[Early detection of colonic cancer in the National Cancer Program--present status and recommendations]

The National Cancer Programme of the German Federal Administration aims to assess the present status of the national fight against cancer in Germany. Experts in their field have analysed the present target-performance comparison in different working groups dealing with topics from cancer prevention to follow-up and have developed recommendations as to how improvements in the various fields of cancer care may be achieved and mainly how these imrpovements may be implemented in day-to-day cancer care. The working group "Advancement of Colon Cancer Screening, Early Detection and Prevention" proposes the establishment of regulatory proposals for a nationwide, population-based, postal invitational process and, according to Pilot-Projects in Bavaria and Baden-Wuerttemberg, to evaluate the essential recommendations in data protection, logistics, documentation and financing. There are already several programmes in preparation--for example, the Saarland Offensive, based on the results of the KolosSal-Study.

[How threatening is a diverticulitis: what do we know about the long-term course?]

In the context of the controversy regarding the appropriate management of colon diverticulitis without generalised peritonitis - conservative or operative - a review of the literature was per-formed. The progress in diagnostic and therapeutic measures has led to a change in the therapeutic approach during the last 10 years. Because of the lack of randomised controlled trials in patients with diverticulitis (without generalised -peritonitis) comparing medical and surgical treatments, there are still several unanswered questions, such as whether and when to operate and what the recurrence rate is, especially after medical treatment. The therapeutic management should be oriented to the individual symptoms, the comorbidity and the age of the patients.

[Sleifting from continuing medical education to continuing professional development. The example of the German assessment system for surgeons]

In addition to medical knowledge and skills, medical competency includes critical self-refection and professional mistake management, the ability to manage the administrative workload and techniques of professional communication and leadership. In addition to that physicians have to develop social competency and empathy for staff members and patients. Continuing medical education (CME) focuses on continuing development of medical knowledge and skills. To develop the additional aspects of medical competency the concept of medical education has to be broadened to continuing professional development (CPD). In different European countries and North America CPD includes a regular mandatory system to evaluate medical competency. Assessment systems like PAR in Alberta/Canada provide doctors with a 360 degree analysis of their daily work, showing the potential for future improvement. ECKO (Evaluation of Surgical Competency) is an adapted assessment system for German surgeons available on a voluntary basis. For the first time in Germany physicians are able to take part in a strength-weakness analysis of their daily work. They receive recommendations on practice improvement and an educational prescription for individual further education.

Pore mutations affecting tetrameric assembly and functioning of the potassium channel KcsA from Streptomyces lividans

Designed mutations within the Streptomyces lividans kcsA gene resulted in a set of mutant proteins, which were characterized in respect to their assembly and channel activities. (i) The amino acid residue leucine 81 located at the external side of KcsA was found to be exchangeable by a cysteine residue without affecting the channel characteristics. (ii) Substitution of the first glycine (G77) residue within the GYG motif by an alanine or substitution of the tyrosine (Y) residue 78 by a phenylalanine (F) led to mutant proteins which form tetramers of reduced stability. In contrast to the AYG mutant protein, GFG functions as an active K(+) channel whose characteristics correspond to those of the wild-type KcsA channel. (iii) The investigated mutant proteins, which carry different mutations (T72A, T72C, V76A, V76E, G77E, Y78A, G79A, G79D, G79E) within the signature sequence of the pore region, do not at all or only to a very small degree assemble as tetramers and lack channel activity.

[Hospital comparison--status quo and prospects]

