Zeitschrift fur arztliche Fortbildung最新文献

Physicians are at higher risk of addiction compared with the general population. Worldwide about 15% of physicians may be addicted to drugs or alcohol. In Germany, accurate epidemiological data are not available. The underlying issues of this occupational risk are the dangers of "role strain", features of a "typical" personality and a high rate of burnout among physicians. Most important is therefore prevention, the need to persuade physicians to "cherish themselves" and reduce work stress as far as possible. An US-program is described regarding identification and therapy of drug users among physicians.

The WHO project "CINDI" (Country-wide Integrated Noncommunicable Diseases Intervention) is being implemented in 23 European countries and in Canada. The central goal of this project is the development of across-country strategies to combat chronic diseases caused by unhealthy lifestyles. The more Europe grows together the more it will be necessary to have such strategies. The health sector of the individual countries is shaped by cultural and/or civilizatory conditions. Such a strategy has to account for the country's specific shape of the health sector and the experience made in this point has to result in the establishment of structures and the creation of measures across Europe and worldwide. In the first step, members of the CINDI family are to ascertain country specific informations which in the second step should be used for the development of the strategy. The paper refers to the contribution made so far by CINDI Germany with regard to the first step. The "3 Level Conception of Family Physicians"-recommended by the Society of physicians of Germany the model "Community - related behavioural medicine" - which has been developed to put the above mentioned conception into practice - and quality assurance in the framework of medical primary care from the focus of the paper.

The treatment and counseling of drug addicts increasingly comes under the responsibility of family physicians. Since the onset of the AIDS epidemic this applies in particular to the methadone treatment of chronically ill heroin addicts. Medical education concerning the treatment of addiction is insufficient. Unprofessional dealing with drug addicts may easily result in serious obstruction of the relation between physician and patient. Thus it endangers the success of treatment. Basic guidelines of interaction, possibilities of abstinence therapy as well as harm reducing strategies are presented.

Infections of the urinary tract occur quite frequently in patients of both sex in the practice as well as in the hospital. They are caused mainly by bacteria. However, virus- and significant fungus-infections of the kidney and the urinary tract are observed due to acquired immuno-suppression or induced by the physician. The current knowledge about this problem is still insufficient. Obtaining a careful history, the physical examination and biochemical analysis are still of great value for a successful treatment. Besides the drug therapy, the physiological immunological mechanisms should be activated by unspecific procedures. If they are the only risk factor, urinary tract infections including chronic courses never lead to kidney failure necessitating a dialysis.

Innovations in diagnosis and therapy of adrenal neoplasms require a discussion about these tumors. Especially, the articles deal with the radiologic evaluation of the adrenal gland, technical as well as perioperative considerations of adrenalectomy, and adrenocortical carcinoma. Several conclusions can be drawn from our own results and a review of the literature. Firstly, the diagnostic accuracy should improve with advances in magnetic resonance imaging. Secondly, all asymptomatic nonfunctional adrenal masses about 3 cm require removal. Thirdly, adrenocortical carcinomas are generally curable only if small and localized. Fourthly, among the adrenal tumors, pheochromocytomas--especially malignant pheochromocytomas--deserve a careful approach: adequate preparation and early ligation of the adrenal vein after transabdominal access are the main goals. Finally, adjuvant treatment regimens for more advanced adrenocortical carcinomas using mitotane and conventional multiagent chemotherapy need to be evaluated in randomized trials.

If arterial hypertension is diagnosed in a patient, it is followed by several consequences. A life-long medical control is necessary. The history, physical examination, and biochemical diagnostics are of great importance. The secondary types of hypertension are specified and the drug therapy is suggested. A special quality in the treatment of arterial hypertension is the treatment during pregnancy.

The knowledge about the pathogenesis of the diabetic nephropathy has significantly increased during the last years. The diabetic nephropathy is one of the best treatable renal disease due to the treatment strategies derived from this knowledge and the new emerging therapeutic perspectives. However, it is a prerequisite that the treatment is started early in the course of the disease. The onset of microalbuminuria is currently the known indication for the development of a nephropathy in a patient with diabetes. Additional to the intensified insulin treatment, the application of an ACE-inhibitor should be taken into account when microalbuminuria occurs.

Hematuria is a common clinical problem. It may arise from benign diseases posing minimal risk to the patient to potentially life-threatening conditions. Due to its many causes, the evaluation of hematuria often requires various different diagnostic procedures. To prevent unnecessary diagnostic tests, the workup should begin with noninvasive techniques such as history, urinalysis, laboratory data and ultrasonography. This proceeding allows a simple and rapid differentiation in renal and non-renal causes of hematuria in most cases.