Deutsches Arzteblatt international最新文献

Background: After a diagnosis of prostate cancer, the 15-year cancer-specific survival probability is high; in suitable patients, active surveillance lessens the side effects of curative treatment. Limited evidence is available on the continuation of active surveillance in young prostate cancer patients in Germany.

Methods: Using data that were reported, as required by law, to the population-based cancer registries of the German federal states of North Rhine-Westphalia, Baden-Württemberg, and Rhineland- - Palatinate, we studied the course of 732 patients under 60 years of age who were under active surveillance after receiving a diagnosis of low-risk localized prostate cancer (ISUP grade 1 or 2) in the years 2016-2021.

Results: The median duration of follow-up was 28 months. 64% [61%; 68%] of the patients were still under active surveillance at two years; this was true for 66% [62%; 70%] of those with ISUP grade 1 disease, 46% [37%; 58%] of those with ISUP grade 2 disease, and 72% [63%; 83%] of those for whom no Gleason grading was available. 62% of discontinuations occurred without any documented progression and without a documented patient-initiated decision.

Conclusion: The two-year probability of young prostate cancer patients remaining under active surveillance was lower in Germany than in other countries. The cancer registries mostly received no information concerning the clinical rationale for the discontin uations. The potentially incomplete reporting of reasons for discontinuing active surveillance suggests that clinical reporting practices should be improved.

Background: Approximately 75 000 men receive a diagnosis of prostate cancer in Germany each year. New data on the early detection, diagnostic evaluation, and treatment of prostate cancer provide the basis for a paradigm shift in the management of locally confined prostate cancer.

Methods: This narrative review is based on the systematic literature search that was carried out for the 2025 update of the German clinical practice guideline on prostate cancer.

Results: Risk-adapted early detection is now recommended. This involves the measurement of a baseline PSA value at age 45 whose magnitude determines the interval of follow-up testing: once every 5 years for baseline values below 1.5 ng/mL, and once every two years for baseline values between 1.5 and 3 ng/mL. Patients with PSA levels above 3 ng/mL should undergo a repeat PSA test and, if these levels are confirmed, receive a urological risk assessment including prostatic volume, family history, and past medical history. High risk patients should undergo magnetic resonance imaging (MRI) and, if necessary, prostate biopsy. This new PSA-MRI algorithm increases accuracy in detecting clinically significant prostate cancers, enabling the previously recommended annual testing and digital rectal examination to be avoided. Another novelty is that the indication for an active surveillance strategy for men with low-risk prostate cancer has been expanded to ISUP grade group 1 and 2 cancers with favorable risk.

Conclusion: The need for high-quality diagnostic testing, including MRI, with broad geographic coverage will be a major challenge to the health care system, especially with regard to accessibility. Patients can be expected to benefit greatly from the new PSA-MRI algorithm, as it eliminates unnecessary diagnostic testing and treatment while enabling necessary treatment to be initiated earlier and therefore with fewer side effects.

Background: There are approximately 150 000 persons over age 80 in Germany who suffer from Parkinson's disease. Eighty percent of patients develop dementia during the course of this disease. Older patients with Parkinson's disease often suffer from the multimorbidity typically seen in this age group. Comorbidities affect the options for treating Parkinson's disease. Older patients are markedly underrepresented in most trials of antiparkinsonian drugs.

Methods: In this narrative review, we propose practical ways to simplify the treatment regimen of older patients with Parkinson's disease to lessen side effects and make treatment more manageable for these patients and the persons caring for them.

Results: The mainstay of treatment is levodopa in combination with a dopa decarboxylase inhibitor, taken during the day as a standardrelease or dispersible formulation and at night in extended-release form; along with a catechol-O-methyltransferase inhibitor if neces - sary. Antiparkinsonian drugs with other mechanisms of action should be used sparingly, if at all. Treatment options for patients with severe fluctuations in efficacy and long "off" (akinetic) phases include a jejunal levodopa pump and the subcutaneous administration of foslevodopa. Parkinson's disease dementia should be treated with rivastigmine, a cholinergic anti-dementia drug (approved in capsule form for this indication). Otherwise intractable psychosis should be treated with quetiapine (off-label) or clozapine (evidence-based; weekly blood tests required). Other neuroleptic drugs should not be given to patients with Parkinson's disease. Physiotherapy and speech therapy are evidencebased components of therapy with proven efficacy in every stage of the disease.

