Unsedated Peroral Endoscopy With a Video Ultrathin Endoscope: Patient Acceptance, Tolerance, and Diagnostic Accuracy

Objective: The aim of this study was to assess patient tolerance of unsedated routine upper endoscopy using a 6-mm ultrathin (UT) video endoscope (Olympus XGIF-N200H) and to compare its optical quality to a standard endoscope (Olympus GIF100).
Methods: A total of 62 outpatients were recruited for unsedated UT endoscopy using topical spray followed by sedated endoscopy using a standard endoscope. After unsedated endoscopy, patients were asked to complete a questionnaire assessing tolerance. When both endoscopies were completed, the endoscopist recorded findings and optical quality of the UT.
Results: Of 62 patients, 19 refused unsedated endoscopy because of anxiety (12) , fear of gagging (3) , and unwillingness to be study patients (4) . Tolerance: Of 43 patients, 37 (86%) had a complete, unsedated UT exam (five patients did not have a GIF100 exam). During insertion, 60% of the patients reported none/mild discomfort, whereas, during the remainder of the examination, 73% had none/mild discomfort. Of 37 patients, 30 (81%) were willing to undergo future unsedated endoscopy with the UT and they tolerated UT endoscopy better than the patients who were unwilling (none/mild discomfort: 83% vs 29%). Of 43 patients, six (14%) failed UT endoscopy because of severe gagging (all were male, mean age 44 yr). Optics: Optical quality was rated as good 84%, 65%, and 78% of the time in the esophagus, stomach, and duodenum, respectively. Optical quality was diminished by excessive fluid and tenacious secretions. The UT missed five of 59 lesions: three hiatal hernias and two gastric erosions.
Conclusion: A total of 69% of outpatients agreed to undergo peroral unsedated endoscopy with a UT endoscope. A total of 86% of patients tolerated a complete unsedated examination, and 81% of these were willing to undergo future unsedated examinations. Diagnostic accuracy of this ultrathin video endoscope was good, with 92% of lesions discovered when compared with a standard instrument.     

Liquid Embolic Agents for Endovascular Embolization: Evaluation of an Established (Onyx) and a Novel (PHIL) Embolic Agent in an In Vitro AVM Model

BACKGROUND AND PURPOSE:Embolization plays a key role in the treatment of arteriovenous malformations. The aim of this study was to evaluate an established (Onyx) and a novel (precipitating hydrophobic injectable liquid [PHIL]) liquid embolic agent in an in vitro AVM model.MATERIALS AND METHODS:An AVM model was integrated into a circuit system. The artificial nidus (subdivided into 28 honeycomb-like sections) was embolized with Onyx 18 (group Onyx; n = 8) or PHIL 25 (group PHIL; n = 8) with different pause times between the injections (30 and 60 seconds, n = 4 per study group) by using a 1.3F microcatheter. Procedure times, number of injections, embolization success (defined as the number of filled sections of the artificial nidus), volume of embolic agent, and frequency and extent of reflux and draining vein embolization were assessed.RESULTS:Embolization success was comparable between Onyx and PHIL. Shorter pause times resulted in a significantly higher embolization success for PHIL (median embolization score, 28 versus 18; P = .011). Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization (median volume per section of the artificial nidus, 15.5 versus 3.6 μL; P < .001).CONCLUSIONS:While the embolization success was comparable for Onyx and PHIL, pause time had a considerable effect on the embolization success in an in vitro AVM model. Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization.

Arteriovenous malformations are complex vascular structures composed of feeding arteries, an intervening network of small pathologic blood vessels (the so-called nidus), and draining veins. The lack of an intervening capillary bed allows high-flow arteriovenous shunting of blood. While AVMs can occur throughout the entire body, cerebral AVMs are of particular relevance due to their ability to cause impairing neurologic symptoms and their considerable risk of hemorrhage.¹Alone or in combination with microneurosurgery and stereotactic radiation therapy, embolization plays an important role in the management of cerebral AVMs.² The aim of AVM embolization is complete filling of the nidus, while unwanted reflux into the feeding arteries should be minimized and premature embolization of the draining veins should be avoided.³A wide variety of embolic agents has been and is currently used for embolization of AVMs. At present, the liquid embolic agents (LEAs) ethylene-vinyl alcohol copolymer (EVOH) and n-butyl cyanoacrylate are used most frequently.⁴ Although the embolization results have improved since the introduction of EVOH-based LEAs with rates of complete obliteration ranging from 16% to 100%, the success rate of AVM embolization, especially for complex AVMs, is not yet satisfying.^2,3 Currently, new LEAs are being introduced to improve embolization features, such as embolization efficacy, intraprocedural handling, and control. Furthermore, their use should improve fluoroscopic visibility and reduce artifacts in postinterventional imaging.The aim of this study was to evaluate an established EVOH-based embolic agent and a novel copolymer-based embolic agent in an in vitro AVM model.     

Occult gastric signet ring cell carcinoma presenting as spermatic cord and testicular metastases: “Krukenberg tumor” in a male patient

Krukenberg tumor is a well-known ovarian metastasis, usually of gastric signet ring cell carcinoma in female patients. Although gastric carcinoma is more frequent in men, to our knowledge, only few cases of counterpart testicular metastases have been described as yet. We report a 64-year-old patient who complained of right testicular pain. Right-sided orchiectomy was performed, and metastatic signet ring cell carcinoma of spermatic cord and testis was diagnosed through histological examination and immunohistochemistry. The following stomach biopsy confirmed the primary signet ring cell carcinoma in the stomach. This extremely rare form of metastatic dissemination resembles the Krukenberg tumor of ovaries. Immunohistochemical staining plays an important role in the differential diagnosis of spermatic cord enlargement.     

