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Ultrasonography is an imaging modality of great importance in everyday clinical practice. Technical innovations continuously expand the diagnostic and therapeutic possibilities of ultrasonography requiring continuous upskilling of sonographers. Only a small number of practitioners, in hospital and practice settings in Germany, currently have the required level of skills. Therefore, these techniques are not as readily available as would be desirable. A modern high-end ultrasound scanner in the hands of a qualified sonographer is a diagnostic high-tech precision instrument, which can compete with any other imaging modality.In conclusion, basic sonography, as it is currently practised should be separated from high-end sonography, requiring extensive training and better remuneration. In this context the introduction of a new medical board speciality for ultrasonography, "Advanced Ultrasonography", with corresponding upgrading should be recommended for high-end sonography., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

A 49-year-old woman presented with unspecific symptoms including polydipsia, increasing fatigue for several weeks, and vague abdominal pain. Serum calcium (5.30 mmol/l; normal range 2.00-2.60) and parathyroid hormone levels (> 2500.0 ng/l; normal range 15.0-68.0) were extremely elevated. Imaging studies showed a huge mediastinal tumor. Based on these findings a hypercalcemic crisis caused by primary hyperparathyroidism was diagnosed. After intensive care treatment and further diagnostic procedures, the patient's parathyroid adenoma was removed by parathyroidectomy. The postoperative course was uneventful.

Objectives: To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks, and additional intervention modules to enhance nutritional education, to increase physical activity and to modify eating behavior., Design: Prospective multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany., Subjects: A total of 8296 participants with a body mass index (BMI) of >30 kg m(-2) included within 8.5 years., Measurements: Main outcome measures were body weight loss, waist circumference (WC), blood pressure, quality of life and adverse events., Results: In females, initial body weight was reduced after the 1-year-intervention by 19.6 kg (95% confidence intervals 19.2-19.9 kg) and in males by 26.0 kg (25.2-26.8) according to per protocol analysis of 4850 individuals. Intention-to-treat (ITT) analysis revealed a weight reduction of 15.2 kg (14.9-15.6) in females and 19.4 kg (18.7-20.1) in males. Overall, the intervention resulted in mean reduction in WC of 11 cm; it reduced the prevalence of the metabolic syndrome by 50% and the frequency of hypertension from 47 to 29% of all participants (ITT, all P<0.001). The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life. The incidence of adverse effects was low; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders., Conclusion: The present non-surgical intervention program is a highly effective treatment of obesity grades I-III and obesity-related diseases, and therefore, could be a valuable basis for future weight maintenance strategies required for sustained success.

The goal of good concepts for treating obesity is to achieve sustained changes in lifestyle. Formula diets are in fact superior to hypocaloric diets, but the results of diet only approaches are consistently disappointing. Formula diets or very low calorie diets should thus be undertaken in conjunction with an overall therapeutic concept under a physician's supervision together with psychological and nutritional education as well as guidance in exercise therapy. These treatment strategies can be carried out successfully in the outpatient setting. On a long-term basis, reducing the costs of health care will only be feasible by implementing prevention programs during childhood and adolescence. Preventive measures focusing on nutrition should lay the foundation in kindergartens and schools to control the epidemic-like spread of obesity.

A transient aplastic crisis (TAC) is a well-known complication in all types of chronic hemolytic anemia but only 2 cases of such an event were described in congenital dyserythropoietic anemias (CDAs). Here, we report a third case, and by retrospective chart review of 78 cases we found evidence of TAC in 8 further patients with CDA II, with serological evidence of previous human parvovirus B19 (B19V) infection in all but one. Although B19V infection results in TAC in only a minority of patients with CDA, physicians responsible for these patients should be aware of such a potentially life-threatening complication. Testing for B19V-specific IgG is recommended in patients with CDA to estimate the risk of a possible future aplastic crisis., (2007 S. Karger AG, Basel)

Treating obesity can significantly reduce morbidity and mortality. Successful treatments comprise interdisciplinary long-term programs. The combined skills of physicians, psychologists, physiotherapists and dieticians are necessary to modify the patient's eating habits. With regard to dietetic measures, the combination of formula diets followed by reduction diets (CLD) has proved successful. Behavioral therapy in combination with professional physiotherapy can reduce the failure rate. In the event that dietetic measures fail, the medications sibutramine, orlistat and rimonabant are available.

