Search

Seventy-seven patients aged more than 60 years from the iodine deficiency area of southern Lower Saxony with hyperthyroidism, diagnosed by assessment of thyroid parameters, showed a nonspecific disease picture with surprising frequency when compared with younger patients. Predominant characteristics were weight loss (86%), general weakness (78%), tachycardia (74%), reduced appetite (66%), exertional dyspnoea (60%), apathy, lack of initiative or depression (48%), and uncharacteristic abdominal complaints (20%). A goitre was not palpable in 30 patients (39%). Laboratory diagnosis was hampered by relative or absolute TBG deficiency and conversion inhibition in the form of a low-T3 syndrome as evidence of non-thyroidal changes in generalised disorders. Neither thyroxine nor triiodothyronine were increased in ten patients (13%). Only by additional routine estimation of the thyroxine-binding index (T3 in vitro test) as indicator of free binding capacity could the diagnosis be ascertained in these cases. The poor prognosis be ascertained in these cases. The poor prognosis of hyperthyroidism in the older age group necessitates generous use of specific diagnostic laboratory investigations in cases with suspicious symptoms.

HISTORY AND CLINICAL FINDINGS: A 34-year-old woman was admitted for treatment of toxic epidermolysis of the skin and mucosa. 16 days previously she had started to take chlormezanone (Muskel Trancopal) and some other medications for pain in the shoulder and neck. On admission she had a fever of 39 degrees C and, in addition to the epidermolysis, diffuse abdominal pain on pressure and blood-streaked stool. INVESTIGATIONS: Liver enzyme activities (GOT 979 U/I, GPT 1496 U/I, gamma GT 201 U/I) alkaline phosphatase 515 U/I), bilirubin (3.9 mg/dl) and pancreatic enzyme activities were raised. Sonography was nondiagnostic, computed tomography demonstrated only a small amount of ascites. TREATMENT AND COURSE: The epidermolytic lesions, cholestatic hepatitis and pancreatitis markedly regressed under aseptic wound treatment, antibiotics and parenteral nutrition. Persistent blood-streaked stools and bilateral pneumonia with progressive respiratory failure developed. Despite intensive medical care the patient died after 14 days from protracted sepsis with multi-organ failure. Autopsy additionally revealed adult respiratory distress syndrome and complete loss of colonic mucosa. CONCLUSION: The severe course of a toxic epidermal necrosis with fatal outcome is the first such case reported in Germany that very probably was caused by chlormezanone. 4 weeks after this case was reported to the German Doctors' Drug Commission, the manufacturers of the drug withdrew it from the market. Language: de

Die Indikationsstellung zur Schilddrusenoperation geschieht heute weder allein nach morphologischen noch nach pathophysiologischen Kriterien, sondern in erster Linie entsprechend dem individuellen Therapieziel. Dieses Ziel ergibt sich aus einer Vielzahl biographischer, medizinischer und personlicher Daten sowie aus verschiedenen Umfeldbedingungen. Daher lassen sich kaum Indikationen kataloghaft zusammenfassen. Bei der Struma mit Euthyreose ergibt sich die Indikation meist aus der Grose der Struma, insbesondere nachdem aus verschiedenen Studien der letzten Jahre deutlich wurde, das der Verkleinerungseffekt durch Medikamente nur relativ begrenzt ist. Bei der Autoimmunhyperthyreose vom Typ Basedow sind in jedem Fall die Vor- und Nachteile der 3 konkurrierenden Verfahren – Operation, Radioiod, Medikamente – zu berucksichtigen. Eine Operation kommt insbesondere dann in Frage, wenn das Ziel eine moglichst schnelle und sichere Beseitigung der Hyperthyreose ist. Die Schilddrusenautonomie mit und ohne Hyperthyreose stellt eine klassische Indikation zur Radioiodtherapie dar. Nur bei isolierten autonomen Knoten ist die Operation gleichwertig. Eine Indikationsstellung zur Operation ergibt sich daruber hinaus, wenn neben dem Adenom auch eine deutliche Schilddrusenvergroserung vorliegt. Eine besondere Operationsindikation stellt die konservativ nicht beherrschbare iodinduzierte Hyperthyreose dar. Das Schilddrusenmalignom in allen seinen Auspragungen stellt, mit sehr wenigen Ausnahmen, eine Indikation zur Operation dar.

