Deutsche medizinische Wochenschrift (1946)最新文献

Medical indications are based on a synthesis of medical expertise, professional ethical standards, and legal requirements. This paper examines the extent to which value judgments influence these determinations and how they can be ethically approached.The interdisciplinary conceptual and normative analysis incorporates theoretical approaches from medical science, case studies, empirical findings, and legal considerations to identify and critically discuss the various levels of value judgments involved in the indication process.Value judgments influence determining medical indications, particularly with regard to the choice of one of the goals of medicine and how probabilities, uncertainties, personal attitudes, and social norms, are handled. Some judgments do not fall within the physician's scope of responsibility, at least not in the context of medical indication, e.g., economic or allocation considerations. For clarity, it is essential to differentiate physicians' assessments and patients' preferences, to explicate professional values, and to integrate assessments and individual values within decision-making processes.Value judgments made in determining a medical indication are unavoidable and must be carefully considered. Values should be made transparent in order to justify medical interventions that are judged to be indicated or not by physicians on a case-by-case basis and to strengthen patients' self-determination. A social debate is needed on how to appropriately address considerations (such as economic) which should not be mixed up with medical indications.

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome in patients with decompensated cirrhosis and is characterized by acute failure of one or more organ systems. Despite advances in clinical management, ACLF continues to be associated with high short-term mortality.This article provides an up-to-date, guideline-based overview of the classification, diagnosis, and therapeutic approaches to ACLF, drawing on the latest literature and consensus definitions.ACLF is defined by acute decompensation of cirrhosis accompanied by failure of the liver and/or other organs including the kidneys, cardiovascular system, lungs, central nervous system, and coagulation. The EASL-CLIF Consortium criteria distinguish three grades of ACLF based on the number and type of organ failures; increasing grade correlates with sharply rising short- and medium-term mortality. Pathophysiologically, ACLF is characterized by an overwhelming systemic inflammatory response typically triggered by bacterial infections, severe alcoholic hepatitis, or gastrointestinal bleeding. Prognostication is guided by CLIF-C OF, CLIF-C ACLF, and CLIF-C AD scores, which can also help to identify patients at high risk for further decompensation. Management focuses on rapid identification and reversal of precipitating factors, organ support, and early evaluation for liver transplantation, as it remains the sole curative option in non-reversible ACLF. Preemptive TIPS placement is reserved for selected cases, with individualized risk assessment being critical due to the increased complication rate in severe multiorgan failure.ACLF remains the most severe complication of cirrhosis, marked by high short-term mortality. Early, guideline-based interventions and multidisciplinary management can improve outcomes. Accurate risk stratification and timely consideration of liver transplantation are essential to enhance patient survival.

Hepatic encephalopathy (HE) is a common and serious complication of liver cirrhosis, associated with significant morbidity and mortality. Pathophysiologically, it results from a complex interplay of hyperammonemia, systemic inflammation, neuroinflammatory processes, and microbial dysbiosis. Clinically, HE ranges from subtle cognitive impairments (minimal HE) to coma (grade 4 HE). Diagnosis requires thorough clinical assessment and the use of specialized testing methods, particularly to detect subclinical alterations. In everyday practice, ammonia levels have limited diagnostic value but may be useful for differential diagnosis. The acute treatment of overt hepatic encephalopathy (OHE) is primarily based on the administration of lactulose, optionally supplemented with intravenous L-ornithine-L-aspartate. For secondary prophylaxis lactulose is the treatment of choice and in patients with recurrent episodes, the combination of rifaximin and lactulose is well established. Nutritional recommendations are a key component of therapy, especially to prevent sarcopenia. In cases of refractory HE or recurrent relapses despite guideline-based treatment, liver transplantation should always be considered. In general, early detection and individualized management of HE is essential to preserve and improve quality of life, prognosis, and functional independence of the affected patients.

