Background:Campylobacter infections are very common overall. They typically affect the gastrointestinal tract and are usually caused by consumption of contaminated meat or water. Older people, men, and people with weakened immune systems are significantly more likely to be affected. Endocarditis caused by Campylobacter fetus, especially of the tricuspid valve, is rarely reported and not easy to diagnose. Case summary:A 48-year-old female patient presented to the emergency department with pain in the upper abdomen and left flank and tenderness in the left chest. After initially ruling out pyelonephritis, within the scope of focus search, vegetation on the tricuspid valve with rapidly progressive tricuspid valve insufficiency was observed. Campylobacter fetus grew in the initial blood cultures. Antibiotic treatment was initiated with ceftriaxone. Due to additional unclear renal insufficiency and further treatment, the patient was transferred to an interdisciplinary centre, where tricuspid valve replacement was performed. The patient was discharged home with a peripherally inserted central catheter for prolonged intravenous antibiotic therapy with meropenem. Discussion:Diagnosis was difficult based on the variety of symptoms, as the patient was a younger female who did not present with typical symptoms of endocarditis. Follow-up examinations and consultation with an interdisciplinary centre were necessary to ensure adequate treatment. The patient initially received intravenous cephalosporin, aminopenicillin, and finally carbapenem antibiotics. Due to a lack of recommendations, antibiotic therapy was based on empirical evidence. Amoxicillin-clavulanic acid and imipenem have been described as effective antibiotics against almost all strains of C. fetus.

Introduction:For the treatment of sudden cardiac death, the prompt deployment of an automated external defibrillator (AED) has been shown to significantly improve survival rates (1). Since 2007, the availability of AEDs on seagoing vessels flying the German flag has been legally mandated. This study aims to assess the availability of AEDs on such vessels and their utilization in emergency situations on board.Subjects and Methods:A monocentric retrospective analysis was conducted to evaluate the utilization of AEDs on board. A total of 43 nautical officers completed a questionnaire covering an observational period of the past 10 years. The ship officers were interviewed on board vessels in the Port of Hamburg between August and December 2018, corresponding to an observation period of 8600 seafarer-years.Results:An AED was present on 100% of German-flagged seagoing vessels and 52.2% of non-German-flagged seagoing vessels. Of the 43 health officers surveyed, 38 did not use an AED. Among living patients, four officers used the AED once to deliver a shock, while one respondent used it twice. The five early defibrillations performed occurred following observed cardiovascular arrests and correspond to an annual prevalence of sudden cardiac death of 6 per 100,000 seafarers. Three patients (60%) were successfully defibrillated.Conclusions:The medical requirements for German-flagged ships are playing a pioneering role internationally in the equipping of seagoing vessels with AEDs. Given the unique conditions at sea and the lack of timely on-site emergency medical care - both of great importance - the availability of an AED on board appears to be highly beneficial.

Health promotion measures on board seagoing vessels are subject to special requirements due to limited access to health services on board. This study examines the needs and digital possibilities for modern health promotion and digital intervention on board merchant ships considering the different occupational groups. The data was collected using questionnaires completed by 903 seafarers (participation rate 99.4%) from 23 countries on 68 seagoing vessels belonging to two German shipping companies. A comparison of the responses was conducted to identify significant differences between ratings and officers, because this could be relevant for future specific interventions. Adjustments were made for cultural background and age using odds ratio. Ratings assessed the relevance of topics for well-being higher than officers did, especially regarding healthy food (p = 0.83), exercise (p = 0.05), and learning relaxation exercises (p = 0.04). The study shows that ratings are more than twice willing to do more sports (p = 0.04), learn relaxation exercises (p = 0.01), and practice measures against fatigue (p = 0.05). Health apps and sports competitions were highly valued in the communication of health information. Ratings and officers used smartphones to a high degree (98.3%) and would use a health app (87.5% ratings vs. 83.1% officers; OR 1.62 (1.07-2.43)) and both professional groups would like to participate in a bonus system based on a reward principle. In the multivariate analysis, interest in health promotion measures was essentially independent of age and cultural background. Key aspects for intervention measures on board include sports, learning relaxation techniques, offering healthy food, and raising awareness about exemplary health behavior of superiors. Modern digital intervention measures involving e-learning platforms, applications and wearables are of interest to seafarers and should be considered when planning health promotion measures at sea.

