[CNS dysfunction as symptom of internal disease]. / Veränderungen des ZNS als Symptome wichtiger innerer Erkrankungen.

Patients with symptoms and signs of central nervous system dysfunction frequently present to outpatient clinics and emergency departments. Disturbances of consciousness and cognition, headache, vertigo, dizziness or light-headedness, seizures, hemiparesis or hemisensory deficits, and other motor dysfunctions may be due to diseases of internal medicine in up to 50% of cases apart from exclusively neurological diseases. A neurological syndrome oriented analysis of each clinical case allows the exact differential diagnosis of the causes of the disease. A combined approach of internal medicine physicians and neurologists is often warranted.

Treatment of severe nephrotic syndrome.

Treatment modalities in severe nephrotic syndrome have to consider (a) the underlying glomerular diseases as well as (b) the extrarenal complications. Occasionally acute renal failure develops on the basis of an unknown nephrotic syndrome; if a primary glomerular disease is diagnosed by biopsy, immunosuppressive therapy is optional. In type I and type II diabetes development of a severe nephrotic syndrome is usually not reversible. To avoid the rapid decline of renal function a consequent antihypertensive therapy is the treatment of choice in this stage of the disease. Treatment of primary glomerular diseases with severe (NS) includes frequently relapsing minimal change nephropathy (MCN) that can be treated with prednisolone 1 mg/kg/day until remission occurs. For prolongation of the remission cyclophosphamide 2 mg/kg/day for eight weeks, or alternatively cyclosporine A 3 to 5 mg/kg/day for six months, can be given. In steroid-resistant focal segmental glomerulosclerosis (FSGS) eight weeks of treatment with cyclophosphamide 2.5 mg/kg/day or six months treatment with cyclosporine A 3 to 5 mg/kg/day can induce a partial or complete remission in up to 20% of the patients. In membranous glomerulopathy with severe NS, one month of therapy with prednisolone followed by chlorambucil for one month (all together 6 months) improves the renal outcome of the patients compared to controls. Alternatively, cyclophosphamide 2 mg/kg/day plus 30 mg prednisolone/day can be given for a couple of months. Extrarenal complications of a severe NS are: (a) edema; (b) thromboembolism; and (c) lipid abnormalities. If nephrotic patients are resistant to orally administered loop diuretics, they should be treated in addition intravenously with hydrochlorothiazide p.o. Nephrotic patients with a serum albumin level < 20 g/liter should be routinely anticoagulated. Extensive hyperlipidemia in severe NS can be treated with HMG-CoA reductase inhibitors.

Computed tomography in the determination of leg geometry.

In 286 adults with misalignment of the lower limb the length and torsional angles of the femur and tibia were determined using a method based on computed tomography. Depending on the location of the axial scan values for femoral antetorsion changed substantially. Normal values obtained in non injured extremities by this technique were an internal torsion of 23.5 +/- 8.6 degrees (mean +/- SD) in the femur and an external torsion of 34.9 +/- 8.6 degrees in the tibia. Mean intraindividual side differences in the femur and tibia were 4 degrees, the 95% confidence interval was 11.0 degrees in the femur and 12.3 degrees in the tibia. CT-methods can only be used for the determination of torsional angles in the femur and tibia if reproducible and standardized locations for the acquisition of axial scans are defined.