Peter Kaufmann

Evaluation of a structured outpatient group education program for intensive insulin therapy.

OBJECTIVE To determine the efficacy and safety of a structured diabetes teaching and treatment program (DTTP) in patients with insulin-dependent diabetes mel-litus (IDDM) in an outpatient setting. RESEARCH DESIGN AND METHODS All patients with IDDM who completed a structured 5-day outpatient DTTP were reevaluated after a mean follow-up of 3 years. A standardized interview was used to assess frequency of severe hypoglycemia, type of insulin treatment, self-monitoring, and other diabetes-related parameters. HbA1c was measured by high-performance liquid chromatography. RESULTS Of 205 patients, 4 (2%) died during the observation period. HbA1c in the 201 surviving patients decreased significantly from 8.7 ± 2.0 to 7.5 ± 1.2% at follow-up (P < 0.001); frequency of severe hypoglycemia decreased from a mean of 0.46 to 0.13 per patient per year (P < 0.001). Hospital admission due to acute metabolic disturbances decreased from 4.5 ± 11.1 to 1.4 ± 6.7 days/patient-year (P < 0.001). At follow-up, intensive insulin therapy was carried out by 98% of the patients, and 80% of the patients reported three or more measurements of blood glucose per day. Diabetes-related knowledge had a positive (P < 0.01) and body mass index a negative (P < 0.02) influence on improving HbA1c assessed by multiple regression analysis. Severe hypoglycemia after DTTP was associated with a history of severe hypoglycemia before DTTP (P < 0.001) and the existence of overt diabetic nephrop-athy (P < 0.05). CONCLUSIONS A structured outpatient DTTP as used in this study is able to improve overall metabolic control and decrease the frequency of severe hypoglycemia in patients with IDDM.

Transient reduction of autoantibodies against oxidized ldl in patients with acute myocardial infarction

Fifteen consecutive patients (mean age 66 +/- 14, range 31-82) with an acute myocardial infarction (MI) suitable for thrombolytic therapy were included in this study. Autoantibodies against oxidized low-density lipoprotein (LDL) were determined by enzyme-linked immunosorbent assay (ELISA). Patients (n = 10) with marked elevation of the MB isoenzyme of creatinine kinase (CK-MB)-mass had significant decreases of oLDL-Ab during the acute phase, with a minimum after 8 h following the onset of thrombolytic therapy (within-group significance: p < .001; between groups: p = .01). Patients (n = 5) with CK-MB-mass values less than 70 ng/ml did not show this phenomenon. Furthermore, significant correlations existed between CK-MB-mass and oLDL-Ab after 6 and 8 h (n = 15; r = .72; p = .003) and the time of the highest CK-MB-mass values (after 12 h) and the time of the maximal decrease of oLDL-Ab (after 8 h) (r = .74; p = .003). Our observations provide further evidence for the release of free radicals and for increased lipid peroxidation during reperfusion after prolonged ischemia. The decrease of oLDL-Ab appears to be a marker for the severity of MI.

Elevated plasma levels of soluble tumor necrosis factor receptor (sTNFRp60) reflect severity of acute pancreatitis

