Was gibt es Neues in der CKD-MBD-Pathogenese?

Knowledge on the pathophysiology of calcium phosphate metabolism has recently been revolutionized by the discovery of Klotho and fibroblast growth factor (FGF) 23. In the presence of its co-receptor Klotho, FGF-23 binds to receptors on renal cells resulting in an increased renal phosphate excretion and reduced synthesis of calcitriol leading subsequently to a negative phosphate balance. Despite these seemingly protective effects, numerous cohort studies identified elevated FGF-23 as a strong predictor of increased cardiovascular morbidity and mortality. In line with these findings experimental studies recently revealed a direct Klotho-independent toxic effect of FGF-23 on myocardial cells. In addition to the membrane bound form, which serves as the FGF-23 co-receptor, a secreted soluble variant (sKlotho) was recently discovered which has been associated with paracrine and endocrine protective functions. Although the biological relevance of sKlotho remains to be elucidated its effects are at least experimentally similar to those of FGF-23.     

Was gibt es Neues in der Hypertonie?

In research into the causes and suitable therapy of high blood pressure, various systemic, molecular and genetic approaches are currently being followed. In recent years several candidate genes could be identified in large cohort studies which could possibly play a role in the development of essential hypertension. An important topic remains the influence of endothelial mechanisms of vascular wall damage on blood pressure. New results from investigations on oxidative stress focus on the molecules ADMA (asymmetric dimethylarginine) and kynurenine and their active effect on vessels. With respect to the health of vessels and their role in the pathogenesis of hypertension, increasing scientific interest has revolved around T cell-mediated inflammatory processes in addition to circadian rhythms. New results have been obtained from interventional studies with respect to the desired blood pressure target values. According to these results a too severe reduction in blood pressure is not desirable especially in certain patient groups. The implantation of a pacemaker in the carotid bifurcation and ablation of sympathetic nerve fibers in the area of the renal arteries are interventional procedures for treatment of hypertension, the initial results of which have recently been presented.     

Pathophysiologie der Hypertonie: Was gibt es Neues?

The pathophysiology of primary hypertension is still unresolved and appears more complex than ever. It is beyond the scope of this article to review all new scientific developments in this field. On clinical grounds, hypertension is divided into primary and secondary forms. Here, the authors discuss the pathophysiology of hypertension associated with three common disease entities showing a large overlap with primary hypertension: chronic kidney disease (CKD), obstructive sleep apnea (OSA), and hyperaldosteronism. Especially in CKD and OSA, the activation of the sympathetic nervous system plays a crucial role. It is the authors' belief that hypertension due to these three diseases is more common than previously appreciated and may account for about 20% of the hypertensive population. The knowledge of the underlying pathophysiology allows early diagnosis and guides optimal treatment of these hypertensive patients.     

Was gibt es Neues in der Behandlung der ambulant erworbenen Pneumonie?

Community Acquired Pneumonia (CAP) is the most important infectious disease in Germany. In the acute phase, lethality is almost 10%, and in the six months follow up period following the acute infection, lethality is more than 15%. Problems with resistances had not been found in Germany, except for a decreasing susceptibility of S. pneumoniae against macrolides. The CRB-65 score allows a reliable discrimination between patients with a high and low risk of dying. The new S3 guideline for diagnosis and treatment of community acquired pneumonia recommends a risk adapted treatment. Low risk patients shall receive a monotherapy with e. g. amoxicillin, high risk patients should be treated with a broad spectrum combination therapy (beta-lactam and macrolide).     

Nicht-invasive Beatmung: was gibt es Neues?

Ohne Zusammenfassung     

Neues aus der Funktionsdiagnostik ?sophagealer Erkrankungen

Modern functional diagnostics should allow an exact as possible assessment of the structure and function of the esophagus in order to be able to reliably assess the symptoms described by patients, the underlying pathology and if possible also the response to be expected from therapy. This article presents new, very promising techniques and methods of manometric diagnostics as well as the diagnostics of gastroesophageal reflux disease.     

Gibt es Neues in der Standardtherapie der CED?

Zum Thema Trotz der Fortschritte in der Erfassung genetischer Grundlagen und im Verst?ndnis der Mechanismen der Entzündungsreaktion in der intestinalen Mukosa ist die Behandlung der chronisch entzündlichen Darmerkrankungen auch am Ende dieses Jahrhunderts noch eine symptomatische Therapie, die keine Heilung, sondern nur eine Behandlung der Schübe der Erkrankung und den Versuch einer Erhaltung einer einmal erreichten Remission beinhaltet. Eine Ausnahme bildet die chirurgische Therapie der Colitis ulcerosa, die die Krankheit heilt, aber mit dem Verlust des Kolons und der Reservoirfunktion im Rektum ihrerseits wieder Beschwerden hervorrufen kann. Angesicht dieser Situation ist ein optimales Verh?ltnis von Wirkung und Nebenwirkungen besonders wichtig. Einer Verbesserung dieses Verh?ltnisses waren viele Bemühungen der letzten Jahre gewidmet.     

Was gibt es Neues für die Rheumatologie im G-DRG-System 2007?

