Ausdauer- und Krafttraining bei Patienten mit Diabetes mellitus Typ 2 und Herzinsuffizienz

Patients with type 2 diabetes mellitus and heart failure represent a relevant population in everyday practice. Several exercise training studies have documented numerous positive changes in cardiovascular risk factors, morbidity and mortality, that can only be achieved through long-term training programs of combined aerobic and strength training. This efficient and cost effective therapy should be offered to as many patients in need as possible.     

Schrittmachertherapie bei Patienten mit Vorhofflimmern

Pacemaker therapy in patients with atrial fibrillation means the best current pacemaker therapy for patients with bradycardias with the aim to avoid the onset of atrial fibrillation and to establish DDD pacing despite of a history of atrial tachyarrhythmias. The newer application of pacing is the suppression of atrial arrhythmias in patients with medical refractory atrial tachyarrhythmias. Patients with slow ventricular rates and permanent atrial fibrillation should receive a VVI-pacemaker, if the bradycardias causes syncope, dizziness or a decrease of their exercise tolerance. In case of chronotropic incompetence the pacemaker should provide rate responsive pacing. Patients with sick sinus syndrome should receive an atrial (AAI) or dual-chamber (DDD) pacemaker, because patients with these in contrast to VVI-pacemakers develop less often atrial fibrillation and subsequent complications such as atrial thromboembolism. A dual-chamber or VDD-pacemaker—the latter connected to a VDD-single-lead—is indicated in patients with advanced AV-block. Atrial fibrillation occurs in 3 to 6% of the patients with no history of arrythmia and is, if pacemakers have no automatic mode switch, an often reason to program the devices to the VVI-pacing mode. Nowadays, most DDD(R)-pacemakers provide an automatic mode switch: During an atrial tachycardia the pacemaker switches to a VVI/VVIR mode and restores the initial DDD(R)-pacing mode with termination of the arrhythmia. In respect to the newer applications, one approach to prevent atrial tachyarrhythmias is permanent atrial pacing. As lower pacing rates of 80 to 90 ppm are usually needed and many patients hardly tolerate these pacing rates, new algorithms are under clinical investigation. Another approach is the simultaneous depolarization of the right and left atrium. Biatrial pacing is performed with one lead in the high right atrium and another lead in the coronary sinus. Another solution is bifocal atrial pacing with leads placed in the high right atrium and in the coronary sinus ostium. One effect of the new pacing techniques is to shorten interatrial conduction times. Therefore, biatrial pacing has become a therapy to prevent atrial arrhythmias deriving from delayed interatrial conduction times. As atrial reentry circuits seem to be important in atrial fibrillation, multisite atrial pacing is also performed in patients with medical refractory paroxysmal atrial fibrillation. Preliminary results suggest a more effective prevention of atrial fibrillation; nevertheless, these techniques should be still restricted to patients enrolled in clinical studies.     

Hypertonie bei Patienten mit Nierenarterienstenosen

Renal artery stenosis (RAS) is often present in patients with severe hypertension and atherosclerotic vascular disease. In this setting it is important to screen patients for renovascular disease, e.g. with Duplex-ultrasound, CT- or MR-angiography. The challenge of treating these patients is to find the evidence proving that the RAS is responsible for hypertension and/or renal dysfunction. Measurement of the intra-arterial pressure gradient is necessary in order to determine hemodynamic relevance. On the other side, in these patients hypertension is often of primary and/or renoparenchymatous origin and is aggravated by a renovascular disease. This explains why hypertension cannot be cured even if a high grade stenosis has been removed. In addition, thromb- and cholesterol-embolic material is often mobilized during an invasive procedure and leads to renaparenchymatous ischemia which sustains hypertension after intervention. An individual evaluation of profit versus risk is important for the decision for or against an invasive procedure, especially since there is no sufficient evidence for a decrease of mortality after interventions of RAS. The optimal conservative treatment, including the treatment of atherosclerotic risk factors is recommended.     

Varizenblutung bei Patienten mit Leberzirrhose

In patients with cirrhosis, portal hypertension induces the development of portosystemic collaterals. Bleeding from these collateral vessels, however, only develops if the portosystemic pressure gradient is below 12 mmHg. Portal hypertension in cirrhosis is mediated by an increased intrahepatic resistance of the liver on the one hand and by an increase in the portal tributary blood flow on the other. Consequently, therapy can aim to reduce intrahepatic resistance or mesenteric blood flow (shunts, pharmacologic therapy) or can act locally on the source of bleeding itself (endoscopic therapy). Four aims can be defined: (1) inhibition of the development of varices, (2) prevention of the first bleeding episode when varices already exist, (3) therapy of the acute bleeding episode, and (4) prevention of recurrent bleeding.     

