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OBJECTIVE: The study aim was to investigate the use of a novel device, the Vscan Air™, for rapidly and effectively performing ultrasound in student teaching during the COVID-19 pandemic. MATERIAL AND METHODS: As part of the ultrasound practical course with integrated hands-on activity required by the regular medical curriculum, 100 medical students were instructed in the use of the Vscan Air™, including duplex mode. They then evaluated the quality of the ultrasound images obtained by the Vscan Air™ from previously selected organs. RESULTS: 100 students were interviewed (female n = 68, male n = 32; age >18 years n = 100). The rated image quality never fell below a mean of 3 for the examined organs and portal vein flow (liver 4,58; spleen 3,99; kidneys 4,29; aorta 4,16; Douglas/rectovesical space 4,14; portal vein 4,43; pancreas 3,53; Focused Assessment with Sonography for Trauma 4,38). Scores below 3 were found sporadically in ultrasounds of the spleen (n = 4), kidneys (n = 3), Douglas/rectovesical space (n = 2), and pancreas (n = 15). The liver was rated the lowest for 59 ratings. The portal vein was evaluated in 68 cases. The hepatic artery and hepatic veins could be also visualized in all 68 examinations. The aorta was evaluated in 62 cases. CONCLUSION: The Vscan Air™ technology offered adequate image quality and provided a new, fast and patient-oriented technique to support continuous ultrasound examinations and education of students, especially during a pandemic. Particularly noteworthy is the uncomplicated compliance with the required high level of hygiene.

Solid tumors have an altered metabolism with a so-called inside-out pH gradient (decreased pHe < increased pHi). This also signals back to tumor cells via proton-sensitive ion channels or G protein-coupled receptors (pH-GPCRs) to alter migration and proliferation. Nothing, however, is known about the expression of pH-GPCRs in the rare form of peritoneal carcinomatosis. Paraffin-embedded tissue samples of a series of 10 patients with peritoneal carcinomatosis of colorectal (including appendix) origin were used for immunohistochemistry to study the expression of GPR4, GPR65, GPR68, GPR132, and GPR151. GPR4 was just expressed weakly in 30% of samples and expression was significantly reduced as compared to GPR56, GPR132, and GPR151. Furthermore, GPR68 was only expressed in 60% of tumors and showed significantly reduced expression as compared to GPR65 and GPR151. This is the first study on pH-GPCRs in peritoneal carcinomatosis, which shows lower expression of GPR4 and GPR68 as compared to other pH-GPCRs in this type of cancer. It may give rise to future therapies targeting either the TME or these GPCRs directly.

Background: Pseudomyxoma peritonei (PMP) is a rare peritoneal condition where mucus-secreting tumorous cells progressively produce a thick, gelatin-like substance. The prognosis of patients with PMP is determined by the degree of cellularity within the mucin (low-grade (LAMN) vs. high-grade (HAMN) histologic features) and by the extent of the disease. Methods: Prognostic relevance of tumor markers CA19-9 and CEA, gender, Peritoneal Cancer Index (PCI), and completeness of cytoreduction (CC) after cytoreductive surgery were evaluated on 193 consecutive PMP patients, based on a retrospective analysis of prospectively gathered data from a German tertial referral center. Results: We demonstrated that low PCI, CC0 status, low-grade histology, and female gender were independent positive prognostic factors for both overall survival (OS) and progression-free survival (PFS). Furthermore, LAMN patients with achieved CC0 status show significantly better OS and PFS compared to those with CC1 status (p = 0.0353 and p = 0.0026 respectively). In contrast, the duration and drug of hyperthermic intraperitoneal chemotherapy (HIPEC) were not prognostic in any comparison. Increased CA19-9 and CEA levels were significantly associated with HAMN cases, but also predicted recurrence in patients with low-grade histologies. Conclusion: Our study confirmed the prognostic role of tumor markers and emphasized the importance of CC status and PCI in a large cohort of PMP- and LAMN patients.

Multiple systemic therapy options have been recently approved for the treatment of hepatocellular carcinoma (HCC). In particular, immuno-oncology combination therapies can now achieve impressive response rates and significantly prolonged survival with good tolerability. These immuno-oncology (IO)-based combinations are currently not only evaluated for the therapy of advanced HCC, but increasingly also in earlier stages in terms of peri-interventional therapy concepts and also for down-sizing to local therapies. In the context of liver transplantation (LTx), a particularly critical benefit/risk assessment must be made before the use of immunotherapeutics in the context of multimodal concepts, since the risk of a potentially lethal rejection can be significantly increased by immunotherapy.This review is based on a selective literature search performed between December 2020 and April 2021 in the PubMed and Cochrane Library databases. Guidelines, expert opinions, and recommendations from professional societies were given special consideration.Nearly one in five LTx in Germany are performed due to HCCs. In this context, LTx is a curative therapy option not only for the underlying liver disease but also for the malignant tumor. Individual case reports indicate that IO therapy prior to LTx may increase the risk of rejection or liver failure after subsequent liver transplantation. Since 2015, immunotherapeutics have also been widely used for tumor therapy in patients after LTx. In small case series, rejection rates of 36%, associated with rejection-related mortality of 20% of treated patients, have been described. A similar incidence of rejection has also been described following the use of immunotherapeutics in patients after other organ transplantations.In the context of organ transplantation, IO therapy carries the risk of graft rejection, which can lead to graft loss and also patient death. However, from today's point of view, IO-based therapy can be considered in the context of organ transplantation with a careful benefit/risk assessment.Für das fortgeschrittene hepatozelluläre Karzinom steht uns seit Kurzem ein deutlich erweitertes Spektrum an systemischen Therapieoptionen zur Verfügung. Insbesondere mit den immunonkologischen Kombinationstherapien können mittlerweile beeindruckende Ansprechraten und ein deutlich verlängertes Überleben bei insgesamt guter Verträglichkeit erreicht werden. Dabei werden diese Immun-Onkologie (IO)-basierten Kombinationen nicht nur zur Therapie des fortgeschrittenen HCC geprüft, sondern zunehmend auch in früheren Stadien im Sinne von periinterventionellen Therapiekonzepten und auch zum down-sizing zu lokalen Therapien. Im Kontext der Lebertransplantation (LTx) muss allerdings eine besonders kritische Nutzen-Risiko-Abwägung vor Einsatz von Immuntherapeutika im Rahmen multimodaler Konzepte erfolgen, da durch die Immuntherapie das Risiko einer potenziell letalen Abstoßung signifikant gesteigert werden kann.Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche, die zwischen Dezember 2020 und April 2021 in den Datenbanken PubMed und Cochrane Library durchgeführt wurde. Leitlinien, Expertenmeinungen und Empfehlungen von Fachgesellschaften wurden besonders berücksichtigt.Fast jede fünfte LTx in Deutschland erfolgt aufgrund eines HCC (DSO Jahresbericht 2019). Die LTx ist dabei eine kurative Therapieoption nicht nur für die zugrunde liegende Lebererkrankung, sondern auch für den malignen Tumor. Einzelfallbeschreibungen weisen darauf hin, dass auch eine IO-Therapie vor einer LTx das Risiko einer Abstoßung bzw. eines Leberversagens bei einer nachfolgenden LTx erhöhen kann. Seit ca. 2015 werden Immuntherapeutika vielfach auch zur Tumortherapie bei Patienten nach einer LTx eingesetzt. In kleinen Fallserien wurden dabei Abstoßungsraten von 36%, die mit einer abstoßungsbedingten Mortalität von 20% der behandelten Patienten einhergingen, beschrieben. Eine ähnliche Inzidenz von Abstoßungsreaktionen wurde auch nach dem Einsatz von Immuntherapeutika bei Patienten nach anderen Organtransplantationen beschrieben.Im Zusammenhang mit einer Organtransplantation besteht durch eine IO-Therapie das Risiko einer Transplantatabstoßung, welches zum Verlust des Transplantates und auch zum Tod des Patienten führen kann. Unter Abwägung der oben dargelegten Überlegungen kann aber nach unserer sorgfältigen Nutzen-Risiko-Abwägung aus heutiger Sicht ein Einsatz einer IO-basierten Therapie im Kontext der Organtransplantation erfolgen.