Um den neuen Erkenntnissen in der einschlagigen Forschung Rechnung zu tragen, hat die „American Diabetes Association“ (ADA) die WHO-Klassifikation von 1985 uberarbeitet und im Juli 1997 eine reformierte Klassifikation des Diabetes mellitus kreiert. Es wurden sowohl atiologische als auch die genetischen Aspekte berucksichtigt. Auch in der diagnostischen Klassifikation gibt es neue, revidierte Kriterien. Der Beitrag beschaftigt sich ausfuhrlich mit der neuen Klassifikation. Beim Typ-1-Diabetes gibt es als Untergruppen eine immunologische und eine idiopathische Form. Fur die Atiologie spielen neben den genetischen Faktoren auch Umwelteinflusse eine Rolle, deren Wirkungsweise aber noch nicht eindeutig geklart ist. Wichtig ist die genetische Beratung. Zuverlassige Erbprognoseziffern geben einen Hinweis auf das Erkrankungsrisiko der Kinder. Auch der Typ-2-Diabetes ist eine Erkrankung mit multifaktoriellem Erbgang, wobei sich auch ethnische Einflusse bemerkbar machen. Aber die Umweltfaktoren haben hier ein wesentlich hoheres Gewicht im Krankheitsgeschehen. Vor allem der westliche Lebensstil und die steigende Lebenserwartung sind ursachlich fur die zunehmende Inzidenz und Pravalenz. Die gebrauchlichen Methoden zur genetischen Erfassung werden beschrieben. Sie dienen der Untermauerung der Hypothesen zur Genese des Diabetes. Demnach durfte ein polygenes Vererbungsmodell bestehen. Fur die genetische Beratung ist der Hinweis auf das hohe Wiederholungsrisiko wichtig. Lebenslange Erkrankungsrisiken bestehen fur Kinder und Geschwister. Als Sonderformen werden ein monogener, autosomal dominant vererbter und ein mitochondrialer Diabetes und deren Genetik beschrieben. Eine separate Form ist auch nach der neuen Klassifikation der Schwangerschaftsdiabetes, ein genetisch herterogenes Krankheitsbild mit variierendem Schweregrad. Als neonataler Diabetes werden Erkrankungen im 1. Lebensmonat bezeichnet, die mit Insulin behandelt werden mussen.

The prevalence of thyroid disorders was investigated in 466 (403 female, 63 male) subjects over the age of 60 years (79.2 +/- 7.5 years; mean +/- SD) from the general population in an area of iodine deficiency. In addition to thyroid hormone assays, thyroid antibodies and urinary iodine excretion were determined. In cases with thyroid dysfunction, ultrasound investigations were performed. Twenty-two of the 466 subjects (4.7%) showed hyper- or hypothyroidism; 7 subjects were hyperthyroid (1.5%), 5 had primary hypothyroidism (1.1%), and 10 showed "subclinical" hypothyroidism (2.2%). The latter constellation is defined as an elevation of thyrotropin (TSH) with normal values for thyroxine and triiodothyronine. Most subjects with hyperthyroidism had a goiter by palpation (6/7); thyroid volume by ultrasound (median) was 26.2 mL with an inhomogeneous echo pattern in 6 of the 7 subjects. In 4 cases, a rise in urinary iodine excretion was documented; none had TSH-receptor antibodies. Most subjects with overt or subclinical hypothyroidism had a homogeneous or low-echogenic pattern by ultrasound; thyroid volume (median) was 12.9 mL and 12.7 mL, respectively. By palpation, 8 of the 15 subjects had no goiter. In general, these persons had no rise in urinary iodine excretion (11/13), but most showed an elevation of antibodies against the microsomal antigen and/or thyroglobulin (11/15).(ABSTRACT TRUNCATED AT 250 WORDS)

Sodium lithium countertransport may be a genetic marker for arterial hypertension and for the risk of diabetic nephropathy in type 1 diabetic patients. Since various factors seem to influence the transport velocity including serum lipid alterations, erythrocytes of seven patients with severe hyperlipoproteinaemia who were chronically and intermittently treated with LDL apheresis were examined before and immediately after therapy. The LDL apheresis reduced sodium lithium countertransport significantly (0.383 vs 0.269, P less than 0.02). Therefore, we conclude that serum lipid composition must be considered when interpreting sodium lithium countertransport velocity.

