The 50 most-cited articles in DMW - Deutsche Medizinische Wochenschrift, 2023

Ehegatten sind seit Anfang 2023 dazu berechtigt, sich bei Einwilligungsunfähigkeit des jeweils anderen in Angelegenheiten der Gesundheitssorge zu vertreten. Damit geht die Pflicht des behandelnden Arztes einher, zu bescheinigen, dass die Voraussetzungen des Ehegattennotvertretungsrechts tatsächlich erfüllt sind. Das neue Gesetz wirft einige Fragen auf, wie im folgenden Artikel erläutert wird. Kernaussagen Ehegatten sind seit dem 01.01.2023 dazu berechtigt, sich im Falle der Einwilligungsunfähigkeit des jeweils anderen gegenseitig in Angelegenheiten der Gesundheitssorge zu vertreten. Hierzu hat der behandelnde Arzt (auch der Notarzt im präklinischen Bereich) zu bestätigen, dass der Patient seine Angelegenheiten der Gesundheitssorge nicht selbst besorgen kann, und sich vom Ehegatten versichern zu lassen, dass keine Ausschlussgründe vorliegen. Ehegatten nehmen damit die Aufgabe der Ermittlung des mutmaßlichen Patientenwillens und der anschließenden rechtswirksamen Zustimmung zu oder Ablehnung von medizinischer Diagnostik und Therapie wahr, die sonst Vorsorgebevollmächtigten und…

BACKGROUND: ME/CFS (Myalgic encephalomyelitis/chronic fatigue syndrome) is an illness that is predominantly viewed as a neuroimmunological multisystem disease, which is still unknown to many doctors in Germany or which they classify as a psychosomatic disease. From their perspective, ME/CFS patients report significant deficits in terms of medical treatment and a doctor-patient relationship (DP relationship) that is perceived as problematic. The aim of the present study is to more precisely analyse the process of finding a diagnosis as an influencing factor on the DP relationship in ME/CFS from the point of view of those affected. METHOD: As part of an explorative qualitative survey, 544 ME/CFS patients (> 20 years; 455 ♀, 89 ♂) with a medical diagnosis of ME/CFS were asked in writing about their experiences with regard to the process of finding a diagnosis. The sampling was previously done by self-activation and via the snowball principle. The questionnaire to be answered was structured analogously to a focused, standardized guideline interview. The evaluation was carried out as…

RISK FACTORS FOR SEVERE COURSES: The CRB-65 score is recommended as a risk predictor, as well as consideration of unstable comorbidities and oxygenation. GROUPING OF COMMUNITY-ACQUIRED PNEUMONIA: Community-acquired pneumonia is divided into 3 groups: mild pneumonia, moderate pneumonia, severe pneumonia. Whether there is a curative vs palliative treatment goal should be determined early. DIAGNOSTIC RECOMMENDATION: An X-ray chest radiograph is recommended to confirm the diagnosis, also in the outpatient setting if possible. Sonography of the thorax is an alternative, asking for additional imaging if negative. Streptococcus pneumoniae remains the most common bacterial pathogen. THERAPY: Community-acquired pneumonia continues to be associated with high morbidity and lethality. Prompt diagnosis and prompt initiation of risk-adapted antimicrobial therapy are essential measures. However, in times of COVID-19, as well as the current influenza and RSV epidemic, purely viral pneumonias must also be expected. At least with COVID-19, antibiotics can often be avoided. Antiviral and…

Zusammenfassung Die Behandlung von Patienten mit chronischen Wunden ist weiterhin eine interdisziplinär und interprofessionell relevante Herausforderung. Die Grundlage einer erfolgreichen Therapie der Betroffenen basiert auf der Behandlung der zugrunde liegenden, pathophysiologisch relevanten Erkrankungen. Zusätzlich sollte aber auch immer eine lokale Wundtherapie erfolgen, um die Wundheilung zu unterstützen und Komplikationen zu vermeiden. Um die Vielzahl von Wundprodukten besser strukturieren zu können, wurde durch eine multidisziplinäre Expertengruppe von WundDACH, dem Dachverband deutschsprachiger Fachgesellschaften, das M.O.I.S.T.-Konzept entwickelt. Hier beschreibt M das Exsudatmanagement (Moisture balance), O die Sauerstoffzufuhr (Oxygenation), I die Infektionskontrolle (Infection control), S die Unterstützung des Heilungsprozesses (Support) und T das Gewebemanagement (Tissue management). Das M.O.I.S.T.-Konzept soll Therapeuten eine Hilfestellung bei der systematischen Planung und auch für die Edukation im Hinblick auf die Lokaltherapie von Patienten mit chronischen Wunden…

ACUTE DYSPNEA: The leading symptom "acute dyspnea" and the causal underlying diseases have a high risk potential for an unfavorable course of treatment with a high letality. This overview of possible causes, diagnostic procedures and guideline-based therapy is intended to help implement a targeted and structured emergency medical care in the emergency department. The leading symptom "acute dyspnea" is present in 10% of prehospital and 4-7% of patients in the emergency department. The most common conditions in the emergency department with the leading symptom "acute dyspnea" are heart failure in 25%, COPD in 15%, pneumonia in 13%, respiratory disorders in 8%, and pulmonary embolism in 4%. In 18% of cases, the leading symptom "acute dyspnea" is sepsis. The in-hospital letality is high and amounts to 9%. In critically ill patients in the non-traumatologic resuscitation room, respiratory disorders (B-problems) are present in 26-29%. In addition to cardiovascular disease, noncardiovascular disease may underlie "acute dyspnea" and requires differential diagnostic consideration. A…

