[Acute hemolysis with subsequent life-threatening pancreatitis in hemodialysis. A complication which is not preventable with current dialysis equipment]. / Akute Hämolyse mit nachfolgender lebensbedrohlicher Pankreatitis bei Hämodialyse. Eine Komplikation, die von den derzeitigen Dialysegeräten nicht verhindert wird.

A retrospective study was undertaken of 14 patients (eleven men, three women; mean age 52 [33-68] years in whom haemolysis had occurred during chronic haemodialysis (n = 12) or haemofiltration (n = 2). The haemolysis was of mechanical cause in eight patients, by an osmotic mechanism in one, and of unknown cause in five. Cardinal symptoms were nausea in 14 patients, abdominal pain in nine, vomiting in eight and raised blood pressure in ten. The plasma was discoloured in all patients and there was also an increase in free haemoglobin (110-2400 mg/dl) and (or) lactate dehydrogenase (311-7403 U/l). In all of eleven patients in whom it was measured the activity of serum amylase and (or) lipase was more than doubled (to 73-2400 U/l and 473-16,740 U/l, respectively). All patients were treated symptomatically, three had a blood exchange, two others plasma separation. Eight patients recovered within a few days, but necrotizing pancreatitis developed in six, three of whom died while two had permanent sequelae. This series shows that dialysis-induced acute haemolysis can cause life-threatening pancreatitis. Narrowings within the extracorporeal circuit, not always recognized in current dialysis equipment, are the most frequent cause of the mechanical haemolysis.

[Cytostatic and immunosuppressive treatment of ocular Behçet syndrome]. / Zytostatische und immunsuppressive Therapie des okulären Behçet-Syndroms.

Ocular symptoms of Behçet's syndrome in 16 patients and the results of cytostatic and immunosuppressive therapy with cyclosporin A (6 patients), chlorambucil (6 patients), and a combination of cyclophosphamide and procarbacin (4 patients) are described. The clinical course and therapeutic outcome were compared to the patients' visual acuity and the duration of the disease prior to institution of cytostatic therapy. Average follow-up was 4.6 years, maximum 9 years. The principal ocular symptom in all patients was hemorrhagic, occlusive periphlebitis. Other symptoms, in descending order of frequency, were chorioretinitis, iridocyclitis, complicated cataract, secondary glaucoma and exudative retinal detachment. The patients in whom cytostatic therapy was instituted no later than 6 months after onset of the disease showed an improvement in or stabilization of visual acuity, as well as a clear reduction in signs of intraocular inflammation and frequency of recurrence. No improvement in visual acuity or ocular symptoms was achieved in cases where the disease was very advanced, despite cytostatic-immunosuppressive therapy. The results support early institution of immunosuppressive therapy in cases with Behçet's syndrome where severe, irreversible damage has not yet occurred and in which vision is threatened in both eyes. However, due consideration must be given to the potential risks of immunosuppressive therapy, in particular the risk of a malignant tumor.

[Initial symptoms of malignant thyroid tumors: the effect of age and sex in an iodine-deficient region. Experiences with 1116 patients]. / Erstsymptome bei Schilddrüsenmalignomen: Einfluss von Alter und Geschlecht in einem Jodmangelgebiet. Erfahrungen an 1116 Patienten.

Initial symptoms of thyroid cancer were collected and analysed for 1116 patients with thyroid cancer in an iodine-deficient region, retrospectively for the period 1960-80 (604 patients), prospectively for 1981-87 (512). Using the WHO classification, 56.1% of patients had papillary, 32.7% follicular, 4.8% C-cell, 3.7% anaplastic and 2.7% various other malignant tumours. In 40% of all patients the initial sign had been a solitary intrathyroid nodule. Cervical lymph node swelling as initial sign had been significantly more frequent in men (21.1%) than in women (10.3%; P less than 0.003). In patients aged under 40 years the cervical lymph node signs were three times as common as among those over 50 years. Distant metastases as initial sign of papillary carcinoma were seen only in those over 60 years. Tumour stages T3 and T4 were seen significantly more frequently in over 60-year-old (42.2%) than under 40-year-old (25.1%; P less than 0.001), independent of histological type. Composition and initial signs of this patient cohort in an iodine-deficient region differed only slightly from those in an iodine-rich region.

