[Antitubercular agents]. / Antituberkulotika.

The personally experienced development of chemotherapy for tuberculosis during the last half century represents some highlights of new knowledges and practical successes: the discovery of antituberculosis drugs; the comprehension of their actions and side effects; the exploration of mechanisms of resistance against antituberculosis agents; the evaluation of therapeutic and epidemiologic consequences of resistant strains; the decoding of the mycobacterial genetic structure. For different economic, social and psychologic reasons, the worldwide results of the battle against tuberculosis are not nearly as good as possible. AIDS is only a partial factor of this failure.

[The Swiss Centre of Pharmacovigilance]. / Le Centre Suisse de Pharmacovigilance.

The Swiss Drug Monitoring Center SANZ operates the spontaneous reporting system in Switzerland and is a private institution founded and funded by the societies of the Swiss health professionals and the Swiss pharmaceutical industries. The goal of SANZ is to collect and evaluate ADRs and thus to create signals. In 1991 SANZ received 792 reports. SANZ informs the health professionals periodically on drug safety problems. Reports on serious ADRs are exchanged with the regulatory authorities.

[Drug side effects on the bronchi and lung]. / Unerwünschte Arzneimittelwirkungen im Bereich der Bronchien und der Lunge.

Diseases of the respiratory organs comprise almost 4% of the adverse drug reactions reported to the Spontaneous Adverse Drug Reactions Center, SANZ (169 of the 4415 reports collected between 1981 and 1990). The most frequent reports were coughing caused by ACE inhibitors, attack of bronchial asthma induced by nonsteroidal anti-inflammatory drugs and beta-blocking agents, interstitial pneumopathy caused by amiodarone and sulfonamides, and respiratory depression due to benzodiazepines. The spontaneous reporting system does not allow one to determine the incidence, the reports are only of a signal-generating function. Classical semiology and special diagnostic techniques in assessing adverse drug reactions are discussed. A precise analysis of the case, temporal correlation with reaction and exposure time as well as comparisons with similar cases, together with a critical study of the literature on adverse drug reactions, remain the most important diagnostic procedures.

[The incidence of drug side effects with reference to organ systems. Experience of the spontaneous reporting system of the Swiss Drug Side Effect Center and Comprehensive Drug Monitoring]. / Die Hüfigkeit der unerwünschten Arzneimittelwirkungen in bezug auf Organsysteme. Erfahrugen des spontanen Meldesystems der Schweizerischen Arzneimittel-Nebenwirkungs-Zentrale und des Comprehensive Hospital Drug Monitoring.

The reporting system of the Spontaneous Adverse Drug Reactions Center (SANZ) and the Comprehensive Hospital Drug Monitoring (CHDM) in Berne and St. Gallen are complementary ADR reporting institutions. The first collects data from the whole patient population as well as all drugs prescribed in Switzerland. The adverse drug reactions reported most frequently are easily detectable skin reactions, psychic disorders and reactions concerning the body as whole. From these reports signals can be generated, contributing to enhanced drug safety. The CHDM provides detailed information on all adverse drug reactions in a selected patient population. Because the number of patients exposed to a drug is known, a quantitative risk assessment can be calculated. The system contributes also to the detection of new ADRs. This relies partly on statistical analysis, partly on thorough clinical observations, but mostly on the combination of both. Allergic and pseudoallergic reactions were studied with some priority.

[Spontaneous reporting system for the assessment of new, unknown and rare undesirable effects of drugs]. / Erfassung von neuen, unbekannten und seltenen unerwünschten Arzneimittelwirkungen im Spontanmeldesystem.

The Swiss Drug Monitoring Center SANZ operates the spontaneous reporting system in Switzerland. Spontaneous reporting schemes represent the systematic approach to the collection of individual case reports on suspected adverse drug reactions (ADR). ADR spontaneous reporting systems are an important component of the postmarketing surveillance of drugs. Spontaneous reporting systems are primarily designed to detect new and unexpected ADR; they generate signals about possible ADR and create hypotheses to be tested in pharmaco-epidemiological studies. Besides collecting, analyzing and evaluating single case reports it is important to extract those cases from the data pool which can be used to produce signals. A computer-assisted early warning system enables SANZ to detect cases with signal function and thus to track down new, rare and unexpected ADR. Carefully selected parameters can help to identify important new hazards. However, the detection of new and unexpected ADR depends to a large extent on the minds of alert physicians and the practicing clinician's awareness of and cooperation with ADR reporting.

[The importance of the clinical differential diagnosis in the evaluation of a suspected drug reaction]. / Die Wichtigkeit der klinischen Differentialdiagnose bei der Beurteilung einer vermuteten Arzneimittelnebenwirkung.

An adverse drug reaction has always to be considered if an obscure clinical picture is encountered. On the other hand every agency involved in drug monitoring has to take note of clinical differential diagnosis. Two examples illustrate how it was possible to explain by simple clinical evaluations suspected adverse drug reactions as manifestations of organic diseases.

[Pleural empyema--rational diagnosis and therapy]. / Das Pleuraempyem--rationale Diagnostik und Therapie.

A pyothorax is a relatively rare occurrence in a general hospital and is posing a number of problems. Among these the long mean duration of hospitalisation is of note lasting 47 days for 24 patients at our clinic. The course and the mortality rate are influenced by early detection and judicious use of interdisciplinary treatment. Small effusions accompanying pneumonia are frequent and likely to disappear after treatment of the underlying disease. In these instances a precipitate punction may lead to secondary infection. In case of a sterile punctate the pH value and consideration of glucose and LDH values determine further measures. Computed tomography is of great value since it yields decisive information not available from conventional radiography. If the empyema is not segregated in compartments a closed drainage with a large caliber chest-tube ist the method of choice. Limited thoracotomy is advised when several empyema chambers develop after short duration of the illness. Persistent disease or widespread scarring necessitate decortication in most cases.

