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A leiomyosarcoma was detected in the region of the left iliac vein in a 37-year-old male patient who had experienced intermittent swelling of the left leg for a period of 3 months prior to admission. The results of the diagnostic imaging procedures carried out (ultrasonography, CT scan, phlebography) all pointed to a thrombus affecting the iliac vein. None of the other diagnostic procedures employed provided any evidence of a malignant disease. The definitive diagnosis was made only on the basis of the histological workup of the material obtained during surgery. The patient died 22 months after establishment of the initial diagnosis with hepatic, pulmonary, renal, and splenic metastatic disease having developed in the meantime. Treatment with chemotherapy and hyperthermia failed to prevent this fatal outcome. This case shows that, in the presence of atypically located “thrombi,” differential diagnostic considerations prior to thrombolytic treatment and surgery should include a tumor, particularly when previous thrombolytic treatment has proved ineffective.

Intraarterial and intravenous infusion of prostaglandin E1 (PGE1) is established treatment for severe peripheral arterial occlusive disease, particularly in Europe and Japan. In this critical appraisal, experimental and clinical studies are reviewed, with special emphasis on cardiopulmonary effects and drug safety. The pulmonary data all indicate dose-dependent dilation of the pulmonary vessels with a reduction in pulmonary resistance. The known hemodynamic effects of PGE1 on the heart include an increase in stroke volume, cardiac index, and left ventricular ejection fraction, and a reduction in left ventricular filling pressure. Analysis of clinical trials shows a low rate of adverse effects, in particular a low incidence of cardiopulmonary side effects. If the recommendations for high-risk patients are observed, PGE1 is both an efficacious and safe therapeutic principle.

Background: There have so far been only partial studies or studies in fairly small groups of Raynaud’s patients to systematically analyse the clinical features, the beginning of first Raynaud’s attacks, the interval between first Raynaud’s attacks and the first clinical examination, the duration of Raynaud’s attacks, inducing factors, frequency of attacks, localization, coloration, accompanying symptoms, laboratory parameters, instrument-based examinational findings on the first examination, fitness for work, and development of the diagnostic classification in the long term. Such studies are, however, necessary for reasons of differential diagnostics and therapeutics. Patients and methods: The disease data of 900 patients with established Raynaud’s symptoms, who underwent an examination between 1973 and 2002, were at first analysed in retrospect on the basis of their case history. This was followed, in 2002 to 2003, by a mail inquiry of all 900 patients, who were sent a comprehensive questionnaire to confirm history data and supplement clinical findings. Answers were received from 419 patients. In addition, 177 of the 900 patients underwent at least one follow-up examination after 2.8 years (1 month – 18 years), on the average, which allowed checking whether and how the diagnostic classification into primary, secondary and suspected secondary Raynaud’s syndrome had changed. All data were analysed statistically. Results: Of the 900 patients, 77% were women and 23% were men. The mean age on the first examination was 45.1 ± 15.5 years. Calculated on all patients, the first Raynaud’s attacks occurred at the age of 39.5 ± 16.9 years. The beginning of Raynaud’s attacks fell mostly between the 21st and 60th year of life (minimum 3rd year, maximum 88th year). There was no statistical difference between primary, secondary and suspected secondary Raynaud’s syndromes as to the time, ranging from 38.8 to 44.3 years of age, when the symptoms began. The duration of Raynaud’s attacks averaged 23.6 ± 23.5 min.; they occurred every day in 59.1%, once to three times a day in 26.8%, and more than three times a day in 31.1% of the cases. Factors inducing Raynaud’s attacks were cold in 96.8% and stress in 19.2%. Raynaud’s phenomenon was observed in both hands in 90.9% and in one hand only in 8.6% of the cases. A white discoloration only was observed in 39.0%, a white-blue discoloration sequence, in 19.3%, a purely blue discoloration, in 7.6%, and a triphasic colour response, in 19.1%. The latter sign was significantly more frequent in women and secondary Raynaud’s syndrome than in men and primary Raynaud’s syndrome. At 64.6%, secondary Raynaud’s syndrome was significantly more often associated with pain than primary Raynaud’s syndrome (47.9%). The mean systolic blood pressure was 125.6 ± 20.9 mmHg, the mean diastolic pressure, 78.3 ± 10.6 mmHg. Concomitant diseases were equally frequent in primary, secondary and suspected secondary Raynaud’s syndrome. Finger, hand and arm artery occlusions were equally often seen in all three forms of Raynaud’s syndrome. The results of the first examination showed that 72.9% of the 900 patients suffered from primary, 5.3% from secondary, and 21.3% from suspected secondary Raynaud’s syndrome. In the long term, primary and suspected secondary Raynaud’s syndromes showed a diagnostic transition in 19.2% of the cases after 2.8 years, on the average, while secondary Raynaud’s syndromes did not. The clinical symptoms of the groups, as found on the first examination, were not altered by this transition, though. Conclusion: The clinical characteristics of Raynaud’s syndromes (age when first Raynaud’s attacks are observed, inducing factors of Raynaud’s attacks, duration frequency of attacks, localization, coloration, and accompanying symptoms of an attack) are not specific and therefore not suitable to distinguish between primary and secondary Raynaud’s syndrome. The case history, a general clinical examination, immunoserologic and capillaroscopic findings, and repeated examinations during 5 or more years are necessary to differentiate between primary, secondary and suspected secondary Raynaud’s syndromes.

