[Characterization and economic impact of medical patients presenting at the emergency department of an university hospital]. / Internistische Patienten in einer universitären Notaufnahme: Charakterisierung und ökonomische Bedeutung für das Gesamtklinikum.

BACKGROUND: The number of patients in German emergency departments has been rising for years. This means additional need of staff and infrastructure for hospitals. METHODS: In this monocentric retrospective analysis the patient population of the central emergency department (ZNA) at the university hospital Frankfurt was investigated. Major symptoms, diagnoses with respect to diagnose-related groups and modes of admission to the emergency department have been analyzed. RESULTS: During 3 months, a total of 7376 patients presented to the ZNA. Analysis focused on 2186 patients referred to the department of internal medicine: most patients presented spontaneously (50.6%), 38.2% were admitted by ambulance services, only 9.7% were admitted by a primary physician. 44.9% of these patients were hospitalized, mainly with cardiological, pneumological and gastroenterological disorders. The predominant major symptoms were acute chest pain (15.4%), abdominal pain (7.1%) and syncope or collapse (6.1%). Patients hospitalized via ZNA contributed 31.9% of the total revenues of internal medicine departments. 31.7% of all hospitalized patients were admitted to the hospital by the ZNA. CONCLUSION: Emergency departments become more and more a regular part of ambulatory patients health care and contribute efficiently to the economic revenue of hospitals.

Assessment of basal insulin requirement using fasting tests in insulin-treated patients with type 2 diabetes mellitus.

AIMS: Characterizing the time course of the rise of blood glucose concentrations in the fasting state during the day and night in patients with type 2 diabetes. METHODS: 40 consecutive insulin-treated patients with type 2 diabetes underwent fasting tests on two different days with either no breakfast and lunch (fasting time of 20 hours) or no dinner (fasting time of 21 hours). Glucose-lowering medication was stopped prior to the test according to the half-life of the medication prescribed. At the start of the fasting tests, blood glucose concentrations were lowered to below 7 mmol/L using an insulin infusion. RESULTS: 26 men and 14 women were included in the study. Mean (+/-SD) age was 61+/-10 years, BMI 31+/-7 kg/m (2), and HbA1c 7.5+/-1%. Diabetes duration was 14+/-8 years and duration of insulin therapy had been prescribed for a mean of 6+/-6 years. During the daytime fast, plasma glucose concentrations rose by a mean of 0.8+/-1.6 mmol/L. During the nighttime fast, plasma glucose concentrations increased particularly after midnight, by 4.3+/-2.1 mmol/L, i.e. significantly more than during the daytime fast. CONCLUSIONS: Fasting blood glucose concentrations in the majority of insulin-treated patients with type 2 diabetes increase markedly after midnight. No similar increase is observed during the day. Thus, for most patients with type 2 diabetes, an intermediate- or long-acting insulin injected at bedtime with a peak action six to eight hours after injection should be appropriate.

Assessment of the arteriovenous cerebrovascular system by multi-slice CT. A single-bolus, monophasic protocol.

PURPOSE: We present a protocol for the non-invasive angiographic assessment of the arterial and venous cerebrovascular (CV) system by multi-slice CT. MATERIAL AND METHODS: Data acquisition was performed in a multi-slice CT scanner with a scan range from the carotid bifurcation to the vertex and manual scan start following i.v. administration of 120 ml iodinated contrast medium with a flow rate of 4 ml/s. This protocol was applied in 12 patients with symptoms of acute CV insuffiency. RESULTS: In all patients, comprehensive imaging of the arteriovenous CV system was achieved including the common carotid bifurcation, the third segment of the major cerebral arteries, the dural sinus and the internal cerebral veins. Various CV pathologies, such as a territorial artery occlusion, a thrombotic obstruction of the internal carotid artery, an intracranial arteriovenous malformation and a sinus vein thrombosis, were successfully evaluated. CONCLUSION: Comprehensive assessment of the arteriovenous CV system is possible by the use of a single-bolus, monophasic multi-slice scan technique.

Assessment of selective arterial calcium stimulation and hepatic venous sampling to localize insulin-secreting tumours.

