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Over 6 million people in Germany suffer from osteoporosis; approximately half of all women over 70 years old and approximately 1 in 5 men over 70 years old are affected. The most relevant clinical consequences of the disease are fractures leading to a clear impairment in the quality of life. Furthermore, following an osteoporotic fracture especially of the hip or vertebra there is increased mortality. Despite higher individual and socioeconomic relevance, too few patients with osteoporosis still receive adequate treatment. Based on the current guidelines of the governing body for osteology (DVO) the indications for specific medicinal treatment can be determined. Furthermore, the selection of the suitable osteoporosis medication can be carried out by considering several factors, including individual ones.In Deutschland leiden über 6 Mio. Menschen unter Osteoporose; etwa die Hälfte aller Frauen über 70 Jahre und etwa jeder Fünfte der über 70-jährigen Männer ist betroffen. Die wichtigste klinische Konsequenz der Erkrankung sind Frakturen, die zu einer deutlichen Einschränkung der Lebensqualität führen. Darüber hinaus besteht nach einer osteoporotischen Fraktur von insbesondere Hüfte oder Wirbelkörper eine erhöhte Mortalität. Trotz hoher individueller und sozioökonomischer Relevanz erhalten immer noch zu wenig Patienten mit Osteoporose eine adäquate Therapie. Anhand der Leitlinien des Dachverbands Osteologie e. V. (DVO) kann die Indikation zur spezifischen medikamentösen Therapie sicher gestellt werden. Darüber hinaus gelingt unter Beachtung zahlreicher, auch individueller, Faktoren die Auswahl des geeigneten Osteoporosemedikaments.

In Germany, over six million people suffer from osteoporosis. Nearly half of the women over 70 years and nearly 20 % of men at the same age are affected. The clinical and socioeconomical relevance of the disease lies in osteoporotic fractures leading to extensive bone-associated morbidity, increased mortality and health care costs. Fracture risk algorithms and guidelines for the diagnosis and treatment of osteoporosis help to assess the individual fracture risk. By calculating the individual fracture risk, the indication for specific osteoporosis treatment can objectively be determined. A consequent specific osteoporosis therapy is required for patients with a high fracture risk and is essential to prevent osteoporotic fractures and their consequences. As first-line therapy a drug with a proven fracture-reducing effect should be taken. However, for successful osteoporosis therapy, many individual factors have to be considered. A personalized treatment approach should be established according to the severity of the disease, the patient's sex and comorbidities as well as the possible additive and side effects of the drug.

Technological progress has led to numerous innovations in diagnostic and therapeutic applications in diabetes and will also improve the treatment of patients with diabetes in the future. The first commercially available hybrid closed-loop system has been available in the USA since 2016 and the next developmental step toward a fully automated artificial pancreas has been made. The automated control of the basal insulin secretion provides a stabilization of blood glucose with a reduction of hypoglycemia and improvement of long-term control as indicated by improved hemoglobin A1c levels. Although closed-loop systems are not yet officially available in Germany, patients with type 1 diabetes mellitus already benefit from a new generation of continuous glucose monitoring (CGM) systems. Apart from the increased accuracy these new devices can be used for up to 180 days and do not require daily calibration. This article provides a short overview of the innovations in CGM systems and the current status in the development of the artificial pancreas.

Adrenal insufficiency is a potentially life-threatening endocrine disorder. Therefore, it is very important to detect the symptoms in sufficient time and treat effectively to avoid acute adrenal insufficiency. This article provides an insight into diagnostically procedures and therapeutically specific aspects of this rare endocrine disease.

The incidence of type 1 and type 2 diabetes mellitus has been increasing simultaneously. Formerly, these two patients' populations could be differentiated easily, but now, due to the overlapping of both groups, specified diagnostics are necessary. In order to substantiate a suspicion on diabetes, quantifying venous plasma glucose is the gold standard in diagnostics. As a precaution, determination of the HbA

Osteoporosis is the most common clinical disorder of bone metabolism. With regard to the growing spectrum of therapy options, treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations. Prioritization of drugs should be based on the form (primary / secondary) and severity of osteoporosis, sex, age, the specific contraindications and precautions of use of the various available medications and in particular, existing comorbidities.