Background: Obesity is associated with elevated morbidity and death rates. The World Health Organization defines obesity as a chronic disease. The percentage of obese persons is increasing worldwide. Many different treatment modalities are available. Long-term success rates are not convincing., Research Focus: Overweight and obesity should be treated in an interdisciplinary and multimodal approach. The best results in loosing body weight, especially body fat use very low calorie diets followed by a fat-reduced, carbohydrate-rich diets. Weight-loss drugs should be used only in a weight-loss program including diet and physical activity. Surgical intervention is necessary in a small group of persons refractory to conservative obesity treatment., Conclusions: New structured guidelines oriented and quality controlled programs for treatment of obese patients are necessary.

Background: Treatment of patients with chronic hepatitis C after failure of an interferon monotherapy remains controversial. While relapse patients have a sustained response after a combination therapy with interferon-alpha 2b 3 x 3 MU/week plus ribavirin 1,000/1,200 mg daily for 24 weeks in up to 49%, the standard therapy for initial non-responders remains to be determined., Methods: We therefore conducted a large multicenter trial to compare efficacy and safety of a combined interferon/ribavirin therapy in 327 non-responders and 181 relapse patients with chronic HCV infection outside of highly specialized institutions., Results: After 6 months therapy with interferon-alpha-2b 3 MU thrice a week plus ribavirin 1,000/1,200 mg daily for 24 weeks 31% of relapse patients and 11% of initial non-responders achieved a sustained response according to an intent to treat analysis., Conclusions: These data could not confirm the high rate of sustained responders in relapse patients. In addition we were only able to induce a sustained response in every tenth non-responder. These results might reflect the realistic sustained response rates in a non-biased European population of HCV-infected patients.

This review is dealing with currently available medications used in the treatment of obesity. Unfortunately currently available drugs did not prove effective in the long term treatment of obese patients. Fenfluramin and D-Fenfluramin has been withdrawn from the market because of severe side effects as pulmonary hypertension and valvular heart disease. Sibutramin, a serotonin noradrenalin reuptake inhibitor, will be available this year. Orlistat, an inhibitor of pancreatic lipases, has proven effective for weight reduction in obese patients. New drugs as alpha 2-adrenergic antagonists, cholecystokinin, neuropeptide y, bombesin and leptin are in the pipeline.

Uniform definition and classification are required premises for the diagnosis of obesity. The indication for treatment of obesity is based on exact diagnostic procedures. This paper will critically discuss clinical and biochemical approaches to the diagnosis of obesity.

In a pilot study we investigated the effect of ursodeoxycholic acid therapy in 11 patients (mean age 45.8 +/- 13.2 years) with chronic active, ANA- and/or SMA-positive autoimmune hepatitis of moderate severity. All patients were clinical asymptomatic and no indication for immunosuppressive therapy could be established in any patient. After a washout period of at least 3 months, the treatment was administrated with 500 mg ursodeoxycholic acid twice daily. A statistically significant improvement in all important hepatic parameters was achieved within 3 months of therapy. No further improvement could be observed once 6 months had elapsed. Significant decreases of SGOT (29.9 +/- 20.2 vs 17.7 +/- 7.1 U/l, p = 0.020), SGPT (43.8 +/- 31.0 vs. 19.6 +/- 6.7 U/l, p = 0.0012), GLDH (20.1 +/- 20.9 vs. 5.2 +/- 2.6 U/l, p = 0.0001) und gamma-GT (152.0 +/- 124.8 vs. 60.6 +/- 49.2 U/l, p = 0.0064) were observed during treatment. Despite tendential improvement, serum biliruhin, levels (18.2 +/- 9.4 vs. 16.9 +/- 9.4 mumol/l, p = 0.287) did not change significantly during treatment. Ursodeoxycholic acid may be beneficial in altering the natural course of chronic active hepatitis and of value in preventing mild attacks of immune hepatitis. The simple fact that ursodeoxycholic acid administration is essentially free of side-effects can go a long way towards justifying further clinically controlled studies.

