Medizinische Klinik最新文献

Patients suffering from severe chronic liver disease, in particular cirrhosis, are at risk for pulmonary complications. The leading clinical symptom is shortness of breath, which can accompany the actual disease as indirect effect because of anemia, faint muscles or ascites. On the other hand, dyspnea can have multiple additive causes in case of accompanying cardial or pulmonary disease. The hepatopulmonary syndrome (HPS) and the portopulmonary hypertension (PoPH) belong to the most relevant pulmonary complications in liver cirrhosis. HPS appears to be more common than PoPH and the presence of either entity increases morbidity and mortality in patients with liver disease. The two diseases have to be strictly distinguished, as they have opposed histological and pathophysiological origin. While the HPS is a dilatative pulmonary- vascular disease, the PoPH is a constrictive or obliterative pulmonary-vascular disease in the context of a liver disease or a portal hypertension. Therefore, these diseases are separate entities also when it comes to diagnostics and therapy.

The financing of clinical studies by the pharmaceutical industry is a controversial topic both internationally and in here in Germany. The well-known unacceptable shortcomings require no further confirmation. It is, however, indisputable that the pharmaceutical industry and medical science are co-dependent. Neither the marketing of industrial products nor the research and education of clinical scientists could function without this cooperation. Therefore, all partners need suggestions concerning goal orientation and consensus. The aim of this discussion is to formulate just such suggestions. To structure this discussion, we have raised the following questions: Must we always be suspicious of the results of studies financed by the pharmaceutical industry? We have to keep in mind that in Germany all clinical trials leading to approval of a drug were supported by the industry. What, exactly, do we want to achieve with our explicit and often justified criticism of these studies? What should be done to achieve a higher validity of the published data if we avoid answering the decisive question of whether we accept the challenge of continuing to let research and teaching be financed by the pharmaceutical industry or reject this kind of cooperation and support altogether.

Case report: A 75-year old female was admitted to the intensive care unit because of a respiratory insufficiency during a bronchoscopy. Extubation was done rapidly. Two months before, the patient suffering from breast cancer without metastases underwent a radical mastectomy. Thoracic x-ray presented a progressive shadow. Differential diagnoses took into consideration neoplastic, infectious or immunologic causes. The following day the patient suffered from dyspnea. A cardiopulmonary resuscitation was without success. Obduction revealed a honeycomb lung. Histology presented an idiopathic lung fibrosis.

In patients with systemic sclerosis or mixed connective tissue disease (MCTD) acral ulcers are considered as frequent manifestations that may lead to amputation and loss of function, respectively, as a result of secondary Raynaud's phenomenon. Thus it is necessary to take advantage of all available medical and supportive measures. Adjuvant treatments such as hyperbaric oxygenation and regional sympathetic block represent interdisciplinary treatment options to improve oxygenation of critical ischemia and analgesia and should be subject of further investigation.

Background and purpose: In Germany there is a lack of general practitioners (GP) that is forecasted to grow. Against this background a study of job satisfaction is of major interest. The purpose of this study was to analyse the job satisfaction of German GPs.

Methods: The study is based on data from an observational study in 676 primary care physicians in Germany between 2004 and 2007 taking part in the European Practice Assessment (EPA). The evaluation of job satisfaction was one part of EPA. Job satisfaction was measured with the 10-item Warr-Cook-Wall (WCW) scale. The possible answers ranged from 1 (extreme dissatisfaction) to 7 (extreme satisfaction). Furthermore the characteristics of GPs (gender, age, working hours) were analysed.

Results: Overall from the 676 primary care physicians 523 were GPs and took part in the survey. Job satisfaction was low by "income", "hours of work" and "mental working condition". A high degree of satisfaction was reported for "colleagues and fellow workers". Mainly working hours had a significant influence of job satisfaction followed by age and gender.

Conclusion: Overall, the results show good values of satisfaction with job situation. However there is space for improvement within the field of payment and working condition. Against this background of the lack of GPs it is important to consider these aspects of job satisfaction for GPs.

