The use of the Siamese combined free flap to reconstruct challenging defects: twin and triplet variants.

The reconstruction of large and intricate defects may need the use of combined flaps due to either the size or requirement for multiple surfaces. The combination may be between free and pedicled tissue transfer, and combined or connected free flaps classified by Koshima. We will discuss the use of the Siamese combined free flap as a method of the reconstructing challenging cases, including one of the largest free tissue transfer reported.

[Age-dependent changes in the sub-epithelial blood supply to the bovine rumen]. / Altersabhängige Veränderungen an den subepithelialen Blutgefässen des Pansens vom Rind.

Qualitative age-related changes in the structure and the position of subepithelial blood vessels in the bovine atrium ruminis were investigated on the electron microscopical level in 39 fetal, peri- and postnatal individuals as well as in adult animals of different ages. Standardized morphometrical methods were applied and the data were statistically evaluated. The distance between epithelium and capillary endothelium, the endothelial fenestration and the thickness of the endothelial wall as well as the endothelial-epithelial exchange sectors facing each other were distinctly a function of age. Crucial changes of these parameters were either finished until the sixth postnatal month and were pronounced during the period of feeding adaptation from milk to roughage or were not markedly influenced during this period. The degree of endothelial vesiculation showed individual variations but was not a function of age or feeding regime.

[Combination therapy of oral antidiabetic drugs with insulin]. / Kombinationstherapie von oralen Antidiabetika mit Insulin.

The treatment of type II diabetes should not only concentrate on blood glucose levels but also should take symptoms like insulin resistance, hyperinsulinemia, low HDL-cholesterol, high VLDL, and systemic hypertension into consideration. These symptoms are well described by the metabolic syndrome and are known to be risk factors of macroangiopathy. In obese type II diabetic patients weight loss by caloric restriction is the most essential therapeutic step. Retarding intestinal carbohydrate uptake glucosidase-inhibitors are able to lower postprandial blood glucose levels without stimulating insulin secretion. The biguanide metformin is suitable to diminish peripheral insulin resistance, gluconeogenesis, and intestinal glucose absorption on cellular mechanisms others than betacytotropic effects. In non obese type II diabetic patients sulfonylureas are advantageous because of meal related stimulation of endogenous insulin which runs the physiological way with first pass through the liver. Therefore, sulfonylurea treatment should be continued when secondary failure indicates the need for exogenous insulin. In accordance with the course of type II diabetes in secondary failure insulin should be added to sulfonylureas in as small amounts as possible to ameliorate poor metabolic control. Thus iatrogenic hyperinsulinemia and resulting insulin resistance can be largely avoided. If there is any long term benefit when different oral antidiabetic agents are administered together with insulin has to be evaluated in further clinical studies.

[Combination therapy with sulfonylurea plus insulin in "secondary failure" of type 2 diabetes]. / Die Kombinationstherapie Sulfonylharnstoff plus Insulin im "Sekundärversagen" des Typ-2-Diabetes.

In the treatment of 'secondary failure of sulfonylurea therapy' in type-2-diabetes, the combination of insulin plus sulfonylureas is well established. The aim of this kind of therapy is to take advantage of the physiological way of endogenous insulin, stimulated by sulfonylureas. Furthermore, insulin deficiency in 'secondary failure' should be treated very early by small amounts of exogenous insulin to avoid hyperinsulinemia as a risk factor of cardiovascular disease. Long-term results in 16 type-2 diabetics show the combination of insulin plus sulfonylureas being advantageous as compared to only insulin treatment in both daily insulin dosage and serum insulin levels.

[Combination therapy with insulin/sulfonylurea in the long-term therapy of type II diabetes following "secondary failure"]. / Die Kombinationstherapie Insulin/Sulfonylharnstoff in der Langzeittherapie des Typ-II-Diabetes nach "Sekundärversagen".

In type 2 diabetes with "secondary failure of sulfonylurea therapy" good metabolic control can seldom be achieved by insulin therapy even with high insulin doses. Hyperinsulinemia however is a possible risk factor of cardiovascular disease in type 2 diabetes. Maintaining the effects of sulfonylurea action insulin should be added in as small amounts as possible to avoid hyperinsulinemia and to ameliorate hyperglycemia. 16 type 2 diabetics with "secondary failure" were treated either with insulin alone (group A; n = 8) or with 3.5 mg b.i.d. glibenclamide plus small amounts of intermediate insulin (group B; n = 8) in a randomised order. After the inpatient period outpatient control was performed monthly up to six months, later on four times a year up to two years. Both groups were comparable with regard to age, duration of diabetes, body weight and metabolic control. The daily insulin dose was 14 +/- 2 IU (means +/- SEM) after one month and 19 +/- 2 IU after two years in group B. In contrast 30 +/- 3 IU and 43 +/- 5 IU respectively were needed in group A (p less than 0.001). All patients B were treated with one daily injection, all patients A needed two injections. Resulting in nearly identical metabolic control in group A basal insulin levels exceeded those in group B after two years significantly (28.6 +/- 3.7 vs. 18.6 +/- 1.6 mcU/ml; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effectiveness of combined treatment with glibenclamide and insulin in secondary sulfonylurea failure. A controlled multicenter double-blind clinical trial]. / Wirksamkeit der Kombinationsbehandlung mit Glibenclamid und Insulin bei Sulfonylharnstoff-Sekundärversagen. Kontrollierte multizentrische doppelblinde klinische Prüfung.