OBJECTIVE: Non-invasive localization modalities such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) often fail to localize insulinomas smaller than 2 cm in diameter. Recent studies have shown that the selective arterial stimulation and hepatic venous sampling (ASVS) technique using intra-arterial calcium as the insulin secretagogue facilitates the regionalization of such occult insulinomas. This study assesses the sensitivity of ASVS in localizing insulin-secreting tumours. SUBJECTS AND METHODS: Eleven consecutive patients (8 women), aged 29-82 years, were studied over the past 4 years at our hospital. Hyperinsulinaemic hypoglycaemia due to an insulin-secreting tumour was proven in all patients. Calcium gluconate (0.025 mEq/kg body weight) was injected directly into the arteries supplying the pancreas and the liver. Insulin levels were measured in samples taken from the right hepatic vein before and 30, 60 and 120 s after each injection. The ASVS technique was performed in all 11 patients; the results were compared with the surgical findings in 10 patients and the autopsy findings in 1 case. The ASVS results were also compared with the findings of other, previously performed imaging modalities. RESULTS: ASVS correctly localized 4 insulin-secreting tumours to the head, 3 to the body, 1 to the tail, 2 to the tail or body of the pancreas and 1 to the liver. Thus, the sensitivity was 100% (11/11) whereas other localization techniques were less sensitive: 7/11 tumours were detected by angiography, 4/8 by endosonography, 3/8 by CT and 1/6 by MRI. Insulinomas (confirmed by histological examination), sized 4-25 mm, were found in 10 patients. All were cured by selective surgery and remained free of hypoglycaemia over the next 1-4 years of follow-up. An insulin-secreting neuroendocrine tumour in the liver was documented in 1 case at autopsy. CONCLUSIONS: Arterial stimulation and hepatic venous sampling is a very sensitive technique for preoperative localization of insulin-producing tumours. It can help to plan minimally invasive surgery and to select an appropriate strategy for patients suffering from malignant tumours in others.

[Therapy of osteoporosis from the viewpoint of evidence-based medicine]. / Die Therapie der Osteoporose aus dem Blickwinkel einer auf Evidenz basierenden Medizin.

DEFINITION AND SOCIOECONOMIC ASPECTS: Osteoporosis is a disease characterized by low bone mass and an increased susceptibility to fractures. It represents an enormous burden for the social security systems in developed countries. In Germany, approximately two million women and 800,000 men suffer from vertebral fractures and estimates for hip fracture incidence are in the range of 70,000-130,000 per year. The resulting costs for hip fractures alone could be calculated to 3-5 billion German marks. THERAPY ACCORDING TO EVIDENCE-BASED MEDICINE (EBM): According to Sackett et al. 1996, evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence from systematic research. OSTEOPOROSIS THERAPY: The goal of osteoporosis therapy is to prevent fractures and several therapeutic options are available for this disease. With respect to proven fracture benefit, however, the quality of evidence from randomized clinical trials varies substantially among therapies. From systematic research the best external evidence is available for a supplementation with calcium and vitamin D and a therapy with the bisphosphonates alendronate or risedronate, as well as the SERM raloxifene. For other therapeutic agents like fluorides, vitamin D metabolites, calcitonin, and etidronate the quality of evidence is much lower. So far, there is no evidence for other pharmaceutical therapies. Hip protectors are effective for the prevention of hip fractures.

Clinical and technical evaluation of a new self-monitoring blood glucose meter: assessment of analytical and user error.

Our study aimed to validate (against the standards of the American Diabetes Association and the International Organization for Standardization) the analytical and clinical accuracy of the new MediSense Precision Plus Electrodes on the QID system when compared with a reference method using the Abbott Vision glucose analyzer. Previous studies have shown that the overall accuracy of the device also depends on the proficiency of the operator, so we also assessed the 'ease of use' of the MediSense system, by comparing the results obtained by the patient and health care professional. Accuracy of the self-monitored blood glucose measurements was evaluated over a wide range of glucose readings (2.6-20.0 mmol/l). Between-run CVs (using the manufacturer's quality control material) were found to be 7% at 2.7 mmol/l and 4.8% at 15.5 mmol/l (n=380). We used the error-grid analysis with target range blood glucose, then separated the data into different subsets. We found that 100% of all measurements were in the clinically acceptable zones of A and B. All measured values of the MediSense QID system complied with the requirements for 'blood glucose monitoring meters', as proposed by the International Organization for Standardization. The rating of the patient questionnaire showed a good to very good overall rating and acceptance with a short instruction time. The results indicate that that the MediSense QID/Precision Plus Electrodes is a reliable and easy to use device, which can be recommended for the majority of patients with diabetes mellitus.

[Psychological reaction in private accident insurance. Differences in legal apprehension]. / Die psychische Reaktion in der Privaten Unfallversicherung. Unterschiede zum Haftungsrecht.

According to the provisions of private accident insurance, mental or psychological reactions are in contrast to basically not covered by insurance. The body is the object of insurance, not like third party insurance, which covers health. Since 1993 private accident insurance companies have been able to offer better coverage for mental or psychological reactions. But these possibilities for modifications of the AUB (terms and conditions of private accident insurance) introduced in 1993 constitute a departure from the traditional terms and conditions of the AUB.

The inferior petrosal sinus: assessment by transcranial Doppler ultrasound using the suboccipital approach.

