The 50 most-cited articles in DMW - Deutsche Medizinische Wochenschrift, 2021

Amyotrophic lateral sclerosis (ALS) is an adult-onset motor neuron disorder which is characterized by progressive motor symptoms, such as muscle weakness, muscle atrophy and spasticity. In Germany, 6000-8000 people are affected by ALS. Between 1200 and 1600 newly diagnosed patients are expected each year. Protein deposits in the cytoplasm of motor neurons are a molecular feature of ALS. The most common protein aggregates result from excessive deposition of TDP-43. Familial ALS is present in 5 to 10 % of all ALS patients. Common causal genes include C9orf72, SOD1, FUS, and TARDBP. Genetic factors may be involved even without a family history of ALS and may be underestimated. The disease course and progression are highly variable. Symptom severity and rate of progression are determined by the ALS Functional Scale (ALSFRS-R). Beyond clinical symptoms and the patient's perception of disease burden, measurement of slow vital capacity (SVC), peak cough flow (PCF), and body mass index (BMI) are used to underscore the indications for ventilatory and nutritional interventions, as well as…

Smoking tobacco is the most important and potentially modifiable risk factor for cancer in Germany. Combining tobacco with alcohol can multiply cancer risks. Up to 30 % of cancer deaths are due to tobacco smoking. 23,3 % of 18-64 year-old Germans are current smokers; in addition, 11 % of the population are regularly exposed to secondhand tobacco smoke. Tobacco smoking is causally associated with oropharyngeal, laryngeal, nose, paranasal sinus, lung, esophageal, gastric, pancreatic, hepatocellular, biliary, colorectal, kidney, ureter, urinary bladder, uterine cervix and ovary cancers and leukemia. Smokers should be encouraged to stop smoking and join programmes of cancer screening. Smoking cessation effectively reduces tobacco-associated cancer risk.

The COVID-19 illness can occur as an occupational disease or work-related accident. According to the German list of occupational diseases, recognition as an occupational disease 3101 requires occupational exposure of an insured person who has been exposed to an increased risk of infection compared to the general population as a result of their occupational activity in one of the four areas: (1) health service or (2) social welfare sector, (3) laboratory or (4) during activities with increased risk of infection comparable to (1) to (3). The insurance cover covers employees, self-employed people - if not exempted from insurance cover - and honorary workers. The COVID-19 disease is subject to legal notification, mostly in conjunction with a contemporary SARS-CoV-2 virus detection. Regarding insured people who are not included within the aforementioned areas (1) to (4), the COVID-19 illness can be acknowledged as an occupational accident if the intense and direct contact with infected people - not intended as in the case of occupational disease 3101 - but otherwise situationally results…

Zusammenfassung Einleitung Die Möglichkeit, mittels Patientenverfügung Einfluss auf die spätere Behandlung im Falle der Einwilligungsunfähigkeit zu nehmen, gilt heutzutage als wichtiges Element zur Wahrung der Patientenautonomie am Lebensende. Behandlungsmaßnahmen bereits im Vorfeld einer Behandlung abzulehnen oder in diese einzuwilligen, ist für Bewohnende stationärer Pflegeeinrichtungen nicht nur vor dem Hintergrund der COVID-19-Pandemie von besonderer Bedeutung. Methoden Es wurde eine Vollerhebung aller Vorsorgedokumente von Bewohnenden in 13 stationären Pflegeeinrichtungen unterschiedlicher Größe und Trägerschaft in der Stadt und dem Landkreis Würzburg durchgeführt. Die Analyse der Dokumente erfolgte nach deduktiv-induktivem Vorgehen mittels kategorialer Zusammenfassungen und deskriptiver Häufigkeitsauszählungen. Ergebnisse In 265 erfassten Patientenverfügungen konnten 2072 Behandlungssituationen und 1673 medizinische Behandlungsmaßnahmen identifiziert werden. Bewohnende stimmen symptomlindernden und pflegerischen Maßnahmen größtenteils zu und lehnen lebensverlängernde bzw.…

This review summarizes the pharmacology and clinical use of HMG-CoA reductase inhibitors, statins. LDL-Cholesterol lowering with statins reduces atherosclerotic cardiovascular risk by approx. one quater per year of treatment. The efficacy and safety of statins are demonstrated by randomized trials irrespective of the patient's age. The synthetic statins, rosuvastatin and atorvastatin, are superior with regard to LDL-C lowering, half-life and drug-interactions compared to the older statins such as simvastatin. Modern lipid lowering therapy uses individualized statin-based combination therapies.

The climate crisis and its consequences represent the greatest challenge facing human health and health care system in the 21st century. It threatens to undermine the last decades of health gains. Rising temperatures, fires, floods and droughts can directly and indirectly cause human pathologies, that are physical and mental. Extreme weather events lead to loss of life, basic life resources and cause severe mental burden. More intense and frequent heat waves due to global warming impact human health and increase mortality, especially for those most vulnerable. The heat-related health risk depends on individual state of health as well as environmental and socioeconomic characteristics of residential areas. Increasing exposure to air pollutants, due to wildfires and anthropogenic emissions, raises respiratory and cardiovascular mortality. Climate warming changes ecosystems and enhances biological invasions that can better adapt to warm environments. Pathogen profiles are changing, transmission and spread of vector-borne diseases as Malaria or Dengue are increasing. Further, rising…

Die Autoimmunthyreoiditis (AIT) ist eine organspezifische Autoimmunerkrankung, die durch eine genetische Prädisposition, epigenetische Mechanismen und auch Umweltfaktoren entstehen kann. Der Beitrag diskutiert die aktuelle wissenschaftliche Literatur zur AIT sowie die Empfehlungen zur Levothyroxin (LT 4 )-Substitution vor dem Hintergrund der aktuellen Leitlinien der American Thyroid Association (ATA) und European Thyroid Association (ETA).