The effectiveness of combined insulin and glibenclamide was compared with that of insulin alone in a multicenter double-blind trial of secondary sulphonylurea failures. Protocols of 176 patients at 26 centers were available, but only 68 could ultimately be included in the analysis. Combined insulin and glibenclamide (Euglucon N) had been taken by 37 patients, combined insulin and placebo by 31. The final criterion, postprandial one-hour blood sugar level of less than or equal to 220 mg/100 ml after 24 weeks, was attained by nearly 75% of patients in both groups. Fasting blood sugar and postprandial one-hour blood sugar as well as HbA1 did not differ during the entire test period of 24 weeks. Mean daily insulin dose was 20 IU in the insulin/glibenclamide group, 35 IU in the insulin/placebo group. This increased the number of second evening insulin injections by 50% in the insulin/placebo group compared with the insulin/glibenclamide group. The frequency of mild hypoglycemia was similar in the two groups. The results indicate that combined insulin/glibenclamide, given over a period of six months to patients with secondary sulphonylurea failure, provided metabolic results as good as those with insulin alone. The required insulin dosage was thus reduced by more than a third.

[Improved insulin action by ACE inhibition in type-2 diabetics]. / Verbesserte Insulinwirkung durch ACE-Hemmung beim Typ-II-Diabetiker.

The effect of the angiotensin converting enzyme inhibitor captopril (25 mg by mouth) on glucose metabolism of skeletal muscle and the whole organism was studied in nine normotensive type II (non-insulin dependent) diabetics using a combination of euglycaemic-hyperinsulinaemic glucose-clamp and forearm catheter techniques. The administration of captopril resulted in a significant rise of both the whole-body glucose elimination and utilization rate in the forearm musculature. At the same time the arterial kinin level rose, while the concentrations of insulin, free fatty acids and gluconeogenesis precursors, as well as the number and activity of insulin receptors (measured in an erythrocyte-binding study) remained unchanged. The data support the view that, in type II diabetics, ACE inhibition raises the insulin-stimulated glucose uptake of the whole organism, predominantly due to an increased glucose uptake by the skeletal musculature. The demonstration of an increased kinin level points to this effect possibly being caused by the reduced breakdown of locally liberated kinins.

[Clinical testing of a new blood glucose measuring system. A cooperative study at 8 centers]. / Klinische Erprobung eines neuen Blutzuckermesssystems. Eine kooperative Studie in acht Zentren.

The glucometer II system is a small measurement device with built-in batch-specific pressbutton calibration. The corresponding test strip "Glucostix" uses a two-color system. The blood glucose test strip can be evaluated both visually and by instrument. The precision determined in series was between 2.0% and 6.7% using control sera. The day-to-day precision was between 1.5% and 7.9%. Comparison of the methods on the basis of 781 and 109 capillary blood samples respectively revealed a good agreement between the hexokinase method or the glucose oxidase method (Beckman analyser) and the glucometer II values. The precision of measurement by the system was comparable in the two test strip batches employed. Visual reading of the test strips revealed a good agreement with the laboratory method in the hypoglycemic and normoglycemic range; at higher concentrations of blood glucose, a trend to underestimation of the measurement values was shown. The easy handling and small size of the instrument facilitates measurement of blood glucose by the patient under everyday conditions.

[Experiences with Reflolux in blood sugar self testing]. / Erfahrungen mit Reflolux in der Blutzuckerselbstkontrolle.

As to correctness and accuracy the Reflolux system is comparable to the conventional measurement of blood glucose under laboratory conditions. Its handling is simple and safe so that diabetic patients are able to check their blood sugar reliably by self-control. Skilled patients achieve just as good results as laboratory personnel.

Efficiency of human insulin (recombinant DNA) in the treatment of diabetic ketoacidosis and severe nonketoacidotic hyperglycemia.

