Peter Walger

Twenty-four-hour blood pressure is not dependent on endogenous circadian rhythm.

The effects of shifted working and sleeping phases on the diurnal blood pressure rhythm were investigated in 15 physically working industrial shift workers at a slowly rotated three-shift system. Ambulatory 24-h blood pressure monitoring was performed during the morning and night shifts. In the two shifts the mean 24-h blood pressure was identical. There were no differences in the blood pressure levels in the sleeping phases or in the working periods between the two 24-h cycles. Diurnal blood pressure fluctuations had equal amplitudes. Corresponding to the lag between the working period there was a phase difference of 8 h between the 24-h blood pressure curves. At this lag, there was a high correlation between the mean hourly blood pressure values (r = 0.683). Twenty-four-hour blood pressure curves during the first and last day of a night shift were nearly equal. Thus the effects of shift rotation on the 24-h blood pressure profile were fully expressed within the first 24 hours. The immediate and complete adaptation of the 24-h blood pressure curve to shifted activity and sleeping phases indicates that activity determines the diurnal blood pressure profile. The blood pressure is largely independent of internal circadian rhythm.

Nocturnal hypertension in renal failure, haemodialysis and after renal transplantation

Diurnal blood pressure variations in 20 patients with advanced renal failure, 20 patients on chronic haemodialysis, and 21 renal transplant recipients were compared with those of matched control groups without renal disease, using 24-h ambulatory blood pressure monitoring. Whereas the blood pressure during the day (from 8 a.m. to 8 p.m.) was roughly the same in the patients compared with their respective control groups, during the night (from 8 p.m. to 8 a.m.) it was substantially higher in all patient groups. The differences between the mean daytime and night-time values were significantly lower in the patients (P less than 0.05 to P less than 0.001). The nocturnal blood pressure decrease may be attenuated or even reversed in renal failure, in haemodialysis and after renal transplantation. In a proportion of these patients, 24-h ambulatory blood pressure monitoring showed an elevated nocturnal blood pressure, which may require some modification of treatment.

Pharmacorefractory Status Epilepticus Due to Low Vitamin B6 Levels during Pregnancy

Summary:  We report a patient with pyridoxine‐dependent epileptic seizures during early childhood. She had been completely seizure free for 23 years until she became pregnant. During the week 14 of her pregnancy, status epilepticus developed and was refractory to antiepileptic drugs but responded to intravenous administration of vitamin B6. Vitamin B6 levels were found to be decreased during pregnancy, although the patient reported continued and regular oral supplementation. Possible reasons for decreased vitamin B6 levels leading to status epilepticus are discussed.

Rapid geographical clustering of wound botulism in Germany after subcutaneous and intramuscular injection of heroin.

BackgroundWound infections due to Clostridium botulinum in Germany are rare and occur predominantly in heroin injectors, especially after subcutaneous or intramuscular injection of heroin (“skin popping”, which is contaminated with spores of C. botulinum. We report a rapid geographical clustering of cases in Germany in a region between Cologne, Bonn, and Aachen with wound botulism and consecutive systemic C. botulinum intoxication in intravenous drug users (IDUs) within 6 weeks in October and November 2005.PatientsA group of 12 IDUs with wound botulism after “skin popping.”ResultsClinical data were available in 11 (92%) of 12 patients; in 7 (58%) of the 12 cases, there was cranial nerve involvement including mydriasis, diplopia, dysarthria, and dysphagia, followed by progressing symmetric and flaccid paralysis of proximal muscles of the neck, arms, trunk, and respiratory muscles. Mechanical respiratory support was necessary. Five of the IDUs were treated with antitoxin, but mechanical respiratory support could not be avoided. The mean ventilation duration was 27.4 days (range 6–77 days). In 4 patients (33%), mechanical ventilation could be avoided; two were treated with antitoxin.ConclusionsThis report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after “skin popping,” which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards “skin popping,” suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because “skin popping” is the main risk factor.

Treatment of Factor VIII Inhibitors with Selective IgG Immunoadsorption – a Single Center Experience in 50 Patients with Acquired Hemophilia*

Background: Acquired hemophilia (AH) is a potentially lifethreatening disease in which severe bleeding events lead to a mortality of up to 22%. In AH autoantibodies of the IgG subtype inactivate clotting factors. Although the incidence of this disease is low (1-3 per 106), the treatment cost can be immense due to long-term clotting factor substitution. The treatment should aim at a rapid and permanent elimination of autoantibodies and the induction of a new immune tolerance to prevent further bleedings. Patients and Methods: 50 high-titer (>5 Bethesda Units(BU)/ml) AH patients were treated by the following protocol: i) inhibitor elimination via IgG immunoadsorption, ii) immunosuppression, iii) i.v. immunoglobulin, and iv) high-dose factor VIII substitution. Follow-up time ranged between 12 months and 7 years. Results: A complete remission was achieved in 46 of 50 patients (92%). Neither bleeding nor therapy-associated mortality occurred after initiation of treatment. The median time to reach undetectable inhibitor levels was 3 days (95% CI 3-6 days), coagulation factors were given at a median of 15 days (95% CI 12-18 days). The median treatment duration was 17 days (95% CI, 14-20 days). Conclusions: IgG immunoadsorption allows for a fast and permanent inhibitor elimination, being the basis of the high immunomodulatory potency of our protocol which results in long lasting complete remissions in 92% of our patients.

Treatment of Adults with Clinically Suspected Severe Thrombotic Thrombocytopenic Purpura - Experiences of a Single Centre

Thrombotic thrombocytopenic purpura (TTP), even though uncommon, has an increasing prevalence and is fatal if untreated. Plasma exchange (PE), if started within 48 h of presentation, has improved the clinical outcome and reduced the mortality rate to 10-35%. Major complications and allergic reactions related to PE are reported to occur in about 50% of patients and catheter-related complications in up to 30% of patients. To further reduce mortality and relapses in patients with TTP, therapeutic strategies should aim at minimizing complications related to treatment. Patients and Methods: A total of 31 patients with clinically suspected severe TTP were treated with the following protocol: i) pre-medication with steroids and antihistamines just before each PE procedure; ii) continuous calcium gluconate substitution; iii) insertion of a jugular central venous catheter using the Seldinger technique under ultrasonic guidance; iv) continuous low-dose anti-coagulation treatment via the central venous catheter. Results: No treatmentrelated mortality occurred. In 434 PE procedures, none of our patients developed allergic reactions or major complications. The incidence of minor complications was less than 10%. Our insertion technique has a low complication rate of 14%. The centrifugal plasma separation technique prevents thrombocyte losses. Over an median follow-up of 3.5 years, the relapse rate amounted to 3%. Conclusion: Our protocol presented here allows a safe treatment of severe TTP with a low incidence of complications and a low relapse rate.