Innere Medizin (Heidelberg, Germany)最新文献

There are specific high-risk situations in routine care that are particularly challenging for medication safety. Examples of such situations include patients with polypharmacy or transitions between health care sectors, such as hospital discharge. Both scenarios become more frequent with increasing patient age and often coincide with a reduced capacity to handle medication in daily life (medication management capacity). This combination increases the risk of critical incidents in care. Therefore, a number of strategies have been developed and tested that aim to increase medication safety. While some of these strategies specifically target older patients (e.g., medication reviews conducted in long-term care facilities), other strategies may be adapted for an older population (e.g., education and training for correct drug administration). This article provides an overview of strategies to improve medication safety in the older population and also highlights specific challenges that may arise when implementing these strategies.

Background: Fibromyalgia syndrome (FMS) is a highly prevalent disorder that predominantly affects women. The absence of clear organ pathology and pathophysiology often leads to a lack of understanding towards those affected.

Objectives: This article aims to provide an overview of the definition, epidemiology, pathophysiology, and treatment options for FMS.

Results: FMS is defined as a syndrome characterized by chronic, multifocal pain lasting for at least 3 months, along with additional symptoms such as sleep disturbances, fatigue, or cognitive impairment. The prevalence in Germany is estimated to be approximately 2%. Risk factors may include genetics and epigenetics, childhood trauma, and adverse lifestyle factors. Pathophysiologically, alterations are found in the peripheral and central nervous systems, as well as in the endocrine and immune systems. Treatment focuses on non-pharmacological modalities such as physical therapy and psychological therapies, supplemented by medications such as amitriptyline, pregabalin, and duloxetine.

Conclusions: FMS is a well-defined entity, but further research is needed to better understand the disorder and its subgroups and to develop causally oriented therapies.

Background: Ambulatory healthcare in Germany is under pressure due to the increasing need for care, medical progress and a shortage of specialist personnel. Making general practitioners mandatory gatekeepers is on the political agenda aiming at more targeted use of specialist care and improved quality of care.

Objective: The study investigated how many persons in the statutory health insurance (SHI) currently consult specialists or psychotherapists without a referral and what additional burden a primary care system would place on general practitioners if these cases also had to be managed by them.

Material and methods: Based on nationwide physician billing data for all SHI patients in 2023, cases of adult SHI patients were selected in which a general practitioner contact fee ("hausärztliche Versichertenpauschale, VP") or a specialist or psychotherapeutic contact fee ("fachärztliche/psychotherapeutische Grundpauschale, GP") was claimed. Specialist or psychotherapy cases without a documented referral were considered as potentially uncontrolled. Various scenarios were considered to calculate the potential additional burden resulting from increased general practitioner control.

Results: Out of 59 million insured adults 33.2 million visited a specialist or psychotherapist at least once without a documented referral. This was associated with 17-102 million potentially uncontrolled specialist or psychotherapy cases. If these had to be additionally managed by general practitioner in a gatekeeper system, this would imply approximately 335-2000 additional contacts per general practitioner per year, depending on the scenario.

Conclusion: The actual additional burden on general practitioner depends largely on the specific design of the primary care system. A moderate additional burden is likely and the decisive factor is a binding of patients for longer periods to the chosen primary care practice.

With the growing use of immunosuppressive therapies, clinicians are increasingly faced with the question of how to manage positive interferon-gamma release assays (IGRA). A tuberculosis infection (TBI, formerly referred to as "latent tuberculosis") is clinically silent and non-contagious but can reactivate as active tuberculosis under immunosuppressive conditions. Diagnosis involves either an IGRA or a tuberculin skin test (TST), alongside microbiological and imaging studies to exclude active disease. Screening is recommended for individuals at increased risk, including those living with human immunodeficiency virus (HIV), those in close contact with tuberculosis patients, and those scheduled to receive certain immunosuppressive treatments, as well as individuals undergoing transplantation or dialysis, or those suffering from silicosis. Preventive therapy with tuberculostatic medication markedly reduces the risk of reactivation and should ideally be initiated at least 4 weeks before starting immunosuppressive therapy.

Cor triatriatum is a rare congenital cardiac anomaly with an estimated incidence among congenital heart diseases of approximately 0.1-0.4%. It is characterized by the presence of a fibromuscular membrane dividing the left atrium or right into two chambers. Approximately 83% of patients with cor triatriatum have cor triatriatum sinistrum (CTS) and 17% have cor triatriatum dextrum (CTD) [1]. CTS usually presents around 31 ± 23 years and is associated with higher rates of cardioembolic events, usually stroke due to mechanisms such as blood flow stagnation within the atrium, its association with atrial fibrillation (AF), and/or the coexistence of an atrial septal defect (ASD) or a patent foramen ovale. In contrast, CTD is associated with a significantly higher rate of cyanosis than CTS and presents earlier in life, usually around 21 ± 20 years [1]. Associated cardiac defects are common, with the most frequent being atrial septal defects (estimated incidence of 53%) and partial or total anomalous pulmonary venous drainage (estimated incidence of 27%) [2]. We describe a case highlighting the role that CTS may play in cardioembolic kidney infarction, provide high-quality cardio magnetic resonance imaging, and two- and three-dimensional echocardiography of the CTS membrane, and outline management strategies for this uncommon clinical scenario.

This case of a patient with Erdheim-Chester disease highlights the problems in diagnosing this very rare, largely unknown, but highly inflammatory non-Langerhans histiocytosis. This disease shows some characteristic clinical and molecular features including the BRAF V600E mutation, which was also demonstrated in this case in a perirenal tissue biopsy. The patient's condition improved under treatment with peginterferon alfa-2a and anakinra. However, remission for what is now 3 years was only achieved with the combination of anakinra and the BRAF inhibitor dabrafenib.

Intravenous antibiotic therapy has traditionally been considered the standard treatment for severe infections. However, recent research shows that early switching to oral antibiotics is often equivalent or even superior. This is made possible by new substances with high oral bioavailability and numerous clinical studies demonstrating the safety and efficacy of oral sequential therapy. Sequential therapy has advantages for patients (fewer catheter complications, better mobility and quality of life) and is beneficial both economically (lower costs, shorter hospital stays, fewer nosocomial infections) and ecologically (less waste). For various serious infections such as bone and joint infections, complicated urinary tract infections and severe pneumonia-as well as for endocarditis and bloodstream infections when certain conditions are met-studies show that switching to oral antibiotics is safe as soon as the patient is clinically stable. The selection of the appropriate oral agent is crucial and depends on bioavailability, the causative pathogen and the severity of the infection. Possible interactions with food and other medications must be taken into account.