Color-coded duplex endoscopic ultrasound of the adrenals.

Imaging of the adrenals by endoscopic ultrasound (EUS) is a valuable technique for detection and localization of adrenal lesions, but endosonomorphological tumor distinction remains difficult. In this single-center study, the amount of blood flow in common adrenal lesions, such as adrenal adenomas, adrenal hyperplasia, and pheochromocytomas, was visualized by color-coded duplex EUS (CD-EUS) and was retrospectively analysed. Therefore, we reviewed our EUS database to evaluate and correlate the perfusion patterns of common adrenal lesions with histologically confirmed diagnosis, possible malignancy, and endosonomorphological features such as echogeneity, echostructure, and tumor size. CD-EUS was performed using an endosonoscope Pentax FG 32 UA with a longitudinal 7.5 MHz sector array and Hitachi EUB 525 ultrasound system. In 38 consecutive patients (male=19; female=19; age: mean 53+/-16 yr SD), perfusion patterns of 46 histologically confirmed adrenal, para- or extra-adrenal lesions of adrenal origin (adenoma: no.=20; nodular hyperplasia: no.=11; pheochromocytoma: no.=15; diameter 26+/-15 mm, range 6-70 mm) were analyzed and classified semiquantitatively as "not" (no.=24), "slightly" (no.=12), "moderately" (no.=4) or "highly" (no.=6) hypervascularized. Compared to adenomas (p=0.003) and nodular hyperplasia (p=0.047), pheochromocytomas showed a significantly higher grade of perfusion. There was no relationship between perfusion patterns and localization of pheochromocytomas (adrenal: 8; paraadrenal: 3; extra-adrenal: 4). Vascularization was not statistically associated with tumor echogeneity, echostructure, malignancy or tumor size. CD-EUS is an additional tool for adrenal endosonographic tumor distinction and seems to improve the endosonographic detection of pheochromocytomas by visualization of hypervascularization. As an overlap of perfusion patterns exists, CD-EUS findings must be interpreted in the context of clinical, laboratory and chemical results.

Short stature and decreased insulin-like growth factor I (IGF-I)/growth hormone (GH)-ratio in an adult GH-deficient patient pointing to additional partial GH insensitivity due to a R179C mutation of the growth hormone receptor.

OBJECTIVE: Genetic factors play an expanding role in understanding growth hormone (GH) disorders, therefore the German KIMS Pharmacogenetics Study was initiated with the aim of genotyping various GH-/IGF-I-axis-related genes of GH-deficient adult patients to investigate genotype:phenotype relationships and response to GH therapy. PATIENTS AND METHODS: 129 consecutively enrolled GH-deficient adult patients were genotyped for variant 1 (V1) of the alternatively spliced noncoding exons in the 5'-untranslated region and for the nine coding exons of the GH receptor (GHR) gene, which obviously play a striking role in the function of the GH-IGF-I-axis. After detection of a heterozygous, non-synonymous mutation R179C in exon 6 in one single patient with acquired GH-deficiency (GHD) in late adulthood, analysis of her clinical data followed, leading to the diagnosis of mild short stature (-1.5SD). For further endocrine evaluation, five pituitary stimulation tests (arginine) of this patient were statistically compared to stimulation tests (arginine) of ten GH-deficient control patients, retrospectively. RESULTS: The formerly in patients with Laron syndrome and idiopathic short stature reported mutation R179C leads to an amino acid change from an arginine residue (codon CGC) to a cysteine residue (codon TGC) in position 179 of the extracellular domain of the GHR. Statistical analysis revealed significant decreased IGF-I/GH(0) ratio (p=0.004) and IGF-I/GH(max) ratio (p=0.001) of the index patient compared to the control patients, implying growth hormone resistance of the index patient at the level of the GHR, according to the detected R179C mutation. CONCLUSIONS: This study reports on the unusual case of a patient with mild short stature, who acquired GHD in late adulthood due to a non-secreting pituitary adenoma and get additionally diagnosed for pre-existing growth hormone insensitivity due to a formerly in two short statured patients described, single, heterozygous, non-synonymous mutation in the GHR. Our findings support the theory that heterozygous mutations in the GHR gene can have mild phenotypical consequences.