Recently, intracranial veins and sinuses have been successfully insonated using the transtemporal and transoccipital approaches by transcranial Doppler ultrasound. The purpose of this study was to prove the capacity of the Doppler method to evaluate the inferior petrosal sinus via the suboccipital approach. Venous transcranial ultrasound was performed with a range-gated 2-MHz transducer in 80 healthy volunteers and patients without central nervous system disorders ranging in age from 15-84 years (mean +/- standard deviation [SD], 37.6 +/- 15.2 years). A venous signal with a flow directed toward the probe was considered to originate from the inferior petrosal sinus because of its proximity to the basilar artery. The inferior petrosal sinus was insonated in 96.3% of the cases at least on one side. It was found bilaterally in 48 (60%), on the right side in 74 (92.5%), and on the left side in 51 (63.8%) subjects, respectively. Mean blood flow velocity ranged from 8-53 cm/s (mean +/- SD, 19.6 +/- 8.7 cm/s). A significant age dependency of venous velocities was found. Weak but significant side-to-side differences were observed, reflecting the known right-sided predominance of venous outflow in humans. Using the suboccipital approach, the inferior petrosal sinus can be insonated in a high percentage of subjects without major difficulties and is defined by its vicinity to the basilar artery.

Venous Doppler ultrasound assessment of the parasellar region.

The purpose of this report is to present normal values for venous blood flow velocities from the parasellar region using transcranial Doppler ultrasound (2-MHz transducer) with both transtemporal and transorbital approaches and to examine the nature of previously reported low-pulsatility signals with velocities in the arterial range from this area. Forty-three subjects ranging in age from 18 to 56 years (mean +/- SD, 31.9 +/- 10.1 years) were examined. In all subjects, a venous signal directed away from the probe with the source lateral to the internal carotid artery siphon was detected on at least one side. A total of 72 parasellar venous signals were insonated. Signals were considered to belong to the main inflow and outflow vessels of the cavernous sinus. The mean blood flow velocity ranged from 6 to 81 cm/s (mean +/- SD, 27.3 +/- 17.4 cm/s). Typical transients in the Valsalva test confirmed the venous character of the signals. No significant gender, side-to-side or age dependency was observed. A separate analysis was done for venous high-velocity signals defined by a mean blood flow velocity greater than 30 cm/s. They were detected in 21 out of 43 subjects (48.9%) via a transtemporal approach and in 6 of them (14%) via the transorbital route, too. Again, no significant gender, side-to-side or age dependency was noted. In summary, we found a greater variability of venous blood flow velocities in the parasellar region compared to other basal cerebral veins, e.g. the basal vein of Rosenthal. The previously reported low-pulsatility signals with velocities in the arterial range proved to be of venous origin.

[Assessment of hypoglycemia]. / Abklärung von Hypoglykämien.

Hypoglycemia is characterized by a set of symptoms, but is not a diagnosis in itself. Initial attention should focus on documentation of the condition by typical symptoms (low blood sugar and disappearance of symptoms after glucose ingestion) before further testing is considered. To evaluate acute hypoglycemia, it is important to make an initial classification into one of three categories based on history: medication- or toxin-induced, fasting (not specifically associated with meals and usually occurring over 4 hours from the last meal) or postprandial hypoglycemia. A pathophysiologic approach to well-documented hypoglycemia leads to a straightforward strategy and to a diagnosis in most cases. True fasting hypoglycemia is almost invariably associated with a significant pathology, whereas postprandial hypoglycemia is not. An observed fast over 48-72 hours is diagnostic in nearly 100%. The diagnosis rests on several simultaneous features: hypoglycemia < 2.2 mmol/l, neuroglycopenic symptoms, and inappropriately elevated plasma insulin (> 30-40 pmol/l) and C-peptide levels (> 200 pmol/l) to document endogenous insulin release. Once the diagnosis of hyperinsulinism has been established, localization of the causative insulinoma (solitary adenomas in 80-90%) has traditionally been by means of the surgeon's fingers at laparotomy. In expert hands most tumors can be accurately located and removed. Although virtually every imaging technique has been advocated for preoperative localization of insulinomas, none has proved sufficiently reliable and surgical exploration is necessary even in the presence of a negative preoperative localization. Most patients who seek evaluation of reactive hypoglycemia describe a postprandial syndrome, which occurs with some regularity 2-4 hours after meals.(ABSTRACT TRUNCATED AT 250 WORDS)

[The disability concept in private accident insurance]. / Der Invaliditätsbegriff in der Privaten Unfallversicherung.

Last year the German personal accident insurers introduced a new set of General Conditions, the "AUB 88". These define permanent disability as the "permanent impairment of the insured's physical or mental faculties", whereas the former conditions defined it as the "permanent impairment of the ability to work". The new definition of permanent disability is something that the medical expert will also have to come to terms with when assessing a claim. Here he must first of all bear in mind that the consequences of an accident affecting limbs or sensory organs have to be assessed--as hitherto--on the basis of the "Gliedertaxe" or scale of disability benefits, which establishes degrees of disability for the loss of, or loss of the use or function of, limbs or sensory organs. If other parts of the body are affected, then, in accordance with Article 7 I. (2) AUB 88, "the degree to which, from a strictly medical point of view, normal physical or mental faculties are handicapped" shall be decisive. In such cases, therefore, it is no longer merely a question of whether and to what degree the insured is able to work. An assessment of permanent disability may not take non-medical circumstances into account.