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Diabetes, hypoglycemia and driving instructions in Switzerland Abstract. Many individuals with diabetes participate in road traffic in a regular and safe manner. Studies suggest that type 1 diabetes leads to more traffic accidents. Hypoglycemia is a risk factor for driving mishaps. Therefore, patients with diabetes medication, which can cause hypoglycemia, have to be informed and adhere to the guidelines regarding suitability for driving. These guidelines are summarized in this review.

Background Hypernatraemia is common in inpatients and is associated with substantial morbidity. Its differential diagnosis is challenging, and delayed treatment may have devastating consequences. The most important hormone for the regulation of water homeostasis is arginine vasopressin, and copeptin, the C-terminal portion of the precursor peptide of arginine vasopressin, might be a reliable new parameter with which to assess the underlying cause of hypernatraemia. Methods In this prospective, multicentre, observational study conducted in two tertiary referral centres in Switzerland, 92 patients with severe hyperosmolar hypernatraemia (Na+ > 155 mmol/L) were included. After a standardised diagnostic evaluation, the underlying cause of hypernatraemia was identified and copeptin levels were measured. Results The most common aetiology of hypernatraemia was dehydration (DH) (n = 65 [71%]), followed by salt overload (SO) (n = 20 [22%]), central diabetes insipidus (CDI) (n = 5 [5%]) and nephrogenic diabetes insipidus (NDI) (n = 2 [2%]). Low urine osmolality was indicative for patients with CDI and NDI (P

Background Hyponatremia is the most common electrolyte abnormality in hospitalized patients and given its impact on mortality and morbidity, a relevant medical condition. Nevertheless, little is known about factors influencing long-term outcome. Methods This is a prospective observational 12-month follow-up study of patients with profound hyponatremia (≤125 mmol/L) admitted to the emergency department of two tertiary care centers between 2011 and 2013. We analyzed the predictive value of clinical and laboratory parameters regarding the following outcomes: 1-year mortality, rehospitalization and recurrent profound hyponatremia. Results Median (IQR) initial serum sodium (s-sodium) level of 281 included patients was 120 mmol/L (116–123). During the follow-up period, 58 (20.6%) patients died. The majority (56.2%) were rehospitalized at least once. Recurrent hyponatremia was observed in 42.7%, being profound in 16%. Underlying comorbidities, assessed by the Charlson Comorbidity Index, predicted 1-year mortality (odds ratio (OR) 1.43, 95% confidence interval (CI) 1.25–1.64, P P = 0.036) and ‘correction of hyponatremia’ defined as s-sodium ≥135 mmol/L at discharge were associated with mortality (OR 0.47, 95% CI 0.23–0.94, P = 0.034). Mortality rate fell with decreasing baseline s-sodium levels and was lower in the hyponatremia category ≤120 mmol/L vs >120 mmol/L (14.8% and 27.8%, P 120 mmol/L. Conclusion Hyponatremia is associated with a substantial 1-year mortality, recurrence and rehospitalization rate. The positive correlation of s-sodium and mortality emphasizes the importance of the underlying disease, which determines the outcome besides hyponatremia itself.

Die notfallmassige Zuweisung der 45-jahrigen Patientin erfolgte aufgrund eines plotzlichen somnolenten Zustands wahrend der Arbeit.