Das primare Raynaud-Phanomen wird durch Vasospasmen der akralen Gefase hervorgerufen, die uberwiegend durch Kalte oder emotionalen Stress induziert werden. Ziel unserer Untersuchung war es, an einer gut selektionierten Patientengruppe durch etablierte psychometrische Testverfahren (Freiburger Aggressionsfragebogen (FAF), Fragebogen zur Abschatzung psychosomatischen Krankheitserlebens (FAPK), Stressverarbeitungsfragebogen (SVF 120)) Erkenntnisse zum Umgang dieser Patienten mit Aggression und Stress zu gewinnen und zu klaren, ob bei ihnen ein psychosomatisches Krankheitserleben vorliegt. In keinem der durchgefuhrten psychometrischen Testverfahren konnten signifikante Unterschiede zwischen den Eichstichproben dieser Tests und der Gesamtgruppe der Patienten gefunden werden. Wahrend sich in der Untergruppe der Raynaud-Patienten mit schlechtem seelischen Befinden Hinweise fur ein depressives Krankheitserleben feststellen liesen, fand sich bei Patienten mit starker korperlicher Beeintrachtigung durch das Raynaud-Phanomen eine Verleugnung bzw. Unfahigkeit zu aggressivem Verhalten. Patienten mit schlechtem seelischem Befinden zum Untersuchungszeitpunkt klagten haufiger uber eine schwere korperlicher Beeintrachtigung durch das Raynaud-Phanomen. Die Durchfuhrung der beschriebenen psychometrischer Testverfahren bei Patienten mit primarem Raynaud-Phanomen ohne begleitende psychiatrische Diagnostik ist nicht sinnvoll. Bei Patienten mit primarem Raynaud-Phanomen und psychiatrischer Komorbiditat hingegen konnen sich durch das Hinzuziehen psychometrischer Testverfahren wichtige klinische Zusatzinformationen ergeben.