Antidiabetic medications in overdose: a comparison of the inquiries made to a regional poisons unit regarding original sulfonylureas, biguanides and insulin.

OBJECTIVE: The drugs most commonly used to treat diabetes mellitus are sulfonylureas, biguanides and insulin. The most serious effects seen in overdose with these agents are hypoglycemia or lactic acidosis which may be fatal or cause cerebral defects. The present investigation analyzes inquiries made to a regional poisons unit involving overdoses with sulfonylureas, biguanides and insulin. PATIENTS AND METHODS: A total of 218,070 made inquiries between 1995 and 2004 were evaluated. The inquiries were received by telephone and a standardized questionnaire was sent subsequently to the physicians calling for follow-up information. The cases were analyzed with regard to gender, age, etiology, symptoms and clinical outcome. RESULTS: 263 inquiries concerning sulfonylureas (48.3% female, 49.4% male, 2.3% sex unknown, average age 39.1 +/- 26.8 years), 172 concerning biguanides (60.5% female, 37.2% male, 2.3% sex unknown, average age 41.5 +/- 24.1 years), and 191 concerning insulin (53.9% female, 41.9% male, 4.2% sex unknown, average age 44.6 +/- 16.7) were made. In cases involving sulfonylureas, the etiology was deliberate self-poisoning in 62.7% and accidental in 31.9% (biguanides 60.5% and 29.1%, insulin 85.3% and 9.4%). Using the Poisoning Severity Score, no symptoms were observed in 41.4% of the patients with sulfonylurea overdose (biguanides 40.1%, insulin 22.5%), minor symptoms in 37.6% (biguanides 32.6%, insulin 33.5%), major symptoms in 14.4% (biguanides 13.4%, insulin 26.2%) and serious symptoms in 4.6% (biguanides 12.2%, insulin 14.7%). Returned questionnaires reporting clinical outcomes showed that a full recovery occurred in most patients (sulfonylureas 97.4%, biguanides 93.0%, insulin 94.4%), cerebral defects persisted in 1.8% of the cases involving sulfonylureas (biguanides 1.5%, insulin 2.4%), and that 0.9% of the patients with sulfonylurea overdose died (biguanides 6.1%, insulin 3.6%). CONCLUSIONS: Sulfonylureas were the most frequently observed medication in cases of overdose with antidiabetic agents. Insulin overdose caused the highest number of major and serious symptoms. Overdose with biguanides led to the most deaths.

[Drug poisonings in childhood at a regional poisons unit]. / Intoxikationen mit Medikamenten im Kindesalter bei einem regionalen Giftinformationszentrum.

BACKGROUND: Drug poisonings in childhood account with about one fourth for the most important group of poisonings in this age group. METHOD: From 1995 to 2004 the inquiries to a poison centre regarding drug poisonings of children < or = 6 years of age were analyzed. Additionally, a standardized questionnaire was sent for follow-up information. RESULTS: During the study period a total number of 17 553 cases of drug poisonings in childhood was determined and follow-up information was obtained for 8 590 cases (48.9 %). Boys were more likely to be affected (53.4 %) and most children were between 2 and 4 years of age (57.5 %). Mostly oral contraceptives, homeopathic drugs, nonsteroidal anti-inflammatory drugs, sodium fluoride and paracetamol were ingested. In 97.8 % of the reported cases none or minor symptoms and in 1.5 % medium or major symptoms (1 death) were observed. In the latter group of patients mostly neuroleptics, antihistaminics, nonsteroidal anti-inflammatory drugs, beta2-sympathomimetics and paracetamol were ingested. In most cases the application of fluids (47.3 %) or activated charcoal (32.0 %) was sufficient. CONCLUSIONS: Severe symptoms have rarely been observed in drug poisonings and in most children a treatment by non-professionals was sufficient. Most frequently activated charcoal was currently used for primary poison elimination. We suggest an early involvement of a poison centre in drug intoxications.

Epidemiology of hydrogen phosphide exposures in humans reported to the poison center in Mainz, Germany, 1983-2003.