[Side effects of antithyroid therapy of hyperthyroidism. A study of 1256 continuously treated patients]. / Nebenwirkungen der antithyreoidalen Therapie der Hyperthyreose. Eine Untersuchung an 1256 fortlaufend betreuten Patienten.

Side effects of antithyroid treatment were retrospectively analysed in 1256 patients with hyperthyroidism. Overall rate of side effects was 14.3%. Skin reactions were the most frequent ones (5.6%), followed by arthropathies (1.6%). The incidence of agranulocytosis was 0.14%. Median duration of all side effects was 1.5 months. In half the cases the side effects were controllable so that treatment was continued, although at a changed dosage. The rate of cross-reaction between carbimazole and thiamazole, on the one hand, and propylthiouracil, on the other, was 13.8% and 15.2%, respectively. The side effects became apparent after a mean of one month's treatment, almost always (in 97.1%) within the first year of treatment. There was a significant dose dependence for an initial thiamazole dose of over 20 mg (relative side effect risk of 2.3), and for an initial dose of over 30 mg for carbimazole (relative side effect risk of 1.6). Although most side effects were not dangerous, in normal instances the lowest possible dosage should be administered to control hyperthyroid metabolism. Long-term treatment with low doses seem to be without problems.

Allogenic bone marrow transplantation in adults: endocrine sequelae after 1-6 years.

Twenty-three patients (13 females, 10 males) with panmyelopathy (N = 9), chronic leukemia (N = 5), and acute leukemias (N = 9) were studied 1 to 6 years following allogenic bone marrow transplantation. All patients had received conditioning treatment with cyclophosphamide prior to aBMT, and 2 of the patients with bone marrow aplasia and all of the leukemia patients had been given radiotherapy. An endocrine assessment was performed by means of TRH, GnRH, oCRF and GHRH tests and estimation of thyroid and gonadal hormones. Whereas pituitary-adrenal function appeared to remain stable, there was a 17.4% incidence of subclinical hypothyroidism (25% of the irradiated patients). Growth hormone reserve was diminished, and ovarian failure occurred in all female patients after radiotherapy, whereas in the men, only a moderate elevation of gonadotropins was observed. Our results warrant observation of thyroid and gonadal function, and in children of growth hormone secretion, after allogenic bone marrow transplantation. They also show that replacement therapy may be needed in some patients.

The sonographical and functional sequelae of de Quervain's subacute thyroiditis: long-term follow-up.

Fifty-three patients with subacute thyroiditis (SAT) were seen during the acute stage of the disease. HLA-Bw 35 was positive in 33 out of 39 tested patients. At first presentation, all examined patients (N = 23) had ultrasound abnormalities (generalized hypodensity, single or multiple hypodense areas). Serum T4 and/or T3 were increased in 24/52, free T4 in 11/23, and the TSH response to TRH was flat in 8/11 patients. Six of 12 in whom volumetry was performed had goitres. Thirty-seven patients were re-examined after a mean follow-up interval of 46.5 months. At this follow-up, serum T4, free T4 and T3 levels as well as the sonographically determined thyroid volume had decreased, but there was still abnormalities by ultrasound detected in 14/36 patients; 19.4% had focal sonolucent lesions, whereas the prevalence of such lesions was only 3.1% in asymptomatic controls. Three patients were subclinically hypothyroid at the follow-up, whereas all others were euthyroid. Patients with abnormal ultrasound findings were of the same age and had a similar thyroid size, but a slightly higher TSH and a significantly (P less than 0.02) lower free T4 than those with normal ultrasound findings. They also had a higher prevalence of thyroid autoantibodies in low titres. Serum thyroglobulin was elevated in more than half of the patients during the acute phase, but only in 1 out of 11 patients during follow-up. Thyroglobulin at the follow-up was not related to TSH, but there was a correlation with thyroid volume (r = 0.57).(ABSTRACT TRUNCATED AT 250 WORDS)

[Thyroid cancer: new knowledge and therapeutic strategy in an endemic area]. / Schilddrüsenkarzinom: Neue Erkenntnisse und therapeutische Strategie im Endemiegebiet.

