The changing face of internal medicine: patient centred care

Patient centred care is now considered the gold standard and there should be 'no decision about me, without me'. Internists who treat patients with complex multi-morbidities should consider patients' preferred outcomes, following a 'goal-oriented' principle. Perhaps the most important barrier to goal-oriented care is that medicine is deeply rooted in a disease-outcome-based paradigm. Rather than asking what patients want, the culture of modern medicine has prioritised optimal disease management according to guidelines and population goals. Doing what is right for the patient should be based on trust. Patients and internists must therefore meet as equals: 'I' and 'you' should be replaced by 'we'.

Clinical manifestations and treatment options in patients with cirrhosis and diabetes mellitus

BACKGROUND

Diabetes is frequently diagnosed in patients with cirrhosis and represents an important risk factor for morbidity and mortality. Pharmacological therapy is limited due to hepatotoxicity and the risk of hypoglycemia. Investigations on medical practice in this patient population, frequency of diabetes-associated complications and the impact of quality of metabolic control are rare.

AIMS AND METHODS

A retrospective analysis was performed to compare the effects of hypoglycemic treatment, the achieved glycemic control under therapy, the prevalence of typical cirrhosis-related or microangiopathic complications, and cardiovascular comorbidities between a group of diabetic patients with cirrhosis (n = 87) and a nondiabetic cirrhotic population (n = 198).

RESULTS

The prevalence of diabetes in our cohort was 30.5%. Of all diabetic patients, 39.1% received therapy which might potentially result in serious side effects in patients with end-stage liver disease. The rate of ongoing alcohol abuse (28.7%) and noncompliance under medication (41.4%) was high. Only 28.7% of all diabetic subjects showed satisfactory (as defined by HbA1c ≤ 6.5%) glycemic control under therapy. Patients achieving satisfactory control experienced a lower rate of certain cirrhosis-related complications such as hepatic encephalopathy (HE) and hepatocellular carcinoma (HCC), arterial hypertension, and hypercholesterolemia. HE was significantly more frequent in diabetic than nondiabetic cirrhotic patients.

A review of modern insulin analogue pharmacokinetic and pharmacodynamic profiles in type 2 diabetes: improvements and limitations

Insulin analogues have been engineered to enhance desired molecular properties without altering immunogenicity. The majority of insulin pharmacology studies are conducted in healthy volunteers and patients with type 1 diabetes. At present, there are more patients with type 2 than type 1 diabetes receiving insulin treatment. As the responsibility for initiating insulin therapy in these patients continues to shift to primary care, it will be important for general practitioners to understand the different pharmacological properties of insulin preparations in patients with type 2 diabetes, so that treatment can be adapted to meet patients' physiological and lifestyle requirements. The purpose of this review is to summarize pharmacological studies of insulin analogues in patients with type 2 diabetes. Faster onset of action of rapid acting insulin analogues has improved postprandial glycaemic control. Biphasic insulin analogues are associated with a lower incidence of nocturnal hypoglycaemia compared with human biphasic preparations and allow for intensification from once to twice or thrice daily dosing. More predictable glycaemic-lowering profiles of the insulin analogues have also led to reductions in nocturnal hypoglycaemia, particularly comparing long-acting insulin analogues with protaminated human insulin. Enhancing insulin self-association and reversible binding with albumin has led to further reductions in variability. However, improvements can still be made. Effective once daily clinical dosing of long-acting insulin analogues is not possible in all patients. In addition, the protaminated component of biphasic insulin analogues do not provide the duration of action or profile for physiological basal insulin replacement and neither insulin glargine nor insulin detemir are suitable for mixing with other insulin analogues as this would substantially alter their pharmacokinetic properties. Enhancing the pharmacological predictability and extending the duration of action could simplify insulin titration and further reduce the incidence of hypoglycaemia.

In vivo effects of TSH receptor antibodies in xenotransplanted human thyroid tissue

From the data presented it can be concluded that the xenotransplantation model is well suited for studies concerning pathogenesis, diagnosis and therapy of AITD. Human thyroid transplants of Graves' disease tissue, depending upon extrinsic stimulators, lose all signs of hyperfunction after transplantation into athymic nude mice, but hyperfunction can again be induced in the transplants by injections of sera or immunoglobulin fractions from patients with active Graves' disease, containing stimulating TSH receptor antibodies. Our data demonstrate that thyroid function and growth are independent phenomena and can be differentiated by means of the xenotransplantation model. Furthermore the presented results indicate that TSH receptor antibodies are able to alter the expression of gene products in human thyroid transplants of Graves' disease, emphasising their important role in inducing/perpetuating immune phenomena related to AITD.

