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Presents a letter to the editor about a prospective multicentre trial on the diagnosis of impaired glucose tolerance in non-diabetic patients with hypertension.

Background and Aims: The multichannel blocker dronedarone is currently indicated for the maintenance of sinus rhythm after successful cardioversion in adult clinically stable patients with paroxysmal or persistent atrial fibrillation (AF), with careful monitoring of cardiac, hepatic and renal function. We aimed to investigate patients' quality of life (QoL) and tolerability and effectiveness of dronedarone under real life conditions., Methods: In the 1-year prospective, non-interventional IMPULS study, 161 office-based cardiologists, general practitioners and internists throughout Germany documented 549 patients with AF who were currently or newly prescribed dronedarone (safety set, SS). Of those, 342 patients (full analysis set, FAS) provided data on QoL at baseline, 6 months and 12 months)., Results: Mean age of patients was 67.6/66.3 years; 53.0 %/57.3 % were men (SS/FAS). AF type at inclusion in the SS/FAS was paroxysmal in 71.9 %/71.3 % and persistent in 26.0 %/26.6 % (missing in 2.0 %/2.0 %). The proportion of patients in sinus rhythm increased from 44.6 % at baseline to 70.2 % (SS). The mean value on the 100-point visual analogue scale (EuroQol EQ-5D) increased from 62.3 ± 17.1 at baseline by 11.4 ± 18.7 points (FAS, p<0.0001). The AF-QoL Psychological Domain improved from 44.6 ± 22.6 at baseline by 16.0 ± 23.5 points at 1 year (p<0.0001), the AF-QoL physical domain from 49.5 ± 22.1 by 10.9 ± 22.5 points (p<0.0001), and the AF-QoL sexual domain from 61.8 ± 27.1 by 6.6 ± 28.2 points (p<0.0001). In all, 136 patients (24.8 % of all patients in the safety set) had at least one adverse drug reaction (ADR) causally related to dronedarone., Conclusions: Various dimensions of quality of life of patients with AF were improved on dronedarone under clinical practice conditions. No previously unknown safety issues were noted.

Objectives: In hypertensive diabetics the cardiovascular risk is substantially increased. Therefore, an effective reduction of both blood pressure and pulse pressure is of particular importance for these patients. The aim of the prospective observational study in hypertensive type 2 diabetics was to assess the effect of a switch from the previous antihypertensive therapy to the angiotensin-II-receptor antagonist irbesartan (alone or in combination with HCTZ) on the reduction of blood pressure and pulse pressure, the reduction of diabetic nephropathy (microalbuminuria), and tolerability., Methods: 8714 general practitioners included 31,793 type 2 diabetics aged at least 18 years in an open observational study. After inclusion in to the study the patients received irbesartan 300 mg as monotherapy or in combination with hydrochlorothiazide 12.5 mg (HCTZ). Main outcome measures for efficacy were the reduction of systolic (SBP) and diastolic (DBP) blood pressures, reduction of pulse pressure, and blood pressure responder (reduction in DBP > or = 10 mmHg or diastolic < 90 mmHg), diastolic normalization (DBP < 90 mmHg) and overall normalization rates (SBP < 140 mmHg and DBP < 90 mmHg) after 3 months. Further outcome measures included the reduction of microalbuminuria or proteinuria, and adverse events (AEs) as a measure of tolerability., Results: Thirty-eight per cent of patients received irbesartan 300 mg and 61% irbesartan in combination with HCTZ. Mean systolic blood pressure was reduced by 22.5 mmHg, diastolic blood pressure by 10.7 mmHg (baseline values: 160.2 and 93.2 mmHg). Pulse pressure fell on average by 11.6 mmHg. 83.4% of the patients were responders, with an overall normalization rate of 42.7% (SBP < 140 mmHg and DBP < 90 mmHg), respectively 73.8% (DBP < 90 mmHg). The antihypertensive benefit was achieved irrespective of the previous medication. Mean albuminuria decreased by about 27.7 mg/L. Only 0.3% of patients experienced adverse events., Conclusions: In type 2 diabetics with hypertension and either uncontrolled or no previous antihypertensive therapy a change to treatment with irbesartan or irbesartan/HCTZ for 3 months resulted in a distinct reduction of systolic and diastolic blood pressures, with concomitant effective reductions of pulse pressure and microalbuminuria.