After successful dissolution therapy of cholesterol gallbladder stones bile again becomes supersaturated and recurrent gallstones may develop. Three different postdissolution treatments [500 mg ursodeoxycholic acid (UDCA) per day (N = 14, group I), 100 mg aspirin per day (N = 14, group II) and diet (N = 15, group III) versus a control group (no treatment, N = 15, group IV) aimed at preventing recurrence of gallstones were investigated in a prospective, randomized study in 58 gallstone patients (33 female, 25 male) after complete stone clearance. Bile samples (prior to dissolution therapy and at stone recurrence) were investigated for biliary cholesterol (C), phospholipids (PL), total bile acid concentration (BA), cholesterol saturation index (CSI), total lipid concentration (TLC), total biliary protein concentration (TP), and nucleation time (NT). In group IV multiple gallstones tended to recur more often than solitary stones (66.7% vs 16.7%) whereas in groups I-III only solitary stones recurred. Recurrent gallbladder stones were detectable in 10 patients (eight patients in group IV and one each in groups I and II, respectively) within one year after dissolution and in two patients (one each in groups III and IV, respectively) after 15 months. Furthermore, the probability of stone recurrence was significantly higher in untreated patients as compared to treated patients. In nine (group IV) of 12 patients with recurrent stones NT, C, CSI, PL, BA, TLC, TP, and bile acid spectrum remained nearly unchanged as compared to their pretreatment values, whereas in three (groups I-III) of 12 cases a decrease in C, CSI, and TP was observed during therapy. However, in each of these three patients, initial and after-treatment TP was significantly higher and NT shorter as compared to groups I-IV. Furthermore, in these cases (N = 3) NT was prolonged, whereas no significant changes were found in PL, BA, TLC, and bile acid spectrum. Recurrence of gallstones, which seems to occur more likely in patients with multiple stones as compared to solitary stones, will happen in the early stage after stone clearance, again causing biliary pain. UDCA, aspirin or diet will reduce the probability for recurrent stones after complete gallstone dissolution.

The essentials of conservative treatment of obesity are supervision by a physician, psychological advice, nutritional information and physical activity. A very successful therapy of massively obese is induced by modified fasting. Drugs should be used only as an adjunct to the diet and should be prescribed only for a limited time period.

Background: Accurate sampling of gallbladder bile for biliary analysis is essential for determining any potential difference between combined bile acid therapy and monotherapy in gallstone patients., Methods: In 104 gallstone patients undergoing extracorporeal shock wave lithotripsy with following bile acid therapy [either chenodeoxycholic acid (500 mg/day) and ursodeoxycholic acid (500 mg/day), group I (n = 53), or ursodeoxycholic acid alone (1000 mg/day), group II (n = 51)], bile samples, obtained by direct fine needle puncture of the gallbladder, were investigated for biliary lipids, total biliary protein concentration, and nucleation time before and after 12 months of bile acid therapy., Results: Initially, a negative correlation was found between nucleation time and number of gallstones and between total biliary protein concentration and nucleation time (r = -0.52 and r = -0.49 in group I vs r = -0.56 and r = -0.51 in group II, p < 0.01 in each group). The correlation between total biliary protein concentration and nucleation time was also found after 12 months of bile acid treatment (r = -0.54 in group I vs r = -0.47 in group II, p < 0.01 in each group). In group I, the decrease in cholesterol saturation index, biliary cholesterol, cholic acid, deoxycholic acid, and total protein concentration was more pronounced than in group II (p < 0.01). The same effect was found concerning the prolongation of nucleation time (p < 0.01). Furthermore, dissolution rates were higher in group I compared with group II (80.4 vs 69.0%, p < 0.01)., Conclusion: In gallstone patients, combined therapy with urso- and chenodeoxycholic acid is superior to either ursodeoxycholic acid alone or biliary parameters in bile samples obtained by direct fine needle puncture of the gallbladder.

Background: Nucleating and antinucleating factors play an important role in the pathogenesis of cholesterol crystal nucleation., Patients and Methods: In 88 gallstone patients (59 female, 29 male) bile was examined for total biliary protein and glycoprotein concentration, nucleation time and cholesterol saturation index. Gallstone density was measured by in vivo computed tomography., Results: Total biliary protein concentration was positively correlated with the number of gallstones (r = 0.84, p < 0.01) and higher in radiologically detectable isodense gallstones as compared to non-isodense stones (p < 0.01). A negative correlation between total biliary protein concentration, glycoprotein concentration and nucleation time was observed (r = -0.45, p < 0.01 and r = -0.49, p < 0.05). Nucleation time was significantly shorter in the case of multiple versus solitary stones (2.6 +/- 1.3 versus 8.5 +/- 3.0 days, p < 0.01). Cholesterol saturation index and biliary cholesterol concentration were similar in both cases, however a negative correlation between cholesterol saturation index and stone density (r = -0.79, p < 0.01) was found. No correlation was found between cholesterol saturation index and nucleation time (r = -0.04, p > 0.1), independent of gallstone number. None of the examined parameters was related to sex, age, weight or gallbladder function., Conclusions: Multiple gallbladder stones seem to be associated with shorter nucleation time and higher biliary concentrations of total protein and glycoprotein than solitary stones.