BACKGROUND: Poisonings with rodenticides containing hydrogen phosphide-releasing compounds may lead to deleterious organ dysfunction and death. Since data of hydrogen phosphide poisonings is limited to case reports/series, this study was intended to elucidate hydrogen phosphide poisonings based on a 20-year data collection. METHODS: Explorative data analysis of the Poison Center Mainz database looking for route of exposure, symptoms, and severity using the Poisoning Severity Score. RESULTS: From 1983-2003, 188 hydrogen phosphide poisonings were reported. Sixty-five percent of these were unintentional residential, 28% attempts to commit suicide (intentional), 5% occupational, and 2% undetermined. In the majority of intentional poisonings the poison was ingested, whereas in unintentional poisoning of adults inhalation exposure dominated, caused by inappropriate self-protection from the released hydrogen phosphide gas during usage. Frequently observed symptoms in unintentional poisonings were nausea, vomiting, pain, coughing, and dizziness with no further worsening of symptoms. In intentional poisonings frequent symptoms were vomiting, somnolence, seizures, coma, and shock with two initially fatal poisonings. Follow-up on these cases showed a significant worsening of symptoms and a two-fold increase in fatal poisonings. CONCLUSION: Route of exposure, severity of symptoms, and the necessary treatment differs substantially between unintentional and intentional poisonings. In this study, two initially symptomatic intentional poisonings were later reported fatal. Careful monitoring is recommended in symptomatic intentional poisonings.

[Systemic fibrinolytic therapy using urokinase in central retinal artery occlusion. A case study]. / Systemische fibrinolytische Therapie mit Urokinase bei Zentralarterienverschluss der Netzhaut. Eine Fallstudie.

BACKGROUND AND OBJECTIVE: Systemic fibrinolysis has become an important therapeutical option in patients with thrombotic occlusion of coronary or pulmonary arteries. In view of the hemorrhagic risk systemic fibrinolytic therapy for retinal vessel occlusion has been discussed controversial. In the present case study results and complications of systemic fibrinolysis should be investigated in patients with central retinal artery occlusion. PATIENTS AND METHODS: From 1995 to 2002 a case series of 19 consecutive patients (8 female, 11 male, age: 63.2+/-14,3 years) with central retinal artery occlusion were treated by systemic application of urokinase using a standardized scheme. The latency from initial symptoms until the initiation of therapy and the medical history of the patients were documented. Visual acuity was determined on admission and before discharge and possible complications were documented. Additionally, screening investigations for genetic thrombophilia were performed. RESULTS: 15 patients showed an improvement of the visual acuity (79 %, 95 %-KI: 54 %-94 %). For 3 patients no improvement and for one patient a decrease of the visual acuity was determined. Hemorrhagic complications were observed in two patients (11 %, 95 %-KI: 1 %-33 %). As these minor bleedings were self-limiting the fibrinolytic therapy was discontinued only in one patient. As risk factors most commonly arterial hypertension (68 %) and smoking (26 %) were identified. In 4 patients a genetic thrombophilia was diagnosed. CONCLUSIONS: Considering the poor prognosis of central retinal artery occlusion and the disappointing results of conservative treatment, an improvement of the visual acuity in the absence of critical complications was observed with systemic fibrinolytic therapy in the presented case study. However, only controlled trials can provide proof for the effect of fibrinolysis versus spontaneous improvement.

Experiences of a poison center network with renal insufficiency in acetaminophen overdose: an analysis of 17 cases.

