Deutsche medizinische Wochenschrift
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WHAT IS NEW?: The following refers only to irritable bowel syndrome (IBS) in adults. The new guideline includes a separate section on IBS for paediatric patients. Irritable bowel syndrome (IBS) presents as a heterogeneous picture with chronic abdominal complaints related to the bowel. These are usually accompanied by changes in bowel movements and lead to impaired quality of life. The genesis is multifactorial and there are complex underlying pathophysiological mechanisms associated with IBS. Thus, disturbances in various components of the gut-brain axis and the increasing importance of the microbiome can be identified. Various psychological comorbidities also play a role. ⋯ There is no proven causal and no established standard therapy. Due to the variable genesis and symptom manifestation of IBS, a broad spectrum of therapy options results, whereby there is no individual prediction regarding effectiveness and therefore every therapy is initially probationary. Symptom-independent general therapies that can be used for all subtypes include dietary methods (e. g. the low-FODMAP diet), probiotics, psychotherapy methods and complementary medicine. The choice of symptom-dependent drug treatments is made according to the subtype/main symptom. In the case of diarrhoea, bile acid binders, the non-absorbable antibiotic rifaximin or, in individual cases, 5-HT3-antagonists can be used in addition to loperamide. In constipation, prucalopride and linaclotide have value in addition to the use of soluble fibre and macrogol/other laxatives. For abdominal pain/cramps, studies show good results for spasmolytics, especially peppermint oil, and for tricyclic-type antidepressants. For the main symptom of flatulence, probiotics, rifaximin and especially the low-FODMAP diet can show positive results in studies.
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As demonstrated in the ADVOCATE-trial avacopan allows for a substantial reduction of glucocorticoid (GC) use during induction of remission. A future role of avacopan in the treatment of GPA and MPA is likely. Likewise, the PEXIVAS-trial showed that GC reduction of up to 60 % compared to standard dose was equal effective. The same trial proved no benefit of plasma exchange in addition to standard induction of remission. Plasma exchange therefore is now mostly obsolete. ⋯ Rituximab is well established as maintenance therapy in AAV. The optimal duration however is still unknown. The MAINRITSAN 3 study indicates that prolonged use of more than 2 years is beneficial. EGPA: In line with earlier clinical evidence a GWAS including 534 EGPA patients indicated at last 2 distinct subgroups. The conception of a predominantly "vasculitis" and a more "eosinophilic" phenotype is supported by this genetic evidence and most likely will lead to more differentiated therapies. With the IL5-antibody mepolizumab a first principle targeting the eosinophilic component of EGPA is now available and proved to be clinically beneficial.
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SGLT2 inhibitors have been developed as antidiabetics. Large randomized prospective studies have shown prognostic benefit in patients with heart and/or renal insufficiency regarding cardiovascular and general endpoints - even in absence of type 2 diabetes mellitus. This extends the indication to large groups of multimorbid patients. ⋯ SGLT2 inhibitors should be paused if a longer fasting period is expected ("sick-day-break"). Due to the soaring number of prescriptions, a significant increase in the prevalence of eKA is expected. Immediate diagnosis and therapy are essential in emergency and intensive care medicine.
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Travelers' diarrhea is the most common infectious disease in travel medicine. This article deals with epidemiology, diagnostics, prophylaxis and therapy. The causative pathogens, important differential diagnoses and indications for extended diagnostic measures are discussed in detail. Furthermore, aspects of travel medicine advice as well as the possibilities and limits of infection prevention are presented.
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A large German registry on superficial vein thrombosis (SVT) documents that risk profiles, clinical presentation and treatment patterns are highly variable in patients with SVT, including a large variation in anticoagulation treatment modalities, intensities and durations. Inspite of a high percentage of initial anticoagulation there is a substantial risk of subsequent venous thromboembolism (VTE), recurrences or extension after three months. Inspite of current guideline recommendations, one third of the patients receives heparins, oral anticoagulants or no anticoagulation at all. At initial presentation about one quarter of the patients with SVT have a concomitant, frequently asymptomatic VTE. Risk factors for this complication include prior hospitalization, immobilization, prior VTE, autoimmune disorders, higher age, cancer and SVT occurring in a non-varicose veins or SVT-extension into the perforator veins. These risk factors are also associated with thromboembolic complications during follow-up. ⋯ Based on a large placebo-controlled trial with clinical endpoints (The CALISTO-Study), guidelines recommend Fondaparinux 2.5 mg once daily administered over 4 to 6 weeks. Alternatively, an intermediate dose of low molecular weight heparin can be considered. In high-risk patients, rivaroxaban 10 mg once daily was noninferior compared to Fondaparinux. A rebound of VTE recurrences was observed in both study arms after treatment had been discontinued after 45 days. Further studies are required to determine whether treatment needs to be extended beyond 45 days in high-risk patients.