[Show abstract][Hide abstract] ABSTRACT: Background and Aims: The introduction of a new type of small handheld ultrasound device brings greater portability and affordability. The basic ultrasound approach with these handheld devices has been defined by European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) as "EchoScopy". The current study aimed to assess the image quality, indications and limitations of a portable pocket "EchoScope" compared with a high-end ultrasound system in abdominal diseases. Methods: 231 consecutive patients were included in this study. Physician A performed ultrasound examinations with a high-end ultrasound system (HEUS), then physician B performed the same ultrasound examination using an EchoScope (Vscan™). In patients with focal lesions, physician B also measured the largest diameters and graded the vascularity by using colour Doppler imaging (CDI) within the lesion on the same plane with both ultrasound systems. Compared with the excellent image quality using HEUS, the image quality of the EchoScope was graded as good, sufficient or non-sufficient. Results: Out of all 231 patients, 167 had focal lesions, 19 patients were found with diffuse pathological findings, six with ascites, six after liver puncture and 33 without any pathological findings. The image quality of the pocket device was considered as being good or sufficient to delineate the pathology in 225/231 (97.4 %). The detection rate of the EchoScope for abdominal focal lesion was 162/167 (97 %), only five superficially located lesions could not be detected. Both systems showed agreement in determination of the best positioning to perform abdominal paracentesis and assessing complications after intervention. Conclusions: The investigated EchoScope displays a sufficient image quality, in some indications such as detection of focal lesions > 20 mm, detection of ascites, hydronephrosis and other pathological findings with comparable results to HEUS. We conclude that pocket sized EchoScopy devices have a promising future but the indications have to be determined by a prospective study.
Zeitschrift für Gastroenterologie 03/2014; 52(3):269-275. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Splenic lesions are rare and characterization is difficult. Secondary spread is more frequent than primary malignant lesions. Thus clinical circumstances are important in the general work-up. Contrast enhanced ultrasound (CEUS) had high accuracy in recent studies but the positive predictive value is low. Biopsy is considered dangerous. Recent studies have brought back this method into focus showing an excellent efficacy and safety. The aim of this study was to estimate the rate of relevant biopsy results in patients with splenic lesions concerning the clinical circumstances.
Patients with unclear splenic lesions which appeared progressively hypoenhancing in the late phase of CEUS with BR1 were included. Biopsy was performed with ultrasound guidance. Patients were sorted into 5 groups according to their clinical symptoms.
44 patients were enrolled, 59% had benign lesions. 73% were rated relevant. For the subgroups the rate was: patients with hints for hemato-oncological diseases 83%, patients without symptoms 38%, patients with infections of unknown origin 100%, patients with suspicion of metastases 33, immunocompromised patients 100%. One bleeding could be managed conservatively, another bleeding was detected incidentally 2 weeks later.
Percutaneous biopsy of unclear splenic lesions which appear hypoenhancing in the late phase of CEUS with BR1 results in a high rate of relevant lesions. The results should be tested in larger numbers of patients.
Clinical hemorheology and microcirculation 01/2014; · 3.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A retrospective multicenter study has been conducted to evaluate domino liver transplantations (DLTs) in Germany. The study provides insight into survival and features having an impact on the assessment of neuropathy after DLT. In addition, a neurologic follow-up program with a scheme to estimate the likelihood of de novo amyloidosis is presented. A series of 61 DLTs at seven transplant centers in Germany was enrolled. The mean age of domino recipients at the time of transplantation was 58 years, 46 of them being men, and 15 being women. The median follow-up was 46 months. The overall 1-, 3-, and 5-year survival of domino recipients was 81.6%, 70.8% and 68.8%, respectively. Causes of death were primarily not related to familial amyloidosis. The main indication of DLT was hepatocellular carcinoma. Two of the reported domino recipients developed symptoms and signs of de novo amyloidosis within 10 years after transplantation. A total of 30 domino graft recipients (49.18%) presented with diabetes post transplantation. In conclusion, an advanced follow-up program is crucial to evaluate the risk of transmitting familial amyloidosis by DLT and to establish more strict selection criteria for domino recipients.
