The 50 most-cited articles in DMW - Deutsche Medizinische Wochenschrift, 2019

In 2018, the PEG-recommendations for calculated initial parenteral treatment of bacterial diseases in adults were updated to a consensus-based S2k-guideline.This summary of guidelines deals with the classification of new antibiotic substances such as cephalosporin/betalactamase inhibitor combinations and MRSA-effective cephalosporines and with a need for further therapeutic drug monitoring.Due to their influence as major disease entities in intensive care, we also outline core issues regarding respiratory infections and sepsis. With this update, latest recommendations on a high scientific level are available for intensive care units and - if applied consistently - might improve the chances of critically ill patients.

Since 2005, invasive long-term ventilation in Germany has increased significantly from around 1000 to 20 000 patients in Germany. Due to complex home care, the health care system incurs additional costs of around 4 billion euros per year. In addition, in the last 2 - 3 years more tracheostomized patients have been discharged home without ventilation (usually after stroke), and they receive the same complex home care. These patients have almost never been given the chance of a professional weaning trial by a weaning center. They are discharged from hospitals directly into the care. As a result, the quality of care is significantly worse than traditional care with structured discharge management via a weaning center. The solutions are difficult to find due to the interface problems between inpatient and outpatient care and the different organizational structures with different delivery systems. Possible solutions are shown, but most of them require a change in the law.

The AWMF and its medical societies perceive an increasing dominance of economic targets in the hospital health care sector, leading to impairment of patient care. While resource use in health care should be appropriate, efficient and fairly allocated, "economization" creates a burdensome situation for physicians, nurses and other health care professionals.The AMWF and the medical societies studied causes and developed measures for a scientific, patient-centred and resource-conscious medical care. Disincentives due to the remuneration system, number and equipment of hospitals resp. specialist departments and their basic funding need to be overcome. Proposed actions relate to the patient-doctor-level, the management level of hospitals and the level of planning and financing hospitals including compensation of hospital care. To place patients and their health in the forefront again, joint efforts of all stakeholders in health care are needed.

INTRODUCTION: Patients with leg ulcers often have severe edema of the lower extremities, which should be treated as part of a successful wound treatment. Today in Germany the necessary compression therapies are often performed with very error-prone and time-consuming short-stretch bandages only. Multicomponent systems, adaptive compression bandages and leg ulcer stocking systems are newer, much less error-prone treatment options. In addition to the often lacking knowledge, the fears of high costs are also mentioned as reasons for the lack of prescription of these systems. It was therefore our aim to investigate the costs of different treatment options, differentiated in the outpatient and inpatient sector. METHODS: For the economic calculations, both material and personnel costs were taken into account for different scenarios. RESULTS: Both material and personnel costs were included in the calculation. We were able to demonstrate that the cost for a continuous compression therapy for inpatients accrues between 5.29 Euros to 18.50 Euros per day. For the outpatient setting costs of…

Zusammenfassung Die Ende 2015 veröffentlichten ESC/ERS-Leitlinien und andere internationale Empfehlungen definierten die pulmonale Hypertonie (PH) bisher durch einen invasiv gemessenen mittleren pulmonal arteriellen Druck (mPAP) ≥ 25 mmHg in Ruhe. Auf dem 6th World Symposium on Pulmonary Hypertension in Nizza wurde eine Modifikation dieser hämodynamischen Definition im Sinne einer Senkung des Schwellenwertes auf > 20 mmHg vorgeschlagen. Für die präkapilläre PH wird zusätzlich ein pulmonaler Gefäßwiderstand (PVR) ≥ 3 Wood-Einheiten (WE) gefordert. Diese Änderung muss im Hinblick auf die zugrunde liegende Rationale und mögliche Konsequenzen kritisch hinterfragt werden; es bedarf daher einer eingehenden Erläuterung. Insbesondere muss klargestellt werden, dass diese Änderung aktuell keinen Einfluss auf die evidenzbasierte und zulassungskonforme Verschreibung von Medikamenten zur gezielten Therapie der pulmonal arteriellen Hypertonie (PAH) hat.

BACKGROUND: The nutritional status of patients with tumor diseases in German out-patient clinics is largely unknown. This cross-sectional survey on patients with tumor diseases aimed to assess the prevalence of the risk of malnutrition in this group. METHODS: In out-patient clinics of oncologists, patients with a diagnosed cancer disease were consecutively interrogated between June 2017 and May 2018 using a standardized questionnaire. In addition to questions on the health status and dietary habits, the validated screening questionnaires Malnutrition Universal Screening Tool (MUST) and the Nutrition Risk Screening Tool-2002 (NRS-2002) were used to assess the risk of malnutrition of these patients (primary endpoint). A descriptive statistical analysis was performed. RESULTS: In total, data from 765 patients with a diagnosed tumor (60.9 % female) were analyzed. The participants had a mean age of 63.1 ± 13.1 years and a mean body mass index (BMI) of 25.2 ± 5.1 kg/m². Using the MUST questionnaire 15.4 % of participants had a moderately increased risk and 19.5 % a high risk of…

