[Fragility Fractures: Preoperative assessment and optimisation]. / Fragilitätsfraktur beim geriatrischen Patienten: Präoperative Abklärung und Optimierung.

Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study.

INTRODUCTION: Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres. METHODS: The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore. RESULTS: GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year). CONCLUSIONS: This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings. LEVEL OF EVIDENCE: Economic, level 2. TRIAL REGISTRATION NUMBER: NCT02297581.

Screening for depression in old age : A comparison of the geriatric depression scale and the depression in old age scale.

OBJECTIVE: Since 1996, older patients have been treated in the Nuremberg Geriatric Day Hospital. The geriatric depression scale (GDS) is an obligatory part of the geriatric assessment at admission but its use in the clinical setting has revealed some problems. The aim of the study was to compare the GDS with the depression in old age scale (DIA-S) in terms of applicability and psychometric characteristics. METHODS: As gold standard a semi-structured interview was used to record the depression criteria according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Using a sample of 375 patients, sensitivity and specificity as well as positive and negative predictive values were calculated for both screening tests. RESULTS: No clear superiority of any screening method could be proven. The sensitivity of the DIA­S in the overall sample was higher than that of the GDS, but the specificity was much lower. In terms of predictive values, there were slight advantages for the GDS. In the sub-samples, poorer values were found in both scales for cognitively impaired or dementia patients with slightly better values for GDS. CONCLUSION: The DIA­S can be used very easily in everyday clinical practice, but no advantages of this method compared to GDS could be demonstrated.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study.

OBJECTIVE: The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN: Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING: International (six countries, three continents) multicentre study. PARTICIPANTS: 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS: Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES: Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS: Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS: Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02297581.

Design and Evaluation of a Hospital-Based Educational Event on Fracture Care for Older Adult.

INTRODUCTION: Surgeons, internal medicine physicians, nurses, and other members of the healthcare team managing older adults with a fracture all have barriers to attending educational courses, including time away from practice and cost. Our planning group decided to create and evaluate a hospital-based educational event to address, meet, and improve the care of older adults with a fracture. MATERIALS AND METHODS: A committee of surgeons and geriatricians defined 3 learning objectives to improve knowledge and attitudes in co-managed care. They designed a 1-day educational event consisting of a departmental visit, a review of cases, a planning session to identify gaps and plan changes, and presentations on selected topics. Thirteen hospitals worldwide completed an 8-question online application form, and 7 sites were selected for delivery over 3 years in Denmark, Colombia, Thailand, Paraguay, Switzerland, and the Dominican Republic. RESULTS: Each event was conducted by 1 or more visiting surgeons and geriatricians, and the local team leaders. The most common challenges reported in the applications were preoperative assessment or optimization, delayed surgery, lack of protocols, access to a geriatrician, teamwork, and specific aspects of perioperative and postoperative care. In each department, 4 or 5 goals and targets for implementation were agreed. The presentations section was customized and attended by 20 to 50 team members. DISCUSSION: Topics selected by a majority of departments were principles of co-managed care (7), preoperative optimization (7), and management of delirium (4). Follow up was conducted after 3 and 12 months to review the degree of achievement of each planned change and to identify any barriers to complete implementation. CONCLUSIONS: Hospital-based events with visiting and local faculty were effective to engage a broader audience that might not attend external courses. A performance improvement component with goal setting and follow up was acceptable to all host departments.

Improved outcome in hip fracture patients in the aging population following co-managed care compared to conventional surgical treatment: a retrospective, dual-center cohort study.

BACKGROUND: Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC). METHODS: We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL). RESULTS: A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up. CONCLUSIONS: Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards. TRIAL REGISTRATION: The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.

Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment.

BACKGROUND: Multimorbidity and polypharmacy are common challenges in the treatment of older trauma patients. Therefore, various integrated care models were developed over the last few years, merging the expertise of geriatricians and trauma surgeons. The aim of this study was to evaluate, if the number of prescriptions of potentially inappropriate medication (PIM) could be reduced in these patients by an interdisciplinary co-managed concept compared to conventional trauma care. METHODS: We conducted a retrospective, dual-center cohort study, including all patients aged 70 years and older admitted with a fracture of the hip or the proximal humerus within the study period. Patients were treated in the universities department of trauma surgery with two different hospital sites, one with conventional trauma care (CTC) and the other one with a certified orthogeriatric trauma unit (OGC). Based on the STOPP/START criteria by O´Mahony et al., PIMs were defined, which should be avoided in (ortho)geriatric patients. Medical records of each patient were analyzed at discharge. Besides patients basic information, all prescribed drugs, changes in the medication plan and who carried out these changes were collected. For statistical analysis based on the data quality and distribution, the t test, Mann-Whitney U test and the Chi-square test were used. RESULTS: A total of 95 patients were included, 73 of them females, with an average age of 82.59 years (SD ± 6.96). Mean length of hospital stay was 12.98 at CTC and 13.36 days at OGC (p = 0.536). Among conventional care (41 patients), prescription of one or more PIMs was found in 85.4% of the patients, whereas at the orthogeriatric ward (54 patients) only in 22.2% (p < 0.001). Besides that, changes in medication were made for 48.1% of the patients during their stay on the orthogeriatric ward. CONCLUSIONS: Our findings show that an integrated care concept can reduce the number of prescriptions of PIMs significantly and potentially avoids adverse drug reactions and additional burdens in older trauma patients.

