Seite 203
Editorial Dr. Jasmine Thibaut, Stuttgart

Nerven behalten

Seite 207 -208
Medizin meets Pharmazie Sven Meuth, Münster

Multiple Sklerose

Basiswissen

Neuroimmunologische Erkrankungen spielen im jungen Erwachsenenalter eine relevante Rolle. Am häufigsten kommt die multiple Sklerose vor, eine meist schubförmig verlaufende Erkrankung, die zu dauerhaften neurologischen Ausfällen führen kann.

English abstract

Multiple Sclerosis - The basics

Multiple Sclerosis (MS) is a chronic inflammatory degenerative disease of the central nervous system (CNS) that mainly manifests itself between the age of 20 and 40. On average, women are affected 2-3 times more often than men. Germany currently counts approximately 250,000 MS patients. The worldwide prevalence strongly fluctuates between regions, with a definite north-south gradient. The multitude of symptoms notably impacts patients on a physical, psychological, and social level. Optic neuritis, an inflammation of the optic nerves, leads to visual problems very early in the disease course. Significant cognitive deficits are evident on several levels, especially concerning information processing speed. A permanent feeling of fatigue, severely limited motor functions in particular regarding gait, and reduced urinary retention further make up the symptom profile. The disease reduces patients' quality of life and greatly limits work productivity.

Seite 209 -210
Medizin meets Pharmazie Sven Meuth, Münster

Multiple Sklerose

Verlaufsformen und Diagnostik

Bei der multiplen Sklerose spielt die frühe Diagnosestellung eine übergeordnete Rolle. Gerade in frühen Erkrankungsstadien können verfügbare Arzneimittel den Verlauf der Erkrankung günstig beeinflussen.

English abstract

Multiple Sclerosis – Disease course and diagnostics

MS is the neurological condition that most frequently leads to permanent disability in adults. The specific disease course may either be relapsing or progressive, with the following known forms: clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), secondary progressive MS (SPMS), and primary progressive MS (PPMS). To specify appropriate treatment algorithms, it is vital to differentiate between active and inactive disease development. Obtaining a detailed medical history, clinical and laboratory evaluations, MRI assessment, plus cerebrospinal fluid (CSF) examination and measuring multimodal evoked potentials (somatosensory, motor, and visual EP) are the essential diagnostics. Animal experiments and human studies have shed light on MS development arising from interactions of genetic and environmental factors that essentially cause a breakdown of the immune tolerance network. Modern therapeutic approaches target different levels of immune system activation to limit disease activity.

Seite 211 -213
Medizin meets Pharmazie Sven Meuth, Münster

Multiple Sklerose

Therapie

Unser Verständnis zu entzündlichen Erkrankungen in der Neurologie, insbesondere zur multiplen Sklerose, hat sich in den letzten Jahren dramatisch verbessert, was sich auch in einer Vielzahl neu zugelassener Therapien widerspiegelt.

English abstract

Multiple Sclerosis – Therapy

Even early in the course of MS, essential neuronal structures are destroyed, making an early-onset therapy crucial. Disease course and degree of disability can be positively influenced by therapeutic agents that protect the CNS from immune cell infiltration. The drugs glatiramer acetate and interferon beta are recommended as therapy for CIS. Regarding RRMS, the level of disease activity dictates the appropriate treatment. A mild to moderate disease course can be treated with dimethyl fumarate, glatiramer acetate, interferon beta, or teriflunomide. For highly active disease courses, first choice therapeutics are alemtuzumab, cladribine, fingolimod, natalizumab, and ocrelizumab. PPMS can currently only be treated with ocrelizumab. Treatment possibilities for MS have improved dramatically in the last two decades.

