Zeitschrift fur die gesamte innere Medizin und ihre Grenzgebiete最新文献

This is a case report on a course of gemini-pregnancy complicated by gestosis, recurrent submassive pulmonary embolism and discordant growth of the hypotrophic twins. It is concluded from this report that: 1. the AT-III-deficiency in gestosis can be caused by loss and consumption; 2. due to decrease below a critical AT-III-level the coagulation-fibrinolysis system tends to decompensate, reflected in a disseminated intravascular coagulation and/or a pulmonary embolism. The tendency consists particularly in immobilisation and stasis; 3. the daily determination of AT III, better of TAT-complex and D-dimer, the daily clinical examination regarding signs of thrombosis and in cases of heparinization the measurement of PTT several times daily, are necessary to avoid or recognise disorders, of the coagulation-fibrinolysis-system at an early stage. 4. The increased consumption in coagulation systems can be avoided by AT-III substitution and correct heparinisation. 5. In cases of risk of pulmonary embolisation in pregnancy a cava filter should be temporarily implanted. The filter must be changed every 3 days, if it is required for a longer period. 6. In high-risk pregnancy the check for factors of thrombophilia is a basic diagnostic procedure.

Cardiovascular diseases have multifactorial causes, as has been shown, and as has been demonstrated via an interactional model. These multifactorial causes must be counteracted by means of multidimensional preventive or rehabilitation measures. Intervention in cardiovascular patients requires interdisciplinary cooperation. Studies conducted so far on rehabilitation of cardiovascular patients have rarely included persons over 60 years of age. This may be explained in part by a poor image of elderly people that exists in the minds of many, discouraging intervention as hardly promising and hence useless. However, persons of an advanced age in particular stand greatly in need of being factually informed at an early date by the physician; such information has a significant influence on the way they can experience and cope with the disease. They must be placed in a position to realise the existing possibilities and limitations to influence their status by means of their attitude, and to look to the future. Successful (secondary) preventive care of elderly persons must also include physical training (kinesitherapy) and psychological aspects when changing dietary habits. On the whole, we are still in need of more research on the problem of possible interventions in cardiovascular patients in general and aged patients in particular. The results of psychological fundamental research in gerontology and intervention supply only few pointers to combatting cardiovascular disease in the elderly. It is however emphasised that psychological measures can merely supplement the medical ones, such supplementation having become so important by now that one should practically not do without it any longer.(ABSTRACT TRUNCATED AT 250 WORDS)

The more than 3 million type II diabetics in Germany constitute a true therapeutic challenge. Type II diabetes mellitus is part of the so-called metabolic syndrome characterized by the problem of insulin resistance/hyperinsulinemia. Treatment of type II diabetes aims at reducing insulin resistance. Oral antidiabetic management must be based on diabetic diet, in conjunction--if needed--with monotherapy with acarbose or metformin. Only after exhausting these principles of management, acarbose or metformin may be combined with sulfonylurea. Primary monotherapy with insulinotropically acting sulfonylureas is, in most cases, no longer appropriate as we are learning more about the pathophysiology of metabolic syndrome.

New findings concerning the dynamic of insulin secretion, insulin action and pharmacokinetics of insulin preparations have caused a complete change of insulin therapy in diabetes mellitus (basis-bolus-concept). At the same time, the discrepancy between insulin substitution and physiologic conditions becomes evident. Even the use of human insulin or the development of insulin-pens and -pumps does not influence that fact. From the beginning of insulin therapy till now the subcutaneous injection of insulin is the safest and easiest way of application. By means of modified insulins (bioengineering) the physico-chemical process of insulin resorption could be elucidated in the last 4 years. In clinical experiments the intraperitoneal and nasal insulin administration is tested extensively. In the field of the intensified insulin therapy including near normoglycemic therapeutic goals the awareness of hypoglycemia is of particular importance.

Autonomic neuropathy is a complication of diabetes which is observed in about 20% of all patients. This complication is often not adequately diagnosed. Neuropathy is a syndrome of various diseases that is classified according to the organs involved in the clinical picture. For the diagnosis of autonomic neuropathy besides the careful examination of the patient (metabolic and neurologic status, diabetic complications) a number of specific tests are available i.e. cardiovascular reflex tests and some other organ-specific tests. The review attempts to give an update of the presently used diagnostic approaches. As far as the therapy of all forms of neuropathy is concerned the careful control of blood glucose of the diabetic patient is still the only therapy which counteracts specifically the pathogenesis of autonomic neuropathy. There is however a number of drugs available which are useful for symptomatic therapy. Their effectiveness is discussed in this review. There is no doubt that diabetic autonomic neuropathies will have consequences for long-term prognosis and quality of life.

