Der Internist
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Reflex syncope predominantly occurs in younger patients and is the most common type of syncope. Typical contributors to reflex syncope are orthostatic stress, followed by a delayed and inadequate circulatory response consisting of bradycardia (cardioinhibitory type) and hypotension (vasodepressor type). Comparably, syncope may occur after direct activation of the vagus nerve, after emotional distress or pain, and in specific situations, such as coughing and post-micturition. The latter situations are mediated by indirect vagus nerve activation by usually unknown mediators. Syncope mediated by orthostatic hypotension occurs in elderly patients and is mediated by insufficient sympathoadrenergic vasoconstriction, occurring shortly after the onset of the orthostatic situation. ⋯ Treatment of both types of syncope consists of avoiding known situations leading to syncope, early reaction to prodromal syndromes, and physical counterpressure manoeuvers. Drug treatment (e.g. alpha-adrenergic agonists and fludrocortisone) are effective only in patients with orthostatic syncope. In selected patients with reflex syncope of a predominantly cardioinhibitory type, pacemaker implantation may be considered in selected patients.
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Vertigo/dizziness and syncope are among the most frequent clinical entities encountered in neurology. In patients with presumed syncope, it is important to distinguish it from neurological and psychiatric diseases causing a transient loss of consciousness due to another etiology. Moreover, central nervous disorders of autonomic blood pressure regulation as well as affections of the peripheral autonomic nerves can be responsible for the onset of real syncope. ⋯ It is of crucial importance in this context, e.g., to establish whether the patient is experiencing an initial manifestation or whether such episodes have been known to occur recurrently over a longer period of time, as well as how long the episodes last. Clinical investigations include a differential examination of the oculomotor system with particular regard to nystagmus. The present article outlines the main underlying neurological diseases associated with syncope and vertigo, their relevant differential diagnoses as well as practical approaches to their treatment.
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Therapeutic efficacy and safety in infections due to multiresistant bacteria can be improved by the clinical development of new compounds and devising new derivatives of already useful antibiotics. Due to a striking global increase of multiresistant gram-negative and gram-positive organisms, new antibiotics are urgently needed. This paper provides a review of new pharmaceuticals which are already in clinical development, mainly in phase III trials. ⋯ Each of these new trials increases the possibility of new antibiotics receiving approval.
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Back pain is a significant medical problem and one of the most common causes of medical consultations and missed work. In acute low back pain, patients with "red flags" indicating a serious underlying spinal or extraspinal disease must be identified by medical evaluation. Most cases of acute back pain are non-specific, and education, physical activity and pain medication is recommended. ⋯ In patients with chronic inflammatory low back pain with onset before the age of 45, rheumatic spondyloarthritis should be considered. Recently, a guideline (S3-Leitlinie) for the management of axial spondyloarthritis including ankylosing spondylitis has become available. It provides evidence of physical and drug therapy including nonsteroidal antirheumatic and Tumor necrosis factor (TNF) inhibitor therapy.
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A 74-year-old multimorbid man was admitted with fever of unknown origin. Over time the fever ceased spontaneously. The patient developed signs of a right heart failure without evidence of a primarily cardiac pathogenesis and died of acute right heart failure. Miliary tuberculosis that had lead to pulmonary artery hypertension was diagnosed at autopsy.