Search

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of parasitic and fungus infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (parasitic and fungus) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of bacterial infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (bacterial) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Atopic dermatitis (AD) is one of the most common skin diseases in small animal practice. Allergen immunotherapy (AIT) is the only curative treatment for the disease, and oral, subcutaneous and intralymphatic administration of allergens are commonly employed.To compare the efficacy of AIT following an induction phase with intralymphatic injections (ILIT) or rush immunotherapy (RIT).Fifty privately owned dogs with AD.In a double-blinded study, dogs were randomly assigned to either four monthly ILIT of allergen extract or RIT with five injections administered subcutaneously at hourly intervals on the first day. They were assessed by validated scores; Canine Atopic Dermatitis Lesion Index (CADLI) and pruritus Visual Analog Scale (PVAS) at the beginning of the study and after 1, 3, 6 and 12 months. The latter were performed daily for 7 days before each revisit. Medication scores and a total clinical score were calculated and compared between each group and time point.There was no significant difference in CADLI and PVAS scores, or CADLI and medication scores between groups at any of the time points. A significant improvement with both ILIT and RIT was seen in total and pruritus scores, respectively. An owner global assessment of good-to-excellent treatment efficacy was seen in 40% of the dogs; total scores improved by 27% and 35% in the RIT and ILIT group, respectively. Adverse effects were not seen.Induction of AIT can be conducted either as RIT or ILIT with no loss in efficacy.La dermatite atopique (DA) est l'une des maladies de la peau les plus courantes chez les petits animaux. L'immunothérapie allergénique (AIT) est le seul traitement curatif de la maladie, et l'administration orale, sous-cutanée et intralymphatique d'allergènes est couramment utilisée.Comparer l'efficacité de l'AIT après une phase d'induction avec des injections intralymphatiques (ILIT) ou une immunothérapie en rush (RIT).Cinquante chiens privés atteints de DA. MATÉRIELS ET MÉTHODES: Dans une étude en double aveugle, des chiens ont été assignés au hasard à quatre ILIT mensuels d'extrait d'allergène ou à RIT avec cinq injections administrées par voie sous-cutanée à des intervalles d'une heure le premier jour. Ils ont été évalués par des scores validés ; Canine Atopic Dermatitis Lesion Index (CADLI) et Prurit Visual Analog Scale (PVAS) au début de l'étude et après un, trois, six et 12 mois. Ces dernières ont été effectuées quotidiennement pendant sept jours avant chaque visite de suivi. Les charges médicamenteuses et un score clinique total ont été calculés et comparés entre chaque groupe et chaque point dans le temps. RÉSULTATS: Il n'y avait aucune différence significative dans les scores CADLI et PVAS, ou les scores CADLI et les médicaments entre les groupes à aucun moment. Une amélioration significative avec ILIT et RIT a été observée dans les scores totaux et de prurit, respectivement. Une évaluation globale par le propriétaire de l'efficacité du traitement allant de bonne à excellente a été observée chez 40 % des chiens ; les scores totaux se sont améliorés de 27 % et 35 % dans les groupes RIT et ILIT, respectivement. Aucun effet indésirable n'a été observé.L'induction de l'AIT peut être réalisée soit en RIT soit en ILIT sans perte d'efficacité.INTRODUCCIÓN: La dermatitis atópica (AD) es una de las enfermedades de la piel más comunes en la práctica de pequeños animales. La inmunoterapia con alérgenos (AIT) es el único tratamiento curativo para la enfermedad, y comúnmente se emplea la administración oral, subcutánea e intralinfática de alérgenos.Comparar la eficacia de AIT después de una fase de inducción con inyecciones intralinfáticas (ILIT) o inmunoterapia rápida (RIT).Cincuenta perros de propietarios particulares con AD MATERIALES Y MÉTODOS: En un estudio doble ciego, los perros fueron asignados aleatoriamente a ILIT de extracto de alérgeno o RIT con cinco inyecciones administradas por vía subcutánea a intervalos de una hora el primer día. Fueron evaluados mediante puntuaciones validadas; Índice de Lesión de Dermatitis Atópica Canina (CADLI) y Escala Visual Análoga de Prurito (PVAS) al inicio del estudio y después de uno, tres, seis y 12 meses. Estos últimos se realizaron diariamente durante siete días antes de cada revisita. Se calcularon y compararon las puntuaciones de medicación y una puntuación clínica total entre cada grupo y punto de tiempo.No hubo diferencias significativas en las puntuaciones de CADLI y PVAS, ni en las puntuaciones de CADLI y de medicación entre los grupos en ninguno de los puntos temporales. Se observó una mejora significativa tanto