Abstract Background Seafarers are exposed to unique occupational stressors that place sustained demands on the autonomic nervous system. Heart rate variability (HRV) represents a promising non-invasive tool for assessing mental and physical strain in maritime settings. However, its methodological application in real field conditions remains poorly characterized, and existing HRV guidelines do not specifically address the methodological challenges of maritime field studies. Methods A scoping review was conducted following PRISMA guidelines. Eleven maritime field studies measuring HRV in operational or semi-operational settings were included and assessed for device selection, measurement quality, analysis methods, HRV metrics, and covariates. Results Chest strap systems were the most frequently used ( n = 8) and showed sufficient validity for field use. Methodological heterogeneity in reporting of recording duration, analysis software, artifact handling and HRV parameters was high across studies. Operational factors including sailing schedule and work-rest organization were the most commonly examined covariates and were most frequently associated with significant HRV findings. Recurring findings were small and predominantly male populations, shared participant cohorts across multiple studies, and incomplete methodological reporting. Conclusion Overall, the studies utilized HRV appropriately for their respective aims. HRV measurement in maritime field settings is feasible but methodologically demanding, and it remains an underexplored domain, which limits the conclusions that can be drawn. More detailed and standardized reporting is necessary. Based on the recurring methodological reporting gaps, this review proposes a maritime-specific reporting checklist and an overview of recommended methodological options for future studies. Larger study populations are needed to account for confounding factors on board ships.

The vaccination rate of seafarers during the COVID-19 pandemic was initially low. Along with the well-known crew change crises, it likely placed a high psychosocial burden on shipping crews. The aim of this work is to assess the vaccination rate, determine triggers for psychosocial symptoms and emphasize preventive-psychological information channels and media for seafarers. In March 2022, 583 seafarers and 24 office workers from the same shipping company were surveyed by using a questionnaire. It included the standardized Fear of Coronavirus Questionnaire and further questions on COVID-19. A total of 479 (81.3%) participants had been vaccinated. However, office workers were 31 times more likely to have received a basic immunization with one booster vaccination than seafarers (CI 12.0-81.9). Seafarers had significantly more often fear of Corona-related health consequences than office workers (73.9% vs. 41.7%, OR 4.0, CI 1.7–9.1) – also, ratings 2.5 times more than officers (81.2% vs. 63.3%; p < 0.001). In addition, seafarers – and among them the ratings in particular – rated the pandemic burden regarding social and financial impacts significantly higher. Although 75% of seafarers felt (very) well informed about COVID-19 issues and vaccination, they were 20.9 times more interested in further information than office workers (CI 2.8-155.5). For all seafarers, the shipping company, ship personnel and international organizations were the most regularly used sources of information. This study indicates that the COVID-19 vaccination rate was lower among seafarers than the shore-based population. This can lead to increased pandemic-related psychosocial stress. Improving the dissemination of information could contribute to better coping strategies in seafaring. Overall, these findings highlight the importance of supporting seafarers in future crises and the need to improve international strategies for the treatment of seafarers as key workers.

BACKGROUND:Seafarers are exposed to a variety of job-specific physical and psychosocial stressors. Health promotion on board is of great importance for the salutogenesis of this occupational group. Due to the difficult accessibility of seafarers, electronically supported health management can be highly valuable. However, surveys on the needs and interests of seafarers in health promotion regarding e-health applications have not yet been carried out. MATERIAL AND METHODS:This pilot study uses a cross-sectional design to assess the need for digital health promotion for seafarers on board. This need was derived from the individual responses of 73 crew members on 3 merchant ships on health as well as addictive behavior, sports, coping strategies, and the level of knowledge regarding health-related issues. Conspicuous parameters on mental health and fatigue were compared to the general population. RESULTS:It was found that 31.9% of seafarers were smokers and 80.6% were alcohol consumers. 82.4% of the seafarers practiced sport. The most common coping strategies for stress were calming down (44.6%), listening to music (32.1%), resting and sleeping (25.0%) and sports (25.0%). The evaluation of the PHQ-9 mental health questionnaires indicated that 85.4% of respondents had moderate to severe symptoms of a depressive mood. The average WHO-5 Well-Being Index resulted in level of 69.7% of the maximum possible score. Knowledge questions on health-related issues were answered correctly in less than 60% of cases. With regard to fatigue, there was an increased score for the Epworth Sleepiness Scale (ESS) in 33.8% and the Pupillary Unrest Index (PUI) was elevated in 47.7%. CONCLUSIONS:Nicotine and alcohol consumption is higher among the participating seafarers compared to a reference population living on land. Various coping strategies for managing stress are already used in the daily live. However, there is a demand and interest in acquiring more knowledge about health-promoting behavior. The risk of daytime sleepiness and depression is elevated among seafarers. This leads to key issues that should be taken into account for preventive medicine, health promotion and possible digitally supported health management on board.

