprazole 40 mg and pantoprazole 40 mg on intragastric pH in healthy subjects. A prospective, open, randomised, two-way cross-over comparative study

OBJECTIVE

The aim of this study was to compare the effect on intragastric acidity over 24 h on days 1 and 3 following treatment with intravenous (i.v.) esomeprazole 40 mg (CAS for esomeprazole sodium: 161796-78-7) and pantoprazole 40 mg (CAS for pantoprazole sodium: 138786-67-1).

METHODS

In an open, randomised, two-way cross-over study, 36 healthy volunteers received esomeprazole (Nexium) 40 mg or pantoprazole 40 mg, both administered once daily as an i.v. bolus injection for 3 consecutive days. Continuous 24-h pH recordings were made under standardised conditions at baseline and on days 1 and 3 of each treatment period. The primary variable was the percentage of time with intragastric pH > 4 during a 24-h period.

RESULTS

Time with intragastric pH > 4 was significantly greater with esomeprazole than with pantoprazole during the first 4 h (47.8% vs. 18.9%), as well as for the 24-h period of day 1 and day 3 (day 1: 38.8% vs. 23.7%; day 3:55.0% vs. 35.2%, p < 0.0001 for all times examined). Mean of median intragastric pH with esomeprazole was significantly higher than with pantoprazole during the 24-h period (day 1:3.2 vs. 2.2, p < 0.0001; day 3: 4.3 vs. 3.1, p < 0.00001).

CONCLUSION

Esomeprazole administered as a 40 mg i.v. bolus injection provided faster and more effective control of intragastric acidity than a 40 mg i.v. bolus injection of pantoprazole, and also maintained pH > 4 longer both during the first 4 h on day 1 and during the 24-h period of day 1 and day 3 of dosing.

Gastrointestinal satiety signals in humans — Physiologic roles for GLP-1 and PYY ?

The present review summarizes the appetite suppressing effects of PYY and GLP-1 in the regulation of food intake in humans. Current evidence supports a role for gastrointestinal peptides as regulators of satiety. The regulation of satiety is, however, complex and it is not surprising that multiple control systems exist. It is interesting to note that nutrients in the small intestine such as hydrolysis products of fat stimulate the release of satiety peptides such as GLP-1 or PYY that serve as satiety signals. Both peptides, released from L-cells from the gastrointestinal tract by the local action of digested food, exert various regulatory functions: stimulation of insulin secretion and inhibition of glucagon secretion as typical actions of GLP-1, inhibition of gastric emptying, and inhibition of appetite for both GLP-1 and PYY. The review focuses on the question, whether the two peptides are true endocrine factors that act as physiologic, hormonal regulators of appetite.

Serum immunoglobin G4 (IgG4): an important marker in autoimmune pancreatitis?

A unique form of chronic pancreatitis has recently become widely recognised as an important clinical entity in the spectrum of pancreatic diseases under the term autoimmune pancreatitis (AIP). This entity is characterised by irregular narrowing of the pancreatic duct, swelling of parenchyma, lymphoplasmacytic infiltration and fibrosis as well as favourable response to corticosteroid treatment. In addition, increased concentration of serum immunoglobulin G4 (IgG4) is a notable characteristic marker. Some patients undergoing pancreaticoduodenectomy for presumed pancreatic ductal adenocarcinoma have instead been found to have AIP. Early recognition of AIP can prevent pancreaticoduodenectomy in these patients and effective treatment with steroids can be introduced. Based on an interesting case, we discuss the entity of AIP with the rare combination of sclerosing cholangitis and we focus on the relevance of serum IgG4 as a factor in diagnosis and monitoring therapy of AIP.

Serum immunoglobin G4 (IgG4): an important marker in autoimmune pancreatitis?

A unique form of chronic pancreatitis has recently become widely recognised as an important clinical entity in the spectrum of pancreatic diseases under the term autoimmune pancreatitis (AIP). This entity is characterised by irregular narrowing of the pancreatic duct, swelling of parenchyma, lymphoplasmacytic infiltration and fibrosis as well as favourable response to corticosteroid treatment. In addition, increased concentration of serum immunoglobulin G4 (IgG4) is a notable characteristic marker. Some patients undergoing pancreaticoduodenectomy for presumed pancreatic ductal adenocarcinoma have instead been found to have AIP. Early recognition of AIP can prevent pancreaticoduodenectomy in these patients and effective treatment with steroids can be introduced. Based on an interesting case, we discuss the entity of AIP with the rare combination of sclerosing cholangitis and we focus on the relevance of serum IgG4 as a factor in diagnosis and monitoring therapy of AIP.