Thoracic aortic aneurysms are a relatively uncommon disease, with an incidence of 10.4/100 000, with an increase in the last decades, due to the increased quality of vascular screening. Several imaging techniques like thoracic radiography, echocardiography, magnetic resonance (MRI) or positron emission tomography (PET) can be used for the diagnosis of such condition, whose first diagnosis is usually incidental. The gold standard for aneurysm evaluation is computed tomography angiography (CTA), which allows precise diameter assessment and accurate preoperative planning. Advancements in imaging techniques, through electrocardiography (ECG)-gated CTA, permit to avoid movement artifacts and have a more precise definition of proximal aortic segments (aortic arch, ascending aorta).The urgent or emergent treatment of thoracic aneurysms is indicated in symptomatic patients and in case of rupture, respectively. The current European Society for Vascular Surgery guidelines recommend the elective treatment of thoracic aneurysms with a diameter > 55 mm, since diameters of 55 - 60 mm are…

DEVELOPMENT OF HOME MECHANICAL VENTILATION (HMV) IN GERMANY: HMV has become a well-established treatment option in Germany. However, during the last decade the number of patients established on HMV is exploding, and this has reached economical and ethical limits. Consequently, a discussion within the health policy concerning this issue is urgently needed. REVISION OF GUIDELINES: The German Respiratory Society has completely revised and thematically complemented its guidelines on HMV. Concerning the professional policy perspective, these guidelines cover essential aspects of the organisation and implementation of HMV, while simultaneously summarizing the current scientific evidence. Based on this, treatment algorithms for different entities are provided. NEW EVIDENCE FOR NON-INVASIVE VENTILATION (NIV) IN COPD: Current data provide evidence that the prognosis of COPD patients can be improved by NIV. This is true for patients with both chronic hypercapnia and persistent hypercapnia following exacerbation treated in the hospital.

BACKGROUND: It may happen that extensive internet search leads to health anxiety in patients, which solidify in the long term. Dealing with such 'cyberchondria' presents a special challenge for the physician. The study highlights general medical attitudes and experiences with regard to patients who are increasingly searching the Internet for symptoms, illnesses or therapies. Particular emphasis will be given to persons who develop health anxieties due to previous Health information on the Internet. It will be determined which procedures make sense in order to respond appropriately to patients with internet-related health concerns. METHODS AND PARTICIPANTS: In the course of a written survey, a total of 844 general practitioners and primary care internists in southern Hesse and additionally in the rural districts of Gießen, Marburg-Biedenkopf, Kassel and the city of Kassel were interviewed between April 20 and June 20, 2018. RESULTS: Two-thirds of respondents assume that 15 % or more of their own patients confront them with the results of their own internet search. 73 % see the…

Alcohol use is one of the most important and potentially modifiable risk factors for cancer in Germany. The more and the longer a person drinks, the higher the risk of cancer. Even modest use of alcohol may increase cancer risk. Statistically, every German drinks more than 100 gram of alcohol per week; this amount is currently considered to be the limit of low-risk use. Alcohol is causally associated with oropharyngeal and larynx cancer, esophageal squamous cell cancer, hepatocellular carcinoma, breast cancer, and colorectal cancer. People with long-term risky alcohol use should be encouraged to join programs of cancer screening. Alcohol cessation appears to be effective in reducing the alcohol-induced, increased cancer risk.

Diagnosing and managing patients in shock is a challenge for the treating clinicians in acute medicine. Early diagnosis and treatment are crucial. Mortality of septic shock is between 40 % and 60 %, and that of the cardiogenic shock about 40 %. This article provides an overview of diagnostic approaches to the patient in shock, different aetiologies and treatment strategies, and it guides the clinician through the management from first contact until definite treatment.

Since the early 1990 s, both experimental and clinical data have clearly demonstrated that inflammatory processes accompany atherosclerotic disease from its initiation to the development of clinical complications. Numerous biomarkers involved at various levels of the inflammation cascade have been shown to be associated with adverse cardiovascular outcomes. Among them, the classical acute phase reactant C-reactive protein (CRP) has been most intensively investigated. Recent research in this field has been driven by the observation that despite low LDL-cholesterol levels, a remarkably high number of patients are still at increased risk for recurrent cardiovascular events. This is argued to be attributable to the presence of a prolonged inflammatory response (reflected by a persistently elevated hsCRP), a concept, which is currently known as "residual inflammatory risk". The unequivocal proof that the inflammatory process is not only a simple bystander but is also causally involved in atherogenesis, came from the recent CANTOS trial, showing a 15 % reduction of primary MACE outcomes…

