Propylene glycol toxicity from compulsive corn starch ingestion.

INTRODUCTION: Propylene glycol (PG) is usually considered safe, however, toxicity can develop with high doses or when used for prolonged periods of time. PG can be found in some medications as well as some food products. We report a case of likely PG toxicity that occurred after compulsive daily ingestion of large amounts of corn starch. CASE REPORT: Our patient initially presented to an outside hospital (OSH) via ambulance for altered mental status. Her mental status improved after her blood sugar of 25 was corrected. On admission to OSH Emergency Department her initial vital signs included a heart rate of 115 bpm, blood pressure 113/59 mm/hg, temperature 35.8C. Pertinent labs included: sodium 119 mEq/L, bicarbonate 9 mEq/L, anion gap 29 mEq/L, creatinine 2.5 mg/dL and lactic acid 20 mEq/L. On transfer to our hospital her repeat lactic acid was 20 mEq/L, osmolar gap was 20. Her PG level, which was drawn several hours after her initial presentation, was 11 mg/dL. Our patient noted that she ingested a 16 oz. package of corn starch mixed with baking soda approximately every 2 days. Given the concerns for PG she was underwent intermittent hemodialysis. PG and lactic acid levels improved, however, she ultimately died due to complications from her hospitalization. DISCUSSION: PG causes toxicity through metabolism to lactic acid. While there are small amounts in food products and medications, under the right circumstances, PG can accumulate and lead to significant toxicity.

Revision surgery for cervical artificial disc: Surgical technique and clinical results.

OBJECTIVE: Cervical artificial disc replacement (C-ADR) was developed with the goal of preserving mobility of the cervical segment in patients with degenerative disc disease. So far, little is known about experiences with revision surgery and explantation of C-ADRs. Here, we report our experience with revision the third generation, Galileo-type disc prosthesis from a retrospective study of two institutions. PATIENTS AND METHODS: Between November 2008 and July 2016, 16 patients with prior implantation of C-ADR underwent removal of the Galileo-type disc prosthesis (Signus, Medizintechnik, Germany) due to a call back by industry. In 10 patients C-ADR was replaced with an alternative prosthesis, 6 patients received an ACDF. Duration of surgery, time to revision, surgical procedure, complication rate, neurological status, histological findings and outcome were examined in two institutions. RESULTS: The C-ADR was successfully revised in all patients. Surgery was performed through the same anterior approach as the initial access. Duration of the procedure varied between 43 and 80min. Access-related complications included irritation of the recurrent nerve in one patient and mal-positioning of the C-ADR in another patient. Follow up revealed two patients with permanent mild/moderate neurologic deficits, NDI (neck disability index) ranged between 10 and 42%. CONCLUSIONS: Anterior exposure of the cervical spine for explantation and revision of C-ADR performed through the initial approach has an overall complication rate of 18.75%. Replacements of the Galileo-type disc prosthesis with an alternative prosthesis or conversion to ACDF are both suitable surgical options without significant difference in outcome.

Azacitidine for treatment of imminent relapse in MDS or AML patients after allogeneic HSCT: results of the RELAZA trial.

This study evaluated azacitidine as treatment of minimal residual disease (MRD) determined by a sensitive donor chimerism analysis of CD34(+) blood cells to pre-empt relapse in patients with CD34(+) myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (HSCT). At a median of 169 days after HSCT, 20/59 prospectively screened patients experienced a decrease of CD34(+) donor chimerism to <80% and received four azacitidine cycles (75 mg/m(2)/day for 7 days) while in complete hematologic remission. A total of 16 patients (80%) responded with either increasing CD34(+) donor chimerism to ≥80% (n=10; 50%) or stabilization (n=6; 30%) in the absence of relapse. Stabilized patients and those with a later drop of CD34(+) donor chimerism to <80% after initial response were eligible for subsequent azacitidine cycles. A total of 11 patients (55%) received a median of 4 (range, 1-11) additional cycles. Eventually, hematologic relapse occurred in 13 patients (65%), but was delayed until a median of 231 days (range, 56-558) after initial decrease of CD34(+) donor chimerism to <80%. In conclusion, pre-emptive azacitidine treatment has an acceptable safety profile and can substantially prevent or delay hematologic relapse in patients with MDS or AML and MRD after allogeneic HSCT.