Overweight and obesity have a negative impact on health and have a detrimental effect on the operational readiness of soldiers. Different prevention and intervention measures against obesity include diet, physical activity, education, coaching or medication or a combination of several aspects have been investigated. This review systematically assesses the effectiveness of lifestyle, dietary, educational, and pharmacological interventions on weight, body composition, and military readiness in active-duty personnel. We carried out a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted in various electronic databases from 2000 to July 2024. The search strategy combined three concepts: military population, outcome terms, interventions or programs. For the review, 21 articles met the inclusion criteria (total n = 1696). Where possible, the effect size (ES) was calculated. In studies that only examined exercise, minor effects were reported, e.g. a reduction in weight (-0.5 kg), Body Mass Index (BMI) (-0.3 kg/m²), waist circumference (-0.1 cm) and body fat percentage (-1.1

Objective: Tendinopathies are diseases that often entail long-term treatment consisting of analgesics, physiotherapy, orthotics, and sparing. The aim of this study was to investigate the effect of a single application of a high-energy PEMF (pulsed electromagnetic field) on pain perception and blood born inflammation parameters. Methods: 34 patients were randomly assigned to a verum group (10 min PEMF, 0,78 T) or a placebo group (10 min sham condition). Prior to and up to one week after the patient blinded treatment (t1-t5), local pain state was assessed by means of algometry as pain pressure threshold (PPT). Accordingly, heat-shock protein 70 (HSP70) levels were analysed. Statistical analyses included 2-way ANOVA (2 x 5). The clinical trial was registered (DRKS00031321). Results: After randomization and drop-out (verum n = 17, placebo n = 13) baseline-analyses did not reveal significant between-group differences for PPT (p = 0,096), for HSP70 (p = 0,524), or any other sample characteristics (p > 0,05). Pain reduction during one week of observation showed to be significantly higher (p = 0,045, eta(2) = 0,013) for the PEMF group (PPT: +83 bis +139%) compared to the placebo group (PPT: +10 bis +36%). There were no HSP70 associated effects. Conclusions: A single bout of high energy PEMF led to an immediate pain relief in tendinopathy patients lasting at least for one week, but the hypothesized underlying HSP70 associated inflammatory pathway could not be confirmed.

Abstract Background Obesity rates are rising in the armed forces of Western democratic countries, impacting military readiness and health. This highlights the need for preventive health risk assessments and countermeasures. Methods Using mandatory health examination data from 2018 to 2022, we analyzed the prevalence of obesity, health risks, and associated specific military risk factors (rank and unit) in 43,214 soldiers of the German Armed Forces. Statistical methods included χ2 contingencies and binary logistic regressions. Results The prevalence of obesity (BMI ≥ 30) was 18.0%. Male soldiers (OR = 3.776) and those with an officer’s rank (OR = 1.244) had an increased chance for obesity. Serving in a combat unit reduced the chance of being obese (OR = .886). Considering BMI and waist circumference, 2.4% of the total sample faced extremely high cardiovascular and metabolic health risks, while 11.0% and 11.6% had very high or high health risks, respectively. Conclusions Our data underscore the importance of targeting obesity-related health risk factors in soldiers to ensure their well-being and deployment readiness.

