[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.

[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.

Anti-amiodarone antibodies: detection and relationship to the development of side effects.

PURPOSE: It has become evident in the past few years that amiodarone, a powerful antiarrhythmic agent, induces considerable side effects. These may be due to an amiodarone-elicited lipid storage disease and to the iodine content of amiodarone, but might also be causally related to amiodarone-induced immune reactions. The latter possibility prompted us to develop a sensitive anti-amiodarone antibody detection assay based on the immunodot technique. PATIENTS AND METHODS: Sera were obtained from 10 untreated control subjects and 33 patients receiving amiodarone. Using serum dilutions of 1:500 and 1:1,000, the lower detection limit was 0.3 microgram/ml of anti-amiodarone antibodies as calculated from a simultaneously performed IgG standard curve. RESULTS: Screening of sera from the untreated control subjects and amiodarone-treated patients revealed that the untreated subjects had no anti-amiodarone antibodies, that only one of 16 patients without clinical side effects had elevated anti-amiodarone antibodies, but that seven of 12 patients with amiodarone-induced thyroid disease and four of five patients with other side effects had elevated anti-amiodarone antibody titers (1.2 to 2.5 micrograms/ml). The combined evaluation of anti-amiodarone antibody titers and cumulative dose was found to be a highly reliable indicator of side effects, as all patients with more than 100-g cumulative dose of amiodarone and more than 0.6 microgram/ml of anti-amiodarone antibodies had side effects. CONCLUSION: The detection of anti-amiodarone antibodies in patients with amiodarone-elicited side effects underscores the possible contribution of immunologic reactions to the development of certain side effects.

The effects of amiodarone on the electrocardiogram of the guinea-pig are not explained by interaction with thyroid hormone metabolism alone.

The iodine-containing contrast medium iopanoic acid induces alterations of thyroid hormone metabolism comparable to those observed with the iodine-containing antiarrhythmic drug amiodarone. Both compounds inhibit the intracellular conversion of thyroxine (T4) to triiodothyronine (T3). Using iopanoic acid, the question was investigated, in guinea-pigs, whether inhibition of T4----T3 conversion is by itself associated with the same changes in the electrocardiogram, i.e. QT prolongation and bradycardia, as those observed during amiodarone treatment. At a dose of 4 g kg-1, iopanoic acid induced maximal inhibition of the T4----T3 conversion. Although these changes were even more pronounced than those in a control group of animals treated with 2.12 g amiodarone kg-1, neither prolongation of the QT nor a slowing of the heart rate was observed. QT prolongation and bradycardia were induced only by amiodarone treatment but not by iopanoic acid. Iopanoic acid at the high toxic dose of 12 g kg-1 induced the same degree of inhibition of T4----T3 conversion as the 4 g kg-1 dose. QT prolongation and slowing of the heart rate were apparent at this dose in parallel with a loss of weight. It is concluded that even a maximal inhibition of the T4----T3 conversion has no effect on the ECG of guinea-pigs. The inhibition of the T4----T3 conversion alone does not explain the QT prolongation and bradycardia observed with amiodarone treatment. The amiodarone effects on the ECG may represent a combination of interactions with thyroid hormones and antiadrenergic activity.

Interactions of amiodarone with digoxin in rats.

1. The influence of oral amiodarone treatment on the blood and tissue concentrations of digoxin was investigated in the anaesthetized rat by use of unlabelled and [3H]-digoxin. 2. Amiodarone diminished the total body clearance and the apparent volume of digoxin distribution by 60%. This reduction was due to a 50% reduction of the hepatobiliary clearance, whereas the renal clearance did not change. 3. Amiodarone treatment increased blood, myocardial and skeletal muscle [3H]-digoxin concentrations by 200% indicating passive equilibration between blood and these tissues, and resulting in unaltered tissue to blood ratios. In contrast, the liver concentration increased by 70% only and the liver to blood ratio therefore decreased under amiodarone treatment. 4. It is concluded that the hepatobiliary elimination of digoxin is decreased in amiodarone-treated rats compared to controls and is responsible for the increased levels of blood and tissue glycoside.

Does amiodarone affect heart rate by inhibiting the intracellular generation of triiodothyronine from thyroxine?

