BACKGROUND:Despite growing evidence on endoscopic full thickness resection (EFTR), data on segment-specific outcomes in real-world patients remain limited. AIM:To investigate segment-specific outcomes of EFTR using a full-thickness resection device (FTRD) for neoplastic colorectal lesions. METHODS:In this multicenter, retrospective study, EFTR was conducted in unselected real-world patients referred to participating German centers after colonoscopy confirmed EFTR eligibility. The primary outcome was histologically complete resection (R0) of the lesion, including segment-specific outcomes and adverse events (AE). Additional efficacy and safety parameters were investigated by colonic topography for up to 30 days. RESULTS:The analysis included 102 patients (64 males, 38 females) with a median age of 70 years. EFTR via FTRD was technically successful in all patients. The R0 rate was 81.4%, segment-specifically ranging from 85.0% (rectum), 84.6% (descending colon), 84.0% (ascending colon), 83.3% (cecum), and 76.5% (sigmoid colon) to 73.3% (transverse colon). Examination time was longer in proximal parts compared to the rectosigmoid (non-significant). Overall, 33 patients (32.4%) experienced AE, including only one major complication (0.98%; perforation of sigmoid colon). Abdominal postsurgical pain (18.6%), hematochezia (9.8%), and hemoglobin decline (7.8%) were the most frequent minor complications. Transverse colon lesions had the numerically highest rate of AE, with 8 of 15 patients (53.3%) affected. CONCLUSION:EFTR is efficacious for neoplastic colorectal lesions, though R0 rates vary by location. This may impact patient education, selection of the operator, and consideration of laparoscopy surgery.

BackgroundAn acute abdomen is a medical emergency that requires early diagnosis and treatment. In pregnancy, this process is significantly more challenging, and radiological findings are sometimes unclear due to the enlarged uterus displacing other structures. Moreover, endometriosis-related complications are rare, and the disease is often undiagnosed.Case presentationWe report a case of acute perforation of the cecum and appendix during pregnancy (35 weeks of gestation) caused by a previously unknown, deep infiltrating endometriosis with focal ulceration of the affected bowel wall, which sonographically seemed to be acute appendicitis.ConclusionDespite the relatively low risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).

Introduction Worldwide, gastrointestinal endoscopies are predominantly performed under sedation. National and international guidelines and recommendations contain very different specifications for the use of sedation in gastrointestinal endoscopy. These differences come from specific requirements for staffing during endoscopy. Aim The aim of the study is to evaluate whether endoscopist-guided sedation without additional sedation assistance is not inferior to endoscopist-guided sedation with additional sedation assistance with respect to the rate of sedation-associated complications in a defined low-risk population (low-risk procedure and low-risk patient). Methods Prospective, multicenter, randomized study. Results 27 German study centers participated in the study. A total of 30 569 endoscopies were recorded during the study period from 1.8.2015 to 10.3.2020. The final data analysis included 28 673 examinations (64.1 % esophagosgastroduodenoscopies and 35.9 % colonoscopies). In 307 (1.1 %) examinations, 322 sedation-associated complications occurred. Of these, 321 (1.1 %) were minor complications and one (0.003 %) was a major complication. There was no statistically significant difference in the frequency of sedation-associated complications between endoscopist-guided sedation with versus without additional sedation assistance. Within the legal framework, a "shadow " sedation assistant was present in the study group without sedation assistance. This assistant intervened because of sedation-associated complications in 101 (0.7 %) of the endoscopies. Conclusion The study documents the safety of propofol-based endoscopist-guided sedation in a low-risk population. In 98.9 % of all endoscopies, no sedation-associated complication occurred or it was so minimal that no intervention (e. g., increase of oxygen supply) was necessary. The study cannot answer to what extent a serious complication was avoided by the active intervention of the "shadow " sedation assistance in the group without sedation assistance.The study proves in a randomized, prospective design that sedation in low-risk endoscopy (low-risk patient, low-risk procedure) can be performed as endoscopist-guided sedation without additional sedation assistance, without demonstrably accepting a reduction in safety.

