The chance of transition: strategies for multidisciplinary collaboration.

Many long-term childhood cancer survivors suffer from treatment-related late effects, which may occur in any organ and include a wide spectrum of conditions. Long-term follow-up (LTFU) is recommended to facilitate early diagnosis and to ensure better health outcomes. Due to the heterogeneity of these sequelae, different specialists work together in the diagnosis and treatment of these conditions. Experts from both pediatric and internal medicine are involved in age-appropriate care by providing a transition process. Hence, LTFU of childhood cancer survivors is a prototypic example of multidisciplinary care for patients with complex needs treated in a specialized setting. International collaborations of healthcare professionals and scientists involved in LTFU of childhood cancer survivors, such as the International Guideline Harmonization Group, compile surveillance recommendations that can be clinically adopted all over the world. These global networks of clinicians and researchers make a joint effort to address gaps in knowledge, increase visibility and awareness of cancer survivorship and provide an excellent example of how progress in clinical care and scientific research may be achieved by international and multidisciplinary collaboration.

[Gastroenteropancreatic neuroendocrine neoplasms-Heterogeneity, management and perspectives of treatment and research]. / Gastroenteropankreatische neuroendokrine Neoplasien ­ Heterogenität, Management und Perspektiven der Versorgung und Forschung.

The term neuroendocrine neoplasms (NEN) encompasses a molecularly and biologically very heterogeneous group of tumors, which have in common their origin in neuroendocrine cells. The also very heterogeneous subgroup of gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) is the best classified and investigated group. This article provides a systematic review of the current classification, diagnostics and treatment options of GEP-NEN. In order to achieve a better overview, it was consciously decided not to use an approach based on the primary localization. Instead, a thematic organization according to classification, clinical phenotype, diagnostics and treatment was chosen.

[Nutrition in type 2 diabetes mellitus]. / Ernährung bei Diabetes mellitus Typ 2.

The increasing incidence of metabolic diseases, such as type 2 diabetes mellitus, poses a major problem for the healthcare system. Healthy food habits represent an important therapeutic measure to prevent health sequelae, such as cardiovascular diseases. According to recent data these are less due to individual dietary components and more to the composition of nutrition. A positive effect on glucose and fat metabolism in type 2 diabetes has been confirmed for various forms of nutrition. In addition to the type of nutrition, the so-called glycemic index of foodstuffs is also decisive for blood glucose control. Additionally, beneficial effects for particular foodstuffs, such as coffee, could be determined in patients with diabetes.

A new fistulose demosponge species from the Persian Gulf.

During a scientific expedition to the Palinurus Rock, Persian Gulf, Iraq, a reef, which was discovered first in 2012, we found a new species which we tentatively assigned to Ciocalypta (Porifera, Demospongiae, Suberitida, Halichondriidae). Genetic results from different authors (Morrow Cardenas, 2015, Redmond et al., 2013, Erpenbeck et al., 2012) suggest that several species of Ciocalypta and other species from Suberitida (e.g. several Axinyssa, Petromica, Topsentia, Cymbastela, Halichondria (Eumastia)) are indeed no Suberitida but belong to taxa yet unnamed. The species described here genetically clearly belongs to this new taxon outside Suberitida which awaits definition. Morphologically the new species clearly would be classified as Ciocalypta. Therefore the new species is described and compared to similar morphological species, some of them, as the type species, true Suberitida and true Ciocalypta, others belong to taxa still in need of a name.

[Late effects following childhood cancer treatment : A special challenge for transition medicine]. / Spätfolgen einer Krebsbehandlung im Kindes- und Jugendalter : Eine Herausforderung für die Transitionsmedizin.

BACKGROUND: Childhood cancer survivors are at risk of cancer- and treatment-related chronic health conditions. Since these sequelae may occur years after the end of treatment, many patients are already adults and have completed pediatric oncological care. Thus, successful transition is essential in order to ensure long-term surveillance. OBJECTIVES: The present review outlines the most frequent late effects of childhood cancer treatment. Moreover, difficulties in transition of these patients are discussed and interdisciplinary models of care are presented. RESULTS: Late effects following childhood cancer treatment occur in over two thirds of patients 30 years after the end of the oncological treatment and can affect different organs. The most frequent sequelae are endocrine disturbances, cardiac conditions, and subsequent neoplasms. Many late effects are effectively manageable if detected early. This necessitates an interdisciplinary approach as well as life-long surveillance. CONCLUSIONS: Transition from pediatric to internal medicine care as well as a change in the focus of care, shifting from relapse centered follow-up to late-effects centered surveillance, constitute a special challenge for a successful transition of long-term childhood cancer survivors. Specialized late-effects survivorship clinics offering interdisciplinary care from pediatric oncologists, specialists of internal medicine, and further disciplines enable the early diagnosis and treatment of late-effects.

