[Opportunities and risks of advance directives : An appraisal of the practice in Germany after legal regulation in 2009].

Background: Living wills/advance directives (AD) are an important tool for specifying patient wishes regarding medical care in the case of future inability to consent. Since 2009, German legislation defines framework conditions for the creation and validity of such directives in § 1901a BGB.

Methods: An extensive literature search in an international and a German-language database was conducted to identify, analyze, and evaluate scientific articles on opportunities, risks, and problems in the creation and implementation of living wills.

Intake of Acetylsalicylic Acid and High Age Are Risk Factors for Iron Deficiency Anemia in Patients with Large Diaphragmatic Hernias.

Introduction: In 15% of patients with iron deficiency anemia, large diaphragmatic hernias are found as the cause of chronic iron loss. Conversely, iron deficiency anemia is present in 10-40% of diaphragmatic hernia patients. However, it is unclear why some patients with large diaphragmatic hernias develop anemia and others do not.

Non-alcoholic fatty liver disease and COVID-19: Harmless companions or disease intensifier?

The pandemics of coronavirus disease 2019 (COVID-19) and non-alcoholic fatty liver disease (NAFLD) coexist. Elevated liver function tests are frequent in COVID-19 and may influence liver damage in NAFLD, while preexisting liver damage from NAFLD may influence the course of COVID-19. However, the prognostic relevance of this interaction, though, is unclear.

Aloe Vera-Containing Matrix in Transdermal Fentanyl Therapy Improves Adhesion, Skin Tolerance and Quality of Life: Results of a German Multicenter Study with a New Fentanyl Patch.

Background: Chronic pain represents a significant and costly healthcare problem especially in the older patient. Transdermal opioid therapy is easy to apply and ensures constant supply of active ingredients. However, skin irritation, poor adhesion and systemic side effects complicate transdermal pain therapy.

Screening for nonalcoholic fatty liver disease-when, who and how?

Nonalcoholic fatty liver disease (NAFLD) is becoming a frequent liver disease, especially in patients with metabolic syndrome and especially in Western countries. Complications of NAFLD comprise progressive fibrosis, cirrhosis and hepatocellular carcinoma. NAFLD also represents an independent risk factor for cardiovascular disease, extrahepatic neoplasia and other organ damage, such as renal insufficiency.

Laparoscopic Appendectomy: A Safe and Definitive Solution for Suspected Appendicitis.

Introduction: Since conservative antibiotic treatment in uncomplicated appendicitis might not solve the clinical problem definitively, it has to compete with the results of today's laparoscopic appendectomy.

Methods: In a county hospital, accommodating also a pediatric department, all cases of appendectomy for suspected appendicitis over 15 years were analyzed retrospectively for the following items: beginning of symptoms, time from admission to surgery, surgical technique as "open," "laparoscopic" or "converted," if perforated at operation and histological confirmation of acute inflammation. Surgical morbidity was detected in distinct categories.

Paraesophageal hernia and iron deficiency anemia: Mechanisms, diagnostics and therapy.

There is ample clinical evidence suggesting that the presence of large axial or paraesophageal hernias may lead to iron deficiency anemia. So-called Cameron lesions, as well as other small mucosa erosions, in the sliding area of these diaphragmatic hernias lead to invisible chronic blood loss and consequently to iron depletion. While the spectrum of symptoms in these patients is large, anemia is often not the only indication and typically not the primary indication for surgical correction of diaphragmatic hernias.

Primary presentation of COVID-19 solely with gastrointestinal symptoms: a problem for the containment of the disease.

An oligosymptomatic patient with initially exclusively gastrointestinal symptoms (massive nausea and mild pancreatitis) turned out to suffer from COVID-19 during the hospital stay. The patient did not exhibit the typical COVID-symptoms cough or fever despite lung involvement. The gastroenterological diagnostic investigations comprised abdominal ultrasound, gastroscopy and endoscopic ultrasound and first revealed no clear cause of these symptoms.

Percutaneous endoscopic gastrostomy - Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen.

The "Aachen sings" study ("Aachen choir engagement study into GERD symptoms"): moderate singing and breathing exercises in a choir reduce reflux symptoms - a cohort study in non-specialist choristers.

Background:  The influence of singing activities and breathing exercises on the presence of gastroesophageal reflux disease (GERD) symptoms is not clear. While an Austrian study found symptom reduction, an Italian study showed more symptoms in professional opera choristers. These contradictory results may be due to differential intensity of the singing exercises.

Changes in drug transport and metabolism and their clinical implications in non-alcoholic fatty liver disease.

The incidence of non-alcoholic fatty liver disease (NAFLD) is rising, especially in Western countries. Drug treatment in patients with NAFLD is common since it is linked to other conditions like diabetes, obesity, and cardiovascular disease. Consequently, changes in drug metabolism may have serious clinical implications.

Molecular changes in hepatic metabolism and transport in cirrhosis and their functional importance.

Liver cirrhosis is the common endpoint of many hepatic diseases and represents a relevant risk for liver failure and hepatocellular carcinoma. The progress of liver fibrosis and cirrhosis is accompanied by deteriorating liver function. This review summarizes the regulatory and functional changes in phase I and phase II metabolic enzymes as well as transport proteins and provides an overview regarding lipid and glucose metabolism in cirrhotic patients.

Commercially available probiotic drinks containing Lactobacillus casei DN-114001 reduce antibiotic-associated diarrhea.

Aim: To investigate the effect of Lactobacillus-containing commercially available probiotic formulations in Germany during antibiotic treatment with an analysis of cost-efficiency.