Conclusion: Further randomized controlled trials tailored to this patient population are needed to provide a better evidence base for the treatment of older patients with Parkinson's disease.

Background: Thyroid nodules are very common, with a prevalence of more than 75% among persons over age 60 in Germany, yet more than 80% of them remain asymptomatic and undetected. Only a small fraction of thyroid nodules pose a relevant risk to health; these include carcinomas of the thyroid gland (prevalence 0.027%) and functionally autonomous adenomas (clinically relevant prevalence 0.34%).

Methods: Systematic literature searches based on the PICO scheme or exploratory key questions were carried out during the development of an S3-level clinical practice guideline for the management of patients with thyroid nodules in primary care. The quality of the pertinent guidelines and studies was assessed with standardized instruments. Selected findings are described in this article.

Results: Most thyroid nodules are discovered incidentally. Further diagnostic evaluation by the primary care physician is generally only indicated if the patient is symptomatic, has a family history of thyroid cancer, or has a low TSH (thyroid-stimulating hormone) level. Ultrasonography should be performed in targeted and standardized fashion (TIRADS classifications) and cascading diagnostic studies should be avoided. If the nodule is considered potentially malignant, the patient should be referred to a specialist. The indications for treatment include symptoms due to compression, esthetic impairment, or functionally relevant autonomous adenomas. Pharmacotherapy with the goal of shrinking the nodule(s) is now obsolete, and other measures can only be carried out after specialized referral.

Conclusion: Rational, patient-centered approaches are needed in primary care so that overdiagnosis and overtreatment can be avoided and appropriate care provided as efficiently as possible. The diagnostic evaluation is focused on the meticulous selection of patients who must be referred to a specialist. For most thyroid nodules, no treatment is indicated.

Background: The daily visit by the treating doctor or medical team at the bedside of the hospitalized patient («rounds») is essential for patient-centered care and interprofessional exchange.

Methods: This narrative review is based on pertinent publications (up to December 2024) that were retrieved by a selective search in the PubMed/Medline database.

Results: Bedside rounds are used to fulfill multiple tasks: medical, communicative, and educational. Complex social interactions, in particular, require precise and empathetic communication. 71% of patients say they primarily expect clear information about their medical situation. Information exchange can nonetheless be difficult, particularly with older and frail patients. So-called teach-back techniques improve patients' understanding of medications and behavioral instructions (OR 1.84 [1.09; 3.12] and 1.83 [1.07; 3.13], respectively). Although many patients would like to take active part in discussions on rounds, the physicians explicitly encouraged them to do so in only 54% of cases. If the team discusses the patient outside the room before entering, the patient's understanding of their condition is no different, but they are less likely to be confused by medical technology (21.3 versus 13.7); team satisfaction is higher (78.0 versus 68.3), and there is more opportunity to discuss sensitive topics (84.3 versus 59.3, each on a visual analog scale VAS 1-100).

Conclusion: Interprofessional discussion of the patient and suitable communication on rounds can improve patient care and are essential for undergraduate, postgraduate, and continuing medical education.

Background: Fractures are a major public health problem, especially in older people. A better understanding of epidemiological trends and risk factors is essential for the development of prevention strategies.

Methods: We analyzed ICD-10 data provided by the German Federal Statistical Office and the Central Institute for Health Care (Zi) on inpatient and outpatient treatments for fracture in the year 2022. The frequency and distribution of fractures were examined according to anatomical site, sex, and age. The prevalence of inpatient cases was standardized to the German population and compared with figures from 2019.

Results: In 2022, there were 683 185 recorded fracture treatments in the inpatient setting, 1% fewer than in 2019. 63% of fractures were in women, and 71% in persons over age 65. The most common types were femoral neck fractures (129 per 100 000 population), pertrochanteric femur fractures (115/100 000), and distal radius fractures (106/100 000). Compared to 2019, there were more fractures of the femoral neck (+8%), femoral shaft (+7%), and distal humerus (+7%), and fewer fractures of the scaphoid bone (-31%), carpal and metacarpal bones (-30%), and ribs (-29%). 2 400 606 fractures were treated in the outpatient setting in 2022, corresponding to a prevalence of 2845.71/100 000. The most common types were distal radius fractures (210.76/100 000), finger fractures (186.1/100 000), and rib fractures (156.51/100 000 population).

Conclusion: Although the overall fracture prevalence declined slightly between 2019 and 2022, certain fracture types remained prevalent or even increased in frequency. This highlights the continued need for targeted preventive strategies, particularly for older adults.