Throughout the past decades, considerable progress has been made in the (early) diagnosis and treatment of gastrointestinal cancers. However, the prognosis for advanced stages of gastrointestinal tumors remains limited for many patients and approximately one third of all tumor patients die as a result of gastrointestinal tumors. The prevention and early detection of gastrointestinal tumors is therefore of great importance.For this reason, we summarize the current state of knowledge and recommendations for the primary, secondary and tertiary prevention of esophageal, stomach, pancreas, liver and colorectal cancer in the following.In den letzten Dekaden wurden erhebliche Fortschritte bei der (frühzeitigen) Diagnostik und Therapie gastrointestinaler onkologischer Erkrankungen erzielt. Allerdings bleibt die Prognose für fortgeschrittene Stadien von gastrointestinalen Tumoren für viele Patienten limitiert, und ungefähr ein Drittel aller Tumorpatienten verstirbt an den Folgen eines gastrointestinalen Tumors. Der Prävention und Früherkennung gastrointestinaler Tumoren kommt somit eine große Bedeutung zu.Aus diesem Grund fassen wir im Folgenden den Wissensstand und Empfehlungen zur primären, sekundären und tertiären Prävention von Ösophagus-, Magen-, Pankreas-, Leberzell- und kolorektalem Karzinom zusammen.

The present observational study demonstrates developments of surgery in Crohn's disease patients undergoing bowel resection at two tertiary referral centers during the recent 3 decades.Consecutive patients undergoing intestinal resections were included. Exclusion criteria were: resection for malignancy, mere stoma formation and closure, bowel resections for other reasons than Crohn's disease, abdomino-perineal resections for anal fistula. Data collection was retrospective between 1992 and 2004, and prospective thereafter. Six time periods were compared: 1992-1995, 1996-2000, 2001-2005, 2006-2010, 2011-2015, and 2016-2020.Between 2000 and 2015 several significant developments could be observed: decline in preoperative steroid intake, increase in preoperative intake of immunomodulators and biologic agents; abandonment of preoperative mechanical bowel preparation, increase in surgery for penetrating disease and more patients with previous bowel resections, increase in laparoscopy use, stoma rate and postoperative morbidity. Since 2016, mechanical bowel preparation and oral antibiotics were (re)introduced, there was significantly more laparoscopic surgery (67%), preoperative steroid and immunomodulator intake diminished, whereas preoperative biological therapy increased; patients were older and less were active smokers; stoma formation rate and morbidity rate decreased significantly.There were several very strong trends in Crohn's disease surgery during the last 3 decades. However, present results cannot be generalized to broader patient' population.Die Behandlung des M. Crohn – vor allem die medikamentöse – erlebte in den letzten 20–30 Jahren einen starken Wandel. Die vorliegende Beobachtungsstudie fasst alle Darmresektionen wegen M. Crohn zusammen, die in den letzten 3 Dekaden an 2 großen spezialisierten Zentren durchgeführt wurden. Die perioperativen Trends und Entwicklungen sollten identifiziert werden.Eingeschlossen wurden alle Darmresektionen bei M. Crohn. Ausschlusskriterien waren: Resektionen bei Malignität, abdominoperineale Rektumexstirpationen wegen Crohn-Analfisteln, ausschließliche Stomaanlagen und -rückverlagerungen und Resektionen, die einen anderen Grund als M. Crohn hatten. Die Daten wurden von 1992 bis 2004 retrospektiv und danach prospektiv gesammelt. Ausgewertet wurden 6 Zeiträume: 1992–1995, 1996–2000, 2001–2005, 2006–2010, 2011–2015 und 2016–2020.Es wurden 811 Darmresektionen ausgewertet. Zwischen 2000 und 2015 konnten gleich mehrere sehr starke Trends beobachtet werden: erhöhte präoperative Einnahme von Immunmodulatoren und Biologika, sinkende präoperative Steroideinnahme, Verzicht auf präoperative Darmvorbereitung, erhöhter Anteil an voroperierten Patienten und Patienten, die sich mit penetrierendem Befallsmuster vorstellten, Einführung neuer Operationstechniken (Laparoskopie, Stapleranastomosen) und signifikante Erhöhung der postoperativen Morbidität und Stomachirurgie. In den letzten 5 Jahren seit 2016 zeigten sich folgenden Entwicklungen: signifikant weniger Operationen unter Steroideinnahme oder Immunmodulatoren, signifikant mehr Operationen unter Biologika, Wiedereinführung der präoperativer Darmvorbereitung, starke Reduktion der Morbidität und Stomaanlage, höheres Alter der Patienten, weniger aktive Raucher, weniger Operationen wegen penetrierenden Befallsmusters, sehr starker Anstieg laparoskopischer Operationen.Vor allem in den letzten 5 Jahren scheint die Crohn-Chirurgie wesentlich sicherer und weniger invasiv zu werden. Die Daten können jedoch nicht auf größere Populationen übertragen werden.

Open abdominal wounds with intestinal fistula formation are challenging complications in abdominal surgery. Special fistula devices (SFD) used along with negative pressure wound therapy with instillation and dwell time (NPWTi-d), may improve management of these wounds, increasing NPWT dressing durability and helping decrease dressing leakage.A 57-year-old, obese (body mass index: 55 kg/m²) female with a long history of Crohn disease and multiple intestinal resections, presented with an incarcerated parastomal hernia, abscess formation, and septic shock. After the hernia was repositioned and the infection controlled, a bovine mesh-augmented hernia repair was performed. Skin rotation flaps for wound closure became necrotic and led to an infected, open abdominal wound measuring about 60 cm x 50 cm with formation of 2 additional small bowel fistulas alongside the ostomy and a massive bacterial and fungal superinfection. After surgical debridement, NPWTi-d with 10 minutes soaking time with isotonic saline solution followed by 2 to 4 hours negative pressure therapy with -125 mm Hg combined with SFDs was initiated; once the infection was controlled approximately 3 weeks after initiation, treatment was switched to traditional NPWT with -125 mm Hg continuous negative pressure and SFDs. Dressings were changed on demand. During the whole treatment period, local infection was brought under control, the wound was clean, and thick granulation tissue formed (even on exposed parts of the mesh). The dressing stability provided a high level of patient comfort.By providing expedient wound cleaning, decontamination, local infection control, and patient comfort, as well as helping generate granulation tissue even on biological mesh, NPWTi-d used with SFDs represents a viable tool for the management of challenging fistulizing abdominal wounds.

Background Orthotopic liver transplantation (OLT) is the treatment option for early-stage hepatocellular carcinoma (HCC). OLT is often associated with high blood loss, requiring blood transfusion. Retransfusion of autologous blood is a key part of blood conservation. There are, however, concerns that the retransfusion of salvaged blood might cause the spread of cancer cells and induce metastasis. Irradiation of salvaged blood before retransfusion eliminates viable cancer cells. Here, we analyzed the incidence of tumor recurrence in patients with HCC undergoing OLT who received irradiated cell-salvaged blood during transplant surgery. Methods We retrospectively analyzed patients undergoing OLT for HCC between 2002 and 2018 at our center. We compared the tumour recurrence in patients who received no retransfusion of autologous blood with patients who received autologous blood with or without preceding irradiation of the blood. Results Fifty-one (40 male, 11 female) patients were included in the analysis; 10 patients developed tumor recurrence within a time period of 2.45 ± 2.0 years. Statistical analysis revealed that there was no significant difference in tumor recurrence between patients who received autologous blood with or without irradiation. Conclusion Intraoperative transfusion of cell-salvaged blood did not increase tumor recurrence rates. Cell salvage should be used in liver transplantation of HCC patients as part of a blood conservation strategy. The effect of blood irradiation on tumor recurrence could not be definitively evaluated.

