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Targeted infection diagnosis supports decision-making in the rational use of antibiotics usually encompassed as Antibiotic Stewardship (ABS). Similar to ABS, the term "Diagnostic Stewardship" (DGS) is suggested, whereas DGS includes, beneath general, predominantly microbiological infection diagnostics - with specific pathogen detection, conventional via culture or immunology, increasingly also using molecular biological methods. Especially in microbiology, pre-analytics, analytics and post-analytics play an essential role. Pathogen characterization is accompanied by an antimicrobial susceptibility test (with S-I-R classification), which deserves special attention, especially in the context of ABS. All of these aspects are dealt with in this work and represented using two practical examples of urinary and bloodstream diagnostics that are relevant for outpatients and inpatients., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Adult-onset Still's disease (ASOD) is an autoinflammatory disease of unknown etiology which is pathogenetically characterized by an involvement of the innate immune response with activation of neutrophils and an increased secretion of IL-1, IL-6, IL-18, type 1 interferons. Still's disease may occur at any age with distinct variability in signs and symptoms. Recently, the German Society of Rheumatology (DGRh) has issued an AOSD guideline which recommends diagnosing AOSD based on a characteristic combination of symptoms including intermittent fever, rash, arthralgia, and arthritis after exclusion of infections, neoplasms and other rheumatological conditions. Classification criteria according to Yamaguchi may support the clinical diagnosis. Therapy is recommended to include glucocorticosteroids and methotrexate or ciclosporin, at higher activity levels IL1-receptor antagonist anakinra, IL-1β antibody canakinumab, or IL6-receptor antibody tocilizumab. At a high disease activity, anakinra or canakinumab may be employed primarily. Local drug licensing policies may have to be considered, as these substances are not universally approved in these scenarios. Important complications to consider consist in perimyocarditis, a multi-faceted pulmonary involvement, and macrophage activation syndrome (MAS). MAS features multi-organ involvement and cytopenias. Besides supportive measures often requiring intensive care, high dose glucocorticosteroids as well as above named biologics, and if necessary, also etoposide based therapeutic regimen are used., Competing Interests: Prof. Stefan Vordenbäumen gibt keine Interessenkonflikte an. Prof. Eugen Feist gibt an, Berater-, Gutachtertätigkeit und/oder Forschungsprojekte mit Abbvie, BMS, MSD, Roche, Lilly, Sanofi, Sobi, Novartis, Pfizer durchgeführt zu haben., (Thieme. All rights reserved.)

