[Less is more in the general practitioner's internistic surgery : Subclinical hypothyroidism, hyperuricemia, routine ECG and NT-proBNP as selected examples]. / Weniger ist mehr in der hausärztlich-internistischen Praxis : Subklinische Hypothyreose, Hyperurikämie, Routine-EKG und NT-proBNP als ausgewählte Beispiele.

Exceeding the need for care in general practitioner (GP) practices is a known problem that affects the work of approximately 16,000 specialists for internal medicine in the family practice context every day in Germany. In order to spare patients unnecessary treatment and measures, these must be critically questioned on a regular basis. Subclinical hypothyroidism (SH) and hyperuricemia (HU) are frequent laboratory constellations. The selected articles by Stott et al., de Montmollin et al. and Mooijaart et al. could show that treatment of SH in older patients is not effective. Furthermore, according to the studies of Li et al. and Badve et al. treatment of HU is only beneficial in the treatment of gout and nephrolithiasis and has no influence on the development of chronic kidney disease. The Canadian group of Bhatia demonstrated that the ECG for low-risk patients that is often part of health check-ups in Canada, usually results in more follow-up examinations without the groups with and without ECG differing with respect to major adverse cardiac events (MACE). Laboratory chemical analysis of N­terminal prohormone of brain natriuretic peptide (NT-proBNP) for managing the treatment of heart failure is also not more effective than traditional treatment methods according to Felker et al., therefore, it can be discarded. "Choosing wisely", "Less is more" and the "Klug entscheiden (Smart decisions)" recommendations by the German Society for Internal Medicine are initiatives that make the process of avoiding overprovision of care accessible for all practitioners in a short and concise form.

[Back pain in the primary care setting : Non-specific back pain]. / Rückenschmerzen in der Hausarztpraxis : Der nichtspezifische Rückenschmerz.

A systematic survey of the symptoms of back pain in terms of the triggering event and onset, nature of the pain and the extent to which pain dynamics can be influenced (lying or standing, under stress, nocturnal pain, localized percussion tenderness, B symptoms, etc.), as well as a structured clinical examination (segment height, radiance, projection, reflex status, sensitivity, and motor function), allows an initial and therefore orienting classification of back pain as non-specific or specific. Thus, in the primary care setting, many patients can be treated extremely effectively and economically from a cost perspective. The more precise the initial findings are, the more effective the measures taken are in general. In addition to the fastest possible pain relief, it is important to prevent the disease taking an unfavorable course and to avoid chronicity. In addition to non-pharmacological measures (initial rest and starting home exercises early on, promoting everyday mobility, physiotherapy, manual therapy, etc.), a wide range of pharmacological treatment alternatives is available. In the further course of treatment, it may be necessary to consult medical specialists in the fields of radiology, orthopedics, neurology, neurosurgery, rheumatology, psychotherapy, and psychiatry, among others. Treatment is managed by the primary care provider, who should also receive and re-evaluate all findings during the course of the disease.

[Renal carbuncle and perirenal abscess in children and adolescents]. / Nierenkarbunkel und perinephritischer Abszess im Kindes- und Jugendalter.

Renal abscesses are rare in childhood. The diagnosis is often complicated by non-specific symptoms and the typical signs of urinary tract infections are frequently absent. The currently available imaging methods are necessary and helpful for a differentiated therapeutic approach; nevertheless, cases are continuously being found in which a renal abscess is only diagnosed intraoperatively. In most patients a combined intravenous therapy including an antibiotic which is effective against staphylococci is sufficient. The therapy is supported if necessary by percutaneous abscess drainage. Open revision or even nephrectomy is rarely required.

Lethal cervical abscess following bisphosphonate related osteonecrosis of the jaw.

