Showing papers in "Deutsches Arzteblatt International in 2013"

Brain development during adolescence: neuroscientific insights into this developmental period.

Abstract: Background Adolescence is the phase of life between late childhood and adulthood. Typically, adolescents seek diversion, new experiences, and strong emotions, sometimes putting their health at serious risk. In Germany, for example, 62% of all deaths among persons aged 15 to 20 are due to traumatic injuries. Neuroscientific explanations have been proposed for typical adolescent behavior; with these explanations in mind, one can derive appropriate ways of dealing with adolescents. Method We selectively review pertinent articles retrieved from the PubMed database about the structural and functional development of the brain in adolescence. Results New findings in developmental psychology and neuroscience reveal that a fundamental reorganization of the brain takes place in adolescence. In postnatal brain development, the maximum density of gray matter is reached first in the primary sensorimotor cortex, and the prefrontal cortex matures last. Subcortical brain areas, especially the limbic system and the reward system, develop earlier, so that there is an imbalance during adolescence between the more mature subcortical areas and less mature prefrontal areas. This may account for typical adolescent behavior patterns, including risk-taking. Conclusion The high plasticity of the adolescent brain permits environmental influences to exert particularly strong effects on cortical circuitry. While this makes intellectual and emotional development possible, it also opens the door to potentially harmful influences.

The epidemiology of osteoporosis--Bone Evaluation Study (BEST): an analysis of routine health insurance data.

Abstract: Osteoporosis is a systemic disease of the skeleton characterized by low bone density and abnormal microarchitecture of bone tissue. It becomes clinically evident through the occurrence of osteoporosis-related fractures (1). Low bone density, other risk factors, and the associated fractures are seen above all in the elderly. The prevalence of osteoporosis and of osteoporotic fractures can be expected to rise, because the population as a whole is growing older. Osteoporotic fractures—particularly of the femoral neck and of the vertebral bodies—impair the quality of life (2, 3) and increase mortality (4, 5). They account for most of the burden of disease in patients with osteoporosis. Fractures also lead to greater utilization of medical services, with the associated high costs (4, 6). The prevalence of osteoporosis in Germany has been assessed in a number of studies, yet these have been heterogeneous with regard to their methods, data sources as well as the age groups and populations studied (7– 10) and have therefore yielded divergent findings. In the telephone health survey of the Robert Koch Institute (RKI), 11.9% of the persons aged 50 and above who were interviewed (5.2% of men and 17.6% of women) said that they had received a medical diagnosis of osteoporosis (8). On the other hand, the BoneEVA study, carried out in 2003, arrived at the conclusion that 25.8% of the insurees aged 50 and above who were studied (9.7% of men and 39.0% of women) were osteoporosis patients (9, 10). Meisinger et al., in 2002, arrived at prevalence figures of 1.2% for men and 7.0% for women between the ages of 25 and 74 (7). The assessment of the MONICA cross-sectional study (Augsburg, Germany) revealed that, in 1994/1995, 31.0% of women and 45.1% of men aged 25 to 74 had at least one fracture, with markedly higher fracture rates in women over age 65 (7). Although the presence of osteoporosis and the circumstances of the fractures were also investigated in this study, it was not stated what percentage of the fractures were due to osteoporosis. Figures on the latter question were reported by Brecht and Schadlich (11). The S3 guideline of the German Osteology Group (Dachverband Osteologie, DVO) was initially issued in 2003 and updated in 2006 and 2009. On the basis of this guideline, we carried out the present study with the goal of analyzing the current epidemiological status of osteoporosis in Germany, and the state of care, by means of routine billing data of a large statutory health-insurance carrier (Techniker Krankenkasse, TK) for the years 2006 to 2009. This article focuses on the frequency of osteoporosis and of fractures; prescribing behavior, the frequency of bone-density measurement, and the costs due to osteoporosis are reported elsewhere. The Bone Evaluation Study (BEST) was conceived by the IGES Institute in cooperation with its project partners, the Scientific Institute of the TK (WINEG) and Prof. Dr. med. Peyman Hadji of Philipps-Universitat Marburg (Germany). The study was supported by Amgen GmbH and Nycomed GmbH.

Treatment Options in Patients With Chylothorax

Abstract: Chylothorax is by definition a collection of chyle in the pleural cavity resulting from leakage from the lymphatic vessels, usually from the thoracic duct. The symptoms of chylothorax can occur in patients of any age; the condition has multiple possible causes, and may therefore be encountered in many fields of medicine. Incidence data are available for only postoperative chylothorax, which can occur after almost any surgical operation in the chest. It is most often observed after esophagectomy (about 3% of cases), or after heart surgery in children (up to about 6% of cases) (1, 2). Treatment options for chylothorax today range from the conservative to surgical and—more recently—interventional radiological procedures. Because of the rarity of the condition, no prospective studies have been carried out on how best to treat it, or for how long. For guidance, therefore, we describe the current state of the art of the diagnosis and treatment of this interdisciplinary disease entity.