Zusammenfassung Hintergrund Die chronische Niereninsuffizienz (CKD) ist eine häufige Diagnose im höheren Alter, meistens bedingt durch die Grunderkrankungen Diabetes mellitus und arterielle Hypertonie. Sie verläuft lange asymptomatisch und nur ein geringer Patiententeil wird im Verlauf eine terminale Niereninsuffizienz entwickeln und eine Nierenersatztherapie benötigen. Betroffene werden primär von Hausärzten behandelt. Ziel Ziel der Studie war es, das Management von Patienten mit einer nicht dialysepflichtigen chronischen Niereninsuffizienz aus Sicht von Hausärzten zu untersuchen. Methoden Es wurden 5 Gruppendiskussionen mit jeweils maximal 5 Hausärzten (n = 22) durchgeführt. Das Material wurde aufgenommen und transkribiert, um inhaltsanalytisch ausgewertet zu werden. Ergebnisse Als wichtigste Behandlungsmaßnahmen bei der CKD wurden die Optimierung der Grunderkrankungen, die Medikamentenanpassung und die Überweisung an einen Nephrologen genannt. Die Hausärzte betonten, beim Management die Individualität ihrer CKD-Patienten zu berücksichtigen. Allerdings gibt es Themenbereiche, bei…

Erysipelas is a bacterial soft tissue infection caused by β-haemolytic streptococci that spreads proximally along the lymphatic system of the skin. The entry sites of the pathogens can be minor injuries or chronic wounds. The diagnosis of erysipelas is made clinically by the spreading eythema and overheating of the skin, the reduced general condition with fever and chills as well as by means of serological inflammation parameters and must be distinguished from numerous differential diagnoses.Systemic therapy is carried out with penicillin usually. In local therapy, the value of measures such as compression therapy or cooling is currently still controversial. Long-term therapy of the lymphoedema and the consistent avoidance and treatment of entry sites are essential, especially for the prevention of recurrence.

BACKGROUND: We assessed the prevalence of SARS-CoV-2 in the staff of a general hospital in North-Rhine-Westphalia in a cross-sectional study. METHOD: Employees (n = 1363) were offered a nasopharyngeal swab and serology for SARS-CoV-2. Additionally, employees completed a questionnaire about preexisting conditions, contacts with SARS-CoV-2-positive individuals and COVID-19-specific symptoms. RESULTS: 1212 employees participated. 19 of 1363 (1.4 %) employees tested positive by PCR (3 within and 16 before the study). 40 (3.3 %) and 105 (8.6 %) had IgG and IgA, respectively, 32 (2.6 %) both IgG and IgA. Overall, 47 employees tested positive. In this group, most frequently reported symptoms were headache (56 %), fatigue (49 %), sore throat (49 %), and cough (46 %); fever was reported by 33 %. SARS-CoV-2-positive employees reported more frequently contact with COVID-19 cases (60.5 % vs. 37.3 %, p = 0.006). Employees testing positive only for IgA reported less symptoms. CONCLUSION: Between 27.04. and 20.05.2020, 3.9 % of the employees working in a general hospital were tested positive for…

Skin-to-skin-contact presents the earliest sensory experience of men and animals. Deprivation of age-relevant touch experiences during infancy results in compromised psychosocial and biological development. The 2021 Nobel Prize in Physiology or Medicine has been awarded for the discoveries of receptors for temperature and touch. Clinical studies have demonstrated the benefit of professional salutary touch for prevention and treatment of various illnesses. However, in the present practice of medicine the application of salutary touch does not meet adequate interest. Proposing a new medical discipline "Touch Medicine" we link the findings of modern touch research to clinical medicine. The treatment of depression which we conceive primarily as a disease afflicting the body will serve as an example to demonstrate the usefulness of touch therapy. Controlled studies and systematic reviews have convincingly shown antidepressive, anxiolytic and analgesic effects of salutary touch. The effectiveness and efficacy of touch therapy has also been demonstrated in many areas such as neonatology,…

Was ist neu? Molekulare Subtypen Die molekularen Alterationen beim Magenkarzinom wurden umfassend charakterisiert. Darauf basiert eine Einteilung in 4 Subtypen, die sich hinsichtlich ihrer Frequenz in unterschiedlichen Lokalisationen des Magens sowie im biologischen Verhalten und der Prognose unterscheiden. Vorsorge und erbliche Formen Chronische Entzündungen der Schleimhaut (unter dem Einfluss von Helicobacter pylori) spielen bei den Nicht-Kardia-Karzinomen eine zentrale pathogenetische Rolle. Patienten mit ausgedehnter Atrophie oder intestinaler Metaplasie sollten endoskopisch überwacht werden. Bei Risikopersonen sollte Helicobacter pylori eradiziert werden. Ein frühes Erkrankungsalter kann auf eine erbliche Disposition hinweisen (Keimbahnmutationen im E-Cadherin-Gen). Patienten mit hereditärem nicht polypösem kolorektalem Karzinom haben ebenfalls ein erhöhtes Risiko, an Magenkarzinomen zu erkranken. Eine humangenetische Beratung ist in beiden Fällen obligat. Therapie des Magenkarzinoms und des Adenokarzinoms des gastroösophagealen Übergangs Frühkarzinome können unter klar…

