[Polydipsia, increasing fatigue and a huge mediastinal tumor in a 49-year-old woman]. / Polydipsie, zunehmende Müdigkeit und große mediastinale Raumforderung bei einer 49-jährigen Patientin.

A 49-year-old woman presented with unspecific symptoms including polydipsia, increasing fatigue for several weeks, and vague abdominal pain. Serum calcium (5.30 mmol/l; normal range 2.00-2.60) and parathyroid hormone levels (> 2500.0 ng/l; normal range 15.0-68.0) were extremely elevated. Imaging studies showed a huge mediastinal tumor. Based on these findings a hypercalcemic crisis caused by primary hyperparathyroidism was diagnosed. After intensive care treatment and further diagnostic procedures, the patient's parathyroid adenoma was removed by parathyroidectomy. The postoperative course was uneventful.

Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life--a prospective study.

OBJECTIVES: To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks, and additional intervention modules to enhance nutritional education, to increase physical activity and to modify eating behavior. DESIGN: Prospective multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany. SUBJECTS: A total of 8296 participants with a body mass index (BMI) of >30 kg m(-2) included within 8.5 years. MEASUREMENTS: Main outcome measures were body weight loss, waist circumference (WC), blood pressure, quality of life and adverse events. RESULTS: In females, initial body weight was reduced after the 1-year-intervention by 19.6 kg (95% confidence intervals 19.2-19.9 kg) and in males by 26.0 kg (25.2-26.8) according to per protocol analysis of 4850 individuals. Intention-to-treat (ITT) analysis revealed a weight reduction of 15.2 kg (14.9-15.6) in females and 19.4 kg (18.7-20.1) in males. Overall, the intervention resulted in mean reduction in WC of 11 cm; it reduced the prevalence of the metabolic syndrome by 50% and the frequency of hypertension from 47 to 29% of all participants (ITT, all P<0.001). The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life. The incidence of adverse effects was low; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders. CONCLUSION: The present non-surgical intervention program is a highly effective treatment of obesity grades I-III and obesity-related diseases, and therefore, could be a valuable basis for future weight maintenance strategies required for sustained success.

Aplastic crisis as a complication of congenital dyserythropoietic anemia type II.

A transient aplastic crisis (TAC) is a well-known complication in all types of chronic hemolytic anemia but only 2 cases of such an event were described in congenital dyserythropoietic anemias (CDAs). Here, we report a third case, and by retrospective chart review of 78 cases we found evidence of TAC in 8 further patients with CDA II, with serological evidence of previous human parvovirus B19 (B19V) infection in all but one. Although B19V infection results in TAC in only a minority of patients with CDA, physicians responsible for these patients should be aware of such a potentially life-threatening complication. Testing for B19V-specific IgG is recommended in patients with CDA to estimate the risk of a possible future aplastic crisis.

[Successful treatment of obesity]. / So behandeln Sie die Adipositas erfolgreich. Schnellster Fettkiller ist die Formula-Diät.

Treating obesity can significantly reduce morbidity and mortality. Successful treatments comprise interdisciplinary long-term programs. The combined skills of physicians, psychologists, physiotherapists and dieticians are necessary to modify the patient's eating habits. With regard to dietetic measures, the combination of formula diets followed by reduction diets (CLD) has proved successful. Behavioral therapy in combination with professional physiotherapy can reduce the failure rate. In the event that dietetic measures fail, the medications sibutramine, orlistat and rimonabant are available.

Real-time ultrasound evaluation of renal transplant failure during the early postoperative period.

In a prospective clinical trial 385 ultrasound (US) examinations were performed on 50 renal allograft patients. Baseline sonograms were obtained within 24 hrs of transplantation, and serial US examinations were performed in two to three days intervals during hospital recovery. 24 out of 28 cases of acute rejections (85.7%) were detected by US with an 8% false positive rate. Using statistical analysis, enlarged and sonolucent pyramids, areas of decreased parenchymal echogenicity and an increase in anterior-posterior diameter of the organ, proved to be the best US-rejection criteria. Fine needle aspiration cytology revealed a high rate of false positive rejection diagnosis (23.8%). The results demonstrate that US is a valuable diagnostic aid in the evaluation of postoperative renal transplant failure.