Glucocorticoids have been shown to improve outcome in community-acquired pneumonia (CAP). However, glucocorticoids have potential side-effects, and treatment response may vary. It is thus crucial to select patients with high likelihood to respond favourably. In critical illness, cosyntropin testing is recommended to identify patients in need for glucocorticoids. We investigated whether cosyntropin testing predicts treatment response to glucocorticoids in CAP.Predefined secondary analysis of a randomized controlled trial.Hospitalized patients with CAP.We performed 1 µg cosyntropin tests in a randomized trial comparing prednisone 50 mg for 7 days to placebo. We investigated whether subgroups based on baseline and stimulated cortisol levels responded differently to glucocorticoids with regard to time to clinical stability (TTCS) and other outcomes by inclusion of interaction terms into statistical models.A total of 326 patients in the prednisone and 309 patients in the placebo group were evaluated. Neither basal cortisol nor a Δcortisol250 nmol/L after stimulation nor the combination of basal cortisol and Δcortisol predicted treatment response as measured by TTCS (all P for interaction0.05). Similarly, we found no effect modification with respect to mortality, rehospitalization, antibiotic treatment duration or CAP-related complications (all P for interaction0.05). However, glucocorticoids had a stronger effect on shortening length of hospital stay in patients with a baseline cortisol of ≥938 nmol/L (P for interaction = 0.015).Neither baseline nor stimulated cortisol after low-dose cosyntropin testing at a dose of 1 µg predicted glucocorticoid responsiveness in mild to moderate CAP. A treatment decision for or against adjunct glucocorticoids in CAP should not be made depending on cortisol values or cosyntropin testing results.

Objectives To assess symptoms and characteristics of hyponatremia, the most common electrolyte disturbance in hospitalized individuals and a condition that is associated with substantial morbidity and mortality. Design Prospective observational multicenter study. Setting Two Swiss academic centers. Participants Individuals with profound hypoosmolar hyponatremia (sodium

Objective Hyponatremia due to excessive fluid intake (i.e. primary polydipsia (PP)) is common. It may culminate in profound hyponatremia—carrying considerable risk of morbidity. However, data on patients with PP leading to hyponatremia is lacking. Herein, we describe the characteristics of polydiptic patients hospitalised with profound hyponatremia, and assess one-year outcomes. Design Substudy of the prospective observational Co-MED Study. Patients Patients with an episode of profound hyponatremia (≤125mmol/l) due to PP in the medical emergency were eligible and classified into psychogenic polydipsia (PsyP), dipsogenic polydipsia (DiP), and beer potomania (BP). Measurements Symptoms, laboratory findings, and factors contributing to hyponatremia (comorbidities, medication, and liquid intake) were assessed. A one-year follow-up was performed to evaluate recurrence of hyponatremia, re-admission rate, and mortality. Results 23 patients were included (median age 56 years [IQR 50-65], 74% female), 7 had PsyP, 8 DiP, and 8 BP. Median serum sodium of all patients was 121mmol/l (IQR 114-123), median urine osmolality 167mmol/l (IQR 105-184), and median copeptin 3.6mmol/l (IQR 1.9-5.5). Psychiatric diagnosis, particularly dependency disorder (43%) and depression (35%), were highly prevalent. Factors provoking hyponatremia were found in all patients (e.g. acute water load, medication, stress). During the follow-up period, 67% of patients were readmitted, 52% of these with re-hyponatremia, and 3 patients (38%) with BP died. Conclusion Patients with PP are more likely to be female, and have addictive and affective disorders. Given the high recurrence, re-hospitalisation, and mortality rate, careful monitoring and long-term follow-up including controls of serum sodium, education and behavioural therapy is needed. This article is protected by copyright. All rights reserved.

Background Hyponatraemia is common and its differential diagnosis and consequent therapy management is challenging. The differential diagnosis is mainly based on the routine clinical assessment of volume status, which is often misleading. Mid-regional pro-atrial natriuretic peptide (MR-proANP) is associated with extracellular and cardiac fluid volume. Methods A total of 227 consecutive patients admitted to the emergency department with profound hypo-osmolar hyponatraemia (Na