With increasing age, infection-induced morbidity and mortality rises. At the same time, the protective capacity of the immune system declines. This phenomenon is known as immunosenescence. It concerns all parts of the immune system and leads to a decline of cellular and humoral immune defense. As a consequence, the ability to resist infections and the immune response to vaccinations could be impaired. In order to protect senior citizens effectively against infections with dangerous pathogens like influenza viruses or pneumococci, new immunisation strategies, e.g. with shortened intervals between vaccinations, new vaccines or new vaccination techniques are required. Intradermal vaccines seem to be a promising approach, for instance. At the same time the acceptance of vaccination ought to be increased in the senior age group. Physicians, especially general practitioners play an important role because of their decisive effect on the willingness of the population to get vaccinated.

Background and purpose: Since 2004, primary care in Germany has increasingly been provided in special general practitioner (GP)-centred health care contracts (HZV). To date there is limited evidence about the characteristics of their beneficiaries regarding morbidity burden and health care utilization.

Methods: We analysed insurance claims data from all beneficiaries of the "Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg" listed in 10 general practices that contracted in a special GP-centred health care contract (HZV). We compared beneficiaries enrolled in the HZV with those who were not enrolled in the contract. Comparisons included the number of hospital admissions in 2007-2008 and the Charlson comorbidity index.

Results: Insurance claims data of 6,026 beneficiaries were available for analysis. In the third quarter of 2009, 51% (3,066) of the beneficiaries were enrolled in the HZV. They were significantly older (mean 61 years [SD 18 years] vs. 49 years [SD 22 years]; p < 0,001) and had a higher number of hospital admissions in 2007 and 2008 (mean 0.64 [SD 1.20] vs. 0.57 [SD 1.21]; p < 0.05) compared with beneficiaries who were not enrolled in the HZV. Charlson comorbidity index was significantly higher for beneficiaries of the HZV (mean 1,55 [SD 1,92] vs. 1,12 [SD 1,86]; p < 0,001).

Conclusion: Beneficiaries of a GP-centred health care contract tended to be older and suffered from a higher morbidity burden when compared with beneficiaries of the same health care fund who were not enrolled in the contract. Besides, beneficiaries of the contract had higher numbers of hospital admissions during the two year period before enrolment. These findings have substantial implications for individualized care management approaches that may be offered to beneficiaries of GP-centred health care contracts.

Purpose: The purpose of this study was the comparison of risk factors for development or progression of diabetic retinopathy in patients with type 2 diabetes between patients of a laser therapy center and a diabetes outpatient clinic. Furthermore, the implementation of the guidelines of the German Diabetic Association for the prevention and therapy of diabetic retinopathy was analysed.

Patients and methods: In a prospective study, patients with type 2 diabetes and diabetic retinopathy of the laser therapy center at the ophthalmology department, Leipzig University, were interviewed and examined. Patients of the reference group without diabetic retinopathy were recruited from the diabetes outpatient clinic Leipzig University.

Results: Between August 2004 and May 2008, a total of 180 patients with type 2 diabetes were included (48 patients with non-proliferative diabetic retinopathy (NPDR), 59 patients with proliferative diabetic retinopathy (PDR) and 73 patients belonging to the reference group). Patients with diabetic retinopathy had significantly higher mean blood pressures of 112 and 110 mmHg as compared to patients without diabetic retinopathy (96 mmHg). ACE/ AT1-inhibitors were used significantly less by patients with as compared to patients without diabetic retinopathy. Only 37% of patients with diabetic retinopathy were treated according to DDG and ADA guidelines.

Conclusion: There are striking deficits for the implementation of guideline oriented prevention and therapy of diabetic retinopathy in daily practice. The possible reasons are insufficient compliance of patients who consulted medical advice only when complications of diabetes occurred, the necessary improvement of the medical therapy and the suboptimal cooperation between ophthalmology and diabetes specialists.

Recommendation for the diagnosis and treatment of Helicobacter pylori Infection are defined in recent national and international guidelines. In Germany, proton pump inhibitor-based triple therapy with clarithromycin and metronidazole or amoxicillin is still the standard in first line therapy. However, success rates have decreased substantially during the last years due to increasing antibiotic resistance, particularly in patients from Southern Europe. In addition, antimicrobial resistance rates against the standard antibiotics further increases dramatically after failure of first line therapy deeming the repeated use of these antibiotics basically impossible. Against this background, a critical appraisal and eventually adaption of therapeutic options both in first line and rescue treatment appears necessary. This paper gives an overview on the current status of therapeutic options and developments in the treatment of H. pylori infection in the light of increasing antibiotic resistance.