[Subacute weakness of the lower limbs]. / Subakute Beinschwäche.

Complete and isolated herniation of the urinary bladder is extremely rare, and the consecutive appearance of bilateral urethral obstruction and renal failure is even rarer. We report about a 73 year old male presenting with massive nausea and muscular weakness. On physical examination he showed a giant inguinal hernia with involvement of the entire bladder along with evidence of bilateral hydronephrosis. His serum creatinine and potassium levels were markedly elevated most likely leading to his presenting symptoms of azotemia (nausea) and hyperkalemia (weakness). After transscrotal drainage and decompression of the bladder, a transurethral catheter was inserted. After gaining full renal recovery, the hernia was repaired successfully performing the Lichtenstein procedure.

["Ghost peak" in gas chromatography in a delirious woman with severe metabolic acidosis. Intoxication with an unknown substance?]. / "Geisterpeak" in der Gas-Chromatografie bei schwerer metabolischer Azidose. Intoxikation mit unbekannter Substanz?

HISTORY AND CLINICAL FINDINGS: A 31-year-old female with known type 1 diabetes mellitus was referred because of symptomatic hyperglycemia. On admission she was delirious and impressed with marked Kussmaul breathing. All other vital signs were normal. INVESTIGATIONS: Blood serum glucose concentration was 26.4 mmol/l. Arterial blood gas analysis revealed massive metabolic acidosis (pH 6.80) with an elevated anion gap (21 mmol/l) and a marginally increased osmolar gap (21,5 mOsm/l). TREATMENT AND COURSE: Despite normalization of the serum glucose and acidemia after administration of normal saline, insulin and bicarbonate, the delirium persisted, and the possibility of an additional intoxication had to be considered. Serum headspace analysis for intoxication with solvents (gas chromatography) finally detected a "ghost peak", which could not be assigned to any established substance. The same peak was, however, found in a healthy subject's serum and was found to be a "toluene peak". Toluene is contained as "contaminator" in gels in blood collection tubes. The patient gradually regained consciousness and "merely" suffered from diabetic ketoacidosis associated with cocaine use. CONCLUSION: The differential diagnosis of high anion gap metabolic acidosis includes among other reasons intoxications with different kinds of solvents. When looking for solvents in the serum when poisoning is suspected (headspace analysis), only blood collection tubes without gel (EDTA plasma) should be used, because all gels contain solvents (in this case toluene).

[Status asthmaticus with rhabdomyolysis of the respiratory muscles]. / Status asthmaticus mit Rhab domyolyse der Atemmuskulatur.

A 40-year-old roofer called the medical emergency team because of sudden dyspnea and chest constriction. He was suffering from bronchial asthma that exacerbated probably due to the inhalation of a solvent while at work. Because of status asthmaticus he was intubated immediately after arrival in the hospital and breathing had to be assisted artificially for ten hours. After extubation he complained of chest pain. In view of an elevated creatinkinase of 4368 U/1 this was interpreted as rhabdomyolysis of the respiratory muscles due to the status asthmaticus. As a cause of chest pain and elevation of creatinkinase after severe respiratory work under hypoxic conditions rhabdomyolysis of the involved musculature has to be considered.

[Maxillary sinus infection with emphysema of the head as a "red herring" in steroid associated colon perforation]. / Kieferhöhleninfekt mit Kopfemphysem als "red herring" bei Steroid-assoziierter Kolonperforation.

Steroid therapy increases the risk of bowel perforation. Bowel perforation may occur at any time of steroid therapy, but the first weeks appear to hold the greatest potential for perforation. However, clinical findings after perforation may be misleading under steroids, and peritonitis may be absent. It is known that bowel perforation can lead to subcutaneous emphysema at various sites. Thus, in any patient with emphysema, bowel perforation must be included in the differential diagnosis, especially in patients receiving steroids. Missing knowledge of this entity may lead to marked delay between onset of initial signs and diagnosis, and hence worsen the survival rate. In this report we present a case of chronic steroid use, where asymptomatic sigma perforation led to a generalized emphysema, which was initially attributed to a maxillary sinus infection due to Aspergillus and anaerobic bacteria.

[Eosinophilia and hepatopathy]. / Eosinophilie mit Hepatopathie: Ein Fallbericht.