Seite 214 -219
Medizin meets Pharmazie Sven Meuth, Münster

Multiple Sklerose

Multiple Sklerose im höheren Lebensalter und Aspekte des alternden Immunsystems

Auch bei Patienten über 65 Jahren kommt die multiple Sklerose vor. Hier stellt sich die Frage nach den unterliegenden immunologischen Krankheitsmechanismen. Daher muss besonders sorgfältig zwischen der potenziellen Wirksamkeit und den Nebenwirkungen der verfügbaren Therapien abgewogen werden.

English abstract

Multiple Sclerosis – MS in older patients and aspects of the aging immune system

The availability of improved therapies has led to a higher average age of MS patients. Also, the prevalence of late-onset MS (LOMS) has increased in recent years. In this context, the aging immune system brings its specific challenges when treating older patients with MS, who may be essentially multimorbid and under concomitant medications. Most clinical studies on MS include patients between the age of 18 and 55, making it difficult to derive therapeutic guidelines that consider the specificities applying to older patients, especially concerning age-related pharmacodynamic and pharmacokinetic changes. For example, the dosage and therapeutic intervals may need to be revised for this group. The processes underlying immunosenescence, the deterioration of the immune system in natural aging, may reduce the effectiveness of immunomodulatory therapies, while side effect profiles remain. A strict risk-benefit analysis needs to be applied by the responsible physician before initiating or discontinuing treatment in older MS patients.

Seite 220 -222
Medizin meets Pharmazie Sven Meuth, Münster

Multiple Sklerose

Patientenfall

Die Therapie der multiplen Sklerose ist abhängig von verschiedenen patientenrelevanten Faktoren, aber auch von der Aktivität der Erkrankung. Im vorliegenden Fall zeigt sich ein „Therapieversagen“ unter Basistherapien, sodass die Empfehlung zu einer weiterführenden Therapie ausgesprochen werden muss.

English abstract

Multiple Sclerosis – A case report

Our case study reports on a 35-year-old RRMS patient who works as a teacher and has two healthy children. Initially diagnosed with CIS in 2012, she received confirmation of RRMS diagnosis in 2013. To stabilize disease progression, a basic therapy with interferon beta 1a was initiated but stopped three months later due to flu-like adverse events. Therapy was switched to glatiramer acetate until severe adverse effects in 2017 led to a therapy change back to interferon beta 1a. During the entire treatment period, MRI assessments and clinical evaluations revealed a continuous increase of relapsing disease activity, finally leading us to recommend an escalation therapy appropriate for highly active MS in 2017. Aspects to consider when selecting the right escalation therapy are the expected effectiveness and adverse effects as well as the patient's circumstances, for example, child-wish and family planning. In this context, "patient empowerment" requires a complete description of all available therapeutic options by the physician, relaying known side effects, treatment schedule and duration, and expected strain on day-to-day life, to enable a fully informed patient decision. Our patient is selected to continue treatment with oral pulsed cladribine.

Seite 223
Medizin meets Pharmazie

Zusammenfassung:

Multiple Sklerose

Alle Antworten auf einen Blick

Seite 227 -233
Übersicht Ingo Stock, Bonn

Enteritische Protozoen-Erkrankungen

Giardiasis und Kryptosporidiose

Die durch Giardia lamblia hervorgerufene Giardiasis und die von Cryptosporidium-Arten verursachte Kryptosporidiose gehören weltweit zu den häufigsten enteritischen Protozoen-Erkrankungen des Menschen. Die mit starken, oft langanhaltenden Durchfällen einhergehenden Enteritiden werden in weniger entwickelten Regionen der Welt besonders oft beobachtet, sind aber auch in Deutschland nicht selten. Für die Therapie der Giardiasis gelten Nitroimidazole wie Metronidazol als Mittel der Wahl. Kryptosporidiosen werden in der Regel symptomatisch behandelt. Bei HIV-Infizierten mit Kryptosporidiose ist die antiretrovirale Therapie zur Verbesserung der Immunfunktion besonders bedeutsam. Die Prophylaxe der Erkrankungen stellt wegen der niedrigen infektiösen Dosis und der Umweltstabilität der Krankheitserreger eine besondere Herausforderung dar.