A follow-up study of first-degree relatives of type 2 diabetic patients presented the opportunity to study the association of components of the metabolic syndrome with oral glucose tolerance in these subjects. In 1992, 25 years after the first analysis of the cohort, we performed 75-g oral glucose tolerance tests and measured anthropometric data (body mass index, waist-hip ratio), insulin and C-peptide concentrations, and parameters of lipoprotein metabolism (free fatty acids, triglycerides, cholesterol, HDL cholesterol). Of 135 participants, 71 had normal glucose tolerance (GT), 22 had impaired GT, and 42 had diabetic GT (WHO 1985 criteria). Impaired glucose tolerance and diabetes were significantly (Kruskal-Wallis test) associated with advanced age (p=0.001), higher body mass index (p=0.005) and waist-hip ratio (p=0.027), systolic hypertension (p=0.031), elevated basal insulin concentrations (p

"Guidelines" as well as "evidence-based medicine" are not primarily economical control instruments, but serve to improve the quality of medical care from a patient-oriented point of view. It is characteristic of evidence-based medicine (EBM) that its exponents base medical actions on the best evidence of usefulness and effectiveness available. The most important evidence is to be gathered from high-quality studies, so-called controlled clinical trials. This requires a certain mental readiness and, moreover, certain skills with regard to the search for studies and the capability to interpret data in an adequate way. At the moment only a small "elite" of physicians is capable to orient to EBM independently. This is why the approach via the development and implementation of evidence-based guidelines is the more important. Guidelines are systematically developed decision-making aids, in the sense of so-called "corridors of action", for medical procedures in special health problems. Only guidelines stating the level of existing evidence for every statement can be called evidence-based. A Clearinghouse at the Agency for Quality in Medicine (AQUMED) supports and promotes scientifically based and practical guideline programs in medicine. At the heart of the present discussion is the question of how to achieve the widespread use in medical care of the findings summarized in guidelines.

Although the case for thyroid surgery is based on morphologic and physiologic criteria, it is mainly based on individual therapeutic goals. The goals are influenced by various biographic, medical and personal facts and by many environmental conditions. Thus, there is no rationale for cataloguing indications. With the euthyroid goitre the indication for surgery is usually given by the size of the thyroid gland, especially since it has become clear in various studies that with drug therapy the achievable size reduction is rather small. With Graves' disease the pros and cons of the three main methods, surgery, medical treatment or radioiodine, have to be considered in each case. Surgery is mainly indicated when the goal is a rapid and reliable normalization of the hormonal status. Thyroid autonomy is a clear-cut case for radioiodine. Only isolated autonomous nodules can equally well be treated by surgery. In addition, a case for surgery is given when besides the autonomy a large goitre is present. A special indication is iodine-induced thyrotoxicosis that cannot be normalized by medical treatment. All kinds of thyroid carcinoma, with very few exceptions, usually have to be operated on as the first choice.

Prolonged oropharyngeal dysphagia occurs in up to 45% of patients presenting with a unilateral hemiplegic stroke. The aim of this study was to investigate esophageal motility in patients with hemiplegic stroke and to evaluate, whether detected motility disorders improve within 10 days after the beginning of symptoms.Fifteen patients with hemiplegic stroke and dysphagia underwent esophageal manometry within the first 2 days after admission to the hospital and 10 days later. Eighteen healthy volunteers served as controls.The following parameters showed no significant differences between the 2 study days (day 2: day 10: controls, p-value [comparison with controls]): resting pressure of the lower esophageal sphincter: 21 +/- 3 mm Hg: 20 +/- 3 mm Hg: 18 +/- 2 mm Hg, NS, contraction amplitude: 67 +/- 8 mm Hg: 72 +/- 11 mm Hg: 78 +/- 9 mm Hg, NS, duration of contraction: 4.2 +/- 1.0 s: 4.2 +/- 0.9 s: 2.2 +/- 0.7 s, p0.001, and contraction velocity: 6.3 +/- 1.1 cm/s: 5.2 +/- 0.9 cm/s: 3.2 +/- 0.8 cm/s, p0.001. As far as the contraction pattern was concerned, on both study days significant pathologic contraction patterns were seen compared with normal controls. Normal propulsive contractions were seen in 54 +/- 5%: 60 +/- 6%: 96 +/- 5%, p0.001. Patients with no dysphagia after 10 days still had demonstrable abnormal motility patterns.The findings indicate that manometrically demonstrable pathologic motility patterns of the tubular esophagus in patients without oropharyngeal dysphagia after 10 days do not induce the symptom dysphagia. The function of the esophagus seems not to be impaired by these measurable pathologic contractions.