Zusammenfassung Das Pankreaskarzinom nimmt in Deutschland stetig an Häufigkeit zu und stellt aktuell die dritthäufigste tumorbedingte Todesursache dar. Voraussichtlich rückt es bis 2030 auf den 2. Platz und bis 2050 auf den 1. Platz der krebsbedingten Todesfälle vor. Das Pankreasadenokarzinom wird in der überwiegenden Mehrzahl der Fälle spät diagnostiziert und die 5-Jahre-Überlebensrate liegt nach wie vor bei nur 10 %. Zu den beeinflussbaren Risikofaktoren zählen das Tabakrauchen, ein übermäßiges Körpergewicht, der Alkoholkonsum, der Typ-2-Diabetes und das metabolische Syndrom. Der Rauchstopp und die gewollte Gewichtsabnahme (bei Adipositas) können das Pankreaskrebsrisiko um etwa 50 % reduzieren. Zudem ist die Früherkennung des sporadischen Pankreaskarzinoms im Stadium IA – nun mit einem 5-Jahre-Überleben von 80 % – bei Menschen über 50 mit neu diagnostiziertem Diabetes eine realistische Perspektive geworden. Aktuelle Entwicklungen hierzu werden kurz beschrieben.

Lipoprotein apheresis (LA) is usually a last resort in cardiovascular high-risk patients in the context of secondary prevention after lifestyle measures and maximal pharmacotherapy have failed to prevent the occurrence of new atherosclerotic cardiovascular events (ASCVDE) or to achieve the internationally accepted target values for LDL cholesterol (LDL-C). Patients with homozygous familial hypercholesterolemia (hoFH), in whom myocardial infarctions can occur even in children < 10 years of age without adequate therapy, often owe their survival to LA (used here in primary prevention). Severe hypercholesterolemia (HCH) can often be well controlled with modern potent lipid-lowering agents, including PCSK9 approaches, so that the need for LA has decreased here over the years. In contrast, the number of patients in whom elevation of lipoprotein(a) (Lp(a)) is relevant to atherogenesis is increasing in applications to the apheresis committees of the associations of panel physicians (KV). For this indication, LA is currently the only therapeutic procedure approved by the Federal Joint…

A comprehensive geriatric assessment (CGA) encompasses medical, psychosocial, and functional aspects that facilitate comprehensive treatment planning and therapy for older adults. It goes beyond a simple screening and typically includes evaluating functionality, mobility, cognition, and emotions, with additional dimensions being relevant based on specific goals. In essence, CGA is suitable for recognizing and evaluating the complexity of frailty and devising suitable interventions.CGA represents a structured way to map the complexity of frail older adults. Employing a multidimensional strategy, it enables the early identification of frailty, facilitating tailored treatment plans, risk assessment and the monitoring of changes over time. A CGA can be conducted in different settings, including acute geriatric wards, in form of a consultation in non-geriatric wards, or directly in outpatient settings and has proven effective in improving care among frail patients.A recent trend in CGA programs involves the use of virtual assessments through telemedicine. Communication occurs via…

INTRODUCTION: Current 2019 ESC/EAS guidelines for the management of dyslipidemia recommend LDL cholesterol (LDL-C) goals according to the patients' cardiovascular (CV) risk. SANTORINI is the first large European observational study since the 2019 guidelines to assess whether lipid management in patients at high and very high CV risk has improved. METHODS: SANTORINI is a multinational, prospective, non-interventional, observational study in 9602 patients ≥ 18 years at high and very high CV risk requiring lipid-lowering therapy. Individual CV risk was assessed by the investigator. The primary study objective is to document, in a real-world setting, the effectiveness of current lipid management regarding LDL-C levels. RESULTS: For this analysis, complete recruitment data was available for 2086 patients in Germany and 6958 patients Europe. Investigators used the 2019 ESC/EAS guidelines as a basis for CV risk classification in > 50 % of the patients and classified 15.6 % (173/1112) of patients in Germany as high and 84.4 % (939/1112) as very high-risk (Europe: 20.7 % [743/3594] high,…

PURPOSE: The purpose of this study was to analyze the diagnostic workflow of patients with alveolar echinococcosis (AE) and to identify possible diagnosis-delaying factors. METHODS: The number and type of diagnostic procedures of patients diagnosed with alveolar echinococcosis were investigated. The disease history was recorded on the basis of questionnaires, the available findings, and data supplements from the hospital information system (SAP). Statistical analyses were performed using SAS version 9.4 and Microsoft Excel version 16.43. The study population of the cross-sectional study included n = 109 patients with confirmed alveolar echinococcosis. RESULTS: The definitive diagnosis of alveolar echinococcosis of the liver was made at 26.5 ± 65.0 (mean ± standard deviation) months (min - max: 0 - 344, median = 3). The majority of patients were diagnosed because of incidental imaging findings of the liver (n = 74/109 (67.9%)). A total of n = 56/74 (75.7%) of all incidental findings were diagnosed in an outpatient setting, while n = 15/74 (20.3%) of cases were diagnosed during…

The Frailty syndrome is usually related to the aging process and chronological age, but it is not an inevitable consequence of it - at least until the final phase of life. Primary care interventions that promote physical activity and nutrition can prevent the progression from pre-frailty to frailty. This article presents the current state of knowledge on primary and secondary prevention of frailty.