[Gingival hyperplasia and visual reduction]. / Zahnfleischschwellung und Visusreduktion.

This case report describes the unilateral acute reduction of vision in the right eye of a 48-year-old woman. The patient was otherwise healthy but 2 days previously had suffered from dizziness and blurred vision. Secondary to this, the patient had already been under dental treatment for 1 week due to gingival swelling. At the first examination a macular branch retinal vein occlusion and Roth spots were found in the right eye by indirect ophthalmoscopy. The immediate diagnostic procedure identified aute amyeloid leukemia (AML) as the cause of the vascular pathology. The AML can be manifested in different ways and the retina is involved in approximately 50% of cases. Due to a secondary hyperviscosity syndrome, which is found in approx. 20% of acute leukaemias, symptomatic central vein occlusion or macular branch vein occlusion can occur. Ophthalmic symptoms can be the first and only signs to be detected. Therefore, ophthalmologists should also consider a systemic disease and initiate a clarification. A differential blood count is indispensable. The results usually improve by a rapidly arranged and suitable therapy. Ophthalmological follow-up examinations are imperative as an initiated chemotherapy can also produce ophthalmological side-effects.

[Carboxyhemoglobin concentration in carbon monoxide poisoning. Critical appraisal of the predictive value]. / Carboxyhämoglobinkonzentration bei Kohlenmonoxidvergiftung. Kritische Betrachtung der prädiktiven Aussagekraft.

In cases of unclear depression of conciousness, arrhythmia and symptoms of cardiac insufficiency inadvertent carbon monoxide intoxication should always be taken into consideration. Rapid diagnosis of acute carbon monoxide intoxication with mostly unspecific symptoms requires an immediate supply of high dose oxygen which enables a distinct reduction of mortality and long-term morbidity. Levels of carboxyhemoglobin, however, should not be used as a parameter to decide whether to supply normobaric or the more efficient hyperbaric oxygen. There is no sufficient coherence between carboxyhemoglobin blood levels and clinical symptoms. Increased carboxyhemoglobin concentrations help to diagnose acute carbon monoxide intoxication but do not allow conclusions to be drawn about possible long-term neuropsychiatric or cardiac consequences.

[A rare coagulation disorder. Diagnostics and management in cases of hereditary dysfibrinogenemia]. / Seltene Ursache einer hämorrhagischen Diathese. Diagnostik und perioperatives Management bei hereditärer Dysfibrinogenämie.

Before elective surgery, it is mandatory that a precise history be taken to detect increased hemorrhagic diathesis and that thrombocytes, Quick/INR, and aPTT be determined. If pathological levels are found, further laboratory tests are necessary after frequent causes (e.g., liver cirrhosis) have been excluded. Single-factor analysis for the von Willebrand's factor antigen and if necessary further tests to check for von Willebrand's syndrome (multimeric analysis) as well as platelet function tests should be performed.Dysfibrinogenemia is a rare coagulation disorder, which causes elevated INR. It shows a wide spectrum of clinical manifestations including thrombophilia, excessive bleeding, and even asymptomatic cases. We present a 72-year-old patient with asymptomatic dysfibrinogenemia who needed hip replacement due to arthrosis. Lowered fibrinogen levels were substituted prior to operation and the clinical course afterwards was uneventful under additional prophylactic anticoagulation in order to prevent thrombosis. The case report illustrates the interdisciplinary teamwork which is very important in the management of patients with coagulation disorders.

[Anaesthesia tube constriction. Small defect--serious effect]. / Narkoseschlauchstenose. Kleine Ursache--grobe Wirkung.

After a problem-free induction of anaesthesia for an elective aortocoronary bypass operation in a 64-year-old female patient, recurrent ventilation problems occurred. An externally intact but internally damaged anaesthesia tube caused an expiratory stenosis of varying extent. Based on this case, the safety of the algorithms for difficult ventilation, the knowledge necessary for a possible differential diagnosis, the necessity for knowledge on the alarm procedure of the anaesthesia apparatus, as well as strategies for risk reduction will be discussed.