The aim of prescribing strict bed rest for acute deep venous thrombosis is to reduce the risk of pulmonary embolism and pain in the legs, as well as swelling. This study was performed in order to compare outcome of mobilization against 5 days of strict bed rest in patients with acute proximal deep venous thrombosis (DVT).103 in-patients with proximal DVT or patients admitted to the hospital because of proximal DVT were recruited to a randomized study. All patients were treated in hospital and given a lower leg and thigh compression bandage as well as therapeutic doses of the low molecular weight heparin, dalteparin-sodium (Fragmin).Seven of 52 patients (13.5%) in the mobile group versus 14 of 50 patients (28.0%) in the immobile group suffered at least one of the outcomes defined under the combined primary endpoint (clinically relevant pulmonary embolisms, pulmonary embolisms detectable by scintigraphy or computer tomography, progression of thrombosis or new thrombosis, nosocomial infections and/or serious adverse events) (p = 0.088), whereby serious adverse events occurred once in the mobile group and three times in the immobile group. New pulmonary embolisms over the course were seen in 10 of 50 patients (20%) with a perfusion disorder at baseline scintigraphy, while such was ascertained only in one of 52 patients (1.9%) without a perfusion disorder at baseline scintigraphy. Leg pain was reduced from 54.1 (+/-30.4) to 20.7 (+/-19.2) in the mobilized group and from 41.0 (+/-26.8) to 14.0 (+/-11.1) in the immobilized patients. Leg pain was assessed using the visual analogue scale (0 = no pain, 100 = maximum pain). More immobilized patients complained of increasing back pain (23% versus 6%) and disturbed micturition (10% versus 2%) as well as defecation (13% versus 6%) on day 5. More patients in the mobile group reported increased stress from the thrombosis and its treatment (15% versus 6%).No benefit of prescribing bed rest in patients with deep venous thrombosis could be detected in this study. Based on data available, strict bed rest for at least 5 days is not justified if adequate therapy with low molecular weight heparin and adequate compression is assured. It remains open whether patients with initial signs of pulmonary embolism might profit from a brief immobilization.

In 318 patients (155 men, 163 women) with an average age of 58.8 years (range 16-97 years), a retrospective study was carried out to determine the incidence of occult malignancies in patients with deep venous thrombosis affecting the pelvis and lower limb, confirmed by phlebography or duplex ultrasonography. It was found that, overall, 7.5% of all patients had occult malignant diseases, the most common being bronchial carcinoma (16%), colonic and renal carcinomas (12% each), and prostatic and pancreatic carcinoma (8% each). Of the patients with occult malignancy, 88% were older than 55 years. This fact shows that acute phlebothromboses may be a paraneoplastic early syndrome more often than was previously thought, and that patients older than 50 should always be screened for the presence of a tumor.

Background: Preliminary investigation done in 100 healthy adults and 20 healthy children had shown that the interpretation of significance of changes in capillary morphology need to be corrected, since capillary changes previously considered to be pathological are also to be found in large numbers in healthy subjects. Against this background, the question has now been investigated whether the capillary microscopic findings in diabetics deviates from those found in normals, and whether the duration of the diabetes, its treatment, its sequelae, or concomitant diseases have any influence on the capillary microscopic appearance. Patients and methods: In 100 patients aged between 44 and 88 years with type 2 diabetes vital capillary microscopy was carried out on all ten fingers in the usual manner. The evaluation of the video recordings was done only when all the examinations had been completed – by two examiners blinded to the clinical data. Results: It was shown that 66% of the patients demonstrated pathological capillary microscopic findings. These findings included pathologically increased apical and non-apical dilatations (32%), haemorrhagic extravasations (20%) and branchings (45%). No differences were found between the therapy groups (insulin – oral medication) nor was any relationship between the appearance of capillary changes and the duration of diabetes observed. Diabetics with concomitant diabetic sequelae (polyneuropathy), demonstrated no differences in capillary morphology as compared with diabetics with no such sequelae. Conclusion: Diabetics are found to have an increased incidence of pathological capillary morphology taking the form of increased apical dilatations, branchings and haemorrhagic extravasations. Neither the treatment, nor the duration of the illness, nor diabetic sequelae appeared to have any influence on the capillary microscopic changes.