The hypothesis that the antiarrhythmic drug amiodarone slows down the heart rate by its inhibitory action on the intracellular conversion of thyroxine (T4) to 3,5,3' triiodothyronine (T3) was investigated. For this purpose we compared the effect of amiodarone with that of another potent inhibitor of the T4----T3 conversion, i.e. the radiographic contrast medium iopanoic acid, on the heart rate of unanaesthetized guinea-pigs. Both amiodarone and, to an even greater extent, iopanoic acid induced an increase in serum 3.5',3' triiodothyronine (reverse T3), indicating effective inhibition of T4----T3 conversion. Both amiodarone and iopanoic acid were accumulated in the liver and in the heart (measured as iodine). While amiodarone induced bradycardia, iopanoic acid did not change the heart rate. Supraphysiological amounts of exogenous T3 reverted the amiodarone induced bradycardia to near normal values. A comparable effect was observed with isoprenaline. The intracellular inhibition of the T4----T3 conversion is not the ultimate mode of the action of the amiodarone effect on heart rate. It is thought that amiodarone interacts with T3 at its receptor or somewhere later along the pathway from the T3-receptor interaction to the final effect of T3 on heart rate.

Low plasma concentrations of ionized calcium in patients with asthma.

It has been suggested that calcium homeostasis is abnormal in the vascular smooth muscle of hypertensive patients and in the bronchial smooth muscle in asthmatics. We have found the mean baseline concentration of plasma ionized calcium to be significantly lower both in 12 asthmatics with exercise-induced asthma (EIA) [1.16 +/- 0.01 (SE) mmol/l, P less than 0.001] and in 20 asthmatics without EIA (1.16 +/- 0.01; P less than 0.001) compared with 42 healthy subjects (1.24 +/- 0.01). The mean concentrations of plasma ionized calcium were not significantly different in asthmatics with and without EIA when measured either before treadmill exercise, during the last seconds of this exercise, or 10 or 20 min after exercise but were significantly lower than in another seven healthy subjects who undertook the same exercise protocol. Total plasma calcium concentrations in the three exercising groups were not significantly different at any point in time. The results suggest that in bronchial asthma an alteration of calcium metabolism may be important, but they also suggest that there is no simple relationship between the plasma ionized calcium concentration and acute exercise-induced bronchoconstriction.

Plasma volume and proteins in voluntary hyperventilation.

In a controlled study the changes of the plasma volume and plasma proteins induced by voluntary hyperventilation (HV) were investigated in nine splenectomized volunteers. The plasma volume changes were calculated from the changes of the hemoglobin and hematocrit. After 20 min of HV in supine position, which lead to a decrease of the venous CO2 partial pressure by 19 Torr and to an increase of plasma epinephrine and norepinephrine levels, the plasma volume was reduced by 12.9%. The intravascular masses of total protein, albumin, and several other proteins decreased during HV but a similar decrease of these proteins was also observed during the control study (C), i.e., rest in supine position without HV. The differences between changes during HV and C were not significant, indicating that the loss of protein was not due to HV. It is concluded that acute HV leads to a rapidly reversible loss of a virtually protein-free solution from the vascular space. The red cell compartment participated in fluid shifts in that the mean red cell volume decreased by 2.2% (P less than 0.02 compared with C). Comparison with earlier work shows that addition of erythrocytes from the normal spleen does not play a part in the HV-induced increase of hemoglobin and hematocrit.

Hyperventilation-induced changes of the blood picture.

In a controlled study of 11 male volunteers the following changes (means +/- SD) were observed in venous blood during (D) and 75 min after (A) a period of 20 min of voluntary hyperventilation in comparison with before (B) hyperventilation (P values referring to the difference between D and B) erythrocyte count 5.18 +/- 0.17 X 10(6) (B), 5.70 +/- 0.21 X 10(6) (D) (P less than 0.001), and 5.18 +/- 0.16 X 10(6)/microliter (A); hemoglobin 15.7 +/- 0.6 (B), 17.2 +/- 0.7 (D) (P less than 0.001), and 15.8 +/- 0.6 g/dl (A); centrifuged hematocrit 46.6 +/- 1.0 (B), 50.4 +/- 1.7 (D) (P less than 0.001), and 47.0 +/- 1.8% (A). The platelets increased from 159 +/- 30 X 10(3) (B) to 205 +/- 40 X 10(3) (D) (P less than 0.001) and returned to 157 +/- 26 X 10(3)/microliter (A). The leukocytes (WBC) were 4,210 +/- 630 (B), 6,220 +/- 1,660 (D) (P less than 0.001), and 6,190 +/- 1,870/microliter (A) (P less than 0.002, as compared with B). The rise of WBC during hyperventilation was mainly due to a 83% increase of lymphocytes, whereas a 93% increase of neutrophil leukocytes accounted for the increased WBC 75 min posthyperventilation. The increase of the ratio of band forms to segmented neutrophils from 9 (B) to 19% (A) (P less than 0.01) indicates that band forms were released from the bone marrow. The results show that WBC and platelets can be mobilized by hyperventilation by as yet unidentified mechanisms.

