[Intraoperative parathyroid hormone measurement is the best predictor of postoperative symptomatic hypocalcemia]. / Die intraoperative Parathormonmessung als bester Indikator einer postoperativen symptomatischen Hypokalzämie.

BACKGROUND: The goal of this study is to evaluate risk factors for transient postoperative hypocalcemia (HC) and to define cutoff values for perioperative parathyroid hormone (PTH) and calcium parameters (Ca) to reduce the morbidity of symptomatic HC. MATERIALS AND METHODS: At our tertiary referral hospital (Luzerner Kantonsspital, Switzerland), a total of 353 patients underwent total thyroidectomy between 2006 and 2013 and were analyzed retrospectively in terms of HC risk. The serum values of calcium and PTH were measured at strictly defined time intervals, and patients' symptoms and the necessity of treatments were determined from patients' charts. RESULTS: The prevalence of transient postoperative HC was 43%; however, only 10% of patients were symptomatic. Significant risk factors for serum and symptomatic HC were calcium values (pre-, intra-, 4 h and 1 d postoperative), PTH values (intraoperative, 4 h and 1 d postoperative), and PTH decline. Interestingly, preoperative PTH values, patient age, weight of the thyroid gland, diagnosis, and sex were not significant risk factors. In the ROC analysis ('receiver operating characteristics'), calcium measurement 4 h postoperatively showed the best predictive ability for detecting serum HC, whereas intraoperative PTH measurements were predictive for symptomatic HC. CONCLUSION: Calcium and PTH values as well as PTH decline are significant risk factors for postoperative HC. Preoperatively, only calcium measurement is prognostically significant. Intraoperative PTH measurement is the most reasonable and sensitive factor for early recognition of temporary postoperative HC in the clinical setting.

[Endocrinologic side effects of oncologic treatment with anti-CTLA-4-antibodies]. / Endokrinologische Nebenwirkungen einer onkologischen Therapie mit Anti-CTLA-4-Antikörpern.

New immune-modulating treatments like the anti-CTLA-4-antibodies-based therapies are increasingly used in medical oncology. The action of Ipilimumab, a monoclonal anti-CTLA-4-antibody used for the treatment of metastasized melanoma and other solid tumors, is well documented. Blocking the CTLA-4-receptors on lymphocytes leads to T-cell activation and hence reduction of the tumor-mediated immunotolerance. This mechanism constitutes the basis of the antiproliferative effects but is also responsible for a spectrum of specific adverse events (immune-related adverse events, IRAE). IRAE of the endocrine system comprise hypophysitis, thyroiditis and adrenalitis. Especially adrenal insufficiency can be fatal when not diagnosed and treated. Symptoms often are unspecific and early diagnosis and targeted treatment are crucial. We present a case report and summarize - based upon the current literature - the diagnosis and treatment of endocrinologic IRAEs.

Simulation of extension, radial and ulnar deviation of the wrist with a rigid body spring model.

A novel computational model of the wrist that predicts carpal bone motion was developed in order to investigate the complex kinematics of the human wrist. This rigid body spring model (RBSM) of the wrist was built using surface models of the eight carpal bones, the bases of the five metacarpal bones, and the distal parts of the ulna and radius, all obtained from computed tomography (CT) scans of a cadaver upper limb. Elastic contact conditions between the rigid bodies modeled the influence of the cartilage layers, and ligamentous structures were constructed using nonlinear, tension-only spring elements. Motion of the wrist was simulated by applying forces to the tendons of the five main wrist muscles modeled. Three wrist motions were simulated: extension, ulnar deviation and radial deviation. The model was tested and tuned by comparing the simulated displacement and orientation of the carpal bones with previously obtained CT-scans of the same cadaver arm in deviated (45 degrees ulnar and 15 degrees radial), and extended (57 degrees ) wrist positions. Simulation results for the scaphoid, lunate, capitate, hamate and triquetrum are presented here and provide credible prediction of carpal bone movement. These are the first reported results of such a model. They indicate promise that this model will assist in future wrist kinematics investigations. However, further optimization and validation are required to define and guarantee the validity of results.

[A rare cause of cardiogenic shock with psychotic symptoms]. / Kardiogener Schock und psychotisches Zustandsbild seltener Ursache.

