Deutsches Arzteblatt international最新文献

Background: Open spinal dysraphism is a congenital malformation that causes major morbidity. Its consequences include sensory and motor impairment as well as bladder- and bowel dysfunction. It is often also associated with prenatal ventriculomegaly, which, in turn, necessitates postnatal treatment with a ventriculoperitoneal shunt in approximately 80% of cases. Prenatal therapy with coverage of neural tube defect can reduce the shunt rate and preserve motor function. In this review, we describe the different surgical procedures and their outcomes.

Methods: This review is based on publications that were retrieved by a selective literature search in the MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane databases, employing pertinent keywords. Studies of all types (except case reports) that were published in English or German in the period 2010-2024 were included.

Results: The randomized, controlled MOMS trial showed that intrauterine surgery for defect closure resulted in less progressive neural tissue damage than postnatal surgery and reduced the need for shunting by approximately half (40% vs. 82%). Since the publication of these results, various prenatal surgical procedures have been established, including hysterotomy-assisted, percutaneous fetoscopic, and laparotomy-assisted fetoscopic closure. The individual surgical methods yield comparable results in terms of motor function and shunt rate. A problem with these procedures is that they increase the likelihood of preterm birth, to an extent that varies from one type of procedure to another.

Conclusion: Prenatal surgery improves motor function and reduces the shunt rate but long-term outcomes beyond adolescence are still lacking. Transparent and interdisciplinary counseling is essential in prenatal communication to inform parents not only about the potential benefits of this treatment, but also about its limitations and risks.

Background: Osteoporosis is a common disease that affects approximately 6 million people in Germany alone. Osteoporotic fractures impair the quality of life and may make independent living impossible. Recommendations on the diagnosis and treatment of osteoporosis are indispensable for the effective care of this large group of patients.

Methods: For a thorough updating of the German clinical practice guideline (an evidence-based guideline with recommendations for clinical practice) on osteoporosis, a comprehensive, systematic search for relevant publications was carried out, including guidelines from other countries. The retrieved literature was assessed with standardized (Oxford) criteria, and clinically relevant key questions were answered according to the PICO scheme ("population, intervention, comparison, outcomes").

Results: The assessment of clinical risk factors for osteoporosis is the basis of osteoporosis diagnostics, which should be carried out quickly after a fracture. If risk factors are present in a postmenopausal woman or a man aged 50 or above, bone densitometry testing with dual-energy x-ray absorptiometry (DXA) is recommended. The further diagnostic evaluation should proceed in stepwise fashion depending on the clinical symptoms, the fracture status, and the degree of bone density reduction. Pharmacotherapy should be adapted to the fracture risk. Osteoanabolic treatment is recommended with high priority if the patient is judged to have a very high risk of fracture (10% or more in the next three years). The further course and duration of treatment should be determined individually, depending on the evolution of the patient's clinical state.

Conclusion: Prerequisites for the optimal treatment of patients with osteoporosis include a correct diagnosis and interdisciplinary and interprofessional collaboration to determine and provide the proper treatment. 71% of persons with osteoporosis in Germany are still untreated, and this gap must be closed.

Background: Systemic therapy (ST) was approved as a further psychotherapy approach in line with the German Psychotherapy Directive's requirements in 2020 for adults and in 2024 for children and adolescents, and is thus covered by statutory health insurance.

Methods: Selective literature review on the theoretical foundations and clinical practice of ST, including recent meta-analyses of its efficacy.

Results: The theoretical foundations of ST include systems and communication theory, moderate constructivism, the multigenera - tional perspective, and, in some manuals, the attachment perspective. Structural-strategic family therapy and the solution-focused therapy approach are key elements of its clinical practice. ST is mostly provided in individual or multi-person settings. Important interventions include solution-focused and circular questions, positive reframing, genograms, sculptures, tasks, and prescriptions. Several disorder-specific ST manuals have been developed. The efficacy of ST has been evaluated in 7 recent meta-analyses: ST has been found effective against various disorders, both in adults (affective disorders, anxiety/obsessive-compulsive disorders, substance use disorders, eating disorders, schizophrenia/psychotic disorders) and in children and adolescents (anxiety/obsessive-compulsive disorders, hyperkinetic disorders, substance use disorders, eating disorders, and mixed disorders). For example, in the treatment of depression in adults, ST was shown to be superior to no add-on treatment (Hedges g: 1.09, 95% confidence interval [0.78; 1.40]).

Conclusion: ST broadens the scope of treatment options for mental disorders, with a specific focus on their social context.

Background: Dengue fever is a common infectious disease in the tropical and subtropical zones, with more than 100 million symptomatic cases per year. Mosquitoes of the genus Aedes (Aedes aegypti, Aedes albopticus) are vectors of the disease, and their spread has led to rising case numbers around the world. Physicians in Europe, too, are increasingly being confronted by this challenge.

Methods: This review is based on the findings of a selective search in international publication databases, as well as on the WHO guideline of 2009 and the current recommendations of the Robert Koch Institute.

