Increased plasma concentrations of circulating intercellular adhesion molecule-1 (cICAM-1) in patients with necrotizing pancreatitis.

The intercellular adhesion molecule-1 (ICAM-1), a membrane glycoprotein, is important in the adhesion of cytokine-stimulated leukocytes to the endothelium of microvessels and their transendothelial migration. Circulating isoforms of ICAM-1 (cICAM-1) are known to be elevated in human serum as an indirect consequence of inflammatory responses. The aim of this study was to investigate whether cICAM-1 levels are elevated in patients with acute pancreatitis within 48 h of the onset of abdominal pain and whether cICAM-1 levels correlate with the severity of the tissue damage. Twenty-five consecutive patients admitted to a medical ICU had elevated cCAM-1 concentrations of 548 +/- 68 ng/ml, significantly different when compared to a control group of 18 healthy subjects (343 +/- 29; p = 0.018). According to the findings of contrast-enhanced CT or laparotomy patients were further divided in a group with acute edematous pancreatitis and a group with acute necrotizing pancreatitis. Pancreatic necrosis was associated with cICAM-1 levels of 729 +/- 106 ng/ml, significantly different from patients with mild disease (367 +/- 48) and controls (p < 0.001). Plasma cICAM-1 levels were not significantly different between healthy subjects and patients with mild pancreatitis. A significant correlation was found between cICAM-1 and C-reactive protein, an acute phase reactant and marker of necrotizing pancreatitis (r = 0.62; p < 0.01). The sensitivity and specificity for the detection of edematous or necrotizing pancreatitis of cICAM-1 plasma concentrations (cutoff point at 500 ng/ml) were 75% and 85%, respectively. These results suggest an enhanced release of ICAM-1 into plasma in the early stage of acute necrotizing pancreatitis. Leukocyte-endothelial cell adhesion may be associated with the inflammatory process of necrotizing tissue damage in acute pancreatitis. It could thus serve as a marker or predictor of a severe clinical course of pancreatitis.

Q.E.D. Alcohol test: a simple and quick method to detect ethanol in saliva of patients in emergency departments. Comparison with the conventional determination in blood.

OBJECTIVE: The aim of this pilot study was to assess whether ethanol concentrations in saliva are comparable to those in blood and to evaluate whether this new non-invasive saliva alcohol test is suitable for use in emergency departments. DESIGN: Prospective, open, non-randomised study. SETTING: University hospital emergency department. PATIENTS AND METHODS: 100 consecutive patients who were admitted to the emergency department whose smell and/or behaviour indicated alcohol abuse. Fifteen patients participated as a control group after they were asked to abstain from alcohol consumption for 24 h before the study. INTERVENTIONS: Blood and saliva samples were obtained at the same time for ethanol measurement. The Q.E.D. Alcohol Test A350 was used in order to measure the concentration of ethanol in saliva. Blood samples were analysed by the alcohol dehydrogenase method. RESULTS: The mean difference between the ethanol levels in blood and saliva was -0.1 mg/dl, whereas the values measured in saliva were on average 0.1 mg/dl higher than those measured in blood (p = 0.002). CONCLUSION: The Q.E.D. Alcohol Test A 350, which uses saliva, is well suited for quantitative determination of alcohol levels. The levels measured in saliva correlate well with those measured in blood at both the lower and the upper end of the scale. Because this test is quick and easy to perform by emergency room personnel and the results are accurate enough for clinical purposes, it should prove valuable to determine whether impaired consciousness is related to alcohol intoxication or to other likely causes.

Severe hypotension and coma secondary to unrecognized chronic anterior hypophysitis.

