[Psychofonia--a neurophysiologic music therapy in migraine]. / Psychofonie--eine neurophysiologische Klangtherapie bei Migräne.

Migraine and other functional disorders are common and often difficult to treat. Alternative treatment modalities are clearly warranted and gain more widespread acceptance. Psychofonia is a new form of music therapy for treating migraine patients. For each patient an individualized sound pattern is created based on his individual EEG by using computer technology. In a cohort study we investigated prospectively 55 migraine patients treated with this EEG-based music therapy. 56% of the patients showed an improvement of at least 50% of their symptoms after a twelve months treatment period. Our results suggest that this form of music therapy is effective in treating migraine patients and should be studied in a prospective, randomized, controlled trial.

Initial treatment of sepsis in non-neutropenic patients: ceftazidime alone versus 'best guess' combined antibiotic therapy.

We conducted a prospective, randomized, multicentric study in community hospitals. Patients with clinical sepsis, rectal temperature > or = 38 degrees C and pulse rate > or = 100 bpm were randomized to receive ceftazidime (group CAZ) or a combination of antibiotics freely chosen by the clinician following his 'best guess' (group COMB). On specified grounds, the clinician could also treat patients in an open group with a free combination of antibiotics (group OPEN). The severity of disease at study admission was assessed by a clinical estimation and an Apache II score. There were 128 patients included: 56 randomized in group CAZ, 50 in group COMB, and 22 in the OPEN group. Ninety-one patients were evaluable: 41 in group CAZ, 30 in group COMB, 20 in OPEN group. At the end of the period of empirical treatment (48-72 h), the clinical success rates (improvement of status) were 93, 93 and 75% (p for group OPEN vs. groups CAZ or COMB: 0.10). The bacteriological success rates (sterile blood cultures) were 91, 88 and 80% (p not significant). mean Apache II score was 16.7 and the score correlated significantly with outcome, as did clinical evaluation. In conclusion, ceftazidime alone was a safe antibiotic therapy in this study and we could not demonstrate a superiority of a combined antibiotic therapy chosen by the clinician following his 'best guess' over ceftazidime.

Efficacy and tolerability of 5 mg of cilazapril plus 12.5 mg of hydrochlorothiazide in mild-to-moderate hypertension: results of 24-hour ambulatory blood pressure monitoring.

The efficacy and tolerability of a fixed combination of 5 mg of cilazapril and 12.5 mg of hydrochlorothiazide against hypertension was evaluated in 36 patients (26 men and 10 women) between 33-68 years old. Twenty-two had newly diagnosed hypertension and 14 had previously treated hypertension. Twenty-four-hour noninvasive ambulatory blood pressure monitoring (ABPM) was performed after a 2-week washout period. Measurements were taken at 20-min intervals during the day (from 8 a.m. to 10 p.m.) and at 30-min intervals during the night (from 10 p.m. to 8 a.m.). Patients with a mean diastolic daytime pressure of > or = 90 < 115 mg Hg were then given 5 mg of cilazapril plus 12.5 mg of hydrochlorothiazide once daily between 6 a.m. and 8 a.m. for 6 weeks. After this period, a second 24-h ABPM was performed. Office blood pressure measurements were taken at weeks -2, 0, 2, and 6. Routine laboratory blood samples were taken at weeks 0 and 6. Single blood pressure readings did not change significantly during the washout period (between weeks -2 and 0). The ABPM 24-h mean systolic pressure changed between weeks 0-6 from 143 +/- 13 to 126 +/- 11 mm Hg (p < 0.0001), and the mean diastolic pressure from 100 +/- 9 to 90 +/- 9 mm Hg (p < 0.0001). Twenty-eight patients (80) responded to treatment (response criteria: mean diastolic daytime pressure at week 6 < 90 mm Hg and/or a difference between weeks 0-6 > or = 5 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastrointestinal hemorrhage: how much evaluation is necessary?]. / Gastrointestinale Blutung: Wieviel Abklärung braucht es?