BACKGROUND: In 2003, disease management programs (DMP) were established to improve the care of chronically ill outpatient patients. Since then, there has been a lot of controversy over the meaning and benefits of structured treatment programs, especially among primary care physicians. The present study examines the attitudes and experiences of general practitioners in relation to DMP, how they assess these one and a half decades after their introduction, and where DMP need to be improved. METHODS AND PARTICIPANTS: In the course of a written survey, a total of 752 general practitioners in Hesse were interviewed between April and June 2019. In addition to the descriptive analysis, a factor analysis was performed. RESULTS: 59 % of the interviewees assess the DMP as positive and consider it a useful contribution to primary care. 89 % are currently participating in one or more DMPs, with 52 % indicating that the treatment of patients included in DMP has benefited significantly. Respondents consider the provision of regular, structured patient care and the improvement of compliance to be…

Was ist neu? Das Konzept der bisherigen Demenztherapie Die klinische Relevanz von Acetylcholinesterase-Inhibitoren (AChE-I) zur symptomatischen Therapie der leichten bis mäßigen Alzheimer-Demenz ist weltweit anerkannt, trotz nur mäßiger Wirksamkeit. Die Anwendung sollte bei Verträglichkeit auch im schweren Krankheitsstadium fortgeführt werden. Bei mäßiger bis schwerer Alzheimer-Demenz ist der NMDA-Rezeptor-Antagonist Memantin indiziert. Die Lewy-Körperchen-Demenz ist in der antidementiven Therapie der Alzheimer-Demenz gleichgestellt, für die Parkinson-Demenz existiert eine Indikation für Rivastigmin. Eine Veränderung der motorischen Symptome unter AChE-I ist zu beachten. Für frontotemporale oder vaskuläre Demenzen gibt es keine evidenz-basierte antidementive Therapie. Therapie-Monitoring und Wirksamkeitsbeurteilung Der Wirksamkeitsnachweis der Demenztherapie im Einzelfall ist schwierig. Jede Demenztherapie sollte deshalb, Verträglichkeit vorausgesetzt, langfristig angelegt und regelmäßig überprüft werden. Andere medikamentöse Therapiestrategien in der Behandlung demenzieller…

Quinolones have recently been reevaluated based on new possible side effects and new risk assessments of known side effects. Several of the recently reported untoward effects are not new to the class, and they are very rare compared with the relatively common neuropsychiatric adverse events. New associations are aortic aneurysm/dissection and long-standing peripheral neuropathy, muscle weakness, mobility and gait disorders with unclear causal relationship to fluoroquinolone treatment and no known effective therapeutic interventions. Based on estimates from comparative data there could be slightly more than 1000 additional cases of adverse drug effects associated with fluoroquinolone treatment versus other common antibiotics per 100 000 treatment episodes - most of them being neuropsychiatric side effects in primary care, tendinopathy and - more rarely and uncertain - liver toxicity. Consequences were safety alerts in the USA and in European countries with recommendations that the use of the marketed fluoroquinolone antibiotics should be restricted and other antibacterial medicines…

Chronic heart failure is associated with high morbidity and mortality and is the most common hospital diagnosis for elderly patients. Concomitant or superimposed acute or chronic kidney injury, as is the case with cardiorenal syndrome, has a dramatic impact on the outcome. The inhibition of the neurohumoral axis and the adequate treatment of hypervolemia are fundamental elements of modern cardiac insufficiency therapies. In addition to optimal conservative therapy, there are other options: VAD implantation, hemodialysis and peritoneal dialysis. The PD offers biological and clinical benefits as an additive therapy for the treatment of patients with heart failure, refractory hypervolemia and non-urinary renal failure.

The determination of the cardiac preload is still a challenge for intensive care physicians. In addition to clinical assessment, both non-invasive and invasive methods exist for evaluating fluid responsiveness. The following article demonstrates one possible approach for systematic assessment of fluid responsiveness using a practical algorithm for critical care patients.

Drug-drug interactions (DDI) represent a significant problem in modern medicine. The number of patients with multi-morbidity, who take multiple drugs, is constantly increasing (polypharmacy). The related exponential increase in potential DDI is almost incomprehensible. In this article, we review pharmacodynamic DDI and provide clinically relevant examples. In addition, we extensively review pharmakokinetic DDI (e. g. through the cytochrome P450-system or p-glycoproteins) that can modify the plasma concentration of many compounds, thereby also increasing the likelihood of unwanted side effects. Finally we provide tools, which may help clinicians in their daily practice to identify and avoid potential DDI. In the context of an ageing society receiving polypharmacy, a better awareness of DDI and of strategies to prevent them is expected to reduce mortality and morbidity.

Abstract Cerebral diseases such as epileptic seizures, cerebral hemorrhages or meningoencephalitis are the primary cause of approximately 50 % of non-traumatic acute disorders of consciousness. For the differential diagnosis, history and other symptoms are important such as hemiplegia, signs of brain stem dysfunction, meningism or headache. Metabolic, endocrinologic, toxicologic or electrolytic causes of coma usually can be diagnosed by laboratory examinations. Anamnestic informations, body inspection, clinical neurological examination as well as laboratory and imaging findings have to be added and categorized by a multilevel composition to establish a conclusive diagnosis. Simultaneously therapeutic measures for suspected primary cerebral diseases must be initiated, for example a rapid antibiotic treatment in case of a possible bacterial meningitis. A fast and structured diagnostic approach is crucial for ensuring a good prognosis and helps to miss relevant diagnostic steps. Potential diagnostic and therapeutic pitfalls must be kept in mind.