Sodium-glucose co-transporter-2 inhibitors (SGLT2is) represent a class of oral antidiabetic drugs that are used in the treatment of type 2 diabetes (T2D), and more recently have been approved for therapy of heart and kidney failure independent of T2D.1 Importantly, SGLT2is have shown the capacity to induce reverse cardiac remodelling,2 together with impressive reductions in cardiovascular, heart failure, and kidney endpoints in outcome trials.3 SGLT2is lower blood glucose levels independently of insulin action by inhibiting reabsorption of filtered glucose in the proximal tubule to increase urinary glucose excretion.4 Therefore, this mode of action is also effective in absolute insulin deficiency in type 1 diabetes (T1D). Consequently, similar to the clinical effects in T2D, clinical trials of SGLT2i use in patients with T1D as an oral adjunct to insulin therapy have shown reductions in HbA1c, body weight, and blood pressure. Moreover, reductions in insulin doses despite improvements in HbA1c, and most importantly, improvements of daily glucose excursions with reduced hypoglycaemia rates and increased time in physiological glucose range, have been observed.5 However, recognized as a rare side effect in T2D, SGLT2is significantly increased the risk for comparatively normoglycaemic diabetic ketoacidosis (DKA) in T1D trials.5, 6 In addition, no outcome trial results are available for the use of SGLT2is in T1D. To date, little is known about patient selection, and the risks and benefits of SGLT2is in T1D in the real world.6, 7 In Europe, the SGLT2i dapagliflozin, at a reduced dose of 5 mg, was licensed in 2019 for use in adults with T1D as an adjunct to insulin therapy for selected patients with a body mass index (BMI) of 27 kg/m2 or higher. The licensing of dapagliflozin in Europe for T1D was mandatorily associated with a risk mitigation strategy for the prevention of DKA, including patient and provider education programmes, provision of self-measurement meters for ketone bodies, and intense patient surveillance.6 Of note, off-label use of SGLT2is in T1D in clinical practice had been observed earlier, well before official licensing.7 The criteria upon which healthcare providers selected patients with T1D for treatment with SGLT2is in the real world are not well characterized. Further, therapeutic effects and adverse events of SGLT2is in T1D in daily clinical practice have not been substantially reported. Therefore, in this trial, we collected data on the characteristics of patients with T1D selected for SGLT2i treatment, and analysed efficacy and safety in clinical practice. The Diabetes Prospective Follow-up Registry DPV (Diabetes-Patienten-Verlaufsdokumentation) has followed patients with diabetes from 1995. DPV data on patients with all types of diabetes (regardless of their disease stage and treatment strategy) are collected every 6 months from centres in Germany, Austria, and Switzerland using DPV software, and the anonymized data are sent to the University of Ulm. Detailed information on the documentation was published previously.8 The DPV initiative was approved by the ethics committee of the University of Ulm, and data collection was approved by the review boards of the participating centres. Data for this study were collected from 2012 to 2020. Inclusion criteria were diagnosis of T1D, age at diabetes onset of 6 months or older, and current age 18 years or older. Characteristics in the year before SGLT2i initiation were compared with patients not selected for SGLT2i treatment. Further, the therapeutic effects of SGLT2is after an average treatment period of 12 months were analysed. The SGLT2is used were dapagliflozin (5-10 mg QD [once daily]) and empagliflozin (10-25 mg QD). Repeated measures (autoregressive [Toeplitz] covariance structure) linear regression models were used for continuous outcomes and logistic regression models for binary outcomes. Models were adjusted for sex, categorized time-dependent age (<40, 40-<60, ≥60 years), diabetes duration (<2, 2-<5, ≥5 years), and respective baseline variables. As a sensitivity analysis we used an unstructured covariance structure for repeated measures models. In total, 50 795 patients with T1D were included in this study. Of these, only 431 patients (0.85%) had initiated an SGLT2i (89% of those off-label) (Table 1); 56% were male, the mean age was 50.2 (standard deviation [SD] 15.3) years, mean BMI was 29.6 kg/m2 (SD 6.5 kg/m2, 63% with BMI ≥ 27 kg/m2), mean diabetes duration was 15.5 (SD 13.1) years, average HbA1c at initiation was 8.58% (SD 1.80%) and mean insulin dose/kg body weight was 0.65 (SD 0.37) IU/kg, and the average overall insulin dose was 57.3 (SD 36.6) IU. Adjusted linear regression models revealed significantly higher baseline mean HbA1c, BMI, overall daily insulin dose, systolic and