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Was ist neu? Schmerz und Schmerzfolgen Chronische Schmerzen bei älteren Pflegebedürftigen, die in der eigenen Häuslichkeit leben, sind aufgrund ihrer Häufigkeit und Intensität von hoher Relevanz. Schmerzfolgen werden in dieser vulnerablen Gruppe insbesondere in Form von ausgeprägten Beeinträchtigungen der Mobilität und Aktivität deutlich. Schmerzkommunikation in der ambulanten Versorgung Sowohl die versorgenden Ärztinnen und Ärzte als auch das Pflegepersonal ambulanter Pflegedienste kommunizieren zu selten mit den schmerzbetroffenen Pflegebedürftigen über Schmerzen, ihre Intensität und Dauer sowie über das Schmerzmanagement. Medikamentöse Schmerztherapie Die in der ambulanten Versorgung schmerzbetroffener Pflegebedürftiger defizitäre Schmerztherapie bedarf einer Überprüfung der Angemessenheit schmerzreduzierender Arzneistoffe, der gleichzeitigen Verordnung von Dauer- und Bedarfsmedikation sowie klarer Angaben zu Dosis und Dosisintervallen auf verbindlichen Medikationsplänen. Interdisziplinäre Ressourcen Den Herausforderungen einer interdisziplinären Versorgung älterer Pflegebedürftiger im ambulanten Setting wurde bisher zu wenig Beachtung geschenkt, obwohl die Interdisziplinarität im Schmerzmanagement schon lange gefordert wird. Multidisziplinäres Handeln, basierend auf abgestimmten Leitlinien und Standards, stellt den Schlüssel für ein angemessenes Schmerzmanagement dar. Die Schnittstellenkommunikation zwischen den Berufsgruppen ist optimierungsbedürftig.

ZusammenfassungDie Entschlüsselung der molekulargenetischen Grundlage der primären Hypertonie ist Gegenstand intensiver Forschung und hat in der jüngsten Vergangenheit einen rasanten Fortschritt erfahren. Hierbei spielen genomweite Assoziationsstudien (GWAS) und deren Metaanalysen eine maßgebliche Rolle. In aktuellen Untersuchungen wurden genomweit insgesamt über 900 unabhängige blutdruckassoziierte Genloci identifiziert. Neben einem besseren Verständnis der Mechanismen, die an der Pathogenese der Hypertonie beteiligt sind, kann basierend auf den Daten in Zukunft feine Risikoabschätzung für die Entwicklung der Hypertonie erfolgen. Weiterhin können die Ergebnisse die Entwicklung neuer Pharmaka und individualisierter Therapiestrategien (Pharmakogenetik) der Hypertonie ermöglichen. Eine Relevanz für das Management der primären Hypertonie in der klinischen Praxis haben diese Ergebnisse derzeit allerdings noch nicht.

Twenty years ago, an enzyme homologous to the previously known angiotensin-converting enzyme (ACE) was identified, and subsequently named ACE2. In the renin-angiotensin system (RAS), ACE2 has counter-regulatory functions against the classical effector peptide angiotensin II, for example in blood pressure regulation and cardiovascular remodeling. However, ACE2 provides an initially unexpected interesting link between virology and cardiovascular medicine. That is, ACE2 represents the binding receptor for the cellular uptake of SARS-CoV and SARS-CoV-2 viruses. Thus, ACE2 is relevant for COVID-19. In this context, it was suspected that therapy with RAS blockers might promote transmission and complications of COVID-19 by upregulation of ACE2 expression. The aim of this short review is, to describe the link between the RAS, particularly ACE2, and COVID-19. Based on our analysis and evaluation of the available findings, we justify our conclusion: important drugs such as ACE inhibitors and angiotensin receptor blockers should continue to be prescribed according to guidelines to stable patients in the context of the COVID-19 pandemic.