Hundreds of thousands of individuals who experience lasting sequelae after sepsis and infections in Germany do not receive optimal care. In this White Paper we present measures for improvement, which were developed by a multidisciplinary expect panel as part of the SEPFROK project. Improved care rests on four pillars: 1. cross-sectoral assessment of sequelae and a structured discharge and transition management, 2. interdisciplinary rehabilitation and aftercare with structural support, 3. strengthening the specific health literacy of patients and families, and 4. increased research into causes, prevention and treatment of sequelae. To achieve this, appropriate cross-sectoral care structures and legal frameworks must be created., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Many recommendations for medical care for women with Turner syndrome (TS) have been published in the past. There are no studies that analyse the care situation of the women in Germany until now., Methods: The study was performed in 2015 based on a questionnaire that was completed by TS women (aged ≥ 18 years; median: 25 years). The questionnaire was devised by a French team and used with their permission. All women had received growth hormone treatment during childhood. The women were identified and addressed in writing through eleven cooperating centers and the support group. In all, 130 questionnaires were evaluated., Results: 79 of the 130 women (61 %) stated that they had health problems. 38 % of the women were under medical care by only one physician and 42 % by two physicians. The gynecologist was mentioned most often (by 80.3 %), followed by the family physician (53.8 %). ENT was mentioned as a problem system by 35 %, but only 3 % of the women attended an ENT physician. The question as to whether at least one of the following examinations (measurements of blood pressure, blood sugar, blood fats, liver function and/or thyroid hormones, echocardiographic and/or audiogram examination) had been performed during a period of 4 years was answered as follows: blood pressure (85 %), blood sugar (47 %), blood fats (41 %), liver function (46 %), thyroid hormones (44 %), echocardiography (57 %) and audiogram (35 %). A comprehensive examination was performed in 9.8 % of the women. 103 women (80.5 %) received sexual hormone replacement therapy. 76 women were on further drugs; thyroid hormones (44 %) and antihypertensive drugs (11 %) were stated most often., Conclusions: This is the first study which analyses the current situation of medical care of TS women in Germany. Our data show that medical care of young adult TS women is not optimal. The study cannot clarify the reasons. Due to the numerous and different comorbidities, the medical care of TS women is complex and should therefore be provided multidisciplinarily by different specialists under the direction of one physician., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht. Ein Teil der Daten wurde im Rahmen einer medizinischen Doktorarbeit verwendet. Wir möchten uns bei Frau Sabine Jeratsch für die Unterstützung bei der Zusammenstellung der Unterlagen bedanken. Wir bedanken uns bei Herrn Elmar Beck von der Fa. Anfomed GmbH für die statistische Auswertung und Beratung. Wir danken der Firma Novo Nordisk Pharma GmbH, die die Kosten der Studie (Übersetzung des Fragebogens, Druckkosten, Briefumschläge, Portokosten) durch eine Spende finanziell unterstützt hat., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Mental strain at the work place involves high potential hazard for health and quality of life. The aim of this study was to examine the relationships between strain consequences of psychological strain and subjective sleep quality as well as daytime sleepiness., Methods: A cross-sectional study with 84 included participants was conducted. Work-related strain consequences were evaluated by means of the 3 scales Cognitive Irritation (CI), Emotional Irritation (EI) and Global Irritation (GI) of the Irritation Scale for Assessing Work-Related Strain Consequences (IS), sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness was measured with the Epworth Sleepiness Scale (ESS)., Results: Regarding the assessed socio-demographical and medical data subjects with good sleep quality did not differ from subjects with poor sleep quality. In all 3 scales of the IS and in the ESS poor sleepers reached unfavourable higher scores, but the difference with respect to the ESS was not significant. Higher scores in all 3 scales of the IS correlated with higher PSQI scores but only higher scores in the EI of the IS correlated with higher ESS scores as well., Discussion, Conclusions: Work-related strain consequences and subjective sleep quality have an interrelationship with great importance in today's world of work. Considerable aspects here are job insecurity and constant availability., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Psychosocial problems such as anxious personality, low self-esteem, late separation from home and/or late sexual experience have been described in girls and women with Turner syndrome (TS)., Methods: The study was performed in 2015 based on a questionnaire that was sent out to 779 women with TS aged 25 years (median). The questionnaire was devised by a French team and used with their permission. In all, 130 questionnaires (16.7 %) could be evaluated. The questions from the individual topics were not always completely answered., Results: (mean ± SD).: 116 women (89.9 %) were not married; 52 women (40 %) lived in their parents' home. 47.6 % had a high-school/technical diploma or university degree. 60 women (46 %) had a job; 51 women (39 %) had not completed vocational training. Puberty was induced at the age of 14.2 ± 2.1 years in 78 % of the women. 80 % of the women received hormone replacement therapy at the time of the questionnaire survey. 