OBJECTIVE: Renal insufficiency is less common than liver failure in acetaminophen overdose but renal tubular damage occurs even in the absence of hepatotoxicity. Data published on this topic are rare consisting mostly of case reports or reports in a small number of patients. Presently, a larger number of patients with renal insufficiency associated with acetaminophen overdose should be analyzed using a multicenter approach. STUDY DESIGN: Retrospective analysis of patients with acetaminophen-related nephrotoxicity reported to a poison center network from 1995 to 2003. Renal insufficiency was defined as elevated serum creatinine of more than double of the normal range (>2.4 mg/dL [212 micromol/L]). Patients were classified into 4 groups (A: creatinine 2.4-5.0 mg/dL, B: creatinine>5.0 mg/dL requiring no dialysis, C: creatinine>5.0 mg/dL requiring dialysis, D: creatinine>5.0 mg/dL with fatal outcome). RESULTS: Seventeen patients were included (8 female, 9 male, average age 31.7 +/- 21.1 yrs) with 6 patients in group A (B: 7, C: 2, D: 2). In 5 patients renal insufficiency occurred without elevation of liver enzymes. Regarding possible risk factors 5 patients concomitantly ingested nephrotoxic substances, 4 presented with dehydration due to vomiting, 4 with chronic excessive dosing (overdose) of acetaminophen, 3 showed pre-existing renal insufficiency, 2 pre-existing liver disease and 2 died with multiple organ failure. CONCLUSIONS: Renal insufficiency in acetaminophen overdose mostly resolved without dialysis and occurred isolated without hepatotoxicity in less than one-third of the investigated patients. Conditions which might play a role as influencing factors for renal complications included concomitant ingestion of nephrotoxic drugs, dehydration, chronic excessive dosing (overdose) of acetaminophen, pre-existing renal or liver disease and multiple organ failure. Renal function should be monitored in acetaminophen overdose particularly in patients showing the latter comorbidity.

Subacute coronary stent thrombosis in a patient developing clopidogrel associated thrombotic thrombocytopenic purpura.

Clopidogrel, in combination with aspirin, is commonly used for the prevention of thrombosis in patients who have received coronary artery stents. As a rare but critical complication, clopidogrel associated thrombotic thrombocytopenic purpura (TTP) has previously been described. A 78 year old man presented with unstable angina and filiform subtotal stenosis of the left anterior descending artery. He was treated with balloon angioplasty and stent implantation. After four days the patient again had angina caused by stent thrombosis, which was treated with balloon angioplasty. During hospital stay the typical course of clopidogrel associated TTP was observed with thrombocytopenia and petechial purpura occurring 14 days after drug initiation and prompt response to therapeutic plasma exchanges. These findings strongly suggest that clopidogrel may have increased platelet activation and aggregation in this immunologically susceptible patient, ultimately leading to a stent thrombosis.

Stem cell factor receptor KIT (CD117) in aseptic hip prosthesis loosening.

OBJECTIVE: This study aimed to investigate specific inflammatory pathomechanisms, i.e. the expression of the stem cell factor receptor KIT (CD117) in tissue specimens from patients with aseptic hip prosthesis loosening (AHPL) with special emphasis on colocalization with the mast cell specific marker tryptase. METHODS: Immunohistochemical analysis of CD117 was performed in tissue specimens from 10 patients with aseptically loosened acetabular components of failed non-cement total hip replacements and compared to control samples obtained at primary hip surgery (n=4). The CD117 expressing cells were characterized further with mast cell tryptase (MCT) by serial section analysis and a double staining method. CD117 and MCT expression was examined by semi-quantitative analysis. Additionally, double labeling of the CD117 or MCT expression by immunohistochemistry and of polyethylene (PE) particles by Oil Red reaction was performed. RESULTS: In AHPL, CD117 was almost exclusively detected in MCT positive cells. Co-expression tended to be highly correlated (r=0.86, p<0.01). CD117 was found mainly in two regions: first, in perivascular lymphocyte-rich areas and; secondly, near macrophages and multinucleated giant cells (MGC). PE particles were not detected in CD117 and MCT positive cells. In control samples, CD117/MCT positive cells were less frequent. CONCLUSION: This is the first report on CD117 expression in AHPL. CD117 is almost exclusively expressed in a distinct mast cell subgroup. As an important growth factor receptor, CD117 could play a major role in recruitment and activation of mast cells in AHPL. Furthermore, mast cells do not contain significant amounts of PE particles. However, it remains to be investigated whether this cell population could influence phagocytosis of PE particles. (Journal of Applied Biomaterials and Biome-chanics 2005; 3: 11-7).

Hepatocytes cultured in alginate microspheres: an optimized technique to study enzyme induction.