We report an endocrine emergency of a 52-year-old woman with chronic anterior-pituitary failure of autoimmune origin who developed hypopituitary crisis with coma and severe hypotension provoked by an intercurrent bronchopneumonia. At admission to the ICU hypopituitarism had not been diagnosed and only Hashimoto's thyroiditis with thyroid replacement therapy could be obtained from the patient's history. Although the patient presented with somatic signs suggestive of hypopituitarism, other causes of coma and hypotension had first to be excluded. In the absence of specific treatment the patient died 18 h later with refractory cardiac arrest. Diagnosis of acute decompensated chronic hypophyseal failure must be considered if hypothermia, refractory hypotension and signs of infection without fever are associated with a short stature and the loss of axillary and public hair. Waiting for laboratory confirmation of the diagnosis must not delay immediate life-saving specific glucocorticoid treatment.

Aborted sudden death in a patient with a structurally normal heart: the Brugada syndrome.

We report a 37-year-old man with documented aborted sudden death. After resuscitation, the patient showed no structural heart disease but the ECG showed a right bundle-branch block with a descending ST segment elevation in leads V(1) and V(2). After transient normalization of the ECG, the administration of ajmaline led to spontaneous development of the distinct descending ST segment elevation in the right precordial leads and therefore to the diagnosis of Brugada syndrome. The incidence of sudden cardiac death among these patients is high. The only treatment is an implantable cardioverter-defibrillator (ICD). The Brugada syndrome should therefore be borne in mind in the differential diagnosis of sudden death.

Near fatal anticholinergic intoxication after routine fundoscopy.

We describe a case of severe anticholinergic intoxication following the topical instillation of tropicamide-containing eyedrops. Tropicamide is a short-acting atropine-like derivative and has been regarded as an effective and safe mydriatic. Half an hour after routine fundoscopy, a 62-year-old man experienced two generalized seizures with respiratory arrest and required intubation and mechanical ventilation. The patient was treated with physostigmine and made a full recovery.

"Lipometer": determining the thickness of a subcutaneous fatty layer.

The "Lipometer" is a new computerized optical measuring system for determining the thickness of a subcutaneous fatty layer. It offers a non-invasive, quick, precise and safe way measuring a fat layer.

Influence of a novel amino acid solution (enriched with the dipeptide glycyl-tyrosine) on plasma amino acid concentration of patients with acute renal failure.

In this randomized, double-blind controlled study we compared the effect of parenteralnutrition with two different amino acid solutions on the plasma concentration of amino acids in 27 patients with acute renal failure. Fourteen patients received the new dipeptide-containing (glycyl-tyrosine) amino acid solution (AADI) in combination with glucose (60%) and fat (10%) as an 'all-in-one' solution over 120 h continuously via a central venous catheter. In the control group (AAST), parenteral nutrition with a standard amino acid solution in isonitrogenous and isocaloric form (0.7 g amino acids/kg BW/day and 25 kcal/kg BW/day) was administered to 13 patients over the same period of time. The administration of the dipeptide-containing amino acid solution caused a return to within the normal range of most of the amino acid concentrations which were decreased at the onset. A significant difference could be found between the AADI and AAST group for the achieved plasma concentrations of threonine (P < 0.01), phenylalanine (P<0.05), isoleucine (P<0.05), tryptophan (P<0.01) and ornithine (P<0.05), The phenylalanine/tyrosine ratio, did not change in the AADI group, while a marked increase was observed in the AAST group. (152.7 +/- 23.5 - 159.8 +/- 37.6 vs 172.6 +/- 24.6 - 310.6 +/- 136.7, respectively). The plasma concentration of glycyl-tyrosine was at the limit of detectability indicating rapid hydrolysis of the dipeptide in acute renal failure. These data suggest that the new dipeptide-containing amino acid solution offers a clear advantage over a standard amino acid formulation in correcting the amino acid imbalances in plasma of patients with ARF and is able to maintain normal tyrosine concentrations and phenylalanine/tyrosine ratio.

Absorption of hydrolysed bovine serum albumin from the human jejunum over a 6-hour period.