[Cardiac arrest caused by an ecstasy intoxication]. / Hyperdynamer Kreislaufstillstand nach Ingestion von Ecstasy.

We report about a 19 years old man, suffering from an cardiac arrest (ventricular fibrillation) caused by an ecstasy intoxication. A supraventricular tachycardia was recorded on day three after resuscitation. No pathological findings were demonstrated by coronary angiography. An slow- fast- av -nodal- reentry- tachycardia (AVNRT) was detected and successfully treated by electrical ablation of the slow pathway during electrophysiological mapping. No severe neurological deficits were found in discharge from hospital.

[Treatment of emergencies in the hospital--problems and management]. / Die Behandlung von Notfällen im Krankenhaus--Probleme und Management.

Due to the growing number of high-risk patients, the increasing proportion of geriatric patients and the expansion of surgical and invasive-diagnostic procedures, medical stuff in hospitals are confronted with a rising number of emergency situations. Nearly 50% are of cardio-circulatory origin and occur during surgical interventions or immediately afterwards. Another cause of life-threatening complications are side-effects of orally or intravenously administered agents, especially after treatment with antibiotics, anaesthetics, analgetics and sedatives. Due to a lack of emergency training and management in most hospitals, the survival rate after cardiopulmonary resuscitation in general wards lies between just two and 35%. Thus it seems necessary to perform special training in CPR procedures and emergency management at regular intervals for the entire medical stuff. In addition, a special infrastructure for giving sufficient treatment in emergencies has to be established (emergency team, emergency telephone number, intra-hospital emergency car). The second part of this review presents current diagnostic and therapeutic strategies for the most common emergency situations, e.g. anaphylaxis, myocardial infarction, pulmonary embolism, gastrointestinal bleeding, and heparin-induced thrombocytopenia (HIT).

[Atraumatic retroperitoneal hemorrhage--interdisciplinary and differential diagnostic considerations based on a case report]. / Atraumatische retroperitoneale Blutungen--Interdisziplinäre und differenzialdiagnostische Uberlegungen anhand einer Kasuistik.

The differential-diagnostic strategy and the order of precedence of most diverse radiologic diagnostic procedures are discussed based on a case of retroperitoneal bleeding. Apart from iatrogen-caused bleedings, the therapeutic anticoagulant therapy in the context of the patient's disease, haemodialysis or a rare, spontaneously-occurring retroperitoneal bleeding play a substantial role. In the order of precedence of radiologic diagnostic procedures for fast diagnosis of a retroperitoneal haematoma, the abdomen CT-scan is the preferred method.

[Ulcerating Herpes simplex infections in intensive care patients]. / Ulzerierende Herpes-simplex-Infektionen bei intensivpflichtigen Patienten.

Herpes simplex infections are potentially a life-threatening situation for immunocompromised as well as critically ill patients. The correct diagnosis is made more difficult in comatose patients by the fact that the characteristic symptom of extreme pain cannot be registered. The clinical dermatological findings (polycyclic configuration, easily bleeding ulcers) are thus especially important in patients under intensive care conditions. As examples, the cases of 3 critically ill patients (subarachnoid bleeding or head injury) developing therapy-resistant, flat sacral or perioral skin ulcers with peripheral blisters are presented. Herpes simplex virus was confirmed immunohistologically and in the smear test. All patients subsequently died. These cases emphasize that patients in the intensive care unit are in danger of developing a chronic persistent Herpes simplex infection due to latent immunosuppression. Chronic persistent Herpes infections may be underrated in intensive therapy, and must always be ruled out in case of therapy-resistant erosions or ulcerations.

Iatrogenic ruptures of the tracheobronchial tree.