Liver cirrhosis is considered as a multisystemic disease that affects also the immune system. The spectrum of immunological alterations that can be found in patients with liver cirrhosis is summarized as cirrhosis-associated immune dysfunction (CAID). The mechanisms that are involved in the development of CAID are complex. Next to immune-mediated mechanisms causing the development of liver cirrhosis, one of the key mechanisms in the development of CAID is portal hypertension, leading to an impaired gut-liver-axis with an increased bacterial translocation to the blood stream. CAID can be assigned in the two key components systemic inflammation and immune deficiency. The intensity of components is variable and dynamic and depends on the stage of liver cirrhosis as well as the presence of incidental events (e.g. bacterial infections). In return, CAID increases the risk of infections and worsens the prognosis of the patient. The reduction of portal hypertension, inter alia by the insertion of a transjugular intrahepatic portosystemic shunt seems to be an important approach in the modulation of CAID. Further therapeutic approaches include the reduction of bacterial components to the blood and the modulation of impaired immune cell functions. Nevertheless, the only targeting approach of liver cirrhosis and CAID is still liver transplantation.

Ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome-acute kidney injury (HRS-AKI) are frequent and clinically significant complications in patients with cirrhosis, each conferring a substantial increase in mortality risk. Their pathogenesis is fundamentally driven by the development of splanchnic and systemic vasodilation secondary to portal hypertension, compounded by intestinal bacterial translocation. The diagnosis of ascites and SBP should be established without delay, employing a combination of laboratory testing and imaging modalities. In contrast, the diagnosis of HRS-AKI relies on the presence of cirrhosis with ascites together with the exclusion of alternative, more common causes of kidney injury. Management strategies vary by complication: ascites is typically addressed with diuretic therapy and placement of a transjugular intrahepatic portosystemic shunt (TIPS); SBP requires prompt initiation of antibiotic therapy combined with albumin administration; and HRS-AKI is treated with vasoconstrictor agents in conjunction with albumin.

In 2025, Germany faces a dual transformation: the institutionalization of a federal Ministry for Digital Affairs and a controversial relaxation of data protection regulations, i.e. register for mentally ill people. These developments coincide with increasing political polarization, which not only shapes public discourse but also exerts measurable effects on health behavior, trust in institutions, and access to care. Despite operating one of the world's most expensive health systems, structural inequalities in Germany persist, with life expectancy differing by up to eight years across socioeconomic groups. Public health authorities (Öffentlicher Gesundheitsdienst, ÖGD) could act as a corrective force, yet they remain underfunded, digitally underdeveloped, and vulnerable to political influence. This article argues that polarization has emerged as a social determinant of health, comparable in significance to income or education. We highlight the urgent need for institutional trustworthiness. We present the OSCADO-AI ethical code, an open-source, inter-operational, and privacy-conscious digital standard designed to enhance the resilience of public health institutions. By enabling transparent data use, secure communication, real-time surveillance, and collaborative platforms, OSCADO-AI strengthens both evidence-based decision-making and public trust. Case examples from Frankfurt illustrate how digital sovereignty and open infrastructures can protect democratic institutions against partisan interference while fostering citizen-centered health governance. Ultimately, the future of the German public health system depends on its capacity to combine medical independence, digital innovation, and civic accountability to reduce inequality and safeguard democracy.

Chronic hyperkalemia is an electrolyte imbalance that occurs mainly in patients with progressive kidney failure. It usually develops over a long period of time and symptoms are often mild. As chronic hyperkalemia is associated with increased morbidity and mortality, it should be treated. Treatment begins with a review of the medications that may be responsible for the hyperkalemia and careful therapy and correction of the metabolism. Dietary assessment now focuses on potassium intake from non-vegetable sources. Reducing the dose and/or discontinuing renin-angiotensin-aldosterone inhibitors should be discouraged, as these drugs improve the prognosis in patients with heart failure and proteinuric kidney disease. In addition to other conservative measures, specific potassium-binding substances should be used.

When discharging geriatric patients from inpatient care, hospital and family doctors must consider numerous factors to ensure seamless and safe follow-up treatment. Geriatric patients are usually multimorbid, take many medications (polypharmacy), and have an increased risk of functional limitations or complications after discharge.