In this study, the risk of iodine-induced thyrotoxicosis in unselected patients from an iodine-deficient area was investigated. The patients were consecutively enrolled. Thyroid hormone values and urinary iodine excretion were determined before, as well as 1, 4 and 12 weeks after iodine contamination by coronary angiography. Two of 788 unselected patients developed hyperthyroidism within 12 weeks. The two patients did not belong to a risk group for iodine-induced thyrotoxicosis (i.e. old people, patients with goiter or possible thyroid autonomy, low TSH). Both patients had normal TSH levels at baseline and ultrasound of the thyroid was without evidence of nodules. The study shows that in euthyroid unselected patients from an iodine-deficient area short-term iodine contamination by contrast media rarely leads to hyperthyroidism. On account of these facts, prophylactic therapy, e.g. by perchlorate or thiamazole, is not generally recommended, because the risk of side-effects is perhaps even greater than the risk of iodine-induced thyrotoxicosis.

As many as 45% of all strokes can lead to permanent dysphagia, usually considered to be due to abnormal oropharyngeal coordination of contraction. It was the aim of the study to compare oesophageal motility in stroke patients with and without dysphagia.The study group consisted of 36 patients (13 men, 23 women, mean age 74.1 +/- 11.3 years) who had sustained a stroke (19 [mean age 70.6 +/- 10.5 years] with and 17 [mean age 77.6 +/- 10.5 years] without dysphagia). All these patients underwent oesophageal manometry within 2 days after hospital admission.There were significant differences in the mean proportion of regular peristaltic waves in the distal oesophagus, 93.5 +/- 1.1% in patients without but in only 53.5 +/- 4.4% of those with dysphagia (P0.0001). Measurement of the proximal oesophagus showed 93.2 +/- 3.4% and 62.1 +/- 7.3% respectively. There was no significant difference between these two patient cohorts with regard to the resting pressure in the upper and lower oesophageal sphincters as well as in the amplitude and duration or speed of contraction in the region of the smooth and striated oesophageal muscles.In patients after a stroke who have dysphagia abnormalities of oesophageal motility are also of importance for their symptoms, being due less to pressure relations than to abnormal contraction patterns.

In July 1997, the American Diabetes Association (ADA) has published new recommendations for the diagnosis and classification of diabetes mellitus. Except for gestational diabetes they should be identical to the new WHO recommendations (not yet published). From now on, only the fasting glucose should be used for clinical routine. The oral glucose tolerance test is no longer recommended for this purpose. The diagnostic cut-off level for fasting glucose was decreased from 140 mg/100 ml (venous plasma) to 126 mg/dl, and the range between 110 and 125 mg/100 ml was defined as impaired fasting glucose (IFG), a new diagnostic category introduced in analogy to impaired glucose tolerance (IGT). The lower diagnostic cut-off level for fasting glucose has been proposed because the risk of developing diabetic late complications (predominantly at the vascular system) is already increased in blood glucose ranges thought to be normal. The diagnostic criteria for gestational diabetes are unchanged and still discrepant between ADA and WHO. The two major forms of diabetes should be designated only as type 1- and type 2-diabetes with respect to etiology and pathogenesis. Type 1-diabetes was subdivided into an immune-mediated and into an idiopathic form. MODY (maturity-onset type diabetes in young people) was listed separately from type 2-diabetes under the category of genetic defects of beta-cell function, also mitochondrial diabetes (maternally inherited diabetes and deafness). Malnutrition-related diabetes has been omitted as a major form of diabetes.

A 34-year-old woman was admitted for treatment of toxic epidermolysis of the skin and mucosa. 16 days previously she had started to take chlormezanone (Muskel Trancopal) and some other medications for pain in the shoulder and neck. On admission she had a fever of 39 degrees C and, in addition to the epidermolysis, diffuse abdominal pain on pressure and blood-streaked stool.Liver enzyme activities (GOT 979 U/I, GPT 1496 U/I, gamma GT 201 U/I) alkaline phosphatase 515 U/I), bilirubin (3.9 mg/dl) and pancreatic enzyme activities were raised. Sonography was nondiagnostic, computed tomography demonstrated only a small amount of ascites.The epidermolytic lesions, cholestatic hepatitis and pancreatitis markedly regressed under aseptic wound treatment, antibiotics and parenteral nutrition. Persistent blood-streaked stools and bilateral pneumonia with progressive respiratory failure developed. Despite intensive medical care the patient died after 14 days from protracted sepsis with multi-organ failure. Autopsy additionally revealed adult respiratory distress syndrome and complete loss of colonic mucosa.The severe course of a toxic epidermal necrosis with fatal outcome is the first such case reported in Germany that very probably was caused by chlormezanone. 4 weeks after this case was reported to the German Doctors' Drug Commission, the manufacturers of the drug withdrew it from the market.