Although there is no evidence of effectiveness of interventional trials concerning macroangiopathy in diabetes mellitus, the focus of primary prophylaxis is based on the treatment of risk factors and optimal adjustment of metabolic parameters. This should contain the prophylaxis of the diabetic foot (foot care, teaching, pressure bearing) in the neuro-ischaemic risk patient. In the secondary prophylaxis acetylsalicylic acid has been proven as effective in the cerebral, cardial, and peripheral vascular regions in different dosages. The aim of the symptomatic therapy is the improvement of the peripheral vascular disease symptoms, which could mean an improvement of the pain-free walking distance or the avoidance of an extremity-threatening ischaemic syndrome. The therapeutic range includes a structured exercise programme, conservative medical treatment, catheter procedures, and bypass surgery as well as amputation. The different procedures are mainly dependent on the general condition of the in many cases multimorbid patients, the clinical stage, the psychological burden and the angiologic status. There should be always an interdisciplinary discussion, which helps to find the right therapeutic decision. All the therapeutic activities should be seen under the guideline of an improvement in the quality of life.

Numerous surveys have shown that in industrial countries diabetic subjects develop hypertension more frequently than non-diabetic persons. In fact, three typical hypertension forms in these patients can be discerned: essential, renal, and isolated systolic hypertension. In type 2-diabetes (NIDDM) hypertension can be seen in close association with obesity, glucose intolerance, lipid changes, and insulin resistance within the framework of the metabolic syndrome. The increased incidence of hypertension in type 1-diabetes (IDDM) is a result of development of diabetic nephropathy. In the elderly type 2-diabetics particularly frequently isolated systolic hypertension is present which reflects increased arterial stiffness and loss of vascular distensibility. In hypertension progression of both macrovascular disease and microangiopathy is increased whereby interaction of hyperglycemia and hypertension seems to be the main risk factor. In most hypertensive diabetic patients drugs will be necessary to lower blood pressure in a therapeutical range. There are several effective substances available which should be prescribed individually according to the needs and accompanying conditions in these patients.

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.

Most aspects of the nutritional therapy of diabetes mellitus apply equally to IDDM and NIDDM patients and are also appropriate for people with high risk of cardiovascular diseases. A restriction of energy, a reduction of saturated fatty acids as well as of alcoholic drinks and simple sugars are the most important measures. This modification of nutritional intake together with increased fibre consumption is not only appropriate to avoid hyperglycaemia in diabetic patients but has also its benefits in patients presenting with the metabolic syndrome (possible reduction of hyperinsulinaemia, hypertension and hyperlipoproteinaemia). Diabetic patients should have regular screening for microalbuminuria. At first signs of an early stage of nephropathy patients should be advised to restrict their protein intake. About 50% of daily energy intake should be derived from carbohydrates and fat intake should be no more than 35% of total energy (saturated fatty acids less than 10% of energy). Carbohydrate exchange units are usually not necessary in NIDDM patients. In addition diabetes specialty foods are not an essential part of the nutritional therapy. The success of the nutritional therapy in diabetic patients is substantially dependent upon qualified counselling and education of the patients by the physician (as far as possible with the assistance of a dietitian).

Since the late 1970's, diabetes therapy has been revolutionized and, in fact, new treatment strategies have been initiated by patient education and the resulting self-monitoring of the patient. The modern management of the chronic lifelong disease diabetes mellitus not only requires the prescription of the appropriate nutritional and pharmacologic regimen by the physician, but also intensive education and counselling of the patient. It is the diabetic himself who ultimately has to secure the treatment as given by the physician in daily life and--in so doing--has to provide a great deal of self-care and self-control. Meeting the individual treatment goal is largely dependent upon the cooperation and motivation of the patient, with the physician as both the sympathetic and critical counterpart. Today, education is the indispensible prerequisite for the limited well-being and health of diabetics and, at this end, education is equal to therapy.