con ILIT como con RIT en las puntuaciones totales y de prurito, respectivamente. Se observó una evaluación global del propietario de la eficacia del tratamiento de buena a excelente en el 40 % de los perros; las puntuaciones totales mejoraron en un 27 % y un 35 % en el grupo RIT e ILIT, respectivamente. No se observaron efectos adversos. CONCLUSIONES Y RELEVANCIA CLÍNICA: La inducción de AIT se puede realizar como RIT o ILIT sin pérdida de eficacia.Die atopische Dermatitis (AD) ist die häufigste Hauterkrankung in der Kleintierpraxis. Die Allergen Immuntherapie (AIT) ist die einzig heilende Behandlung dieser Erkrankung, wobei häufig eine orale, subkutane und intralymphatische Verabreichung der Allergene angewendet wird.Der Vergleich der Wirksamkeit von AIT nach einer Induktionsphase mit intralymphatischen Injektionen (ILIT) oder einer Rush Immuntherapie (RIT).Fünfzig Hunde in Privatbesitz mit AD.In einer doppelblinden Studie wurden Hunde zufällig eingeteilt, um entweder alle vier Monate ILIT eines Allergenextrakts oder RIT mit fünf Injektionen am ersten Tag, die stündlich subkutan verabreicht wurden, zu erhalten. Sie wurden mit validierten Methoden beurteilt; dazu wurde der Canine Atopic Dermatitis Lesion Index (CADLI) und die Pruritus Visual Analog Scale (PVAS) am Beginn der Studie, sowie nach einem, drei, sechs und 12 Monaten eingesetzt. Letztere wurde vor jedem neuerlichen Besuch täglich sieben Tage lang angewendet. Es wurde die Medikation und eine totale klinische Bewertung kalkuliert und zwischen den einzelnen Gruppen und Zeitpunkten verglichen.Es bestand zwischen den Gruppen zu keinem der Zeitpunkte ein signifikanter Unterschied bei CADLI und PVAS-Bewertungen, oder zwischen CADLI und Medikationen. Eine signifikante Verbesserung sowohl mit ILIT als auch mit RIT konnte anhand der Gesamtverbesserung bzw der verbesserten Juckreizwerte gesehen werden. Eine Gesamtbewertung der BesitzerInnen ergab bei 40% der Hunde eine gut-bis-exzellente Wirksamkeit der Behandlung; die Gesamtwerte verbesserten sich um 27% bzw 35% in der RIT bzw ILIT Gruppe. Es wurden keine Nebenwirkungen gesehen.Die Einführung der AIT kann ohne einen Wirksamkeitsverlust sowohl mit RIT wie auch mit ILIT gestartet werden.背景: アトピー性皮膚炎(AD)は、小動物診療において最も一般的な皮膚疾患の一つである。アレルゲン免疫療法(AIT)は本疾患の唯一の根治療法であり、アレルゲンの経口、皮下、リンパ内投与が一般的である。 目的: 本研究の目的は、 導入期を経たAITの効果を、リンパ内注射(ILIT)またはラッシュ免疫療法(RIT)と比較することであった。 対象動物: ADを有するオーナー所有犬50頭 材料と方法: 月4回のアレルゲン抽出物によるILIT、または初日に1時間間隔で5回皮下投与するRITに犬を無作為に割り付け、二重盲検試験を実施した。犬アトピー性皮膚炎病変指数(CADLI)および痒みのVisual Analog Scale(PVAS)を、試験開始時および1、3、6、12ヵ月後に評価した。PVASは、各再診の7日前から毎日実施した。投薬スコアおよび臨床的な総スコアを算出し、各群間および各時点で比較した。 結果: CADLIおよびPVASスコア、CADLIおよび薬物療法スコアは、いずれの時点でも群間で有意差はなかった。ILIT、RITの両方で、総スコア、PVASスコアにそれぞれ有意な改善がみられた。オーナーグローバル評価では、40%の犬で治療効果が良~優と評価され、総スコアはRIT群、ILIT群でそれぞれ27%、35%改善した。また、有害事象は認められなかった。 結論と臨床的意義: AITの導入はRITでもILITでも有効性を損なうことなく実施できる。.背景: 特应性皮炎 (AD) 是小动物临床中最常见的皮肤病之一。过敏原免疫治疗 (AIT) 是该病唯一的根治方法，通常采用过敏原口服、皮下和淋巴结内给药。 目的: 比较淋巴内注射 (ILIT) 或快速免疫治疗 (RIT) 诱导期后 AIT 的疗效。 动物: 50只私人拥有的 AD 犬。 材料和方法: 在一项双盲研究中，犬被随机分配到4个月 ILIT 过敏原提取物或 RIT 组，第1天皮下注射5次，每小时一次。在研究开始时以及1、3、6和12个月后，通过经验证的评分进行评估；犬特应性皮炎病变指数 (CADLI) 和瘙痒视觉模拟量表 (PVAS)。后者在每次复诊前每天进行，持续7天。计算并比较各组和时间点的用药评分和临床总评分。 结果: 在所有时间点，组间 CADLI 和 PVAS 评分、CADLI和药物治疗评分均无显著差异。ILIT 和 RIT 分别观察到总评分和瘙痒评分显著改善。在40%的犬中观察到良好-极佳治疗有效性的犬主人整体评估；RIT和 ILIT 组的总分分别改善了27%和35%。未见不良反应。 结论和临床相关性: 可以进行RIT 或 ILIT作为AIT的诱导，不会降低有效性。.A dermatite atópica (DA) é uma das dermatopatias mais comuns na clínica de pequenos animais. A imunoterapia alergênica (AIT) é o único tratamento curativo para a doença, e a administração subcutânea, oral e intralinfática de alérgenos são comumente empregadas.Comparar a eficácia da AIT após fase de indução com injeções intralinfáticas (ILIT) ou imunoterapia em rush (RIT).Cinquenta cães de proprietários com DA. MATERIAIS E MÉTODOS: Em um estudo duplo-cego, os cães foram aleatoriamente designados para ILIT mensal de quatro extratos de alergênicos ou RIT com cinco injeções administradas por via subcutânea em intervalos de uma hora no primeiro dia. Eles foram avaliados por escores validados; Canine Atopic Dermatitis Lesion Index (CADLI) e prurido Visual Analog Scale (PVAS) no início do estudo e após um, três, seis e 12 meses. Estes últimos foram realizados diariamente durante sete dias antes de cada revisita. Escores de medicação e um escore clínico total foram calculados e comparados entre cada grupo e ponto de tempo.Não houve diferença significativa nos escores CADLI e PVAS, ou CADLI e escores de medicação entre os grupos em nenhum dos momentos. Uma melhora significativa com ILIT e RIT foi observada nos escores total e de prurido, respectivamente. Uma avaliação global do proprietário da eficácia do tratamento de bom a excelente foi observada em 40% dos cães; os escores totais melhoraram em 27% e 35% no grupo RIT e ILIT, respectivamente. Efeitos adversos não foram observados. CONCLUSÕES E RELEVÂNCIA CLÍNICA: A indução de AIT pode ser realizada como RIT ou ILIT sem perda de eficácia.