BACKGROUND: In addition to standard vaccination for patients aged 60 and older, the Standing Committee on Vaccination (STIKO) recommends immunization against pneumococci for anyone at increased risk, including patients with chronic vaccine-relevant underlying conditions. In Germany, the Robert Koch Institute (RKI) regularly publishes vaccination coverage rates (VCRs) for these patient groups, without stratifying by other parameters. This study examines VCRs of patients with underlying chronic diseases, stratified by disease groups and entities, the re-vaccination rate, and VCRs in patients aged 60 years and older. METHODS: This descriptive retrospective cohort study is based on a sample of about 4 million SHI-insured patients aged 16 years and older for the years 2014 to 2019, from the Institute for Applied Health Research (InGef) database. The sample is representative of age and sex distribution in the German population. RESULTS: Extrapolated to the total SHI-population, the overall pneumococcal VCR in patients aged 60 years and older was 45.9 % (of n= InGef standard vaccination…

In the event of the loss of the ability to give consent and thus the possibility of legally validating one's own will, the law regularly provides for a mandatory third-party representation for the patient. However, their design can be influenced preventively, for which purpose those affected are given three options. These options are: patient's decree, health Power of Attorney, guardianship order. The patient's decree makes content related specifications as to which medical interventions are accepted or not accepted in which illnesses. Health Power of Attorney authorizes another person to make the necessary treatment decisions on behalf of the patient and guardianship order relates solely to the case of a possible guardianship appointment by the guardianship court. The written form of the advance directives forms an objective basis for mutual control of future decision-makers in the event of questions of interpretation. Absolute certainty that the current will of the patient corresponds to the future and that it is reliably determined and implemented in the decision-making situation…

The spread of multidrug-resistant Mycobacterium tuberculosis bacteria jeopardizes tuberculosis control, especially in the WHO Europe region. Following the availability of novel drugs and treatment regimens the World Health Organization has updated management recommendations for patients affected by drug-resistant tuberculosis. These novel recommendations include a significant reduction in the duration of therapy. This review presents the epidemiology and diagnostics of antibiotic-resistant tuberculosis as well as up-to-date treatment recommendations.

Extrapulmonary tuberculosis (TB) presents unique diagnostic and therapeutic challenges. The site of involvement can vary widely, with common sites including the lymph nodes, pleura, skin, ear, nose and throat, genitourinary system, pericardium, gastrointestinal tract, bones and joints, and central nervous system. Clinical manifestations of extrapulmonary TB are diverse and often non-specific. Diagnosis is based on a combination of clinical suspicion, imaging, histopathology, and microbiology. Treatment of extrapulmonary TB generally follows similar principles to pulmonary TB, but the duration of treatment depends on the site of involvement and the extent of the disease. Increased awareness among healthcare providers is essential for the timely recognition and effective management of extrapulmonary TB cases.

Frailty increases the older adult's vulnerability to suffer adverse health outcomes. To date, no gold standard for the diagnosis of frailty exists. This article provides an overview of the most relevant frailty instruments and their scope of application.

, TSH, transaminases, creatinine, urea, protein and protein in the urine are useful. Since virtually all routine methods for LDL-C are biased by high triglycerides, lipoprotein electrophoresis is indicated for triglycerides above 400 mg/dl (4.7 mmol/l). Primary HLPs have known or yet unknown genetic causes. Primary hyperlipidemias should be taken into consideration especially in young patients with an LDL cholesterol concentration are above 190 mg/dl (4.9 mmol/l) and/or triglycerides above 400 mg/dl (10 mmol/l) and secondary HLP (obesity, alcohol, diabetes mellitus, kidney disease) is excluded. The basic diagnostics is meaningfully extended by the measurement of lipoprotein (a) (Lp(a)). It is indicated in moderate and high risk of vascular disease, progression of atherosclerosis in "well-controlled" LDL cholesterol, familial clustering of atherosclerosis or high Lp(a), evidence for elevated Lp(a) coming from lipoprotein electrophoresis, aortic stenosis and in patients in whom statins have a poor effect. Genetic diagnostics needs to be considered if primary HLP is suspected. It is…

Diabetes mellitus is the most common metabolic disease with >500 million people affected worldwide and currently 8,7 million in Germany. About 90% of diabetes cases are due to type 2 diabetes mellitus (T2D). This form of diabetes is characterized by an increased release of proinflammatory adipokines, endothelial dysfunction and hyperglycemia, among others. Hypertension and dyslipidemia are also very commonly present. The prevalence of cardiovascular disease is about 2-3 times higher in T2D than in age-matched individuals without a diagnosis of diabetes. Cardiovascular mortality is also about twice as high in people with diabetes compared to a non-diabetic population. People with diabetes are therefore generally considered a high-risk cardiovascular group and require special attention in the diagnosis and treatment of cardiovascular disease. Contributing factors to reduce high cardiovascular risk include a healthy lifestyle, normalization of blood pressure, optimization of blood lipid levels, and specific diabetes therapy tailored to cardiovascular risk. This review addresses the…

