Der Internist
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Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. ⋯ A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.
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Due to the effectiveness of vaccines some particularly threatening infectious diseases have become rare; however, vaccines are meanwhile the victims of their own success. Due to insufficient compliance and inadequate vaccination rates, there is a danger that the effectiveness of vaccination as a preventive measure will continuously disappear. ⋯ The following topics are covered: comparison of naturally acquired immunity and that acquired by vaccination, factors that necessitate a refresher vaccination, the role of herd immunity, prerequisites for successful eradication of a disease, influence of various T cells on the effect of vaccination, the role of immunologic memory, factors that influence protection by vaccination, vaccinations in cases of immunodeficiency, the potential and areas of implementation of passive immunization. In view of the corona pandemic and the running vaccination campaign, it must be hoped that this triggers a general renaissance of vaccinations against infectious diseases.
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Infections are an important warning sign for a weakened immune system. In the internal medical practice acquired (secondary), particularly drug-induced immunodeficiencies, are much more frequent than congenital (primary) immunodeficiencies. The management starts as early as the planning phase before initiation of immunosuppression. ⋯ Patients with chronic severe lymphocytopenia, in particular with CD4 positive T (helper) cells < 200/µl, are at increased risk for opportunistic infections so that an antibiotic prophylaxis is recommended. In patients with significantly increased proneness to infections and detection of a relevant quantitative (IgG < 4 g/l) and/or qualitative antibody deficiency (impaired vaccine response), additional immunoglobulin replacement therapy may be necessary and can be administered intravenously (IVIG) or subcutaneously (SCIG) as home treatment. In accordance with the localization of the infection, multidisciplinary clarification and management is warranted.
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Here, we report on a patient with deep vein thrombosis of the right leg, in whom diagnostic work-up revealed a previously unknown chondrosarcoma of the tibia. Physical examination revealed a firm, nondisplaceable mass on the dorsal side of the right knee that appeared as a cystic formation on ultrasound. ⋯ After resection of the tumor, anticoagulation was continued. In a review of all findings, a final diagnosis of highly differentiated chondrosarcoma with thrombosis of the popliteal vein was made.