According to the ‘constrained model’, there are compensations in resting metabolic rate (RMR) at high levels of physical activity (PA). Here, we have used a standardized combat-swimmer training protocol (CST) to investigate whether changes in RMR (i) confirm the ‘constraint model’, and (ii) differ between successful participants and dropouts. Controlled 84d CST in 44 male soldiers with 13 finally successful. Fat mass (FM) and fat-free mass (FFM) were measured using Quantitative Magnetic Resonance. RMR was assessed by indirect calorimetry, VO2max, and work efficiency by treadmill spiroergometry. Plasma levels of thyroid hormones, testosterone, and cortisol were analysed by standard laboratory methods. CST increased VO2max (+ 6.9

Tendinopathien sind Erkrankungen, die häufig eine langfristige Behandlung mit Analgetika, Physiotherapie, Orthesen und Schonung erfordern. Ziel dieser Studie war es, die Wirkung einer einmaligen Anwendung von hochenergetischem PEMF (pulsed electromagnetic field) auf das Schmerzempfinden und unspezifische Entzündungsparameter zu untersuchen. 34 Patienten wurden nach dem Zufallsprinzip einer Verumgruppe (10 min PEMF; 0,78 T) oder einer Placebogruppe (10 min Scheinbehandlung) zugeteilt. Vor und bis zu einer Woche nach der patientenverblindeten Behandlung (t1–t5) wurde der lokale Schmerzzustand (Algometrie) als Druckschmerzschwelle (PPT, pain pressure threshold) ermittelt. Gleichzeitig wurden Hitzeschockprotein 70 (HSP70) Blutkonzentrationen analysiert. Das zweifaktorielle Datenmodell wurde varianzanalytisch ausgewertet (2-way ANOVA). Die Studie wurde als „clinical trial“ registriert (DRKS00031321). Nach Randomisierung und Drop-out (Verum n = 17, Placebo n = 13) ergaben Baseline-Analysen keine signifikanten Gruppenunterschiede für PPT (p = 0,096) oder HSP70 (p = 0,524), oder in Stichprobenmerkmalen (p > 0,05). Für die PEMF Gruppe zeigte sich ein signifikant stärkerer Anstieg (p = 0,045, η2 = 0,013) der Druckschmerzschwelle (PPT: +83 bis + 139

Background The coronavirus disease 2019 (COVID-19) pandemic is driven by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which has led to an enormous burden on patient morbidity and mortality. The renin–angiotensin–aldosterone system (RAAS) plays a significant role in various pulmonary diseases. Since SARS-CoV-2 utilizes the angiotensin-converting enzyme (ACE)2 receptor to exert its virulence and pathogenicity, the RAAS is of particular importance in COVID 19. Methods Our preliminary study investigates retrospectively the influence of selected ACE-polymorphisms (I/D location at intron 16 in the B-coding sequence (rs4646994) and A-240T (rs 4291) at the A-promoter) as well as ACE1 and ACE2 serum levels on disease severity and the inflammatory response in inpatients and outpatients with COVID-19. Results Our study included 96 outpatients and 88 inpatients (65.9% male, mean age 60 years) with COVID-19 from April to December 2020 in four locations in Germany. Of the hospitalized patients, 88.6% participants were moderately ill (n = 78, 64% male, median age 60 years), and 11.4% participants were severely ill or deceased (n = 10, 90% male, median age 71 years). We found no polymorphism-related difference in disease, in age distribution, time to hospitalization and time of hospitalization for the inpatient group. ACE1 serum levels were significantly increased in the DD compared to the II polymorphism and in the TT compared to the AA polymorphism. There was no significant difference in ACE 1 serum levels l between moderately ill and severely ill patients. However, participants requiring oxygen supplementation had significantly elevated ACE1 levels compared to participants not requiring oxygen, with no difference in ACE2 levels whereas females had significantly higher ACE2 levels. Conclusions Although there were no differences in the distribution of ACE polymorphisms in disease severity, we found increased proinflammatory regulation of the RAAS in patients with oxygen demand and increased serum ACE2 levels in women, indicating a possible enhanced anti-inflammatory immune response. Clinical trial registration : PreBiSeCov: German Clinical Trials Register, DRKS-ID: DRKS00021591, Registered on 27th April 2020.

