[Hypoglycemia - frequency, causes, induced costs]. / Hypoglykämie - Häufigkeit, Ursachen, induzierte Kosten.

BACKGROUND AND AIM: Hypoglycemic episodes are negative sequelae of inadequate treatment of diabetes. Many of them lead to hospitalization. METHODS: Between 8/2003 und 9/2007 110 consecutive patients who had been admitted because of hypoglycemia to a tertiary hospital were analyzed. The underlying causes of hypoglycemia and associated individual psychosocial factors were assessed. Hypoglycemia was diagnosed when glucose at admittance was < 2.8 mmol/l (50 mg/dl) with or < 2.2 mmol/l (40 mg/dl) without symptoms. RESULTS: 76 patients were women and 99 patients suffered from type 2 diabetes. The mean age was 77.8 ± 9.4 years. The HbA1c of the patients with type 2 diabetes at admission was 6.5 ± 1.5 %. The greatest number of hypoglycemia episodes were associated with sulfonylurea and analoga (25), insulin (67), and the combination insulin and sulfonylurea (17). The applied sulfonylureas were in 38 % glibenclamide, in 55 % glimepiride and in 7 % repaglinide. The mean in-hospital stay was 10.4 days after admittance for hypoglycemia, the mean stay was 8.4 days for patients without hypoglycemia. Concerning creatinine there was a normal kidney function in 37.6 % of the patients, the calculated creatinine clearance was normal in only about 15 % of the patients. In 13 patients (12 %) any antidiabetic medication was stopped at time of discharge. 20 patients, chosen randomly, were analyzed concerning the costs associated with the hospital admittance. The mean age of these patients was 76.8 years and their mean stay in hospital was 10.2 day. The costs covered 3,158 €. The mean costs for the other internal patients was 2,716 €. CONCLUSION: Patient adapted treatment of diabetes is of importance for prevention of hypoglycemia especially in the elderly. The costs resulting from hospitalization and the complications linked to hypoglycemia can be largely prevented.

[Cardiopulmonary exercise tests -- proposals for standardization and interpretation]. / Spiroergometrie -- Vorschläge zur Standardisierung und Interpretation.

I give some recommendations concerning methodology and interpretation of cardiopulmonary exercise tests. The recommendations are based on our comprehensive data bank of exercise tests (282 tests and about 200 single parameters assessed during each test). When I expect an exercise capacity lower than 100 W I perform a ramp test; concerning expected higher exercise capacity steps of 25 W every 2 min are preferred. In order to achieve an optimal assessment of exercise capacity an exhaustion or symptom limited test should be performed. The achieved maximum oxygen consumption does not allow differing between cardiac or pulmonary causes of exercise limitation. It is only a marker of cardiopulmonary exercise capacity. A lot of algorithms to assess the maximum oxygen consumption are available, yet the results of calculating oxygen consumption with these algorithms differ considerably. Therefore it is mandatory to mention the used algorithm when referring to a calculated predicted oxygen consumption value. There are also several methods to assess the ventilatory and metabolic anaerobic threshold. For clinical purposes assessing lactate values is not necessary. The so called 4 mmol x l(-1) threshold accords primarily to the threshold assessed with the V-slope method. The Hf-slope may be used as an index for classification of heart failure stages analogous to the NYHA classification. Changes in dead space ventilation are mainly an expression of changed ventilation perfusion relationships and do not give evidence for any specific cardiac or pulmonary disorder. The slope of the equivalent for CO(2) is a relevant parameter of prognosis in cardiac failure. The value of the breathing reserve is not indicative of pathologic ventilatory limitation of exercise. You may find a reduced breathing reserve of about 0 also in healthy volunteers who are driven to exhaustion limited exercise. The value of the breathing reserve depends strongly on the kind of calculation or measuring mode and depending on the mode you can get normal or extremely reduced values in the same test person. The analysis of the flow volume curve during exercise provides some criteria of ventilatory exercise limitation. Pulse oxymetry is relevant only as a safety parameter. Because of its inaccuracy it should not be used to prove desaturation during exercise. The assessment of the alveolar-arterial pO (2) difference is of diagnostic relevance. The Borg scale, the course of the oxygen equivalent of O(2), the respiratory exchange ratio, and the aerobic capacity are of no major relevance for differential diagnosis.