An important application of hepatocyte cultures is identification of drugs acting as inducers of biotransformation enzymes that alter metabolic clearance of other therapeutic agents. In the present study we optimized an in vitro system with hepatocytes cultured in alginate microspheres that allow studies of enzyme induction with excellent sensitivity. Induction factors obtained with standard inducers, such as 3-methylcholanthrene or phenobarbital, were higher compared to those with conventional hepatocyte co-cultures on collagen coated dishes. This is illustrated by activities of 7-ethoxyresorufin-O-deethylase (EROD) after incubation with 5 microM 3-methylcholanthrene (3-MC), a standard inducer for cytochrome P4501A1 and 1A2. Mean activities for solvent controls and 3-MC exposed cells were 2.99 and 449 pmol/min/mg protein (induction factor: 150) for hepatocytes cultured in microspheres compared to 2.72 and 80.6 pmol/min/mg (induction factor: 29.6) for hepatocytes on collagen coated dishes. To compare these in vitro data to the in vivo situation male Sprague Dawley rats, the same strain that was used also for the in vitro studies, were exposed to 3-MC in vivo using a protocol that guarantees maximal induction. Activities were 29.2 and 1656 pmol/min/mg in liver homogenate of solvent and 3-MC treated animals (induction factor: 56.7). Thus, the absolute activities of 3-MC exposed hepatocytes in microspheres are lower compared to the in vivo situation. However, the induction factor in vitro was even higher compared to the in vivo situation (150-fold versus 56.7-fold). A similar scenario was observed using phenobarbital (0.75 mM) for induction of CYP2B and 3A isoenzymes: induction factors for testosterone hydroxylation in position 16beta were 127.5- and 50.4-fold for hepatocytes in microspheres and conventionally cultured hepatocytes, respectively. The new in vitro system with hepatocytes embedded in solid alginate microspheres offers several technical advantages: (i) the solid alginate microspheres can be liquefied within 60s, allowing a fast and complete harvest of hepatocytes; (ii) alginate capsules are stable allowing transport and mechanical stress; (iii) high numbers of hepatocytes can be encapsulated in short periods; (iv) defined cell numbers between 600 hepatocytes, the approximate number of cells in one capsule, and 18 x 10(6) hepatocytes, the number of hepatocytes in 6 ml alginate, can be transferred to a culture dish or flask. Thus, encapsulated hepatocytes allow a flexible organization of experiments with respect to cell number. In conclusion, we optimized a technique for encapsulation of hepatocytes in alginate microspheres that allows identification of enzyme induction with an improved sensitivity compared to existing systems.

Changes in bone mineral content after surgical treatment of morbid obesity.

Weight loss reduces bone mass and increases the risk of osteoporosis. This study was undertaken to assess changes of bone metabolism following Roux-en-Y gastric bypass (RYGB) and adjustable silicone gastric banding (ASGB) as compared to nonoperated controls of morbidly obese subjects. Fourteen female and 5 male patients with a mean (+/-SEM) age of 44.3 +/- 1.8 years participated in the 24-month prospective study. Nine patients underwent ASGB, 4 patients RYGB operation, and 6 patients were included in the control group. Bone metabolism was assessed by determination of serum parathyroid hormone (PTH), osteocalcin, urinary deoxypyridinoline, and dual energy x-ray absorptiometry (DXA) before, and 6, 12, and 24 months after intervention. The body mass index (BMI) decreased from 41.0 +/- 1.1 to 34.0 +/- 1.4 kg/m2 in the ASGB group (P = .001), from 42.7 +/- 2.2 to 30.5 +/- 2.2 kg/m2 in the RYGB group (P = .006), and remained unchanged in the control group (from 41.2 +/- 1.2 to 41.4 +/- 1.4 kg/m2) after 24 months. Bone mineral content (BMC) showed no significant change in the ASGB group (from 3,079 +/- 140 to 3,064 +/- 129 g) and in the control group (from 2,945 +/- 130 to 2,940 +/- 111 g), whereas it decreased from 2,968 +/- 111 to 2,621 +/- 139 g in the RYGB group (P = .005). The loss in BMC was accompanied by significant increases in urinary deoxypyridinoline (P < .05) and in serum osteocalcin (P < .01) after RYGB, suggesting both, increased bone resorption and increased bone formation. The authors were aware of the fact that the study groups were small and conclusions need to be regarded as preliminary. However, the RYGB operation resulted in enhanced weight loss and significant net loss of bone mass in comparison to ASGB and obese control subjects. Patients losing large amounts of body weight should be monitored regularly regarding prevention of osteoporosis.