Methods: In an observational study, we analyzed the frequency of bowel movements from 258 patients with infections in a primary care hospital in western Germany; 107 of the patients were offered a probiotic drink containing at least 10 billion cultures of Lactobacillus casei DN 114001 b.i.

Effect of drug transporter pharmacogenetics on cholestasis.

Introduction: The liver is the central place for the metabolism of drugs and other xenobiotics. In the liver cell, oxidation and conjugation of compounds take place, and at the same time, bile formation helps in extrusion of these compounds via the biliary route. A large number of transporters are responsible for drug uptake into the liver cell and excretion into bile or efflux to the sinusoidal blood.

Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher.

Introduction: The German guideline for sedation in gastrointestinal endoscopy was published in 2008. Several recommendations in this guideline, especially concerning staffing and structural requirements for sedation, have low evidence and therefore are subject to discussion in the field.

Aim: Comparison of endoscopic complications in a department specialized for gastrointestinal and pulmological diseases before and after implementation of the German guideline grouped in sedation-associated and non-sedation-associated complications.

Efficacy of submucosal injection of different solutions inclusive blood components on mucosa elevation for endoscopic resection.

Background: Endoscopic resection has become the standard treatment for noninvasive gastrointestinal malignancies. In flat mucosal tumors, normal saline is frequently used for submucosal fluid injection in order to reduce the risk of complications during endoscopic resection. Recent studies have demonstrated longer-lasting mucosa elevation by injection of agents such as hyaluronic acid or glyceol, rather than normal saline.

Downregulation of breast cancer resistance protein in colon adenomas reduces cellular xenobiotic resistance and leads to accumulation of a food-derived carcinogen.

Several molecular changes in colorectal adenomas provide the basis of the adenoma-carcinoma sequence. We investigated the expression of xenobiotic ATP-binding cassette (ABC) transporters in humans and in ApcMin mice and conducted functional studies estimating the importance of the expression changes. Twenty-nine adenomas from 21 patients and eight adenomas from four ApcMin mice were analyzed using Western blotting and quantitative Real-time polymerase chain reaction (RT-PCR).

Origin of and therapeutic approach to cardiac syndrome X: results of the proton pump inhibitor therapy for angina-like lingering pain trial (PITFALL trial).

Aim: To investigate the frequency of gastroenterological diseases in the etiology and the efficacy of proton pump inhibitors (PPIs) in the treatment of cardiac syndrome X (CSX) as a subform of non-cardiac chest pain (NCCP).

Methods: We investigated 114 patients with CSX using symptom questionnaires. A subgroup of these patients were investigated regarding upper gastrointestinal disorders (GIs) and treated with PPI.

Hepatocyte nuclear factor-4alpha is a central transactivator of the mouse Ntcp gene.

Sodium taurocholate cotransporting polypeptide (Ntcp) is the major uptake system for conjugated bile acids. Deletions of hepatocyte nuclear factor (HNF)-1alpha and retinoid X receptor-alpha:retinoic acid receptor-alpha binding sites in the mouse 5'-flanking region corresponding to putatively central regulatory elements of rat Ntcp do not significantly reduce promoter activity. We hypothesized that HNF-4alpha, which is increasingly recognized as a central regulator of hepatocyte function, may directly transactivate mouse (mNtcp).

Extrahepatic cholestasis downregulates Oatp1 by TNF-alpha signalling without affecting Oatp2 and Oatp4 expression and sodium-independent bile salt uptake in rat liver.

Hepatic uptake of bile salts is mediated by sodium-dependent and sodium-independent transport systems. During extrahepatic cholestasis, both the function and the expression of the Na(+)/taurocholate cotransporting polypeptide (Ntcp) are downregulated. To test whether sodium-independent organic anion-transporting polypeptides are also affected by extrahepatic cholestasis, the function and expression of all three Oatps have been determined in common bile duct-ligated (CBDL) rats.

Fasting induces basolateral uptake transporters of the SLC family in the liver via HNF4alpha and PGC1alpha.

Fasting induces numerous adaptive changes in metabolism by several central signaling pathways, the most important represented by the HNF4alpha/PGC-1alpha-pathway. Because HNF4alpha has been identified as central regulator of basolateral bile acid transporters and a previous study reports increased basolateral bile acid uptake into the liver during fasting, we hypothesized that HNF4alpha is involved in fasting-induced bile acid uptake via upregulation of basolateral bile acid transporters. In rats, mRNA of Ntcp, Oatp1, and Oatp2 were significantly increased after 48 h of fasting.

Principles of hepatic organic anion transporter regulation during cholestasis, inflammation and liver regeneration.

Hepatic uptake and biliary excretion of organic anions (e.g., bile acids and bilirubin) is mediated by hepatobiliary transport systems.

Cytokine blockade inhibits hepatic tissue inhibitor of metalloproteinase-1 expression and up-regulates matrix metalloproteinase-9 in toxic liver injury.

Background: Tissue inhibitor of metalloproteinases (TIMP)-1, the most important endogenous inhibitor of matrix metalloproteinases, plays a pivotal role in the pathogenesis of liver fibrosis and may represent an effective therapeutic target in the design of antifibrotic strategies for chronic liver diseases.

Methods: Intraperitoneal application of a single dose of either tumor necrosis factor (TNF)-alpha or interleukin (IL)-1beta in mice led to an enhanced expression of hepatic TIMP-1 after 4-16 h. Male Sprague-Dawley rats were treated with carbon tetrachloride (CCl4) in the presence and absence of specific TNF-alpha and IL-1beta inhibitors.