Deutsches Arzteblatt International 

About: Deutsches Arzteblatt International is an academic journal published by Deutscher Ärzte-Verlag. The journal publishes majorly in the area(s): Medicine & Population. It has an ISSN identifier of 1866-0452. Over the lifetime, 2643 publications have been published receiving 66496 citations. The journal is also known as: Aerzteblatt-international.de.

Non-Specific Low Back Pain.

Abstract: Background For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition. Methods The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process. Results If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible. Conclusion A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Potentially Inappropriate Medications in the Elderly: The PRISCUS List

Abstract: In Germany, the Federal Statistical Office (Statistisches Bundesamt) currently predicts a marked rise in the percentage of elderly people in the population, with the number of people over age 80 rising by more than 4 million, to approximately 10 million, by the year 2050 (e1). Multimorbidity is more common in advanced age (1) and leads inevitably to polypharmacy. According to an annual report of medical prescribing in Germany (Arzneiverordnungsreport), persons over age 60 participating in the German statutory health insurance system received an average of 3.1 defined daily doses (DDD) of medication as long-term treatment in the year 2008 (2). This age group was given 66% of all prescribed drugs, even though it accounts for only 26.8% of the population. Comparable figures have been published in the United Kingdom, Sweden, the Netherlands, Ireland, the USA, and other countries (3, e2– e5). The more drugs a patient takes, the greater the risk of drug interactions and adverse effects (e6, e7). Aside from adverse effects in the narrow sense of the term, patients commonly suffer from adverse drug events (ADE), often because of multiple prescribing. In this article, we will make frequent use of the term “adverse drug events” and the abbreviation ADE. Old age is commonly associated with multiple illnesses, as well as with altered pharmacokinetics and pharmacodynamics (4, e8, e9)—for example, delayed renal elimination of drugs and increased sensitivity to anticholinergic and sedating effects. Many drugs are thus inappropriate for elderly patients because of their pharmacological effects and/or potential adverse effects. Many types of ADE are difficult to distinguish from the manifestations of diseases that the patient already has or might develop, and many drugs can elevate the risk of complications, such as falls, that typically affect the elderly (e10). Medications whose risk of ADE exceeds their expected clinical benefit when they are given to elderly persons, and which can be replaced by better-tolerated alternatives, are called potentially inappropriate medications (PIM) (5). Efforts have been made recently in the USA, Canada, France, Ireland, and Norway (6– 11) to identify PIM among the drugs that are available in each of these countries. The best known list of this type is the so-called Beers list (6). The medication recommendations for multimorbid elderly patients that have been published to date in countries outside Germany are variable in both form and content and often do not apply to the German situation because of differences in approved drugs, in prescribing behavior, and in therapeutic guidelines. Propoxyphene, for example, appears on international lists as a PIM but is not available as a medication in Germany. The creation of a specifically German list of potentially inappropriate medications that elderly persons should not take, or whose doses require special adjustment for elderly patients (6, 7), was made a goal of the German Health Ministry’s Drug Safety Initiative (Aktionsplan Arzneimitteltherapiesicherheit) for 2008/2009 (e11), on the recommendation of a council of experts for the evaluation of developments in health care (e12). The joint project was entitled PRISCUS (Latin for “old and venerable”). The PIM list that it created can be found in full at www.priscus.net (in German). This PIM list is described in the present article, and its potential uses are discussed.

The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee.

Abstract: Osteoarthritis is the most common disease of joints in adults around the world (1). Felson et al. reported that about one-third of all adults have radiological signs of osteoarthritis, although Andrianakos et al., in an epidemiological study, found clinically significant osteoarthritis of the knee, hand, or hip in only 8.9% of the adult population (2, 3). Knee osteoarthritis was the most common type (6% of all adults). The likelihood of developing osteoarthritis increases with age. Studies have shown that knee osteoarthritis in men aged 60 to 64 is more commonly found in the right knee (23%) than in the left knee (16.3%), while its distribution seems to be more evenly balanced in women (right knee, 24.2%; left knee, 24.7%) (3, 4). The prevalence of osteoarthritis of the knee is higher among 70- to 74-year-olds, rising as high as 40% (e2). When the diagnosis is based on clinical signs and symptoms alone, the prevalence among adults is found to be lower, at 10% (e3). The radiological demonstration of typical signs of osteoarthritis of the knee is not correlated with symptoms: Only about 15% of patients with radiologically demonstrated knee osteoarthritis complain of knee pain (e4). The incidence of the disorder among persons over 70 is estimated at 1% per year (e5). Epidemiological studies have revealed that there are both endogenous and exogenous risk factors for osteoarthritis (table 1). Genetic factors unquestionably play a role. In a clinical study involving female twins, Spector et al. showed an effect of heredity on the development of osteoarthritis of the hip and knee (e6). In only very few cases, however, can osteoarthritis be attributed to the effect of a single gene. Its development and progression are more likely due to an interaction among multiple genes, in combination with further risk factors. Cross-sectional studies have shown that the risk of knee osteoarthritis is 1.9 to 13.0 times higher among underground coal miners than in a control population (e7– e9); presumably, the main risk factor in this occupational group is frequent work in the kneeling or squatting position. Construction workers, too, particularly floorers, have a significantly elevated prevalence of knee osteoarthritis (e10). In another epidemiological study, Grotle et al. found a significant dose-effect relationship for overweight (BMI >30) as a risk factor for knee osteoarthritis, but not for hip osteoarthritis (e11). Table 1 Endogenous and exogenous risk factors for osteoarthritis of the knee*1 Epidemiology Osteoarthritis is the most common adult joint disease. The present article will discuss osteoarthritis of the knee on the basis of a selective review of relevant scientific and clinical publications and an intensive evaluation of current data from clinical trials. The information given here should enable the reader to recognize the risk factors for osteoarthritis of the knee, be familiar with the diagnostic tests used to demonstrate it, and know how it can be prevented and what joint-preserving treatment options are available.

The Diagnosis of Urinary Tract Infection: A Systematic Review

Abstract: SUMMARY Background: Urinary tract infections (UTI) are among the leading reasons for treatment in adult primary care medicine, accounting for a considerable percentage of antibiotic prescriptions Because this problem is so common and so significant in routine clinical practice, a high level of diagnostic accuracy is essential Antibiotics should not be prescribed excessively, particularly in view of the increasing prevalence of antibiotic resistance Method: Systematic review of relevant articles that were retrieved by a search of the Medline, Embase, and Cochrane Library databases The recommendations of selected international guidelines were also taken into account, as were the German national quality standards for microbiological diagnosis Results: The diagnosis of UTI by clinical criteria alone has an error rate of approximately 33% The use of refined diagnostic algorithms does not completely eliminate uncertainty Conclusion: With the aid of a small number of additional diagnostic criteria, antibiotic treatment for UTI can be provided more specifically and thus more effectively Differentiating UTI from asymptomatic bacteriuria, which usually requires no treatment, can lower the frequency of unnecessary antibiotic prescriptions

On the Proper Use of the Crossover Design in Clinical Trials: Part 18 of a Series on Evaluation of Scientific Publications

Abstract: Background Many clinical trials have a crossover design. Certain considerations that are relevant to the crossover design, but play no role in standard parallel-group trials, must receive adequate attention in trial planning and data analysis for the results to be of scientific value.