The present review focusses on perioperative diagnosis and treatment of resectable colon cancer. In UICC stages associated with a higher risk of recurrence, adjuvant chemotherapy after resection of the primary tumor is an established standard. While initial data also indicate the benefit of Neoadjuvant, pre-operative chemotherapy, a final evaluation is still pending. The main focus of molecular testing in the perioperative setting is the analysis of microsatellite instability, which should routinely be performed in defined subgroups. In UICC stage II without risk factors, adjuvant therapy has a limited benefit and therefore is not a preferred option. In UICC stage II with risk factors, adjuvant therapy can be performed. The approach here is based on the recommendations applicable to stage III. In UICC stage III with low risk, adjuvant chemotherapy with CAPOX for 3 months is preferentially recommended. In UICC stage III with high risk, adjuvant chemotherapy over 6 months is recommended, preferentially with FOLFOX. Microsatellite instability (MSI) is clearly associated with favorable…

Type-2-diabetes (T2D) increases the risk for several cancers and cancer has become the major cause of death of T2D-patients. T2D is causally associated with colorectal, pancreatic, gallbladder, biliary, hepatocellular, gastric, esophageal, oral, breast, endometrial, ovary, kidney and thyroid cancers as well as leukemias. When T2D goes along with tobacco smoking, alcohol use, physical inactivity, excess body weight, poor diet, familial risk or certain chronic infections, the cumulative cancer risk rises, and T2D-patients often suffer from cancer disease at younger age. T2D-patients should be encouraged to join cancer screening programmes even at younger age than the average non-diabetic population.

BACKGROUND: According to current oncological guidelines, early integration of specialist palliative care (SPC) represents standard cancer care supporting not only the patients, but also their family caregivers. Data on the actual implementation in daily oncology practice in Germany are lacking. METHODS: The Palliative Care Working Group of the network of Comprehensive Cancer Centers certified by the German Cancer Aid (CCC) assessed the implementation of measures for family caregiver support and involvement within the CCC/within SPC in the CCC/local outside the CCC in all 17 CCC locations. RESULTS: In the CCC/in SPC psycho-oncological (100 %/94 %), social (94 %/100 %) and spiritual counselling of family caregivers (94 % each) as well as support for children with parental cancer (88 %/100 %) and information materials for family caregivers (88 % each) are well established. Training on nursing skills (77 %/94 %) and family conferences (59 %/88 %) are established more frequently within SPC than in the rest of the CCC. SOPs are rather rare (23 %/18 %) as well as screenings for family…

The COVID-19 pandemic poses new challenges for the healthcare systems world-wide which will go beyond prevention, acute and intensive care treatment of patients with severe illness. A large proportion of "COVID-survivors" - and not only elderly patients - suffers from "post-COVID-syndrome". Risk factors are preexisting somatic multimorbidity, cognitive and cerebral changes together with pneumonia and hypoxemia, intensive care treatment and confusional states during the acute phase of illness. Post-COVID cognitive deficits usually manifest as a frontal dysexecutive syndrome combined with fatigue and dysphoria and/or with attentional and memory deficits. Several pathogenetic mechanisms of COVID encephalopathy are understood, but no specific treatment strategies have been established so far. We assume that general practitioners, psychiatrists, neurologists and social workers will need to take care of the activation, reintegration and expert appraisals of patients with post-COVID fatigue and cognitive deficits during the years to come.

Stroke prophylaxis with non-vitamin K-dependent oral anticoagulants (NOAKs) in patients with non-valvular atrial fibrillation (nvVHF) is now firmly established in routine clinical practice. The definition of nvVHF includes the absence of a mechanical heart valve and AF not associated with moderate- or high-grade mitral valve stenosis. The management of oral anticoagulation (OAC) requires a high degree of interdisciplinarity. Not least for this reason, uncertainties are repeatedly observed in practice, which can have far-reaching consequences for the individual patient. For this reason, a committee consisting of representatives from general medicine, geriatrics, cardiology, nephrology and neurology has gathered to identify aspects of practical relevance from the various disciplines and to jointly develop practical guidelines to improve therapy safety for patients in everyday life.

Zusammenfassung Hintergrund Das seltene Multisystem Inflammatory Syndrome ist bisher bei Kindern als neuartiges Hyperinflammationssyndrom mit Beteiligung verschiedener Organsysteme nach stattgehabter Infektion mit SARS-CoV-2 beschrieben worden. Nachdem bisher vereinzelte Fälle aus Großbritannien und den USA mit „Multisystem Inflammatory Syndrome in Adults“ (MIS-A) beschrieben wurden, werden erstmals 2 Fälle von „Multisystem Inflammatory Syndrome in Adults“ (MIS-A) aus Deutschland vorgestellt, die sich initial zeitgleich und atypisch präsentierten. Anamnese #1: 27-jähriger Patient mit Fieber bis 40 °C, rechtsseitigen Unterbauchschmerzen und Diarrhöen, Peritonismus. #2: 21-jährige Patientin mit okzipital betonten Kopf- sowie Nackenschmerzen, Somnolenz, Fieber bis 40 °C. Befunde #1: Es zeigten sich erhöhte Entzündungsparameter und ein erhöhtes Nt-proBNP. Im CT-Abdomen wurden initial Zeichen einer Ileitis terminalis und Kolitis beschrieben. Koloskopisch konnte ein Morbus Crohn ausgeschlossen werden. In der transthorakalen Echokardiografie zeigte sich ein schmaler Perikarderguss ohne…

