Besonderheiten des Azinuszellkarzinoms des Pankreas

Pancreatic acinar cell carcinoma (ACC) is a rare tumor of the exocrine pancreas. Demonstration of acinar differentiation by immunohistochemistry defines the diagnosis. ACC is an aggressive tumor; however, it has a less dismal prognosis than ductal adenocarcinoma. Molecular alterations that are found in ductal adenocarcinomas, such as KRAS mutations, are absent in ACCs. In contrast, genome-wide and epigenome-wide analyses have described altered DNA methylation patterns, chromosomal amplifications and deletions, and mutational signatures typical for defective DNA repair mechanisms. Up to 14% of ACCs show mismatch repair deficiencies, resulting in the possibility to treat these tumors with recently approved checkpoint inhibitor pembrolizumab.     

Die Behandlung des kindlichen Rheumas: Pharmakotherapie

The treatment of juvenile idiopathic arthritis has changed a great deal in the last few years. Pharmacomedical treatment, physiotherapy and teaching the patients and parents are the mainstays of successful therapy. Using all available treatment options and thanks to new therapeutic options (TNFalpha-blockade) and due to a better understanding of the pathogenesis, individual therapeutic strategies provide adequate disease control in the large majority of cases. According to the subtype of juvenile idiopathic arthritis, different medications are used in combination with nonsteroidal antiinflammatory drugs (NSAID) which are used initially. Methotrexate (MTX) and steroids in various applications are the drugs of choice for the systemic and polyarticular courses; intraarticular steroids, sulfasalazine and hydroxychloroquine for the oligoarticular subtype. The new option of TNFalpha-blockade (Etanercept, Infliximab, Adalimumab) offers significant clinical benefit in patients with polyarticular involvement, who do not respond to MTX. Further biological agents (Anakinra, Abatacept, Atlizumab) are used in children and adolescents in clinical studies. Rarely azathioprine, cyclosporine A, leflunomide and cyclophosphamide are used. Stem cell transplantation has been tried as a very last resort but interpretation of the results is controversial. Due to the improvement of the therapeutic options, the approaches to the patients and their disease has changed and cautious optimism is justified.     

Die Behandlung des kindlichen Rheumas: Pharmakotherapie

Die Behandlung der juvenilen idiopathischen Arthritis hat sich in den letzten Jahren deutlich gewandelt. Die medikamentöse Therapie zusammen mit (Eltern-)Aufklärung und Physiotherapie bilden die Trias der Behandlung des kindlichen Rheumas. In Folge eines besseren Verständnisses der Pathogenese und durch konsequente Anwendung aller verfügbaren Möglichkeiten sowie mit Hilfe neuerer medikamentöser Strategien (TNFα-Blockade) wird trotz teilweise komplexem Krankheitsgeschehen in den meisten Fällen ein günstiger therapeutischer Weg gefunden. Nach den nichtsteroidalen Antirheumatika als Standardtherapie kommen je nach Subtyp verschiedene Medikamente zum Einsatz: bei der systemischen und polyartikulären Form vor allem Methotrexat und systemische Steroide in unterschiedlicher Applikation und bei der oligoartikulären Form insbesondere intraartikuläre Steroide, Sulfasalazin und Hydroxychloroquin. Die neuere Therapieoption der TNFα-Blockade (Etanercept, Infliximab, Adalimumab) findet überwiegend bei der Polyarthritis, aber auch bei den schwerer verlaufenden Spondylarthropathien ihren Einsatz. Weitere Biologicals (Anakinra, Atlizumab, Abatacept) werden in klinischen Studien bei Kindern und Jugendlichen eingesetzt. Seltener muss auf Reservemedikamente wie Azathioprin, Cyclophosphamid, Leflunomid und Cyclosporin A zurückgegriffen werden. Die Stammzelltransplantation steht als ultima ratio am Ende aller therapeutischen Möglichkeiten. Durch die Verbesserung der therapeutischen Möglichkeiten hat sich die Herangehensweise an den Patienten und seine Erkrankung gewandelt, und ein vorsichtiger Optimismus ist gerechtfertigt.     

Besonderheiten und Herausforderungen des spezifischen Rheumalabors in der Praxis

In Germany rheumatological laboratory investigations are increasingly being carried out by rheumatologists in private practice. The professional and economic value is shown in association with the historical development of laboratory medicine and the current discussion on vocational politics.     

Tonnenkonkremente – Besonderheiten beim Hochbetagten

Endoscopic sphincterotomy and stone extraction are established therapeutic procedures for common bile duct stones. Various nonsurgical techniques are available to increase the success rate, especially in patients with giant stones; these include mechanical lithotripsy, extracorporeal shock wave lithotripsy, intraductal lithotripsy, and percutaneous transhepatic procedures. Endoscopic intervention in the treatment of symptomatic common bile stones in elderly patients and especially in cases of giant bile duct stones is also safe and is not associated with a higher complication rate compared with the normal population.     