There is broad consensus that energy intake and diet are major causes of obesity and thereby main contributors to non-insulin-dependent diabetes (NIDDM). Today’s diet, which is rich in fats and relatively low in carbohydrates and fibres, the so-called westernized diet, is highly associated with the occurrence of NIDDM. It is therefore concluded that dietary modifications are the mainstay of treatment for NIDDM. These modifications, concentrating on fat restriction to reduce energy intake and body weight, should be the starting point of long-term treatment of NIDDM. Many patients with this disease who comply with dietary advice will show improvement in the major metabolic abnormalities associated with the condition. The main goal will be to obviate the need for oral agents and insulin. But even for those who cannot be managed without drug therapy, attention to dietary advice may modify blood lipids and will thereby reduce the risk for coronary heart disease. Even in insulin-dependent diabetes mellitus (IDDM), the role of diet is not only to help minimize the short-term fluctuations of blood glucose but also to reduce the risk of long-term complications by helping to achieve optimum glycaemic control and satisfactory levels of blood lipids.

Der Diabetes mellitus geht haufig mit charakteristischen Symptomen wie Polydipsie, Polyurie, Gewichtsverlust oder den verschiedenen Zeichen einer diabetischen Ketoazidose einher, kann aber auch weitgehend symptomfrei verlaufen. Die Definition der Erkrankung mus daher unabhangig von den klinischen Symptomen erfolgen. Die einfachste und trotzdem umfassende Definition lautet, das der Diabetes mellitus eine Erkrankung ist, die unbehandelt mit einer chronischen Erhohung der Blutglukosekonzentration einhergeht.

An unusual cardiac metastasis, occurring in a 63-year-old man 19 years after nephrectomy because of renal cell carcinoma, is reported. The tumor extended from the right ventricle apex to the mid-portion of the interventricular septum. A complete excision could be achieved. To our knowledge, this is the third case of a renal cell carcinoma metastasis to the right ventricle which could be detected during a patient's lifetime and treated surgically. A review of the literature is also reported.

A prong-type caval filter fractured and disintegrated within 4 months after its implantation in a 21-year-old woman. The fragments and the disrupted filter were removed surgically and the vena cava was plicated. Seven similar cases were found in the literature. Possible etiologic factors and measures to avoid this complication are discussed.

The so-called "waddling gait" caused by paresis or mechanical insufficiency of the hip muscles is an ambiguous clinical guiding symptom. This pelvifemorally accentuated muscular weakness coinciding with pain in the range of the locomotor system should make one consider the diagnosis of osteomalacia due to deficiency of vitamin D, especially in Asian patients. In the present case, the course of investigation is described in detail, as well as the effective therapy. The diagnosis of this clinical picture ought to be familiar to any neurologist, since its more frequent appearance must be expected as an increasing number of Asians seek asylum in the years ahead. Social integration of the affected persons may be made easier by treatment on the lines described here.

Eine Gabe von Medikamenten, welche die Schilddrusenhormonsynthese oderausschuttung unterdrucken, stellt eine der moglichen Behandlungsformen von Schilddrusenuberfunktionen dar. Sie ist im Gegensatz zur Operation oder zur Radiojodtherapie reversibel und kann daher jederzeit abgesetzt werden, wenn eine Remission eingetreten ist.

Persisting dietary iodine deficiency in the Federal Republic of Germany is reflected in endemic goiter, in particular in the elderly. Among 581 over-60-year-olds, 48.8% revealed enlargement of the thyroid gland on sonography. Thyroid nodules were present in 101 cases, and a cystic lesion in another 43. Goiter is appreciably less responsive to levothyroxine in the elderly than in younger patients. The indication for initiating such medication should therefore be established on an individual basis. A specific problem of iodine deficiency goiter in the elderly is the increasing development with age of autonomously functioning nodules in the thyroid. Iodine contamination can induce thyrotoxicosis, which is often difficult to treat; in the individual case, thyroidectomy must be performed.