For venous thromboembolism (VTE) treatment, patient satisfaction was shown to improve with rivaroxaban versus standard anticoagulation in the phase III EINSTEIN DVT and EINSTEIN PE trials. This substudy of the prospective, noninterventional XALIA study of rivaroxaban for deep-vein thrombosis treatment assessed if this was also observed in routine clinical practice. Patients enrolled in XALIA who received rivaroxaban or standard anticoagulation treatment were eligible for inclusion in this substudy. Treatment decisions were at the physician's discretion. Patients completed the 17-item Anti-Clot Treatment Scale (ACTS, comprising a 12-item Burdens subscale, a 3-item Benefits subscale and one global item per subscale) during follow-up. The propensity score-matched set (PMS) was used for the main analysis; the adjusted safety analysis (ASAF) set was used for confirmatory purposes. Analyses by follow-up visit and subgroup, including age, sex, and previous VTE, were also conducted. The PMS-ACTS analysis included 458 rivaroxaban-treated and 434 standard anticoagulation-treated patients. Baseline demographic and clinical characteristics were generally similar across treatment arms. ACTS Burdens scores significantly improved with rivaroxaban versus standard anticoagulation (least-squares mean difference of 2.4 ± 0.4 points; p

Background The noninterventional XALIA study compared rivaroxaban with standard anticoagulation for deep vein thrombosis treatment. This substudy describes the demographics, clinical characteristics, and outcomes of the patients with cancer. Methods Therapy type, dose, and duration were at the physician's discretion. The cohorts identified were rivaroxaban (rivaroxaban alone or after heparin or fondaparinux for ≤48 hours); early switchers (rivaroxaban after heparin or fondaparinux for >48 hours to 14 days and/or a vitamin K antagonist [VKA] for 1–14 days); standard anticoagulation (heparin or fondaparinux and a VKA); low-molecular-weight heparin (LMWH) alone; and miscellaneous (other heparins, fondaparinux alone, VKA alone). Primary outcomes were major bleeding, recurrent venous thromboembolism, and all-cause mortality. Results In XALIA, 587 patients (11.4% of the XALIA cohort) were with cancer: 146 (24.9%) rivaroxaban, 30 (5.1%) early switchers, 141 (24.0%) standard anticoagulation, 223 (38.0%) LMWH, and 47 (8.0%) miscellaneous. Patients with gastrointestinal or lung cancer more commonly received LMWH than rivaroxaban; the opposite occurred in patients with breast or genitourinary cancer. Rates of primary outcome in the rivaroxaban group were as follows: major bleeding, 1.4% (n = 2); recurrent venous thromboembolism, 3.4% (n = 5); and all-cause mortality, 4.8% (n = 7). Conclusion In XALIA, physicians treated cancer-associated thrombosis with various anticoagulant regimens, most commonly LMWH. In addition, the choice of anticoagulant varied with cancer type. In rivaroxaban-treated patients, rates for the primary outcomes were low, suggesting that patients administered rivaroxaban were a good prognosis group.

Background Overall, 30 to 50% of lower-limb deep-vein thrombosis (DVT) cases are isolated distal DVT (IDDVT). The recurrent venous thromboembolism (VTE) risk is unclear, leaving uncertainty over optimal IDDVT treatment. We present data on patients with IDDVT and proximal DVT (PDVT) from the prospective, noninterventional XALIA study of rivaroxaban for acute and extended VTE treatment. Methods Patients aged ≥18 years scheduled to receive ≥3 months' anticoagulation with rivaroxaban or standard anticoagulation were eligible, with follow-up for ≥12 months. We describe baseline characteristics, management strategies, and incidence proportions of VTE recurrence, major bleeding, and all-cause mortality in patients with IDDVT or PDVT, with or without distal vein involvement. Findings Overall, 1,004 patients with IDDVT and 3,098 with PDVT were enrolled; 641 (63.8%) and 1,683 (54.3%) received rivaroxaban, respectively. Patients with IDDVT were younger and had lower incidences of renal impairment, cancer, and unprovoked VTE than those with PDVT. On-treatment recurrence incidences for IDDVT versus PDVT were 1.0 versus 2.4% (adjusted hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.29–1.08), and incidences posttreatment cessation were 1.1 versus 2.1% (adjusted HR: 0.65; 95% CI: 0.32–1.35), respectively. On-treatment major bleeding incidences were 0.9 versus 1.4% and mortality was 0.8 versus 2.2%, respectively. Median treatment duration in patients with IDDVT was shorter than in those with PDVT (102 vs. 192 days, respectively). Interpretation Patients with IDDVT had fewer comorbidities and were more frequently treated with rivaroxaban than those with PDVT. On-treatment and posttreatment recurrences were less frequent in patients with IDDVT. Trial registration number: NCT01619007.