For this study data from a total of 362 patients covering a time period of 10 years (1979-1989) were analyzed. Referal to the medical outpatient clinic of Zurich occurred in over 90% of the cases for evaluation of incidental iron deficiency anemia or suspected of gastrointestinal bleeding because of melanea/hematemesis. The evaluation comprised endoscopy, in part radiography of the upper intestinal tract and rarely angiography and scintigraphic tracer studies. 95 patients (26%) had benign lesions in the gastro-intestinal tract, 88 patients (26%) had endoscopy without abnormal findings. Iron deficiency was thought to be due to hypermenorrhea in 45 patients (13%) and to other non-gastrointestinal causes in 43 patients (13%) by exclusion. A malignancy of the gastrointestinal tract was found in 25 patients (7%): 18 carcinomas of the colon, 6 carcinomas of the stomach and 1 metastasis of a melanoma to the coecum. In 80% of the patients with malignancies occult fecal blood was detected. In 154 patients (42%) extensive diagnostic investigation including sometimes even repeated endoscopy could not disclose the cause of blood loss. 88 (24%) of these patients had slight iron deficiencies (hemoglobin > 10 g/dl, hemoccult-test positive in 65% of cases), 66 (18%) had severe iron-deficiencies (hemoglobin < 10 g/dl, hemoccult-test positive in 90% of cases). Selective small bowel radiography was performed in 36 patients without any positive findings. Patients with gastro-intestinal bleeding of undetermined etiology present a diagnostic challenge for the general practitioner.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reversible spinal cord compression caused by extramedullary hematopoietic foci in thalassemia]. / Reversible Rückenmarkskompression durch extramedulläre Blutbildungsherde bei Thalassämie.

A now 42-year-old Thai woman was known to have been anaemic since childhood. When aged 33 years she was diagnosed as having beta zero/HBE thalassaemia. Computed tomography demonstrated a tumour in the posterior mediastinum, histologically found to be an extramedullary haematopoietic focus. Subcutaneous infusion of deferoxamine (2 g five times weekly), initiated because of massive iron overload, reduced the serum ferritin level from 3,460 ng/ml to less than 500 ng/ml. The haemoglobin level in the subsequent years was between 6 and 8 g/dl. Five years later sensory deficits were noted from the 5th thoracic vertebra downwards. Magnetic resonance imaging demonstrated a tumour which compressed the spinal cord: it, too, was an ectopic haematopoietic focus. The neurological symptoms disappeared after radiotherapy with 3,000 cGy, but they recurred 4 years later. Because of the low radiation reserve of the spinal cord, hypertransfusion treatment was initiated, namely 16 RBC concentrates within 4 months and afterwards two transfusions every 3 months. By this means the haemoglobin level was kept at about 9 g/dl. The tumour had regressed 4 months after onset of treatment. For 2 years since the beginning of the hypertransfusion treatment the patient has remained free of neurological symptoms.

[The "sarcoidosis-lymphoma syndrome"--a lymphocyte dysregulation?]. / Das "Sarkoidose-Lymphom-Syndrome"--Eine Lymphozyten-Fehlregulation?

Sarcoidosis and malignant lymphoma can occur in the same patient; sarcoidosis appears first, the malignant lymphoma follows later. The case histories of three patients illustrate what Brinker first coined as the "sarcoidosis-lymphoma syndrome". In two patients a pulmonary sarcoidosis stage I was diagnosed over 30 years respectively 4 years prior to the histological diagnosis of highly malignant Non-Hodgkin lymphoma. The third patient suffered from generalized sarcoidosis with splenomegaly, , granulomatous hepatitis and interstitial lung disease, in addition to which a lymphoproliferative syndrome was diagnosed. Comparing the pathogenesis of malignant lymphoma and sarcoidosis, parallels such as T-cell dysfunction, which probably facilitates malignant transformation of B-cells, become apparent. In both diseases the transforming gene could be the Ebstein-Barr virus.

[Suspicion of anemia-inducing gastrointestinal bleeding: how far should assessment go?]. / Verdacht auf anämisierende gastrointestinale Blutung: Wieviel Abklärung braucht es?

In a retrospective evaluation of 362 patients with iron deficiency anemia or visible blood loss from the gastrointestinal tract (hematemesis or melena), the bleeding source could not be found in 18% of cases (66 patients) even by extensive gastrointestinal endoscopy. In these cases neither small bowel studies nor repetitive endoscopic examinations increased the diagnostic yield. On the other hand, gastrointestinal endoscopy resulted in the diagnosis of gastrointestinal malignancy in 25 cases, most of whom could be resected curatively. The fecal occult-blood test was positive in 85% of the cancer patients, indicating the usefulness of this test as a diagnostic tool. If the bleeding source remains obscure in spite of extensive gastrointestinal endoscopy and gastrointestinal malignancy has been excluded, further investigation by small bowel studies or angiography is unrewarding and only indicated in selected cases.