OBJECTIVE: Quantitative assessment of intestinal absorption of total and single amino acids in a hydrolysed bovine serum albumin solution over a 6-h period. DESIGN: Ten healthy volunteers underwent segmental jejunal perfusion using a multi-lumen tube assembly with a proximal occluding balloon. Prehydrolysed bovine serum albumin served as protein source. In one set of experiments we used a washout phase before the equilibration period to eliminate any contents present in the test segment. In another set we started directly with the equilibration period. Absorption rates of total and single amino acids were measured over a period of 6 h. RESULTS: Absorption rates remained constant throughout this period and there was no significant difference in absorption rates whether a washout phase was used or not. Absorption rates of total amino acids ranged from 6.4 +/- 1.9 (mean +/- SEM) to 10.7 +/- 0.7 g/h and 30 cm, when a washout phase was used. Percentage absorption of the perfusion load per hour was 24 +/- 7% to 40 +/- 2% with a washout phase. Although a highly concentrated perfusion load was used there was a correlation (r = 0.66, P < 0.05) between absolute concentration in the perfusion solution and the amount of individual amino acid absorbed. Individual amino acids showed a wide range of percentage absorption. Percentage absorption of 50% or more of the perfusion load was seen for alanine, phenylalanine, arginine, leucine, methionine and tyrosine. The highest absorption rate was seen for methionine with 86%, the lowest for cysteine with 3%. CONCLUSION: When hydrolysed bovine serum albumin is used, amino acid absorption is constant over a period of 6 h in the human jejunum. A washout phase has no influence on total and single amino acid absorption.

[Clinical assessment and therapy of barbiturate poisoning (based on 2 case reports)]. / Klinische Beurteilung und Therapie von Barbituratvergiftungen (an Hand von zwei Fallberichten).

The clinical features, complications and course of barbiturate poisoning are described and illustrated by two case histories in order to recommend therapeutic guidelines on the basis of practical experience. For the intensive care physician it is essential to get information on the composition of barbiturate-containing drugs as rapidly as possible in order to determine the correct therapeutic management. A table is presented of the components of the most commonly used barbiturates.

[Ketoacidotic diabetic metabolic dysregulation: pathophysiology, clinical aspects, diagnosis and therapy]. / Ketoazidotische diabetische Stoffwechselentgleisung: Pathophysiologie, Klinik, Diagnose und Therapie.

When glucose utilisation is impaired due to decreased insulin effect, ketones are produced by the liver from free fatty acids to supply an alternate source of energy. This adaptation may be associated with severe metabolic acidosis and tends to occur in patients with type I (insulin-dependent) diabetes mellitus. In addition, hypovolemia is an almost invariable finding with marked hypoglycemia and is primarily induced by the associated glucosuria. Ketoacidosis stimulates both the central and peripheral chemoreceptors controlling respiration, resulting in alveolar hyperventilation (Kussmaul's respiration). With the ensuing fall in pCO2 the patient tries to raise the extracellular pH. A fruity odor of acetone on the patient's breath sometimes suggests that ketoacidosis is present. The classical triad of symptoms associated with hyperglycemia are polyuria, polydipsia, and weight loss. Circulatory insufficiency with hypotension is not uncommon due to the marked fluid loss and acidemia. In more severely affected patients, neurologic abnormalities may be seen, including lethargy, seizures or coma. Some patients also have marked vomiting and abdominal pain. The history and physical examination may provide important clues to the presence of uncontrolled diabetes mellitus. Once suspected, the diagnosis can be easily confirmed by measuring the plasma glucose concentration. Glucosuria and ketonuria can be semiquantitatively detected with reagent sticks. Blood gas analysis and anion gap give objective information as to the severity of the metabolic acidosis. Therapy must be directed toward each of the metabolic disturbances: hyperosmolality, ketoacidosis, hypovolemia and potassium, and phosphate depletion. The mainstays of therapy are the administration of low-dose insulin and volume repletion.(ABSTRACT TRUNCATED AT 250 WORDS)

Intensive care management of acute pancreatitis: recognition of patients at high risk of developing severe or fatal complications.