Background: An intervention trial found a trend for shorter length of stay (LOS) in patients with community-acquired pneumonia (CAP) when the CURB65 score was combined with the prognostic biomarker proadrenomedullin (ProADM) (CURB65-A). However, the efficacy and safety of CURB65-A in real life situations remains unclear. Methods: From September, 2011, until April, 2012, we performed a post-study prospective observational quality control survey at the cantonal Hospital of Aarau, Switzerland of consecutive adults with CAP. The primary endpoint was length of stay (LOS) during the index hospitalization and within 30 days. We compared the results with two well-defined historic cohorts of CAP patients hospitalized in the same hospital with the use of multivariate regression, namely 83 patients in the observation study without ProADM (OPTIMA I) and the 169 patients in the intervention study (OPTIMA II RCT). Results: A total of 89 patients with confirmed CAP were included. As compared to patients with CURB65 only observed in the OPTIMA I study, adjusted regression analysis showed a significant shorter initial LOS (7.5 vs. 10.4 days; −2.32; 95% CI, −4.51 to −0.13; p = 0.04) when CURB65-A was used in clinical routine. No significant differences were found for LOS within 30 days. There were no significant differences in safety outcomes in regard to mortality and ICU admission between the cohorts. Conclusion: This post-study survey provides evidence that the use of ProADM in combination with CURB65 (CURB65-A) in “real life” situations reduces initial LOS compared to the CURB65 score alone without apparent negative effects on patient safety.

Concerns about inadequate performance and complexity limit routine use of clinical risk scores in lower respiratory tract infections. Our aim was to study feasibility and effects of adding the biomarker proadrenomedullin (proADM) to the confusion, urea >7 mmol·L−1, respiratory rate ≥30 breaths·min−1, blood pressure, Proof-of-concept trial: how to shorten LOS in patients with LRTIs by reducing medically unnecessary days in the hospital http://ow.ly/nI7z4

Background Fluid restriction (FR), the first-line treatment for hyponatraemia due to the syndrome of inappropriate antidiuresis (SIAD), often does not lead to successful correction of hyponatraemia. Therefore, predictive markers of treatment response are desirable. We evaluated routinely measured serum (s) and urine (u) parameters, s-copeptin and s-mid-regional pro-atrial natriuretic peptide (s-MR-proANP), as possible predictors of FR response. Methods In this prospective observational study, we included patients with profound hyponatraemia (s-sodium 3 mmol L−1 within 24 h) or nonresponders (increase of ≤3 mmol L−1 within 24 h). Initial laboratory parameters were compared between groups with logistic regression analysis. Results Of 106 SIAD patients analysed, 82 underwent treatment with FR; 48 (59%) patients showed a successful response to FR and 34 (41%) were considered nonresponders. High levels of u-sodium and u-osmolality were significantly associated with nonresponse to FR [odds ratio (OR) 15.0, 95% confidence interval (CI) 2.4–95.8, P = 0.004 and OR 34.8, 95% CI 1.2–1038.8, P = 0.041, respectively). The association of u-sodium and nonresponse remained significant also after adjustment for diuretic use. Lower levels of s-MR-proANP were associated with nonresponse (OR 0.03, 95% CI 0.003–0.3, P = 0.004), whereas s-copeptin was not significantly associated with response to FR. Conclusion Easily measured laboratory parameters, especially u-sodium, correlate with therapeutic response and identify patients most likely to fail to respond to FR. Measurement of these parameters may facilitate early treatment choice in patients with SIAD.

Context: Apelin and arginine vasopressin are antagonists in the regulation of body fluid and osmotic homeostasis. There are no data about apelin levels in patients with polyuria-polydipsia syndrome (PPS). Objective: To investigate plasma apelin levels and plasma apelin to copeptin ratios in patients with PPS and healthy volunteers using copeptin as a surrogate marker for arginine vasopressin. Design, Participants, and Setting: We included 41 patients with PPS in this post hoc analysis of a prospective study performed in tertiary care hospitals in Switzerland and Germany and 113 healthy volunteers as a control group. Outcome Measures: Plasma apelin and copeptin levels were measured in 15 patients with complete central diabetes insipidus (DI), seven patients with complete nephrogenic DI, 19 patients with primary polydipsia (PP), and 113 healthy volunteers. Results: Plasma apelin levels were highest in patients with complete nephrogenic DI (413 pmol/L; interquartile range, 332-504 pmol/L; P = .01) and lower in patients with PP (190 [172-215] pmol/L; P < .001) or complete central DI (209 [174-241] pmol/L; P = .02) as compared to healthy volunteers (254 [225-311] pmol/L). Plasma apelin to copeptin ratio in patients with PP (53 [38-92] pmol/pmol; P > .9) was similar to healthy volunteers (57 [37-102] pmol/pmol). In contrast, the apelin to copeptin ratio was higher in patients with complete central DI (89 [73-135] pmol/pmol; P = .02) and lower in patients with complete nephrogenic DI (7 [6-10] pmol/pmol; P < .001) compared to healthy volunteers. Conclusion: In PP, normal plasma apelin to copeptin ratio attests a normal water homeostasis. In contrast, in patients with central or nephrogenic DI, the increased or decreased apelin to copeptin ratio, respectively, reflects a disturbed osmotic and body fluid homeostasis.