This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients. Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System). 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p 0.001) and CEUS on-site (62.7 %; p 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site. This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms. Diese prospektive, multizentrische, DEGUM-geförderte Studie untersucht die diagnostische Genauigkeit standardisierter Algorithmen für die Kontrastmittelsonografie (CEUS-Algorithmen) in der nichtinvasiven Diagnostik des hepatozellulären Karzinoms (HCC) bei Hochrisikopatienten. HCC-Hochrisikopatienten mit histologisch gesicherter Leberläsion im B-Bild-Ultraschall wurden prospektiv multizentrisch eingeschlossen. Klinische Daten und Bildgebungsbefunde wurden über Online-Eingabemasken erfasst. Es erfolgte ein direkter Vergleich der diagnostischen Genauigkeiten für die konventionelle CEUS-Befundung zum Untersuchungszeitpunkt (CEUS-on-site) und die CEUS-Algorithmen ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) und CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System). 321 Patienten an 43 Zentren wurden eingeschlossen (93,1 % Leberzirrhose). Der histologische Befund ergab 256 HCCs und 23 intrahepatische cholangiozelluläre Karzinome (iCCA). Die höchste Sensitivität bei Zirrhose-Patienten (n = 299) erzielten der CEUS-Algorithmus ESCULAP (94,2 %) und CEUS-on-site (90,9 %), die geringste Sensitivität der CEUS LI-RADS-Algorithmus (64 %; p 0,001). Die Spezifität war höher für CEUS LI-RADS (78,9 %) versus ESCULAP (50,9 %) und CEUS on-site (64,9 %; p 0,001). Der negativ prädiktive Wert (NPW) war für CEUS LI-RADS niedriger als für ESCULAP (34,1 % vs. 67,4 %; p 0,001) und CEUS-on-site (62,7 %; p 0,001). Der positiv prädiktive Wert (PPW) war für alle Modalitäten hoch (rund 90 %). Dies ist die erste prospektive, multizentrische Studie zum Vergleich der standardisierten Kontrastmittelsonografie mit den kürzlich entwickelten CEUS-Algorithmen in histologisch gesicherten Leberläsionen bei Zirrhose-Patienten. Unsere Ergebnisse bestätigen die exzellente diagnostische Genauigkeit der Kontrastmittelsonografie in der nichtinvasiven HCC-Diagnostik bei Hochrisikopatienten. Die On-site-Diagnose eines erfahrenen Untersuchers erzielt dabei eine beinahe ebenso gute diagnostische Genauigkeit wie die CEUS-basierten Diagnosealgorithmen.

Background Endoscopic en bloc resection of larger polyps is relevant because risk of advanced neoplasia or malignancy correlates with tumor size. Recurrence rates after piecemeal endoscopic mucosal resection (EMR) are high and endoscopic submucosal dissection (ESD) is associated with higher complication rates in the western world. Aim To develop a modified endoscopic en bloc resection technique using an external additional working channel and novel agent for submucosal injection. Methods EMR+ was considered as modified grasp and snare technique. For simultaneous use of a grasping and cutting device a novel additional working channel was used (AWC®, Ovesco Endoscopy, Tubingen, Germany). AWC® is installed on the outer surface of the endoscope, covered with a plastic sleeve and designed for single use. For submucosal injection a new agent consisting of poloxamers was used (LiftUp®, Ovesco Endoscopy, Tubingen, Germany). The agent is liquid at room temperature and forms a stable and permanent gel cushion after injection. Safety of LiftUp® has been shown in a pre-clinical study in domestic pigs. LiftUp® is commercially not yet available but approval is expected in early 2019. EMR+ was first developed ex vivo (explanted pig stomach) and subsequently evaluated in vivo (stomach, porcine model, 3 domestic pigs). Main outcome measurements were: Procedure time, macroscopic en bloc resection and adverse events. Results Concept of EMR+ was first developed ex vivo (explanted pig stomach). Ex vivo, 22 resections were performed after technique was established. Median procedure time (measured from begin of injection to extraction of resection specimen) was 7 min (range 5-11, SD 1.68) and median size of resection specimens was 30 mm × 26 mm × 11 mm ex vivo. Subsequently 13 resections were performed in vivo (stomach, porcine model, 3 domestic pigs). In vivo, median procedure time (measured from begin of injection to extraction of resection specimen) was 5 min (range 3-12, SD 2.72) and median size of resection specimens was 35 mm × 35 mm × 11 mm. In vivo, resection was macroscopic complete in 92.3%, major adverse events were not observed. In one case (7.7%) minor periprocedural bleeding was observed and managed by coagulation. Conclusion EMR+ appeared to be effective and safe and was easy and fast to perform in the porcine model. EMR+ needs to be further evaluated clinically in comparative trials.