We present the case of a 70-year old Patient with diffuse abdominal pain, severe eosinophilia, and increased liver parameters hospitalized for further evaluation. An idiopathic hypereosinophilic syndrome was postulated and the patient was treated with highdose methylprednisolone with rapid normalisation of the eosinophil numbers and decrease of the liver parameters. Later on strongyloidosis could be diagnosed (positive ELISA Test) as the cause of eosinophilia, and the patient was successfully treated with mebendazole. Blood eosionophilia most commonly reflects an allergic, infectious or neoplastic process; increased blood and/or tissue eosinophilia range in severity from self-limited to life-threatening conditions. Strongyloides infection can persist for years without prominent symptoms and should be suspected in any patient with unexplained eosinophilia.

[Neuroleptic malignant syndrome after 30 years treatment with clozapine: a rarely seen differential diagnosis on intensive care units]. / Malignes neuroleptisches Syndrom nach 30-jähriger Behandlung mit Clozapin: Eine seltene Differenzialdiagnose auf der Intensivstation.

The neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal side effect of conventional and atypical antipsychotic drugs. We present a 62 years old male patient who was admitted to our institution because of sudden onset of mild hyperthermia, muscle rigidity, stupor, leucocytosis and massive rhabdomyolysis after 30 years uneventful treatment with clozapine. The medication with clozapine was suspended because of the suspicion of NMS. When the acute symptoms were abated, the treatment with clozapine was resumed again after 14 days. The very next day, the patient suffered again from raised body core temperature, leucocytosis, elevated serum creatine kinase and new catatonia. The therapy with clozapine was stopped definitively and benzodiazepines were administered assuming a relapse of an alleviated, probably reconvening NMS. Under the treatment with benzodiazepines the patient was free of symptoms even after 1 month. To our knowledge, the latency of 30 years between the beginning of the treatment with clozapine and the onset of NMS is the longest period in the literature. According to our case, the differential diagnosis of NMS is not always trivial and is therefore discussed.

[Errors and complications in internal medicine]. / Fehler und Komplikationen in der Inneren Medizin.

The "Komplikationenliste" (list of complications) of the association of the heads of departments of the Swiss society of internal medicine is a clinical tool for the registration and reduction of complications/errors of medical treatment. It is the aim to improve patient safety in hospital medicine. By the systematic and prospective analysis of interventions and complications in the 26 participating medical departments it is possible to collect also rare incidents. All the complications and errors are communicated to all the departments of internal medicine in Switzerland in order to reduce them. The principle for the reduction of such events is the elimination of unsafe actions and conditions and apparently harmless errors in daily diagnostic and therapeutic interventions in order to avoid potentially serious consequences.

[List of complications--reduction of errors and complications by elimination of unsafe actions and conditions]. / Komplikationenliste--Verminderung von Komplikationen und Fehlern durch Elimination unsicherer Handlungen und Bedingungen.

The "Komplikationenliste " (list of complications) of the association of the heads of departments of the Swiss society of internal medicine is a clinical tool for the registration and reduction of complications/errors of medical treatment. It is the aim to improve patient safety in hospital medicine. By the systematic and prospective analysis of interventions and complications in the participating medical departments it is possible to collect also rare incidents. All the complications and errors are communicated to all the departments of internal medicine in Switzerland in order to reduce them. The principle for the reduction of such events is the elimination of unsafe actions and conditions and apparently harmless errors in daily diagnostic and therapeutic interventions in order to avoid the potentially serious consequences.

[Sudden incapacity of walking]. / Plötzliche Gehunfähigkeit.

Two cases of pain and sudden incapacity of walking are presented. In one case aortic dissection, and in the other a massive cholesterol embolism due to aortography were the causing events. The diagnostic evaluation of the patients and the organisation of the emergency services were insufficient in both cases. There was also a lack of adequate communication with patients and relatives, leading to a loss of trust in the hospitals. Although the diagnoses were incorrect, this had no influence on the clinical courses. Nevertheless, the demonstrated deficiencies should stimulate the reevaluation of one's own emergency concept.

[Complications in internal medicine. A study for clinical epidemiology and for prevention of medical complications in Swiss hospitals]. / Komplikationen in der Inneren Medizin. Eine Untersuchung zur klinischen Epidemiologie und zur Verminderung der Komplikationen medizinischer Eingriffe in Schweizer Spitälern.