Increased economization in the German health care system may have an impact on medical decisions. A selective literature search presents an overview of the current evidence on the influence of financial incentives on inpatient healthcare in Germany. Due to the current economic pressure, physicians increasingly feel subjected to financial constraints concerning indication and treatment decisions. There is evidence for financially initiated upcoding and volume expansion. Little is known about the extent, the impact on quality of care, nor on vulnerable groups. The literature clearly documents effects of financial pressure on job satisfaction, perceived stress, and the health of attending physicians. The current discussion on the economization of physician practice is important, especially with regard to disincentives and job satisfaction. Little is known about the risks to patient health.

Was ist neu? Aktuelle Leitlinien zum Telemonitoring bei chronischer Herzinsuffizienz Die telemedizinische Mitbetreuung führt bei Risikopatienten zur Reduktion von Herzinsuffizienz-Hospitalisierungen und zu einer Lebensverlängerung. Deshalb hat der Gemeinsame Bundesausschuss (G-BA) das Telemonitoring bei Patienten mit einer Herzinsuffizienz als eigenständige Methode anerkannt und zur Abrechnung als Regelleistung der gesetzlichen Krankenkassen zugelassen. Damit haben seit 2022 in Deutschland ca. 200000 Patient*innen einen Anspruch auf eine telemedizinische Mitbetreuung. Die Implementierung in den kardiologischen Praxisbetrieb ist komplex, weil sie neben der Einführung der telemedizinischen Technik die Strukturierung zahlreicher Prozesse wie Patientenschulungen, die Erarbeitung von „Standard operation procedures” (SOPs) beim Vitaldatenmonitoring sowie Qualitätssicherungsmaßnahmen umfasst. Aktuelle Studienlage In den letzten 3 Jahren wurden mehrere randomisierte klinische Studien, überwiegend mit dem Ziel der Indikationserweiterung, durchgeführt. Dazu wurden mit der bereits in…

In case of hypoxemia, the oxygen content is often still in the lower normal range, so that there is no hypoxia in the tissue. If the hypoxia-threshold is reached in the tissue in hypoxic, anemic and also cardiac-related hypoxemia, identical counterregulations occur in the cell metabolism, regardless of the cause of hypoxemia. In clinical practice, this pathophysiologic fact is sometimes ignored, although depending on the cause of hypoxemia, assessment and therapy vary widely. While restrictive and generally accepted rules are specified in the transfusion guidelines for anemic hypoxemia, in the case of hypoxic hypoxia, the indication for invasive ventilation is made very early. The clinical assessment and indication are limited to the parameters oxygen saturation, oxygen partial pressure and oxygenation index. During the corona pandemic, misinterpretations of pathophysiology have become evident and may have led to unnecessary intubations. However, there is no evidence for the treatment of hypoxic hypoxia with ventilation. This review addresses the pathophysiology of the different…

Infections represent one of the most frequent complications during therapy of acute myeloid leukemia (AML). In addition to associated prolonged phases of neutropenia, damage to the mucosal barrier by cytotoxic agents favors infections caused by endogenous pathogens. The source often remains unknown with bacteremia being the most common evidence of infection. Infections with gram-positive bacteria predominate, however, infections with gram-negative bacteria more often lead to sepsis and death. Due to prolonged neutropenia, patients with AML are furthermore at risk for invasive fungal infections. Viruses, on the other hand, are rarely the cause of neutropenic fever. Because of the limited inflammatory response in neutropenic patients, fever is often the only sign of infection and therefore always represents a hematologic emergency. Prompt diagnosis and initiation of an adequate anti-infective therapy are critical to avoid progression to sepsis and possibly death.

Pandemics and epidemic outbreaks caused by emerging pathogens can usually only be curbed in the longterm through establishment of protective population-wide immunity. With the unprecedented rapid development and supply of highly effective vaccines against COVID-19, science and industry delivered the critical medical breakthrough for the successful management of the COVID-19 pandemic. By May 2023, WHO could end the public health emergency. Nevertheless, the pandemic and its consequences for medicine, science, and society continue to reverberate. This article reviews at the development and implementation of COVID-19 vaccines, focusing on the situation in Germany, and seeks to draw lessons from the past three years to improve our readiness to combat future outbreaks and pandemics more effectively.

Was ist neu? Assessment und Risikostratifizierung anhand von Frailty Frailty betrifft ungefähr jeden zweiten über 70-jährigen Patienten in der Notaufnahme. Diese werden mit herkömmlichen Triage-Instrumenten nur unzureichend als Risikopatienten identifiziert. Ein Frailty-Screening verbessert die Identifizierung von Hochrisikopatienten mit erhöhter Hospitalisierungs- und Wiederaufnahmerate, 30-Tage- und Ein-Jahres-Mortalität. Medizinische Notfallversorgung von Menschen mit Frailty Unspezifische Beschwerden und geriatrische Syndrome sollten als Red Flag erkannt, altersspezifische Besonderheiten der Vitalparameter beachtet werden. Eine ganzheitliche Evaluation sollte bereits in der Notaufnahme durchgeführt werden, da die Fokussierung auf einzelne Probleme nicht zielführend ist. Alle im Screening identifizierten Patienten sollten im Verlauf geriatrisch evaluiert werden. Patientenzentrierte Versorgung von Menschen mit Frailty Für Patienten mit Frailty steht die Verbesserung des subjektiven Wohlbefindens im Vordergrund. Eine stationäre Aufnahme ist teilweise vermeidbar, auch wenn dies mit…