Epidemiological assessment of 160 cases of insulin overdose recorded in a regional poisons unit.

OBJECTIVE: Overdoses with insulin are common, and cases of hypoglycemic coma can be fatal and cause cerebral defects. However, data published on this topic are rare, consisting mostly of case reports or reports in a small number of patients. The present investigation analyzes inquiries made to a regional poisons unit involving overdoses with insulin. PATIENTS AND METHODS: A total of 175,890 inquiries for the years 1995-2003 (until September) were evaluated. 160 inquiries were received by telephone concerning insulin overdoses, and a standardized questionnaire was sent to the physicians asking for follow-up information. The cases were analyzed in regard to etiology, type of insulin used, concomitant substances being taken by the patient, symptoms and clinical outcome. RESULTS: Of the 160 inquiries investigated, 53.1% of the patients were female, 43.1% male and in 3.8% the sex of the patient was unknown. The average age was 44.7 years. 89.4% involved suicidal or parasuicidal cases, 5.0% were accidental overdoses and 1.9% involved cases of criminal overdose (3.7% were for other reasons). Rapidly acting insulins (57.8%) were used more commonly than long-acting formulations (42.8%). Benzodiazepines were the most frequently ingested concomitant medication (37.5%) with ethanol 15.6%, antihypertensive drugs 12.5% and antidepressants 10.0%. Most patients presented with a delay of 2-3 hours after insulin administration (15.0%). Almost 50% of the patients presented within the first 6 hours. According to the Poisoning Severity Score, no symptoms were observed in 16.8% of the patients, minor symptoms in 36.8%, major symptoms in 25.2% and serious symptoms in 21.3%. Information concerning the clinical outcome (75 cases) showed that a full recovery occurred in most patients (94.7%), but in 2.7% there were cerebral defects and 2.7% of the patients died. CONCLUSIONS: The etiology of overdoses with insulin was mainly deliberate self-poisoning. Physicians should take into account that long-acting insulin formulations and concomitant substances were frequently used. For overdoses with insulin, relatively high rates of serious symptoms and deaths were observed.

Experiences of a poison center with metformin-associated lactic acidosis.

Metformin is widely used in the treatment of type 2 diabetes, though it is recognized to be associated with the risk of lactic acidosis. A case of pronounced lactic acidosis with cardiac arrest (pH 6.60, lactate 17.5 mmol/l, base excess - 30, standard bicarbonate 2.5 mmol/l, core body temperature 27.8 degrees C) is presented in a 61-year-old woman under metformin therapy. The key laboratory abnormalities observed during the intensive care treatment including repeated hemodialysis are described. The patient showed a complete recovery with residually reduced mental capabilities. Furthermore, an explorative data analysis of our poison center database from 1995 until 2003 concerning metformin was performed. In 109 inquiries for metformin a lactic acidosis (mean pH 6.87 +/- 0.11, mean lactate 20.9 +/- 8.1 mmol/l) was present in 14 cases (9 female, 5 male, average age 57.7 years) with 8 patients under regular metformin therapy and 6 patients who ingested large amounts of metformin to attempt suicide. 4 patients did not survive the severe metabolic disturbance. The present report demonstrates that metformin-associated lactic acidosis is a rare but critical complication of metformin therapy of type 2 diabetes as well as in acute suicidal ingestion of metformin. Early diagnosis and rapid correction of the metabolic acidosis using hemodialysis provides the possibility of a positive outcome even in severe cases. If metformin-associated lactic acidosis is suspected we recommend early involvement of a poison center.

Epidemiology of cardiac dysrhythmias in acute intoxication.