The committee of the heads of the swiss hospital departments of internal medicine are conducting a study for the prospective registration of complications of medical interventions in patients treated in hospitals. The objective is the reduction of complications by means of postgraduate and continuing education of the hospital staff and by organisational measures. The kind and number of all the interventions performed in each patient and the respective complications are registered by a means of multiple choice form. With this method the percentage of complications can be calculated for each kind of intervention and therefore is also a contribution to the clinical epidemiology of complications. The data are collected anonymously and regular feedback information on pertinent statistic and casuistic material from all the hospitals is provided to all the participants. The casuistic information is commented on by a group of experts. The results demonstrate that the study is well practicable and from 1998 to 2000 42,000 patients have been evaluated.

[Vasculitis and mononeuritis multiplex]. / Vaskulitis und Mononeuritis multiplex.

In 1991, a 67 year old patient, suffering from an adenocarcinoma of the colon, had to undergo hemicolectomy. In the five following years, isolated metastases developed in the liver and have been surgically removed. In 1997, acute mononeuritis multiplex appeared and nerve biopsy revealed vasculitis. There were no signs of inflammatory rheumatic illness, collagenosis, cryglobulinemia, infection or hypersensitivity to medication. We have therefore postulated a relation between the vasculitis and the malignancy. Tumorous relapse could however not be detected at that time. Under immunosuppressive therapy, the neurological deficiencies receded partially, though the carcinoma of the colon reappeared with systemic metastases in the wake of the vasculitis. Diagnostic measures and the relationship between malignancy and vasculitis are discussed.

[Esophageal surgery in the regional hospital]. / Osophaguschirurgie am Regionalspital.

In a small series of surgically treated patients with esophageal cancer (n = 22) modern trends are observed, namely--the frequent occurrence of adenocarcinoma (50% of cases) and of early stage (pT1) (36% of cases),--a low operative mortality (5%),--favorable oncological results for tumors not penetrating the esophageal wall (pT1, 2)(64% of patients at life without recurrence 2-7 1/2 years after surgery). For curative or palliative resection of distal tumors the abdomino-cervical (transhiatal) resection was favored (n = 17) with no instance of anastomotic insufficiency and with 2 cases only of locoregional recurrence. In a case of spontaneous esophageal perforation (Boerhaave) primary suture through an abdomino-transhiatal approach was successful. The interdisciplinary intensive care, necessary in surgery of the esophagus, may be of a high standard in the district hospital.

[Iatrogenic falls]. / Iatrogener Sturz.

One third of community-dwelling people, aged 65 years and over, experience a fall each year, and for institutionalized persons the fall frequency is 1.6 times a year. A fracture results in 5% of falls, one in five of which is a hip fracture. In view of this epidemic among the elderly it is obvious that preventive measures are needed. From the patient's history and the clinical assessment a risk of falls can be defined and this should influence decisions regarding drug treatment. Anamnestic data from relatives or neighbours can be important clues to the circumstances of a fall. Supine and standing blood pressure readings (orthostatic drop?) and testing of mobility provide relevant clinical information. To reduce the fall risk in elderly people, drug therapy should not induce daytime fatigue, sedation or drowsiness. Confusion and orthostatic blood pressure drop should be avoided. Long-term drug therapy should be modified or interrupted during acute illness. Electrolyte imbalance should be prevented.

Plasma potassium response to acute respiratory alkalosis.

Acute respiratory alkalosis (hyperventilation) occurs in clinical settings associated with electrolyte-induced complications such as cardiac arrhythmias (such as myocardial infarction, sepsis, hypoxemia, cocaine abuse). To evaluate the direction, magnitude and mechanisms of plasma potassium changes, acute respiratory alkalosis was induced by voluntary hyperventilation for 20 (18 and 36 liter/min) and 35 minutes (18 liter/min). The plasma potassium response to acute respiratory alkalosis was compared to time control, isocapnic and isobicarbonatemic (hypocapnic) hyperventilation as well as beta- and alpha-adrenergic receptor blockade by timolol and phentolamine. Hypocapnic hypobicarbonatemic hyperventilation (standard acute respiratory alkalosis) at 18 or 36 liter/min (delta PCO2-16 and -22.5 mm Hg, respectively) resulted in significant increases in plasma potassium (ca + 0.3 mmol/liter) and catecholamine concentrations. During recovery (post-hyperventilation), a ventilation-rate-dependent hypokalemic overshoot was observed. Alpha-adrenoreceptor blockade obliterated, and beta-adrenoreceptor blockade enhanced the hyperkalemic response. The hyperkalemic response was prevented under isocapnic and isobicarbonatemic hypocapnic hyperventilation. During these conditions, plasma catecholamine concentrations did not change. In conclusion, acute respiratory alkalosis results in a clinically significant increase in plasma potassium. The hyperkalemic response is mediated by enhanced alpha-adrenergic activity and counterregulated partly by beta-adrenergic stimulation. The increased catecholamine concentrations are accounted for by the decrease in plasma bicarbonate.