Today, more than 50 % of adults in Germany are overweight, 20 million people are obese and 10 to 30 % suffer from non-communicable diseases (NCD). Unhealthy dietary patterns contribute to NCD, thus, NCD are at least partly avoidable. During the last decades nutrition research has changed from nutrients to foods identifying healthy food patterns characterizing healthy diets, e. g., Mediterranean diet, DASH diet and/or the New Nordic Diet. Scientifically, these diets have been shown to be effective strategies of primary and secondary prevention of NCD. Based on this evidence prevention of NCD is now urgently needed at the population level. However, effective public health strategies of prevention and health promotion go beyond daily medical practice and require re-thinking of our food system within a greater context of our environment and climate. To become sustainable, strategies and measures of behavior prevention addressing individuals have to be extended to measures against the obesogenic environment and its systemic drivers within our food system. Thus, social and political…

Was ist neu? Gerinnungshemmende Therapie nach peripherer Intervention In Analogie zur Koronarintervention wird nach Katheterinterventionen peripherer Gefäße meist passager eine duale Thrombozytenaggregationshemmung (TZAH) mit ASS 100 mg und Clopidogrel 75 mg durchgeführt. Größere Studien zu diesem Vorgehen fehlten bisher und die Empfehlungen der aktuellen Leitlinien haben den Charakter eines Expertenkonsens. Gerinnungshemmende Therapie nach peripherer Bypassoperation Nach peripherer Bypassanlage empfehlen die aktuellen Leitlinien in der Regel die Monotherapie mit einem TZAH (ASS 100 mg oder Clopidogrel 75 mg). In Einzelfällen wird bei venösen Bypässen eine orale Antikoagulation oder bei Kunststoffbypässen eine duale TZAH eingesetzt. Diese Empfehlungen beruhen jedoch auf wenigen, teils kleinen Studien. Duale gerinnungshemmende Therapie mit niedrigdosiertem Rivaroxaban und ASS Die VOYAGER-PAD-Studie ist mit 6564 Patienten die größte randomisierte Studie zur gerinnungshemmenden Therapie nach Revaskularisation. Es wurde das Konzept einer niedrigdosierten Rivaroxaban-Gabe (2-mal 2,5 mg)…

The updated guidelines for the management of dyslipidaemias 2019 sticks to the concept of individual risk-based intervention strategies, but intensifies LDL-C goals. Next to the established SCORE system non-invasive imaging techniques such as coronary CT or ultrasound of carotid or femoral arteries are now recommended for improved risk stratification. Screening for lipoprotein(a) identifies persons at higher cardiovascular risk. Non-statin trials with ezetimibe and PSCK9-inhibitors demonstrated further relative risk reduction for cardiovascular events. Cardiovascular risk reduction depends on the absolute lowering of LDL-C, duration of therapy and the individual cardiovascular risk. For patients at very high risk the new LDL-C goal is < 1.4 mmol/l (55 mg/dl) and reduction of ≥ 50 % from baseline. The overall aim is to reduce "cholesterol life years".

Salerno kann als Geburtsstätte der modernen europäischen Hochschulmedizin angesehen werden. Aus der Mönchs- und Klostermedizin entstand eine praktische und wissenschaftlich orientierte Heilkunde. Durch die Übersetzung und Ergänzung zahlreicher Texte aus der arabischen Sprache und die Etablierung fester Lehrpläne sowie eines öffentlichen Gesundheitssystems wurde Salerno zu einem wichtigen medizinischen Ausbildungszentrum für Frauen und Männer.

Was ist neu? Pulmonale Manifestation Eine Mehrheit der COVID-19-Erkrankten leidet 6 Monate nach akuter Erkrankung an Spätfolgen. Dyspnoe gehört zu den häufigsten Symptomen und geht oft mit pathologischen Veränderungen der Lunge einher. Husten und Schlafstörungen finden sich ebenfalls häufig in der postakuten Phase. Die Abnormalitäten der Lunge und die damit verbundenen Symptome zeigen mit der Zeit enorme Verbesserungen. Schlaf bei Post-COVID Nach COVID-19-Erkrankung zeigt der Schlaf vieler Betroffener Auffälligkeiten. Insbesondere die REM-Schlafphase (REM = Rapid Eye Movement) zeigt Störungen, die zu häufigem Erwachen in der Nacht unqd zu Tagesmüdigkeit führen. Das chronische Fatigue-Syndrom (CFS), das als Folge einer viralen Infektion auftreten kann, kann sich durch die Therapie von Schlafstörungen verbessern. Belastungsspezifische Besonderheiten In der postakuten Krankheitsphase haben viele Patienten eine eingeschränkte körperliche Leistungsfähigkeit. Ursachen für eine reduzierte körperliche Belastbarkeit können Anämie, eingeschränkte Sauerstoffextraktion und myopathische…

Was ist neu? Reizdarmsyndrom: Was ändert sich? Folgende Ausführung bezieht sich nur auf das Reizdarmsyndrom (RDS) beim Erwachsenen. Die neue Leitlinie enthält einen eigenständigen Anteil Reizdarmsyndrom für pädiatrische Patienten. Das RDS präsentiert sich als heterogenes Bild mit chronisch-abdominellen Beschwerden, die auf den Darm bezogen werden. Diese gehen in der Regel mit Stuhlgangveränderungen einher und führen zu einer Beeinträchtigung der Lebensqualität. Die Genese ist multifaktoriell und es liegen komplexe pathophysiologische Mechanismen zugrunde, die mit einem RDS assoziiert sind. So konnten Störungen in verschiedenen Komponenten der Darm-Hirn-Achse und auch die zunehmende Bedeutung des Mikrobioms identifiziert werden. Auch verschiedene psychische Komorbiditäten spielen eine Rolle. Diagnostik Die Diagnosestellung erfolgt durch eine gründliche Anamnese und symptomorientierten Ausschluss wichtiger Differenzialdiagnosen (Ausschlussdiagnose). Eine Unterteilung in verschiedene Subtypen je nach Hauptsymptom ist für das weitere Management der RDS-Patienten vorteilhaft. Die…