Peripheral arterial disease (PAD) is considered a marker disease of multi-locular atherosclerosis and is associated with a high risk of cardiovascular events. PAD is both underdiagnosed and undertreated in everyday clinical practice. The disease is often asymptomatic and is often only diagnosed at an advanced stage, especially in diabetics. Therefore, the early diagnosis of PAD is of central importance to provide patients with stage-appropriate therapy at an early stage.

Obesity is a highly prevalent, chronically progressing disease. Obesity represents a challenge for people living with obesity, health care professionals and the society, because it is also associated with several comorbid diseases. For people with obesity in Germany, there is a significant deficit in the medical treatment infrastructure. The treatment access gap is mainly caused by a lack of legal frameworks for the guideline-driven obesity management. A currently developed disease management program for obesity has the potential to fill the gap in obesity management in the future.

BACKGROUND: Advance directives are important to preserve the autonomy of patients for future situations in which they are uncapable of expressing their will. They are considered helpful by many healthcare professionals in their professional practice. However, their knowledge on these documents is not well known. Misconceptions can adversely affect decisions at the end of life. This study examines healthcare professionals' knowledge of advance directives and relevant correlates. METHODS: In 2021 healthcare professionals from various professions and institutions in Wuerzburg were surveyed using a standardized questionnaire on previous experiences with, advice on and use of advance directives, as well as an objective knowledge test containing 30 questions. Apart from the descriptive analysis of single questions out of the knowledge test, various parameters were screened for their influence on knowledge level. RESULTS: 363 healthcare professionals from different care settings participated in the study, including physicians, social workers, nurses and emergency services personnel. 77.5%…

Was ist neu? Epidemiologie Das Still-Syndrom kann sich vom Kindes- bis ins höhere Erwachsenenalter manifestieren – mit jeweils leicht unterschiedlicher klinischer Ausprägung. Pathogenese Das Still-Syndrom ist eine autoinflammatorische Erkrankung unklarer Ätiologie, bei der pathogenetisch das angeborene Immunsystem in Form einer Aktivierung von neutrophilen Granulozyten mit Freisetzung von pro-inflammatorischen Zytokinen IL1, -6, -18, und Typ-1-Interferonen eine zentrale Rolle einnehmen. Diagnose und Differenzialdiagnose In der kürzlich erschienenen DGRh-S2e-Leitlinie zum adulten Still-Syndrom (AOSD) wird empfohlen, die Diagnose anhand der charakteristischen Symptomkonstellation aus u.a. intermittierendem Fieber, Exanthem, Arthralgien/Arthritis nach Ausschluss von Infektionen, Neoplasien und anderen rheumatologischen Erkrankungen zu stellen. Die Erfüllung der Yamaguchi-Klassifikationskriterien kann hierbei die Diagnose unterstützen. Komplikationen Relevante Komplikationen mit Verschlechterung der Prognose sind insbesondere eine Perimyokarditis, eine vielgestaltige Lungenbeteiligung…

Many epidemiological studies found low plasma levels of high-density lipoprotein (HDL) cholesterol (HDL-C) associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). In cell culture and animal models, HDL particles show many anti-atherogenic actions. However, until now, clinical trials did not find any prevention of ASCVD events by drugs elevating HDL-C levels, at least not beyond statins. Also, genetic studies show no associations of HDL-C levels altering variants with cardiovascular risk. Therefore, the causal role and clinical benefit of HDL-C elevation in ASCVD are questioned. However, the interpretation of previous data has important limitations: First, the inverse relationship of HDL-C with the risk of ASCVD is limited to concentrations < 60 mg/dl (< 1.5 mmol/l). Higher concentrations do not reduce the risk of ASCVD events and are even associated with increased mortality. Therefore, neither the higher-the-better strategies of earlier drug developments nor the assumption of linear cause-and-effect relationships in Mendelian randomization trials are…

The treatment of chronic wounds often poses a therapeutic challenge. Assessment of the pathogenesis of the wound, causative and symptomatic interventions are key. Concerning treatment-concepts the evaluation of comorbidities, pain management, the nutrition status of as well as the mobility of the patient are recommended.