diastolic blood pressure, and frequency of albuminuria in patients selected for SGLT2i treatment compared with patients not selected for SGLT2i treatment (Table 1). No differences in baseline average daily insulin dose/kg or estimated glomerular filtration rate (eGFR) were observed. Data on 12 months of SGLT2i treatment were available for 233 patients (mean age 46.9 [SD 15.4] years, and diabetes duration 15.7 [SD 12.8] years, at SGLT2i initiation). Compared with the year before SGLT2i initiation, after an average of 12 months of treatment, a significant decrease in mean HbA1c, as well as small reductions in systolic and a significant decrease in diastolic blood pressure, were observed (Table 2). Moreover, total cholesterol and LDL-cholesterol decreased significantly during follow-up. An average of 12 months of SGLT2i treatment in T1D did not result in significant changes in mean BMI, mean insulin dose/kg, HDL-cholesterol, triglyceride, eGFR, and the proportion of individuals with microalbuminuria (Table 2). Using an unstructured instead of autoregressive covariance structure did not change the results. The proportion of patients with at least one severe hypoglycaemia in the year prior to SGLT2i initiation and in the first 12 months with an SGLT2i was low (3%), as were other safety variables (Table S1). Of note, none (0%) of the patients had a DKA in the year before or during the 12 months of SGLT2i treatment. Based on this nationwide observational trial in Germany, Austria, and Switzerland, we conclude that overall use of SGLT2is in adults with T1D is rare in real-world clinical practice. In the prospective randomized licensing trials for dapagliflozin in T1D, the major clinical outcomes were substantial reductions in HbA1c, BMI, insulin requirements, blood pressure, and glucose excursions.5 Therefore, if healthcare providers in the real world may have chosen patients with T1D for SGLT2i treatment according to these results, it could be envisioned that the selection criteria would have been inadequate glycaemic control with high HbA1c, elevated BMI, high insulin requirements and large glucose excursions, and maybe also accompanying arterial hypertension. Indeed, in this observational trial in clinical practice, the selection of patients with T1D for SGLT2i treatment appears to be primarily triggered by the presence of higher HbA1c and BMI in combination with requirements of higher insulin doses, higher blood pressure, and the presence of microalbuminuria. This preselection of patients may also explain in part the somewhat larger HbA1c reductions in this real-world evidence study compared with the results of controlled licensing trials of SGLT2is in T1D. Of note, 89% of patients with T1D in this observational cohort received SGLT2i treatment off-label, that is, before official licensing of dapagliflozin for the use in T1D. Therefore, we conclude that the criteria for selection of patients with T1D for SGLT2i treatment may have been translated from the well-known clinical results in patients with T2D to similarly ‘expected’ outcomes in selected patients with T1D. Similar results were recently observed in a trial within the US type 1 diabetes exchange registry (T1DX) in adults.9 There, SGLTi use was also rare and reported by less than 3% of adults. Compared with non-users, those who used SGLTis were more probably of an older age, with a longer diabetes duration, of white race, had private insurance, the use of an insulin pump or continuous glucose monitor, higher BMI, and used other adjuvant diabetes medication, which mirrors the observations in our DPV study. In contrast to the significant results from prospective trials of SGLT2i treatment in T1D, in real-world practice after 1 year of treatment in routine care, a clinically relevant but smaller improvement in HbA1c, and more importantly negligible changes in BMI or insulin requirements, were observed. In addition, effects on blood pressure, eGFR, or frequency of microalbuminuria were not substantiated after 1 year of treatment either, indicating that clinical responses of these variables to SGLT2i treatment in T1D in real-world practice may be more heterogeneous than implied by randomized trials. As a limitation to this statement, we acknowledge that the overall number of patients with T1D in this population receiving SGLT2i treatment in this observational trial was small, and the treatment interval was only 12 months. Further, 1-year follow-up data were only available for a subset of 233 SGLT2i users of the overall group of 431 patients. We cannot exclude that results for systolic blood pressure and body weight would change if 1-year follow-up data were available for the whole subset of 431 patients. As an additional limitation, in this real-world trial, we were unable to acquire sufficient data for