Search

The debate on corporate social responsibility (CSR) has been going on for decades, without leading to a clearer understanding of the term. Furthermore, the current literature on the topic remains relatively silent on the actual impact of CSR, especially the impact on issues of international development, for example poverty reduction in the Global South. By developing a conceptual assessment framework with a bipolar differentiated definition of CSR and a Sen-based notion of poverty, the article analyses the effects and impact of two different types of CSR-strategies on the reduction of poverty. For this, two case studies have been conducted in Phnom Penh, Cambodia. The results imply that CSR measures which are built into the core business of a company (both transnational companies and small/medium sized companies) have larger effects on poverty than CSR measures which are located outside of the core business activities.

Geschildert wird der Fall eines Neurofibromatosepatienten mit chronischen abdominellen Schmerzen und einer Eisenmangelanamie. Eine Abklarung mittels Osophagogastroduodenoskopie und Ileokoloskopie hatte bislang keinen wegweisenden Befund ergeben. In einer Computer- und Magnetresonanztomographie konnten zahlreiche intraluminale Tumoren im Bereich des Dunndarms, v. a. im Ileum nachgewiesen werden. Dies wurde auch durch eine Doppelballonenteroskopie bestatigt. Auf Grund der Grose und Anzahl der Polypen erfolgte keine endoskopische Abtragung, sodass zum sicheren Malignomausschluss eine Laparotomie durchgefuhrt wurde. Hier konnte ein Konglomerattumor des Ileums reseziert werden. Histologisch fanden sich 13 inflammatorische Polypen sowie 2 gastrointestinale Stromatumore.

To estimate risk factors associated with long-term outcome (i.e., 1-year survival) in patients with Staphylococcus aureus bacteremia (SAB).This was a retrospective study in which the microbiological laboratory data records of patients admitted to the University Hospital of Regensburg between January 2004 and June 2005 were examined to identify those patients with blood cultures positive for S. aureus. Corresponding clinical records for all patients were reviewed using a standardized questionnaire. Of the 119 patients identified with SAB, 80 were available for the1-year follow-up.Crude 1-year mortality was 47.5; 30- and 90-day mortality was 28.8 and 37.5%, respectively. In-hospital mortality was 28.8%. There were no significant differences in 1-year survival in terms of age, gender, antibiotic resistance, and mode of acquisition (nosocomial vs. community-acquired). A significantly better survival was observed with an identifiable focus present, if the chosen empiric antibiotic therapy was adequate or if the body mass index of the patient was24.In summary, in this patient cohort, considerable additional mortality due to SAB beyond 30 or 90 days was present. Our results suggest that long-term survival data should be taken into account in outcome studies involving patients with S. aureus bacteremia.

The AMP activated kinase plays an important role in metabolic control, and pharmacologic enhancement of AMPK activity is used to improve insulin resistance. We hypothesized that high dose of folic acid supplementation might improve insulin sensitivity and hepatic inflammation and examined this by a dietary intervention in (a) the high fat fed rat model of the metabolic syndrome, which shows sole hepatic steatosis as well as (b) in rats fed with a high cholesterol, high cholate diet inducing nonalcoholic steatohepatitis (NASH). Male Wistar rats were fed with folic acid supplemented (40 mg/kg) high fat diet [based on lard, fat content 25% (wt/wt)] or NASH inducing diet (containing 15% fat, 1.25% cholesterol, 0.5% sodium cholate). Metabolic profiling was performed by measuring the animals' visceral fat pads, fasting plasma glucose, insulin, and adipokines as well as in vivo insulin tolerance tests. Hepatic steatosis and inflammation were analyzed semiquantitatively by histological analysis. Folic acid supplementation reduced visceral obesity and improved plasma adiponectin levels. In vivo insulin sensitivity was improved, and in HF-FA rats folic acid increased activation of hepatic AMPK. Further, folic acid supplementation improved hepatic inflammation in animals fed with NASH-inducing diet. Dietary folic acid improved parameters of insulin resistance and hepatic inflammation in rodent models. This might be due to an increased AMK activation.

Introduction Spontaneous bacterial peritonitis (SBP) is mainly caused by bacterial translocation of enteric Gram-negative bacteria, predominantly Escherichia coli . The sympathetic nervous system (SNS) is activated in advanced cirrhosis, particularly in the splanchic circulation, and exerts potent immunosuppressive actions. However, the role of splanchnic SNS activity in bacterial translocation and bacterial spreading in cirrhosis remains unclear. Methods E coli or Stapylococcus aureus (10 6 CFU) were given intraperitoneally. After 6 h, mesenteric lymph nodes (MLN), liver, spleen, lung and peripheral blood were harvested from ascitic cirrhotic rats (LC) and healthy controls with and without splanchnic sympathectomy (SE). The bacterial tissue burden was determined by standard microbiological culture techniques. In vitro phagocytic activity of peritoneal polymorphonuclear leucocytes was assessed by FACS analysis. Results Under basal conditions SE reduced bacterial translocation to MLN in LC rats from 45% to 17%. LC rats had a marked increase in bacteraemia after E coli and S aureus challenge and an increased incidence and degree of E coli translocation to MLN, liver, spleen and lung compared with control rats. SE prevented bacteraemia in LC rats after E coli but not after S aureus challenge. Prior SE abolished the difference in incidence as well as the bacterial tissue burden in each organ after E coli application in LC rats, being no longer significantly different from control rats with or without SE. The protective effects of SE against E coli were associated with a greater influx of mononuclear cells into the peritoneal cavity and increased phagocytic activity of peritoneal polymorphonuclear leucocytes. Conclusions In cirrhosis with bacterial peritonitis, hyperactivity of the splanchnic sympathetic nervous system contributes to the translocation of E coli but not S aureus to MLN and extraintestinal sites. This indicates a key role for sympathetic drive in the impairment in host defence against Gram-negative bacteria in cirrhosis.