GASTROINTESTINAL BLEEDING: Gastrointestinal bleeding occurs frequently in clinical practice. The presence of gastrointestinal bleeding usually is suspected by typical clinical history and results of clinical examination and laboratory findings. Endoscopic treatment of gastrointestinal bleeding is associated with high success rates over 90%. Different techniques for endoscopic hemostasis are available and for most indications, a combination of two modalities is recommended. Endoscopic management of recurrent or persistent bleeding is technically more challenging and associated with increased mortality (up to 10%, especially in patients with high age and comorbidities). In this situation, endoscopic hemostasis using an over-the-scope clip has shown to be superior to standard treatment for recurrent peptic ulcer bleeding in the upper gastrointestinal tract. Recent studies also have shown superiority for first-line over-the-scope clip treatment of non-variceal upper gastrointestinal bleeding in high-risk patients. In this review, management of gastrointestinal bleeding is summarized…

Inflammatory bowel disease (IBD) is often diagnosed in young adults. Starting a family is an important step in life and can be further complicated by Crohn's disease. Therefore, family planning should be discussed with every patient early in the disease course. Counseling about the importance of disease remission and the safety of IBD medication during pregnancy can ameliorate the pregnancy outcome. Active disease during pregnancy can lead to adverse pregnancy outcomes such as preterm birth and low birthweight. To maintain disease remission most therapies should be continued despite the wish to have children. Only a few substances currently used to treat Crohn's disease are contraindicated during pregnancy and should be stopped before conception. This includes Januskinase (JAK)-inhibitors and Methotrexate. Biologics including anti-TNF-therapy, anti-IL-12/anti-IL-23 and anti-integrin therapies should be continued during pregnancy.

What happens when you are no longer able to make medical decisions yourself? The constant increase in the number of people in need of care has led to the concept of advance care planning (ACP). This is a forward-looking, ongoing, and constantly reflective process of discussion regarding preferences and values for future medical and nursing treatments. ACP can sustainably improve the medical and nursing landscape as well as psychosocial care, so that people are treated according to their wishes, even if they can no longer be asked about their treatment wishes. The implementation strategy is dependent on this, as presented in studies. This also includes the financial support of such implementation projects, because only the talks alone, which are exclusively refinanced by §132g SGB V, do not lead to a cultural change regarding the importance of self-determination and dealing with living wills, as well as an improvement in treatment, care, and support for people in the health system.

Was ist neu? Algorithmen auf Basis großer Datenmengen: Voraussetzung für die Anwendung von KI-Algorithmen ist eine hochqualitative Digitalisierung von Präparaten mit ausreichender Auflösung. Ferner ist die zuverlässige Annotation einer ausreichenden Menge von Trainings- und Testdaten nötig. Umfangreiche Bilddatenbanken für die KI-gestützte Leukämiediagnostik: Zur Entwicklung von datengetriebenen Algorithmen wie z.B. neuronaler Netze ist die Bereitstellung großer, kuratierter Datenbanken nötig. Im Bereich der morphologischen Leukozyten-Differenzierung kann dazu z.B. die Annotation von Zehntausenden von Einzelzellen nötig sein. Neuere Methoden benötigen weniger manuelle Annotationen, jedoch in der Regel noch größere Trainingsdatensätze. Methoden zur Nachvollziehbarkeit der Vorhersagen: Die „erklärbare KI“ stellt eine Reihe von Methoden bereit, die den Vorhersageprozess von neuronalen Netzen transparenter machen und für die Vorhersage relevante Anteile der Eingangsdaten erkennen. Dies ermöglicht Anwendern, die Vorhersagen des Algorithmus auf Plausibilität zu überprüfen und z.B. zu…

Was ist neu? Uneinheitliche Datenlage zur optimalen Zieltemperatur. Fiebervermeidung ist die derzeit einzige Maßnahme mit nachgewiesenem Nutzen, um nach einem Herz-Kreislauf-Stillstand das Überleben mit gutem neurologischem Outcome zu verbessern. Unklarheit besteht, ob und welche Patienten von einer niedrigeren Zieltemperatur profitieren. Die ERC-Leitlinien von 2021 empfahlen für alle Patienten, nach inner- und außerklinischem Herz-Kreislauf-Stillstand eine Zieltemperatur von 32−36°C über mindestens 24 Stunden konstant zu halten. Diese Empfehlungen wurden 2022 durch die ERC-ESICM-Leitlinien überarbeitet. So wird aktuell lediglich eine Fiebervermeidung über 72 Stunden nach dem Ereignis empfohlen. Grund dafür sind divergente Studienergebnisse der vergangenen Jahre. Zwei große randomisierte, kontrollierte Studien kommen zu unterschiedlichen Ergebnissen in Bezug auf die Verbesserung des neurologischen Outcomes unter Hypothermie. Ursächlich sind hierfür möglicherweise unterschiedliche Patientenkollektive, welche sich auf die Lage in Deutschland zudem nur eingeschränkt übertragen lassen.…

Pharmacological reduction of LDL-cholesterol (LDL-C) is a major treatment strategy in limiting atherosclerotic cardiovascular (ASCVD) risk. Statins remain the primary therapeutic cornerstone in ASCVD prevention. Furthermore, ezetimibe, bempedoic acid, and PCSK9 inhibition have recently also shown to reduce cardiovascular risk. Unfortunately, a treatment gap remains between guideline-recommended LDL-C goals and what is achieved in real-world practice. An important reason for this is the limited use of novel and effective non-statin lipid-lowering therapies. In order to achieve LDL-C treatment goals and, ultimately, reduction of cardiovascular events, a combination lipid-lowering therapy needs to be considered as the standard of care for patients at very high cardiovascular risk.

Therapeutic fasting has found its way into modern medicine in the last decade through a multitude of experimental work and animal studies as well as increasing clinical research. It is a procedure with a tradition dating back thousands of years and thus comes with a variety of different practices. What they all have in common, is the reduction of daily food intake for a limited period of time. This has a variety of effects on metabolism, cells and organ systems, which can make it a potent tool in medical practice.