The purpose of this study was to analyze imaging findings in hepatic epithelioid hemangioendothelioma (HEHE) with a particular focus on contrast-enhanced ultrasound (CEUS). This retrospective multicenter study included 10 patients with histologically proven HEHE from 5 European centers. All existing ultrasound images/videos were independently analyzed by 2 experienced examiners (DEGUM level III, internal medicine) using a standardized evaluation form. Patterns of contrast enhancement were correlated with computed tomography (CT), magnetic resonance imaging (MRI), and pathological findings. B-mode ultrasound, CEUS, CT, and MRI were performed in 90 %, 70 %, 100 %, and 90 % of patients, respectively. Multifocal HEHE could be observed in 80 % with affection of both liver lobes in 70 %. Analysis of CEUS revealed 3 characteristic patterns that correlated well with contrast patterns on CT and MRI: (a) peripheral nodular enhancement with centripetal fill-in and wash-out in the portal venous and late venous phase (PVLP), (b) rim-like arterial enhancement with wash-out in the PVLP, and (c) inversed target sign with/without wash-out in the PVLP. Wash-out in the PVLP as a sign suspicious of malignancy was observed in 6/7 patients (85.7 %). Knowledge of the different characteristic CEUS patterns is of importance to avoid misdiagnosis due to resemblance of patterns A and B to the much more common focal liver lesions hemangioma and intrahepatic cholangiocarcinoma. Of importance, sonographers should be aware that wash-out in the PVLP might be absent in some patients.ZIEL: Analyse bildgebender Befunde des epithelioiden Hämangioendothelioms der Leber (HEHE) unter besonderer Berücksichtigung der Kontrastmittelsonografie (CEUS). In diese retrospektive, multizentrische Studie wurden 10 Patienten mit histologisch gesichertem HEHE aus 5 europäischen Zentren eingeschlossen. Alle vorhandenen Ultraschallbilder/-videos wurden mithilfe eines standardisierten Auswertungsbogens unabhängig von zwei erfahrenen Untersuchern (DEGUM-Stufe III, Innere Medizin) analysiert. Die nachgewiesenen CEUS-Muster wurden mit Ergebnissen von Computertomografie (CT), Magnetresonanztomografie (MRT) und Pathologie korreliert. B-Bild-Sonografie, CEUS, CT und MRT wurden bei 90 %, 70 %, 100 % und 90 % der Patienten durchgeführt. Bei 80 % zeigt sich ein multifokales HEHE, in 70 % mit Beteiligung beider Leberlappen. Die Analyse der Kontrastmittelsonografie ergab drei charakteristische Muster, welche gut mit den CT- und MRT-Befunden korrelierten: A) Periphere noduläre Kontrastierung in der arteriellen Phase mit zentripetalem Anfluten und Auswaschphänomen in der portalvenösen und späten venösen Phase (PVSP) B) Ringförmige arterielle Kontrastierung mit Auswaschphänomen in der PVSP C) Inverses Target-Zeichen mit/ohne Auswaschphänomen in der PVSP. Ein Auswaschphänomen als Hinweis auf das Vorliegen einer malignen Läsion fand sich bei 6/7 Patienten (85,7 %). Die Kenntnis der beschriebenen charakteristischen CEUS-Muster ist bedeutend zur Vermeidung von Fehlinterpretationen, da die CEUS-Muster A und B den sehr viel häufigeren fokalen Leberläsionen Hämangiom und intrahepatisches Cholangiokarzinom ähneln. Wichtig ist auch, dass ein für maligne Leberläsionen typisches Auswaschphänomen in der portalvenösen und späten venösen Phase fehlen kann.

Background & Aims Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation. Methods A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors. Results Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1–6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9–5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation. Conclusions The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation. Lay summary Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.

Background: To evaluate medical versus interventional treatment (transjugular thrombus fragmentation, local thrombolysis with or without stent implantation) in patients with acute non-cirrhotic, non-malignant portal vein thrombosis (PVT). Methods: This prospective, observational study enrolled 65 patients with acute (

BACKGROUND Transjugular intrahepatic portosystemic shunt has been increasingly used in patients with portal vein thrombosis to obtain patency, but evidenced-based decisions are challenging. AIM To evaluate published data on efficacy and safety of endovascular therapy in portal vein thrombosis. METHODS Systematic search of PubMed, ISI, Scopus, and Embase for studies (in English, until October 2017) reporting feasibility, safety, 12-month portal vein recanalisation, transjugular intrahepatic portosystemic shunt patency, and survival in patients with benign portal vein thrombosis undergoing endovascular treatment. An independent extraction of articles using predefined data fields and quality indicators was used; pooled analyses based on random-effects models; heterogeneity assessment by Cochran's Q, I statistic, subgroup analyses, and meta-regression. RESULTS Thirteen studies including 399 patients (92% cirrhosis; portal vein thrombosis: complete 46%, chronic 87%, cavernous transformation 17%, superior mesenteric vein involvement 55%) were included. Transjugular intrahepatic portosystemic shunt was technically feasible in 95% (95% CI: 89%-98%) with heterogeneity (I = 57%, P

We present a report on ultrasound findings in extragenital endometriosis and a literature review accompanied by illustrations. Intestinal endometriosis should be considered in female patients of reproductive age who present with constipation, gastrointestinal bleeding, nausea, vomiting, cramp-like abdominal pain, diarrhoea and pelvic pain. Although definitive preoperative diagnosis of endometriosis is difficult, clinical suspicion and appropriate imaging might prevent extensive surgical procedures with higher morbidity. Contrast-enhanced ultrasound is an efficient non-invasive imaging method without any radiation exposure that supports the early diagnosis of intestinal endometriosis and may help assess the vascularization of endometriotic lesions within the distinct layers of the intestinal wall.