BACKGROUND: So far physical activity counseling and exercise referral in primary health care are not well established Germany. The exercise referral scheme "Rezept für Bewegung" ("exercise on prescription", "EoP") represents an appropriate tool. The initiative aims to reinforce the physicians' verbal advice via the written prescription. The aim of this study was to assess patients' perceptions of the counseling and their self-reported intention to increase their level of physical activity. METHODS: 3.9 ± 1.0 months after physical activity counseling and referral 173 patients were invited to fill out a 17-item self-administered questionnaire regarding counseling satisfaction and the impact on physical activity behavior. Study participants were recruited through 12 medical offices in 8 areas of the sports association in Hessen. RESULTS: Data of 51 patients (aged 56.1 ± 13.3; 35 female) were included in the evaluation. Almost 2/3 of patients reported ≤ 60 min/week physical activity prior to counseling. 63 % of the interviewees rated the counseling good to very good. Following the…

Enterococci with special resistance patterns (mainly vancomycin-resistant enterococci) play an important role in everyday clinical practice. Rising resistance rates to linezolid, daptomycin or tigecycline are also increasingly reported. Therapeutically, linezolid and daptomycin are the most important substances mainly in infections due to vancomycin-resistant enterococci. Several systematic meta-analyses of bloodstream infections showed discrepant results in the comparison of mortality of linezolid and daptomycin-treated bacteraemias. The containment of enterococci with special resistance patterns is currently receiving great attention. The key hygienic issue in all recommendations for dealing with multidrug-resistant enterococci can be summarized very simply: current scientific evidence is often inconsistent and studies that have clearly tested a single intervention for efficacy are lacking. The present work gives an insight into the current epidemiology and therapeutic strategies. Furthermore, the recently published German KRINKO recommendations are presented.

Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing. The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate-) high-risk patients. For haemodynamically unstable patients, a treatment decision should preferable be made in interdisciplinary "Pulmonary Embolism Response Teams" (PERT). Being comparably efficient and due to a preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered to be the treatment of choice for initial and prolonged…

BACKGROUND: A palliative care team is recognized as a quality indicator in the consultation and care of patients with a tumor disease and is used nationally (92 %) in the National Cancer Institutes, model of the German Comprehensive Cancer Center (CCC). This begs the question of how palliative care teams are presently integrated into the CCCs. METHOD: From July to August 2017, a paper-based quantitative survey of 16 locations of the CCCs, supported to that date, gathered information on the existence, personnel situation, use and prospects of a specialized inpatient palliative care service. The survey was addressed to the heads of the palliative medical units of the CCCs. The data were evaluated in SPSS (frequency, median, mean, range). RESULTS: Fifteen CCCs took part in the survey (response 94 %). Thirteen of the fifteen CCCs have a service that also treats palliative patients. Twelve of thirteen CCCs of these are attainable during regular working hours (8a. m.-4 p. m. on weekdays). All services are staffed by physicians, additional eleven are staffed by nurses. Seven services are…

Invasive pulmonary aspergillosis is a life-threatening disease occurring in patients with severe immunosuppression. It is classically associated with severe neutropenia following hematopoietic stem cell transplantation, but other risk factors include COPD, corticosteroid therapy, solid organ transplant, liver failure and preceding severe influenza infection. Due to the high mortality of the disease, rapid diagnosis and treatment are crucial. Diagnosis is based on CT scan and bronchoscopy including microscopy, culture and galactomannan detection in BAL. Histopathology remains the gold standard diagnosis but is not feasible in many cases. First line treatment is voriconazole, new recommendations also support the triazole isavuconazole.

Was ist neu? Stand der Dinge Innovationen in der Informations- und Kommunikationstechnologie haben in der Rheumatologie eine jahrzehntelange Tradition, die Deutsche Gesellschaft für Rheumatologie hat im Jahr 2018 die Kommission „Digitale Rheumatologie“ gegründet. Digitale Anwendungen in der deutschen Rheumatologie Mobile Datenerfassung rheumatologischer Patienten ist valide möglich. Sie eröffnet damit neuartige Möglichkeiten bei der Umsetzung moderner Behandlungsstrategien. Zum Screening auf entzündlich-rheumatische Systemerkrankungen stehen Interessierten z. B. mit dem „Rheuma-Check“ und dem „Bechterew-Check“ jederzeit digitale Anwendungen zur Verfügung. Die digitalen Angebote sowie moderne Netzwerkstrukturen erlauben eine Triage der Patienten. Mit dem Rhekiss- und dem RABBIT-SpA-Register stehen erstmals vollständig digitalisierte Register zur Verfügung, die kurzfristig Daten zu Fragestellungen liefern, die in klinischen Studien der pharmazeutischen Industrie nicht abgebildet werden. Ausblick Durch die Digitalisierung in der Rheumatologie können wichtige Fragen der…

Delirium is a potentially life-threating acute disease accompanied by a mortality up to 30 % of all affected patients. It occurs more frequently in older patients ≥ 65 years. Delirium is defined as acute onset of disturbances in attention, awareness and cognition that develops within a short period of time and fluctuates in severity. It can be subdivided in hyperactive, hypoactive and a mixed type. The hypoactive type occurs more frequently in geriatric patients and has the highest mortality of all types. Differential diagnosis of delirium include stroke, central nervous system infection, metabolic diseases, disturbances in electrolytes as well as Wernicke encephalopathy and psychiatric diseases. Treatment should be initiated rapidly and includes non-pharmacological interventions and specific pharmacological treatments. The review summarizes diagnosis and clinical management of patients with delirium.