Effect of gastric distension prior to eating on food intake and feelings of satiety in humans

The factors that regulate food intake and satiation are complex; it has been suggested that signals arising from the small intestine and the stomach play an important role. It is still unknown, to what extent pure mechanical distension of the gastric fundus and antrum can alter food intake. Our aim was therefore to investigate whether transient gastric fundus and antrum distension applied prior to meal ingestion can trigger satiation in healthy humans. Two sequential, randomized, double-blind, four-period cross-over designed studies were performed in 24 healthy male volunteers: (1) 12 subjects underwent four intragastric balloon distension experiments of the fundus (0, 400, 600, 800 ml) before a standard meal intake; (2) 12 subjects underwent intragastric balloon distension experiments of the antrum under the following conditions: 0 ml balloon distension of the antrum plus intraduodenal (ID) saline or ID fat, and 300 ml antrum distension plus ID saline or ID fat. Shortly after the distension period, subjects were free to eat and drink as much as they wished. Neither gastric fundus nor antrum distension showed a reduction in calorie intake. Distending the fundus affected the mean Visual Analogue Scale (VAS) in the premeal period: subjects experienced a reduced degree of hunger and a concomitant feeling of fullness, but the effect was only apparent during distension with a volume of 600 ml or even 800 ml. Cholecystokinin (CCK) and peptide YY (PYY) were not altered by gastric distension. Transient pure mechanical distension of the fundus or the antrum prior to a meal does not trigger satiation.

Adaptive regulation of the ileal apical sodium dependent bile acid transporter (ASBT) in patients with obstructive cholestasis

BACKGROUND/AIMS

The apical sodium dependent bile acid transporter ASBT (SLC10A2) contributes substantially to the enterohepatic circulation of bile acids by their reabsorption from the intestine. In the rat, its adaptive regulation was observed in the kidneys, cholangiocytes, and terminal ileum after bile duct ligation. Whether adaptive regulation of the human intestinal ASBT exists during obstructive cholestasis is not known.

METHODS

Human ASBT mRNA expression along the intestinal tract was analysed by real time polymerase chain reaction in biopsies of 14 control subjects undergoing both gastroscopy and colonoscopy. Their duodenal ASBT mRNA expression was compared with 20 patients with obstructive cholestasis. Additionally, in four patients with obstructive cholestasis, duodenal ASBT mRNA expression was measured after reconstitution of bile flow.

RESULTS

Normalised ASBT expression in control subjects was highest (mean arbitrary units (SEM)) in the terminal ileum (1010 (330)). Low ASBT expression was found in colonic segments (8.3 (5), 4.9 (0.9), 4.8 (1.7), and 1.1 (0.2) in the ascending, transverse, descending, and sigmoid colon, respectively). Duodenal ASBT expression in control subjects (171.8 (20.3)) was found to be approximately fourfold higher compared with patients with obstructive cholestasis (37.9 (6.5); p<0.0001). Individual ASBT mRNA expression was inversely correlated with bile acid and bilirubin plasma concentrations. In four cholestatic patients, average ASBT mRNA increased from 76 (18) before to 113 (18) after relief of cholestasis (NS). Immunohistochemical assessment indicated that ASBT protein was expressed on the apical surface of duodenal epithelial cells.

CONCLUSION

Obstructive cholestasis in humans leads to downregulation of ASBT mRNA expression in the distal part of the human duodenum.

Capsule endoscopy of the upper gastrointestinal tract -- the need for a second endoscopy

BACKGROUND AND AIMS

Capsule endoscopy (CE) has been recognised as an important investigational tool in the diagnosis of gastrointestinal disease. Studies have shown that CE can identify lesions in the upper gastrointestinal tract as well as in the small intestine. However, contrary to conventional oesophagogastroscopy results, the role of CE findings in the diagnostic algorithm of disorders such as gastrointestinal bleeding has not been well understood. We evaluated the frequency of lesions identified in the oesophagus and the stomach as well as their significance.

METHODS

We retrospectively evaluated patients who had undergone video CE over the last 2 years at our institution. Indication and findings in the oesophagus and the stomach were analysed and compared to previous oesophagogastroscopy findings. Patients in whom lesions were identified were followed up retrospectively for the significance of these findings.

RESULTS

95 patients were included in the analysis (47 males, 48 females, mean +/- SD age of 54.62 +/- 19.2 years). The commonest indication for CE was gastrointestinal bleeding (45%), the second commonest anaemia (28%). CE identified significant lesions in the stomach of 11/95 (11.57%) patients. These lesions had been overlooked in 9/95 (9%) of patients by conventional oesophagogastroscopy prior to CE examination (p value < 0.05). Eight of 95 (8%) patients had oesophageal abnormalities detected by CE. The diagnosis changed the treatment of 8/11 (82%) patients with significant lesions.