continuous glucose monitoring during the course of SGLT2i treatment. Therefore, we are unable to report any treatment effects on glucose excursions in response to SGLT2i therapy, and cannot report times in ranges, as were published for the randomized trial in this patient population.5 Before dapagliflozin was officially licensed for use in T1D, it was known that DKA is a rare but significant adverse clinical complication of SGTL2i treatment in T2D over the observational time interval analysed in this real-world trial.1 As a higher DKA rate is generally envisioned in T1D, the fear of this complication in these patients in response to SGLT2i therapy may have prevented healthcare providers from using this type of treatment in more patients with T1D in clinical practice. Of note, in contrast to results from randomized trials with SGLT2is in T1D, this observational trial revealed no increase in the rate of DKA in response to SGLT2i treatment in real-world practice. While this may indicate that the risk of DKA as a side effect of SGLT2i therapy in T1D may be overestimated in daily clinical practice, the overall low DKA rate in this patient population may also reflect a highly restrictive patient selection for this treatment or an intense surveillance of patients during the course of the treatment. This is somewhat different to the observations of the T1DX trial,9 in which participants with SGLT2i therapy experienced a minimal non-significant increase in DKA, but unexpectedly, also a higher rate of severe hypoglycaemia. It should be noted that no data exist from outcome trials of SGLT2i use in T1D, despite the fact that prevention of cardiovascular and kidney endpoints would be similarly desired in patients with T1D, as in those patients with T2D. However, we do not know whether wishfully anticipated cardioprotective and nephroprotective effects may have triggered, to some extent, the selection of patients with T1D in this trial for SGLT2i therapy. In summary, SGLT2i therapy in T1D may represent an effective and safe oral adjunct therapy in highly selected patients with T1D not reaching their glycaemic goals by insulin therapy alone. While the effects of SGLTis on blood pressure, BMI, and albuminuria may be smaller in T1D versus T2D, and to date no results of outcome trials exist, it may be envisioned that SGLT2is also reduce cardiovascular and kidney outcomes in T1D in longer duration therapy. The authors thank all the participating centres of the DPV initiative, especially the collaborating centres in this investigation. Special thanks to Andreas Hungele and Ramona Ranz for support and the development of the DPV documentation software, and Katharina Fink and Esther Bollow for the DPV data management (in each case clinical data manager, Ulm University). This study was supported by DZD and Diabetes Agenda 2010. The authors report no conflicts of interest with respect to this study. SL and JS wrote the manuscript and analysed the data; SL, JS, and RWH researched and analysed the data, reviewed and edited the paper; and TD, PB, SMS, FK, SK, PF, and CS contributed to discussions and reviewed/edited the manuscript. SL is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The peer review history for this article is available at https://publons.com/publon/10.1111/dom.14620. The data that support the findings of this study are available from the corresponding author upon reasonable request. Table S1 Safety outcomes with an average of 12 months SGLT2i treatment in T1D Table S2 Changes in outcomes with an average of 12 months SGLT2i treatment in T1D Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background Conventional endoscopic resection of lesions affecting the appendiceal orifice is difficult. Endoscopic full-thickness resection (EFTR) is a novel technique in interventional endoscopy. As EFTR near the appendiceal orifice is associated with a subtotal appendectomy, it remains unclear whether the risk of developing appendicitis is increased. We conducted a retrospective analysis of lesions involving the appendiceal orifice treated by EFTR. Methods This was a multicenter retrospective analysis of patients (n = 50) treated with EFTR for lesions involving the appendiceal orifice between 2014 and 2019. The objective was to evaluate the occurrence of appendicitis. Results Acute appendicitis occurred in seven patients (14%) during follow-up. Conservative treatment was sufficient in four cases, and three patients underwent appendectomy. Conclusions EFTR of lesions involving the appendiceal orifice may be associated with an imminent risk of developing appendicitis and a consecutive need for appendectomy. Patients should be informed about this specific risk prior to resection. It is unclear why some patients develop appendicitis while the majority remains asymptomatic.