HISTORY AND FINDINGS: A 40-year-old man was admitted to the emergency department with psychotic symptoms and marked hypothermia. He was known to have had a macroadenoma of the pituitary gland which had been excised 10 years before. No information about his current medication was available. Several hours after admission the patient developed signs of acute cardiac failure and cardiogenic shock. He was admitted to the intensive care unit, intubated and treated with vasoactive drugs. Later investigations revealed that the patient had stopped his hormonal therapy (hydrocortisone and thyroxine) at least 3 months previously. INVESTIGATIONS: Transthoracic electrocardiography revealed diffuse myocardial contractile abnormalities with an ejection fraction of 30%. Acute ischemic damage was ruled out by serial troponin-T test and electrocardiography. Severe hypothyroidism and hypocortisolism were confirmed by laboratory tests. DIAGNOSIS, THERAPY AND COURSE: The diagnosis of acute pituitary insufficiency with myxedema coma and hypocortisolism was suspected and the patient was treated with parenteral cortisone and L-thyroxine. The response was favorable and the patient was extubated after 5 days. Cardiac contractility and ejection fraction normalized. CONCLUSIONS: Myxedema coma can be a predominant finding of acute anterior pituitary insufficiency. There are important effects on the cardiovascular system and cerebral functions (altered mentation). Immediate diagnosis and therapy are crucial to reduce the otherwise high mortality.

[Eosinophilia, diarrhea and asthma in a young woman]. / Eosinophilie, Diarrhoe und Asthma bei einer jungen Frau.

We present the case of a young woman that was diagnosed with Churg-Strauss syndrome. The classical as well as the atypical symptoms, signs and findings are discussed in the context of clinically relevant differential diagnoses. The diagnostic criteria and the relevant aspects of pathogenesis, clinical course and treatment are reviewed. In addition, the similarities and differences with respect to the other idiopathic interstitial eosinophilic pneumopathies are described.

[Rare cause of right heart failure: two cases]. / Seltene Ursache einer Rechtsherzinsuffizienz: zwei Fälle.

HISTORY AND ADMISSION FINDINGS: Two asylum seekers (patient A, 30 year old man from Mongolia; patient B, 18 year old woman from the Sudan) were referred to our outpatient clinic because of acute and chronic deterioration of their general condition and shortness of breath. Both patients presented with a clear clinical picture of systemic venous hypertension and moderate pulmonary congestion. Patient B had a paradoxical pulse compatible to cardiac tamponade. INVESTIGATIONS: In patient A, the chest radiogram revealed a markedly enlarged cardiac silhouette and an infiltrate in the upper left lobe of the lung. The echocardiogram confirmed a pericardial effusion causing a cardiac tamponade. A therapeutic and diagnostic pericardiocentesis was performed immediately. In patient B, the chest radiogram revealed a thickened and calcified pericardium and a left-sided pleural effusion. The pleural fluid revealed a lymphocyte-predominant exudate. In both patients the tuberculin skin test was positive. DIAGNOSIS, TREATMENT AND COURSE: In both patients we initiated an antituberculous therapy (four-drug therapy with isoniazid, rifampin, pyrazinamide and ethambutol; in patient A in addition corticosteroids). In patient A the PCR for Mycobacterium tuberculosis complex from pericardial fluid was positive. In patient B we started the antibiotic treatment despite negative microbiological studies because of the high degree of suspicion in a person at high risk. Due to the impaired ventricular filling, patient B required additional pericardectomy. After completion of treatment, both patients have been doing well. CONCLUSION: Despite a clear reduction in the incidence of tuberculous pericarditis in Europe this multifaceted condition should still be of concern in patients at high risk as e. g. immigrants from areas with a high tuberculosis prevalence. Early diagnosis and adequate treatment are required for prevention of severe complications and disabling constrictive pericarditis.

[Dyspnea and hemoptysis in a young woman with unclear renal alterations]. / Dyspnoe und Hämoptyse bei einer jungen Frau mit unklaren Nierenveränderungen.

We describe the clinical course and treatment of a young woman diagnosed with tuberous sclerosis. Classical as well as atypical clinical findings are discussed with regards to the differential diagnosis. The most important components of the pathogenesis and the criteria necessary for diagnosis are highlighted. In addition the similarities and differences to lymphangioleiomyomatosis are discussed.