The clinical spectrum of acute pancreatitis ranges from mild, self-limiting disease of fulminant illness that may rapidly lead to multiple organ failure and death. To identify factors associated with a subsequent severe course and/or high mortality we investigated retrospectively 91 patients admitted to the medical intensive care unit (ICU) with acute pancreatitis during a 2 year period. 67% of the attacks were mild (< or = 1 complication). The overall mortality rate was 9%, whereby 3% of patients with alcoholic and 13% with biliary pancreatitis died. 75% of the patients in the group with a fatal outcome were aged over sixty and 30% in the group with a mild course (p < 0.05). Females with pancreatitis of biliary origin had a mild course in 57% and a severe (> or = 2 complications) or fatal outcome in 43%. In males with alcohol abuse we observed a mild form of pancreatitis in 79% and a severe or fatal course in 21%. The delay between onset of abdominal pain and commencement of treatment in hospital was greater than 12 hours in 70% of all patients studied and there was no association with severity and development of subsequent complications. The median of the acute physiology and chronic health evaluation scoring system (APACHE-III) on the day of admission was 19 in patients with mild disease, which was significantly lower than in patients with severe (40) or fatal acute pancreatitis (53) (p < 0.0001). Serial APACHE-III measurements over 5 days after admission provided further differentiation between mild and severe or fatal cases (p < 0.0001), but no significant difference was observed between survivors with severe course and fatal outcome. In addition, RANSON scores were calculated for comparison with APACHE-III at admission and after 48 hours: concerning the recognition between mild and severe/fatal pancreatitis both scoring systems exhibited similar significant differences on day 1 and day 2. The RANSON scoring system provided further a significant differentiation between survivors with a severe course of pancreatitis when compared to deaths on day 2, whereas the APACHE-III scoring system did not. Advanced age, female sex, biliary obstruction and elevated RANSON and APACHE-III scores are risk factors for an increased rate of life-threatening complications in acute pancreatitis. The daily assessment of such scoring systems may allow the recognition of such patients and may be helpful in the routine clinical management and monitoring of acute pancreatitis.

Diagnostic value of Vbeta2-positive T-cell expansion in toxic shock syndrome.

BACKGROUND: diagnostic dilemma in toxic shock syndrome (TSS) is that the results of microbiologic investigations are often not available immediately because of the need for incubation, or no obvious entry point can be found. METHODS: We describe three patients with a clinical diagnosis of TSS in whom microbiologic tests were negative. RESULTS: All patients had complicated courses with vasopressor-dependent shock, renal and respiratory failure, and disseminated intravascular coagulation for at least 1 week. In all three patients, diagnosis was considerably faster with the assessment of the expansion of T-cell-receptor Vbeta2-positive T cells (> 15%) than by Centers for Disease Control and Prevention (CDC) diagnosis, because of the complicated clinical picture or the delay caused by waiting for the results of microbiologic investigations. CONCLUSIONS: Our results indicate that diagnostic procedures incorporating Vbeta2-positive T cells could be a useful tool for the diagnosis of TSS.

A holistic approach to MRSA eradication in critically ill patients with MRSA pneumonia.