Dementia as a multi-facetted ailment demands multimodal approaches. Music Therapy has gained sufficient evidence as therapeutic concept in many areas of traditional medicine. Standards for research, methods and quality of application are established. For people suffering from dementia music offers a variety of beneficial effects, especially enhancing communication and quality of life. Care givers appreciate relief in emotionally aversive situations as well.

A delirium in patients in the intensive care unit (ICU) is a manifestation of a severe acute dysfunction of the brain. It has a high prevalence and is associated with a relevant increase in morbidity and mortality. A cholinergic deficit and dopaminergic overactivity are considered to be a cause of delirium. Polypharmacy, which is often present before admission to the ICU, especially in the elderly, plays a key role as a trigger. The knowledge and identification of risk factors for delirium is a precondition for the early and effective prevention of delirium. The aim is the pre-operative or pre-interventional optimization of modifiable risk factors. Early and effective prevention of delirium can improve clinical outcome, reduce mortality, and positively impact long-term functional outcome. Non-pharmacological measures are always the basis for the prevention of delirium: maintenance of the day-night rhythm, sleep promotion at night and stimulation during the day, involvement of relatives, the avoidance of dehydration and malnutrition, and others more. They are pharmacologically…

Hyperkalemia increases morbidity and mortalilty risk in both in- and outpatients. Common causes are decreased renal excretion, excess intake or potassium shifting from the intra- to the extracellular space in combination with reduced renal excretion or impairment of regulation. Hyperkalemia may alter the cellular transmembrane potential and cause life-threatening arrhythmias. Heart failure patients with comorbid renal insufficiency and/or diabetes mellitus are at increased risk of developing hyperkalemia, which thus constitutes a common reason for insufficient up-titration, down-titration or discontinuation of prognostically relevant heart failure medications predisposing to hyperkalemia (e. g. angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers and mineralocorticoid receptor antagonists). New oral potassium binders may enhance treatment opportunities in this respect.

Not every disease which relates to work qualifies as an occupational disease according to German law. As there is a legal duty for doctors to report occupational diseases, doctors should know in which case a disease fulfils the requirements to be notified as occupational disease. This article gives an introduction to the legal framework applying to occupational diseases in Germany. It describes different types of occupational diseases and the requirements for a recognition. Expert opinions given by medical experts often are necessary to determine whether a disease can be recognized as occupational disease. Medical experts examine whether a disease was caused by a specific exposure at the workplace. Occupational diseases can lead to an impairment of earning capacity. Medical experts provide help with assessing such an impairment of earning capacity. This article provides useful information for medical experts as to the legal requirements for rendering medical expert opinions in court procedures, administrative procedures concerning occupational diseases.

A finely balanced control system keeps the extracellular calcium concentration within narrow limits. Disorders of calcium metabolism are often based on altered parathormone levels. Symptoms are not always clear, sometimes they are even missing: the more it is important to know possible associated diseases. The author presents basics, current diagnostics and concrete therapy options. Central hormone for the regulation of the calcium balance is the parathyroid hormone. With decreasing calcium, PTH leads to an increase in extracellular free calcium concentration in three ways. The classic symptoms of pHPT (polyuria, polydipsia, "stone, leg, and stomach pain") are rare now, as the condition is diagnosed much earlier. Treatment of choice in all symptomatic patients with pHPT is surgery. FHH and pHPT are both characterized by hypercalcaemia and increased parathyroid hormone. The differential diagnosis of urinary calcium excretion, which is usually lower in FHH but normal or elevated in pHPT, is crucial. In primary hypoparathyroidism, parathyroid failure interferes with calcium homeostasis…

Oncology has experienced a massive growth in knowledge over the last years. However, the growing amount of knowledge and data increases the complexity of clinical decisions and presents oncologists with new challenges. Currently, oncology-specific IT solutions are being developed with the aim to improve survival of cancer patients.The complexity of treatment decisions in oncology has greatly increased due to introduction of novel biomarkers and targeted therapeutics. First "intelligent" systems that suggest therapies based on available data have been developed, however, these systems are not yet widely adopted and lack sufficient clinical validation.Increasing implementation of electronic health records enables structured collection and analysis of data from routine patient care. These real-world data are used for post marketing surveillance and can help to develop therapy guidelines. Currently it is being discussed if real world data can provide sufficient evidence for regulatory decisions.Broad availability of internet access and smartphones provides an opportunity to involve…