Hospitals are competing with each other for the limited financial resources available in the health care sector. Comparison of hospitals is legally required (BPf1V section 5) to improve financial efficiency in the health care sector and make competition between hospitals keener, while also objectivizing it. If comparison of the hospitals is really to enhance profitability or efficiency, and not just to reduce the prices for hospital stays regardless of quality, it must extend to far more than the global figures in the compilation summarizing performance and calculation and the hospital statistics (no. of cases, days of care, length of stay, case lump sums and special fees). Documentation of particular features of the patient population, the potentials of the hospital and description of the treatment processes yield valuable information on capacity and performance level. With rising costs, the danger is growing that the quality and risk dimension of the actual medical treatment will not be promoted with the same enthusiasm by those offering the service. Hospital audit does not only allow a check on the hospital's own situation with regard to performance, quality, efficiency and patient satisfaction, but can also provide a basis of structural planning. The fact is that all efforts made and steps taken by the responsible persons in the hospital to improve the quality of structures, processes and results can only be successful if they are also perceived by the patients, the doctors who refer them and the visitors. If hospital audit is restricted to the bed occupancy and the invoicing data, it is only realistic to expect cuts in performance level. This would be bad for the patient and, in view of the consequent costs, also for the overall costs in the health care sector. Against the backdrop of a future performance-related system of remuneration instead of the principle of covering one's own costs that has been in place hitherto, openness about treatment results gains in importance as a competition parameter for qualified hospitals.

[Continuing medical education seminars of the professional society as preparation for specialist certification (surgery specialty and subspecialties)]

The Berufsverband der Deutschen Chirurgen (BDC) established the Academy for Surgical Education and Training and started in 1986 a structured educational program. It consists of an annual congress (Chirurgentag) and different seminars. In the meantime 15 seminars--nine in general surgery and six in surgical specialities such as traumatology and vascular, visceral, and thoracic surgery--are offered annually in 12 different locations in Germany. The basic seminars (since 1986) 5,264 and the specialised seminars (since 1992) have attracted 1,078 participants. The evaluation of these educational efforts by the BDC in respect to the annual certifications by the official authorities (Landesärztekammer, Bundesärztekammer) demonstrates a high level of acceptance.

[Performance and cost transparency as quality assurance measures]

The use of a Hospital Information System--Network Configuration, Information--Storage and Retrieval, Medical-Administration and -Documentation--lead in the Department of Surgery to positive effects concerning transparency and consciousness of costs and allowed an accurate budget planing and controlling of proceeds.

[Embolism detection after carotid endarterectomy]

Embolic phenomena, early after endarterectomy of the internal carotid artery, were observed in 8 of 28 cases. No patient suffered from ischemic events. 24 h later, no further embolic signals could be detected. These and other observations of an increased risk of perioperative thrombosis and cerebral infarction, in the case of persistent embolic signals during the early recovery period, confirm the probably important role of the transcranial emboli detection in the monitoring of carotid surgery.

[Surgical technical guidelines in intestinal ischemia]

Acute occlusive mesenteric ischemia is caused by a local impairment of splanchnic blood flow and poses a particular surgical challenge. Acute superior mesenteric occlusion is a medical/surgical emergency mandating prompt diagnosis (clinical awareness, angiography) and therapy (exploratory laparotomy with possible arterial reconstruction; embolectomy, thrombectomy; and/or bowel resection). The difficulty of early diagnosis is probably the most important cause of the high mortality which varies from 70% to 90% in arterial and functional mesenteric ischemia and from 20% to 70% in an acute thrombosis of the mesenteric veins. Improved survival from nonocclusive mesenteric ischemia is dependent upon the identification of high-risk groups and on aggressive diagnostic and therapeutic measures (intra-arterial infusion of papaverine through the angiographic catheter with or without bowel resection). For assessment of bowel viability, the clinical judgement during first- or second-look exploration is still the most reliable parameter. The surgical management of chronic mesenteric ischemia includes aortomesenteric grafting and transaortic endarterectomy in the majority of patients with comorbidity of cardiovascular arteriosclerotic diseases and results in a high rate of symptom-free patients. Prophylactic reconstruction of visceral arteries is indicated only in certain limited circumstances.

[Interdisciplinary guidelines: inflammatory bowel diseases (Crohn disease, ulcerative colitis)]

Crohn's disease and ulcerative colitis are characterized by common problems and findings but also disease-specific differences. The most frequent indication for surgery concerns the refractory situation occurring both after and during systematic conservative treatment. The aim of surgery in patients with Crohn's disease is to induce remission of symptoms by removing the segment of diseased bowel. Because of the relatively high rate of postoperative recurrence, extensive resections should be avoided. Proctocolectomy with ileal pouch--anal anastomosis has become the surgical treatment of choice for most patients with uncontrolled ulcerative colitis. This technique offers these patients cure of the disease and in most cases a better quality of life.