BACKGROUND: The number of Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia cases is increasing in many European countries. In this observational study in one medical and three surgical ICUs multiple interventions for the treatment and eradication of nosocomial MRSA-pneumonia were used. PATIENTS AND METHODS: Twenty-one critically ill patients (age: 59 +/- 14 years, 15 males/6 females, 18 ventilator-associated, 3 nosocomial, clinical pulmonary infection score > 6 in all patients, APACHE II 18 +/- 5) were enrolled. The patients were treated with a 7-day course of iv linezolid (600 mg bid) plus rifampicin (600 mg bid), endotracheal vancomycin 100 mg qid, thrice daily mouth and throat washing with chlorhexidine 1% fluid and nasal mupirocin ointment, twice daily skin and hair washings with chlorhexidine gluconate 4% and tracheostomy (n = 8) wound care with povidone-iodine spray. Control samples (endotracheal secretions, nose, wound, and pharyngeal swabs) were taken 2, 3, 4, 7 days and 2 months thereafter. Multilobular pneumonia was seen in 16, pleural effusion in 12, and MRSA bacteremia in 4 patients. RESULTS: One patient died during the follow-up period due to cerebral bleeding. In the remaining 20 patients, pneumonia was clinically cured in all patients and all patients were free of MRSA after eradication. Six patients died due to myocardial infarction (n = 3), gram-negative septic shock (n = 2), herpes encephalitis (n = 1) > 7 days after eradication. No MRSA reinfection occurred during the control period. CONCLUSION: We conclude that in patients with MRSA pneumonia an approach using a 7-day course of intravenous linezolid plus rifampicin, intratracheal vancomycin, nasal mupirocin, cutaneous and oropharyngeal chlorhexidin plus povidone-iodine cures pneumonia and is effective for MRSA eradication.

[Acute management of poisonings]. / Akutversorgung von Intoxikationen.

The incidence of intoxications has inclined rapidly in the last years. Formerly intoxications with barbiturates were seen frequently, but now the centre of interest has shifted to overingestion of psychotherapeutic drugs and non barbiturate hypnotics. In some intensive care units 50% of the patients are admitted with various intoxications. The latest effectively employed methods and their relevance are tabulated as follows.

[Differential indications: parenteral-enteral nutrition in intensive care patients]. / Differentialindikationen: parenterale-enterale Ernährung beim Intensivpatienten.

The number of patients admitted to the intensive care unit because of malabsorption is remarkably high. Therefore nutritional therapy plays an important role in the management of intensive care patients. At the beginning of nutritional support the extent of deficiency and severity of nutritional disturbances as well as estimated duration of impossibility for oral alimentation have to be set up. Furthermore advantages and disadvantages of parenteral and enteral nutrition have to be considered to avoid any possible complications.

Intradialytic parenteral nutrition in malnourished patients on chronic haemodialysis therapy.

BACKGROUND: Malnutrition is frequently encountered in patients on regular haemodialysis therapy and presents an important determinant of morbidity and mortality. Usual therapeutic approaches to alleviate malnutrition have been unsuccessful. The objective of this study was to assess the impact of intradialytic parenteral nutrition (IDPN) with amino acids (in combination with a glucose-containing dialysate) on nutritional parameters and immunocompetence in patients on regular haemodialysis treatment. METHODS: Effects of IDPN were evaluated in 16 malnourished patients. After a run-in period of 4 weeks (to define stable baseline conditions) 0.8 g amino acids/kg bodyweight using a novel amino-acid solution (adapted to metabolic alteration of uraemia and including the dipeptide glycyl-tyrosine as tyrosine source) was infused thrice weekly during each haemodialysis session for 16 weeks. RESULTS: Intradialytic amino-acid infusion was well tolerated and the dipeptide was rapidly utilized with only traces being detectable in plasma after dialysis. Visceral protein synthesis was improved, serum albumin, prealbumin, and cholinesterase increased during IDPN (P < 0.05). As indicators of augmented immunocompetence skin test reactivity against multiple antigens was improved (P < 0.02) and total lymphocyte count was raised (P < 0.05). Plasma amino acid pattern did not deteriorate but failed to normalize during IDPN and phenylalanine/tyrosine ratio remained stable. Anthropometric measurements and eating behaviour as assessed by dietary records were not altered during IDPN. CONCLUSIONS: Even using a simple and limited intradialytic nutritional support with amino acids can improve visceral protein status and stimulate immunocompetence in malnourished patients on regular haemodialysis therapy.

[Course of atypical nodular sclerosing lymphogranulomatosis with intestinal polyposis in a 62-year-old female]. / Verlauf einer atypischen nodulärsklerosierenden Lymphogranulomatose mit intestinaler Polyposis bei einer 62jährigen Frau.

