The 50 most-cited articles in DMW - Deutsche Medizinische Wochenschrift, 2016

BACKGROUND: Medical specialty training is the basis for career development of young internists and it is vital for the delivery of high-quality medical care. In 2014 the young internists of two professional bodies in Germany conducted a survey among their young members and described major factors influencing training and working conditions. We present the results of a follow-up survey to describe changes of these factors over time. An additional focus is set on the difficulties of balancing medical career and family. METHODS: In the end of 2016 we conducted an online-based survey of all members in training of the German Society of Internal Medicine (DGIM) and the Professional Association of German Internists (BDI). The questionnaire used in the 2014 survey was modified and items investigating the balance between career and family were added. RESULTS: A total of 1587 questionnaires were returned and analysed. Mayor findings did not change over time. Psychosocial strain remains very high among medical trainees in internal medicine. A structured training curriculum and meaningful…

BACKGROUND: In 40 % of all ventilated patients weaning is problematic. Prolonged weaning is associated with an increased mortality. METHODS: For the first time, data on epidemiology and outcomes of 6899 patients with prolonged weaning from the WeanNet register are published in this study. RESULTS: Patients with prolonged weaning suffer from profound comorbidities (median 5 relevant comorbidities). The majority of patients (62.2 %) were successfully weaned from the ventilator and dischared from the weaning unit without invasive ventialtion after a median of 33 days. Caused by chronic ventilatory insufficiency after prolonged weaning, non-invasive ventilation (NIV) was initiated in 19.4% of patients. The patients who were discharged with NIV were significantly younger than the average (68 vs. 71 years).In 22.9 % of the patients weaning definitively failed and continuous invasive ventilation was needed. Compared to other main reasons for mechanical ventilation patients with chronic obstructive pulmonary disease (COPD) were rarely completely weaned from the respirator and more often…

There is no agreement about the frequency of nosocomial infections and infections caused by multidrug resistant organisms (MDRO) in Germany. The aim of this review is to generate updated estimates of the national burden of these infections and to discuss them in an international context. The most important sources of this analysis are the data of the national prevalence studies conducted in various European countries and in the U.S. It can be assumed that there are between 400,000 and 600,000 patients with nosocomial infections each year in Germany. The mortality attributable to them is between 6000 and 15,000 patients. About 30,000 to 35,000 patients develop nosocomial infections caused by MDRO. Currently there are no robust data how many patients die each year because of MDRO infections. According to the best available estimate, the annual number may be between 1000 and 4000 cases. The problems of nosocomial infections and the increase of antimicrobial resistance are highly relevant and should not be belittled. However, an overestimation of this dangerous trend may lead to…

In emergency departments, patients present with different severities of diseases and traumatic injuries. However, patients with severe and life-threatening conditions compete for the same resources such as personal and structure. As a general rule, each patient should receive immediate diagnostic and treatment, independent of his or her severity of disease or traumatic injury. However, an unexpected number of patients presenting to the emergency department at the same time may exceed available resources. Thus, waiting times will occur and management of patients may be impeded. As a consequence, patients with diseases or traumatic injuries with a need for time-critical management, have to be detected at the time of presentation. After categorization, patients have to be prioritized and guided to the correct place of treatment ("triage"). Starting in Australia and the United States, nurse-driven triage systems have been introduced in the emergency departments. Aim of triage is to correctly identify at increased risk of death and guide them to rapid and correct treatment. In Germany,…

The management of patients with SLE still brings significant challenges, also on intellectual grounds. However, for most of the standard situations, clear principles can be delineated for diagnosis and therapy. New drugs and international definitions of strategies in SLE patient care constitute significant improvement and promise further progress for the coming years.

Pulmonary hypertension (PH) is characterized by an increase in PAPmean > 25 mmHg associated with a reduced life expectancy. Recent advances in the management of these patients provided the basis for the updated recommendations of the 2015 joint guidelines of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) on the diagnosis and treatment of pulmonary hypertension. The updated version includes important modifications with regards to hemodynamic definitions, clinical classification and diagnostic assessment of patients with PH. In addition, risk stratification and PH treatment were profoundly modified, introducing novel drugs and improved treatment strategies such as early combination therapy. Finally, the new ESC /ERS guidelines provide formal recommendations for the management of PH due to left heart or chronic lung disease and chronic thromboembolic pulmonary hypertension, and define criteria for specialized PH expert centers.