The Etiology, Diagnosis and Prevention of Liver Cirrhosis: Part 1 of a Series on Liver Cirrhosis

Abstract: Cirrhosis is the final stage attained by various chronic liver diseases after years or decades of slow progression. There are, however, ways to prevent cirrhosis, because the diseases that most commonly lead to it progress slowly, and measures are available to prevent and treat them. Moreover, most cases of hepatocellular carcinoma (HCC) arise in a cirrhotic liver, so cirrhosis prevention is, in fact, also HCC prevention (Figure 1). The risk of developing HCC depends on the underlying disease: It is low, for example, when the underlying disease is autoimmune hepatitis (2.9% in 10 years) (1), and high when the underlying disease is chronic hepatitis B with a viral burden greater than 107copies/mL (19.8% in 13 years) (2). Aside from chronic viral hepatitis, fatty liver disease due to any of the very common underlying disorders (obesity, diabetes, alcohol abuse) commonly progresses to cirrhosis and thus merits both specialized medical treatment and close follow-up by the primary-care physician. Figure 1 The course of chronic liver disease: This article, based on a selective review of the literature, deals with approaches to cirrhosis prevention that involve the proper diagnostic work-up for early detection of chronic liver disease, followed by risk-adapted treatment.

Increase in opiate prescription in Germany between 2000 and 2010: a study based on insurance data.

Abstract: Opioids are among the most important substances in the treatment of cancer pain, and since the 1990s they have been increasingly used for the management of chronic non-cancer pain (CNP) (e1). At that time there was a broad consensus that many cancer and CNP patients were undertreated, due largely to very restrictive use of opioids (e2– e5). “Opiophobia” was viewed as the principal barrier to adequate pain therapy (e6– e9). In parallel with the problemization of inadequate prescription of analgesics and particularly opioids to patients with chronic pain, statistics from German statutory health insurance providers and equivalent figures from many other countries show an uninterrupted rise in prescription of opioids since the mid-1990s (1– 5). In Germany, the number of dispensed daily doses of opioids first exceeded that of non-opioid analgesics in 2002 (1). The increase in prescription of opioids has been interpreted in various ways. Schwabe reported that in the year 2000, 96% of cancer patients received strong-acting opioids—a calculation based on the assumption that these substances were being prescribed exclusively to patients with cancer (e10). This assumption of practically complete provision was energetically refuted by pain specialists (e11). Regardless of this criticism, the 2011 edition of the annual Drug Prescription Report (Arzneiverordnungsreport) for Germany continued to see the increase in prescription of opioids in direct connection with “improved implementation of the WHO’s ladder for cancer pain relief” (1). Data from Norway demonstrate that a considerable proportion of opioids are prescribed to CNP patients (6). Long-term opioid treatment for CNP—the benefit of which is currently debated—is also increasingly being criticized, with demands for close monitoring (7– 11). In Germany, the debate over adequate administration of opioids has become more heated in recent years, partly fueled by the publication of an S3 guideline on long-term opioid treatment of CNP patients (12). The guideline’s conclusion, that there is no sufficient scientific evidence for treatment exceeding 3 months in duration, was controversial, and the discussion did not always remain objective: One group of authors wrote that rampant “opiophobia” was causing “harm” for both patient and physician (e12). The currently available data and opinions cannot be used to demonstrate whether the current situation with regard to the prescription of opioids is satisfactory or whether there is undersupply or otherwise inappropriate provision. The aim of our study was therefore to investigate, over a period of 11 years (2000 to 2010), the prevalence of treatment with different types of opioids and their use in patients with cancer and non-cancer diseases.

Health in the long-term unemployed

Abstract: SUMMARY Background: Although the unemployment rate in Germany is currently low, more than a million persons in the country have been out of work for more than a year. In this review article, we address these persons' state of health, the effect of unemployment on health, and the influence of macroeconomic factors and social policy. Methods: This article is based on a selective review of pertinent literature in the PubMed database. Results: Large-scale meta-analyses and systematic reviews have shown that the long-term unemployed have an at least twofold risk of mental illness, particularly depression and anxiety disorders, compared to employed persons. Their mortality is 1.6-fold higher. Unemployment seems to be not only an effect of illness, but also a cause of it (i.e., there is evidence for both selection and causality). Learned helplessness is an important psychological explanatory model. Limited evidence indicates that the long-term unemployed have a moderately elevated prevalence of alcoholism; unemployment can be both an effect and a cause of alcoholism. Unemployment also seems to be associated with higher risks of heart attack and stroke. Cancer can lead to loss of employment. The link between unemployment and poorer health is strengthened by macroeconomic crises and weakened by governmental social interventions. Conclusion: The long-term unemployed carry a markedly higher burden of disease, particularly mental illness, than employed persons and those who are unemployed only for a short time. The burden of disease increases with the duration of unemployment. The vicious circle of unemployment and disease can be broken only by the combined effects of generally available health care, special health-promoting measures among the unemployed, and social interventions. ►Cite this as:

Pulsatile Tinnitus: Imaging and Differential Diagnosis

Abstract: Tinnitus is the conscious, usually unwanted perception of sound that arises or seems to arise involuntarily in the ear of the affected individual. In most cases there is no genuine physical source of sound. This nonpulsatile tinnitus is caused by a hearing malfunction (1). Less than 10% of tinnitus patients suffer from pulsatile tinnitus (2). If tinnitus can also be detected by a clinician, it is described as objective. Pulsatile tinnitus requires hearing, as there is usually a genuine physical source of sound (3). Pulsatile tinnitus is therefore included under the umbrella terms “physical tinnitus” and “somatosounds” (4). There are two plausible causes of pulsatile tinnitus: Bloodflow accelerates, or changes in bloodflow disrupt laminar flow, and the resulting local turbulence is audible. Normal flow sounds within the body are perceived more intensely, either as a result of alterations in the inner ear with increased bone conduction or as a result of disturbance of sound conduction leading to loss of the masking effect of external sounds. Pulsatile tinnitus is usually unilateral, unless the underlying vascular pathology is bilateral. Recently, a disorder known as “somatosensory pulsatile tinnitus” has been discussed. This is bilateral tinnitus with no vascular cause (5). It is often possible to identify the cause of pulsatile tinnitus. In addition to the patient’s medical history and targeted clinical examination, imaging procedures also play an important role in diagnosis. However, despite careful examination, no cause is found in up to 30% of patients (6). This review article is based on a selective search of the literature and analysis of our patient records. The search of the literature was performed using PubMed and included review articles, case series, and case studies, with no restrictions on date of publication. We performed a retrospective search of our own patients’ radiology reports for 2003 to 2012 using the keywords “pulssynchron” or “pulsierend” (“pulsatile”) and “Ohrgerausch” or “Tinnitus” (“tinnitus”). Table 1 shows the results for the 77 identified patients (male/female 26/51, mean age 56 years). Tinnitus was right-sided in 38 cases, and left-sided in 27. It was bilateral in 12 cases. A cause was found significantly less frequently in these cases of bilateral tinnitus than in unilateral tinnitus (42% versus 88%, Fisher’s exact test, p = 0.001). Frequencies reported in the largest case series published to date vary enormously, as a result of both differing patient selection and different diagnostic pathways. There are no prospective studies. Table 1 Frequency of causes of pulsatile tinnitus

Nosocomial infection and antibiotic use: a second national prevalence study in Germany.

Abstract: Data on the frequency of nosocomial infections (NIs) and antibiotic use are important indicators of quality, and the increasing problem of antibiotic resistance has major consequences: It reduces infected patients’ treatment options and results in additional morbidity, mortality, and costs (1– 3). Rational antibiotic use can reduce selective pressure for the development of resistance to antibiotics (4). Prevalence studies provide an opportunity to gain an overview of the current situation regarding NIs and antibiotic use (5). Since Germany’s first national prevalence study on NIs and antibiotic use in representatively selected hospitals, in 1994 (NIDEP 1), no more have been conducted (6, 7). National prevalence studies have also been organized in many other European countries over the last 20 years, either once or several times (7). During the same period, the European Center for Disease Prevention and Control (ECDC) has developed a single Europe-wide protocol for conducting point prevalence studies (PPSs) and requested all European countries to conduct national PPSs on the prevalence of NIs and antibiotic use in 2011/12 (8). When this project was implemented in Germany, the National Reference Center for Surveillance of Nosocomial Infections was entrusted with gathering data for Germany and submitting them to the ECDC in anonymized form. This national prevalence study had the following main aims: To estimate the prevalence of nosocomial infections (NIs) and antibiotic use in acute care hospitals in Germany To describe the types of infections and the pathogens that cause them To describe the antibiotics used and the indications for antibiotic use To forward the data to the ECDC.

The Diagnosis and Treatment of Giant Cell Arteritis

Abstract: The typical symptoms and findings of giant cell arteritis (GCA) are still too often misinterpreted, and urgently needed treatment is delayed. Often, head and muscle pain in older patients are wrongly assessed for weeks, or patients are not referred to an ophthalmologist until they have become blind in one or both eyes. GCA was first described clinically in 1890 under the name “arteritis of the aged,” and later histologically characterized by Horton et al. (1). It manifests in patients over the age of 50 years and is associated in about half of the cases with polymyalgia rheumatica (PMR). The earlier term “arteritis temporalis,” once often used as a synonym, was abandoned in the internationally current Chapel Hill Consensus Conference (CHCC 1994) nomenclature, because not all patients with GCA have involvement of the temporal artery (2). Moreover, in rare cases the temporal artery may be affected in other forms of vasculitis, for example in granulomatosis with polyangiitis (Wegener). These secondary forms must be distinguished from GCA, which makes it essential not to use “temporal arteritis” and GCA as synonyms. In the 2012 revised version of the CHCC nomenclature, GCA is defined as a large-vessel vasculitis, affecting the aorta and its large arterial branches more often than do other vasculitides. Characteristically in GCA, it is branches of the carotid and vertebral arteries that are preferentially affected by the inflammatory process. However, smaller vessels can also be affected: for example, often not just the ophthalmic artery with its extraparenchymal branches are affected, but also small ciliary arteries (2). Giant cell arteritis Characteristically, branches of the carotid artery and the vertebral artery are involved in the inflammatory process.

Descemet stripping endothelial keratoplasty--rapid recovery of visual acuity.