Grundlagen Das Erstellen guter Arztbriefe macht vor allem Berufsanfangern Schwierigkeiten. Seit funf Jahren lehren wir das Verfassen von Arztbriefen im vierten Studienjahr. Ziel ist es, unseren Studenten den Start in die klinische Arbeit zu erleichtern und ihnen gleichzeitig ein Schema an die Hand zu geben, sich Krankengeschichten besser zu merken. Zwei Jahre nach der Ubung baten wir unsere Absolventen, die Ubung hinsichtlich ihres Lerneffektes und klinischen Nutzens zu bewerten.

Preparing high quality discharge summaries is difficult for first year residents. For 5 years we have been training fourth year students how to write discharge summaries. Our goal is to facilitate the students' start into clinical work. Moreover, we intend to provide the students with a scheme to better memorize patients' histories. Two years after the tutorial the graduates were asked to evaluate the tutorial and to comment on its learning effects.A total of 1228 fourth year students wrote a discharge summary on a patient in whose care the specific student was involved during his or her training in internal medicine. All summaries were read, commented on and graded by a consultant. Two years after the tutorial 310 graduates were invited to complete an online survey on this tutorial.106 (34%) of all invited graduates completed the survey. The opinions on the tutorial greatly differed. In principal the students agreed that the tutorial was an important part of medical training and helped to better structure patients' medical data. The majority of the surveyed graduates, however, were not convinced of its practical usefulness for daily work. The students with the poorer grading found their grade less appropriate than the students with the better grading.Though our main goal could not be achieved in the view of the graduates, the overall opinion was rather positive. Problems with this kind of tutorial lay in the enormous effort of correction and in the discouraging effect of grading on the students with difficulties in the task.

Treatment-resistant hypertension is a common problem in an outpatient setting and often results in hospital admission. Non-identified secondary hypertension, hypertensive nephrosclerosis and non-compliance are major reasons for treatment resistance.A 75-year old woman was admitted to the emergency room because of a hypertensive crisis with alleged treatment-resistant hypertension and progressive headache. Two months ago, renal artery stenosis had been ruled out and a diagnosis of hypertensive cardiomyopathy was established. On admission, the patient had a blood pressure of 210/100 mmHg despite an antihypertensive treatment with nine different drugs. Further investigations ruled out secondary hypertension due to an endocrine cause but were consistent with hypertensive nephrosclerosis. With a supervised drug intake the blood pressure was rather normal to hypotensive, resulting in the need for significant reduction of the antihypertensive medication. The apparent discrepancies were discussed in detail with the patient who finally admitted a previous inconsistent intake of the antihypertensive drugs. Following thorough training and education on the purpose of continued antihypertensive therapy, the patient could be discharged with a normotensive blood pressure profile.Therapy of treatment-resistant hypertension should always consider non-compliance and secondary hypertension as possible reason.

Amputations are relevant problems not only for the surgeon. Physicians and dialectologists are also involved into the wound treatment, the coordination of the attending problems which leads to impaired wound healing (e.g. hyperglycaemia, infection, arterial occlusive disease). Internists should be part of the interdisciplinary setting and also of the decision for the necessary amputation. A well coordinated and interdisciplinary procedure allows to control appearing wound healing disturbances and to receive a functionally optimal result by employing minimal surgical interventions.