66 of 93 women (71 %) found that the disease had a negative influence on emotional life. "Love life and sexual relationship" was the topic mentioned most frequently by 44 women (66.6 %). 116 women answered questions on sexuality. Here, 77 % had the first French kiss at the age of 16.4 ± 3.6 years and 62.4 % had sexual intercourse for the first time at the age of 19.0 ± 3.4 years. 81 % of the women stated that they had a partner relationship for more than 6 months (94 women had a male partner and 5 had a female partner). The question as to the wish to have children was answered in the affirmative by 89 of 124 women (71.8 %); 38.2 % desired spontaneous pregnancy and 44.9 % had considered in vitro fertilization or adoption., Discussion: The women's answers show that care needs to be improved. There are deficits in the topics of family, emotional life, relationships, sexuality, fertility and pregnancy. Therefore, the medical team should also include psychologists and social workers., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht. Ein Teil der Daten wurde im Rahmen einer medizinischen Doktorarbeit verwendet. Wir danken der Firma Novo Nordisk Pharma GmbH, die die Kosten der Studie (Übersetzung des Fragebogens, Druckkosten, Briefumschläge, Portokosten) durch eine Spende finanziell unterstützt hat., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Aim of this study was to investigate the influence of diabetes mellitus (DM) onto the early postoperative and long-term oncosurgical outcome after surgery for rectal cancer using data prospectively obtained in a representative number of patients., Methods: Data (using a registration form of 68 items) from the ongoing multicenter observational study "rectal cancer (primary tumor) - elective surgery" on Quality Assurance was used including years 2008 to 2011. A voluntary and frequent follow-up was done to gain long-term data. Patients were grouped as non-diabetic and not-/insulin-dependent DM (NIDDM/IDDM)., Results: In total, 10 442 patients were enrolled; 11.0 % had NIDDM and 7.2 % IDDM. Average age of patients without DM was 67.3 [95 %-CI: 67,07; 67,55] years (yr) and was lower than in IDDM- (71.7 [95 %-CI: 71,01; 72,35] yr) and NIDDM-patients (70.9 [95 %-CI: 70.41; 71.45] yr) (p < 0.001). Tumor stages according to classification by UICC were comparable (p = 0.547). Patients with DM were more likely to be obese and to have cardiovascular and renal risk factors as well as a more critical ASA-classification (p < 0.001 each). Postoperative morbidity (in the group 65 - 74 yr; p = 0.006) and in-hospital mortality (< 65 yr; p = 0.011) was higher in patients with DM. The 5-year overall survival (OS) was 60.6 % in patients without DM. IDDM (46.4 %) and NIDDM (53.3 %) decreased the OS (p < 0.001 each). The 5-year disease-free survival (DFS) was also worsened by IDDM (p < 0.001) and NIDDM (p = 0.004). No difference was observed concerning 5-year local recurrence rate, neither for IDDM (p = 0.524) nor NIDDM (P = 0.058)., Discussion: The metabolic disorder DM has a significant impact onto the outcome after surgery for rectal cancer most likely due to its own risk potential and associated comorbidities. Postoperative morbidity and mortality were increased and the oncological survival was worsened., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and admission findings  An 84-year old patient with persistent atrial fibrillation and chronic renal failure received a subcutaneous injection with low molecular weight heparin (LMWH) during a hospital stay. Over the course of her hospitalization, the patient developed abdominal pain. There was a marked hematoma at the injection site. A large tumor was palpable in the right abdominal quadrant. Examinations  Due to the significant reduction in hemoglobin, we performed a CT-angiogram of the abdomen. Diagnosis  We were able to visualize an intramuscular hematoma within the rectus abdominis muscle. Therapy and clinical course  After visualization with digital subtraction angiography and application of microcoils and histoacryl-glue, we were able to stop bleeding. After implantation of left atrial appendage occluder, oral anticoagulation therapy could be stopped. Conclusion  LMWH-treated patients with nonspecific abdominal pain should be meticulously examined to exclude iatrogenic abdominal muscle hematoma., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aim: In Germany, data of cancer patients are recorded not only in epidemiological registers but also in clinical cancer registers. To ensure the networking of all included medical partners, quality control, and clinical research it is necessary that cancer cases are captured more or less completely. The aim of the present study was to compare the data sets of two registers., Patients and Methods: Data from patients with colorectal cancer from two large surgical clinics in Magdeburg are recorded in two registers - the Clinical Cancer Registry Magdeburg and the Institute of Quality Assurance in Operative Medicine at the Otto-von-Guericke University Magdeburg. Here we compared the data sets in order to check the completeness of data capturing and to determine factors influencing the degree of completeness., Results: From all patients captured in the Institute of Quality Assurance, 78.9% are found also in the clinical cancer registry. The percentage improves over the course of time, but also depends on diagnostic criteria such as the staging. There are some differences between both registries, explainable by their specific objectives. Particularly, it is demonstrated that incomplete follow-up record may bias estimates of survival rates from registries., Conclusion: Ensuring the completeness and correctness of data is a major challenge for cancer registries. It has distinct influence on estimated quality parameters such as survival rates., (© Georg Thieme Verlag KG Stuttgart · New York.)