Autoimmune hemolysis is a rare complication of systemic rheumatic diseases. We report on a 68-year-old female patient with established, long-standing rheumatoid arthritis, who complained of progressive weakness and worsening of her arthralgia under therapy with leflunomide. Physical and laboratory examination revealed autoimmune hemolysis due to cold agglutinin disease. As hemolysis and arthritis were refractory to steroid treatment, B-cell depletion with rituximab was performed leading to a marked reduction of hemolytic parameters as well as remission of her rheumatoid arthritis.

Background: At the moment, there is only poor specificity of HCC-detection in tumors smaller than 2 cm in a cirrhotic liver. Thus, efforts have to be made to optimize the distinction between regenerative nodules and HCC. Aims: The aim of our study was to describe the particular perfusion pattern of hepatocellular carcinoma using a specific quantification software. Methods: We evaluated 25 patients with proven hepatocellular carcinoma, who underwent dynamic contrast-enhanced ultrasound (CEUS) using a second generation contrast agent (SonoVue ® , Bracco, Germany). Retrospectively, we applied the quantification software Qontrast ® (Bracco, Milan, Italy) to obtain contrast-enhanced sonographic perfusion maps for each lesion. Results: We found a close positive correlation of the perfusion parameters peak, time-to-peak and regional blood volume between the entire tumors, the center (center/total) and the periphery of the tumors (periphery/total), respectively. Moreover, we found significant higher peak values, a significant higher regional blood volume and a trend to lower time-to-peak in the center of the tumors compared to the tumor periphery. Conclusion: These results suggest a better established vascular bed in the center of the tumors. This could be a sonographic marker of HCC in contrast to regenerative nodules.

Traumatic portal vein thrombosis is a rare cause of nonmalignant, noncirrhotic portal hypertension. We report a case of a 19-year old patient, who presented with variceal bleeding and splenomegaly. Diagnosis was based on the history of kickboxing and an otherwise negative etiological investigation. The patient underwent endoscopic therapy and portosystemic shunt operation (Warren-shunt) due to cavernous transformation and severe hypersplenism. Thereafter the patient remained asymptomatic.

Die akute Pankreatitis nimmt in bis zu 20% der Falle einen schweren Verlauf und ist dann mit einer hohen Mortalitat von bis zu 40% behaftet. Eine wesentliche Komplikation stellt dabei die Infektion der (peri)pankreatischen Nekrosen dar. Therapeutisches Ziel ist es, den Infektfokus zu entfernen. Wahrend chirurgische Methoden hierfur bislang den Goldstandard darstellen, gewinnen minimal-invasive, interventionelle Methoden immer mehr an Bedeutung. Diese Ubersicht soll die verschiedenen interventionellen Therapieverfahren, insbesondere die perkutane, CT-gesteuerte Drainagenanlage und die perkutane Nekrosektomie vorstellen. Therapiealternativen, ebenso wie Limitierungen und Risiken fur diese neuen Therapieverfahren werden erlautert. Des Weiteren soll eine Zusammenfassung uber die derzeit publizierten Untersuchungen zu diesem Thema einen Uberblick verschaffen.

Chronic inflammatory diseases can induce further complications such as secondary amyloidosis. Being a rare but serious complication it affects typically the kidneys resulting in a nephrotic syndrome. Further sites of AA amyloid deposition are liver, heart and the autonomic nervous system. We report about a patient with congenital neutropenia, AA amyloidosis and chronic intestinal bowel inflammation due to amyloid deposition in the bowel.

