Innere Medizin (Heidelberg, Germany)最新文献

The classic therapeutic goals of chronic inflammatory bowel disease (IBD) are, on the one hand, clinical remission and, on the other, the prevention of disease progression. The introduction of additional "targets" such as normalization of laboratory inflammation values, endoscopic and, possibly, histological mucosal healing and transmural parameters (ultrasound, magnetic resonance imaging and computed tomography) is intended to improve prognosis. A good response to therapy is usually (also) evident from these targets, although the obligatory change in medication in order to improve the prognosis if the additional treatment goals are not achieved is not evidence-based. In the case of Crohn's disease and ulcerative colitis, individual and, if possible, personalized medicine should continue to be provided instead of strict target specifications.

The cornerstone of treatment for mild ulcerative colitis is still the oral or topical (rectal) application of aminosalicylates (5-ASA). 5‑ASA preparations are often only administered orally in mild ulcerative colitis. Study data show that in ulcerative proctitis and left-sided colitis, rectal 5‑ASA preparations are even more effective than oral administration. In a next step, steroid-containing topical therapies should be used. Topical steroids such as budesonide are also primarily used in mild Crohn's disease. However, it is controversial whether treatment is necessary in symptom-free patients. There is still a lack of evidence to prove that more aggressive treatment (using immunosuppressants, biologics or small molecules) has a long-term benefit in these patients. Most guidelines are critical of the use of 5‑ASA in mild Crohn's disease. Nevertheless, there is some evidence for sufficiently high-dose treatment with 5‑ASA, although one must be aware of its limited effectiveness. However, there is clear evidence for the postoperative use of 5‑ASA in cases of mild recurrence.

Background: The treatment options for chronic inflammatory bowel diseases (IBD) have been greatly expanded due to a better understanding of the underlying pathogenesis. A total of five classes of advanced treatment are available.

Objective: A practical overview of advanced treatment of IBD.

Methods: Narrative review.

Results and discussion: Advanced treatments are indicated for moderate to severe IBD. A timely use is recommended to achieve better response rates and to avoid irreversible bowel damage. Tumor necrosis factor (TNF) inhibitors and Janus kinase (JAK) inhibitors have a broad efficacy, also for extraintestinal disease manifestations. The risk of reactivation of varicella zoster virus is increased with JAK inhibitors. In high-risk patients and an age >65 years there is possibly a moderately elevated cardiovascular risk and neoplastic side effects. The integrin alpha4beta7 inhibitor vedolizumab and the interleukin (IL) 12 and 23 inhibitor ustekinumab have very good safety profiles. Selective IL-23 inhibitors are sometimes superior to ustekinumab with comparable safety profiles with respect to efficacy. The sphingosine-1-phosphate receptor modulators ozanimod and etrasimod are approved for oral treatment of ulcerative colitis. The treatment success of the medications remains still limited and a minority of patients will not respond to every individual treatment. Thus, sequential administration of several treatments is often needed. Due to the lack of comparative studies, the personalized choice, sequence and decision for treatments are usually based on personal experience and should take patient preferences, efficacy, safety and individual patient profiles into consideration.

Pediatric-onset inflammatory bowel disease (PIBD) is increasingly recognized in Germany. Patients with PIBD often present with more extensive and active disease. Clinical suspicion of IBD requires early initiation of the diagnostic work-up (e.g., non-invasive fecal marker for inflammation) and referral to a pediatric gastroenterology center. In the presence of very early-onset IBD, as well as further criteria such as family history, relevant comorbidities, and extraintestinal manifestations, genetic testing for monogenic forms of IBD should be considered. The aim of treatment is to normalize quality of life and prevent bowel damage and complications, thereby enabling normal physical, social, and emotional development of the child. The selection of treatment is based on individual risk stratification, which considers disease severity and activity. PIBD patients often receive more intensified therapies, including biologics and small molecules. However, anti-tumor necrosis factor (TNF) antibodies are the only approved biologics for PIBD (above the age of 6 years). Therefore, licensed anti-TNF is a mainstay of PIBD therapy. Regular PIBD and drug monitoring should be performed according to the treat-to-target approach. Patients with PIBD and their families have special health care needs and require an interdisciplinary team of specialized medical doctors, psychologists, social workers, dieticians, and nurses. Close cooperation between the local pediatrician/family doctor and the pediatric gastroenterologist is important to achieve the long-term goals. Psychosocial consequences are important but are often underestimated.

A young man presented with exertional dyspnea and thoracic pain following pharyngitis. The findings included pulmonary melting, left-sided pleural empyema and spondylitis. Cultures for detection of the pathogen were negative and sequencing for bacterial DNA was additionally carried out resulting in detection of Fusobacterium necrophorum that is typical for oropharyngeal infections. Furthermore, environmental diagnostics revealed two infected molars as a possible source of the infection and a jugular vein thrombosis. The results were compatible with Lemierre syndrome. This case highlights the potential of molecular diagnostics of pathogens.

Recognizing anemia and thrombpenia in acute and emergency medicine is easy. Acute (microangiopathic hemolytic) anemia and thrombopenia can be a sign of thrombotic microangiopathy (TMA). TMA syndromes are potentially life-threatening diseases. Diagnosing a TMA syndrome, causal differentiation and treatment require specialist knowledge that is not always available in acute and emergency medicine. Many differential diagnoses and examinations are usually necessary to make a correct diagnosis. Therefore, a standardized diagnostic algorithm is helpful for early diagnosis and treatment initiation.

A 42-year-old patient with return of spontaneous circulation (ROSC) following an out-of-hospital cardiac arrest was referred to the authors' emergency department. The initial rhythm was ventricular fibrillation. A computed tomography scan and subsequent coronary angiography revealed anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome as the cause of this condition. A thickened right coronary artery with significant collateral blood flow to the left coronary artery was observed. After initial treatment in the authors' intensive care unit, surgical intervention was performed. The patient was discharged from hospital without any neurological damage.