The etiology of a diarrhoea is in most of the cases a bacterial or viral infection or of allergic origin. In some cases histopathologic alterations of the gut like carcinomas or systemic involvement in other malignancies can lead to similar clinical symptoms.

Impact of long-term hemodialysis on nutritional status in patients with end-stage renal failure.

We evaluated the way in which duration of hemodialysis treatment affects nutritional status in 96 end-stage renal failure patients. According to the length of previous hemodialysis treatment patients were divided into the groups: onset hemodialysis (ON-HD), early-stage hemodialysis (ES-HD, 1-8 months), mid-stage hemodialysis (MS-HD, 9-69 months), and advanced-stage hemodialysis (AS-HD, 70-207 months). Nutritional status was assessed by laboratory data (serum proteins, total lymphocyte count), intradermal skin antigen testing, anthropometric measurements (body mass index [BMI], infrared interactance), and records of food intake. ON-HD patients on a low-protein diet exhibited abnormally low values for serum total protein, albumin, transferrin, and total lymphocyte count and a high prevalence of anergy to skin antigens (69%). In the ES-HD and MS-HD groups values for serum proteins and total lymphocyte count were in the normal range and significantly higher than in ON-HD patients. In addition, a lower proportion of cutaneous anergy was observed (50% and 27%, respectively). Long-term hemodialysis therapy for 6-17 years (AS-HD) was associated with normal levels for all measured serum proteins. Subnormal levels of total lymphocyte count, significantly lower than in MS-HD patients, were associated with an increase in anergy to skin antigens (46%). Serum prealbumin, complement C3c, BMI, body fat, and lean body mass exhibited normal values in all patients and showed no differences between groups. These results indicate that diminished visceral protein stores, lymphopenia, and anergy to skin antigens are widespread in undialyzed uremic patients with end-stage renal failure but become uncommon after the initiation of regular hemodialysis therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Isolated unilateral otitis with facial nerve paralysis as initial symptom of Wegener granulomatosis. An unusual clinical course]. / Isolierte einseitige Otitis mit Fazialisparese als Erstsymptom bei Wegener-Granulomatose. Ein ungewöhnlicher klinischer Verlauf.

BACKGROUND: Wegener's granulomatosis is an immunepathogenic disease of unknown origin. The histopathological picture shows granulomatous inflammation with epitheloid cells, granulomas, and general vasculitis. The diagnosis of Wegener's granulomatosis is made on the basis of the clinical picture, serum cANCA, and histologic examination of biopsies. PATIENT: We present the case of a 57-year-old white male patient who was admitted to our ENT Hospital with a six weeks' history of otalgia and incomplete ipsilateral facial palsy since the day before admission. The patient had clinical features of acute otitis media without signs of mastoiditis. Despite a ten days' course of intravenous antibiotic treatment, the intensity of facial palsy progressed and the general condition of the patient worsened. A mastoidectomy and decompression of the facial nerve were performed, demonstrating sclerosis of the mastoid cells. Three weeks after release from the hospital, the patient was admitted again with recurrent fever, cephalea, loss of weight, and arthritic pain. There were no signs of recurrent otitis media or mastoiditis, and sigmoid sinus thrombosis was ruled out. Even under aggressive, intravenous antibiotic treatment the general physical condition continued to worsen; septic temperatures and signs of beginning renal failure occurred. The patient was transferred to the ICU with the diagnosis of sepsis of unknown origin. There bloodtests were positive for cANCA, which is highly specific for Wegener's granulomatosis. Under therapy with cyclophosphamide and i.v. corticosteroid, the patient recovered with 14 days. CONCLUSION: The lack of symptoms in the upper respiratory tract in our patient was unusual, indicating that in patients with recurrent otitis media, facial palsy, mastoiditis, or external otitis Wegener's granulomatosis should be ruled out as differential diagnosis.