CONTEXT: Bisphosphonates are common drugs used in the management of bone metabolic diseases. Because of their recently increased use, their adverse effects, especially bisphosphonate-related osteonecrosis of the jaw (BRONJ), are monitored more frequently. BRONJ is a critical challenge in craniofacial surgery and is difficult to treat. Its occurrence is either spontaneous or follows dentoalveolar surgery. Typical complications of BRONJ are painful exposed bone, pathological fractures, extra-oral fistula, and local infections. OBJECTIVE: The aim of this paper is to report a rare case of bacterial embolism in the internal jugular vein after a BRONJ-induced submandibular abscess resulting in bacterial sepsis, multi-organ failure syndrome, and death. CASE ILLUSTRATION: A 59-year-old female patient developed severe BRONJ (stage II) with recurrent abscesses after oral osteoporosis therapy with alendronic acid. A subsequent submandibular abscess led to bacterial embolism of the left internal jugular vein, causing sepsis and death. DISCUSSION: Prevention, early detection and management of BRONJ remain a crucial challenge in craniofacial clinical practice. Despite several therapeutic approaches described in the current literature, none have undergone bedside application. CONCLUSION: Considering this report of death after recurrent abscesses following BRONJ, the use of bisphosphonates should be carefully monitored in order to prevent such severe complications.

Pathways involved in alanyl-glutamine-induced changes in neutrophil amino- and alpha-keto acid homeostasis or immunocompetence.

We examined the effects of DON [glutamine-analogue and inhibitor of glutamine-requiring enzymes], alanyl-glutamine (regarding its role in neutrophil immunonutrition) and alanyl-glutamine combined with L-NAME, SNAP, DON, beta-alanine and DFMO on neutrophil amino and alpha-keto acid concentrations or important neutrophil immune functions in order to establish whether an inhibitor of *NO-synthase [L-NAME], an *NO donor [SNAP], an analogue of taurine and a taurine transport antagonist [beta-alanine], an inhibitor of ornithine-decarboxylase [DFMO] as well as DON could influence any of the alanyl-glutamine-induced effects. In summary, irrespective of which pharmacological, metabolism-inhibiting or receptor-mediated mechanisms were involved, our results showed that impairment of granulocytic glutamine uptake, modulation of intracellular glutamine metabolisation and/or de novo synthesis as well as a blockade of important glutamine-dependent metabolic processes may led to significant modifications of physiological and immunological functions of the affected cells.

[Comparison of hypoglycemia perception and hormonal counterregulation in controlled hypoglycemia. A contribution to diagnosis of hypoglycemia unawareness syndrome in type 1 diabetic patients]. / Vergleich des Hypoglykämieempfindens und der hormonellen Gegenregulation während einer kontrollierten Hypoglykämie. Ein Beitrag zur Diagnostik des Hypoglykämie-Unawareness-Syndroms bei Typ-1-Diabetikern.

BACKGROUND AND OBJECTIVE: Diabetics with abnormal hypoglycaemia awareness cannot recognize hypoglycaemic symptoms early and adequately enough to respond, thus endangering in everyday life not only themselves but also others. Thus it is important to diagnose such symptoms early and assess the extent to which the diabetic is at risk of severe hypoglycaemia. This study was designed to contribute to the evaluation of hypoglycaemia awareness in type 1 (IDDM) diabetics. PATIENTS AND METHODS: In 57 diabetics (IDDM) awareness of typical hypoglycaemic warning symptoms and of hormonal counterregulation were tested during controlled induced hypoglycaemia. A questionnaire was used to measure at fixed time intervals, along a four-point scale, the severity of 6 autonomic and 6 cerebral warning symptoms, and compare them with synchronously obtained plasma levels of glucagon and epinephrine. RESULTS: The cohort was divided into three groups according to the rise of epinephrine levels induced by the hypoglycaemia. Group A (n = 22) showed a significant rise in epinephrine level at the onset of hypoglycaemia; group B (n = 22): significantly increased epinephrine only after 30 min of hypoglycaemia; group C (n = 15): no epinephrine rise at any time during hypoglycaemia. None of the patients had a significant rise in glucagon levels. There were significant differences between the three groups regarding HbA1c levels and the duration of diabetes. Low levels of HbA1c and duration of diabetes were commonly associated with a loss of hormonal counterregulation. In only 40% of patients was it possible to draw any conclusion about epinephrine-induced hypoglycaemia from symptoms revealed in the past history. CONCLUSIONS: The past history of hypoglycaemic symptoms is an unreliable and inadequate guide for objectively assessing the actual risk of hypoglycaemia in type 1 diabetics. The results of this study indicate that when severe hypoglycaemic attacks (requiring outside help etc.) are suspected, standardized diagnostic tests of hypoglycaemia awareness should be performed in specialized centres, particularly if an official medical report ist required.