Alveolar echinococcosis is a life-threatening parasitosis occurring in countries in the Northern hemisphere. The diagnosis of an Echinococcus multilocularis infection is routinely performed by radiological techniques and by the detection of specific antibodies in the sera of infected patients. However, because serodiagnosis fails in 5%-10% and radiological techniques are difficult to interpret in some cases, we developed a polymerase chain reaction for the detection of echinococcal-specific messenger RNA from fine-needle biopsy specimens. This technique was applied to the diagnosis of alveolar echinococcosis in a 20-year-old seronegative woman. Detection of messenger RNA not only allowed the diagnosis of echinococcal disease but also proved to be a reliable measure for determining the efficacy of an antiparasitic therapy.

Bile sampling without the risk of contamination by pancreatic and duodenal secretions and avoiding unpredictable influences of general anesthesia during biliary surgery on biliary analytics are feasible with percutaneous puncture of the gallbladder. In 207 patients with gallstones, gallbladder puncture was performed under local anesthesia with a 22-gauge spinal needle under continuous real-time ultrasound guidance. Bile samples were investigated for biliary lipids and nucleation time. Complete aspiration of gallbladder bile could be achieved in all patients without complications such as bleeding, bile leak, or inflammation. Of these patients, 11.6% reported mild abdominal problems, 3.4% required analgetics, and in 1.0% biliary colics were observed. Elective cholecystectomy was performed in 1 patient. Of the bile samples, 10.1% were contaminated with bactobilia. Biliary lipids, cholesterol saturation index (CSI), total lipid concentration (TLC), and bacteriological contamination were independent of gallstone number, whereas patients with solitary gallbladder stones exhibited a significantly longer nucleation time (NT) in comparison with those with multiple stones. In patients with gallstones, fine-needle puncture of the gallbladder represents an important diagnostic procedure and can be performed within minutes without major side effects if performed by an experienced sonographer.

Background: Biliary lipids and nucleation time are increasingly of importance in the understanding of the cholesterol nucleation process in gallstone patients., Methods: Biliary lipids, total lipid concentration (TLC), cholesterol saturation index (CSI) and nucleation time (NT) were studied in 221 bile samples from patients with solitary (n = 120) and multiple (n = 101) gallbladder stones., Results: Biliary cholesterol concentration and CSI did not differ between patients with solitary or multiple stones; however, it was positively correlated with the CSI (r = 0.93; p < 0.01). We found a negative correlation between CSI and TLC (r = -0.77 for solitary stones and r = -0.79 for multiple stones; p < 0.01). Furthermore, levels of total bile acids and phospholipids were similar in cases with solitary and multiple gallbladder stones. TLC did not correlate with single or multiple stones, whereas NT was determined to be negatively correlated with the number of gallstones (r = -0.39; p < 0.01). Patients with solitary stones had a significantly (p < 0.01) longer NT than those with multiple gallbladder stones (7.5 +/- 4.2 days versus 2.3 +/- 1.5 days)., Conclusions: Our findings suggest that there exists a nucleation-promoting activity, which seems to be more pronounced in patients with multiple gallbladder stones than in those with solitary stones, indicating a major risk factor for the higher recurrence rate seen in these patients.

Objective: The objective of this study was to determine the effect of ursodeoxycholic acid (UDCA), 1000 mg/day, on nucleation time and cholesterol saturation index (CSI) in human gallbladder bile., Methods and Results: In 48 patients with cholesterol gallbladder stones undergoing extracorporeal shockwave lithotripsy, bile samples exhibited a significant longer median nucleation time in the case of solitary stones (7.9 +/- 5.1 days) than in patients with multiple stones (1.7 +/- 1.0 days; p < 0.0001). Stone number and nucleation time were correlated inversely (r = -0.79). UDCA led to a significant prolongation of nucleation time (solitary stones 17.9 +/- 5.8 days, multiple stones 18.0 +/- 5.7 days; p < 0.01) with a concomitant disappearance of cholesterol liquid crystals and cholesterol monohydrate crystals in gallbladder bile. Initially, there was no difference in the CSI between patients with solitary stones or multiple gallbladder stones (1.4 +/- 0.3 vs. 1.4 +/- 0.4, respectively). UDCA caused a significant decrease in CSI by 64.3% (p < 0.01)., Conclusions: We conclude that UDCA prolongs the nucleation time by decreasing the cholesterol saturation index, as well as by diminishing cholesterol liquid crystals and cholesterol monohydrate crystals in gallbladder bile from patients with cholesterol gallstones. Second, recurrent stones essentially occur in patients with multiple cholesterol gallstones, reflected by a concomitant short nucleation time.