Objectives Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. Designs A cute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. Results A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. Conclusions T his large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients.

Current international guidelines recommend endoscopic resection for T1 colorectal cancer (CRC) with histological low-risk features and oncologic resection for those at high-risk of lymphatic metastasis. Exact risk stratification is therefore crucial to avoid under- as well as over-treatment.

Rectal carcinoids show an increasing incidence and are malignant tumors that can metastasize [1]. According to the recent guidelines of the European Neuroendocrine Tumor Society, rectal carcinoids of less than 2 cm in diameter could be resected endoscopically [2]. As highlighted in a recent systematic review and meta-analysis, the best endoscopic treatment option is endoscopic submucosal dissection (ESD) or so-called modified endoscopic mucosal resection techniques, including the band-ligation and cap-fitted techniques [3] [4].

Background: Like other mental illnesses, depression is a culturally sensitive topic. Hence, findings cannot be transferred between countries. We investigated the frequency of depressed mood and its association with diabetes-related factors in a large type 2 diabetes (T2D) cohort from real-life care in Germany.Methods: 17,563 adults (median [IQR]: 64.5[55.9-71.1] years) from the multicenter diabetes follow-up registry, DPV (diabetes prospective follow-up), were investigated. All had completed the WHO-5 questionnaire, a screening tool for depression. Logistic regression was applied to study the association of demographic and diabetes-related factors with depressed mood (SAS 9.4). P < 0.05 was considered significant.Results: Using a WHO-5 cut-off of < 13, 27.4% of patients were at risk for depressed mood. A clinical depression diagnosis was recognized in 8.4%. Female sex (OR: 1.5[95%-CI: 1.4-1.6]), young age (1.2[1.1-1.4]), longer diabetes duration (1.2[1.1-1.3]), and living in Northern Germany (1.3[1.2-1.4]) were each associated with increased odds for depressed mood. After adjusting for these confounders, worse glycemic control (1.4[1.3-1.5]), insulin use (1.3[1.2-1.4]), myocardial infarction (1.3[1.2-1.5]), stroke (1.8[1.5-2.0]), retinopathy (1.4(1.3-1.6]), renal failure (1.4[1.2-1.8]), diabetic foot syndrome (1.3[1.2-1.4]), severe hypoglycemia (1.5[1.2-1.9]), two or more inpatient admissions (2.1[1.8-2.4]), and longer duration of hospital stay (1- < 14 days: 1.3[1.2-2.3]; >= 14 days: 2.1[1.9-2.3]) were related to depressed mood.Limitation: Due to the cross-sectional design, no causality can be drawn.Conclusions: In T2D, depressed mood is not uncommon. However, in routine care a clinical depression might be missed and regular screening is advisable. Besides the well-known associations with depressed mood, northern German residence and mainly life-compromising diabetes comorbidities were identified as related factors.

Perioperative treatment is a standard of care in locally advanced gastroesophageal cancer (GEC) (gastric adenocarcinoma and gastroesophageal junction (GEJ) adenocarcinoma). While preoperative treatment can be applied to the majority of patients, postoperative chemotherapy can be given only to a fraction. The NeoFLOT-study therefore investigates the application of prolonged neoadjuvant chemotherapy (NACT). Patients with T3, T4, and/or node-positive adenocarcinoma (GEC) were eligible for this multicenter phase II trial. NACT consisted of 6 cycles of oxaliplatin 85 mg/m(2) , leucovorin 200 mg/m(2) , 5-fluorouracil 2600 mg/m(2) and docetaxel 50 mg/m(2) (FLOT) applied q 2 wks. Application of adjuvant chemotherapy was explicitly not part of the protocol. R0-resection rate was evaluated as a primary endpoint. Of 59 enrolled patients, 50 patients underwent surgery and were assessable for the primary endpoint. R0-resection rate was 86.0% (43/50). Pathologic complete response (pCR) was 20.0% (10/50) and a further 20% (10/50) of patients achieved near complete histological remission (<10% residual tumor). Among these very good responders, 85% (17/20) had intestinal type tumors, 10% (2/20) had diffuse and 5% (1/20) had mixed type tumors. After 3 cycles of NACT, 6.9% (4/58) of patients developed progressive disease. Median disease-free survival was 32.9 months. The 1-year survival-rate was 79.3%. Grade 3-4 toxicities included neutropenia 29.3%, febrile neutropenia 1.7%, diarrhea 12.1% and mucositis 6.9%. This study indicates that intensified NACT with 6 cycles of FLOT is highly effective and tolerable in resectable GEC. Very good response (pCR and <10% residual tumor) was predominantly observed in patients with intestinal type tumors.

Caveolin-1 (Cav1) is a scaffold protein and pathogen receptor in the mucosa of the gastrointestinal tract. Chronic infection of gastric epithelial cells by Helicobacter pylori (H. pylori) is a major risk factor for human gastric cancer (GC) where Cav1 is frequently down-regulated. However, the function of Cav1 in H. pylori infection and pathogenesis of GC remained unknown. We show here that Cav1-deficient mice, infected for 11 months with the CagA-delivery deficient H. pylori strain SS1, developed more severe gastritis and tissue damage, including loss of parietal cells and foveolar hyperplasia, and displayed lower colonisation of the gastric mucosa than wild-type B6129 littermates. Cav1-null mice showed enhanced infiltration of macrophages and B-cells and secretion of chemokines (RANTES) but had reduced levels of CD25+ regulatory T-cells. Cav1-deficient human GC cells (AGS), infected with the CagA-delivery proficient H. pylori strain G27, were more sensitive to CagA-related cytoskeletal stress morphologies ("humming bird") compared to AGS cells stably transfected with Cav1 (AGS/Cav1). Infection of AGS/Cav1 cells triggered the recruitment of p120 RhoGTPase-activating protein/deleted in liver cancer-1 (p120RhoGAP/DLC1) to Cav1 and counteracted CagA-induced cytoskeletal rearrangements. In human GC cell lines (MKN45, N87) and mouse stomach tissue, H. pylori down-regulated endogenous expression of Cav1 independently of CagA. Mechanistically, H. pylori activated sterol-responsive element-binding protein-1 (SREBP1) to repress transcription of the human Cav1 gene from sterol-responsive elements (SREs) in the proximal Cav1 promoter. These data suggested a protective role of Cav1 against H. pylori-induced inflammation and tissue damage. We propose that H. pylori exploits down-regulation of Cav1 to subvert the host's immune response and to promote signalling of its virulence factors in host cells.