SummaryIn addition to parenteral anticoagulants and vitamin K antagonists (standard AC), non-vitamin K antagonist oral anticoagulants (NOAC) are increasingly being used for the acute and long-term treatment of deep vein thrombosis (DVT).The international, prospective, non-interventional XALIA study compared the acute and long-term treatment of DVT with rivaroxaban or standard AC under routine clinical practice and confirmed the safety and efficacy of rivaroxaban demonstrated in Phase III studies: annual event rates for major bleeding, VTE and all-cause mortality were 1.2 %, 2.4 % and 0.8 % respectively, compared to 3.4 %, 3.9 %, and 6.2 % with standard AC.The XALIA-DE subgroup analysis examined whether the XALIA results were applicable to Germany. The 586 rivaroxaban patients were younger and fewer had active cancer than the 355 treated with standard AC. As in XALIA, the incidence of major bleeding (1.6 vs. 4.1/100 patient-years [PY]), recurrent VTE (1.9 vs. 4.7/100 PY) and all-cause mortality (1.6 vs. 6.8/100 PY) were lower under rivaroxaban than under standard AC. These rates indicate a favourable benefit-risk profile of rivaroxaban under the conditions of everyday practice.

Hypertonie und Alkoholkonsum gehoren beide zu den funf wichtigsten Risikofaktoren fur Krankheitslast in Westeuropa, insbesondere aufgrund ihres Einflusses auf nicht ubertragbare Krankheiten. Unter Hausarzt-Patienten findet man haufig eine Uberlappung beider Risikofaktoren. Durch ein Alkohol-Screening bei Hypertonie-Patienten in der Hausarztpraxis, gekoppelt mit einer im Bedarfsfall anschliesenden Kurzintervention bzw. formellen Behandlung, konnte ein wichtiger Schritt zur Erreichung der WHO-Ziele bei der Pravention und Bekampfung von nicht-ubertragbaren Krankheiten vollzogen werden. Zusatzlich konnte durch eine solche Intervention auch das Therapiemanagement von Hypertonie-Patienten in Deutschland verbessert werden. In einer Arbeitsgruppe von Experten aus Wissenschaft und Praxis wurden Rationale und mogliche Barrieren fur eine solche Intervention diskutiert und sinnvolle Implementierungsschritte fur Hausarztpraxen entwickelt.

BACKGROUND AND AIM Arterial hypertension is a common health problem in older nursing home residents (NHR). The aim of this study was to prospectively analyze blood pressure (BP) patterns, antihypertensive therapy, and visit-to-visit BP variability in NHR. METHODS BP, visit-to-visit variability (estimated by standard deviation of means) of systolic BP (SBP) were analyzed in 12 nursing homes in Germany. NHR who were at least 65 years old and had no moderate or severe dementia were studied at baseline (T0), after 3 and 6 months, respectively. RESULTS BP data were available for 177 NHR (mean age 83.8, 69.5% female) at T0. A total of 90.4% NHR was affected by hypertension. Mean systolic/diastolic blood pressure was 130,1/75,5 mmHg. BP values of ≥ 140/90 mmHg were found in 29.9%, while 33.9% of NHR exhibited SBP values

Pharmakokinetische Arzneimittelinteraktionen, die uber CYP3A4 und / oder P-gp vermittelt werden, betreffen im Rahmen der antithrombotischen Therapie nicht nur die neuen direkten oralen Antikoagulanzien, sondern auch die wichtigen Thrombozytenaggregationshemmer vom Typ der P2Y12-Antagonisten. Hierbei sollen Kenntnisse uber die hier dargestellten Grundlagen und Beispiele dem Kliniker eine Basis fur rationale Therapieentscheidungen beim Einsatz der P2Y12-Antagonisten liefern.