The 2015 European Guidelines on Pulmonary Hypertension did not cover only pulmonary arterial hypertension (PAH), but also other significant subgroups of pulmonary hypertension (PH). In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany to discuss open and controversial issues surrounding the practical implementation of the European Guidelines. Several working groups were initiated, one of which was dedicated to the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). In every patient with PH of unknown cause CTEPH should be excluded. The primary treatment option is surgical pulmonary endarterectomy (PEA) in a specialized multidisciplinary CTEPH center. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. For balloon pulmonary angioplasty (BPA), there is currently only limited experience. This option…

BACKGROUND: Patients' lack of knowledge about their discharge medication can endanger patients' safety after their hospital stay. This is especially the case with regard to medications that were newly prescribed during the hospital stay and are intended to be used after discharge or medications with an increased risk for adverse drug reactions (high-risk drugs). The aim of this study was to analyse the patients' level of knowledge about their discharge medication and to identify influence factors. METHODS: In a bicentric survey patients were interviewed prior to their discharge from an acute and a geriatric rehabilitation hospital. They were asked about their discharge medication in a structured interview. Influence factors were statistically analysed by Tobit regression. RESULTS: In total, 179 patients were interviewed. On average, patients named 48% of their discharge medication correctly (95% CI: 46-50%). Influence factors for knowledge deficits were the lack of a medication plan, an older age, the hospitalization in a rehabilitation hospital and a long hospitalization. 81% of…

Any recommendations of the previous practice guidelines on prevention of venous thromboembolism have been put to the test and have been revised in the latest edition in case new evidence had become available. Recommendations which have proven themselves in clinical practice have remained unchanged such as algorithms for risk assessment, however there are now updates on the recommendations of novel oral anticoagulants for prevention of venous thromboembolism, on the use of mechanical prophylaxis, on heparin-induced thrombocytopenia and on prophylaxis in outpatients after surgical procedures.

INTRODUCTION: Six years after introduction of a law for advance directives (AD) in 2009, AD are still discussed controversially. For the first time in Germany, this study investigates intensive care physicians' perspectives on implementation of AD, and corresponding experience of ethical issues. METHODS: A standardized questionnaire was sent to German hospitals with > 300 beds and anesthesiologist-led intensive care units. The questionnaire was based on results of a previous qualitative study and was intended to be answered by one leading intensive care physician per hospital. RESULTS: N = 222/299 (74.2 % response) physicians answered the survey. Despite a number of reported problems regarding the implementation of AD, 70.6 % (n = 154/218) rated AD generally as helpful. 86.5 % (n = 185/214) would prefer a more goal-oriented approach to an intervention-oriented approach to formulate AD. Furthermore 95.9 % (n = 207/216) plead for qualified professional counseling for intensive care topics in AD. Acceptance for interventions that equal termination of treatment can be perceived.…

Die Deutsche Gesellschaft für Innere Medizin (DGIM) beobachtet die Entwicklung der Medizin in Krankenhäusern und Kliniken mit Sorge: Ärzte geraten zunehmend unter den Druck, ihr Handeln einer betriebswirtschaftlichen Nutzenoptimierung des Krankenhauses unterzuordnen. Der materielle und immaterielle Schaden der Ökonomisierung ist beträchtlich. Die DGIM macht in diesem Positionspapier Vorschläge, um diese Entwicklung einzudämmen und Schaden abzuwenden.

This review article reports on practical and clinical aspects of contrast enhanced ultrasound (CEUS). We discuss practical recommendations and advice on the use of CEUS.

UNLABELLED: Background and Problem: Acute nonspecific back pain disorders are typically self-limiting. According to the national guideline low back pain, only in case of clinical suspicion of a serious course radiological imaging should take place immediately. Otherwise, the guideline recommends waiting at least six weeks. PATIENTS AND METHODOLOGY: Using Statutory Health Insurance (SHI) routine data of the Techniker Krankenkasse we analyzed how many of the insured persons suffering from acute back pain for the first time with no indication of a serious outcome received a non-indicated diagnostic imaging. RESULTS: In about 10 % diagnostic imaging is conducted after initial diagnosis. If an imaging is carried out, roughly one third of these cases takes place ahead of time or is completely unnecessary. Methodically this is a very conservative estimation, thus it seems likely that the extent of overdiagnosis in actual medical care situation is even larger. CONCLUSIONS: Every third patient who received radiological diagnostics due to first acute nonspecific back pain underwent the…

Laboratory parameters in emergency medicine can be divided into 3 categories. Urgent obligatory parameters are necessary for immediate therapeutic decisions and must be available within 60 minutes. For these, testing in the emergency department (ED) as point-of-care-testing (POCT) should be considered. The second category are obligatory parameters which require diagnostic / therapeutic consequences in the emergency department, but are not necessary for immediate life-saving actions. Due to international consensus of a 4-hour length of stay target for ED, results should be available within this time. The third category are parameters which do not lead to immediate diagnostic or therapeutic consequences, but are important for process management and patient flow in the ED. They should therefore be available as emergency tests. POC-testing should be used for a limited number of very urgent parameters and should be organized as a satellite laboratory in cooperation with the central laboratory.

