A consecutive and prospective stroke database covers the state of Baden-Wuerttemberg with 10.8 million inhabitants in Germany.

BACKGROUND: In 1998 Baden-Wuerttemberg (BW), a federal state in southwest Germany with 10.8 million inhabitants, implemented a structured medical concept for the treatment of acute stroke. METHODS: Since 2004 participation in the BW stroke database is mandatory for all hospitals in BW involved in acute stroke care. The stroke database includes all inpatients ≥18 years of age who have suffered an ischemic or hemorrhagic stroke within 7 days before hospitalization. This article presents methodological aspects and first results of the BW stroke database in the time period from 2007 to 2011. RESULTS: Annual inclusion numbers increased continuously (29,422 vs. 35,724, p < 0.001). Median age of stroke onset was stable over time. The proportion of stroke patients ≥80 years increased from 36.9 to 38.8% (p < 0.001). Rates of patients treated in neurology departments rose from 50.7 to 60.9% (p < 0.001) and numbers of patients treated in stroke units rose from 59.1 to 68.4% (p < 0.001). Admission via emergency medical systems increased from 42.8 to 49.7% (p < 0.001) and arrival within 3 h increased from 29.8 to 34.4% (p < 0.001). CONCLUSION: We present results from a large, prospective and consecutive stroke patient database. This first analysis demonstrates a continuous increase of absolute and relative numbers of stroke patients who arrive within 3 h after onset, are hospitalized in neurology departments and treated in stroke units, and are aged ≥80 years.

Schistosoma japonicum infection and rectal carcinoid tumour: underreported coincidence or neglected association?

Schistosoma japonicum infection associated with a rectal carcinoid in an asymptomatic 44-year-old female from the Philippines is described. A systematic review of the literature could not identify similar reports, suggesting a rare coincidence. However, epidemiological data on the frequency of both conditions as well as published results of a colorectal screening programme from China indicate that underreporting of this concurrence is likely. Moreover, several studies suggest a causal link between schistosomiasis caused by S. japonicum and more common gastrointestinal malignancies such as colorectal carcinoma. Hence the presented case and the apparent neglect of this observation in the current literature allow speculation on a role of S. japonicum in the pathogenesis of rare gastrointestinal neoplasms such as carcinoid tumours as well. Future reports on similar observations could help to determine the need for systematic investigations and are strongly encouraged.

[Characterization of medical and neurological care of stroke patients. An analysis of the data from the project, "Safeguarding Quality in Stroke Care," of the Regional Medical Council of Baden-Württemberg]. / Charakterisierung internistisch und neurologsich versorgter Schlaganfallpatienten. Eine Analyse der Daten des Projektes "Qualitätssicherung in der Schlaganfallversorgung" der Landesärztekammer Baden Württemberg.

BACKGROUND AND OBJECTIVE: Patients with stroke are treated in either medical or neurological units. This study investigated whether the two cohorts differ regarding their demographic composition, previous diseases, severity of the stroke and comorbidity. PATIENTS AND METHODS: Data were collected prospectively on 2890 patients with acute stroke (50.2 % males, 49.8 % females) admitted to medical or stroke units of hospitals in Baden-Württemberg. RESULTS: The mean age of patients treated on a medical ward was significantly higher (77 vs. 71 years). They also had significantly higher, age-related incidence of pre-existing disease (Ranking scale) and of previous cerebral episodes (32.9 % vs. 19.1 %). They had a higher incidence of atrial fibrillation (27.6 % vs. 20.5 %) and treated diabetes mellitus (31.5 % vs. 25.4 %) Various neurological deficits were also significantly more pronounced: abnormal awareness (42.4 % vs. 26.7 %), level of consciousness (29.3% vs. 12.8%), swallowing (20.3 % vs. 10.8 %), speaking (40.0 % vs. 31.5%) and speech (20.3% vs. 10.8 %) and transitory ischaemic attacks (21.2 % vs. 25.5 %). Rankin scale and Barthel index differed similarly. The patients treated in medical wards remained in hospital significantly longer (14.9 % vs. 13.9 %) and they had a higher death rate (10.6 % vs. 5.6 %) and were more disabled. CONCLUSION: Patients after an acute stroke treated in medical wards differ significantly from those in stroke units by being older. Previous diseases and acute neurological deficits are more common, independent of age, and they are more disabled at discharge.