Objective: To investigate the role of activated leukocytes in acute pancreatitis, we measured soluble receptors of tumour necrosis factor alpha (sTNFR, p60 subtype) in plasma and evaluated the association of sTNFR with the clinical severity of the disease. Design: Prospective, descriptive study. Setting: A medical intensive care unit (ICU) in a university hospital. Patients: 25 consecutive ICU admissions of adult patients with acute pancreatitis. Measurements and results: The clinical severity of the disease was assessed using weights for the worst 17 physiological abnormalities of the Acute Physiology and Chronic Health Evaluation III score over a 24-h period after admission. According to the sum of these weights (giving the Acute Physiology Score, APS) patients were divided into a group with mild pancreatitis (APS < 25) and into a group with severe pancreatitis (APS ≥ 25). Soluble TNFR was determined in plasma using an enzyme-linked immunoadsorbent assay. In patients with clinically severe pancreatitis, plasma sTNFR concentrations of 8.8 (16) ng/ml (median, interquartile range) were significantly higher when compared to patients with mild disease [2.7 (1.5) ng/ml; p < 0.0001]. The sensitivity and specificity of sTNFR plasma concentrations (cutoff point at 5 ng/ml) for the prediction of severe pancreatitis were 90 and 100 %, respectively. A highly positive correlation between sTNFR and deviations of physiological parameters from normal (APS score) was demonstrated (r = 0.81). The development of multiple organ failure (MOF) and death was associated with significantly higher sTNFR levels when compared to patients without MOF and survivors [16.4 (17) vs 3.2 (2) ng/ml, p = 0.0014 and 16.0 (18) vs 3.3 (4) ng/ml, p = 0.016, respectively]. For evidence of necrotizing pancreatitis, plasma C-reactive protein concentrations were measured and a significant exponential regression was found with sTNFR (r = 0.77, p < 0.0001). Patients developing pancreatic necrosis, as demonstrated by contrast-enhanced computed tomography, had significantly higher sTNFR concentrations when compared to patients with edematous pancreatitis [9.1 (17) vs 3.2 (2) ng/ml, p = 0.0018). Conclusion: The p60 subtype of soluble TNFR is elevated in the plasma of patients with clinically severe acute pancreatitis. This elevation is positively correlated to abnormalities in physiological parameters, development of MOF, and mortality. The association with pancreatic necrosis suggests that, by mediating the effects of TNF, TNFRp60 reflects inflammatory tissue damage leading to severe systemic complications.

Increased Plasma Concentrations of Circulating Intercellular Adhesion Molecule-1 (cICAM-1) in Patients with Necrotizing Pancreatitis

The intercellular adhesion molecule-1 (ICAM-1), a membrane glycoprotein, is important in the adhesion of cytokine-stimulated leukocytes to the endothelium of microvessels and their transendothelial migration. Circulating isoforms of ICAM-1 (cICAM-1) are known to be elevated in human serum as an indirect consequence of inflammatory responses. The aim of this study was to investigate whether cICAM-1 levels are elevated in patients with acute pancreatitis within 48 h of the onset of abdominal pain and whether cICAM-1 levels correlate with the severity of the tissue damage. Twenty-five consecutive patients admitted to a medical ICU had elevated cCAM-1 concentrations of 548 +/- 68 ng/ml, significantly different when compared to a control group of 18 healthy subjects (343 +/- 29; p = 0.018). According to the findings of contrast-enhanced CT or laparotomy patients were further divided in a group with acute edematous pancreatitis and a group with acute necrotizing pancreatitis. Pancreatic necrosis was associated with cICAM-1 levels of 729 +/- 106 ng/ml, significantly different from patients with mild disease (367 +/- 48) and controls (p < 0.001). Plasma cICAM-1 levels were not significantly different between healthy subjects and patients with mild pancreatitis. A significant correlation was found between cICAM-1 and C-reactive protein, an acute phase reactant and marker of necrotizing pancreatitis (r = 0.62; p < 0.01). The sensitivity and specificity for the detection of edematous or necrotizing pancreatitis of cICAM-1 plasma concentrations (cutoff point at 500 ng/ml) were 75% and 85%, respectively. These results suggest an enhanced release of ICAM-1 into plasma in the early stage of acute necrotizing pancreatitis. Leukocyte-endothelial cell adhesion may be associated with the inflammatory process of necrotizing tissue damage in acute pancreatitis. It could thus serve as a marker or predictor of a severe clinical course of pancreatitis.

Autoantibodies to Oxidized Low Density Lipoproteins in Restenosis following Coronary Angioplasty

Oxidized low density lipoproteins (oLDL) play an important role in the pathogenesis of atherosclerosis. Recently, elevated oLDL autoantibodies in serum were shown in patients with severe peripheral atherosclerosis. To evaluate their role in restenosis after percutaneous transluminal coronary angioplasty (PTCA), oLDL autoantibodies were determined in a randomly selected series of 48 males following successful PTCA. Follow-up angiography as well as blood sampling were done 12 months after PTCA; restenosis was defined as > or = 50% reduction in diameter of the coronary artery. Twenty-six patients (mean age: 56 years) showed restenosis (Restenosis Group), whereas 22 (mean age: 53 years) had open vessels (Patent Vessel Group). Both groups did not differ in age, past medical history, fibrinogen and lipid profile as well as in initial angiographic findings. Oxidized LDL autoantibodies were 13 +/- 21 U in the Restenosis Group and 6 +/- 4 U in the Patent Vessel Group, showing no significant difference. Six of 26 patients in the Restenosis Group and 3 of 22 in the Patent Vessel Group (NS) had elevated oLDL autoantibody levels (> or = 10 U). Thus, although there is a trend to elevated oLDL autoantibodies in males with restenosis of coronary arteries, oLDL cannot serve as a strong marker for stenosis following PTCA.