P38/Mk2 (mitogen-activated protein kinase (MAPK)-activated protein kinase-2, also known as MAKAP kinase-2) is a member of the mitogen-activated protein kinases (MAPKs) family, and participates in inflammatory responses directly or indirectly. WIN55, 212-2 (WIN55) is a synthetic non-selective agonist of cannabinoid (CB) receptors with remarkable anti-inflammatory properties. This study was to explore the roles of WIN55 and p38/Mk2 signaling pathway in dextran sodium sulfate (DSS)-induced mouse colitis and ascertain their anti-inflammatory mechanisms. Colitis was induced in C57BL Mk2 gene homozygous deletion (Mk2−/−) and wild-type mice by replacing the drinking water with 4% DSS solution for 7 days. DSS-treated mice developed bloody stool, weight loss, and eye-visible multiple bleeding ulcers on colon mucosa. The mRNA expressions levels of TNF-α and IL-6, as well as the protein levels of p38 and its phosphorylated form (p-p38), were upregulated in the colon. The plasma levels of TNF-α, IL-6, cytokine-induced neutrophil chemoattractant-1 (CINC-1), monocyte chemoattractant protein-1 (MCP-1), and lung myeloperoxidase (MPO) activities were raised; however, all these changes were less severe in Mk2−/− mice. After WIN55 intervention, the Mk2−/− mice recovered faster and better from the induced colitis than their wild-type counterparts. The results indicate that the Mk2 homozygous deletion in mice impedes the induction of experimental colitis by DSS, confirming the notion that p38/Mk2 is involved in this inflammatory response. WIN55 protects mice against DSS-induced colitis, in particular when the p38/Mk2 pathway is obstructed, implying that the activation of CB system, together with blocking of p38/Mk2 pathway, serves as a potential drug target for colitis treatment.

The endocannabinoid system has been shown to mediate beneficial effects on gastrointestinal inflammation via cannabinoid receptors 1 (CB(1)) and 2 (CB(2)). These receptors have also been reported to activate the MAP kinases p38 and c-Jun NH(2)-terminal kinase (JNK), which are involved in early acinar events leading to acute pancreatitis and induction of proinflammatory cytokines. Our aim was to examine the role of cannabinoid receptor activation in an experimental model of acute pancreatitis and the potential involvement of MAP kinases. Cerulein pancreatitis was induced in wild-type, CB(1)-/-, and MK2-/- mice pretreated with selective cannabinoid receptor agonists or antagonists. Severity of pancreatitis was determined by serum amylase and IL-6 levels, intracellular activation of pancreatic trypsinogen, lung myeloperoxidase activity, pancreatic edema, and histological examinations. Pancreatic lysates were investigated by Western blotting using phospho-specific antibodies against p38 and JNK. Quantitative PCR data, Western blotting experiments, and immunohistochemistry clearly show that CB(1) and CB(2) are expressed in mouse pancreatic acini. During acute pancreatitis, an upregulation especially of CB(2) on apoptotic cells occurred. The unselective CB(1)/CB(2) agonist HU210 ameliorated pancreatitis in wild-type and CB(1)-/- mice, indicating that this effect is mediated by CB(2). Furthermore, blockade of CB(2), not CB(1), with selective antagonists engraved pathology. Stimulation with a selective CB(2) agonist attenuated acute pancreatitis and an increased activation of p38 was observed in the acini. With use of MK2-/- mice, it could be demonstrated that this attenuation is dependent on MK2. Hence, using the MK2-/- mouse model we reveal a novel CB(2)-activated and MAP kinase-dependent pathway that modulates cytokine expression and reduces pancreatic injury and affiliated complications.