[Histiocytosis X. Clinical aspects and course in 5 patients]. / Histiocytosis X. Klinik und Verlauf bei fünf Patienten.

Histiocytosis X developed in five patients (one woman and four men) when aged between 15 and 44 years. The initial sign in four of them was eosinophilic granuloma of the bone, in one it was pulmonary involvement. In three patients the disease remained confined to bone, while in two it involved the lungs and central nervous system, respectively. Osteolysis regressed spontaneously in one of the men, while in the woman there has been no recurrence 8 years after resection of the focus. In another man an osteolytic focus in a rib was noted after a 9-year recurrence-free interval. The man with pulmonary and bone involvement received chemotherapy with vinblastine and prednisone: dyspnoea and cough disappeared, vital capacity improved and the interstitial lung changes regressed. The osteolytic foci were repeatedly irradiated in the man with bone and CNS involvement. This brought about considerable reduction in pain but no significant radiological changes of the foci. Two courses of chemotherapy were given over 12 years, once with vincristine and prednisone, afterwards with cyclophosphamide. This arrested the progression of the osteolytic foci, but each time they recurred when the drugs were stopped.

[Malignant lymphoma: a study of an outpatient cohort]. / Das maligne Lymphom: eine Studie an einem poliklinischen Krankengut.

Data from 168 patients with malignant lymphoma were collected. 57 had Hodgkin's disease, 76 suffered from non Hodgkin's lymphoma and 35 presented with chronic lymphocytic leukemia. All patients were treated between January 1980 and December 1986 at the medical policlinic of the university of Zurich either as in- or outpatients. Presentation at the time of diagnosis, therapeutic regimen and treatment success as well as prognostic features of disease were evaluated. Overall the therapeutic results in this patient cohort were good and comparable with the results of large prospective studies. Complete remission rate (CRR) was 91% and overall survival rate (OSR) after 5 years was 72% for Hodgkin's disease. In Non Hodgkin's lymphoma of low malignancy OSR was 60% after 5 years and 39% in NHL of intermediate or high malignancy. In NHL CRR varied according to histologic subtype. In Hodgkin's disease staging according to the Ann Arbor classification and extranodal involvement including the spleen proved meaningful for prognosis. In NHL the international working formulation (IWF) was a useful prognostic tool. Anemias, higher age and relapses carried a poorer prognosis whereas induction of remission was a favorable prognostic sign. For chronic lymphocytic leukemia staging according to Binet was found a useful prognostic criterion.

[Nosebleed, vision disorders]. / Nasenbluten, Sehstörungen.

A 79-year-old man had repeated episodes of nose bleeding, disturbances of vision and anemia. Elevated WBC and lymphocytosis suggested chronic lymphatic leukemia. Serum electrophoresis revealed IgM paraproteinemia. The disease progressed rapidly under appropriate therapy. An autopsy revealed NHL of the lymphoplasmocytoid type (IWF: A--LP-immunocytoma), a NHL carrying a slightly poorer prognosis than classical chronic lymphatic leukemia.

[Combined GM-CSF and erythropoietin therapy in myelodysplastic syndrome]. / Kombinierte GM-CSF- und Erythropoietintherapie bei myelodysplastischem Syndrom.

A 60-year-old patient with a myelodysplastic syndrome (MDS) corresponding to refractory anemia with an increase in blast cells (RAEB) was treated with granulocyte-macrophage colony stimulating factor (GM-CSF) and erythropoietin (EPO) for severe symptomatic pancytopenia. During the GM-CSF treatment a distinct increase in granulocytes was observed, but the reticulocytes and thrombocytes decreased to the point where treatment had to be discontinued after eight days. After subsequent treatment with EPO the reticulocyte count rose from 0% to 2%. However, this rise alone was insufficient to decrease the number of blood transfusions required. The thrombocyte count rose to the original values after the cessation of GM-CSF therapy while continuing treatment with EPO. Bone marrow investigations were performed before and after GM-CSF treatment and indicated a distinct increase in the myeloid precursor cells after therapy, without an increase in blasts. On the other hand, an obvious decrease in erythro- and megakaryopoiesis was observed.

