Der Internist
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The central circadian pacemaker in the suprachiasmatic nucleus and interaction of clock genes with the hypothalamus pituitary adrenal axis are responsible for very distinct cortisol concentrations. Unphysiologically high doses of glucocorticoids that do not follow the circadian rhythm lead to increased rates of morbidity, mortality and reduced quality of life. ⋯ Novel modified-release hydrocortisone preparations offer diverse benefits with regard to their effect on metabolism, cardiovascular risk, immunity and sleep, which might be beneficial in particular in multimorbid elderly.
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Rare work-related illnesses do not usually meet the requirements to be recognised and compensated as a legal occupational disease. However, common diseases (e.g. ovarian carcinoma) are sometimes caused by occupational influences (e.g. asbestos), making the occupational disease ovarian cancer caused by occupational exposure to asbestos a rare disease. Since in our modern working world the occupational influences that are harmful to health are decreasing qualitatively (substitutes) and quantitatively (limit values), the diseases they cause are also becoming increasingly rare.
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There is evidence that the treatment of overt hyperthyroidism with thyroid hormones is able to reduce mortality as well as cardiovascular and musculoskeletal morbidity. It remains unclear whether these data can be extrapolated to the mildest form of hypothyroidism, subclinical hypothyroidism. Furthermore, it is uncertain whether and to what extent the threshold for therapeutic intervention needs to be modified in the elderly, in whom hypothalamo-pituitary regulation is increasingly insensitive to the negative feedback by thyroid hormones and the patients' response to thyroid hormones changes. ⋯ According to new original data and meta-analyses, therapy with thyroid hormones does not alter morbidity and mortality in patients with subclinical hypothyroidism with thyroid stimulating hormone (TSH) below the range of 7-10 mU/l. These data support the TSH threshold of 10 mU/l recommended in guidelines, particularly in elderly patients over the age of 65 years, in whom TSH serum levels increase with age. In contrast to the recommendations, the prescription of thyroxine more than doubled in a large study from Denmark and TSH levels decreased from 10 mU/l to under 7 mU/l between 2001 and 2015. As (the primarily unspecific) symptoms and quality of life are not altered by thyroxine replacement in studies on subclinical hypothyroidism and elderly patients are more susceptible to side effects, thyroid hormone substitution should generally not be started at TSH levels <10 mU/l.
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Peri- and postmenopausal disorders can have a significant impact on quality of life. Hormone replacement therapy (HRT) might be necessary in order to decrease women's symptoms. ⋯ Both ongoing analyses of subgroups and other studies extenuated the WHI data, since the increased risks were neither generalizable to the typical postmenopausal patient (regarding age and risk profile) nor to the medication being used today. This article summarizes all aspects of HRT in peri- and postmenopausal women (indications, contraindications, practical approaches, risks, prevention) and provides recommendations with respect to the most recent S3 guideline.