Wilson's disease and HFE-hemochromatosis are autosomal-recessively inherited metabolic diseases of the liver. Copper overload in case of Wilson's disease and iron overload in case of hemochromatosis lead to organ damage of the liver and other organs. In order to diagnose these diseases at an early stage and introduce therapy, knowledge of the symptoms and diagnostic criteria of these diseases is important. Iron overload in hemochromatosis patients is treated with phlebotomies and copper overload in Wilson's disease patients with either chelating medications (D-penicillamine or trientine) or zinc salts. After introduction of lifelong therapy both diseases typically have a favorable disease course and further development of organ-damage can be prevented, especially with respect to liver-damage.

BACKGROUND: The rate of mistakes and near misses in clinical medicine remains staggering. The tendency to cover up mistakes is rampant in "name-blame-shame" cultures. The need for safe forums where mistakes can be openly discussed in the interest of patient safety is evident. Following a comprehensive review of the literature, a semi-structured weekly conference, named "mistake of the week" (MOTW), was introduced, enabling physicians to voluntarily discuss their mistakes and near-misses. The MOTW is intended to encourage cultural change in how physicians approach, process, accept and learn from their own and their peers' mistakes. This study seeks to assess if physicians appreciate, benefit from and are motivated to participate in MOTW. METHODS: at the Academic Teaching Hospital Klinikum Konstanz (Germany) were eligible to participate voluntarily. Four groups of physicians (n=3-6) and one group of medical students (n=5) volunteered to participate in focus group interviews, which were videotaped, transcribed and analyzed. RESULTS: The following success factors are crucial for dealing…

Was ist neu? Aktuelle Studiendaten Die randomisierte Disrupt-III-Studie verglich die intravaskuläre Lithotrypsie verkalkter Plaques zur Läsionsvorbereitung vor medikamentenbeschichteter Ballon-Angioplastie (DCB) mit einer Vordilatation mit einem herkömmlichen Ballon. Die einarmige REALITY-Studie untersuchte die direktionale Atherektomie zur Läsionsvorbereitung vor DCB-Angioplastie. Beide Studien zeigten, dass sich auch schwer verkalkte Stenosen und Verschlüsse der femoropoplitealen Arterie bis zu 30cm Länge erfolgreich mit einer geringen Stent-Implantationsrate behandeln lassen. Dies ist von besonderer Bedeutung, da sich in einer multivariaten Analyse eine Residualstenose > 30% nach DCB-Angioplastie als einziger unabhängiger Risikofaktor für eine Restenose erwiesen hat. Der potenzielle Nutzen der Lithotrypsie wurde auch in einer Studie an Zugangsarterien, die für die transfemorale Implantation von Aortenklappenprothesen benötigt werden, mit einer hohen Erfolgs- und niedrigen Komplikationsrate untersucht. Technisches Verfahren zur Behandlung verkalkter Plaques: Intravaskuläre…

most common cause of death and due to our extended life expectancy cancer per se has substantially increased, being highly prevalent after cardiovascular diseases. Evidence also generated from the COVID-19 pandemic, that defined gender differences exist in symptom and disease courses, and have advocated the need to assess gender, ethnic/racial and minority differences in cancer care and treatment more meticulously. It is becoming increasingly evident that in novel cancer care/precision oncology, representation of minorities, elderly and frail patients in clinical trials remains largely unbalanced, thus distribution of cancer success is iniquitous. This article focusses on these aspects and suggests solutions, how this can be improved.

Gender-sensitive medicine takes into account differences of men and women in various diseases with regard to the biological ("sex") as well as the sociocultural ("gender") dimension. This article highlights gender differences in cardiovascular disease and the different prevention strategies based on these differences.

Seasonal influenza causes a significant burden of disease in the German population and is associated with high societal costs. Persons aged 60 years and older are particularly at risk due to immunosenescence and chronic disease and account for a large proportion of influenza-associated hospitalizations and deaths. Adjuvanted, high-dose, recombinant and cell-based influenza vaccines have been developed to improve the effectiveness compared with conventional vaccines. Recent observational studies show better effectiveness of adjuvanted vaccine over conventional vaccines and similar effectiveness to the high-dose vaccine in older adults. Some countries have already considered the new evidence in their vaccination recommendations for the current or earlier seasons. The availability of the vaccines for older adults should also be ensured in Germany to guarantee a high level of vaccination protection.