A prokaryotic potassium ion channel with two predicted transmembrane segments from Streptomyces lividans

We report the identification, functional expression, purification, reconstitution and electrophysiological characterization of an up to now unique prokaryotic potassium ion channel (KcsA). It has a rectifying current-voltage relationship and displays subconductance states, the largest of which amounts to A approximately equal to 90 pS. The channel is blocked by Cs- ions and gating requires the presence of Mg2+ ions. The kcsA gene has been identified in the gram-positive soil bacterium Streptomyces lividans. It encodes a predicted 17.6 kDa protein with two potential membrane-spanning helices linked by a central domain which shares a high degree of similarity with the H5 segment conserved among eukaryotic ion channels. Multiple alignments of deduced amino acids suggest that the novel channel has the closest kinship to the S5, H5 and S6 regions of voltage-gated K+ channel families, mainly to the subfamily represented by the Shaker protein from Drosophila melanogaster. Moreover, KcsA is most distantly related to eukaryotic inwardly rectifying channels with two putative predicted transmembrane segments.

Soluble interleukin-2 receptor, interleukin-6 and interleukin-1 beta in patients with Crohn's disease and ulcerative colitis: preoperative levels and postoperative changes of serum concentrations

Crohn's disease (CD) and ulcerative colitis (UC) show an intestinal activation of T cells and macrophages within the inflamed lesions. The aim of the present prospective study was to determine whether circulating interleukins (IL) represent useful markers of immune activation in vivo and to characterize their respective roles in monitoring disease activity. Serum concentrations of the soluble IL-2 receptor (sIL-2R), IL-6 and IL-1 beta were measured in 10 patients with CD and 10 patients with UC before, at day 10 and 2 years after resection of inflamed bowel segments. The data were correlated with neopterin, C-reactive protein and other standard parameters of disease activity. Preoperatively, mean sIL-2R concentration was 495 +/- 62 U/ml (mean +/- SEM; healthy controls; 210 +/- 25 U/ml; p less than 0.02) in CD and 705 +/- 120 U/ml (p less than 0.00002) in UC. The corresponding IL-6 serum concentrations were 37 +/- 6 U/ml in CD (controls: 11 +/- 0.6 U/ml; p less than 0.0036) and 33 +/- 6 U/ml (p less than 0.04) in UC. Two years postoperatively, sIL-2R was still elevated in 6 out of 9 patients in both disease groups. These patients did not differ from the remaining group with respect to disease activity. Serum IL-6, elevated in 7 patients with CD and in 6 patients with UC at day 10 postoperatively, had returned to normal in all patients by this time.(ABSTRACT TRUNCATED AT 250 WORDS)

Activation and signaling status of human lamina propria T lymphocytes

In this study, proliferative responses of human lamina propria T lymphocytes were examined in vitro. The response of lamina propria T lymphocytes to Sepharose-bound anti-CD3 antibody plus interleukin 2 was significantly lower than the response of autologous peripheral blood T lymphocytes, whereas the responses of lamina propria T lymphocytes to anti-T11(2/3) antibodies plus sheep erythrocytes or anti-CD28 antibody plus interleukin 2 were largely preserved. After coculture with mucosa supernatant, peripheral blood T lymphocytes showed a similar pattern of reactivity as lamina propria T lymphocytes. This reduced reactivity to T-cell antigen receptor stimulation appears to exist at the level of signal transduction, because triggering of CD3 induces low amounts of intracellular inositol 1,4,5-triphosphate and no free calcium increase in lamina propria T lymphocytes when compared with peripheral blood T lymphocytes. This study indicates that the antigen receptor-dependent activation pathway of lamina propria T lymphocytes for proliferation is down-regulated by intestinal mucosa derived factor(s) and that the alternative pathways mediated by CD2 or CD28 are largely preserved. Based on previous data that lamina propria T lymphocytes can provide help to B cells, it is possible that these alternative activation pathways play an important role in T-B cell interaction in the gut.

