Innere Medizin (Heidelberg, Germany)最新文献

Dementia, delirium, and depression are the main geriatric psychiatric syndromes, and their prevalence is increasing significantly due to demographic aging. At the same time, multimorbidity and polypharmacy lead to increased interaction rates and a higher frequency of side effects, as well as reduced adherence. In Germany, the number of dementia cases is projected to rise from the current 1.8 million to 2.8 million by 2050. The most common etiologies are Alzheimer's disease and vascular dementia. Progressive cognitive and motor function loss often results in apraxia and dysphagia, which complicate pharmacotherapy. Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine are used therapeutically. Newly approved amyloid antibodies (lecanemab, donanemab) show efficacy in the early stages of Alzheimer's disease, but carry the risk of amyloid-associated imaging abnormalities (ARIA). Dementia is considered a predisposing risk factor for delirium, which is characterized by fluctuations in attention and consciousness. Delirogenic factors include polypharmacy as well as other medications such as opioids and benzodiazepines. Due to the increased risk of mortality and stroke, neuroleptics should only be administered to geriatric patients when strictly indicated, in minimal doses, and for a limited duration. Non-pharmacological interventions take precedence. Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for depressive disorders in older adults, while tricyclic antidepressants should be avoided. Regular medication reviews, reduction of anticholinergic burden, and technical aids to facilitate medication intake are essential for optimizing treatment adherence.

Advanced technical developments of small-caliber disposable endoscopes as well as EUS imaging and EUS-assisted procedures have changed the management of biliary and pancreatic diseases and expanded the spectrum of diagnostics and endoscopic interventions. Cholangioscopy enables the direct visualization of the biliary system. Endoscopic and endosonographic (EUS) procedures nowadays provide versatile and often minimally invasive approaches for assessment of the pancreatic duct system. The digital single-operator cholangioscopy (dSOC) and digital single-operator pancreatoscopy (dSOP) are increasingly becoming an integral component of the treatment of various diseases and disorders of both duct systems. This article familiarizes the reader with the various diseases and disorders of the biliary duct and pancreatic duct system and presents the most important indications, techniques of the diagnostics and therapeutic interventions as well as their clinical value.

Primary biliary cholangitis (PBC) is a chronic inflammatory, autoimmune-mediated liver disease that progresses to fibrosis and cirrhosis if left untreated. In addition to preventing complications, the management of burdensome symptoms, particularly pruritus, represents a key therapeutic goal. Ursodeoxycholic acid (UDCA) is the established first-line treatment; however, up to 40% of patients show an inadequate response and require second-line treatment. Bezafibrate, a pan-peroxisome proliferator-activated receptor (PPAR) agonist, has long been used off-label as an effective option to improve parameters of cholestasis and relieve pruritus. More recently, two new PPAR agonists, elafibranor (PPAR alpha/delta) and seladelpar (PPAR delta), have received conditional approval in Germany. Both demonstrated strong biochemical efficacy and a favorable safety profile in clinical trials. This article provides a comprehensive update on the diagnostics, risk stratification and treatment of PBC, with a particular focus on the role of novel PPAR agonists in second-line treatment. Practical strategies for the treatment of pruritus are also discussed. The aim is to support guideline-based care and to improve the treatment of patients with PBC through timely treatment adjustment and individualized treatment concepts.

Chronic inflammatory bowel diseases (IBD), primarily ulcerative colitis and Crohn's disease, are chronic relapsing-remitting inflammations of the gastrointestinal tract. The pathogenesis involves a dysregulation of the intestinal immune system in response to commensal components of the intestinal microbiome. A genetic predisposition forms the foundation for the sustained inflammatory reaction. While treatment approaches in the past focused mainly on the control of clinical symptoms through medication, the results of recent studies indicate that an endoscopically detected remission is superior to mere clinical symptom control in terms of disease progression and prognosis. This review article highlights the importance of endoscopy in the management of IBD, presents established scoring systems for the endoscopic grading of inflammatory activity and outlines in which situations and according to which guidelines endoscopic diagnostics are indicated. Finally, yet importantly applications and algorithms of artificial intelligence as well as advanced technologies in microscopy are increasingly being integrated into endoscopic procedures for patients with IBD and are also discussed in this article.

The following article provides an overview of artificial intelligence (AI) applications in gastrointestinal endoscopy. It presents AI-supported polyp detection systems, which, according to one of the latest meta-analyses of over 40 randomized studies, increase the adenoma detection rate by an average of 7.5%. However, the gain mainly affects small adenomas without a significant effect on the number of advanced adenomas identified. A microsimulation model based on these data predicts that for every 10,000 people screened, colorectal cancer will only decrease from 82 to 71 and cancer-related deaths from 15 to 13 within 10 years. In addition to the positive effects, risks arising from human-machine interaction, including overreliance and de-skilling, are highlighted in the article. AI-supported optical diagnosis is presented as a second important domain. It is designed to distinguish between neoplastic and non-neoplastic lesions in real time and enable strategies such as "resect-and-discard" or "diagnose-and-leave." The threshold of a negative predictive value of ≥ 90% required by the American Society for Gastrointestinal Endoscopy (ASGE) in its Preservation and Incorporation of Valuable Endoscopic Innovations(PIVI) statement is often not met in current studies-mainly due to low specificity and lower performance of the systems in the proximal colon. Overall, the cost effects are small, and implementation is primarily realistic for diminutive polyps. Other AI applications in gastroscopy, capsule endoscopy, cholangioscopy, and endosonography show promising accuracy and greatly reduced evaluation times, but their implementation outside Asia is limited. Overall, the long-term benefits for patients remain unclear.

Background: With the increasing number of endoscopic examinations, the requirements for safety, hygiene and diagnostic precision are also growing. Quality assurance in endoscopy is of crucial importance not only to meet legal requirements but also to improve patient care. The current S2k guidelines for gastrointestinal endoscopy have brought this topic further into focus.

Research question: The aim of this study is to examine the various dimensions of quality in endoscopy, in particular structural, procedural and outcome quality and to investigate the practical challenges of quality assurance using exemplary procedures.

Material and methods: A literature search was carried out to identify relevant studies, meta-analyses and guidelines.

Results: Quality in endoscopy can be measured using various instruments. Ensuring high quality in endoscopy requires systematic evaluation of quality indicators, structured training and continuing education for endoscopists and the development of specialized centers.

Discussion: Innovative technologies such as artificial intelligence and green endoscopy offer potential for improvement but also raise questions regarding data quality and ethical responsibility. Continuous updating of guidelines and the integration of new scientific findings are crucial for quality improvement in endoscopy.

Background: Individuals affected by rare diseases often describe the path to diagnosis as an odyssey, and even after diagnosis, there is a need for improvement in the subsequent care. Registries represent one of many building blocks for improving healthcare and research.

Objectives: What can registries achieve in the field of rare diseases, and what kind of challenges arise?

Methods: This article demonstrates what registries can achieve in the field of rare diseases with concrete examples and provides insights into the technical basics, as well as the topics of ethics and data protection, based on current literature.

Results: Multicentric data collection in registries is especially important in the field of rare diseases due to the small number of cases. However, this presents particular challenges regarding technical implementation, data protection aspects and financial resources.

Conclusion: Registries are an important tool for improving the care of individuals affected by rare diseases. However, a simplification and standardisation of the framework conditions would be desirable.