Cardiac dysrhythmias are common in acute intoxications. However, epidemiological data is rare and restricted to specific substances. From 1995 to 2003 (until September) 91 285 inquiries of physicians and paramedics to a poison center regarding acute intoxications were analyzed revealing 9888 patients (10.8%) suffering from disturbances of the cardiac rhythm. In a first step of the explorative data analysis dysrhythmias were graduated into three categories (I: tachycardia/bradycardia; II: arrhythmia/conduction disorder; III: ventricular dysrhythmia/cardiac arrest) and the frequencies of the involved substances were determined. In a second step substances which resulted to be of significant interest were investigated for their specific pattern of dysrhythmias. For category I (n = 8730) predominantly tricyclic antidepressants, neuroleptics, benzodiazepines, betablockers, and nonsteroidal antiinflammatory drugs were registered (II: [n = 949] tricyclic antidepressants, digitalis glycosides, benzodiazepines, neuroleptics, Ca antagonists; III: [n = 209] tricyclic antidepressants, neuroleptics, sotalol, ethanol, central nervous system stimulants). Tricyclic antidepressants resulted in 23.4% of the reported cases in symptoms of category I (II: 2.3%, III: 0.6%; n = 8535). The highest rates of dysrhythmias were observed for sotalol (I: 34.7%, II: 21.6%, III: 8.0%; n = 176) as compared to the lowest rates found for paracetamol (I: 5.2%, II: 0.3%, III: 0.1%; n = 6429). The present investigation provided a comprehensive clinical overview about the frequency of dysrhythmias and involved substances during acute poisonings in emergency medicine. Furthermore, the specific effects of selected substances concerning dysrhythmias could be determined in view of a clinical database.

Size of pancreatic islets of Langerhans: a key parameter for viability after cryopreservation.

Large amounts and excellent viabilities of pancreatic islets are prerequisites for recent advances in islet transplantation. Cryopreservation has been shown to enlarge transplanted cell mass, but has been accompanied by reduced viability. In this study rat pancreatic islets were differentiated into small (<200 micro m), medium (200-400 micrometers) and large (>400 micrometers) categories and their susceptibilities to different freezing conditions were evaluated: concentration of cryoprotectant (0.7-3.1 M), equilibration (15 vs. 45 min, 22 degrees C vs. on ice) and post-thaw removal of cryoprotectant (15 vs. 30 min, stepwise vs. one-step). The most prominent finding was a negative correlation between islet size and viability observed in non-frozen islets to a minor degree (r=-0.44) and significantly enhanced after cryopreservation (r<-0.8). The concentration of cryoprotectant showed the most significant influence on viability affecting small, medium and large islets. Different techniques of equilibration with the cryoprotectant resulted in significant changes of islet viability of medium islets, whereas small and large islets were unaffected. For different techniques of removal of the cryoprotectant, no significant influence on viabilities was found. We conclude that large islets represented a highly susceptible population concerning damage due to cryopreservation.

[Endosonographically controlled transluminal fine needle aspiration biopsy: diagnostic quality by cytologic and histopathologic classification]. / Endosonographisch gesteuerte transluminale Feinnadelpunktion: Untersuchung zur diagnostischen Qualität.

BACKGROUND AND OBJECTIVE: EUS-guided fine needle aspiration (EUS-FNA) has emerged as a highly accurate technique for detecting and classifying mediastinal and pancreatic lesions as well as abdominal and recently retroperitoneal masses with a minimum of risk for the patient. PATIENTS AND METHODS: To objectify these statements, we evaluated the quality of 72 EUS-FNA specimens by cytologic and histopathologic classification, investigated their contamination with tissue from the needle pathway and observed puncture-related complications in a retrospective study of 44 EUS-FNA in 41 consecutive patients (56 +/- 14 years, m = 24, f = 17; 13 pancreatic, 9 adrenal, 6 abdominal and 13 mediastinal masses). EUS-FNA was performed using a PENTAX 32 UA endosonoscope (longitudinal 7.5 MHz sector array) in combination with a needle system type "Hancke-Vilmann". RESULTS: 16 vs. 11 of 34 histopathologic and 38 cytologic specimens were classified "excellent", 7 vs. 10 "sufficient", 7 vs. 13 "poor" and 4 vs. 4 "failed". Analysis of contamination with tissue from the needle pathway showed 4 vs. 2 specimens "highly", 3 vs. 14 "clearly", 8 vs. 19 "slightly" and 19 vs. 3 "not" contaminated. Specimens classified "excellent" were less contaminated (p = 0,037). EUS-FNA identified 35 benign and 24 malignant masses. Definite diagnosis failed in 13 specimens. One nonfatal complication occurred. EUS-FNA is an accurate (89 %) and low-risk procedure to examine primary undiagnosed mediastinal, pancreatic, intraabdominal and especially adrenal lesions in most of the cases. Contamination with tissue from the needle pathway seems to be a major predictive factor of poor specimen quality and failed diagnosis. CONCLUSION: EUS-FNA expands the diagnostic approach of mediastinal, abdominal, pancreatic and adrenal masses and provides accurate specimens for reaching new differential-diagnostic competence, especially in endocrinologic cases.

