Erythema migrans disease. 3 case examples with neurologic complications

The erythema-migrans-disease is closely related to Lyme-disease as described in the USA, and represents a tickborne spirochetosis with highest incidence during summer and autumn. Besides nonspecific general symptoms in its earlier stages, it is characterized by a distinctive erythema migrans; later, additional neurological, cardiac and/or arthritic symptoms may develope. Its typical neurologic complication, the lymphocytic meningoradiculitis Garin-Bujadoux-Bannwarth, was observed in three children whose clinical features illustrate the great variability of symptoms of Erythema-migrans-disease. Serological tests for specific spirochete antibodies are valuable aids in differential diagnosis, especially for cases with late complications if a tick bite is not remembered, or as is not uncommon, the typical skin lesion has not occurred, or has not been noted. Antibiotic therapy with penicillin or tetracycline is a successful treatment of the earlier stages of the disease and can prevent, or at least ameliorate, subsequent complications.     

Untersuchungen an 1,3-Thiazinen, 25. Mitt. Transacylierende N-Acyl-tetrahydro- und N-Acyl-dihydro-1,3-thiazin-derivate

1,3-Thiazines, XXV: Transacylating Derivatives of N-Acyltetrahydro- and N-Acyldihydro-1,3-thiazine Novel N-acyl-2-thioxo-3,4-dihydro-1,3-thiazine-4-ones 4 and N-acyl-tetrahydro-1,3-thiazine-2,4-diones 7 were preparee by acylation of the N-unsubstituted 1,3-thiazine derivatives 3 and 6 with acid chlorides. Their characteristics are compared with those of known N-acylthiazine derivatives.     

Endothelial function in the forearm circulation of patients with the metabolic syndrome--effect of different lipid-lowering regimens

We compared the effect of statin therapy (either alone or combined with ezetimibe) on the inhibition of cholesterol resorption and endothelial function by measuring forearm blood flow in male patients with the metabolic syndrome. Compared to 40 mg atorvastatin alone, combination therapy with 10 mg ezetimibe and 10 mg atorvastatin for 8 weeks resulted in significantly decreased total serum cholesterol and triglycerides levels (n = 14). Endothelium-dependent, acetylcholine-mediated vasodilation was significantly better with combination therapy (p < 0.05). In contrast, endothelium-independent forearm blood flow response to sodium nitroprusside was comparable in both groups. Our data suggest a more effective restoration of endothelial function with the statin/ezetimibe combination compared to statin monotherapy in patients with the metabolic syndrome.     

Metabolic syndrome: "common soil" for diabetes and atherosclerosis. Novel approaches to an integrated therapy

Type 2 diabetes and atherosclerotic vascular disease develop in parallel. Prospective epidemiologic studies have shown a striking communality of major risk factors for both diseases. This raises the question of a "common soil". The traits of the metabolic syndrome including dyslipidemia, visceral obesity and hypertension are predictors of type 2 diabetes as well as coronary heart disease. The same applies to the environmental factors: overnutrition, physical inertia and smoking. Visceral obesity, insulin resistance and low-grade inflammation are known as major components of the common soil for metabolic syndrome and coronary heart disease. Depending on the quality of metabolic control diabetes will accelerate the progression of atherosclerosis via unstable plaque formation.The "common soil" concept provides a paradigm for an integrated therapeutic approach. This applies to a lifestyle intervention as well as a rational use of drugs in diseases of the metabolic syndrome.The medication should consider coexisting disorders of the metabolic syndrome to use pleiotropic effects. On the other hand, side effect such as the worsening of blood glucose levels caused by beta-blockers and diuretics should be avoided.The following medication should be preferred in context of the metabolic syndrome: oral antidiabetics such as acarbose, metformin and thiazolidinediones, antihypertensives such as ACE inhibitors and ARBs (angiotensin receptor blockers) and lipid-lowering drugs such as atorvastatin, rosuvastatin, and the modern nicotinic acid derivative Niaspan, respectively.The strategy using synergies in drug treatment can reduce polypharmacy and costs and improve the patients' compliance.     

Prandial insulin substitution with insulin lispro or insulin lispro mid mixture vs. basal therapy with insulin glargine: a randomized controlled trial in patients with type 2 diabetes beginning insulin therapy