BACKGROUND: A complete overview on the patient's medication is one precondition for medication safety. For this, a complete and current medication plan (MP) is an appropriate instrument. We aimed to develop and implement software to evaluate and exchange medication plans in local software systems of general practitioners (GPs) and community pharmacies (CPs). Furthermore, it was the aim to evaluate feasibility and acceptance of the defined processes. METHODS: CPs and GPs were involved to pilot the software in several steps. Additionally, they generated and updated MP according to pre-defined processes and responsibilities. Feasibility and acceptance were evaluated in a survey and a workshop. RESULTS: For the first time in Germany, the technical requirements were established to generate and exchange MP electronically. Four software systems of CPs and one software system of GPs were involved. Solved Problems were technical errors, errors relevant for medication safety, differences in display of the medication data, and limited capacity of the barcode on the MP printout. Eleven GP and…

Atherosclerotic cardiovascular disease is the leading cause of premature mortality and morbidity worldwide. Dyslipidemia is a commonly encountered clinical condition and is an important determinant of cardiovascular disease. The causality of plasma low-density lipoprotein-cholesterol (LDL-C) in the pathophysiology of cardiovascular disease has been established beyond any reasonable doubt. In this context, individual risk estimation, the determination of target values and lipid-lowering strategies represent an essential part and a challenge in the daily clinical practice to prevent cardiovascular events. Statins are recommended as first-line therapy for patients with hypercholesterolemia in secondary prevention. Controversies remain in the context of primary prevention, however, as to which kind of subjects to treat, the magnitude of the benefit, and potential harm. This article gives a brief overview of the current evidence, guideline recommendations and strategies for lowering of LDL-C in the primary prevention of cardiovascular disease.

Was ist neu? Prävention von Gallensteinen Lifestyleänderungen im Sinne von regelmäßiger körperlicher Aktivität und bedarfsgerechter Ernährung können der Entwicklung von Cholesteringallenblasensteinen vorbeugen. Ursodeoxycholsäure sollte bei ABCB4-Defizienz präventiv eingesetzt werden. Diagnostik Der Nachweis einer akuten Cholezystitis soll primär sonografisch in Kombination mit den klinischen Befunden erfolgen. Die Endosonografie sollte bei unklaren Fällen wegen ihrer hohen Sensitivität und Spezifität für Gallengangsteine eingesetzt werden. Therapie Die medikamentöse Therapie der biliären Kolik sollte mit nichtsteroidalen Antiphlogistika erfolgen. Die akute Cholezystitis stellt eine Indikation zur frühzeitigen (innerhalb von 24 Stunden nach stationärer Aufnahme) laparoskopischen Cholezystektomie dar. Nach ERC bei Choledocholithiasis sollte bei Cholezystolithiasis eine frühe (innerhalb von 72 Stunden) Cholezystektomie durchgeführt werden, ebenso nach milder biliärer Pankreatitis (während desselben stationären Aufenthalts).

Exacerbations are major events in the disease process in patients with chronic obstructive pulmonary disease (COPD). They have a negative effect on the quality of life and the progression of the disease. Frequent exacerbations are associated with increased mortality. In addition to the optimal therapy, the prevention of further exacerbations and the attention to concomitant diseases are prognostically crucial for the patients. In this review article, current recommendations for the diagnosis, therapy and follow-up care of COPD exacerbations are summarized.

Zusammenfassung Einleitung Der ungedeckte medizinische Bedarf ist ein wichtiger Indikator für die Qualitätsbeurteilung eines Gesundheitssystems. Methodik Der EU-SILC-Survey wird seit 2005 in Deutschland jährlich erhoben. Im EU-SILC-Survey 2014 wurde in Deutschland eine Stichprobe von 12 744 Haushalten mit 22 695 Personen ab 16 Jahren randomisiert gezogen und interviewt. Ergebnisse Zwischen den EU-SILC-Survey-Wellen 2005 bis 2014 nahm der Bevölkerungsanteil in Deutschland, der auf notwendige medizinische oder zahnmedizinische Untersuchungen bzw. Behandlungen verzichtete, stark ab. Im EU-SILC-Survey 2014 berichteten insgesamt 8,5 % der Befragten (ab 16 Jahren) entweder einen ungedeckten medizinischen Versorgungsbedarf (6,4 %) oder einen zahnmedizinischen Versorgungsbedarf (3,8 %). Finanzielle Gründe sind eine Hauptursache dafür, dass notwendige zahnmedizinische Untersuchungen oder Behandlungen nicht in Anspruch genommen wurden. Beim ungedeckten medizinischen Bedarf dominieren persönliche Gründe. Ein schlechter Gesundheitszustand hat in den multivariaten logistischen…

Pain or misery strike us - but it is up to us how to deal with them. Suffering is a verb; this underlines the active nature of suffering. The present paper develops a constructive concept of suffering by taking up approaches from existential philosophy and psychology. It suggests that suffering, if allowed and accepted, has the potential to facilitate transformation and, subsequently, to release from pain. The text ends with reflections on how a transformative understanding of suffering can be opened up in the accompaniment of suffering or dying.