Transplant International 04/2013; · 3.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Familial amyloid polyneuropathy (FAP; also known as familiar amyloidosis and hereditary amyloidosis) is an autosomal dominant inherited disease due to mutations of the transthyretin (TTR) gene coding for the corresponding protein, consisting of 127 amino acids. The gene is located on chromosome 18q. More than 100 different mutations are known. Other mutant precursor proteins produced in the liver, such as apolipoprotein I and II, lysozyme and fibrinogen Aα, may be of etiological importance as well. Amyloidogenic mutations of the TTR gene lead to decreased stability of the corresponding protein and subsequently to extracellular deposition of amyloid in several tissues (peripheral and autonomic nerves, walls of the gastrointestinal tract, heart, etc.). The Val30Met mutation is the most prevalent cause of FAP worldwide. There are endemic regions in Portugal, Sweden and Japan. The onset of symptoms is usually between 25 and 35 years of age, but late-onset families are also known. The most common clinical symptoms are polyneuropathy of the lower limbs, rhythmological disturbances and diarrhea/obstipation. TTR amyloid is predominantly produced in the liver; only as few as 5% are synthesized in the retina and choroid plexus. Therefore, liver transplantation has become widely accepted as the ultimate curative treatment of this disease in order to prevent the ultimately fatal outcome and ameliorate disabling symptoms. Because of shortage of donor grafts, livers of FAP patients are used for domino liver transplantation. Last year, a new therapeutic option was approved by the European Medical Authority (EMA) for therapy of early-stage FAP. The first results of a multicenter-controlled trial have been published and show a benefit in patients with an early stage of disease regarding neurological symptoms as well as modified BMI. There are several other pharmacologic approaches that have been reported in the last years which may lead to stabilization of the TTR tetramer. Therefore, this might be the beginning of new therapeutic options with pharmacological therapies in patients with FAP.
[Show abstract][Hide abstract] ABSTRACT: The focus of this article is the emergent and potential indications of contrast-enhanced ultrasound (CEUS). Emergent applications of CEUS techniques include extravascular and intracavitary contrast-enhanced ultrasound, quantitative assessment of microvascular circulation for tumor response assessment, and tumor characterization using dynamic contrast-enhanced ultrasound (DCE-US). Potential indications for microbubble agents include novel molecular imaging and drug and gene delivery techniques, which have been successfully tested in animal models. "Comments and Illustrations of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Non-Liver Guidelines 2011" which focus more on established applications are published in the same supplement to Ultraschall in der Medizin (European Journal of Ultrasound).
Ultraschall in der Medizin 07/2012; 33 Suppl 1:S39-47. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Germany the extent of organ donation is still low and not sufficent to duly address all patients on the waiting lists. It is likely that a lack of information and a consecutive uncertainty in the adult population relate to this imbalance. Virtually no data exist about teenagers' knowledge of the facts of organ donation.
4000 questionnaires were distributed in secondary schools in the state capital city Mainz, Germany. The students were asked to respond to 12 questions. The survey was voluntary and performed in class, without the students using any information sources.
Data from 1155 questionnaires were analysed. Overall 11.3 % of the teenagers carried an organ donor card. 48.9 % of the students had spoken about organ donation and brain death in their families. 37.0 % of the students declined organ donation. Of these, 72.4 % named a lack of education and informations as the primary reason for this statement. More non-German than German pupils declined organ donation (43.4 % vs. 36.2 %).
More than half of the pupils between 14 years and 20 years of age support the concept of organ transplantation as therapeutic option. Nevertheless the proportion of organ card holders is small among these students. These regional results identify an information deficit in young people in Germany as one of the main causes for inadequate acceptance of organ donation. Therefore, information and structured education should be intensified in German schools as possible measure to increase the number of future organ donor card holders in Germany.
[Show abstract][Hide abstract] ABSTRACT: Drug-induced tubulointerstitial nephritis and acute tubular necrosis are common, and are often caused by drugs especially antibiotics or non-steroidal anti-inflammatory drugs. Drug-induced liver dysfunction and renal failure after subcutaneous injection of phosphatidylcholine was not reported so far. 3-sn-Phosphatidylcholine has been described as a cell lysis reaction-inducing drug. Its in vitro data indicated a relevant toxicity potential. In particular human cell types such as fibroblast-like preadipocytes, vascular and skeletal muscle cells, or renal epithelial cells react more sensitive than other human cell types.
We present a 28-year-old woman who received 3.5 g (70 mL) of 3-sn-phosphatidylcholine (Lipostabil®) at once subcutaneously (s. c.) in both gluteal regions. The drug was originally introduced to prevent fat embolism. Nevertheless, its off-label use in aesthetic therapy for treatment of localized fat deposits through subcutaneous administration is becoming increasingly common. Three hours after injection the patient suffered from severe nausea and emesis. Within 24 hours a dramatic increase of liver enzymes and a beginning liver dysfunction were observed. Subsequently, renal function deteriorated two days later making a temporary haemodialysis necessary. Hepatic improvement was observed after three days of treatment. Renal function was fully recovered after two weeks.