Objective: To assess characteristics and outcome of emergency patients with acute malaria., Patients and Methods: We retrospectively assessed the clinical and laboratory parameters of 137 consecutive patients (87 males, 50 females; median age 37 years, range 17 - 67 years) presenting with acute malaria to our tertiary care center between 1992 and 2002., Results: Falciparum malaria was diagnosed in 116/137 and tertian malaria in 19/137 patients; a single patient was infected with both parasites while in another case the type of parasite remained unclear. Infections were acquired in Africa (121), Asia , and in the Americas . One traveler visited multiple continents. Only 36 % (50/137) of patients had used malaria chemoprophylaxis. 128/137 patients were treated as in-patients; 22 of these had to be treated on an intensive care unit. According to the criteria of the German Society of Tropical Medicine, 44/137 (32 %; 95 % confidence interval (CI): 25 - 40 %) patients suffered from complicated malaria. The overall mortality rate was 2/137 (1.5 %; 95 % CI: 0,4 - 5.2 %); the mortality rate of complicated malaria tropica was 2/44 (4,5 %; 95 % CI 1,3 - 15 %). Patients with complicated malaria were significantly older than those with uncomplicated malaria. Median length of hospital stay was 4 days in uncomplicated and 9 days in complicated cases. Based on costs of EUR 2500 per case, an attack rate of > 3 % in East African travelers and a cost of EUR 55 for a chemoprophylaxis with mefloquine, chemoprophylaxis is cost-effective., Conclusion: In our retrospective analysis, complicated malaria tropica was associated with older age. Although malaria causes considerable morbidity, the overall mortality from severe malaria is low. Reinforcement of chemoprophylaxis especially in travelers to Africa could reduce malaria cases and is cost-effective.

Background/aim: The admission to intensive care is controversially discussed in patients with HIV infection, since life expectancy is limited. Therefore, we analyzed indications, outcomes and follow up of all patients with confirmed HIV-infection and Aids defining symptoms who had been admitted to the intensive care unit (ICU) of our department between 1985-1996., Results: 49 patients were admitted to the ICU, 42 of them with CDC stage C of HIV infection before admission. The leading indications were pneumonia (n = 15; PCP: 10, bacterial: 5), acute bleedings (n = 14), acute neurological diseases (n = 6), and gastrointestinal perforation (n = 5). Overall mortality was 39% (19/49) with a higher mortality seen in patients with respiratory disorders (53%) compared to non-respiratory disorders (22%, n.s.). The only significant predictor of mortality was the serum creatinine (p = 0.001), while differences in the APACHE II score between survivors and non-survivors did not reach statistical significance (22 +/- 7, 16 +/- 5; p = 0.14). During follow up no difference was seen in the life expectancy of HIV-infected survivors of intensive care as compared to those patients with AIDS who had never been admitted to ICU (8.4 months versus 9 months)., Discussion: The need for intensive care in HIV infected patients does not accelerate the progression of HIV infection to death, if the complications requiring ICU intervention can be managed successfully. Respiratory infections and impaired renal function are risk factors for a fatal outcome. Thus, HIV infected patients benefit from intensive care therapy.

History and Clinical Findings: A 33-year-old man with fulminant hepatitis B infection was to have an orthotopic liver transplantation (OLTX) because of the otherwise poor prognosis. During preparations for it he was found also to have an HIV-infection., Investigations: Preoperatively the Quick value was 9%, and he had a grade 2 encephalopathy. His immune status was impaired: 477 CD4-T-helper cells/microliter. Virus load, measured with a quantitative HIV-RNA test, was < 80 copies/ml (i.e. below demonstrable level)., Diagnosis, Treatment and Course: After the first transplantation had ended in organ failure, a second one two days later was successful. But there were several complications postoperatively: ischaemic-toxic tubular renal failure requiring haemodialysis, underperfusion of the right lobe of the liver due to arterial stenosis, pleural effusion, cytomegalovirus infection and cyclosporin-induced hypertension. But all these were successfully managed. At the time of this report, 27 months later, the patient felt well and his immune state was stable. During these 2 years he had a practically normal T-helper count and HIV-RNA measured below 80 copies/ml with good liver function. There has been no indication for antiviral treatment and there have been no complications relating to immunosuppression., Conclusion: The low life expectancy before effective antiviral drugs are available explains the reluctance to perform OLTX in HIV-infected patients. The favourable course in this case, using highly efficacious combined antiretroviral treatment now being available, indicates that after careful consideration, OLTX can be performed in selected patients with HIV.

