Deutsches Arzteblatt international最新文献

Background: Gynecomastia (GM) is the most common abnormality of the male breast; it is benign and usually bilateral. GM is a manifestation of disease and not a diagnosis in itself. An important differential diagnosis of unilateral GM is breast cancer.

Methods: This narrative review is based on pertinent publications from 2010 onward that were retrieved by a PubMed search, with special attention to the guidelines of the AWMF and the European Academy of Andrology (EAA) and the recommendations of the German Society for Gynecology and Obstetrics.

Results: GM can occur physiologically in newborns, during puberty, and in men over age 65. The basic diagnostic evaluation of GM consists of a thorough history and physical examination (especially of the breast area and genitals), breast and testicular sonography, and laboratory testing for total testosterone (tT), estradiol (E2), luteinizing hormone (LH), human chorionic gonadotropin (hCG), and prolactin (PRL) levels. Further tests to be carried out as indicated according to the clinical findings include the determination of follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), fT4, alpha-1-fetoprotein (AFP), dehydroepiandrosterone (DHEA), and free testosterone (fT) levels, liver and kidney function tests, chromosomal analysis, and supplementary imaging procedures. The treatment depends on the underlying disease and the severity of symptoms, ranging from further observation alone to pharmacotherapy and surgery. Approximately 700 men receive a diagnosis of breast cancer each year in Germany. Because breast cancer in men is rare, there are no pertinent studies, and its treatment is analogous to the treatment of breast cancer in women as recommended in the guidelines.

Conclusion: Men should be included in clinical trials of treatment for breast cancer whenever this is fea - sible, so that the evidence base can be enlarged and men can be given access to innovative treatment methods.

Background: The Global Polio Eradication Initiative (GPEI), founded in 1988, has contributed to a drastic reduction in the number of cases of wild poliovirus (WPV) infection. Progress has stalled for years, however, even though the GPEI has become a very costly global health program. Poliomyelitis is caused by WPV types 1, 2, and 3, as well as by mutated vaccine viruses.

Methods: This review is based on publications retrieved by a selective literature search relating to challenges that currently face the GPEI, with an emphasis on the situation in Germany, e.g., the problem of maintaining the high rate of vaccination coverage.

Results: WPV1 remains endemic in Pakistan and Afghanistan. In addition, outbreaks caused by viral mutants of oral live polio vaccines (OPV) have become a problem in countries with low vac cination coverage, with several thousand cases since 2000. Industrialized countries have also had rare cases of poliomyelitis in recent years, caused by mutated vaccine viruses, which often circulate undetected. Aside from the dysfunctionality of the health care systems of many countries, geopolitical tensions, international and civil wars, mass human migration, hesitancy and skepticism of the population about vaccination, and funding fatigue on the part of donor countries, there are a variety of technical problems confronting the GPEI in its quest for success.

Conclusion: Maintaining high polio vaccination rates may be a more realistic solution to the problem of polio than continuing to pursue the GPEI's objective of putting all polioviruses out of existence. Doctors in Germany can actively contribute to the achievement of both these goals by checking the polio vaccination status of their patients, as recommended by the German Standing Committee on Vaccination (STIKO). This is especially important when doctors care for refugees and asylum-seekers who have arrived in Germany from abroad.

Background: An increase in dementia is expected worldwide because of the aging of the population. However, recent studies suggest that its incidence is declining.

Methods: Claims data from the German statutory health insurance system (covering 88% of the population) were analyzed for the years 2015 to 2022. Insurees aged 65 and older were included for whom a confirmed diagnosis of dementia was documented in at least two of four consecutive quarters. The incidence and prevalence of dementia were calculated and standardized by age and sex.

Results: The incidence of dementia declined by 26% percent (95% confidence interval: -26.2; -25.3), from 2020 per 100 000 insured individuals in 2015 to 1500 per 100 000 in 2022. Over the same period, its prevalence fell by 18% [-18.6; -18.2], from 10 380 to 8470 per 100 000 insured individuals. These trends were more pronounced in younger age groups and in women and were particularly evident in primary care practices. The number of individuals with a documented diagnosis of dementia fell from 1.56 million in 2015 to 1.43 million in 2022, corresponding to a decline by 8.4% [-8.5; -8.3]. Over the same period, the number of people with a diagnosis of mild cognitive impairment (MCI) increased by 62%, albeit from a very low initial level.

Conclusion: Despite the aging of the population, the incidence and prevalence of diagnosed dementia in German primary care practices are declining. Further analysis is needed to determine whether this is due to a lower individual risk of dementia, changes in diagnostic behavior, or structural factors, such as a shift to specialized memory clinics.

Background: In this study (NCT04333303), we investigated whether a complex advance care planning (ACP) intervention improves care consistency with care preferences in nursing home residents.

Methods: Forty-four German nursing homes were randomly assigned to an ACP intervention addressing the individual, institutional, and regional levels or to a control group (no intervention). The hospitalization rate over an observation period of 12 months (primary outcome) was analyzed as a surrogate for care consistency with care preferences at the nursing home level. Secondary outcomes comprised process-related and clinical parameters, including care consistency with care preferences (analysis level: residents/ nursing homes). Outcomes were evaluated by means of Poisson and logistic regression models with incidence rate ratios (IRR) and odds ratios (OR) as effect estimators in an intention-to-treat analysis.

Results: Of 44 nursing homes, 23 received the intervention. The hospitalization rate did not differ between the two groups (IRR 1.0; 95% CI: [0.97; 1.1]) but declined to a similar extent in both during the COVID-19 pandemic. The consistency of care with care preferences was similar in both groups as well (OR 0.9 [0.4; 1.9]). The predefined exploratory analysis suggests that care consistency with care preferences was more likely in the 6 out of 23 nursing homes that met predefined adherence criteria (OR 1.9 [0.7; 5.3]). Written emergency plans were significantly more common in the intervention group (IRR 11.6 [8.2; 16.4]), and even more so in adherent nursing homes (IRR 30.1 [15.7; 57.6]).

Conclusion: The intervention did not permeate sufficiently, especially due to the COVID-19 pandemic that may, in addition, have masked intrinsic shortcomings of the intervention. Thus, this trial does not allow a conclusive assessment of whether or not the intervention can promote care consistency with care preferences. However, exploratory analyses indicate that successful institutional implementation in conjunction with individual ACP conversations may increase care consistency with care preferences.

Background: When raw incidence rates are compared across populations, age can be a major confounding factor if the populations differ in age structure. In this paper, we elucidate the principles of age standardization of rates.

Methods: Crude and age-standardized rates are derived, and methodological aspects explained, in the light of pertinent publications from a selective literature search and by means of a particular example: a comparison of the incidence of stomach cancer in Cali, Colombia, and in the German federal state of North Rhine-Westphalia (NRW) (2013-2017, men).

Results: The crude incidence rates were 21.5 per 100 000 personyears in Cali and 22.9 per 100 000 person-years in NRW, but the corresponding age-standardized incidence rates (old European standard) were 30.0 and 15.7 per 100 000 person-years, respec - tively. Because of the markedly different age structures of the two populations, the crude incidence misleadingly suggested a practically identical incidence of stomach cancer in Cali and in North Rhine-Westphalia. Age standardization revealed a markedly higher incidence in Cali.

Conclusion: The numerical value of a standardized rate is an artificial rate that can only be interpreted in the light of the standard used. Standardization only makes sense if rates are to be compared across populations, where a difference in a particular factor (e.g., age) might distort the comparison. Standardization is not needed to describe the epidemiological situation in a single population.