Background Diabetic ketoacidosis and the hyperosmolar hyperglycemic state are the most serious diabetic emergencies. Before the discovery of insulin in 1921 by Banting and Best the diagnosis of type 1 diabetes was fatal ending in diabetic ketoacidosis equivalent to a torturous death. Today, mortality from diabetic ketoacidosis is low at approximately 2 %. But each death from these two acute metabolic complications of diabetes is potentially avoidable by improved patient and healthcare professional education. Therefore, there is a need to raise awareness of hyperglycemic crisis and its management amongst physicians. Pathogenesis Insulin deficiency or resistence and increased concentrations of counterreulatory hormones (glucagon, catecholamines, cortisol and growth hormone) are responsible for the development of diabetic ketoacidosis and the hyperosmolar hyperglycemic state. Hyperglycemia develops as a result of increased gluconeogenesis and accelerated glyconeogenesis. In DKA, the absolute insulin deficiency additionally leads to increased lipolysis and production of ketone bodies and resulting metabolic acidosis. Diagnosis Both DKA and HHS require prompt recognition and management. The diagnosis can be suspected by clinical features and confirmed by laboratory findings. Treatment The treatment of DKA and HHS is similar, including correction of fluid and electrolyte abnormalities and the administration of insulin. Die Diabetische Ketoazidose (DKA) und das hyperglykämische Koma sind akut lebensbedrohliche Komplikationen des Diabetes mellitus. Vor der Entdeckung des Insulins 1922 war die Diagnose eines Typ-1-Diabetes gleichbedeutend mit einem qualvollen Tod in der DKA. Heute liegt die Letalität der DKA mit 2 % vergleichbar niedrig. Dennoch bleibt jeder dieser Todesfälle vermeidbar, nicht zuletzt durch die geeignete Schulung von Patienten und Ärzten.

Compared to its more common counterpart papillary thyroid cancer (PTC), follicular thyroid cancer (FTC) has a less favorable outcome, due to its higher incidence of distant metastases and advanced stages at diagnosis. Despite radioiodine (RAI) avidity, metastatic FTC often progresses after radioiodine treatment (RAIT). We aimed at evaluating the indications and outcomes of surgery for cervical relapse of radioiodine refractory FTC. Patients receiving RAIT between 2005 and 2015 at the University Hospital of Cologne, Germany, were screened. Patients with FTC were identified. Demographics, clinic-pathologic characteristics, treatment, and outcome of patients diagnosed with RAI refractory FTC, who underwent cervical surgery in the course of disease, were analyzed. FTC accounted for 8.8% of all thyroid carcinomas undergoing RAIT. In 35.2% of FTC patients, disease persisted or recurred despite a cumulative mean RAI activity of 18.7 GBq ± 11.6 (follow-up 83.5 ± 56.7 months). Distant metastases were diagnosed in 75% of these patients, as bone (57.6%), lung (54.6%), and liver metastases (12.1%). Cervical relapse occurred in 63.6% of these patients and was treated in 57.1% with surgery with, and without, external beam radiation therapy (EBRT). Despite surgery and EBRT, in 75% of patients, cervical relapse recurred again. In conclusion, surgery for cervical radioiodine refractory FTC relapse is often performed in metastatic setting. With and without EBRT, cure is rare, although metastases can appear radioiodine avid. Early biological marker and systemic treatments for these patients are still needed.

In about 20% of all cases, the fine needle aspiration cytology (FNAC) results are equivocal, delivering the two common categories of indeterminate cytology, Bethesda III and IV. The observed rates of malignancy vary widely among institutions, with the urgent need for a more precise risk stratification. 99mcTc methoxyisobutylisonitrile scintigraphy (MIBI) is less expensive than molecular testing and has been shown to have a high negative predictive value. For this reason, the results of MIBI scintigraphy in adult patients with indeterminate FNAC were collected, and correlated with the final pathology reports of surgical specimens. Patients receiving FNAC, MIBI scintigraphy and surgery for sonographic suspicious hypofunctional thyroid nodules between 2015 and 2019 at the University Hospital of Cologne, Germany were identified. Sensitivity, specificity, positive predictive and negative predictive value of MIBI scintigraphy were calculated. Seventy-eight patients with sonographic suspicious hypofunctional thyroid nodules underwent surgery after interdisciplinary case discussion of both FNAC and MIBI results. In 49 (62.5%) cases, FNAC consisted of Bethesda III and IV results. In 39 (79.6%) of these cases, MIBI scintigraphy resulted in mismatch and intermediary results, but in only 4 (10.2%) of these cases was a carcinoma diagnosed. The negative predictive value of MIBI scintigraphy was 90–100%, respectively. Relying on the negative predictive value of MIBI match results might have obviated the need for surgery in 20.4% cases; one papillary microcarcinoma, however, would have been missed. MIBI scintigraphy has an underused potential for improving the diagnostic precision of hypofunctional thyroid nodules.

The optional use of a saturated solution of potassium iodide in the immediate preoperative period to reach euthyroidism is included both in the American Thyroid Association (ATA) and in the European Thyroid Association (ETA) guidelines for the treatment of Graves’ disease (GD). The recent literature though, shows that it does not translate to more clinically meaningful differences in surgical outcome. In our experience, potassium iodide should not be seen as a means for reducing operative time or complications; it is an effective way for reaching euthyroidism quickly. Herein, we describe three selected cases in which concentrated potassium iodide 65 mg tablets - instead of a saturated solution - were administered for thyroid blocking preoperatively, as recommended in the event of a nuclear emergency. One of the patients was pregnant. After oral treatment with potassium iodide 130 mg daily (two pills), euthyroidism was reached in all three cases within 24 hours. There were no side effects and surgery was performed without complications. Although the current literature did not report a significant benefit concerning operative time and complications, in our opinion preoperative potassium iodide plays an important role in selected cases for reaching euthyroidism preoperatively quickly. Potassium iodide 65 mg tablets, which are recommended in case of a nuclear emergency, are a very effective alternative to saturated solutions, which are not always quickly available and generally need to be administered over seven to 10 days.