Current evidence assigns to the Helicobacter pylori infection an essential role and major risk in gastric carcinogenesis. In high risk groups and populations a H. pylori screen-and-treat strategy is recommended and already implemented in some countries. A general screen-and-treat is the way to go as it may reduce the burden of gastric cancer for the community and prevent deleterious individual destinies., (© Georg Thieme Verlag KG Stuttgart · New York.)

In primary and secondary medicine "non-specific, functional, and somatoform bodily complaints" are common and often take a chronic course, with the patients' quality of life usually markedly impaired, and give rise to high direct and indirect costs. They are challenging as they can deteriorate in case of inappropriate behavior on the physician's part. Coordinated by both German professional associations of Psychosomatic Medicine a new evidence based guideline was developed, aiming to transfer relevant diagnostic and therapeutic knowledge to all physicians who are in charge of these patients. After establishing a stable therapeutic alliance a symptom- and coping-oriented attitude could be demonstrated to be helpful. A biopsychosocial diagnostic evaluation combines a thorough assessment of bodily complaints and early introduces a sensitive discussion of signs of psychosocial stress, which can be extended carefully in case problems of this type are present. In less severe courses, physical/social activation is recommended and the patient's explanatory disease model should be extended towards a psychological dimension. More severe and complicated courses require a more structured approach consisting of regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse) and an active cooperation of the patient. A coordinated, multimodal management includes additional measures as graded activation, psychotherapy, relaxation training or--if indicated--temporary medication., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and Findings: A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma., Diagnosis, Treatment and Course: As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful., Conclusion: ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated., (Georg Thieme Verlag KG Stuttgart · New York.)

History and Clinical Findings: During a screening examination a pulmonary mass in the left lower lobe was detected in a 39-year-old man. The patient was asymptomatic and had hitherto been healthy. CT pulmonary angiography revealed an intralobar pulmonary sequestration with an afferent arterial branch from the thoracic aorta., Diagnosis, Treatment and Course: Thoracotomy with resection of the sequestration was performed. On the first postoperative day hemiparesis of the left side occurred because of an infarction of the arteria cerebri media. After aspiration of the thrombus and intraarterial thrombolysis the patient recovered completely. Histology of the sequestration showed invasive growth of aspergillus and severe inflammation, caused by invasive mycosis. Subsequently the patient received voriconazol for four weeks., Conclusion: Diagnosis of pulmonary sequestration in adults is rare. In asymptomatic patients there is still controversy about the treatment. Surgery, arterial embolisation and a "watch and wait" strategy can be taken into account. Because of the risk of infection an operative approach should be favoured., (© Georg Thieme Verlag KG Stuttgart · New York.)