Antagonists of the human TSH receptor: in vitro and in vivo studies of their functional and immunological effects

We have developed and characterized a prototype of a TSH receptor antagonist derived from the hCG molecule. This may be used to block human TSH receptor both functionally and immunologically, particularly in the study of Graves' disease. Our hCG derived TSH receptor blocker compares favorably with other substances (e.g. deglycosylated forms of TSH, synthetic peptides of the alpha or beta subunit of TSH) that hare been reported to inhibit bTSH binding or bTSH-stimulated cAMP response (Joshi et al., 1981; Morris et al., 1988). It has a much higher affinity for human TSH receptor than the TSH subunit peptides and it is the only substance an efficacy of which has been proven in vivo so far. Recent progress in the synthesis of recombinant glycoprotein hormones should permit to biosynthetically produce this or a similar TSH receptor antagonist. With respect to Graves' disease, the data suggest that TSH receptor, in addition to its role in maintaining thyroid hyperfunction, plays also a role in propagating the thyroid autoimmune disease itself. Stimulation of TSH receptor by bTSH as well as TSAb enhances the expression of HLA class II antigens on the surface of thyrocytes, and a blockade of TSH receptor results in a substantial inhibition of this immunological key event. This could possibly explain why suppression of TSH by administering levothyroxine was found in a recent study by Hashizume and coworkers (1991) to decrease TSAb titers and to reduce relapse rate in patients with Graves' hyperthyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of Graves' intrathyroidal lymphocytes. Effect of Graves' disease intrathyroidal lymphocytes (ITL) on xenotransplants of human thyroid tissue in athymic nude mice

It has been suggested that ITL are of importance in the pathogenesis of human autoimmune thyroid disease. Aim of our study was to investigate function and morphology of xenotransplanted human thyroid tissue in nude mice following systemic application of lymphocyte preparations from patients with Graves' disease (GD) and non-toxic nodular goiter (NTG). ITL obtained from 13 patients with GD and peripheral blood lymphocytes (PBL) from 12 patients with NTG were injected into nude mice bearing 8 weeks old xenografts of normal human thyroid tissue. ITL- and PBL-subsets were analyzed by flow cytometer (FACScan) before engraftment. Two days after injection the thyroid transplants were examined histologically (HE) as well as immunohistologically by staining with: CD3, CD31, CD45R, HLA class II, ICAM-1, VCAM-1, IgG, IgM and Ki67. Flow cytometry showed a significant higher number of the lymphocyte-subsets CD3, DR+ and CD4 in GD-ITL as compared to the subsets in NTG-ITL. After injection of GD-ITL to the nude mice also a significant higher number of CD3+ human lymphocytes was found in the transplants. GD-lymphocytes stimulated thyroid tissue function significantly more pronounced than NTG-lymphocytes (histomorphological evaluation). In addition, a significant increase of HLA-class II, ICAM-1-, VCAM-1-, CD45-expression and number of Ig presenting plasma cells were observed only after injection of GD-ITL. Our data demonstrate, for the first time in vivo (nude mouse model), that GD-lymphocytes of both peripheral and intrathyroidal origin selectively migrate into human thyroid transplants ("homing"). They survive there for at least two days and induce significant functional as well as histological changes, like expression of gene products and IgG synthesis. These results suggest an important role of ITL in the pathogenetic mechanisms and clinical course of GD.

[Hepatogenous diabetes - diagnostics and treatment]

BACKGROUND

Patients with liver cirrhosis develop frequently disturbances of glucose metabolism e. g. glucose intolerance or hepatogenous diabetes which are caused by the hepatocellular functional loss and insulin resistance due to chronic liver disease.