Induced transgene expression for the treatment of solid tumors by hematopoietic stem cell-based gene therapy

Tumor microenvironment is composed of different cell types including immune cells. Far from acting to eradicate cancer cells, these bone marrow-derived components could be involved in carcinogenesis and/or tumor invasion and metastasis. Here, we describe an alternative approach to treat solid tumors based on the genetic modification of hematopoietic stem and progenitor cells with lentiviral vectors. To achieve transgene expression in derivative tumor infiltrating leukocytes and to try to decrease systemic toxicity, we used the stress inducible human HSP70B promoter. Functionality of the promoter was characterized in vitro using hyperthermia. Antitumor efficacy was assessed by ex vivo genetic modification of lineage-negative cells with lentiviral vectors encoding the dominant-negative mutant of the human transforming growth factor-β receptor II (TβRIIDN) driven by the HSP70B promoter, and reinfusion of cells into recipient mice. Subsequently, syngeneic GL261 glioma cells were subcutaneously injected into bone marrow-transplanted mice. As a result, a massive antitumor response was observed in mice harboring TβRIIDN under the HSP70B promoter, without the need of any external source of stress. In summary, this study shows that stem cell-based gene therapy in combination with spatial and temporal control of transgene expression in derivative tumor-infiltrating cells represents an alternative strategy for the development of novel antitumor therapies.     

Häufigkeit und Verteilung von Schlafproblemen und Insomnie in der deutschen Erwachsenenbevölkerung

Sleep disturbances are associated with a variety of physical and mental health disorders and cause high direct and indirect economic costs. The aim of this study was to report the frequency and distribution of problems of sleep onset and maintaining sleep, sleep quality, effective sleep time, and the consumption of sleeping pills in the adult population in Germany. During the 4 weeks prior to the interview, about one third of the respondents reported potentially clinically relevant problems initiating or maintaining sleep; about one-fifth reported poor quality of sleep. When additionally considering impairments during the daytime such as daytime fatigue or exhaustion, a prevalence of 5.7?% for an insomnia syndrome was found. Women were twice as likely to be affected by insomnia-syndrome as men. Significant age differences were not seen. Persons with low socioeconomic status had an increased risk of insomnia (OR: 3.44) as did people residing in West Germany (OR: 1.53). Women with low socioeconomic status (OR: 4.12) and West German men (OR: 1.79) were more affected. The results illustrate the considerable public health relevance of insomnia-related sleep disturbances. An English full-text version of this article is available at SpringerLink as supplemental.     

Nicotine dependence criteria and nicotine withdrawal symptoms in relation to pain among an adult general population sample

Background: Evidence has shown that people who have smoked at any point in life have a higher probability of pain than those who have never smoked. The goal of this study was to analyze whether there are associations between nicotine dependence including nicotine withdrawal with pain and the number of pain locations. Methods: Data stems from a cross‐sectional survey study with a probability sample of residents of a northern German area with 4075 study participants, aged 18–64 years (participation rate 70.2%). Face‐to‐face in‐home computer‐aided interviews (Composite International Diagnostic Interview) were used to assess single pain locations, the diagnostic criteria of nicotine dependence, alcohol dependence, depressive, and anxiety disorders according to the Diagnostic and Statistical manual of the American Psychiatric Association (DSM‐IV). Results: Ever smokers with three or more nicotine dependence criteria after controlling for alcohol dependence, depressive, anxiety disorders, age and gender revealed an odds ratio (OR) of 4.2 (95% confidence interval, CI, 2.0–9.0) compared to ever smokers without nicotine dependence criteria, and ever smokers with four or more nicotine withdrawal symptoms displayed an OR of 3.6 (CI 1.5–8.7) compared to ever smokers who had not experienced withdrawal symptoms. Current smokers who used 20 or more cigarettes per day had an OR of 0.5 (CI 0.3–0.8) of experiencing pain in three or more locations compared to former smokers. Conclusion: Nicotine dependence criteria are associated with a higher probability of pain than having no nicotine dependence criteria in this general population sample.     

Health behavior of smokers--results of the TACOS (Transitions in Alcohol Consumption and Smoking) Study

The German TACOS Project (Transitions in Alcohol Consumption and Smoking) provided an opportunity to examine the patterns of health behaviours (nutrition, physical activity, alcohol consumption) of current smokers, ex-smokers and non-smokers with special regard to different degrees of severity of nicotine dependence. Data were collected in the adult general population of Lübeck and 46 surrounding communities, resulting in a representative sample of 4075 individuals. In this sample, 37.3% were current smokers, 22.5% were ex-smokers, 25.0% of smokers were severely nicotine-dependent. As in other empirical investigations, current smokers had an unhealthy lifestyle in general. Smokers compared to ex-smokers and non-smokers consumed unhealthy foods more frequently, reported less physical activity and were more likely to consume hazardous levels of alcohol. Special attention was paid to comparing different degrees of severity of nicotine dependence. A high degree of nicotine dependence was associated with poor health behaviours. Data show that smoking, unhealthy nutrition, lack of physical activity, and hazardous levels of alcohol consumption occur in combination and that unhealthy behaviour patterns vary according to the severity of nicotine dependence. The presence of multiple unhealthy behaviours requires special secondary preventive interventions for smokers. The association of these combined health hazards must be controlled in determining the independent health risk due to one of these factors.