Development and initial evaluation of a point-of-care educational app on medical topics in orthogeriatrics.

INTRODUCTION: Research by AOTrauma's orthogeriatrics education taskforce identified ongoing educational needs for surgeons and trainees worldwide regarding the medical management of older adults with a fracture. To address practicing surgeons' preference for increased use of mobile learning, a point-of-care educational app was planned by a committee of experienced faculty. The goals were to deliver the app to surgeons, trainees, and other healthcare professionals, to measure usage, and to evaluate the impact on patient care. MATERIALS AND METHODS: The committee of geriatricians and surgeons designed and developed four modules on osteoporosis, delirium, anticoagulation, and pain based on published evidence and the content was programmed into mobile app formats. A registration form was integrated and a 14-question online evaluation survey was administered to users. RESULTS: The AOTrauma Orthogeriatrics app was installed by 17,839 users worldwide between September 2014 and October 2015: Android smartphones (44%), iPhones (32%), iPads (15%), Android tablets (9%). 920 users registered and 100 completed the online evaluation: orthopedic/trauma surgeons (67%), residents/fellows (20%), and other professionals (13%). Ratings for all aspects were 4 or higher on a 1-5 Likert scale (5 = Excellent). 80% of evaluation respondents found the answer to their question or educational need on their last visit, and 26 of 55 respondents (47%) reported making a change in an aspect of their management of patients as a result of their learning from the app. CONCLUSION: The orthogeriatrics app reached its intended audiences and was rated highly as a method of providing education to help improve patient care. Content input by experienced faculty and app improvements based on user feedback were key contributors to successful implementation.

[Analgesics in geriatric patients. Adverse side effects and interactions]. / Analgetika beim geriatrischen Patienten. Unerwünschte Arzneimittelwirkungen und Interaktionen.

Pain is a widespread symptom in clinical practice. Older adults and chronically ill patients are particularly affected. In multimorbid geriatric patients, pharmacological pain treatment is an extension of a previously existing multimedication. Besides the efficacy of pain treatment, drug side effects and drug-drug interactions have to be taken into account to minimize the health risk for these patients. Apart from the number of prescriptions, the age-related pharmacokinetic and pharmacodynamic changes significantly increase the risk among older adults. The use of non-steroidal anti-inflammatory drugs (NSAID) is widespread but NSAIDs have the highest risk of adverse drug reactions and drug interactions. In particular, the gastrointestinal, cardiovascular, renal and coagulation systems are affected. Apart from the known toxic effect on the liver (in high doses), paracetamol (acetaminophen) has similar risks although to a lesser degree. According to current data, metamizol is actually better than its reputation suggests. The risk of potential drug interactions seems to be low. Apart from the risk of sedation in combination with other drugs, tramadol and other opioids can induce the serotonin syndrome. Among older adults, especially in the case of polypharmacy, an individualized approach should be considered instead of sticking to the pain management recommended by the World Health Organization (WHO) in order to minimize drug-drug interactions and adverse drug reactions.

Predictors of Postoperative Cognitive Decline in Very Old Patients With Hip Fracture: A Retrospective Analysis.

BACKGROUND: To investigate incidence and predictors of the various postoperative cognitive declines in old patients with hip fracture. METHODS: This retrospective chart study evaluated 411 patients (age ≥80 years, follow-up 5 years). After exclusion of 82 patients (preexisting dementia or delirium), 70 patients showing either diagnosed postoperative delirium (POD; group 1; N = 18, 5.5%) or an unspecified cognitive dysfunction and behavior (group 2; N = 52, 15.8%) were analyzed and compared with those without any acute postoperative cerebral impairment (control group; N = 259, 78.7%). Medical history, anesthesiological, orthopedic, and rehabilitation data were assessed using the medical database of the hospital information system. Relative ratio was calculated with Fisher exact test: P value Bonferroni corrected ≤.003. RESULTS: Acute cognitive complications were observed in 70 (21.3%) patients. Our data in group 1 showed that patients with a medical history of stroke (relative risk [RR] = 16.2, P = .0001) or nicotine abuse (RR = 14.4, P = .001) and perioperative surgical bleeding (RR = 6.54, P = .002) are more likely to develop POD. Unspecified cognitive dysfunction and behavior (group 2) was significantly associated with a medical history of stroke (RR = 12.5, P = .0001) and postoperatively with depression (RR = 3.32, P = .001). In the follow-up, significantly more patients in group 1 (55.6%, RR = 21.8, P = .0001) and group 2 (13.5%, RR = 3.88, P = .001) developed dementia as compared to controls (1.9%). Mortality did not differ significantly between the groups (group 1: RR = 1.75, P = .5 and group 2: RR = 0.66, P = 1.0). CONCLUSION: These data show that various predictors can identify a greater likelihood of developing postoperative cognitive decline in very old patients with hip fracture. Not identifying or labeling of POD limits the opportunity for evaluation, treatment, and planning. Thus, routine cognitive assessments need to be performed in the scope of multidisciplinary orthogeriatric comanagement.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]. / Ablauforganisation - unfallchirurgisches und anästhesiologisches Management bei Hüftfrakturen.