OBJECTIVE: Iatrogenic tracheobronchial ruptures are seldom but severe complications after intubation or bronchoscopy. Therefore, we evaluated the reasons, the subsequent therapy and the outcome of patients with tracheal rupture, who were admitted to our hospital. METHODS: In a retrospective study we examined 19 patients (15 women, four men; 43-87 years) treated for acute tracheobronchial lesions. Eleven (58%) patients had a tracheobronchial rupture by single-lumen tube, four (21%) by double-lumen tube and two patients (10%) by tracheal cannula. A total of 47% of whom were carried out under emergency conditions. Two patients had a rupture due to a stiff bronchoscopy. Mean symptoms were mediastinal and subcutaneous emphysema. Two emergency collar incisions had been done. RESULTS: The localization of ruptures was in all cases in the paries membranaceus, length: 1-7 cm (mean: 4.8 cm). The interval between the onset of symptoms and the diagnose differed widely (up to 72 h), nine (47%) diagnoses were made during intubation/bronchoscopy. One patient, with a small tear (1 cm) was treated conservatively with fibrin-glue. The other 18 patients had surgical repair through a thoracotomy. The postoperative mortality was determined with 42%, which was not dependent on the rupture but basically by the underlying diseases requiring intubation. CONCLUSIONS: Iatrogenic tracheal rupture is a dangerous complication with potentially high postoperative mortality, mostly influenced by the underlying disease. Early surgical repair must be the preferred treatment.

Electromyographic evidence of reduced muscle activity when ULF-TENS is applied to the Vth and VIIth cranial nerves.

The object of this study was to determine if the resting muscle activity of TMD patients with measured hyperactivity (EMGave > 2.0 microvolts) could be reduced by the application of ULF-TENS (Ultra-Low-Frequency-Transcutaneous Electrical Neural Stimulation) [(BioTENS) BioResearch, Inc. Milwaukee, WI]. Twenty-nine patients with resting muscle hyperactivity and ten without resting muscle hyperactivity were selected from a series of 124 consecutively diagnosed TMD patients. Electromyographic records were taken bilaterally (with the mandible at rest) from the superficial masseter, anterior temporalis, anterior digastric, and posterior temporalis muscles before and after the application of ULF-TENS. The EMG data were averaged. For the 85 muscles that were found initially to exceed the usual cutoff of 2.0 microvolts, means and standard deviations were calculated. The "before TENS" levels were: mean = 3.353 +/- 1.44227 and the "after TENS" values were: mean = 1.844 +/- 0.92421. Using a student t-test, we found the difference between the before and after levels significant (p < .0005). Additionally, means and standard deviations were calculated for each muscle (Ta, Mm, etc.) separately and also found to be significantly different (before Vs after TENS). In these "hyperactive" patients, the nonhyperactive muscles were also pooled, the means calculated before (mean = 1.21 +/- 0.456) and after (mean = 1.00 +/- 0.345) TENS and found to be significantly different (p < 0.01). For the ten patients exhibiting no muscle exceeding the 2.0 microvolt cutoff (mean = 1.08 +/- 0.415), no significant change (in levels) was observed after ULF-TENS (mean = 0.96 +/- 0.359; p > 0.88); however, when we calculated the "paired difference," we found a significant reduction, albeit very slight, in these patients' muscles, too. We conclude that ULF-TENS has an activity-reducing effect on the resting EMG levels of both hyperactive and relaxed muscles. It also appears that while the > 2.0 microvolt cutoff is useful for identifying patients that are hyperactive at rest, it does not identify complete relaxation of masticatory muscles.

Defining the cell cycle for the tachyzoite stage of Toxoplasma gondii.

Tachyzoite endodyogeny is characterized by a three phase cell cycle comprised of major G1 and S phases with mitosis following immediately upon the conclusion of DNA replication. Cytokinesis, which begins with the formation of daughter apical complexes, initiates in late S phase and overlaps mitosis. There is no evidence to support an extended G2 period in these parasites. In all strains, parasites with a 2 N DNA content are a relatively small subpopulation and when tachyzoites expressing a fluorescent nuclear marker (green-fluorescent-protein fused to proliferating-cell-nuclear-antigen) were observed by time-lapse microscopy, there appeared to be little delay between S phase and mitosis. Measurements of the DNA content of RH parasites by flow cytometry demonstrated that the G1 and S periods were approximately 60 and approximately 30% of a single division cycle, although these phases were longer in strains that display a slower growth rate. The overall length of S phase was determined by [3H]-thymidine autoradiography using transgenic parasites expressing herpes simplex thymidine kinase and validated by Northern analysis of S phase specific genes during synchronous growth. The fraction of S phase parasites by flow cytometry paralleled autoradiography, however, within S phase, the distribution of parasites was bimodal in all strains examined. Parasites containing a 1-1.7 N DNA complement were a small fraction when compared to the major S phase population which contained a near-diploid ( approximately 1.8 N) complement, suggesting parasites in late S phase have a slower rate of DNA replication. In lieu of a short or missing G2, where checkpoints are thought to operate in other eukaryotes, the bimodal replication of tachyzoite chromosomes may represent a distinct premitotic checkpoint associated with endodyogeny.