Review of acarbose therapeutic strategies in the long-term treatment and in the prevention of type 2 diabetes.

Acarbose--the most extensively investigated and widely prescribed alpha-glucosidase inhibitor--reduces postprandial plasma glucose excursions by delaying the absorption of carbohydrate from the small intestine. Acarbose is an effective first-line therapy for patients with newly diagnosed type 2 diabetes, and induces a further improvement in glycemic control when used in combination with other antidiabetes agents. By decreasing postprandial hyperglycemia and improving insulin sensitivity, acarbose therapy also reduces fasting and postprandial serum insulin, fasting plasma glucose, and hemoglobin A1c levels. As the burden of type 2 diabetes continues to grow, there is a great need for an oral antidiabetes agent with a proven ability to prevent the development of micro- and macrovascular complications, and maintain long-term glycemic control. More than 15 years of clinical investigation have confirmed the sustained efficacy, tolerability, and excellent safety profile of acarbose in a wide range of patient types. Furthermore, the results of the recent Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM) showed that acarbose therapy significantly decreased the risk of cardiovascular events in high-risk individuals with glucose intolerance. Acarbose is therefore a convenient and effective long-term option for the treatment of type 2 diabetes, with the added benefit of reducing cardiovascular risk.

Hypertriglyceridemia: a review of clinical relevance and treatment options: focus on cerivastatin.

The triglyceride (TG) level is one of several lipid parameters that can aid prediction of coronary heart disease (CHD) risk. An elevated plasma TG level is strongly associated with an increased risk of CHD. Hypertriglyceridemia, the second most common dyslipidemic abnormality in hypertensive subjects after increased low-density lipoprotein cholesterol (LDL-C), is defined by the National Cholesterol Education Programme (NCEP) as a fasting TG level of > 2.26 mmol/l (> 200 mg/dl) and is recognised as a primary indicator for treatment in type IIb dyslipidemia. Raised TG levels can be present in individuals at risk for CHD when the total cholesterol is normal. However, not all individuals with raised TG levels have increased risk of CHD. Factors such as: diet, age, lifestyle, and a range of medical conditions, drug therapy and metabolic disorders, can all affect the TG level. In some of these circumstances, other factors protect against the risk of CHD, and can minimise or negate the effect of the risk factors present. Although TG reducing therapy has been shown to be associated with an improved clinical outcome, more research is needed to determine whether this is an independent effect of TG reduction or an effect of normalising the overall lipid profile in hypertriglyceridemic patients. Further trials are required to quantify the clinical benefits of lowering TG to 'target' levels and to confirm targets defined by NCEP-II (shown in Table 1). The role of TG in CHD pathogenesis is thought to involve several direct and indirect mechanisms, such as effects on the metabolism of other lipoproteins, transport proteins, enzymes, and on coagulation and endothelial dysfunction. More research is required to fully elucidate the role of TG, the ways in which it can influence other risk factors and the mechanism of its own more direct role in the atherogenic process. Patients with hypertriglyceridemia have been shown to respond well to dietary control and to the use of lipid lowering drugs such as 3-hydroxy-3-methylglutaryl-Coenzyme A (HMG CoA) reductase inhibitors (known as statins), fibrates and nicotinic acids. However, recent retrospective real-life clinical studies show that only 38% of patients receiving some form of lipid-lowering therapy achieved NCEP-defined LDL-C target levels, demonstrating the need for the use of more aggressive treatment. In hypertriglyceridemic patients, the newer statins, cerivastatin and atorvastatin, have shown comparable efficacy in reducing TG compared with the older statins. Achieving NCEP target lipid levels has been shown to reduce the risk of cardiovascular disease in dyslipidemic individuals, including high-risk patient groups such as those with additional risk factors, existing heart disease, diabetes mellitus and metabolic syndrome. Although the latest clinical studies investigating combination therapies, i.e. dual therapy with both a statin and a fibrate, have demonstrated them to be effective for overall control of lipid parameters and reducing coronary events, it is not yet clear whether this offers any significant advantage over monotherapy. Results from ongoing longer-term end-point clinical studies may provide further information in this area and consequent reviews of primary care management policies for dyslipidemia. Statin monotherapy may be a reliable option for primary care treatment of dyslipidemia (including hypertriglyceridemia).