Abstract: The most frequent indications for corneal grafting include diseases of the corneal endothelium, such as Fuchs endothelial dystrophy, bullous keratopathy, and endothelial failure following keratoplasty. Fuchs endothelial dystrophy is a hereditary disorder of the corneal endothelium that affects women more often than men and advances through various stages over a period of years (1). First, central asymptomatic thickening (guttae) appears on the Descemet membrane, the basal membrane of the endothelium, at the inner surface of the cornea. As the disease progresses there is increasing corneal edema, leading to light sensitivity and blurred vision. This is followed by subepithelial vesicle formation (bullous keratopathy); the patient experiences severe pain when the bullae burst. Finally the corneal stroma becomes fibrotic, with irreversible loss of transparency. Among persons over the age of 40 years, up to 3.8% have cornea guttata and 0.1% have bullous keratopathy (e1). There may be other causes of bullous keratopathy, including post-inflammatory, post-traumatic, or postoperative endothelial damage. Since these processes frequently involve inflammation with pronounced loss of endothelial cells, the prognosis for corneal transplantation is limited (2). The first corneal grafting procedure was carried out by Eduard Zirn (3, 4) in 1905. This was the so-called penetrating keratoplasty (PKP), in which typically all five layers of the cornea (epithelium, Bowman layer, stroma, Descemet membrane, endothelium) are transplanted (Figure 1a). Because the only layer affected by the above-mentioned diseases is the endothelium, as early as 1956 Tillet (5) proposed replacing only the rear part of the cornea (posterior lamellar keratoplasty). This was intended to avoid some of the problems that can occur after PKP, such as postoperative astigmatism and wound healing disorders. Although the technical principle of the operation could be implemented, the visual results proved unsatisfactory for the patients. Figure 1 Figure 1: Techniques of corneal grafting

Olfactory dysfunction: common in later life and early warning of neurodegenerative disease.

Abstract: SUMMARY Background: Disturbances of smell and taste are common. About 5% of the general population have anosmia (absence of the sense of smell). Olfactory dysfunction can markedly impair the quality of life. Methods: Review of pertinent literature retrieved by a selective search. Results: In recent years, simple and reliable tests of the sense of smell have been introduced in otorhinolaryngology. Olfactory testing has become a new focus of attention in neurology as well, mainly because many patients with neurodegenerative diseases—including the majority of those with Parkinson’s or Alzheimer’s disease—have olfactory loss early on in the course of their disorder. Olfactory dysfunction is thus regarded as an early sign of neuro degenerative disease that may allow a tentative diagnosis to be made years before the motor or cognitive disturbances become evident. As for the treatment of olfactory loss, anti-inflammatory drugs and surgery can help in some cases, and olfactory training can lead to significant improvement of post-viral olfactory deficits. Conclusion: Olfactory dysfunction is common and becomes more common with advancing age. It is increasingly receiving attention as an important sign for the early diagnosis and the differential diagnosis of neurodegenerative disorders. ►Cite this as:

The diagnosis, treatment and follow-up of extracranial carotid stenosis: a multidisciplinary German-Austrian guideline based on evidence and consensus.

Abstract: SUMMARY Background: Extracranial atherosclerotic lesions of the carotid bifurcation cause 10% to 20% of all cases of cerebral ischemia. Until now, there have been no comprehensive evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenosis in Germany and Austria. Methods: The literature was systematically searched for pertinent publications (1990–2011). On the basis of 182 randomized clinical trials (RCTs) and 308 systematic reviews, 30 key questions were answered and evidence-based recommendations were issued. Results: The prevalence of extracranial carotid stenosis is more than 5% from age 65 onward. Men are affected twice as frequently as women. The most important diagnostic technique is Doppler- and color-coded duplex ultrasonography. RCTs have shown that the treatment of high-grade asymptomatic carotid stenosis with carotid endarterectomy (CEA) can lower the 5-year risk of stroke from 11% to 5%. Intensive conservative treatment may lower the stroke risk still further. Moreover, RCTs have shown that CEA for symptomatic 50% to 99% carot id stenosis lowers the 5-year stroke risk by 5% to 16%. Meta-analyses of the 13 available RCTs comparing carotid artery stenting (CAS) with CEA have shown that CAS is associated with a 2% to 2.5% higher risk of periprocedural stroke or death and with a 0.5% to 1% lower risk of periprocedural myocardial infarction. If no particular surgical risk factors are present, CEA is the standard treatment for high-grade carotid stenosis. CAS may be considered as an alternative to CEA if the rate of procedure-related stroke or death can be kept below 3% or 6% for asymptomatic and symptomatic stenosis, respectively. Conclusion: Further studies are needed so that better selection criteria can be developed for individually tailored treatment. ►Cite this as:

Malignant Pleural Mesothelioma: Incidence, Etiology, Diagnosis, Treatment, and Occupational Health

Abstract: Background The incidence of malignant mesothelioma in Germany is about 20 cases per million persons per year Its association with asbestos exposure, usually occupational, has been unequivocally demonstrated Even though the industrial use of asbestos was forbidden many years ago, new cases of mesothelioma continue to appear because of the long latency of the disease (median, 50 years) Its diagnosis and treatment still present a major challenge for ambulatory and in-hospital care and will do so for years to come

Urethral stricture: etiology, investigation and treatments.

Abstract: Background Urethral stricture is a narrowing of the urethra due to scar tissue, which leads to obstructive voiding dysfunction with potentially serious consequences for the entire urinary tract. Its prevalence among men in industrial countries is estimated at 0.9%. It produces obstructive and irritative urinary symptoms and can ultimately impair renal function. Urethral strictures can be caused by diagnostic or therapeutic urological procedures. These procedures are being performed ever more commonly, because the population is aging; thus, urethral strictures will probably become more common as well.

The Treatment and Natural Course of Peripheral and Central Vertigo

Abstract: Background Recent studies have extended our understanding of the pathophysiology, natural course, and treatment of vestibular vertigo. The relative frequency of the different forms is as follows: benign paroxysmal positional vertigo (BPPV) 17.1%; phobic vestibular vertigo 15%; central vestibular syndromes 12.3%; vestibular migraine 11.4%; Meniere’s disease 10.1%; vestibular neuritis 8.3%; bilateral vestibulopathy 7.1%; vestibular paroxysmia 3.7%.