Study objective: Syncope is one of the most common presentation of patients seen in emergency departments (ED). Risk assessment of syncope is challenging. The San Francisco Syncope Rule is the most widely used risk assessment, but has moderate accuracy. The aim of our study was to investigate blood biomarkers as prognostic factors for adverse outcome. Methods: In this observational study we included consecutive adults presenting with syncope to our ED. Management decisions were left to the discretion of the treating physicians. Patients were monitored for adverse events until discharge and underwent a phone interview 30 days after enrolment. Adverse outcome was defined as recurrent syncope, rehospitalization and death within 30 days. Results: We included 132 adult patients of whom 19 (14%) had an adverse event (recurrent syncope = 3, rehospitalisation = 12, death = 4). No difference in the San Francisco Syncope Rule was found in patients with and without adverse events (SFSR ≥ 1: 37% vs. 39%, p = 0.877). Median levels of ProADM (1.23 vs. 0.81 nmol/l; p = 0.006) and NT-proBNP (454 vs 134ng/l; p = 0.035) were higher and median levels for cholesterol (3.68 vs 4.57 mmol/l; p = 0.008) and prealbumin (0.19 vs0.26 g/l; p = 0.005) were lower in patients with adverse events. Prealbumin (AUC 0.72) and ProADM (AUC 0.70) had the highest prognostic accuracy. Conclusion: Biomarkers predicted poor outcome and might be helpful in the context of a clinical algorithm for an improved triage of syncope patients in the ED.

Context: The polyuria-polydipsia syndrome comprises primary polydipsia (PP) and central and nephrogenic diabetes insipidus (DI). Correctly discriminating these entities is mandatory, given that inadequate treatment causes serious complications. The diagnostic “gold standard” is the water deprivation test with assessment of arginine vasopressin (AVP) activity. However, test interpretation and AVP measurement are challenging. Objective: The objective was to evaluate the accuracy of copeptin, a stable peptide stoichiometrically cosecreted with AVP, in the differential diagnosis of polyuria-polydipsia syndrome. Design, Setting, and Patients: This was a prospective multicenter observational cohort study from four Swiss or German tertiary referral centers of adults >18 years old with the history of polyuria and polydipsia. Measurements: A standardized combined water deprivation/3% saline infusion test was performed and terminated when serum sodium exceeded 147 mmol/L. Circulating copeptin and AVP levels were measured regularly throughout the test. Final diagnosis was based on the water deprivation/saline infusion test results, clinical information, and the treatment response. Results: Fifty-five patients were enrolled (11 with complete central DI, 16 with partial central DI, 18 with PP, and 10 with nephrogenic DI). Without prior thirsting, a single baseline copeptin level >21.4 pmol/L differentiated nephrogenic DI from other etiologies with a 100% sensitivity and specificity, rendering a water deprivation testing unnecessary in such cases. A stimulated copeptin >4.9 pmol/L (at sodium levels >147 mmol/L) differentiated between patients with PP and patients with partial central DI with a 94.0% specificity and a 94.4% sensitivity. A stimulated AVP >1.8 pg/mL differentiated between the same categories with a 93.0% specificity and a 83.0% sensitivity. Limitation: This study was limited by incorporation bias from including AVP levels as a diagnostic criterion. Conclusion: Copeptin is a promising new tool in the differential diagnosis of the polyuria-polydipsia syndrome, and a valid surrogate marker for AVP. Primary Funding Sources: Swiss National Science Foundation, University of Basel.