BACKGROUND Endoscopic en bloc resection of larger polyps is relevant because risk of advanced neoplasia or malignancy correlates with tumor size. Recurrence rates after piecemeal endoscopic mucosal resection (EMR) are high and endoscopic submucosal dissection (ESD) is associated with higher complication rates in the western world. AIM To develop a modified endoscopic en bloc resection technique using an external additional working channel and novel agent for submucosal injection. METHODS EMR+ was considered as modified grasp and snare technique. For simultaneous use of a grasping and cutting device a novel additional working channel was used (AWC®, Ovesco Endoscopy, Tübingen, Germany). AWC® is installed on the outer surface of the endoscope, covered with a plastic sleeve and designed for single use. For submucosal injection a new agent consisting of poloxamers was used (LiftUp®, Ovesco Endoscopy, Tübingen, Germany). The agent is liquid at room temperature and forms a stable and permanent gel cushion after injection. Safety of LiftUp® has been shown in a pre-clinical study in domestic pigs. LiftUp® is commercially not yet available but approval is expected in early 2019. EMR+ was first developed ex vivo (explanted pig stomach) and subsequently evaluated in vivo (stomach, porcine model, 3 domestic pigs). Main outcome measurements were: Procedure time, macroscopic en bloc resection and adverse events. RESULTS Concept of EMR+ was first developed ex vivo (explanted pig stomach). Ex vivo, 22 resections were performed after technique was established. Median procedure time (measured from begin of injection to extraction of resection specimen) was 7 min (range 5-11, SD 1.68) and median size of resection specimens was 30 mm × 26 mm × 11 mm ex vivo. Subsequently 13 resections were performed in vivo (stomach, porcine model, 3 domestic pigs). In vivo, median procedure time (measured from begin of injection to extraction of resection specimen) was 5 min (range 3-12, SD 2.72) and median size of resection specimens was 35 mm × 35 mm × 11 mm. In vivo, resection was macroscopic complete in 92.3%, major adverse events were not observed. In one case (7.7%) minor periprocedural bleeding was observed and managed by coagulation. CONCLUSION EMR+ appeared to be effective and safe and was easy and fast to perform in the porcine model. EMR+ needs to be further evaluated clinically in comparative trials.

Coal mine discharges in several European countries were investigated as part of the European Commission’s MANAGER project. The emphasis of the project was identification of priority pollutants and potential remedial approaches. The main identified priority pollutants were sulphate (all countries) and iron (all countries except Greece). High concentrations of chloride (particularly in Germany and Poland) were associated with discharge of saline mine waters linked to the presence of fossil sea water; these mine waters also had high boron concentrations, in contrast to chloride-rich waters in UK that are linked to recent sea water inflow. Concentrations of trace metals vary among countries, but radium is an important contaminant in barium-rich waters with low sulphate concentrations, essentially in Poland. Concentrations of trace metals and metalloids were generally low because of their relative scarcity in coal strata and adsorption onto ferric oxides and hydroxides, but they still often exceeded the environmental quality thresholds.

Der medizinische Ultraschall ist seit Ende der 1940er Jahre zu einem Universalgenie gereift: Er macht viele OPs überflüssig, fördert den Organerhalt – etwa beim schweren Milzhämatom – und macht Eingriffe wie Aszites-Punktionen sicherer. Die Zerstörung bestimmter Tumore kann er ebenfalls ermöglichen. Nun wird sogar seine stimulierende Wirkung auf das Immunsystem bei Lebermetastasen diskutiert.

The purpose of this study was to determine accuracy and necessity of long-term Doppler ultrasound (DU) surveillance of transjugular intrahepatic portosystemic shunt (TIPS) patency after implantation of an ePTFE-covered stent-graft (Viatorr).This single-center retrospective study includes 228 consecutive cirrhotic patients with TIPS implantation due to portal hypertensive complications. Standardized DU surveillance was scheduled 3 - 5 days, 3 months, and 6 months after TIPS implantation and every 6 months thereafter. Portal venography was performed in case of DU findings suspicious of TIPS dysfunction, clinical signs of recurrent portal hypertension, or refractory hepatic encephalopathy.During a mean follow-up of 16.6 ± 23.4 months, 866 DU examinations were performed. Twenty-two cases of TIPS dysfunction were observed in 16 patients with no first dysfunction more than 4 years after implantation. Routine DU in asymptomatic patients had little therapeutic impact (0.75 %). DU and venography were concordant in 39/46 (84.8 %) paired examinations, and 1-, 2-, and 5-year primary TIPS patency was 87.4 %, 83.7 %, and 79.97 %, respectively. Patients with TIPS dysfunction and subsequent successful revision during the first 2 years of follow-up had a significantly higher risk (p = 0.001) of new dysfunction compared to those without TIPS dysfunction. Cumulative 1-, 2-, and 5-year survival was 68.7 %, 61.3 %, and 42.7 %, respectively.Despite acceptable accuracy, scheduled DU surveillance proved to have minor therapeutic impact. Thus, detailed DU surveillance is not useful in asymptomatic patients after 2 years of unremarkable follow-up. In contrast, long-term DU surveilleance should be performed in patients after successful revision of TIPS dysfunction and patients with prothrombotic states (e. g., portal vein thrombosis, Budd-Chiari syndrome).ZIEL: Evaluation der diagnostischen Genauigkeit und Notwendigkeit einer langfristigen dopplersonografischen Überwachung der TIPS-Funktion nach Implantation eines ePTFE-beschichteten Stents (Viatorr).In diese retrospektive monozentrische Studie wurden 228 Patienten eingeschlossen, die aufgrund portal hypertensiver Komplikationen einer Leberzirrhose eine TIPS-Anlage erhielten. Standardisierte dopplersonografische Kontrollen wurden 3 – 5 Tage, 3 Monate und 6 Monate nach TIPS-Implantation, sowie anschließend halbjährlich geplant. Eine Portografie erfolgte bei dopplersonografischem Verdacht einer TIPS-Dysfunktion sowie bei klinischen Zeichen einer erneuten portalen Hypertension oder einer refraktären hepatischen Encephalopathie.Während einer mittleren Nachbeobachtungszeit von 16.6 ± 23.4 Monaten wurden 866 Doppler-Kontrollen durchgeführt. Bei 16 Patienten wurden 22 Fälle einer TIPS-Dysfunktion beobachtet. Keine erstmalige Dysfunktion trat später als 4 Jahre nach TIPS-Implantation auf. Bei asymptomatischen Patienten hatten die Dopplerkontrollen nur selten eine therapeutische Konsequenz (0.75 %). Dopplersonografie und Portografie ergaben konkordante Ergebnisse bei 39/46 Untersuchungen (84.8 %). Die primäre 1-, 2- und 5- Jahres TIPS-Offenheit betrug 87.4 %, 83.7 % und 79.97 %. Patienten mit erfolgreicher Revision einer TIPS-Dysfunktion innerhalb der ersten zwei Jahre hatten ein signifikant höheres Risiko (p = 0.001) einer erneuten TIPS-Dysfunktion im Vergleich zu Patienten ohne TIPS-Dysfunktion in diesem Zeitraum. Das kummulative 1-, 2-und 5-Jahres Überleben betrug 68.7 %, 61.3 % und 42.7 %.Trotz guter diagnostischer Genauigkeit hatte die Doppler-Surveillance nur selten eine therapeutische Konsequenz. Eine Fortführung regelmäßiger Dopplerkontrollen ist bei asymptomatischen Patienten nach unauffälliger Nachbeobachtung über zwei Jahre unnötig. Langfristige Dopplerkontrollen sollten hingegen nach erfolgreicher Revision einer TIPS-Dysfunktion sowie bei Patienten mit prothombotischen Erkrankungen (z. B. Pfortaderthrombose, Budd Chiari Syndrom) durchgeführt werden.