[Guidelines for the diagnostics of deep pelvic/lower limb vein thrombosis]. / Leitlinien zur Diagnostik der tiefen Becken-/Beinvenenthrombose - Empfehlungen des Arbeitskreises Vaskulärer Ultraschall in der DEGUM.

As a result of availability and failing invasiveness the technique of compression sonography led to a change in the indication of thrombosis examination - from the proof of thrombosis shown by phlebography to exclusion of thrombosis by ultrasound. Compression sonography showed the same sensitivity and specificity as phlebography for proximal limb thrombosis and reaches high safety due to actual treatment studies in the diagnosis of deep vein thrombosis. For the distal limb the compression sonography has provided > 90 % specificity, with an examinator dependent sensitivity of 50 to 95 %, and hence examination of the distal limb must be recommended. These guidelines for the diagnosis of deep vein thrombosis are recommendations by the Section of Vascular Ultrasound of DEGUM for examination technique and documentation. It also contains an algorithm of diagnosis for thrombosis as a result of the actual treatment studies.

[Stroke unit at a medical clinic providing general medical care. Model and initial clinical results]. / Schlaganfallstation an einer Medizinischen Klinik der Regelversorgung. Modell und erste klinische Erfahrungen.

BACKGROUND AND OBJECTIVES: To achieve in Germany complete therapeutic cover for patients after a stroke, models will have to be formulated that incorporate such units within the confines of departments of general medicine, where most stroke patients are at present being treated. Preliminary experience of such a unit is reported here. PATIENTS AND METHODS: The stroke unit, conceived for "mixed assessment", has 6 beds within a normal ward but an increased number of specially trained personnel and specialized equipment. The aim was the rapid diagnosis, targeted treatment, monitoring, early mobilization and, if necessary, smooth and direct transfer to an installation for rehabilitation to which the patient can be taken during the entire stay in the acute stroke unit. RESULTS: During a period of 11 months 120 patients (68 men, 52 women; mean age 71 years) were treated in the stroke unit, 47% having been admitted within 3 hours of the acute episode. An acute ischaemic attack had occurred in 85%, cerebral haemorrhage in 15%. The median European stroke scale (ESS) was 76 on admission, 90.5 on discharge, the Barthel index 45 and 90, the ranking scale 3.2 and 2.3, respectively. The complication rate per patient during hospital stay was 0.5. There were 12 deaths (10%), 22.2% among those with cerebral bleeding, 7.7% of those with ischaemia. Mean hospital stay was 13.3 days. 57.4% patients were transferred to a rehabilitation unit, 34.2% discharged home, 2.8% directly to a nursing home. The remaining 6 had undergone immediate vascular (4) or neurological (2) procedures. CONCLUSION: A "mixed assessment" stroke unit within a general medical department is feasible. It improves working conditions and patient care as well as reducing the length of hospital stay.

[Severe cholestasis with kidney failure from anabolic steroids in a body builder]. / Schwere Cholestase mit Nierenversagen durch Anabolika bei einem Bodybuilder.

HISTORY AND ADMISSION FINDINGS: A 28-year-old body builder was admitted because of jaundice. For 80 days, until 3 weeks before hospitalization, he had been taking moderately high doses of anabolic steroids: metandienone (methandienone), 10-50 mg daily by mouth, and stanozolol, 50 mg intramuscularly every other day. Physical examination was unremarkable except for yellow discoloration of the skin and sclerae. INVESTIGATIONS: Bilirubin concentration was raised to 4.5 mg/dl, cholestasis enzymes were normal, while transaminase activities were raised. Liver biopsy was compatible with cholestasis induced by anabolic steroids. TREATMENT AND COURSE: Although the steroids had been discontinued, the patient's general condition deteriorated over 7 weeks. Serum bilirubin rose up to a maximum of 77.9 mg/dl. In addition renal failure developed with a creatinine concentration of 4.2 mg/dl. The patient's state improved simultaneously with the administration of ursodeoxycholic acid and the biochemical values gradually reached normal levels after several weeks. CONCLUSION: Anabolic steroids can cause severe cholestasis and acute renal failure. In this case there was a notable temporal coincidence between the administration of ursodeoxycholic acid and the marked clinical improvement.