[Brugada-Brugada syndrome. An atypical case]. / Das Brugada-Brugada-Syndrom. Eine (un)typische Kasuistik.

The Brugada-Brugada syndrome is a rhythmologic disorder which can be diagnosed because of typical ECG criteria. A high-take off descending ST segment localized to the right chest leads, associated with right bundle branch block and ventricular fibrillation or syncopes are characteristic of the syndrome. ECG alterations in the right precordial leads were recorded in a 47 year old female patient who was admitted to hospital because of enteritis and associated syncope. The ECG alterations were initially not realized as Brugada-Brugada syndrome. Because of "recognizing" comparable ECG alterations during a congress lecture, the diagnosis was made. The patient was treated with an ICD.

[Aspiration pneumonia caused by vertebrae of a dove in a 39 year old patient with Down syndrome]. / Aspirationspneumonie durch Täubchenwirbel bei einem 39jährigen Patienten mit Down-Syndrom.

Undetected foreign body aspiration is a well-known problem not only in children and patients with predisposing conditions like mental retardation, seizures or brain tumours, but also in healthy subjects. The clinical signs are quite different. Haemoptysis, cough, recurrent or chronic penumonia and bronchitis may occur. These symptoms are often accompanied by fever, weight loss and night sweat. Atelectasis, respiratory distress or death have been described. We demonstrate the case of a 39-year old man with Down syndrome who was transferred to our hospital because of pneumonia in the left lower lobe that had been lasting for about two months. It had been resistant to several antibiotic regimens. Computerised tomography led to the suspicion of a bronchial carcinoma with poststenotic infiltration of the lower lobe. Fibreoptic bronchoscopy and biopsy confirmed the diagnosis of a foreign body in the distal part of the left main bronchus. After two weeks of treatment with ciprofloxacin regression of the acute inflammation occurred. During a second bronchoscopy we could extract the foreign body (a 1 x 1.7 cm vertebra of a dove). It is concluded that undetected foreign body aspiration can occur in various clinical settings and fibreoptic bronchoscopy is a suitable approach providing an exact diagnosis.

Amiodarone-induced severe hepatitis mediated by immunological mechanisms.

A 64-year-old man developed a fulminant hepatitis 4 days after initiation of amiodarone treatment and a total dose of 7.1 g. The direct Coombs test was positive and became negative again soon after stopping treatment. Immediately after stopping treatment the extremely increased parameters of hepatic failure returned to normal again. A rechallenge with 200 mg of amiodarone was accompanied by a positive Coombs test which again became negative after several days. We conclude that the occurrence of an acute hepatitis soon after initiation of amiodarone treatment is mediated by immunological mechanisms. There should be high vigilance with respect to this rare life-threatening adverse drug reaction.

Nisoldipine versus isosorbide dinitrate in coronary heart disease: results of a double-masked study.

The efficacy and tolerability of a twice-daily dose of 5 mg of nisoldipine versus 40 mg of sustained-release isosorbide dinitrate (ISDN) were compared in a randomized, double-masked study in 91 patients. During the 21-day treatment period, the mean time taken during bicycle ergometry to the appearance of an ST segment depression of at least 0.1 mV compared with the resting value increased from 287 +/- 129 seconds to 391 +/- 150 seconds in the nisoldipine group and from 254 +/- 140 seconds to 350 +/- 191 seconds in the ISDN group. The mean value at the end of treatment calculated by using analysis of covariance was 383 seconds in both groups. The difference between the two treatment groups was not statistically significant. The mean ST segment depression at individually maximal workload decreased from 0.19 +/- 0.07 mV to 0.12 +/- 0.08 mV in the nisoldipine group and from 0.18 +/- 0.07 mV to 0.14 +/- 0.08 mV in the ISDN group. The mean total duration of exercise increased from 420 +/- 161 seconds to 497 +/- 140 seconds in the nisoldipine group and from 425 +/- 167 seconds to 456 +/- 168 seconds in the ISDN group. In the nisoldipine group, 9 patients reported 12 adverse events that were considered to be possibly or probably related to the test medication; in the ISDN group, 13 patients reported 26 adverse events. Although the anti-ischemic effect of the two treatments was comparable, nisoldipine was descriptively superior to ISDN in terms of tolerability.