The aim of this study was to analyze Toll-like receptor (TLR) expression in preadipocytes and mature adipocytes and to investigate whether TLR ligands influence the release of cytokines, chemokines, and adipokines. Murine 3T3-L1 preadipocytes and mature adipocytes were used for stimulation experiments. The effects of lipopolysaccharide (LPS), flagellin, Poly (U), Poly (I:C), macrophage-activating lipopeptide-2 (MALP2), Pam3Cys, and CpG on the release of interleukin-6 (IL-6), resistin, and monocyte chemoattractant protein-1 (MCP-1) were determined by enzyme-linked immunosorbent assay (ELISA). Nuclear translocation and promoter binding of NFkappaB were analyzed by electrophoretic mobility shift assays. TLR expression was investigated by reverse-transcriptase (RT-PCR). All TLRs except TLR5 and TRL7 are expressed in the stromal vascular cell (SVC) fraction and in mature adipocytes of different fat stores. Whereas basal and LPS-induced IL-6 release is higher in preadipocytes, basal and LPS-induced MCP-1 release is higher in mature adipocytes. Mature adipocytes respond to corticosterone regarding MCP-1 and resistin release. The ligands for TLRs influence IL-6, MCP-1, and resistin release differentially. Some of these ligands induce nuclear translocation and promoter binding of NFkappaB. Besides TLR5, that is not expressed in mature adipocytes, all TLR family members are involved. There exists a functional TRL pathway in adipocytes that connects innate immunity with adipocyte function. As a consequence, the role of the adipose tissue in both immunity and metabolism has to be investigated in future studies. The results of this approach will help to explain the metabolic changes such as insulin resistance observed during infection and the immunological phenomena such as macrophage infiltration of adipose tissue seen in obesity.

Eine 36-jahrige Patientin wird uber den Notarzt mit einem hypoglykamischen Schock eingewiesen. Die initiale Diagnostik lies einen Diabetes mellitus, eine Hypoglycaemia factitia, eine postprandiale Hypoglykamie, ein Tumorleiden und ein Insulinom ausschliesen. Erst die wiederholte Anamnese ergab, dass die Patientin nach einer komplikationslosen Schwangerschaft vor 3 Jahren nicht stillen konnte. Die endokrinologische Diagnostik zeigte eine komplette Insuffizienz der adrenokortikotropen Achse bei einem Sheehan-Syndrom. Zugleich fand sich in der Magnetresonanztomographie ein Empty-Sella-Syndrom. Die um 3 Jahre verzogerte Diagnosestellung fuhrte zur Erstmanifestation eines Sheehan-Syndroms in Form eines hypoglykamischen Komas. Agalaktie, Oligomenorrhoe, Mudigkeit und Gewichtsverlust im Anschluss an eine Schwangerschaft mussen auch bei komplikationslosem Geburtsverlauf an eine postpartale Hypophyseninsuffizienz denken lassen.

According to the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD), ultrasound (US) is the recommended tool for surveillance of patients at risk of developing hepatocellular carcinoma (HCC). Larger HCCs can be diagnosed with a high accuracy by conventional US. However, the differentiation of smaller malignant lesions in cirrhotic livers can be improved by contrast-enhanced ultrasound (CEUS). Second-generation contrast agents consisting of microbubbles enable us to visualize specific tumor vascularization patterns. With CEUS, it is not only possible to detect and characterize HCC nodules, but to control the effects of ablation techniques of HCC as well, evaluating the former lesion with respect to complete necrosis or residual viable tumor. Limitations of CEUS are its inability to characterize lesions distant to the applicator. Moreover, so far the use of contrast agents in US did not result in increased sensitivity in the detection of small HCCs (

A 52-year-old male patient was admitted to the emergency department with dyspnea and hypertensive urgency. During the previous 6 months, the patient had noticed leg edema, weight gain (particularly in the face and abdomen), and impotence. 1.5 years ago, he was diagnosed with hypertension resistant to medication. After an accident at work 1 year ago, osteoporosis was diagnosed with vertebral and rib fractures. Measurement of sleeping midnight salivary cortisol levels together with 24-h urine free cortisol excretion and an overnight low-dose 1-mg dexamethasone suppression test proved overt hypercortisolism. The high-dose 8-mg dexamethasone suppression suggested an adrenal or ectopic source of hypercortisolism. By contrast, elevated adreno-corticotropic hormone (ACTH) levels and a corticotropin-releasing hormone stimulation test gave evidence for a pituitary source of hypercortisolism. However, pituitary magnetic resonance imaging failed to reveal a pituitary adenoma. Moreover, computed tomography scans of thorax and abdomen were negative. In this situation, an inferior petrosal vein sampling was performed and revealed an ACTH gradient (central-systemic) >3 with lateralization to the right side. The patient underwent a selective, partial, transsphenoidal resection and was cured from clinical signs and symptoms caused by hypercortisolism. Subsequent hormonal replacement therapy of postoperative pituitary insufficiency was necessary.

HISTORY AND CLINICAL FINDINGS A 52-year-old man with liver cirrhosis and ascites, hepatorenal syndrome and severe pancytopenia was admitted to hospital for treatment and consideration for future liver transplantation. INVESTIGATIONS Laboratory tests revealed severe leukocytopenia and thrombocytopenia, which had persisted after otherwise successful treatment of spontaneous bacterial peritonitis and a hepatorenal syndrome. There was no evidence of a toxic cause such as drugs or alcohol nor of an underlying haematologic disease. The most likely diagnosis was hypersplenism. DIAGNOSIS, THERAPY AND CLINICAL COURSE Because of the high risk of a splenectomy it was decided to perform a partial splenic arterial embolization. Both leukocyte and thrombocyte counts rose after the intervention and continued to stay within normal range. This made it possible to discharge the patient from inpatient treatment until he was admitted again for a subsequently successful liver transplantation. CONCLUSIONS Partial splenic artery embolization can be successfully used to treat severe leukocytopenia and thrombocytopenia in patients with liver cirrhosis and hypersplenism.