PURPOSE: To compare the effects of prandial insulin therapy focusing on postprandial glucose control vs. basal insulin therapy focusing on fasting glucose control in patients with type 2 diabetes. METHODS: This was an open-label, randomized, parallel, three-arm multicenter trial in patients with type 2 diabetes starting insulin treatment. Patients (n=159) were randomly assigned to 24-week treatment with 3x daily insulin lispro, 3x daily lispro mid mixture (MidMix; 50% lispro, 50% protaminated lispro), or 1x daily insulin glargine; oral antihyperglycemic agents were discontinued. Primary end point was the postprandial glucose excursion 2 h after breakfast at the end of study. Secondary outcomes included HbA1c, self-monitored blood glucose profiles, hypoglycemic episodes, body weight, and patient satisfaction. RESULTS: At the end of study, glucose excursions 2 h after breakfast were significantly lower with lispro and MidMix than with glargine (P<.001 for each vs. glargine): lispro, -0.6+/-2.0 mmol/l; MidMix, +0.8+/-2.4 mmol/l; glargine, +2.5+/-2.4 mmol/l. Fasting glucose decreases were significantly greater with glargine (-2.6+/-2.4 mmol/l) than with lispro or MidMix (-0.9+/-2.2 mmol/l; +0.9+/-1.8 mmol/l). Nevertheless, HbA1c decreased by 1.1% (lispro) and 1.2% (MidMix), vs. 0.3% with glargine. Hypoglycemic episodes were rare with 1-1.5 self-reported episodes per 100 patient-days. CONCLUSIONS: In patients with type 2 diabetes starting insulin, 3x daily prandial treatment with a rapid-acting analog focusing on postprandial glucose values enabled better control of postprandial and circadian blood glucose profiles than once-daily glargine, in spite suboptimal fasting glucose levels, which targets fasting glucose values. These results support studies suggesting that control of postprandial hyperglycemia plays a key role in achieving HbA1c targets.     

First Responder for In-Hospital Resuscitation: 5-Year Experience with an Automated External Defibrillator-Based Program

Background

The survival of in-hospital cardiac arrest (8–25%) has not changed substantially in the past. Until now, most hospitals in Germany had no standardized protocols available for a course of action in case of emergency, and there are no continuous registry data for in-hospital cardiac arrest and survival.

Objective

Our aim was to improve survival and receive outcomes data, so we implemented a structured hospital-wide automated first-responder system in the hospital. Here our 5-year experience with 443 emergency calls is outlined.

Methods

Throughout the hospital, 15 automated external defibrillator (AED) “access spots,” which can be easily reached within 30 s, were identified. AEDs were then installed at these locations (Lifepak 500 and Lifepak 1000, Medtronic equipped with a Biolog 3000i portable ECG monitor). At the same time, a training program was initiated in which the employees of the hospital participated once a year. Participants learned how to apply and activate an AED in case of cardiac arrest even before the designated Cardiac Arrest Team arrived at the scene.

Results

A witnessed cardiac arrest event was confirmed in 126 cases. In 56 of the 126 cases, the primary arrest rhythm was either ventricular tachycardia or ventricular fibrillation and the AED delivered a shock. In this group, spontaneous circulation was reached in 44 cases (79%) and 23 patients (41%) were discharged. In 44% (24 from 55 patients) of the cases, a shock was recommended by AED and delivered by the first responders before the rescue team arrived.

Conclusions

The first-responder AED program successfully gave training lessons to the hospital staff. The training included how to initiate the cardiac arrest call, how to use the AED, and how to start immediate resuscitation. As a result, a higher survival rate after in-hospital cardiac arrest can be accomplished.     

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria. Results: The reduction in lifetime for 65 + ?years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + ?years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20–25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.     

Evaluation of the potential clinical and economic effects of bodyweight stabilisation with acarbose in patients with type 2 diabetes mellitus. A decision-analytical approach

Bodyweight is an acknowledged independent risk factor for coronary heart disease (CHD). The present model analysis was undertaken to investigate the clinical and economic impact of bodyweight gain in patients with type 2 (non-insulin-dependent) diabetes mellitus and its effects on the development of CHD. Based on a retrospective re-evaluation of data from the Diabetes Intervention Study (DIS), patients with type 2 diabetes mellitus and stable bodyweight (group A) had a significantly lower rate of combined CHD events (30.3%) than patients showing a bodyweight gain (group B; 38.2%) over 10 years. Prevention of bodyweight gain, therefore, appears to be a meaningful strategy in the management of diabetes mellitus. In addition to this clinical advantage, prevention of CHD will also result in economic savings associated with avoided treatment of coronary events. Based on the clinical outcomes from the DIS, the calculated per-patient net savings for a patient with type 2 diabetes mellitus and stable bodyweight amounted to 1085 deutschmarks (DM) when compared with a patient experiencing a bodyweight increase. In a further step, the above situation was projected to current type 2 diabetes mellitus practice. Oral first-line treatment of type 2 diabetes mellitus is usually initiated with glibenclamide (glyburide), which is known to increase bodyweight (reflecting group B). The novel alpha-glucosidase inhibitor acarbose, in contrast, appears to be as effective as glibenclamide, but has the advantage of being bodyweight-neutral (reflecting group A). From the clinical viewpoint, acarbose can thus be considered an alternative to glibenclamide. From the viewpoint of drug costs, monotherapy with acarbose is 4 times as expensive as glibenclamide in Germany, resulting in per-patient incremental costs of DM3527 for acarbose over 10 years. Balanced against the potential 10-year cost saving of DM1085 resulting from the potential of acarbose to prevent CHD, around one-third of the incremental cost of acarbose may be recouped by this single effect. However, further possible benefits of acarbose, including the avoidance of hypoglycaemia and the deferral of costly insulin therapy, may improve the economic value of this novel antidiabetic agent. Given the indirect approach of this evaluation and its many limitations, the above findings need critical appraisal, and comparative trials are urgently required to substantiate our preliminary results.