[A gene probe test for serum RNA proteolipid in neoplasia]. / Ein Gensondentest für RNA-Proteolipid in Serumproben bei Neoplasie.

We describe for the first time the specific determination of a tumor associated nucleic acid found in 50 of 57 sera from cancer patients. The novel tumor marker "RNA-proteolipid" described by us contains an mRNA of about 10 kilobases. We have established a test to determine this RNA by hybridization. A cDNA was obtained by reversed transcription from RNA using serum from a patient with Hodgkin's lymphoma. The cDNA was then ligated into a M13 phage and cloned in Escherichia coli. The phage DNA was sulfonated chemically and hybridized to RNA from neoplastic sera which was immobilized on nylon. The bound DNA was detected by an immunoassay.

[Serum erythropoietin levels: a new diagnostic tool?]. / Serumerythropoietinwerte: ein neues diagnostisches Hilfsmittel?

The development of highly specific antibodies against recombinant human erythropoietin (EPO) has recently made the accurate radioimmunological measurement of serum levels of this hormone possible. In this study we determined the serum-EPO levels in 100 healthy volunteers, in 54 patients suffering from polycythemia vera and in 51 patients with secondary polyglobulia. The mean levels for the healthy group were found to be 11.3 +/- 3.4 mU/ml in females and 8.0 +/- 3.2 mU/ml in males. Patients with polycythemia vera had serum-EPO levels of 4.3 mU/ml, while those with secondary polyglobulia had significantly higher levels averaging 30.3 mU/ml (p less than 0.0001). However, an overlapping of serum-EPO values in the range between 10 and 20 mU/ml occasionally occurs. Our results show that measurement of the serum-EPO level can be useful in the differential diagnosis of polyglobulias. Additionally, sequential EPO level measurements after phlebotomy and after hemorrhage show a pronounced increase in serum-EPO in secondary polyglobulia, while in polycythemia vera the level only increases slightly.

[Dyspnea, cough, febrile state]. / Dyspnoe, Husten, Status febrilis.

A 71-year old man was admitted because of increasing dyspnea and fever. Myelomonocytic leukemia was diagnosed on blood films. Diffuse bilateral pulmonary infiltrates detected on chest radiographs were related to the febrile state. Because leukemic infiltrates as well as pneumonia were possible causes for the pulmonary lesions antibiotic therapy followed by prednisone on the same day was initiated. An unusually rapid improvement of the pulmonary infiltrates within 4 days was indicative of a leukemic infiltrate. The patient died a few days later and the diagnosis of diffuse leukemic pulmonary infiltrates was confirmed at autopsy.

[Serum erythropoietin levels in several diseases]. / Serumerythropoietinwerte bei verschiedenen Krankheitszuständen.

The accurate radioimmunological measurement of serum erythropoietin (EPO) levels has only been possible since the development of highly specific antibodies directed against recombinant human EPO. In the present study, we determined the serum EPO levels in 100 healthy volunteers and in over 300 patients with anemias and hyperglobulinemia of various causes. In the healthy group, the females had levels of 11.3 +/- 3.4 mU/ml, while the males had levels of 8 +/- 3.2 mU/ml. The serum EPO concentrations were inversely related to the degree of anemia in patients with nonrenal anemias, while predialysis patients with renal anemias showed only partially such a tendency. Hemodialysis patients exhibited EPO-levels that were inadequately low relative to the degree of anemia. Patients with hyperglobulinemia had significantly higher serum EPO-levels than healthy individuals and polycythemia vera patients, the latter having particularly low serum EPO levels. Our results show that the determination of serum EPO levels can be of value in the differential diagnosis of hyperglobulinemia. Finally, sequential measurements document fluctuating serum EPO-levels after gastrointestinal hemorrhages and in patients with iron deficiency anemias receiving iron substitution. The probable reason for this phenomenon seems to be the intermittent utilisation of the hormone by EPO-sensitive erythropoietic precursor cells.

[Plasma cell leukemia]. / Plasmazelleukämie.