Osteomalacia is a metabolic bone disease associated with impaired mineralization of the bone due to Vitamin D and Calcium deficiency that can develop in gastrointestinal disorders. Gastrointestinal malabsorption after surgery, in disorders of the small bowl, in diseases of the hepatobiliary tree and in pancreatic insufficiency can lead to decreased enteral resorption of the fat-soluble Vitamin D and/or depletion of endogenous Vitamin D stores due to abnormal enterohepatic circulation. As a consequence of the Vitamin D deficiency in combination with the underlying condition patients develop an impaired calcium absorption resulting in hypocalcaemia, which leads to defective bone mineralization. Additionally chronic gastrointestinal inflammation and corticosteroid therapy - which is often needed in these patients - have a negative effect on bone metabolism as well. The therapy consists of oral substitution of Vitamin D and Calcium as well as sufficient sun light exposure or in severe cases the use of artificial UVB-radiation.

Migration of colonic lamina propria fibroblasts (CLPF) plays an important role during mucosal wound healing as well as fibrosis and fistula formation in Crohn's disease (CD). Recently, we showed that the migratory potential of CD-CLPF was significantly reduced compared to control CLPF. Fistula-derived CD-CLPF migrated less and fibrosis-CLPF more than CLPF from inflamed CD mucosa. These changes in migratory behavior were associated with changes in production of the migration-inducing fibronectin (FN) isoforms ED-A and ED-B. A permanent reduction of the migratory potential of CLPF was mediated by IFN-gamma and tumor necrosis factor (TNF) modulate FN isofom expression in CLPF and thereby might regulate CLPF migration.Control CLPF were incubated for 72 h with IFN-gamma, TNF, IFN-gamma plus TNF, or TGF-beta1. Messenger RNA (mRNA) was isolated and expression of FN and isoforms ED-A and ED-B was quantified by real-time polymerase chain reaction. FN, ED-A, and ED-B were investigated by Western blotting. FN receptor integrin alpha5beta1 was analyzed by FACS.No difference was found for the surface display of integrin alpha5beta1 between stimulated and non-stimulated cells. In TGF-beta1 incubated CLPF mRNA amount of FN and isoforms ED-A and ED-B was slightly increased. IFN-gamma only decreased FN in CLPF, TNF significantly reduced FN-mRNA by 40%, FN ED-A mRNA by 25%, and ED-B mRNA by 50%. The TNF-mediated mRNA downregulation resulted in a decreased protein amount as revealed by Western blotting.Cytokines such as IFN-gamma, TNF, and TGF-beta1 modulate the production of fibronectin isoforms. Our data indicate that inflammation-induced modulation of FN-isoform production is involved in the alterations of migratory potential of CLPF isolated from CD mucosa.

The accuracy of ultrasonography in the detection of liver metastases was studied in 245 patients. Sensitivity, specificity and positive and negative accuracy were defined and calculated. Taking into account only metastases more than 15 mm in diameter, sensitivity was 75.5%, positive accuracy was even higher at 83.0%. Specificity and negative accuracy were above 90%. The results are largely dependent on the type of primary tumour. Sensitivity for metastases of a bronchial or gastric carcinoma was about 50%. The results indicate that a positive ultrasound finding generally need not be checked by other methods, while a negative result, especially in certain types of tumour, is by no means sufficient to exclude metastases.

History and findings A 45-year-old woman sustained an ankle fracture in an accident. At examination she was found to have marked pallor of skin and mucosae. There was no hint for melaena or haematemesis. Investigations Biochemical tests showed marked iron deficiency anaemia (haemoglobin 7.5 g/dl) and raised serum bilirubin and C-reactive protein levels (1.94 mg/dl and 85.2 mg/l, respectively). Abdominal sonography revealed a cystic space-occupying mass (8 x 4.5 cm) projecting onto the gallbladder, interpreted as a choledochal cyst of unknown origins without bleeding. After treatment of the ankle fracture an endoscopic retrograde cholangiopancreatography was performed. This showed a large cyst of the choledochal duct into which the cystic and choledochal ducts entered, without evidence of tumour or haematoma. There was also a 1 cm prepapillary common choledochal and Wirsung duct. Treatment and course With these findings, the diagnosis of a congenital choledochal cyst (type Ia of Todani) could be made. After healing of the ankle fracture the cyst was removed and a Roux Y-anastomosis created. The cystic tissue was benign. At follow-up 6 months later the patient was symptom-free and no longer anaemic. Conclusions Congenital choledochal cysts are very rare in Europeans. The symptom-free course with anaemia and no manifestation until adulthood is also very unusual.