Rare, progressive, and fatal is a short description for autosomal dominant hereditary transthyretin (TTR) amyloidosis (ATTR). In the absence of a family background, delays in diagnosis are common. ATTR is often represented by a progressive, axonal fiber-length-dependent polyneuropathy (motor, autonomic, sensory). Cardiovascular, gastrointestinal, renal and ocular manifestations are frequently observed. ATTR is caused by mutated serum protein transthyretin (TTRm), which results in amyloid deposits.The three current concepts of ATTR treatment aim to replace, stabilize and reduce TTR synthesis. (i) The mutant TTRm is almost completely replaced in the peripheral blood after orthotopic liver transplantation by the synthesis of the wild-type (TTRwt) in the donor liver. (ii) Low molecular weight compounds stabilize the TTR tetramer and thereby minimize the formation of amyloid precursors. (iii) Gene silencers (mRNA-inhibiting oligonucleotides) reduce liver-secreted TTRm and TTRwt.Liver transplantation (LTx) is an established procedure in ATTR patients. LTx significantly prolongs survival,…

Liver cirrhosis is a major healthcare problem and is associated with an increased mortality due to the development of complications. Therefore, after diagnosis of liver cirrhosis, it is highly clinically relevant to evaluate the reason for liver cirrhosis and to assess the presence of complications in order to prevent progression of liver cirrhosis.

Was ist neu? Kristallarthritiden – Mikroskopie für die Diagnose essenziell Für die Diagnosesicherung der Kristallarthritiden ist für den Rheumatologen der mikroskopische Nachweis von Harnsäure- und/oder Kalziumpyrophosphat-Kristallen rasch bettseitig durchführbar. Ist eine Punktion nicht möglich, kann die Dual-Energy-Computertomografie helfen, Harnsäurekristalle sichtbar zu machen. Gemeinsame Pathophysiologie der Kristall-vermittelten Entzündung Kristalle stellen „Gefahrensignale“ für das angeborene Immunsystem dar. Die unmittelbare Freisetzung von Interleukin 1β erklärt die anfallsartige Klinik, die allen Kristallarthritiden gemeinsam ist. Antientzündliche Therapie der Kristallarthritiden Neben unspezifisch wirkenden antientzündlichen Therapien erklärt die gemeinsame Pathophysiologie (Aktivierung des Inflammasom-Komplexes und Interleukin-1β-Freisetzung) die Wirksamkeit von IL-1β-Antikörper-Therapien. Niedrig dosiertes Colchicin ist zur Anfallstherapie und in der Prophylaxe von entzündlichen Schüben eine wertvolle Therapieoption. Kausale Therapie mit guter Evidenz bisher nur für die…

In Germany, baricitinib and tofacitinib have been approved for the treatment of at least moderately active rheumatoid arthritis after the failure of conventional disease modifying anti-rheumatic drugs in 2017, and tofacitinib also for psoriatic arthritis and ulcerative colitis. Both baricitinib and tofacitinib can be taken orally and reversibly inhibit Janus kinases (JAK) and therefore the signaling of a large number of cytokines via the JAK/STAT pathway. JAK inhibitors have been shown to be at least as efficacious in rheumatoid arthritis as adalimumab and tofacitinib was also efficacious in psoriatic arthritis. Since they inhibit many cytokines, it is likely that in the future they will be applied for the treatment of further chronic inflammatory disorder such as connective tissue diseases and vasculitis. The adverse events of JAK inhibitors are comparable to those observed with biologicals, only herpes zoster is slightly more common. In the placebo-controlled trials, venous thromboembolic events (VTE) were more common in the baricitinib treated patients. The VTE rate does not…

HISTORY AND FINDINGS: A 25-year-old female patient was treated with the anti-IL-4/IL-13 receptor antibody Dupilumab due to severe atopic dermatitis (AD). In addition, the patient had been suffering from alopecia areata (AA) for 5 years. EXAMINATION AND DIAGNOSIS: At first presentation a severe AD (Scoring Atopic Dermatitis [SCORAD] 76.0; Eczema Area and Severity Index [EASI] 37.4) with a total-IgE of 1108 kU/l and an Alopecia areata was observed. THERAPY AND COURSE: One year ago, treatment with the anti-IL-4/IL-13 receptor antibody Dupilumab was initiated. After 5 months, there was a marked improvement in AD (SCORAD 32.2; EASI 3.8) and increased hair growth. After 11 months, the AE remained stably improved (SCORAD 27,0; EASI 2,7) and almost all hairs had regrown. CONCLUSIONS: The comorbidity between AD and AA is known. The influence of dupilumab on AA is a new finding. The present case report supports the hypothesis that inhibition of IL-4 and IL-13 signalling pathways has a real and long-term effect on hair growth in AA. In patients with AD and concomitant AA, a positive effect on…

Abstract In Giant Cell Arteritis (GCA), a timely diagnosis is required to avoid severe complications such as blindness or structural vascular damage. The heterogeneous symptoms are mainly due to local and systemic inflammatory processes. Diagnostics are based on increased inflammation parameters in the laboratory, imaging, in which color-coded duplex sonography (FKDS), high-resolution magnetic resonance imaging (MRI), computer tomography (CT) or CT angiography (CTA) and 18F fluorodeoxyglucose-positron emission tomography with CT (FDG-PET-CT) have become established, as well as histopathological findings in temporal artery biopsy.