DISCUSSION

Until now there are no recommendations comparable to guidelines on the diagnosis of and therapy for hepatogenic diabetes. Regarding basic treatment a sufficient daily energy and protein supply should be guaranteed since the majority of patients with liver cirrhosis are malnourished. The risk of hypoglycaemia must be considered carefully under pharmacological treatment of hepatogenous diabetes. Biguanide and PPAR gamma agonists are contraindicated due to side effects in liver cirrhosis. Suitable oral antidiabetics are glinides and short-acting sulfonylureas. If a sufficient diabetes adjustment does not succeed by oral antidiabetics a prandial insulin therapy using short-acting insulins or rapid-acting insulin analogues should be applied.

CONCLUSION

Optimisation of diabetic metabolic conditions is not only important to avoid typical diabetic late complications but also cirrhosis-associated complications, e. g., gastrointestinal bleeding, hepatic encephalopathy or the occurrence of hepatocellular carcinoma.

[How much do inpatient treated diabetics know about their disease?]

AIM OF STUDY

The aim of the study was to find to find out which factors are able to predict the disease-specific knowledge of in-patient diabetic patients and to characterize this group of patients.

METHODS

The disease-specific knowledge of diabetic patients of a Hospital in Munich, Germany (department of diabetology) was tested using a general questionnaire and a specific diabetes knowledge test. All data manipulation and statistical calculations were conducted with the statistical software package SAS (version 9.1).

RESULTS

On average type-1-diabetics achieved 73% of the possible points in the knowledge test, type-2-diabetics achieved 68% of total points. In bivariate analyses, using logistic regression, existence of diabetes related complications was a significant predictor of poor knowledge (OR = 4.36; 95%-KI: 1.38-13.77) in type-1-diabetics. Other factors, e. g. lack of diabetes education were associated with low test results but reached no statistical significance (OR = 6.13; 95%-KI: 0.67-56.42). In multivariate logistic regression (female) gender was a significant risk factor for low test results (OR = 7.66; 95%-KI: 1.18-49.8). In type-2-diabetics lack of diabetes education (OR = 3.86; 95%-KI: 1.51-9.84), low self-assessment of information about diabetes (OR = 3.90; 95%-KI: 1.36-11.21) and lack of knowledge about diabetes diet (OR = 4.06; 95%-KI: 1.60-10.28) were predictors of poor test results. The existence of diabetes related complications was associated with poor test results but showed no statistical significance in multivariate analysis (OR = 2.99; 95%-KI: 0.85-10.43).

CONCLUSIONS

There is a group of diabetic inward-patients that is less informed about diabetes and shows knowledge deficits in testing. These patients often lack diabetes education and show an unfavourable course of the disease, already having diabetes related complications. Type-2-diabetes patients who feel that they have poor information about their disease actually achieve lower results in knowledge testing. Efforts to assure diabetes education for these patients are essentially necessary.

[Controversial therapeutic strategies in the treatment of type 2 diabetes mellitus]

At the time of the diagnosis insulin resistance is present in the majority of type 2 diabetics. Only in those type 2 diabetics who are of normal weight at diagnosis must a disturbance of insulin secretion be assumed. These pathophysiological facts, discovered in recent years, mandate a differentiated treatment of type 2 diabetics. The primary aim must be the treatment of the insulin resistance. Insulinotropic drugs are indicated only during the further course of the disease. The use of glitazones makes possible a largely causal treatment of insulin resistance. Over the long term better glycemic control is achieved with glitazones rather than sulfonylureas. As a secondary effect, the insulin-producing beta cells are protected, and such cardiovascular risk factors as diabetic dyslipoproteinemia, hypertension or microalbuminuria are favorably influenced.

[Endocrinological transition clinic]

Patients with chronic endocrinological diseases, whether congenital or manifesting in childhood, have to date been the domain of the pediatric clinic long beyond puberty into adulthood. The reason for this is the complete lack of adequate communication between pediatricians and internists specialized in endocrinology. However, intensive and constant cooperation between the two specialties is a prerequisite for the successful transition of adolescent to adult patients. The transition clinic is of central importance for the appropriate management and a stable status of the patient. Nevertheless, only very few university centers so far established such a clinic. Only by overcoming sectoral boundaries, and the creation of a network structure between university policlinic, non-university outpatient department, specialty practice and the family doctor can the intensity and quality of management be improved. The requirement fortransition clinics urgently needs to be met, also in the form of model projects.