IMPACT OF LONG-TERM HEMODIALYSIS ON NUTRITIONAL STATUS IN PATIENTS WITH END-STAGE RENAL FAILURE

We evaluated the way in which duration of hemodialysis treatment affects nutritional status in 96 end-stage renal failure patients. According to the length of previous hemodialysis treatment patients were divided into the groups: onset hemodialysis (ON-HD), early-stage hemodialysis (ES-HD, 1–8 months), mid-stage hemodialysis (MS-HD, 9–69 months), and advanced-stage hemodialysis (ASHD, 70–207 months). Nutritional status was assessed by laboratory data (serum proteins, total lymphocyte count), intradermal skin antigen testing, anthropometric measurements (body mass index [BMI], infrared interactance), and records of food intake. ON-HD patients on a low-protein diet exhibited abnormally low values for serum total protein, albumin, transferrin, and total lymphocyte count and a high prevalence of anergy to skin antigens (69%). In the ES-HD and MS-HD groups values for serum proteins and total lymphocyte count were in the normal range and significantly higher than in ON-HD patients. In addition, a lower proportion of cutaneous anergy was observed (50% and 27%, respectively). Long-term hemodialysis therapy for 6–17 years (AS-HD) was associated with normal levels for all measured serum proteins. Subnormal levels of total lymphocyte count, significantly lower than in MS-HD patients, were associated with an increase in anergy to skin antigens (46%). Serum prealbumin, complement C3c, BMI, body fat, and lean body mass exhibited normal values in all patients and showed no differences between groups. These results indicate that diminished visceral protein stores, lymphopenia, and anergy to skin antigens are widespread in undialyzed uremic patients with end-stage renal failure but become uncommon after the initiation of regular hemodialysis therapy. Even patients on long term hemodialysis for 6–17 years can maintain their serum protein levels, BMI, body fat, and lean body mass in the normal range. The catabolic stimulus of the dialysis procedure itself does not seem to outweigh its beneficial effect of removing uremic toxins when patients are treated for so many years. The occurrence of lymphopenia and a higher proportion of anergy to skin antigens in AS-HD patients indicates that hemodialysis treatment of very long duration has a depressive effect on immunological functions, but not on nutritional status.

Q.E.D. Alcohol Test : A simple and quick method to detect ethanol in saliva of patients in emergency departments : Comparison with the conventional determination in blood

Objective: The aim of this pilot study was to assess whether ethanol concentrations in saliva are comparable to those in blood and to evaluate whether this new non-invasive saliva alcohol test is suitable for use in emergency departments. Design: Prospective, open, non-randomised study. Setting: University hospital emergency department. Patients and methods: 100 consecutive patients who were admitted to the emergency department whose smell and/or behaviour indicated alcohol abuse. Fifteen patients participated as a control group after they were asked to abstain from alcohol consumption for 24 h before the study. Interventions: Blood and saliva samples were obtained at the same time for ethanol measurement. The Q.E.D. Alcohol Test A 350 was used in order to measure the concentration of ethanol in saliva. Blood samples were analysed by the alcohol dehydrogenase method. Results: The mean difference between the ethanol levels in blood and saliva was − 0.1 mg/dl, whereas the values measured in saliva were on average 0.1 mg/dl higher than those measured in blood (p = 0.002). Conclusion: The Q.E.D. Alcohol Test A 350, which uses saliva, is well suited for quantitative determination of alcohol levels. The levels measured in saliva correlate well with those measured in blood at both the lower and the upper end of the scale. Because this test is quick and easy to perform by emergency room personnel and the results are accurate enough for clinical purposes, it should prove valuable to determine whether impaired consciousness is related to alcohol intoxication or to other likely causes.