In-vivo studies do not support a major functional role for the Gly389Arg beta 1-adrenoceptor polymorphism in humans.

beta 1-adrenoceptors play a pivotal role in regulating contractility and heart rate in the human heart. Recently, a polymorphism of the beta 1-adrenoceptor has been detected: at amino acid position 389 either Gly or Arg has been found with the Gly389 exhibiting reduced responsiveness upon agonist-induced stimulation in vitro. In order to find out whether the Gly389 polymorphism exhibits blunted responsiveness also in vivo we studied, in healthy volunteers, the effects of exercise on heart rate and heart rate-corrected duration of electromechanical systole (QS2c as a measure of inotropism) which, in humans, is mediated by beta 1-adrenoceptors stimulation. Twenty-four healthy volunteers (12 female, 12 male) homozygous for the Gly389 or Arg389 exercised on a bicycle in supine position (25, 50, 75 and 100 W for 5 min each), and heart rate and QS2c were assessed; in addition, plasma renin activity (PRA) was determined which is also regulated by beta 1-adrenoceptors in humans. Exercise caused work-load dependent increases in heart rate and PRA, and shortening of QS2c; however, these changes were not significantly different between the Gly389 and Arg389 polymorphism. Thus, these three beta 1-adrenoceptor responses did not differ between volunteers with the Arg389 versus the Gly389 polymorphism. Intragroup analysis, however, revealed that exercise induced increase in heart rate and shortening of QS2c were higher in female than in male volunteers. In conclusion, our data do not support the idea that the reduced responsiveness of Gly389 against agonist-induced stimulation observed in vitro is of major functional importance in vivo.

Experiences with continuous intra-arterial blood gas monitoring.

Management of critically ill patients requires frequent arterial blood gas analyses for assessing the pulmonary situation and adjusting ventilator settings and circulatory therapeutic measures. Continuous arterial blood gas analysis is a real-time monitoring tool, which reliably detects the onset of adverse pulmonary effects. It gives rapid confirmation of ventilator setting changes and resuscitation and helps to ensure precise adjustment of therapy. In this study a newly available fiber optic sensor system has been employed for continuous intraarterial blood gas monitoring. The measurement performance was compared with a bench top blood gas analyzer. A prospective study was performed enrolling 20 patients undergoing surgery. A comparison between intermittent blood gas analyses (ABL Radiometer 610) and the results of continuous blood gas monitoring (Paratrend 7+, Agilent Technol.) was performed by simultaneous measurements. Statistical analysis in agreement with the method of "Bland and Altman" was employed. Two case reports are provided of patients with Acute Adult Respiratory Distress Syndrome and rapid changes in ventilator settings. Over a range of arterial oxygenation from 10 to 50 kPa the bias for pO2-measurement was 0.2 (limits of agreement 4), R2 = 0.9. If the arterial pO2 was higher than 50 kPa the bias was -7 (10) kPa. PCO2-measurement showed a bias of 0.25 (limits of agreement 0.45), R2 = 0.7. pH bias was -0.02 (limits of agreement 0.04), R2 = 0.7. The Paratrend 7+ sensor proved to be clinical feasible and showed an improved precision in terms of clinical situations with an arterial pO2 smaller than 50 kPa. However, the results are not much different regarding the findings with older systems consisting of hybrid technology combining optodes and electrochemical oxygen measurement. The advantages might be seen if the sensor is used for a period over several days in patients on ICU as demonstrated by the two case reports.