The aim of this study was to assess body mass index (BMI) and the prevalence of overweight and obesity at entry and release of service at the German Armed Forces and related associations to service duration. In a cohort study, 85,076 paired BMI data sets (entry and release of service) of German soldiers (5.4% females) between 2010 to 2022 were analyzed retrospectively to assess BMI alterations and the prevalence of overweight (BMI ≥ 25) and obesity (BMI ≥ 30) after service durations of ≤2 years, 2–5 years, or ≥5 years. Between 2010 and 2022, we observed a trend for BMI increases of about 0.5 kg/m2 (X2 = 27.104, p = 0.007). BMI increases differed significantly (X2 = 7622.858, p < 0.001) after ≤2 years (0.0 kg/m2), after 2–5 years (1.1 kg/m2), and after ≥5 years (2.4 kg/m2) and were correlated to service duration (r = 0.34, p < 0.001). The prevalence of overweight increased from 33.0% to 39.5%. Obesity prevalence increased from 3.7% to 6.3%. The switch to obesity was more pronounced for longer service durations. Although secular trends for BMI increases among soldiers were in line with the general population, service duration was related to BMI increases. Especially, the service time depending on pronounced prevalence of obesity should be a matter of debate leading to counteracting measures at the German Armed Forces.

Cobalt intoxications from fractured hip endoprostheses have been described since the early 2000s. Typical symptoms include cardiomyopathy, neurological symptoms with visual and hearing loss and hypothyroidism. Less is known about long-term progression of these pathologies. This case report shows the long-term course of complications caused by cobalt and chromium exposure after substantial elimination of the source of intoxication. We report here a 63-year-old male Caucasian with severe cobalt and chromium intoxication. He presented 1 month after 2nd revision surgery of a broken hip endoprosthesis in a reduced general condition with signs of heart failure, pale skin and diminished hearing and vision. Blood analyses showed a cobalt concentration of 600 μg/L (reference value < 0.45 μg/L). Because the blood cobalt concentration decreased rapidly after surgery and symptoms improved, chelation therapy was not applied. Close clinical and toxicological monitoring was performed. The intoxication was not diagnosed until 6 years after the faulty hip joint revision and 3 years of clear signs of intoxication during a 2nd revision of the prosthesis. The patient’s ordeal could have been much shorter if his cobalt intoxication with neurologic, cardiac and thyroid symptoms had been detected earlier by toxicological blood tests. After the elimination of the source of poisoning, the long-term course showed constant excretion of cobalt and chromium over several years without chelation. Specific symptoms such as cardiomyopathy and neurological symptoms were declining. However, due to the continuous release of metal ions from the tissue, complete recovery did not occur.

BackgroundCOVID-19 can show a variable course, from asymptomatic infections to acute respiratory failure and death. For efficient allocation of resources, patients should be stratified according to their risk for a severe course as early as possible.Methods135 hospitalized patients with COVID-19 pneumonia at four German hospitals were prospectively included in this observational study. A standardized clinical laboratory profile was taken at hospital admission and a panel of serum markers with possible roles in the COVID-associated cytokine storm were also determined. 112 patients could be evaluated. The primary endpoint of ventilator requirement or death within 30 days of symptom onset was met by 13 patients.ResultsSerum elevations of interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) at hospital admission were each highly significantly (p < 0.001) associated with ventilator requirement/death within 30 days of symptom onset. With a sensitivity of 92% and a specificity of 65–67%, IL-6 ≥ 52.8 pg/ml, PCT ≥ 0.11 ng/ml, and CRP ≥ 71.1 mg/L were predictive of a severe course of COVID-19. Positive likelihood ratios were between 2.6–2.8 and negative likelihood ratios were between 0.11–0.13 for these three markers.ConclusionNegative likelihood ratios indicate that IL-6, PCT, and CRP at hospital admission can be used for identifying patients at low risk for severe COVID-19 progression.