[Thyroid and pregnancy]. / Schilddrüse und Schwangerschaft.

During pregnancy thyroid hormones have profound effects on embryonal/fetal development and maternal health. Therefore, thyroid gland disorders should be immediately diagnosed and adequately treated. Pregnancy-specific physiological alterations during pregnancy cause changes in the reference interval for thyroid-stimulating hormone levels and trimester-specific thresholds must be taken into account. This article summarizes the most important diagnostic and therapeutic aspects before, during and after pregnancy. With reference to the period prior to pregnancy, the article discusses iodide supplementation, preconceptional examination of thyroid gland metabolism and the importance of thyroid gland functional disorders for fertility and fulfilling the desire to have children. With a view to the period during pregnancy, the effect of hypothyroxinemia, hypothyroidism, and hyperthyroidism as well as the effects of their treatment on the development of the child are explained. Finally, a description is given of what must be paid attention to in the breast-feeding period and in postpartum thyroiditis.

Structural and Functional Adaptation of the Remnant Kidney After Living Kidney Donation: Long-Term Follow-up.

OBJECTIVE: Several adjustments occur after nephrectomy (NT) in the donor's remnant kidney. We investigated kidney donors 10 years after NT and compared several parameters before and after transplantation. METHODS: A total of 42 kidney donors of the University of Luebeck's Transplant Center were scheduled for a 10-year follow-up and were offered several investigations: laboratory tests, urinalysis and kidney ultrasound examination including determination of kidney volume (KV), resistive index (RI) and pulsatility index (PI). Moreover, a 24-hour ambulatory blood pressure monitoring (ABPM) was performed. A review of the medical records allowed comparison of the investigated parameters before (t0), 1 month after (t0.1), and 10 (t10) years after NT. RESULTS: Creatinine clearance decreased from 94.3 ± 23 (t0) to 52.4 ± 22 mL/min/1.73 m2 (t0.1) and increased to 78.2 ± 19 mL/min/1.73 m2 after 10 years (t10). Tubular proteinuria (α1-microglobuline) increased from 6.1 ± 1.5 (t0) to 63 ± 4.8 (t0.1) (P < .05) and decreased to 36 ± 2.4 mg/g creatinine at t10 (P < .05). Ultrasound examinations revealed a growth of the KV from 159.8 ± 23.1 (t0) to 175.5 ± 22.1 mL (t10) (P < .05) and an increase of RI and PI from t0 of 0.63 ± 0.01 and 1.03 ± 0.03 to t10 of 0.72 ± 0.04 (P < .05) and 1.24 ± 0.11 (P < .05), respectively. Post-NT ABPM values were not significantly different from pre-NT values. CONCLUSIONS: NT leads to hypertrophy of the remnant kidney associated with an increase of organ volume and creatinine clearance after 10 years of follow-up. Our results indicate an excellent prognosis for the kidney donors without any signs of renal damage.

[Diabetic emergencies : Hypoglycemia, ketoacidotic and hyperglycemic hyperosmolar nonketotic coma]. / Diabetologische Notfälle : Hypoglykämie, ketoazidotisches und hyperglykämisches Koma.

The diabetic emergencies diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS) and hypoglycemia represent severe and potentially life-threatening complications of diabetes mellitus that require prompt diagnostics and treatment. Absolute or relative insulin insufficiency is characteristic of DKA und HHS along with severe dehydration. They differ by the prevalence of ketone bodies and the severity of acidosis; however, the treatment regimens are similar. In contrast, hypoglycemia is the limiting factor for achieving ambitious glucose targets. This article decribes the clinical presentation, diagnostics and emergency management of these metabolic derangements.

[Modulation of the intestinal microbiota by nutritional interventions]. / Modulation der intestinalen Mikrobiota durch Ernährungsinterventionen.

Humans live in symbiosis with billions of commensal bacteria. The so-called microbiota live on different biological interfaces such as the skin, the urogenital tract and the gastrointestinal tract. Commensal bacteria replace potentially pathogenic microbes, synthesize vitamins and ferment dietary fibre. An imbalance in the bacterial composition of the intestinal microbiota has been associated with various diseases including gut-associated disorders such as inflammatory bowel diseases, colorectal cancer and nonalcoholic fatty liver disease. Furthermore, a shift in the microbiota composition appears to be of pathophysiological relevance which renders the specific modulation of the intestinal microbiota a promising approach in the treatment of the above mentioned diseases. Our intestinal microbiota composition is mainly modulated by dietary macro- and micronutrients but also by secondary plant compounds and synthetic food additives such as emulsifiers and artificial sweeteners. Nutritional interventions with the purpose to modulate the intestinal microbiota show only limited therapeutic potential in the treatment of gut-associated disorders, which may be due to individual differences in the intestinal microbiota composition and a lack of specificity. A combination of newly established technical analytic approaches involving a machine-learning algorithm may bridge the currently existing limitations by providing a personalized, highly-specific and consequently therapeutically effective microbiota modulation.