BACKGROUND: In Germany both scientific and public debates on physician assisted suicide often focus on patients with unbearable suffering in terminal condition. Proponents of physician assisted suicide bring forward the argument that there are end-of-life situations where only assisted suicide can bring relief from intolerable pain, dyspnea or other symptoms. But does focusing on unbearable symptoms in terminal condition reflect the reality of assisted suicide? Our data from 117 assisted suicides in Germany indicates that the reasons for assisted suicide are more complex than the current debate in Germany suggests. METHODS: We analyzed diagnoses and reasons that prompted patients to suicide with the help of the German right-to-die organization "Sterbehilfe Deutschland" (StHD) between 2010 and 2013. 118 case reports of assisted suicide published by StHD were evaluated retrospectively. RESULTS: Between 2010 and 2013 StHD provided assistance in 118 suicides. 71 % of the deceased were women. 67 % were aged 70 years or older. 25,6 % suffered from metastasized cancer, 20,5 % had a severe…

Peri-interventional management of anticoagulation in patients receiving long-term anticoagulation can be challenging. The concept of "bridging" is known as an application of an anticoagulant with a short half-life (e. g. low-molecular-heparin) during interruption of therapy with vitamin-k-antagonists. Multiple studies have critically investigated the concept of bridging. Recently data from the ORBIT-AF-Register and the prospective randomized BRDIGE-Study have been released. The most common complication of bridging is bleeding. Overall the concept of bridging has lost some of its attractivity, especially concerning low or intermediate risk interventions or patients with a low risk of thromboembolism. An individual peri-interventional management based on individual patients' risk profile and interventional factors is recommended for VKA and NOACs. Main points of consideration are individual thromboembolic risk, specific bleeding risk of the planned intervention as well as patient factors (e. g. renal insufficiency).

Elevated liver enzymes are a frequent finding in both symptomatic and asymptomatic patients necessitating further evaluation to clarify the underlying disease. Three different patterns of increased liver enzymes can be defined to allow for a more precise and rational further diagnostic approach. A predominant increase in transaminase activities reflects a disturbance of hepatocellular integrity which can be found in patients with viral hepatitis, genetic liver diseases like Wilson`s disease or hemochromatosis, and drug-induced liver diseases. A second pattern is characterized by high serum alkaline phosphatase and γ-glutamyltranspeptidase activities indicating cholestatic liver diseases. The next important diagnostic measure in this group is an ultrasound study discerning intra- from extrahepatic cholestasis. Intrahepatic cholestatic diseases include primary and secondary sclerosing cholangitis, genetic disturbances of canalicular membrane transporters or drug-induced liver dieseases. Extrahepatic cholestasis involves obstruction of the large bile ducts by gall stones or tumors. The…

Background | Relapsing fever is divided into tick borne relapsing fever (TBRF) and louse borne relapsing fever (LBRF). This report describes 25 refugees from East Africa who were diagnosed to suffer from LBRF within a period of 6 month only at a single hospital in Munich / Germany. Material & Methods | The aim was to point out common clinical features as well as laboratory findings and clinical symptoms before and after initiation of treatment in 25 patients with louse borne relapsing fever (LBRF) who were diagnosed and treated at Klinikum München Schwabing from August 2015 to January 2016. To the best of our knowledge this is the largest case series of LBRF in the western world for decades. Main focus of the investigation was put on clinical aspects. Results | All 25 patients suffered from acute onset of high fever with chills, headache and severe prostration. Laboratory analysis showed high CRP and a marked thrombocytopenia. A Giemsa blood stain was procured immediately in order to look for malaria. In the blood smear spirochetes with typical shape and aspect of borrelia species…

Die chronische Herzinsuffizienz ist eine der häufigsten chronischen Erkrankungen weltweit mit steigender Prävalenz und Inzidenz. Aufgrund der hohen Morbidität und Mortalität ist eine möglichst standardisierte und evidenz-basierte Therapie essentiell. Diese übersicht stellt neue Entwicklungen in der Pharmakotherapie, Innovationen im Bereich von Therapie und Diagnostik relevanter Komorbiditäten sowie interventionelle Behandlungskonzepte des linksventrikulären Remodelings und der Telemedizin vor.