The primary care sector is of key importance for the management of patients with diabetes mellitus. The authors investigated (a) the prevalence of diabetes mellitus type 1 and type 2, (b) the type and frequency of non-drug and drug treatment and its association with the presence of diabetic complications, and (c) the quality of metabolic control by HbA1c.Using a nationwide probability sample of 3,188 general practices (response rate [RR] 50.6%), a total of 55,518 (RR 93.5%) patients were assessed in a prospective cross-sectional study by their physicians in September 2003 in a standardized manner using questionnaires, physician interview, and laboratory assessments. In addition to diabetes mellitus, 28 diseases were explicitly screened for, among them typical macrovascular (coronary heart disease, cerebrovascular disease, peripheral arterial disease) and microvascular disease (neuropathy, nephropathy, retinopathy, diabetic foot) complications.The prevalence of diabetes mellitus was 0.5% (type 1) and 14.7% (type 2), respectively. 49.5% (type 1) and 50.2% (type 2) of patients had micro- or macrovascular complications. 6.8% did not receive any treatment, 13.5% received non-drug treatment, and 75.3% received oral antidiabetic drugs and/or insulin (26.6% a combination of two or more). Compared to diabetics without any complications, treatment intensity was significantly higher in patients with microvascular complications (odds ratio [OR] 3.02), but not in those with macrovascular complications only (OR 0.98). An HbA1c valueor=7.0% was recorded in 39.6% of patients.Compared to previous studies in this setting, the proportion of diabetics with drug treatment has increased. More patients receive antidiabetic drug combinations. Quality of blood sugar control appears to have improved as well.

Hintergrund und Ziel: Der hausärztliche Bereich ist von zentraler Bedeutung für die Betreuung von Patienten mit Diabetes mellitus. Die Autoren untersuchten a) die Prävalenz von Diabetes mellitus Typ 1 und Typ 2, b) die Art und Häufigkeit von nichtmedikamentösen und medikamentösen Behandlungen und deren Zusammenhang mit dem Vorliegen von diabetestypischen Komplikationen sowie c) die Qualität der Stoffwechseleinstellung anhand des HbA1c. Methodik: Auf der Grundlage einer bundesweiten Zufallsstichprobe von 3 188 Arztpraxen („response rate“ [RR] 50,6%) wurden 55 518 Patienten (RR 93,5%) im September 2003 in einer prospektiven Querschnittsstudie standardisiert mit Fragebögen, Arztgespräch und Labormessungen untersucht. Neben Diabetes mellitus wurden 28 weitere Erkrankungen explizit erfasst, darunter auch die typischen makrovaskulären (koronare Herzkrankheit, zerebrovaskuläre Erkrankungen, periphere arterielle Verschlusskrankheit) und mikrovaskulären Komplikationen (Neuropathie, Nephropathie, Retinopathie, diabetischer Fuß). Ergebnisse: Es wurde eine Prävalenz des Diabetes mellitus von 0,5% (Typ 1) bzw. 14,7% (Typ 2) dokumentiert. 49,5% (Typ 1) bzw. 50,2% (Typ 2) der Patienten hatten bereits mikro- oder makrovaskuläre Folge- bzw. Begleiterkrankungen. 6,8% der Patienten erhielten keine Therapie, 13,5% wurden nur mit Diät/Bewegung behandelt, und 75,3% erhielten orale Antidiabetika und/oder Insulin, davon 26,6% eine Kombinationstherapie mit verschiedenen Antidiabetika. Die Behandlungsintensität war im Vergleich zu Diabetikern ohne Komplikationen bei Patienten mit mikrovaskulären Kom- plikationen deutlich höher (Odds-Ratio [OR] 3,02) als bei denen mit makrovaskulären Komplikationen (OR 0,98). Ein HbA1c-Wert ≥ 7,0% fand sich bei 39,6% der Patienten. Schlussfolgerung: Im Vergleich zu früheren Untersuchungen im hausärztlichen Bereich hat die Rate der medikamentös behandelten Diabetiker zugenommen. Eine Kombinationstherapie wird häufiger eingesetzt. Die Qualität der Einstellung scheint sich ebenfalls verbessert zu haben. Background and Purpose: The primary care sector is of key importance for the management of patients with diabetes mellitus. The authors investigated (a) the prevalence of diabetes mellitus type 1 and type 2, (b) the type and frequency of non-drug and drug treatment and its association with the presence of diabetic complications, and (c) the quality of metabolic control by HbA1c. Method: Using a nationwide probability sample of 3,188 general practices (response rate [RR] 50.6%), a total of 55,518 (RR 93.5%) patients were assessed in a prospective cross-sectional study by their physicians in September 2003 in a standardized manner using questionnaires, physician interview, and laboratory assessments. In addition to diabetes mellitus, 28 diseases were explicitly screened for, among them typical macrovascular (coronary heart disease, cerebrovascular disease, peripheral arterial disease) and microvascular disease (neuropathy, nephropathy, retinopathy, diabetic foot) complications. Results: The prevalence of diabetes mellitus was 0.5% (type 1) and 14.7% (type 2), respectively. 49.5% (type 1) and 50.2% (type 2) of patients had micro- or macrovascular complications. 6.8% did not receive any treatment, 13.5% received non-drug treatment, and 75.3% received oral antidiabetic drugs and/or insulin (26.6% a combination of two or more). Compared to diabetics without any complications, treatment intensity was significantly higher in patients with microvascular complications (odds ratio [OR] 3.02), but not in those with macrovascular complications only (OR 0.98). An HbA1c value ≥ 7.0% was recorded in 39.6% of patients. Conclusion: Compared to previous studies in this setting, the proportion of diabetics with drug treatment has increased. More patients receive antidiabetic drug combinations. Quality of blood sugar control appears to have improved as well.