[Miliary pneumonia after the intravesical BCG therapy of a superficial urothelial carcinoma of the bladder]. / Miliare Pneumonie nach intravesikaler BCG-Therapie eines oberflächlichen Urothelkarzinoms der Harnblase.

HISTORY AND ADMISSION FINDINGS: A multilocular superficial epithelial carcinoma (T1G3) and carcinoma in situ (Cis G3) of the bladder were resected transurethrally followed by intravesical instillation of BCG. The initial cycle of BCG administration had been free of complication, but then high fever, fatigue, cough and dyspnoea had developed with subsequent BCG maintenance treatment. Physical examination on admission revealed fever, clearly reduced general condition, and increased breath sounds with fine rales in the upper and middle lobes. INVESTIGATIONS: A clearly raised erythrocyte sedimentation rate (86 mm/h) and a CRP level at the upper limit of normal (13.6 mg/dl) indicated marked inflammatory reaction. The chest radiogram showed diffuse miliary opacities. Mycobacteria were not demonstrated in either gastric juice or bronchial secretion. TREATMENT AND COURSE: As BCG-induced miliary pneumonia was diagnosed, triple tuberculostatic treatment was commenced (ethambutol, 1200 mg/d; rifampicin, 600 mg/d; isoniazid, 300 mg/d). Nonetheless his condition deteriorated further. When prednisolone, 40 mg/d was added the symptoms improved rapidly. The tuberculostatic drugs were continued for 6 months. All symptoms had disappeared after 4 months. CONCLUSION: Miliary pneumonia is a rare complication of intravesical BCG installation of a superficial bladder cancer. As living bacteria cannot be excluded as the cause, triple tuberculostatic treatment must be started at once. If this fails to bring about improvement, additional steroid medication is recommended.

[Isolated thrombosis of the vena profunda femoris as the source of embolisms. A diagnosis easy to supply using duplex sonography]. / Die isolierte Thrombose der Vena profunda femoris als Emboliequelle. Eine mit der Duplexsonographie leicht zu stellende Diagnose.

HISTORY AND ADMISSION FINDINGS: A 79-year old man was admitted because of increasing dyspnoea. At physical examination he had dyspnoea at rest, auscultation of the lung was unremarkable and there was no peripheral oedema or unilateral swelling of a leg to suggest venous thrombosis. INVESTIGATIONS AND DIAGNOSIS: Chest radiogram was unremarkable. Perfusion scintigraphy of the lung, performed to exclude pulmonary embolism, revealed several defects typical of emboli. Duplex sonography revealed an isolated thrombosis of the left profunda femoris vein, while the deep veins were patent. TREATMENT AND COURSE: Anticoagulation with heparin followed by phenprocoumon rapidly improved the symptoms and the patient was discharged after 10 days. CONCLUSION: Thrombosis of the profunda femoris vein can cause clinically relevant pulmonary embolism. While this vessel cannot be visualized by phlebography, duplex sonography easily establishes the diagnosis and should be used routinely in the investigation of suspected thrombosis of the leg veins.

[Lead poisoning caused by a Greek ceramic cup]. / Bleivergiftung durch griechische Keramiktasse.