BACKGROUND: Palliative sedation (pS) is indicated in the presence of end-stage disease with treatment-refractory symptoms not tolerable for the patient. We investigated the practice of pS at a university palliative care unit. METHODS: Before starting pS the following data were documented: indication and decision making, type of sedation, life expectancy evaluated by the physician using the palliative prognostic index. Over the time of pS communication skills, depth of sedation, relief in symptoms, substitution of fluid and nutrition and used medications were collected. RESULTS: During evaluation time 99 patients died. 34 patients received pS (34 %). All patients suffered from cancer. Indications for palliative sedation were: terminal restlessness (56 %), dyspnea (39 %), pain (32 %), psychological distress (15 %), agitated delir (9 %), vomiting (3 %) and bleeding (3 %) (multiple nominations possible). In 31 cases (91 %) nurses were included for decision making. In 33 cases continuous sedation were initiated immediately (median duration 27.5 hours). The most applied medication was…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the targeted therapy of PAH. This article summarizes the results and recommendations of the working group…

Die bettseitige Sonografie in der Notaufnahme umfasst zum einen die Echoskopie, um „Point-of-Care“-Fragestellungen zu beantworten. Zum anderen sollen diverse Protokolle (RUSH, FATE, etc.) in Notfallsituationen helfen, möglichst rasch, zielgerichtet und ohne Unterbrechung notwendiger Maßnahmen lebensbedrohliche Situationen richtig zu erkennen. Eine Auswahl an aktuell verbreiteten Protokollen wird vorgestellt. Daneben werden die Notfallechokardiografie und die fokussierte Ultraschalluntersuchung des Herzens verglichen. Zuletzt wird auf die Kompressionssonografie der tiefen Venen der Extremitäten eingegangen. Fallbeispiele sollen die Anwendbarkeit demonstrieren.

Zwei Metaanalysen über Religiosität und psychische Gesundheit decken die Jahre 1978 bis 2010 ab. In diesen Jahren haben mehr als 70 % der Studien ergeben, dass Religiosität ein protektiver Faktor für die psychische Gesundheit ist. Aufgeschlüsselt auf die ICD-10-Diagnosegruppen kann man mit hohen Evidenzgrad festhalten, dass bei drei psychiatrischen Diagnosegruppen (Depression, Suchterkrankungen und Suizidalität) eine statistisch signifikante Korrelation zwischen Religiosität und besserer psychischer Gesundheit besteht. Zudem besteht es eine gewisse wissenschaftliche Evidenz, bei neurotischen Störungen und organischen psychischen Störungen, dass eine statistisch signifikante Korrelation zwischen Religiosität und besserer psychischer Gesundheit besteht. Ungenügende Evidenz findet sich bei der bipolaren Störung und beim schizophrenen Formenkreis aufgrund der niedrigen Qualität der wenigen vorliegenden Studien und den widersprüchlichen Ergebnissen. Abschließend gibt es keine Evidenz über den Zusammenhang von Religiosität und Essstörungen, Sexualstörungen, Phobien, Zwangserkrankungen,…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted and supportive treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to general and supportive therapy of PAH. This article summarizes the results and…

Fecal incontinence is defined by the unintentional loss of solid or liquid stool, and anal incontinence includes leakage of gas and / or fecal incontinence. Anal-fecal incontinence is not a diagnosis but a symptom. Many patients hide the problem from their families, friends, and even their doctors. Epidemiologic studies indicate a prevalence between 7-15 %, up to 30 % in hospitals and up to 70 % in longterm care settings. Anal-fecal incontinence causes a significant socio-economic burden. There is no widely accepted approach for classifying anal-fecal incontinence available. Anal-fecal continence is maintained by anatomical factors, rectoanal sensation, and rectal compliance. The diagnostic approach comprises muscle and nerve injuries by iatrogenic, obstetric or surgical trauma, descending pelvic floor or associated diseases. A basic diagnostic workup is sufficient to characterize the different manifestations of fecal incontinence in most of the cases. This includes patient history with a daily stool protocol and digital rectal investigation. Additional investigations may include…

