Medizinische Klinik最新文献

Background: Infections by cytomegalovirus (CMV) cause substantial morbidity and mortality in immunocompromised patients, whereas immunocompetent individuals generally experience mild disease or remain asymptomatic.

Case report: A 54-year-old immunocompetent man undergoing CMV mononucleosis and hepatitis after primary infection is reported. Symptoms were pronounced with considerably reduced general condition and sustained highly febrile temperatures. Only therapy with intravenous ganciclovir led to rapid resolution of the disease. A second case describes a 31-year-old woman who, having had contact with a CMV-infected infant, developed a mononucleosis-like illness during her pregnancy. Due to the risk of congenital CMV infection, the exclusion of CMV-caused infection or the discrimination between primary and secondary infection is of particular importance, and the second case illustrates the relevant diagnostic difficulties and pitfalls.

Conclusion: As demonstrated by the two cases, even in immunocompetent patients and pregnant women CMV should be considered in the differential diagnosis of symptomatic viral infections. Particularly during pregnancy and after organ transplantation, early diagnosis and prognostic markers are necessary because of possible severe complications such as congenital CMV infection and organ transplant failure.

Access to health care always has been one of the most critical issues for offshore crews. Therefore, telemedicine has a long and outstanding tradition in the maritime environment. Since 1931 Cuxhaven medical center (Medico Cuxhaven) operates as a hospital-based radio medical advice center (RMA) for ships worldwide providing one of the first routine telemedical services worldwide. For a long time this task was performed on a honorary basis by the hospital's physicians. In 1994 Germany accepted the IMO/ILO (International Maritime Organisation and International Labour Organisation) solution 164. Therefore, in 1998 a formal contract of the German Ministry of Transport officially installed Medico Cuxhaven as the TMAS Center for Germany. According to IMO/ILO solution 164, the RMA provides an expert level of care 24 h/day, 365 days/year. Cuxhaven hospital is a busy general hospital with departments of anesthesia and intensive care, internal medicine, surgery, gynecology and obstetrics, urology, pediatrics, ENT, radiology, and pain medicine. All physicians directly responding to TMAS calls have practical experience in maritime routine and emergency medicine. All incoming emergency calls are primarily handled by board-certified anesthesiologists, experienced in martime emergency medicine (e. g., staffing coastal SAR helicopters, working on rescue boats, carrying out repatriation services for sailors worldwide). If needed, other medical specialists are included. Today, Medico Cuxhaven takes an average workload of one to two emergency calls (response time < 20 s), two to three follow-up calls and approximately one informative call per day. Since 2000 transmission of digital photos has been used for routine RMA. Recently, a system for online and trenddata telemetry of twelve-lead ECG, NIBP (noninvasive blood pressure measurement), CO(2), SaO(2), pulse and respiration rates including the transmission of video images was developed. This system allows worldwide communications as it is capable of all possible means of telecommunication such as GSM, Inmarsat-ISDN or Iridium-Satellite-Transmission. So far, this system has been installed on board several German SAR rescue boats.However, radio telephone and the simple transmission of digital photography remain the basis of maritime radio medical advice service.

Extraintestinal manifestations of Crohn's disease and ulcerative colitis are found in > 50% of all patients. These extraintestinal manifestations sometimes impair the overall life quality much more than the bowel-related symptoms. Extraintestinal manifestations need to be distinguished from secondary diseases or complications of inflammatory bowel diseases, as they require a different and specific therapy. Complications of the intestinal disease, such as vitamin deficiency or osteoporosis, can be treated specifically by substitution of vitamin D, calcium, or other vitamins. However, extraintestinal manifestations of Crohn's disease and ulcerative colitis, such as primary sclerosing cholangitis, arthritis or granulomatous inflammation of the skin, lung, or liver, are much more difficult to treat sufficiently. Almost every organ can be a localization of extraintestinal symptoms of inflammatory bowel diseases. It is important to acquire knowledge on these extraintestinal manifestations of Crohn's disease and ulcerative colitis to start the respective treatment early. Perhaps even more important, these extraintestinal symptoms can be the primary manifestation of Crohn's disease and ulcerative colitis. Therefore, they have to be recognized as extraintestinal manifestations to adequately treat the intestinal disease.