HISTORY AND ADMISSION FINDINGS: A 24-year-old woman, an administrative employee, was admitted with colicky abdominal pain and constipation, as well as breathing-related chest pain of recent onset with cough and sometimes blood-streaked sputum. She had previously been unsuccessfully treated for gastritis and adnexitis. On physical examination revealed diffuse, ill-defined abdominal pain on pressure and mild tachycardia, but was otherwise unremarkable. INVESTIGATIONS: Electrocardiogram, chest radiogram, lung scintigraphy, abdominal sonography, oesophago-gastro-duodenoscopy and gynaecological examination indicated nothing abnormal. Laboratory tests showed microcytic anemia, slight leucocytosis and anisocytosis, as well as polychromasia and basophilic stippling of erythrocytes. The 24-h urinary porphyrin concentration was elevated. DIAGNOSIS TREATMENT AND COURSE: Precise differentiation of porphyrins in urine, stool and erythrocytes by enzymatic measurement first raised the suspicion of lead poisoning. Whole-blood lead concentration was markedly raised to 600 micrograms/l (normal up to 90 micrograms/l) and 170 micrograms/dl in urine (normal up to 80 micrograms/dl). A ceramic cup from Greece was traced as the source of the lead, the patients having regularly for over 2 1/2 months drunk lemon instant-tea from it. She was treated with oral doses of DMPS (sodium salt of 2,3-dimercapto-1-propanesulphonic acid), 5-10 mg/kg 3x daily for 2 days, followed by 2.5 mg/kg 2 x daily, until lead concentrations in blood and urine had become normal, when all symptoms disappeared: detoxification was complete within 4 months. CONCLUSION: This case impressively illustrates how difficult it can be to diagnose lead poisoning and identify its source. Oral DMPS is a practicable and efficacious form of treatment.

[Imaging methods in intensive care]. / Bildgebende Verfahren in der Intensivmedizin.

Imaging procedures are important for diagnosis and surveillance of patients in intensive care units. Radiologic examination, ultrasound and echocardiography are of paramount importance because they can be done bedside. Portable chest x-ray examination is the procedure of choice for documentation of tubes, lines and devices, estimation of cardiopulmonary function, demonstration of pulmonary edema, ARDS pneumonia, atelectasis and pneumothorax Plainfilm radiologic imaging of the abdomen is indicated when perforation ileus or acute intestinal pseudoobstruction is suspected Echocardiography can give information about ventricular function, pericardial effusion, cardiac valves, functional importance and complications of myocardial infarction, and hemodynamic changes of pulmonary embolism. Transesophageal echocardiography (TEE) is the method of choice when endocarditis, aortic dissection or cardiac thromboembolism is considered. Ultrasound can show many pathologic changes important for the management of intensive care patients concerning liver, gallbladder, bile duct, pancreas, kidney, spleen, pleural space and vessels. Other imaging procedures such as CT, methods of nuclear medicine, MRT, angiography etc. are done outside the intensive care unit and therefore need a more restricted indication.

Exogenous surfactant application in respiratory failure due to chronic obstructive pulmonary disease.

Recent results of basic research on regulation of surfactant secretion and surfactant physiology not only in the alveolus but also in peripheral small airways allow the conclusion that disorders in surfactant homeostasis may contribute to the pathophysiology of airway obstruction and hyperinflation. We therefore hypothesized that patients with respiratory failure due to obstructive lung disease may benefit from exogenous surfactant. Here we report a case that indicates the clinical situation to be considered for treatment with exogenous surfactant. The benefit for the patient was successful weaning from the ventilator. Improvements in effective compliance, resistance and blood gas parameters were observed following surfactant application.

[Acute poisoning in patients of a medical intensive care unit]. / Akute Intoxikationen bei Patienten einer medizinischen Intensivstation.

Data on 674 patients, admitted between 1986 and 1990 to a medical intensive care unit with acute poisoning (8.8% of total admissions), were analysed retrospectively. Females slightly predominated (53.4%); the age distribution peaked in the third decade of life. Attempted suicide made up 68.7 of all cases (64.8% in females), while 30% of intoxications were accidental (70.8% in males). Alcohol was the most common form of poison (41.4%), followed by benzodiazepines (27%) and psychoactive drugs (24.5%), more than one drug having been taken in 36.1% of cases. Artificial ventilation was needed in 14.2% of cases, while resuscitation was necessary in 1.6%. Forms of detoxication were: gastric lavage (58%), forced diuresis (6.4%), haemoperfusion (10.1%), haemodialysis (3.4%). An anticholinergic syndrome developed in 8% of cases, pneumonia in 3%, acute renal failure in 1.2%. Rhabdomyolysis occurred in 2.5%. The death rate was 1.2%.