To the best of our knowledge, this is the first reported patient presenting with acute liver dysfunction and renal failure after subcutaneous injection of 3-sn-phosphatidyl-choline (Lipostabil®) indicating the risk of an off-label use of this drug.
Zeitschrift für Gastroenterologie 03/2011; 49(3):340-3. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since the introduction of model for end-stage liver disease (MELD) in 2006, post-orthotopic liver transplantation (OLT) survival in Germany has declined. The aim of this study was to evaluate risk factors and prognostic scores for outcome. All adult OLT recipients in seven German transplant centers after MELD implementation (December 2006-December 2007) were included. Recipient data were analyzed for their influence on 1-year outcome. A total of 462 patients (mean calculated MELD = 20.5, follow-up: 1 year) were transplanted for alcoholic cirrhosis (33.1%), hepatocellular carcinoma (26.6%), Hepatitis-C (17.1%), Hepatitis-B (9.5%), primary sclerosing cholangitis (5.6%) and late graft-failure after first OLT before December 2006 (8.7%). 1-year patient survival was 75.8% (graft survival 71.2%) correlating with MELD parameters and serum choline esterase. MELD score >30 [odds ratio (OR) = 4.17, confidence interval: 2.57-6.78, 12-month survival = 52.6%, c-statistic = 0.669], hyponatremia (OR = 2.07), and pre-OLT hemodialysis (OR = 2.35) were the main death risk factors. In alcoholic cirrhosis (n = 153, mean MELD = 21.1) and hepatocellular carcinoma (n = 123, mean MELD = 13.5), serum bilirubin and the survival after liver transplantation score were independent outcome parameters, respectively. MELD >30 currently represents a major risk factor for outcome. Risk factors differ in individual patient subgroups. In the current German practice of organ allocation to sicker patients, outcome prediction should be considered to prevent results below acceptable standards.
Transplant International 01/2011; 24(1):91-9. · 3.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Teaching ultrasound (US) has not been sufficiently standardised yet. Most educational devices in US consist of 2-dimensional B-mode images. However, the identification of anatomic structures in the 3-dimensional space can only be learned by practical hands-on education. In US simulators, US images of real pathologies are created by the examination of a dummy with a mock transducer. The resulting US images were previously recorded in a 3-dimensional format and were processed in a way which facilitates the reconstruction and projection of the images on a screen corresponding to the sectional plane of the mock transducer, simulating the conventional B-mode images. This enables standardised, real-time, hands-on training of US pathology detection. In June 2007, a hands-on workshop on US simulators was performed in the 1st Department of Internal Medicine of the Johannes Gutenberg-University in Mainz/Germany. During 15 days, 209 participants from all parts of Germany were trained. The workshop included an evaluation to elucidate the value and acceptance of this kind of US training. 149 evaluation forms could be analysed (72 %). The participants were fairly heterogeneous and belonged to the following subspecialties: internal medicine (50 %), surgery (11 %), others (18 %). 72 % were residents, 22 % consultants. 40 % of the participants worked in university hospitals, 12 % in hospitals of highest clinical level, and 42 % in hospital of basic care. Baseline knowledge in US was quite different, too, reflected in the number of independently performed US examinations prior to this course: 0 - 400 examinations (44 %), 401 - 1000 examinations (14 %), 1001 - 4000 examinations (7 %), and > 4000 examinations (2 %). Of note, 56 % of the participants had not received any kind of formal training in US. In daily practice 77 % were trained by tutors, whose formal qualification in US was unknown. Only a small proportion of the tutors had received training in US according to the standards of the German Association of US in Medicine (DEGUM). This evaluation shows the high level of acceptance of simulator-based training in US despite the heterogeneity of the participants. 95 % rated the teaching value as "high" and 95 % wished an integration of US simulators in training curricula. In summary, this analysis proves the need for standardised training programmes in US teaching in Germany and a high level of acceptance of simulator-based US training.
Zeitschrift für Gastroenterologie 11/2010; 48(11):1279-84. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Long term immunosuppression and therapy of acute rejections result in a 20-120-fold increased risk to develop Non Hodgkin lymphoma (NHL). Since immunosuppressive therapy and immunological disorders are major risk factors for the development of NHL in the non-transplant population we aimed to analyze risk factors for PTLD in our cohort of liver transplanted (LT) patients.
We analyzed retrospectively 431 patients liver transplanted between 1998 and 2008.