Long-term low-dose aspirin intake leads to a 2 - 4-fold risk of risk for upper gastrointestinal bleeding. The additional intake of clopidogrel further increases the risk of upper GI bleeding (OR 7.4). Because of the potential interaction between proton pump inhibitors (PPI) and clopidogrel that compromises the efficacy of clopidogrel on platelet aggregation, there has been a warning in the product information by health authorities in the US and in Europe who discourage the concomitant use of PPI and clopidogrel. In the present study we performed a selected review of the published literature on the indications for gastric protection with PPI in patients on mono- or dual antiplatelet therapy focussing on the possible interaction between clopidogrel and PPI. In ex vivo analyses of platelet function, a reduced efficacy of clopidogrel was observed in patients on comedication with omeprazole. This was not the case with the comedication of other PPIs. To date, clear evidence is missing to state that comedication with PPI reduces the efficacy of clopidogrel IN VIVO. If both Clopidogrel and PPI need to be prescribed, a split dosage regimen of PPI in the morning and clopidogrel in the evening can be recommended. The short half-life of both medications explains the rationale of this recommendation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Specialized stroke units offer optimal treatment of patients with an acute stroke. Unfortunately, their installation is limited by an acute lack of experienced neurologists and the small number of stroke patients in sparsely populated rural areas. This problem is increasingly being solved by the use of telemedicine, so that neurological expertise is made available to basic and regular care. It has been demonstrated by national and international pilot studies that solidly based and rapid decisions can be made by telemedicine regrading the use of thrombolysis, as the most important acute treatment, but also of other interventions. So far studies have only evaluated improvement in the quality of care achieved by networking, but not of any lasting effect on any economic benefit. Complementary to a medical evaluation, the qualitative economic assessment presented here of German and American concepts of telemetric care indicate no difference in efficacy between various ways of networking. Most noteworthy, when comparing two large American and German studies, is the difference in their priorities. While the American networks achieved targeted improvements in efficacy of care that go beyond the immediate wishes of the doctors involved, this was of only secondary importance in the German studies. Also, in contrast to several American networks, the German telemetry networks have not tended to be organized for future growth. In terms of economic benefits, decentralized organized networks offer a greater potential of efficacy than purely local ones. Furthermore, the integration of inducements into the design of business models is a fundamental factor for achieving successful and lasting existence, especially within a highly competitive market., (Georg Thieme Verlag KG Stuttgart.New York.)

Because of their anti-inflammatory, analgesic and antipyretic properties non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed throughout all medical fields. Both gastrointestinal as well as cerebro- and cardiovascular risk needs to be considered. Especially before starting a long-term medical treatment with NSAIDs the individual gastrointestinal and cardiovascular risk of the patient has to be assessed carefully., (Georg Thieme Verlag KG Stuttgart *New York.)

Two thirds of all neuroendocrine tumors (NET) are located in the gastroentero-pancreatic system. Depending on its localisation, each tumor presents a different histological pattern as well as different clinical symptoms and prognosis. Symptoms are usually due to the mass effects of the local tumor or tumor-related fibrosis. The classical "carcinoid-syndrome" with flush and diarrhea is seen in fewer than 10 %. Tests like chromogranin A (serum) or 5-hydroxyindolacetic acid (24h urine-collection) are indicators for the initial diagnosis of NET. Somatostatin-receptor scintigraphy is the most valuable imaging modality. In addition CT/MRI can be used for further topographical definition. Endoscopic techniques like the use of capsule endoscopy are being evaluated for the diagnosis of small intestinal NETs. The only curative treatment of NET is still complete surgical resection. However, it can only be done in 20 %, depending on localization and local extension of the primary tumor. If the liver is involved local ablation techniques should be considered. The gold standard for medical treatment is the use of somatostatin analogs, although interferons show a comparable therapeutic potential. Traditional cytotoxic agents should only be used for poorly differentiated tumors refractory to other forms of treatment. New compounds that target different pathways at the intra- and intercellular level are under investigation. Supportive therapy should be considered for the control of symptoms.

In patients with craniopharyngioma, pituitary failure and often lifelong hormone replacement therapy, persisting ophthalmological problems with impaired vision, cranial nerve palsies, and psychoneurological deficits will lead to a persisting impairment in quality of life and social competence. Some patients completely depend on assistance. To prevent this, a major goal is an early diagnosis and limitation of operative radicality to minimize postoperative complications. Surgery in centers with special expertise is mandatory. Radiotherapeutical strategies are relatively safe and improve the outcome and recurrence-free survival after incomplete surgical resection or after local recurrence. Multidisciplinary concepts and prospective data acquisition are desirable with regard to therapy and outcome in patients with craniopharyngioma. Problems in the follow-up period are the development of atherosclerotic complications and metabolic syndrome as a consequence of occasionally excessive obesity, which may impair the long-term survival of the patients. Cause and progression of these complications are not fully understood, therapeutical strategies for the morbid obesity are not available. Only interdisciplinary co-operation will help to develop and evaluate therapeutical concepts for the management of this rare disease.