During recent years several studies have been published comparing different ways of pharmacological treatment of a goiter due to iodine deficiency. These studies usually were performed with 300 to 500 micrograms of iodine, 100 to 150 micrograms levothyroxine, or a combination of in most cases 100 micrograms levothyroxine and 100 micrograms iodine. The largest data have been accumulated in 166 patients with in most cases diffuse goiter. Group A (n = 61) received 150 micrograms levothyroxine per day, group B (n = 50) 400 micrograms iodine per day and group C (n = 55) a combination of 75 micrograms levothyroxine and 200 micrograms iodine per day. During the eight months of therapy, in all three groups a significant and comparable mean decrease in goiter size was documented (-32.1% in group A, -37.3% in group B and -38.7% in group C [n.s. between the three groups]). Striking differences between the three groups are evident in the changes of basal and thyrotropin releasing hormone (TRH) stimulated thyrotropin (TSH). In group A, after eight months a sharp and significant decrease of TSH occurred (from 1.2 mU/l to 0.4 mU/l; mean; p0.05), while in group B TSH showed only a minor decrease (from 1.3 mU/l to 0.9 mU/l) and remained significantly higher compared to both, group A and C (p0.01). Similar changes were documented when the TSH after TRH administration was calculated. It is concluded, that all three therapeutic approaches are effective for goiter reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Free thyroxine (FT4) represents the metabolically active fraction of the circulating thyroid hormone thyroxine (T4). In this paper the results of the evaluation of a newly developed FT4 assay are reported. This assay system is based on an enzyme-labelled one-step immunoassay. The within-run imprecision, checked using serum pools and several commercial reference materials, showed a coefficient of variation (CV) of between 0.8 and 9.8%, depending on the reference material used. The between-run imprecision showed a CV of between 1.0 and 13.2%. Accuracy experiments yielded values between 80 and 116%. When the new FT4 was compared with the calculation of an index for free thyroxine (FT4I; derived from either the ratio of T4/thyroxine binding coefficient of from T4/thyroxine binding globulin) in a number of samples in the hypo-, eu- and hyperthyroid range, a good correlation was obtained. The same was true when the new FT4 assay was compared with a widely used two-step radioimmunoassay (y = -0.146 + 0.943 x). In euthyroid subjects the measured FT4 concentration was 10.3-25.8 pmol/l. No effect was evident when the influence of EDTA and citrate was investigated, whereas addition of heparin led to an increase in FT4 concentration of about 12 to 15%. Investigation of the possible influence of a large number of drugs showed that probenezid, carbamazepine and furosemide led to an increase in the measured FT4 concentration. Dialysis increased the FT4 concentration, as measured in patients before and after haemodialysis. No effect of alteration in protein concentration and/or protein distribution of FT4 concentration could be detected. In pregnancy, FT4 values were within the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)

The fructosamine assay is about to be used for the control of diabetic patients and for the diagnosis of diabetes mellitus. An analysis of the original literature is presented to answer the question whether the evaluation of the test is methodologically reliable. Altogether 65 studies are evaluated. Thirty of these studies deal with technical aspects of the test (phase 1). A comparison of the distributions of test results for diabetic and non-diabetic patients is presented in 28 studies (phase 2). However, serious shortcomings in methodology and presentation are apparent. "Significant" differences and correlation coefficients are the basis for optimistic conclusions. Only 7 studies are identified where fundamental test parameters such as sensitivity and specificity are given, or can be calculated (phase 3). None of them achieves a satisfactory standard of methodology (selection of patients unclear, assessment made not mutually blind). There is no reliable phase-3-study for the metabolic control of diabetes mellitus. It can be concluded that the fructosamine test is not evaluated sufficiently to allow its routine clinical use. In fact, contrary to a widely quoted opinion, the results presented so far do not suggest a reliable test.

Im vorliegenden Kapitel wird betont, das „Struma“ in Wirklichkeit ein Symptom darstellt, nicht jedoch eine Krankheitseinheit. Der Titel des Buches ist also nicht ganz zutreffend, soll er sich doch allein auf die jodmangelbedingte Struma mit Euthyreose beziehen. Diese Storung steht aber unter allen Krankheiten mit Struma in Deutschland so sehr im Vordergrund, das u. E. die leichte Unexaktheit zu vertreten ist.