CONCLUSIONS

CE has an undefined role in evaluating upper gastrointestinal lesions. Significant lesions missed at oesophagogastroscopy were identified during CE examination. This study underpins the importance of a second conventional endoscopy in the diagnostic algorithm.

Effect of tegaserod on gut transit in male and female subjects

Tegaserod is a novel selective serotonin receptor type-4 (5-HT(4)) partial agonist that stimulates gastrointestinal (GI) motility. Tegaserod has proven efficacy in irritable bowel syndrome with constipation in women and in men and women with chronic idiopathic constipation. The effects on gastric emptying, small bowel transit and colonic transit have not been studied in detail in male and female subjects. This study aimed therefore to assess the effect of gender on GI transit with and without tegaserod. A randomized, placebo-controlled, double-blind, crossover study was performed in 40 healthy subjects (23 males, 17 females). Each treatment period involved three and a half days of bid treatment with either 6 mg tegaserod or an identical placebo. Transit parameters were assessed by a scintigraphy. Tegaserod significantly accelerated gastric emptying, small bowel and colonic transit times (P<0.05-0.0001). The effect was more apparent in male subjects than in females (P=0.044 to P<0.0001). The most striking prokinetic effects were observed in the upper GI tract (stomach and small intestine). In both healthy male and female subjects, tegaserod markedly accelerated small intestinal transit, and induced a significant increase in gastric emptying time and colonic transit. The results imply that tegaserod is a potent prokinetic agent throughout the GI in both sexes.

Effect of peptide YY3-36 on food intake in humans

BACKGROUND & AIMS

Studies in animals and humans suggest a role for peptide YY (PYY3-36) in regulating satiety. The physiologic role of PYY3-36, however, has not been investigated in detail.

METHODS

The present study was designed to examine PYY release in response to 2 meals differing in their calorie content and to relate the plasma levels to those obtained after exogenous infusion. In a second step, the effect of graded intravenous doses (0, 0.2, 0.4, and 0.8 pmol.kg(-1).min(-1)) of synthetic human PYY3-36 on food intake was investigated in healthy male volunteers in a double-blind, placebo-controlled fashion.

RESULTS

Plasma PYY concentrations increased in response to food intake reflecting the size of the calorie load. Graded PYY3-36 infusions resulted in a dose-dependent reduction in food intake (maximal inhibition, 35%; P < .001 vs control) and a similar reduction in calorie intake (32%; P < .001). Fluid ingestion was also reduced by PYY (18% reduction; P < .01). Nausea and fullness were the most common side effects produced by PYY, especially at the highest dose. Furthermore, subjects experienced less hunger and early fullness in the premeal period during PYY3-36 infusion at the highest dose (P < .05).

CONCLUSIONS

This study shows that intravenous infusions of PYY3-36 decrease spontaneous food intake; the inhibition is, however, only significant at pharmacologic plasma concentrations. Whether PYY3-36 has a physiologic role in the regulation of satiety in humans remains to be defined.

Effect of a protein preload on food intake and satiety feelings in response to duodenal fat perfusions in healthy male subjects

The control of food intake and satiety requires a coordinated interplay. Oral protein and duodenal fat inhibit food intake and induce satiety, but their interactive potential is unclear. Our aim was therefore to investigate the interactions between an oral protein preload and intraduodenal (ID) fat on food intake and satiety feelings. Twenty healthy male volunteers were studied in a randomized, double-blind, four-period crossover design. On each study day, subjects underwent one of the following treatments: 1) water preload plus ID saline perfusion, 2) water preload plus ID fat perfusion, 3) protein preload plus ID saline perfusion, or 4) protein preload plus ID fat perfusion. Subjects were free to eat and drink as much as they wished. An oral protein preload significantly reduced caloric intake (19%, P < 0.01). Simultaneous administration of an oral protein preload and ID fat did not result in a positive synergistic effect with respect to caloric consumption, rejecting the initial hypothesis that the two nutrients exert a positive synergistic effect on food intake. An oral protein preload but not ID fat altered the feelings of hunger and fullness. These data indicate that the satiety effect of an oral protein preload is not amplified by ID fat; indeed, the effect of a protein preload does not seem to be mediated by cholecystokinin, glucagon-like peptide-1, or peptide YY. Much more information is necessary to understand the basic physiological mechanisms that control food intake and satiety.