A 4-year-old ball python was presented 3 weeks after multiple bite wounds from a prey rat with large skin lesions, a concurrent deep bacterial pyoderma and clinical signs for septicemia, including neurolo -gical symptoms. Affected tissue separated from the underlying muscular layer revealing parts of the muscles. Clinical examination and cyto -logy was consistent with bacterial pyoderma; septicemia was an additional tentative clinical diagnosis. Empirical lincomycin and marbo -floxacin (bacterial culture revealed a multi-resistant

Ultrasound findings in autoimmune hepatitis (AIH) have not been reported systematically so far. The use of reliable and accurate noninvasive methods for determining fibrosis stage is important in evaluation of treatment efficacy and fibrosis regression in AIH. Imaging plays an important role in detection of complications and ruling out other possible causes of chronic liver diseases. Ultrasound elastography cut-off values in AIH patients are not the same as those in patients with chronic viral hepatitis or non-alcoholic fatty liver disease. AIH is characterized by wide fluctuations in inflammatory activity. Here we report on current knowledge of ultrasound findings in AIH.

To determine safety and efficacy of transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis (PVT).This retrospective study includes 17 consecutive patients with chronic non-cirrhotic PVT (cavernous transformation n = 15). PVR-TIPS was indicated because of variceal bleeding (n = 13), refractory ascites (n = 2), portal biliopathy with recurrent cholangitis (n = 1), or abdominal pain (n = 1). Treatment consisted of a combination of transjugular balloon angioplasty, mechanical thrombectomy, and-depending on extent of residual thrombosis-transjugular intrahepatic portosystemic shunt and additional stenting of the portal venous system.Recanalization was successful in 76.5 % of patients despite cavernous transformation in 88.2 %. Both 1- and 2-year secondary PV and TIPS patency rates were 69.5 %. Procedure-related bleeding complications occurred in 2 patients (intraperitoneal bleeding due to capsule perforation, n = 1; liver hematoma, n = 1) and resolved spontaneously. However, 1 patient died due to subsequent nosocomial pneumonia. During follow-up, 3 patients with TIPS occlusion and PVT recurrence experienced portal hypertensive complications.PVR-TIPS is safe and effective in selected patients with chronic non-cirrhotic PVT. Due to technical complexity and possible complications, it should be performed only in specialized centers with high experience in TIPS procedures.ZIEL: Untersuchung der Sicherheit und Effektivität der transjugulären Pfortaderrekanalisation mit intrahepatischem portosystemischem Shunt (PVR-TIPS) bei Patienten mit chronischer nicht-zirrhotischer, nicht-maligner Pfortaderthrombose (PVT).In diese retrospektive Studie wurden 17 konsekutive Patienten mit chronischer nicht-zirrhotischer PVT (kavernöse Transformation, n = 15) eingeschlossen. Indikationen zur interventionellen Therapie waren Varizenblutung (n = 13), therapierefraktärer Aszites (n = 2), portale Biliopathie mit rezidivierenden Cholangitiden (n = 1) sowie abdominelle Schmerzen (n = 1). Die interventionelle Therapie bestand aus einer Kombination von transjugulärer Ballonangioplastie, mechanischer Thrombektomie und Anlage eines transjugulären intrahepatischen portosystemischen Shunts (TIPS). Abhängig von der Ausdehnung einer evtl. noch vorhandenen Restthrombose erfolgte ggf. eine zusätzliche Stenteinlage im portalvenösen System.Die Rekanalisation mittels PVR-TIPS war bei 76,5 % der Patienten erfolgreich, obwohl bei 88,2 % eine kavernöse Transformation vorlag. Die sekundären 1- und 2-Jahresoffenheitraten betrugen 69,5 %. Selbstlimitierende Blutungskomplikationen traten bei 2 Patienten auf (intraperitoneale Blutung aufgrund einer Perforation der Leberkapsel, n = 1; Leberhämatom, n = 1). Einer der beiden Patienten verstarb jedoch im Verlauf des Indexaufenthalts aufgrund einer nosokomialen Pneumonie. Während des Follow-Ups entwickelten drei Patienten aufgrund eines PVT-Rezidivs portalhypertensive Komplikationen.PVR-TIPS ist eine sichere und effektive Methode zur Behandlung ausgewählter Patienten mit chronischer nicht-zirrhotischer PVT. Aufgrund der Komplexität des Eingriffs sowie der möglichen Risiken sollte die Methode nur in spezialisierten Zentren mit einer hohen Erfahrung bezüglich TIPS-Prozeduren durchgeführt werden.