[Fulminant pulmonary edema in falciparum malaria [corrected]]. / Fulminantes Lungenödembei Malaria tropica.

HISTORY AND ADMISSION FINDINGS: A 54-year-old man was admitted because of intermittent fever for 2 days. Ten days earlier he had returned from Kenya. He had not taken any antimalarial drugs prophylactically. INVESTIGATIONS: Initial blood smears showed Plasmodium falciparum in 10.4% of erythrocytes. Laboratory tests indicated hyponatremia and disseminated intravascular coagulation. Also, laboratory markers of infection and hemolysis were clearly positive and accompanied by a low-grade normocyticanaemia. Chest radiograph showed the heart size to be at the upper limit of normal and no signs of congestion, pleural effusion or inflammatory infiltrates. Sonography demonstrated hepatosplenomegaly with diffusely increased echogenicity of the liver. TREATMENT AND COURSE: Falciparum malaria [corrected] with quartan fever was diagnosed and treatment with quinine and doxycycline was initiated. Despite the successful elimination of parasites and a negative fluid balance the patient died two days after admission from pulmonary edema and heart failure. CONCLUSIONS: A negative fluid balance failed to prevent acute pulmonary edema in this case of severe malaria,supporting the view that fluid imbalance is not an essential feature in malaria-induced lung injury and that cytokines play and important role.

[Deliberate self-poisoning with paracetamol (acetaminophen): an analysis from 1995 to 2002]. / Suizidale und parasuizidale Intoxikationen mit Paracetamol - Eine Analyse von 1995 bis 2002.

BACKGROUND AND OBJECTIVE: Paracetamol is frequently used in deliberate self-poisoning resulting in a major risk for the patients due to its dose-dependent hepatotoxicity. In the present study the cases of intoxications consulting our Poison Center should be analysed illustrating recent results and trends. PATIENTS AND METHODS: From 38 065 patients (25 098 female, 12447 male, 520 sex unknown, average age 36.8 years) registered during the study period from 1.1.1995 until 31.5.2002 4021 with paracetamol intoxication were analysed with respect to the ingested dose, concomitant substances, the degree of observed symptoms and the length of hospital stay. RESULTS: The use of paracetamol in deliberate self-poisoning continuously increased during the study period from 8.9 % in the year 1995 to 12.4 % in 2002. Paracetamol was mainly used from female patients and patients in the age group between 10 and 29 years. 88.6 % of cases were reported to the poison center within the first twelve hours after ingestion. Concomitantly non-steroidal antirheumatics (38.0 %), ethanol (20.6 %) and antibiotics (15.0 %) were ingested. Monointoxications as well as mixed intoxications with paracetamol caused severe intoxications and deaths less frequently as compared to the group of the remainder substances with the degree of symptoms tended to be dose-dependent. In 73.7 % of cases the length of hospital stay did not exceed 3 days. CONCLUSIONS: In recent years, an increasing importance of paracetamol in deliberate self-poisoning was determined particularly concerning female and younger patients. The dose of paracetamol and the duration of exposition are crucial for prognosis. With an early antidote therapy hospitalization is usually observed for a few days only. A risk for complications are frequently used concomitant substances requiring a detailed registration.