BACKGROUND:For seafarers on the high seas health hazards are various and due to the setting also specific. The spectrum of job-related health impairments and accidents is mainly influenced by the maritime characteristics. The aim of this study is to assess the kind of accidents and the frequency of diseases and health complaints among seafarers on German container ships by evaluating medical log books. METHODS:A systematic analysis of 14,628 medical entries from 95 medical log books of 58 container ships under German flag from 1995 to 2015 was performed. This monocentric retrospective and descriptive study used information on accidents, diseases and health complaints among different occupational groups and medical treatment procedures for the analysis and evaluation. RESULTS:The analysis showed that more than one third of all consultations with the Health Officer on board are related to internal (33.7%) and surgical (31.3%) symptoms. Almost twenty percent of consultations were due to respiratory infections (19.6%) and accidents (17.9%). Accidents represented the most frequent reason for unfitness for sea service (31.2%). Based on occupational categories, most injuries occurred among deck crew (22.5%), followed by ratings working in the engine room (18.9%). In 106 cases, telemedical contact with a physician ashore was necessary. In total, 15 seafarers had to be evacuated from the ship for further medical treatment onshore. Medicine/drug application was the most common therapeutic measure on board, accounting for 77% of all consultations. CONCLUSIONS:The high proportion of health complaints and accidents among seafarers shows that there is a need to optimize medical care at sea and accident prevention, e.g. by standardized treatment algorithms or improving the medical training of Health Officers. The development and introduction of a digital patient file to record medical treatments on the vessels could also improve medical documentation on board.

In 2020, as part of the COVID-19 pandemic, governments around the world enacted a wide variety of regulations and laws to contain the incidence of infection. One of these measures was the relocation of work to the home office. The objective of this review was to analyze the influence of the home office in correlation with regulations on sedentary and activity behavior. A search was conducted on various electronic databases from November 2019 to January 2022, using the search terms physical activity (PA), COVID-19, and working from home. The primary outcomes were changes in PA and sedentary behavior (SB). Secondary outcomes included pain, mood, and parenting stress. The risk of bias was assessed using the (NHLBI) Quality Assessment Tool. For the review, 21 articles met the inclusion criteria (total n = 1268). There was a significant increase in SB (+16%) and a decrease in PA (−17%), Light PA (−26%), and moderate to vigorous PA (−20%). There was also an increase in pain and parenting stress and a decrease in well-being. Due to our significant results, programs that promote movement should be created. Future studies should explore how an increase of PA and a reduction of SB in the home office could be achieved.

INTRODUCTION A wide variety of different types of wearable sensors are being developed around the world and introduced into the armed forces for military purposes. Competing states must rapidly develop ready-to-use systems that are robust, functional, valid, and practical. There appears to be potential for optimizing the successful and effective introduction of wearable sensors into the German armed forces (Bundeswehr) for military medical applications. The purpose of this study was to identify specific options for improving and optimizing the introduction of modern technologies such as wearable sensors into the structures of the German armed forces. MATERIALS AND METHODS Nine stakeholders were identified who could provide a qualified statement on the introduction of wearable sensors, of which six agreed to participate in an expert interview. The six qualitative expert interviews, which were conducted for a master's thesis at the Bundeswehr University in Hamburg, were selected on the basis of their thematic involvement and readiness for an interview and provided the basis for exploring processes that can possibly optimize the introduction of wearable sensors into modern armed forces such as the Bundeswehr. These interviews were carried out and analyzed using the Lamnek's method. RESULTS Six expert interviews were analyzed and the most relevant statements were summarized and presented. Thirteen options for optimization were identified and included, for example, interdisciplinary networking, optimization of information flow, and strategic weighting. CONCLUSIONS Several potential options have been identified that can optimize the introduction of wearable sensors into the German armed forces to a greater or lesser extent. Bundeswehr experts agree that above all structurally relevant improvements such as "development of data analysis standards," "legal requirements," "interdisciplinarity," "acceleration of development," and "centralization and structured cooperation" should play an important role in the implementation of wearable sensors.

Zusammenfassung Anamnese Wir berichten von einer 46-jährigen Patientin, die sich mit intermittierenden Wahrnehmungsstörungen bei Nahrungskarenz in unserer Notaufnahme vorstellte. Diagnostik Im diagnostischen Fastentest wurde bereits nach 7 h eine hyperinsulinämische Hypoglykämie festgestellt. Bei unauffälliger Sonographie wurde eine 68Ga-HA-DOTATATE-Positronenemissionstomographie-Computertomographie durchgeführt; das Bild passte zu einer neuroendokrinen Neoplasie, was den Verdacht auf ein Insulinom lenkte. Therapie und Verlauf Es erfolgte die Verlegung in ein externes Krankenhaus zur operativen Therapie, anschließend war die Patientin symptomfrei. Folgerung Bei Präsentation von multiplen Symptomen passend zu einer Hypoglykämie sollte differenzialdiagnostisch auch an ein Insulinom gedacht werden.