Human insulin (recombinant DNA) was compared with pork insulin in the treatment of diabetic ketoacidosis and severe nonketoacidotic hyperglycemia using a continuous, intravenous, low-dose regimen. Seven patients (age range 48 +/- 26 yr, mean +/- SD) with diabetic ketoacidosis and three (52, 65, and 70 yr) with nonketoacidotic hyperglycemia were studied. In the ketoacidotic group the initial values of blood glucose, pH, and base excess were 808 +/- 353 mg/dl, 7.06 +/- 0.1, and -22.8 +/- 5.9 mmol/L, respectively. The mean initial values of blood glucose and osmolality of the three patients with nonketoacidotic hyperglycemia were 731 +/- 127 mg/dl and 355 +/- 49 mosmol/kg, respectively. Within 24 h insulin therapy led to continuous improvement in blood glucose to 187 +/- 90 (ketoacidotic patients) and 172 +/- 28 mg/dl (nonketoacidotic group) and normalization of pH, base excess, and osmolality. The mean insulin requirement was 84 +/- 45 U/24 h in ketoacidotic and 86 +/- 18 U/24 h in nonketoacidotic patients, respectively. The comparison groups receiving pork insulin did not differ significantly in either clinical or initial and subsequent biochemical data or in insulin requirement.

Human insulin (recombinant DNA) in the treatment of patients with newly diagnosed insulin-dependent diabetes mellitus (IDDM).

Human insulin (recombinant DNA) was administered subcutaneously to 16 patients with newly diagnosed insulin-dependent diabetes mellitus (IDDM), whereas a control group of 11 patients received highly purified pork insulin (PPI). The control group was only available for the inpatient period, while the HI-treated patients could be observed monthly afterward. For metabolic control, basal and post-prandial blood glucose, plasma C-peptide, and HbA1 were measured. During the outpatient period, blood glucose self-monitoring was also performed. Within 6 days of therapy, blood glucose levels were lowered to normal without any statistical differences between the HI and PPI groups. Mean insulin requirement was 35 U/day in both groups. Plasma C-peptide levels were not different at any time. In the human insulin group, HbA1 values were continuously lowered from the initial 13% to the normal range within 2-3 mo and remained normal after 6 mo of therapy. No allergic reaction and no other side effects could be seen. The results suggest that in the first period of treatment, the metabolic situation of patients with IDDM could be well controlled by human insulin as well as by PPI. Human insulin has been proven to be an effective and safe insulin.

Binding of biosynthetic human insulin to erythrocytes of normal and insulin-dependent diabetic subjects: comparison with pork and human pancreatic insulin.

Biosynthetic human insulin (BHI) was compared with highly purified human pancreatic and pork insulin with regard to its ability to bind to erythrocytes of normal and insulin-dependent diabetic subjects (type I diabetes). The binding affinity or capacity of erythrocyte from both normal and diabetic subjects were comparable for biosynthetic and pancreatic human insulin. In contrast, binding of pork insulin to erythrocytes was significantly decreased at low insulin concentrations in normal as well as in diabetic subjects due to a reduced receptor affinity. The affinity of the "empty sites" was 5.25 x 10(-8) M-1 with pork insulin in normal subjects and 6.1 x 10(-8) M-1 in diabetic subjects; with both human insulins, the affinities were 6.9 x 10(-8) M-1 in normal subjects and 8.6 x 10(-8) M-1 in diabetic subjects. The number of insulin receptors per erythrocyte was calculated as being 30 in normal subjects and 35 in diabetic patients.

Muscle triglycerides in diabetic subjects. Effect of insulin deficiency and exercise.

Muscle triglycerides and glycogen were measured in biopsy specimens of the vastus lateralis muscle before and after 1 h of ergometric exercise at 50 to 60% of maximal capacity (i. e. at a pulse rate during exercise of 180 minus age) in 3 groups of 19 to 35 year old, non-obese male subjects: 10 normals, 10 insulin dependent diabetic patients in relatively good control and 10 poorly controlled insulin dependent diabetic patients in whom insulin was withdrawn 24 h prior to examination. At rest in all subjects muscle triglyceride content was positively correlated with serum triglycerides(p < 0.001) and blood glucose (p < 0.05), resulting in elevated muscle triglyceride stores in the insulin deficient diabetic patients (17.9 +/- 1.8 mumol/g protein vs. 13.4 +/- 1.3 and 9.4 +/- 1.2 in the normal subjects and the well controlled diabetic patients; p < 0.05 and < 0.001). During exercise, utilisation of muscle triglycerides and glycogen were directly related to content at rest (p < 0.001), including the insulin-deprived patients with decreased glycogen. The decrease of muscle fat was associated with a rise in serum glycerol (p < 0.001) and non-esterified fatty acids (p < 0.001) during exercise.