Age-related physiologic changes, a higher prevalence of chronic illness, and concomitant (often multiple) medication account for a higher susceptibility of elderly patients to syncope. Although elderly patients are the largest group with syncope, the causes frequently remain unclear. Multifactorial causes, lack of witnesses, overlap with falls, and additional cognitive impairment often confound the assessment of syncope in the elderly. Thus, strategic investigation is often needed to establish the diagnosis and to unmask the cause. In addition to a comprehensive medical history (by both patient and witnesses), a thorough physical examination including supine and standing blood pressure measurements and a standard 12 lead ECG remain the mainstay of diagnosis. The decision whether additional tests are needed depends on indications whether organic heart disease is present or not. Without evidence of structural heart disease, tilt table testing and studies of autonomic function are the next steps. In contrast, additional cardiac investigation (including invasive studies) is needed in patients with suspected or documented cardiac disease. External or implantable loop recorders represent a significant improvement in the diagnosis of rare episodes of (brady- or tachy)-arrhythmias. Prognosis is determined by the underlying (heart) disease.

L-arginine is the substrate for the enzyme nitric oxide synthase (NOS), which is responsible for the production of nitric oxide (NO), an endogenous messenger molecule involved in many of the processes associated with the development of atherosclerosis. Acute and chronic administration of L-arginine has been shown to improve endothelial function in animal models of hypercholesterolemia and atherosclerosis. Therefore, a lot of studies were conducted to elucidate whether dietary L-arginine supplementation can augment NO production in man and thereby improve vascular health. In this review the results of studies of intravenous and oral L-arginine supplementation with a colorful spectrum of doses, study duration and surrogate parameters of endothelial function are summarized. The pharmacokinetics of L-arginine have been investigated, side effects are rare and mostly mild and dose-dependent. Several possible mechanisms of action of L-arginine are discussed. An assessment of L-arginine as a therapeutic agent from the point of view of a clinical pharmacologist is given.

Background and Objective: Conflicting data regarding new onset or deterioration of gastroesophageal reflux disease (GORD) following eradication of Helicobacter pylori infection have been reported. Successful eradication therapy may influence gastric acid output. The study aimed to to investigate whether patients with pre-existing GORD or peptic ulcer disease may experience deterioration of GORD., Patients and Methods: 75 consecutive patients of a prospective longitudinal study (median age 66 years, n = 45 males) had received successful H. pylori eradication therapy because of the following main diagnosis: peptic ulcer (n = 37), GORD (n = 16), functional dyspepsia (n = 22). Two to three years later, they had an interview regarding the course of their dyspeptic and reflux symptoms. Negative H. pylori status at present was confirmed by (13)C-urea breath test in all patients. Ten patients were excluded because of proton pump inhibitor treatment., Results: Patients with deterioration of GORD (new onset or increasing reflux symptoms) were found significantly more frequently in the group with functional dyspepsia (36 %) compared to pre-existing GORD (16 %) or peptic ulcer disease (5 %). Improvement of pre-existing reflux complaints were reported mostly by patients with peptic ulcer disease. There was no significant impact of initial reflux manifestations like reflux symptoms or reflux oesophagitis on the course., Conclusions: During long-term follow-up after H. pylori eradication, patients experience improvement as frequently as deterioration of reflux symptoms. There is a tendency towards improvement of reflux symptoms if peptic ulcer disease had been the indication for eradication, but towards deterioration in patients with initial functional dyspepsia. A clinical relevant prediction, however, is not feasible.

History and Clinical Findings: A 61-year-old man was transferred from a peripheral hospital with the diagnosis of interstitial lung disease and an unclear mediastinal tumour. At the time of admission the patient had congestive heart disease NYHA class IV., Investigations: The echocardiogram showed a small left ventricle with concentric hypertrophy and a left ventricular ejection fraction of 35 %. The myocardium was relatively echo-rich with solid structures inside. Chest X-ray showed a massive rightsided pleural effusion. The abdominal ultrasound demonstrated ascites and hepatomegaly. The bronchoalveolar lavage showed an increased part of CD3 negative and CD16/CD56 positive cells, which were identified as plasma cells by light and electron microscopy. Aspiration and investigation of the bone marrow verified the diagnosis of a IgG multiple myeloma, highly differentiated characterised by monoclonal expression of light-lambda chains. Additionally Bence-Jones-proteins were found in the urine and osteolysis in the x-ray of the skull and the humerus., Diagnosis: Multiple myeloma, IgG-lambda, stage IIA., Therapy and Clinical Course: Chemotherapy with prednisolone and melphalan was initiated. His general condition increased after administration of the first cycle of chemotherapy., Conclusion: Cardiopulmonary involvement is seldom seen in multiple myeloma but should be excluded when clinical symptoms are present.