Was ist neu? Erregerspektrum, Verlauf, Therapieoptionen Prinzipiell können Bakterien, Viren oder Parasiten eine Reisediarrhö verursachen. Im Vordergrund steht die symptomatische Behandlung der Reisediarrhö. Krankheitsbild und Erregerart beeinflussen das weitere Vorgehen. Diagnostik Eine spezifische Erregerdiagnostik ist bei unkomplizierten Durchfällen mit häufiger Selbstlimitierung meist nicht erforderlich. Kommt es zu prolongierten und blutigen Durchfällen, Fieber oder Exsikkose, ist eine spezielle Diagnostik indiziert. Präventionsmaßnahmen und reisemedizinische Beratung Umfassend und qualifiziert sollte sie vor jeder größeren Fernreise stattfinden und Präventionsmaßnahmen, Malaria-Chemoprophylaxe, Impfungen, Möglichkeiten der Selbsttherapie und Verhalten bei reiseassoziierten Erkrankungen beinhalten. Therapiestrategien Sie umfassen den Flüssigkeits- und Elektrolytausgleich, die Gabe von Antidiarrhoika und die antimikrobielle Therapie.

BACKGROUND: Increasing evidence suggests that some patients suffer from persistent symptoms for months after recovery from acute COVID-19. However, the clinical phenotype and its pathogenesis remain unclear. We here present data on complaints and results of a diagnostic workup of patients presenting to the post-COVID clinic at the University Medical Center Freiburg. METHODS: Retrospective data analysis of persistently symptomatic patients presenting to our clinic at least 6 months after onset of acute COVID-19. All patients were assessed by a doctor and routine laboratory analysis was carried out. Quality of life was assessed using SF-36 questionnaire. In case of specific persisting symptoms, further organ-specific diagnostic evaluation was performed, and patients were referred to respective departments/specialists. FINDINGS: 132 Patients (58 male, 74 female; mean age 53.8 years) presented to our clinic at least 6 months after COVID-19. 79 (60 %) had been treated as outpatients and 53 (40 %) as inpatients. Most common complaints were persistent fatigue (82 %) and dyspnea on exertion…

Treatment of critically ill non-trauma patients is challenging, due to the broad spectrum of underlying diseases in this clinical setting. It has been shown that outcome in these patients is poor due to high age, comorbidities and severeness of acute disease. In most cases it is crucial to establish diagnosis and start specific treatment immediately to improve patients' outcome. In contrast to the management of severely injured patients, general guidelines for the initial diagnostic and therapeutic approaches in these patients have been lacking until now. As a consequence, little is known about both: patients' characteristics and outcome. This article provides an overview of the current information available on this group of patients.All critically ill patients should first be managed in the resuscitation room, as it is necessary to provide the optimal infrastructure, including material and personal resources, to maintain high quality care. For non-trauma patients, indication can be defined using the ABCDE approach. Expertise in emergency ultrasound as a key diagnostic tool,…

The state of the art of osteoporosis management and treatment is being continuously refined according to recent progress in data availability, drug development and strategies as determined by health authorities. The recent approval of the sclerostin-antibody romosozumab as a novel first in class anabolic drug is another milestone that enriches our therapeutic portfolio. Neutralisation of the wnt-pathway inhibitor sclerostin by romosozumab leads to rapid stimulation of bone formation and a rise in bone mineral density that translates into robust > 70 % reduction of fracture risk at the lumbar spine. Already after one year of treatment romosozumab is stopped and followed by antiresorptive maintenance treatment. The indication for this strategy is severe osteoanabolic compounds can now be applied as a first line treatment without prior antiresorptive medication. The new data helped in alleviating restrictions by the authorities for first line use of anabolic strategies. Romosozumab and teriparatide represent two anabolic strategies that differ in their mode of action although the…

Elevated troponin values are frequently detected in patients with acute ischemic stroke, requiring adequate diagnostic work-up due to the high cardiac mortality after stroke. Since dual platelet inhibition can cause secondary intracerebral hemorrhage careful consideration of invasive coronary intervention is mandatory. Based on three case reports, this review article presents a diagnostic algorithm taking into account latest findings from the literature.

BACKGROUND: The majority of patients with non-dialysis chronic kidney disease are cared for by general practitioners. Especially for Germany, the evidence of this topic is still very low. The aim of the survey was to estimate the perceived frequency of non-dialysis chronic kidney disease in general practice, the use of diagnostics and therapy, used tools considering the professional background and experience of the responding general practitioners. METHODS: A questionnaire was self-designed in the cooperation of several disciplines. 1130 general practitioners from Saxony and Saxony-Anhalt were randomly selected and the questionnaire was sent by post. Data were collected from June 2019 to July 2019. RESULTS: Of the 1,130 questionnaires sent, 372 returned analysable (response rate: 32.9 %). The prevalence of non-dialysis chronic kidney disease was estimated to be 6-15 %. 97 % of the general practitioners rated the adjustment of high blood pressure and diabetes mellitus as a high to very high priority. Concerning the diagnosis of proteinuria, the use of a urine dipstick test was stated…

As the pandemic continues, there is increasing hope vaccinations are becoming available. As a solution for a nationwide immunization against the virus, a compulsory vaccination is repeatedly discussed. However, some opponents of vaccination are threatened by the idea of a possible mandatory vaccination. It is therefore necessary to discuss whether such a compulsory vaccination is theoretically legally enforceable. This article discusses the current legal situation in Germany. The introduction of a potential compulsory vaccination against the SARS-CoV-2 virus represents an encroachment on the fundamental right of physical integrity. According to § 20 (6) IfSG, a protective vaccination for threatened parts of the population is permissible by statutory order, if a transmissible disease with clinically severe courses occurs and its epidemic spread can be expected.