Chronic Pancreatitis—Definition, Etiology, Investigation and Treatment

Abstract: Most patients with chronic pancreatitis are treated on an outpatient basis, yet a large number are still hospitalized: There were 10 267 inpatient admissions for chronic pancreatitis (ICD-10 code K86) in Germany in 2008, according to the German Federal Statistical Office. The incidence of the disease is rising and has now reached 23 cases per 100 000 persons per year in Germany (1). One-third of patients can no longer work in their original profession, and 40% become temporarily or permanently disabled because of the disease (2). The mortality of persons with chronic pancreatitis exceeds that of the general population by a factor of 3.6 (3). Reported mortality figures over time periods of 6 to 10 years range from 13% to 20% (4). The 10-year survival rate is 70% and the 20-year survival rate is 45%, compared to 93% and 65% in age-matched controls (4). The goal of this German, Austrian, and Swiss guideline is to summarize and evaluate current knowledge of the definition, etiology, diagnostic investigation, and treatment of chronic pancreatitis in adults and children and to derive evidence-based clinical recommendations.

Headache in School Children: Prevalence and Risk Factors

Abstract: Background Recurrent headache is a common problem in school children. Evaluation generally leads to the diagnosis of a primary headache syndrome (migraine or tension-type headache). This review is addressed to the question whether headaches in school children are becoming more common and, if so, what risk factors are associated with the rise in frequency.

Local treatment of chronic wounds: in patients with peripheral vascular disease, chronic venous insufficiency, and diabetes.

Abstract: Chronic wounds are often treated unsystematically in routine practice, even though successful wound healing depends to a large extent on continuity in the re-evaluation of the state of the wound and reassessment of the treatment strategy. Chronic wounds are associated with severe impairment of quality of life (1), long treatment times, and high costs (2). In addition, they restrict patients’ everyday activities and mobility and cause emotional distress. As far as quality of life is concerned, systematic reviews have shown that pain is the most serious physical impairment of all (1, 3– 6). Inadequate venous return is the cause of about 1.2% of all days lost from work in Germany. About 1% of the total cost of inpatient medical care in Germany is spent on the treatment of venous leg ulcers (7). On average, one patient in three has a recurrence (8). It does seem, however, that the incidence and prevalence of venous leg ulcers are both lower than they were reported to be in the 1970s. Large-scale studies in the Rhineland region of Germany have revealed a current prevalence of about 0.08%, which would imply that about 50 000 to 80 000 persons in the country suffer from this condition. Chronic wounds on the lower limbs can arise because of arterial hypoperfusion (arterial leg ulcers), often in combination with diabetes (diabetic foot ulcers). The prevalence of peripheral arterial hypoperfusion in the overall population is 3% to 10%, depending on the definition. 15% to 20% of persons over age 70 have peripheral arterial occlusive disease (PAOD) (9). No reliable figures are available for the prevalence or incidence of stage IV PAOD or of leg ulcers of mixed arterial and venous pathogenesis. Studies of diabetic foot ulcers in various countries have yielded prevalence figures ranging from 2% to 10% of the diabetic population, with an annual incidence of 2% to 6% (10). Foot ulcers can lead, in the worst case, to amputations of toes, the foot, or the entire lower limb. According to data from the German AOK health insurance company, amputations are carried out in about 29 000 diabetic patients in Germany every year (11). Although no precise epidemiological data are available on the frequency of recurrence of chronic wounds, individual studies have shown that both diabetic foot ulcers and venous insufficiency ulcers tend to recur, particularly when peripheral arterial hypoperfusion is also present (12). Recurrent diabetic foot ulcers are the most likely of all to necessitate amputation (in up to 60% of cases) (13).

Adverse drug events in older patients admitted as an emergency: the role of potentially inappropriate medication in elderly people (PRISCUS).

Abstract: The number and proportion of emergency admissions of elderly patients with multiple morbidities and correspondingly extensive medication plans has been increasing continuously in recent years (1, 2). Adverse drug events (ADEs) are common reasons for treatment, but are often not recognized as such (1, 3– 6). Adverse drug events are caused by either conventional adverse drug reactions (ADRs) (7) or medication errors (MEs) (6) that lead to clinical symptoms. Overall, greater attention to drug therapy safety seems to be necessary in elderly patients. To identify and prevent risks more easily, lists of potentially inappropriate medications (PIMs) for elderly patients have been developed on the basis of expert consensus. Well-known examples are the Beers list (8), the STOPP and START criteria (9), and, since 2010 in Germany, the PRISCUS list (10, 11). It is assumed that these potentially inappropriate medications are associated with an increased risk of ADEs in elderly patients. Current studies, however, indicate that PIMs are responsible for only a relatively small percentage of ADEs in elderly patients (1, 12, 13). Moreover, in the international literature on PIMs a substantial percentage of drugs and cases were excluded from analyses, and no distinction was made between MEs and ADRs (1, 14). This raises the question of the extent to which errors caused by methodological shortcomings when data on ADEs were collated led to database bias, causing the potential number of PIMs to be underestimated. There are currently no studies available on the occurrence of such events in acute clinical care for drugs on the PRISCUS list. This study therefore aimed to investigate the effects of PIMs on elderly patients admitted as emergency cases regarding ADEs, involving and not involving MEs.