Although the ultrasonic detection of gallbladder sludge is relatively frequent, its clinical importance remains unclear, partly because of the paucity of reliable investigations regarding its natural course in patients without stones. In a retrospective study we investigated the course and clinical significance of gallbladder sludge in patients without stones or other identified gallbladder abnormalities. The diagnosis of gallbladder sludge was made by ultrasound scan in 286 (1.7%) of 17,021 patients. The mean follow-up period for these patients was 20.3 +/- 11.5 mo. Of this group 56 patients were without both stones and sludge at the initial examination, and gallbladder sludge developed after a mean observation period of 11.2 +/- 10.6 mo. Within 2.0 +/- 3.5 mo after sludge detection, 40 (71.4%) patients were free of sludge and showed normal gallbladder findings. Gallbladder stones without sludge persistence developed in five patients (8.9%) within 2.5 +/- 0.6 mo after diagnosis of sludge, and gallstones with persistence of sludge developed in two other patients (3.6%) after 6.1 and 30.7 mo, respectively. In no cases did the stones become clinically symptomatic in the course of the follow-up period. Acute acalculous cholecystitis developed in four patients (7.1%) from 6.5 to 37.5 mo after the first examination. In five patients, sludge persisted after a mean 22.3 +/- 13.5 mo of follow-up. Although our data show that gallbladder sludge disappeared spontaneously within a relatively short time in 71.4% of patients, gallbladder sludge must be considered an important pathologic entity because gallbladder stones or complications such as acute cholecystitis occurred in 19.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the risk of gallbladder stone recurrence in these patients, 58 of the first consecutive 61 patients with solitary stones achieving complete stone clearance after ESWL and adjuvant bile acid therapy were included in a prospective study. All patients were observed for at least 12 months following discontinuation of oral bile acids. Twenty-one patients fulfilled our postulated ideal criteria (solitary radiolucent stones between 10-20 mm initial diameter, initial stone density < 50 HU, gallbladder ejection fraction > 70%). The remaining patients (n = 37) fulfilled the criteria of the Munich study group. In patients fulfilling our ideal criteria, stone recurrence was not observed in any patient, while in those fulfilling solely the criteria of the Munich group, five instances of stone recurrence were observed (13.5% [n = 37], p < 0.1). Initial stone count is only one factor influencing the probability of gallstone recurrence following ESWL and discontinuation of oral bile acids. Our data suggest that factors such as low initial stone density at gallbladder CT and good gallbladder function not only accelerate initial stone clearance but also reduce the risk of stone recurrence after ESWL once oral bile acids have been discontinued.

Five weeks after a four-day visit to Malta, a 39-year old white male German national developed septic temperatures of up to 40 degrees C, progressive jaundice and a pronounced hepatosplenomegaly. The initial examination showed a very sick, somnolent patient with jaundice, cyanosis, tachypnea and a markedly enlarged liver on both physical examination and sonography. The laboratory evaluation revealed a moderate leukocytosis, markedly accelerated ESR, poor liver function with strongly elevated gamma-GT and alkaline phosphatase levels. Primary antibiotic therapy consisted of doxycycline. Ultrasound examination of the liver four days after admission revealed multiple hypodense abscesses. On the sixth day after admission, gram-negative rods were first isolated from blood cultures; antibiotic therapy was switched to ofloxacin (2 x 400 mg/day) and amoxycillin (3 x 2 g/day) after sensitivity testing. As a result of treatment with this combination of antibiotics, the patient was free of fever 10 days after hospitalization; on the same day yersinia enterocolitica was isolated from the first blood cultures taken on admission. The diagnosis of non-enteric forms of yersinia infection can prove very difficult, especially if the serology is not clear cut and there are no immunological complications. A presentation including intermittent fever, moderate leukocytosis, strongly accelerated ESR and multiple hypodense abscesses in the liver should lead one to consider a non-enteric type of yersinia infection. Hepatic abscesses usually occur in patients who have an iron overload.