HISTORY AND CLINICAL FINDINGS About 10 weeks before admission to hospital a 73-year-old woman developed a fever of up to 40 degrees C for three days. She then had subfebrile temperature for several weeks with some rises to 39 degrees C. She was known to have type II a diabetes mellitus and pulmonary silicosis, having worked in a porcelain and ceramic factory for many years. Before admission her cerebral functions were rapidly deteriorating, especially short-term memory. This was followed by increasing paraplegia of the legs with inability to walk. She finally had urinary and faecal incontinence and swallowing difficulties with tendency to aspiration, which necessitated hospitalisation. INVESTIGATIONS Both lactate dehydrogenase (339 U/l) and C-reactive protein (112 mg/l) were elevated; the platelet count was low (73000/microliters). Cerebrospinal fluid was unremarkable, as was computed tomography of the skull. But magnetic resonance imaging revealed multiple spotty lesions with low contrast-medium uptake throughout the brain, pointing to a disseminated bacterial or mycotic infection. 3 days later the chest-ray showed small nodular soft shadows in the lungs, and lung functions had decreased. Mycobacteria were found in the urine and liver biopsy showed granulomatous hepatitis, establishing the diagnosis of miliary tuberculosis in the presence of silicosis. TREATMENT AND COURSE Tuberculostatic treatment was instituted with four drugs (pyrazinamide, ethambutol, isoniazid and streptomycin. After 6 weeks the patient was again able to walk and continent of urine during the day. All cerebral functions gradually improved. CONCLUSION Miliary tuberculosis should be included in the differential diagnosis of ill-defined feverish disease, especially in the elderly.

Anamnese und klinischer Befund: Bei einem 57jahrigen Patienten mit chronischer Diarrhoe war seit Jahren keine Diagnose gefunden worden. Die bis zu 15 wasrigen Stuhle pro Tag waren unabhangig von der Nahrungsaufnahme und ohne Blutbeimengung. Begleitend waren Muskelkrampfe vor allem in den Beinen aufgetreten. Seit 15 Jahren waren rezidivierende Ulcera ventriculi et duodeni bekannt, deswegen war vor 13 Jahren eine selektive proximale Vagotomie durchgefuhrt worden. Der korperliche Untersuchungsbefund war unauffallig. Untersuchungen: Leicht erhoht war die Aktivitat der alkalischen Phosphatase (182 U/l) und der Spiegel des C-reaktiven Proteins (9,3 mg/l); der Serumeisenspiegel betrug 42 µg/dl. Alle anderen Parameter des Routinelabors einschlieslich Eiweiselektrophorese, Blutbild und Differentialblutbild, lagen im Normbereich. Eine Gastroskopie erbrachte eine ulzerierende Duodenitis, eine erosive Gastritis mit zahlreichen Ulcera und eine Refluxosophagitis III°-IV°. Endosonographisch fiel ein vergrobertes Schleimhautrelief des Magens auf als Zeichen der foveolaren Hyperplasie und ein etwa 4 × 3 cm groser Tumor neben dem Bulbus duodeni. Der daraufhin bestimmte Gastrinspiegel war auf 7537 pg/ml erhoht (Normwert

BACKGROUND: Almost all patients in departments of internal medicine routinely undergo abdominal ultrasound examination in which liver changes indicating hepatic steatosis are often detected. The aim of this study was to assess the occurrence of pathological oral glucose tolerance, manifest diabetes mellitus and other changes indicative of a metabolic syndrome in patients with sonographic signs of hepatic steatosis. PATIENTS AND METHODS: 577 patients were examined during a period of 6 months: 90 patients fulfilled the inclusion criteria. RESULTS: Among the 90 patients with echodense liver who were included in the study (42 female, 48 male) 36 patients presented with previous diagnosis of diabetes mellitus (40%). The oral glucose tolerance test was impaired in 19 patients (21%) and in four patients with manifest diabetes mellitus (4%). Among patients with echodense liver a high percentage presented with obesity and impaired fat metabolism. CONCLUSIONS: The large number of patients with an impaired oral glucose tolerance test converting to manifest diabetes, as well as the large number of patients with manifest disorders of fat metabolism suggest that screening for diabetes should be performed in patients who present with sonographic signs of hepatic steatosis.