Objective: To analyse the course of acute liver failure and the indications for liver transplantation., Patients and Methods: In 16 patients who developed acute liver failure between July 1992 and July 1997 the indications for liver transplantation and total survival time were analysed retrospectively., Results: Intensive medical care (ventilation, dialysis) was necessary in 60% of the patients to bridge organ failure until liver transplantation. In 14 patients liver transplantation was indicated. Eleven of the patients, with a minimal Quick value of less than 10%, presented with the prognostically poorest London criteria. In two patients the combination of three additional criteria of the London classification led to liver transplantation being indicated. In one patient with Wilson's disease the transplantation was undertaken despite good clotting factor synthesis, because an encephalopathy occurred. In two patients liver transplantation was not undertaken even though indicated, in one because liver functions improved, in the other because necrotizing pancreatitis had occurred. In another patient, who had been poisoned by eating the mushroom Amanita phalloides, the attempted transplantation was cut short, because intestinal necrosis had developed, and the patient died during the operation. Nine of the eleven patients who had a transplantation and three of the four treated conservatively survived., Conclusion: The 60-day survival rate in this series, achieved in a recently established transplantation programme, is high (12 of 16; 75%), being comparable to those in larger transplantation centres.

We observed three cases of severe ventilator-associated pneumonia due to Aspergillus fumigatus in non-immunosuppressed, non-neutropenic patients. Autopsy confirmed an angioinvasive pattern of spreading with septic foci. In all cases conditions associated with temporary immunodysfunction like underlying diseases, antecedent sepsis or pneumonia, coinfections or steroid therapy were present. Although Aspergillus fumigatus was isolated in all cases in cultures of tracheobronchial secretions, the correct diagnosis was not obtained during lifetime. Our cases demonstrate that pneumonia due to Aspergillus fumigatus must be taken into account also in this patient population.

History and Clinical Findings: A 67-year-old man with known bronchial asthma was admitted to hospital because of deteriorating general state of health, fever, progressive renal failure and confusional states., Investigations: Erythrocyte sedimentation rate was 70/95 mm and the concentration of C-reactive protein raised to 30 mg/dl. WBC count was 19,000/microliter with 39% eosinophilia. Anticytoplasmatic antibodies (cANCA) had a high titre (1:160). On admission the creatinine level was 5.6 mg/dl. Renal biopsy indicated marked glomerular and tubulo-interstitial scarring. Chest radiograms showed transient pulmonary infiltrates. Churg-Strauss syndrome (CSS) was diagnosed on the basis of the clinical and biochemical findings., Treatment and Course: Haemodialysis was instituted to counteract the renal failure with water retention. Inflammatory parameters and clinical symptoms rapidly responded to administration of corticosteroids (prednisolone, initially 250 mg/d for 3 days, then 150 mg/d for 5 days followed by slowly decreasing doses). Two weeks after starting prednisolone he had secondary generalised seizures. Magnetic resonance imaging (MRI) of the skull demonstrated marked hyperintense focal changes which in their pattern were characteristic of cerebral vasculitis. As a steroid-refractory condition had to be assumed, cyclophosphamide was also given (100 mg/d). Within 6 weeks the clinical symptoms gradually regressed and the MRI changes became practically normal., Conclusion: Early combined immunotherapy should be given if CSS runs a complicated course, rather than the usually recommended corticosteroid monotherapy.

About 15 years ago, treatment with intravenous immune globulin (IVIG) for primary immunodeficiency diseases was introduced. The concept of replacement of deficient circulating antibodies to prevent infections in these patients subsequently proved to be beneficial. Up-to-date IVIG therapy is considered to be the treatment of choice in many primary or secondary immunodeficiency states. The observation of a significant increase in the platelet count in patients with agammaglobulinemia and severe thrombocytopenia after IVIG therapy developed interest in possible modulatory effects of IVIG on the immune system. Although the mode of action of IVIG in autoimmune diseases is not completely understood, therapeutic benefit has been shown in some diseases. It has to be stated that IVIG in autoimmune diseases are rarely first therapeutic choice; however, IVIG might be indicated in patients where conventional and cheaper therapy has failed. This review summarizes the status of IVIG therapy in primary and secondary immunodeficiency states and possible indications in autoimmune diseases.

Spontaneous splenic rupture as a complication of infectious mononucleosis was diagnosed in a 19-year-old woman. Sonographic and MRI investigations revealed subcapsular hematoma of the spleen without overt rupture. The patient was managed conservatively. Somatostatin treatment was initiated in order to reduce splanchnic blood flow. Further clinical course of the patient was favourable. Seven days after the diagnosis of splenic rupture the patient was discharged from hospital. Non-operative management should be considered in patients with subcapsular splenic rupture to avoid complications of splenectomy (e.g. post-splenectomy sepsis).