Results: Dengue fever takes a mild course in more than 90% of cases. Severe dengue fever, up to and including shock and/or mucosal hemorrhages, is rare and carries a mortality of 1-5%. The disease characteristically takes a triphasic course (febrile phase, critical phase, recovery phase). It is diagnosed by the direct demonstration of the pathogen (e.g., with the reverse transcriptase polymerase chain reaction [RT-PCR] up to day 5 of the illness) or by serology. Patients are classified into one of three risk groups depending on their findings and comorbidities and are then treated either as outpatients or in the hospital. The treatment is symptomatic, as no treatment directed against the cause of the disease is available. The key measures are adequate volume replacement and, in patients with hemorrhage, the transfusion of blood products. Preventive steps include vaccination after a documented initial infection and the meticulous avoidance of mosquito bites.

Conclusion: Climate change and global mobility have led to a worldwide increase in dengue fever. The disease only rarely takes a severe course. In such cases, rapid symptomatic treatment as needed is the key to the avoidance of severe complications.

Background: The standard aortic valve replacement operations in young patients are bioprosthetic or mechanical aortic valve replacement. In this study, we present the long-term results of the Ross operation in young patients.

Methods: The Ross operation with root replacement was performed on 795 patients between 1995 and 2020. The endpoints were overall survival, re-operation/reintervention rates on the autograft and homograft/RV-PA conduit (RV, right ventricle; PA, pulmonary artery), and the occurrence of serious adverse events.

Results: 795 patients (75% male, 25% female; mean age 43 ± 14 years) underwent the Ross operation with root replacement. The 30-day mortality was 1% (8 patients) with a 95% confidence interval of [0.48; 1.9]. The follow-up was 96 % complete and covered 9540 patient-years, with a mean follow-up time of 12 ± 7 years. The survival rates at 5, 10, 15 and 20 years were 97% [96; 98], 96% [93; 96], 92% [89; 94] and 86% [83; 90]. The rate of autograft survival without reoperation was 94% [92; 96] at 10 years and 80% [76; 85] at 20 years. The rate of homograft/RV-PA conduit survival without reoperation was 95% [93; 97] at 10 years and 85% [81; 90] at 20 years. There were 5 cases of hemorrhage, 14 of thromboembolic complications or apoplexy, and 19 of endocarditis.

Conclusion: The Ross operation with root replacement was associated with high survival rates over 25 years of follow-up. The rates of reoperation and reintervention, the morbidity and mortality, and the rate of endocarditis are low. The Ross operation is thus an effective surgical treatment option for young patients with aortic valve disease.

Background: The risk of persistent postoperative opioid use (PPOU) and its association with the type of surgery are still unclear in Germany.

Methods: We conducted a nationwide retrospective cohort study on the basis of claims data from BARMER, a statutory health insurance carrier in Germany. Opioid-naive adults who did not have cancer and who underwent inpatient surgery in 2018 were included in the study. The operations were divided into 103 categories. PPOU was defined as the prescribing of opioids between post - operative days 1 and 90 and also between postoperative days 91 and 180 after hospital discharge. Patient-associated risk factors in the 12 months before surgery were investigated.

Results: 203 327 patients were included. 1.4% had PPOU (95% confidence interval [1.4; 1.5]). There were major differences between operation groups: major amputations and orthopedic procedures carried the greatest risk for the development of PPOU. The type of surgery had a larger effect on the risk of PPOU than preexisting risk factors (explained variance 22.3% vs. 14.3%). Among such factors, alcohol abuse and preexisting treatment with antidepressant drugs were associated with the highest risk for PPOU (odds ratios [OR] 1.515 [1.277; 1.797] and 2.131 [1.943; 2.336]).

Conclusion: The incidence of PPOU in Germany is low (1.4%). The type of surgery plays an important role in its development.

Background: Observational epidemiological studies often yield different results on the same research question. In this article, we explain how this comes about.

Methods: In this review, which is based on publications retrieved by a selective search in PubMed and the Web of Science, we use information from international publications, simulation studies on sampling error, and a quantitative bias analysis on fictitious data to demonstrate why the results of epidemiological studies are often uncertain, and why it is, therefore, generally necessary to perform more than one study on any particular question.

Results: Sampling errors, imprecise measurements, alternative but equally appropriate methods of data analysis, and features of the populations being studied are common reasons why studies on the same question can yield different results. Simulation studies are used to illustrate the fact that effect estimates such as relative risks or odds ratios can deviate markedly from the true value because of sampling error, i.e., by chance alone. Quantitative bias analysis is used to show how strongly effect estimates can be distorted by misclassification of exposures or outcomes. Finally, it is shown through illustrative examples that different but equally appropriate methods of data analysis can lead to divergent study results.

Conclusion: The above reasons why epidemiological study results can be heterogeneous are explained in this review. Quantitative bias analyses and sensitivity analyses with alternative data evaluation strategies can help explain divergent results on one and the same question.