Human cytomegalovirus (CMV) remains a major cause of mortality and morbidity in human liver transplant recipients. Anti-CMV therapeutics can be used to prevent or treat CMV in liver transplant recipients, but their toxicity needs to be balanced against the benefits. The choice of prevention strategy (prophylaxis or preemptive treatment) depends on the donor/recipient sero-status but may vary between institutions. We conducted a series of consultations and roundtable discussions with German liver transplant center representatives. Based on 20 out of 22 centers, we herein summarize the current approaches to CMV prevention and treatment in the context of liver transplantation in Germany. In 90% of centers, transient prophylaxis with ganciclovir or valganciclovir was standard of care in high-risk (donor CMV positive, recipient CMV naive) settings, while preemptive therapy (based on CMV viremia detected during (bi) weekly PCR testing for circulating CMV-DNA) was preferred in moderate- and low-risk settings. Duration of prophylaxis or intense surveillance was 3&ndash, 6 months. In the case of CMV infection, immunosuppression was adapted. In most centers, antiviral treatment was initiated based on PCR results (median threshold value of 1000 copies/mL) with or without symptoms. Therefore, German transplant centers report similar approaches to the prevention and management of CMV infection in liver transplantation.

Importance Total neoadjuvant therapy has been increasingly adopted for multimodal rectal cancer treatment. The optimal sequence of chemoradiotherapy (CRT) and chemotherapy needs to be established. Objective To report the long-term results of the secondary end points prespecified in the Randomized Phase 2 Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy (CAO/ARO/AIO-12 trial) for Locally Advanced Rectal Cancer. Design, Setting, and Participants This secondary analysis of a randomized clinical trial included 311 patients who were recruited from the accrued CAO/ARO/AIO-12 trial population from June 15, 2015, to January 31, 2018, from 18 centers in Germany. Patients with cT3-4 and/or node-positive rectal adenocarcinoma were included in the analysis. Data were analyzed from June 15, 2015, to January 31, 2018. The follow-up analysis was conducted between January 31, 2018, and November 30, 2020. Interventions Patients were randomly assigned to group A for 3 cycles of fluorouracil, leucovorin, and oxaliplatin before fluorouracil/oxaliplatin CRT (50.4 Gy), or to group B for CRT before chemotherapy. Total mesorectal excision was scheduled on day 123 after the start of total neoadjuvant therapy in both groups. Main Outcomes and Measures The end points assessed in this secondary analysis included long-term oncologic outcomes, chronic toxicity, patient-reported outcome measures for global health status (GHS) and quality of life (QoL), and the Wexner stool incontinence score. Results Of the 311 patients enrolled, 306 were evaluable, including 156 in group A (mean [SD] age, 60 [11] years; 106 men [68%]) and 150 in group B (mean [SD] age, 62 [10] years; 100 men [67%]). After a median follow-up of 43 months (range, 35-60 months), the 3-year disease-free survival was 73% in both groups (hazard ratio, 0.95; 95% CI, 0.63-1.45,P = .82); the 3-year cumulative incidence of locoregional recurrence (6% vs 5%,P = .67) and distant metastases (18% vs 16%,P = .52) were not significantly different. Chronic toxicity grade 3 to 4 occurred in 10 of 85 patients (11.8%) in group A and 8 of 66 patients (9.9%) in group B at 3 years. The GHS/QoL score decreased after total mesorectal excision but returned to pretreatment levels 1 year after randomization with no difference between the groups. Stool incontinence deteriorated 1 year after randomization in both groups and only improved slightly at 3 years, but never reached baseline levels. Conclusions and Relevance This secondary analysis of a randomized clinical trial showed that CRT followed by chemotherapy resulted in higher pathological complete response without compromising disease-free survival, toxicity, QoL, or stool incontinence and is thus proposed as the preferred total neoadjuvant therapy sequence if organ preservation is a priority. Trial Registration ClinicalTrials.gov identifier:NCT02363374

Patients with peritoneal metastases of gastric cancer have a poor prognosis with a median survival of 7 months. A benefit of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) could be shown in several selected patient cohorts but remains controversial. The aim of this study was, to reflect the results of a national German HIPEC registry initiated by the German Society of General and Visceral Surgery (DGAV). The DGAV HIPEC registry StuDoQ|Peritoneum documents patients with peritoneal malignancy contributed from 52 hospitals. All consecutive documented patients from 2011 until 2016 (n = 3078) were treated with CRS and HIPEC and were analysed. A total of 315 (10%) suffered from gastric cancer and were analysed. A complete data set of 235 patients was available for this study, including 113 male (48.1%) and 122 female (51.9%) patients with a median age of 53.4 years (SD ± 11.9). The median PCI was 8.0 (range 1–30). A complete cytoreduction was achieved in 121 patients (71.6%). Postoperative complications (Clavien–Dindo grades 3–4) occurred in 40 patients (17%). The median overall survival (OS) time was 13 months. The 5-year survival rate was 6%. According to the PCI from 0–6 (n = 74); 7–15 (n = 70) and 16–39 (n = 24) the median OS differs significantly (18 months vs. 12 months vs. 5 months; p = 0.002). CRS and HIPEC in selected patients with gastric cancer and peritoneal spread can improve survival when they are treated in centers. An accurate staging and patient selection are of major importance to achieve long-term survival.

Background 5-Fluorouracil (5FU), Folinic acid (FA), and Oxaliplatin (FOLFOX) or 5FU, FA, and Irinotecan (FOLFIRI) are standard regimens for palliative chemotherapy of metastatic colon cancer. Since data showing the influence of dose reduction in palliative treatment are rare, the objective of this single center, retrospective study was to further characterize the influence of dose reduction on efficacy of these therapeutic regimens. Methods One hundred nine patients, diagnosed with stage IV colon cancer between 2004 and 2012 and receiving palliative first-line chemotherapy with either FOLFOX or FOLFIRI regimens in our outpatient clinic were analyzed for treatment efficacy. Patients who received dose reductions due to side effects usually received doses of 80% or lower of per protocol dose. Survival data were obtained from the Regensburg Tumor Registry. Survival analysis was performed using Kaplan-Meier statistical analysis and multivariable analysis. Results A dose reduction due to side effects was necessary in 46 (42%) patients. Dose reduction was independent of age. Major reasons for dose reduction were neutropenia (30%) followed by polyneuropathy (16%) and diarrhea (14%). Dosage was more often reduced in patients receiving FOLFOX based therapy. Comparison of patients with dose reduction versus patients with full dosage showed no significant difference on overall survival (p = 0.430). Subgroup analysis revealed dose reduction in patients with N2 stage disease was associated with improved survival. Patients who underwent dose reduction received more cycles of chemotherapy (13.7 vs. 10.8 cycles) and cumulative dosage was similar in both groups. Conclusion Contrary to our expectations, the need to reduce chemotherapy dosage due to side effects does not indicate a worse prognosis in our retrospective analysis. We believe this can in part be explained by better adaption to interindividual pharmacokinetics and longer time of treatment. Electronic supplementary material The online version of this article (10.1186/s12885-018-4380-z) contains supplementary material, which is available to authorized users.

Augmenter of liver regeneration (ALR), which is critically important in liver regeneration and hepatocyte proliferation, is highly expressed in cirrhotic livers and hepatocellular carcinomas (HCC). In the current study, the functional role of ALR in hepatocancerogenesis was analyzed in more detail. HepG2 cells, in which the cytosolic 15 kDa ALR isoform was reexpressed stably, (HepG2-ALR) were used in migration and invasion assays using modified Boyden chambers. Epithelial-mesenchymal transition (EMT) markers were determined in HepG2-ALR cells in vitro and in HepG2-ALR tumors grown in nude mice. ALR protein was quantified in HCC and nontumorous tissues by immunohistochemistry. HepG2-ALR, compared with HepG2 cells, demonstrated reduced cell motility and increased expression of the epithelial cell markers E-cadherin and Zona occludens-1 (ZO-1), whereas SNAIL, a negative regulator of E-cadherin, was diminished. Matrix metalloproteinase MMP1 and MMP3 mRNA expression and activity were reduced. HepG2-ALR cell-derived subcutaneously grown tumors displayed fewer necrotic areas, more epithelial-like cell growth and fewer polymorphisms and atypical mitotic figures than tumors derived from HepG2 cells. Analysis of tumor tissues of 53 patients with HCC demonstrated an inverse correlation of ALR protein with histological angioinvasion and grading. The 15 kDa ALR isoform was found mainly in HCC tissues without histological angioinvasion 0. In summary the present data indicate that cytosolic ALR reduces hepatoma cell migration, augments epithelial growth and, therefore, may act as an antimetastatic and EMT reversing protein.