English abstract

Enteritic protozoan diseases: giardiasis and cryptosporidiosis

Giardiasis due to Giardia lamblia and cryptosporidiosis caused by Cryptosporidium species belong to the most common enteric protozoan diseases in humans worldwide. The intestinal diseases are associated with severe, often long-lasting diarrhea as well as some other symptoms. Giardiasis and cryptosporidiosis are observed most frequently in less developed regions of the world, but they are also not uncommon in industrialized countries such as Germany. For the treatment of giardiasis, nitroimidazoles such as metronidazole are the treatment of choice. Cryptosporidiosis, however, is usually treated symptomatically. In HIV-infected people with cryptosporidiosis, antiretroviral therapy for improvement of the immune function is particularly important. The prophylaxis of the diseases presents a special challenge due to the low infectious dose and the environmental stability of these pathogens.

Seite 234 -241
Klinische Pharmazie Ronja Mathis, Marburg/Fulda, Roland Radziwill, Annette Freidank, Fulda, und Carsten Culmsee, Marburg

Objective Structured Clinical Examinations (OSCE)

Die Implementierung im Fach Klinische Pharmazie – Ein Schritt zur praxis- und kompetenzorientierten Lehre und Prüfung

Das Berufsbild des Apothekers hat einen starken Wandel erfahren: Über die Arzneimittelversorgung und -herstellung hinaus leisten Apotheker einen wesentlichen Beitrag zur Arzneimitteltherapiesicherheit und zur Therapieoptimierung. Die universitäre, pharmazeutische Ausbildung muss sich hinsichtlich der geforderten Kompetenzen im Bereich der Medikationsanalyse, des Medikationsmanagements und der Patientenbetreuung entsprechend weiterentwickeln. International sind Objective Structured Clinical Examinations (OSCE) vor allem in englischsprachigen Ländern bereits fester Bestandteil der universitären Lehre. In Deutschland ist diese kompetenzorientierte Lehr- und Prüfungsform im Fach Pharmazie Neuland. Um eine wissenschaftliche Basis für die Implementierung von OSCE im Fach Klinische Pharmazie zu schaffen, wurde an der Philipps-Universität Marburg ein Promotionsprojekt initiiert. Seit 2018 wird im 8. Fachsemester ein 10-Stationen-OSCE für etwa 100 Studierende durchgeführt. Das Ergebnis: OSCE stellen ein reliables und praktikables, wenn auch Ressourcen-intensives Lehr- und Prüfungsformat zur Evaluierung klinisch-pharmazeutischer Kompetenzen dar.

English abstract

The implementation of objective structured clinical examinations (OSCE) in clinical pharmacy course – one step towards practice-related and competency-based education and assessment

The role of the pharmacists has changed significantly over the last decades. In particular, the patient moved to the center of multi-professional therapeutic approaches. Therefore, the demands on pharmacists to participate in patient care and patients' therapy as a part of a multi-professional team are increasing. Competency standards have been defined to meet these current developments in pharmacy practice. Medication therapy management, pharmacotherapy safety and inter-professionalism are becoming more relevant in community and hospital pharmacy settings. To prepare future pharmacists for the challenges they will have to face in pharmacy practice, pharmacy education has to evolve accordingly.

Objective structured clinical examinations (OSCE) are an adequate tool to assess clinical competencies such as the students' clinical-pharmaceutical knowledge, problem-solving, communication and counselling skills. OSCE are an assessment method in which the examinees rotate through a series of time limited stations and are assessed with regards to their professional performance in a simulated environment against a standardized scoring system. OSCE show a high degree of objectivity and standardization. Certainly in the UK, USA, Canada and Australia, OSCE have proved their role as a reliable and valid assessment method in medicine and pharmacy courses. However, at German universities there is still the need for progression in practice-related, competency-based education and assessment methods to meet the current changes in the pharmacists' world. Only very few OSCE approaches have been established so far.