Background: Systemic mastocytoses are a group of diseases, which are characterized by accumulation and unusual growth of mast cells infiltrating two different organs or types of tissue. Two case reports are introduced.

Classification: According to the new WHO classification of 2000, mastocytoses are separated into cutaneous and systemic mastocytoses. Systemic mastocytosis is subdivided into an indolent course with good prognosis and four subgroups with poor prognosis (systemic mastocytosis with associated clonal hematologic non-mast-cell disease, aggressive systemic mastocytosis, mast cell leukemia, and mast cell sarcoma).

Genetics: Systemic mastocytoses are clonal disorders of mast cells and their progenitor cells, which may show point mutations of the protooncogene c-kit. This gene codes for the stem cell receptor (CD117).

Therapy: Therapy of systemic mastocytosis depends on patient's symptoms. There is no known cure of the disease. Besides diet and avoidance of skin irritations, symptoms are treated with H(1)- or H(2)-blockers, steroids, leukotriene receptor antagonists, and PUVA therapy. If patients suffer from systemic reactions such as hypotension or syncope, epinephrine solution should be prescribed for emergency use.

Background: The quality of medical reports on diagnostic procedures has a considerable impact on the quality of medical care. Handwritten or otherwise unstructured reports tend to be incomplete, whereas structured questionnaires are of limited flexibility and not considered case-adequate. Thus, medical reports of this kind may promote an incomplete and misleading documentation and, therefore, be problematic with respect to their reliability.

Methods: SonoConsult (SC), an expert system for structured and case-adequate documentation of sonographic findings with an additional diagnostic component, was evaluated with respect to user acceptance and suitability for enhancing the quality of reports and supporting sonographic beginners. The expectations and the attitudes of the users toward the program were evaluated by anonymous questionnaires. The documentation of findings and the diagnostic conclusions in 103 free text reports made by experienced examiners were evaluated by subjecting their information to a subsequent input into SC. Free text reports were checked for information that was asked by SC but not mentioned in the reports. In a series of 150 cases, the system diagnoses were blinded during input of findings into SC-questionnaires and the examiners' diagnostic conclusions were compared with the uncovered SC-diagnoses with respect to forgotten diagnoses.

Results: The structured and data-driven acquisition of information by the program was well accepted by the users. However, only a medium interest in the system-delivered diagnoses was noted. The program-generated reports were characterized by a more detailed description of the findings and a higher number of diagnoses in comparison to the unstructured reports before introduction of SC as the only documentation system. When unaware of the system diagnoses, information was entered into the questionnaires, and SC generated some diagnoses which were not mentioned by the examiners in their conclusions. The possibility to inspect the system diagnoses led to an enhancement of the number of diagnoses the examiners mentioned in their conclusions. By contrast, the examiners meant that the influence of the program on their conclusions was minimal or dispensable. Beginners in sonography acknowledged that the program led them to perform a complete examination in an adequate sequence.

Conclusion: An expert system for the data-driven, case-adequate information acquisition of abdominal ultrasound examinations may enhance the quality of the reports and, potentially, of the examinations at the same time. In addition, it may help beginners to learn a structured problem- and finding-adequate examination sequence.

Background: Microangiopathic hemolytic anemia (MAHA) represents a rare manifestation of malignant tumors. This complication, which is mainly lethal within a few weeks, is most commonly observed in association with mucin-producing adenocarcinomas, especially gastric cancer. The pathogenesis of tumor-associated mechanical hemolysis remains unclear. A standard therapy of this hematologic disturbance is not established.

Case report: The authors report on a 51-year-old patient, who presented himself in their clinic with severe anemia, thrombopenia and deterioration of his general condition. Extensive investigations revealed signet-ring carcinoma metastases in the whole vertebral column, pelvis and bone marrow. The primary tumor could neither be located endoscopically nor in imaging examinations. Under palliative chemotherapy with cisplatin, epirubicin and 5-fluorouracil continuous infusion, a rapid objective and subjective improvement could be achieved, which was reflected in normalization of the blood picture and regression of the osteoplastic bone metastases indicating partial remission. 9 months later, the patient died because of a new progression of his disease.

Conclusion: MAHA can be the first manifestation of malignant tumors. Upon the diagnosis of a MAHA, rapid diagnostics should be done to detect a possible underlying tumor, as effective antineoplastic therapy can induce both tumor and hematologic remission.