Nous avons evalue les resultats cliniques a long terme de 33 patients soignes pour un traumatisme arteriel du membre superieur au centre medical universitaire de Ratisbonne entre 1996 et 2004. Les parametres cliniques, le score d'handicap du bras, d'epaule, et de la main (DASH) et le formulaire court d'enquete epidemiologique Form-36 (SF-36) de chaque patient etaient rassemblees au cours du suivi. Les resultats de l'evaluation clinique etaient compares aux resultats obtenus des scores DASH et du questionnaire SF-36. La duree mediane de suivi etait de 42 mois. Toutes les lesions arterielles avaient ete reconstruites et etaient permeables au moment du suivi. La predominance des lesions nerveuses et/ou orthopediques concomitantes etait elevee (24/33, 72%). L'influence des lesions nerveuses avait de loin plus d'impact que les autres facteurs sur les resultats fonctionnels a long terme. En outre, les traumatismes explosifs et le besoin d'aponevrotomies immediates etaient d'autres marqueurs de mauvais retablissement fonctionnel. Le score DASH et le SF-36 etaient correles a l'evaluation clinique de la severite des deficits fonctionnels. Le traumatisme vasculaire du membre superieur est presque toujours associe a des lesions orthopediques et/ou nerveuses concomitantes graves. L'atteinte du plexus brachial et des nerfs peripheriques du membre superieur est un facteur predictif de mauvais resultats fonctionnels a long terme.

We assessed the long-term clinical outcome of 33 patients treated for arterial trauma of the upper extremity at the Regensburg University Medical Center between 1996 and 2004. Along with clinical parameters, the Disabilities of Arm, Shoulder, and Hand (DASH) score and the Short Form-36 Health Survey (SF-36) score of each patient were collected at the time of follow-up. Findings of the clinical assessment were compared to results obtained with the DASH score and the SF-36 questionnaire. The median follow-up time was 42 months. All arterial injuries had been reconstructed and were open at the time of follow-up. The prevalence of concomitant neural and/or orthopedic injuries was high (24/33, 72%). The influence of neural injury was by far greater than the impact of other factors on the long-term functional outcome. Furthermore, blunt trauma and the need for immediate fasciotomy were further markers for deficient functional recovery. Both the DASH and the SF-36 scores correlated with the clinical assessment of the severity of functional deficits. Upper extremity vascular trauma is almost always associated with severe concomitant orthopedic and/or neural injuries. The involvement of the brachial plexus and the peripheral nerves of the upper extremity is a predictor of worse long-term functional outcome.

Evaluamos el pronostico clinico a largo plazo de 33 pacientes tratados para un traumatismo arterial de la extremidad superior en el Regensburg University Medical Center entre 1996 y 2004. Durante el seguimiento, junto a los parametros clinicos, de cada paciente se obtuvo la puntuacion en la escala Disabilities of Arm, Shoulder, and Hand (DASH) al igual que la puntuacion del cuestionario Short Form-36 Health Survey (SF-36). Los hallazgos de la evaluacion clinica se compararon con los resultados obtenidos en la puntuacion de la DASH y en el cuestionario SF-36. El tiempo de seguimiento mediano fue de 42 meses. En el momento del seguimiento se habian reconstruido todas las lesiones arteriales y se mantenia la permeabilidad de los vasos. La prevalencia de lesiones nerviosas y/u ortopedicas concomitantes fue elevada (24/33, 72%). La influencia de una lesion nerviosa fue con diferencia mayor que las de otros factores en el pronostico funcional a largo plazo. Ademas, un traumatismo contuso y la necesidad de una fasciotomia inmediata fueron marcadores adicionales de un restablecimiento funcional deficiente. Las puntuaciones obtenidas tanto en la DASH como en el SF-36 se correlacionaron con la evaluacion clinica de la gravedad de los deficit funcionales. Un traumatismo vascular de la extremidad superior se asocia casi siempre con lesiones ortopedicas y/o nerviosas concomitantes. La afectacion del plexo braquial y de los nervios perifericos de la extremidad superior es una variable predictora de un peor pronostico funcional a largo plazo.

To investigate the immunopathogenesis of inflammation-associated fibrosis we analyzed the chronic colitis and late-developing fibrosis occurring in BALB/c mice administered weekly doses of intrarectal trinitrobenzene sulfonic acid (TNBS). We showed first in this model that an initial T helper type 1 response involving interleukin (IL)-12p70 and interferon-gamma subsides after 3 weeks to be supplanted by an IL-23/IL-25 response beginning after 4-5 weeks. This evolution is followed by gradually increasing production of IL-17 and cytokines ordinarily seen in a T helper type 2 response, particularly IL-13, which reaches a plateau at 8-9 weeks. We then show that IL-13 production results in the induction of an IL-13 receptor formerly thought to function only as a decoy receptor, IL-13Ralpha(2), and this receptor is critical to the production of tumor growth factor (TGF)-beta(1) and the onset of fibrosis. Thus, if IL-13 signaling through this receptor is blocked by administration of soluble IL-13Ralpha(2)-Fc, or by administration of IL-13Ralpha(2)-specific siRNA, TGF-beta(1) is not produced and fibrosis does not occur. These studies show that in chronic TNBS colitis, fibrosis is dependent on the development of an IL-13 response that acts through a novel cell-surface-expressed IL-13 receptor to induce TGF-beta(1).

In previous studies, we described a “counter-immunosurveillance” mechanism initiated by tumor-activated, interleukin-13 (IL-13)–producing natural killer T cells that signal Gr-1+ cells to produce transforming growth factor-β1 (TGF-β1), a cytokine that suppresses the activity of tumor-inhibiting cytolytic CD8+ T cells. Here, we show that in two tumor models (the CT-26 metastatic colon cancer and the 15-12RM fibrosarcoma regressor models), this counter-surveillance mechanism requires the expression of a novel IL-13 receptor, IL-13Rα2, on Gr-1intermediate cells, because down-regulation of IL-13Rα2 expression or the activator protein-1 signal generated by the receptor via in vivo administration of specific small interfering RNA or decoy oligonucleotides leads to loss of TGF-β1 production. Furthermore, acting on prior studies showing that IL-13Rα2 expression is induced (in part) by tumor necrosis factor-α (TNF-α), we show that receptor expression and TGF-β1 production is inhibited by administration of a TNF-α–neutralizing substance, TNF-αR-Fc (etanercept). Taking advantage of this latter fact, we then show in the CT-26 model that counter-immunosurveillance can be inhibited, anti-CT-26–specific CD8+ cytolytic activity can be restored, and CT-26 metastatic tumor nodules can be greatly decreased by administration of TNF-αR-Fc. Corroborative data were obtained using the 15-12RM fibrosarcoma model. These studies point to the prevention of metastatic cancer with an available agent with already known clinically acceptable adverse effects and toxicity. [Cancer Res 2008;68(9):3467–75]

Nine patients (4 women and 5 men; mean age 31 [20-48] years) with severe posttraumatic adult respiratory distress syndrome (ARDS) were treated with continuous postural change (kinetic bed) and pressure-limited ventilation. Seven patients survived; only one patient died as a result of pulmonary insufficiency. As compliance was markedly reduced (less than 20 ml/cm H2O), low stroke volumes (up to 380 ml) and high respiratory rate (up to 45/min) were employed to keep airway peak pressure below 40 mmHg. Kinetic treatment lasted for a mean of 14 (2-28) days; artificial ventilation was maintained for 31 (9-49) days. Practical problems of the method are the intensive nursing care required for the kinetic bed and the risk of decubitus ulcers, as well as disconnection of infusion tubing. The results indicate that kinetic treatment with pressure-limited ventilation constitutes a low-risk and, in many cases, effective treatment of severe ARDS.