Hintergrund | Über die Seroprävalenz von Infektionserkrankungen, insbesondere von sexuell übertragbaren Erkrankungen wie Syphilis und HIV bei Flüchtlingen und Asylbewerbern, die im Rahmen der aktuellen Flüchtlingskrise nach Deutschland migrieren, existieren derzeit nur Schätzungen. Ziel der Arbeit: Pseudonymisierte Erhebung der Seroprävalenz von Syphilis und HIV bei Flüchtlingen und Asylbewerbern in Norddeutschland im Jahr 2015. Material und Methoden | In einer Querschnittsuntersuchung erfolgte in fünf Erstaufnahmeeinrichtungen in Norddeutschland im August 2015 bei 790 Flüchtlingen aller Altersgruppen eine Bestimmung der serologischen Marker für Treponema pallidum und bei 789 Flüchtlingen für HIV. Ergebnisse | 76,6% der Flüchtlinge waren männlich, das mittlere Alter lag bei 28,7 ± 11,4 Jahren. 8,2% waren Kinder unter 18 Jahren. Bei einem männlichen Flüchtling (1/790; 0,13%, [95%-KI: 0 –0,4 %]) wurde ein auffälliger Treponema pallidum Antikörper festgestellt (CLIA). Klinisch zeigten sich hier Hinweise auf endemische Syphilis. Bei zwei weiblichen Flüchtlingen (2/789; 0,25%, [95%-KI:…

BACKGROUND: Similarities and differences of integration of palliative care in clinical care, research and education structures at German Comprehensive Cancer Centers (CCC) are not known in detail. OBJECTIVE: Provide an overview of availability and the way of integration of specialized palliative care at CCCs funded by the German Cancer Aid (Deutsche Krebshilfe, DKH). METHOD: We conducted structured interviews from May to August 2014 with heads of palliative care departments (personally or by telephone). The interviews included a quantitative and a qualitative part. Other stakeholders of CCCs were asked the questions of the qualitative part. We evaluated the qualitative data using the content analysis by Mayring and MAXQDA 11.0. SPSS 21.0 was used for quantitative analysis. RESULTS: 26 interviews were realized in 13 CCCs with 14 sites, which received funding, by DKH till August 2014 (one CCC had two university hospitals). Of these, 12 sites had a palliative care unit (86%), 11 sites had palliative care consulting services available (79%). Participation of palliative care specialists…

New studies increase the evidence, that different applications of physical therapy are effective. In patients with rheumatoid arthritis (RA) physiotherapy of the hands improve strength, joint mobility and activity without increased risk of pain nor inflammation. A theory-based physiotherapy of the hands shows clinical effectiveness and cost-utility. In patients with spondyloarthritides supervised group exercise training is more effective than home exercise programs. Compared with biologics only combined exercise training and tumour necrosis factor alpha inhibitor therapy improve mobility and disease activity more effectively. Aerobic exercise training reduces fatigue in RA. Working wrist splints and static resting splints improve pain and grip strength. Static resting splints reduce the risk of hand deformities. Local and whole body cryotherapy show short term improvement of pain and inflammatory activity. German S3-guidelines recommend enhanced utilisation of physical therapy as well as coordinated multiprofessional team care and rehabilitation.

End-of-life decisions in neurology have repeatedly given occasion for controversies. Often these are based on lack of knowledge of the juridical and ethical framework conditions. This review describes the juridical-ethical basis for the implementation and continuation, and for withholding and withdrawal of life-sustaining measures, in particular, the significance of medical indication and patient's will. The different forms of assisted dying ("Sterbehilfe"), namely homicide by request, assisted suicide, palliative symptom relief and treatment withdrawal are characterized. The "Principles of the German Medical Association" in end-of-life situations are illustrated. Specific features of neurological treatment scenarios are discussed such as the preclinical and clinical emergency and acute situation, the decompensation of stable chronic severe brain injury situations, and chronically progressive neurodegenerative diseases. In the latter situations, an early "Advance Care Planning" could contribute to improved end-of-life decision-making.

Die Inzidenz der arzneimitteltoxischen Hepatopathie liegt bei etwa 14 – 20 pro 100 000 Einwohner. Der Schlüssel zur Diagnosestellung ist eine ausführliche, akkurate Anamnese und ein Ausschluss anderer Lebererkrankungen. Die am häufigsten mit medikamentös-toxischer Hepatopathie in Verbindung stehenden Substanzgruppen sind Antibiotika, verschiedene Analgetika und nichtsteroidale Antirheumatika. In den meisten Fällen ist eine Restitutio ad integrum zu erwarten. Die wichtigsten therapeutischne Maßnahmen sind die frühzeitige Identifikation und das Absetzen der auslösenden Substanz.

