[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).

[Dysphagia and tonsillitis in a 25-year-old male patient : The nearly forgotten severe complication of a common ailment]. / Dysphagie und Angina tonsillaris bei einem 25-jährigen Patienten : Die fast vergessene schwere Komplikation einer häufigen Krankheit.

We report the case of a patient with a severe dysphagia accompanying progressive tonsillitis. The clinical examination supported the possibility of a severe septic soft tissue infection. The blood cultures revealed a largely anaerobic sepsis with Fusobacterium necrophorum. This unusual pathogen is the most common cause of Lemierre's syndrome. A duplex sonogram and magnetic resonance imaging (MRI) of the neck region and vessels suggested a thrombophlebitis of the left internal jugular vein with partial occlusion, so that Lemierre's syndrome could be diagnosed. The patient was treated with appropriate antibiotics according to the resistogram and also with rivaroxaban.

[Ectopic production of calcitriol by non-Hodgkin lymphoma as a cause of hypercalcemic crisis]. / Ektope Calcitriol-Produktion durch ein Non-Hodgkin-Lymphom als Ursache einer hyperkalzämischen Krise.

HISTORY AND ADMISSION FINDINGS: A 92-year-old woman was admitted because her general condition had deteriorated during the last two weeks and acute kidney injury had developed. Moreover, she suffered from periods of disorientation and confusion while heretofore she was autonomous. INVESTIGATION, TREATMENT AND COURSE: Clinical and biochemical evaluation revealed a hypercalcemic crisis with markedly increased serum levels of calcium (3.77 mmol/l; reference values 2.2-2.65), an acute kidney injury and neuropsychiatric disturbances. Ultrasound scan and magnetic resonance imaging of a palpable mass in the right abdomen showed a tumor in the retroperitoneal space. Histological evaluation specified the tumor as non-Hodgkin lymphoma. Further investigation revealed no other reason for the hypercalcemia but enhanced levels of calcitriol. Since serum levels of calcidiol were increased while levels of calcidiol were normal, we assumed ectopic production of calcitriol by non-Hodgkin lymphoma as the cause of hypercalcemic crises. This could been proven by the decrease of calcium and calcitriol levels during the course of lymphoma treatment. CONCLUSION: Hypercalcemia of malignancy is the most common cause of hypercalcemia in the inpatient setting. The evaluation of these cases should consider ectopic production of calcitriol a cause of hypercalcemia.

[Renal side effects of long-term lithium therapy]. / Nephrologische Nebenwirkungen einer Langzeittherapie mit Lithium.

Lithium is widely used in the treatment of bipolar disorders. Long-term administration of lithium often leads to side effects concerning the subjects: nephrology, endocrinology and surgery. This review emphasizes nephrotoxicity.Lithium treatment may disturb responsiveness to antidiuretic hormone (ADH), causing a nephrogenic diabetes insipidus. Furthermore long-term lithium therapy may trigger hyperparathyreoidism with hypercalcemia and chronic interstitial nephritis with development of microcysts. Long-term patients have an increased risk to develop impaired renal function. Lithium-induced endstage renal disease is rare. Termination of lithium treatment may decrease the risk of progression.To ensure security of lithium treatment regular controls of urine osmolarity, lithium-, creatinine- , thyroid stimulating hormone- and calcium-levels are essential. Patients with decreased renal function should be referred to a specialist early.

[Myalgia in Neuro-Behçet's disease. Medication side effects or expression of underlying disease]. / Myopathie beim Behçet-Syndrom. Medikamentennebenwirkung oder Ausdruck der Grunderkrankung?

In this report we present the 9-year course of disease in a woman of Turkish origin suffering from Behçet's disease with parenchymal CNS involvement combined with myalgia. Differential diagnoses, such as drug-induced neuromyopathy were excluded on the basis of electromyographic and bioptic tests. We were able to arrest progression of symptoms of both the myopathy and the Neuro-Behçet's disease by means of increased combined immunosuppressive therapy.

[Surgical therapy of penis carcinoma]. / Operative Therapie des Peniskarzinoms.

Primary therapy of penile cancer (carcinoma in situ/T1 tumors) consists of circumcision, microsurgical excision, application of 5-fluorouracil cream, radiation, or laser treatment. In cases of larger T1 tumors or T2 and distal T3 tumors, partial penectomy with a 2-cm margin of clearance is mandatory. Secondary therapy includes inguinal lymphadenectomy 4-6 weeks after primary treatment and antibiotic prophylaxis. Independent prognostic factors for the presence of lymph node metastases are T stage and grading. Only patients with noninvasive G1 or G2 tumors and nonpalpable inguinal lymph nodes are candidates for surveillance with careful follow-up. Inguinal lymphadenectomy is performed in a radical or modified (Catalona) manner. Sentinel biopsy (Cabanas) may regain importance with the use of gamma probes. Complication rates of inguinal lymphadenectomy correlate to the extent of the procedure and must be weighed against the possibility of cure with lymphadenectomy. In cases of inguinal lymph node metastasis, removal of the iliac lymph nodes (one- or two-step procedure) is necessary.

Burn-out of urologists in the county of Schleswig-Holstein, Germany: a comparison of hospital and private practice urologists.