Was ist neu? Stand der Dinge Intensivstationen sind prädestiniert für den Einsatz digitaler Hilfsmittel. Digitale Systeme bieten eine gute Plattform für modernes Qualitätsmanagement und Forschungsprojekte. Patientendatenmanagementsysteme (PDMS) Die Verwendung von Patientendatenmanagementsystemen ist die Grundvoraussetzung für eine erfolgreiche Digitalisierung in der Intensivmedizin und sollte nachhaltig gefördert werden. Telemedizin Es gibt vielversprechende neue Konzepte zur Nutzung der Telemedizin in der Intensivmedizin. Telemedizin ermöglicht die Betreuung von Intensivstationen in Krankenhäusern der Grundversorgung durch spezialisierte Zentren. Digitale Stationsorganisation Die Logistik der Patientenversorgung ist ein häufig unterschätzter Faktor auf Intensivstationen. Digitale Systeme zur Stationsorganisation können hier eine Lücke schließen. Ausblick Die weitere Digitalisierung kann dabei helfen, die Prozesse auf einer Intensivstation zu optimieren und eine Patientenversorgung auf dem aktuellen wissenschaftlichen Stand zu erleichtern.

Celebrating the 200th anniversary of its founder, Friedrich Theodor von Frerichs, the German Society of Internal Medicine (DGIM) publishes perspectives for its work in the coming years, which will be shaped by challenges for medicine and science. Based on ten critically analyzed topics - namely physicians as researchers, "choosing wisely", digital medicine, the economization of medicine, medical education, demographic changes and multimorbidity, systems medicine, infectious diseases and hygiene, intensive care and emergency departments, and nursing and medical assistance jobs - this paper outlines the fundamental positions of the society.

Respiratory tract infections and acute bronchitis are one of the major indications for which antibiotics are prescribed. As most of respiratory tract infections are caused by viruses and antibiotic therapy is rarely indicated. Reasons for the unnecessary prescription of antibiotics in this patient population are false expectations regarding the course and duration of common cold symptoms and especially coughing. After exclusion of severe diseases acute coughing should be treated with a symptom-oriented therapy. There is no reliable data on the use of antibiotic therapy in patient groups with an increased risk for severe complications. Studies on the use of laboratory makers to identify persons with bacterial infections who might benefit from antibiotic therapy and to reduce unnecessary prescriptions have been negative for CRP and inconclusive for procalcitonin. Peer-review and delayed prescribing could be demonstrated to reduce the rate of unneeded antibiotic prescriptions. Most of the symptomatic therapies employed for cough and the common cold are not studied in methodologically…

Already in 1664, the Danish anatomist and naturalist Niels Stensen proved that the heart is a muscle. But for a long time it remained unclear what triggered the heart contractions.The Dutch physiologist Willem Einthoven registered the electrical processes in the contraction of the heart muscle and thus provided the first electrophysiological basis of cardiac muscle activity. Since 1903, Sunao Tawara was assistant to Ludwig Aschoff in Marburg. Both left Marburg in 1906: Tawara went back to Japan and Aschoff to Freiburg. In 1905, Tawara discovered the connections of the His' bundle to the AV node and the Purkinje fibers. At that time, there was no thought of a functional interpretation. Tawara discovered a kind of "knot" that linked to the adjacent myocardial cells, as well as the "Tawara thighs", which frayed and went into structures known as Purkinje fibers. Tawara detected the tree-like structure he had discovered as a muscle-fiber system that controlled the arousal of the heart's musculature. Thus the old dispute between myogenic and neurogenic arousal of the heart was decided in…

Abstract Background Clinicians are commonly confronted with the differential diagnosis of altered mental status, impaired cognition and altered level of consciousness in hospitalized patients including those admitted to medical, geriatric, emergency, intensive and post-operative care units. Although delirium is the most common acute neuropsychiatric condition in the acute hospital setting this diagnosis is commonly delayed, made too late or missed altogether. Difficulties and importance of timely diagnosis The causes of delirious states are manifold. Both, direct damage to the brain tissue as well as encephalopathy as a result of other medical diseases, can be the cause of delirium. Depending on the predisposition delirious syndromes can be provoked by minor medical interventions. Clinical presentation is very variable, but remains largely independent of the triggering mechanisms. Purely catatonic, hypoactive, hyperactive and excitatory types as well as mixed forms can be distinguished. Immediate diagnosis of a delirious syndrome and rapid elucidation of its causes are keys for the…