Tip Design of Hemodialysis Catheters Influences Thrombotic Events and Replacement Rate.

OBJECTIVE/BACKGROUND: Central venous tunnelled hemodialysis catheters (CVTC) are used for initial vascular access in patients with renal failure. Tip design of the CVTC may play an important role in catheter function and complication rates, influencing adequate hemodialysis treatment of these patients. METHODS: This prospective, observational cohort study compared the function and complication rates of two CVTCs in patients with end stage renal disease (ESRD) within a follow-up period of 24 months. The study included patients with ESRD who received either a CVTC with a split tip (ST) or a shotgun tip (SG). All patients underwent dialysis within 24 h of intervention. Blood flow was documented initially (Qb0) and was followed up after 6 (Qb6), 12 (Qb12), and 24 (Qb24) months. Analysis of blood flow and complication rates within the follow-up period was performed by questionnaires. RESULTS: In total, 185 patients were included, of whom 93 received a ST CVTC and 92 a SG CVTC. Baseline parameters did not differ significantly between groups. CVTC blood flow was not significantly different between the two devices. Thrombolytic therapy with Alteplase was used significantly more often in the ST group (29%) than in the SG group (16%) (p < 0.05). The CVTC replacement rate was significantly higher in the ST group (19.3%) compared with the SG group (8.7%) (p < 0.05). CONCLUSIONS: The tip design of CVTC (split or shotgun) appears to be irrelevant for long-term blood flow during dialysis treatment. However, patients may benefit from SG catheters over ST catheters where replacement rates and thrombolytic treatment are concerned.

[Prevention and treatment of cachexia : Exercise and nutritional therapy]. / Prävention und Behandlung der Kachexie : Bewegungs- und Ernährungstherapie.

BACKGROUND: Cachexia is a multifactorial and complex syndrome characterized by progressive functional impairment and ongoing loss in quality of life, which lead to a deterioration of the prognosis for affected patients. The prevalence of cachexia can be very high and is up to 80 % in patients with malignant tumors. OBJECTIVE: The aim of the study was to assess the relevance of exercise and nutrition in the prevention and therapy of cachexia. METHODS: An evaluation of the current literature on exercise and nutritional therapy in patients with cachexia or with advanced stage diseases where a high prevalence of cachexia is probable, was carried out. RESULTS: There is a lack of scientific evidence for the benefits of exercise in cachexia. A major problem of relevant studies was that cachexia was frequently not defined according to valid criteria; however, data indicate a benefit of exercise training in patients with advanced diseases associated with a high prevalence of cachexia. A solely nutritional intervention and dietary counselling seem to be of minimal benefit. The administration of omega 3 fatty acids is controversially discussed. CONCLUSION: Although there is a lack of data on the effects of exercise and nutritional therapy in cachexia, there is evidence for the benefits. The present data indicate the necessity for the use of a multimodal treatment including exercise, nutritional and pharmacological therapy in cachexia. There is a great necessity for prospective studies.

[Ethical aspects of palliative medicine]. / Ethische Aspekte der Palliativmedizin.

BACKGROUND: The aim of palliative medicine is to adequately care for and attend to patients suffering from life-threatening and incurable medical conditions according to their needs. This implies that for these patients it is not a matter of dealing with diseases that can be treated separately but with their existence in the face of their approaching death. OBJECTIVE: This article investigates which ethical questions are currently prioritized for discussion in palliative medicine. METHOD: Review of the current medical and ethical literature and own reflections with a relational ethics approach that puts patient wishes at the centre of attention. RESULTS: Palliative medicine is not a "luxury medicine" but has to be considered as primary care to which every person is entitled. If there is a need for improvement of care, promoting it is an ethical obligation. In this respect the question of a "good death" is extremely complex. The term is connected to the ethics of a good life and includes the dimensions of happiness-suffering as well as meaning-futility; therefore, the best possible treatment of symptoms, most of all pain is just as important as recognizing subjective questions of meaning. Dealing with the wishes of patients, including possible wishes to die, are the starting point for elaborating palliative care measures. It is concerned with finding the right point in time for each patient individually, in their best interests and according to their wishes, at which dying should no longer be held back but for their own benefit the patient should be accompanied and supported during dying. CONCLUSION: In the current construction of palliative medicine, including its normative configuration within the law and medical ethics, the criteria which are essential for the quality of life up to death are being discussed.