Die Regulation des Säure-Basen-Haushaltes und des pH ist entscheidend für den Organismus. Das zentrale Puffersystem ist das CO 2 / HCO 3 - – System. Die Niere steuert die systemische Bikarbonatproduktion und damit die metabolische Regulation. Die Lunge ist relevant für die respiratorische Regulation, da CO 2 sehr effektiv eliminiert wird. Die bekannten Säure-Basen-Haushaltsstörungen umfassen zwei metabolische und zwei respiratorische Störungen (jeweils Azidose und Alkalose). Die Anionenlücke erlaubt es, metabolische Azidosen weiter zu differenzieren.

In Germany in 5.5% of all births diabetes is registered. In patients with type 1 and type 2 diabetes planning pregnancy, preconception counseling, diabetologic care with optimized periconceptional metabolic control and folic acid supplementation are essential for good pregnancy outcome. Gestational diabetes (GDM) should be diagnosed timely and managed according to existing guidelines. GDM is treated with insulin in approximately 20%. In 1-2% of GDM cases a glucokinase gene mutation is present (MODY 2). Pregnancies after bariatric-metabolic surgery are increasing and show high risks.

Colour coded Duplex ultrasound is the diagnostic tool of choice in case of suspicion of a deep vein thrombosis of the leg. In the hand of an experienced examiner a thrombosis can be confirmed or excluded, but also differential diagnoses can be detected. In this article we show you how to perform a systematic ultrasound examination of the leg veins.

Acute gastrointestinal bleeding is a common major emergency (Internal medical or gastroenterological or medical), approximately 85 % of which occur in the upper GI tract. It is estimated that about a half of upper GI bleeds are caused by peptic ulcers. Upper GI bleeds are associated with more severe bleeding and poorer outcomes when compared to middle or lower GI bleeds. Prognostic determinants include bleeding intensity, patient age, comorbid conditions and the concomitant use of anticoagulants. A focused medical history can offer insight into the bleeding intensity, location and potential cause (along with early risk stratification). Initial measures should focus on rapid assessment and resuscitation of unstable patients. The oesophagogastroduodenoscopy (OGD) is the gold standard method for localizing the source of bleeding and for interventional therapy. Bleeding as a result of peptic ulcers is treated endoscopically with mechanical and / or thermal techniques in combination with proton pump inhibitor (PPI) therapy. When variceal bleeding is suspected, pre-interventional use of…

In acute exacerbations of COPD with acute hypercapnic respiratory failure and a pH 7.25 - 7.35, the initiation of non-invasive ventilation is the gold standard. However, absolute and relative contraindications have to be taken into account. The implementation of non-invasive ventilation in case of a severe respiratory acidosis necessitates a skilled therapeutic team and a close monitoring in order to avoid or perceive a NIV failure in time. In this case, the intubation and invasive mechanical ventilation is recommended. Ventilator settings have to aim at the prevention of an overinflation and increase of intrinsic PEEP. If severe hypercapnia and respiratory acidosis cannot be managed by mechanical ventilation, extracorporeal CO2 removal (ECCO2R) is a new treatment option. There are some reports about its use in awake patients in order to avoid an intubation. However, its general and primary use without optimizing medical therapy and mechanical ventilation is not indicated. ECCO2R is an experimental therapy in COPD with acute hypercapnic respiratory failure, its significance is still…

Background | In Germany, place of death is recorded on death certificates, but is not analyzed further. In consequence, only little is known about the place of death among cancer patients at the population level. The aim of the study was to describe the changes of places of death in cancer patients over a time period of 10 years. Material and methods | This study examined death certificates from 2001 and 2011 of selected regions of Westphalia-Lippe (Germany). Cancer patients were identified on the basis of cause of death. Description of frequencies of place of death and subgroup analyses by tumor entity (ICD-10, C00-C96) were performed. Results | A total of 24 009 death certificates were analyzed (2001: 11,585; 2011: 12,424). Cancer was the underlying or contributory cause of death in 34.0%. For the years 2001 and 2011, respectively, the following distributions of place of death were observed: home, 24.1% vs. 24.7% (p=0.553); hospital, 62.8% vs. 51.4% (p=0.001); palliative care unit, 0.0% vs. 2.2%; hospice, 5.5% vs. 12.5% (p=0.001); nursing home, 7.4% vs. 10.9% (p=0.001); other,…

For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Premature discontinuation of dual antiplatelet therapy is associated with an increased risk of ischaemic events. However, antiplatelet therapy is also associated with an increased risk of bleeding that should not be under- or overestimated. To ensure an optimal care of patients receiving dual antiplatelet therapy after an acute coronary syndrome, an interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology gathered bleeding-related information and developed recommendations relevant to daily clinical practice. These include the significance of bleeding events in the course of treatment, measures for bleeding prevention and the adequate care of patients with bleedings.

