Formen der Insulintherapie

Rigid algorithms providing identical glycemic treatment goals and intervention thresholds for all patients with both type 1 and type 2 diabetes are obsolete. In patients with type 1 diabetes, intensive insulin therapy using short-acting and long-lasting basal analog insulins are superior compared to normal or intermediate human insulins with respect to the risks of hypoglycemia, quality of glycemic control and quality of life. If correctly indicated, insulin pump therapy with continuous subcutaneous insulin infusion (CSII) offers superior glycemic control compared to intensive insulin treatment. In patients with type 2 diabetes, individualized and patient-centered treatment strategies tailored to the respective phase of the chronic progressive disease are warranted. The best point in time to start insulin therapy depends on the extent of hyperglycemia and comorbidities taking into account the state of the disease, safety aspects (e.g. hypoglycemia, adverse effects and body weight gain) and the preferences of the patient. In patients with severe (skeletal muscle) insulin resistance and poor glycemic control, very high doses of insulin with the aim to override insulin resistance do not seem prudent as muscle insulin resistance also serves as a protective mechanism preventing further nutrient drainage into the muscle tissue. Instead, strategies to improve insulin sensitivity by reducing nutrient load, such as calorie restriction, increase of physical activity as well as administration of metformin, incretin-based treatment and sodium-glucose-linked transporter-2 (SGLT-2) inhibitors should form the basis for therapy in such patients. Transient, short-term treatment with insulin, often started at manifestation of the disease -if plasma glucose values are high, quickly removes the negative effects of glucotoxicity and may offer beneficial metabolic long-term effects.     

Maximale Blutalkoholkonzentration nach forciertem Konsum von alkoholfreiem Bier

In recent years sales of non-alcoholic beer have constantly increased. In Germany, so-called non-alcoholic beer may still have an ethanol content of up to 0.5% (by volume). This marginal amount of ethanol might have negative implications for certain groups of persons such as novice drivers. So far no reliable data regarding the blood ethanol concentration after consumption of non-alcoholic beer have been published. Therefore, a drinking experiment was performed as follows: after 5 days of abstinence from ethanol 78 test persons were asked to drink 1.5?l of non-alcoholic beer (ethanol content 0.41–0.42%) within 1?h. Blood samples were taken on a regular basis and analyzed for ethanol by headspace gas chromatography-flame ionization detection (HS-GC-FID). A total of 67 data sets could be interpreted and in 20 test persons ethanol was detected in blood with a limit of detection (LOD) of 0.0005?g/l. The maximum blood ethanol concentration was 0.0056‰. The results of the study suggest that even after consumption of unrealistically high amounts of non-alcoholic beer negative forensic implications are not to be expected.     

Dysurische Beschwerden und Flankenschmerz bei dialysepflichtiger Patientin mit Diabetes mellitus

A 41-year-old female patient presented with a well-known long history of diabetes mellitus type 1 with diabetic nephropathy, dysuria, left-sided flank pain, nausea and vomiting. The patient was previously treated with ciprofloxacin for the same symptoms but after improvement of symptoms was discharged of her own volition. This case underlines that even young people in need of dialysis are endangered by infections due to uremic immune dysfunction.     

Basiskoronarchirurgie

Indications, procedural concepts and technical details of the coronary artery bypass graft (CABG) operation are continuously reassessed by cardiac surgeons and cardiologists. In particular, CABG in patients presenting with complex coronary artery disease is continuously challenged by interventional cardiology. However, considering current comparative studies, CABG remains the first line therapy for patients presenting with coronary three-vessel disease and/or left main stem stenosis. This is even more important for severely diseased coronary arteries or in complex lesions. However, cardiac surgeons now more than ever before need a profound knowledge of their own and the cardiologists’ work scope to be a strong partner in heart team discussions and a reliable guardian of the patient. The current educational paper aims at presenting important and well accepted aspects of coronary artery bypass surgery. Technical aspects as well as updated study results on early and late patient outcome will be discussed.     

Sinus pilonidalis

Pilonidal sinus disease is most probably caused by a chronic infection due to hyperactivity of pluripotent hair follicles in the midline of the natal cleft. Young males with a dark hair type are most often affected by the disease. Currently, excising the infected area is still the basic treatment. Open healing is a safe and easy treatment option; nevertheless, it is associated with long lasting wound management and recurrences. Closure of the wound in the midline does not offer satisfactory results in any aspect and should therefore be avoided. In contrast to midline closure, asymmetric closure techniques and flap procedures provide better results. At present it is not yet clear which of the abovementioned asymmetric or flap techniques is superior. Although a large number of randomized trials have been conducted no conclusive evidence of superiority of one technique was found.     

Analrandkarzinom bei Rezidivrektumprolaps

Surgery for third degree rectal prolapse and its sequelae in the elderly still represents a challenge. We report the case of a 92-year-old patient with a history of recurrent third degree rectal prolapse of at least 2?years?? standing. The patient had already had abdominal rectopexy for the same disease 16 years previously. In addition, she now suffered a large perianal ulcer. The patient underwent abdominal rectopexy and biopsy from the ulcer. The histology from the ulcer margin revealed a squamous cell anal cancer. In conclusion, we postulate that the anal cancer can be considered as a consequence of the long-standing rectal prolapse. The patient had previously been informed by her family practitioner that the prolapse could not be operated due to her advanced age. This case highlights that a third degree rectal prolapse should be operated regardless of age in order to avoid late sequelae.