Ausgepragte Knochenschmerzen, eine schwere Demineralisierung des Skeletts, Frakturen der Darmbeinschaufeln, des Sitz- und Schambeins sowie ausgedehnte Loosersche Umbauzonen in diesen Bereichen fuhrten bei einer 38jahrigen Patientin zur Diagnose einer hypophosphatamischen Osteomalazie. Die computergesteuerte Osteodensitometrie zeigte eine um 31 % reduzierte Hydroxylapatitdichte des Achsenskelettes. Histologisch war ein groser Anteil des Knochens nicht mineralisiert, Osteoklasten fehlten fast vollstandig. Klinisch-chemisch fanden sich eine ausgepragte Hypophosphatamie (0,48 mmol/l), eine erhohte Phosphat-Clearance (36 ml/min), eine verminderte renal-tubulare Phosphatruckresorption (73 %) und eine erhohte alkalische Phosphatase (355 U/l). Parathormon und 1,25-Dihydroxycholecalciferol waren normal. Angeborene Storungen des Calciumstoffwechsels wie auch eine Paraneoplasie konnten ausgeschlossen werden. Eine Behandlung mit Calcitriol (0,25µg/d) und Phosphatsubstitution (1200 mg/d) wurde eingeleitet. Kontrolluntersuchungen nach 6 Monaten liesen erkennen, das damit zumindest ein weiteres Fortschreiten der Erkrankung verhindert werden konnte. Hypophosphataemic osteomalacia occurred in a 38-year-old woman. The leading clinical symptom was severe bone pain. X-ray studies demonstrated fractures of the iliac crest and pubic and ischiadic bone, as well as Looser's zones and demineralization of the skeleton. Computerized densitometry of the bone revealed a 31 % reduction of hydroxyapatite. Histological evaluation showed nearly absence of osteoclasts and extensive demineralisation of the bone. Hypophosphataemia (0.48 mmol/l), increased urinary phosphate clearance (36 ml/min), reduced renal-tubular reabsorption for phosphate (73 %) and increased alkaline phosphatase (355 U/l) were present. Parathyroid hormone and 1,25-dihydroxyvitamin D were normal. No inborn errors, disturbances of the calcium metabolism or paraneoplastic signs could be detected. Defective renal tubular reabsorption of phosphate is likely to be the underlying cause of the disease. Phosphate supplementation and intermittent vitamin D administration remains the therapy of choice.

In 502 patients, length, thickness and width of the spleen as well its location with respect to the ipsilateral kidney were determined by means of ultrasonography, and a relationship was established with the incidence of diseases accompanied by enlargement of the spleen. A significant correlation to the incidence of such diseases was found only with respect to spleen thickness. The probability of a corresponding disease was 80% for a spleen thickness of 5 cm, 90% for 6 cm and 100% for more than 7 cm. A comparison between palpation and ultrasonography supported the fact that enlargement of the spleen can, in many cases, not be ascertained by palpation, but that palpation findings are indeed positive in splenic enlargement of minor degree. The most suitable parameter for ultrasonographic detection of splenomegaly is thus spleen thickness, for which a limit value of 5 cm should be assumed. If the spleen is found to exceed this value, further examinations are indicated to clarify the underlying disease.

HISTORY AND ADMISSION FINDINGS: A 26-year-old woman, for 3 years known to have systemic lupus erythematodes (SLE), was admitted because of fever, muscle and joint pains as well as nausea and vomiting. Maintenance therapy of 50 mg azathioprine, three times daily, had been stopped by the patient several weeks earlier. Physical examination was unremarkable except for pale skin and mucosae as well as pain on pressure over muscle groups of the upper arms and thighs and paravertebrally. DIAGNOSIS, TREATMENT AND COURSE: Laboratory tests showed a pancytopenia with a decrease of the haemoglobin level of 3.0 g/dl. The differential diagnosis included an acute exacerbation of SLE, toxic damage to the bone-marrow by azathioprine or a viral infection involving the bone-marrow. Serological tests and the further course confirmed an acute paravirus B19 infection as the cause. CONCLUSION: Paravirus B19 infection should be included in the differential diagnosis when an acute exacerbation of SLE is suspected.

19% of 1490 abdominal sonograms from 1192 patients led to findings which were not related to the original purpose of the sonogram or to the actual disease, and of which neither the treating physician nor the patient were aware. The most frequent findings were those in liver, kidneys and gallbladder. The majority of ultrasonographically detected lesions were benign; tumour diseases were suspected only in 26 cases. The incidence of such findings increased with the patients' age. The positive, predictive value of the findings was around 90%. In 20% of the patients with unexpected findings, further diagnostic measures were taken; therapeutic consequences were recorded in only twelve cases. Further measures were recommended in 20% of the patients, a majority of which had pancreatic and vascular abnormalities. Because such findings may considerably facilitate the diagnosis of subsequent complaints, all accessible organs should be examined during abdominal ultrasonography.

Complications occurred in 29 of 37 patients after ascites retransfusion (n = 16) or introduction of a peritoneovenous shunt (n = 21). Blood clotting disturbances, that could either be successfully treated with drugs or which led to interruption of the reinfusion, appeared in 38%. Estimation of plasminogen proved to be of reliable prognostic value thus enabling prophylactic measures to be taken. Post-operatively 14 patients had transient fever not requiring specific treatment. Local fibrinolysis or shunt revision was successful in three patients with shunt thromboses. According to our experience most complications can be avoided by prophylactic and therapeutic measures.