The efficacy of cognitive training programs in children and adolescents: a meta-analysis.

Abstract: Background\ Cognitive therapies are intended to improve basic cognitive functions, whatever the cause of the deficiency may be. Children and adolescents with various cognitive deficits are treated with behavioral therapeutic and computer-supported training programs. We here report the first meta-analysis of the efficacy of such programs.

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)/Lynch Syndrome

Abstract: SUMMARY Background: Hereditary nonpolyposis colorectal cancer (HNPCC, Lynch syndrome) is a genetic disease of autosomal dominant inheritance. It is caused by a mutation in one of four genes of the DNA mismatch repair system and confers a markedly increased risk for various types of cancer, particularly of the colon and the endometrium. Its prevalence in the general population is about 1 in 500, and it causes about 2% to 3% of all colorectal cancers. Lynch syndrome is diagnosed in two steps: If it is suspected (because a patient develops cancer at an unusually young age or because of familial clustering), the tumor tissue is analyzed for evidence of deficient mismatch repair (micro satellite instability, loss of mismatch repair protein expression). If such evidence is found, a genetic mutation is sought. The identification of a pathogenic mutation confirms the diagnosis in the patient and enables predictive testing of other family members. Diagnostic evaluations for Lynch syndrome should be carried out with appropriate genetic counseling. Method: Selective literature review. Results: Prospective cohort studies from Germany, Finland and the Netherlands have shown that colorectal cancers detected by systematic colonoscopic surveillance tend to be at an earlier stage than those that are discovered after the patients present with symptoms. The Finnish study also showed an overall reduction in cancer risk from colonoscopic polypectomy at regular intervals. Conclusion: The studies conducted so far have not yet clearly documented the putative benefit of an individualized, risk-adapted surveillance strategy. Until this is done, patients with Lynch syndrome and healthy carriers of causative mutations should be monitored with annual colonoscopy and (for women) annual gynecological examination.

The prevalence of nosocomial and community acquired infections in a university hospital: an observational study

Abstract: Data from Germany’s Hospital Infection Surveillance System (Krankenhaus-Infektions-Surveillance-System, KISS) (www.nrz-hygiene.de) and the national prevalence study NIDEP-1 conducted in 1994 (1) show that 400 000 to 600 000 nosocomial infections (NI) occur annually in Germany, with 10 000 to 15 000 deaths (mortality = 2.6%; up to 10% in intensive care units) (2). The length of stay in an intensive care unit is prolonged by an average 5.3 (± 1.6) days if the patient acquires an NI (3). Apart from the high morbidity and mortality, NI is associated with higher costs: Graf et al. calculated additional expenditure of € 22 905 for surgical site infection following sternotomy (4). An investigation of the costs incurred by nosocomial pneumonia from Staphylococcus aureus revealed that additional charges of € 17 281 per patient could be attributed to methicillin resistance in S. aureus pneumonia (5). Prevention of NI is therefore crucial, and adequate preventive measures have to be established. Particularly important in this regard is knowledge of the distribution of NI, the risk areas, and the patient-related risk factors. These efforts are supported by the 2011 amendment of the German Protection against Infection Act (Infektionsschutzgesetz, IfSG) and the related establishment and alignment of the hygiene regulations in the German federal states. These regulations created the conditions necessary for improvement of hygiene and medical quality in patient care. Prevalence studies can reveal weaknesses which allow needed measures such as quality and process parameters to be established. This in turn allows good standards of hygiene to be secured, for example via the implementation of guidelines. Studies of NI prevalence in various European countries show rates between 3.5% and 11.6% (1, 6– 10). Urinary tract infections (UTI) are the most frequent NI, followed by pneumonia, surgical site infection, and primary sepsis. These prevalence studies are multicenter investigations and seldom reflect the individual distribution of the different NI or the respective risk factors in medical facilities with particularly high rates of NI. In the knowledge of the impending amendment of the IfSG and the lack of data on NI at high-level university hospitals with a focus on surgery, we decided to conduct a prospective study of the prevalence of NI. Our aims were to detect all infections (nosocomial and community-acquired), identify the risk factors for NI, and accordingly modify the practices of infection control in our own institution, introducing new prevention measures if necessary.

Degenerative Lumbar Spinal Stenosis in Older People: Current Treatment Options

Abstract: Because of the aging of the population, neurosurgeons, orthopedists, trauma surgeons, and spine surgeons are now increasingly confronted with a very wide variety of degenerative changes of the lumbar spine. The treatment of symptomatic lumbar spinal stenosis is surely among the major clinical challenges of this kind. As the available scientific evidence on the diagnosis and treatment of this entity is not very reliable (1, 2), there is no currently valid overall assessment of treatment strategies for older patients (i.e., persons over age 65). Not only do older people make up a higher percentage of the population than before; there has also been a disproportionate rise in the frequency of lumbar spinal surgery in this age group (3) (Figure 1). The precise nature of this rise is hard to determine, however, because of the broad range of spinal procedures that are performed, with widely varying degrees of complexity. In 2005, lumbar spinal stenosis (ICD-10 code M48.06) was given as the main admitting diagnosis of 28 001 hospitalized patients over age 65 in Germany. By 2011, this figure had more than doubled, to 55 793 (3). Figure 1 The number of Osteoporosis and other typical spinal problems of advanced age, multiple comorbidities, and the lessened physical performance that goes along with age are now accompanied, at least as far as our experience suggests, by markedly heightened expectations on the part of our older patients. Thus, the value of different treatment strategies needs to be rationally assessed. In this article, we ask what the existing scientific evidence tells us about the current methods of diagnosis and treatment of symptomatic lumbar spinal stenosis in older people. Possible treatment strategies are indicated. Spinal stenosis Neurosurgeons, orthopedists, trauma surgeons, and spine surgeons are now increasingly confronted with a very wide variety of degenerative changes of the lumbar spine.