PURPOSE: Mental and physical burden of physicians, especially surgeons, is high. The degree of burn-out was estimated among urologists in the German federal county of Schleswig-Holstein, with special emphasis on differences related to age, qualification and hospital versus private practice. MATERIALS AND METHODS: The Maslach Burnout Inventory was mailed to all urologists and urologists in training registered in the county of Schleswig-Holstein to determine the frequency and intensity of the 3 burn-out subscales of emotional exhaustion, depersonalization and low personal accomplishment, together with a questionnaire covering demographic data. RESULTS: Of 128 urologists 75 (58.6%) replied. Levels of burn-out in the subscales of emotional exhaustion and depersonalization were increased among hospital urologists, urologists in training and urologists younger than 45 years. Urologists in private practices, fully trained urological specialists and urologists older than 45 years showed a low degree of burn-out, corresponding to normal values, whereas young urologists in training and working in hospitals had the highest risk of burn-out. The personal accomplishment level was generally high in all groups. CONCLUSIONS: The constellation of being a urologist in private practice and older than 45 years appears to provide some protection against burn-out that might be due to a more personal relationship to the patients, lesser hierarchical situation and workload related income. In times of increasing pressure on the health care system, the personal situation of physicians in training should not be overlooked.

Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial.

BACKGROUND: Parameters of splanchnic regional perfusion, like intramucosal pH (pHi) and pCO(2) (pCO(2)i), may predict outcome in septic shock patients. Continuous venovenous haemofiltration (CVVH) has been considered beneficial in haemodynamically unstable septic shock patients. In a prospective, randomized, clinical study, we investigated whether CVVH, in comparison to intermittent haemodialysis (IHD), is able to improve splanchnic regional perfusion in critically ill patients. METHODS: Thirty septic shock patients with acute renal failure were randomized to either CVVH (n=20) or IHD (n=10) groups for renal replacement therapy. Patient characteristics at baseline were not different in terms of severity of illness (APACHE II scores), haemodynamics, and pHi/pCO(2)i values. Systemic haemodynamics, oxygen transport variables, and splanchnic regional perfusion parameters were measured at 0.5, 2, 4 and 24 h after initiation of renal replacement therapy. There were no major changes in vasopressor support throughout the 24-h study period. RESULTS: In contrast to IHD, CVVH caused a decrease in heart rate (-3+/-11 vs +9+/-8/min, P<0.01) and an increase in systolic blood pressure (+12+/-1 vs -5+/-17 mmHg, P<0.05) after 2 h. After 24 h, increased systemic vascular resistance was found in the CVVH group in comparison with the IHD group (+312+/-755 vs -29+/-89 dyne/cm(5), P<0.05) and was accompanied by a decrease in cardiac output (-1.54+/-1.4 vs -0.25+/-0.9 l/min, P<0.01). However pHi values remained constant throughout the 24-h study period in both groups and were not different between the groups (CVVH 7.19+/-0.1 vs IHD 7.19+/-0.1, n.s.) as did the pCO(2)i values (CVVH +7+/-17 vs IHD 0+/-15 mmHg, n.s.) and pCO(2) gap values (CVVH +6+/-15 vs IHD +5+/-12 mmHg, n.s.). CONCLUSIONS: Despite different changes of systemic haemodynamics between CVVH and IHD, CVVH did not improve parameters of splanchnic regional perfusion like pHi, pCO(2)i or pCO(2) gap in septic shock patients.

The influence of ketanserin or urapidil on haemodynamics, stress response and kidney function during operations for myocardial revascularisation.

The study was performed to investigate the different effects of ketanserin and urapidil on haemodynamics, kidney function and plasma catecholamine and aldosterone levels. Forty male patients scheduled for myocardial revascularisation were assigned at random to two groups: group K received ketanserin, group U received urapidil. Anaesthesia consisted of fentanyl, flunitrazepam and pancuronium. Haemodynamic variables were evaluated at eight predefined time points of the operation. Creatinine and free-water clearance as well as plasma levels of adrenaline, noradrenaline and aldosterone were measured in three different periods of the operation. While the groups showed no clinically relevant differences in the haemodynamic variables and the hormone plasma concentrations, the creatinine clearance in group K was slightly increased in the period after cardiopulmonary bypass. Both ketanserin and urapidil prevented hypertension even in the presence of elevated catecholamine plasma levels during and after cardiopulmonary bypass.

[Essential cryofibrinogenemia with generalized livedo racemosa]. / Essentielle Kryofibrinogenämie mit generalisierter Livedo racemosa.

A 45-year-old male patient presented with cold-induced generalized livedo reticularis, repeated acral ulcerations and purpura, Raynaud's phenomenon, and peripheral polyneuropathy. The patient also experienced malaise, vertigo, and transient amaurosis whenever he was exposed to low temperatures. Skin biopsies of the livedo reticularis revealed marked dilatation of the small dermal blood vessels and circumscribed leukocytoclastic vasculitis. Essential cryofibrinogenaemia was diagnosed on the basis of detection of this cryoprotein in the chilled blood plasma with increased viscosity. Pulsed therapy with dexamethasone and cyclophosphamide resulted in marked relief of the symptoms, and cryofibrinogen was no longer detectable in the patient's plasma.