Harsch Ia

Leptin and ghrelin levels in patients with obstructive sleep apnoea: effect of CPAP treatment

Serum leptin and ghrelin levels were investigated in patients with obstructive sleep apnoea (OSA) syndrome before and during continuous positive airways pressure (CPAP) treatment and compared with body mass index (BMI)-matched controls without OSA. Male patients (n=30) with OSA (apnoea/hypopnoea index=58±16, BMI=32.6±5.3u2005kg·m−2) underwent CPAP treatment. Fasting leptin and ghrelin were measured atbaseline and 2 days, and in the case of leptin 2 months after initiation of treatment. Baseline plasma ghrelin levels were significantly higher in OSA patients than in controls. After 2 days of CPAP treatment, plasma ghrelin decreased in almost all OSA patients (n=9) to levels that were only slightly higher than those of controls (n=9). Leptin levels did not change significantly from baseline after 2 days of CPAP treatment, but were higher than in the control group. After 8 weeks, leptin levels decreased significantly, although the BMI of the patients showed no change. The decrease in leptin levels was more pronounced in patients with a BMI <30u2005kg·m−2. These data indicate that the elevated leptin and ghrelin levels are not determined by obesity alone, since they rapidly decreased during continuous positive airways pressure therapy.

Traffic hypoglycaemias and accidents in patients with diabetes mellitus treated with different antidiabetic regimens

Objectives.u2002 Insulin‐treated patients with diabetes are at a higher risk than the general population in causing traffic accidents due to hypoglycaemias. Preceeding investigations focused on insulin‐treated patients and hypoglycaemia‐induced accidents as ‘end‐points’. We studied the incidence of symptomatic hypoglycaemia and hypoglycaemia‐induced accidents during driving and put it in relation to the different treatment modes of insulin therapy (Conventional Insulin Treatmentu2003=u2003CT, Intensified Conventional Insulin Treatmentu2003=u2003ICT, Continuous Subcutaneous Insulin Infusionu2003=u2003CSII) as well as to patients treated with oral hypoglycaemia‐inducing agents and the two main types of diabetes mellitus.

Reduced Frequency of Peripheral Dendritic Cells in Type 2 Diabetes

OBJECTIVEnIt is a common clinical experience that type 2 diabetic patients are susceptible to opportunistic infections. The underlying reasons for this immune deficiency are not yet understood. Dendritic cells (DC) play a key role in initiating innate and adapted immune responses.nnnDESIGNnIn order to investigate changes in the DC compartment in the peripheral blood in type 2 diabetes, we analyzed blood from patients under poor and good metabolic control and compared them to healthy controls.nnnPATIENTSn5 mls of blood were collected from 15 healthy controls, 15 diabetic patients with an HbA1c <7.0 and 15 patients with an HbA1c >9.5%. Age range was 44-80 years. Patients were age-matched with the control group.nnnMEASUREMENTnBlood DC were enumerated by flow cytometry after staining with antibodies against the blood dendritic cells antigens 1-3 (BDCA 1-3). This allows quantification of the DC subtypes: myeloid dendritic cells type 1 (mDC1, mDC2) and plasmacytoid dendritic cells (pDC).nnnRESULTSnThe relative and absolute frequency for both mDC1 and pDC was clearly diminished in patients with poor metabolic control as compared to healthy controls. In patients with good metabolic control the reduction of DC was less pronounced but still significant, particularly for mDC1.nnnCONCLUSIONnHyperglycemic metabolism does affect the pool of peripheral DCs and leads to a reduction of both, mDC1 and pDC. Even patients considered to be under good metabolic control appear to have a reduced peripheral pool of DC.