History and admission findings A 69-year-old man, a known carrier of hepatitis B virus (HBV) after blood transfusion, developed increasingly severe jaundice with high transaminase levels after receiving steroids in high doses. Significant preceding conditions included chronic obstructive pulmonary disease, coronary heart disease, ulcerative colitis in remission and diabetes mellitus. On admission he was jaundiced and experienced pain on pressure below the right costal margin. Investigations Serology demonstrated reactivated hepatitis B with an increase of the HBV-DNA concentration in serum, as well as seroconversion with HBe antigen, anti-HBc-IgM antibodies and absence of anti-HBe antibodies. Diagnosis, treatment and course The history and serological findings indicated reactivation of the hepatitis B by the steroid treatment. Progressive liver failure developed. A marked reduction of virus particles in the blood occurred after a therapeutic trial with the nucleoside analog lamivudine, but the patient died of liver failure 30 days after admission. Conclusion Steroids should be given to known hepatitis B carriers only if strictly indicated, because of the danger of acute deterioration of liver functions by reactivation of the disease with possibly fatal consequences. If steroids are administered, liver functions and serological hepatitis markers should be closely monitored so that any necessary treatment can be quickly initiated.

HISTORY AND CLINICAL FINDINGS: A 26-year-old man was admitted urgently because of breathing-related pain in the left thorax. This pain had started 3 months before, but had at first improved spontaneously. He had lost 13 kg during those weeks and had no recollection of any injury. Physical examination was unremarkable except for slight pain on upper-abdominal pressure and a palpably enlarged spleen. INVESTIGATIONS: All laboratory tests were normal, including the Quick value (100%), partial thromboplastin time (38 sec) and hemoglobin (14.2 g/dl). Chest radiogram showed a high left diaphragm. Abdominal sonography revealed a 12 x 10 cm moderately echogenic tumour in the spleen, extending from the splenic hilus to the upper splenic pole. Contrast-enhanced computed tomography demonstrated a hypodense tumour from which 300 ml of old blood were removed by needle puncture. Biopsy of the wall of the haematoma revealed pseudocystic transformation. TREATMENT AND COURSE: The pseudocyst again filled with blood in a few days. A drain was inserted and remained for 32 days. Six installations of alcohol achieved complete obliteration of the cystic haematoma, which did not recur. CONCLUSION: Splenic haematoma should be considered in the differential diagnosis of pain in the lower left thorax, even in the absence of a history of injury. Sonographically such a haematoma my imitate a solid tumor. Obliteration of the cavity by alcohol installation can be a successful alternative to surgical treatment.

Summary Recently we identified galectin-3 (gal-3), which is secreted by colonic epithelial cells (CEC), to be a strong activator of colonic lamina propria fibroblasts (CLPF). Modulation of CLPF function may play a role during stricture and fistula formation in inflammatory bowel disease (IBD). Therefore, we investigated further the expression of gal-3 and effects on CLPF. The aim of this study is to perform a direct comparison of gal-3 between tissue from healthy controls and from patients with either Crohn's disease (CD) or ulcerative colitis (UC). CEC, CLPF and intestinal macrophages (IMAC) were isolated from control and IBD colonic tissue. Interleukin-8 secretion as a readout of CLPF activation was quantified by enzyme-linked immunosorbent assay. Gal-3 in cell cultures and tissue samples was evaluated by Western blot, immunofluorescence and immunohistochemistry. CLPF-migration was assayed in the 48-well modified Boyden chamber. Gal-3 expression was found in all segments of the colon. In the terminal ileum, less gal-3 was found compared with the colon. Immunohistochemistry and immunofluorescence revealed a homogenous distribution of gal-3 in CEC and IMAC of control mucosa and UC. However, significantly less gal-3 was found in IMAC from CD patients. In CD fistulae and stenoses, gal-3 expression was reduced significantly and barely detectable. In co-incubation studies lactose reduced significantly the CLPF-stimulatory potential of gal-3, indicating that the C-terminal domain of gal-3 is responsible for CLPF activation. Gal-3 stimulated CLPF migration in CLPF derived from fistulae. In conclusion, gal-3 expression is down-regulated in CD-fistulae and stenoses as well as in IMAC in CD patients. Gal-3 induces migration of CLPF derived from fistulae. Its role for stricture and fistula formation warrants further investigation.

Fifty consecutive patients suffering from acute pancreatitis were studied prospectively with regard to the role of ultrasound (US) in diagnosis, in detection of a biliary origin, and in initial assessment of prognosis. In six patients the pancreas could not be visualised, whereas in 19 only partial examination was possible. In 34% no diagnostic abnormalities were found. US was superior to computed tomography (CT) in respect to the detection of small amounts of ascites, but less suitable than CT for the detection of necrosis. Compared to endoscopic retrograde cholangiography US was of little help in detecting bile duct stones. Neither a lethal outcome nor a severe course could be predicted with sufficient accuracy. The positive predictive value for the presence of necrosis was 33% and the negative predictive value 67%. The data demonstrate a limited role of US in diagnosis and staging in acute pancreatitis.