Use of Health Care Services by People With Mental Illness: Secondary Data From Three Statutory Health Insurers and the German Statutory Pension Insurance Scheme

Abstract: Facing the current challenges in the care of patients with mental illness requires reliable data on their health care. The problems to be addressed include not only increased use of health care services, incapacity for work, and early retirement due to mental disorders (1, 2), but also the lack of specialized physicians with associated long waiting times, the further development required in intersectoral and interdisciplinary care, and the implementation of new care structures and new compensation systems. Germany’s health care system is very complex. Studies of care provided often include only individual sectors such as outpatient care (3). There are essentially two representative research works available on the prevalence and care of mental illness in Germany: the 1998 German National Health Interview and Examination Survey (4) and a European study (5). The research presented here was the first to bring together secondary data from three insurers (DAK-Gesundheit, KKH-Kaufmannische Krankenkasse [formerly KKH-Allianz], and hkk-erste Gesundheit) and the German statutory pension insurance scheme over a three-year study period (2005 to 2007), forming a dataset that includes almost 3.3 million insurance holders with mental illness. This dataset differs from the German National Health Interview and Examination Survey (1998) in its use of routine data, sample size, and longitudinal design. This makes it possible to assess health care service use objectively and representatively on the basis of rehabilitation and benefit payments. This article presents the prevalence of use of outpatient, inpatient, and rehabilitational care services by those with mental illnesses (ICD-10, F0 to F5) during the study period of 2005 to 2007. For example, for serious depressive illnesses analysis examined the specialties and sectors of care used. This study aims to identify any shortcomings, such as problems at the interface of different sectors of care, and areas in which the care of mental illness might be optimized, through interdisciplinary and intersectoral analyses of the care pathway.

Early orthogeriatric treatment of trauma in the elderly: a systematic review and metaanalysis.

Abstract: As a result of demographic change, with the number of elderly persons in industrialized countries rising, the number of fractures in geriatric patients is also increasing. Typical geriatric fractures are fractures of the proximal femur, the proximal humerus, the distal radius, vertebral bodies, and the pelvis, and increasingly also periprosthetic fractures (1). These fractures, which are associated with osteoporosis and falls, pose great challenges to treating physicians. On the one hand, altered bone structure complicates surgical care, and on the other comorbidities often lead to complications (2). The most significant socio-economic factor in this setting is proximal femoral fractures. These are fractures of the neck of the femur and pertrochanteric and subtrochanteric fractures (ICD-10 S72.0 to S72.2 [3]). In 2009 more than 125 000 patients over the age of 70 years received inpatient treatment for the principal diagnosis proximal femoral fracture in Germany alone (4). Despite great advances in surgical care, treatment outcomes remain disappointing (5). One-year mortality for proximal femoral fractures is approximately 25% (6), and around one-third of patients lose their independence within the same period (7). The direct annual costs of illness are estimated at €2.5 billion in Germany alone (8). Clearly, then, optimum patient care is important. In order to be able to deal better with these patients’ multimorbidity, various models for collaborative orthogeriatric care of patients with proximal femoral fractures have been developed worldwide in recent years (9). To date it has only been shown that patients with proximal femoral fractures benefit from orthogeriatric care during rehabilitation (10). It has not yet been possible to provide unambiguous evidence of an advantage for interdisciplinary orthogeriatric care begun perioperatively, although individual studies have been published, some of the results of which are promising (9). This systematic review and metaanalysis is intended to represent the current state of scientific knowledge on the possible benefit for patients with typical geriatric fractures of orthogeriatric care begun perioperatively.

The prevention, diagnosis and treatment of premature labor.

Abstract: Preterm birth, defined as birth before gestational week (GW) 37 + 0, is a central problem in obstetrics and the single most important risk factor for perinatal morbidity and mortality (1). In 2011, 9% of all children born in Germany were born before the end of GW 37 (2). This rate is high compared to that of most other European countries (3) (Figure 1); it has remained stable over the last 10 years, yet the rate of extremely premature birth, i.e., birth before GW 28, has risen by 65% (Figure 2). Although the reasons for this development are not yet fully clear, it is attributed in large part to known demographic factors such as the trend toward higher maternal age in pregnancy and the rising prevalence of diabetes mellitus (4). Figure 1 The frequency of preterm birth before the end of the 37th week of gestation Figure 2 The percentage of very early preterm births (before GW 28) in Germany, 2001–2010 In 2010, 77% of perinatal deaths were of prematurely born infants (2). Mortality was especially high (32%) for infants born before GW 28, while late preterm infants, i.e., those born after GW 32, still had 1.3% perinatal mortality (more than ten times that of non-premature infants). In addition to high mortality, very small preterm infants are at high risk for serious long-term complications (2). The goal of all attempts to prevent and treat premature labor is to improve newborn infants’ chances of surviving with as few complications as possible.