Structured reporting of medical findings: evaluation of a system in gastroenterology.

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Occult gallbladder perforation: an unusual complication of gallstone lithotripsy.

Three days following extracorporeal shock-wave lithotripsy of a solitary, calcified gallstone, a 69-year-old white male patient was re-admitted with E. coli sepsis and fever of up to 39.4 degrees C. Ultrasound and CT both revealed a smooth-rimmed hypodense paravasate in the middle portion of the left liver lobe adjacent to the gallbladder, with a density identical to gallbladder fluid. The evidence for perforation was based on CT scanning, and a diagnosis of occult gallbladder perforation was made. Conservative treatment was performed successfully. Following elective cholecystectomy two months thereafter, gallbladder histology showed signs of chronic cholecystitis and E. coli was isolated in bile cultures. The paravasate had granulated and finally cicatrized. By combining ESWL and chemical dissolution, treatment of multiple, calcified and pigment gallstones is possible and this approach has become an attractive alternative therapy modality for a selected group of gallstone patients. Further assessments of the efficacy and safety of this technique are necessary. Conservative treatment of occult gallbladder perforation is possible and should be performed in high-risk patients.

Solitary versus multiple gallstones: the importance of total biliary protein concentration and other factors.

BACKGROUND: Nucleating and antinucleating factors play an important role in the pathogenesis of cholesterol crystal nucleation. PATIENTS AND METHODS: In 88 gallstone patients (59 female, 29 male) bile was examined for total biliary protein and glycoprotein concentration, nucleation time and cholesterol saturation index. Gallstone density was measured by in vivo computed tomography. RESULTS: Total biliary protein concentration was positively correlated with the number of gallstones (r = 0.84, p < 0.01) and higher in radiologically detectable isodense gallstones as compared to non-isodense stones (p < 0.01). A negative correlation between total biliary protein concentration, glycoprotein concentration and nucleation time was observed (r = -0.45, p < 0.01 and r = -0.49, p < 0.05). Nucleation time was significantly shorter in the case of multiple versus solitary stones (2.6 +/- 1.3 versus 8.5 +/- 3.0 days, p < 0.01). Cholesterol saturation index and biliary cholesterol concentration were similar in both cases, however a negative correlation between cholesterol saturation index and stone density (r = -0.79, p < 0.01) was found. No correlation was found between cholesterol saturation index and nucleation time (r = -0.04, p > 0.1), independent of gallstone number. None of the examined parameters was related to sex, age, weight or gallbladder function. CONCLUSIONS: Multiple gallbladder stones seem to be associated with shorter nucleation time and higher biliary concentrations of total protein and glycoprotein than solitary stones.

American Indian law on child abuse and neglect.

A wide variety of American Indian tribal codes on child abuse and neglect are currently in effect. They range from anachronistic codes that were promulgated about fifty years ago and have never been revised to recently enacted codes that are innovative and incorporate the best practices in the field of protective services. The efforts, now underway, to collect and analyze Indian tribal codes on child abuse and neglect is supportive of the national interest to improve Indian child welfare services. The knowledge gained will be helpful to Indian tribes as they assess their own codes and will provide a new body of information on the laws in the U.S. on child abuse and neglect. In the past few years, increased national support in the United States has been focused on the protection of the best interest of Indian children with specific resources provided for the support of local Indian children and family programs operated by Indian tribal governments. Many Indian tribes are using these resources to develop and revise their child welfare codes, including those elements pertaining to child abuse and neglect. The momentum under way in the United States to improve Indian child welfare services can be expected to continue to include developments in Indian tribal codes on child abuse and neglect.

Influence of increased fibre intake on biliary lipids.