4072 Background: The rationale of the NeoFLOT-trial was the intensification of neoadjuvant chemotherapy (NACT) by prolongation of preoperative treatment. This strategy is based on the notion that while perioperative treatment is notably beneficial in locally advanced gastroesophageal cancer (GEC), postoperative chemotherapy can only be applied in a fraction of patients (pts). Methods: Pts with T3, T4 and/or N+ adenocarcinoma (GEC) were eligible for this multicenter phase II trial. NACT consisted of 6 cycles of oxaliplatin 85 mg/m2, leucovorin 200 mg/m2, fluorouracil 2600 mg/m2 and docetaxel 50 mg/m2 (FLOT) applied q 2 wks. Staging was performed after 3 cycles to select pts with progressive disease (PD) for immediate surgery. Primary endpoint was the R0-resection rate. Secondary endpoints included the pathological complete response rate (pCR), histologic tumor regression grade (Becker 2003), safety, and progression-free survival (PFS). Results: From 10/2009 to 06/2011, 59 pts were enrolled of whom 58 pts were assessable for safety. Median age was 61 years (range: 32-79), 58.6% (34/58) had tumors of the gastroesophageal junction. 50 pts underwent surgery and were assessable for the primary endpoint. R0-resection rate was 86.0% (43/50). pCR was achieved in 20.0% (10/50) of pts. During NACT, 6.9% (4/58) of pts developed progressive disease. Dose reduction was performed in 43.1% (25/58) of pts resulting in a median dose intensity of 89.2%. Grade 3/4 neutropenia was observed in 29.3% (17/58) of pts, febrile neutropenia grade 3/4 in 1.7% (1/58). Common grade 3/4 non-hematologic adverse events were diarrhea (13.8% (8/58)) and mucositis (6.9% (4/58)). Treatment related mortality was 3.4% (2/58) with 2 cases of sepsis. After a median follow-up of 9.1 months, median PFS and OS have not been reached. Conclusions: These data indicate that NACT with 6 cycles FLOT is well-tolerated and highly effective in resectable GEC.

A role of heat shock protein 27 (HSP27) as a potential biomarker has been reported in various tumour entities, but comprehensive studies in pancreatic cancer are lacking. Applying tissue microarray (TMA) analysis, we correlated HSP27 protein expression status with clinicopathologic parameters in pancreatic ductal adenocarcinoma specimens from 86 patients. Complementary, we established HSP27 overexpression and RNA-interference models to assess the impact of HSP27 on chemo- and radiosensitivity directly in pancreatic cancer cells. In the TMA study, HSP27 expression was found in 49% of tumour samples. Applying univariate analyses, a significant correlation was found between HSP27 expression and survival. In the multivariate Cox-regression model, HSP27 expression emerged as an independent prognostic factor. HSP27 expression also correlated inversely with nuclear p53 accumulation, indicating either protein interactions between HSP27 and p53 or TP53 mutation-dependent HSP27-regulation in pancreatic cancer. In the sensitivity studies, HSP27 overexpression rendered HSP27 low-expressing PL5 pancreatic cancer cells more susceptible towards treatment with gemcitabine. Vice versa, HSP27 protein depletion in HSP27 high-expressing AsPC-1 cells caused increased gemcitabine resistance. Importantly, HSP27 expression was inducible in pancreatic cancer cell lines as well as primary cells. Taken together, our study suggests a role for HSP27 as a prognostic and predictive marker in pancreatic cancer. Assessment of HSP27 expression could thus facilitate the identification of specific patient subpopulations that might benefit from individualized treatment options. Additional studies need to clarify whether modulation of HSP27 expression could represent an attractive concept to support the incorporation of hyperthermia in clinical treatment protocols for pancreatic cancer.