Hepatic homeostasis is essential for survival in critically ill and burned patients. Insulin administration improves survival and decreases infections in these patients. To determine the molecular mechanisms, the aim of the present study was to establish a stress model using primary human hepatocytes (PHHs) and to study the effects of insulin on the hepatic inflammatory signaling cascade. Liver tissue was obtained from general surgical patients, and PHHs were isolated and maintained in culture. Primary hepatocyte cultures were challenged with various doses of lipopolysaccharide (LPS), and the inflammatory signal transcription cascade was determined by real-time PCR. In subsequent experiments, primary hepatocyte cultures were challenged with LPS and insulin was added in various doses. Glucose was determined by colorimetric assays. PHHs treated with 100 microg/mL LPS showed a profound inflammatory reaction with increased expression of interleukin (IL)-6, IL-10, IL-1beta, tumor necrosis factor (TNF), and signal transducer and activator of transcription 5 (STAT-5). Insulin at 10 IU/mL significantly decreased IL-6, TNF, and IL-1beta at pretranslational levels, an effect associated with decreased STAT-5 mRNA expression (P0.05). Glucose concentration and cellular metabolic activity were not different between controls and insulin-treated cells. Based on our results, we suggest that primary hepatocyte cultures can be used to study the effect of LPS on the inflammatory cascade. Insulin decreases hepatic cytokine expression, which is associated with decreased STAT-5 expression.

A standardized procedure for dealing with nonresectable liver metastases does not currently exist. It is important that an interdisciplinary approach to treatment be taken, in order to look for the optimum solution for each individual patient. High response rates appear to be important, in order to make more patients with nonresectable liver metastases 'resectable' and thus provide a chance of cure. A series of randomized phase II-III trials found a clear increase in response rates and an improvement in the R0 resection rate as a result of more intensive therapy (triple chemotherapy or combination chemotherapy plus cetuximab or bevacizumab). In the NO16966 trial, too, under blinded conditions, more liver metastasis resections were carried out among patients who had received bevacizumab than among patients in the control arm without bevacizumab, although the response rates in the two arms were the same. A gap of 6-8 weeks between the last dose of bevacizumab and surgery is clinically optimal from the point of view of perioperative safety. If neoadjuvant treatment is given, then resection should be carried out as soon as the metastases are resectable. If the patient's response is not adequate, then consideration should be given to an adaptation or change of the treatment regimen. Regular evaluation for secondary resectability is important. Surgically, in addition to 2- or multi-stage surgery, other possible techniques include portal embolization and intraoperative ablation. The goal remains R0 resection. In order to minimize complications, clinicians must select patients carefully, take account of comorbidities, and know the critical resection volume.

Pathological disorders of the liver were shown to be associated with an impairment of hepatic drug metabolism mediated in part by growth factors. Augmenter of liver regeneration (ALR) is a novel liver-specific hepatotrophic growth factor, whereas its action on cytochrome P450 (P450) metabolism is completely unknown. Application of ALR to primary human hepatocytes in vitro reduced P450 isoenzyme activities (1A2 and 2A6) in a dose-dependent manner. Time-course analysis revealed that the maximal inhibitory effect was reached after 24 to 72 h of exposure with 50 nM ALR. The reduction of basal activities upon ALR treatment was 35% for CYP1A2, 56% for CYP2A6, 18% for CYP2B6, and 45% for CYP2E1. Additionally, after induction of P450 with specific inducers, ALR revealed an inhibitory effect on the isoenzyme activities (CYP1A2, 41%; CYP2B6, 35%). Investigations of protein and mRNA expression of basal and induced CYP1A2 and CYP3A4 after ALR treatment by Western blotting and real-time reverse transcriptase-polymerase chain reaction, respectively, suggest a regulation on the transcriptional level. Furthermore, ALR treatment increased nuclear factor kB activity and reduced constitutive androstane receptor but not pregnane X receptor or aryl hydrocarbon receptor expression. In contrast, ALR revealed no effects on phase II reactions (glutathione/oxidized glutathione, UDP-glucuronyltransferase conjugation). Our results indicate that ALR, as a member of hepatotrophic factors, down-regulates basal and induced P450 in human liver and therefore cross-links growth signals to regulation of hepatic metabolism. These findings further imply a possible role of ALR in drug interactions during impaired hepatic function, whereas liver regeneration is triggered.

Das vorliegende, von den Herausgebern in Zusammenarbeit mit den Autoren erarbeitete Themenheft der Viszeralmedizin steht unter dem Motto «Kolorektales Karzinom – Standard und neue Wege». Wir freuen uns, dass wir zu dieser Thematik ausgewiesene Experten aus der Inneren Medizin, der Chirurgie und der Strahlentherapie gewinnen konnten, die zu den nachfolgenden, unterschiedlichen Themenkomplexen Stellung beziehen: Laparoskopische Chirurgie wird zunehmend von Patienten nachgefragt. Ihr Stellenwert in der kolorektalen Tumorchirurgie wird von Hanno Spatz, Bernd Geissler, Rieke Paschwitz und Matthias Anthuber (Augsburg) [1] dargestellt. Nach der deutschen Rektumkarzinom-Studie CAO/ARO/ AIO-04 wurde die praoperative Radiochemotherapie Standard in Deutschland. Seit der Publikation der Studie gab es jedoch Verbesserungen in der chirurgischen Technik (Stichwort: totale mesorektale Exzision (TME)) und in der onkologischen Systemtherapie. Daher wird uberlegt, unter welchen Kriterien eventuell auf eine Strahlentherapie – oder bei durchgefuhrter Radiochemotherapie – auf eine Operation verzichtet werden konnte. Ralf-Dieter Hofheinz (Mannheim) und Claus Rodel (Frankfurt/M.) [2] stellen den Standard der perioperativen Therapie des Rektumkarzinoms dar und diskutieren die Frage, ob und wie sich dieser Standard andern wird. Die Resektion von Lebermetastasen ist neben den «Targeted Therapies» einer der wesentlichen Fortschritte der letzten Jahre in der Versorgung von Patienten mit metastasiertem kolorektalem Karzinom. Die verbesserte Technik ermoglicht heute ein Resektionsausmas, das bis vor einigen Jahren nicht denkbar gewesen ware, z.B. in Form der zweizeitigen Resektion nach Pfortaderembolisation. Die intraoperative Radiofrequenzablation entwickelte sich zu einer komplementaren Masnahme, die zentral gelegene Lasionen, insbesondere beim Rezidiv, effektiv behandeln kann. Alexander Stein und Dirk Arnold (Hamburg) [3] zeigen in ihrem Artikel die aktuellen multimodalen Therapiestrategien bei Lebermetastasen kolorektaler Karzinome. Auch die Prognose der Patienten im Stadium IV, bei denen nicht durch eine Lebermetastasenresektion Tumorfreiheit erzielt werden kann, konnte durch Einfuhrung neuer Chemotherapeutika, der «Targeted Therapies» und neuer Therapiestrategien in den letzten Jahren deutlich verbessert werden. Durch die hohere Effektivitat der systemischen Chemotherapie wird heute haufiger uber die operative Entfernung der Metastasen nachgedacht, auch weil die chirurgische Therapie sich weiterentwickelt hat, die Methoden weniger belastend sind und die Technik optimiert ist. Selbst wenn die Rezidivrate der Metastasen noch verhaltnismasig hoch ist, kann zumindest eine Kontrolle der Erkrankung bei vielen Patienten erreicht werden. Anke Reinacher-Schick (Bochum) [4] erlautert dazu den «State of the Art» der Therapie des metastasierten kolorektalen Karzinoms. Qualitatssicherung in der Versorgung von Patienten mit kolorektalem Karzinom ist ein zunehmend wichtiges Thema, das durch die DKG-zertifizierten Darmkrebszentren auf genom men wurde. Stefan Benz (Nagold) [5], einer der Vor sit zenden der Arbeitsgemeinschaft DKG-zertifizierter Darmkrebszentren, stellt diese Zentren in einer Standort bestimmung vor. Abgerundet wird das Themenheft durch ein interdisziplinares Gesprach [6], in dem Schlusselfragen zum Thema kolorektales Karzinom von den Experten beantwortet werden. Relativ neu ist die Frage bezuglich der multimodalen Therapie der Peritonealkarzinose. Ahnlich wie bei den Lebermetastasen, spielt hier die regionale Ausbreitung eine wichtige Rolle. Die lokale Ablation in Form der Resektion wird mit einer regionalen Chemotherapie und Hyperthermie kombiniert. Wenn eine hamatogene Metastasierung fehlt und eine komplette Tumorentfernung gelingt, kann die Prognose verbessert werden.