Erythrocyte adenosine triphosphate depletion during voluntary hyperventilation.

Chronic hypophosphatemia in humans is associated with a slow depletion of adenosine triphosphate (ATP) and 2,3-diphosphoglycerate (2,3-DPG) in erythrocytes, combined with shape alteration, impaired deformability, and viability of the cells. Likewise, incubation of erythrocytes in alkaline solution is associated with ATP depletion. Since in hyperventilation both hypophosphatemia and alkalosis are present, we have investigated red cell organic phosphates, shape, deformability, and osmotic fragility before, during, and after 20 min of voluntary hyperventilation. On the average, red cell ATP decreased by 42%, the blood pH increased by 0.2 units, and plasma inorganic phosphorus decreased by 46% compared with the initial values. Red cell 2,3-DPG, shape, deformability, and osmotic fragility remained unchanged. After the end of hyperventilation ATP increased rapidly to control values in parallel with the normalization of the blood pH, whereas inorganic plasma phosphorus remained at the low level observed during hyperventilation. It is concluded that the combined effects of hypophosphatemia and alkalosis in acute hyperventilation lead to an isolated fall of red cell ATP, which occurs as rapid as after total inhibition of red cell glycolysis in vitro.

Creatine kinase and MB-fraction after a long distance race.

In 18 well-trained athletes creatine kinase (CK) and the CK-MB isoenzyme were measured immediately after a 100 km race and 10 days later for control purposes. The CK was 1970 +/- 1505 U/l (mean +/- SD, range 481--5558 U/l) after the race and 50 +/- 23 U/l on the control day (p less than 0.001). The CK-MB fraction was 72 +/- 70 U/l (range 14--228 U/l) and 8.6 +/- 2.3 U/l (p less than 0.01). The ratio CK-MB/CK was 3.4 +/- 1.1% and never exceeded 6%. The study indicates that elevated CK and CK-MB are a common finding after a long distance race. CK-MB/CK ratios up to 6% may be observed.

Myocardial infarction during a football game: empiric estimation of the contribution of skeletal muscle damage to the serum creatine kinase activity.

A 40-year-old untrained participant of a competitive football game experienced chest pain after 20 minutes of playing time. An acute anterior myocardial infarction was diagnosed by electrocardiographic criteria and the creatine kinase rose to its maximum of 3900 U/l (normal range less than 125 U/l) by 24 h with a CK-MB fraction of 6.1%. In order to estimate the contribution of skeletal muscular work to CK activity, the course of CK activity was prospectively measured in 11 untrained participants of a competitive football game, who had normal electrocardiographic findings on exercise testing. Individual peak values of CK correlated positively (p less than 0.01) with the time spent in play. Based on this observation we could estimate that, at most, 14% of the total CK was contributed by skeletal muscle damage in our patient. When total CK was elevated above 125 U/l, the percentage of CK-MB activity did not exceed 6% of total CK in any case. 3-methylhistidine, methylhistidine, an indicator of contractile protein turnover and creatinine were prospectively determined in spot urine samples before the game and for up to 48 h after the game. 3-methylhistidine/creatinine ratios did not change from baseline after the game and no correlation with CK was found. Urine 3-methylhistidine/creatinine, measured within 48 h after a football game, does not contribute to the quantification of skeletal muscle damage.

The influence of L-sorbose on red cell flow properties, shape and packing ability.

Since the sweet ketohexose L-sorbose causes overt hemolysis in dogs but not in man, we examined the possibility that L-sorbose induces a "prehemolytic state" of human red cells, manifesting itself as impairment of rheological red cell properties. After 2 hours incubation at 37 degrees C relative viscosity of red cell suspensions measured by radial spreading in filter paper and packing ability of red cells were normal. Incubation for 24 and 48 hours of red cells in media containing L-sorbose, glucose or no sugar showed that relative viscosity was best maintained in glucose. Relative viscosity and packing ability of red cells in L-sorbose containing suspensions decreased less than in suspensions without sugar. This difference was independent of the glucose metabolism, red cell ATP, osmolality and pH of the suspending media, but appeared to be related to different degrees of spheroechinocytic red cell shape transformation observed in different suspending media. It is possible that L-sorbose has some antiechinocytic properties and/or that it induces an alteration of red cell membrane flexibility. There is no indication of an L-sorbose induced "prehemolytic state" in human red cells.

[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.

[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.

[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.

[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.

[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.