Bile acids from duodenogastric reflux promote inflammation and increase the risk for gastro-oesophageal cancers. FXR (farnesoid X receptor/NR1H4) is a transcription factor regulated by bile acids such as CDCA (chenodeoxycholic acid). FXR protects the liver and the intestinal tract against bile acid overload; however, a functional role for FXR in the stomach has not been described. We detected FXR expression in the normal human stomach and in GC (gastric cancer). FXR mRNA and protein were also present in the human GC cell lines MKN45 and SNU5, but not in the AGS cell line. Transfection of FXR into AGS cells protected against TNFα (tumour necrosis factor α)-induced cell damage. We identified K13 (keratin 13), an anti-apoptotic protein of desmosomes, as a novel CDCA-regulated FXR-target gene. FXR bound to a conserved regulatory element in the proximal human K13 promoter. Gastric expression of K13 mRNA was increased in an FXR-dependent manner by a chow diet enriched with 1% (w/w) CDCA and by indomethacin (35 mg/kg of body weight intraperitoneal) in C57BL/6 mice. FXR-deficient mice were more susceptible to indomethacin-induced gastric ulceration than their WT (wild-type) littermates. These results suggest that FXR increases the resistance of human and murine gastric epithelial cells to inflammation-mediated damage and may thus participate in the development of GC.

In acute pancreatitis, endoplasmic reticulum (ER) stress prompts an accumulation of malfolded proteins inside the ER, initiating the unfolded protein response (UPR). Because the ER chaperone tauroursodeoxycholic acid (TUDCA) is known to inhibit the UPR in vitro, this study examined the in vivo effects of TUDCA in an acute experimental pancreatitis model. Acute pancreatitis was induced in Wistar rats using caerulein, with or without prior TUDCA treatment. UPR components were analyzed, including chaperone binding protein (BiP), phosphorylated protein kinase-like ER kinase (pPERK), X-box binding protein (XBP)-1, phosphorylated c-Jun NH(2)-terminal kinase (pJNK), CCAAT/enhancer binding protein homologues protein, and caspase 12 and 3 activation. In addition, pancreatitis biomarkers were measured, such as serum amylase, trypsin activation, edema formation, histology, and the inflammatory reaction in pancreatic and lung tissue. TUDCA treatment reduced intracellular trypsin activation, edema formation, and cell damage, while leaving amylase levels unaltered. The activation of myeloperoxidase was clearly reduced in pancreas and lung. Furthermore, TUDCA prevented caerulein-induced BiP upregulation, reduced XBP-1 splicing, and caspase 12 and 3 activation. It accelerated the downregulation of pJNK. In controls without pancreatitis, TUDCA showed cytoprotective effects including pPERK signaling and activation of downstream targets. We concluded that ER stress responses activated in acute pancreatitis are grossly attenuated by TUDCA. The chaperone reduced the UPR and inhibited ER stress-associated proapoptotic pathways. TUDCA has a cytoprotective potential in the exocrine pancreas. These data hint at new perspectives for an employment of chemical chaperones, such as TUDCA, in prevention of acute pancreatitis.

To compare the diagnostic accuracy of a standard bi-directional, three-dimensional (3D) CT colonography (CTC) fly-through (standard view, SV) with a unidirectional, 3D unfolding technique (panoramic view, PV).

Acute pancreatitis (AP) is an inflammatory process in which cytokines and chemokines are involved. After onset, extrapancreatic stimuli can induce the expression of cytokines in pancreatic acinar cells, thereby amplifying this inflammatory loop. To further determine the role and mechanism of irritating agents in the pathogenesis of AP, rat pancreatic tissues were stimulated with ascitic fluid (APa) and serum (APs) from rats with AP or with lipopolysaccharide (LPS). In addition, the alteration of heat shock protein 60 (HSP60) expression was evaluated. Rat pancreas was removed and meticulously snipped to fragments. The snips were cultured for up to 48 h. During this period, the tissue viability as well as amylase and TNF-α levels in the supernatant and the HSP60 expression in the pancreatic tissue before and after stimulation by APa, APs, and LPS were assayed time-dependently. At different time-points during the culture, the viability and the amylase activity in the pancreatic tissue remained largely stable. After stimulation with APa, APs, or LPS for 1 h, the pancreatic tissues showed some damage, and this was followed by a sharp decrease in the viability accompanied by increased levels of amylase and TNF-α in the culture medium 2 or 4 h after stimulation (p < 0.05). In contrast, both the HSP60 mRNA and protein levels had a relatively high expression in the freshly prepared tissue fragments (0 h). As the culturing period was extended, the expression of HSP60 mRNA decreased only slightly; at the same time, the HSP60 protein levels decreased over a prolonged culture time, significantly so from 12 through 48 h (p < 0.05). After stimulation with APs, APa, or LPS, both the expression of HSP60 mRNA and protein in the tissue fragments increased slightly at 1 h and decreased significantly thereafter at 2 and 4 h (p < 0.05). APa, APs, or LPS induce injuries on isolated pancreatic tissues, accompanied by an altered HSP60 expression pattern in a time-dependent manner.