IMMUNOLOGICAL AND MICROBIOLOGICAL ASPECTS OF DIABETIC FOOT INFECTIONS: Diabetic patients are at increased risk of severe skin and bone infections. Immunological disturbances are reasonable and due to altered specific and unspecific cellular immune responses. Analysis of epidemiology and microbial pathogenicity shows that staphylococci seem to be predestined to induce such infections. Staphylococcus aureus and coagulase-negative staphylococci are able to adhere to the wound ground by a sequela of mechanisms. Initial bacterial adherence is due to hydrophobicity, ion exchanges, and specific binding of bacterial adhesion molecules to cellular receptors. Moreover, staphylococci secrete polysaccharides which form a biofilm together with multilayer cell clusters. The highly structured communities within a biofilm are resistant to distinct immunoeffectors and have a decreased susceptibility to antibiotics in vivo.Assessing the severity of an infection is essential to selecting an antibiotic regimen, the mode of drug administration, and the duration of therapy. Regimens for severe and chronic infections are broader spectrum and often intravenously to obtain high drug concentrations immediately. Infections of the bone often require an antibiotic therapy for4 weeks, while a 1- to 2-week therapy for mild to moderate infections has been found to be effective.Because of the tremendous progress in diagnostics and therapy of diabetic foot infections, infectious complications can be successfully treated by appropriate wound care, metabolic control, and early surgical and antibiotic intervention. Bacterial biofilms involved into chronic infections are new aspects currently not visualized by clinical therapy. Besides the classic antimicrobial therapy, new concepts of an enzymatic therapy or the inhibition of bacterial "communication" (quorum sensing) are in progress and the hope for the future.

The diabetic foot syndrome represents a considerable problem of health care. Due to the systemic character of diabetes mellitus, disturbances on the molecular level of wound healing are assumed.Growth factors and proteases affect the process of normal wound healing, and changes of their activity are relevant to the pathogenesis of the chronic wound. First studies describe the transition of a diabetic foot lesion to a nonhealing chronic wound on the molecular and cellular level.This review reports on the current status of research and new implications for the treatment of diabetic foot syndrome.

In a 31-year-old patient a conventional X-ray was performed due to persistent pain at the lumbar spine level after a cesarean section. It revealed compression fractures of L2 and L3. Besides very clear clinical signs of hypercortisolism, multiple hyperpigmentations and naevi in the patient's face including the lips and the conjunctiva of the right eye were visible, suggesting a Carney complex.Insuppressible cortisol levels confirmed an adrenal origin of hypercortisolism. A selective catheterization of adrenal veins supported the presence of bilateral adrenal cortisol production. The computed tomography showed nodular lesions in the right and a hyperplasia of the left adrenal gland.A bilateral adrenalectomy was performed and a primary pigmented nodular adrenal hyperplasia was confirmed histologically. Clinical signs of hypercortisolism rapidly resolved after adrenalectomy.The diagnosis of Cushing's syndrome as a part of Carney complex was diagnosed at the end of a pregnancy although signs of hypercortisolism were present a long time before. The rare diagnosis of Carney complex should be considered in patients exhibiting symptoms of hypercortisolim and the typical clinical signs (hyperpigmentations).