Die pharmakologischen Charakteristika der neuen oralen Antikoagulantien (NOAKs) Dabigatran, Rivaroxaban und Apixaban belegen wesentliche und wunschenswerte Vorteile im Vergleich mit den bisherigen etablierten Therapieprinzipien. Hierzu zahlen die orale Applikation, der rasche Wirkeintritt und das schnelle Abklingen der Wirkung nach Beendigung der Therapie. Ein entscheidender Vorteil ist die vorhersehbare Pharmakodynamik und Pharmakokinetik, die eine Anwendung in fixer Dosierung ohne die Notwendigkeit eines Routinemonitoring der Gerinnungshemmung erlaubt. Allerdings sind auch diese Medikamente nicht frei von Anwendungseinschrankungen bei Niereninsuffizienz und aufgrund von Arzneimittelinteraktionen. Auserdem sind einige Vorgehensweisen in der praktischen Handhabung dieser Medikamente noch nicht (gut) etabliert, wie z. B. das Monitoring der Gerinnungshemmung in bestimmten klinischen Situtationen und die Antagonisierung der Wirkung bei Blutungen. Hierbei konnen Kenntnisse uber die pharmakologischen Grundlagen der NOAKs wichtige Hinweise und Grundlagen fur rationale Entscheidungen liefern.

Objective To analyse and evaluate the use of antihypertensive medication in elderly patients of nursing homes in Germany. Methods Data from a large German health insurance company were collected in a cross sectional study. Included were all insured persons aged 65 years or older, who were residents of a nursing home between 1 April and 30 June 2007 throughout Germany. Antihypertensive drugs were those classified according to the current guidelines published by the German Hypertension Society. Results The study comprised 8,685 residents of nursing homes, 84 % women. The mean age was 84 years (range 65 - 106 years). Antihypertensive drug prescriptions accounted for 17 % of all drug prescriptions and about 70 % of all residents received at least one prescription for antihypertensive drugs. The most frequently prescribed antihypertensive drugs were diuretics, of which 70 % were loop diuretics. Potentially inappropriate combinations of antihypertensive drugs were noted in 5.2 % of patients receiving these drugs. Conclusion Antihypertensive drugs account for a notable part (17 %) of all drug prescriptions in elderly residents of nursing homes throughout Germany. These results indicate that only a minority of all residents were treated with potentially inappropriate or potentially harmful drug combinations. However, the relatively high rate of prescriptions for loop diuretics is a matter of potential concern in this vulnerable group of patients.

Pain is the most common health-related complaint in older persons. International estimations mention up to 80% of nursing home residents suffering from pain. In the meantime, no reliable epidemiological data on pain in nursing home residents are available for Germany, because of restricted access to the nursing-home population. This pilot study aimed to evaluate whether routine data from a German statutory health insurance fund can be used to generate data on pain prevalence and analgesic therapy in nursing home residents. To this end, data of all insured persons of Deutsche BKK who received long-term care insurance benefits for nursing-home care between April and June 2007 were selected anonymously. These data were combined with data on diagnoses and analgesic prescriptions. 3 pain-related diagnoses were selected: R 52 (pain, not elsewhere classified), M 16 (coxarthrosis) and G 53.0 (postherpetic neuralgia) and analysed for corresponding prescriptions. The study sample shows similar characteristics regarding age distribution and care needs in terms of long-term care insurance benefits compared to the official data on nursing-home residents for Germany in 2007. The rate of dementia was within the expected range, too. Therefore, external validity of the sample is assumed. One of the 3 selected diagnoses had been documented in 15% of the sample. About 58% of those received an analgesic prescription. Deficits were discovered regarding the documentation of postherpetic neuralgia, the combination of different analgesics and prescriptions for adjuvant drugs. Prevalence rate and numbers of prescriptions were as frequent as expected. The routine method for this analysis proved to be practicable and reliable. Data quality is deemed sufficient so that the main study will proceed to include a longer period of time and additional data.

