[Management of cardiac tamponade in uremic pericarditis]. / Behandlung der Herztamponade bei urämischer Perikarditis.

Pericarditis with tamponade is known to occur in patients with chronic renal failure. It is an acute life-threatening emergency which requires immediate intervention. 6 patients with cardiac tamponade complicating uremic pericarditis who were treated at our institution from 1975 to 1984 are described. The diagnosis of pericardial tamponade was made by 2 D-echocardiography in the presence of jugular vein distension and pulsus paradoxus. Drainage by a percutaneously inserted pigtail catheter after subxiphoidal puncture was performed. Initial drainage of 707 (200-1660) ml fluid resulted in rapid improvement of the hemodynamic findings: the systolic blood pressure increased from 118 +/- 18 (SD) mm Hg to 157 +/- 16 mm Hg, the pulse pressure from 45 +/- 9 mm Hg to 79 +/- 11 mm Hg and the central venous pressure decreased from 21 +/- 6 cm H2O to 14 +/- 4. The catheters were left in place for a mean 61 (23-90) hours until no further fluid accumulated. As supportive measures, non-absorbable steroids were instilled via the percardial catheters and dialysis treatment was intensified. No complications were observed and no recurrence of effusion or development of constriction was noted for 9 to 35 months. In conclusion, subxiphoidal pericardiostomy with prolonged drainage and local steroid instillation has been found to be an effective and safe method which provides immediate and lasting relief.

Microalbuminuria and nerve conduction velocity in type-I diabetics during conventional therapy and during continuous i.v. insulin infusion.

The objective of this study was to follow the development of microalbuminuria and nerve conduction velocity under continuous i.v. insulin therapy over a limited period of 4 months. For this purpose, 8 labile type I diabetics were selected (age 33 +/- 8 years, duration of diabetes 16 +/- 9 years) and treated conventionally with two insulin injections daily over 4 months. Afterwards, the same patients were treated with continuous i.v. insulin infusion and finally again with two injections daily over 4 months each. This procedure allowed each diabetic to serve as his own control. HbA1, microalbuminuria, nerve conduction velocity and relative refractory period of the ulnar nerve were checked at monthly intervals. During the continuous i.v. infusion over 4 months, blood sugar values were significantly lower, glucosuria had disappeared almost completely and the glycosylated hemoglobin had fallen to near normal values. The mean rate of albumin excretion was 16 +/- 5 micrograms/min at rest and 76 +/- 26 micrograms/min during exercise (normal: 3.9 +/- 0.4 and 4.8 +/- 1.2 microgram/min, respectively) and did not change significantly. Nerve conduction velocity in the ulnar nerve rose significantly under i.v. insulin therapy from 47.9 +/- 0.6 m/sec to 52 +/- 0.6 m/sec. Similarly, the relative refractory period of the same nerve fell significantly from 3.7 +/- 0.2 to 1.9 +/- 0.1 msec (i.e. to within normal range). It is concluded that functional disturbances of peripheral nerve can regress by improved blood sugar control with continuous i.v. insulin infusion over 4 months. On the other hand, incipient microangiopathy measured as microalbuminuria remains unchanged over the same period of time. If an improvement is at all possible, considerably longer periods of euglycemia are likely to be necessary.

[Control of the juvenile diabetic with the insulin dosage device: indications and uses]. / Die Einstellung des juvenilen Diabetikers mit dem Insulindosiergerät: Indikation und Nutzen.

The Clinitest was used to assess the effect of inpatient treatment in 24 labile insulin-dependent diabetics with a portable open loop insulin infusion device. The Clinitest results one month prior to hospitalization were compared with those during 3 months following inpatient treatment. During the first month after the hospital stay 21 patients (88%) were better controlled. Only 15 (63%) maintained better control for the whole period of 3 months. After the hospital stay the patients experienced an average of 4 more slight hypoglycemic episodes than before hospitalization. In patients who were better controlled for the whole period of 3 months the insulin dose had been adjusted considerably. Besides inadequate daily adjustment of the insulin dose, half the patients were not sufficiently motivated and did not cooperate with their diabetologists. One third of the patients did not follow a diet and one fifth practiced inadequate insulin injection techniques. These were the major causes of poor control prior to hospitalization. The results show that short term treatment with an open loop insulin infusion device is worth while for all diabetics in whom less than one third of all Clinitests are sugarfree, and also for all those in whom there are doubts about the actual insulin requirement.

[Improvement in the treatment of diabetes by means of a portable insulin-infusion apparatus. Preliminary results in 4 unstable juvenile diabetics]. / Verbesserung der Diabetesbehandlung durch tragbare Insulin-Infusionsgeräte. Vorläufige Resultate bei 4 labilen juvenilen Diabetikern.

Four type 1 diabetics, 10 to 21 years after onset of diabetes and with no detectable levels of plasma C-peptide, were kept on intravenous insulin for 4 months by a portable open-loop insulin infusion system (Siemens, Germany). Using this system, a constant basal rate of insulin was continuously infused into the superior vena cava. During meals additional insulin was delivered for one hour. The patients went home after a few days on the ward, during which time the doses of insulin (basal and extra rates) were established. All four patients maintained the same diet, went to work and continued their personal habits as before. Blood sugar (Glucoquant) and glucosuria (Clinitest) were regularly controlled before, during and after this period. During long-term ambulatory treatment with the insulin pump improved metabolic control was achieved, as shown by lower mean blood glucose values, decreased urinary glucose excretion and by lowering of hemoglobin AIc. All four patients felt well and the number of complications, all technical, was relatively small.