The epidemiological data of thyroid carcinoma are difficult to evaluate. Several variables influence the biologic behaviour and the great number of occult papillary carcinomas obscure the picture. Among our 1116 patients we found as first symptoms solitary nodules in 41,4% being localized in differentiated carcinomas significantly more frequently in the right than is the left lobe. Multinodular goiter was seen in 24,2%, cervical lymph nodes in 10,9% and distant metastases in 3,2%. In medullary carcinoma cervical lymph nodes were seen in 27% and thus the second most frequent leading symptom. Together with sonography, thyroid scan and fine needle biopsy it is possible today to assure preoperatively at a high degree the diagnosis. A differentiated therapy is generally applied taking into account the particular prognosis of the patient, especially in papillary carcinoma. A more radical initial treatment is necessary in follicular carcinoma. In medullary carcinoma only the thyroidectomy without radiation has been proven as effective means.

[Localization of an ACTH-producing pituitary microadenoma using bilateral and simultaneous catheterization of the inferior petrosal sinus]. / Lokalisation hypophysärer, ACTH-produzierender Mikroadenome mittels bilateraler und simultaner Katheterisierung des Sinus petrosus inferior.

The experience with bilateral simultaneous inferior petrosal sinus catheterization and determination of the ACTH-concentration in 21 patients is reported. Venous blood sampling in the right and left inferior petrosal sinus was obtained before and after stimulation with Corticotropin-Releasing-Hormone (CRH). In 13 patients with Cushing's Syndrome a ACTH gradient (central versus peripheral) was measured. In all patients who were operated (11/13) a microadenoma was confirmed. In all patients with a central/peripheral gradient of the ACTH-levels at the same time an ipsi versus contralateral gradient between the two sides could be established after administration of CRH, which allowed a correct localization of the microadenoma. In 11 of 13 patients the site of the microadenoma was confirmed intraoperatively.

[Simultaneous bilateral catheterization of the inferior petrosal sinus in Cushing's syndrome. ACTH determination for the diagnosis and location of the side of a hypophyseal microadenoma before and after administration of corticotropin-releasing hormone]. / Bilaterale und simultane Katheterisierung des Sinus petrosus inferior beim Cushing-Syndrom.Bestimmung nach ACTH zur Diagnostik und Seitenlokalization eines hypophysären Mikroadenoms vor und nach Gabe von Corticotropin-Releasing-Hormon.

ACTH concentration was measured in simultaneously drawn blood samples from the left and right inferior petrosal sinuses before and after administration of corticotropin-releasing hormone (CRH). Such samples were successfully obtained in 20 of 21 patients with ACTH-dependent Cushing's syndrome on whom it was attempted. In 11 of the 20 patients there was no concentration difference between petrosal sinus and peripheral blood. But 13 of 19 patients had a unilateral central to peripheral concentration gradient greater than 1.4 after CRH administration. In the other six patients no ipsi- to contralateral gradient was demonstrable. Two of these patients had a proven ectopic ACTH-producing tumor; no adenoma was found at operation in three; on patient is awaiting operation. In 10 of 13 patients with unilateral gradient a microadenoma was found on the same side at operation. One patient had a hemi-hypophysectomy on the side of the higher gradient: hypocortisolemia developed in her postoperatively. Two other patients are awaiting operation. The results indicate that simultaneous bilateral catheterization of the inferior petrosal sinus with CRH stimulation is a highly informative examination with few side-effects and will contribute to better diagnosis and treatment of Cushing's syndrome.