PTLD was diagnosed in eleven of 431 patients (2.6%). PTLD, especially late PTLD, was significantly more frequent in patients who received steroids before LT (Kaplan-Meier: p<0.001). Moreover PTLD in immunocompromised patients with preoperative steroid treatment occurred at a significantly younger age (49.5+/-4.7 years) compared to patients without steroids (60.6+/-5.1 years; p=0.006). Multivariate analysis revealed pretransplant steroid treatment and liver transplantation for autoimmune hepatitis as main risk factors for the development of PTLD after liver transplantation (p<0.001).
Liver transplanted patients who received steroids before LT due to immunological disorders and patients with autoimmune hepatitis seem to be at particular high risk to develop PTLD. Prospective cohort studies including immunoepidemiologic investigations of abnormalities of cellular, humoral and innate immunity should be carried out to identify predictive factors and patients at risk.
European Journal of Internal Medicine 06/2010; 21(3):208-15. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Amyloidosis is a rare group of diseases with a variety of symptoms that occurs not only in multimorbid elderly but also in young patients. However, sonographic signs of amyloidosis have not been described so far.
30 patients with different forms of amyloidosis (19 patients with TTR-amyloidosis (familial amyloid Polyneuropathy [FAP]), 11 patients with other forms of systemic amyloidosis) were sonographically evaluated in a standardised fashion. In all patients amyloidosis was histologically verified.
Typical signs of cardiac amyloidosis were myocardial thickness, pericardial effusion, pleural effusion and typical echorich subendocardial depositions. Signs of kidney infiltration were stage dependent and rather unspecific. Spontaneous subcapsular haemorrhages were the typical signs of liver and spleen infiltration. Intestinal affection was characterised by patchy-like inhomogeneous depositions. Rare sites of amyloidal affection could also be verified, e. g. gallbladder and thyroid infiltration.
Typical sonographic signs of amyloidosis could be found in the heart, bowel wall, liver, spleen, gallbladder and thyroid and were illustrated as pictorial assays.
Zeitschrift für Gastroenterologie 09/2009; 47(8):731-9. · 1.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The number of incidentally discovered adrenal masses is growing due to the increased use of modern high-resolution imaging techniques. However, the characterization and differentiation of benign and malignant adrenal lesions is challenging. This study aimed to evaluate contrast-enhanced ultrasound for the characterization of adrenal masses.
We studied 58 patients with adrenal masses detected with computed tomography, magnetic resonance imaging, or ultrasound. 7 patients had bilateral adrenal lesions. Contrast-enhanced ultrasound was performed using high-resolution ultrasound (3.5 - 7 MHz) and intravenous injection of 2.4 ml SonoVue. The contrast enhancement pattern of all adrenal lesions was documented.
The 18 malignant adrenal tumors were significantly larger at the time of diagnosis compared to the 40 benign lesions (p < 0.03). The majority of benign adrenal lesions (37 / 40) had a nonspecific type of contrast enhancement (24 / 40) or a peripheral to central contrast filling (13 / 40) described as the iris phenomenon. Similar findings were observed in malignant adrenal tumors: most malignant lesions also showed nonspecific (6 / 18) or peripheral to central contrast filling (9 / 18). Peripheral to central contrast filling had 50 % sensitivity (26 - 74 %) and 68 % specificity (51 - 81 %) for indicating malignancy.
Contrast-enhanced ultrasound facilitates the visualization of vascularization even in small adrenal masses, but it does not help to distinguish malignant and benign lesions.
Ultraschall in der Medizin 04/2009; 31(2):163-8. · 4.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recurrent cirrhosis (RC) due to pretransplant underlying disease leads to organ failure and subsequent death after orthotopic liver transplantation (OLT). RC occurs in up to 30% of patients with recurrent hepatitis C (HCV) within 5 years after OLT. We sought to identify early risk factors for rapid RC within the first year after OLT in HCV-positive patients.
Among 404 liver transplanted patients at the University of Mainz between 1998 and 2008, 90 were HCV-RNA positive. To identify predictive factors for rapid RC, we compared HCV-positive patients with advanced fibrosis stages within 1 year after OLT (n = 13) with these without RC at 5 years after OLT (n = 23).
Overall, poorer patient survival was associated with advanced fibrosis scores in the 1-year protocol biopsy and nonresponse to interferon treatment before OLT. The strongest predictive factors for rapid RC were persistently high levels of alkaline phosphatase, bilirubin, viral load at 6 months after OLT, and multiple steroid pulse therapies. The CCR2-V64I polymorphism was not associated with rapid RC.
We presented a group of patients with HCV-related rapid RC within the first year after OLT to identify predictive factors for rapid fibrosis progression.