Necrosis and stenosis of the ureter are severe complications after kidney transplantation and occur with mean incidence of 2,9-13,4 %. Several surgical techniques like simple nephrostomy or complex urinary tract reconstruction have been applied for repair. In this study, our experience with native pyeloureterostomy (NPUS) using the native ureter is presented. Between March 1978 and June 1996, 2,592 kidney transplantations were performed in our institution. In 48 patients (1,9%), secondary urinary tract reconstruction by NPUS was necessary. These patients were evaluated retrospectively by review of the case notes. At the time of operation the mean age was 45 +/- 14 years. Indications for NPUS were distal ureteral stenosis (n = 29), necrosis (n = 17), bleeding (n = 1) or iatrogenic lesion of the ureter (n = 1). The mean time period between transplantation and urinary tract reconstruction was 20 +/- 23 days (range: 1-90 days) for necrosis and 404 +/- 637 days (range: 14-2,385 days) for stenosis. A pyeloureterostomy was technically feasible in all patients using the recipient's ipsilateral ureter. In 40 out of 48 patients the graft developed a normal function postoperatively (follow up: 39 +/- 48 months). A graft nephrectomy was necessary only in one patient, because of complete pyelonnecrosis 6 days after NPUS. Two grafts were lost due to acute rejection. Data of five patients were not available15 years after successful reconstruction. We can conclude that NPUS is a safe and simple rescue technique for the treatment of distal ureteral complications after kidney transplantation. Therefore, this technique should be the therapy of choice when secondary reconstruction by re-ureteroneocystostomy is not possible.

In this retrospective study, we have investigated the early intragraft inflammatory events of 12 liver allografts leading to chronic rejection. The cytological findings and clinical follow-up were analyzed in detail. Nine patients underwent at least one typical lymphoid activation of acute rejection, and three of them were treated more than once. Diagnosis of rejection was based on biopsy histology, cytology and liver dysfunction. In addition to the acute rejections, cytological analysis demonstrated in 11 of 12 grafts an unidentified lymphoid episode that differed from that of rejection. These lymphoid responses were associated with viral infections; cytomegalovirus (CMV) infection in 10 of 12 patients, hepatitis C virus (HCV) infection in 2 of 12 patients, 1 combined with CMV, and hepatitis B virus (HBV) infection in 1 patient. Graft dysfunction was still seen at the end of the follow-up. Thus, intragraft inflammation caused either by acute rejection or by viral infections may be involved in the induction of chronic rejection.

Donor lungs contain large amounts of passenger leukocytes which are transferred to the recipient by organ transplantation. In this study we have analysed the fate of these cells and have studied the population of donor leucocytes detectable in the blood circulation of ten lung transplanted patients during the first postoperative weeks. To this aim we have applied immunocytological as well as flow cytometric analyses using monoclonal antibodies against polymorphic HLA class I antigens that differed between donor and recipient as well as antibodies against cell differentiation markers. The results demonstrate that donor cells can be detected in the circulation of all lung transplanted patients but there is a considerable interindividual variability between 0.9% and 17.5% (mean 5.1%) on postoperative day 3. Cells were usually detectable for 2–4 weeks and had disappeared in all patients after 1 month. The circulating donor cells consisted exclusively of lymphocytes. T cells were the predominant population, most of which seemed to be CD45R0+, but B and NK (natural killer) cells were also present. Probably due to the small numbers of patients studied no correlation between clinical parameters and the extent of donor lymphocyte persistence; there were no clinical graft-versus-host reactions. The findings demonstrate the regular existence of a transient (macro)chimerism due to passenger lymphocytes in the early phase after lung transplantation. The immunological function and the relation between this phenomenon and the long-term microchimerism which frequently develops after solid organ transplantation remain unclear.

Background Mice lacking Foxp3+ regulatory T (Treg) cells develop severe tissue inflammation in lung, skin, and liver with premature death, whereas the intestine remains uninflamed. This study aims to demonstrate the importance of Foxp3+ Treg for the activation of T cells and the development of intestinal inflammation. Methods Foxp3-GFP-DTR (human diphtheria toxin receptor) C57BL/6 mice allow elimination of Foxp3+ Treg by treatment with Dx (diphtheria toxin). The influence of Foxp3+ Treg on intestinal inflammation was tested using the CD4+ T-cell transfer colitis model in Rag−/− C57BL/6 mice and the acute DSS-colitis model. Results Continuous depletion of Foxp3+ Treg in Foxp3-GFP-DTR mice led to dramatic weight loss and death of mice by day 28. After 10 days of depletion of Foxp3+ Treg, isolated CD4+ T-cells were activated and produced extensive amounts of IFN-γ, IL-13, and IL-17A. Transfer of total CD4+ T-cells isolated from Foxp3-GFP-DTR mice did not result in any changes of intestinal homeostasis in Rag−/− C57BL/6 mice. However, administration of DTx between days 14 and 18 after T-cell reconstitution, lead to elimination of Foxp3+ Treg and to immediate weight loss due to intestinal inflammation. This pro-inflammatory effect of Foxp3+ Treg depletion consecutively increased inflammatory cytokine production. Further, the depletion of Foxp3+ Treg from Foxp3-GFP-DTR mice increased the severity of acute dSS-colitis accompanied by 80% lethality of Treg-depleted mice. CD4+ effector T-cells from Foxp3+ Treg-depleted mice produced significantly more pro-inflammatory cytokines. Conclusion Intermittent depletion of Foxp3+ Treg aggravates intestinal inflammatory responses demonstrating the importance of Foxp3+ Treg for the balance at the mucosal surface of the intestine.

Activation of receptor tyrosine kinases, such as fibroblast growth factor receptor (FGFR), platelet-derived growth factor receptor (PDGFR), and VEGF receptor (VEGFR), has been implicated in tumor progression and metastasis in human pancreatic cancer. In this study, we investigated the effects of TKI258, a tyrosine kinase inhibitor to FGFR, PDGFR, and VEGFR on pancreatic cancer cell lines (HPAF-II, BxPC-3, MiaPaCa2, and L3.6pl), endothelial cells, and vascular smooth muscle cells (VSMC). Results showed that treatment with TKI258 impaired activation of signaling intermediates in pancreatic cancer cells, endothelial cells, and VSMCs, even upon stimulation with FGF-1, FGF-2, VEGF-A, and PDGF-B. Furthermore, blockade of FGFR/PDGFR/VEGFR reduced survivin expression and improved activity of gemcitabine in MiaPaCa2 pancreatic cancer cells. In addition, motility of cancer cells, endothelial cells, and VSMCs was reduced upon treatment with TKI258. In vivo, therapy with TKI258 led to dose-dependent inhibition of subcutaneous (HPAF-II) and orthotopic (L3.6pl) tumor growth. Immunohistochemical analysis revealed effects on tumor cell proliferation [bromodeoxyuridine (BrdUrd)] and tumor vascularization (CD31). Moreover, lymph node metastases were significantly reduced in the orthotopic tumor model when treatment was initiated early with TKI258 (30 mg/kg/d). In established tumors, TKI258 (30 mg/kg/d) led to significant growth delay and improved survival in subcutaneous and orthotopic models, respectively. These data provide evidence that targeting FGFR/PDFGR/VEGFR with TKI258 may be effective in human pancreatic cancer and warrants further clinical evaluation. Mol Cancer Ther; 10(11); 2157–67. ©2011 AACR.