Was ist neu? Neue Herausforderung der Ersteinschätzung Es ist davon auszugehen, dass Notfallpatienten zukünftig deutlich mehr kanalisiert werden und über gemeinsame Anlaufstellen der Notfallversorgung zugeführt werden. Ging es bis dato immer um die zuverlässige Identifikation der Hochrisikopatienten und Zuordnung der Behandlungsdringlichkeit, rückt zunehmend der Aspekt der Lenkung in eine Versorgungsstruktur (KV vs. ZNA) in den Vordergrund. Manchester-Triage-System als „Gatekeeper“ Das Manchester-Triage-System (MTS) ist in mehreren Studien hinsichtlich einer „Gatekeeper-Funktion“ untersucht worden. Es scheint, dass das MTS nicht ausreichend valide ist, um Patienten sicher zu identifizieren und um sie anschließend in die hausärztliche Versorgung umzuleiten. Ressourcenzuteilung und Dringlichkeitseinstufung „in einem“ Aktuell befinden sich 2 unterschiedliche Systeme in der wissenschaftlichen Untersuchung. Die Herausforderung liegt in der Kombination einer Dringlichkeitseinstufung mit ausreichender Güte und einer adäquaten Ressourcenzuteilung. Im Einzelnen sind es das „Strukturierte…

BACKGROUND: The World Conference on PH recommended differentiation of isolated postcapillary (Ipc) and combined post- and precapillary (Cpc) PH according to pulmonary vascular resistance alone. The aim of this study was the haemodynamic and functional characterization of patients diagnosed IpcPH and CpcPH according to the current recommendation of the latest World Symposium on Pulmonary Hypertension (PH) with an exploratory data analysis. METHODS: We evaluated all consecutive patients presenting at the PH outpatient clinic of Mission Medical Hospital from 2008-2015. All received a complete diagnostic work-up according to the guidelines. We analyzed data of patients with mPAP≥ 25 mmHg and pulmonary capillary wedge pressure (PCWP) > 15 mmHg. We compared anthropometric, hemodynamic and functional data of six-minute walking test (6 MWT), cardiopulmonary exercise testing (CPET) and echocardiography of patients with IpcPH and CpcPH. RESULTS: Out of 726 patients 58 showed a postcapillary PH: IpcPH: n = 20; CpcPH: n = 38. Patients with IpcPH had a significantly lower mPAP and PVR than…

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer with an increasing incidence. The major HCC risk factor in 80 % of all patients is liver cirrhosis followed by chronic hepatitis B infection or non-alcoholic steatohepatitis (NASH) in non-cirrhotic HCC patients. In early BCLC stages curative treatment applying liver resection, liver transplantation or local ablation is feasible, but, despite increased usage of surveillance programmes two-thirds of HCC patients are diagnosed in advanced BCLC stages. Transarterial chemoembolization (TACE) and selective internal radiation therapy (SIRT) show improved tumor control in BCLC stage B. In fact, major advances in HCC therapy concern medical treatment with the implementation of immunotherapy. The combination of atezolizumab with bevacizumab comprises the new first-line treatment in BCLC stage C. Tyrosine kinase inhibitors (TKI) are indicated in case of contraindications or as second line therapy.

An elevated intra-abdominal pressure (IAP) above 12 mmHg is a pathological finding in critically ill patients. IAP are classified into different degrees of intra-abdominal hypertension and, in the presence of associated organ failure, as abdominal compartment syndrome. Both disease entities represent an underestimated factor in intensive care patients and are associated with increased mortality and prolonged intensive care and hospital stay. The measurement of intra-abdominal pressure in critically ill patients in intensive care units is not widely established and there is often considerable uncertainty regarding measurement conditions and methods. If risk factors are present, intra-abdominal pressure should be monitored every 4 hours. Bladder pressure measurement is the gold standard for determining intra-abdominal pressure. The measurement is a non-invasive, cost-effective, easy to perform bedside and safe method for the patient.

Specifying a singular specific cause of death or an appropriate causal chain in the death certificate can be challenging, especially in cases of elderly, multimorbid deceased persons.The German cause of death statistics suggest that mental illnesses, including dementia, are beneath the most frequent causes of death. But when looking at death certificates in the context of dementia considerable information gaps and a lack of plausibility in the causal chain can be observed quite regularly.In this article we give recommendations for the correct designation of the cause of death and underlying diseases in the death certificate. These recommendations are not only to be seen against an academic background. The correct registration of dementia in the causes of death statistics may be a basis for decision making in health politics and is hence in the interest of optimal patient care.

ATP-Citrate-Lyase is a key enzyme of cholesterol biosynthesis. Its liver-specific inhibition by the bempedoic acid opens new possibilities to effectively escalate a cholesterol-lowering therapy while avoiding muscle-related side effects. Herein, we present the properties of this new first-in-class pharmaceutical agent and discuss potential consequences for pharmacotherapy.