Das rupturierte abdominelle Aortenaneurysma (AAA) hat auch heute noch eine hohe Krankenhaussterblichkeit von ca. 50 % (Interventionen und nicht-korrigierende Behandlung zusammengefasst). Mit einer einfachen, nicht-invasiven und preiswerten Maßnahme wie dem Ultraschall-Screening lassen sich rupturgefährdete Aneurysmen rechtzeitig erkennen und dann prophylaktisch versorgen, der Blutungsschock kann so vermieden werden. In den Screening-Programmen Englands und Schwedens wird aktuell eine AAA-Prävalenz bei den gescreenten 65-jährigen Männern von 1,5 % beschrieben. Damit ist das Screening bei dieser Zielgruppe mit einer absoluten Risikoreduktion für einen Aneurysma-bezogenen Tod von 15,1 pro 10.000 zum Screening eingeladene Männer und Kosten von £7370 pro gewonnenes Qualitätsadjustiertes Lebensjahr (QALY) hoch kosteneffektiv. Ein flächendeckendes AAA-Screening setzt ein Screening-Programm mit definierten Anforderungen an die Qualität der Ultraschall-Untersuchung und die der operativen Versorgung der durch Screening entdeckten großen AAA voraus. Die Konzentration dieser Eingriffe in…

Glucocorticoid-induced osteoporosis is the most common cause of secondary osteoporosis. Moreover, it is the most common reason for an osteoporosis among young adults. The clinical use of oral glucocorticoids increases the fracture incidence already within three months after starting the therapy. There does not seem to be a lower threshold: even doses as low as 2,5 mg of prednisone equivalent increase the risk of fractures. Adequate diagnostic and therapy are able to significantly reduce the resulting fracture risk. This article will discuss the pathophysiology of glucocorticoid-induced osteoporosis and give a summary of the current recommendations including the recently updated German guidelines.

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more common forms of PH such as PH due to left heart disease. Despite the lack of data, targeted PAH treatments are increasingly being used for PH associated with left heart disease. This development is of concern because of limited ressources and the need to base treatments on scientific evidence. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease, representing an unmet need of targeted PH therapies. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed information about the diagnosis of pulmonary hypertension, and furthermore provide novel recommendations for risk stratification and follow-up assessments. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to risk stratification and follow-up…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for different forms of PH, and specifically address PH associated with congenital heart disease (CHD). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH in grown-ups with congenital heart disease (GUCH). This article…

Wir haben wissenschaftliche Evidenz für viele diagnostische und vor allem therapeutische Verfahren. Diese Evidenz hat die Prognose und Lebensqualität unserer Patienten entscheidend verbessert. Der Siegeszug der modernen Medizin ist wissenschaftsbasiert. Andererseits wird Evidenz in Studien für ein Musterkollektiv erhoben, das für unseren Alltag in Klinik und Praxis nicht zwangsläufig repräsentativ ist, zum Beispiel was Alter, Geschlecht oder mögliche Komorbiditäten betrifft. Der Arzt, auch wenn er selbst nicht mehr forscht, muss wissen, wie Forschung funktioniert, um neue wissenschaftliche Erkenntnisse auf seine Patienten anzuwenden. Aber auch dafür, festzustellen, wo es in der Medizin an wissenschaftlicher Erkenntnis fehlt: banale Erkrankungen, die wir ohnehin nur symptomatisch behandeln, Beschwerden, bei denen wir keine Krankheit für die Beschwerden finden, oder aber multimorbide Patienten, die in klinischen Studien meist nicht vorkommen und auf die wir dennoch, mit der gebotenen Vorsicht und Kenntnis, die Ergebnisse der klinischen Studien anwenden. Jede schwierige Diagnose ist…

Depression is common in heart failure and associated with impaired quality of life. It impacts adversely on clinical outcomes. Both diseases are widespread in the general population with increasing prevalence and treatment costs. They are therefore also of socio-economic relevance. Various interrelated biological and behavioral factors (e.g. lower treatment adherence in depressed patients with heart failure) seem to play a pathophysiological role, and there is growing evidence that both diseases may also share genetic susceptibilities. Simple screening tools ease depression diagnosis in clinical practice, although the clinical profile of both disorders overlaps. To date, there is no evidence that antidepressant pharmacotherapy improves depressive symptoms, mortality and morbidity in patients with heart failure and comorbid depression, but physical training, cognitive behavioral therapy and comprehensive disease management improved symptoms and/or prognosis in individual randomized studies.