An amplifiable and deletable chloramphenicol-resistance determinant of Streptomyces lividans 1326 encodes a putative transmembrane protein

A genetically unstable chloramphenicol resistance gene from Streptomyces lividans 1326 was cloned and characterized. This gene and adjacent DNA regions can be lost spontaneously or amplify within variants. Biochemical studies proved that chloramphenicol is not modified by an acetyltransferase or any other enzyme and that ribosomes of the resistant strain are sensitive to chloramphenicol. Sequence data revealed that the resistance gene encodes a hydrophobic protein predicted to have 12 membrane-spanning alpha-helices and a hydropathic profile similar to the membrane of proteins required for the efflux of tetracycline. Variable proportions of the amino acids (about 16-24%) within the presumed chloramphenicol-resistant protein are identical to various aligned tetracycline-resistant proteins from Gram-negative and Gram-positive bacteria and to transporters for citrate in Klebsiella pneumonaie and for ferrichrome in Escherichia coli.

Down-regulation of protein kinase C activation in human lamina propria T lymphocytes: influence of intestinal mucosa on T cell reactivity

Human lamina propria T lymphocytes (LPL-T) were shown to have lower proliferative responses to CD3 triggering than autologous peripheral blood T lymphocytes (PBL-T), yet preserved their responsiveness to CD2 stimulation. In order to elucidate the basis of these differences, freshly recovered human LPL-T and autologous PBL-T were stimulated with CD2 monoclonal antibodies anti-T11(2/3) plus sheep red blood cells and phorbol 12,13-dibutyrate (PBu2) plus ionomycin, respectively. LPL-T showed invariably lower responses to PBu2 plus ionomycin than PBL-T. In contrast, LPL-T still preserved proliferation to CD2 activation even when their responses to PBu2 plus ionomycin were decreased almost to background levels. Preincubation of PBL-T with intestinal mucosa supernatant led to a similar reactivity as observed in fresh LPL-T. Moreover, the protein kinase C (PKC) inhibitor sphinganine was able to inhibit DNA synthesis to stimulation with PBu2 plus ionomycin but not to CD2 triggering. This study suggests that CD2-induced proliferation is not dependent on PKC activation and that down-regulation of PKC activation may be one of the mechanisms for inhibition of the CD3-Ti-dependent activation pathway in LPL-T by intestinal mucosa-derived influences in vivo.

Proliferative activity of neuroendocrine tumours of the gastroenteropancreatic endocrine system: DNA flow cytometric and immunohistological investigations

The proliferative activity of 16 tumour specimens from 13 patients with neuroendocrine tumours of the gastroenteropancreatic endocrine system was studied by DNA flow cytometry and immunohistology for the nuclear Ki67 proliferation antigen. Equivalent results were obtained with both methods, which showed the proliferative activity of gastroenteropancreatic neuroendocrine tumours to be heterogeneous. In four malignant small intestinal carcinoids and one extravisceral carcinoid localised in the retroperitoneum the percentage (index) of proliferating tumour cells as measured by DNA flow cytometry ranged from 2.9 to 36.2% corresponding to low, moderate, or high proliferative activity. In four malignant pancreatic endocrine tumours and their metastases indices ranged from 8.7 to 18.3%, corresponding to low, moderate, or high proliferative activity. In four benign pancreatic endocrine tumours indices ranged from 4.3 to 7.7%, all corresponding to low proliferative activity. This heterogeneity of proliferative activity may in part explain the heterogeneous results reported of chemotherapy treatment. As chemotherapy of tumours is largely affected by favourable cell cycling kinetics, individual diagnostic investigations of the proliferative activity of these neuroendocrine tumours may be of value for identifying patients suitable for this treatment.