The following article describes five patients with plasma cell leukemia treated during the last two years at a Medical University Polyclinic. Plasma cell leukemia is a disease which was seen extremely rarely in the past. The disease can develop in patients with multiple myeloma or, even more rarely, as a "de novo" disease. Generally patients with plasma cell leukemia are younger than the multiple myeloma patients and have a higher incidence of organomegaly. Despite the fact that patients with plasma cell leukemia received the same intensive chemotherapy as those with multiple myeloma, their prognosis was considerably worse, with a median survival time of only five month.

[Polycythemia vera: clinical aspects and course in 86 patients]. / Polycythaemia vera: Klinik und Verlauf bei 86 Patienten.

We analyze symptoms, clinical course, and survival time of 86 patients with polycythemia vera treated between 1966 and 1987 at the medical polyclinic of the University Hospital of Zürich. The mean age of disease onset in 40 men and 46 women studied was 59 years. Most commonly the first symptoms were vertigo and headache (49%) and pain in the extremities (42%). Clinically, plethora was found in half of the cases and 56% showed signs of abnormal arterial and venous circulation. Two thirds of the patients had thromboembolic complications and 40% had hemorrhages chiefly occurring in the gastrointestinal tract. 48% of the patients died after an average survival time of 10 years. The most common cause of death (46%) was acute myelogenous leukemia, followed in 32% by thrombosis and/or embolism and in 7% by death due to hemorrhage. 18 of the 19 leukemia patients were treated with myelosuppressive agents. Patients treated with 32P showed a substantially higher incidence of malignancy than the group of patients not receiving 32P (p less than 0.001). The development of malignancies also seems to be related to the dosage of 32P. Patients who developed malignancies generally received higher doses of 32P (30 vs 20 mCi). Therefore, consistent phlebotomy therapy and restrictive chemotherapy combined with low dosage salicylates appears to be superior to 32P-therapy.

[Malignant lymphomas in HIV-infected patients]. / Maligne Lymphome bei HIV-infizierten Patienten.

Eleven patients with non-Hodgkin's lymphoma and three patients with Hodgkin's disease were observed among 876 anti-HIV-positive subjects attending the AIDS clinic at the University Hospital, Zurich, Switzerland. Compared to the general population this represents a 50-fold (95% confidence limits: 25-90) increased risk of non-Hodgkin's lymphoma and an 11.4-fold (2.3-33) increased risk for Hodgkin's disease in anti-HIV-positive men. High malignancy, advanced stage of disease at the time of diagnosis, and extranodal localization are characteristic of non-Hodgkin's lymphoma in AIDS patients, which carries a poor prognosis. However, remissions and prolonged disease-free survival are possible in individual cases. Only one opportunistic infection was observed during 92 months of treatment and observation using a mild chemotherapeutic regimen (m-BACOD). Less myelosuppressive chemotherapeutic schedules appear to be more beneficial than aggressive regimens in anti-HIV-positive patients due to the lower incidence of opportunistic infections.

Effects of platelet activating factor (PAF) on human citrated whole blood.

Effects of PAF on citrated whole blood (C-WB) from 38 healthy donors have been studied by impedance aggregometry and by morphologic examination of blood cells using scanning and transmission electron microscopy. In the aggregometer, the C-WB samples showed distinct differences in PAF sensitivity. C-WB specimens from high responders (= 15 donors) displayed a dose-related response to PAF stimulation but those from low responders (= 23 donors) did not indicate an impedance alteration even after the addition of high PAF doses (greater than or equal to 10(-6) mol/l). Morphologic studies revealed shape-changed platelets and primary aggregates in all C-WB samples, whereas secondary aggregates occurred only in C-WB specimens from high responders. Monocytes and neutrophil PMNs showed typical morphologic alterations which were observed in PAF-stimulated C-WB samples from all donors. Both cell types appeared polarized in shape and exhibited large vacuoles in the cytoplasm after PAF activation. In addition, monocytes came into close contact with shape-changed platelets as well as primary and secondary aggregates, whereas PMNs had no special relationship to single or aggregated platelets. In summary, our study indicates that PAF acts on different cell types in C-WB including platelets, monocytes and PMNs. The sensitivity of platelets against PAF stimulation appears to vary between different donors and in certain cases seems to be limited to the formation of primary aggregates.