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

Rehabilitation after hip fracture.

Low-trauma hip fracture in old age leads to impairment, increased need of care and mortality. Rehabilitation should start in the department for traumatology and accompany the patient through different settings until the pretraumatic status is reached. Besides the surgical procedure and the medical management of an aged person with complex disease and polypharmacy, the multidisciplinary rehabilitation process is an important factor for regaining ability for self-care and autonomous decisions. Pain management supports the process. The ideal setting is not clear yet. Besides established rehabilitation facilities for elderly people, including the departments for 'Akutgeriatrie/Remobilisation', the 'Outreach Geriatric Remobilisation' project offers new perspectives. It was designed to remobilise patients with multimorbidity in their own homes.

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium.

The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases.

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.

Long-term functional outcome in geriatric hip fracture patients.

BACKGROUND: Fragility fractures are a major health care problem worldwide. The proportion of the geriatric population and the overall life expectancy will increase. Hip fractures are the most common fragility fractures needing surgery and nowadays treatment concepts are changing. We studied the long-term functional outcome and their influencing factors in patients treated without any interdisciplinary aspects. DESIGN AND SETTING: A retrospective cohort study with functional long-term follow-up examination was carried out in a level one trauma centre on hip fracture patients 80 years old and above treated without any formalized interdisciplinary aspects ("usual care"). PATIENTS: Of 281 consecutive patients who were treated 2005 and 2006 with usual care, 246 patients with a mean age of 86.8 years met our inclusion criteria. 69.1% died within the study period of 4.9 years. On the remaining patients, the residential status, the Barthel Index and the Parker Score were assessed. RESULTS: The mean Barthel Index was 49.6 and the mean Parker Score was 2.7. More than one-fourth of the survivors were found to be bedridden and 45% were not able to walk outside. 88% are bound to one floor and only 8% are able to walk unaided. Patients with more comorbidities and patients with subsequent fractures had significant higher mortality rates. Patients with trochanteric fractures had significant better functional outcome scores compared to patients with femoral neck fractures. Nursing home residents showed significant higher mortality rates and lower functional outcome scores. Patients who were transferred to a nearby acute geriatric hospital for further treatment had significantly higher functional outcome scores. CONCLUSION: This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function.

[Polypharmacy is of major concern in cardiology]. / Polypharmazie in der Kardiologie - ein beachtliches Problem bei Synkopen, QT-Zeit-Verlängerung, Bradykardie und Tachykardie.

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

[Oral anticoagulation and risk of bleeding in elderly patients - the aspect of polypharmacy]. / Blutungskomplikationen bei geriatrischen Patienten unter oraler Antikoagulation - Aspekte der Polypragmasie.

Oral anticoagulant therapy has been shown to be of benefit also in elderly patients in various therapeutic and prophylactic indications. Despite strong evidence in literature, doctors still refuse to prescribe oral anticoagulants to geriatric patients in daily routine. Main reason for this decision is the fear of secondary bleeding complications. According to clinical trial data, distinct risk factors for bleeding attributed to anticoagulant treatment may be determined: age >70 years, female gender, recurrent bleeding events, alcohol/drug abuse, diabetes, anaemia and polypharmacy. The entire article reveals the literature in Medline and Cochrane Library from 1980 to 2009 including the hits "polypharmacy - anticoagulant treatment - elderly patients". It further highlights risk assessment strategies in elderly patients, and possible pharmacokinetic and -dynamic interactions of drugs co-administered with oral anticoagulants.

[Diuretics-related complications in elderly patients]. / Komplikationen durch Diuretikatherapie bei geriatrischen Patienten.

Diuretics are well studied and evaluated for their beneficial use in geriatric patients. However those drugs are often used without taking care of subjects condition or functional impairment. Known side effects of those substances may be increased by combinations of multiple drugs. Polypharmacy is a strong risk factor for the incidence of adverse drug reactions (ADR). ADRs are frequently found in combination with the use of diuretics. The remodelling of human body in aging process and uncontrolled therapeutic strategies seem to be causal for that finding. This article tries to work out the potential risk of the usage of those drugs in geriatric patients and its clinical relevance by using literature published in PubMed.

[Polypharmacy and pain treatment]. / Polypharmazie und Schmerztherapie.

Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.