Correct values for radium have been rewritten in Table 1 and Table 2. Correct radium units in Figure 2(c) are Bq/L (Becquerel per liter). The same applies to discussion about radium in the text (page 21).

The ultrasound-guided liver biopsy is an important tool to obtain histological samples of suspicious lesions. The technique is effective and complications are rare. After the procedure a standardized monitoring of the patient is necessary. We describe the procedure and the post-interventional monitoring of a liver biopsy step by step.

Treatment of non-malignant portal vein thrombosis (PVT) in patients with cirrhosis has been neglected in the past because of the fear of bleeding complications when using anticoagulation and due to the technical difficulties associated with the implantation of the transjugular intrahepatic portosystemic shunt (TIPS). However, PVT has a negative impact on outcome and compromises liver transplantation, warranting treatment by using anticoagulation and TIPS.This review considers studies on the treatment of PVT in cirrhosis published in the last 10 years. Unfortunately, many of these studies are limited by their retrospective design and a small sample size.Anticoagulation using low-molecular-weight heparin (LMWH) or vitamin K antagonists is effective in the treatment of patients with limited and recent PVT, resulting in a recanalization in up to 50% of the patients. TIPS (plus local measures) results in a recanalization of up to 100% and reduces the rebleeding rate considerably in patients with recent or chronic PVT.Based on the presently limited knowledge, a therapy algorithm is suggested favouring the TIPS as a first-line treatment for PVT in patients with symptomatic portal hypertension. Patients with thus far asymptomatic portal hypertension may first receive anticoagulation, preferably using LMWH. If these patients have a condition where anticoagulation is not promising (complete, extended, chronic PVT) or ineffective, or if they are candidates for liver transplantation, the TIPS may be implanted without delay.Die nichtmaligne Pfortaderthrombose (PVT) beim Zirrhosepatienten galt bis vor wenigen Jahren als schicksalhafte Komplikation, deren spezifische Behandlung mittels Antikoagulation aus Sorge vor Blutungskomplikationen nicht durchgeführt wurde. Auch die Implantation eines transjugulären intrahepatischen portosystemischen Shunt (TIPS) galt lange Zeit aus technischen Gründen als kontraindiziert. Die Probleme, die durch den Pfortaderverschluss im Rahmen der Lebertransplantation auftraten, zwangen zum Umdenken und bewirkten die ersten Therapieversuche sowohl mit Antikoagulanzien als auch mit TIPS.Diese Übersichtsarbeit wertet Studien aus, die in den letzten 10 Jahren zu diesem Thema publiziert wurden. Bei den meisten Studien handelt es sich jedoch um retrospektive Auswertungen mit einer geringen Patientenzahl. Dies schränkt die Qualität der hieraus gewonnenen Empfehlung ein.Die Antikoagulation mit niedermolekularem Heparin oder Vitamin-K-Antagonisten ist effektiv und resultiert in einer Rekanalisation bei bis zu 50% der Patienten. Die Effektivität ist abhängig vom Grad der Thrombose (partiell oder komplett), von ihrer Ausdehnung (begrenzt oder in die zuführenden Venen reichend) und von deren Alter (frisch oder chronisch). Die Anlage eines TIPS (eventuell zusammen mit lokalen Maßnahmen) kann in bis zu 100% zu einer Rekanalisation des Portalsystems führen. Bei chronischer oder kavernomatöser PVT kann ebenfalls eine TIPS-Anlage sinnvoll sein, da sie die Blutungsrate signifikant reduziert.Auf der Grundlage der begrenzten Datenlage wird ein Therapiealgorithmus vorgestellt. Bei Patienten mit symptomatischer portaler Hypertension (insbesondere Varizenblutungen und Aszites) erscheint die frühe TIPS-Anlage empfehlenswert, da sie nicht nur die PVT, sondern auch die Symptome der portalen Hypertension bessert und zu einer Lebensverlängerung beitragen kann. Asymptomatische Patienten können mit einer Antikoagulation behandelt werden, wenn diese Erfolg versprechend erscheint (inkomplette und/oder begrenzte Thrombose, keine chronische PVT). Bei kompletter, ausgedehnter oder chronischer PVT, ungenügendem Ansprechen auf eine vorausgegangene Antikoagulation oder bevorstehender Lebertransplantation ist auch bei asymptomatischen Patienten an die Anlage eines dünnlumigen TIPS zu denken.