The CARE guidelines: consensus-based clinical case reporting guideline development.

Abstract: A case report is a detailed narrative that describes, for medical, scientific, or educational purposes, a medical problem experienced by one or several patients. Case reports present clinical observations customarily collected in healthcare delivery settings. They have proved helpful in the identification of adverse and beneficial effects, the recognition of new diseases, unusual forms of common diseases, and the presentation of rare diseases (1). For example, our understanding of the relationship between thalidomide and congenital abnormalities (2) and the use of propranolol for the treatment of infantile hemangiomas began with case reports (3). Case reports may generate hypotheses for future clinical studies, prove useful in the evaluation of global convergences of systems-oriented approaches, and guide the individualization and personalization of treatments in clinical practice (4, 5) Furthermore, case reports offer a structure for case-based learning in healthcare education and may facilitate the comparison of healthcare education and delivery across cultures. Case reports are common and account for a growing number of articles in medical journals (6); however their quality is uneven (7, 8). For example, one study evaluated 1316 case reports from four peer-reviewed emergency-medicine journals and found that more than half failed to provide information related to the primary treatment that would have increased transparency and replication (9). Written without the benefit of reporting guidelines, case reports often are insufficiently rigorous to be aggregated for data analysis, inform research design, or guide clinical practice (7, 9). Reporting guidelines exist for a variety of study designs including randomized controlled trials (Consolidated Standards of Reporting Trials, CONSORT) (10), observational studies (Strengthening the Reporting of Observational studies in Epidemiology, STROBE) (11), and systematic reviews and meta-analyses (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRISMA) (12). Empirical evidence suggests that a journal’s adoption of the CONSORT statement as a guide to authors is associated with an increase in the completeness of published randomized trials (13). Guidelines have been developed for adverse-event case reports (14); however, general reporting guidelines for case reports do not exist. Our primary objective was to develop reporting guidelines for case reports through a consensus-based process.

The treatment of proximal humeral fracture in adults.

Abstract: SUMMARY Background: The incidence of proximal humeral fractures lies between 105 and 342 per 100 000 persons per year. Around the world, this type of fracture remains a major challenge for treating surgeons. While non-displaced fractures can be managed conservatively, displaced ones are often treated surgically. Methods: Selective literature review Results: There are still no evidence-based schemes or guidelines for the treatment of proximal humeral fractures, and very few prospective randomized trials are available. The few that have been published recently show a trend in favor of conservative treatment, but they were carried out on small groups of patients and their findings are not directly generalizable. For younger patients, the goal of treatment is generally anatomical repositioning and osteosynthetic stabilization; for older patients, primary treatment with a prosthesis is a further option. Depending on the mode of treatment, complications can arise such as shoulder stiffness, necrosis of the humeral head, pain, infection, loss of reposition, and “cutting out.” Conclusion: Current evidence supports the individualized treatment of proximal humeral fractures. Treatment decisions must always be made jointly with the patient in consideration of his or her individual needs and characteristics. Particularly for elderly patients, the possibility of conservative treatment should be carefully considered. If conservative treatment is not possible, then the type of operation performed should also be a function of the surgeon’s individual skills and experience with particular types of implant.

The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors.

Abstract: Background When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use.

Klinefelter syndrome: the commonest form of hypogonadism, but often overlooked or untreated.

Abstract: Klinefelter syndrome 47,XXY was first described 70 years ago (1). With an incidence of 0.1% to 0.2% of male neonates (i.e. 1 to 2 per 1000), it is one of the commonest congenital chromosome disorders resulting in hypogonadism and genetically-determined infertility (2, 3). Klinefelter syndrome is associated with a significantly higher morbidity rate compared to the male population as a whole. The main associated disorders are varicose veins, thrombosis, embolism, type 2 diabetes, bone fractures, epilepsy, and other neurological and mental disorders (4– 6) (Table 1). This leads to a life expectancy 11.5 years below that of the male population as a whole (6). Table 1 Comorbidities in Klinefelter syndrome: prevalence and mortality As a result of this increased morbidity, Klinefelter syndrome patients require doctor and hospital treatment disproportionately often. However, a survey completed by 290 practising primary care physicians, internal medicine specialists, and urologists showed that two-thirds of primary care physicians and internal medicine specialists had had not knowingly seen any cases of Klinefelter syndrome in recent years, although their theoretical knowledge of it was good; urologists fared a little better regarding diagnosis of Klinefelter syndrome (7). On the basis of patient registries in Denmark, it is suspected that only 25% of all Klinefelter syndrome patients are diagnosed during their lifetimes (8). Nevertheless, suspected Klinefelter syndrome is easy to diagnose if physicians know the syndrome and thorough clinical examination is performed. Because knowledge of Klinefelter syndrome can only be derived from diagnosed cases, it is not known whether other cases remain undetected because they have a different range of symptoms. Furthermore, the known symptoms are not exclusive: Only one-quarter of patients in whom Klinefelter syndrome was suspected following clinical examination in a specialized facility actually showed a corresponding karyotype (9). This article aims to attract greater medical attention to this important syndrome, in order to provide more patients with appropriate treatment. It is based on a selective search of the literature using a regular PubMed search over a 40-year period of clinical and scientific consideration of Klinefelter syndrome.