Deutsches Arzteblatt international最新文献

Background: It is estimated that 6% of persons over age 75 have clinically relevant tricuspid regurgitation (TR). This condition carries a high mortality and is of particular interest because of the recent development of new interventional treatments.

Methods: This review is based on publications that were retrieved by a selective search in the PubMed database for randomized controlled trials (RCTs), observational studies, registry studies, expert recommendations, and current international guidelines.

Results: The evidence reveals that TR is an independent cause of mortality. Mortality is correlated with the severity of TR: approximately 35% of patients with severe TR and right heart failure die within 1 year, and about 60% within 3 years. The clinical course varies depending on the etiology (primary TR, atrial/ventricular secondary TR, association with pacemaker systems). In the outpatient setting, timely diagnosis by transthoracic echocardiography is crucial. The options for pharmacotherapy are essentially limited to diuretic treatment (grade 2a recommendation). Early referral to a specialized heart valve center is essential for the prevention of irreversible damage of the right heart and secondary end-organ damage, including cardiohepatic and cardiorenal syndromes. In the heart valve center, an extended diagnostic evaluation with multimodal imaging is followed by a case discussion by the interdisciplinary cardiac team, with individual evaluation of the treatment options. The first randomized controlled trial of treatment for TR yielded a win ratio of 1.48 (95% confidence interval, [1.06; 2.13]) for interventional treatment (edge-to-edge repair) compared to optimal medical therapy.

Conclusion: As the understanding of tricuspid regurgitation improves, strategies for its interventional treatment are undergoing steady development, with the aim of lowering the mortality of this condition.

Background: We studied whether an individualized digital decision aid can improve decision-making quality for or against knee arthroplasty.

Methods: An app-based decision aid (EKIT tool) was developed and studied in a stepped-wedge, cluster-randomized trial. Consecutive patients with knee osteoarthritis who were candidates for knee replacement were included in 10 centers in Germany. All subjects were asked via app on a tablet about their symptoms, prior treatments, and preferences and goals for treatment. For the subjects in the intervention group, the EKIT tool was used in the doctor-patient discussion to visualize the individual disease burden and degree of fulfillment of the indication criteria, and structured information on knee arthroplasty was provided. In the control group, the discussion was conducted without the EKIT tool in accordance with the local standard in each participating center. The primary endpoint was the quality of the patient's decision on the basis of the discussion of indications, as measured with the Hip and Knee Quality Decision Instrument (HK-DQI). (Registration number: ClinicalTrials.gov:NCT04837053).

Results: 1092 patients were included, and data from 1055 patients were analyzed (616 in the intervention group and 439 in the control group). Good decision quality, as rated by the HKDQI, was achieved by 86.0% of patients in the intervention group and 67.4% of patients in the control group (relative risk, 1.24; 95 % confidence interval, [1.15; 1.33]).

Conclusion: A digital decision aid significantly improved the quality of decision-making for or against knee replacement surgery. The widespread use of this instrument may have an even larger effect, as this trial was conducted mainly in hospitals with high case numbers.

Background: Nerve lesions often heal incompletely, leading to lifelong functional impairment and high costs for the health care system. The updated German clinical practice guideline is intended to promote the early recognition of nerve lesions and the timely initiation of proper treatment for optimal restoration of function.

Methods: The recommendations are based on an assessment of all the evidence revealed by a systematic search of the literature, as well as on the expertise of the multiprofessional guideline group.

Results: Only a few publications contain high-quality evidence. This version of the guideline contains a more detailed discussion of war injuries, iatrogenic injuries, MR neurography, and specific treatments than the previous version. As for the different methods of nerve replacement, a comparison of autologous transplantation versus the use of conduits and tubes revealed no significant difference between these two methods on the mBMRC scale, and minimal superiority of autologous transplantation with respect to two-point discrimination. As for the use of nerve transfers when nerve reconstruction is not feasible or unlikely to succeed, nerve transfer yielded slightly better results than proximal reconstruction for elbow flexion, but the difference did not reach statistical significance (mBMRC ≥ 3: RR 1.16, 95% confidence interval [1.02; 1.32]). The treatment of neuromas with targeted muscle reinnervation was superior to the classic approach in decreasing both stump pain (MD 2.0 +/- 2.8) and phantom limb pain (MD 3.4 +/- 4.03).

Conclusion: The delayed or improper treatment of peripheral nerve lesions can lead to severe impairment. Timely diagnosis, the use of appropriate treatments in conformity with the guidelines, and interdisciplinary collaboration among specialists are all essential for optimizing the outcome.