[Euglycemic ketoacidosis - rare condition on the rise]. / Euglykäme Ketoazidose ­ ein Kolibri, der zur Taube werden könnte.

SGLT2 inhibitors have been developed as antidiabetics. Large randomized prospective studies have shown prognostic benefit in patients with heart and/or renal insufficiency regarding cardiovascular and general endpoints - even in absence of type 2 diabetes mellitus. This extends the indication to large groups of multimorbid patients. SGLT2 inhibitors induce ketogenesis comparable to fasting conditions. This may - in presence of additional catabolic factors - deteriorate into life-threatening ketoacidosis - probably due to increased reabsorption of ketone bodies from urine as well as the blockage of SGLT2 receptors on α-cells of the pancreas. Euglycaemic ketoacidosis (eKA) under SGLT2 inhibition occurs in about 2:1000 years of treatment. The diagnosis is challenging: in eKA, blood sugar levels are often normal, and ketone detection in urinalysis can be falsely negative, while glucosuria is excessive compared to euglycemic blood-glucose. The management corresponds to classical diabetic ketoacidosis, but special features of blood glucose target, hydration and potassium management should be considered. SGLT2 inhibitors should be paused if a longer fasting period is expected ("sick-day-break"). Due to the soaring number of prescriptions, a significant increase in the prevalence of eKA is expected. Immediate diagnosis and therapy are essential in emergency and intensive care medicine.

Self-management in adrenal insufficiency - towards a better understanding.

Patients with adrenal insufficiency (AI) require life-long glucocorticoid (GC) replacement treatment and dose adjustment in stress situations to prevent life-threatening adrenal crises. Herein this study we evaluated the patients' healthcare situation and their knowledge on AI, comparing various aspects to a prior survey in 209 physicians. Using a questionnaire, we conducted a comprehensive survey among 33 AI patients who were treated at the endocrine outpatient clinics of two University Hospitals in Germany. The majority of AI patients (97%) named their treating physician as main source for information. Overall, 89.7% of interviewees were satisfied with their medical treatment; however, about 1/3 reported controversies with healthcare professionals regarding GC replacement in various situation. Two thirds of AI patients increased their substitution dose temporarily within the last 12 months. However, not all patients had an emergency ID, and only 64.5% an emergency kit. None of the interviewed patients identified the need for adjustment in all given situations correctly. Almost 80% of patients did not correctly identify all symptoms of GC over- and under-replacement. Interestingly, we found no significant differences between patients and physicians regarding specific aspects of GC replacement. We showed that: (i) AI patients have some knowledge gaps on modalities and adequacy of GC replacement therapy; (ii) long-term management of patients with AI remains a challenge requiring an experienced specialist; and (iii) further education of physicians as primary source of information is necessary. Additional education may help AI patients to empower them to adequate self-treatment.

Lucky guess or knowledge: a cross-sectional study using the Bland and Altman analysis to compare confidence-based testing of pharmacological knowledge in 3rd and 5th year medical students.

Multiple-choice-questions are common in medical examinations, but guessing biases assessment results. Confidence-based-testing (CBT) integrates indicated confidence levels. It has been suggested that correctness of and confidence in an answer together indicate knowledge levels thus determining the quality of a resulting decision. We used a CBT approach to investigate whether decision quality improves during undergraduate medical education. 3rd- and 5th-year students attended formative multiple-choice exams on pharmacological issues. Students were asked to indicate their confidence in a given answer. Correctness of answers was scored binary (1-correct; 0-wrong) and confidence levels were transformed to an ordinal scale (guess: 0; rather unsure: 0.33; rather sure: 0.66; very sure: 1). 5th-year students gave more correct answers (73 ± 16 vs. 49 ± 13 %, p < 0.05) and were on average more confident regarding the correctness of their answers (0.61 ± 0.18 vs. 0.46 ± 0.13, p < 0.05). Correlation of these parameters was stronger for 5th-year students (r = 0.81 vs. r = 0.52), but agreement of confidence and correctness ('centration') was lower. By combining the Bland-and-Altman approach with categories of decision-quality we found that 5th-year students were more likely to be 'well-informed' (41 vs. 5 %), while more 3rd-students were 'uninformed' (24 vs. 76 %). Despite a good correlation of exam results and confidence in given answers increased knowledge might be accompanied by a more critical view at the own abilities. Combining the statistical Bland-and-Altman analysis with a theoretical approach to decision-quality, more advanced students are expected to apply correct beliefs, while their younger fellows are rather at risk to hesitate or to act amiss.