Neopterin Plasma Concentrations Predict the Course of Severe Acute Pancreatitis

Abstract In a prospective, descriptive study in 25 patients with acute pancreatitis neopterin plasma concentrations were found to be associated with the severity of the disease, which was assessed using weights of the worst 17 physiological abnormalities of the APACHE-III score over a 24 h period after hospital admission. Neopterin concentrations were higher in severe pancreatitis (n = 10) compared to mild disease, and there existed a positive exponential correlation between neopterin and the Acute Physiology Score (r = 0.66). Higher neopterin concentrations were associated with the development of multiple organ failure (p = 0.012) and death (p = 0.019). At a cut-off concentration of 12 nmol/l the sensitivity (80 %) and specificity (100 %) of neopterin for the discrimination between mild and severe clinical course of pancreatitis was more accurate than C-reactive protein at a risk threshold of 1.2 g/l (70 % and 87 %). Development of pancreatic necrosis was associated with higher neopterin concentrations than edematous pancreatitis (p < 0.001).

Near fatal anticholinergic intoxication after routine fundoscopy.

We describe a case of severe anticholinergic intoxication following the topical instillation of tropicamide-containing eyedrops. Tropicamide is a short-acting atropine-like derivative and has been regarded as an effective and safe mydriatic. Half an hour after routine fundoscopy, a 62-year-old man experienced two generalized seizures with respiratory arrest and required intubation and mechanical ventilation. The patient was treated with physostigmine and made a full recovery.

Pilzvergiftungen: Toxidrome, Diagnose und Therapie

SummaryThe major syndromes of mushroom poisoning can be divided by presentation timing: Early syndromes (symptom onset < 6 hrs after ingestion) have little probability to cause organ damage. Epigastric pain, nausea, vomiting and diarrhea occur in most cases and treatment includes initial gastrointestinal decontamination with oral activated charcoal and fluid rehydration. In addition, an acute gastrointestinal syndrome can be combined with cholinergic toxicity, epileptiformic response or immunohemolytic anemia. Neurotoxic Syndromes may present as dysphoria, delirium, hallucinations or disulfiram-like reactions. Treatment is entirely supportive and if performed in hospital, the prognosis is good. Late syndromes (symptom onset > 6 hrs after ingestion) are life-threatening due to liver- and renal failure. Patients who are jaundiced after an acute gastrointestinal episode, are suspected to be poisoned with Amatoxins. Patiens with flank pain, hematuria, polyuria or oliguria in the absence of jaundice are suspected to have an intoxication with Cortinarius mushrooms. In both cases an intensive care management is indicated.ZusammenfassungPilzvergiftungen sind in der Regel nicht organschädigend, wenn Krankheitssymptome nach der Mahlzeit rasch, innerhalb von 6 Stunden auftreten. Mit einem isolierten Brechdurchfall ist bei der Mehrzahl dieser Intoxikationen zu rechnen und die Gabe von Medizinalkohle ist zur Verminderung der intestinalen Gift-resorption gerechtfertigt. Ein akutes Abdomen kann jedoch auch mit einer cholinergen Reaktion, einem epileptiformen Syndrom oder einer Immunhämolyse kombiniert sein. Die Therapie ist supportiv und konzentriert sich primär auf den Ersatz der gastrointestinalen Elektrolyt- und Flüssigkeitsverluste. Neurotoxische Syndrome inkludieren Rauschzustände, Halluzinationen und Alkoholunverträglichkeitsreaktionen. Die Behandlung ist symptomatisch und sollte ausnahmslos stationär erfolgen, bis die Symptome vollständig abgeklungen sind. Dann ist die Prognose gut. Treten Beschwerden nach einer längeren Latenzzeit als 6 Stunden auf, besteht Lebensgefahr infolge Leberund Nierenversagens. Nach Brechdurchfällen weist eine Gelbsucht auf Knollenblätterpilzvergiftung hin, während bei fehlendem Ikterus Nierenschmerzen, blutiger Urin, Harnflut oder Harnverhalten eine Intoxikation mit Haarschleierlingen wahrscheinlich machen. In beiden Fällen ist eine intensivmedizinische Behandlung unabdingbar.