Auto-CPAP therapy based on the forced oscillation technique. Auto-CPAP-Therapie auf der Basis der Oszilloresistometrie

Autoadjusting CPAP devices (APAP) are designed to continuously adjust the positive pressure to the required levels, and thus increase treatment quality and patient compliance. The results of APAP treatment strongly depend on the control mechanism of the respective APAP device. In agreement with other working groups, we have recently shown that the forced oscillation technique (FOT) is capable of detecting incipient upper airway obstruction prior to physiological reactions such as the onset of increasing esophageal pressure swings or microarousals. Therefore we studied efficacy and acceptance of a novel APAP device controlled exclusively by FOT. 100 consecutive patients with OSAS confirmed by polysomnography (mean AHI 47.9 +/- 22.6) and daytime sleepiness (Epworth sleepiness scale, ESS 12.6 +/- 3.9) were randomized to either APAP treatment (n = 50) or conventional CPAP treatment (n = 50). Polysomnographies were performed at the second treatment night and subjective sleepiness (modified ESS) was established in the morning. The respiratory disturbance was largely normalized in both treatment groups in the second treatment night (AHI 4.7 +/- 5.3 vs. 3.7 +/- 3.4; n.s.). Both groups showed largely improved sleep profiles and had markedly reduced ESS-scores (6.6 +/- 3.6 vs. 7.0 +/- 3.4; n.s.). The mean treatment pressure during APAP was significantly lower than during CPAP treatment (6.0 +/- 2.0 vs. 9.0 +/- 1.8 mbar; p < 0.001). There were no significant differences between APAP and CPAP treatment in any parameter of efficacy or acceptance. APAP treatment with this device controlled exclusively by FOT is well accepted by the patients and permits an adequate treatment of OSAS without the need for invidiual CPAP titration.

Effect of CPAP on insulin resistance in patients with obstructive sleep apnoea and type 2 diabetes

West et al are to be commended for the laborious study of the impact of continuous positive airway pressure (CPAP) on insulin resistance and glycaemic control in males with obstructive sleep apnoea syndrome (OSAS) and type 2 diabetes ( Thorax 2007; 62 :969–74). The authors did not demonstrate an improvement in insulin sensitivity and glycaemic control in obese patients after 3 months of therapeutic CPAP compared with placebo CPAP. The presentation of the apnoea–hypopnoea index (AHI) results (shown as mean (SD, 0–100% range)) …

Sweet-Syndrom als seltene kutane Komplikation eines Morbu Crohn

B einer 45jährigen Patientin waren etwa fünf Jahre vorher erstmals zehn bis 15 wäßrige Diarrhöen pro Tag ohne Blutbeimengungen oder weitere abdominelle Symptome aufgetreten, die für die Dauer von etwa einem Jahr persistierten. Vor vier Jahren war ein periproktitischer Abszeß operativ saniert worden. Nach einem Auslandsaufenthalt waren wiederum gehäufte Diarrhöen und nun erstmals krampfartige abdominelle Schmerzen aufgetreten. Unter dem Verdacht einer Amöbenruhr war eine ambulante antibiotische Therapie durchgeführt worden, die aber nicht zu einer Beschwerdebesserung geführt hatte. Die Aufnahme in unsere Klinik erfolgte in deutlich reduziertem Allgemeinzustand und mit Fieber bis 38,8 °C. Es bestanden eine Leukozytose mit Linksverschiebung, eine CRP-Erhöhung und eine Erhöhung der BKS auf 40/90 mm n. W. Der mehrmalige Versuch eines Amöbennachweises im warmen Stuhl gelang nicht. Koloskopisch zeigten sich vom Zökum bis in das proximale Rektum multiple, ausgestanzte, zum Teil tiefe Ulzerationen in makroskopisch gesunder Schleimhaut als typischer endoskopischer Befund eines Morbus Crohn. Kurz nach der stationären Aufnahme war es bei der Patientin zu einem Auftreten von disseminierten düsterroten, druckschmerzhaften, papulösen bis plaqueförmigen Läsionen an Unterschenkeln (Abbildung 1), Rumpf und Streckseiten der Arme gekommen. Histologisch zeigten sich einzelne epidermotroAbbildung 1. Akuter Befund des Exanthems an Unterschenkeln und Füßen der Patientin.