Fragestellung: Ziel war die Bewertung der Arzneimittelverordnungen und Nierenfunktion bei geriatrischen Notfallpatienten unter besonderer Berucksichtigung der antihypertensiven Therapie. Patienten und Methodik: Die einjahrige Beobachtungsstudie erfolgte bei Patienten aus Pflege- und Altenheimen oder ambulanter Betreuung, die notarztlich behandelt werden mussten. Insgesamt wurden 109 Patienten (85 Frauen) mit einem Durchschnittsalter von 85±8 Jahren eingeschlossen. Auf der Basis von Kreatinin- und Cystatin-C-Serumkonzentrationen wurde die glomerulare Filtrationsrate (eGFR) mit Formeln errechnet. Ergebnisse: Die haufigste Akutdiagnose in der Notfallsituation war die Synkope (n = 23), die haufigsten Grunderkrankungen waren Demenz (n = 61) und arterielle Hypertonie (n = 60). Die Gesamtanzahl verschriebener Wirkstoffe betrug 603 (Durchschnitt 5,5 ± 3; Bereich 0 – 13), wobei 65 (60 %) der Patienten ≥ 5 Medikamente taglich erhielten. Von 60 Patienten mit bekannter arterieller Hypertonie wurden 55 (92 %) behandelt, und 71 % erhielten mindestens 2 Antihypertensiva. Die am haufigsten verordneten Wirkstoffe waren ACE-Hemmer (n = 33), Schleifendiuretika (n = 28), Betablocker (n = 22) und Hydrochlorothiazid (n = 15). Die durchschnittlichen Konzentrationen von Kreatinin und Cystatin C waren mit 1,33 ± 0,66 mg/dl und 1,78 ± 0,83 mg/l erhoht. Die Analyse der gemittelten eGFR-Werte zeigte bei bis zu 2/3 der Patienten eine relevante Einschrankung

The main pathomechanism of acute renal failure (ARF) is acute tubular necrosis (ATN) due to reduced perfusion of renal cortex resulting in ischemic injury. ATN has the potential for complete restitution. However, acute renal failure is often complicated by pre-existing renal disease, ongoing toxic injury or non-recovery of systemic circulation. From a clinical point of view, the reason of tubular injury may be based on pre-renal causes, glomerular- and/or interstitial disorders or obstructive nephropathy. Therapy must be specifically targeted on the underlying causes to overcome ARF. If kidney function is not reconstituted in an appropriate time period, renal replacement therapy has to be initiated. Recent evidence for improved patient survival supports an augmented dialysis dose to achieve a maximum of metabolic, volume and electrolyte control. To reach these goals, daily intermittent or continuous forms of hemodialysis or hemofiltration are appropriate measures.

BACKGROUND AND OBJECTIVE Early specialist care of patients with renal disease, including timely and planned onset of dialysis, determine the course of the disease, quality of life, hospitalization and life expectancy. A multi-centre enquiry by standardized questionnaire was undertaken to define and analyse medical care of newly dialysis-requiring patients. PATIENTS AND METHODS Data on 551 patients in five different regions of Germany who for the first time required renal replacement treatment were prospectively collected between July 2002 and March 2003. Documentation of history, clinical findings and biochemical tests was done on consecutive patients with a standardized questionnaire, until the desired number of cases was reached. RESULTS The mean age of the patients (55.4% males) was 64.8 years. 30.7% had diabetes mellitus, 22.3% arterial hypertension/nephrosclerosis and 16.9% glomerulonephritis/vasculitis. Early predominantly nephrological care had been undertaken in 38.7% of patients. 59.0% were cared for almost exclusively by their general practitioner until the time when dialysis was started. 229 patients (41.6%) were referred to specialist (nephrologists) only when dialysis had become necessary. The onset of dialysis was at the right time in only 50.5% of this group. Comparing the care given by nephrologists with that by general practitioners, elective (i.e. planned) dialysis was begun in 81.0% vs. 48.0% (p