Patients with prolonged ulcerative colitis (UC) frequently develop colorectal adenocarcinoma for reasons that are not fully clear. To analyze inflammation-associated colonic tumorigenesis, we developed a chronic form of oxazolone-induced colitis in mice that, similar to UC, was distinguished by the presence of IL-13-producing NKT cells. In this model, the induction of tumors using azoxymethane was accompanied by the coappearance of F4/80+CD11b(high)Gr1(low) M2 macrophages, cells that undergo polarization by IL-13 and are absent in tumors that lack high level IL-13 production. Importantly, this subset of macrophages was a source of tumor-promoting factors, including IL-6. Similar to dextran sodium sulfate-induced colitis, F4/80+CD11b(high)Gr1(intermediate) macrophages were present in the mouse model of chronic oxazolone-induced colitis and may influence tumor development through production of TGF-β1, a cytokine that inhibits tumor immunosurveillance. Finally, while robust chronic oxazolone-induced colitis developed in myeloid differentiation primary response gene 88-deficient (Myd88-/-) mice, these mice did not support tumor development. The inhibition of tumor development in Myd88-/- mice correlated with cessation of IL-6 and TGF-β1 production by M2 and F4/80+CD11b(high)Gr1(intermediate) macrophages, respectively, and was reversed by exogenous IL-6. These data show that an UC-like inflammation may facilitate tumor development by providing a milieu favoring development of MyD88-dependent tumor-supporting macrophages.

Background: Successful liver gene therapy depends on efficient gene transfer techniques and long-lasting gene expression after successful transfer. Over the last decades important progress has been made with the introduction of viral vectors using animal models, but their use is hampered by a complex and costly preparation when compared to the simple and cost-effective preparation of plasmid DNA. These problems become even more critical when considering application of viral vectors in human gene therapy and gene therapy trials. In a recent report we were able to show that the hydrodynamics-based gene transfer of plasmid-DNA, containing the adeno-associated-virus specific inverted terminal repeats (AAV-ITR), prolong gene expression in the liver, but it remained unclear if plasmid gene transfer could achieve similar expression levels compared to viral-vector gene transfer. Methods: Rat livers were transfected in-vivo with AAV-ITR-containing plasmid-DNA using a modified hydrodynamics-based procedure. Expression levels were monitored thereafter and compared with expression levels after viral-vector gene transfer. Results: A high and stable long-term expression was achieved after in vivo transfection of rat livers with AAV-ITR-containing plasmids. The expression course resembled that after AAV-mediated gene transfer, and expression was at least as high, and lasted as long, as with rAAV-mediated gene transfer. Conclusion: We consider AAV-ITR-containing plasmids as a simple and cost-effective alternative to recombinant viral vectors, especially for liver-directed gene therapy in rodents. With ongoing progress in gene transfer methods for naked DNA, these plasmids may also become a successful alternative to recombinant viral vectors in human gene therapy.

Liver regeneration is a multistep and well-orchestrated process which is initiated by injuries such as tissue loss, infectious or toxic insults. Augmenter of liver regeneration (ALR) is a hepatotrophic growth factor which has been shown to stimulate hepatic regeneration after partial hepatectomy and therefore seems to be regulated during the regenerative process in the liver. Our aim was to analyze how ALR is regulated in hepatic tissues and which transcription factors might regulate its tissue-specific expression. Promoter studies of ALR (−733/+527 bp) revealed potential regulatory elements for various transcription factors like Foxa2, IL-6 RE-BP and C/EBPβ. Analysis of the promoter activity by performing luciferase assays revealed that co-transfection with Foxa2 significantly induced the activity of ALR promoter in HepG2 cells. EMSA and Supershift analysis using anti-Foxa2 antibody confirmed the specific binding of Foxa2 to ALR promoter and this binding was inducible when the cells were simultaneously stimulated with IL-6. The increased binding after activation with IL-6 and/or Foxa2 was confirmed by elevated ALR protein levels using Western blot technique. In addition, we could not detect any binding of C/EBPβ and IL-6 RE-BP to the promoter of ALR. In conclusion, these results indicate that ALR is regulated by Foxa2, and this regulation may be amplified by IL-6.

The murine monoclonal antibody BMA 031 (IgG2b) is directed to a monomorphic epitope on the human alpha/beta T-cell receptor. In contrast to anti-CD3 antibodies of the IgG2b isotype, BMA 031 is able to induce a proliferative response in T-cells from IgG2b low responders. This response occurs independently of cross-linking conditions indicating that the mode of activation differs from stimulation by the anti-CD3 antibody OKT3 (IgG2a) which strictly depends on cross-linking conditions. to further characterize the stimulatory potential of the two antibodies we studied the lymphocyte subsets responsive to stimulation by BMA 031 and OKT3. In CD45RA+ cells both antibodies exhibited similar effects. They induced weak expression of the 55-kDa chain of the interleukin-2 receptor (CD25), virtually no interleukin-2 secretion, but nevertheless strong proliferation. In CD45R0+ cells OKT3 and BMA 031 showed markedly different effects. OKT3 stimulated strong CD25 expression, strong interleukin-2 production, and marked proliferation. In contrast, CD45R0+ cells stimulated by BMA 031 showed only weak CD25 expression but neither interleukin-2 production nor proliferation. These data suggest that CD45RA+ and CD45R0+ cells differ in their capability to produce interleukin-2 upon stimulation via the CD3/T-cell receptor complex and also in the requirement for interleukin-2 to mount a proliferative response. The differential effect of OKT3 and BMA 031 in CD45R0+ cells probably results from the failure of BMA 031 to trigger interleukin-2 production which may be a consequence of its inability to induce CD3/T-cell receptor cross-linking in IgG2b low responders BMA 031 is therefore a useful tool for the selective activation of CD45RA+ cells in these individuals.

Percutaneous endoscopic gastrostomy (PEG) is the preferable method to provide enteral nutrition for a longer time period. Safe placement of a PEG tube requires passage of the esophagus and transillumination of the stomach through the abdominal wall. Surgical placement of a PEG tube has been shown to be feasible although the local complication rate ranges above the endoscopic procedure. We are presenting a new technique (percutaneous laparoscopically assisted gastrostomy, PLAG) to provide enteral access for patients with pharyngoesophageal obstruction not suitable for PEG placement.We have developed a laparoscopic method that allows full control of the stoma location at the anterior gastric wall. The tube has a deployable bumper mechanism, which can be inserted through a minimal gastric incision. Combined with the fixation by transcutaneous sutures, the risk for leakage or dislodgement is low.Fifty-one PLAGs were inserted in 45 male and six female patients suffering from pharyngoesophageal obstruction due to malignancy. Patients were referred after unsuccessful endoscopic PEG placement (n = 39) or received their PLAG when they underwent staging laparoscopy (n = 12). Success rate was 96.2%. No procedure-related mortality was observed. Infectious complications occurred in three (5.9%) cases. In five patients, minor leaks were managed conservatively (n = 4) or required relaparoscopy (n = 1) and placement of an additional suture (overall complication rate of 15.8%, n = 8). Nutritional goals were reached after 7.8 ± 2.3 days.PLAG is a safe and easy procedure. It can well be used to provide enteral access for patients with pharyngoesophageal obstruction not suitable for endoscopic PEG placement.

