Der Internist
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Clostridium difficile (C. difficile) is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus. It is transmitted via a fecal-oral route and can be found in 1-3 % of the healthy population. Symptoms caused by C. difficile range from uncomplicated diarrhea to a toxic megacolon. ⋯ The degree of evidence of medicated treatment in this situation is low; the significance of metronidazole i. v. as an additional therapeutic measure is controversial. Tigecycline i. v. is an alternative option. Surgical treatment must be considered in patients with a toxic megacolon or an acute abdomen.
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Not only in Europe and USA, but also in many other countries rare disorders-so-called orphan diseases-have attracted more and more attention. The formation of specialized centers for rare disorders has enabled the diagnosis of diseases that have been widely unknown before. In addition, pharmaceutical companies have recognized orphan diseases as a profitable source of revenue. ⋯ The standard placebo-controlled, double-blind clinical trial is often inappropriate for the approval procedure of an orphan drug; thus other study designs or other parameters (e.g. biomarkers) have to be used to prove clinical efficacy of the study drug. Only relatively small amounts of drugs can be sold to the generally few patients affected by an orphan disease and clinical trials require an high amount of financial investment; therefore orphan drugs have in general extremely high prices. How long these high expenses can be borne by the health care system in view of the great number of rare diseases remains questionable.
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Pharmacotherapy in the elderly is challenging due to age-related physiological changes, high interindividual variability, and increasing frequency of multimorbidity. The resulting polypharmacy increases the risk of drug-drug interactions and requires an individual risk assessment. Some drug-drug interactions are documented to be associated with harm in older adults including intoxication, gastrointestinal bleeding, or falls. ⋯ Moreover, frequent risk factors and continuous physiological alterations in the elderly should be taken into account during risk assessment. This review exemplifies clinically relevant drug-drug interactions and risk factors in the elderly. In addition, assessment tools as well as prevention and management strategies for clinical practice are presented.
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Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.