Adiponectin in obese patients with obstructive sleep apnoea syndrome

Adiponectin in obese patients with obstructive sleep apnoea syndrome Aims: Adiponectin is an adipocyte-derived hormone with anti-inflammatory and insulin-sensitizing properties. Insulin resistance is a typical feature of the obstructive sleep apnoea syndrome (OSAS). Objectives: Since nasal continuous positive airway pressure (CPAP) treatment improves insulin sensitivity in patients with OSAS, we investigated the changes of serum adiponectin levels before and during nCPAP treatment to clarify possible interactions between the adiponectin levels and insulin sensitivity in patients with OSAS. Objectives and Methods: Thirty non-diabetic, obese patients with OSAS (mean age: 56.4±11.1 years; AHI: 46.03±19.57) underwent nCPAP treatment. Adiponectin levels, as well as the levels of proinflammatory cytokines and proteins reflecting platelet activation RANTES (Regulated on Activation Normally T-cell Expressed and Secreted) and soluble P-selectin (sCD 62p), as well as the insulin sensitivity index (ISI), measured by hyperinsulinemic euglycemic clamp, were measured before, and after 2 days and 3 months of CPAP treatment. Results: Insulin sensitivity increased significantly under nCPAP treatment, whereas adiponectin levels decreased after 2 days of nCPAP treatment, but returned to baseline levels after 3 months of nCPAP treatment. The increase of insulin sensitivity was more pronounced in patients with the highest adiponectin levels at baseline (p=0.021) after adjustment for body fat (p=0.003). During treatment, changes in adiponectin levels were highly predictable by ISI. Conclusions: We found a significant relation between adiponectin and ISI in overweight patients with OSAS. The lack of a long-lasting change in adiponectin may be explained by the overwhelming influence of BMI on the adiponectin secretion, which was unchanged during nCPAP treatment.

Rezidivierende “kalte Abszesse” mit Spontanperforation als seltene Verlaufsform einer abdominellen Tuberkulose

E 65jährige türkische Patientin stellte sich wegen eines äußerlich erkennbaren, druckdolenten Tumors der rechten Flanke vor. Zwei Jahre zuvor war ein zystischer, oberhalb des Pankreas gelegener Prozeß reseziert worden. Histologisch hatten sich seinerzeit multiple nichtnekrotisierende Epitheloidzellgranulome gezeigt. Vor anderthalb Jahren war gastroskopisch eine granulomatöse Gastritis ohne Nachweis von Mykobakterien diagnostiziert worden. Seinerzeit war ein Tuberkulintest areaktiv gewesen, und ein Röntgenbild des Thorax war als unauffällig beschrieben worden. Vor einem Jahr war eine laparoskopische Nephrektomie wegen einer hydronephrotischen Schrumpfniere vorgenommen worden. Zu diesem Zeitpunkt hatte sich computertomographisch neben der Hydronephrose als Zufallsbefund eine polyzystische Raumforderung im Bereich des linken Beckens gezeigt (Abbildung 1). Aktuell war die Patientin nun beschwerdefrei. Im CT imponierte jetzt ein polyzystischer Tumor im rechten Unterbauch, der auf den rechten Musculus psoas und den Musculus iliacus übergriff und die Bauchwand rechts lateral infiltrierte (Abbildung 2). Die Raumforderung im Bereich des linken Beckens war nun nicht mehr darstellbar. Wir führten in dieser Situation eine Punktion des Tumors durch und gewannen dabei eine gelbliche, trübe, nichtfötide Flüssigkeit. Zytologisch fand sich granulozytär durchsetzter Detritus mit autolytischen Zellelementen. Säurefeste Stäbchen konnten nicht nachgewiesen werden, doch gelang der kulturelle Nachweis von Mycobacterium tuAbbildung 1