Monoclonal antibodies (mAb) against the CD3/T cell receptor (TcR) complex were analyzed for their ability to activate human thymocytes. In addition to mAb detecting epitopes on the CD3 complex (OKT3, BMA 030) the activation potential of recently developed mAb against common epitopes on the alpha/beta T-cell receptor (anti-TcR mAb: BMA 031, BMA 032) was evaluated. Several differences were observed between the two types of mAb: (a) Binding of the tested anti-CD3 mAb to thymocytes resulted in a rapid increase in the level of cytoplasmic free calcium ions [Ca2+]i, whereas no significant changes in [Ca2+]i were detected in thymocytes stimulated with BMA 031 or BMA 032. (b) Induction of effective proliferation induced by mAb OKT3 depended on exogenous IL-2 and in addition on the presence of accessory cells or phorbol-ester. Proliferation induced by BMA 031 only required exogenous IL-2. (c) OKT3 but not BMA 031 inhibited proliferation of thymocytes induced via the CD2 molecule. These studies indicate that anti-CD3 and anti-TcR mAb transduce different signals in thymocytes. Since the two types of mAb are directed to the same molecular complex the observed differences also support the idea that there are functionally different compartments in the CD3/TcR complex which may activate different signaling pathways.

The aim of this study was to analyse the immunosuppressive contribution of cyclosporin metabolites in liver-grafted patients. Therefore the immunosuppressive potency of 17 metabolites, alone and in combination, was tested in human mixed lymphocyte cultures, and the results were correlated with metabolite blood levels in liver-grafted patients. Of the 17 metabolites tested only six highly lipophilic metabolites showed a detectable immunosuppressive activity of up to 10% of the activity of cyclosporin; the effect of combining metabolites was additive. For calculation of the in vivo activity, blood levels of seven major cyclosporin metabolites were determined in liver-grafted patients with normal liver function (group A, 43 episodes) and with severe hyperbilirubinaemia (group B, 66 episodes). Both patient groups had comparable levels of parent drug (122.9 +/- 17.4 vs. 111.1 +/- 23.5 ng/ml by HPLC) and similar blood levels of the highly lipophilic metabolites 17, 1 and 18. By contrast, blood levels of the less lipophilic metabolites 8, 9, 26 and 203-218 were substantially increased in group B (P less than 0.05). High overall metabolite blood levels in group B were also indicated by a non-specific monoclonal RIA (520 +/- 199 ng/ml for group A vs. 1318 +/- 407 ng/ml for group B). Despite the very high levels in group B, however, the overall contribution of the metabolites to immunosuppression was similar in both groups (12.6 +/- 5.0% for group A vs. 13.8 +/- 5.6% for group B). These findings indicate that, despite a marked accumulation of cyclosporin metabolites in patients with severe cholestatic liver dysfunction, their immunosuppressive contribution remains low.(ABSTRACT TRUNCATED AT 250 WORDS)

Multimodal management approaches and innovative surgical techniques have completely transformed treatment and prognosis for patients with liver metastases, bringing considerable improvements. Whether patients with resectable liver metastases should be given neoadjuvant and/or adjuvant chemotherapy is still a matter of controversy. If a R0 resection is possible (either first-line or after pretreatment), then from a surgical point of view this should be carried out without delay. A limited resection (subsegment/segment/non-anatomical resection) is sufficient if the metastases can be removed completely - and has the advantage of retaining more functional liver tissue, thus allowing a 2nd or 3rd resection to be carried out in the event of tumor recurrence. A small disease-free margin (1 cm) is enough, and does not worsen the prognosis. Perioperative chemotherapy with FOLFOX4 was shown to reduce the risk of recurrence by approximately 25% (7.3% in absolute terms) in patients with metastases that are resectable (EORTC 40983) - and this in a group of patients who, in terms of their metastasis patterns, with a median of only 1 solitary metastasis, were "ideal" candidates for primary resection. The difference was not significant in intention to treat (ITT) analysis, but was significant in the 'eligible' patients. It is notable, however, that the whole of the overall difference arose as a result of events in the first 10 weeks - thereafter the curves run in parallel. The EORTC and the majority of the experts now, on the basis of the clinically relevant improvement in disease-free survival, recommend adopting pre- and postoperative chemotherapy with FOLFOX4 (3 months before and after surgery) as the new standard. This recommendation is, however, controversial. The question of whether cetuximab or bevacizumab should be given in addition is still open, but clinical trials have started. The evidence concerning adjuvant chemotherapy alone after R0 metastasis resection is less clear. Despite this, and especially among specialist surgeons, adjuvant chemotherapy is however more widely supported than is perioperative chemotherapy - because the risk of presurgical toxicity and thus potential inoperability or tumor progression during chemotherapy is avoided. The new S3 guidelines from 2008 also favor adjuvant treatment - even if data are only available for adjuvant treatment with bolus 5-FU. If adjuvant treatment is given, then combination chemotherapy should be used. Surgeons, for the most part, continue to regard primary resection as the standard.

Mutations within the low density lipoprotein (LDL)-receptor gene result in familial hypercholesterolemia, an autosomal dominant inherited disease. Clinical homozygous affected subjects die of premature coronary artery disease as early as in early childhood. We identified a girl at the age of five yr with clinical homozygous familial hypercholesterolemia presenting with achilles tendon xanthomas and arcus lipoides. Her total cholesterol reached up to 1050 mg/dL. Molecular characterization of the LDL-receptor gene revealed a homozygous p.W577R mutation. Despite intensive treatment interventions with the combination of diet, statins, colestipol, and LDL-apheresis, the patient developed symptomatic coronary artery disease at the age of 16 yr. Subsequently, orthotopic liver transplantation was performed to cure the defective LDL-receptor gene. Clinical follow-up for almost nine yr post-transplantation revealed excellent liver function, normal liver enzymes, normal LDL-cholesterol, and regression of both tendon xanthomas and symptomatic coronary artery disease. In conclusion, liver transplantation can effectively reduce LDL-cholesterol in a familial hypercholesterolemia recipient with subsequent regression of xanthomas and atherosclerosis. Timing is extremely important in these exceptional cases to exclude the demand for heart transplantation due to severe coronary artery disease. In addition, the identification of the LDL-receptor as etiology of clinical homozygous hypercholesterolemia is a prerequisite once liver transplantation is considered as therapeutic option.

Background The Krukenberg tumor represents ovarian metastases associated with gastric cancer or other gastrointestinal malignancies. Histology shows typical mucus-production and numerous signet-ring cells. Occasionally Krukenberg tumors have endocrine function and, as a consequence, some patients demonstrate hirsutism and virilization. Case presentation Here we report a case of virilization associated with an extensive gastric adenocarcinoma and Krukenberg tumor in a premenopausal woman. Virilization occurred three months after diagnosis of gastric cancer and the ovarian tumors. Palliative chemotherapy was initiated as primary therapy, but gastric outlet obstruction required a gastrojejunostomy. In addition, oopherectomy was performed to relieve abdominal tension and to abate hormonal effects. It is likely that virilization of the patient could have been prevented by earlier oopherectomy prior to development of hormone production. Conclusion Despite the limitation in survival time early oopherectomy should be considered to prevent the development of virilization even in palliative situations if a Krukenberg tumor is diagnosed with gastric cancer.

BMA031 is an IgG2b antibody directed towards the human alpha/beta T-cell receptor that is able to induce proliferation of peripheral blood mononuclear cells independent of antibody crosslinking. The proliferative response to BMA031 during the first 3 days of culture is usually of similar magnitude to that induced by the IgG2a CD3 antibody OKT3 but decreases quickly afterwards. Stimulation by BMA031 induces no measurable IL-2 release, very low expression of the IL-2 receptor, and does not trigger cytotoxic effector function. However, cross-linking of the antibody or addition of IL-2 leads to enhanced and prolonged proliferation, strong IL-2 receptor expression, and cytotoxic activity, features that are usually found after stimulation by the IgG2a CD3 antibody OKT3 in soluble form. The stimulatory effect of BMA031 cannot be diminished by IL-2 receptor blocking, whereas stimulation by OKT3 is strongly reduced. Moreover, proliferation induced by BMA031 has lower sensitivity to inhibition by ciclosporin than OKT3. From these results two major conclusions can be drawn: (1) an IL-2-independent way of activation may be important for the short-term proliferation of the T cells stimulated by BMA031 and (2) after stimulation by BMA031, cells reach a state of activation that is different from that induced by OKT3. These differences are most likely related to the different specificities of the antibodies, alpha/beta TcR versus CD3, suggesting that different activation signals are triggered via CD3 and via the alpha/beta TcR.