Omitting breakfast and lunch after injection of different long-acting insulin preparations at bedtime: a prospective study in patients with type 2 diabetes.

AIMS/HYPOTHESIS: The aim of this prospective trial was to compare the effect of different long-acting insulin preparations injected at bedtime on glucose concentrations in patients with type 2 diabetes omitting breakfast and lunch the next day. METHODS: Twenty patients (ten women) with type 2 diabetes who were on an intensified insulin therapy participated. Mean (+/-SD) age was 63 +/- 10 years, diabetes duration 18 +/- 9 years, BMI 32.5 +/- 5 kg/m(2), and HbA(1c) 7.3 +/- 0.7%. Patients received neutral protamine Hagedorn (NPH) insulin, insulin detemir or insulin glargine for at least 2 months; doses were adjusted to achieve morning blood glucose levels of <7 mmol/l. At the end of the respective treatment period, the long-acting insulin was injected at bedtime (at 22:45 hours) as usual but patients refrained from breakfast and lunch the next day; glucose was measured by a continuous glucose monitoring system (CGMS). RESULTS: Comparable glucose target ranges were reached at midnight (5.8 to 6.1 mmol/l) and at 07:00 hours (6.7 to 6.9 mmol/l) with all three insulin preparations, using mean doses of 29 +/- 10 U (NPH insulin), 33 +/- 13 U (insulin detemir), and 32 +/- 12 U (insulin glargine). Glucose levels between midnight and 07:00 hours were not significantly different for the three insulin preparations. Symptomatic hypoglycaemia did not occur from 08:00 to 16:00 hours; glucose concentrations during this time were slightly lower with NPH insulin than with insulin detemir (p = 0.012) and insulin glargine (p = 0.049). CONCLUSIONS/INTERPRETATION: Following bedtime injection of NPH insulin or of the analogues insulin detemir or insulin glargine, fasting glucose <7 mmol/l was achieved in the morning, without subsequent hypoglycaemia when participants continued to fast during the day.

[Diagnosis and treatment of iron deficiency without anaemia]. / Diagnostic et traitement de la carence en fer sans anémie.

Iron deficiency (ID) without anaemia frequently remains undiagnosed when symptoms are attributed to ID with anaemia. Serum ferritin is the primary diagnostic parameter, whereas <10 microg/l represent depleted iron stores, 10-30 microg/l can confirm ID without anaemia and 30-50 microg/l might indicate functional ID. In case of increased CRP or ALT, normal/elevated ferritin should be interpreted with caution. IV iron is indicated if oral iron is not effective or tolerated. At ferritin <10 microg/l, a cumulative dose of 1000 mg iron and at ferritin 10-30 microg/l, a cumulative dose of 500 mg is advised. At ferritin 30-50 microg/l a first dose of 200 mg might be considered. Ferritin shall be reassessed not sooner than 2 weeks after the last oral or 8-12 weeks after the last IV iron administration.

[Diagnosis and treatment of iron deficiency without anaemia]. / Diagnose und Behandlung von Eisenmangel ohne Anämie.

Iron deficiency (ID) without anaemia frequently remains undiagnosed when symptoms are attributed to ID with anaemia. Serum ferritin is the primary diagnostic parameter, whereas <10 microg/l represent depleted iron stores, 10-30 microg/l can confirm ID without anaemia and 30-50 microg/l might indicate functional ID. In case of increased CRP or ALT, normal/elevated ferritin should be interpreted with caution. Intravenous iron is indicated if oral iron is not effective or tolerated. At ferritin <10 microg/l, a cumulative dose of 1000 mg iron and at ferritin 10-30 microg/l, a cumulative dose of 500 mg is advised. At ferritin 30-50 microg/l a first dose of 200 mg might be considered. Ferritin shall be reassessed not sooner than 2 weeks after the last oral or 8-12 weeks after the last iv iron administration.

[Emergency landing due to a passanger with chest pain, dyspnea, and vomiting]. / Notlandung wegen Thoraxschmerz, Dyspnoe und Erbrechen.

A 20-year old student had suffered since 3 years from diabetes mellitus type I, which was well-controlled by insulin-pump therapy. During a flight from Moscow to Los Angeles, the student all of a sudden had chest pain, dyspnea, and he vomitted repetitively--emergency landing at Zurich airport was necessary. The student presented at the emergency unit in a poor general condition with tachypnea (32/min) and tachycardia (136/min). Arterial blood gas analysis showed severe metabolic acidosis (pH 7.04), while pulmonary or cardiac disease could be ruled out. Diabetic ketoacidosis was caused by the pump running short of insulin. Treatment included rehydration and administration of insulin. Administration of insulin by an insulin-pump allows to continuously and flexibly adjust the dosage according to the requirement of the body. Interruption of insulin administration can cause, however, relatively fast ketoacidosis because exclusively short-acting insulin is used.

[Subacute thoracic pain]. / Subakuter Thoraxschmerz.

A 75-year old woman with essential hypertension presented two days after the onset of a sudden and strong thoracic pain. The pain did neither increase during breathing nor decrease after the ingestion of nitroglycerine, and could not be triggered by physical manipulation of the thoracic wall. Electrocardiogram showed a left bundle branch block, chest X-ray showed a widened upper mediastinum. Rupture/dissection of an aberrant right subclavian artery (a. lusoria) could be diagnosed by computed tomography. Successful implantation of an endovascular stent-graft was carried out. Evaluation of (sub)acute thoracic pain should include two-plane chest X-ray and, in case of a widened mediastinum, further investigation by computed tomography. In case of highly suspected rupture/dissection of an intrathoracic artery, a specific imaging procedure such as computed tomography is crucial.

[Insidious aspects of small pulmonary coin lesions]. / Die Tücke kleiner Lungenrundherde.

After his girl friend had been diagnosed with active pulmonary tuberculosis, a 45-year old male was referred to rule out transmission of this disease. The chest x-ray showed no signs of tuberculosis, however a small retrosternal lung nodule was found on the lateral film. Three months later, the nodule showed an increase in size and a CT of the chest was performed: No nodule could be found in the expected retrosternal location, but incidentally a small nodule in the right upper lobe was identified. This nodule could retrospectively be identified on the previous chest X-rays, its size had been increasing. After surgical removal, the lesion was diagnosed to be an adenocarcinoma T1, N0, M0. Careful follow-up of small intrapulmonary nodules detected on chest X-rays is highly advisable, especially in smokers of middle and older age bronchial carcinoma and therefore a straight forward approach with excision of the nodule should be considered. Nodules have to be surgically removed if an increase in size can be noted.