Wir berichten uber einen 42-jahrigen Landwirt mit Leukozytose und Transaminasenerhohung bei Leberzirrhose. Die Diagnose einer Q-Fieber-Hepatitis erfolgte uber Leberpunktion und Serologie. Unter Therapie mit Doxycyclin kam es zunachst zu einem erneuten Transaminasenanstieg, nach Umstellung auf Ciprofloxacin konnte der Patient drei Wochen nach Aufnahme entlassen werden. Q-Fieber wird durch Coxiella burnetii verursacht. Die haufigste akute Manifestation ist eine selbstlimitierende grippeahnliche Erkrankung. Chronisches Q-Fieber tritt meist als Endokarditis auf. Die Diagnostik erfolgt mittels Histologie („Doughnut“-Granulome), PCR, Serologie (akut: Anti-Phase-II-Antikorper, chronisch: Anti-Phase-I-Antikorper) und Kultur. Die Therapie erfolgt mit Doxycyclin.

Das Auftreten von Aszites ist ein unspezifisches klinisches Symptom, das in Abhangigkeit von der zugrundeliegenden Ursache unterschiedlichste therapeutische und/oder prognostische Konsequenzen haben kann. Erlautert werden die pathophysiologischen Grundregeln der Aszitesformation und die sich daraus ableitenden Parameter, die in der Differenzialdiagnose eines Aszites wichtig sind. Insbesondere der Differenzierung eines portalen Aszites, der haufigsten Aszitesform, von einem Aszites anderer Ursache, der Unterscheidung eines infizierten vom nichtinfizierten und eines malignen von einem benignen Aszites kommt entscheidende klinische Bedeutung zu. Geschildert werden stadiengerechte Therapieempfehlungen und -optionen fur einen portalen Aszites, damit assoziierte mogliche Nebenwirkungen und zu beachtende Kontraindikationen. Das Auftreten eines portalen Aszites sollte stets die Uberprufung der Notwendigkeit oder Moglichkeit einer Lebertransplantation, der einzigen kurativen Therapieform, nach sich ziehen.

INTRODUCTION: Cell culture media with high glucose concentration are normally used. Data on the secretion of the adipokines adiponectin and resistin from adipocytes in response to insulin and growth hormone (GH) both under normo- and hyperglycemic conditions are not available. It was the aim of the study to investigate the impact of standard metabolic conditions (normo-/hyperglycemia, normo-/hyperinsulinemia) and of GH on the secretion of adiponectin and resistin. MATERIAL AND METHODS: 3T3-L1 preadipocytes were differentiated into adipocytes and then incubated under normoglycemia (100 mg/dl), hyperglycemia (450 mg/dl), in combination with insulin (0, 0.2, 2.0 nM) and/or GH (1 nM). Adiponectin and resistin secretion was measured by ELISA. RESULTS: Insulin significantly stimulates adiponectin and resistin secretion under normo- and hyperglycemia. Hyperglycemia PER SE stimulates adiponectin and resistin secretion both in the absence and presence of low or high insulin concentrations. GH stimulates adiponectin secretion both under normoglycemic and hyperglycemic conditions. Whereas insulin does not modulate GH-induced adiponectin secretion under normoglycemia, insulin augments adiponectin release under hyperglycemia. GH stimulates resistin secretion only under normoglycemia, but not under hyperglycemic conditions. Since scavenger receptor B-I expression did not change, these effects are specific and not caused by a simple enhancement of adipocyte differentiation. DISCUSSION: Glucose, insulin and growth hormone have significant and interfering effects on the secretion of resistin and adiponectin. Several of the well-known in vivo phenomena such as diurnal variation or effects of re-feeding and weight-loss might be explained by direct effects of these hormones on adipocytes. Finally, when effects of hormones on adipocyte function are investigated, it is a prerequisite to take glucose levels of the cell culture media into account.

Background and study aims: Negative results from diaphanoscopy are often regarded as a contraindication for percutaneous endoscopic gastrostomy (PEG). The aim of this study was to evaluate whether ultrasonography can identify the reasons for failure of diaphanoscopy and help in guiding the PEG procedure. Patients and methods: From December 2002 to May 2006 ultrasonography was used to guide PEG in patients with inadequate findings on diaphanoscopy (n = 15). The results and safety of this procedure were evaluated retrospectively. Results: In 14 of 15 cases, sonographic guidance enabled completion of the procedure. Gastrostomies were satisfactory in all 14 cases. In the 15th patient, no safe introduction site could be identified due to a previous Billroth II operation. The reasons for failure of diaphanoscopy were: scar formation, unusual stomach location, obesity, tumor infiltration of the stomach and peritoneal carcinosis. In four patients, decompressive gastrostomy was carried out as palliative therapy for vomiting or gastric outlet obstruction that was resistant to medical therapy and was caused by peritoneal carcinosis, linitis plastica or malignant infiltration of the duodenum. Conclusions: Sonographic guidance enables completion of PEG despite inadequate findings on diaphanoscopy, usually rendering radiological or surgical gastrostomy procedures unnecessary.