Innere Medizin (Heidelberg, Germany)最新文献

Insomnia, especially chronic insomnia, is a common condition that is also listed as a separate clinical entity in the new International Classification of Diseases (ICD). The diagnosis of chronic insomnia is based on the patient's own and third-party medical history, questionnaires on sleep and quality of life, a sleep-wake log, and, if necessary, a measurement of sleep quality. In addition, other factors that disrupt sleep as well as other sleep disorders must be ruled out, if necessary in a sleep laboratory. Cognitive behavioral therapy should be used as a preventive measure and as the first step in treatment. However, there is a lack of structured, comprehensive services. Therefore, digital services can also be used. Moderate to severe insomnia often requires treatment with sleep-promoting medication, as is also stipulated in the guidelines. However, there is a lack of structured, individualized treatment pathways. The authors recommend step-by-step treatment, starting with mild sleep-promoting agents such as melatonin and progressing to hypnotics such as daridorexant. Drug therapy is successful when it is used in a targeted manner and under medical supervision. Since the care situation for people with insomnia is inadequate, there is a need for more education of those affected and the medical profession, as well as collaboration between family doctors, general practitioners, specialists, and sleep medicine physicians.

Sleep is a fundamental biological function that affects nearly all organ systems, yet it has been insufficiently documented and considered in internal medicine practice to date. The aim of this review is to present the physiological basis of sleep, clinically relevant sleep disorders, and their significance for internal medicine conditions, as well as to outline practical approaches to prevention, diagnosis, and treatment. Sleep deprivation and sleep disorders are associated with an increased risk of hypertension, type 2 diabetes mellitus, obesity, cardiovascular events, and neurodegenerative diseases. Common disorders such as insomnia, obstructive sleep apnea, and circadian dysregulation have close bidirectional interactions with internal medicine conditions. Validated screening instruments such as questionnaires, digital health applications (DiGA), and evidence-based prevention strategies now enable low-threshold, structured care. Sleep is therefore a central but often underestimated health factor in internal medicine. Internists should systematically record sleep, integrate it into treatment planning, and use evidence-based measures. Greater implementation of sleep medicine in prevention and care could contribute significantly to improving patient care.

Cardiovascular diseases and sleep-disordered breathing (SDB) often coexist and influence each other. Observational studies show a strong association between SDB and arterial hypertension (aHT), coronary heart disease (CHD), and heart failure (HF). Treatment of SDB is indicated in sleepy or otherwise symptomatic patients. However, randomized controlled trials (RCTs) testing the effects of positive airway pressure (PAP) treatment of SDB on hard cardiovascular endpoints have been conducted primarily in oligosymptomatic and non-sleepy patients. This narrative review aims to describe the relationship between SDB and individual cardiovascular diseases and their treatment. SDB is a common and potentially modifiable risk factor for cardiovascular disease. There is strong evidence in favor of PAP therapy as a supplement to antihypertensive medication in SDB and aHT. The effect of PAP therapy on blood pressure increases with the severity of SDB. Conversely, successful treatment of HF or CHD may also lead to an improvement in SDB. Patients with SDB and low daytime sleepiness can be phenotyped on the basis of alternative quantitative parameters from polygraphy or polysomnography (e.g., hypoxemic burden, heart rate response to apneas, etc.), allowing for a better assessment of the prognostic effectiveness of PAP therapy before treatment begins. The diagnosis and treatment of SDB is an important component of multimodal cardiovascular preventive medicine, and symptomatic improvement can be achieved in many patients.

Central sleep apnea (CSA) is a sleep-related breathing disorder characterized by repeated cessation of respiratory drive during sleep. Unlike obstructive sleep apnea, CSA is not caused by upper airway obstruction but by a dysfunction in central respiratory regulation. The prevalence of CSA is low in the general population (0.9-1.5%), but significantly higher in risk groups such as patients with heart failure (up to 50%). Pathophysiologically, CSA is marked by instability of respiratory brainstem drive, prolonged circulation time, and increased CO₂ sensitivity. Cheyne-Stokes respiration, a common manifestation in heart failure patients, is associated with increased mortality. Diagnosis is primarily based on polysomnography, which allows differentiation between central and obstructive apneas, as well as sleep stages. A central apnea-hypopnea index (cAHI) ≥ 5/h is considered pathological. Additional assessments, such as echocardiography and blood gas analysis, are important for evaluating underlying conditions. Treatment focuses on treating the underlying disease, especially in heart failure patients. Device-based treatments such as continuous positive airway pressure (CPAP) and adaptive servo-ventilation (ASV) are available, although ASV is contraindicated in symptomatic heart failure patients with reduced left-ventricular ejection fraction (LV-EF) ≤ 45%. Implantable transvenous phrenic nerve stimulation is a promising new treatment option for CSA, particularly for heart failure patients who cannot receive ASV. In the case of neurological diseases and high-altitude exposure, CSA treatment needs to be individually tailored. Clinically, early identification and treatment of CSA are crucial to improve quality of life. Improvement in prognosis through CSA treatment has not yet been conclusively demonstrated, highlighting the need for further research on this topic. CSA remains a dynamic field in sleep and cardiovascular medicine with high clinical relevance.

Following oral ingestion of 40 g of caffeine with suicidal intent, a 34-year-old male patient presented with worsening nausea, emesis and polyuria. The patient's lab results showed lactic acidosis, rhabdomyolysis, hypokalemia and hypernatremia. Symptomatic treatment as well as fluid and electrolyte replacement were initiated. By means of hemodialysis, sufficient elimination of caffeine could be achieved. After stabilization, the patient was transferred to the department of psychiatry and psychotherapy for treatment of his depression.

Obstructive sleep apnea (OSA) is one of the most common widespread diseases and is associated with significant health risks and a considerable reduction in quality of life. Treatment is multimodal. Risk assessment tools such as the STOP-BANG questionnaire are commonly used, while the Epworth Sleepiness Scale helps evaluate subjective daytime sleepiness. Sleep studies play a central role in diagnosis. While in-lab polysomnography is considered the gold standard, for many patients, home sleep apnea testing (HSAT) using polygraphy provides sufficient objective data to confirm the diagnosis. The primary treatment option is positive airway pressure (PAP) therapy. In addition, alternative approaches are available today, including mandibular advancement devices (MAD), hypoglossal nerve stimulation, and positional therapy. Long-term treatment success depends on good therapy adherence and structured follow-up care - for example, using the S-O-S scheme.

The use of a beta-blocker has been an integral part of treatment following myocardial infarction for decades. However, some of the studies on which this treatment recommendation is based were carried out half a century ago. In the meantime, the widespread establishment of coronary reperfusion in particular has fundamentally changed the treatment of acute myocardial infarction. For patients with preserved systolic left ventricular function, the benefit of beta-blocker therapy following myocardial infarction can currently no longer be clearly demonstrated. This review summarizes the evidence for beta-blocker therapy from the pre-coronary reperfusion era to the present era of coronary reperfusion.

A 63-year-old woman presented with a 5-day history of high-grade fever, petechiae on the lower legs and severe thrombocytopenia. Clinical findings included left inguinal lymphadenopathy and an encrusted wound on the left tibia, which the patient had sustained from a rotten piece of wood. Her pet dog had sporadically licked the wound. After more than 2 days of blood culture incubation, Capnocytophaga canimorsus was finally detected. Antibiotic treatment with amoxicillin/clavulanic acid led to a complete recovery.