[Non-healing foot wound]. / Nichtheilende Fusswunde.

A young man from Sri Lanka developed a suppurative chronic wound on the right foot after a minor trauma. In spite of several surgical interventions a closure of the ulcer did not occur. Only six months later after serious miliary tuberculosis had developed the correct diagnosis was established and tuberculostatic therapy initiated. This manifestation of tuberculosis--rare in recent times--is reviewed. Emphasis is placed on the causal relation between trauma and reactivation of tuberculosis as well as the pathogenesis of secondary miliary tuberculosis.

[Abdominal tuberculosis and open lung tuberculosis caused by mycobacterium bovis]. / Abdominale Tuberkulose und offene Lungentuberkulose durch Mycobacterium bovis.

Abdominal tuberculosis is a rare disease in Western countries and remains difficult to diagnose. The most frequent symptoms are abdominal pain, weight loss, fever, vomiting, constipation and/or diarrhea. Clinical findings include abdominal tenderness, a palpable mass (often in the right fossa due to ileocecal infection), paleness, cachexia and ascites. Suggested radiological investigations include plain abdominal film, upper GI-series and barium enema. Chest X-rays often show signs of either active or inactive tuberculosis. Sputum and gastric juice should be cultured. Coloscopy serves to sample specimens for histology and bacteriology and may help to confirm the diagnosis, which is, however, not ruled out by negative findings. The same holds good for peritoneal biopsy and laparoscopy. Bowel perforation and ileus are frequent complications and always require surgery, whereas uncomplicated cases can be treated by drugs only.

[Efficient diagnosis of pleural effusion]. / Rationale Diagnostik bei pleuraler Ergussbildung.

Under physiological conditions the pleural cavities contain a few millilitres of a fluid film with a protein content of about 1.7 g%. Because of the different capillary pressure, there is a regular flow of fluid from the parietal pleura to the visceral pleura. In cases of increased hydrostatic pressure or reduced colloid osmotic pressure in the absence of pleural disease, transudation takes place; in disturbances of permeability resulting from various types of inflammation, neoplasms or vascular disorders, and in disturbances of lymph backflow, exudates are formed. A pleural effusion is easily recognizable in typical cases. Reference is made to particular radiological manifestations which are not always correctly interpreted, viz. subpulmonary effusion, encapsulated interlobar effusion ("vanishing tumour") and predominantly mediastinal effusion. Precise examination of the neighbouring organs, together with thoracentesis and pleural biopsy, are decisive for the etiological diagnosis. When examining the effusion, it is of great importance to differentiate between transudate and exudate. Light's definition of transudate proved to be valid in this study (protein content below 3 g% and LDH index below 0.6). For the basic examination, we further recommend cytology and--to save time--tuberculosis bacteriology as well. The significance, sensitivity and specificity of various other chemical tests are discussed. For diagnostic strategy it is always necessary to take into consideration the entire clinical situation, including radiology and laboratory tests. With this proviso, a specific investigation scheme may be recommended. After application of the usual diagnostic methods, including pleural biopsy, aetiologically unclear effusions remain in about 20-25% of cases. Approximately 2/3 of these can be diagnosed by means of optimized biopsy technique under thoracoscopy and are predominantly tumoral effusions. Approximately 1/3 (5-10% of the total number) still remain unclear as "idiopathic" effusions, even after thoracoscopy. The relative importance of early diagnosis of a malignant pleural effusion is discussed.

[Acute hypercalcemia syndrome in sarcoidosis]. / Akutes Hypercalciämiesyndrom bei der Sarkoidose.

In a 26-year-old patient admitted to the emergency ward with acute abdomen, all the symptoms--nausea, vomiting, indeterminate abdominal pain, constipation, renal failure, polyuria and polydipsia--could be explained by calcium intoxication syndrome. Investigation revealed generalized sarcoidosis. Under medical treatment with prednisone all the pathologic findings rapidly regressed. The pathogenesis of hypercalcemia in sarcoidosis, and particularly the disorder of vitamin D metabolism with raised levels of 1,25-dihydroxycholecalciferol, are discussed.

[Traumatic pulmonary pseudocysts]. / Traumatisch bedingte pulmonale Pseudozysten.

In three patients traumatic pulmonary pseudocysts were observed. In one the cause was a barotrauma due to hyperbaric oxygenation with positive end-expiratory pressure. In the other two an accident was the cause. Expectant management is always indicated because in most cases there is spontaneous regression, as long as there are no important complications. In ventilated patients mean and peak pressure values should be as low as possible.

[Goodpasture syndrome and (idiopathic) immune complex glomerulonephritis with pulmonary hemorrhage: 2 different syndromes?]. / Goodpasture-Syndrom und (idiopathische) Immunkomplex-Glomerulonephritis mit Lungenblutungen: zwei verschiedene Krankheitsbilder?

While Goodpasture syndrome was previously defined purely clinically by the combination of pneumorrhagia and glomerulonephritis, today the following immunologic criteria must also be satisfied: evidence, provided by immunofluorescent investigation of the kidneys and lungs, of antibasement membrane antibodies in the serum and linear deposits of immunoglobulins, due to direct apposition of antibasement membrane antibodies. Cases where the lesions are caused by immune complexes should no longer be designated as Goodpasture syndrome. In the light of one of our own cases of immune complex glomerulonephritis with pneumorrhagia, the question is raised whether this subdivision by means of immunologic investigations is meaningful for the clinician.