CARDIOVASCULAR RISK PROFILE OF PATIENTS WITH INFLAMMATORY ARTHRITIS: Patients with inflammatory arthritis have an increased risk of cardiovascular disease compared to the general population. The discovery of this fact dates back to over a decade ago, but cardiovascular morbidity and mortality in these patients have not yet significantly improved. In 2021, the management of cardiovascular risk in patients with inflammatory arthritis remains an important aspect for general practitioners, rheumatologists and researchers. CARDIOVASCULAR RISK ASSESSMENT: Risk scores used for the general population often underestimate the increased cardiovascular risk in patients with inflammatory arthritis. Inflammation was repeatedly found to be an independent cardiovascular risk factor. However, attempts to incorporate inflammation markers into risk scores has not yielded an improved risk prediction so far. Further studies need to investigate the influence of disease-specific factors like disease activity or treatment effect on cardiovascular risk. Currently, there is no independent risk assessment…

Oxygen treatment is being widely used in intensive care and emergency medicine and is required to maintain aerobic metabolism. It may be administered by nasal cannula, face mask, high-flow therapy, and by ventilation. Under clinical circumstances, blood oxygen concentration is not relevantly increased above a partial pressure of 80 mmHg. Although oxygen therapy is often life-saving, it has recently been shown that its indiscriminate administration may increase morbidity and mortality, presumably due to a formation of reactive-oxygen species.For ventilated critically ill patients the optimal targets need to be further defined but harm has been shown for mild hyperoxia. For patients with acute exacerbation of chronic obstructive lung disease hyperoxia may lead to an increase of hypercarbia. Hyperoxia may increase myocardial necrosis in myocardial infarction. For patients with stroke, data do not show any benefit or harm from oxygen administration.On the other hand, hyperoxia shall be used for treatment in patients with cardiac arrest until return of spontaneous circulation and in…

The microcirculation includes all blood and lymph vessels with a diameter < 100 µm. Microcirculatory dysfunction is common in critically ill patients and is closely associated with both the severity of (multi-)organ dysfunction and mortality. The nature and extent of microcirculatory dysfunction differ depending on the underlying disease and are most pronounced in patients with systemic inflammation (e. g. sepsis), specific infections (e. g. malaria, dengue) or thrombocytopenia-associated multiple organ failure. This manuscript provides an overview of the pathophysiology, monitoring and therapy of microcirculatory dysfunction in the critically ill patient.

Zusammenfassung Hochverarbeitete Lebensmittel sind Teil eines modernen Lebensstils und machen in Deutschland ca. 46 % der täglichen Energieaufnahme aus. Querschnitts- und Kohortenstudien belegen Assoziationen zwischen dem Verzehr hochverarbeiteter Lebensmittel und nichtübertragbaren Erkrankungen (Übergewicht, Diabetes, Krebs, Herz-Kreislauf-Erkrankungen sowie Depressionen). Als Ursache für diesen Zusammenhang werden neben einer hohen Energiedichte und einer veränderten Lebensmittelmatrix eine ernährungsphysiologisch unausgewogene Zusammensetzung, ein hoher glykämischer Index, sowie abträgliche Zusatzstoffe und Kontaminanten durch Verarbeitung und Verpackung diskutiert. Um die anteilige Bedeutung dieser potenziellen Mechanismen zu verstehen und eine wissenschaftlich begründete, risikoassoziierte Definition hochverarbeiteter Lebensmittel zu geben, sind sowohl Interventionsstudien als auch eine bessere Erfassung der Zusammensetzung der verzehrten verarbeiteten Lebensmittel in prospektiven Kohortenstudien nötig.

"Acute kidney injury" (AKI) describes any acute deterioration in kidney function but also only injury to the kidneys without a severe loss of function. It is a common and severe complication in patients on the intensive care unit with a significant impact on patient's mortality and morbidity. Since no specific pharmacological therapy exists, the early identification of patients at risk for AKI or with acute kidney damage is most important before renal function further deteriorates. A stage-based management of AKI comprises more general measures like discontinuation of nephrotoxic agent but most importantly early hemodynamic stabilization. Recent research has contradicted that AKI is renal ischemia caused by vasoconstriction with consecutive tubular necrosis. In septic AKI renal blood flow is even increased. Intrarenal vasodilation together with microcirculatory changes and redistribution of blood flow are leading to a drop in glomerular filtration by functional changes. Accordingly, it had to be learned that not vasodilators, but vasoconstrictors are beneficial in AKI. A mean…

BACKGROUND: The free choice of hospital by patients is promoted by health policy and is to be supported by the quality reports of hospitals. But how do patients choose a hospital? How many can decide for themselves, where do they inform themselves and what are their decision criteria in the specific situation? This will be answered for inpatients of internal medicine in comparison to those of other specialties. METHODS: The data originate from an observational study. The random sample, stratified by specialties and hospital care levels, was collected in 46 departments of 17 hospitals from 15 cities and municipalities in North Rhine-Westphalia. The weighted sample evaluates 758 patients of internal medicine and 1168 patients of other specialties descriptively and inferentially. RESULTS: Internal medicine patients are older, more often men, without a migration background and chronically ill, and also more often pretreated as inpatients. About half decide on the hospital themselves, with their own knowledge of the hospital through a previous stay being the most important source of…

BACKGROUND: General practitioners are considered to be well suited when it comes to addressing the information and care needs of family caregivers. The aim of the present study is to examine how general practitioners assess their possibilities to support caregivers, what priorities they set and to what extent they experience challenges. METHODS AND PARTICIPANTS: In the course of an online survey with a postal cover letter, a total of 3,556 GPs in in Baden-Württemberg, Hesse and Rhineland-Palatinate were interviewed between February and June 2021. Due to the exploratory approach of the study, only a descriptive data analysis was carried out. RESULTS: 68 % of the GPs surveyed often deal with family caregivers in everyday practice; 77 % consider the GP's office to be well suited as the primary point of contact for family caregivers and care coordination. Often it is caregiving relatives who ask the GP about the issue of care (89 %). Frequent contents concern a deterioration in the care situation (75 %) and a change in the need for care (84 %); consultations in the initial phase of care…

Contrast media use in patients with renal disease regularly ensures discussions in everyday clinical practice. Both X-ray and MRI contrast media are predominantly eliminated by the kidneys and therefore closely linked to kidney function. Risk stratification prior to contrast media use in patients with pre-existing renal dysfunction should be based on eGFR-determination. Patients with an eGFR ≥ 30 ml/min require an individual risk assessment. In patients with advanced renal insufficiency ensuring euvolemia is crucial. Currently, there is no evidence for any other preventive approach. Therefore, no further specific procedures preventing contrast-associated kidney injury are recommended. Timing of contrast media injection and dialysis sessions in patients with end stage renal disease is necessary only after MRI contrast media use. Independently, acute kidney injury requires a patient individual decision.