Clinical trials yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of community-acquired pneumonia. We assessed whether short-term corticosteroid treatment reduces time to clinical stability in patients admitted to hospital for community-acquired pneumonia.In this double-blind, multicentre, randomised, placebo-controlled trial, we recruited patients aged 18 years or older with community-acquired pneumonia from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomly assigned (1:1 ratio) to receive either prednisone 50 mg daily for 7 days or placebo. The computer-generated randomisation was done with variable block sizes of four to six and stratified by study centre. The primary endpoint was time to clinical stability defined as time (days) until stable vital signs for at least 24 h, and analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00973154.From Dec 1, 2009, to May 21, 2014, of 2911 patients assessed for eligibility, 785 patients were randomly assigned to either the prednisone group (n=392) or the placebo group (n=393). Median time to clinical stability was shorter in the prednisone group (3·0 days, IQR 2·5-3·4) than in the placebo group (4·4 days, 4·0-5·0; hazard ratio [HR] 1·33, 95% CI 1·15-1·50, p0·0001). Pneumonia-associated complications until day 30 did not differ between groups (11 [3%] in the prednisone group and 22 [6%] in the placebo group; odds ratio [OR] 0·49 [95% CI 0·23-1·02]; p=0·056). The prednisone group had a higher incidence of in-hospital hyperglycaemia needing insulin treatment (76 [19%] vs 43 [11%]; OR 1·96, 95% CI 1·31-2·93, p=0·0010). Other adverse events compatible with corticosteroid use were rare and similar in both groups.Prednisone treatment for 7 days in patients with community-acquired pneumonia admitted to hospital shortens time to clinical stability without an increase in complications. This finding is relevant from a patient perspective and an important determinant of hospital costs and efficiency.Swiss National Science Foundation, Viollier AG, Nora van Meeuwen Haefliger Stiftung, Julia und Gottfried Bangerter-Rhyner Stiftung.

Objective: Disorders of water balance caused by disturbances in arginine vasopressin (AVP) secretion remain a common cause of complicated hospital stay after pituitary surgery. Copeptin, the stable C-terminal glycopeptide of the AVP prohormone, is a reliable surrogate of plasma AVP. Our aim is to elucidate[for full text, please go to the a.m. URL], 65. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC)

Eine 15-jährige Patientin mit Thrombotisch Thrombozytopenischer Purpura (TTP) wurde uns zur weiteren Abklärung und Therapie bei fehlendem Ansprechen auf Steroide und IVIG zugewiesen. Aufgrund des Nachweises von Antikörpern gegen ADAMTS13 wurde die Diagnose einer erworbenen TTP gestellt. Komorbiditäten wie zum Beispiel ein Systemischer Lupus erythematodes wurden nicht gefunden. Trotz Plasmaaustausches und hochdosierter Steroidtherapie blieb ein anhaltender Therapieerfolg zunächst aus, weshalb wir uns zur Gabe von Rituximab entschlossen. Bereits nach der ersten von zwei Gaben von Rituximab kam es innerhalb einer Woche zu einer Normalisierung der Thrombozytenzahl. Nebenwirkungen auf Rituximab wurden nicht beobachtet und der Therapieerfolg hielt auch nach Ausschleichen der Plasmaaustausche und der Steroide an.

A 15-year-old female patient with TTP was admitted to our hospital for further evaluation after the initial treatment with IVIG and prednisone failed. With the detection of anti-ADAMTS13 antibodies the acquired form of TTP could be diagnosed. Despite of therapeutic plasma exchange and high dose steroids no sustained remission could be achieved. However, application of rituximab led to a normalisation of platelet counts within one week allowing the termination of plasma exchanges and reduction of oral steroids. No side effects of rituximab were observed and the patient remained in clinical remission during the following months.

Clinical trials yielded conflicting data about the benefit of adding systemic corticosteroids for community-acquired pneumonia (CAP). We evaluated whether short-term corticosteroid treatment reduces time to clinical stability in patients hospitalized for CAP.