Was ist neu? Ösophagus-Karzinom Immun-Checkpoint-Inhibitoren (ICI) sind Bestandteil der adjuvanten Therapie des Plattenepithelkarzinoms und des Karzinoms des ösophagogastralen Übergangs nach vorheriger neoadjuvanter Radiotherapie. Die Kombination von ICI mit Chemotherapie (CTx) ist in der palliativen ersten (Nivolumab und Ipilimumab) und zweiten (Nivolumab) Therapielinie zugelassen. Plattenepithelkarzinome sprechen wahrscheinlich besser auf ICI an als Adenokarzinome und es gibt eine Zulassung für Ipilimumab und Nivolumab als alleinige ICI-Therapie für Plattenepithelkarzinome. Magenkarzinom Die Kombination von Chemotherapie mit ICI ist auch beim metastasierten Magenkarzinom wirksam und zugelassen. Mikrosatelliten-instabile (MSI-H) Tumore sprechen besonders gut auf ICI an und können in der 2. Linie mit Pembrolizumab behandelt werden. Kolorektales Karzinom Pembrolizumab ist als Erstlinientherapie und Nivolumab in Kombination mit Ipilimumab als Zweitlinientherapie für MSI-H/dMMR metastasierte Kolorektale Karzinome (CRC) etabliert. Für andere CRC ist bislang keine Zulassung erfolgt.…

INNOVATIVE ONCOLOGICAL DIAGNOSTICS AND THERAPIES: Compared to other European countries, Germany has a large number of innovative therapy options for the treatment of patients with cancer. Currently, the main challenge in care is to be able to offer these options at the right time to all patients, regardless of their place of residence and treatment setting, who could benefit from innovative therapies. ACCESS VIA CLINICAL TRIALS, MOLECULAR TUMOR BOARDS: Clinical trials are often the first opportunity for controlled access to oncology innovation. Reducing bureaucratic processes and increasing transparency about currently recruiting trials is imperative to allow more patients early access across sectors. The concept of decentralized clinical trials and (virtual) molecular tumor boards is also appropriate to allow more patients potential trial inclusion. COSTS OF INNOVATIVE ONCOLOGICAL THERAPY: The best possible use of a growing number of innovative and cost-intensive diagnostic and therapeutic options for a wide variety of patient-specific situations requires low-threshold…

Was ist neu? Risikofaktoren Hormonelles Ungleichgewicht, Gynäkomastie, Lifestyle-Faktoren und genetische Veränderungen (insbesondere BRCA2-Mutationen) zählen zu den Hauptrisikofaktoren für das Mammakarzinom beim Mann. Prognose Die Brustkrebserkrankungen von Männern gehen mit einer schlechteren Prognose einher als die der Frauen. Diagnostik Zur Abklärung eines suspekten Befunds in der männlichen Brust sollten nach Anamnese und klinischer Untersuchung eine Mammasonografie und Mammografie durchgeführt werden. Therapie Die Behandlung wird in enger Anlehnung an das Vorgehen bei der Brustkrebserkrankung der Frau durchgeführt. Es steht eine Vielzahl an medikamentösen Therapiemöglichkeiten zur Verfügung. Einige sind jedoch nur als Off-Label-Use anzuwenden, da eine Zulassung beim Mann fehlt. Nachsorge Die Nachsorge erfolgt nach einem standardisierten Nachsorgeschema analog dem weiblichen Mammakarzinom. Bei positiver Familienanamnese für das Mammakarzinom und/oder Ovarialkarzinom erfolgt die Beratung und Testung gemäß den Kriterien des Deutschen Konsortiums Familiärer Brust- und…

Was ist neu? Periprothetische Infektionen: Diagnostik, Prothesenerhalt und Therapielänge. Nach einer neuen Studie kann bei Vorliegen einer hämatogenen periprothetischen Infektion und weiteren einliegenden Gelenkprothesen, die in der klinischen Untersuchung unauffällig sind, auf weitere invasive oder bildgebende Diagnostik verzichtet werden. Periprothetische Infektionen, die spät auftreten (> 3 Monate nach Implantation) haben ein schlechteres Outcome. Neue Studien versuchen Faktoren zu identifizieren, wann der Prothesenerhalt weiterhin eine Option ist. Eine neue randomisierte Landmarkstudie aus Frankreich konnte keine Nichtunterlegenheit für 6 versus 12 Wochen Therapielänge zeigen. Somit ist anzunehmen, dass dies aktuell der Standard für alle OP-Modalitäten (Erhalt oder Wechsel) wird. Wünschenswert wären weitere Studien zu dem Thema, die v.a. mehr Patienten mit spätem Prothesenwechsel betrachten. Spondylodiszitis: Inzidenz und Erregerprofil. Die Spondylodiszitis ist eine eher seltene Knocheninfektion, deren Inzidenz in den vergangenen Jahren aber weiter stark gestiegen ist (erneut…

Obwohl Lungen- und Herzerkrankungen häufig zusammen auftreten, liegt der Fokus in der akuten medizinischen Notfallversorgung oft nur auf der Behandlung der kardiologischen Beschwerden. Dies führt vielfach zu einer Wiedervorstellung des Patienten und einer verminderten Lebensqualität. Wie also lässt sich diese Behandlungslücke schließen?

20 years of colonoscopy for early cancer detection and screening in Germany. A success story - there is no longer any doubt about that, but a critical look should not be missing either.

Since the first endoscopic polypectomies have been performed, the resection of premalignant lesions during colonoscopy has become a success story in the field of gastroenterology: Incidence and mortality of colorectal cancer have been significantly reduced with the implementation of screening programs. Most polyps in the lower gastrointestinal tract are small and easy to remove. However, larger polyps, early carcinomas and subepithelial lesions can be removed with modern endoscopic resection techniques as well. Minimally invasive endoscopic resections offer an organ-preserving alternative to surgery in a growing number of patients. In this review, we discuss the advantages and limitations of traditional and novel endoscopic resection techniques, including endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic full thickness resection.