Der Internist
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Case Reports
[An unusually painful leg ulcer in an 81-year-old patient: an interdisciplinary challenge].
An 81-year-old male patient with a history of peripheral arterial disease (PAD) was admitted to the authors' outpatient clinic with a painful lower leg ulcer. As the degree of PAD did not correspond to the clinical findings, multiple biopsies were taken from the base and edge of the ulcer. This resulted in the histopathological and clinical diagnosis of pyoderma gangrenosum (PG). ⋯ A mass in the gastric antrum suspicious for malignancy was histopathologically identified as gastric cancer (signet ring cell carcinoma). The PG was successfully treated with cortisone p.o. and tacrolimus ointment. Since the cancer was locally limited, the patient underwent surgery involving gastric resection with D2 lymphadenectomy and gastrojejunostomy (Roux-en‑Y anastomosis).
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Patients with rare diseases often receive insufficient medical care. The European Reference Networks (ERNs) were initiated by the European Union to improve healthcare for patients with rare and complex diseases within Europe. ⋯ Standardization of treatment, coordination of research projects as well as training and teaching of patients, patient representatives and healthcare professionals are means to reach this goal. Virtual case discussions are offered via a web-based platform (Clinical Patient Management System), in which experts from the ERNs advise treating physicians on the diagnosis and therapy of rare diseases.
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High-quality medical care including the concepts of "patient-centered medicine" and "precision medicine" imply medical awareness of measures that are "too much" and thus not appropriate for certain patients in a certain context. Physicians occupy a central role as stewards of limited social resources. Numerous influencing factors can cause a cascading into medical overuse. How to identify and avoid overuse? When is "less medicine" the better medicine for an individual patient?
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Cardiovascular medicine is one of the most resource-consuming parts of the healthcare system and many examples of overdiagnostic and overtreatment can be found. The present article presents just three of these, one from cardiology and two from vascular medicine. ⋯ The potential for harm caused by overdiagnostics in both cases lies not only in the unnecessary use of resources but, more importantly, in the subsequent overtreatment. The few appropriate indications are described in detail.