History and Admission Findings: A 51-year-old man with polyarticular rheumatoid arthritis since the age of 10 years, which had required three total joint replacements, presented in a generally good condition for replacement of the left elbow joint, which was swollen and had reduced movement., Treatment and Course: The postoperative condition was without complication until the 7th day when arthritic signs set in, interpreted as part of the underlying disease, and cortisone was administered. After microbiological tests had been done and the patient's general state had deteriorated, antibiotic treatment with flucloxacillin and gentamycin as well as local irrigation and suction-drainage of all involved joints was started. Granulocyte and monocyte functions were analysed. Staphylococcal isolates from the patient induced reduced "respiratory burst" activity of the neutrophil granulocytes, apparently the cause of the septic dissemination. He was discharged on the 32. postoperative day, to be followed-up as an out-patient., Conclusion: Both adequate antibiotic administration and, especially, thorough local reduction of pathogens are needed for efficacious treatment. Rapid restoration of granulocyte function and of the "immunocompetence" of monocytes within normal limits are part of the reason for a good therapeutic response. This indicates the need for up-to-date preoperative immunological diagnosis in patients with suppressed immunity to assess the risk of infection and thus plan elective intervention.

Objective: To determine how often gastroenterologists know their own Helicobacter pylori status, how they diagnose the infection and what consequences they draw from the findings., Methods: Between November 1995 and March 1996 questionnaires were sent to gastroenterologists in hospitals (592, with five not reached) or private practice in Germany (431, 12 not reached), with a response rate of 24.4% and 55.4%, respectively., Results: Of the 375 respondents 27 were female; the average age was 47.6 +/- 7.8 years. 151 knew their own H. pylori status (40.3%), with an infection rate of 55.6%. Most of the doctors had used noninvasive diagnostic tests (serology: 18.5%, breath test: 37.7%, serology + breath test 2.0%). 54 doctors (among them three without prior testing) had treated themselves between 1992 and 1995, ulcer or dyspepsia having been the most common indication (in 60%). Between 1992 and 1994 omeprazole plus amoxycillin was the most common form of treatment, while in 1995 a triple regimen with omeprazole and two antibiotics was most common during 1995. Either regimen was well tolerated in 85% of those treated, but about a quarter of doctors reported difficulties in compliance. Only half of the participants tested the result of treatment, similar numbers using either the breath test (n = 14) or biopsy (n = 13) for confirmation., Conclusions: A significant percentage of gastroenterologists in Germany knew their own H. pylori status. However, the diagnostic procedures and indications for treatment often did not respond to recommended guidelines. The frequency of treatment and the regimen used mirrored the improved knowledge of the significance of H. pylori infection and the development of antibacterial treatment during the last few years.

History and Clinical Findings: For 5 years a 59-year-old man had been treated with thyrostatic drugs for hyperthyroidism of unknown aetiology. As he had been losing weight, computed tomography had been performed in the search for a malignancy. It revealed a hypophyseal space-occupying lesion., Investigations: Peripheral thyroid hormone activities were raised, while thyroid-stimulating hormone (TSH) was also raised to 12.4 mU/l and there was evidence of partial hypophyseal insufficiency. Octreotide scintigraphy demonstrated increased activity in the area of the hypophysis., Treatment and Course: The transsphenoidal surgery and immunohistochemical tests confirmed the diagnosis of TSH-producing hypophyseal adenoma. The patient became euthyroid after the operation., Conclusion: TSH-producing hypophyseal adenoma should be considered as a rare cause of hyperthyroidism when it is combined with non-suppressed TSH.