The aim of this randomized study was to compare the reliability of the treadmill test at constant-load (C-test, 3 km/hr; fixed grade of 12%) recommended in Germany with that of the graded-exercise test (G-test, 3 km/hr; increase in grade of 3.5% every 3 minutes) propagated in the United States. In 50 patients with an absolute claudication distance (ACD) in the C-test of between 50 and 400 m, the two treadmill tests were carried out in randomized order on one and the same day, and repeated on 3 days within 1 week. For the initial claudication distance (ICD), the intraclass correlation was 0.88 in the C-test and 0.87 in the G-test. For the ACD the coefficients were identical at 0.91. The within-subject variation (CVwithin) in the C-test and G-test was 25% and 27% for the ICD and for the ACD 24% and 21%, respectively. The between-subject variation was very similar with 72% and 73% (ICD) and with 78% and 68% (ACD). However, in ACDs below 100 m and between 100 to 150 m, the C-test showed significantly smaller coefficients of variation than the G-test: 13% vs 81% and 14% vs 50%, respectively. In conclusion, the results showed that both C-test and G-test are equally well reproducible.

□ AimTo investigate the influence of unfractionated heparin on heparin-induced thrombocytopenia (HIT) type II.□ Patients and MethodIn 162 patients with internal diseases treated therapeutically or prophylactically with unfractionated heparin (heparin sodium, heparin calcium), we carried out a prospective study to determine the incidence of HIT type I and II. 55.6% of the patients were female (n=90) with an average age of 76.5 years (range: 25 to 96 years) and 44.4% male (n=72) with an average age of 67.5 years (range: 17 to 93 years). A platelet count was taken regularly before the start of heparin treatment, on the first day of treatment and then every second day from day 5 to 20. Whenever HIT II was suspected, an HIPA test was performed.□ ResultType I HIT occurred in 10%, type II in 3% of the cases. Two of the 5 patients with type II developed severe thrombotic complications.□ ConclusionIn view of the high incidence of HIT, regular platelet counts should always be carried out in patients receiving heparin treatment.

AIM To investigate the question whether and how walking distances measured under standardized conditions on the treadmill and on the level correlate with the patients walking ability under everyday conditions. PATIENTS AND METHOD In 49 patients (33 men, 16 women, age 34 to 84 years) with Fontaine Stage II peripheral arterial occlusive disease the pain-free and absolute walking distance on the treadmill were measured under standardized conditions, as also the walking distance on the level at freely selected speed. RESULT It was found that the pain-free walking distance under everyday conditions was about 2 to 3 times longer than that measured under standardized conditions on the treadmill.

The incidence of heparin-induced thrombocytopenia (HIT) types I and II was investigated retrospectively in 500 heparin-treated patients. In our department of internal medicine 500 patients were treated with unfractionated, middle- or low-molecular heparin (s.c. or i.v.) during 1995 as inpatients. Excluded were patients with other known causes of thrombocytopenia. There were 306 females (61%), mean age 76 years (17–98 years) and 194 males (39%), mean age 73 years (24–93 years). The incidence of HI type I was 4.4% and of HIT type II 0.6% with a positive heparin-induced-platelet-activation test (HIPA test). In addition, HIT type II was suspected in another 1.4% of cases with negative or missing HIPA test. Because of our results on the incidence of HIT type I and type II a close control of thrombocyte count during heparin therapy is necessary. In the case of HIT type II disease, heparin therapy must be stopped immediately.

@ After 10 days of minocycline therapy, stomatitis, glossitis and esophagitis were seen in a 62-year-old male patient, who had previously tolerated minocycline for > 20 years without complications. This typical side effect of minocycline was initially misinterpreted in the differential diagnosis and was only diagnosed, when the patient was reexposed to a new 7-day minocycline therapy. Healing was achieved by termination of the minocycline therapy and the initiation ofantimycotic treatment.

Twenty-two patients with normal carbohydrate metabolism and 16 diabetic patients, all 38 having peripheral occlusive arterial disease, took part in an investigation into the effect of pentoxifylline on blood glucose and serum insulin following an oral glucose tolerance test (OGTT). Pentoxifylline was administered by the i.v. route and the investigation took the form of an acute study (200 mg) and a 14-day chronic study (400 mg). Neither acute nor chronic medication elicited any change in blood glucose or serum insulin. Pentoxifylline does not affect blood glucose.