Thus, a study at Philipps-University Marburg was conducted with the aim to provide a scientific basis for the implementation and quality assurance of OSCE in pharmacy curricula in Germany. The reliability of the OSCE was assessed by means of Cronbach's Alpha. For further quality assurance “Cronbach’s Alpha, If Item Deleted” was calculated to identify OSCE stations that decrease overall reliability. The emerging costs and personnel needed were recorded to determine OSCE feasibility.

The results indicate a moderate to high reliability, comparable to international and national OSCE of internal medicine. None of the implemented OSCE stations was identified as decreasing overall reliability and needed to be subject to revision. Therefore, all OSCE stations used in the OSCE are applicable and appropriate for further use. The development and conduction of OSCE in cohorts of up to 100 students are feasible. However, there are high personnel and financial requirements for a well-functioning OSCE. In conclusion, the results shown in this study provide a basis for the implementation of OSCE in a clinical pharmacy course within the pharmacy curriculum with the important aspect of quality assurance. To meet the current changes in pharmacy practice, pharmacy education has to evolve accordingly. OSCE could be a step towards practice-related, competency-based education and assessment.

Seite 242 -247
Referiert & kommentiert Simone Reisdorf, Erfurt

Morbus Parkinson

Apomorphin in neuer Applikationsform – wirksam gegen Off-Episoden

In einer multizentrischen, doppelblinden, randomisierten, Placebo-kontrollierten Phase-III-Studie wurden Off-Episoden bei Parkinson-Patienten mit einem neuartigen Apomorphin-Präparat in sublingualer Formulierung behandelt. Die vom Arzt beurteilte Beweglichkeit der Patienten besserte sich nach Anwendung von Apomorphin-Sublingual-Film in der morgendlichen Off-Episode signifikant stärker als nach Placebo. Apomorphin-Sublingual-Film bewährte sich auch in weiteren Wirksamkeitsendpunkten. Unerwünschte Ereignisse traten vor allem im Magen-Darm-System und im Mund-Rachen-Bereich auf.

Seite 242 -247
Referiert & kommentiert Dr. Larissa Tetsch, Maisach

Multiple Sklerose

Rauchen als Risikofaktor

Zigarettenrauch begünstigt die Entstehung der multiplen Sklerose und ist außerdem mit einer erhöhten Krankheitsaktivität sowie einer schlechten Krankheitsprognose assoziiert. Da die negativen Folgen des Rauchens rückgängig gemacht werden können, sollten rauchende Patienten dabei unterstützt werden, das Rauchen aufzugeben.

Seite 242 -247
Referiert & kommentiert Dr. Maren Mundt, Duingen

Brustkrebs

Antioxidanzien vor und während der Chemotherapie nicht zu empfehlen

Viele Krebspatienten verwenden Nahrungsergänzungsmittel, unter anderem um die Nebenwirkungen der gegen den Tumor gerichteten Therapien zu lindern. Ein wichtiger Mechanismus von Chemotherapien gegen Brustkrebs ist die Erzeugung von zytotoxischen Sauerstoffradikalen. Einige Nahrungsergänzungsmittel wirken antioxidativ und könnten die Wirksamkeit der Chemotherapie negativ beeinflussen.

Seite 242 -247
Referiert & kommentiert Dr. Sabine Fischer, Stuttgart

Protonenpumpeninhibitoren

Risiko einer Darmbesiedlung mit multiresistenten Mikroorganismen

Protonenpumpeninhibitoren hemmen die Magensäuresekretion und stören das Darmmikrobiom. Ob Säuresuppression das Kolonisationsrisiko mit multiresistenten Mikroorganismen erhöht, ist unklar. Im vorliegenden Review untersuchten die Autoren einen möglichen Zusammenhang systematisch.

Seite 242 -247
Referiert & kommentiert Dr. Tanja Saußele, Stuttgart

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