Background & aims Therapeutic anticoagulation is the standard treatment in patients with acute non-cirrhotic portal vein thrombosis (PVT). In critically ill patients, anticoagulation only may not suffice to achive rapid and stable recanalization. This study evaluates efficacy and safety of transjugular interventional therapy in acute non-cirrhotic PVT. Methods This retrospective study includes 17 consecutive patients with acute noncirrhotic, non-malignant PVT. Main indication for interventional therapy was imminent intestinal infarction (n = 10). Treatment consisted of a combination of transjugular thrombectomy, local fibrinolysis and – depending on thrombus resolution – transjugular intrahepatic portosystemic shunt. Results Recanalization was successful in 94.1%. One- and two-year secondary PV patency rates were 88.2%. Major complications (n = 3) resolved spontaneously in all but one patient (heparin induced thrombocytopenia type 2 with intestinal infarction). Symptoms improved in all patients. However, segmental bowel resection had to be performed in two (11.8%). During a median follow-up of 28.6 months, no patient experienced portal hypertensive complications. Presence of JAK2 V617F mutation predicted both short-term and long-term technical success. Conclusions Transjugular recanalization is safe and effective in patients with acute non-cirrhotic, non-malignant PVT. It should be considered especially in patients with imminent bowel infarction and low likelihood of recanalization following therapeutic anticoagulation. Patients with JAK2 mutation ought to be followed meticulously.

To evaluate the reproducibility of serum testing for total thyroxine (T4) in three German laboratories.Serum was taken from 53 dogs with suspected hypothyroidism and divided into five aliquots. Three aliquots of each sample were marked with different names and sent to one laboratory (two aliquots simultaneously and one aliquot 1-3 days later). The remaining aliquots were sent to two other laboratories. Laboratory 1 used an enzyme immunoassay for T4 measurements, whereas laboratories 2 and 3 used a chemiluminescence immunoassay. The agreement between the three laboratories (values within or below the reference interval) was determined using the Cohen's Kappa test. The intra- and interassay variability was calculated for each laboratory and the agreement between samples submitted to the same laboratory was also determined using the Cohen's Kappa test.For n = 23/41 patients tested simultaneously in the three laboratories, all three values were either uniformly below, within or above the respective reference interval. The Cohen's Kappa value for intra- and interassay agreement was 1.0 in laboratory 2 (n = 15, complete agreement), 0.33 in laboratory 1 (n = 16) and 0.37 (intra-) and 0.19 (interassay agreement) in laboratory 3 (n = 16, low agreement). There was a low agreement between laboratories 1 and 2 and between laboratories 1 and 3 (κ = 0.30 and 0.25, respectively), while a high agreement was determined between laboratories 2 and 3 (κ = 0.68). The intrassay variability of laboratories 1, 2 and 3 was 13.6%, 5.0% and 10.4%, the interassay variability 17.2%, 5.1% and 17.4%, respectively.The differences in the measurement of thyroxine concentrations of the same serum sample in different laboratories and at different time points in the same laboratory underline the high relevance of interpreting laboratory results in context with the clinical signs of hypothyroidism as well as other laboratory values such as TSH concentration.

Behavioral and cognitive improvements in children with ADHD have been consistently reported after neurofeedback-treatment. However, neurofeedback has not been commonly accepted as a treatment for ADHD. This study addresses previous methodological shortcomings while comparing a neurofeedback-training of Theta-Beta frequencies and training of slow cortical potentials (SCPs). The study aimed at answering (a) whether patients were able to demonstrate learning of cortical self-regulation, (b) if treatment leads to an improvement in cognition and behavior and (c) if the two experimental groups differ in cognitive and behavioral outcome variables. SCP participants were trained to produce positive and negative SCP-shifts while the Theta/Beta participants were trained to suppress Theta (4-8 Hz) while increasing Beta (12-20 Hz). Participants were blind to group assignment. Assessment included potentially confounding variables. Each group was comprised of 19 children with ADHD (aged 8-13 years). The treatment procedure consisted of three phases of 10 sessions each. Both groups were able to intentionally regulate cortical activity and improved in attention and IQ. Parents and teachers reported significant behavioral and cognitive improvements. Clinical effects for both groups remained stable six months after treatment. Groups did not differ in behavioural or cognitive outcome.

The ultrasound-guided liver biopsy is an important tool to obtain histological samples of suspicious lesions. The technique is effective and complications are rare. After the procedure a standardized monitoring of the patient is necessary. We describe the procedure and the post-interventional monitoring of a liver biopsy step by step.

BACKGROUND AND STUDY AIMS Previous studies have shown superior patency rates for self-expandable metal stents (SEMS) compared with plastic stents in patients with malignant biliary obstruction. The aim of this study was to compare stent patency, patient survival, and complication rates between a newly designed, wing-shaped, plastic stent and SEMSs in patients with unresectable, malignant, distal, biliary obstruction. PATIENTS AND METHODS A randomized, multicenter trial was conducted at four tertiary care centers in Germany. A total of 37 patients underwent randomization between March 2010 and January 2013. Patients underwent endoscopic retrograde cholangiography with insertion of either a wing-shaped, plastic stent without lumen or an SEMS. RESULTS Stent failure occurred in 10/16 patients (62.5 %) in the winged-stent group vs. 4/18 patients (22.2 %) in the SEMS group (P = 0.034). The median time to stent failure was 51 days (range 2 - 92 days) for the winged stent and 80 days (range 28 - 266 days) for the SEMS (P = 0.002). Early stent failure (

Mine water in the former uranium mine of Konigstein (Saxony, Germany) contains high concentrations of acid, sulfate, iron, aluminum, various heavy metals, radionuclides, and nitroaromatics. Research has been conducted for several years to establish the extent to which reduction of pollutant concentrations can be positively influenced and accelerated by storage of reactive materials in mine cavities. Investigations were made at different scales to test and select materials with respect to maximum fixation of contaminants (underground column tests) to examine hydraulic effects (underground large-scale column tests) and to optimize material properties (laboratory tests). The investigations have shown that a mixture of Fe chips and lignitic coal is capable of efficiently cleaning acid and contaminant-containing mine water. The examined material is easily available and compatible with the environment. A large-scale application of such a reactive barrier is being considered for mine water treatment in the future and is deemed to be a reasonable conception for a safety component after conclusion of the flooding.