Ecological components and evolution of selfing in the freshwater snail Galba truncatula

The reproductive assurance hypothesis emphasizes that self-fertilization should evolve in species with reduced dispersal capability, low population size or experiencing recurrent bottlenecks. Our work investigates the ecological components of the habitats colonized by the snail, Galba truncatula, that may influence the evolution of selfing. Galba truncatula is a preferential selfer inhabiting freshwater habitats, which vary with respect to the degree of permanence. We considered with a population genetic approach the spatial and the temporal degree of isolation of populations of G. truncatula. We showed that patches at distances of only a few meters are highly structured. The effective population sizes appear quite low, in the order of 10 individuals or less. This study indicates that individuals of the species G. truncatula are likely to be alone in a site and have a low probability of finding a partner from a nearby site to reproduce. These results emphasize the advantage of selfing in this species.

Fat in the intestine as a regulator of appetite--role of CCK

The present review summarizes the appetite-suppressing effects of intestinal fat in the regulation of food intake in humans, with a special focus on the role of cholecystokinin (CCK). Current evidence supports a role for intestinal fat (especially long-chain free fatty acids) acting via the peptide CCK as a physiological satiety pathway. The regulation of satiety is, however, complex and it is not surprising that multiple control systems exist. It is interesting to note that nutrients, such as hydrolysis products of fat in the small intestine, stimulate the release of satiety peptides, such as CCK or PYY, that serve as satiety signals. CCK, released from the gastrointestinal tract by the local action of digested food, exerts various functions: stimulation of gallbladder contraction and exocrine pancreatic secretion, inhibition of gastric emptying, and inhibition of appetite. CCK functions therefore (1) as a positive feedback signal to stimulate digestive processes and (2) as negative feedback signal to limit the amount of food consumed during an individual meal.

P-glycoprotein and surfactants: effect on intestinal talinolol absorption

BACKGROUND AND OBJECTIVE

Surfactants used in pharmaceutical formulations can modulate drug absorption by multiple mechanisms including inhibition of intestinal P-glycoprotein (P-gp). Our objective was to analyze the effect of 2 surfactants with different affinity for P-gp in vitro on the intestinal absorption and bioavailability of the P-gp substrate talinolol in humans.

METHODS

In vitro, the influence of surfactants on talinolol permeability was studied in Caco-2 cells. In vivo, an open-label 3-way crossover study with 9 healthy male volunteers was performed. Subjects were intubated with a 1-lumen nasogastrointestinal tube. The study solution, containing either talinolol (50 mg), talinolol and D-alpha-tocopheryl polyethylene glycol 1000 succinate (TPGS) (0.04%), or talinolol and Poloxamer 188 (0.8%), was administered through the tube.

RESULTS

TPGS, but not Poloxamer 188, inhibited the P-gp-mediated talinolol transport in Caco-2 cells. In healthy volunteers TPGS increased the area under the plasma concentration-time curve with extrapolation to infinity (AUC 0-infinity ) of talinolol by 39% (90% confidence interval, 1.10-1.75) and the maximum plasma concentration (C max) by 100% (90% confidence interval, 1.39-2.88). Poloxamer 188 did not significantly alter the AUC 0-infinity or C max of talinolol.

CONCLUSIONS

This in vivo intraduodenal perfusion study showed that low concentrations of TPGS, close to the concentrations that showed P-gp inhibition in vitro, significantly increased the bioavailability of talinolol. The study design excluded modulation of solubility by TPGS and unspecific surfactant-related effects. The latter was supported by the absence of modulation of the talinolol pharmacokinetics by Poloxamer 188, which does not modulate P-gp. Therefore we consider intestinal P-gp inhibition by TPGS as the major underlying mechanism for the increase in talinolol bioavailability.

Ileocecal reservoir reconstruction after total mesorectal excision: functional results of the long-term follow-up

BACKGROUND

The aim of this study is to obtain functional results of the long-term follow-up after TME and ileocecal interposition as rectal replacement.

METHODS

The study included patients operated on between March 1993 and August 1997 who received an ileocecal interposition as rectal replacement. Follow-up was carried out 3 and 5 years postoperatively. For statistical analysis, the paired t-test, rank test (Wilcoxon), and chi-square or Fisher's exact test were applied; level of significance, P<0.05.

RESULTS

Forty-four patients were included in the studies. Of these, five were not available and four patients could not be evaluated (dementia 1, radiation proctitis 1, fistula 1, pouchitis 1). Seventeen patients died during the observation period; 12 died of the disease. Recurrence of the disorder occurred in 2 of 35 patients (5.7%); 26 and 18 patients, 3 and 5 years postoperatively, respectively remained in the study. At 5 years, 78% of the patients were continent; mean stool frequency was 2.5+/-1.6 per day.

CONCLUSIONS

Functional results and subjective assessment of ileocecal interposition were constant at 3 and 5 years postoperatively. If construction of a colonic J-pouch is not possible due to lack of colonic length, especially after prior colonic resections, the ileocecal interpositional reservoir may offer an alternative to rectal replacement.