After extensive revision the partners of the self-administration"Selbstverwaltung" reached an amicable agreement on the new version 2007 of the G-DRG system. Like in the years before, version 2007 brings about large-scale changes for its users. A better representation of inpatient services in Germany combined with an improved economic homogeneity and appropriateness can be assumed. This is based on various factors, e. g. considerably increased data-quality and the optimization of technical influences on the system. Due to the rising level of complexity it is hardly possible to maintain a clinically homogeneous classification on the basis of G-DRGs. There is need [This calls] for a new approach in strategic matters. Various initiatives succeeded in a continuous improvement how the services provided by specialised rheumatologic clinics and departments are represented in the G-DRG system. Meanwhile, even under the pressure caused by the period of convergence, quality standards were focused on as well. The systematic changes of version 2007 as well as modifications concerning co-payments, coding and accounting rules relevant for rheumatologic clinics are presented and the consequences for users are discussed.     

Telemedizin bei Patienten mit COPD – gibt es eine Evidenz?

The enormous socioeconomic significance of chronic obstructive pulmonary disease (COPD) is nationally and internationally undisputed. Telemonitoring can potentially improve the routine treatment in important areas of treatment quality and quality management, patient compliance, self-responsibility, quality of life and safety, especially for older patients and independent of the location. On the basis of current evidence-based analyses this article gives an overview of the therapeutic benefits of telemedicine for COPD with respect to important target variables, such as the number of exacerbations, quality of life, necessity for inpatient treatment and mortality.     

Nachweis und klinische Bedeutung von Candida albicans bei nicht immunsupprimierten Patienten – Neues aus der Grundlagenforschung

The clinical significance of isolation of Candida albicans from mucous membranes of the respiratory or intestinal tract from patients in intensive care units is still debatable. Many patients are colonized; however despite the increased risk, relatively few invasive infections are detectable. This is the rationale why antimycotic therapy in this setting is strongly discouraged. In reality, however, many patients receive antimycotic drugs during the course of their illness as a preemptive therapy. In the light of new results of basic research on pathogenicity of C.albicans, the recommendation not to treat should be discussed anew. Without becoming invasive, C.albicans is able to modify the immune system in an anti-inflammatory sense (Th2) at least by means of two distinct mechanisms. Within biofilms on mucous membranes C.albicans grows in the hyphal form, which interacts with toll-like receptors (TLR2) on antigen-presenting cells, resulting in increased IL-10 levels as an expression of an anti-inflammatory response. Concurrently C.albicans produces farnesol, acting as a “quorum sensing molecule”, e.g., regulating the transition from blastoconidia to hyphae. In animal experiments, it was demonstrated that farnesol also triggers the immune system in an anti-inflammatory sense, e.g., application of LPS together with farnesol leads to an impaired immune response with decreased IL-12 levels. It is conceivable that patients in the phase of CARS or MARS can be further endangered by concomitant colonization of mucous membranes by C.albicans in the sense of an anti-inflammatory immune response. Treatment with an azole like fluconazol which interacts with ergosterol synthesis may aggravate the anti-inflammatory response, because the concentration of farnesol increases by negative feedback. Results of basic research indicate that these mechanisms found in animal experiments should be investigated in clinical trials.     

Bedeutung der Zytokine für den Knochenverlust – gibt es Interventionsmöglichkeiten?

Ohne Zusammenfassung     

EHEC 2011 – aus der Sicht des Klinikers

In early summer 2011 northern Germany was overrun by the greatest Entero-Haemorrhagic Escherichia coli (EHEC) O104:H4 outbreak so far. In contrast to earlier reported EHEC outbreaks young adults were affected mainly, and complications were frequent with 72% of 61 hospitalized patients in our cohort. In consequence of the genetic and clinical characteristics we concur with Brzuszkiewicz et al. to describe this syndrome as EAHEC syndrome (??Entero-Aggregative-Haemorrhagic Escherichia coli??). Because of the variability of the clinical courses, intensified monitoring at close intervals is necessary; we suggest the ??Altona EAHEC Monitoring Standard??. From the clinical point of view we could not observe an unfavorable influence of antibiotics.     

Neues zur Pathobiochemie der diabetischen Dyslipid?mie

Diabetic dyslipidemia is an important cardiovascular risk factor in patients with type 2 diabetes. In particular insulin resistance, which favors excessive production of large, triglyceride-rich very-low-density lipoprotein (VLDL) 1 particles and consequently hypertriglyceridemia, is responsible for the alterations in lipid metabolism. Increased VLDL plasma levels result on the one hand from increased VLDL production due to the enhanced flow of free fatty acids to the liver and on the other hand from diminished VLDL degradation due to insulin resistance and low adiponectin plasma levels. The accumulation of triglyceride-rich lipoproteins causes an increased number of so-called small-dense LDLs (sdLDL) and a reduced concentration of high density lipoprotein (HDL) particles which transport cholesterol to the liver. The exchange of triglycerides from VLDL and chylomicrons for cholesteryl esters from LDLs and HDLs, respectively, is facilitated by cholesterylester transfer protein (CETP). Hydrolysis of triglyceride-rich LDLs and HDLs ultimately results in the atherogenic composition of sdLDL and small, dysfunctional HDL particles, which are rapidly metabolized.