Die Brucellose ist eine vor allem mit Schafen, Ziegen und Rindern assoziierte Zoonose. Sie tritt in Deutschland selbst nicht endemisch auf, ist aber eine wichtige importierte Infektionserkrankung. Bei Patienten, die nach einem Aufenthalt in den hochendemischen Ländern des Mittelmeerraums oder der arabischen Welt eine unklare fieberhafte Erkrankung aufweisen, sollte die Brucellose daher diagnostisch ausgeschlossen werden. Vor den serologischen Verfahren ist der Erregerdirektnachweis das wichtigste Instrument zur Diagnosestellung. Aufgrund besonderer Anforderungen bei der Anzucht des Erregers muss das Labor vorab über die Verdachtsdiagnose informiert werden. Therapeutisch bedarf es einer mindestens 6-wöchigen antimikrobiellen Kombinationstherapie, deren Dauer und Zusammensetzung von der Schwere des Krankheitsbildes und eventuell auftretenden Komplikationen abhängt. Dafür ist meist eine besondere Therapieadhärenz des Patienten nötig.

Acute myeloid leukemia (AML) has been genetically characterized extensively and can now be subdivided into 9 to 11 pathogenetically different subtypes according to their profile of driver mutations. In clinical practice karyotyping and molecular analysis of NPM1, cEBPa and FLT3-ITD are required for treatment stratification and potentially genotype specific treatment. Some markers such as NPM1 not only offer prognostic information but can also serve as markers of minimal residual disease and thus have the potential to guide therapy in the future.The basis of curative treatment is intensive combination chemotherapy comprizing cytarabine and an anthracycline ("7 + 3" regimen). The prolonged duration of aplasia can be reduced significantly by accelerated therapy ("S-HAM" regimen). Following achievement of a complete remission patients with a low risk of relapse - based on genetic and clinical features - receive chemotherapy based consolidation therapy whereas high risk patients - and potentially also those with an intermediate risk - receive an allogeneic stem cell transplantation.…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the management of decompensated right heart failure, intensive care management and perioperative management…

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed information about the clinical classification and diagnosis of pulmonary hypertension, and furthermore provide novel recommendations for risk stratification and follow-up assessments. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the…

Autoimmune encephalitis, an inflammatory disease of the brain, is usually attributed to antibody-mediated damage and dysfunction of neuronal structures. A distinction is made between onconeuronal antibodies (directed against intracellular neuronal antigens with resulting paraneoplastic neurological syndromes) and antibodies directed against neuronal cell surface proteins (with resulting synaptic encephalopathies). Anti-NMDA-Receptor-Encephalitis, the most common form of autoimmune encephalopathy, is characterized by a phased course of disease. Early disease phase involves nonspecific prodromes (fatigue, fever, headache) which lead to family doctor or emergency department consultation. Subsequently, neuropsychiatric behavioural problems, seizures, disturbance of memory and finally coma, dysautonomia and respiratory insufficiency often result in major complications (e.g. status epilepticus) necessitating intensive care treatment. The diagnosis is secured by detection of auto-antibodies in serum or cerebrospinal fluid. An intensive search for tumors is also recommended. The treatment…

Sepsis is defined as "life-threatening organ dysfunction caused by a dysregulated host-response to infection". Presence of organ dysfunction is associated with a mortality of 10% and higher in hospitalized sepsis patients.Introduction of standards in diagnosis and treatment of sepsis in intensive care units has not considerably reduced sepsis mortality. About 80% of patients with sepsis are transferred to intensive care units from usual care wards and emergency departments. Thus, it is tempting to speculate whether opportunities for further improvement of sepsis management exist outside of intensive care units. Performing a "quick sequential organ assessment" (qSOFA; two of following criteria have to be present: respiratory rate >22/min; sytolic blood pressure <100mmHg; altered mental status) supports to identify patients with suspicion of an infection and an increased risk of death within the hospital. Subsequent treatment according to current guidelines on sepsis management will reduce in-hospital mortality of sepsis patients. Indeed, we were able to show a substantial decrease of…