Was ist neu? Klinische, serologische, histopathologische Diagnostik der ANCA-assoziierten Vaskulitis Zentraler Bestandteil der Diagnostik der AAV mit renaler Manifestation sind die Bestimmung von PR3- und MPO-ANCA sowie die Nierenbiopsie. Die Behandlung sollte in einem in AAV erfahrenen Zentrum erfolgen und rasch begonnen werden. Remissionsinduktion Die Remissionsinduktion bei ANCA-assoziierter GN erfolgt mit Cyclophosphamid oder Rituximab in Kombination mit Kortikosteroiden. Die Leitlinie gibt Hilfestellung zur Therapieauswahl. Studienbasiert wird eine schnellere Steroidreduktion empfohlen. Remissionserhaltung Zur Remissionserhaltung stehen Rituximab und Azathioprin zur Verfügung. Die Leitlinie gibt Hilfestellung zu Auswahl und Dauer der Therapie, die sich insbesondere nach dem Rezidivrisiko richtet. Anti-GBM-Erkrankung Die Plasmapherese gehört zur Standardtherapie der Anti-GBM-Erkrankung, ist jedoch bei der ANCA-assoziierten GN einer Einzelfallentscheidung bei fulminantem Verlauf vorbehalten. Transplantation Eine Nierentransplantation kann bei ANCA-assoziierter GN nach mindestens…

Asthma-COPD Overlap (ACO) is a fuzzy and controversial term intended to characterize patients who have characteristics of asthma and COPD. Since there is no uniform definition, the information on prevalence varies considerably. There is no special diagnostic algorithm and no clear therapy recommendations, as ACO is underrepresented in therapeutic studies. The current clinical consequence of this dilemma should be to differentiate the leading obstructive airway disease asthma or COPD and to treat the predominant phenotype.

Most people recover completely after an acute infection with the novel corona virus SARS-CoV2. But some people continue to experience symptoms after their recovery. This phenomenon is called post-acute or long-COVID (from week 4 after the infection up to week 12) and persistent post-COVID (symptoms for effects that persist 12 or more weeks after onset). The exact processes that cause long COVID remain unknown.Most of those patients suffer from long-term symptoms of lung damage, including breathlessness, coughing, fatigue and limited ability to exercise. Today, 18 months after the first infections in Europe we have access to the first practical guidelines for the long-/post-COVID syndrome. Further on first prospective studies analysing the incidence of post-COVID are now available.In this review we will discuss some questions about treatment and follow up of patients suffering from pulmonary sequelae after their COVID-19 infection, based on the actual literature.

EPIDEMIOLOGY AND RISK FACTORS: A large German registry on superficial vein thrombosis (SVT) documents that risk profiles, clinical presentation and treatment patterns are highly variable in patients with SVT, including a large variation in anticoagulation treatment modalities, intensities and durations. Inspite of a high percentage of initial anticoagulation there is a substantial risk of subsequent venous thromboembolism (VTE), recurrences or extension after three months. Inspite of current guideline recommendations, one third of the patients receives heparins, oral anticoagulants or no anticoagulation at all. At initial presentation about one quarter of the patients with SVT have a concomitant, frequently asymptomatic VTE. Risk factors for this complication include prior hospitalization, immobilization, prior VTE, autoimmune disorders, higher age, cancer and SVT occurring in a non-varicose veins or SVT-extension into the perforator veins. These risk factors are also associated with thromboembolic complications during follow-up. TREATMENT: Based on a large placebo-controlled trial…

Was ist neu? Gliflozine/SGLT2-Hemmer: Shooting-Stars in Diabetologie, Kardiologie und Nephrologie Gliflozine wurden als Antidiabetika entwickelt. Sie blockieren den sodium-glucose linked transporter 2 (SGLT2) im proximalen Nierentubulus und führen zu Glukosurie und Natriurese. Unabhängig vom Vorliegen eines Diabetes mellitus zeigen aktuelle Phase-III-Studienergebnisse zur SGLT2-Hemmer-Therapie einen prognostischen Benefit bei Patienten mit Herz- und/oder Niereninsuffizienz bezüglich kardiovaskulärer Ereignisse, Hospitalisierung und Tod. Damit ergibt sich eine Ausweitung der Indikation auf große, oft polymorbide Patientenkollektive mit genuin hohem Risiko für katabole Episoden und akute Organdysfunktion. Ketoazidose unter SGLT2-Hemmern SGLT2-Inhibitoren induzieren eine hungerähnliche Ketogenese. Unter katabolen Umständen wie kritische Erkrankung, Dehydrierung, perioperative Nüchternperiode oder „low-carb“-Fastendiät kann diese zu einer lebensbedrohlichen euglykämen Ketoazidose entgleisen. Hierzu tragen vermutlich die vermehrte Rückresorption von Ketonkörpern aus dem Primärharn sowie…