Influence of increased fibre intake on biliary lipids. The influence of dietary fibres (30 g wheat bran per day) on the lithogenicity of the bile was studied in ten healthy persons, whose body weight was 76.8 +/- 2.3 kg, height 189.9 +/- 2.1 cm, age 25.5 +/- 0.26 years. These 10 young male volunteers were given twice daily 15 g wheat bran additionally for six weeks in addition to their normal diet. The bile was obtained endoscopically prepapillarily following stimulation of the gallbladder with ceruletid. The contraction of the gallbladder was controlled sonographically. Increased dietary fibre intake resulted in significant lowering of cholesterol concentration in the bile from 3.27 +/- 0.89 mmol/1 to 2.50 +/- 0.67 mmol/1. The lithogenic index (Admirand and Small, 1968) decreased statistically significant from 1.01 +/- 0.14 to 0.67 +/- 0.11. Total cholesterol and HDL and LDL cholesterol remained unchanged; likewise, there was no change in serum triglyceride and phospholipid concentrations. Hence, an increased intake of dietary fibres of the wheat bran type should be the first dietary measure in both prevention and treatment of cholesterol gallstone disease.

[Significance of nutrition in obesity]. / Stellenwert der Ernährung bei Adipositas.

The goal of good concepts for treating obesity is to achieve sustained changes in lifestyle. Formula diets are in fact superior to hypocaloric diets, but the results of diet only approaches are consistently disappointing. Formula diets or very low calorie diets should thus be undertaken in conjunction with an overall therapeutic concept under a physician's supervision together with psychological and nutritional education as well as guidance in exercise therapy. These treatment strategies can be carried out successfully in the outpatient setting. On a long-term basis, reducing the costs of health care will only be feasible by implementing prevention programs during childhood and adolescence. Preventive measures focusing on nutrition should lay the foundation in kindergartens and schools to control the epidemic-like spread of obesity.

[Significance of the gallbladder in the regulation of duodenogastric reflux]. / Bedeutung der Gallenblase in der Regulation des duodenogastralen Refluxes.

Interdigestive motility of the gallbladder the duodenum and the antrum is coordinated by cyclic motor activity or the interdigestive myoelectric complex. Cholecystokinin and parasympathetic stimulation are regulating digestive and interdigestive contractility of the gallbladder. Duodenogastric reflux often can be found in patients with disturbances of gallbladder motility, e.g. cholecystolithiasis, post cholecystectomy and in patients with patholoc cyclic motor activity e.g. ulcer of the stomach or the duodenum. A strong correlation is not yet proven between duodenogastric reflux and gastritis or ulcer.

[Dietary treatment following gastrectomy]. / Diätetische Behandlung nach Gastrektomie.

A number of nutritional complications occur after total gastrectomy, such as protein malnutrition, dumping syndrome, diarrhoea, weight loss, iron deficiency and osteomalacia. Lack of appetite, absence of the sensation of hunger, oesophagitis, dysphagia and the limited capacity for food in most cases are the causes of suboptimal dietary intake after total gastrectomy. To avoid underweight and symptoms after gastrectomy it is necessary that all patients are seen soon after operation and at regular intervals thereafter not only by physicians but by dietitians additionally.

[Reliable diagnosis of obesity]. / Sinnvolle Diagnostik der Adipositas.

Uniform definition and classification are required premises for the diagnosis of obesity. The indication for treatment of obesity is based on exact diagnostic procedures. This paper will critically discuss clinical and biochemical approaches to the diagnosis of obesity.

[Drug therapy of obesity]. / Medikamentöse Therapie der Adipositas.

This review is dealing with currently available medications used in the treatment of obesity. Unfortunately currently available drugs did not prove effective in the long term treatment of obese patients. Fenfluramin and D-Fenfluramin has been withdrawn from the market because of severe side effects as pulmonary hypertension and valvular heart disease. Sibutramin, a serotonin noradrenalin reuptake inhibitor, will be available this year. Orlistat, an inhibitor of pancreatic lipases, has proven effective for weight reduction in obese patients. New drugs as alpha 2-adrenergic antagonists, cholecystokinin, neuropeptide y, bombesin and leptin are in the pipeline.