Insulintherapie bei Patienten mit Herzerkrankungen

Insulin therapy in patients with heart failure and coronary artery disease is controversially discussed. While early short-term interventions after a myocardial event seem to exert a positive influence on the later mortality rate, long-term cohort studies have not been able to confirm any positive effect of insulin in comparison to other anti-diabetic strategies. However, in these studies insulin was given at a very late stage of the disease to multimorbid patient populations and it is not possible to extract the individual effects of insulin on the prognosis in a clear way. There are indications that negative outcome with insulin therapy may be related to the degree of endothelial insulin resistance. Short-term interventions with insulin in combination with insulin sensitizers have already shown indications of an improved vascular condition. However, further confirmatory long-term studies are necessary before any practical recommendations can be given in this respect to practicing physicians.     

Antidiabetika bei Patienten mit Niereninsuffizienz

Background

Many antidiabetic drugs have to be adjusted for administration to patients with renal impairment.

Objectives

Drug dose adjustment of antidiabetic drugs to renal function, specific risks and contraindications.

Material and methods

Review of current recommendations based on the German summary of product characteristics and published articles from the scientific literature.

Results

The selection of an antidiabetic drug should be made after individual consideration of expected benefits and potential risks. Metformin is contraindicated in patients with renal impairment. Pioglitazone may be used but a number of potential risks have to be considered. Gliquidone and repaglinide are considered as being kidney-independent. Glucagon-like peptide 1 (GLP-1) analogues should be avoided in patients with severe renal impairment but dipeptidyl peptidase 4 (DPP-4) inhibitors may be used (with dose adjustment). Sodium-glucose linked transporter 2 (SGLT2) inhibitors are inefficient in patients with renal impairment and alpha glucosidase inhibitors are contraindicated in cases of severe renal impairment.

Conclusion

Oral antidiabetic drugs can also be prescribed for patients with renal impairment but recommended drug dose adjustments and contraindications must be considered.     

Nierenersatztherapie bei Patienten mit Diabetes mellitus

When chronic renal replacement therapy began, the diagnosis of diabetes mellitus was a contradiction for acceptance into a chronic dialysis program. But today, diabetes mellitus is the major reason for initiation of dialysis therapy. This report provides information about special problems of renal replacement therapy in patients with diabetes mellitus. Complications of dialysis treatment due to late diabetic syndrome are generally described, as well as specific problems of hemodialysis and peritoneal dialysis.     

Thrombusaspiration bei Patienten mit akutem Myokardinfarkt

Recent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.     

Pflegerische Betreuungskonzepte bei Patienten mit Demenz

Background

Today there are approximately one million people with dementia in Germany. Because most forms of dementia cannot be cured the focus of treatment is to provide adequate care, aiming at the maintenance of cognitive functioning, the ability to perform everyday tasks and quality of life. Important approaches for dementia care are multisensory stimulation, validation, reality orientation and reminiscence therapy. However, the efficacy of these approaches is unclear.

Methods

A systematic review of the literature was performed. We included randomised controlled trials with at least 30 participants on the efficacy of multi-sensory stimulation, validation, reality orientation and reminiscence therapy for dementia. No restrictions were defined with regard to the endpoints under investigation.

Results

A total of 14 studies with 1,513 patients could be included of which 5 studies assessed reminiscence therapy, 4 multi-sensory stimulation, 3 validation and 2 reality orientation. The studies analysed cognitive functioning, behavioural outcomes, psychological symptoms and quality of life. Most studies did not find significant differences between the intervention and the control group.

Conclusion

The studies conducted to date provide only little evidence for the efficacy of the approaches for dementia care considered in this review. However, only few methodologically robust studies could be identified for this review which highlights the need for more interventional studies.     

Cefiximtherapie bei Patienten mit nachgewiesener Gonorrhoe

Cefixim ist ein neues, oral wirksames Cephalosporinderivat der sogenannten dritten Generation. Die Substanz besitzt hohe antimikrobielle Aktivität gegenNeisseria gonorrhoeae, einschließlich Betalaktamase-positiver Stämme. In der vorliegenden offenen, unkontrollierten Studie wurden 14 männliche Patienten mit akuter Gonorrhoe im Alter von 23 bis 48 Jahren ambulant mit einer Einmaldosis von 400 mg Cefixim behandelt. Alle 13 vollauswertbaren Patienten wurden klinisch und bakteriologisch geheilt. Unerwünschte Begleiterscheinungen wurden nicht beobachtet.Cefixime is a new third generation oral cephalosporin that exibits excellent antibacterial activity againstNeisseria gonorrhoeae, including betalactamase-positive strains. In an open uncontrolled clinical trial 14 male patients suffering from acute gonorrhea, aged 23 to 48 years, were treated with a single dose of 400 mg of cefixime. All 13 fully evaluable patients were clinically and bacteriologically cured. Side effects were not reported.     

Therapie mit Certolizumab pegol bei Patienten mit destruierender Arthritis

Certolizumab pegol is a new anti-TNF-alpha inhibitor which has been approved for the treatment of rheumatoid arthritis since October 2009. Due to the modification of the antibody fragment by the adherence of polyethylene glycol (PEG) a sufficient distribution in inflammatory tissue was found in animal experiments. In two individual case reports a remission of therapy refractive arthritis was achieved by administration of certolizumab pegol.