Besonderheiten der Infarkttherapie bei Diabetes

Therapy of acute myocardial infarction (STEMI and NSTEMI) in diabetics does not principally differ from that of non-diabetic patients. Due to the higher mortality in diabetics reperfusion measures, such as direct percutaneous coronary intervention (PCI), should be rapidly performed. An intensive drug treatment with thrombocyte aggregation inhibitors, angiotensin-converting enzyme (ACE) inhibitors and beta-receptor blocking agents must be carried out according to the current guidelines. An important factor is the high risk of renal failure due to the contrast dye administered during PCI in the presence of pre-existing diabetic kidney damage which should be limited to 100?ml if possible. Direct PCI should be limited to the infarcted vessel. After stabilization a comprehensive strategy to cure coronary artery disease, whether with PCI or coronary artery bypass graft (CABG) should be finalized. If severe coronary 3-vessel disease is present, CABG should be favored in diabetic patients. After surviving an acute myocardial infarction differentiated metabolic monitoring is mandatory.     

Besonderheiten der Nachsorge nach kardialer Resynchronisationstherapie

Zusammenfassung Resynchronisationssysteme nutzen zwar klassische Schrittmacher- und ICD-Technologie, ihr therapeutischer Zweck ist aber, inter- und intraventrikuläre Asynergien zu minimieren und bei erhaltenem Sinusrhythmus eine optimale AV-Sequenz herzustellen. Dieser Beitrag focussiert auf Szenarien, welche dieses therapeutische Ziel gefährden und in der Nachsorge von KRT-Systemen erkannt, nach Möglichkeit auch korrigiert werden sollten: unsichere Reizantwort der linken Kammer, ventrikuläre Doppelwahrnehmung, Inhibition der Resynchronisationsimpulse, Vorhof- und Kammerrhythmusstörungen, Frequenzadaptation. Er diskutiert die technische Prüfung aktiver Implantate nur soweit, wie sie für die Belange der KRT bedeutsam scheinen.     

Besonderheiten der perioperativen Intensivmedizin beim geriatrischen Patienten

Background

Demographic change has also caused changes in perioperative intensive care because the proportion of geriatric patients who must undergo surgical procedures is increasing. With the current preoperative assessment instruments, it is still not possible to identify high-risk patients of this collective or to make a reliable prognosis concerning postoperative course.

Materials and methods

In addition to pain control, important aspects to minimize complications in postoperative intensive care include adequate oxygenation, adequate fluid management, an adequate supply of energy and nutrients, good control of blood sugar levels, and early mobilization of patients.

Results

The perioperative intensive care treatment of geriatric patients requires the readiness to engage in interdisciplinary collaboration because only with this close dialog can the treatment results be sustained.     

Besonderheiten der Insulintherapie im Kindes- und Jugendalter

Although the therapeutic principles of flexible insulin therapy and the goal of the best possible long-term metabolic control are the same for all patients with type 1 diabetes, when planning therapy for children and adolescents it is necessary to take into account the individual’s developmental status. Therefore, specialised paediatric diabetes care is a must. The basic principles of planning diabetes therapy for children and adolescents are outlined here.     

Besonderheiten in der Therapie von Nierenerkrankungen im Alter

Background

Due to the aging population and increasing life span, geriatrics and thus geriatric nephrology have become important topics in medical care. Treatment of kidney disease in the elderly often consists of complicated pharmaceutical therapy. Elderly patients often have multiple comorbidities and also due to the anatomical and physiological changes in the kidneys, normally straightforward treatment procedures become vastly complicated networks of therapeutic strategies. Additionally, difficulties during dialysis are more frequent in elderly patients due to a difficult vascular access and an increased occurrence of cardiovascular problems.

Conclusions

To allow an optimal treatment, considerations of all these factors is essential. Developing optimal diagnostic procedures and algorithms, deciding which diagnostic procedures should be applied and give benefit to the patient have become major challenges in therapeutic strategies. Medical and ethical considerations are entwined in a complex system consequently nephrologists play a key role in patient care. This article discusses the most common nephrological complications in the elderly which must be taken into consideration in the treatment.     

Diabetes mellitus: Besonderheiten der Insulintherapie im Alter

Until recently, diabetic treatment of the elderly was a neglected area. A distinct definition of the therapeutic goal or common treatment procedure was lacking. Now, however, maintaining functionality and quality of life has been put before near-normoglycemia. This article attempts to generate a structured assessment of quality of life and to develop individual treatment options which take the dignity and essential wishes of elderly diabetics into consideration. Thus, diabetic therapy is carefully adapted to daily routine and the accepted expectations of patients and their carers without changes to usual habits. Detailed insulin treatment strategies for the elderly are discussed on the way from self-determination to helplessness.     

Besonderheiten von Patienten mit diabetischem Fußsyndrom und ihren Therapeuten

Zum Thema Der Autor dieser Arbeit versucht, das Problem des diabetischen Fu?-Syndroms über medizinische Gesichtspunkte hinaus unter philosophischen und psychologischen Aspekten zu sehen und zu behandeln. Das Theorem der okkludierenden diabetischen Mikroangiopathie – so wird vorgetragen – gelte im Bereich der naturwissenschaftlichen Medizin unver?ndert, obwohl es seit wenigstens 10 Jahren als falsch erkannt sei. Verschleppte Erkennung diabetischer Fu?l?sionen, versp?tete Krankenhauseinweisungen und unn?tige hohe Amputationen seien Ausdruck dieses Irrtums. Ob die in dieser Arbeit angestellten überlegungen neue Wege weisen und dem Ziel dienen, unsere Patienten m?glichst effektiv zu führen und zu beraten und mit evaluierten Methoden konservativ und operativ optimal zu behandeln, bleibt dem kritischen professionellen Leser dieser Zeitschrift zur Entscheidung vorbehalten.