Mononuclear cells in peripheral venous blood of patients with Crohn's disease: preoperative status and postoperative course, influence of duration, activity and extent of disease

In Crohn's disease (CD) the intestinal lesion is supposed to be the cause of the observed systemic immunologic changes. Based on this assumption, peripheral blood mononuclear cells (PBMC) are of specific interest as a possible indicator of intestinal activity of the disease. From 151 surgical patients CD3+, CD4+, CD8+, B cells, macrophages, leucocytes and the relative number of lymphocytes were analysed preoperatively and 10 days, 3 and 6 months postoperatively. The cell data were correlated with the main clinical data of disease. There was a highly significant preoperative increase of leucocytes, macrophages, CD8+, and B cells in the CD group, and a marked decrease of CD3+, CD4+ cells, and the relative lymphocyte count in the same group. Six months postoperatively, highly elevated macrophages, and leucocytes, and a depressed number of CD4+ cells were the only changes. The preoperative cell data did not correlate with the duration of illness, CDAI, localisation, and extent of the intestinal lesion nor did they correlate with any modality of preoperative drug treatment. Thus, the determination of PBMC characteristics in CD is only of limited value for routine diagnostic purposes. However, the persistence of some pathological values long after operation might be caused by residual microscopic lesions and thus reflect the intestinal process.

Partial recovery of lymphocyte activity in patients with colorectal carcinoma after curative surgical treatment and return of plasma glutamate concentrations to normal levels

Glutamate was recently found to inhibit the membrane transport of cystine and to impair the function of macrophages and lymphocytes in vitro. Elevated plasma glutamate concentrations in patients with advanced carcinoma were also found to be quantitatively correlated with reduced lymphocyte reactivity in these persons. We now investigated the questions whether glutamate levels in tumor patients would decline to approximately normal levels after tumor resection and, if so, whether this would be correlated with a recovery of lymphocyte reactivity. We report that plasma glutamate levels as well as the concomitantly elevated plasma lactate levels of patients with colorectal carcinoma return to practically normal levels within 1 week after curative surgery. This is accompanied by a rapid recovery of the lymphocyte reactivity against concanavalin A. Lymphocyte responses against pokeweed mitogen and phytohemagglutinin, in contrast, remain impaired for at least 6 months, indicating that elevated glutamate levels in patients with colorectal carcinoma are associated with a long-lasting defect in the immune system.

Differential responsiveness to CD3-Ti vs. CD2-dependent activation of human intestinal T lymphocytes

Human lamina propria lymphocytes were recovered from surgical specimens of unaffected large bowel and compared with peripheral blood lymphocytes (PBL) from the same individual. We investigated their capacities to respond to triggering stimuli delivered by mitogenic monoclonal antibodies directed at the T cell receptor/CD3 complex or, alternatively, the CD2 glycoprotein. In marked contrast to PBL, expression of the interleukin 2/interleukin 2 receptor system was markedly reduced in LPL following activation through the CD3/T cell receptor. Perhaps, more important, responses to CD2 triggering were similar or even stronger in LPL as opposed to PBL. This indicates that the CD2-dependent alternative pathway of T cell activation might serve a functional role in local immunity in the gut.

Chromogranin A, neuron-specific enolase and synaptophysin as neuroendocrine cell markers in the diagnosis of tumours of the gastro-entero-pancreatic system

Neuroendocrine (NE) tumours of the gastro-entero-pancreatic tract were analysed immunohistochemically for the expression of chromogranin A, neuron-specific enolase and synaptophysin. In all cases at least one marker was present and in 17 out of 19 investigated neoplasms, at least one of the three markers could be demonstrated in more than 75% of the NE tumour cells. Monoclonal antibody chromogranin A stained a much higher proportion of NE cells in tumours with hormonal activity than in hormonally inactive ones. Immunostaining of the primary tumour as compared to its respective metastases was almost identical. Thus, chromogranin A, neuron-specific enolase and synaptophysin identify NE tumours and their metastases regardless of their localization and their state of hormonal activity. As 'panendocrine' markers of NE tumours they are of special diagnostic value in NE tumours that do not produce hormones and peptides.

Cloning and analysis of a deletable tetracycline-resistance determinant of Streptomyces lividans 1326

An unstable determinant encoding resistance to tetracycline and minocycline has been cloned and characterized. It could be demonstrated that this determinant shares extensive homology with the otrA gene identified in Streptomyces rimosus. Tetracycline-sensitive variants of Streptomyces lividans derive mostly by deletion of this resistance determinant and neighbouring DNA regions.

Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring

Sutureless colonic anastomosis using a biofragmentable anastomosis ring (BAR) has been evaluated in a prospective randomized comparison with sutures and staples for elective colorectal surgery. One hundred and one patients underwent BAR anastomosis, 85 a sutured anastomosis, and 16 a stapled anastomosis. There were two anastomotic leaks in the patients undergoing BAR anastomosis, seven in patients having a sutured anastomosis, and one in a patient who had a stapled anastomosis. Wound infection occurred in ten BAR patients, ten sutured patients and no stapled patient. There was no statistically significant difference in these or in other postoperative complications between the groups. The BAR was easy to use and is a safe alternative to sutures and staples for large bowel anastomosis.

[Carcinoid tumor of the ampulla of Vater. Morphology, diagnosis and therapy of a rare papilla tumor]

We report on a patient with a carcinoid tumour of the ampulla of Vater and review the 33 known cases of the literature with regard to clinical presentation, morphology and therapy. As it is apparent from the location of the tumour, obstructive jaundice, pancreatitis and nonspecific upper abdominal complaints are the most frequent symptoms. The ampullary carcinoid belongs histogenetically to the APUD cell system with the ability of multiple endocrine activity. The expression of somatostatin peptide and neuron-specific enolase are the most common histopathological findings. A systemic function of these hormones, however, has not yet been shown. For diagnostic purposes in surgical pathology we found synaptophysin and chromogranin A to be important markers. For surgical treatment, partial duodenopancreatectomy remains the current therapy of choise, if the tumour exceeds two centimeters in diameter.

[Preoperative diagnosis, pathologic anatomy and clinical significance of mucoceles of the appendix from the gynecologic viewpoint]

Owing to their proximity to the true pelvis and their topography, mucoceles of the appendix frequently cause clinical symptoms which call a gynecologic condition to mind. Sonographically, the structures of mucoceles are often similar to those of ovarian tumors. Within 12 months four patients with mucoceles underwent surgery at Heidelberg University Gynecological Clinic following diagnosis of a gynecologic disease (two tentative diagnoses of ovarian carcinoma, one of advanced ovarian carcinoma, one chance finding during Wertheim's operation). The problems of this rare condition are discussed with reference to the clinical findings, the intraoperative site, and the different morphology and maturity. Pathoanatomically and biologically, however, the clinical picture is not uniform. In mucoceles there is an accumulation of mucus with cystic dilatation of the lumen of the appendix. This is usually due to a tumor, which may be anything from a simple mucous membrane hyperplasia with extreme mucous formation, or an adenoma, to a mucilaginous adenocarcinoma. The rupture of a mucocele or metastasization of a carcinoma often lead to peritoneal mucous spread or peritoneal metastasization: in their patterns of distribution these are similar to a pseudomyxoma peritonei or a metastasizing ovarian carcinoma.

Plasma glutamate concentration and lymphocyte activity

Elevated glutamate concentrations are commonly observed in tumor patients, and glutamate was recently found to competitively inhibit the membrane transport of cystine. We therefore investigated the possibility that elevated plasma glutamate levels may damage the immune system. The experiments in this report demonstrate a link between the individual plasma glutamate level and the individual immunological reactivity as measured by mitogenic responses. This correlation has been analyzed in 39 colorectal carcinoma patients, 40 oat cell carcinoma patients, 24 large cell lung carcinoma patients, and 31 apparently healthy persons (blood donors). Blood cells from all three groups of tumor patients in comparison with cells from healthy persons produced markedly reduced mitogenic responses against PWM, and all three groups of tumor patients had on average significantly elevated plasma glutamic acid concentrations. Our analysis revealed a linear regression of the logarithm of the individual plasma glutamate levels (before therapeutic treatment) on the logarithm of the corresponding mitogenic reactivity against PWM for the entire population of 134 persons tested (correlation coefficient -0.80; level of significance P less than 0.00001). A statistically significant linear correlation with a similar regression equation was also observed in the group of the healthy blood donors (n = 31; correlation coefficient -0.56; P less than 0.01), indicating that this correlation is universal and not dependent on the presence of a tumor. Mitogenically stimulated murine lymphocyte cultures revealed an inverse correlation between glutamate concentration and cell proliferation in response to the mitogens PHA and PWM.