[Leiomyosarcoma in the thyroid gland--primary tumor or metastasis?]. / Leiomyosarkom in der Schilddrüse--Primärtumor oder Metastase?

In a 69-year-old female patient a moderately pleomorphic spindle-cell thyroid tumour measuring 5 cm in diameter was initially misinterpreted as primary anaplastic thyroid carcinoma. During clinical investigations to elucidate the cause of severe anaemia, 17 months later an ulcerated duodenal leiomyosarcoma was detected and removed by duodenopancreatectomy. Reevaluation of the thyroid nodule led to revision of the initial diagnosis to metastatic leiomyosarcoma. Six months later the patient died from cerebral stroke. Autopsy findings confirmed the diagnosis of primary leiomyosarcoma of the duodenum with initial manifestation as thyroid metastasis.

[Hypokalemia in the course of a Bartter syndrome]. / Hypokaliämie im Rahmen eines Bartter-Syndroms.

We report on diagnostic and differential diagnostic considerations in the case of a 30 year old Italian woman with hypokalemic alkalosis, fatigue and muscular weakness. The symptoms were caused by a Bartter syndrome with distinctly increased renin but almost normal aldosterone levels in the serum and increased aldosterone values in the urine.

Hyperventilation-induced changes of blood cell counts depend on hypocapnia.

Voluntary hyperventilation for 20 min causes haemoconcentration and an increase of white blood cell and thrombocyte numbers. In this study, we investigated whether these changes depend on the changes of blood gases or on the muscle work of breathing. A group of 12 healthy medical students breathed 36 l.min-1 of air, or air with 5% CO2 for a period of 20 min. The partial pressure of CO2 decreased by 21.4 mmHg (2.85 kPa; P < 0.001) with air and by 4.1 mmHg (0.55 kPa; P < 0.005) with CO2 enriched air. This was accompanied by haemoconcentration of 8.9% with air (P < 0.01) and of 1.6% with CO2 enriched air (P < 0.05), an increase in the lymphocyte count of 42% with air (P < 0.001) and no change with CO2 enriched air, and an increase of the platelet number of 8.4% with air (P < 0.01) and no change with CO2 enriched air. The number of neutrophil granulocytes did not change during the experiments, but 75 min after deep breathing of air, band-formed neutrophils had increased by 82% (P < 0.025), whereas they were unchanged 75 min after the experiment with CO2 enriched air. Adrenaline and noradrenaline increased by 360% and 151% during the experiment with air, but remained unchanged with CO2 enriched air. It was concluded that the changes in the white blood cell and platelet counts and of the plasma catecholamine concentrations during and after voluntary hyperventilation for 20 min were consequences of marked hypocapnic alkalosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Stability of blood sedimentation rate following repeated mixing of the blood in a vacutainer tube (Seditainer)]. / Stabilität der Blutsenkungswerte nach wiederholtem Mischen des Blutes in einem Vacutainer-Röhrchen (Seditainer).

The stability of the sedimentation rate (read at 1 hour) was tested after repetitive mixing of the blood in the same Vacutainer Sedimentation tube ("Seditainer", Becton-Dickinson). The results of 275 sedimentation probes were collected by the nursing staff during routine clinical work on 5 internal medical wards. Sequential sedimentation tests with the same tube after mixing the blood by 6 inversions for the first run and 10 inversions for the second run, or 10 inversions for the first run and 6 inversions for the second, gave identical results. This shows that 6 inversions provide sufficient mixing of the blood. Our definition of one inversion includes turning of the tube axis by 180 degrees plus turning back to the original (vertical) position. If only 3 inversions were performed, the results were less consistent with those after 6 inversions. In 38 of 623 sedimentation runs the readings were too late by 7.6 +/- 4.7 minutes. The corresponding sedimentation rates were 113 +/- 24% of the control values read in time. In 17 of the 275 probes (6.2%) it was the first sedimentation run which was read too late. This shows that repetitions of the sedimentation test may be necessary in routine clinical work. The study clearly demonstrates that repetition is possible with the original sedimentation probe, which provides a reliable result if the blood is remixed by 6 inversions.